{"_id": "WikiPedia_Surgical_specialties$$$corpus_1", "text": "Endocrine surgery  is a surgical sub-speciality focusing on surgery of the  endocrine glands , including the thyroid gland, the parathyroid glands, the adrenal glands, glands of the endocrine pancreas, and some neuroendocrine glands. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2", "text": "Surgery of the  thyroid gland  constitutes the bulk of endocrine surgical procedures worldwide. This may be done for a variety of conditions, help ranging from benign  multinodular goiter  to  thyroid cancer . In the United Kingdom it was developed as a separate specialty from general surgery by Richard Welbourne and John Lynn, surgeons at what was then the 'Royal Postgraduate Medical School' and is now the  Hammersmith Hospital  and contains the Department of Thyroid and Endocrine Surgery staffed by consultant surgeons Professor Fausto Palazzo, Professor Neil Tolley and Miss Aimee Di Marco.\nOperations involve removal of the thyroid gland ( thyroidectomy ) either as a part of the gland (lobectomy or hemithyroidectomy), or the whole gland (total thyroidectomy). Incomplete resections (sub-total or near total thyroidectomy) are also infrequently performed, but are disfavored by most surgeons [ citation needed ] ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3", "text": "Removal of the parathyroid gland(s) is referred to as  parathyroidectomy  and is most commonly performed for  primary hyperparathyroidism .  Parathyroidectomy is also performed to treat tertiary hyperparathyroidism arising from chronic  kidney failure ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4", "text": "Adrenalectomy , the surgical removal of the adrenal gland, is performed to treat conditions including  Conn syndrome ,  pheochromocytoma , and  adreno-cortical cancer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5", "text": "Diseases of the endocrine pancreas occur very infrequently; these include  insulinomas ,  gastrinomas  etc. Surgery for these conditions range from simple tumor enucleation to more larger resections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6", "text": "Endocrine surgery is generally well developed. Endocrine surgery has developed as a sub-specialty surgical category because of the technical nature of these operations and the associated risks of operating in the neck. In  Surgery: Basic Science and Clinical Evidence , the book the efficacy prior research: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7", "text": "Surgeons and physicians have advanced endocrine surgery by careful description of unusual patients and families with endocrine syndromes...Surgeons have also improved techniques for preparation for surgery and methods..."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8", "text": "In the 1970s, a specialty training program at  Hammersmith Hospital  was the primary location for early work in training a large number of surgeons. [ 3 ]  It is well established that complications are much less common if performed by surgeons who do at least 100 thyroid operations per year. In the United Kingdom most thyroid surgery is performed by surgeons doing less than 20 thyroid operations per year. [ citation needed ]  Permanent damage to both voice box nerves is an extreme rarity and needs in most cases a permanent tracheostomy.  Data on the outcomes of all surgeons performing endocrine surgery in the UK is publicly available via the ' British Association of Endocrine and Thyroid Surgeons ' website."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9", "text": "Some surgical teams leave wound drains in place after surgery to the thyroid gland. [ 4 ]  There is no strong evidence that wound drains improve outcomes following surgery and there is low-quality evidence that wound drains increase the length of time a person stays in the hospital following thyroid surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10", "text": "Endoscopic endonasal surgery  is a  minimally invasive technique  used mainly in  neurosurgery  and   otolaryngology . A neurosurgeon or an otolaryngologist, using an  endoscope  that is entered through the nose, fixes or removes brain defects or tumors in the anterior  skull base . Normally an otolaryngologist performs the initial stage of surgery through the  nasal cavity  and  sphenoid bone ; a neurosurgeon performs the rest of the surgery involving drilling into any cavities containing a neural organ such as the  pituitary gland . The use of endoscope was first introduced in Transsphenoidal Pituitary Surgery by R Jankowsky, J Auque, C Simon et al. in 1992 G (Laryngoscope. 1992 Feb;102(2):198-202)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11", "text": "Antonin Jean Desomeaux, a urologist from Paris, was the first person to use the term, endoscope. [ 1 ] \nHowever, the precursor to the modern endoscope was invented in the 1800s when a physician in Frankfurt, Germany by the name of  Philipp Bozzini , developed a tool to see the inner workings of the body. [ 2 ]  Bozzini called his invention a Light Conductor, or Lichtleiter in German, and later wrote about his experiments on live patients with this device that consisted of an eyepiece and a container for a candle. [ 1 ]  Following Bozzini's success, The University of Vienna starting using the device to test its practicality in other forms of medicine. After Bozzini's device received negative results from live human trials, it had to be discontinued. However,  Maximilian Nitze  and Joseph Leiter used the invention of the light bulb by Thomas Edison to make a more refined device similar to modern day endoscopes. This iteration was used for urological procedures, and eventually otolaryngologists began to use Nitze and Leiter's device for  eustachian tube  manipulation and removal of foreign bodies. [ 2 ]  The endoscope made its way to the US when Walter Messerklinger began teaching David Kennedy at Johns Hopkins Hospital. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12", "text": "The  transsphenoidal  and intracranial approaches to pituitary tumors began in the 1800s but with little success. Gerard Guiot popularized the transphenoidal approach which later became part of the neurosurgical curriculum, however he himself discontinued the use of this technique because of inadequate sight. [ 1 ]  In the late 1970s, the endoscopic endonasal approach was used by neurosurgeons to augment microsurgery which allowed them to view objects out of their line of sight. Another surgeon,  Axel Perneczky , is considered to be a pioneer of the use of an endoscope in neurosurgery. Perneczky said that endoscopy, \"improved appreciation of micro-anatomy not apparent with the microscope.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13", "text": "The surgery was pioneered in Algeria by  Bouyoucef Kheireddine  and  Faiza Lalam . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14", "text": "The endoscope consists of a glass fiber bundle for cold light illumination, a mechanical housing, and an optics component with four different views: 0 degree for straight forward, 30 degrees for forward plane, 90 degrees for lateral view, and 120 degrees for retrospective view. [ 5 ]  For endoscopic endonasal surgery, rigid rod-lens endoscopes are used for better quality of vision, since these endoscopes are smaller than the normal endoscope used  colonoscopies . [ 2 ]  The endoscope has an eyepiece for the surgeon, but it is rarely used because it requires the surgeon to be in a fixed position. Instead, a video camera broadcasts the image to a monitor that shows the surgical field. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_15", "text": "Several specialties need to be involved to determine the complete surgical plan. These include: an Endocrinologist, a Neuroradiologist, an Ophthalmologist, a Neurosurgeon, and an Otolaryngologist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_16", "text": "An endocrinologist is only involved in preparation for an endoscopic endonasal surgery, if the tumor is located on the pituitary gland. The tumor is first treated  pharmacologically  in two ways: controlling the levels of  hormones  that the  pituitary gland  secretes and reducing the size of the tumor. If this approach does not work, the patient is referred to surgery. The main types of  pituitary adenomas  are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_17", "text": "A neuroradiologist takes images of the defect so that the surgeon is prepared on what to expect before surgery. This includes identifying the  lesion  or  tumor , controlling the effects of the medical therapy, defining the spatial situation of the lesions, and verifying the removal of the lesions. [ 5 ]   The lesions associated with endoscopic endonasal surgery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_18", "text": "Some  suprasellar  tumors invade the  chiasmatic cistern , causing impaired vision. In these cases, an ophthalmologist maintains optic health by administering pre-surgical treatment, advising proper surgical techniques so that the optic nerve is not in danger, and managing post-surgery eye care. Common problems include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_19", "text": "The transnasal approach is used when the surgeon needs to access the roof of the nasal cavity, the  clivus , or the  odontoid . This approach is used to remove  chordomas ,  chondrosarcoma , inflammatory lesions of the clivus, or  metastasis  in the cervical spine region. The anterior  septum  or posterior septum is removed so that the surgeon can use both sides of the nose. One side can be used for a microscope and the other side for a surgical instrument, or both sides can be used for surgical instruments. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_20", "text": "This approach is the most common and useful technique of endoscopic endonasal surgery and was first described in 1910 concurrently by  Harvey Cushing  and  Oskar Hirsch . [ 6 ] [ 7 ]  This procedure allows the surgeon to access the sellar space, or  sella turcica . The sella is a cradle where the pituitary gland sits. Under normal circumstances, a surgeon would use this approach on a patient with a pituitary adenoma. The surgeon starts with the transnasal approach prior to using the transsphenoidal approach. This allows access to the sphenoid ostium and sphenoid sinus. The sphenoid  ostium  is located on the anterosuperior surface of the sphenoid sinus. The anterior wall of the sphenoid sinus and the sphenoid  rostrum  is then removed to allow the surgeon a panoramic view of the surgical area. [ 2 ]  This procedure also requires the removal of the posterior  septum  to allow the use of both nostrils for tools during surgery. There are several triangles of blood vessels traversing this region, which are just very delicate areas of blood vessels that can be deadly if injured. [ 2 ] [ 8 ]  A surgeon uses stereotactic imaging and a micro Doppler to visualize the surgical field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_21", "text": "The invention of the angled endoscope is used to go beyond the  sella  to the suprasellar (above the sellar) region. This is done with the addition of four approaches. First the transtuberculum and  transplanum  approaches are used to reach the suprasellar  cistern . The lateral approach is then used to reach the medial  cavernous sinus  and  petrous apex . Lastly, the inferior approach is used to reach the superior  clivus .  Endoscopic endonasal transclival approaches are often described according to which segment of the  clivus  is involved in the approach, with the  clivus  typically divided into three regions. [ 9 ]  Depending on which segment of the  clivus  is involved in the surgical approach, different neurovascular structures are placed at risk. The upper third lies inferior to the dorsum sellae and posterior clinoid processes and superior to the petrous apex, the middle third lies at the level of the petrous segments of the internal carotid artery (ICA), and the inferior third extends from the jugular tubercle to the foramen magnum. [ 9 ]  It is important that the Perneczky triangle is treated carefully. This triangle has optic nerves, cerebral arteries, the  third cranial nerve , and the  pituitary stalk . Damage to any of these could provide a devastating post-surgical outcome. [ 2 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_22", "text": "The transpterygoidal approach enters through the posterior edge of the  maxillary sinus   ostium  and posterior wall of the maxillary sinus. This involves penetrating three separate sinus cavities: the  ethmoid sinus , the  sphenoidal sinus , and the maxillary sinus. Surgeons use this method to reach the  cavernous sinus , lateral  sphenoid sinus , infra  temporal fossa ,  pterygoid fossa , and the  petrous apex . Surgery includes a uninectomy (removal of the osteomeatal complex), a medial maxillectomy (removal of maxilla), an ethmoidectomy (removal of ethmoid cells and/or ethmoid bone), a sphenoidectomy (removal of part of sphenoid), and removal of the maxillary sinus and the palatine bone. The posterior septum is also removed at the beginning to allow use of both nostrils. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_23", "text": "This approach makes a surgical corridor from the  frontal sinus  to the  sphenoid sinus . This is done by the complete removal of the  ethmoid  bone, which allows a surgeon to expose the roof of the ethmoid, and the medial orbital wall. This procedure is often successful in the removal of small  encephaloceles  of the ethmoid  osteomas  of the  ethmoid sinus  wall or small  olfactory  groove  meningiomas . However, with larger tumors or lesions, one of the other approaches listed above is required. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_24", "text": "For removal of a small tumor, it is accessed through one nostril. However, for larger tumors, access through both nostrils is required and the posterior nasal  septum  must be removed. Then the surgeon slides the endoscope into the nasal  choana  until the sphenoid  ostium  is found. Then the mucosa around the ostium is cauterized for microadenomas and removed completely for macroadenomas. Then the endoscope enters the ostium and meets the sphenoid  rostrum  where the  mucosa  is retracted from this structure and is removed from the  sphenoid sinus  to open the surgical pathway. At this point, imaging and Doppler devices are used to define the important structures. Then the floor of the  sella turcica  is opened with a high speed drill being careful to not pierce the  dura mater . Once the dura is visible, it is cut with microscissors for precision. If the tumor is small, the tumor can be removed by an  en bloc  procedure, which consists of cutting the tumor into many sections for removal. If the tumor is larger, the center of the tumor is removed first, then the back, then the sides, then top of the tumor to make sure that the  arachnoid membrane  does not expand into the surgical view. This will happen if the top part of the tumor is taken out too early. After tumor removal, CSF leaks are tested for with fluorescent dye, and if there are no leaks, the patient is closed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_25", "text": "This technique is the same as to the sellar region. However the   tuberculum sellae  is drilled into instead of the sella. Then an opening is made that extends halfway down the sella to expose the dura, and the  intercavernous sinuses  is exposed. When the  optic chiasm ,  optic nerve , and  pituitary gland  are visible, the pituitary gland and optic chasm are pushed apart to see the  pituitary stalk . An  ethmoidectomy  is performed, [ 2 ]  the dura is then cut, and the tumor is removed. These types of tumors are separated into two types:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_26", "text": "When there is a tumor, injury, or some type of defect at the skull base whether the surgeon used an endoscopic or open surgical method, the problem still arises of providing separation of the  cranial cavity  and cavity between the sinuses and nose to prevent  cerebrospinal fluid  leakage through the opening referred to as a defect. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_27", "text": "For this procedure, there are two ways to start: with a free graft repair or with a vascularized flap repair. The free grafts use secondary material like  cadaver  flaps or titanium mesh to repair the skull base defects, which is very successful (95% without CSF leaks) with small CSF fistulas or small defects. [ 12 ]   The local or regional vascularized flaps are pieces of tissue relatively close to the surgery site that have been mostly freed up but are still attached to the original tissue. These flaps are then stretched or maneuvered onto the desired location. When technology advanced and larger defects could be fixed endoscopically, more and more failures and leaks started to occur with the free graft technique. The larger defects are associated with a wider dural removal and an exposure to high flow CSF, which could be the reason for failure among the free graft. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_28", "text": "This surgery is turned from a very serious surgery into a minimally invasive one through the nose with the use of the endoscope. For instance  craniopharyngiomas  (CRAs) are starting to be removed via this method. Dr. Paolo Cappabianca described the perfect CRA for this surgery to be a median lesion with a solid parasellar component (beside the sellar) or encasement of the main neuromuscular structures that are localized in the subchiasmatic (below the  optic chiasm ) and retrochiasmatic (behind the optic chiasm) regions. He also says that when these conditions are met, endoscopic endonasal surgery is a valid surgical option. [ 13 ]  For a case study on large adenomas, the doctors showed that out of 50 patients, 19 had complete tumor removal, 9 had near complete removal, and 22 had partial removal. The partial removal came from the tumors extending into more dangerous areas. They concluded that endoscopic endonasal surgery was a valid option for surgery if the patients used pharmacological therapy after surgery. [ 14 ]  Another study showed that with endoscopic endonasal surgery 90% of  microadenomas  could be removed, and that 2/3 of normal  macroadenomas  could be removed if they did not go into the  cavernous sinus , which means fragile blood vessel triangles would have to be dealt with so only 1/3 of those patients recovered. [ 15 ]  Endoscopic endonasal approach has been shown even among young patients to be superior to traditional microscopic transsphenoidal surgery. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_29", "text": "The newer 3-D technique is gaining ground as the ideal way to do surgery because it gives the surgeon a better understanding of the spatial configuration of what they are seeing on a computer screen. Dr. Nelson Oyesiku at Emory University helped develop the 3-D technique. In an article he helped write, he and the other authors compared the effects of the 2-D technique vs the 3-D technique on patient outcome. It showed that the 3-D endoscopy gave the surgeon more depth of field and stereoscopic vision and that the new technique did not show any significant changes in patient outcomes during or after surgery. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_30", "text": "In a case study from 2013, they compared the open vs endoscopic techniques for 162 other studies that contained 5,701 patients. [ 18 ]   They only looked at four tumor types: the olfactory groove  meningiomas  (OGM), tuberculum sellae meningiomas (TSM),  craniopharyngiomas  (CRA), and clival  chordomas  (CHO). They looked at gross total resection and  cerebrospinal fluid  (CSF) leaks, neurological death, post-operative visual function, post operative  diabetes insipidus , and post-operative obesity. The study showed that there was a greater chance of CSF leaks with endoscopic endonasal surgery. The visual function improved more with endoscopic surgery for TSM, CRA, and CHO patients. Diabetes insipidus occurred more in open procedure patients. The endoscopic patients showed a higher recurrence rate. In another case study on CRAs, [ 19 ]  they showed similar results with the CSF leaks being more of a problem in endoscopic patients. Open procedure patients showed a higher rate of post operative seizures as well. Both of these studies still suggest that despite the CSF leaks, that the endoscopic technique is still an appropriate and suitable surgical option. Otologic surgery, which is traditionally performed via an open approach using a microscope, may also be performed endoscopically, and is called  Endoscopic Ear Surgery  or EES. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_31", "text": "Donald Stuart Gann  (1932\u00a0\u2013 February 3, 2020) was an American  trauma surgeon . He chaired surgical departments at  Case Western Reserve University ,  Brown University ,  Johns Hopkins School of Medicine , and the  University of Maryland School of Medicine . He was a past president of the  Biomedical Engineering Society  and the  American Association for the Surgery of Trauma \u00a0[ Wikidata ] ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_32", "text": "Gann was born in 1932 [ 1 ]  in  Baltimore  to educator Beatrice Gann and physician Mark Gann. He was raised on  Eutaw Street  in Baltimore and  Catonsville, Maryland . Gann attended  Baltimore Polytechnic Institute  until leaving in 11th grade to attend college at the age of 16. He double majored in physics and philosophy at  Dartmouth College , graduating with  magna cum laude  and  Phi Beta Kappa  honors in 1952. Gann completed a medical degree at  Johns Hopkins School of Medicine  in 1956. He conducted a residency in surgery at Johns Hopkins University and an assistant residency at  MedStar Union Memorial Hospital . [ 2 ]  Gann trained under  Vernon Benjamin Mountcastle  in neurosurgery before shifting to endocrine surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_33", "text": "In 1967, Gann was the first chair of the biomedical engineering department at  Case Western Reserve University . In 1970, he became a professor of biomedical engineering and associate professor of surgery. In 1974, Gann became a professor of  emergency medicine  and director of the division of emergency medicine. From 1979 to 1988, Gann was chair of the new department of surgery at  Brown University  and was the second surgeon in chief of  Rhode Island Hospital . He led the division of surgical  critical care  at the  University of Maryland Medical Center  from 1992 to 2000. He held other positions at  University of Maryland School of Medicine  (UMMS) including section chief of  trauma surgery  and critical care, and  endocrine surgery . He retired from UMMS in 2010. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_34", "text": "Gann and physiologist Dan Darlington founded Shock Therapeutics Biotechnologies Inc. based on a patent for treating  hemorrhagic shock . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_35", "text": "He was the president of the  Biomedical Engineering Society  (1971\u20131972) and of the  American Association for the Surgery of Trauma \u00a0[ Wikidata ]  from 1987 to 1988. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_36", "text": "Gann was a  Quaker . He was married to nurse practitioner Gail Burgan. He had three sons and a daughter. He died on February 3, 2020, at his  Brooklandville, Maryland , residence. Gann was 87. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_37", "text": "Gann was a member of the  American Association of Endocrine Surgeons ,  American College of Surgeons , Halsted Society,  Endocrine Society , and the Southern Surgical Association. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_38", "text": "Parathyroidectomy  is the  surgical  removal of one or more of the (usually) four  parathyroid glands . This procedure is used to remove an  adenoma  or  hyperplasia  of these glands when they are producing excessive  parathyroid hormone  (PTH):  hyperparathyroidism . The glands are usually four in number and located adjacent to the posterior surface of the  thyroid gland , but their exact location is variable. When an elevated PTH level is found, a  sestamibi scan  or an  ultrasound  may be performed in order to confirm the presence and location of abnormal parathyroid tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_39", "text": "The main indication for parathyroidectomy is primary hyperparathyroidism, a condition in which one or more of the parathyroid glands produce excessive parathyroid hormone. Not all cases of primary hyperparathyroidism require surgery, but it is recommended if the condition causes significant symptoms or if it affects the kidneys ( nephrocalcinosis ) or bone health ( osteoporosis ), and also in people under 50 even if they do not have symptoms. [ 1 ]  It is not always possible to anticipate if a parathyroid tumor is  malignant  (i.e. capable of invading other tissues or  spreading elsewhere ). Any suspicion of parathyroid carcinoma is therefore also an indication for surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_40", "text": "Parathyroidectomy may also be required in secondary hyperparathyroidism. This situation arises mainly in people with severe  chronic kidney disease  in which the parathyroid glands are overactive to compensate for the low calcium and vitamin D levels often present in CKD. In many cases, the parathyroid hormone production improves when these abnormalities are treated with medication. A small proportion, however, have persistently raised hormone levels six months after treatment has started, thought to be autonomous production of hormone by the glands and loss of feedback mechanisms. In this situation surgical parathyroidectomy may be required, especially if calcium and phosphate levels remain elevated, there is calcium deposition in the wall of blood vessels ( calciphylaxis  in severe cases) or there is worsening bone disease. In people on  dialysis , parathyroidectomy can improve their survival. It does appear that the procedure may be underused. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_41", "text": "The  operation  requires a  general anesthetic  (unconscious and pain free) or a  local anesthetic  (pain free). The surgeon makes an incision around an inch long in the neck just under the  larynx  ( Adam's apple ), and locates the offending parathyroid glands. Preoperative testing using  sestamibi scanning  can help identify the location of glands. It can also be used to limit the extent of surgical exploration when used in conjunction with intraoperative PTH hormone monitoring. [ 3 ]   The particular problem or disease process will determine how many of the parathyroid glands are removed. Some parathyroid tissue must be left in place to help prevent  hypoparathyroidism ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_42", "text": "Recovery after the operation tends to be swift. The  PTH  level is back to normal within 10\u201315 minutes, and can be confirmed by intraoperative rapid assessment during the operation.  However, the remaining parathyroid glands may take hours to several weeks to return to their normal functioning levels (as they may have become dormant).  Calcium supplements are therefore often required to prevent symptoms of  hypocalcemia  and to restore lost bone mass. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_43", "text": "The patient is placed in a semi-Fowler position and the neck is extended. An abbreviated Kocher incision is made and the platysma muscle is dissected horizontally. The strap muscles are released off of the thyroid gland. Then the thyroid gland is mobilized and the parathyroid arterial blood supply is suture ligated. The entire parathyroid adenoma is identified and dissected out. Intraoperative PTH monitoring can begin at this time and will show falling PTH levels if the entire adenoma has been resected. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_44", "text": "While mild hypocalcemia is common after partial parathyroidectomy, some people experience persistently prolonged low calcium levels. This is called  hungry bone syndrome . Despite the reactivation of unresected parathyroid glands producing normal to elevated levels of PTH, serum calcium continues to be low. The balance between calcium influx and efflux within the bone continues to be disrupted, favoring the former. The bone is said to be \"hungry\" as it consumes minerals without regard to PTH; calcium, magnesium, and phosphate continue to be deposited into the bones, resulting in hypocalcemia, hypomagnesemia, and hypophosphatemia. Prolonged calcium supplementation may be required. Hungry bone syndrome is particularly common in people who are on long-term regular dialysis. [ 2 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_45", "text": "Pinealectomy  is a  surgical procedure  in which the  pineal gland  is removed. It is performed only in rare cases, where a  pineocytoma  or a  pineal gland cyst  has become life-threatening. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_46", "text": "This  surgery  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_47", "text": "A  thyroidectomy  is an operation that involves the  surgical  removal of all or part of the  thyroid gland .  In  general surgery , endocrine or head and neck surgeons often perform a thyroidectomy when a patient has thyroid  cancer  or some other condition of the thyroid  gland  (such as  hyperthyroidism ) or goiter. Other indications for surgery include cosmetic (very enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). Thyroidectomy is a common surgical procedure that has several potential complications or sequelae including: temporary or permanent change in voice, temporary or permanently low calcium, need for lifelong thyroid hormone replacement, bleeding, infection, and the remote possibility of airway obstruction due to bilateral vocal cord paralysis.  Complications are uncommon when the procedure is performed by an experienced surgeon. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_48", "text": "The thyroid produces several  hormones , such as  thyroxine  (T4),  triiodothyronine  (T3), and  calcitonin . After the removal of a thyroid, patients usually take a prescribed oral synthetic thyroid hormone\u2014 levothyroxine  (Synthroid)\u2014to prevent  hypothyroidism . Less extreme variants of thyroidectomy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_49", "text": "A thyroidectomy should not be confused with a  thyroidotomy  ( thyrotomy ), which is a cutting into ( \u2011otomy ) the thyroid, not a removal ( \u2011ectomy , literally \u201cout-cutting\u201d) of it. A thyroidotomy can be performed to get access for a  median laryngotomy , or to perform a  biopsy . (Although technically a biopsy involves removing some tissue, it is more frequently categorized as an  \u2011otomy  than an  \u2011ectomy  because the volume of tissue removed is minuscule.)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_50", "text": "Traditionally, the thyroid has been removed through a neck incision that leaves a permanent scar. More recently,  minimally invasive  and \"scarless\" approaches such as  transoral thyroidectomy  have become popular in some parts of the world. In the United States it is a common procedure, performed over 100,000 times per year.  [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_51", "text": "Thyroidectomy is used in the treatment of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_52", "text": "Al-Zahrawi , a tenth century  Arab  physician, sometimes referred to as the \"father of surgery\", [ 8 ]  is credited with the performance of the first thyroidectomy. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_53", "text": "Media related to  Thyroidectomy  at Wikimedia Commons"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_54", "text": "Vascular surgery  is a surgical subspecialty in which  vascular diseases  involving the  arteries ,  veins , or  lymphatic vessels , are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from  general  and  cardiovascular surgery  where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular (minimally invasive) techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_55", "text": "Early leaders of the field included Russian surgeon  Nikolai Korotkov , noted for developing early surgical techniques, American  interventional radiologist   Charles Theodore Dotter  who is credited with inventing minimally invasive angioplasty (1964), and Australian Robert Paton, who helped the field achieve recognition as a specialty. Edwin Wylie of San Francisco was one of the early American pioneers who developed and fostered advanced training in vascular surgery and pushed for its recognition as a specialty in the United States in the 1970s. The most notable historic figure in vascular surgery is the 1912 Nobel Prize winning surgeon,  Alexis Carrel  for his techniques used to suture vessels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_56", "text": "The specialty continues to be based on operative arterial and venous surgery but since the early 1990s has evolved greatly. There is now considerable emphasis on minimally invasive alternatives to surgery. The field was originally pioneered by  interventional radiologists  like Dr.  Charles Dotter , who invented angioplasty using serial dilatation of vessels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_57", "text": "The surgeon Dr.  Thomas J. Fogarty  invented a  balloon catheter , designed to remove clots from occluded vessels, which was used as the eventual model to do endovascular angioplasty. Further development of the field has occurred via joint efforts between  interventional radiology , vascular surgery, and  interventional cardiology . This area of vascular surgery is called Endovascular Surgery or Interventional Vascular Radiology, a term that some in the specialty append to their primary qualification as Vascular Surgeon. Endovascular and endovenous procedures (e.g.,  EVAR ) can now form the bulk of a vascular surgeon's practice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_58", "text": "The treatment of the aorta, the body's largest artery, dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century AD. Modern treatment of aortic diseases stems from development and advancements from  Michael DeBakey  and  Denton Cooley . In 1955, DeBakey and Cooley performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the  Dacron  graft, resulting in a revolution for surgeons in the repair of aortic aneurysms. He also was first to perform cardiopulmonary bypass to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_59", "text": "Dr.  Ted Diethrich , one of Dr. DeBakey's associates, went on to pioneer many of the  minimally invasive  techniques that later became hallmarks of endovascular surgery. [ 2 ]  Dietrich later founded the  Arizona Heart Hospital  in 1998 and served as its medical director from 1998 to 2010. In 2000, Diethrich performed the first endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm. Dietrich trained several future leaders in the field of endovascular surgery at the Arizona Heart Hospital including  Venkatesh Ramaiah, MD [ 3 ]  who succeeded him as medical director of the institution in 2010. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_60", "text": "The development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in  general surgery . Most vascular surgeons would now confine their practice to vascular surgery and, similarly, general surgeons would not be trained or practise the larger vascular surgery operations or most endovascular procedures. More recently, professional vascular surgery societies and their training program have formally separated vascular surgery into a separate specialty with its own training program, meetings and accreditation. Notable societies are  Society for Vascular Surgery  (SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZSVS). Local societies also exist (e.g., New South Wales Vascular and Melbourne Vascular Surgical Association (MVSA)). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella (e.g.,  Royal Australasian College of Surgeons  (RACS))."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_61", "text": "Arterial and venous disease treatment by  angiography ,  stenting , and non-operative varicose vein treatment  sclerotherapy ,  endovenous laser treatment  have largely replaced major surgery in many first world countries. These procedures provide reasonable outcomes that are comparable to surgery with the advantage of short hospital stay (day or overnight for most cases) with lower morbidity and mortality rates. Historically performed by interventional radiologists, vascular surgeons have become increasingly proficient with endovascular methods. [ 5 ]  The durability of endovascular arterial procedures is generally good, especially when viewed in the context of their common clinical usage i.e. arterial disease occurring in elderly patients and usually associated with concurrent significant patient comorbidities especially ischemic heart disease. The cost savings from shorter hospital stays and less morbidity are considerable but are somewhat balanced by the high cost of imaging equipment, construction and staffing of dedicated procedural suites, and of the implant devices themselves.\nThe benefits for younger patients and in venous disease are less persuasive but there are strong trends towards nonoperative treatment options driven by patient preference, health insurance company costs, trial demonstrating comparable efficacy at least in the medium term."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_62", "text": "A recent trend in the United States is the stand-alone day angiography facility associated with a private vascular surgery clinic, thus allowing treatment of most arterial endovascular cases conveniently and possibly with lesser overall community cost. [ citation needed ]  Similar non-hospital treatment facilities for non-operative vein treatment have existed for some years and are now widespread in many countries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_63", "text": "NHS England  conducted a review of all 70 vascular surgery sites across England in 2018 as part of its Getting It Right First Time programme. The review specified that vascular hubs should perform at least 60 abdominal aortic aneurysm procedures and 40 carotid endarterectomies a year. 12 trusts missed both targets and many more missed one of them. A programme of concentrating vascular surgery in fewer centres is proceeding. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_64", "text": "Vascular surgery encompasses surgery of the  aorta ,  carotid arteries , and  lower extremities , including the  iliac ,  femoral ,  vascular trauma  and  tibial arteries . Vascular surgery also involves surgery of veins, for conditions such as  May\u2013Thurner syndrome  and for  varicose veins . In some regions, vascular surgery also includes  dialysis access surgery  and  transplant surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_65", "text": "The management of arterial pathology excluding coronary and intracranial disease is within the scope of vascular surgeons. Disease states generally arise from narrowing of the arterial system known as  stenosis  or abnormal dilation referred to as an  aneurysm . There are multiple mechanisms by which the arterial lumen can narrow, the most common of which is  atherosclerosis . [ 7 ]  Symptomatic stenosis may also result from a complication of  arterial dissection . Other less common causes of stenosis include  fibromuscular dysplasia , radiation induced fibrosis or  cystic adventitial disease . Dilation of an artery which retains histologic layers is called an aneurysm. An aneurysms can be fusiform (concentric dilation), saccular (outpouching) or a combination of the two. Arterial dilation which does not contain three histologic layers is considered a  pseudoaneurysm . Additionally, there are a number of congenital vascular anomalies which lead to symptomatic disease that are managed by the vascular surgeon, a few of which include  aberrant subclavian artery ,  popliteal artery entrapment syndrome  or persistent sciatic artery. [ 8 ]  Vascular surgeons treat arterial diseases with a range of therapies including lifestyle modification, medications, endovascular therapy and surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_66", "text": "An  abdominal aortic aneurysm  (AAA) refers to aneurysmal dilation of the aorta confined to the abdominal cavity. Most commonly, aneurysms are asymptomatic and located in the infrarenal position. Often, they are discovered incidentally or on screening exams in patients with risk factors such as a history of smoking. Patients with aneurysms which have a diameter less than 5\u00a0cm are at <1% rupture risk per year. When the aneurysm meets size criteria it can be treated with  aortic replacement  or  EVAR ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_67", "text": "Thoracic aortic aneurysms  are contained in the chest. Aneurysms of the descending aorta can often be treated with thoracic endovascular aortic repair or  TEVAR . Treating aneurysms which involve the ascending aorta are generally within the scope of cardiac surgeons, but upcoming endovascular technology may allow for a more minimally invasive approach in some patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_68", "text": "Thoroacoabdominal aneurysms are those which span the chest and abdominal cavities. The  Crawford classification  was developed and describes five types of thoracoabdominal aneurysms. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_69", "text": "In addition to treating aneurysms which arise from the  aorta , vascular surgeons also treat aneurysms elsewhere in the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_70", "text": "Visceral artery aneurysms include those isolated to the  renal artery ,  splenic artery ,  celiac artery , and  hepatic artery . Of these, data shows that splenic artery aneurysms are the most common. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_71", "text": "Indications for repair differ slightly between arteries. For instance, current guidelines recommend repair of renal and splenic artery aneurysms greater than 3\u00a0cm, and those of any size in women of childbearing age; whereas celiac and hepatic artery aneurysms are indicated for repair when their size is greater than 2\u00a0cm. This is in contrast to superior mesenteric artery aneurysms which should be repaired regardless of size when they are discovered. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_72", "text": "A  popliteal artery aneurysm  is an arterial aneurysm localized in the  popliteal artery  which courses behind the  knee . Unlike aneurysms located in the abdomen, popliteal artery aneurysm rarely present with rupture but rather with symptoms of  acute limb ischemia  due to embolization of thrombus. Thus, when a patient presents with an asymptomatic popliteal aneurysm that is greater than 2\u00a0cm in diameter a vascular surgeon are able to offer vascular bypass or endovascular exclusion depending on several factors. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_73", "text": "The artery wall is composed of three concentric layers: the  intima ,  media  and  adventitia . In general, an  arterial dissection  is a tear in the innermost layer of the arterial wall that makes a separation which allows blood to flow, and collect, between the layers. Arterial dissections include: an  aortic dissection  ( aorta ), a  coronary artery dissection  ( coronary artery ), two types of  cervical artery dissection  involving one of the arteries in the neck \u2013 a  carotid artery dissection  ( carotid artery ), and a  vertebral artery dissection  ( vertebral artery ), a pulmonary artery dissection is an extremely rare condition as a complication of chronic  pulmonary hypertension . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_74", "text": "Whereas  cardiac surgeons  are usually in charge of managing type A dissections, type B dissections are typically managed by vascular surgeons. The most common risk factor for type B aortic dissection is  hypertension . The first line treatment for type B aortic dissection is aimed at reducing both  heart rate  and  blood pressure  and is referred to as anti-impulse therapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_75", "text": "Should initial medical management fail or there is the involvement of a major branch of the aorta, vascular surgery may be needed for these type B dissections. Treatment may include thoracic endovascular aortic repair (TEVAR) with or without extra-anatomic  bypass  such as carotid-carotid bypass, carotid-subclavian bypass, or subclavian-carotid transposition. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_76", "text": "Visceral artery dissections are arterial dissections involving the  superior mesenteric artery ,  celiac artery ,  renal arteries ,  hepatic artery  and others. When they are an extension of an aortic dissection, this condition is managed simultaneously with aortic treatment. In isolation, visceral artery dissections are discovered incidentally in up to a third of patients and in these cases may be managed medically by a vascular surgeon. In cases where the dissection results in organ damage it is generally accepted by vascular surgeons that surgery is necessary. Surgical management strategies depend on the associated complications, surgical ability and patient preference. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_77", "text": "Mesenteric ischemia results from the acute or chronic obstruction of the  superior mesenteric artery  (SMA). The SMA arises from the abdominal aorta and usually supplies blood from the distal  duodenum  through two-thirds of the  transverse colon  and the  pancreas ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_78", "text": "The symptoms of chronic mesenteric ischemia can be classified as  abdominal angina [ 17 ]  which is abdominal pain which occurs a fixed period of time after eating. Due to this, patient's may avoid eating, resulting in unintended weight loss. The first surgical treatment is thought to be performed by R.S. Shaw and described in the  New England Journal of Medicine  in 1958. The procedure Shaw described is referred to as mesenteric  endarterectomy . [ 18 ]  Since then, many advances in treatment have been made in minimally invasive,  endovascular  techniques including  angioplasty  and stenting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_79", "text": "Acute mesenteric ischemia (AMI) results from the sudden  occlusion  of the  superior mesenteric artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_80", "text": "The renal arteries supply oxygenated blood to the kidneys. The kidneys serve to filter the flood and control blood pressure through the renin-angiotensin system. One cause of resistant hypertension is atherosclerotic disease in the renal arteries and is generally referred to as  renovascular hypertension . If renovascular hypertension is diagnosed and maximal medical fails to control high blood pressure, the vascular surgeon may offer surgical treatment, either endovascular or open surgical reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_81", "text": "Vascular surgeons are responsible for treating extracranial cerebrovascular disease as well as the interpretation of non-invasive vascular imaging relating to extracranial and intracranial circulation such as  carotid ultrasonography  and  transcranial doppler . The most common of cerebrovascular conditions treated by vascular surgeons is  carotid artery stenosis  which is a narrowing of the  carotid arteries  and may be either clinically symptomatic or asymptomatic (silent). Carotid artery stenosis is caused by  atherosclerosis  whereby the buildup of  atheromatous plaque  inside the artery causes narrowing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_82", "text": "Symptoms of carotid artery stenosis can include  transient ischemic attack  or  stroke . Both symptomatic and asymptomatic carotid stenosis can be diagnosed with the aid of carotid duplex ultrasound which allows for the estimation of severity of narrowing as well as characterize the plaque. Treatment can include medical therapy,  carotid endarterectomy  or  carotid stenting ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_83", "text": "The  Society for Vascular Surgery  publishes clinical practice guidelines for the management of extracranial cerebrovascular disease. [ 19 ]  Less common diseases involving cerebral circulation treated by vascular surgeons include  vertebrobasilar insufficiency ,  subclavian steal syndrome ,  carotid artery dissection ,  vertebral artery dissection ,  carotid body tumor  and carotid artery aneurysm among others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_84", "text": "Peripheral artery disease  PAD is the abnormal narrowing of the arteries which supply the limbs. Patients with this condition can present with  intermittent claudication  which is pain mainly in the calves and thighs while walking. If there is progression, a patient may also present with  chronic limb threatening ischemia  which encompasses pain at rest and non-healing wounds. Vascular surgeons are experts in the diagnosis, medical management, endovascular and open surgical treatment of PAD. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_85", "text": "A vascular surgeon may diagnose PAD using a combination of  history ,  physical exam  and  medical imaging . Medical imaging may include  ankle-brachial index ,  doppler ultrasonography  and  computed tomography angiography , among others. Treatments are individualized and may include medical therapy, endovascular intervention or open surgical options including  angioplasty ,  stenting ,  atherectomy ,  endarterectomy  and  vascular bypass , among others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_86", "text": "Chronic venous insufficiency  is the abnormal pooling of blood in the lower extremity venous system which can lead to reticular veins, varicose veins, chronic edema and inflammation among other things. Population data suggests that chronic venous insufficiency affects up to 40% of females and 17% of males. [ 21 ]  When chronic insufficiency leads to pain, swelling and skin changes it is referred to as  chronic venous disease . Chronic venous insufficiency (CVI) is distinguished from  post-thrombotic syndrome  (PTS) in that CVI is primarily an issue of valvular incompetence of the  superficial  or  deep veins  whereas PTS may occur as a long-term complication of  deep venous thrombosis . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_87", "text": "The vascular surgeon has several modalities to treat lower extremity venous disease which including medical, interventional and surgical procedures. For instance, venous ulceration may be treated with  Unna's boots , superficial venous reflux with  radiofrequency ,  laser ablation  or  vein stripping  if indicated. When indicated, insufficiency in the deep veins may be treated with reconstruction of the venous valves with internal or external valvuloplasty. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_88", "text": "Lower extremity  varicose veins  is the condition in which the  superficial veins  become tortuous (snakelike) and dilated (enlarged) to greater than 3\u00a0mm (0.12\u00a0in) in the upright position. [ 24 ]  Incompetent or faulty valves are often present in these veins when investigated with  duplex ultrasonography . Vascular treatments can include  compression stockings , venous ablation or  vein stripping , depending on specific patient presentation, severity of disease, among other things."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_89", "text": "Nonthrombotic iliac vein lesions (NIVL) include  May-Thurner Syndrome  (MTS) whereby there is compression of the left iliac venous outflow usually by the right iliac artery leading to left leg discomfort, pain, swelling and varicose veins. NIVL encompasses compression of the iliac veins on either the right or left side. [ 25 ]  Vascular surgeons may offer different treatment modalities depending on the patient presentation. Minimally invasive diagnostic and therapeutic options might include  intravascular ultrasound , venography and iliac vein stenting whereas surgical management may be offered in refractory cases. [ 26 ]  Surgical management strategies involve reconstruction or bypass of the affected segment such as cross-pubic venous bypass, also known as the Palma procedure. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_90", "text": "Deep vein thrombosis  (DVT) is the formation of thrombus in a  deep vein . DVT is more likely to occur in the lower extremity than the upper extremity or  jugular vein . When a DVT involves the pelvic and lower extremity veins it can sometimes be classified as an  iliofemoral DVT . Some evidence to suggests that performing an intervention in these cases may be beneficial whereas other evidence does not. [ 29 ]  Overall, the data shows that there may be a reduction in the incidence in  post-thrombotic syndrome  in patients who undergo certain procedures for iliofemoral DVT but it is not without risks. [ 30 ]  A vascular surgeon may offer venogram, endovascular suction or mechanical thrombectomy and in some cases pharmacomechanical thrombectomy. [ citation needed ]  Some lower extremity DVT can be severe enough to cause a condition called  phlegmasia cerulea dolens  or  phlegmasia alba dolens  and can be limb-threatening events. When phlegmasia is present, intervention is often warranted and may include venous thrombectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_91", "text": "Post-thrombotic syndrome  (PTS) is a medical condition that sometimes occurs as a long-term complication of DVT and is characterized by long term  edema  and skin changes following DVT. Presenting symptoms may include itchiness, pain, cramps and paresthesia. It is estimated that between 20% and 50% of patients will experience some degree of PTS. [ 31 ]  A treatment strategy for PTS may involve the use of compression stockings."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_92", "text": "Surgical management of an acute  pulmonary embolism  ( pulmonary thrombectomy ) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit certain people. [ 32 ]  Chronic pulmonary embolism leading to  pulmonary hypertension  (known as  chronic thromboembolic hypertension ) is treated with a surgical procedure known as a  pulmonary thromboendarterectomy . [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_93", "text": "Compression of large veins by adjacent structures or masses may lead to distinct  clinical syndromes  including  May\u2013Thurner syndrome  (MTS),  nutcracker syndrome  and  superior vena cava syndrome  to name a few. Treatment modalities include  venography ,  intravascular ultrasound  and venous  stenting  as well as more invasive open venous reconstruction and bypass."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_94", "text": "Patients with  chronic kidney disease  may have progression of disease which requires  renal replacement therapy  to filter their blood. One strategy for this therapy is  hemodialysis , which is a procedure that involves filtering a patient's blood to remove waste products and returning their blood back to them. One method which avoids repeated arterial trauma is to create an  arteriovenous fistula  (AVF). The first procedure described for this purpose is named the  Cimino fistula , after one of the surgeons who first had success with it. Vascular surgeons may create an AVF for a patient as well as undertake minimally invasive procedures to ensure the fistula remains  patent ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_95", "text": "One way that vascular trauma may be understood is by categorizing vascular injury by three criteria: mechanism of injury, anatomical site of injury and contextual circumstances. Mechanism of injury refers to etiology, e.g.  iatrogenic ,  blunt ,  penetrating ,  blast injury , etc. Anatomical site functionally refers to whether there is compressible versus non-compressible hemorrhage, while contextual circumstances refers to injuries sustained in the civilian or military realm. Each context can be further broken down: military into combatant vs. noncombatant and civil into urban vs rural trauma. [ 34 ]  This categorization scheme is of both epidemiologic and clinical significance. For instance, arterial injury in military combatants currently occurs predominantly in males in their twenties who are exposed to improvised explosive devices or gunshot wounds; whereas in the civilian realm, one study conducted in the United States showed the most common mechanisms to include motor vehicle collisions, firearm injuries, stab wounds and falls from heights. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_96", "text": "Advances in vascular surgery, specifically endovascular technologies, have led to a dramatic change in the operative approach to  blunt thoracic aortic injury  (BTAI). BTAI results from a high speed insult to the thorax such as a  motor vehicle collision  or a fall from a height. One widely-used classification scheme is based on the extent of injury to the anatomic layers of the aorta as seen with  computed tomography angiography  or  intravascular ultrasound . Grade 1 BTAI are those which tear the aortic intima; grade 2 injuries refer to intramural hematoma; grade 3 injuries are pseudoaneurysm and are only contained by adventitial tissue; and grade 4 refer to free rupture of blood into the chest and surrounding tissue. [ 36 ]  When indicated, first line intervention involves  TEVAR ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_97", "text": "Previously considered a field within  general surgery , it is now considered a specialty in its own right. As a result, there are two pathways for training in the United States. Traditionally, a five-year general surgery residency is followed by a 1-2 year (typically 2 years) vascular surgery fellowship. An alternative path is to perform a five or six year vascular surgery residency. In many countries, Vascular surgeons can opt for additional training in  cardiac surgery  as well as post-residency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_98", "text": "Programs of training vary slightly between different regions of the world."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_99", "text": "Abdominal aortic aneurysm  ( AAA ) is a localized enlargement of the  abdominal aorta  such that the diameter is greater than 3\u00a0cm or more than 50% larger than normal. [ 1 ]  An AAA usually causes no symptoms, except during rupture. [ 1 ]  Occasionally, abdominal, back, or leg pain may occur. [ 2 ]  Large aneurysms can sometimes be felt by pushing on the abdomen. [ 2 ]   Rupture  may result in pain in the abdomen or back,  low blood pressure , or  loss of consciousness , and often results in death. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_100", "text": "AAAs occur most commonly in men, those over 50 and those with a family history of the disease. [ 1 ]  Additional risk factors include  smoking ,  high blood pressure , and other  heart or blood vessel diseases . [ 3 ]  Genetic conditions with an increased risk include  Marfan syndrome  and  Ehlers\u2013Danlos syndrome . [ 4 ]  AAAs are the most common form of  aortic aneurysm . [ 4 ]  About 85% occur below the  kidneys , with the rest either at the level of or above the kidneys. [ 1 ]  In the  United States ,  screening  with  abdominal ultrasound  is recommended for males between 65 and 75 years of age with a history of smoking. [ 7 ]  In the  United Kingdom  and  Sweden , screening all men over 65 is recommended. [ 1 ] [ 8 ]  Once an aneurysm is found, further ultrasounds are typically done on a regular basis until an aneurysm meets a threshold for repair. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_101", "text": "Abstinence from cigarette smoking is the single best way to prevent the disease. [ 1 ]  Other methods of prevention include treating high blood pressure, treating  high blood cholesterol , and avoiding being  overweight . [ 1 ]  Surgery is usually recommended when the diameter of an AAA grows to >5.5\u00a0cm in males and >5.0\u00a0cm in females. [ 1 ]  Other reasons for repair include the presence of symptoms and a rapid increase in size, defined as more than one centimeter per year. [ 2 ]  Repair may be either by  open surgery  or  endovascular aneurysm repair  (EVAR). [ 1 ]  As compared to open surgery, EVAR has a lower risk of death in the short term and a shorter hospital stay, but may not always be an option. [ 1 ] [ 9 ] [ 10 ]  There does not appear to be a difference in longer-term outcomes between the two. [ 11 ]  Repeat procedures are more common with EVAR. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_102", "text": "AAAs affect 2-8% of males over the age of 65. [ 1 ]  They are five times more common in men. [ 13 ]  In those with an aneurysm less than 5.5\u00a0cm, the risk of rupture in the next year is below 1%. [ 1 ]  Among those with an aneurysm between 5.5 and 7\u00a0cm, the risk is about 10%, while for those with an aneurysm greater than 7\u00a0cm the risk is about 33%. [ 1 ]   Mortality  if ruptured is 85% to 90%. [ 1 ]  Globally, aortic aneurysms resulted in 168,200 deaths in 2013, up from 100,000 in 1990. [ 5 ] [ 14 ]  In the United States AAAs resulted in between 10,000 and 18,000 deaths in 2009. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_103", "text": "The vast majority of aneurysms are asymptomatic. However, as the abdominal aorta expands and/or ruptures, the aneurysm may become painful and lead to pulsating sensations in the abdomen or pain in the chest, lower back, legs, or scrotum. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_104", "text": "The complications include rupture, peripheral  embolization , acute aortic occlusion, and aortocaval (between the aorta and  inferior vena cava ) or aortoduodenal (between the aorta and the  duodenum )  fistulae . On physical examination, a  palpable  and pulsatile abdominal mass can be noted.  Bruits  can be present in case of renal or visceral arterial  stenosis . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_105", "text": "The signs and symptoms of a ruptured AAA may include severe pain in the lower back, flank, abdomen or groin. A mass that pulses with the heart beat may also be felt. [ 6 ]  The bleeding can lead to a  hypovolemic shock  with  low blood pressure  and a  fast heart rate , which may cause  fainting . [ 6 ]  The mortality of AAA rupture is as high as 90 percent. 65 to 75 percent of patients die before they arrive at the hospital and up to 90 percent die before they reach the operating room. [ 17 ]  The bleeding can be  retroperitoneal  or into the  abdominal cavity . Rupture can also create a connection between the aorta and intestine or  inferior vena cava . [ 18 ]  Flank  ecchymosis  (appearance of a bruise) is a sign of retroperitoneal  bleeding  and is also called  Grey Turner's sign . [ 16 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_106", "text": "The exact causes of the degenerative process remain unclear. There are, however, some hypotheses and well-defined  risk factors . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_107", "text": "The most striking  histopathological  changes of the aneurysmatic aorta are seen in the  tunica media  and  intima  layers. These changes include the accumulation of lipids in  foam cells , extracellular free  cholesterol  crystals,  calcifications ,  thrombosis , and  ulcerations  and ruptures of the layers.  Adventitial   inflammatory   infiltrate  is present. [ 18 ] \nHowever, the  degradation  of the tunica media by means of a  proteolytic  process seems to be the basic  pathophysiologic  mechanism of AAA development. Some researchers report increased expression and activity of matrix  metalloproteinases  in individuals with AAA. This leads to elimination of  elastin  from the media, rendering the aortic wall more susceptible to the influence of  blood pressure . [ 16 ]  Other reports have suggested the  serine protease   granzyme B  may contribute to aortic aneurysm rupture through the cleavage of  decorin , leading to disrupted  collagen  organization and reduced tensile strength of the adventitia. [ 26 ] [ 27 ]  There is also a reduced amount of  vasa vasorum  in the abdominal aorta (compared to the thoracic aorta); consequently, the tunica media must rely mostly on diffusion for nutrition, which makes it more susceptible to damage. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_108", "text": "Hemodynamics  affect the development of AAA, which has a  predilection  for the  infrarenal  aorta. The histological structure and mechanical characteristics of the infrarenal aorta differ from those of the  thoracic aorta . The diameter decreases from the root to the  aortic bifurcation , and the wall of the infrarenal aorta also contains a lesser proportion of  elastin . The mechanical  tension  in the abdominal aortic wall is therefore higher than in the thoracic aortic wall. The  elasticity  and  distensibility  also decline with age, which can result in gradual  dilatation  of the segment. Higher  intraluminal  pressure in patients with arterial hypertension markedly contributes to the progression of the pathological process. [ 18 ]  Suitable hemodynamic conditions may be linked to specific intraluminal thrombus (ILT) patterns along the aortic lumen, which in turn may affect AAA's development. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_109", "text": "An abdominal aortic aneurysm is usually diagnosed by  physical exam ,  abdominal ultrasound , or  CT scan . Plain abdominal radiographs may show the outline of an aneurysm when its walls are calcified. However, the outline will be visible by X-ray in less than half of all aneurysms. Ultrasonography is used to screen for aneurysms and to determine their size if present. Additionally, free peritoneal fluid can be detected. It is noninvasive and sensitive, but the presence of bowel gas or obesity may limit its usefulness. [ 30 ]  CT scan has nearly 100% sensitivity for an aneurysm and is also useful in preoperative planning, detailing the anatomy and possibility for endovascular repair. In the case of suspected rupture, it can also reliably detect retroperitoneal fluid. Alternative less often used methods for visualization of an aneurysm include  MRI  and  angiography . [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_110", "text": "An aneurysm ruptures if the mechanical stress (tension per area) exceeds the local wall strength; consequently, peak wall stress (PWS), [ 32 ]  mean wall stress (MWS), [ 33 ]  and peak wall rupture risk (PWRR) [ 34 ]  have been found to be more reliable parameters than diameter to assess AAA rupture risk. Medical software allows computing these rupture risk indices from standard clinical CT data and provides a patient-specific AAA rupture risk diagnosis. [ 35 ] [ 36 ] [ 37 ]  This type of biomechanical approach has been shown to accurately predict the location of AAA rupture. [ 36 ] [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_111", "text": "Abdominal aortic aneurysms are commonly divided according to their size and symptomatology. An aneurysm is usually defined as an outer aortic diameter over 3\u00a0cm (normal diameter of the  aorta  is around 2\u00a0cm), [ 43 ]  or more than 50% of normal diameter. [ 44 ]  If the outer diameter exceeds 5.5\u00a0cm, the aneurysm is considered to be large. [ 42 ]  Ruptured AAA should be suspected in any person older than 60 who experiences collapse, unexplained low blood pressure, or sudden-onset back or abdominal pain. Abdominal pain, shock, and a pulsatile mass is only present in a minority of cases. [ citation needed ]  Although an unstable person with a known aneurysm may undergo surgery without further imaging, the diagnosis will usually be confirmed using CT or ultrasound scanning. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_112", "text": "The suprarenal aorta normally measures about 0.5\u00a0cm larger than the infrarenal aorta. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_113", "text": "Aortic aneurysm rupture may be mistaken for the  pain of kidney stones , or muscle related  back pain . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_114", "text": "In terms of prevention we find the following: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_115", "text": "The  U.S. Preventive Services Task Force  (USPSTF) recommends a single screening  abdominal ultrasound  for abdominal aortic aneurysm in males age 65 to 75 years who have a history of smoking. [ 46 ]  Among this group who does not smoke, screening may be selective. [ 46 ]  It is unclear if screening is useful in women who have smoked and the USPSTF recommend against screening in women who have never smoked. [ 7 ] [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_116", "text": "In the United Kingdom the NHS AAA Screening Programme invites men in England for screening during the year they turn 65. Men over 65 can contact the programme to arrange to be screened. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_117", "text": "In Sweden one time screening is recommended in all males over 65 years of age. [ 1 ] [ 8 ]  This has been found to decrease the risk of death from AAA by 42% with a number needed to screen of just over 200. [ 47 ]  In those with a close relative diagnosed with an aortic aneurysm, Swedish guidelines recommend an ultrasound at around 60 years of age. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_118", "text": "Australia has no guideline on screening. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_119", "text": "Repeat ultrasounds should be carried out in those who have an aortic size greater than 3.0\u00a0cm. [ 51 ]  In those whose aorta is between 3.0 and 3.9\u00a0cm this should be every three years, if between 4.0 and 4.4\u00a0cm every two years, and if between 4.5 and 5.4\u00a0cm every year. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_120", "text": "The treatment options for asymptomatic AAA are  conservative  management, surveillance with a view to eventual repair, and immediate repair. Two modes of repair are available for an AAA:  open aneurysm repair , and endovascular aneurysm repair ( EVAR ). An intervention is often recommended if the aneurysm grows more than 1\u00a0cm per year or it is bigger than 5.5\u00a0cm. [ 52 ]  Repair is also indicated for symptomatic aneurysms. Ten years after open AAA repair, the overall survival rate was 59%. [ 53 ]  Mycotic abdominal aorta aneurysm (MAAA) is a rare and life-threatening condition. Because of its rarity, there is a lack of adequately powered studies and consensus on its treatment and follow up. A management protocol on the management of mycotic abdominal aortic aneurysm was recently published in the Annals of Vascular Surgery by Premnath et al. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_121", "text": "Conservative management is indicated in people where repair carries a high risk of mortality and in patients where repair is unlikely to improve life expectancy. The mainstay of the conservative treatment is  smoking  cessation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_122", "text": "Surveillance is indicated in small asymptomatic aneurysms (less than 5.5\u00a0cm) where the risk of repair exceeds the risk of rupture. [ 52 ]  As an AAA grows in diameter, the risk of rupture increases. Surveillance until an aneurysm has reached a diameter of 5.5\u00a0cm has not been shown to have a higher risk as compared to early intervention. [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_123", "text": "No medical therapy has been found to be effective at decreasing the growth rate or rupture rate of asymptomatic AAAs. [ 1 ]   Blood pressure  and  lipids  should, however, be treated per usual. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_124", "text": "The threshold for repair varies slightly from individual to individual, depending on the balance of risks and benefits when considering repair versus ongoing surveillance. The size of an individual's native aorta may influence this, along with the presence of comorbidities that increase operative risk or decrease life expectancy. Evidence, however, does not usually support repair if the size is less than 5.5\u00a0cm. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_125", "text": "Open repair is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms. The aorta must be clamped during the repair, denying blood to the abdominal organs and sections of the  spinal cord ; this can cause a range of complications. As it is essential to perform the critical part of the operation quickly, the incision is typically made large enough to facilitate the fastest repair. Recovery after open AAA surgery takes significant time. The minimums are a few days in intensive care, a week total in the hospital and a few months before full recovery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_126", "text": "Endovascular repair first became practical in the 1990s and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a portion of AAAs, depending on the morphology of the aneurysm. The main advantages over open repair are that there is less peri-operative mortality, less time in  intensive care , less time in hospital overall and earlier return to normal activity. Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews and a higher chance of further required procedures. According to the latest studies, the EVAR procedure does not offer any benefit for overall survival or health-related  quality of life  compared to open surgery, although aneurysm-related mortality is lower. [ 57 ] [ 58 ] [ 59 ] [ 60 ]  In patients unfit for open repair, EVAR plus conservative management was associated with no benefit, more complications, subsequent procedures and higher costs compared to conservative management alone. [ 61 ]  Endovascular treatment for paraanastomotic aneurysms after aortobiiliac reconstruction is also a possibility. [ 62 ]  A 2017  Cochrane review  found tentative evidence of no difference in outcomes between endovascular and open repair of ruptured AAA in the first month. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_127", "text": "In those with  aortic rupture  of the AAA, treatment is immediate surgical repair. There appear to be benefits to allowing  permissive hypotension  and limiting the use of intravenous fluids during transport to the operating room. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_128", "text": "Although the current standard of determining rupture risk is based on maximum diameter, it is known that smaller AAAs that fall below this threshold (diameter<5.5\u00a0cm) may also rupture, and larger AAAs (diameter>5.5\u00a0cm) may remain stable. [ 67 ] [ 68 ]  In one report, it was shown that 10\u201324% of ruptured AAAs were less than 5\u00a0cm in diameter. [ 68 ]  It has also been reported that of 473 non-repaired AAAs examined from autopsy reports, there were 118 cases of rupture, 13% of which were less than 5\u00a0cm in diameter. This study also showed that 60% of the AAAs greater than 5\u00a0cm (including 54% of those AAAs between 7.1 and 10\u00a0cm) never experienced rupture. [ 69 ]  Vorp  et al.  later deduced from the findings of Darling  et al.  that if the maximum diameter criterion were followed for the 473 subjects, only 7% (34/473) of cases would have died from rupture prior to surgical intervention as the diameter was less than 5\u00a0cm, with 25% (116/473) of cases possibly undergoing unnecessary surgery since these AAAs may never have ruptured. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_129", "text": "Alternative methods of rupture assessment have been recently reported. The majority of these approaches involve the numerical analysis of AAAs using the common engineering technique of the finite element method (FEM) to determine the wall stress distributions. Recent reports have shown that these stress distributions have been shown to correlate to the overall geometry of the AAA rather than solely to the maximum diameter. [ 70 ] [ 71 ] [ 72 ]  It is also known that wall stress alone does not completely govern failure as an AAA will usually rupture when the wall stress exceeds the wall strength. In light of this, rupture assessment may be more accurate if both the patient-specific wall stress is coupled together with patient-specific wall strength. A noninvasive method of determining patient-dependent wall strength was recently reported, [ 73 ]  with more traditional approaches to strength determination via tensile testing performed by other researchers in the field. [ 74 ] [ 75 ] [ 76 ]  Some of the more recently proposed AAA rupture-risk assessment methods include: AAA wall stress; [ 32 ] [ 77 ] [ 78 ]  AAA expansion rate; [ 79 ]  degree of asymmetry; [ 72 ]  presence of intraluminal thrombus (ILT); [ 80 ]  a rupture potential index (RPI); [ 81 ] [ 82 ]  a finite element analysis rupture index (FEARI); [ 83 ]  biomechanical factors coupled with computer analysis; [ 84 ]  growth of ILT; [ 85 ]  geometrical parameters of the AAA; [ 86 ]  and also a method of determining AAA growth and rupture based on mathematical models. [ 87 ] [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_130", "text": "The postoperative mortality for an already ruptured AAA has slowly decreased over several decades but remains higher than 40%. [ 89 ]  However, if the AAA is surgically repaired before rupture, the postoperative mortality rate is substantially lower, approximately 1-6%. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_131", "text": "The occurrence of AAA varies by ethnicity. In the United Kingdom, the rate of AAA in Caucasian men older than 65 years is about 4.7%, while in Asian men it is 0.45%. [ 91 ]  It is also less common in individuals of African, and Hispanic heritage. [ 1 ]  They occur four times more often in men than in women. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_132", "text": "There are at least 13,000 deaths yearly in the U.S. secondary to AAA rupture. [ 1 ]  The peak  number of new cases per year  among males is around 70 years of age, and the  percentage of males affected  over 60 years is 2\u20136%. The frequency is much higher in smokers than in non-smokers (8:1), and the risk decreases slowly after  smoking cessation . [ 92 ]  In the U.S., the incidence of AAA is 2\u20134% in the adult population. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_133", "text": "Rupture of the AAA occurs in 1\u20133% of men aged 65 or more, for whom the mortality rate is 70\u201395%. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_134", "text": "The first historical records about AAA are from  Ancient Rome  in the 2nd century AD, when Greek surgeon  Antyllus  tried to treat the AAA with  proximal  and  distal   ligature , central  incision  and removal of  thrombotic  material from the  aneurysm .\nHowever, attempts to treat the AAA surgically were unsuccessful until 1923. In that year,  Rudolph Matas  (who also proposed the concept of endoaneurysmorrhaphy), performed the first successful aortic ligation on a human. [ 93 ]  Other methods that were successful in treating the AAA included wrapping the aorta with polyethene  cellophane , which induced  fibrosis  and restricted the growth of the aneurysm. Endovascular aneurysm repair was first performed in the late 1980s and has been widely adopted in the subsequent decades. Endovascular repair was first used for treating a ruptured aneurysm in Nottingham in 1994. [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_135", "text": "Theoretical physicist  Albert Einstein  underwent an operation for an abdominal aortic aneurysm in 1949 that was performed by  Rudolph Nissen , who wrapped the aorta with polyethene  cellophane . Einstein's aneurysm ruptured on April 13, 1955. He declined surgery, saying, \"I want to go when I want. It is tasteless to prolong life artificially. I have done my share, it is time to go. I will do it elegantly.\" He died five days later at age 76. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_136", "text": "Actress  Lucille Ball  died April 26, 1989, from an abdominal aortic aneurysm. At the time of her death, she was in  Cedars-Sinai Medical Center  recovering from emergency surgery performed just six days earlier because of a  dissecting aortic aneurysm  near her heart. Ball was at increased risk as she had been a heavy smoker for decades. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_137", "text": "Musician  Conway Twitty  died in June 1993 from an abdominal aortic aneurysm at the age of 59, two months before the release of what would be his final studio album,  Final Touches . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_138", "text": "Actor  George C. Scott  died in 1999, aged 71, from a ruptured abdominal aortic aneurysm. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_139", "text": "In 2001, former presidential candidate  Bob Dole  underwent surgery for an abdominal aortic aneurysm in which a team led by  vascular surgeon   Kenneth Ouriel  inserted a stent graft: [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_140", "text": "Ouriel said that the team inserted a Y-shaped tube through an incision in Dole's leg and placed it inside the weakened portion of the aorta. The aneurysm will eventually contract around the stent, which will remain in place for the rest of Dole's life. [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_141", "text": "\u2014  Associated Press"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_142", "text": "Actor  Robert Jacks , who played  Leatherface  in  Texas Chainsaw Massacre: The Next Generation , died from an abdominal aneurysm on August 8, 2001, one day shy of his 42nd birthday. When Jacks was a child, his father died from the same cause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_143", "text": "Actor  Tommy Ford  died of abdominal aneurysm in October 2016 at 52 years old. [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_144", "text": "Gary Gygax , co-creator of  Dungeons & Dragons , died from an abdominal aortic aneurysm in 2008, at the age of 69."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_145", "text": "Harvey Korman  died on May 29, 2008, aged 81, at UCLA Medical Center as the result of complications from a ruptured abdominal aortic aneurysm he had suffered four months earlier. He is interred at Santa Monica's Woodlawn Cemetery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_146", "text": "John Ritter  died from AAA on September 11, 2003. He was initially treated by emergency room physicians for a heart attack; however, his condition quickly worsened. He was then diagnosed with aortic dissection and was taken into surgery, but was pronounced dead at 10:48 p.m., at the age of 54."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_147", "text": "There have been many calls for alternative approaches to rupture risk assessment over the past number of years, with many believing that a biomechanics-based approach may be more suitable than the current diameter approach. Numerical modeling is a valuable tool to researchers allowing approximate wall stresses to be calculated, thus revealing the rupture potential of a particular aneurysm. Experimental models are required to validate these numerical results and provide a further insight into the biomechanical behavior of the AAA.  In vivo , AAAs exhibit a varying range of material strengths [ 99 ]  from localised weak hypoxic regions [ 100 ]  to much stronger regions and areas of calcifications. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_148", "text": "Finding ways to predict future AAA growth is seen as a research priority. [ 102 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_149", "text": "Another related line of research is utilizing mathematical decision modeling (e.g.,  Markov decision processes ) to determine improved treatment policies. Initial results suggest that a more dynamic policy could provide benefits, although such claims have not been clinically verified. [ 103 ] [ 104 ]  A study recently showed that aneurysms can be accurately predicted as to whether they are stable (lacking repair or intervention), requiring repair, or at risk of rupture from scans years prior to any event based on a machine-learning based classification tool. [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_150", "text": "Experimental models can now be manufactured using a novel technique involving the injection-moulding lost-wax manufacturing process to create patient-specific anatomically correct AAA replicas. [ 106 ]  Work has also focused on developing more realistic material analogues to those  in vivo , and recently a novel range of silicone-rubbers was created allowing the varying material properties of the AAA to be more accurately represented. [ 107 ]  These rubber models can also be used in a variety of experimental situations, from stress analysis using the photoelastic method [ 108 ]  New endovascular devices are being developed that are able to treat more complex and  tortuous  anatomies. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_151", "text": "An animal study showed that removing a single protein prevents early damage in blood vessels from triggering a later-stage, complications. By eliminating the gene for a signaling protein called cyclophilin A (CypA) from a strain of mice, researchers were able to provide complete protection against abdominal aortic aneurysm. [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_152", "text": "Other recent research identified Granzyme B ( GZMB ) (a protein-degrading enzyme) to be a potential target in the treatment of abdominal aortic aneurysms. Elimination of this enzyme in mice models both slowed the progression of aneurysms and improved survival. [ 111 ] [ 112 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_153", "text": "The mechanisms that lead to AAA development are still not completely understood at a cellular and molecular level. In order to better understand the pathophysiology of AAA, it is often necessary to use experimental animal models. It is often questioned how well do these models translate to human disease. Even though there is no animal model that exactly represents the human condition, all the existing ones focus on one different pathophysiological aspect of the disease. Combining the results from different animal models with clinical research can provide a better overview of the AAA pathophysiology. The most common animal models are rodents (mice and rats), although for certain studies, such as testing preclinical devices or surgical procedures, large animal models (pig, sheep) are more frequently used. The rodent models of AAA can be classified according to different aspects. There are dissecting models vs non-dissecting models and genetically determined models vs chemically induced models. The most commonly used models are the angiotensin-II infusion into ApoE knockout mice (dissecting model, chemically induced), the calcium chloride model (non-dissecting, chemically induced) and the elastase model (non-dissecting, chemically induced model). [ 113 ] [ 114 ]  A recent study has shown that \u03b2-Aminopropionitrile plus elastase application to abdominal aorta causes more severe aneurysm in mice as compared to elastase alone. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_154", "text": "An  aortic aneurysm  is an enlargement (dilatation) of the  aorta  to greater than 1.5 times normal size. [ 1 ]  Typically, there are no symptoms except when the  aneurysm   dissects  or  ruptures , which causes sudden, severe pain in the abdomen and lower back. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_155", "text": "The  etiology  remains an area of active research. Known causes include trauma, infection, and  inflammatory disorders . Risk factors include cigarette smoking, extreme  alcoholism , advanced age,  dyslipidemia ,  hypertension , and  coronary artery disease . [ 4 ]  The pathophysiology of the disease is related to an initial arterial insult causing a cascade of inflammation and extracellular matrix protein breakdown by  proteinases  leading to arterial wall weakening. [ 5 ]  They are most commonly located in the  abdominal aorta , but can also be located in the  thoracic aorta ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_156", "text": "Aortic aneurysms result from a weakness in the wall of the aorta and increase the risk of  aortic rupture . When rupture occurs, massive internal  bleeding  results and, unless treated immediately,  shock  and death can occur. One review stated that up to 81% of people having abdominal aortic aneurysm rupture will die, with 32% dying before reaching a hospital. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_157", "text": "According to a review of global data through 2019, the prevalence of  abdominal aortic aneurysm  worldwide was about 0.9% in people under age 79 years, and is about four times higher in men than in women at any age. [ 4 ]  Death occurs in about 55-64% of people having rupture of the AAA. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_158", "text": "Screening with  ultrasound  is indicated in those at high risk. Prevention is by decreasing risk factors, such as  smoking , and treatment is either by open or  endovascular surgery . Aortic aneurysms resulted in about 152,000 deaths worldwide in 2013, up from 100,000 in 1990. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_159", "text": "Aortic aneurysms are classified by their location on the aorta."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_160", "text": "Most intact aortic aneurysms do not produce symptoms. As they enlarge, symptoms such as  abdominal pain  and  back pain  may develop. Compression of nerve roots may cause leg pain or numbness. Untreated, aneurysms tend to become progressively larger, although the rate of enlargement is unpredictable for any individual. Rarely, clotted blood which lines most aortic aneurysms can break off and result in an  embolus . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_161", "text": "Aneurysms cannot be found on physical examination. Medical imaging is necessary to confirm the diagnosis and to determine the anatomic extent of the aneurysm. In people presenting with aneurysm of the arch of the aorta, a common sign is a hoarse voice from stretching of the left  recurrent laryngeal nerve , a branch of the vagus nerve that winds around the aortic arch to supply the muscles of the  larynx . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_162", "text": "Abdominal aortic aneurysms (AAAs) are more common than their thoracic counterpart. One reason for this is that  elastin , the principal load-bearing protein present in the wall of the aorta, is reduced in the abdominal aorta as compared to the thoracic aorta. Another is that the abdominal aorta does not possess  vasa vasorum , the nutrient-supplying blood vessels within the wall of the aorta. Most AAA are  true aneurysms  that involve all three layers ( tunica intima ,  tunica media  and  tunica adventitia ). The prevalence of AAAs increases with age, with an average age of 65\u201370 at the time of diagnosis. AAAs have been attributed to  atherosclerosis , though other factors are involved in their formation. [ 8 ]  Risk factors for AAA include the male gender, aging, a history of smoking,  hypercholesterolemia , and hypertension. [ 4 ] [ 8 ] [ 11 ]  Reviews reported estimates for prevalence rates of AAA were 0.9-9% in men and 1\u20132% in women, where, generally, the incidence of AAA is four times greater in men compared to women at the same age. [ 4 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_163", "text": "The risk of rupture of an AAA is related to its diameter; once the aneurysm reaches about 5\u00a0cm, the yearly risk of rupture may exceed the risks of surgical repair for an average-risk patient. Rupture risk is also related to shape; so-called \"fusiform\" (long) aneurysms are considered less rupture-prone than \"saccular\" (shorter, bulbous) aneurysms, the latter having more wall tension in a particular location in the aneurysm wall. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_164", "text": "The prevalence of AAA worldwide in 2019 was about 0.9% in people under age 79 years, [ 4 ]  whereas a 2014 review reported a range of 2-12%, occurring in about 8% of men more than 65 years of age. [ 13 ]  Men are about four times more likely to have AA compared to women at any age, with death occurring in about 55-64% of people having AAA rupture. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_165", "text": "Before rupture, an AAA may present as a large,  pulsatile  mass above the  umbilicus . A  bruit  may be heard from the turbulent flow in the aneurysm. Rupture may be the first sign of AAA. Once an aneurysm has ruptured, it presents with classic symptoms of abdominal pain which is severe, constant, and radiating to the back. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_166", "text": "The diagnosis of an abdominal aortic aneurysm can be confirmed by the use of  ultrasound . Rupture may be indicated by the presence of free fluid in the abdomen. A contrast-enhanced abdominal  CT scan  is the best test to diagnose an AAA and guide treatment options. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_167", "text": "In 2019, some 170,000 people worldwide died from AAA rupture, with aging, smoking, and hypertension as principal factors. [ 4 ] [ 11 ]  Annual mortality from ruptured aneurysms in the United States is about 15,000. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_168", "text": "An aortic aneurysm can rupture from wall weakness. Aortic rupture is a surgical emergency and has a high mortality even with prompt treatment. Weekend admission for a ruptured aortic aneurysm is associated with increased mortality compared with admission on a weekday, and this is likely due to several factors including a delay in prompt surgical intervention. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_169", "text": "An aortic aneurysm can occur as a result of trauma, infection, or, most commonly, from an intrinsic abnormality in the  elastin  and  collagen  components of the aortic wall. Aortic aneurysm development and progression have been directly associated with a deficiency of elastin as well as a loss of collagen type 1. [ 19 ]  The elastin-to-collagen ratio is also significantly higher in aneurysmal abdominal aortas compared to healthy abdominal aortas. [ 19 ]  While definite genetic abnormalities were identified in true genetic syndromes (Marfan, Elher-Danlos and others) associated with aortic aneurysms, both thoracic and abdominal aortic aneurysms demonstrate a strong genetic component in their aetiology. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_170", "text": "The risk of aneurysm enlargement may be diminished with attention to the patient's blood pressure, smoking and  cholesterol  levels. There have been proposals to introduce  ultrasound scans  as a screening tool for those most at risk: men over the age of 65. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_171", "text": "Anacetrapib  is a cholesteryl ester transfer protein inhibitor that raises high-density lipoprotein (HDL) cholesterol and reduces low-density lipoprotein (LDL) cholesterol.\nAnacetrapib reduces progression of atherosclerosis, mainly by reducing non-HDL-cholesterol, improves lesion stability and adds to the beneficial effects of atorvastatin [ 23 ] \nElevating the amount of HDL cholesterol in the abdominal area of the aortic artery in mice both reduced the size of aneurysms that had already grown and prevented abdominal aortic aneurysms from forming at all. In short, raising HDL cholesterol is beneficial because it induces programmed cell death. The walls of a failing aorta are replaced and strengthened. New lesions should not form at all when using this drug. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_172", "text": "Screening for an aortic aneurysm so that it may be detected and treated prior to rupture is the best way to reduce the overall mortality of the disease. The most cost-efficient screening test is an abdominal aortic ultrasound study. Noting the results of several large, population-based screening trials, the US  Centers for Medicare and Medicaid Services  (CMS) now provides payment for one ultrasound study in all smokers aged 65 years or older (\"SAAAVE Act\"). [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_173", "text": "Surgery (open or endovascular) is the definitive treatment of an aortic aneurysm. Medical therapy is typically reserved for smaller aneurysms or for elderly, frail patients where the risks of surgical repair exceed the risks of non-operative therapy (observation alone)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_174", "text": "Medical therapy of aortic aneurysms involves strict  blood pressure  control. This does not treat the aortic aneurysm per se, but control of  hypertension  within tight blood pressure parameters may decrease the rate of expansion of the aneurysm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_175", "text": "The medical management of patients with aortic aneurysms, reserved for smaller aneurysms or frail patients, involves cessation of smoking, blood pressure control, use of  statins  and occasionally  beta blockers . Ultrasound studies are obtained on a regular basis (i.e. every 6 or 12 months) to follow the size of the aneurysm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_176", "text": "Despite optimal medical therapy, patients with large aneurysms are likely to have continued aneurysm growth and risk of aneurysm rupture without surgical repair. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_177", "text": "Decisions about repairing an aortic aneurysm are based on the balance between the risk of aneurysm rupture without treatment versus the risks of the treatment itself. For example, a small aneurysm in an elderly patient with severe  cardiovascular disease  would not be repaired. The chance of the small aneurysm rupturing is overshadowed by the risk of cardiac complications from the procedure to repair the aneurysm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_178", "text": "The risk of the repair procedure is two-fold. First, there is consideration of the risk of problems occurring during and immediately after the procedure itself (\"peri-procedural\" complications). Second, the effectiveness of the procedure must be taken into account, namely whether the procedure effectively protects the patient from aneurysm rupture over the long term, and whether the procedure is durable so that secondary procedures, with their attendant risks, are not necessary over the life of the patient. A less invasive procedure (such as  endovascular aneurysm repair ) may be associated with fewer short-term risks to the patient (fewer peri-procedural complications) but secondary procedures may be necessary over long-term follow-up."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_179", "text": "The determination of surgical intervention is determined on a per-case basis. The diameter of the aneurysm, its rate of growth, the presence or absence of  Marfan syndrome ,  Ehlers\u2013Danlos syndromes  or similar connective tissue disorders, and other  co-morbidities  are all important factors in the overall treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_180", "text": "A large, rapidly expanding, or symptomatic aneurysm should be repaired, as it has a greater chance of rupture. Slowly expanding aortic aneurysms may be followed by routine diagnostic testing (i.e.:  CT scan  or  ultrasound  imaging)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_181", "text": "For abdominal aneurysms, the current treatment guidelines for abdominal aortic aneurysms suggest elective surgical repair when the diameter of the aneurysm is greater than 5\u00a0cm (2\u00a0in). However, recent data on patients aged 60\u201376 suggest medical management for abdominal aneurysms with a diameter of less than 5.5\u00a0cm (2\u00a0in). [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_182", "text": "Open surgery starts with exposure of the dilated portion of the aorta via an incision in the abdomen or abdomen and chest, followed by insertion of a synthetic ( Dacron  or  Gore-Tex ) graft (tube) to replace the diseased aorta. The graft is sewn in by hand to the non-diseased portions of the aorta, and the aneurysmal sac is closed around the graft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_183", "text": "The aorta and its branching arteries are cross-clamped during open surgery. This can lead to inadequate blood supply to the spinal cord, resulting in  paraplegia . A 2004 systematic review and meta analysis found that cerebrospinal fluid drainage (CFSD), when performed in experienced centers, reduces the risk of ischemic spinal cord injury by increasing the perfusion pressure to the spinal cord. [ 28 ]  A 2012 Cochrane systematic review noted that further research regarding the effectiveness of CFSD for preventing a spinal cord injury is required. [ 29 ]  A 2023 systematic review suggested that rates of postoperative spinal cord ischaemia can be kept at low levels after open repair of thoracoabdominal aneurysm with the adequate precautions and perioperative manoeuvres. [ 30 ]  The majority of the surgeons believe prophylactic lumbar drains are effective in reducing spinal cord ischaemia. [ 31 ]  Neuromonitoring with motor-evoked potentials (MEP) can provide the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and somatosensory-evoked potentials (SSEP) seems to be the most reliable method. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_184", "text": "Endovascular treatment of aortic aneurysms  is a minimally invasive alternative to open surgery repair. It involves the placement of an endo-vascular  stent  through small incisions at the top of each leg into the aorta."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_185", "text": "As compared to open surgery, EVAR has a lower risk of death in the short term and a shorter hospital stay but may not always be an option. [ 2 ] [ 32 ] [ 33 ]  There does not appear to be a difference in longer term outcomes between the two. [ 34 ]  After EVAR, repeat procedures are more likely to be needed. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_186", "text": "Globally, aortic aneurysms resulted in about ~170,000 deaths in 2017. [ 4 ]  This figure represents an increase from approximately ~100,000 in 1990. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_187", "text": "Aortic dissection  ( AD ) occurs when an injury to the  innermost layer  of the  aorta  allows blood to flow between the layers of the aortic wall,  forcing the layers apart . [ 3 ]  In most cases, this is associated with a sudden onset of agonizing  chest or back pain , often described as \"tearing\" in character. [ 1 ] [ 2 ]  Vomiting,  sweating , and  lightheadedness  may also occur. [ 2 ]  Damage to other organs may result from the decreased blood supply, such as  stroke , lower extremity ischemia, or  mesenteric ischemia . [ 2 ]  Aortic dissection can quickly lead to death from  insufficient blood flow to the heart  or complete  rupture of the aorta . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_188", "text": "AD is more common in those with a history of  high blood pressure ; a number of  connective tissue diseases  that affect blood vessel wall strength including  Marfan syndrome  and  Ehlers\u2013Danlos syndrome ; a  bicuspid aortic valve ; and previous  heart surgery . [ 2 ] [ 3 ]   Major trauma ,  smoking ,  cocaine  use,  pregnancy , a  thoracic aortic aneurysm ,  inflammation of arteries , and  abnormal lipid levels  are also associated with an increased risk. [ 1 ] [ 2 ]  The diagnosis is suspected based on symptoms with  medical imaging , such as  CT scan ,  MRI , or  ultrasound  used to confirm and further evaluate the dissection. [ 1 ]  The two main types are Stanford type A, which involves the  first part of the aorta , and type B, which does not. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_189", "text": "Prevention is by blood pressure control and smoking cessation. [ 1 ]  Management of AD depends on the part of the aorta involved. [ 1 ]  Dissections that involve the first part of the aorta (adjacent to the heart) usually require surgery. [ 1 ] [ 2 ]  Surgery may be done either by an  opening in the chest  or from  inside the blood vessel . [ 1 ]  Dissections that involve the second part of the aorta can typically be treated with medications that lower blood pressure and heart rate, unless there are complications which then require surgical correction. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_190", "text": "AD is relatively rare, occurring at an estimated rate of three per 100,000 people per year. [ 1 ] [ 3 ]  It is more common in men than women. [ 1 ]  The typical age at diagnosis is 63, with about 10% of cases occurring before the age of 40. [ 1 ] [ 3 ]  Without treatment, about half of people with Stanford type A dissections die within three days and about 10% of people with Stanford type B dissections die within one month. [ 3 ]  The first case of AD was described in the examination of  King George II of Great Britain  following his death in 1760. [ 3 ]  Surgery for AD was introduced in the 1950s by  Michael E. DeBakey . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_191", "text": "About 96% of individuals with AD present with severe pain that had a sudden onset. The pain may be described as a tearing, stabbing, or sharp sensation in the chest, back, or abdomen. [ 4 ] [ 5 ]  About 17% of individuals feel the pain migrate as the dissection extends down the aorta. [ 6 ]  The location of pain is associated with the location of the dissection. [ 7 ]   Anterior  chest pain is associated with dissections involving the ascending aorta, while interscapular back pain is associated with descending aortic dissections. If the pain is  pleuritic  in nature, it may suggest acute  pericarditis  caused by bleeding into the  sac surrounding the heart . This is a particularly dangerous eventuality, suggesting that acute  pericardial tamponade  may be imminent. Pericardial tamponade is the most common cause of death from AD. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_192", "text": "While the pain may be confused with that of a  heart attack , AD is usually not associated with the other suggestive signs, such as  heart failure  and  ECG  changes. Less common symptoms that may be seen in the setting of AD include  congestive heart failure  (7%),  fainting  (9%),  stroke  (6%), ischemic  peripheral neuropathy ,  paraplegia , and  cardiac arrest . [ 9 ]  If the individual fainted, about half the time it is due to bleeding into the pericardium, leading to pericardial tamponade. Neurological complications of aortic dissection, such as  stroke  and  paralysis , are due to the involvement of one or more arteries supplying portions of the  central nervous system . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_193", "text": "If the AD involves the abdominal aorta, compromise of one or both  renal arteries  occurs in 5\u20138% of cases, while  ischemia of the intestines  occurs about 3% of the time. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_194", "text": "People with AD often have a history of  high blood pressure . The blood pressure is quite variable at presentation with acute AD. It tends to be higher in individuals with a distal dissection. In individuals with a proximal AD, 36% present with hypertension, while 25% present with  hypotension . Proximal AD tends to be associated with weakening of the vascular wall due to  cystic medial degeneration . In those who present with distal (Stanford type B) AD, 60\u201370% present with high blood pressure, while 2\u20133% present with  low blood pressure . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_195", "text": "Severe hypotension at presentation is a grave prognostic indicator. It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta. Accurate measurement of blood pressure is important. Pseudohypotension (falsely low blood-pressure measurement) may occur due to involvement of the  brachiocephalic artery  (supplying the right arm) or the  left subclavian artery  (supplying the left arm). [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_196", "text": "Aortic insufficiency  (AI) occurs in half to two-thirds of ascending AD, and the diastolic  heart murmur  of aortic insufficiency is audible in about 32% of proximal dissections. The intensity (loudness) of the murmur depends on the blood pressure and may be inaudible in the event of low blood pressure. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_197", "text": "Multiple causes exist for AI in the setting of ascending AD. The dissection may dilate the annulus of the  aortic valve , preventing the leaflets of the valve from coapting. The dissection may extend into the aortic root and detach the aortic valve leaflets. Alternatively, following an extensive intimal tear, the intimal flap may prolapse into the  left ventricular outflow tract , causing intimal  intussusception  into the aortic valve, thereby preventing proper valve closure. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_198", "text": "Heart attack  occurs in 1\u20132% of aortic dissections. Infarction is caused by the involvement of the  coronary arteries , which supply the heart with oxygenated blood, in the dissection. The right coronary artery is involved more commonly than the left coronary artery. If the myocardial infarction is treated with  thrombolytic  therapy, the mortality increases to over 70%, mostly due to bleeding into the pericardial sac, causing  cardiac tamponade . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_199", "text": "A  pleural effusion  (fluid collection in the space between the  lungs  and the chest wall or  diaphragm ) can be due to either blood from a transient rupture of the aorta or fluid due to an inflammatory reaction around the aorta. If a pleural effusion were to develop due to AD, it is more common in the left hemithorax rather than the right hemithorax. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_200", "text": "Aortic dissection is associated with  hypertension  (high blood pressure) and many  connective tissue  disorders.  Vasculitis  ( inflammation  of an artery) is rarely associated with aortic dissection. It can also be the result of chest trauma. About 72 to 80% of individuals who present with an aortic dissection have a previous history of hypertension. Illicit drug use with stimulants such as  cocaine  and  methamphetamine  is also a modifiable risk factor for AD. [ 20 ] [ 21 ]  It can also be caused by smoking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_201", "text": "A  bicuspid aortic valve  (a type of  congenital heart disease  involving the  aortic valve ) is found in 7\u201314% of individuals who have an aortic dissection. These individuals are prone to dissection in the ascending aorta. The risk of dissection in individuals with bicuspid aortic valves is not associated with the degree of  stenosis  of the valve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_202", "text": "Connective tissue disorders  such as  Marfan syndrome ,  Ehlers\u2013Danlos syndrome , and  Loeys\u2013Dietz syndrome  increase the risk of aortic dissection. [ 13 ]  Similarly, vasculitides such as  Takayasu's arteritis ,  giant cell arteritis ,  polyarteritis nodosa , and  Beh\u00e7et's disease  have been associated with a subsequent aortic dissection. [ 13 ] [ 20 ]   Marfan Syndrome is found in 5\u20139% of individuals who had an aortic dissection. In this subset, the incidence in young individuals is increased. Individuals with Marfan syndrome tend to have aneurysms of the aorta and are more prone to proximal dissections of the aorta. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_203", "text": "Turner syndrome  also increases the risk of aortic dissection, by aortic root dilatation. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_204", "text": "Chest trauma leading to aortic dissection can be divided into two groups based on cause: blunt chest trauma (commonly seen in  car accidents ) and  iatrogenic . Iatrogenic causes include trauma during  cardiac catheterization  or due to an  intra-aortic balloon pump . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_205", "text": "Aortic dissection may be a late sequela of  heart surgery . About 18% of individuals who present with an acute aortic dissection have a history of open-heart surgery. Individuals who have undergone aortic valve replacement for  aortic insufficiency  are at particularly high risk because aortic regurgitation causes increased blood flow in the ascending aorta. This can cause dilatation and weakening of the walls of the ascending aorta. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_206", "text": "Syphilis  only potentially causes aortic dissection in its tertiary stage. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_207", "text": "As with all other arteries, the aorta is made up of three layers, the  intima , the  media , and the  adventitia . The intima is in direct contact with the blood inside the vessel, and mainly consists of a layer of  endothelial cells  on a  basement membrane ; the media contains connective and muscle tissue, and the vessel is protected on the outside by the adventitia, comprising connective tissue. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_208", "text": "In an aortic dissection, blood penetrates the intima and enters the media layer. The high pressure rips the  tissue  of the media apart along the laminated plane splitting the inner two-thirds and the outer one-third of the media apart. [ 26 ]  This can propagate along the length of the aorta for a variable distance forward or backward. Dissections that propagate towards the iliac bifurcation (with the flow of blood) are called anterograde dissections and those that propagate towards the aortic root (opposite of the flow of blood) are called retrograde dissections. The initial tear is usually within 100\u00a0mm of the  aortic valve , so a retrograde dissection can easily compromise the pericardium leading to a hemopericardium. Anterograde dissections may propagate all the way to the iliac bifurcation of the aorta, rupture the aortic wall, or recanalize into the intravascular lumen leading to a double-barrel aorta. The double-barrel aorta relieves the pressure of blood flow and reduces the risk of rupture. Rupture leads to hemorrhaging into a body cavity, and prognosis depends on the area of rupture. Retroperitoneal and pericardial ruptures are both possible. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_209", "text": "The initiating event in aortic dissection is a tear in the intimal lining of the aorta. Due to the high pressures in the aorta, blood enters the media at the point of the tear.  The force of the blood entering the media causes the tear to extend. It may extend proximally (closer to the heart) or distally (away from the heart) or both. The blood travels through the media, creating a  false lumen  (the true lumen is the normal conduit of blood in the aorta). Separating the false lumen from the true lumen is a layer of intimal tissue known as the intimal flap. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_210", "text": "The vast majority of aortic dissections originate with an intimal tear in either the  ascending aorta  (65%), the  aortic arch  (10%), or just distal to the  ligamentum arteriosum  in the  descending thoracic aorta  (20%). [ clarification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_211", "text": "As blood flows down the false lumen, it may cause secondary tears in the intima. Through these secondary tears, the blood can re-enter the true lumen. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_212", "text": "While it is not always clear why an intimal tear may occur, quite often it involves degeneration of the  collagen  and  elastin  that make up the media. This is known as  cystic medial necrosis  and is most commonly associated with Marfan syndrome and is also associated with Ehlers-Danlos syndrome. [ 28 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_213", "text": "In about 13% of aortic dissections, no evidence of an intimal tear is found. In these cases, the inciting event is thought to be an intramural  hematoma  (caused by bleeding within the media). Since no direct connection exists between the true lumen and the false lumen in these cases, diagnosing an aortic dissection by  aortography  is difficult if the cause is an intramural hematoma. An aortic dissection secondary to an intramural hematoma should be treated the same as one caused by an intimal tear. [ 28 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_214", "text": "Because of the varying symptoms of aortic dissection, the diagnosis is sometimes difficult to make. Concern should be increased in those with low blood pressure, neurological problems, and an unequal pulses. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_215", "text": "While taking a good history from the individual may be strongly suggestive of an aortic dissection, the diagnosis cannot always be made by history and physical signs alone.  Often, the diagnosis is made by visualization of the intimal flap on a diagnostic imaging test. Common tests used to diagnose an aortic dissection include a  CT scan  of the chest with iodinated contrast material and a  transesophageal echocardiogram . The proximity of the aorta to the  esophagus  allows the use of  higher-frequency ultrasound  for better anatomical images. Other tests that may be used include an aortogram or magnetic resonance angiogram of the aorta.  Each of these tests has pros and cons, and they do not have equal sensitivities and specificities in the diagnosis of aortic dissection. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_216", "text": "In general, the imaging technique chosen is based on the pretest likelihood of the diagnosis, availability of the testing modality, patient stability, and the sensitivity and specificity of the test. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_217", "text": "A measurement of blood  D-dimer  level may be useful in diagnostic evaluation. A level less than 500\u00a0ng/ml may be considered evidence against a diagnosis of aortic dissection, [ 1 ] [ 31 ]  although this guideline is only applicable in cases deemed \"low risk\" [ 32 ]  and within 24 hours of symptom onset. [ 33 ]  The  American Heart Association  does not advise using this test in making the diagnosis, as evidence is still tentative. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_218", "text": "Chest radiography  may although demonstrate a change in the morphology of the thoracic aorta which can be seen in aortic dissection. Classically, new widening of the  mediastinum  on radiograph is of moderate  sensitivity  for detecting an ascending aortic dissection; however, this finding is of low  specificity , as many other conditions can cause apparent widening of the mediastinum. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_219", "text": "There are several other associated radiographic findings: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_220", "text": "Importantly, about 12 to 20% of aortic dissections are not detectable by chest radiograph; therefore, a \"normal\" chest radiograph does not rule out aortic dissection. If there is high clinical suspicion, a more sensitive imaging test ( CT angiogram ,  MR angiography , or  transesophageal echo ) may be warranted. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_221", "text": "Computed tomography angiography  is a fast, non-invasive test that gives an accurate three-dimensional view of the aorta. These images are produced by taking rapid, thin-cut slices of the chest and abdomen, and combining them in the computer to create cross-sectional slices. To delineate the aorta to the accuracy necessary to make the proper diagnosis, an iodinated contrast material is injected into a peripheral vein. Contrast is injected and the scan performed using a  bolus tracking  method. This type of scan is timed to injection to capture the contrast as it enters the aorta. The scan then follows the contrast as it flows through the vessel. It has a sensitivity of 96 to 100% and a specificity of 96 to 100%. Disadvantages include the need for iodinated contrast material and the inability to diagnose the site of the intimal tear. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_222", "text": "Magnetic resonance imaging  (MRI) is also used for the detection and assessment of aortic dissection, with a sensitivity of 98% and a specificity of 98%. An MRI examination of the aorta produces a three-dimensional reconstruction of the aorta, allowing the physician to determine the location of the intimal tear and the involvement of branch vessels, and to locate any secondary tears. It is a noninvasive test, does not require the use of iodinated contrast material, and can detect and quantitate the degree of aortic insufficiency. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_223", "text": "The disadvantage of the MRI scan in the face of aortic dissection is that it may be available only in larger hospitals, and the scan is relatively time-consuming, which could be dangerous in people who are already very unwell. Due to the high-intensity magnetic fields used during MRI, it cannot be used on individuals with metallic implants. In addition, some individuals experience  claustrophobia  while surrounded by the MRI magnet. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_224", "text": "The  transesophageal echocardiogram  (TEE) is a good test in the diagnosis of aortic dissection, with a sensitivity up to 98% and a specificity up to 97%. It has become the preferred imaging modality for suspected aortic dissection. It is a relatively noninvasive test, requiring the individual to swallow the echocardiography probe. It is especially good in the evaluation of AI in the setting of ascending aortic dissection and to determine whether the ostia (origins) of the coronary arteries are involved. While many institutions give sedation during transesophageal echocardiography for added patient comfort, it can be performed in cooperative individuals without the use of sedation. Disadvantages of TEE include the inability to visualize the distal ascending aorta (the beginning of the  aortic arch ), and the descending abdominal aorta that lies below the  stomach . A TEE may be technically difficult to perform in individuals with esophageal strictures or  varices . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_225", "text": "An aortogram involves the placement of a catheter in the aorta and injection of contrast material while taking X-rays of the aorta. The procedure is known as  aortography . Previously thought to be the diagnostic  gold standard , it has been supplanted by other, less-invasive imaging modalities. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_226", "text": "Several different classification systems have been used to describe aortic dissections. One such classification is based on chronicity and labels aortic dissections as hyperacute (<24 hours duration), acute (2\u20137 days), subacute (8\u201330 days), and chronic (>30 days). [ 20 ]  The systems commonly in use are based on either the anatomy of the dissection or the duration of onset of symptoms before the presentation. The Stanford system is used more commonly now, as it is more attuned to the management of the patient. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_227", "text": "The DeBakey system, named after cardiothoracic surgeon  Michael E. DeBakey , is an anatomical description of the aortic dissection. It categorizes the dissection based on where the original intimal tear is located and the extent of the dissection (localized to either the ascending aorta or descending aorta or involving both the ascending and descending aorta). [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_228", "text": "The Stanford classification is divided into two groups, A and B, depending on whether the ascending aorta is involved. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_229", "text": "The Stanford classification is useful as it follows clinical practice, as type A ascending aortic dissections generally require primary surgical treatment, whereas type B dissections generally are treated medically as initial treatment with surgery reserved for any complications. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_230", "text": "The main indication for surgical repair of type A dissections is the prevention of acute hemorrhagic pericardial tamponade due to leakage of blood through the dissected layers of the intrapericardial proximal aorta. A secondary indication is acute aortic valve insufficiency (regurgitation): ascending aortic dissections often involve the aortic valve, which, having lost its suspensory support, telescopes down into the aortic root, resulting in aortic incompetence. The valve must be resuspended to be reseated, as well as to repair or prevent coronary artery injury. Also, the area of dissection is removed and replaced with a Dacron graft to prevent further dissection from occurring. However, type B dissections are not improved, from a mortality point of view, by the operation, unless leaking, rupture, or compromise to other organs, e.g. kidneys, occurs. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_231", "text": "Among the recognized risk factors for aortic dissection, hypertension,  abnormally high levels of lipids (such as cholesterol) in the blood , and smoking tobacco are considered preventable risk factors. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_232", "text": "Repair of an enlargement of the ascending aorta from an aneurysm or previously unrecognized and untreated aortic dissections is recommended when greater than 5.5\u00a0cm (2.2\u00a0in) in size to decrease the risk of dissection. Repair may be recommended when greater than 4.5\u00a0cm (1.8\u00a0in) in size if the person has one of the several connective-tissue disorders or a family history of a ruptured aorta. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_233", "text": "In an acute dissection, treatment choice depends on its location. For Stanford type A (ascending aortic) dissection, surgical management is superior to medical management. [ 4 ]  For uncomplicated Stanford type B (distal aortic) dissections (including abdominal aortic dissections), medical management is preferred over surgery. [ 42 ]  Complicated Stanford type B aortic dissections require surgical intervention after initiation of medical therapy, with endovascular stent-grafting (TEVAR) available as a less invasive alternative to surgery. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_234", "text": "The risk of death due to aortic dissection is highest in the first few hours after the dissection begins, and decreases afterward. [ 42 ]  Because of this, the therapeutic strategies differ for the treatment of an acute dissection compared to a chronic dissection. An acute dissection is one in which the individual presents within the first two weeks. If the individual has managed to survive this window period, their prognosis is improved. [ 42 ]  About 66% of all dissections present in the acute phase. Individuals who present two weeks after the onset of the dissection are said to have chronic aortic dissections. [ 42 ]   These individuals have been self-selected as survivors of the acute episode and can be treated with medical therapy as long as they are stable. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_235", "text": "Aortic dissection generally presents as a hypertensive emergency, and the prime consideration of medical management is to decrease the  shear stress  in the aortic wall (dP/dt (force of ejection of blood from the  left ventricle )) by decreasing blood pressure and the heart rate. The target blood pressure should be a  mean arterial pressure  (MAP) of 60 to 75  mmHg , or the lowest blood pressure tolerated. Initial decreases should be by about 20%. [ 2 ]  The target heart rate is less than 65 beats per minute. Long-term blood pressure control is required for every person who has experienced aortic dissection. [ 42 ]   [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_236", "text": "Beta blockers  are the first-line treatment for patients with acute and chronic aortic dissection. In acute dissection, fast-acting agents can be given intravenously and have doses that are easier to adjust (such as  esmolol ,  propranolol , or  labetalol ) is preferred. Vasodilators such as  sodium nitroprusside  can be considered for people with ongoing high blood pressure, but they should never be used alone, as they often stimulate a  reflexive increase in the heart rate . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_237", "text": "Calcium channel blockers  can be used in the treatment of aortic dissection, particularly if a contraindication to the use of beta-blockers exists.  The calcium channel blockers typically used are  verapamil  and  diltiazem , because of their combined vasodilator and negative  inotropic  effects. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_238", "text": "If the individual has refractory hypertension (persistent hypertension on the maximum doses of three different classes of antihypertensive agents), involvement of the renal arteries in the aortic dissection plane should be considered. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_239", "text": "Indications for the surgical treatment of aortic dissection include an acute proximal aortic dissection and an acute distal aortic dissection with one or more complications.  Complications include compromise of a vital organ, rupture or impending rupture of the aorta, retrograde dissection into the ascending aorta. These are more common with a history of Marfan syndrome or Ehlers-Danlos syndrome. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_240", "text": "The objective in the surgical management of aortic dissection is to resect (remove) the most severely damaged segments of the aorta and to obliterate the entry of blood into the false lumen (both at the initial intimal tear and any secondary tears along the vessel). While excision of the intimal tear may be performed, it does not significantly change mortality. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_241", "text": "The particular treatment used depends on the segment or segments of the aorta involved. Some treatments are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_242", "text": "A number of comorbid conditions increase the surgical risk of repair of an aortic dissection.  These conditions include the following: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_243", "text": "Patients who have suffered aortic dissection are at risk of  Aortic aneurysm  formation at the site of the dissection, thought to be due to weakening of the aortic wall.  [ 43 ]  The risk of this aneurysm degeneration is 10 times higher in individuals who have uncontrolled hypertension, compared to individuals with a systolic pressure below 130 mmHg."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_244", "text": "The risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period. About 29% of late deaths following surgery are due to rupture of either a dissecting aneurysm or another aneurysm. In addition, a 17% to 25% incidence exists of new aneurysm formation, typically due to dilatation of the residual false lumen. These new aneurysms are more likely to rupture, due to their thinner walls. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_245", "text": "Serial imaging of the aorta is recommended, although guidelines on modality (CT vs MRI vs ultrasound) and interval (timing of imaging tests) do not exist. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_246", "text": "Of all people with aortic dissection, 40% die immediately and do not reach a hospital in time. Of the remainder, 1% die every hour, making prompt diagnosis and treatment a priority. Even after diagnosis, 5\u201320% die during surgery or in the immediate postoperative period. [ 25 ]  In ascending aortic dissection, if surgery is decided to be not appropriate, 75% die within 2 weeks. With aggressive treatment, 30-day survival for thoracic dissections may be as high as 90%. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_247", "text": "Establishing the incidence of aortic dissection has been difficult because many cases are only diagnosed after death (which may have been attributed to another cause), and is often initially misdiagnosed. Aortic dissection affects an estimated 2.0\u20133.5 people per every 100,000 every year. Studies from Sweden suggest that the incidence of aortic dissection may be rising. [ 46 ]  Men are more commonly affected than women: 65% of all people with aortic dissection are male. The mean age at diagnosis is 63 years. [ 25 ]  In females before the age of 40, half of all aortic dissections occur during  pregnancy  (typically in the third trimester or early  postpartum  period). [ 47 ]  Dissection occurs in about 0.6% of pregnancies. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_248", "text": "The earliest fully documented case of aortic dissection is attributed to  Frank Nicholls  in his  autopsy  report of  King George II of Great Britain , who had been found dead on 25 October 1760; the report describes a dissection of the aortic arch and into the pericardium. [ 3 ] [ 49 ]  The term \"aortic dissection\" was introduced by the French physician J. P. Maunoir in 1802, and  Ren\u00e9 Laennec  labeled the condition \"dissecting aneurysm\". [ 3 ] [ 50 ]  London cardiologist  Thomas Bevill Peacock  contributed to the understanding of the condition by publishing two series of the cases described in the literature so far: 19 cases in an 1843 review, and 80 in 1863. [ 50 ]  The characteristic symptom of tearing pain in the chest was recognized in 1855 when a case was diagnosed in life. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_249", "text": "Surgery for aortic dissection was first introduced and developed by  Michael E. DeBakey ,  Denton Cooley , and Oscar Creech, cardiac surgeons associated with the  Baylor College of Medicine , Houston, Texas, in 1954. DeBakey developed aortic dissection himself at age 97 in 2005, [ 3 ]  and underwent surgery in 2006. [ 51 ]  Endovascular treatment of aortic dissection was developed in the 1990s. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_250", "text": "Aortopexy  is a surgical procedure in which the  aortic arch  is fixated to the  sternum . It results in the  tracheal  lumen being pulled open. It is used to treat severe  tracheomalacia  or tracheal compression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_251", "text": "The procedure was originally proposed as a treatment for tracheomalacia Filler et al. [ 1 ]  in 1976."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_252", "text": "Arteriotomy  (or  arterotomy ) is a medical term for an opening or cut of an  artery  wall. [ 1 ]  It is a common step in many  vascular surgical  procedures and operations. The corresponding term for an incision into a vein is a  venotomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_253", "text": "Either a transverse or a longitudinal incision can be made (with respect to the direction of the artery), depending on the situation. The incision is typically made with a  scalpel  and extended with surgical  scissors . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_254", "text": "Atherectomy  is a  minimally invasive  technique for removing  atherosclerosis  from blood vessels within the body. It is an alternative to  angioplasty  for the treatment of  peripheral artery disease , but the studies that exist are not adequate to determine whether it is superior to angioplasty. [ 1 ]  It has also been used to treat  coronary artery disease , albeit without evidence of superiority to angioplasty. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_255", "text": "Atherectomy is used to treat  narrowing  in  arteries  caused by  peripheral artery disease  and  coronary artery disease . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_256", "text": "The use of atherectomy instead of or in addition to angioplasty remains an area of controversy, as atherectomy typically involves the use of more costly disposable devices, and clear evidence to justify its use is lacking. [ 1 ]  Atherectomy has high physician reimbursement relative to angioplasty alone. [ 3 ]  According to the New York Times, \u2018Medical device makers have bankrolled a cottage industry of doctors and clinics that perform artery-clearing procedures that can lead to amputations.\u2019 [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_257", "text": "Unlike  angioplasty  and  stents , which push plaque into the vessel wall, atherectomy cuts plaque from the wall of the artery. While atherectomy is usually employed to treat  arteries  it can be used in  veins  and  vascular bypass  grafts as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_258", "text": "Atherectomy falls under the general category of  percutaneous   revascularization , which implies re-canalizing blocked vasculature via a needle puncture in the skin. The most common access point is near the groin through the  common femoral artery  (CFA). Other common places are the  brachial artery ,  radial artery ,  popliteal artery ,  dorsalis pedis , and others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_259", "text": "There are four types of atherectomy devices: orbital, rotational, laser, and directional."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_260", "text": "The decision to use which type of device is made by the interventionist, based on a number of factors. They include the type of lesion being treated, the physician's experience with each device, and interpretation of the devices' risks and effectiveness, based on a review of the medical literature."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_261", "text": "Directional atherectomy is an intravascular procedure guided by  optical coherence tomography  termed as  lumivascular atherectomy . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_262", "text": "Autoamputation  is the spontaneous detachment ( amputation ) of an  appendage  or organ from the body. [ 1 ]  This is not to be confused with  self-amputation . It is usually due to destruction of the blood vessels feeding an extremity such as the finger tips. Once the vessels are destroyed, the tissue is  starved of oxygen  and  dies , which is often followed by  gangrene .\nAutoamputation is a feature of  ainhum ,  cryoglobulinemia [ 2 ]  and  thromboangiitis obliterans . In 1881, Thornton made the case of autoamputation. [ 3 ]   Autoamputation could be the result of severe cases of certain chronic wounds, such as  frostbite . These chronic wounds might be due to some vascular and pathogenic conditions [ 4 ]  like  Buerger disease  or  Reynaud's phenomenon . Also, uncontrolled  diabetes  can predispose one to autoamputation. [ 4 ]  However, autoamputation has been described as spontaneous. [ 5 ]  Autoamputation has often been associated with fingers and toes but other parts of the body can suffer this condition as well. There have been reported cases of ovarian autoamputation in a newborn [ 6 ]  and also in a mature ovary of adults. [ 3 ]  Autoamputation has been reported to affect the tip of fingers. [ 7 ]  Though autoamputation is often regarded as an acquired ailment, it could also be congenital. [ 3 ]  Chronic torsion or a delay in the diagnosis of acute adnexal torsion has been attributed as causes of acquired autoamputation [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_263", "text": "Though its facts are being unraveled and analyzed, autoamputation can be categorized as acute, subacute or chronic. [ 3 ]  Acute autoamputation is characterized by tumor necrosis. This is accompanied by inadequate supply of blood to the heart and other body parts (ischemia) leading to the degeneration of the cells, a condition known as atropy. [ 3 ]  Chronic or subacute autoamputation is evident in the attachment of the tumor to other cells surrounding it. [ 3 ]  There is a rare possibility of the tumor detaching itself from the  pedicle . When this happens, it could be parasitic."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_264", "text": "Balloon-occluded retrograde transvenous obliteration  ( BRTO ) is an  endovascular procedure  used for the treatment of  gastric varices . When performing the procedure, an  interventional radiologist  accesses blood vessels using a catheter, inflates a balloon (e.g. balloon occlusion) and injects a substance into the variceal blood vessels that causes blockage of those vessels. To prevent the flow of the agent out of the intended site (variceal blood vessels), a balloon is inflated during the procedure, which occludes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_265", "text": "BRTO is used for the treatment of bleeding from gastric varices. In addition to  transjugular intrahepatic portosystemic shunt  (TIPS), BRTO is a first line treatment for the prevention of recurrent bleeding from gastric varices (GOV2 or IGV1). [ 1 ]  BRTO may be used for the treatment of ectopic varices. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_266", "text": "As BRTO results in a blockage of a portosystemic shunt, the procedure may result in increased portal hypertension, which may worsen esophageal varices or ascites. [ 2 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_267", "text": "BRTO was developed as a procedure in the early 1990s. [ 2 ]  Initially, the procedure was performed using  ethanolamine oleate  as a sclerosant. [ 2 ] [ 3 ]  Between 2006 and 2007, American physicians began using  sodium tetradecyl sulfate  (3% STS) as an alternative sclerosing agent. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_268", "text": "A  vascular bypass  is a  surgical procedure  performed to redirect  blood flow  from one area to another by reconnecting blood vessels. Often, this is done to bypass around a diseased artery, from an area of normal blood flow to another relatively normal area. It is commonly performed due to inadequate blood flow ( ischemia ) caused by  atherosclerosis , as a part of  organ transplantation , or for  vascular access  in  hemodialysis . In general, someone's own  vein  (autograft) is the preferred graft material (or conduit) for a vascular bypass, but other types of grafts such as  polytetrafluoroethylene  (Teflon),  polyethylene terephthalate  (Dacron), or a different person's vein ( allograft ) are also commonly used.  Arteries  can also serve as vascular grafts. A surgeon sews the graft to the source and target vessels by hand using  surgical suture , creating a  surgical anastomosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_269", "text": "Common bypass sites include the  heart  ( coronary artery bypass surgery ) to treat coronary artery disease, and the legs, where  lower extremity bypass surgery  is used to treat  peripheral vascular disease ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_270", "text": "Cardiac bypass is performed when the arteries that bring  blood  to the  heart muscle  (coronary arteries) become clogged by  plaque . [ 1 ] [ 2 ]  Such a condition may cause chest pain from  angina pectoris  or a heart attack. Dimensional aspects, material selection, and manufacturing methods influence mechanistic behaviours of artificial grafts and chosen to receive artery-like behaviour  [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_271", "text": "In the legs, bypass grafting is used to treat  peripheral vascular disease ,  acute limb ischemia ,  aneurysms  and  trauma . While there are many anatomical arrangements for vascular bypass grafts in the lower extremities depending on the location of the disease, the principle is the same: to restore blood flow to an area without normal flow.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_272", "text": "For example, a femoral-popliteal bypass ( \"fem-pop\" ) might be used if the  femoral artery  is occluded. A fem-pop bypass may refer to the above- or below-knee popliteal artery. Other anatomic descriptions of lower extremity bypasses include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_273", "text": "A vascular bypass is often created to serve as an access point to the  circulatory system  for  hemodialysis . Such a bypass is referred to as an  arteriovenous fistula  if it directly connects a  vein  to an  artery  without using synthetic material. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_274", "text": "In the skull, when blood flow is blocked or a damaged  cerebral artery  prevents adequate blood flow to the  brain , a cerebral artery bypass may be performed to improve or restore flow to an oxygen-deprived (ischemic) area of the brain. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_275", "text": "There are two main types of cerebral artery bypass: direct and indirect. Direct revascularization is also known as EC-IC bypass because it involves directly connecting an extracranial artery outside the brain to an intracranial artery inside the brain. This is also sometimes called STA-MCA bypass because the superficial temporal artery and the middle cerebral artery are the most commonly used arteries for the surgery. [ 6 ]  STA-MCA bypass surgery has been shown to be ineffective in reducing the risk of ischemic stroke in an international, randomized clinical trial [ 7 ]  led by   clinical scientist    Dr. Henry Barnett . Indirect revascularization involves placing part of an artery, in the case of EDAS (encephaloduroarteriosynangiosis), or part of a muscle, in the case of EMS (encephalomyosynangiosis), on the surface of the brain and allowing it to revascularize the brain through new vessel growth. Both types of indirect revascularization typically take 3-6 months to see effects. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_276", "text": "When several arteries are blocked and several bypasses are needed, the procedure is called multiple bypass. The number of bypasses needed does not always increase the risk of surgery, which depend more on the patient's overall health."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_277", "text": "Prior to constructing a bypass, most surgeons will obtain or perform an imaging study to determine the severity and location of the diseased blood vessels. For cardiac and lower extremity disease, this is usually in the form of an  angiogram . For hemodialysis access, this can be done with ultrasound. Occasionally, a  CT angiogram  will take the place of a formal angiogram. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_278", "text": "The lack of an adequate venous conduit is a relative contraindication to bypass surgery, and depending on the area of disease, alternatives may be used. Medical conditions such as  ischemic heart disease  or  chronic obstructive pulmonary disease  that increase the risk of surgery are also relative contraindications. For coronary and peripheral vascular disease, lack of \"runoff\" to the distal area is also a contraindication because a vascular bypass around one diseased artery to another diseased area does not solve the vascular problem. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_279", "text": "If a patient is deemed to be too high-risk to undergo a bypass, he or she may be a candidate for  angioplasty  or  stenting  of the relevant vessel. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_280", "text": "Dogma in vascular bypass technique says to obtain  proximal  and  distal  control. This means that in a vessel with flow through it, a surgeon must have exposure of the furthest and nearest extents of the blood vessel in which the bypass is being created, so that when the vessel is opened, blood loss is minimized. After the necessary exposure, clamps are usually used on both the proximal and distal end of the segment. Exceptions exist where there is no blood flow through the target vessel at the area of proposed entry, as is the case with an intervening occlusion. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_281", "text": "If the organ perfused by an artery is sensitive to even temporary occlusion of blood flow, such as in the brain, various other measures are taken. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_282", "text": "In  neurosurgery , excimer laser assisted non-occlusive anastomosis (ELANA) is a technique use to create a bypass without interrupting the blood supply in the recipient blood vessels. This reduces the risk of stroke or a rupture of an  aneurysm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_283", "text": "Several complications can arise after vascular bypass. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_284", "text": "Risks of the bypass: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_285", "text": "General risks of surgery: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_286", "text": "Immediately following coronary artery or neurosurgical vascular bypass surgery, patients recover in an  intensive care unit  or  coronary care unit  for one to two days. Provided that recovery is normal and without  complications , they can move to a less intensively monitored unit such as a  step-down unit  or a  ward bed . Depending on the extent of the surgery, recovery from a leg bypass may start from a step-down or ward bed.  Monitoring  immediately after bypass surgery focuses on signs and  symptoms  of bleeding and graft occlusion. If bleeding is detected, treatment can range from  transfusion  to  reoperation . Later on in the hospital course, common complications include  wound infections ,  pneumonia ,  urinary tract infection , and graft occlusion. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_287", "text": "At discharge, patients are often prescribed oral painkillers, and should be prescribed a  statin  and an  anti-platelet medication  if not contraindicated and their bypass was performed for  atherosclerosis , (e.g.,  peripheral vascular disease  or  coronary artery disease ). Some patients start feeling normal after one month, while others may still experience problems several months after the procedure. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_288", "text": "During the first twelve weeks after most bypass operations, patients are advised to avoid heavy lifting, house work, and strenuous recreation like  golf ,  tennis , or  swimming  while their surgical wounds heal, particularly the sternum after coronary bypass. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_289", "text": "Part of the recovery after any bypass surgery includes regular visits to a physician to monitor the patient's recovery. Normally a follow-up visit with a surgeon is scheduled for two to four weeks after surgery. The frequency of these visits gradually lessens as the patient's health improves. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_290", "text": "For vascular bypass operations performed for atherosclerosis, the operation does not cure the metabolic problem that led to the vascular disease. Lifestyle changes that include  quitting smoking , making  diet  changes, and getting regular exercise are required to cure the underlying condition. [ 10 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_291", "text": "Carotid endarterectomy  is a  surgical  procedure used to reduce the risk of stroke from  carotid artery stenosis  (narrowing the  internal carotid artery ). In  endarterectomy , the surgeon opens the artery and removes the plaque. The plaque forms and thickens the inner layer of the artery, or  intima , hence the name of the procedure which simply means removal of part of the internal layers of the artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_292", "text": "An alternative procedure is  carotid stenting , which can also reduce the risk of stroke for some patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_293", "text": "Carotid endarterectomy is used to reduce the risk of strokes caused by  carotid artery stenosis  over time. Carotid stenosis can either have symptoms (i.e., be symptomatic), or be found by a doctor in the absence of symptoms (asymptomatic) - and the risk-reduction from endarterectomy is greater for symptomatic than asymptomatic patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_294", "text": "Carotid endarterectomy itself can cause strokes, so to be of benefit in preventing strokes over time, the risks for combined 30-day mortality and stroke risk following surgery should be <\u00a03% for asymptomatic people and \u2264 6% for symptomatic people. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_295", "text": "Carotid endarterectomy does not treat symptoms of prior strokes. It is controversial if carotid endarterectomy can improve cognitive function in some patients. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_296", "text": "Symptomatic people have had either a stroke or  transient ischemic attack  or amaurosis fugax."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_297", "text": "In symptomatic patients with a 70\u201399% stenosis, for every six people treated, one major stroke would be prevented at two years (i.e., a  number needed to treat  of six). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_298", "text": "Unlike asymptomatic patients, symptomatic people with moderate carotid stenosis (50\u201369%) still benefit from endarterectomy, albeit to a lesser degree, with a number needed to treat of 22 at five years. Recent evidence demonstrated that unstable carotid atherosclerotic plaques are responsible for cerebral ischemic events and symptoms (stroke or  transient ischemic attack ) in these patients. [ 4 ] [ 5 ]  In addition, co-morbidity adversely affects the outcome: people with multiple medical problems have a higher post-operative  mortality rate  and hence benefit less from the procedure. For maximum benefit people should be operated on soon after a stroke or transient ischemic attack, preferably within the first 2 weeks. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_299", "text": "Asymptomatic people have narrowing of their carotid arteries, but have not experienced a transient ischemic attack or stroke. The annual risk of stroke in patients with asymptomatic carotid disease is between 1% and 2%, although some patients are considered to be at higher risk, such as those with ulcerated plaques. This low rate of stroke means that there is less potential stroke risk-reduction from endarterectomy for asymptomatic patients relative to symptomatic patients. However, for asymptomatic patients with severe carotid stenosis (80-99%), carotid endarterectomy plus treatment with a  statin  medicine and  anti-platelet therapy  does reduces stroke risk further than medication alone in the five years following surgery. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_300", "text": "The most feared complication of carotid endarterectomy is stroke. Risks of stroke at the time of surgery are higher for symptomatic (3\u20135%) than asymptomatic patients (1\u20133%). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_301", "text": "Bleeding, infection, and  cranial nerve  injury are also risks at the time of surgery. Following surgery, a rare early complication is  cerebral hyperperfusion syndrome , also known as reperfusion syndrome, which is associated with headache and high blood pressure following surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_302", "text": "Long term complications include restenosis of the endarterectomy bed, although the clinical significance of this is controversial in asymptomatic patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_303", "text": "The procedure should be avoided when:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_304", "text": "High risk criteria for carotid endarterectomy include the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_305", "text": "Carotid artery stenting  is an alternative to carotid endarterectomy in cases where endarterectomy is considered too risky."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_306", "text": "An incision is made on the midline side of the  sternocleidomastoid muscle . The incision is between 5 and 10\u00a0cm (2.0 and 3.9\u00a0in) in length. The internal, common and external carotid arteries are carefully identified, controlled with vessel loops, and clamped. The lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed.  The artery is closed using  suture  with or without a patch to increase the size of the  lumen .  Hemostasis  is achieved, and the overlying layers closed with suture. The skin can be closed with suture which may be visible or invisible (absorbable). Many surgeons place a temporary  shunt  to ensure blood supply to the brain during the procedure.  The procedure may be performed under general or local  anaesthesia . The latter allows for direct monitoring of neurological status by intra-operative verbal contact and neurological assessment. [ 8 ]   With general anaesthesia, indirect methods of assessing cerebral perfusion must be used.  Electroencephalography  (EEG), transcranial doppler analysis, cerebral oximetry, or carotid artery stump pressure monitoring can guide the placement of a shunt,  or a shunt may be routinely used.  At present there is still ongoing debate related to difference in outcome between local and general anaesthesia, and methods of determining the need for a shunt. [ 3 ]  However, excellent outcomes can be achieved by performing carotid endarterectomy under local  anaesthesia . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_307", "text": "The endarterectomy procedure was developed and first done by the Portuguese surgeon Joao Cid dos Santos in 1946, when he operated an occluded subsartorial artery, at the  University of Lisbon . In 1951 an Argentinian surgeon repaired a carotid artery occlusion using a bypass procedure. The first endarterectomy was successfully performed by  Michael DeBakey  around 1953, at the  Methodist Hospital  in Houston, TX, although the technique was not reported in the medical literature until 1975. [ 10 ]  The first case to be recorded in the medical literature was in The Lancet in 1954; [ 10 ] [ 11 ]  the surgeon was Felix Eastcott, a consultant surgeon and deputy director of the surgical unit at  St Mary's Hospital, London , UK. [ 12 ]  Eastcott's procedure was not strictly an endarterectomy as we now understand it; he excised the diseased part of the artery and then resutured the healthy ends together. [ citation needed ]  Carotid endarterectomy was finally shown to be effective in stroke prevention after a landmark clinical trial [ 13 ]  spearheaded by the Canadian clinical scientist  Dr. Henry Barnett . Since then, evidence for its effectiveness in different patient groups has accumulated. In 2003 nearly 140,000 carotid endarterectomies were performed in the US, however, the number of procedures has continued to decrease over time. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_308", "text": "Carotid artery stenting  is an  endovascular procedure  where a  stent  is deployed within the  lumen  of the  carotid artery  to treat  narrowing of the carotid artery  and decrease the risk of  stroke . It is used to treat narrowing of the carotid artery in high-risk patients, when  carotid endarterectomy  is considered too risky."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_309", "text": "Carotid stenting is used to reduce the risk of stroke associated with  carotid artery stenosis . Carotid stenosis can have no symptoms, or have symptoms such as  transient ischemic attacks  (TIAs) or  strokes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_310", "text": "While historically  endarterectomy  has been the treatment for  carotid stenosis , stenting is an alternative intervention for patients who are not candidates for surgery.  High risk factors for endarterectomy, which would favor stenting instead, include medical comorbidities (severe heart disease,  heart failure , severe lung disease) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that would make surgery difficult and risky. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_311", "text": "While rates of stroke and death after both surgery and stenting are low, rates of stroke and death after stenting may be higher than with endartererectomy, particularly for transfemoral stenting in patients over age 70. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_312", "text": "Carotid stenting involves the placement of a  stent  across the  stenosis  in the carotid artery. It can be performed under general or local  anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_313", "text": "The stent may be placed from the  femoral artery ,  radial artery , or from the  common carotid artery  at the base of the neck. Critical steps in both approaches are vascular access, crossing the stenosis with a wire, deploying a stent across the lesion, and removing the  vascular access . A number of other steps may or may not be performed, including the use of a cerebral protection device, pre- or post-stent  balloon angioplasty  and cerebral angiography."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_314", "text": "The trans-femoral route is the traditional approach to carotid stenting. The vast majority of these procedures are performed under local anesthesia. In this technique, puncture of the  common femoral artery  is used to gain access to the arterial system. Wire and sheath are advanced through the  aorta  to the  common carotid artery  on the side to be treated. Flow reversal or filter cerebral protection may be used. The procedure is typically performed  percutaneously . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_315", "text": "Trans-carotid artery stenting involves a surgical incision at the base of the neck over the  common carotid artery . It is performed under either local or general anesthesia. Wire access is obtained at that location and used to deliver the stent to the  internal carotid artery . Cerebral protection is usually obtained by flow reversal - the common carotid artery is clamped, and arterial blood from the internal carotid is run through a filter and returned to a  femoral vein  during the highest risk portions of the procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_316", "text": "The trans-radial route has been introduced as an alternative in the past few years. The vast majority of these procedures are performed under local anesthesia. In this technique, puncture of the radial artery is used to gain access to the arterial system. Wire and sheath are advanced through the  aorta  to the  common carotid artery  on the side to be treated. Flow reversal or filter cerebral protection may be used. The procedure is typically performed  percutaneously . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_317", "text": "Recovery after carotid artery stenting depends not only on the presence of complications during the procedure, but also on the presence of symptoms at the time of arrival to the hospital. Asymptomatic patients typically leave the hospital in 0\u20131 days. The blood pressure is kept at a goal below 140 mmHg systolic. Elevated blood pressure in the 2\u201310 days post-operatively may lead to  reperfusion syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_318", "text": "The most feared short-term complication of any stroke prevention procedure on the carotid artery is stroke itself.  Patients must still be carefully selected for surgery or stenting in order to reduce the risks related to the procedure and ensure the long-term benefit after such intervention. Other short-term complications might include bleeding, infection and heart problems such as  myocardial infarction  related to anesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_319", "text": "Late complications such as recurrent stenosis may occur, and surveillance with  duplex ultrasound  or  CT-Angiography  may be performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_320", "text": "The risk-reduction from intervention for carotid stenosis (stenting or endarterectomy) is greatest when the indication for intervention is symptoms (i.e., the patient is symptomatic) - typically  stroke  or  TIA . [ 6 ]  \nA new generation of double-layer stents is currently being developed to reduce the risk of stroke during or after the procedure.  [ 7 ]  There is insufficient evidence to say that stenting or endarterectomy is better for symptomatic patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_321", "text": "Angioplasty and carotid stenting in patients with asymptomatic carotid atherosclerotic stenosis should not be performed except in the context of randomized clinical trials. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_322", "text": "Cholesterol embolism  occurs when  cholesterol  is released, usually from an  atherosclerotic plaque , and travels as an  embolus  in the bloodstream to lodge (as an  embolism ) causing an obstruction in  blood vessels  further away. Most commonly this causes skin symptoms (usually  livedo reticularis ),  gangrene  of the extremities and sometimes  kidney failure ; problems with other organs may arise, depending on the site at which the  cholesterol crystals  enter the bloodstream. [ 2 ]  When the  kidneys  are involved, the disease is referred to as  atheroembolic renal disease . [ 3 ]  The diagnosis usually involves  biopsy  (removing a tissue sample) from an affected organ. Cholesterol embolism is treated by removing the cause and giving supportive therapy;  statin  drugs have been found to improve the prognosis. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_323", "text": "The symptoms experienced in cholesterol embolism depend largely on the organ involved.  Non-specific symptoms  often described are  fever ,  muscle ache  and  weight loss . Embolism to the legs causes a mottled appearance and purple discoloration of the  toes , small  infarcts  and areas of  gangrene  due to  tissue death  that usually appear black, and areas of the skin that assume a marbled pattern known as  livedo reticularis . [ 3 ]  The pain is usually severe and requires opiates. If the ulcerated plaque is below the renal arteries the manifestations appear in both lower extremities. Very rarely the ulcerated plaque is below the aortic bifurcation and those cases the changes occur only in one lower extremity. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_324", "text": "Kidney involvement leads to the symptoms of  kidney failure , which are non-specific but usually cause  nausea , reduced  appetite  ( anorexia ), raised  blood pressure  (hypertension), and occasionally the various symptoms of  electrolyte disturbance  such as an  irregular heartbeat . Some patients report  hematuria  (bloody urine) but this may only be detectable on microscopic examination of the urine. Increased amounts of  protein  in the urine may cause  edema  (swelling) of the skin (a combination of symptoms known as  nephrotic syndrome ). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_325", "text": "If emboli have spread to the  digestive tract , reduced appetite, nausea and vomiting may occur, as well as nonspecific  abdominal pain ,  gastrointestinal hemorrhage  (vomiting blood, or  admixture of blood in the stool ), and occasionally  acute pancreatitis  (inflammation of the  pancreas ). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_326", "text": "Both the  central nervous system  (brain and  spinal cord ) and the  peripheral nervous system  may be involved. Emboli to the brain may cause  stroke -like episodes,  headache  and episodes of loss of vision in one eye (known as  amaurosis fugax ). [ 3 ]  Emboli to the eye can be seen by  ophthalmoscopy  and are known as  plaques of Hollenhorst . [ 4 ]  Emboli to the spinal cord may cause  paraparesis  (decreased power in the legs) or  cauda equina syndrome , a group of symptoms due to loss of function of the distal part of the spinal cord \u2013 loss of control over the  bladder ,  rectum  and skin sensation around the anus. [ 3 ]  If the blood supply to a single nerve is interrupted by an embolus, the result is loss of function in the muscles supplied by that nerve; this phenomenon is called a  mononeuropathy . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_327", "text": "It is relatively unusual (25% of the total number of cases) for cholesterol emboli to occur spontaneously; this usually happens in people with severe  atherosclerosis  of the large arteries such as the  aorta . In the other 75% it is a complication of medical procedures involving the blood vessels, such as  vascular surgery  or  angiography . In  coronary catheterization , for instance, the incidence is 1.4%. [ 5 ]  Furthermore, cholesterol embolism may develop after the commencement of  anticoagulants  or  thrombolytic  medication that decrease blood clotting or dissolve blood clots, respectively. They probably lead to cholesterol emboli by removing blood clots that cover up a damaged atherosclerotic plaque; cholesterol-rich debris can then enter the bloodstream. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_328", "text": "Findings on general investigations (such as  blood tests ) are not specific for cholesterol embolism, which makes diagnosis difficult. The main problem is the distinction between cholesterol embolism and  vasculitis  (inflammation of the small blood vessels), which may cause very similar symptoms - especially the skin findings and the kidney dysfunction. [ 3 ]  Worsening kidney function after an angiogram may also be attributed to kidney damage by substances used during the procedure ( contrast nephropathy ). Other causes that may lead to similar symptoms include  ischemic kidney failure  (kidney dysfunction due to an interrupted blood supply), a group of diseases known as  thrombotic microangiopathies  and  endocarditis  (infection of the  heart valves  with small clumps of infected tissue embolizing through the body). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_329", "text": "Tests for  inflammation  ( C-reactive protein  and the  erythrocyte sedimentation rate ) are typically elevated, and abnormal  liver enzymes  may be seen. [ 3 ]  If the kidneys are involved, tests of  kidney function  (such as  urea  and  creatinine ) are elevated. [ 3 ]  The  complete blood count  may show particularly high numbers of a type of  white blood cell  known as  eosinophils  (more than 0.5 billion per liter); this occurs in only 60-80% of cases, so normal eosinophil counts do not rule out the diagnosis. [ 3 ] [ 5 ]  Examination of the urine may show  red blood cells  (occasionally in  casts  as seen under the microscope) and increased levels of protein; in a third of the cases with kidney involvement, eosinophils can also be detected in the urine. [ 3 ]  If vasculitis is suspected,  complement  levels may be determined as reduced levels are often encountered in vasculitis; complement is a group of proteins that forms part of the innate  immune system . Complement levels are frequently reduced in cholesterol embolism, limiting the use of this test in the distinction between vasculitis and cholesterol embolism. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_330", "text": "The microscopic examination of tissue ( histology ) gives the definitive diagnosis.  The diagnostic  histopathologic  finding is intravascular cholesterol crystals, which are seen as cholesterol clefts in routinely processed tissue (embedded in  paraffin wax ). [ 7 ]  The cholesterol crystals may be associated with  macrophages , including  giant cells , and  eosinophils . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_331", "text": "The  sensitivity  of small core biopsies is modest, due to  sampling error , as the process is often patchy.  Affected organs show the characteristic histologic changes in 50-75% of the clinically diagnosed cases. [ 3 ] [ 5 ]  Non-specific tissue findings suggestive of a cholesterol embolization include  ischemic changes ,  necrosis  and unstable-appearing complex  atherosclerotic plaques  (that are cholesterol-laden and have a thin fibrous cap).  While biopsy findings may not be diagnostic, they have significant value, as they help exclude alternate diagnoses, e.g.  vasculitis , that often cannot be made confidently based on clinical criteria. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_332", "text": "Treatment of an episode of cholesterol emboli is generally symptomatic, i.e. it deals with the symptoms and complications but cannot reverse the phenomenon itself. [ 5 ]  In kidney failure resulting from cholesterol crystal emboli,  statins  (medication that reduces cholesterol levels) have been shown to halve the risk of requiring  hemodialysis . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_333", "text": "The phenomenon of embolisation of cholesterol was first recognized by the  Danish   pathologist  Dr.  Peter Ludvig Panum  and published in 1862. [ 8 ]  Further evidence that eroded atheroma was the source of emboli came from American  pathologist  Dr. Curtis M. Flory, who in 1945 reported the phenomenon in 3.4% of a large  autopsy  series of older individuals with severe atherosclerosis of the  aorta . [ 3 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_334", "text": "A  Cimino fistula , also  Cimino-Brescia fistula ,  surgically created arteriovenous fistula  and (less precisely)  arteriovenous fistula  (often  abbreviated   AV fistula  or  AVF ), is a type of vascular access for  hemodialysis . It is typically a surgically created connection between an  artery  and a  vein  in the arm, although there have been acquired arteriovenous fistulas which do not in fact demonstrate connection to an artery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_335", "text": "The radiocephalic arteriovenous fistula (RC-AVF) is a shortcut created between  cephalic vein  and  radial artery  at the wrist. It is the recommended first choice for hemodialysis access. However, after a period of usage, failures can occur. Possible causes for failure are stenosis and thrombosis especially in diabetics and those with low blood flow such as due to narrow vessels, arteriosclerosis and advanced age. Reported patency of fistulae after 1 year is about 60%, when primary failures were included. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_336", "text": "Juxa-anastomotic site (venous segment that is between 2 and 5\u00a0cm distal to the anastomotic site) is the most common site of stenosis. One of the reasons affecting the rate of stenosis could be the anastomotic angle. [ 3 ] [ 4 ]  In  computational fluid dynamics  study, the ideal anastomotic angle should be less than 30 degrees to ensure  laminar flow  of the blood, thus prolong the  endothelial cell  survival, and prevent smooth muscle proliferation within vessel wall, and clogging the vessel. However, in another study using  angiographic  images of the juxta-anastomotic sites, the ideal anastomotic angle of less than 46.5 degrees was obtained. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_337", "text": "Surgically created AV fistulas work effectively because they:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_338", "text": "The procedure was invented by doctors  James Cimino  and M. J. Brescia at the  Bronx Veterans Administration Hospital  in 1966. [ 6 ]  Before the Cimino fistula was invented, access was through a  Scribner shunt , which consisted of a  Teflon  tube with a needle at each end. Between treatments, the needles were left in place and the tube allowed blood flow to reduce clotting. But Scribner shunts lasted only a few days to weeks. Frustrated by this limitation, James E. Cimino recalled his days as a  phlebotomist  (blood drawer) at  New York City 's  Bellevue Hospital  in the 1950s when  Korean War   veterans  showed up with  fistulas  caused by trauma. Cimino recognized that these fistulas did not cause the patients harm and were easy places to get repeated blood samples. He convinced surgeon Kenneth Appell to create some in patients with  chronic kidney failure  and the result was a complete success. Scribner shunts were quickly replaced with Cimino fistulas, and they remain the most effective, longest-lasting method for long-term access to patients' blood for hemodialysis today."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_339", "text": "Distal Revascularization and Interval Ligation  (DRIL) is a  surgical  method of treating  vascular access steal syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_340", "text": "DRIL was first proposed by Harry Schanzer and colleagues in 1988. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_341", "text": "A short distal bypass is created and the artery just distal to the AV  anastomosis  is ligated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_342", "text": "In  medicine , a  distal splenorenal shunt procedure  ( DSRS ), also  splenorenal shunt procedure  and  Warren shunt , [ 1 ]  is a  surgical procedure  in which the  distal   splenic vein  (a part of the  portal venous system ) is attached to the left  renal vein  (a part of the  systemic venous system ).  It is used to treat  portal hypertension  and its main complication ( esophageal varices ). [ 2 ]  It was developed by  W. Dean Warren ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_343", "text": "DSRS is typically done with splenopancreatic and gastric disconnection (ligation of the  gastric veins  and  pancreatic veins  (that drain into the  portal vein ) and complete detachment of the  splenic vein  from the  portal venous system ), as it improves the outcome. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_344", "text": "Survival with a  transjugular intrahepatic portosystemic shunt  (TIPS) versus a DSRS is thought to be approximately similar, [ 4 ] [ 5 ]  but still an area of intensive research. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_345", "text": "Both TIPS and DSRS lead to decreased rates of  variceal bleeding  at the expense of  hepatic encephalopathy ; however, TIPS appears to have more shunt dysfunction and lead to more encephalopathy and bleeds. [ 5 ]  DSRS appears to be more cost effective than TIPS. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_346", "text": "Endovascular aneurysm repair  ( EVAR ) is a type of minimally-invasive  endovascular surgery  used to treat  pathology  of the  aorta , most commonly an  abdominal aortic aneurysm  (AAA). When used to treat  thoracic aortic  disease, the procedure is then specifically termed  TEVAR  for \"thoracic endovascular aortic/aneurysm repair.\" EVAR involves the placement of an expandable  stent graft  within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed  open aortic surgery  as the most common technique for repair of AAA, [ 1 ]  and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_347", "text": "Standard EVAR is appropriate for aneurysms that begin below the  renal arteries , where there exists an adequate length of normal  aorta  (the  \"proximal aortic neck\" ) for reliable attachment of the endograft without leakage of blood around the device (\" endoleak \"). [ 3 ]  If the proximal aortic neck is also involved with the aneurysm, the patient may be a candidate for complex visceral EVAR with a fenestrated or branched EVAR."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_348", "text": "Patients with aneurysms require elective repair of their aneurysm when it reaches a diameter large enough (typically greater than 5.5\u00a0cm) such that the risk of rupture is greater than the risk of surgery. Repair is also warranted for aneurysms that rapidly enlarge or those that have been the source of  emboli  (debris from the aneurysm that dislodges and travel into other arteries). Lastly, the repair is also indicated for aneurysms that are the source of  pain  and  tenderness , which may indicate impending rupture. The options for repair include traditional  open aortic surgery  or endovascular repair. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_349", "text": "Endovascular procedures aim to reduce the morbidity and mortality of treating arterial disease in a patient population that is increasingly older and less fit than when major open repairs were developed and popularized. Even in the early days, significant risks were accepted in the understanding that the large open operation was the only option. That is not the case in most patients today. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_350", "text": "Studies that assign aneurysm patients to treatment with EVAR or traditional open surgery have demonstrated fewer early complications with the minimally invasive approach. Some studies have also observed a lower mortality rate with EVAR. [ 4 ] [ 5 ]  The reduction in death, however, does not persist long-term. After a few years, the survival after repair is similar to EVAR or open surgery. This observation may be the result of durability problems with early endograft, with a corresponding need for additional procedures to repair endoleaks and other device-related issues. Newer, improved technology may reduce the need for such secondary procedures. If so, the results of EVAR may improve to the point where long-term survival benefit becomes evident. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_351", "text": "EVAR is also used for  rupture  of the abdominal and descending thoracic aorta, and in rare cases used to treat pathology of the  ascending aorta . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_352", "text": "Endografts have been used in patients with  aortic dissection , noting the extremely complex nature of open surgical repair in these patients. In uncomplicated aortic dissections, no benefit has been demonstrated over medical management alone.\nIn uncomplicated type B aortic dissection, TEVAR does not seem either to improve or compromise 2-year survival and adverse event rates. [ 7 ]  Its use in complicated aortic dissection is under investigation. In the Clinical Practice Guidelines of the European Society for Vascular Surgery, it is recommended that in patients with complicated acute type B aortic dissection, endovascular repair with thoracic endografting should be the first line intervention. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_353", "text": "Before people are deemed to be suitable candidates for this treatment, they have to go through a rigorous set of tests.  These include a CT scan of the complete thorax/abdomen/pelvis and blood tests.  The CT scan gives precise measurements of the aneurysm and the surrounding anatomy. In particular, the calibre/tortuosity of the iliac arteries and the relationship of the neck of the aneurysm to the renal arteries are important determinants of whether the aneurysm is amenable to endoluminal repair. In certain occasions where the renal arteries are too close to the aneurysm, the custom-made fenestrated graft stent is now an accepted alternative to doing open surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_354", "text": "A patient's anatomy can be unsuitable for EVAR in several ways. Most commonly, in an infrarenal aneurysm, a potential EVAR candidate lacks adequate length of the normal-diameter aorta between the aneurysm and the takeoff of the renal arteries, the \"infra-renal neck\". Another relative  contraindications  include prohibitively small  iliac arteries , aneurysmal iliac arteries, prohibitively small  femoral arteries , or circumferential calcification of the femoral or iliac arteries. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_355", "text": "In addition to a short proximal aortic neck, the neck may be angulated, large in diameter, or shaped like a funnel (conical) where the neck diameter at the top is larger than the neck diameter at the bottom. Along with a short proximal aortic neck, necks with any of these characteristics are called \"hostile necks\" and endovascular repair can be either contraindicated or associated with early-late complications of endoleak, or endograft migration, or both. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_356", "text": "Many of the advances in EVAR technique aim to adapt EVAR for these situations, and advanced techniques allow EVAR to be employed in patients who previously were not candidates. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_357", "text": "The procedure is carried out in a sterile environment under  fluoroscopic  guidance.  It is usually carried out by a  vascular surgeon ,  interventional radiologist  or  cardiac surgeon , and occasionally,  general surgeon  or  interventional cardiologist . [ 9 ] [ 10 ] [ 11 ] [ 12 ]  The procedure can be performed under  general ,  regional (spinal or epidural)  or even  local anesthesia . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_358", "text": "Access to the patient's femoral arteries can be with surgical incisions or  percutaneously  in the groin on both sides. Vascular sheaths are introduced into the patient's femoral arteries, through which guidewires, catheters, and the endograft are passed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_359", "text": "Diagnostic angiography images are captured of the aorta to determine the location of the patient's renal arteries, so the stent-graft can be deployed without blocking these. Failure to achieve this will cause  kidney failure . With most devices, the \"main body\" of the endograft is placed first, followed by the \"limbs\" which join the main body and extend to the iliac arteries, effectively protecting the aneurysm sac from blood pressure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_360", "text": "The abdominal aneurysm extends down to the common iliac arteries in about 25%-30% of patients. In such cases, the iliac limbs can be extended into the external iliac artery to bypass a common iliac aneurysm. Alternatively, a specially designed endograft, (an iliac branch device) can be used to preserve flow to the  internal iliac arteries . The preservation of the hypogastric (internal iliac) arteries is important to prevent buttock  claudication  and  impotence , and every effort should be made to preserve flow to at least one hypogastric artery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_361", "text": "The endograft acts as an artificial lumen for blood to flow through, protecting the surrounding aneurysm sac. This reduces the pressure in the aneurysm, which itself will usually thrombose and shrink in size over time. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_362", "text": "Staging such procedures is common, particularly to address aortic branch points near the diseased aortic segment. One example in the treatment of thoracic aortic disease is revascularization of the left common carotid artery and/or the left subclavian artery from the innominate artery or the right common carotid artery to allow treatment of a thoracic aortic aneurysm that encroaches proximally into the aortic arch. These \"extra-anatomic bypasses\" can be performed without an invasive  thoracotomy . Another example in the abdominal aorta is the embolization of the internal iliac artery on one side prior to coverage by an iliac limb device. Continued improvement in stent-graft design, including branched endografts, will reduce but not eliminate multi-stage procedures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_363", "text": "Standard EVAR involves a surgical cut-down on either the femoral or iliac arteries, with the creation of a 4\u20136\u00a0cm incision. Like many surgical procedures, EVAR has advanced to a more  minimally invasive  technique, by accessing the femoral arteries  percutaneously  In percutaneous EVAR ( PEVAR ), small, sub-centimeter incisions are made over the femoral artery, and endovascular techniques are used to place the device over a wire. Percutaneous EVAR has been systematically compared to the standard EVAR cut-down femoral artery approach. [ 15 ]  Moderate quality evidence suggests that there are no differences in short-term mortality, aneurysm sealing, long and short-term complications, or infections at the wound site. [ 15 ]  Higher quality evidence suggests that there are no differences in post-repair bleeding complications or haematoma between the two approaches. [ 15 ]  The percutaneous approach may have reduced surgical time. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_364", "text": "Fenestrated endovascular aortic/aneurysm repair (FEVAR) is performed in the cases where the aneurysm extends near or involves the visceral vessels (such as juxta-renal, para-renal, thoraco-abdominal aortic aneurysms). A custom-made graft with fenestrations (holes on the graft body to maintain the patency of the visceral arteries) is used for the procedure. When the aneurysm involves the visceral arteries, standard EVAR is  contraindicated  due to the lack of suitable infra-aortic segment for the endograft attachment; FEVAR achieves seal between the stent graft and para-visceral segment and/or more proximal segment while preserving the flow of the visceral arteries. FEVAR has been in use in the United Kingdom for over a decade and early results were published in Jun 2012.\n [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_365", "text": "Thoracoabdominal aortic aneurysms (TAAA) involve the aorta in the chest and abdomen. As such, major branch arteries to the head, arms, spinal cord, intestines, and kidneys may originate from the aneurysm. An endovascular repair of a TAAA is only possible if blood flow to these critical arteries is preserved. Hybrid procedures offer one option, but a more direct approach involves the use of a branched endograft. However, the complex anatomy associated with the supra-aortic vessels is particularly difficult to accommodate with branched endograft devices. [ 17 ]  Dr. Timothy Chuter pioneered this approach, with a completely endovascular solution. After partial deployment of the main body of an endograft, separate endograft limbs are deployed from the main body to each major aortic branch. This procedure is long, technically difficult, and currently only performed in a few centers.\nWhen the aneurysm begins above the renal arteries, neither fenestrated endografts nor \"EndoAnchoring\" of an infrarenal endograft is useful (an open surgical repair may be necessary). Alternatively, a \"branched\" endograft may be used. A branched endograft has graft limbs that branch off of the main portion of the device to directly provide blood flow to the kidneys or the visceral arteries. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_366", "text": "On occasion, there is inadequate length or quality of the proximal or distal aortic neck. In these cases, a fully minimally invasive option is not possible. One solution, however, is a hybrid repair, which combines an open surgical bypass with EVAR or TEVAR. In hybrid procedures, the endograft is positioned over major aortic branches. While such a position would normally cause problems from disruption of blood flow to the covered branches (renal, visceral, or branches to the head or arms), the prior placement of bypass grafts to these critical vessels allowed the deployment of the endograft at a level that would otherwise not be possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_367", "text": "If a patient has calcified or narrow femoral arteries that prohibit the introduction of the endograft transfemorally, an iliac conduit may be used. This is typically a piece of PTFE that is sewn directly to the iliac arteries, which are exposed via an open retroperitoneal approach. The endograft is then introduced into the aorta through the conduit. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_368", "text": "In patients with thoracic aortic disease involving the arch and descending aorta, it is not always possible to perform a completely endovascular repair. This is because head vessels of the aortic arch supplying blood to the brain cannot be covered and for this reason, there is often an inadequate landing zone for stent-graft delivery. A hybrid repair strategy offers a reasonable choice for treating such patients. A commonly used hybrid repair procedure is the \"frozen elephant trunk repair\". [ 20 ]  This technique involves midline sternotomy. The aortic arch is transected and the stent-graft device is delivered in an ante-grade fashion in the descending aorta. The aortic arch is subsequently reconstructed and the proximal portion of the stent-graft device is then directly sutured into the surgical graft. Patients with anomalies of the arch and some disease extension into the descending aorta are often ideal candidates. Studies have reported successful use of hybrid techniques for treating Kommerell diverticulum [ 21 ]  and descending aneurysms in patients with previous coarctation repairs. [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_369", "text": "In addition, hybrid techniques combining both open and endovascular repair are also used in managing emergency complications in the aortic arch, such as retrograde ascending dissection and endoleaks from previous stent grafting of descending aorta. A \"reverse frozen elephant trunk repair\" is shown to be particularly effective. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_370", "text": "The complications of EVAR can be divided into those that are related to the repair procedure and those related to the endograft device. For example, a  myocardial infarction  that occurs immediately after the repair is normally related to the procedure and not the device. By contrast, the development of an endoleak from degeneration of endograft fabric would be a device-related complication. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_371", "text": "Durability and problems such as 'endoleaks' may require careful surveillance and adjuvant procedures to ensure the success of the EVAR or EVAR/hybrid procedure. CT angiography (CTA) imaging has, in particular, made a key contribution to planning, success, durability in this complex area of vascular surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_372", "text": "A major cause of complications in EVAR is the failure of the seal between the proximal, infra-renal aneurysm neck and the endovascular graft. [ 27 ] [ 28 ] [ 29 ]  Risk of this form of failure is especially elevated in adverse or challenging proximal neck anatomies, where this seal could be compromised by unsuitable geometric fit between the graft and vessel wall, as well as instability of the anatomy. [ 30 ] [ 31 ] [ 32 ]  New recent techniques have been introduced to address these risks by utilizing a segment of the supra-renal portion of the aorta to increase the sealing zone, such as with fenestrated EVAR, chimneys and snorkels. [ 33 ]  These techniques may be suitable in certain patients with qualifying factors, e.g., configuration of renal arteries, renal function.  However, these are more complex procedures than standard EVAR and may be subject to further complications. [ 34 ] [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_373", "text": "An approach that directly augments the fixation and sealing between the graft and aorta to mimic the stability of a surgical anastomosis is EndoAnchoring. [ 37 ] [ 38 ]  EndoAnchors are small, helically shaped implants that directly lock the graft to the aortic wall with the goal to prevent complications of the seal, especially in adverse neck anatomies. [ 39 ] [ 40 ]  These EndoAnchors may also be used to treat identified leaks between the graft and proximal neck. [ 41 ] [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_374", "text": "Arterial dissection, contrast-induced kidney failure, thromboembolizaton,  ischemic colitis , groin  hematoma , wound infection, type II endoleaks, myocardial infarction, congestive heart failure, cardiac arrhythmias, respiratory failure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_375", "text": "Endograft migration, aneurysm rupture, graft limb stenosis/kinking, type I/III/IV endoleaks, stent graft thrombosis, or infection. [ 44 ]  Device infection occurs in 1-5% of aortic prosthesis placements and is a life-threatening complication. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_376", "text": "An endoleak is a leak into the aneurysm sac after endovascular repair. Five types of endoleaks exist: [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_377", "text": "Type I and III leaks are considered high-pressure leaks and are more concerning than other leak types. Depending on the aortic anatomy, they may require further intervention to treat. Type II leaks are common and often can be left untreated unless the aneurysm sac continues to expand after EVAR. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_378", "text": "Spinal cord injury is a devastating complication after aortic surgery, specifically for thoracoabdominal aortic aneurysm repair; severe injury could lead to urine and fecal incontinence, paresthesia and even paraplegia. [ 47 ]  The risk varies between studies with two metanalysis demonstrating a pooled incidence of spinal cord injury 2.2% [ 48 ]  and 11%. [ 49 ]  Predictive factors include increasing extent of coverage, hypogastric artery occlusion, prior aortic repair and perioperative hypotension. [ 50 ]  Spinal cord injury related to aortic repair occurs due to impaired blood flow to the spine after coverage of blood vessels, important to the blood circulation of the spine, namely intercostal- and lumbar arteries. [ 51 ]  Neuromonitoring appears to be effective in detecting perioperative spinal cord injury risk during TEVAR. While the incidence of spinal cord injury remains variable, identification of risk factors may guide clinical decisions, particularly in high-risk procedures. [ 52 ]  A few methods exist for potentially reversing spinal cord injury, if it arises, elevated blood pressure, increased oxygenation, blood transfusion and cerebrospinal fluid drainage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_379", "text": "Cerebrospinal fluid drainage is one of the adjunct methods used to reverse spinal cord injury. With increased drainage of spinal fluid, the intrathecal pressure decreases which allows for increase blood perfusion to the spine, possibly reversing the ischemic injury of the spinal tissue due to lessened blood supply. The benefits of this procedure have been established in open aortic repair [ 53 ]  and suggested in endovascular aortic repair. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_380", "text": "As compared to the traditional aortic repair, standard recovery after EVAR is faster with earlier ambulation. However, there is still risk of spinal cord injury early after the procedure. Patients who have undergone EVAR typically spend one night in the hospital to be monitored, although it has been suggested that EVAR can be performed as a same-day procedure. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_381", "text": "Patients are advised to slowly return to normal activity. There are no specific activity restrictions after EVAR, however, patients typically are seen by their surgeon within one month after EVAR to begin post-EVAR surveillance. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_382", "text": "There is limited research looking at patients' experience of recovery after more complex and staged EVAR for thoracoabdominal aortic diseases. One qualitative study found that patients with complex aortic diseases struggle with physical and psychological setbacks, continuing years after their operations. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_383", "text": "Dr.  Juan C. Parodi  introduced the minimally-invasive endovascular aneurysm repair (EVAR) to the world and performed the first successful endovascular repair of an abdominal aortic aneurysm on 7 September 1990 in Buenos Aires on a friend of  Carlos Menem , the then President of Argentina. The first device was simple, according to Parodi: \"It was a graft I designed with expandable ends, the extra-large Palmaz stent, a Teflon sheath with a valve, a wire, and the valvuloplasty balloon, which I took from the cardiologists.\" Parodi's first patient lived for nine years after the procedure and died from pancreatic cancer. [ 56 ] [ 57 ] \nThe first EVAR performed in the United States was in 1992 by Drs.  Frank Veith ,  Michael Marin ,  Juan Parodi  and  Claudio Schonholz  at  Montefiore Medical Center  affiliated with  Albert Einstein College of Medicine . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_384", "text": "The modern endovascular device used to repair abdominal aortic aneurysms, which is bifurcated and modular, was pioneered and first employed by Dr. Timothy Chuter while a fellow at the  University of Rochester . [ 58 ]  The first clinical series of his device was published from Nottingham in 1994. [ 59 ]  The first endovascular repair of a ruptured abdominal aortic aneurysm was also reported from Nottingham in 1994. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_385", "text": "By 2003, four devices were on the market in the United States. [ 61 ]  Each of these devices has since been either abandoned or further refined to improve its characteristics  in vivo ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_386", "text": "Women are known to have smaller aortas on average than men, so are potential candidates for AAA treatment at smaller maximum aneurysm diameters than men. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_387", "text": "As immunosuppressive medications are known to increase the rate of aneurysm growth, transplant candidates are AAA repair candidates at smaller maximum aneurysm diameters than the general population. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_388", "text": "Due to the expense associated with EVAR stent-graft devices and their specificity to human aortic anatomy, EVAR is not used in other animals. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_389", "text": "Endovenous laser treatment  ( ELT ) is a minimally invasive ultrasound-guided technique used for treating  varicose veins  using  laser  energy commonly performed by a  phlebologist ,  interventional radiologist  or  vascular surgeon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_390", "text": "Endovenous laser treatment treats  varicose veins  using an  optical fiber  that is inserted into the vein to be treated, and  laser  light, normally in the  infrared  portion of the  spectrum , [ 1 ]  shines into the interior of the vein. This causes the vein to contract, and the optical fiber is slowly withdrawn. Some minor complications can occur, including  thrombophlebitis ,  pain ,  hematoma ,  edema  and  infection , which can lead to  cellulitis . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_391", "text": "EVLT has the same meaning as ELT, but it is a trademark name owned by Diomed and used as the name for their 910\u00a0nm laser treatment unit for ELT.  [ citation needed ] The 810\u00a0nm laser is the original laser fiber wavelength as pioneered by Dr. Luis Navarro, Dr. Carlos Bone and Dr. Robert Min, at the Vein Treatment Center in New York, New York.  [ citation needed ] Subsequently, various other fibers with different wavelengths have become available. The varying wavelength each aim to maximize local damage to a component of the varicose vein or the  blood  contained in it while minimizing damage to adjacent tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_392", "text": "During the procedure, a  catheter  bearing a laser fiber is inserted under ultrasound guidance into the  great saphenous vein  (GSV) or  small saphenous vein  (SSV) through a small puncture. The catheter is then advanced, also under ultrasound guidance, to the level of the groin or knee crease. Dilute  local anesthesia  is injected around and along the vein (perivascular infiltration) using ultrasound imaging to place the local anesthetic solution around the vein, mostly in a sub-facial location. This technique derives from the tumescent local anesthesia (TLA) method long used and proven safe and effective for some methods of  liposuction . The laser is activated whilst the catheter or laser fiber is slowly withdrawn, resulting in obliteration of the saphenous vein along its entire length. The treatment, which is performed without  sedation , usually takes between 1 and two hours, and the patient walks out under his or her own power. The leg is bandaged and/or placed in a stocking that the patient wears for up to three weeks afterwards."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_393", "text": "Foam  sclerotherapy  or  ambulatory phlebectomy  is often performed at the time of the procedure or within the first 1\u20132 weeks to treat branch varicose veins. However, some physicians do not perform these procedures at the time of the ELT because the varicose veins can improve on their own as a result of reduced reflux from the great saphenous vein."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_394", "text": "Complications of endovenous laser treatment can be categorized as minor, or serious. Minor complications include  bruising  (51%),  hematoma  (2.3%), temporary numbness (3.8%),  phlebitis  (7.4%),  induration  (46.7%), and a sensation of tightness (24.8%). More serious complications include skin  burns  (0.5%),  deep venous thrombosis  (0.4%),  pulmonary embolism  (0.1%), and nerve injury (0.8%). These rates of complications are derived from the Australian MSAC review of all available literature on the procedure. [ 3 ] \n Retinal  damage is a serious but very rare complication (<1%) that can occur during the use of lasers. If the fiber breaks or if the laser is activated when the laser is outside of the body, reflected laser light may cause a focal permanent retinal deficit or \"blind spot\" or  scotoma . The nominal hazard zone (NHZ) [ 4 ]  or space within which the level of direct, scattered, or reflected laser radiation exceeds the maximum permissible exposure (MPE), varies by the wavelength of the laser and is shorter (17 inches) with the newer 1470\u00a0nm laser. Use of appropriate protective eyeware specific to the wavelength laser being used prevents accidental injury. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_395", "text": "A 2005 report from one practice, summarising results of 1,000 limbs treated over a 5-year period with EVLT showed that 98% of the treated vessels at up to 60 months follow-up remained closed, with complications and side effects such as temporary paresthesia and DVTs below 0.5%. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_396", "text": "The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins \"appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins.\" [ 3 ]  It also found in its assessment of available literature, that \"occurrence rates of more severe complications such as DVT,  nerve injury  and  paresthesia , post-operative infections and hematomas, appears to be greater after ligation and stripping than after EVLT\". A study of 516 treated veins over 69 months by Elmore and Lackey reported a success rate of 98.1%. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_397", "text": "Endovenous thermal ablation (EVTA) by radiofrequency or laser is a safe and effective treatment of refluxing great saphenous veins  [ 7 ]  (GSVs) and has replaced traditional high ligation and stripping in official recommendations of various leading Vascular Societies in the United States and the United Kingdom."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_398", "text": "Patients are usually fitted with Class 3 (30-40mmHg) graduated compression stockings and/or bandages for up to 12 hours weeks. Duplex ultrasound is used during follow-up to assess the success of treatment, if there is a need for additional sclerotherapy or any deep vein thrombosis that has formed as an EHIT secondary to procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_399", "text": "In  cardiac surgery  and  vascular surgery ,  external support  (or  external stent ) is a type of scaffold made of metal or plastic material that is inserted over the outside of the  vein   graft  in order to decrease the intermediate and late  vein graft failure  after  bypass surgery  (e.g.  CABG )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_400", "text": "An external support (external stent) should be differentiated from a  stent . An external support is placed on the outside of the  vessel  whereas a stent is inserted into the  lumen  of a vessel. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_401", "text": "Veins are adapted to an environment of low pressure and low flow. In order to bypass the coronary obstruction and restore blood flow, veins are transferred and integrated into the  arterial circulation , where they exposed to high pressure and flow. These new  hemodynamic  conditions cause  intimal hyperplasia  and  atherosclerosis  that cause intermediate and late  vein graft failure . [ 1 ] [ 2 ]  The idea of placing an external support on the vein graft was first suggested in 1963. [ 3 ]  The rational being that it will diminish the circumferential strain of the graft wall, therefore inhibiting intimal hyperplasia and later superimposed atherosclerosis, aiding with the adaptation of the vein toward the arterial environment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_402", "text": "The external scaffold provides a mechanical support for the vein graft, absorbs the high arterial pressure, constrict the vein graft dilatation, reduces lumen irregularities and mitigates intimal hyperplasia formation. As shown both in human  tissue cultures  and  experimental models . [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ]  However, until recently there were a limited number of  clinical studies  that showed less positive results. [ 9 ] [ 10 ] [ 11 ]  It was hypothesized that graft patency rates were lower with external support, because of aggressive over constriction of the vein graft, unsuitable material of the devices and the use of  fibrin glue  that has shown to cause tissue damage,  fibrosis  and intimal hyperplasia. [ 12 ] [ 13 ] [ 14 ]  Lately, more promising results with second generation devices showed that external support can mitigate intimal hyperplasia development, improve vein graft lumen uniformity and improve the flow pattern inside the graft. [ 15 ] [ 16 ] [ 17 ] [ 18 ] \nThese benefits shown to remain for up to five years follow up. [ 19 ] \nIn addition to improving the vein graft failure rates in bypass surgeries, other research studies showed that external support might allow the use of conduits that previously have been considered to be unsuitable for surgery. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_403", "text": "To date the technique is practiced in several cardiac centers in Europe, Israel and South Africa. Further clinical studies are ongoing in Europe and the US on a larger number of patients. [ 22 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_404", "text": "Isolated superior mesenteric artery dissection (ISMAD)  is a rare but potentially life-threatening condition that causes acute abdominal pain. It refers to a dissection that occurs solely in the  superior mesenteric artery  (SMA), typically spontaneously, and does not involve the  aorta . [ 1 ] \nAlthough  aortic dissection  can frequently extend into its peripheral territories, it is rare for these branches to have dissection without main aortic trunk involvement. The SMA is the most common site of dissection among visceral arteries compared to other gastrointestinal arteries. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_405", "text": "ISMAD primarily manifests through a sudden onset of pain, which can vary in location and intensity. [ 2 ]   The nature of the pain and its location can provide clues to the diagnosis of ISMAD. [ 2 ]  The types of pain reported in ISMAD cases include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_406", "text": "ISMAD is more common in males, accounting for 80.6% of cases, and typically occurs in individuals in their fifth decade of life, with a mean age of 55.7 years. [ 2 ]  Other risk factors include smoking and hypertension. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_407", "text": "ISMAD can be associated with isolated arterial dissections and aneurysms, such as those in the celiac and renal arteries, suggesting a systemic component. [ 5 ]  It has been linked to certain vascular diseases like  fibromuscular dysplasia , medial degeneration, and  atherosclerosis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_408", "text": "The structure of the SMA itself can contribute to ISMAD. Certain anatomical variants are more susceptible to shear stress, leading to dissection. This stress occurs when the SMA, lacking mechanical support from the pancreas, bends within the mesenteric root. The anterior wall, the most common site of ISMAD, faces increased stress due to the SMA's convexity after bending. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_409", "text": "Genetics also plays a role in ISMAD. It has been hypothesized that a genetic component exists, as most reported cases are from East Asia. This hypothesis is supported by a familial case of ISMAD from China linked to a chromosomal locus of 5q13\u201314. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_410", "text": "In terms of the diagnosis of ISMAD, the following is done: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_411", "text": "The management of isolated superior mesenteric artery dissection (ISMAD) often involves conservative treatment, which includes blood pressure lowering therapy,  analgesics , and initial bowel rest. [ 4 ]  Periodic follow-ups with  CT angiography  are a part of the conservative treatment approach. Over time, many patients show improvement or no change in their condition as observed through these follow-ups. A small percentage of patients reported mild abdominal discomfort during the follow-up period, but no patient developed recurrent abdominal pain following conservative treatment. Importantly, there was no mortality related to SISMAD. These observations suggest that conservative treatment can be an effective approach for managing patients with SISMAD. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_412", "text": "In cases where conservative treatment is not sufficient, endovascular procedures may be considered. These include stenting/stent-grafting of the true lumen, (coil) embolization of the false lumen/aneurysm, catheter-directed local thrombolysis, percutaneous transluminal angioplasty, and catheter-directed local papaverine infusion at 30 mg/h. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_413", "text": "In related surgical procedures such as Minimally Invasive Pancreaticoduodenectomy (MIPD), various approaches for dissection around the SMA have been reported, including anterior, posterior, right, and left approaches. [ 7 ] While these methods are not specifically used for ISMAD, understanding these surgical techniques could potentially inform future treatment strategies for ISMAD. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_414", "text": "The prognosis for patients with ISMAD who undergo conservative treatment is generally positive. Follow-up studies show that the majority of patients either improve or do not show progression of the condition. This is evidenced by CT angiograms, which often show a decrease in the size of the false lumen, a decrease in the length of the dissection, or complete remodeling of the dissection. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_415", "text": "During the follow-up period, some patients reported mild, nonspecific abdominal discomfort. However, no patient developed recurrent abdominal pain following conservative treatment, and there was no mortality related to ISMAD. These findings further support the effectiveness of conservative treatment for managing patients with ISMAD. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_416", "text": "In cases where conservative treatment is not sufficient, endovascular procedures may be considered. These include stenting/ stent -grafting of the true lumen, (coil) embolization of the false lumen/aneurysm, catheter-directed local thrombolysis, percutaneous transluminal angioplasty, and catheter-directed local papaverine infusion at 30 mg/h. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_417", "text": "MIRA ( Minimally Invasive  Reconstructive  Angiography ) is a  multidisciplinary  and  complementary  method for treating many  chronic diseases . It basically consists in  medically grafting  live rejuvenated  tissue  in the form of  autologous   adipose   adult stem cells  to a damaged organ in order to restore it and improve its function. This method is currently approved by the U.S.  Food and Drug Administration  (FDA)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_418", "text": "The MIRA Procedure is a result of combining efforts from different medical fields developed in the  University of Chicago  in 1992."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_419", "text": "The MIRA Procedure originated as a result of combining medical innovations and was developed as a multidisciplinary technique for applications in a wide range of medical fields. In other words, this procedure was not developed for a specific application, it is a compilation from data and experience retrieved through years of research as well as practice that have been put together to create a new alternative to treat many diseases and other applications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_420", "text": "In 1989 Dr.  Christoph Broelsch  performed the first successful  living donor liver transplantation  in the University of Chicago. [ 1 ]  Nearly two years old Alyssa Smith was the first to receive part of a living\u2019s person liver donated in this case by her mother. [ 2 ]  The remarkable results improved current  prognosis  on patients who required a  liver transplant  but even then there were far from meeting the demand and many hundreds to this date die waiting for a donor. This procedure has also sparked some controversial and legal issues for enticing  organ trafficking  and its practice is currently restricted in some countries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_421", "text": "In 1992, at the University of Chicago Dr.  Fushih Pan  is amongst the first to attempt repairing damaged organ tissue by  tissue grafting , but with little success due to technological limitations for keeping the grafted tissue live and functional. Dr. Fushih Pan later becomes much more involved in the steps that followed in order to develop the MIRA procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_422", "text": "In 1995, the  University of Pennsylvania  caught the first glimpse of  regenerative medicine  after successfully regenerating  cranial bone . [ 3 ]  During the same year these results led to determination pressure of adequate tissue growth in cases with  anophthalmia . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_423", "text": "In 1998 Dr. J. Peter Rubin from the  University of Pittsburgh  developed a basic science research program in the biology of adipose derived stem cells and serves as co-director of the Adipose  Stem Cell  Center at the University of Pittsburgh. [ 5 ]  More recently he has determined the safety on fat derived  stem cells  for breast reconstruction after  mastectomy  as long as there is no evidence of  cancer . [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_424", "text": "In the year 2002 the  UCLA  under direction of Dr. Marc H. Hedrick M.D. [ 8 ]  started research on possible applications of  adult stem cells  generating positive results. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_425", "text": "Opting for research on  adult stem cells  rather than  embryonic stem cells  resulted amidst the  stem cell controversy  that involve diverse ethical concerns and  religious groups , most prominently the  Catholic Church .  Embryonic stem cells  till this day are frowned upon many for the implication of the destruction of  human embryos , yet the progress of adult stem cells has produced more promising results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_426", "text": "After the introduction of the subject of stem cells into the mainstream, it was of utmost importance to keep the public aware of the difference of  embryonic Stem Cells  and adult stem cells. To help clarify the matter, in 2006 the  Pope  of the Catholic Church openly stated the encouragement on research on adult stem cells. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_427", "text": "In 2008, after years of research the University of Pittsburgh and the UCLA come together sharing their progress in order to the develop a viable stem cell treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_428", "text": "Dr. Kotaro Yoshimura was one of the first to implement an alternative to  breast augmentation  by safely grafting fat  stem cells  in 2006. [ 12 ] [ 13 ] [ 14 ] [ 15 ]  In 2009 at the  University of Tokyo  he was able to determine the adequate pressure for grafting ADSC more effectively, paving the road to diverse applications for the future. After this breakthrough the engraftment rate was improved even further thanks to the development of a nanoscale shielding using  biomaterials  approved by the U.S.  Food and Drug Administration  (FDA). With this, Dr. Fushih Pan was able to successfully develop a safe and reliable medical procedure now known as the MIRA Procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_429", "text": "The concept of the MIRA procedure can be considered more off as a  minimally invasive   tissue graft  which function restoring capabilities work under the principles of adult stem cells. The treatments potential use lies in improving patients with chronic diseases such as heart and  liver failure  as well as those with neurodegenerative diseases like  Alzheimer's disease  and  multiple sclerosis . In 2010, the MIRA procedure spawned highly efficient alternatives to some operations in the field of cosmetics. The MIRA Lift is now an alternative for a  face lift  that rejuvenates the face's skin cells in order to produce more  collagen  for better and more natural results. Currently an alternative for  breast augmentation  surgery is also being implemented. All this is done in a  minimally invasive  way that involves almost no  downtime  to the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_430", "text": "The MIRA procedure consists of the following steps:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_431", "text": "The MIRA Procedure has numerous applications for different fields and many more are still in development:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_432", "text": "Clinical applications"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_433", "text": "Cosmetic  applications"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_434", "text": "Medical field:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_435", "text": "Cosmetic field:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_436", "text": "Patients who are not physically adequate to undergo a  liposuction  may not be subject for a MIRA procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_437", "text": "A drawback for the breast augmentation surgery is that it only provides half the extra volume when compared to current  implants ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_438", "text": "Currently the MIRA Procedure is most well known as an alternative to  cosmetic surgery  but has proved to be successful in restoring health to patients with chronic heart disease and cirrhotic liver. Soon enough further research will be employed to develop an adequate treatment for certain types of  cancer  as well as neuro-degenerative diseases with more efficacy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_439", "text": "The MIRA Procedure has proven to be a significant alternative to Embryonic Stem Cell treatments which still are under development. The procedure also has some advantages over Embryonic Stem Cell treatments due to its simplicity and therefore its financial cost."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_440", "text": "Open aortic surgery  ( OAS ), also known as  open aortic repair  ( OAR ), describes a technique whereby an  abdominal ,  thoracic  or  retroperitoneal  surgical incision is used to visualize and control the  aorta  for purposes of treatment, usually by the replacement of the affected segment with a prosthetic  graft . OAS is used to treat  aneurysms  of the  abdominal  and  thoracic  aorta,  aortic dissection ,  acute aortic syndrome , and  aortic ruptures .  Aortobifemoral bypass  is also used to treat  atherosclerotic  disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by  endovascular aneurysm repair  (EVAR) as the most common technique for repairing  abdominal aortic aneurysms  in the United States. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_441", "text": "Depending on the extent of the aorta repaired, an open aortic operation may be called an  Infrarenal aortic repair , a  Thoracic aortic repair , or a  Thoracoabdominal aortic repair . A thoracoabdominal aortic repair is a more extensive operation than either an isolated infrarenal or thoracic aortic repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_442", "text": "OAS is distinct from  aortic valve repair  and  aortic valve replacement , as OAS describes surgery of the aorta, rather than of the heart valves. When the  aortic valve  is diseased in addition to the  ascending aorta , the  Bentall procedure  is used to treat the entire  aortic root . An axillary-bifemoral bypass is another type of  vascular bypass  used to treat aortic pathology, however it is not true open aortic surgery as it reconstructs the flow of blood to the legs from the arm, rather than in the native location of the aorta."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_443", "text": "Open aortic surgery (OAS) is used to treat patients with aortic aneurysms greater than 5.5\u00a0cm in diameter, to treat  aortic rupture  of an  aneurysm  any size, to treat  aortic dissections , and to treat  acute aortic syndrome . It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the  valve-sparing aortic root replacement ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_444", "text": "Prior to the advent of  endovascular aneurysm repair  (EVAR), OAS was the only surgical treatment available for aortic aneurysms. The shift away from open aortic surgery towards endovascular surgery since 2003 has been driven by worse  perioperative mortality  associated with OAS, particularly in patients in relatively frail health. [ 2 ]  Unlike endovascular repair, there are no strict anatomic contra-indications to open repair; Rather, open repair is viewed as the fall back option for patients with unfavorable anatomy for endovascular repair. [ 3 ]   The main drawback of open repair is the larger physiologic demand of the operation, which is associated with increased rates of short term mortality in most studies. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_445", "text": "OAR is still preferred to EVAR at some institutions and by some patients as it may be more durable than EVAR, [ 5 ]  and does not require post-operative surveillance  CT scans ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_446", "text": "Patients younger than 50 years with descending and thoracoabdominal aortic aneurysm have low surgical risks, and open repairs can be performed with excellent short-term and durable long-term results. Open surgical repairs should be considered initially in younger patients requiring descending and thoracoabdominal aortic aneurysm repairs. Heritable thoracic aortic disease (HTAD) warrants closer postoperative surveillance. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_447", "text": "OAS is sometimes required for patients who have previously undergone EVAR but need further treatment, such as for degeneration of the EVAR seal zones leading to continued aneurysm growth. OAS is also sometimes required in cases of EVAR graft infection where the stent graft is removed to treat the infection. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_448", "text": "Open surgery typically involves exposure of the dilated portion of the aorta and insertion of a synthetic ( Dacron  or  Gore-Tex ) graft (tube). Once the graft is sewn into the proximal (toward the patient's head - and more specifically, towards their aortic valve) and distal (toward the patient's foot) portions of the aorta, the aneurysmal sac is closed around the graft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_449", "text": "The aorta and its branching arteries are cross-clamped during open surgery. This can lead to inadequate blood supply to the spinal cord, resulting in  paraplegia , when repairing thoracic aneurysms. A 2004 systematic review and meta analysis found that cerebrospinal fluid drainage (CFSD), when performed in experienced centers, reduces the risk of ischemic spinal cord injury by increasing the perfusion pressure to the spinal cord. [ 8 ]  A 2012 Cochrane systematic review noted that further research regarding the effectiveness of CFSD for preventing a spinal cord injury is required. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_450", "text": "The infrarenal aorta can be approached via a transabdominal midline or paramedian incision, or via a retroperitoneal approach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_451", "text": "The paravisceral and thoracic aorta are approached via a left-sided posteriolateral thoracotomy incision in approximately the 9th intercostal space. [ 10 ]  For a thoracoabdominal aortic aneurysm, this approach can be extended to a median or paramedian abdominal incision to allow access to the iliac arteries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_452", "text": "At medical centers with a high volume of open aortic surgery, the fastest option for open aortic surgery was sequential aortic clamping or \"clamp-and-sew\", whereby the aorta was clamped  proximally  and  distally  to the diseased segment, and a graft sewn into the intervening segment. [ 11 ]  This technique leaves the branches of the aorta un-perfused during the time it takes to sew in the graft, potentially increasing the risk of  ischemia  to the organs which derive their arterial supply from the clamped segment. Critics of this technique advocate intra-operative aortic perfusion. [ 12 ]  In infrarenal aneurysms, the relative tolerance of the lower extremities to ischemia allows surgeons to clamp distally with low risk of ill effect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_453", "text": "A number of techniques exist for maintaining perfusion to the viscera and spinal cord during open thoracoabdominal aortic aneurysm repair, including left heart bypass, balloon perfusion catheter placement in the visceral arteries, selective spinal drainage and cold crystalloid renal perfusion. [ 13 ]  There is limited evidence supporting these techniques. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_454", "text": "In OAS for infra-renal aneurysms, the abdominal aorta is anastomosed preferentially to the main limb of a tube or bifurcated graft in an end-to-end fashion to minimize turbulent flow at the proximal anastomosis. If normal aorta exists superior to the iliac bifurcation, a tube graft can be sewn distally to that normal aorta. If the distal aorta is diseased, a bifurcated graft can be used in an aorto-billiac or aorto-bifemoral configuration. If visceral vessels are involved in the diseased aortic segment, a branched graft can be used with branches sewn directly to visceral vessels, or the visceral vessels can be separately revascularized. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_455", "text": "Because of collateral blood flow from the  superior mesenteric artery  (SMA) via the  marginal artery , the  inferior mesenteric artery  usually does not have to be reimplanted into the aortic graft when performing an open abdominal aortic aneurysm repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_456", "text": "OAS is widely recognized as having higher rates of perioperative morbidity and mortality than endovascular procedures for comparable segments of the aorta. For example, in infrarenal aneurysms, perioperative mortality with endovascular surgery is approximately 0.5%, against 3% with open repair. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_457", "text": "Besides the risk of death, other risks and complications with OAS depend on the segment of aorta involved, and may include renal failure, spinal cord ischemia leading to paralysis, buttock claudication, ischemic colitis, embolization leading to acute limb ischemia, infection, and bleeding. [ 16 ]  Development of spinal cord injury is associated with increased\nperioperative mortality after the complex aortic repair. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_458", "text": "Aortic graft infections occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are  Staphylococcus aureus , and coagulase-negative staphylococci, followed by  Enterobacterales  and uncommon bacteria. In case of gut involvement also fungi may play a role. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive antibiotic therapy. In selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_459", "text": "Recovery time after OAS is substantial. Immediately following surgery, patients can expect to spend 1\u20133 days in the intensive care unit, followed by 4\u201310 days on the hospital ward. After discharge, patients will take 3\u20136 months to fully recover their energy and return to their pre-operative daily activities. [ citation needed ]  However, enhanced recovery after surgery (ERAS) protocols can improve recovery following surgery. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_460", "text": "Open repair for thoracoabdominal aneurysms requires a very large incision that cuts through muscles and sometimes bones making recovery very difficult and painful for the patient. Intraoperative intercostal nerve cryoanalgesia has been used during procedure to help reduce pain after TAAA. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_461", "text": "The history of aortic surgery dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century CE.  Many advancements of OAS have been developed in the past century."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_462", "text": "In 1955, cardiovascular surgeons, Drs.  Michael DeBakey  and  Denton Cooley  performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the Dacron graft, resulting in a revolution for surgeons in the surgical repair of aortic aneurysms. [ 21 ]  DeBakey was first to perform  cardiopulmonary bypass  to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_463", "text": "By the mid-1960s, at  Baylor College of Medicine , DeBakey\u2019s group began performing surgery on thoracoabdominal aortic aneurysms (TAAA), which presented formidable surgical challenges, often fraught with serious complications, such as paraplegia, paraparesis and renal failure. DeBakey prot\u00e9g\u00e9 and vascular Surgeon, E. Stanley Crawford, in particular, began dedicating most of his time to TAAAs.  In 1986, he classified TAAA open surgery cases into four types: [ 22 ]  Extent I, extending from the left subclavian artery to just below the renal artery; Extent II, from the left subclavian to below the renal artery; Extent III, from the sixth intercostal space to below the renal artery; and Extent IV, from the twelfth intercostal space to the iliac bifurcation (i.e. total abdominal)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_464", "text": "In 1992, another classification, Extent V, characterized by  Hazim J. Safi , MD, identified aneurysmal disease extending from the sixth intercostal space to above the renal arteries.  Safi's group used experimental animal models for a prospective study on the use distal aortic perfusion, cerebrospinal fluid drainage, moderate hypothermia and sequential clamping to decrease in the incidence of neurological deficit. In 1994, they presented their experiences, showing that the incidence for Extent I and II dropped from 25% to 5%. [ 23 ]  This marked a new era for protecting the spinal cord, brain, kidneys, heart and lungs during OAS on TAAA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_465", "text": "Postoperative paraplegia and paraparesis have been the scourge of thoracoabdominal aortic repair since the inception of the procedure. [ 24 ]  However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_466", "text": "A  peripheral vascular examination  is a medical examination to discover  signs  of  pathology  in the  peripheral vascular system . It is performed as part of a  physical examination , or when a patient presents with leg pain suggestive of a cardiovascular pathology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_467", "text": "The exam includes several parts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_468", "text": "Position \u2013 patient should be lying in the  supine position  and the bed or examination table should be flat. The patient's hands should remain at their sides with their head resting on a pillow."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_469", "text": "Lighting \u2013 adjusted so that it is ideal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_470", "text": "Draping \u2013 the legs should be exposed, the groin and thigh covered. Drapes are usually placed between the legs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_471", "text": "On inspection the clinician looks for signs of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_472", "text": "The  Perthes test  is a clinical test for assessing the patency of the deep femoral vein prior to varicose vein surgery. [ 1 ]  It is named after German surgeon  Georg Perthes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_473", "text": "The limb is elevated and an elastic bandage is applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only. With the bandage applied the patient is asked to walk for 5 minutes. If deep system is competent, the blood will go through and back to the heart.\nIf the deep system is Blocked(has a thrombus), the patient will feel pain in the leg."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_474", "text": "This test is sometimes referred to as the Delbet-Mocquot test, named after French physicians  Pierre Delbet  and  Pierre Mocquot ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_475", "text": "The test is done by applying a tourniquet at the level of the sapheno-femoral junction to occlude the superficial pathway, and then the patient is asked to move in situ. If the deep veins are occluded, the dilated veins increase in prominence.This is essential before performing a surgery for varicose veins i.e. The Trendelenberg procedure so as to ascertain the patency of deep venous system before removing or ligating the superficial system"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_476", "text": "This is a more objective test as it does not depend on patient's pain threshold."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_477", "text": "This  medical  diagnostic article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_478", "text": "Phlebotomy  is the process of making a puncture in a  vein , usually in the arm, with a  cannula  for the purpose of  drawing blood . [ 1 ]  The procedure itself is known as a  venipuncture , which is also used for  intravenous therapy . A person who performs a phlebotomy is called a  phlebotomist , although most doctors, nurses, and other technicians can also carry out a phlebotomy. [ 2 ]  In contrast,  phlebectomy  is the removal of a vein."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_479", "text": "Phlebotomies that are carried out in the treatment of some  blood disorders  are known as  therapeutic phlebotomies . [ 3 ]  The average volume of whole blood drawn in a therapeutic phlebotomy to an adult is 1 unit (450\u2013500 ml) weekly to once every several months, as needed. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_480", "text": "From  Ancient Greek :  \u03c6\u03bb\u03b5\u03b2\u03bf\u03c4\u03bf\u03bc\u03af\u03b1  ( phlebotomia  \u2013  phleb  'blood vessel, vein' +  tomia  'cutting'), via  Old French :  flebothomie  (modern French  phl\u00e9botomie ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_481", "text": "Phlebotomies are carried out by phlebotomists \u2013 people trained to draw blood mostly from veins for clinical or medical testing, transfusions, donations, or research. Blood is collected primarily by performing  venipunctures , or by using  capillary blood sampling  with [ 5 ]   fingersticks  or a  heel stick  in infants for the collection of minute quantities of blood. [ 6 ]  The duties of a phlebotomist may include interpreting the tests requested, drawing blood into the correct tubes with the proper additives, accurately explaining the procedure to the person and preparing them accordingly, practicing the required forms of  asepsis , practicing standard and  universal precautions , restoring  hemostasis  of the puncture site, giving instructions on post-puncture care, affixing tubes with electronically printed labels, and delivering specimens to a laboratory. [ 7 ]  Some countries, states, or districts require that phlebotomists be licensed or registered. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_482", "text": "A  therapeutic phlebotomy  may be carried out in the treatment of some blood disorders (example:  Hemochromatosis ,  polycythemia vera ,  porphyria cutanea tarda ), and  chronic hives  (in research). [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_483", "text": "In  Australia , there are a number of courses in phlebotomy offered by educational institutions, but training is typically provided on the job. The minimum primary qualification for phlebotomists in Australia is a Certificate III in Pathology Collection (HLT37215) from an approved educational institution. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_484", "text": "In the  UK  there is no requirement for holding a formal qualification or certification prior to becoming a phlebotomist as training is usually provided on the job. The  NHS  offers training with formal certification upon completion. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_485", "text": "Special state certification in the  United States  is required only in four states:  California ,  Washington ,  Nevada , and  Louisiana . A phlebotomist can become nationally certified through many different organizations. However, California currently only accepts national certificates from six agencies. These include the  American Certification Agency  (ACA),  American Medical Technologists  (AMT),  American Society for Clinical Pathology  (ASCP),  National Center for Competency Testing / Multi-skilled Medical Certification Institute  (NCCT/MMCI),  National Credentialing Agency  (NCA), and  National Healthcareer Association  (NHA). [ 12 ]  These and other agencies such as the American Society of Phlebotomy Technicians also certify phlebotomists outside the state of California. To qualify to sit for an examination, candidates must complete a full phlebotomy course and provide documentation of clinical or  laboratory  experience."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_486", "text": "In  South Africa  learnerships to qualify as a Phlebotomy Technician are offered by many public and private educational institutions as well as by private academies owned up by pathology laboratories (such as Ampath Laboratories, Lancet, PathCare) and healthcare service providers (such as  Netcare ,  South African National Blood Service ). Some of the larger retail pharmacy chains offering in-store clinical services (such as Clicks,  Dis-Chem ) also provide training for aspirant phlebotomists. Certification can be obtained from a number of examination and testing institutions. To work as a phlebotomist in South Africa, registration with the  Health Professions Council of South Africa  (HPCSA) is required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_487", "text": "(\"light blue\")"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_488", "text": "(weak calcium chelator/ anticoagulant )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_489", "text": "Plasma separator gel"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_490", "text": "(\"navy\")"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_491", "text": "Fluoride Oxalate"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_492", "text": "Grey, Green, Yellow, Purple"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_493", "text": "1. Grey (nil) tube \n2. Green (TB1 antigen) tube \n3. Yellow (TB2 antigen) tube \n4. Purple (mitogen) tube"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_494", "text": "A phlebotomy draw station is a place where blood is drawn from patients for laboratory testing, transfusions, donations, or research purposes. The blood is typically drawn via  venipuncture  or a  finger stick  by a healthcare professional such as a  phlebotomist ,  nurse , or  medical assistant . [ 21 ] \nThe draw station typically includes a padded chair or a bed for patients prone to fainting during blood draws.\nDraw stations can be found in various settings, such as hospitals, clinics, blood donation centers, and independent laboratories or as part of  patient service centers  (PSC)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_495", "text": "Early phlebotomists used techniques such as  leeches  and incision to extract blood from the body. Bloodletting was used as a therapeutic as well as a prophylactic process, thought to remove toxins from the body and to balance the  humors . While physicians did perform bloodletting, it was a specialty of  barber surgeons , the primary provider of health care to most people in the medieval and early modern eras."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_496", "text": "Polidocanol  is a  local anaesthetic  and  antipruritic  component of  ointments  and bath additives. It relieves itching caused by   eczema  and dry skin. [ 2 ]  It has also been used to treat  varicose veins , [ 3 ]   hemangiomas , and  vascular malformations . [ 4 ]  It is formed by the  ethoxylation  of  dodecanol ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_497", "text": "Polidocanol is also used as a  sclerosant , an  irritant  injected to treat  varicose veins , under the trade names  Asclera ,  Aethoxysklerol [ 5 ]  and  Varithena . [ 6 ]  Polidocanol causes  fibrosis  inside varicose veins, occluding the  lumen  of the vessel, and reducing the appearance of the varicosity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_498", "text": "The FDA has approved polidocanol injections for the treatment of small varicose (less than 1\u00a0mm in diameter) and reticular veins (1 to 3\u00a0mm in diameter). Polidocanol works by damaging the cell lining of  blood vessels , causing them to close and eventually be replaced by other types of tissue. [ 7 ] [ 8 ]  Polidocanol in the form of Varithena injected in the greater saphenous vein can cause the eruption of varicose and spider veins throughout the lower leg. This procedure should be done with caution and with the knowledge that the appearance of the leg may be forever compromised."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_499", "text": "This  drug  article relating to the  cardiovascular system  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_500", "text": "This  dermatologic   drug  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_501", "text": "The  popliteal artery entrapment syndrome  (PAES) is an uncommon  pathology  that occurs when the popliteal artery is compressed by the surrounding popliteal fossa myofascial structures. [ 1 ]  This results in  claudication  and chronic leg  ischemia . This condition mainly occurs more in young athletes than in the elderlies. [ 2 ]  Elderlies, who present with similar symptoms, are more likely to be diagnosed with  peripheral artery disease  with associated  atherosclerosis . [ 2 ]  Patients with PAES mainly present with intermittent feet and calf pain associated with exercises and relieved with rest. [ 3 ]  PAES can be diagnosed with a combination of medical history, physical examination, and advanced imaging modalities such as  duplex ultrasound ,  computer tomography , or  magnetic resonance angiography . Management can range from non-intervention to open surgical decompression with a generally good prognosis. [ 4 ]  Complications of untreated PAES can include stenotic artery degeneration, complete popliteal artery occlusion, distal arterial thromboembolism, or even formation of an  aneurysm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_502", "text": "In 1879, the syndrome was first described in a 64 years old male by Anderson Stuart, a  medical student . [ 1 ]  In 1959, Hamming and Vink first described the management of the PAES in a 12-year-old patient. The patient was treated with  myotomy  of the medial head of the  gastrocnemius muscle  and  concomitant   endarterectomy  of the popliteal artery. They later reported four more cases and claimed that the incidence of this pathology in patients younger than 30 years old with claudication was 40%. Servello was the first to draw attention to diminished distal pulses observed with forced plantar- or dorsiflexion in patients with this syndrome. [ 5 ]  In 1981, Bouhoutsos and Daskalakis reported 45 cases of this syndrome in a population of 20,000 Greek soldiers. [ 6 ]  Over the last few decades, the increasing frequency with which popliteal artery entrapment is reported, strongly suggests greater awareness of the syndrome. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_503", "text": "In the general population, popliteal artery entrapment syndrome (PAES) has an estimated  prevalence  of 0.16%. [ 8 ]  It is most commonly found in young, physically active males. [ 2 ]  In fact, sixty percent of all cases of this syndrome occur in athletically active males under the age of 30. [ 9 ]  The predilection of this syndrome presents in a male to female ratio of 15:1. [ 8 ]  This discrepancy in prevalence may be overestimated due the findings that males are generally found to be more physically active than females or because a large portion of the data is from military hospitals that treat mostly male populations. [ 9 ]  People, who participate in running, soccer, football, basketball, or rugby, are at increased risk. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_504", "text": "Newborns and young children are also at increased PAES risk due to congenital causes. During  embryonic development , the medial head of  gastrocnemius  migrates medially and superiorly. This migration can cause structural abnormalities, such as irregular positioning of the  popliteal artery , and can account for the rare instances of entrapment caused by the  popliteus muscle . [ 9 ]  Less than 3% of all people are born with this anatomical defect that progresses into PAES, and of those who are born with the anatomical defect, the majority never develop  symptoms . [ 10 ]  Bilateral presentation of PAES is found in approximately 30% of cases. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_505", "text": "PAES can be classified as either congenital or functional. [ 3 ]  Analysis of human embryological development has shown that the popliteal artery and the medial head of the gastrocnemius muscle arise at approximately the same time. Because of that, abnormal development of muscle's position in relation to the nearby vessels can result in potential vascular compromise. [ 3 ]  The varying types of PAES can be classified based on aberrant migration and resultant attachments of the medial head of the gastrocnemius muscle. Type VI PAES (functional PAES) describes a subtype that is due to repeated  microtrauma  resulting in the destruction of the internal elastic lamina and damage to the smooth muscles resulting in  fibrosis  and scar formation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_506", "text": "Additionally, a more practical classification system was introduced by Heidelberg et al. [ 12 ]  This system classifies PAES into three main types:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_507", "text": "Patients with PAES are typically healthy young males without previous history of cardiovascular risk factors such as smoking,  hypertension ,  hypercholesterolemia , or  diabetes . [ 13 ]  Typically, patients present with  intermittent claudication  that is worsened with exercise and relieved with rest. [ 3 ]  Associated symptoms include numbness, discoloration, pallor, and coolness in the affected lower extremity. [ 13 ]  Physical examination of suspected PAES may show  hypertrophy  of the calf muscles, as well as diminished, unequal, or absent pulses in the lower extremity upon plantar- or dorsiflexion. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_508", "text": "PAES should be suspected in young healthy male patients with clinical symptoms consistent with compression of the vascular structures and without significant cardiovascular risk factors such as smoking. [ 13 ]  Multiple imaging modalities are used to confirm the diagnosis of PAES. [ 23 ]  Based on a systemic review by Sinha et al,  digital subtraction angiography  (DSA) is the most common imaging used for PAES diagnosis, followed by  ankle\u2013brachial index  (18 percent),  computed tomography angiography  (CTA) (12 percent),  magnetic resonance angiography  (MRA) (12 percent),  duplex ultrasonography  (DU) (10 percent), exercise ankle-brachial index (4 percent), and other modalities (4 percent). [ 23 ]  According to a recent study by Willimas et al, a combination of DU and MRA is far superior in diagnosing PAES. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_509", "text": "Provocative maneuvers can be used to improve visualization of PAES on the imagines. [ 25 ]  The patient is initially positioned supine with the legs straight, and then instructed to forcefully plantar-flex. A plantarflexion force of 0 to 70 percent maximum has been shown to maximize the sensitivity and specificity for PAES diagnosis. [ 25 ]  The DU can be a quick, inexpensive, and noninvasive initial screening for PAES. Flow velocities in the popliteal artery will increase, as the popliteal artery is compressed, which is reflected on the DU. If DU is negative but there is still strong suspicion for PAES, MRA or CTA with provocative maneuvers are needed as follow-up imaging. MRA would demonstrate a focal occlusion or narrowing of the mid-popliteal artery, post-stenotic dilatation, or aneurysm of the distal popliteal artery. If MRA or CTA is [ 13 ]  non-conclusive, DSA may be used as a further option with a high sensitivity (> 97%) for PAES diagnosis. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_510", "text": "Additionally, functional PAES in which the gastrocnemius hypertrophy causes arterial compression during exercise can be best evaluated with dynamic CT. [ 23 ]  For dynamic CT, initial images are taken with the patient still. Further images are taken following a series of provocative maneuvers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_511", "text": "The outcome following the surgery is usually favorable. Successful resolution of PAES occurs in 77 percent of cases. [ 23 ]  Surgical complications include deep vein thrombosis, hematoma, wound infection, or seroma. [ 23 ]  After the surgery, patient is usually monitored using arterial duplex ultrasonography 1, 3, 6, and 12 months, and annually after that. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_512", "text": "Early detection and management of PAES can lead to a favorable outcome. [ 23 ]  However, prolonged compression of popliteal artery can lead to extensive arterial damage and permanent claudication or limb loss. [ 28 ]  Complications of PAES may include: [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_513", "text": "Nonetheless, the course of PAES is often slow and takes time, thus, limbs loss is rarely seen, even in PAES patients. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_514", "text": "A  portacaval shunt ,  portocaval shunt , or  portal-caval shunt  is a surgical procedure where a connection (a  shunt ) is made between the  portal vein  and the  inferior vena cava ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_515", "text": "Under normal circumstances, the portal vein drains blood from the abdomen to the liver. The blood is deoxygenated and carries nutrients and waste products from the intestines, spleen, pancreas, and gallbladder to the liver. [ 1 ]  The deoxyenated blood then exits the liver through the  hepatic vein  and empties into the  inferior vena cava , the vein that carries blood from the lower two-thirds of the body to the heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_516", "text": "The portacaval shunt connects the portal vein to the inferior vena cava, allowing blood to travel directly from the portal vein to the inferior vena cava, bypassing the liver entirely. The shunt is typically used to manage complications of  portal hypertension , such as  upper gastrointestinal bleeding . However, technological advancements have shifted towards minimally invasive methods rather than surgical shunting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_517", "text": "Portal hypertension is commonly seen with liver  cirrhosis  and/or other liver diseases such as  Budd\u2013Chiari syndrome ,  primary biliary cirrhosis  (PBC), and  portal vein thrombosis . [ 2 ]  The purpose of the shunt is to divert blood flow away from the liver, reducing the high pressure in the portal venous system and decreasing the risk of bleeding. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_518", "text": "A  portacaval anastomosis  is analogous in that it diverts circulation; as with shunts and  anastomoses  generally, the terms are often used to refer to either the naturally occurring forms or the surgically created forms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_519", "text": "Portacaval shunts were first developed and performed in the mid-20th century to control bleeding  varicose veins  in cases of portal hypertension. These efforts successfully controlled the bleeding; however, liver failure remained a concern and often worsened after shunt placement. Eventually, selective shunts were introduced, and soon liver transplantation became the definitive surgical solution to treating portal hypertension. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_520", "text": "Over time, less invasive treatments for portal hypertension were developed.  Sclerotherapy , a minimally invasive procedure that uses chemicals to shrink  varicose veins  through  endoscopy , was later enhanced with the introduction of variceal band ligation. Technological advancements also led to pharmacological therapies and interventional radiologic procedures like  transjugular intrahepatic portosystemic shunt  (TIPS), which is now the preferred treatment for managing portal hypertension. [ 5 ]  Portacaval shunting is no longer commonly used as the first line treatment for variceal bleeding due to the increased safety and effectiveness of the newer treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_521", "text": "Portacaval shunting is primarily indicated for uncontrolled upper gastrointestinal bleeding when medical therapy, endoscopic methods, or TIPS are not possible or ineffective. [ 6 ]  Additionally, surgical shunting may also be indicated for patients with a history of splenectomy, splenic vein or hepatic vein thrombosis, a splenorenal shunt, or  ascites , as minimally invasive methods would not be recommended in these cases. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_522", "text": "The purpose of the shunt is to redirect blood flow from the portal venous system into the systemic venous system, which reduces the pressure gradient in the portal venous circulation, thereby lowering the risk of bleeding  varices . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_523", "text": "Several types of shunts connect the portal circulation to the systemic venous circulation. The portacaval shunt specifically connects the portal vein to the inferior vena cava through a direct connection. There are two major types of portacaval shunts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_524", "text": "Both surgical procedures reduce portal venous pressure by diverting blood flow away from the portal venous circulation and into the systemic venous circulation. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_525", "text": "The success rate depends on several factors, including the patient's condition and the severity of the disease. Studies have shown that surgical shunting is highly effective in controlling upper gastrointestinal bleeding. [ 8 ]  The  Child\u2013Pugh score  can be used to help determine the severity and prognosis of patients with severe liver disease. Additionally, factors such as the event's timing, whether an emergent or elective procedure is performed, and the technical success of the surgical procedure can affect the outcomes and prognosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_526", "text": "The primary complication of the procedure is  hepatic encephalopathy  (HE), a cognitive dysfunction caused by the liver's reduced ability to filter toxins from the blood. Signs of symptoms of HE include confusion, disorientation, impaired memory, changes to mood, lethargy, and  asterixis . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_527", "text": "Patients that undergo portacaval shunting may have an increased risk of HE because blood bypasses the liver and allows unfiltered toxins to enter the bloodstream and reach the brain, causing cognitive dysfunction. [ 10 ]  Additionally, increased intestinal absorption of encephalopathogenic substances in combination with the reduced hepatic blood flow may also contribute to the high risk of developing HE. [ 10 ]  Surgical shunts have a higher risk of encephalopathy compared to less invasive measures due to the total redirect of blood flow away from the liver. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_528", "text": "There are general surgical risks, such as bleeding and infection, along with specific complications related to liver function with portacaval shunting. Compared to the less invasive approaches (endoscopy, TIPS), surgical shunts have an increased risk of morbidity and mortality, especially in patients with advanced disease. [ 3 ]  Complications include liver dysfunction due to altered blood flow, shunt thrombosis, and hepatic insufficiency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_529", "text": "Alternatives to surgical portacaval shunts include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_530", "text": "An interventional radiologist typically performs TIPS, which involves placing a stent between the portal vein and hepatic veins to lower blood pressure in the portal circulation. Compared to portacaval shunting, TIPS is less invasive, safer, and is now the preferred option for patients with advanced liver failure or those at high surgical risk. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_531", "text": "Both TIPS and portacaval shunting effectively reduce portal pressure but share the risk of hepatic encephalopathy (HE) due to bypassing the liver's detoxification process. In TIPS, HE symptoms can often be managed by adjusting the stent, whereas portacaval shunting provides a permanent solution without the ability to make such adjustments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_532", "text": "Additionally, portacaval shunting carries significantly higher morbidity and mortality rates, making TIPS the more favorable option in most cases. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_533", "text": "In medical and surgical  therapy ,  revascularization  is the restoration of  perfusion  to a body part or  organ  that has had  ischemia . It is typically accomplished by  surgical  means. [ 1 ]   Vascular bypass  and  angioplasty  are the two primary means of revascularization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_534", "text": "The term derives from the prefix  re- , in this case meaning \"restoration\" and  vasculature , which refers to the circulatory structures of an organ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_535", "text": "It is often combined with \"urgent\" to form urgent vascularization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_536", "text": "Revascularization involves a thorough analysis and  diagnosis  and treatment of the existing diseased vasculature of the affected organ, and can be aided by the use of different imaging modalities such as  magnetic resonance imaging ,  PET scan ,  CT scan , and  X-ray  fluoroscopy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_537", "text": "For  coronary artery disease  (ischemic heart disease),  coronary artery bypass surgery  and  percutaneous coronary intervention  (coronary balloon angioplasty) are the two primary means of revascularization. [ 2 ]  When those cannot be done,  transmyocardial revascularization  or percutaneous myocardial revascularization, done with a laser, may be an option."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_538", "text": "Treatment for  gangrene  often requires revascularization, if possible. [ 3 ]  The surgery is also indicated to treat  ischemic wounds  (inadequate  tissue  perfusion) in some forms of  chronic wounds , such as  diabetic  ulcers. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_539", "text": "Revision Using Distal Inflow  (RUDI) is a surgical treatment for  Dialysis-associated Steal Syndrome . RUDI was first proposed by David J. Minion and colleagues in 2005. In the procedure, the  fistula  is ligated at a location slightly proximal to the anastomosis. A bypass to the venous outflow is then created from a distal arterial source. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_540", "text": "In a review of a three studies on the efficacy of the technique, RUDI was shown to provide good patency (80%-100%) and 100% symptom resolution. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_541", "text": "Sclerotherapy  (the word reflects the Greek  skleros , meaning  hard ) [ 1 ] \nis a procedure used to treat blood vessel malformations ( vascular malformations ) and also malformations of the  lymphatic system .  A medication is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults, sclerotherapy is often used to treat  spider veins , smaller  varicose veins ,  hemorrhoids , [ 2 ]  and  hydroceles . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_542", "text": "Sclerotherapy is one method for the treatment of spider veins, varicose veins (which are also often treated with surgery,  radiofrequency , and  laser ablation ), and venous malformations. In  ultrasound -guided sclerotherapy,  ultrasound  is used to visualize the underlying  vein  so the physician can deliver and monitor the injection. Sclerotherapy often [ quantify ]  takes place under ultrasound guidance after venous abnormalities have been diagnosed with duplex ultrasound. Sclerotherapy under ultrasound guidance and using microfoam sclerosants has been shown [ by whom? ]  to be effective in controlling reflux from the sapheno-femoral and sapheno-popliteal junctions. [ 4 ] [ 5 ]  However, some authors [ which? ]  believe that sclerotherapy is not suitable for veins with reflux from the greater or lesser  saphenous junction , or for veins with axial reflux. [ 2 ]  This is due to the emergence of more effective technologies, including laser ablation and radiofrequency, which have demonstrated superior efficacy to sclerotherapy for treatment of these veins. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_543", "text": "Sclerotherapy has been used in the treatment of spider veins and occasionally varicose veins for over 150 years. Like varicose vein surgery, sclerotherapy techniques have evolved during that time. Modern techniques including ultrasonographic guidance and foam sclerotherapy are the latest developments in this evolution."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_544", "text": "The first reported attempt at sclerotherapy was by D Zollikofer in Switzerland in 1682, who injected an acid into a vein to induce  thrombus  formation. [ 7 ]   Both Debout and Cassaignaic reported success in treating varicose veins by injecting perchlorate of iron in 1853. [ 8 ]  Desgranges in 1854 cured 16 cases of varicose veins by injecting iodine and tannin into the veins. [ 7 ]  This was approximately 12 years after the probable advent of  great saphenous vein   stripping  in 1844 by Madelung. [ 8 ]  However, due to high rates of side-effects with the drugs used at the time, sclerotherapy had been practically abandoned by 1894. [ 9 ]  With the improvements in surgical techniques and  anaesthetics  over that time, stripping became the treatment of choice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_545", "text": "Work continued on alternative sclerosants in the early 20th century. During that time carbolic acid and perchlorate of mercury were tried and whilst these showed some effect in obliterating varicose veins, side-effects also caused them to be abandoned. Prof. Sicard and other French doctors developed the use of sodium carbonate and then sodium salicylate during and after the First World War. [ 9 ]  Quinine was also used with some effect during the early 20th century. At the time of Coppleson's book in 1929, he was advocating the use of sodium salicylate or quinine as the best choices of sclerosant. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_546", "text": "Further work on improving the technique and development of safer more effective sclerosants continued through the 1940s and 1950s. Of particular importance was the development of  sodium tetradecyl sulfate  (STS) in 1946, a product still widely used to this day. George Fegan in the 1960s reported treating over 13,000 patients with sclerotherapy, significantly advancing the technique by focussing on fibrosis of the vein rather than thrombosis, concentrating on controlling significant points of reflux and emphasizing the importance of compression of the treated leg. [ 8 ]  The procedure became medically accepted in mainland Europe during that time. However, it was poorly understood or accepted in England or the United States, a situation that continues to this day amongst some sections of the medical community. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_547", "text": "The next major development in the evolution of sclerotherapy was the advent of  duplex ultrasonography  in the 1980s and its incorporation into the practise of sclerotherapy later that decade. Knight [ 10 ]  was an early advocate of this new procedure and presented it at several conferences in Europe and the United States. Thibault's article [ 11 ]  was the first on this topic to be published in a peer-reviewed journal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_548", "text": "The work of Cabrera [ 12 ]  and Monfreaux [ 13 ]  in utilising foam sclerotherapy along with Tessari's \"3-way tap method\" of foam production [ 14 ]  further revolutionised the treatment of larger varicose veins with sclerotherapy. This has now been further modified by Whiteley and Patel [ 15 ]  to use 3 non-silicone syringes for more long lasting foam."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_549", "text": "Injecting the unwanted veins with a sclerosing solution causes the target vein to immediately shrink, and then dissolve over a period of weeks as the body naturally absorbs the treated vein. The initial \"shrinkage\" is caused by spasm of the muscular layer of the vein wall.  The sclerosing solution damages the vein wall, causing inflammation and gradual scarring (\"sclerosis\") over the following weeks. The sclerosis is caused by an increase in fibroblasts in the cell wall which causes contraction of the vein. The process requires carefully assessing the strength of the sclerosing solution so it is strong enough to cause a clinically significant effect in the target vein without causing excessive damage to surrounding tissues. [ 16 ]  Sclerotherapy is a non-invasive procedure taking only about 10 minutes to perform. The downtime is minimal, in comparison to an invasive varicose vein surgery. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_550", "text": "Sclerotherapy is the \"gold standard\" and is preferred over laser for eliminating large spider veins  telangiectasias . [Telangiectasia is a condition in which broken or widened small blood vessels that sit near the surface of the skin or mucous membranes create visible], and smaller varicose leg veins. [ 18 ]  Unlike a laser, the sclerosing solution additionally closes the  reticular veins  also known as  feeder veins  under the skin that are causing the spider veins to form, thereby making a recurrence of the spider veins in the treated area less likely. Multiple injections of dilute sclerosant are injected into the abnormal surface veins of the involved leg. The patient's leg is then compressed with either stockings or bandages that they wear usually for one week after treatment. [ 19 ]  Patients are also encouraged to walk regularly during that time. It is common practice for the patient to require at least two treatment sessions separated by several weeks to significantly improve the appearance of their leg veins."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_551", "text": "Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the great and small saphenous veins. [ 20 ]  After a map of the patient's varicose veins is created using ultrasound, these veins are injected whilst real-time monitoring of the injections is undertaken, also using ultrasound. The sclerosant can be observed entering the vein, and further injections performed so that all the abnormal veins are treated. Follow-up ultrasound scans are used to confirm closure of the treated veins and any residual varicose veins can be identified and treated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_552", "text": "Foam sclerotherapy [ 21 ]  is a technique that involves injecting  \"foamed sclerosant drugs\" within a blood vessel using a pair of syringes \u2013 one with sclerosant in it and one with gas (originally air). The original Tessari method has now been modified by the Whiteley-Patel modification which uses 3 syringes, all of which are silicone-free. [ 15 ]  The  sclerosant  drugs ( sodium tetradecyl sulfate ,  bleomycin  or  polidocanol ) are mixed with air or a physiological gas ( carbon dioxide ) in a syringe or by using mechanical pumps. This increases the  surface area  of the  drug . The foam sclerosant drug is more efficacious than the liquid one in causing  sclerosis [ 22 ]  (thickening of the vessel wall and sealing off the blood flow), for it does not mix with the blood in the vessel and in fact displaces it, thus avoiding dilution of the drug and causing maximal sclerosant action. It is therefore useful for longer and larger veins. Experts in foam sclerotherapy have created \u201ctooth paste\u201d like thick foam for their injections, which has revolutionized the non-surgical treatment of  varicose veins [ 23 ]  and venous malformations, including   Klippel\u2013Tr\u00e9naunay syndrome . [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_553", "text": "Bleomycin electrosclerotherapy consists of locally delivering the sclerosant bleomycin and applying short high voltage electrical pulses to the area to be treated, resulting in a local and temporary increased permeability of the  cell membranes , increasing the intracellular concentration of bleomycin by a factor of up to several thousand. [ 25 ]  Preclinical studies also indicated that electroporation in combination with bleomycin impaired the barrier function of the  endothelium  by interacting with the organization of the  cytoskeleton  and the integrity of the junctions. This can lead to extravasation, interstitial edema and a desired collapse of the vascular structures. [ 26 ] \nThe procedure has been researched as  electrochemotherapy  of skin tumors since the early 1990s [ 27 ]  and was first used in 2017 for vascular malformations. [ 28 ]  Initial reports indicated that the use of bleomycin in combination with reversible electroporation can potentially enhance the sclerotherapy effect. [ 29 ] [ 30 ]  A retrospective study of 17 patients with venous malformations who did not respond to previous invasive therapies showed an average decrease in lesion volume measured on  MRI  images of 86% with clinical improvement in all patients after an average of 3.7 months and 1.12 sessions per patient, with a reduced dose of bleomycin and a reduced number of sessions compared to standard bleomycin sclerotherapy [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_554", "text": "A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution. [ 4 ]  Padbury and Benveniste [ 5 ]  found that ultrasound guided sclerotherapy was effective in controlling reflux in the small saphenous vein. Barrett et al. found that microfoam ultrasound guided sclerotherapy was \"effective in treating all sizes of varicose veins with high patient satisfaction and improvement in quality of life\". [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_555", "text": "A  Cochrane Collaboration  review of the medical literature concluded that \"the evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins.\" [ 33 ]  A second  Cochrane Collaboration  review comparing surgery to sclerotherapy concluded that sclerotherapy has greater benefits than surgery in the short term but surgery has greater benefits in the longer term. Sclerotherapy was better than surgery in terms of treatment success, complication rate and cost at one year, but surgery was better after five years. However, the evidence was not of very good quality and more research is needed. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_556", "text": "A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux from the sapheno-femoral or sapheno-popliteal junctions. It did not study the relative benefits of surgery and sclerotherapy in varicose veins with junctional reflux. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_557", "text": "The European Consensus Meeting on Foam Sclerotherapy in 2003 concluded that \"Foam sclerotherapy allows a skilled practitioner to treat larger veins including saphenous trunks\". [ 36 ]  A second European Consensus Meeting on Foam Sclerotherapy in 2006 has now been published. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_558", "text": "Complications, while rare, include  venous thromboembolism , visual disturbances,  allergic reaction , [ 38 ]   thrombophlebitis , skin necrosis, and hyperpigmentation or a red treatment area. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_559", "text": "If the sclerosant is injected properly into the vein, there is no damage to the surrounding skin, but if it is injected outside the vein, tissue necrosis and scarring can result. [ 40 ]  Skin necrosis, whilst rare, can be cosmetically \"potentially devastating\",  and may take months to heal. It is very rare when small amounts of dilute (<0.25%) sodium tetradecyl sulfate (STS) is used, but has been seen when higher concentrations (3%) are used. Blanching of the skin often occurs when STS is injected into arterioles (small artery branches). Telangiectatic matting, or the development of tiny red vessels, is unpredictable and usually must be treated with repeat sclerotherapy or laser. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_560", "text": "Most complications occur due to an intense inflammatory reaction to the sclerotherapy agent in the area surrounding the injected vein. In addition, there are systemic complications that are now becoming increasingly understood. These occur when the sclerosant travels through the veins to the heart, lung and brain. A recent report attributed a stroke to foam treatment, [ 42 ]  although this involved the injection of an unusually large amount of foam.\nMore recent reports have shown that bubbles from even a small amount of sclerosant foam injected into the veins quickly appear in the heart, lung and brain. [ 43 ]  The significance of this is not fully understood at this point and large studies show that foam sclerotherapy is safe. [ 44 ]  Sclerotherapy is fully FDA approved in the USA. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_561", "text": "Contraindications include: bed rest, severe systemic diseases, poor patient understanding, needle phobia, short life expectancy, late stage cancer, known allergy to the sclerosing agent, and treatment with  tamoxifen . [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_562", "text": "The   Society for Vascular Surgery  (SVS) an American  academic society  for  vascular surgery . Its mission includes education, research, career development and advocacy. [ 1 ]  The SVS is the national organization for more than 6,000 vascular surgeons and other medical professionals involved in the prevention and cure of  vascular disease . The association was founded in 1947. The SVS is the sponsor organization for the Journal of Vascular Surgery (JVS) and for the national Vascular Annual Meeting (VAM)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_563", "text": "The Society for Vascular Surgery was founded in 1947 as the  Society for Cardiovascular Surgery . The society changed its name to the Society for Vascular Surgery in 1953 to reflect its focus on vascular disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_564", "text": "In the early years of the society, the focus was primarily on the surgical treatment of  arterial occlusive disease . However, over time, the scope of the society's work expanded to include the treatment of all types of vascular disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_565", "text": "The Society for Vascular Surgery is a professional medical society that represents vascular surgeons in the United States and around the world. The society has over 5,500 members, including vascular surgeons, trainees, and allied health professionals. The society is governed by a board of directors, which is made up of elected members of the society."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_566", "text": "The society has several committees that are responsible for various aspects of the society's work, including research, education, advocacy, and quality improvement. The society also has a foundation, the SVS Foundation, which funds research into vascular disease and advocates for improved patient care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_567", "text": "The Society for Vascular Surgery  develops  clinical practice guidelines  for the diagnosis and management of vascular disease. The society's guidelines are developed by expert panels, based on the best available evidence, and are designed to help healthcare providers make informed decisions about the care of patients with vascular disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_568", "text": "The SVS publishes of the Journal of Vascular Surgery and its associated co-journals. In addition, the society also has an active Patient Safety Organization and Vascular Quality Improvement program."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_569", "text": "JVS is a subscription based,  peer reviewed  academic journal published by  Elsevier . It has been in circulation since 1984 and has published several of the most notable academic papers in the field of vascular surgery. [ 2 ]  The journal publishes original research articles, review articles, case reports, and editorials related to the diagnosis, treatment, and prevention of vascular diseases. In 2013, JVS had an impact factor of 2.98. [ 3 ]  In 2014, JVS launched an additional journal, \"JVS: Venous and Lymphatic Disorders\". [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_570", "text": "In addition to the JVS, the SVS also publishes several co-journals:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_571", "text": "The SVS Patient Safety Organization (PSO) was established in 2011 as a response to the growing need for improved patient safety in vascular surgery. The PSO is dedicated to improving patient outcomes and reducing medical errors by collecting and analyzing data on adverse events and near misses in vascular surgery. The PSO provides its members with tools and resources to promote a culture of safety and to reduce the risk of medical errors. The organization also conducts research and provides educational programs focused on patient safety."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_572", "text": "The SVS Vascular Quality Improvement Program (VQI) was established in 2011. The VQI is a national registry that collects and analyzes data on the outcomes of vascular surgeries performed at participating institutions. The registry enables participating institutions to track their own performance and compare it to national benchmarks. The VQI provides feedback to participating institutions to help them improve patient outcomes and reduce the risk of medical errors. In addition, the VQI conducts research and provides educational programs focused on improving the quality of vascular surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_573", "text": "The SVS is governed by a Board of Directors and is supported by a number of committees, task forces, and sections. The Board of Directors is responsible for setting the strategic direction of the society and overseeing its operations. The committees, task forces, and sections are responsible for carrying out specific functions and activities of the society. These include activities such as education, research, advocacy, and quality improvement. The society also has regional chapters and international affiliates that provide additional support to its members."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_574", "text": "The SVS offers educational programs and resources for its members. These include the SVS Vascular Annual Meeting and online educational resources, including webinars, podcasts, and online courses."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_575", "text": "1940s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_576", "text": "1950s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_577", "text": "1960s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_578", "text": "1970s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_579", "text": "1980s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_580", "text": "1990s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_581", "text": "2000's"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_582", "text": "2010's"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_583", "text": "2020s"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_584", "text": "Subclavian steal syndrome (SSS) , also called  subclavian steal steno-occlusive disease , is a medical condition characterized by retrograde (reversed)  blood flow  in the  vertebral artery  or the  internal thoracic artery . This reversal occurs due to  proximal   stenosis  (narrowing) or occlusion of the  subclavian artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_585", "text": "The phenomenon of flow reversal is called  subclavian steal  or  subclavian steal  phenomenon, regardless of whether signs or symptoms are present. [ 1 ]  In this condition, the affected arm may receive blood supply flowing in a retrograde direction down the vertebral artery, potentially compromising the vertebrobasilar circulation. Subclavian steal syndrome is considered more severe than typical  vertebrobasilar insufficiency ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_586", "text": "There are multiple processes that can cause obstruction of the subclavian artery before the vertebral artery, giving opportunity for SSS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_587", "text": "Atherosclerosis  is the most common cause of SSS; [ 2 ]  all atherosclerotic risk factors are risk factors for SSS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_588", "text": "Thoracic outlet syndrome  (TOS) increases the risk for SSS. [ 2 ]  TOS doesn't directly cause SSS, because the site of subclavian artery compression is over the first rib, which is distal to the vertebral artery. TOS has been reported to cause stroke through theorized clot propagation towards the vertebral artery; [ 3 ]  a similar mechanism could explain how TOS causes SSS. Presence of a  cervical rib  is a risk factor for both TOS and SSS. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_589", "text": "Takayasu's arteritis  is a disease causing inflammation of arteries, including the subclavian artery. Inflammation leaves behind dense scar tissue, which can become stenotic and restrict blood flow. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_590", "text": "SSS can be  iatrogenic , meaning a complication or side effect of medical treatment, one example being the obstructive fibrosis or thrombosis resulting from repair of  aortic coarctation . [ 5 ]  Another example is  Blalock\u2013Taussig anastomosis  for treatment of  tetralogy of Fallot . The procedure involves dividing the subclavian artery and reconnecting the proximal portion to the  pulmonary arteries , leaving the vertebral artery as the primary supply to the distal subclavian artery. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_591", "text": "Various congenital vascular malformations cause SSS, examples including aortic coarctation and  interrupted aortic arch . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_592", "text": "Classically, SSS is a consequence of a redundancy in the circulation of the brain [ 8 ] [ 9 ]  and the  flow of blood ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_593", "text": "SSS results when the short low resistance path (along the subclavian artery) becomes a high resistance path (due to narrowing) and blood flows around the narrowing via the arteries that supply the brain (left and right vertebral artery, left and right internal carotid artery).  The blood flow from the brain to the  upper limb  in SSS is considered to be  stolen  as it is blood flow the brain must do without. This is because of collateral vessels. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_594", "text": "As in vertebral-subclavian steal,  coronary -subclavian steal may occur in patients who have received a  coronary artery bypass graft  using the  internal thoracic artery  (ITA), also known as internal mammary artery. [ 10 ]  As a result of this procedure, the distal end of the ITA is diverted to one of the coronary arteries (typically the  LAD ), facilitating blood supply to the  heart . In the setting of increased resistance in the proximal subclavian artery, blood may flow backward away from the heart along the ITA, causing  myocardial ischemia  due to  coronary steal . Vertebral-subclavian and  coronary -subclavian steal can occur concurrently in patients with an ITA  CABG . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_595", "text": "Blood, like  electric current , flows along the path of least  resistance . Resistance is affected by the length and width of a vessel (i.e. a long, narrow vessel has the greatest resistance and a short, wide one the least), but crucially, in the human body, width is generally more limiting than length because of  Poiseuille's Law . Thus, if blood is presented with two paths, a short one that is narrow (with a high overall resistance) and a long one that is wide (with a low overall resistance), it will take the long and wide path (the one with the lower resistance). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_596", "text": "The  blood vessels  supplying the  brain  arise from the  vertebral arteries  and  internal carotid arteries  and are connected to one another by communicating vessels that form a circle (known as the  circle of Willis ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_597", "text": "Normally, blood flows from the  aorta  into the subclavian artery, and then some of that blood leaves via the vertebral artery to supply the brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_598", "text": "In SSS a reduced quantity of blood flows through the proximal subclavian artery.  As a result, blood travels up one of the other blood vessels to the brain (the other vertebral or the carotids), reaches the basilar artery or goes around the cerebral arterial circle and descends via the (contralateral) vertebral artery to the subclavian (with the proximal blockage) and feeds blood to the distal subclavian artery (which supplies the upper limb and shoulder). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_599", "text": "The evaluation for this condition includes: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_600", "text": "Management for this condition includes: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_601", "text": "Blood pressure in toes  can be measured using special equipment, and is often valuable in assessment of severe  peripheral artery disease , in particular in patients with  diabetes  where measurement of  ankle pressure  /  ABPI  is often unreliable (because of local stiffening of arterial wall)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_602", "text": "Feet are often cold and to make sure measurement is not affected by local vasoconstriction, the patient's feet may be pre-warmed in water or by warm air to a skin temperature of around 30 \u00b0C.\nMeasurement is done with the patient lying flat, with feet at heart level, using sphygmomanometry: the big toe is slightly emptied of blood by squeezing, and a small cuff is inflated around the base of the toe. Cuff pressure is then slowly lowered until flow can be detected in the distal part of the toe, e.g. by optical means (photocell), by expansion of the toe as measured with  strain gauge plethysmography , or by visual assessment of color change by an experienced examiner, and the pressure at which this occurs is recorded."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_603", "text": "The toe pressure is usually slightly lower than arm blood pressure, a difference of up to 50mmHg is considered acceptable. Toe pressures below 30 mmHg (in diabetics 50mmHg) are pathological and associated with reduced viability of the tissue and risk of amputation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_604", "text": "Transjugular intrahepatic portosystemic shunt  ( TIPS  or  TIPSS ) is an artificial channel within the  liver  that establishes communication between the inflow  portal vein  and the outflow  hepatic vein . It is used to treat  portal hypertension  (which is often due to  liver cirrhosis ) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding ( esophageal varices ) and the buildup of fluid within the abdomen ( ascites )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_605", "text": "An  interventional radiologist  creates the shunt using an image-guided  endovascular  (via the  blood vessels ) approach, with the  jugular vein  as the usual entry site."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_606", "text": "The procedure was first described by  Josef R\u00f6sch  in 1969 at  Oregon Health and Science University . It was first used in a human patient by Dr. Ronald Colapinto, of the  University of Toronto , in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. R\u00f6ssle, G.M. Richter, G. N\u00f6ldge and J. Palmaz at the  University of Freiburg . [ 1 ]  The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical  portacaval shunt  in that role."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_607", "text": "TIPS is a life-saving procedure in bleeding from esophageal or gastric varices. A randomized study showed that the survival is better if the procedure is done within 72 hours after  bleeding . [ 2 ]  TIPS has shown some promise for people with  hepatorenal syndrome . [ 3 ]  It may also help with  ascites . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_608", "text": "Severe procedural complications during a TIPS procedure, including catastrophic bleeding or direct liver injury, are relatively uncommon. In the hands of an experienced physician, operative mortality is less than 1% [ medical citation needed ] . On the other hand, up to 25% of patients who undergo TIPS will experience transient post-operative  hepatic encephalopathy  caused by increased porto-systemic passage of nitrogen from the gut. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_609", "text": "A less common, but more serious complication, is hepatic ischemia causing acute liver failure. While healthy livers are predominantly oxygenated by portal blood supply, long-standing portal hypertension results in compensatory hypertrophy of and increased reliance on the hepatic artery for oxygenation. Thus, in people with advanced liver disease the shunting of portal blood away from hepatocytes is usually well tolerated. However, in some cases suddenly shunting portal blood flow away from the liver may result in acute liver failure secondary to hepatic ischemia. [ 6 ]  Acute hepatic dysfunction after TIPS may require emergent closure of the shunt. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_610", "text": "A rare but serious complication is persistent TIPS infection, also known as endotipsitis. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_611", "text": "Lastly, the TIPS may become blocked by a blood clot or in-growth of endothelial cells and no longer function. This has been significantly reduced with the use of  polytetrafluoroethylene  (PTFE)\u2013covered stents. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_612", "text": "Portal hypertension, an important consequence of liver disease, results in the development of significant  collateral circulation  between the portal system and systemic venous drainage (porto-caval circulation). Portal venous congestion causes venous blood leaving the stomach and intestines to be diverted along auxiliary routes of lesser resistance in order to drain to systemic circulation. With time, the small vessels that comprise a collateral path for porto-caval circulation become engorged and dilated. These vessels are fragile and often hemorrhage into the GI tract. ( See  esophageal ,  gastric ,  rectal varices ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_613", "text": "A TIPS procedure decreases the effective  vascular resistance  of the liver through the creation of an alternative pathway for portal venous circulation. By creating a shunt from the portal vein to the hepatic vein, this intervention allows portal blood an alternative avenue for draining into systemic circulation. In bypassing the flow-resistant liver, the net result is a reduced  pressure drop  across the liver and a decreased portal venous pressure. Decreased portal venous pressure in turn lessens congestive pressures along veins in the intestine so that future bleeding is less likely to occur.  The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_614", "text": "Transjugular intrahepatic portosystemic shunts are typically placed by an interventional radiologist under  fluoroscopic  guidance. [ 9 ]  Access to the liver is gained, as the name 'transjugular' suggests, via the  internal jugular vein  in the  neck .  Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the  shunt 's placement.  This enables the interventional radiologist to gain access to the patient's  hepatic vein  by traveling from the  superior vena cava  into the  inferior vena cava  and finally the  hepatic vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_615", "text": "Once the catheter is in the hepatic vein, a wedge pressure is obtained to calculate the pressure gradient in the liver. Following this, carbon dioxide is injected to locate the portal vein. Then, a special needle known as a Colapinto is advanced through the liver parenchyma to connect the hepatic vein to the large  portal vein , near the center of the liver.  The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle.  The shunt is completed by placing a special mesh tube known as a  stent  or endograft to maintain the tract between the higher-pressure portal vein and the lower-pressure hepatic vein.  After the procedure, fluoroscopic images are made to show placement. Pressure in the portal vein and inferior vena cava are often measured. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_616", "text": "Varicose veins , also known as  varicoses , are a medical condition in which  superficial veins  become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain,  itching , and  nighttime leg cramps . [ 1 ] [ 2 ] [ 5 ]  These  veins  typically develop in the legs, just under the skin. [ 3 ]  Their complications can include bleeding,  skin ulcers , and  superficial thrombophlebitis . [ 1 ] [ 2 ]   Varices  in the  scrotum  are known as  varicocele , while those around the  anus  are known as  hemorrhoids . [ 1 ]  The physical, social, and psychological effects of varicose veins can lower their bearers'  quality of life . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_617", "text": "Varicose veins have no specific cause. [ 2 ]  Risk factors include  obesity , lack of exercise, leg trauma, and  family history  of the condition. [ 3 ]  They also develop more commonly during  pregnancy . [ 3 ]  Occasionally they result from  chronic venous insufficiency . [ 2 ]  Underlying causes include weak or damaged valves in the veins. [ 1 ]  They are typically diagnosed by examination, including observation by  ultrasound . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_618", "text": "By contrast,  spider veins  affect the  capillaries  and are smaller. [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_619", "text": "Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance. [ 1 ]  Lifestyle changes may include wearing  compression stockings , exercising, elevating the legs, and weight loss. [ 1 ]  Possible medical procedures include  sclerotherapy ,  laser surgery , and  vein stripping . [ 2 ] [ 1 ]  However, recurrence is common following treatment. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_620", "text": "Varicose veins are very common, affecting about 30% of people at some point in their lives. [ 8 ] [ 3 ] [ 9 ]  They become more common with age. [ 3 ]  Women develop varicose veins about twice as often as men. [ 7 ]  Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_621", "text": "People with varicose veins might have a positive  D-dimer  blood test result due to chronic low-level thrombosis within dilated veins ( varices ). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_622", "text": "Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_623", "text": "Varicose veins are more common in women than in men and are linked with  heredity . [ 16 ]  Other related factors are  pregnancy ,  obesity ,  menopause ,  aging , prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles. [ 17 ]  Less commonly, but not exceptionally, varicose veins can be due to other causes, such as  post-phlebitic obstruction  or incontinence, venous and arteriovenous malformations. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_624", "text": "Venous reflux  is a significant cause. Research has also shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux. [ 19 ] [ 20 ]  Both ovarian and internal  iliac vein  reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins. [ 21 ]  In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_625", "text": "There is increasing evidence for the role of incompetent  perforator veins  (or \"perforators\") in the formation of varicose veins. [ 23 ]  and recurrent varicose veins. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_626", "text": "Varicose veins could also be caused by  hyperhomocysteinemia  in the body, which can degrade and inhibit the formation of the three main structural components of the artery:  collagen ,  elastin  and the  proteoglycans .  Homocysteine  permanently degrades  cysteine   disulfide  bridges and  lysine   amino acid  residues in  proteins , gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e.  collagen  or  elastin , or lifelong proteins, i.e.  fibrillin . These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline.  Klippel\u2013Trenaunay syndrome  and  Parkes Weber syndrome  are relevant for  differential diagnosis . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_627", "text": "Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_628", "text": "Clinical tests that may be used include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_629", "text": "Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using  lower limbs venous ultrasonography . The results from a  randomised controlled trial  on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_630", "text": "The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) Classification, developed in 1994 by an international ad hoc committee of the  American Venous Forum , outlines these stages [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_631", "text": "Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic (S) or asymptomatic (A), e.g. C2S. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_632", "text": "Treatment can be either active or conservative."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_633", "text": "Treatment options include surgery,  laser  and   radiofrequency ablation , and ultrasound-guided foam  sclerotherapy . [ 8 ] [ 30 ] [ 31 ]  Newer treatments include  cyanoacrylate  glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_634", "text": "The  National Institute for Health and Clinical Excellence  (NICE) produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins (C2S) and worse should be referred to a vascular service for treatment. [ 33 ]  Conservative treatments such as support stockings should not be used unless treatment was not possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_635", "text": "The symptoms of varicose veins can be controlled to an extent with the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_636", "text": "Stripping consists of removal of all or part the saphenous vein ( great/long  or  lesser/short ) main trunk. The complications include  deep vein thrombosis  (5.3%), [ 37 ]   pulmonary embolism  (0.06%), and wound complications including infection (2.2%). There is evidence for the  great saphenous vein  regrowing after stripping. [ 38 ]  For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease). [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_637", "text": "Other surgical treatments are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_638", "text": "A commonly performed non-surgical treatment for varicose and \"spider leg veins\" is  sclerotherapy , in which medicine called a sclerosant is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are  polidocanol  (POL branded Asclera in the United States, Aethoxysklerol in Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), hypertonic saline,  glycerin  and chromated glycerin. STS (branded Fibrovein in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO 2  or O 2  to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial [ medical citation needed ] , and there is no clear evidence that foams are superior. [ 42 ]  Sclerotherapy has been used in the treatment of varicose veins for over 150 years. [ 15 ]  Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping. [ 43 ] [ 44 ]  Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_639", "text": "There is some evidence that sclerotherapy is a safe and possibly effective treatment option for improving the cosmetic appearance, reducing residual varicose veins, improving the quality of life, and reducing symptoms that may be present due to the varicose veins. [ 42 ]  There is also weak evidence that this treatment option may have a slightly higher risk of deep vein thrombosis. It is not known if sclerotherapy decreases the chance of varicose veins returning (recurrent varicose veins). [ 42 ]  It is also not known which type of substance (liquid or foam) used for the sclerotherapy procedure is more effective and comes with the lowest risk of complications. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_640", "text": "Complications of sclerotherapy are rare, but can include blood clots and ulceration.  Anaphylactic  reactions are \"extraordinarily rare but can be life-threatening,\" and doctors should have resuscitation equipment ready. [ 47 ] [ 48 ]  There has been one reported case of  stroke  after ultrasound-guided sclerotherapy when an unusually large dose of sclerosant foam was injected. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_641", "text": "There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_642", "text": "The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that  endovenous laser treatment /ablation (ELA) for varicose veins \"appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins.\" [ 51 ]  It also found in its assessment of available literature, that \"occurrence rates of more severe complications such as DVT, nerve injury, and paraesthesia, post-operative infections, and haematomas, appears to be greater after ligation and stripping than after EVLT\". Complications for ELA include minor skin burns (0.4%) [ 52 ]  and temporary  paresthesia  (2.1%). The longest study of endovenous laser ablation is 39 months. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_643", "text": "Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery. [ 54 ] [ 55 ]  Myers [ 56 ]  wrote that open surgery for  small saphenous vein  reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. By comparison ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical  phlebitis  and slightly higher rates of  deep vein thrombosis  (0.57%) and  pulmonary embolism  (0.17%). One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_644", "text": "Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency. [ 57 ]  The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.) [ 58 ]  Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities). [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_645", "text": "ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a  general anaesthetic . Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_646", "text": "Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an  ambulatory phlebectomy . The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins. [ 60 ]  Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_647", "text": "Also called medical super glue, medical adhesive is an advanced non-surgical treatment for varicose veins during which a solution is injected into the diseased vein through a small catheter and under the assistance of ultrasound-guided imagery. The \"super glue\" solution is made of cyanoacrylate, aiming at sealing the vein and rerouting the blood flow to other healthy veins. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_648", "text": "Post-treatment, the body will naturally absorb the treated vein which will disappear. Involving only a small incision and no hospital stay, medical super glue has generated great interest within the last years, with a success rate of about 96.8%. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_649", "text": "A follow-up consultation is required after this treatment, just like any other one, in order to re-assess the diseased vein and further treat it if needed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_650", "text": "In the field of varicose veins, the latest medical innovation is high-intensity focused ultrasound therapy ( HIFU ). This method is completely non-invasive and is not necessarily performed in an operating room, unlike existing techniques. This is because the procedure involves treating from outside the body, able to penetrate the skin without damage, to treat the veins in a targeted area. [ 63 ]  This leaves no scars and allows the patient to return to their daily life immediately."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_651", "text": "Varicose veins are most common after age 50. [ 64 ]  It is more prevalent in females. [ 65 ]  There is a hereditary role. It has been seen in smokers, those who have  chronic constipation , and in people with occupations which necessitate long periods of standing such as wait staff, nurses, conductors (musical and bus), stage actors, umpires (cricket, javelin, etc.), the King's guards, lectern orators, security guards, traffic police officers, vendors, surgeons, etc. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_652", "text": "Vascular access steal syndrome  is a  syndrome  caused by  ischemia  (not enough  blood flow ) resulting from a vascular access device (such as an  arteriovenous fistula  or synthetic vascular graft\u2013AV fistula) that was installed to provide access for the inflow and outflow of  blood  during  hemodialysis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_653", "text": "Symptoms are graded by their severity: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_654", "text": "The fistula flow can be restricted through banding, or modulated through surgical revision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_655", "text": "If the above methods fail, the fistula is ligated, and a new fistula is created in a more proximal location in the same limb, or in the contralateral limb."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_656", "text": "DASS occurs in about 1% of AV fistulas and 2.7-8% of  PTFE  grafts. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_657", "text": "Within the  contexts  of nephrology and dialysis, vascular access steal syndrome is also less precisely just called steal syndrome (for short), but in wider contexts that term is ambiguous because it can refer to other steal syndromes, such as  subclavian steal syndrome  or  coronary steal syndrome . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_658", "text": "Venous cutdown  is an emergency procedure in which the vein is exposed surgically and then a  cannula  is inserted into the vein under direct vision. It is used for  venous access  in cases of  trauma , and  hypovolemic shock  when the use of a  peripheral venous catheter  is either difficult or impossible. The  great saphenous vein  is most commonly used. This procedure has fallen out of favor with the development of safer techniques for  central venous catheterization  such as the  Seldinger technique , the modified Seldinger technique, [ 1 ] [ 2 ] [ 3 ]   intraosseous infusion , as well as the use of ultrasound guidance for placement of central venous catheters without using the cutdown technique. [ 4 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_659", "text": "The skin is cleaned, draped, and  anesthetized  if time allows. The greater saphenous vein is identified on the surface above the medial  malleolus , a full-thickness transverse skin incision is made, and 2\u00a0cm of the vein is freed from the surrounding structures. The vessel is tied closed distally, the proximal portion is sliced open (venotomy) and gently dilated, and a cannula is introduced through the venotomy and secured in place with a more proximal ligature around the vein and cannula. An  intravenous  line is connected to the cannula to complete the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_660", "text": "Complications of venous cutdown include  cellulitis ,  hematoma ,  phlebitis , perforation of the posterior wall of the vein,  venous thrombosis  and nerve and arterial transection. This procedure can result in damage to the  saphenous nerve  due to its intimate path with the great saphenous vein, resulting in loss of cutaneous sensation in the medial leg. Over the years, the venous cutdown procedure has become outdated by the introduction and recent prehospital developments of  intraosseous infusion  in trauma/hypovolemic shock patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_661", "text": "Venous stasis , or  venostasis ,  is a condition of slow  blood  flow in the  veins , usually of the legs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_662", "text": "Potential complications of venous stasis are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_663", "text": "Causes [ 2 ]  of venous stasis include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_664", "text": "Ultrasonography-Doppler ultrasound"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_665", "text": "Orthopedic surgery  or  orthopedics  ( alternative spelling   orthopaedics ) is the branch of  surgery  concerned with conditions involving the  musculoskeletal system . [ 1 ]  Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal  trauma ,  spine diseases ,  sports injuries ,  degenerative diseases , infections,  tumors , and  congenital disorders ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_666", "text": "Nicholas Andry  coined the word in French as  orthop\u00e9die , derived from the  Ancient Greek  words  \u1f40\u03c1\u03b8\u03cc\u03c2   orthos  (\"correct\", \"straight\") and  \u03c0\u03b1\u03b9\u03b4\u03af\u03bf\u03bd   paidion  (\"child\"), and published  Orthopedie  (translated as  Orthop\u00e6dia: Or the Art of Correcting and Preventing Deformities in Children [ 2 ] ) in 1741. The word was  assimilated  into English as  orthop\u00e6dics ; the  ligature   \u00e6  was common in that era for  ae  in Greek- and Latin-based words. As the name implies, the discipline was initially developed with attention to children, but the correction of spinal and bone deformities in all stages of life eventually became the cornerstone of orthopedic practice. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_667", "text": "As with many words derived with the  \"\u00e6\" ligature , simplification to either \"ae\" or just \"e\" is common, especially in North America. In the US, the majority of college, university, and residency programmes, and even the  American Academy of Orthopaedic Surgeons , still use the spelling with the digraph  ae , though hospitals usually use the shortened form. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; \"orthopaedics\" is the normal spelling in the UK in line with other fields which retain \"ae\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_668", "text": "Many developments in orthopedic surgery have resulted from experiences during wartime. [ 3 ]  On the battlefields of the  Middle Ages , the injured were treated with bandages soaked in horses' blood, which dried to form a stiff, if unsanitary, splint. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_669", "text": "Originally, the term orthopedics meant the correcting of musculoskeletal deformities in children. [ 4 ]   Nicolas Andry , a professor of medicine at the  University of Paris , coined the term in the first textbook written on the subject in 1741. He advocated the use of exercise, manipulation, and splinting to treat deformities in children. His book was directed towards parents, and while some topics would be familiar to orthopedists today, it also included 'excessive sweating of the palms' and freckles. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_670", "text": "Jean-Andr\u00e9 Venel  established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He developed the club-foot shoe for children born with foot deformities and various methods to treat curvature of the spine. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_671", "text": "Advances made in surgical technique during the 18th century, such as  John Hunter 's research on  tendon  healing and  Percival Pott 's work on  spinal deformity  steadily increased the range of new methods available for effective treatment.  Robert Chessher , a pioneering British orthopedist, invented the double-inclined plane, used to treat lower-body bone fractures, in 1790. [ 6 ]   Antonius Mathijsen , a Dutch military surgeon, invented the  plaster of Paris   cast  in 1851. Until the 1890s, though, orthopedics was still a study limited to the correction of deformity in children. One of the first surgical procedures developed was percutaneous tenotomy. This involved cutting a tendon, originally the Achilles tendon, to help treat deformities alongside bracing and exercises. In the late 1800s and first decades of the 1900s, significant controversy arose about whether orthopedics should include surgical procedures at all. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_672", "text": "Examples of people who aided the development of modern orthopedic surgery were  Hugh Owen Thomas , a surgeon from  Wales , and his nephew,  Robert Jones . [ 7 ]  Thomas became interested in orthopedics and  bone-setting  at a young age, and after establishing his own practice, went on to expand the field into the general treatment of fracture and other musculoskeletal problems. He advocated enforced rest as the best remedy for  fractures  and  tuberculosis , and created the so-called \"Thomas splint\" to stabilize a fractured femur and prevent infection. He is also responsible for numerous other medical innovations that all carry his name: Thomas's collar to treat tuberculosis of the cervical spine, Thomas's maneuvere, an orthopedic investigation for fracture of the hip joint, the  Thomas test , a method of detecting hip deformity by having the patient lying flat in bed, and Thomas's wrench for reducing fractures, as well as an  osteoclast  to break and reset bones. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_673", "text": "Thomas's work was not fully appreciated in his own lifetime. Only during the  First World War  did his techniques come to be used for injured soldiers on the  battlefield . His nephew, Sir Robert Jones, had already made great advances in orthopedics in his position as surgeon-superintendent for the construction of the  Manchester Ship Canal  in 1888. He was responsible for the injured among the 20,000 workers, and he organized the first comprehensive accident service in the world, dividing the 36-mile site into three sections, and establishing a hospital and a string of first-aid posts in each section. He had the medical personnel trained in fracture management. [ 8 ]  He personally managed 3,000 cases and performed 300 operations in his own hospital. This position enabled him to learn new techniques and improve the standard of fracture management. Physicians from around the world came to Jones' clinic to learn his techniques. Along with Alfred Tubby, Jones founded the British Orthopedic Society in 1894."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_674", "text": "During the First World War, Jones served as a  Territorial Army  surgeon. He observed that treatment of fractures both, at the front and in hospitals at home, was inadequate, and his efforts led to the introduction of military orthopedic hospitals. He was appointed Inspector of Military Orthopedics, with responsibility for 30,000 beds. The hospital in Ducane Road,  Hammersmith , became the model for both British and American military orthopedic hospitals. His advocacy of the use of  Thomas splint  for the initial treatment of  femoral  fractures reduced mortality of open fractures of the femur from 87% to less than 8% in the period from 1916 to 1918. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_675", "text": "The use of  intramedullary rods  to treat fractures of the femur and  tibia  was pioneered by  Gerhard K\u00fcntscher  of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during  World War II  and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world.  Traction  was the standard method of treating thigh bone fractures until the late 1970s, though, when the  Harborview Medical Center  group in Seattle popularized intramedullary fixation without opening up the fracture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_676", "text": "The modern total  hip replacement  was pioneered by Sir  John Charnley , expert in  tribology  at  Wrightington Hospital , in England in the 1960s. [ 10 ]  He found that joint surfaces could be replaced by implants cemented to the bone. His design consisted of a  stainless steel , one-piece femoral stem and head, and a  polyethylene  acetabular component, both of which were fixed to the bone using  PMMA  (acrylic)  bone cement . For over two decades, the Charnley low-friction arthroplasty and its derivative designs were the most-used systems in the world. This formed the basis for all modern hip implants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_677", "text": "The  Exeter  hip replacement system (with a slightly different stem geometry) was developed at the same time. Since Charnley, improvements have been continuous in the design and technique of  joint replacement  (arthroplasty) with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_678", "text": "Knee replacements, using similar technology, were started by McIntosh in  rheumatoid arthritis  patients and later by Gunston and Marmor for  osteoarthritis  in the 1970s, developed by  John Insall  in New York using a fixed bearing system, and by Frederick Buechel and Michael Pappas using a mobile bearing system. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_679", "text": "External fixation of fractures was refined by American surgeons during the  Vietnam War , but a major contribution was made by  Gavril Abramovich Ilizarov  in the  USSR . He was sent, without much orthopedic training, to look after injured Russian soldiers in  Siberia  in the 1950s. With no equipment, he was confronted with crippling conditions of unhealed, infected, and misaligned fractures. With the help of the local bicycle shop, he devised ring external  fixators  tensioned like the spokes of a bicycle. With this equipment, he achieved healing, realignment, and  lengthening  to a degree unheard of elsewhere. His  Ilizarov apparatus  is still used today as one of the distraction osteogenesis methods. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_680", "text": "Modern orthopedic surgery and musculoskeletal research have sought to make surgery less invasive and to make implanted components better and more durable. On the other hand, since the emergence of the opioid epidemic, orthopedic surgeons have been identified as one of the highest prescribers of opioid medications. [ 13 ] [ 14 ]  Decreasing prescription of opioids while still providing adequate pain control is a development in orthopedic surgery. [ 14 ] [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_681", "text": "In the United States, orthopedic surgeons have typically completed four years of undergraduate education and four years of medical school and earned either a  Doctor of Medicine  (MD) or  Doctor of Osteopathic Medicine  (DO) degree. Subsequently, these medical school graduates undergo  residency  training in orthopedic surgery. The five-year residency is a categorical orthopedic surgery training."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_682", "text": "Selection for residency training in orthopedic surgery is very competitive. Roughly 700 physicians complete orthopedic residency training per year in the United States. About 10% of current orthopedic surgery residents are women; about 20% are members of minority groups. Around 20,400 actively practicing orthopedic surgeons and residents are in the United States. [ 17 ]  According to the latest Occupational Outlook Handbook (2011\u20132012) published by the  United States Department of Labor , 3\u20134% of all practicing physicians are orthopedic surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_683", "text": "Many orthopedic surgeons elect to do further training, or fellowships, after completing their residency training. Fellowship training in an orthopedic sub-specialty is typically one year in duration (sometimes two) and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_684", "text": "These specialized areas of medicine are not exclusive to orthopedic surgery. For example,  hand surgery  is practiced by some  plastic surgeons , and spine surgery is practiced by most  neurosurgeons . Additionally,   foot and ankle surgery  is also practiced by doctors of  podiatric medicine  (DPM) in the United States. Some  family practice  physicians practice  sports medicine , but their scope of practice is nonoperative."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_685", "text": "After completion of specialty residency or  registrar  training, an orthopedic surgeon is then eligible for board certification by the  American Board of Medical Specialties  or the  American Osteopathic Association Bureau of Osteopathic Specialists . Certification by the American Board of Orthopedic Surgery or the  American Osteopathic Board of Orthopedic Surgery  means that the orthopedic surgeon has met the specified educational, evaluation, and examination requirements of the board. [ 18 ] [ 19 ]  The process requires successful completion of a standardized written examination followed by an oral examination focused on the surgeon's clinical and surgical performance over a 6-month period. In Canada, the certifying organization is the  Royal College of Physicians and Surgeons of Canada ; in Australia and New Zealand, it is the  Royal Australasian College of Surgeons ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_686", "text": "In the United States, specialists in hand surgery and orthopedic sports medicine may obtain a certificate of added qualifications  in addition to their board primary certification by successfully completing a separate standardized examination. No additional certification process exists for the other subspecialties."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_687", "text": "According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are: [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_688", "text": "A typical schedule for a practicing orthopedic surgeon involves 50\u201355 hours of work per week divided among clinic, surgery, various administrative duties, and possibly teaching and/or research if in an academic setting. According to the  American Association of Medical Colleges  in 2021, the average work week of an orthopedic surgeon was 57 hours. [ 21 ] [ 22 ]  This is a very low estimation however, as research derived from a 2013 survey of orthopedic surgeons who self identified as \"highly successful\" due to their prominent positions in the field indicated average work weeks of 70 hours or more. [ 23 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_689", "text": "The use of arthroscopic techniques has been particularly important for injured patients.  Arthroscopy  was pioneered in the early 1950s by  Masaki Watanabe  of Japan to perform minimally invasive cartilage surgery and reconstructions of torn ligaments. Arthroscopy allows patients to recover from the surgery in a matter of days, rather than the weeks to months required by conventional, \"open\" surgery; it is a very popular technique. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today, and is often combined with meniscectomy or chondroplasty. The majority of upper-extremity outpatient orthopedic procedures are now performed arthroscopically. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_690", "text": "Arthroplasty is an orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by  osteotomy  or some other procedure. [ 25 ]  It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis ( rheumasurgery ) or some other type of trauma. [ 25 ]  As well as the standard total knee replacement surgery, the unicompartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, may be performed, [ 25 ]  but it bears a significant risk of revision surgery. [ 26 ]  Joint replacements are used for other joints, most commonly the  hip [ 27 ]  or  shoulder . [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_691", "text": "A post-surgical concern with joint replacements is wear of the bearing surfaces of components. [ 29 ]  This can lead to damage to the surrounding bone and contribute to eventual failure of the implant. [ 29 ]  The plastic chosen is usually ultra-high-molecular-weight  polyethylene , which can also be altered in ways that may improve wear characteristics. [ 29 ]  The risk of revision surgery has also been shown to be associated with surgeon volume. [ 28 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_692", "text": "Between 2001 and 2016, the prevalence of musculoskeletal procedures drastically increased in the U.S, from 17.9% to 24.2% of all operating-room (OR) procedures performed during hospital stays. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_693", "text": "In a study of hospitalizations in the United States in 2012, spine and joint procedures were common among all age groups except infants. Spinal fusion was one of the five most common OR procedures performed in every age group except infants younger than 1 year and adults 85 years and older. Laminectomy was common among adults aged 18\u201384 years. Knee arthroplasty and hip replacement were in the top five OR procedures for adults aged 45 years and older. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_694", "text": "[ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_695", "text": "Artificial ligaments  are devices used to replace damaged  ligaments . Today, the most common use of artificial ligaments is in  anterior cruciate ligament reconstruction . [ 1 ]  Although  autotransplantation  remains the most common method of ligament reconstruction, numerous materials and structures were developed to optimize the artificial ligament since its creation in the  World War I  era. [ 2 ]  Many modern artificial ligaments are made of synthetic polymers, such as  polyethylene terephthalate . [ 3 ]  Various coatings have been added to improve the biocompatibility of the synthetic polymers. [ 3 ]  Early artificial ligaments developed in the 1980s were ineffective due to material deterioration. [ 4 ]  Currently, the Ligament Advanced Reinforcement System (LARS) artificial ligament has been utilized extensively in clinical applications. [ 5 ]   Tissue engineering  is a growing area of research which aims to regenerate and restore ligament function. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_696", "text": "Artificial ligament research began in the  World War I  era. [ 2 ]  In the first documented case of an artificial ligament in 1914, Dr. Corner utilized a piece of silver filament as synthetic graft to reconstruct a ruptured  anterior cruciate ligament  ( ACL ). [ 2 ]  A ligament made of silk was used to replace an ACL in 1918. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_697", "text": "In the early 1980s, technological progress in chemistry and materials science promoted the development of medically suitable materials. Doctors utilized these synthetic materials in clinical applications. The  Food and Drug Administration  (FDA) approved an artificial ligament made of  Gore-Tex  for use in ACL reconstruction in 1986. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_698", "text": "The design of artificial ligaments in the 1980s consisted of two major parts: a relatively stiff cable or tape, and silicone rubber cylinders on one or both ends. [ 2 ]  The cable or tape was usually made of  polyethylene ,  nylon  or  carbon fiber . The  silicone rubber  cylinder varied in size to fit different sized patients. [ 2 ] [ 7 ] [ 1 ]  Theoretically, the flexibility of the  silicone rubber  would allow some deformation under relatively low loads, and the artificial ligament would stiffen to maintain its shape under higher loads. [ 7 ] [ 1 ]  Practically, this design never achieved its goal to mimic the property of a natural ligament. [ 8 ]  The mechanical performance of the artificial ligaments was inadequate for widespread clinical application. In the long term, performance loss, complications, and failure occurred. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_699", "text": "Material deterioration contributed to the ineffectiveness of early artificial ligaments. [ 4 ]  Issues would occur in the months and years following treatment. [ 2 ] [ 4 ]  J.E. Paulos indicated in a report about  Gore-Tex  usage in  ACL  reconstruction: \"Early results of the  Gore-Tex  prosthesis used for  ACL  reconstruction showed low rates of failure. Unfortunately, with extended follow-up, our rate of complications continues to increase. Mechanical failure, effusions, and infections continue to occur\". [ 2 ]  At the time, the materials used in artificial ligaments could not sustain adequate mechanical performance. [ 2 ] [ 4 ]  For many of these materials, their mechanical performance diminished in the long-term. [ 1 ] [ 8 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_700", "text": "The primary usage of modern artificial ligaments is in  anterior cruciate ligament reconstruction . Many artificial ligaments seek to mimic or exceed the performance of the native  ACL . [ 5 ]  The mechanical performance of an artificial ligament can be characterized by  abrasion  resistance, withstanding flexural and rotational  fatigue , [ 2 ]  and preventing graft slippage or rupture. [ 9 ]  Biocompatibility is important to the performance of the artificial ligament in vivo. [ 3 ]  Biocompatibility is related to new tissue ingrowth, [ 10 ]  fibroblast migration,  osseointegration  of bone, reduction of  inflammation , preventing scar tissue infiltration, and improving hydrophilicity. [ 3 ]  Tissue ingrowth and fibroblast migration have been shown to improve the mechanical strength of the artificial ligament, [ 10 ]  and osseointegration with the surrounding bone can reduce the likelihood of graft slippage. [ 9 ]  Many artificial ligaments are designed to minimize inflammation and scar tissue infiltration because they can hinder the mechanical strength and can cause graft rupture. [ 3 ]  Artificial ligament design strives to improve hydrophilicity because hydrophobicity can trigger the host's natural response to foreign bodies. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_701", "text": "The Ligament Advanced Reinforcement (LARS) is a leading artificial ligament in ACL repair surgery. They are made of  polyethylene terephthalate  (PET). [ 3 ]  They consist of an intraosseous and an intra-articular portion. The intraosseous section consists of longitudinal fibers bounded by a knitted transverse structure. This knitted structure can help prevent deformation and abrasion. [ 5 ] [ 11 ]  The intra-articular portion is made of longitudinal fibers pretwisted at a 90\u00a0degree angle. This section is designed to resist fatigue and promote tissue ingrowth. [ 5 ]  Leeds Keio ligaments consist of a  polyester  mesh structure. It seeks to mimic the mechanical properties of the native ACL. The porous nature of the ligament can promote tissue ingrowth which has been shown to improve mechanical properties. [ 5 ]  The PGA Dacron artificial graft consists of 75% braided biodegradable  polyglycolic acid  and 25% permanent  Dacron  thread. [ 11 ]  The Kennedy LAD artificial ligament is made of  polypropylene  ribbons. It is designed to promote tissue ingrowth and the progressive transfer of load onto the new ligament. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_702", "text": "The native ACL of a human has a  tensile strength  on the order of kilonewtons, [ 3 ]  and an elongation at failure of approximately 10%. [ 10 ]  The mechanical properties of the native ACL vary throughout the human population. The strength of a child's ACL tends to be greater than that of an adult. [ 10 ]  PGA Dacron artificial ligaments have an ultimate tensile strength near 3500 N and a mean ultimate elongation of approximately 20%. [ 10 ]  Kennedy LAD ligaments have a tensile strength at failure of approximately 1500 N and an approximate stiffness of 50 N/mm. [ 10 ]  Leeds-Keio artificial ligaments have an ultimate tensile strength near 2000 N and a stiffness around 250 N/mm after tissue ingrowth. [ 10 ]  LARS artificial ligaments have varying mechanical properties depending on the amount of fibers used. A higher gauged ligament will have a greater tensile strength. During testing, a 60 gauge LARS ligament exhibited an ultimate tensile strength of 2500 N while a 120 gauge ligament exhibited a tensile strength of 5600 N. [ 5 ] [ 12 ]  The ingrown tissue has been shown to improve viscoelastic properties and reduce friction. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_703", "text": "Coatings have been added to artificial ligaments to improve their biocompatibility. 58S bioglass and  hydroxyapatite  coatings have been shown to improve osseointegration and cellular activity in vitro and in animal studies [ 3 ]  when deposited onto PET ligaments using the soaking method. [ 2 ] [ 3 ]  Hydroxypropyl cellulose surface treatments have been shown to improve osseointegration for PET ligaments in animal studies. [ 2 ]  Uncoated PET is hydrophobic, so coatings are designed to improve hydrophilicity. [ 3 ]   Hyaluronic acid  coatings can reduce hydrophobicity and have been shown to reduce scar tissue formation and inflammation in vivo. [ 3 ]  Hyaluronic acid and  chitosan  composite coatings can be deposited onto artificial ligament surfaces by the layer-by-layer technique, and they have been shown to enhance new bone formation at the ligament interface in mice. [ 9 ]  The chitosan is used to reduce hydrophobicity and improve osseointegration and mineral deposition, while the hyaluronic acid promotes cell differentiation and growth. [ 9 ]   Poly(sodium styrene sulfonate)  coatings have been shown in animal studies to improve knee functionality and mimicry of the native ACL. [ 2 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_704", "text": "The  anterior cruciate ligament  (ACL) is a frequently injured human body structure that may cause secondary damages to the knees, such as meniscal tears and articular cartilage degeneration, without medical treatment.  ACL reconstruction  is a commonly practiced technique for ACL injury, conducted on 30% of patients, which manages to restore stability to the knee structure. [ 2 ] [ 14 ]  Traditional ACL reconstructions uses autografts or allografts which demand a long rehabilitation time and in most cases, develop donor morbidity in the long term. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_705", "text": "The early interests in artificial ligaments led to the implementation of non-human tissue, such as Proplast ligaments made of  Teflon  and carbon fibers and Polyflex made of  polypropylene . [ 10 ] [ 15 ]  The results demonstrated poor resistance to torsion forces. [ 11 ]  Approved by FDA in 1986 and adopted in clinics later,  Gore-Tex  cruciate ligament prosthesis demonstrated low rates of mechanical failure but high rates of rupture in follow-up. [ 16 ]  Gore-Tex was then abandoned in ACL surgery and  Leeds-Keio  (LK) ligament was then adopted. In the later long term follow-up research, LK ligament demonstrated promising performance at first but still showed low stability rates in 2 years and increased degenerative changes compared with their opposite joint in one decade. [ 17 ] [ 18 ]  In the 21st century, the  Ligament Advanced Reinforcement  (LARS) ligament became the most popular artificial ligament on the market.  LARS ligaments not only provide satisfactory outcomes initially but also do not perform differently in at least 2 years. [ 19 ]  LARS ligaments demonstrate higher stability and lower morbidity rate compared to autograft in short-term research and in a 9-year study, LARS ligament showed a 100% survival rate. [ 5 ]  Synthetic ACL grafts always develop creep, fatigue and failure so the demand for synthetic grafts with sufficient supply, satisfactory mechanical properties, and low morbidity rate is essentially high. [ 5 ]  Currently, the LARS ligament is the most comparable to both autografts and other synthetic grafts. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_706", "text": "Complications that commonly occur in the artificial ligaments after the first ten years are breakage, wear debris, synovitis, recurrent instability, osteolysis and chronic effusions. [ 10 ]  Complications do not commonly surface right after the surgery or after a relatively short term, and in a few cases, start to show up after the first ten years. Follow-up research is required to study the performance of certain synthetic materials for artificial ligament and to monitor the health of patients. [ 10 ]  Rupture rates are usually recorded in 2 to 5 years. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_707", "text": "While the future of artificial ligaments is unknown, leading researchers in  tissue engineering  aim to regenerate and repair the ligament to restore normal function. [ 2 ] \u00a0 ACL tissue engineering will be based on the healing of the  medial collateral ligament  (MCL), since the ACL does not heal naturally. [ 2 ]  \u00a0A seed cell will be used in tissue engineering for the repair of ACL ligaments. The seed cell must have qualifications such as: easily available, potent to proliferate, and efficient in elaborating a mature extracellular matrix.\u00a0 Stem cells such as bone marrow-derived  mesenchymal stem cells , adipose-derived stem cells, perivascular stem cells, and human foreskin  fibroblasts  are commonly used in tissue engineering. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_708", "text": "Bone malrotation  refers to the situation that results when a  bone  heals out of rotational alignment from another bone, or part of bone. It often occurs as the result of a  surgical  complication after a  fracture  where  intramedullary nailing (IMN)  occurs, [ 1 ]  especially in the femur and tibial bones, but can also occur genetically at birth. The severity of this complication is often neglected due to its complexity to detect and treat, [ 1 ]  yet if left untreated, bone malrotation can significantly impact regular bodily functioning, and even lead to severe  arthritis . Detection throughout history has become more advanced and accurate, ranging from clinical assessment to  ultrasounds  to CT ( computed tomography ) scans. Treatment can include an  osteotomy , a major surgical procedure where bones are cut and realigned correctly, or compensatory methods, where individuals learn to externally or internally rotate their limb to compensate for the rotation. Further research is currently being examined in this area to reduce occurrences of malrotation, including detailed computer navigation to improve visual accuracy during surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_709", "text": "Bone malrotation predominantly occurs after an injury where a bone is fractured, however malrotation can genetically occur during  foetal development . It usually occurs during a surgery which involves  intramedullary nailing , which is the insertion of metal rods and nails to stabilise bones. Nailing is used as it requires minimal surgical dissection, less disruption of the fracture  hematoma  and allows faster functionality to a patient post-surgery. [ 1 ] [ 3 ]  However, due to the semi-closed nature of IM, it is impossible to correct under direct vision, so there is less rotational control compared to traditional open methods such as plate fixation. [ 3 ]  As a result, in many cases of intramedullary nailing, the bone is misaligned which causes malrotated regrowth. This torsional error is a major problem for femoral and tibial fractures, and occurs in 17 to 35% of patients who receive these surgeries, [ 4 ]  and up to 40% of femur fracture patients. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_710", "text": "Femoral malrotation is the most significant bone malrotation issue, and these errors cause cosmetic problems but can also cause drastic physical problems. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_711", "text": "Historically, bone malrotation occurred due to a lack of adequate treatment measures, where fixation methods such as  traction ,  casting  and non-locked nails provided poor torsional stability. Currently, the utilisation of locked intramedullary nailing, has reduced the occurrence of rotational malalignment during fracture healing, yet femoral malrotation continues to remain very prevalent due to surgeon's inability to reliably restore the pre-injury alignment during operation. [ 1 ]  A high attention to detail is necessary intra-operatively to avoid this complication when locking the intramedullary device. [ 5 ]  The utilisation of both radiological and clinical assessment techniques to compare with an injured limb would also help prevent bone malrotation, however these can be difficult and inexact methods of assessment, which is why complications are so common. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_712", "text": "It is difficult to assess and diagnose the rotational malalignment of a bone after an operation, and many methodologies have been developed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_713", "text": "Clinical assessment and observation  is one methodology, however it is unreliable, and can lead to complications. For femoral or tibial malrotation, many surgeons use the patient's ankle or patella to symmetrically align them with the injured side or to the floor but this method does not consider the position of the proximal fragment and could be moved during reduction attempts. [ 5 ]  In order to measure femoral malalignment, many doctors will compare the internal and external rotation of both hips, while the patient is supine or prone, and a change in a patient's range of movement indicates malrotation. However, while clinical assessment can indicate the direction of malrotation, it often reports inaccurate measurements of the degree of malalignment, so it is unreliable in determining the potential impacts and necessary treatment methods. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_714", "text": "Another diagnosis methodology sometimes utilised are  radiographs ; however, they are unreliable as they require difficult patient positioning to quantify the rotational deformity. [ 5 ]   This difficulty is due to a patient's restriction in movement, as they may exhibit post-traumatic deformities and severe pain. To determine the level of femoral malrotation, with this method, two radiographs of the pelvis and upper legs must be made. Firstly, an anteroposterior (AP) perspective which shows the degree of difference between the femoral neck and femur, and another view where the hips and knees are both flexed to a right angle, which determines antetorsion. Both of these radiographs are utilised to calculate the angle of anteversion of the femoral neck. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_715", "text": "Ultrasounds  can also be used to measure bone malrotation, and are considered highly reliable. The main issue with utilising ultrasound measurement is that it relies largely on the skills of an ultrasound technician, and consequently is not widely used. When measuring femoral malrotation with ultrasounds, a patient's thighs are fixed symmetrically while the degree of rotation of the femoral shaft is measured. This methodology requires exact positioning of a patient to correctly measure any deformity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_716", "text": "MRI scans  can be utilised and are proven to be reliable and effective at determining malrotation of bones. However, they are not as readily available as CT scanners, and are also time consuming and very expensive. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_717", "text": "The standard bone malrotation detection practice utilised are  computed tomography scans , which are able to exactly quantify the amount of rotational malalignment. [ 5 ]  It is also considered highly reliable and utilised because of its reproducibility. For femoral malrotation, the scan involves doctors measuring the angle between a line through the axis of the femoral neck and a line tangential to the femoral condyles. The angle difference between the uninjured and injured sides determines the degree of malrotation.  An increase in the anteversion of the femoral neck of the injured side denotes internal rotation, and a decrease means external rotation has occurred. Another advantage of CT scans is that patient positioning does not impact the measurement accuracy of femoral torsion, which is unlike radiographs and ultrasounds.  However, inaccurate measurements of malrotation can still occur in CT scans, but are mostly related difficulty in drawing clear and accurate lines along the femoral neck within the image. To avoid this inaccuracy, there needs to be improved accuracy of the line drawn, and this can be fixed by the utilisation of multi-image superimposed projection of the CT images so a more accurate measurement can be drawn. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_718", "text": "Whilst malrotation of a bone can be tolerated for most cases, it can still cause severe impacts on functional outcome for some patients. Whilst tibial fractures are the most common long bone fractures, it is malrotation of the femur which can cause the most significant impacts on regular functioning. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_719", "text": "If untreated, femoral malrotation can cause considerable gait disturbance and abnormal hip joint pressures. [ 2 ]  Malrotation of the femur in the setting of a mid-shaft fracture has an impact on the axis of the entire leg, which shifts the centre of force in the knee away from its neutral position. Consequently, femoral malrotation has significant impacts on the mechanical axis and force vectors within the knee. This can cause pain in the hip and knee, and patients may be limited in their movement, which can impair their function, especially in physically demanding activities such as walking up stairs and running. [ 3 ]  This can impact a person's satisfaction in life, as they may be physically unable to do things they want and need to, such as for laborious work, leisure activities, or raising a family, which can have significant impacts on their psychological health. Femoral malrotation can also cause an abnormally rotated foot, as the angle of a person's foot is directly related to the angle of the femur. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_720", "text": "Another significant long term consequence of femoral malrotation if untreated is  degenerative arthritis  of the hip and knee. [ 3 ]  This joint arthrosis occurs as there is a proven correlation between rotational error, axis deviation and  arthrosis  of the knee and hip joints. However, the severity of the arthrosis is dependent on the percentage of malrotation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_721", "text": "Whilst most malrotation problems occurred during surgery, patients with 10\u00b0 or less difference of malrotation compared with the uninjured side rarely complained of any issues. [ 8 ]  However, patients with differences greater than 15\u00b0 found noticeable issues, and above 30\u00b0 malrotation difference resulted in serious complaints. [ 5 ]  External femoral malrotation is usually much better tolerated than internal malrotation. [ 1 ]  However, older studies have found that external rotational deformities are more poorly tolerated, [ 9 ]  which shows the need for more research in this area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_722", "text": "There are two main treatment methods; corrective surgery to fix the malrotation, or compensatory methods where patients learn to compensate for any malrotation when walking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_723", "text": "Many people with bone malrotation, such as femoral malrotation are able to functionally tolerate and learn  compensatory methods , such as externally or internally adjusting their limb. Patients will compensate for even considerable rotational malalignment when they are active.  However, femoral malrotation is more difficult to compensate for and maintain with non-operative treatment methods. [ 5 ]  Patients with femoral malrotation of less than 15 degrees give less complaints than those with higher amounts of malalignment, yet many patients are able to tolerate the deformity well. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_724", "text": "In extreme cases, the malalignment can be treated by means of a derotational  osteotomy  which is a major surgical procedure. [ 3 ]  It can be conducted around the existing intramedullary fixtures, but it usually requires a subtrochanteric osteotomy, which is an invasive surgical approach where bone is cut and realigned. As this is a major procedure, it is beneficial if discovered early, before callus has set, and consequently, patients should be assessed for malrotation in the early post-operative period and a CT scan should occur if abnormalities are found. [ 5 ]  Correct measurement of bone malalignment with a CT scan is vital when considering an osteotomies in fixing rotational deformities, as torsional differences below 15 degrees are often easily compensated for with non surgical treatment. [ 3 ]  Revision surgery should be avoided, if not necessary, as implementing femoral nails for a second time leads to higher rates of problems such as infection, nonunion, or nail destabilisation due to overlapping holes for the interlocking screws. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_725", "text": "There is currently limited clinical attention in the area of bone malrotation and research into more accurate methods, likely due to the complexity of the issue. [ 1 ]  Whilst computed tomography scans are useful in determining the degree of bone malrotation after a surgery has occurred, research is being conducted into how to prevent this deformity occurring at all during surgery. CT scans are impractical intraoperatively due to high cost, lack of equipment portability and increased exposure to radiation. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_726", "text": "Consequently, one area being researched is that of  computer navigation,  which could be utilised during these surgeries to avoid malalignment issues.  Computer assisted surgery  (CAS) matches a patient's anatomy with pre or intraoperatively generated fluoroscopic image data, by using camera detected infrared signals. The computer then calculates the positioning of each component and creates a visual of their position on the monitor. As a result, the surgeon can monitor in real time the position of the surgical instruments in relation to the patient's anatomy and conducts the procedure accordingly. [ 11 ]  The surgeon can plan the torsional adjustment and control the fracture reduction and nail insertion on a touchscreen of the navigation module."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_727", "text": "Currently, this navigation may add extra time during surgery, so it is sometimes considered unnecessary in an urgent surgery. However, without computer navigation, the risk of bone malrotation is significantly increased. The benefit of computer navigation means that surgeons are able to view more clearly and restore axial alignment, but also ensure the injured limb and matches the alignment and length of the uninjured limb. [ 2 ]  CAS provides increased surgical accuracy and safety for both patients and surgeons, radiation time is reduced, and it utilises minimally invasive techniques which means less tissue damage, improved wound healing, and reduced infections and scarring for patients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_728", "text": "Dorsal intercalated segment instability  ( DISI ) is a deformity of the  wrist  where the  lunate bone  angulates to the dorsal side of the hand. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_729", "text": "The main cause of DISI is [ 4 ]  wrist trauma, with or without a fracture:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_730", "text": "This  human musculoskeletal system  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_731", "text": "The  Drehmann sign  describes a clinical test of examining orthopedic patients and is widely used in the functional check of the  hip  joint. \nIt was first described by Gustav Drehmann (Breslau, 1869\u20131932). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_732", "text": "The Drehmann sign is positive if an unavoidable passive external rotation of the hip occurs when performing a hip flexion. In addition, an internal rotation of the respective hip joint is either not possible or accompanied by  pain  when forcefully induced. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_733", "text": "The positive Drehmann sign is a typical clinical feature in slipped capital femoral  epiphysis  (SCFE), the  impingement syndrome of the acetabulum-hip ,  or in  osteoarthritis  of the hip joint. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_734", "text": "EOS imaging  is a medical device company based in  Paris, France , that designs, develops, and markets EOSedge and the EOS system, innovative, orthopedic medical imaging systems, associated with several orthopedic solutions along the patient care pathway \u2013 from  diagnosis  to post-operative treatments. The EOS platform targets  musculoskeletal disorders  and  orthopedic surgical care  through 2D  X-ray  scans and 3D skeletal models from stereo-radiographic images of patients in a seated or standing position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_735", "text": "The philosophy of EOS imaging surrounds three main principles: reduction of the  radiation  dose emitted by the technology, relevance and manipulability of calculated clinical parameters, and optimization of the patient care workflow. Currently, over 300 EOS systems are installed in medical centers in 51 different countries, including the United States, Japan, Korea, China, and throughout the European Union."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_736", "text": "The EOS imaging technology stems from the scientific findings of  Georges Charpak  ( Nobel Prize in Physics , 1992) concerning radiation detection and  particle physics , especially the  multi-wire chamber . [ 1 ]  Since then, physicists, engineers, radiologists, and surgeons have collaborated to transform these findings into a new technology called the EOS system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_737", "text": "EOS imaging began in 1989 as Biospace Med, a medical company founded by Georges Charpak for the development of his detection technology. In 1999, Marie Meynadier became the CEO of Biospace Med; she developed the company's first subsidiary dedicated to imaging solutions for pre-clinical research \u2013 the EOS system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_738", "text": "In 2004, hospitals in Paris, France and Brussels, Belgium finished running clinical tests on the EOS prototype, and in 2005, the first fundraising efforts commenced with the company's first venture capital round."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_739", "text": "From 2007 to 2011, the company obtained  CE marking  in Europe and  FDA  approval to market the EOS system and the sterEOS 2D/3D workstation in the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_740", "text": "The first installations of EOS in European and North American hospitals and clinics occurred from 2008 to 2010. In 2011, the EOS system was being integrated into clinical routines of medical centers in 10 countries, including the United States, Canada, and Australia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_741", "text": "In 2010, Biospace Med changed its name to EOS imaging."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_742", "text": "In 2012, EOS imaging entered the  Euronext Paris  stock exchange (name: EOSI) and had its first installation in Asia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_743", "text": "In 2013, EOS acquired the medical company oneFIT Medical (see Acquisition of oneFIT Medical).\nIn 2014, EOS provided the EOS system in the Vietnam market (Medic - Medic Hoa Hao) through Bluelight."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_744", "text": "In 2015, the CFDA certification in China and the NECA designation in Korea were obtained, allowing the company to further expand its market."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_745", "text": "In 2016, the company entered into the Latin American market with the signing of its first contract in Brazil."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_746", "text": "In 2019, the company launched EOSedge, its new generation imaging system powered by photon-counting technology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_747", "text": "While based in Paris, France, EOS imaging has five other corporate locations in various regions around the world:  Besan\u00e7on, France ;  St. Paul, Minnesota , US;  Montreal, Quebec , Canada;  Frankfurt, Germany , and in  Singapore ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_748", "text": "In 2013, EOS imaging acquired oneFIT Medical (based in Besan\u00e7on, France), a  medical software  engineering and manufacturing company dedicated to the development of  surgical planning  software for spine, hip, and knee surgeries and patient-specific orthopedic surgical cutting guides. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_749", "text": "EOS imaging platforms\u2014EOSedge and EOS\u2014deliver unique and specific capabilities that are used in conjunction with EOS Advanced Orthopedic Solutions to generate highly accurate 3D representations of patient anatomy and enable a seamless surgical planning experience."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_750", "text": "The EOS examination takes place in an upright scanning cabin where the patient can either stand or sit. With a vertically traveling arm supporting two fine X-ray beams perpendicular to one another, the EOS system acquires frontal and lateral, weight-bearing images of the patient in a functional \u2013 standing or sitting \u2013 position. These biplanar images are then used to create a 3D model of the patient's skeleton."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_751", "text": "The ALARA principle (As Low As Reasonably Achievable) represents a movement to \u201cminimize radiation doses and releases of radioactive materials\u201d by minimizing the time of exposure to radiation, increasing the distance between the human body and the radiation source, and using absorber materials to shield the body from  beta particles , X-rays, and  gamma rays . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_752", "text": "EOS imaging aligns itself with this principle, providing reduced exam times and amounts of radiation in comparison with conventional imaging systems. [ 4 ] [ 5 ]  Furthermore, EOS developed a Micro Dose option that further reduced the radiation exposure by 5.5 times compared to a typical low-dose EOS exam protocol, resulting in a nearly negligible radiation dose. [ 6 ]  Additionally, with Flex Dose technology, EOSedge can deliver up to an 80% overall radiation reduction compared to same acquisition without Flex Dose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_753", "text": "Having reduced-radiation options available for patients has become critical in the world of medical imaging as radiation exposure from artificial sources, such as medical imaging, has increased over the last two decades, [ 7 ]  and many patients require multiple examinations throughout the course of their medical treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_754", "text": "The sterEOS workstation enables the generation of patient-specific 3D models of the spine and/or lower limbs from weight-bearing low dose or Micro Dose EOS exams. Once the models are created, clinical parameters are automatically calculated and may be exported as a patient report including 2D images and 3D captures. This report is used by physicians for diagnosis, post-operative assessment, and patient follow-up. sterEOS also enables the exportation of 3D anatomical biomarkers for pre-operative planning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_755", "text": "The EOSapps (kneeEOS, hipEOS, and spineEOS) are online, 3D surgical planning solutions based on the weight-bearing EOS images. Frontal and lateral EOS images are uploaded to the EOS Portal, where the EOS 3DServices team prepares the 3D models and dataset and makes the planning case available online. Surgeons can have access to the patient's anatomy information in 3D, with which they can plan and simulate the effect of different implant selections and positions in 3D. spineEOS is used to plan spine surgeries, hipEOS is used for the planning of  total hip arthroplasty , and kneeEOS is geared towards the planning of  total knee arthroplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_756", "text": "Foot Levelers  is a foot care, footwear, and whole body health company based in Roanoke, Virginia, and owned by Kent S. Greenawalt."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_757", "text": "Foot Levelers began in Iowa, in 1952, by Chiropractor Monte H. Greenawalt. Greenawalt earned his degree from Lincoln Chiropractic College and began to notice a pattern in patients with foot problems\u2014his adjustments did not hold. Dr. Monte referred these patients to a podiatrist, but their problems persisted."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_758", "text": "Monte began to experiment with orthotics, and through trial and error, developed a formula based on 16 unique measurements of the foot. Unlike off-the-shelf orthotics or even those made by podiatrists, Monte\u2019s orthotic was designed to support all three arches of the foot, rather than just one. Through Greenawalt's orthotics invention, his patients began to show positive results and his adjustments held longer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_759", "text": "In Foot Levelers multi-decade history, they have served tens of thousands of doctors and millions of patients [ 1 ]  through their patented orthotic technology. [ 2 ]  They have offices in the U.S., Europe, and Australia and serve customers in over 80 countries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_760", "text": "Foot Levelers holds title sponsorship of \"America's Toughest Road Marathon\", the  Blue Ridge Marathon , since 2012."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_761", "text": "Halo-gravity traction  (HGT) is a type of  traction  device utilized to treat spinal deformities such as  scoliosis , [ 1 ] [ 2 ]   congenital  spine deformities,  cervical instability ,  basilar invagination , and  kyphosis . [ 3 ]  It is used prior to surgical treatment to reduce the difficulty of the following surgery and the need for a more dangerous surgery. [ 4 ] [ 5 ] [ 6 ]  The device works by applying weight to the spine in order to stretch and straighten it. Patients are capable of remaining somewhat active using a  wheelchair  or a walker whilst undergoing treatment. Most of the research suggests that HGT is a safe treatment, and it can even improve patients'  nutrition  or  respiratory functioning . However, some patients may experience side effects such as  headaches  or neurological complications.  The halo device itself was invented in the 1960s by doctors working at the  Rancho Los Amigos hospital . [ 7 ] [ 8 ] [ 9 ]  Their work was published in a paper entitled \"The Halo: A Spinal Skeletal Traction Fixation Device.\" [ 10 ]  The clinician  Pierre Stagnara  utilized the device to develop Halo-Gravity traction. [ 11 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_762", "text": "Halo-gravity traction works by straightening and stretching the compressed  spine . [ 14 ] [ 15 ]  It relies on the  viscoelastic  properties of  vertebrae . This means vertebrae can stretch over time. Doctors will apply weight to the spine, and gradually increase it over time, slowly straightening and stretching it. [ 16 ]  Patients undergoing the procedure will typically spend the entire course of the treatment, which is usually three to eight weeks, in a  hospital . Usually, halo-gravity traction is the first step in the treatment plan for a child with severe spinal deformity. Following the procedure, it is common for a surgical operation such as  spinal fusion surgery  to be performed afterward to permanently mend the issue. [ 14 ] [ 17 ]  It is utilized before the operation to reduce the need for a more dangerous surgery and to reduce the risk of damage to the soft  tissues  or  nerves  that surround the spine during the surgery. [ 15 ] [ 18 ] [ 19 ]  In addition, HGT has also been found to reduce the risk of complications during the following surgery. [ 20 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_763", "text": "To perform halo-traction therapy a surgeon will use six to ten small pins to attach a \"halo\" made of a metal ring to the patient's skull. [ 23 ] [ 24 ] [ 25 ]  Doctors will typically leave one to two centimeters of distance between the halo and the patient's head. It is common for older patients to be given eight pins while younger patients are given 10. Prior to pin placement, some patients may undergo hair removal. It is not required for successful treatment, but it can help to reduce the risk of pin infection from hair getting caught in a pin or  scalp necrosis . [ 7 ]  The pins will be placed into the  forehead   bones  to prevent the head from moving. Pin placement is determined using a  CT scan . The chosen area will be cleaned with  betadine  swabs. Usually, two to three pins are placed in the  frontal  and  occipital  areas. Pins placed on the occipital area will have to be placed one centimeter above and behind the  auricle  of the ear. Pins placed on the  anterior  of the head will likely be placed one centimeter to above the sides of the eyebrow to avert potential damage to the  supraorbital  and the  supratrochlear nerves , and potential  muscle  damage.  Parietal  placements are generally avoided as the skull around this area is generally softer, which risks the pins puncturing the  temporal artery . Typically, the pins will tightened to a  torque  equivalent to the age of the child using a  torque wrench . Adults can withstand tighter torques than children can. [ 26 ]  Whilst this operation is being performed the child will be given general  anesthesia . [ 7 ]  In  infant  children, significantly less torque is required to tighten the pins. This allows for the pins to be placed in more areas than they could be placed in older patients. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_764", "text": "Afterward, the halo will be attached to a  pulley system  which is attached to the patient's bed,  walker , or  wheelchair . [ 28 ]  Spring-type pulleys are typically used as they allow for the patient to self-regulate the weight applied to the pulley, which improves the safety of the device. [ 29 ] :\u200a390\u200a  Spring-based HGT devices are also cheaper and easier to build than other methods of construction. [ 30 ]  It is common for patients to begin the procedure with 5-10 pounds of weight on the pulley system. [ 29 ] :\u200a387\u200a  Over the next few weeks, clinicians will add weight to the pulley, which will slowly straighten the patient's spine over time. Eventually, a weight greater than 50% of the patient's body weight may be achieved. [ 23 ] [ 31 ]  Doctors will monitor the movements and strength and will take  x-rays  of the patient to track their progress. They will adjust the amount of weight on the pulley system based on the results. All patients will undergo  cranial nerve  testing during the procedure. [ 23 ]  After the spine has reached its optimal position, spinal fusion surgery will be performed on the patient. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_765", "text": "Whilst undergoing the procedure, patients are encouraged to remain as active as possible. Activities such as low-impact play, walking, or standing can all increase the benefits of halo-traction therapy. However, patients are limited to leaving the traction for only a short time span. They can leave for activities such as repositioning, changing clothes, daily medical care,  showering , or using the  toilet .  Baby shampoo  is required to be used for bathing purposes as other shampoos could contain chemicals that react negatively with the metal halo. Patients will be required to utilize a special bed for  sleeping  whilst in the traction. After ending treatment the patient is required to avoid strenuous activities for a few months as their spine and muscles will still need to recover. Some patients may wear an orthopedic vest or a  halo vest . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_766", "text": "Halo-gravity traction has been found to be almost completely safe. [ 29 ] :\u200a385\u200a [ 32 ]  Patients who have undergone the procedure report that they have a greater ability to stand upright, an increased appetite, and an improved  body image . [ 33 ]  It can improve  respiratory  functioning by relieving pressure on the lungs caused by a deformed spine. [ 13 ] [ 34 ] [ 35 ]  Patients often  gain weight  and have improved  nutrition  following HGT. [ 36 ]  This may occur since HGT can correct issues associated with spinal deformities, such as  exercise ,  comorbid   metabolic disorders , and  gastrointestinal  malformations. These issues are associated with malnutrition and low weight, and HGT can lead to weight gain by correcting them. [ 37 ]  When in combination with surgical release, HGT may improve the  flexibility  of the spine and lead to more spinal correction. [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_767", "text": "Patients may experience pain from the pins, which is usually caused by the loosening of the pins. This can be remedied by tightening them. Up to 20% of patients may experience  infections  at the site where the pins were applied. These infections are typically treated with  antibiotics . One rare, but serious complication of the procedure can be the development of intra-cranial  abscesses  due to  septic  contamination of the pin site. [ 13 ]  Some patients experience  headaches  around the area where the pins were applied for a short while after the halo is attached. It is common for patients to recover from this pain in less than 24 hours. [ 29 ] :\u200a384\u200a  Halo therapy will leave small  lesions  in the skin when the pins are first removed. Typically, they will turn into  scabs  after a few days. Patients who have undergone the procedure will also have small  scars  on their foreheads. These scars will typically fade over time. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_768", "text": "If the traction that is applied is greater than the tolerable amount, the patient may feel  cervical pain ,  cranial nerve lesions ,  nausea ,  vertigo , [ 40 ]  or  dizziness . These side effects are treated by lowering the level of weight applied. [ 41 ]  Some patients may suffer from  motor paresis  after the application of the device. Typically it is present in patients with preexisting spinal cord abnormalities. [ 29 ] :\u200a389\u200a  Generally, HGT does not cause neurological side effects due to the slow progression of traction. The spine adjusts slowly over time, and as a result, consequences are generally limited. Children are less likely than adolescents or adults to experience neurological side effects, due to the softness and flexibility of their spine, as well as their low weight. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_769", "text": "Erb's palsy  has been identified as a rare neurological side effect of HGT. [ 43 ]  One 2006 study published in the journal \"Studies in Health Technology and Informatics\" found that in extremely rare cases HGT could induce  Erb's palsy , ulnar nerve paralysis, and  median nerve palsy  in cases. In the seven cases identified by the study, all patients had fully recovered within a few months of treatment. The likelihood of developing Erb's palsy due to HGT is associated with the weight of the traction. [ 44 ]  Another study published in the  Journal of Spinal Disorders & Techniques  found that patients may experience Erb's palsy or  sensory loss  during or after treatment. However, none of the patients who had experienced these side effects reported in this study had permanent neurological loss. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_770", "text": "One 2016 clinical study published in  BioMed Research International  found that HGT resulted in reduced bone density among patients with kyphoscoliosis. [ 46 ]  However, little other research has investigated this potential side effect or found any evidence to support this claim. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_771", "text": "Patients with bone conditions such as  fibrous dysplasia  or  osteogenesis imperfecta  may be unsuitable for treatment if the pins are not capable of safely being applied to the bone. [ 29 ] :\u200a385\u200a   Osteoporosis  is considered a contraindication that sometimes may prevent treatment,  however, doctors may avert complications by utilizing more pins with a lower torque. [ 40 ]   Absolute contraindications  for halo-gravity traction include the presence of a  stenotic segment , an  intradural or extradural lesion , lesions in the skull by the sites of pin application, [ 12 ]  any lesion or  tumor  by the spine cord, [ 23 ]  severe skull deformity, and  spine instability . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_772", "text": "Most of the research conducted on HGT found that it is mostly a safe, [ 47 ]  reliable, [ 47 ]  and effective treatment. [ 48 ] [ 49 ] [ 50 ]  The average correction rate of HGT has been shown to be 19.4% for  sagittal curves  and 24.1%  coronal  curvature. [ 12 ]  One 2013 study on 33 patients published in the journal  Spine Deformity  found an average correction rate of 33% for coronal curves and 35% for sagittal. [ 51 ]  According to a  cohort study  conducted on 75 subjects investigating the efficacy of Halo traction therapy found an improvement rate of 31% to 66% for the spine. They found a  coronal  curvature improvement of 19.6% for adolescents, and 12% for adults. Kyphosis had improved at a rate of 23.9% for adolescents. Afterward, spinal surgery performed on people who had undergone the procedure had a greater than 50% chance of success. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_773", "text": "One study conducted on 20 patients with either scoliosis, kyphosis, or kyphoscoliosis found that the most improvement occurred within the first 3 weeks of treatment. According to this study, the spinal curve had improved by 63.7% during the first two weeks, which decreased to 24.3% at 3 weeks, and to 15.9% at 4 weeks. [ 38 ]  Other studies have found similar results. One study conducted on 21 patients found that 45% of improvement occurred within the first 3 weeks. [ 53 ]  Another study on 24 patients found that a mean improvement of 82% occurred during the first three weeks. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_774", "text": "Much of the research utilized as evidence of the efficacy of HGT has been criticized for a lack of a  control group  and a small  sample size . [ 55 ]  Some research has suggested that HGT leads to  statistically insignificant  improvement. [ 56 ]   Paul Sponseller, an  Orthopedic surgeon  at  Johns Hopkins University , claims in his study \"The use of traction in the treatment of severe spinal deformity\" that his research found \"no statistically significant difference in main coronal curve correction (62% vs. 59%), operative time, blood loss, and total complication rate (27% vs. 52%).\" However, his data did showcase that people who had not undergone HGT required  surgical resection  30% more often. [ 55 ]  In a study on 25 patients with severe spinal deformities who had been treated with spinal surgery, a mean correction of 44 degrees was found in patients who had not undergone HGT prior to the operation, and a mean correction of 52 was found in patients who had been treated with HGT. The researchers concluded that this difference was not statistically significant, and therefore HGT should not be used as the general treatment for these issues, and should be reserved for specific cases. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_775", "text": "Some research suggests that HGT may be less effective than other forms of traction, such as Halo-femoral traction or Halo-pelvic traction. [ 58 ] [ 59 ]  HGT also has been found to require lengthy hospital stays, which many patients dislike about the treatment. [ 60 ]  In the study by Paul Sponsellor, he found that patients who had undergone HGT spent almost twice the amount of time hospitalized as those who had not received the treatment. [ 55 ]  HGT is significantly safer than other forms of traction. It is less likely to produce significant complications such as  blood loss , [ 59 ] [ 61 ]  neurological side effects, and spine stiffness or degeneration. [ 62 ]  HGT also allows patients to remain social and active, whilst other forms of traction severely restrict movement. [ 63 ]  These reasons have led to HGT becoming the standard preoperative treatment for patients with severe spinal deformities. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_776", "text": "The treatment of broken bones and dislocated joints can be traced as far back as the  Ancient Greeks .  Hippocrates  is credited with a method of reduction of a  dislocated shoulder . 16th century Spanish texts talk about the  Aztecs  use of  reduction  of fractures using fir branches. The modern discipline of orthopaedics in trauma care developed during the course of World War I, but it was not until after World War II that orthopaedics became the dominant field treating fractures in much of the world. Today, the discipline encompasses conditions such as bone fractures and bone loss, as well as spinal pathology and joint disease. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_777", "text": "Several volumes of the  Hippocratic Corpus ,  Articulations or On Joints, On Fractures, On the Instruments of Reduction  discuss  Ancient Greek medicine  relating to orthopaedics, [ 2 ]  and  Hippocrates  is credited with a method of reduction of a  dislocated shoulder ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_778", "text": "16th century Spanish texts talk about the  Aztecs  use of  reduction  of fractures, as well  intramedullary  fixation using fir branches. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_779", "text": "Peter Lowe  was the first surgeon to use the term  amputation  in his 1597 book  A discourse of the Whole Art of Chirurgerie . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_780", "text": "Nicolas Andry  has been credited with the term 'orthopaedics', taken from the title of his 1741 book  Orthop\u00e9die  on childhood deformity correction. [ 5 ]   The frontispiece of the book bore an engraving of a sapling being splinted with a stake, a symbol now referred to as the  Tree of Andry  and adopted by many orthopaedic associations internationally."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_781", "text": "In 1768,  Percivall Pott  published his book  Some Few Remarks upon Fractures and Dislocations  following his compound femoral fracture on the use of  splinting  to avoid  amputation . [ 6 ]   Pott's student,  John Hunter , expanded on the knowledge of bone healing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_782", "text": "Around the same time,  Jean-Andr\u00e9 Venel  published his work  Orthopaedia, or the Art of Preventing and Correcting Deformities in Children , one of the first surgeons to discuss the practical application for treating  congenital deformities ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_783", "text": "Even after the  Medical Act 1858 ,  bonesetters  continued to practice unlicensed within England, with one of the last being Evan Thomas. His son,  Hugh Owen Thomas , is considered by many to be the father of modern orthopaedics in the UK, [ 7 ]  with many published works such as  Diseases of the hip, knee and ankle joints (1876), Principles of the treatment of diseased joints (1883), The principles of the treatment of fractures and dislocations (1886), Fractures, dislocations, diseases and deformities of the bones of the trunk and upper extremities (1887) and Fractures, dislocations, deformities and diseases of the lower extremities (1890)' . The use of his  traction splint  during the  First World War  lead to a dramatic reduction in the mortality following  femoral fractures ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_784", "text": "Thomas' nephew,  Robert Jones  continued his work, and was the first person to publish on the use of  radiography  in orthopaedics. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_785", "text": "The developing field of orthopaedics was originally focused on deformities in children, and subsequently adults. The involvement of orthopaedics in trauma care developed in the course of World War I, the interwar period, and World War II. [ 9 ]  It was not until after World War II that orthopaedics became the dominant field treating fractures in much of the world."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_786", "text": "Later in the 20th century,  John Charnley  pioneered  hip replacement , [ 10 ]  as well as published on the conservative treatment of fractures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_787", "text": "Orthopedic surgery  is the branch of  surgery  concerned with conditions involving the  musculoskeletal system .  Orthopedic surgeons  use both surgical and nonsurgical means to treat  musculoskeletal injuries ,  sports injuries , degenerative diseases, infections,  bone tumours , and  congenital limb deformities .   Trauma surgery  and  traumatology  is a sub-specialty dealing with the operative management of  fractures ,  major trauma  and the multiply-injured patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_788", "text": "List excludes anatomical terminology covered in  index of anatomy articles ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_789", "text": "Abbreviated Injury Scale \n-  Acetabular fracture \n-  Acheiropodia \n-  Achilles tendon rupture \n-  Acromioplasty \n-  Adamantinoma \n-  Adhesive capsulitis of shoulder \n-  Advanced trauma life support \n-  Ainhum \n-  Akin osteotomy \n-  Albers-Schonberg disease \n-  Albright's hereditary osteodystrophy \n-  Allis test \n-  ALPSA lesion \n-  Amelia (birth defect) \n-  American Joint Replacement Registry \n-  Amphiarthrosis \n-  Andersson lesion \n-  Aneurysmal bone cyst \n-  Ankle replacement \n-  Anterior cruciate ligament injury \n-  Anterior cruciate ligament reconstruction \n-  Antley\u2013Bixler syndrome \n-  Apert syndrome \n-  Apley grind test \n-  Apley scratch test \n-  Apprehension test \n-  Arachnodactyly \n-  Arm fracture \n-  Arthralgia \n-  Arthritis \n-  Arthrocentesis \n-  Arthrodesis \n-  Arthrogram \n-  Arthrogryposis \n-  Arthroplasty \n-  Arthroscopy \n-  Arthrotomy \n-  Articular capsule \n-  Articular cartilage repair \n-  Astragalectomy \n-  Autologous chondrocyte implantation \n-  Avascular necrosis \n-  Avulsion fracture"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_790", "text": "Baastrup's sign \n-  Baker's cyst \n-  Baksi's prosthesis \n-  Ballottement \n-  Bankart lesion \n-  Bankart's fracture \n-  Barlow maneuver \n-  Barr\u00e9\u2013Li\u00e9ou syndrome \n-  Barton's fracture \n-  Baumann's angle \n-  Beals syndrome \n-  Bechterew's \n-  Bennett's fracture \n-  Bifid rib \n-  Bimalleolar fracture \n-  Blount's disease \n-  Blumensaat's line \n-  Blunt trauma \n-  Bohler's angle \n-  Bone cutter \n-  Bone cyst \n-  Bone density \n-  Bone disease \n-  Bone fracture \n-  Bone fracture healing \n-  Bone grafting \n-  Bone healing \n-  Bone metastases \n-  Bone mineral \n-  Bone pathology \n-  Bone remodeling \n-  Bone resorption \n-  Bone tumor \n-  Bone \n-  Bosworth fracture \n-  Bouchard's nodes \n-  Boutonniere deformity \n-  Boxer's fracture \n-  Brachydactyly \n-  British Orthopaedic Association \n-  Brodie abscess \n-  Brostr\u00f6m procedure \n-  Brown tumor \n-  Bruck syndrome \n-  Brunelli procedure \n-  Bryant's traction \n-  Buddy wrapping \n-  Bumper fracture \n-  Bunion \n-  Burst fracture"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_791", "text": "Calcaneal fracture \n-  Camurati\u2013Engelmann disease \n-  Cancellous bone \n-  Cartilage \n-  Cartilaginous joint \n-  Catel\u2013Manzke syndrome \n-  Cenani\u2013Lenz syndactylism \n-  Cervical dislocation \n-  Cervical fracture \n-  Cervical rib \n-  Chalkstick fracture \n-  Chance fracture \n-  Chandler's disease \n-  Charnley prosthesis \n-  Charnley retractor \n-  Chauffeur's fracture \n-  Child bone fracture \n-  Chondroblast \n-  Chondroblastoma \n-  Chondrocyte \n-  Chondrogenesis \n-  Chondromalacia patellae \n-  Chondromyxoid fibroma \n-  Chondrosarcoma \n-  Chopart's fracture-dislocation \n-  Clarke's test \n-  Clavicle fracture \n-  Clay-shoveler fracture \n-  Cleidocranial dysostosis \n-  Clinodactyly \n-  Club foot \n-  Clubbed thumb \n-  Cobb angle \n-  Codman triangle \n-  Cole carpenter syndrome \n-  Colles' fracture \n-  Combined tibia and fibula fracture \n-  Compartment syndrome \n-  Complex regional pain syndrome \n-  Compression fracture \n-  Computer-assisted orthopedic surgery \n-  Congenital knee dislocation \n-  Congenital limb deformities \n-  Congenital patellar dislocation \n-  Conradi\u2013H\u00fcnermann syndrome \n-  Coopernail's sign \n-  Cortical bone \n-  Cotrel\u2013Dubousset instrumentation \n-  Coxa valga \n-  Coxa vara \n-  Cozen's test \n-  Crus fracture \n-  Crush injury \n-  Crush syndrome \n-  Cubitus valgus \n-  Cubitus varus \n-  Cunningham shoulder reduction \n-  Currarino syndrome"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_792", "text": "Danis\u2013Weber classification \n-  Darrach's procedure \n-  Darrah procedure \n-  De Quervain syndrome \n-  Denis Browne bar \n-  Denis classification \n-  Destot's sign \n-  Diaphysis \n-  Diffuse idiopathic skeletal hyperostosis \n-  Discectomy \n-  Discoid meniscus \n-  Dislocated shoulder \n-  Dislocation of hip \n-  Displacement (orthopedic surgery) \n-  Distal radius fracture \n-  Distraction osteogenesis \n-  Drawer test \n-  Dupuytren's contracture \n-  Durkan's test \n-  Duverney fracture \n-  Dynamic compression plate \n-  Dynamic hip screw \n-  Dysplasia epiphysealis hemimelica"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_793", "text": "Early appropriate care \n-  Ecchondroma \n-  Ectrodactyly \n-  Ectromelia \n-  Ehlers\u2013Danlos syndrome \n-  Eiken syndrome \n-  Elbow examination \n-  Elbow extension test \n-  Ellis\u2013van Creveld syndrome \n-  Enchondroma \n-  Enchondromatosis \n-  Ender's nail \n-  Endochondral ossification \n-  Endosteum \n-  Enthesis \n-  Epiphyseal plate \n-  Epiphysiodesis \n-  Epiphysis \n-  Erlenmeyer flask deformity \n-  Essex-Lopresti fracture \n-  Evans technique \n-  Evans-Jensen classification \n-  Ewing's sarcoma \n-  Exostosis \n-  External fixation \n-  Extraskeletal chondroma"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_794", "text": "Fairbank's changes \n-  Fairbanks disease \n-  Fat embolism \n-  Femoral fracture \n-  Femoral head ostectomy \n-  Fibrocartilage callus \n-  Fibrocartilage \n-  Fibrosarcoma \n-  Fibrous dysplasia of bone \n-  Fibrous joint \n-  Fibular fracture \n-  Ficat classification \n-  Finkelstein's test \n-  Fixation (surgical) \n-  Flat bone \n-  Flat feet \n-  Flexion teardrop fracture \n-  Foot drop \n-  Foot fracture \n-  Forearm fracture \n-  Frankel's sign \n-  Freiberg disease \n-  Froment's sign \n-  Frykman classification"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_795", "text": "Gaenslen's test \n-  Galeazzi fracture \n-  Galeazzi test \n-  Gamekeeper's thumb \n-  Garden classification \n-  Garre's sclerosing osteomyelitis \n-  Gartland classification \n-  Genu recurvatum \n-  Genu valgum \n-  Genu varum \n-  Gerber's test \n-  Gerdy's tubercle \n-  Geriatric trauma \n-  Giant-cell tumor of bone \n-  Gigli saw \n-  Gilula's Lines \n-  Girdlestone's Procedure \n-  Gorham's disease \n-  Gosselin fracture \n-  Greenstick fracture \n-  Grosse-Kempf nail \n-  Gruen zone \n-  Gustilo open fracture classification \n-  Guyon's Canal"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_796", "text": "Haglund's deformity \n-  Hajdu\u2013Cheney syndrome \n-  Hallux rigidus \n-  Hallux valgus \n-  Hallux varus \n-  Hammer toe \n-  Hand deformity \n-  Hand fracture \n-  Hand of benediction \n-  Hand surgery \n-  Hangman's fracture \n-  Haruguchi classification \n-  Hardinge lateral approach to the hip \n-  Harrington rod \n-  Harris Hip Score \n-  Harris lines \n-  Harrison's groove \n-  Haversian canal \n-  Hawkin's classification \n-  Hawkins-Kennedy test \n-  Heberden's node \n-  Hemarthrosis \n-  Hematoma \n-  Hemimelia \n-  Herbert classification \n-  Herbert screw \n-  Herscovici classification \n-  High ankle sprain \n-  High tibial osteotomy \n-  Hilgenreiner's line \n-  Hill\u2013Sachs lesion \n-  Hip dysplasia (human) \n-  Hip examination \n-  Hip fracture \n-  Hip replacement \n-  Hip resurfacing \n-  Hip spica cast \n-  Hoffa fracture \n-  Holdsworth fracture \n-  Holstein\u2013Lewis fracture \n-  Hubscher's maneuver \n-  Hueter-Volkmann law \n-  Human musculoskeletal system \n-  Hume fracture \n-  Hume fracture \n-  Humerus fracture \n-  Humphrey's ligament \n-  Hyaline cartilage \n-  Hydroxylapatite \n-  Hyperostosis \n-  Hypertrophic pulmonary osteoarthropathy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_797", "text": "Ideberg classification \n-  Ilizarov apparatus \n-  Infantile cortical hyperostosis \n-  Injury Severity Score \n-  Internal fixation \n-  Intervertebral disc annuloplasty \n-  Intervertebral disc arthroplasty \n-  Intramedullary rod \n-  Intramembranous ossification \n-  Involucrum \n-  Irregular bone \n-  Iselin's disease"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_798", "text": "Jansen's metaphyseal chondrodysplasia \n-  Jefferson fracture \n-  Jobe's test \n-  Joint dislocation \n-  Joint locking (symptom) \n-  Joint replacement \n-  Joint replacement registry \n-  Joint stiffness \n-  Joint \n-  Jones fracture \n-  Juvenile osteoporosis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_799", "text": "Kanavel's cardinal signs \n-  Kapandji score \n-  Kashin\u2013Beck disease \n-  Keller procedure \n-  Kellgren-Lawrence grading scale \n-  Khyphoplasty \n-  Kienbock's disease \n-  Kirschner wire \n-  Klein's line \n-  Klippel\u2013Feil syndrome \n-  Klippel\u2013Tr\u00e9naunay\u2013Weber syndrome \n-  Knee cartilage replacement therapy \n-  Knee examination \n-  Knee replacement \n-  Kniest dysplasia \n-  Kocher criteria \n-  Kocher manoeuvre \n-  K\u00f6hler disease \n-  Krukenberg procedure \n-  Kuntscher nail"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_800", "text": "Lachman test \n-  Larrey's sign \n-  Larsen syndrome \n-  Las\u00e8gue's sign \n-  Latarjet procedure \n-  Lauge-Hansen classification \n-  Legg\u2013Calv\u00e9\u2013Perthes syndrome \n-  Ligamentous laxity \n-  Limb lengthening methods \n-  Lisfranc fracture \n-  Lisfranc joint \n-  Lisfranc ligament \n-  List of orthopedic implants \n-  Lister's tubercle \n-  Lobstein syndrome \n-  Loder classification \n-  Long bone \n-  Loosers zone \n-  Lunotriquetral shear test \n-  Luxating patella"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_801", "text": "Madelung's deformity \n-  Maffucci syndrome \n-  Maisonneuve fracture \n-  Major trauma \n-  Malgaigne's fracture \n-  Malunion \n-  March fracture \n-  Marfan syndrome \n-  Marie-Str\u00fcmpell disease \n-  Marshall syndrome \n-  Marshall\u2013Smith syndrome \n-  Martin-Gruber Anastomosis \n-  Mayfield classification \n-  McCune\u2013Albright syndrome \n-  McMurray test \n-  Medullary cavity \n-  Melnick\u2013Needles syndrome \n-  Melorheostosis \n-  Mesenchymal chondrosarcoma \n-  Metaphysis \n-  Metatarsophalangeal joint sprain \n-  Microfracture surgery \n-  Milch classification \n-  Mirel's Score \n-  Monostotic fibrous dysplasia \n-  Monteggia fracture \n-  Moore or Southern posterior approach to the hip \n-  Moore's fracture \n-  Moore's pin \n-  Morton's neuroma \n-  Morton's toe \n-  Mulder's sign \n-  M\u00fcller AO Classification of fractures \n-  Multiple epiphyseal dysplasia \n-  Mumford procedure \n-  Musculoskeletal injury \n-  Myxoid chondrosarcoma"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_802", "text": "National hip fracture database \n-  Neer classification \n-  Neer impingement sign \n-  Neer's prosthesis \n-  Nonossifying fibroma \n-  Nonunion \n-  Nonunion of fracture \n-  Nursemaid's elbow"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_803", "text": "O'Brien's test \n-  Ober's test \n-  Oligodactyly \n-  Ollier disease \n-  Orthopaedic pathology \n-  Orthopaedic procedure \n-  Orthopedic cast \n-  Orthopedic plaster casts \n-  Orthopedic plates \n-  Orthopedic surgery \n-  Orthotics \n-  Ortolani test \n-  Ortolani test \n-  Osgood\u2013Schlatter disease \n-  Osseointegration \n-  Osseous tissue \n-  Ossification center \n-  Ossification \n-  Ostectomy \n-  Osteitis fibrosa cystica \n-  Osteitis \n-  Osteoarthritis \n-  Osteoblast \n-  Osteoblastoma \n-  Osteochondritis dissecans \n-  Osteochondritis \n-  Osteochondrodysplasia \n-  Osteochondroma \n-  Osteochondromatosis \n-  Osteochondrosis \n-  Osteoclast \n-  Osteocyte \n-  Osteofibrous dysplasia \n-  Osteogenesis imperfecta \n-  Osteoid osteoma \n-  Osteoid \n-  Osteolysis \n-  Osteoma \n-  Osteomalacia \n-  Osteomyelitis \n-  Osteon \n-  Osteopetrosis \n-  Osteophyte \n-  Osteoporosis \n-  Osteosarcoma \n-  Osteosclerosis \n-  Osteostimulation \n-  Osteotomy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_804", "text": "Paget's disease of bone \n-  Panner disease \n-  Patella alta \n-  Patella baja \n-  Patella fracture \n-  Patellar dislocation \n-  Patellar tendon rupture \n-  Pathologic fracture \n-  Patrick's test \n-  Patrick's test \n-  Pauwel's angle \n-  Pauwel's classification \n-  Pectus carinatum \n-  Pectus excavatum \n-  Pediatric trauma \n-  Pelvic fracture \n-  Penetrating trauma \n-  Perichondrium \n-  Periosteal reaction \n-  Periosteum \n-  Periostitis \n-  Perkin's line \n-  Perthes Lesion \n-  Pes cavus \n-  Phalen maneuver \n-  Phocomelia \n-  Physical therapy \n-  Pigeon toe \n-  Pigmented villonodular synovitis \n-  Pilon fracture \n-  Pipkin classification \n-  Pipkin fracture-dislocation \n-  Pivot-shift test \n-  Plafond fracture \n-  Polydactyly \n-  Polyostotic fibrous dysplasia \n-  Polytrauma \n-  Ponseti method \n-  Porotic hyperostosis \n-  Pott's fracture \n-  Preiser disease \n-  Proteus syndrome \n-  Protrusio acetabuli \n-  Pseudarthrosis \n-  Pulled hamstring \n-  Pycnodysostosis \n-  Pyogenic osteomyelitis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_805", "text": "Quadriceps tendon rupture"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_806", "text": "Radius fracture \n-  Rapadilino syndrome \n-  Reduction (orthopedic surgery) \n-  Resuscitation \n-  Resuscitative thoracotomy \n-  Rett syndrome \n-  Revised Trauma Score \n-  Rib fracture \n-  Rickets \n-  Rocker bottom foot \n-  Rolando fracture \n-  Rotationplasty \n-  Rotator cuff tear \n-  Rowe Score \n-  Rubinstein\u2013Taybi syndrome \n-  Ruedi-Allgower classification \n-  Rush nail"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_807", "text": "Sacralization of the fifth lumbar vertebra \n-  Salter\u2013Harris fracture \n-  Sanders classification \n-  Sarcoma \n-  Scaphoid fracture \n-  Scapular fracture \n-  Schenck classification \n-  Scheuermann's disease \n-  Schmorl's nodes \n-  Schober's test \n-  Schwartz\u2013Jampel syndrome \n-  Scoliosis \n-  Seddon classification \n-  Segond fracture \n-  Seidel nail \n-  Seinsheimer classification \n-  Separated shoulder \n-  Sequestrum \n-  Sesamoid bone \n-  Sesamoiditis \n-  Sever's disease \n-  Shenton's Line \n-  Shepherd's fracture \n-  Shin splints \n-  Short bone \n-  Shoulder examination \n-  Shoulder fracture \n-  Shoulder replacement \n-  Shoulder surgery \n-  Silver\u2013Russell syndrome \n-  Simmonds' test \n-  Skeletal fluorosis \n-  SLAP tear \n-  Slipped capital femoral epiphysis \n-  Slipped Upper Femoral Epiphysis \n-  Smith Peterson nail \n-  Smith-Petersen anterior approach to the hip \n-  Smith's fracture \n-  Soft tissue injury \n-  Southwick angle \n-  Speed's test \n-  Spina bifida occulta \n-  Spinal curvature \n-  Spinal fracture \n-  Spinal fusion \n-  Spiral fracture \n-  Splint (medicine) \n-  Spondylolisthesis \n-  Sports injury \n-  Sprained ankle \n-  Sprengel's deformity \n-  Steinmann pin \n-  Stener lesion \n-  Sternal fracture \n-  Stieda fracture \n-  Straight leg raise \n-  Stress fracture \n-  Subacromial bursitis \n-  Sudeck's atrophy \n-  Sulcoplasty \n-  Supracondylar fracture \n-  Swan neck deformity \n-  Swanson prosthesis \n-  Swanson's arthroplasty \n-  Symphysis \n-  Synchondrosis \n-  Syndactyly \n-  Syndesmosis \n-  Synovectomy \n-  Synovial fluid \n-  Synovial joint"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_808", "text": "Talipes equinovarus \n-  Talwalkar nail \n-  Taylor Spatial Frame \n-  Tear of meniscus \n-  Teisen classification \n-  Tendon transfer \n-  Tension band wiring \n-  Teunissen\u2013Cremers syndrome \n-  Thomas test \n-  Thompson and Epstein classification \n-  Thompson test \n-  Thurstan Holland sign \n-  Tibia fracture \n-  Tibial plateau fracture \n-  Tietze syndrome \n-  Tile classification \n-  Tillaux-Chaput avulsion fracture \n-  Tinel sign \n-  Toddler's fracture \n-  Tommy John surgery \n-  Trabecula \n-  Traction (orthopedics) \n-  Traction splint \n-  Trauma center \n-  Trauma surgery \n-  Trauma team \n-  Traumatology \n-  Trendelenburg gait \n-  Trendelenburg's sign \n-  Trethowan's sign \n-  Trevor's disease \n-  Triage \n-  Trimalleolar fracture \n-  Triple arthrodesis \n-  Tscherne classification \n-  Tumoral calcinosis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_809", "text": "Ulnar fracture \n-  Unhappy triad \n-  Unicompartmental knee arthroplasty \n-  Upington disease"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_810", "text": "Valgus deformity \n-  Valgus stress test \n-  Vancouver classification \n-  Varus deformity \n-  Vertebral osteomyelitis \n-  Villonodular synovitis \n-  Volkmann's canals \n-  Volkmann's contracture \n-  Volkmann avulsion fracture"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_811", "text": "Waddell's signs \n-  Wagstaffe-Le Fort avulsion fracture \n-  Wallis\u2013Zieff\u2013Goldblatt syndrome \n-  Wassel classification \n-  Watson-Jones anterolateral approach to the hip \n-  Watson's test \n-  Weaver\u2013Dunn procedure \n-  Webbed toes \n-  Wedge fracture \n-  Weil's osteotomy \n-  Wilson test \n-  Winged scapula \n-  Wolff's law \n-  WOMAC \n-  Wound healing \n-  Wrist drop \n-  Wrist osteoarthritis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_812", "text": "Yergason's test \n-  Young-Burgess classification"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_813", "text": "Zadek's procedure"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_814", "text": "James H-C. Wang  is a Chinese American orthopedic biomechanist and  academic . Currently, he is a  Professor  at the Departments of  Orthopaedic Surgery ,  Bioengineering , and PM&R at the  University of Pittsburgh . [ 1 ]  In addition, he is a Faculty Member at the  McGowan Institute for Regenerative Medicine . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_815", "text": "Wang is most known for his work on tissue biomechanics,  tissue engineering , and cell  mechanobiology . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_816", "text": "Wang is a Fellow of the International Orthopaedic Research (FIOR), and  American Institute for Medical and Biological Engineering  (AIMBE). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_817", "text": "Wang completed his  Bachelor of Science  in Engineering Mechanics in 1982 and  Master of Science  in Experimental Biomechanics in 1989 from  Tongji University . Later in 1996, he obtained  PhD  in  Bioengineering  from the  University of Cincinnati  in the US. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_818", "text": "In 1982, Wang joined Tongji University as an Assistant Instructor in the Department of Engineering Mechanics. After moving to USA, he finished his PhD at the University of Cincinnati and later completed postdoctoral training in  Biomedical Engineering  at  Johns Hopkins School of Medicine  and  Washington University in St. Louis . After his postdoctoral training, he joined the  University of Pittsburgh  in 1998, where he was  Assistant Professor  at the Department of Orthopaedic Surgery from 1998 to 2005. Subsequently, he held the position of tenured  Associate Professor  at the Department of Orthopaedic Surgery and associate professor at the Departments of Bioengineering,  Mechanical Engineering  and  Materials Science , and PM&R between 2005 and 2012. Since 2012, he has been serving as Professor at the Department of Orthopaedic Surgery and also Professor at the Departments of Bioengineering and PM&R. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_819", "text": "In 2017, he was appointed  Vice Chair  of Research at the Department of Orthopaedic Surgery at the University of Pittsburgh. Since 2004, he has been the Director of the MechanoBiology Laboratory in the same department. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_820", "text": "At the University of Pittsburgh, Wang has developed a research program in cell mechanobiology, which particularly focuses on the role of tendon cells in the development of  tendinopathy . He has been consistently receiving substantial funding support from  NIH  and  NSF . Additionally, he has been awarded research grants from DOD for several projects that aim to develop practical and clinically actionable strategies for the prevention and treatment of tendinopathy. He has authored numerous publications spanning the areas of tissue biomechanics, tissue engineering, and cell mechanobiology. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_821", "text": "To understand the inflammatory and degenerative responses of tendon due to overuse injury, Wang's group has established a validated animal model of tendinopathy by using mouse treadmill running that mimic human tendinopathy development. Additionally, his work emphasized the role of HMGB1 as a pivotal molecule in mechanically induced tendinopathy and proposed glycyrrhizin and metformin as potential therapeutic agents to inhibit HMGB1 activity, thereby offering preventive and treatment options for tendinopathy. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_822", "text": "Wang's research team has also worked on the identification and characterization of tendon stem cells (TSCs) in humans, mice, rats, and rabbits. [ 7 ]  Wang's tendon stem cell research has focused on the effects of different mechanical loading conditions on TSC growth and differentiation. [ 8 ]  Focusing on TSCs, his work highlighted the role of  TSC mechanobiology in tendon homeostasis as well as the development of degenerative tendinopathy. [ 8 ] [ 9 ]  His group showed that in normal conditions, the multi-differentiation potential of TSCs allows these stem cells to differentiate into tenocytes; however, under high stress and injurious conditions TSCs can undergo aberrant differentiation into adipocytes, chondrocytes, and osteocytes. Wang's team has established the beneficial effects of modest exercise on tendons via moderate treadmill running by the virtue of its effect in enhancing the function of TSCs resulting in the formation of normal-like tendon tissue at the site of injury. [ 10 ] [ 11 ]  In their examination of treatment options for tendon injuries, [ 12 ]  his group has provided insights into the application of biologics such as PRP [ 13 ]  for the effective treatment of tendon injuries. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_823", "text": "Wang also focuses his research on tissue engineering. His approach to regenerate tendons after injury includes the use of PRP. His group showed that PRP with minimal leukocytes, known as pure-PRP (P-PRP), induces TSC differentiation into active tenocytes. These tenocytes produce abundant collagens, enabling P-PRP to effectively repair tendon injuries. His team demonstrated that the combined application of kartogenin and PRP effectively enhanced the formation of a fibrocartilage region connecting the tendon graft and bone interface, thereby improving the biomechanical strength of the tendon-bone junction. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_824", "text": "The  management of scoliosis  is complex and is determined primarily by the type of scoliosis encountered: syndromic, congenital, neuromuscular, or idiopathic. [ 1 ]  Treatment options for idiopathic scoliosis are determined in part by the severity of the curvature and  skeletal maturity , which together help predict the likelihood of progression. Non-surgical treatment (conservative treatment) should be pro-active with intervention performed early as \"Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish.\" [ 2 ]  Treatment options have historically been categorized under the following types:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_825", "text": "For adults, treatment usually focuses on relieving any pain, [ 3 ] [ 4 ]  while physiotherapy and braces usually play only a minor role. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_826", "text": "Treatment for idiopathic  scoliosis  also depends upon the severity of the curvature, the spine\u2019s potential for further growth, and the risk that the curvature will progress."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_827", "text": "Mild scoliosis (less than 30 degrees deviation) has traditionally been treated through observation only. [ 7 ]  However, the progression of adolescent idiopathic scoliosis has been linked to rapid growth, [ 8 ]  suggesting that observation alone is inadequate as progression can rapidly occur during the pubertal growth spurt. Another study has further shown that the peak rate of growth during puberty can actually be higher in individuals with scoliosis than those without, further exacerbating the issue of rapid worsening of the scoliosis curves. [ 8 ]  Moderately severe scoliosis (30\u201345 degrees) in a child who is still growing requires bracing. A 2013 study by Weinstein et al. [ 9 ]  found that rigid bracing significantly reduces worsening of curves in the 20-45 degree range and found that 58% of children receiving \"observation only\" progressed to surgical range. Recent guidelines [ 10 ]  published by the Scientific Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) in 2016 state that \u201cthe use of a brace is recommended in patients with evolutive idiopathic scoliosis above 25\u00ba during growth\u201d based on a review of current scientific literature. Severe curvatures that rapidly progress may be treated surgically with spinal rod placement. Thus, early detection and early intervention prior to the pubertal growth spurt provides the greatest correction and prevention of progression to surgical range. [ 11 ]  In all cases, early intervention offers the best results. A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_828", "text": "Physical therapists  and  occupational therapists  help those who have experienced an injury or illness regain or maintain the ability to participate in everyday activities. For those with scoliosis, a physical therapist and/or occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition. This helps them manage physical symptoms and/or use compensatory techniques so that they can participate in  daily activities  like self-care, productivity, and leisure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_829", "text": "One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. [ 13 ]  Studies demonstrate that preventing force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, [ 14 ]  while other studies have also shown that braces can be used by individuals with scoliosis during physical activities. [ 15 ]  It is important to note that scoliosis is not merely a lateral or sideways deformity, but occurs in three dimensions [ 16 ]  as a rotational component is often present."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_830", "text": "Other interventions include postural strategies, such as posture training in sitting, standing, and sleeping positions, and in using positioning supports such as pillows, wedges, rolls, and corsets. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_831", "text": "Adaptive and compensatory strategies are also employed to help facilitate individuals to returning daily activities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_832", "text": "Scoliosis specific exercises have been found to improve treatment outcomes when utilized in addition to bracing and other standards of care. [ 18 ]  Scoliosis specific exercises include methods such as Schroth [ 19 ]  which specifically aim to correct aesthetic differences and strengthened muscles and connective tissue that may have atrophied as a result of scoliosis and asymmetric posture. Schroth exercises and other scoliosis specific exercises should be utilized in conjunction with bracing and other standards of care, [ 20 ]  and be performed under the guidance of a trained professional to ensure the exercises are effective and target the individual's curve pattern so that the correct muscles are strengthened. Strengthening spinal  muscles  is a crucial preventive measure. This is because the muscles in the back are essential when it comes to supporting the  spinal column  and maintaining the spine's proper shape.  Exercises  that will help improve the strength of the muscles in the back include rows and leg and arm extensions. [ 21 ]  Elastic  resistance exercise  may also be able to sustain the progression of  spinal curvature . [ 22 ]  This type of exercise is able to sustain progression by equalizing the strength of the torso muscles found on each side of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_833", "text": "Disability caused by scoliosis, as well as physical limitations during recovery from treatment-related surgery, often affects an individual\u2019s ability to perform  self-care  activities. [ 23 ]  One of the first treatments of scoliosis is the attempt to prevent further curvature of the spine. Depending on the size of the curvature, this is typically done in one of three ways: bracing, surgery, or postural positioning through customized cushioning. [ 23 ] [ 24 ] [ 25 ]  Stopping the progression of the scoliosis can prevent the loss of function in many  activities of daily living  by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_834", "text": "Occupational therapists  are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_835", "text": "For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of  occupational therapy  treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. [ 26 ]   For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist self-dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_836", "text": "Productive activities include paid or  unpaid work , household chores, school, and play. [ 27 ]  Recent studies in healthcare have led to the development of a variety of treatments to assist in the management of scoliosis thereby maximizing productivity for people of all ages.  Assistive technology  has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. [ 28 ]  As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_837", "text": "A common assistive technology intervention is specialized seating and postural control. For children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. [ 29 ]  A child's well-being in a productive sense involves the ability to participate in classroom and play activities. [ 27 ]  Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with  muscular dystrophy . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_838", "text": "With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position 20\u00b0 forward (toward the thighs), seating pressure is significantly redistributed, so sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward-sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. An open hip angle can benefit the used lung volume and respiration. [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_839", "text": "For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_840", "text": "Physical symptoms such as chest pains, back pains, shortness of breath, and limited spinal movement can hamper or preclude participation in leisure activities of a physical nature. The occupational therapist's role is to facilitate participation by helping the patient manage these symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_841", "text": "Bracing is a common strategy recommended by an occupational therapist, in particular, for individuals engaging in sports and exercise. [ 15 ]  An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_842", "text": "To help a person manage heart and lung symptoms, such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. [ 26 ]  This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy.  Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. [ 26 ]  Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An occupational therapist and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_843", "text": "Bracing is most effective when the patient has bone growth remaining (is skeletally immature) and should aim to both prevent progression of the curve (prevent progression to surgery), as well as reduce the scoliosis curve. Reduction of the curve is important as the natural history of idiopathic scoliosis suggests it can continue to progress at a rate ~1 degree per year in adulthood, [ 33 ]  while the treatment results of bracing have been shown to hold over >15 years. [ 34 ]  In some cases with juveniles, bracing has reduced curves significantly, going from a 40 degrees (of the curve, mentioned in length above.) out of the brace to 18 degrees in it. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers the torso; in some cases, it extends to the neck. The most commonly used brace is a  TLSO , such as a  Cheneau type brace , a  corset -like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is worn upwards of 18\u201323 hours a day, depending on the doctor's prescription, and applies pressure on the curves in the spine. The effectiveness of the brace depends not only on brace design and  orthotist  skill; patient compliance; and amount of wear per day, but also the \"stiffness\" of the spine resulting from a shortened spinal cord [ 35 ] [ 36 ]  and/or nerve tension. [ 37 ]  as evidence by the force necessary (mean force ~121 lbs) to physically correct scoliosis during spinal surgery [ 38 ] \nThe typical use of braces for idiopathic scoliosis is to prevent progression to surgical range as well as reduce the scoliotic curve of the spine as spinal fusion surgery can reduce mobility due to fusion of the vertebrate while potentially increasing pain long term. [ 39 ]  For non-idiopathic scoliosis (ie. neuromuscular, congenital, etc.) and those with additional comorbidities (ie.  Marfans Syndrome ) spinal surgery may be required due to structural changes in the spine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_844", "text": "Indications for Scoliosis Bracing:  Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient\u2019s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression [ 40 ]  as surgery can be prevented with early intervention of conservative treatment. [ 41 ]  Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29-degree Cobb angle and a Risser sign three or four might not need to be braced because there is reduced potential for progression. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_845", "text": "Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees [ 10 ]  and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. [ 43 ]  SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_846", "text": "Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period.  A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_847", "text": "The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25\u00b0, curves presenting between 30 and 45\u00b0,  Risser sign  0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_848", "text": "Progressive scolioses exceeding 25\u00b0 Cobb angle in the pubertal growth spurt should be treated with a pattern-specific brace like the Ch\u00eaneau brace and its derivatives, with an average brace-wearing time of 16 hours/day (23 hours/day assures the best possible result)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_849", "text": "The latest standard of brace construction is with CAD/CAM technology. With the help of this technology, it has been possible to standardize the pattern-specific brace treatment. Severe mistakes in brace construction are largely ruled out with the help of these systems. This technology also eliminates the need to make a plaster cast for brace construction. The measurements can be taken in any place and are simple (and not comparable to plastering). Available CAD/CAM braces include the Regnier-Ch\u00eaneau brace, the Rigo-System-Ch\u00eaneau-brace (RSC brace), the Silicon Valley Brace, and the Gensingen brace; braces can and should be customized to fit the individual's curve pattern and reduce the curve as much as possible as immediate in-brace correction has been shown to be associated with better treatment outcomes. [ 46 ] [ 47 ]  Many patients prefer the \"Ch\u00eaneau light\" brace as it has good in-brace corrections reported in international literature and is easier to wear than other braces in use today. [ 48 ] [ 49 ]  However, this brace is not available for all curve patterns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_850", "text": "Prior to 2013 the efficacy of bracing has not been definitively demonstrated in randomised clinical studies, with more limited studies giving inconsistent conclusions. [ 50 ]  In 2013 the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) published results establishing benefits of bracing in adolescents with idiopathic scoliosis. In the randomized cohort, 72% in the group instructed to wear a brace for 18 hours per day against 48% in the observation group sustained curve progression to under 50 degrees, the proxy used for not requiring surgery. Additionally results suggested that the more a patient wore the brace, the better the result. [ 51 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_851", "text": "In progressive infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible [ 53 ]  to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on a specialized frame under corrective traction, which helps to \"mould\" the infant's soft bones and work with their growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. [ 54 ]  EDF casting is now the only clinically known nonsurgical method of complete correction in progressive infantile scoliosis. Complete correction may be obtained for curves less than 50\u00b0 if the treatment begins before the second year of life. [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_852", "text": "Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45 to 50\u00b0 of magnitude), curves that would be cosmetically unacceptable as an adult, curves in patients with  spina bifida  and  cerebral palsy  that interfere with sitting and care, and curves that affect physiological functions such as breathing. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_853", "text": "Surgery for scoliosis is performed by a  surgeon  specializing in spine surgery. For various reasons, [ specify ]  it is usually impossible to completely straighten a scoliotic spine, but in most cases, significant corrections are achieved. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_854", "text": "The two main types of surgery are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_855", "text": "One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, takes four to eight hours. A Cochrane review could not draw conclusions on how effective surgical interventions were when compared to non-surgical interventions in patients with adolescent idiopathic scoliosis. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_856", "text": "Spinal fusion  is the most widely performed surgery for scoliosis. In this procedure, bone [either harvested from elsewhere in the body ( autograft ) or from a donor ( allograft )] is  grafted  to the vertebrae so when they heal, they form one solid bone mass and the  vertebral column  becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the  thoracic  or  abdominal  cavities, or more commonly, performed from the back (posterior). A combination may be used in more severe cases, though the modern pedicle screw system has largely negated the need for this. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_857", "text": "In recent years all-screw systems have become the gold-standard technique for adolescent idiopathic scoliosis.  Pedicle  screws achieve better fixation of the  vertebral column  and have better biomechanical properties than previous techniques, so enabling greater correction of the curve in all planes. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_858", "text": "Pedicle screw-only  posterior spinal fusion  may improve major curve correction at two years among patients with adolescent idiopathic scoliosis (AIS) [ 50 ]  as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a  retrospective, matched-cohort study . [ 58 ]  The prospective cohorts were matched to the retrospective cohorts according to patient age, fusion levels, Lenke curve type, and operative method. The two groups were not significantly different in regard to age, Lenke AIS curve type, or Riser grade. The numbers of fused vertebrae were significantly different (11.7\u00b11.6 for pedicle screw versus 13.0\u00b11.2 for hybrid group). This study's results may be biased due to the pedicle screw group's being analyzed prospectively versus retrospective analysis of the hybrid instrumentation group."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_859", "text": "In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. However a systematic review of  PubMed  papers in 2008 concluded \"Scoliosis surgery has a varying but high rate of complications\", although the non-standardised data on complications was difficult to assess and was incomplete. [ 59 ]  Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_860", "text": "A complementary surgical procedure a surgeon may recommend is called thoracoplasty (also called costoplasty). This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve. A rib hump is evidence of some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery, entirely."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_861", "text": "Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back straight."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_862", "text": "Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10\u201315% is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is the surgeon might inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity,  hemothorax  or  pneumothorax , respectively. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_863", "text": "Implants that aim to delay spinal fusion and to allow more spinal growth in young children is the gold standard for surgical treatment of early onset scoliosis. Surgery without fusion can be divided into three principles: distraction of the entire spine, compression of the short segment of spine, and guided-growth techniques. Distraction-based systems include Vertical, Expandable Prosthetic Titanium Ribs (VEPTR) & growing rods. The concept uses distraction to create additional soft-tissue space in-between the vertebrae, for the bone to later grow into. Its universal application was thrusted through the use of traditional growth rods which required repeated invasive surgeries every 6\u201312 months for the sustenance of growth, via distraction. Nowadays developed countries only use MAGEC (MAGnetic Expansion Control) rods to non-invasively lengthen the spine. In contrast, developing and under-developed countries still use traditional growing rods, which require invasive surgery every 6\u201312 months, because of high initial cost associated with procurement of MAGEC rods. Compression-based system include tethering using a flexible rope-like implant and are relatively new to receive FDA approval. Guided-growth technique include SHILLA (named after a hotel in Korea, where the concept was initiated). SHILLA has the advantage of being one-time surgery and is technologically less demanding compared with MAGEC rod. However, there are still two major disadvantages of using SHILLA: loss of correction and need for osteotomies. [ 62 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_864", "text": "The failure of most of these standalone techniques has shown that the concept of \u201cone size fits all\u201d is not applicable for the surgical management of EOS. Therefore, newer concepts employing two or more of the above philosophies, i.e. various combinations of distraction-based, guided-growth, and compression-based approaches might be more suitable and biomechanically-speaking, a more optimal surgical intervention. One such combination currently used for surgery includes  active apex correction (APC) . It is a hybrid of guided-growth and compression-based management of deformity. The technique simply consists of replacing the apical fusion (of traditional SHILLA) with unilateral compression (via pedicle screws or any other means) on the convex side. The latest clinical results presented by spine researchers  Aakash Agarwal  and Alaaedldin Azmi Ahmad on APC shows good clinical results with no economic barrier to use the technology. [ 62 ] [ 64 ] [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_865", "text": "The risk of undergoing surgery for scoliosis was estimated in 2008 to be varying, but with a high rate of complications. Possible complications may be inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding and nerve injuries. It is not yet clear what to expect from spine surgery in the long term. [ 66 ] [ 67 ]  Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains primarily a cosmetic indication [ dubious  \u2013  discuss ] , only especially in patients with adolescent idiopathic scoliosis, the most common form of scoliosis never exceeding 80\u00b0. [ 66 ] [ 68 ]  However, the cosmetic effects of surgery are not necessarily stable. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_866", "text": "For spinal fusion surgery on AIS cases, with instrumentation attached using pedicle screws, complication rates were reported in 2011 as transient neurological injuries between 0% to 1.5%, a pedicle fracture rate of 0.24%, screw malposition assessed by radiography at 1.5%, 6% when assessed by CT scans though these patients were asymptomatic not requiring screw revision, and screw loosening noted in 0.76% of patients. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_867", "text": "For surgery without fusion in growing children, substantial percentage of patients undergoing SHILLA technique experience loss of correction via crankshafting or adding-on (eg, distal migration). In addition, the need for osteotomies on the concave side has the potential of severe complications. For MAGEC rods, higher distraction magnitude resulted in the generation of higher distraction forces, and this in combination with off-axis loading (exemplified by \u201cgrowth marks\u201d) result in wear and breakage of MAGEC rod\u2019s components. [ 69 ] [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_868", "text": "In the event of surgery to correct scoliosis, pain medications and  anesthesia  will be administered. Before the surgery, the patient will receive anesthesia. With adults, the anesthesia will be administered through an IV in the antecubital region of the arm. With young children, however, the child will be asked to breathe in  nitrous oxide , or laughing gas. Because needles can be frightening for a young child, the nitrous oxide will put them to sleep so the  anesthesiologist  can then insert the IV in order to give them the anesthesia. After the surgery, the patient will most likely be given  morphine . Until the patient is ready to take the medicine by mouth, an IV will be giving them their medication. Morphine is the most common pain medicine used after scoliosis surgery, and is often administered through a  patient-controlled analgesia  (PCA) system.  The PCA system allows the patient to push a button when they are feeling pain, and the PCA will emit the drugs into the IV and then into the body.  To prevent overdoses, there is a limit on the number of times a patient can push the button. If a patient pushes the button too much at once, the PCA will reject the request. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_869", "text": "For the patient's bladder control, a  catheter  will be inserted so that a patient can urinate without having to move. A catheter is inserted because the patient will not have much free movement to be able to get up and walk to the bathroom. The most common type of catheter used after major surgeries is an indwelling  Foley catheter . The indwelling Foley catheter is most often put in the  urethra , with a tube leading into a drainage bag. Once the catheter is inserted into the urethra, a balloon is blown up inside the bladder in order to keep it from falling out. The balloon allows the catheter to remain inside the urethra until the patient is able to get up and go to the bathroom on their own. [ 72 ]  The drainage bag is connected to the side of the bed, and must be changed or emptied out once it is full."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_870", "text": "Bowel control can vary from patient to patient. The combination of no food, very little fluids, and a lot of  prescription drugs  has the potential to cause many patients to become constipated. The body is used to a normal diet, and used to excreting waste in a system. Interrupting the system can cause bowel problems. This  constipation  can be resolved in a couple of ways. The first way, and the most common way, is to administer a  rectal suppository . A rectal suppository is administered through the  anus , and into the  rectum . They are bullet-shaped and contain medicine that will help the patient's bowels get back on track. Once the suppository is inserted, it is designed to melt off the wax-like case, and put the medicine in the body. [ 73 ]  If the suppository does not work, a laxative may be continued at home to keep the bowels in full function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_871", "text": "When first returning home after surgery, a nutritional diet is necessary in order to keep the body operating correctly. Junk food is not a good idea, as the grease and sugar can irregulate the bowels. Fruit, vegetables, and juices will be a vital part in the diet. [ 74 ]  Food and drink will be limited for the patient after surgery. Because the bowels are not fully active because of anesthetic, clear water and ice may be the only acceptable thing to ingest. After the digestive tract is back up to speed, soft food and drink like pudding, soup broth, and orange juice are acceptable. [ 75 ]  Very dark urine with a strong odor means that the person is most likely dehydrated and needs more fluids. In order for the urine to become a pale or clear color, the patient will need to drink a lot of water. Juices such as prune juice are a healthy option and prune juice also helps with constipation, a common factor after surgery. When it comes to food, whole grains should be added into the diet. Whole grains can be broken down easily by the body whereas processed grains and flour cannot be broken down easily. Processed grains and flour also add to  constipation . [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_872", "text": "In 1962,  Paul Harrington  introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The original (now obsolete)  Harrington rod  operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. The Harrington rod represented a major advance in the field, as it obviated the need for prolonged casting, allowing patients greater mobility in the postoperative period and significantly reducing the quality of life burden of fusion surgery. Additionally, as the first system to apply instrumentation directly to the spine, the Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming of the Harrington method was it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early-onset arthritis, disc degeneration, muscular stiffness, and pain with eventual reliance on painkillers, further surgery, inability to work full-time, and disability.  \"Flatback\"  became the medical name for a related complication, especially for those who had lumbar scoliosis. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_873", "text": "In the 1960s, the gold standard for idiopathic scoliosis was a posterior approach using a single Harrington rod. Post-operative recovery involved bed rest, casts, and braces. Poor results became apparent over time. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_874", "text": "In the 1970s, an improved technique was developed using two rods and wires attached at each level of the spine. This segmented instrumentation system allowed patients to become mobile soon after surgery. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_875", "text": "In the 1980s,  Cotrel-Dubousset instrumentation  improved fixation and addressed  sagittal  imbalance and rotational defects unresolved by the Harrington rod system. This technique used multiple hooks with rods to give stronger fixation in three dimensions, usually eliminating the need for post-operative bracing. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_876", "text": "Orthopaedic Nurse, Certified  (ONC) is the designation for an  orthopaedic nurse  who has earned  nursing board certification  from the Orthopaedic Nurses Certification Board (ONCB)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_877", "text": "ONBC supports the advancement of health of orthopaedic patients by administering a certificate to the Orthopaedic nurse that improves their knowledge and practice to support patients with orthopaedic conditions or injuries. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_878", "text": "An Orthopaedic nurse is responsible for assessing new patients, monitoring the condition of their current patients, and providing treatments and medication. As part of this role, the nurse also monitors vital signs, assess the surgical sight, provide dressing changes, and notifies the doctor of any changes in the patient's condition. Finally, the Orthopaedic nurse also performs general nursing techniques, such as changing bedpans, assisting the patient with ambulation, maintaining care plans, providing IV medication, and informing and supporting the patient and their families."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_879", "text": "The optimal goal for the Orthopaedic nurse is to keep the patient comfortable, which may require turning the patient and providing pain relievers as needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_880", "text": "The Orthopaedic certification exam contains 150 questions, 135 of which are scored while the other 15 do not affect the test score. 97/135 is needed to pass the exam. Results are hosted by AMP, which is ONCB's test vendor. The ONCB then distributes the results directly to the new certified holder. The ONCB does not distribute the results to individual agencies. [ 2 ]  The exam is usually given in the Fall and Spring and is offered around the United States. To take the certification exam the nurse has to be licensed and have at least 2 years experience but doesn't need a bachelor's degree. Nurses must have 1000 hours of Orthopaedic patient care within the last 3 years. Certification lasts for 5 years, after which recertification or continuing education is required. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_881", "text": "Recertification in Orthopeadic Nursing requires 1000 practice hours logged in an applicant's past 5 years and 100 hours of education: 70 hours in Orthopaedics and 30 hours in general nursing. The application can take 8 weeks to process. Paper applications should be mailed with a return receipt. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_882", "text": "This  nursing -related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_883", "text": "The  Orthopaedic Research Society  ( ORS ) is a professional, scientific, and medical organization focused on  orthopaedic  research. [ 1 ] [ 2 ]  The stated mission of the ORS is to advance orthopaedic research through education, collaboration, communication, and advocacy. [ 3 ] [ 4 ]  The ORS aims to raise resources for orthopaedic research and increase the awareness of the impact of such research on patients and the public. Annual meetings are held across the US to discuss current research, with a number of  awards  available to further career trajectories of members."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_884", "text": "In 1940, the Research Committee of the  American Academy of Orthopaedic Surgeons , chaired by  Alfred R. Shands , [ 5 ]  conducted a survey of its members which indicated that over 180 members were conducting some type of research. [ 6 ]  This finding prompted several  musculoskeletal  investigators to express the desire for having a forum to present and share their work. [ 7 ]   Philip D. Wilson Jr. , a member of the Academy, along with several others, met in San Francisco and proposed the idea of starting an organization focused solely on musculoskeletal research. This idea gained unanimous support from the  American Academy of Orthopaedic Surgeons  at their Annual Meeting in 1951. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_885", "text": "In 1952, the first meeting of the founding members of the ORS took place. At this first meeting,  Philip D. Wilson Jr.  created a draft constitution and set of by-laws for the fledgling society. [ 8 ]   It was determined that the purpose of the society was to \"encourage and coordinate investigation and research in basic principles or clinical problems related to the special field of Orthopaedic Surgery.\" [ 7 ]    Due to the unexpected death of  Dallas B. Phemister , who had agreed to take on the role of chairman, the formal organization of the society was delayed. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_886", "text": "1954 marked the first official meeting of the group at the Palmer House in Chicago under the Chairmanship of Wilson. [ 8 ]   At this first meeting there were twenty-nine people in attendance.  Cultivating the relationship between clinicians and scientists while providing them with opportunities to come together and share ideas was the driving factor in establishing the society. \"The close relationship of between clinicians and basic scientists would help ensure the prominent role of orthopaedic surgeons in delivering care to patients with injuries and diseases of the  musculoskeletal system ,\" explained Eugene R. Mindell, [ 9 ]  MD who served as president of the ORS from 1972\u20131973. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_887", "text": "As of June\u00a02018 [update] , membership had grown to more than 4,100 members from across the globe. [ 10 ]   Once a role only held by surgeons, in 1982 the ORS elected  Van C. Mow  as the first PhD president.  Currently, Presidents are elected from each of the three disciplines represented in the membership: clinicians, biologists, and engineers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_888", "text": "Past presidents of the ORS have included  Farshid Guilak  and  Marjolein C. van der Meulen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_889", "text": "Members of the ORS conduct cutting-edge research on the full range of musculoskeletal tissues\u00a0:  bone ,  tendon ,  cartilage  &  synovium ,  meniscus ,  skeletal muscle , and the  intervertebral disc . Researchers focus on all aspects of these tissues, including  development , structure and function, mechanics, diagnostics, injury and healing, and potential therapeutics. Special emphasis is given to pathologies that cause significant morbidity in patients, such as  osteoarthritis ,  osteoporosis ,  osteopenia ,  rheumatoid arthritis ,  fracture healing ,  ACL tears ,  tendinopathies , and  meniscus tears ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_890", "text": "More recently a number of research subsections have been formed, starting with the Spine Section in 2015. These small communities bring together like-minded researchers with a focus on a specific topic of research. Since then, the number of sections has expanded to include: International Section of Fracture Repair, Meniscus Section, Orthopaedic Implants Section, Preclinical Models Section, Strategies in Clinical Research Section, and the Tendon Section. Each of these meets annually at the regular meeting, and some have added satellite meetings to create more opportunity for collaboration in their respective field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_891", "text": "The  Journal of Orthopaedic Research  is a peer-reviewed journal that is published in cooperation with  John Wiley & Sons, Inc . [ 11 ]  The journal provides an essential forum for the orthopaedic community to share and communicate new information in the different research areas of orthopaedics, including  life sciences ,  engineering ,  translational  and  clinical studies . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_892", "text": "JOR Spine  is a fully open access and peer-reviewed journal that was established by the ORS. [ 12 ]  The journal provides a platform to share original and innovative information focusing on basic and translational research of the spine. Publications in this journal include the following topics in spine research:  ageing ,  biomaterials ,  biomechanics ,  bioreactors ,  degeneration ,  genetics ,  inflammation ,  pain , remodeling,  tissue engineering , etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_893", "text": "Coordinated by the ORS Basic Science Education Committee,  On the Horizon  presents brief articles discussing current scientific investigations that may have future orthopaedic clinical applications.\nThis feature was previously presented quarterly in the  Journal of the American Academy of Orthopaedic Surgeons  (January, April, July, and October), where archived articles remain available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_894", "text": "The ORS is invested in developing partnerships and collaborations dedicated to research, outreach and education worldwide:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_895", "text": "LearnORS  is an online platform that offers courses suited for PhD candidates, medical students, postdoctoral fellows, orthopaedic residents, orthopaedic fellows, and industry researchers interested in learning more about orthopaedic research. Courses include those geared towards improving grant writing, basic musculoskeletal science, and clinical research, among others. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_896", "text": "The  Musculoskeletal Knowledge Portal (MSK-KP)  is currently in development by a team of scientists and software engineers at the  Broad Institute  in collaboration with the International Federation of Musculoskeletal Research Societies (IFMRS). The site enables browsing, searching, and analysis of human genomic information associated with musculoskeletal traits and pathology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_897", "text": "ORS Open Door is an outreach activity aimed at communicating orthopaedic/musculoskeletal science to the general public, and takes place during the annual meeting in the local community. Open Door 2023\u2019s target audience was middle school- and high school-aged students from the Dallas area, with the goal of sharing potential careers and topics in musculoskeletal science to under-represented minorities and first-generation students in STEM (science, technology, engineering, mathematics) fields."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_898", "text": "Open Door 2024 will be held in Long Beach CA just prior to the annual meeting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_899", "text": ")"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_900", "text": "Orthopaedic Studio  is an application designed to help  orthopaedic  specialists perform several common quantitative hip examinations that are based on standard  x-ray images ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_901", "text": "The application is implemented as a plugin for the medical image viewer  OsiriX  and thereby only runs on  Mac OS X ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_902", "text": "Orthopaedic Studio evaluates four different types of hip  radiographs  (standing anteroposterior, Von Rosen, false profile and frog). On such images a number of standardized angles, offsets and ratios can be measured, including: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_903", "text": "The following visual scores can also be registered:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_904", "text": "This article related to  health software  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_905", "text": "This article about  orthopedic surgery  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_906", "text": "OrthoPediatrics  is an American  bio-science  company engaged in designing, developing, manufacturing, and distributing orthopedic  implants  and  instruments  for  pediatric  issues. [ 1 ]  It is based in  Warsaw, Indiana . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_907", "text": "Founded in 2006, OrthoPediatrics is an orthopedic company focused on providing  product offerings to the pediatric  orthopedic  market to improve the lives of children with  orthopedic conditions . [ 3 ] [ 4 ]  They currently market 24 surgical systems spanning trauma and deformity,  scoliosis  and sports medicine among others. [ 3 ] [ 4 ] [ 5 ]  They hold exclusive rights to the Hamann-Todd Human Osteological Collection at the  Cleveland Museum of Natural History . [ 6 ]  The company is dedicated to clinical research and education and licensed its name to establish a  501(c)(3)  public charity focused on advancements in the field of pediatric orthopedics. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_908", "text": "In October 2017, they went public with a common stock of 4,000,000 shares and raised $52 M with $13 per share. [ 8 ] [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_909", "text": "OrthoPediatrics has partnerships with 31 independent distributors selling products to children's hospital in the United States and 34 countries globally."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_910", "text": "They signed a license agreement with the Sydney Children's Hospitals Network in 2016 and a partnership agreement with Mighty Oak Medical for FIREFLY Technology in 2017. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_911", "text": "OrthoPediatrics holds nine patents for bottom loaded pedicle screw, bone screw, graft fixation, bone screw, surgical connectors and instrumentation, pediatric long bone support or fixation plate, pediatric intramedullary nail, compression bone fragment wire, convertible threaded compression device and its method of use. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_912", "text": "This United States corporation or company article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_913", "text": "Orthotics  ( Greek :  \u039f\u03c1\u03b8\u03cc\u03c2 ,  romanized :\u00a0 ortho ,  lit. \u2009 'to straighten, to align') is a  medical specialty  that focuses on the design and application of  orthoses , sometimes known as braces, calipers, or splints. [ 1 ]  An  orthosis  is \"an externally applied device used to influence the structural and functional characteristics of the  neuromuscular  and  skeletal systems .\" [ 2 ]   Orthotists  are medical professionals who specialize in designing orthotic devices such as braces or foot orthoses."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_914", "text": "Orthotic devices are classified into four areas of the body according to the international classification system (ICS): [ 2 ]  orthotics of the  lower extremities , orthotics of the  upper extremities , orthotics for the  trunk , and orthotics for the head. Orthoses are also classified by function: paralysis orthoses and relief orthoses. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_915", "text": "Under the  International Standard  terminology, orthoses are classified by an acronym describing the anatomical joints they support. [ 2 ]  Some examples include KAFO, or knee-ankle-foot orthoses, which span the knee, ankle, and foot; TLSO, or thoracic-lumbar-sacral orthoses, supporting the  thoracic ,  lumbar  and   sacral  regions of the  spine . The use of the International Standard is promoted to reduce the widespread variation in the description of orthoses, which is often a barrier to interpreting research studies. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_916", "text": "The transition from an orthosis to a  prosthesis  can be fluid. An example is compensating for a leg length discrepancy, equivalent to replacing a missing part of a limb. Another example is the replacement of the forefoot after a forefoot  amputation . This treatment is often made from a combination of a prosthesis to replace the forefoot and an orthosis to replace the lost muscular function (ortho prosthesis). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_917", "text": "An orthotist is a specialist responsible for the customising, manufacture, and repair of orthotic devices (orthoses). [ 5 ]  The manufacture of modern orthoses requires both artistic skills in modeling body shapes and manual skills in processing traditional and innovative materials\u2014  CAD / CAM ,  CNC machines  and  3D printing  are involved in orthotic manufacture. [ 6 ]  Orthotics also combines knowledge of anatomy and physiology,  pathophysiology ,  biomechanics  and engineering. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_918", "text": "In the United States, while orthotists require a prescription from a licensed healthcare provider, physical therapists are not legally authorized to prescribe orthoses. In the U.K., orthotists will often accept referrals from doctors or other healthcare professionals for orthotic assessment without requiring a prescription. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_919", "text": "Orthoses are offered as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_920", "text": "Both custom-fabricated products and semi-finished products are used in long-term care and are manufactured or adapted by the orthotist or by trained orthopedic technicians according to the prescription. In many countries the physician or clinician defines the functional deviations in his prescription, e.g. paralysis ( paresis ) of the calf muscles ( M. Triceps Surae ) and derives the indication from this, e.g. orthotic to restore safety when standing and walking after a  stroke . The orthotist creates another detailed physical examination and compares it with the prescription from the physician. The orthotist describes the configuration of the orthosis, which shows which orthotic functions are required to compensate for the functional deviation of the neuromuscular or skeletal system and which functional elements must be integrated into the orthosis for this. Ideally, the necessary orthotic functions and the functional elements to be integrated are discussed in an interdisciplinary team between physician,  physical therapist , orthotist and patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_921", "text": "All orthoses that affect the foot, the ankle joint, the lower leg, the knee joint, the thigh or the hip joint belong to the category of orthoses for the lower extremities. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_922", "text": "Paralysis  orthoses are used for partial or complete paralysis, as well as complete functional failure of muscles or muscle groups, or incomplete paralysis ( paresis ). They are intended to correct or improve functional limitations or to replace functions that have been lost as a result of the paralysis. Functional leg length differences caused by paralysis can be compensated for by using orthosis. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_923", "text": "For the quality and function of a paralysis orthosis, it is important that the orthotic shell is in total-contact  with the patient's leg to create an optimal fit, which is why a custom-made orthotic is often preferred. As reducing the weight of an orthosis significantly lessens the energy needed to walk with it, the use of light weight and highly resilient materials such as  carbon fiber ,  titanium  and  aluminum  is indispensable for the manufacture of a custom-made orthosis. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_924", "text": "The production of a custom-made orthotic also allows the integration of orthotic joints, which means the dynamics of the orthotic can be matched exactly with the pivot points of the patient's anatomical joints. As a result, the dynamics of the orthosis take place exactly where dictated by the patient's anatomy. Since the dynamics of the orthosis are executed via the orthotic joints, it is possible to manufacture the orthotic shells as stable and torsion-resistant, which is necessary for the quality and function of the orthosis. The orthosis thus offers the necessary stability to regain the security that has been lost due to paralysis when standing and walking. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_925", "text": "In addition, an orthosis can be individually configured through the use of orthosis joints. In this way, the combination of the orthotic joints and the adjustability of the functional elements can be adjusted to compensate for any existing functional deviations that have resulted from the muscle weakness. [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ]  The goal of a high-quality orthotic fitting is to adjust the functional elements so precisely that the orthosis provides the necessary support while restricting the dynamics of the lower extremities as little as possible to preserve the remaining functionality of the muscles. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_926", "text": "In the case of paralysis due to disease or injury to the spinal/peripheral nervous system, a  physical examination  is needed to determine the strength levels of the affected leg's six major muscle groups and the orthosis's necessary functions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_927", "text": "According to Vladimir Janda, a muscle function test is carried out to determine strength levels. [ 18 ]  The degree of paralysis is given for each muscle group on a scale from 0 to 5, with the value 0 indicating complete paralysis (0%) and the value 5 indicating normal strength (100%). The values between 0 and 5 indicate a percentage reduction in muscle function. All strength levels below five are called  muscle weakness ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_928", "text": "The combination of strength levels of the muscle groups determines the type of orthosis (AFO or KAFO) and the functional elements necessary to compensate for restrictions caused by the reduced muscular strength levels. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_929", "text": "Paralysis may be caused by injury to the spinal or peripheral nervous system after  spinal cord injury , or by diseases such as  spina bifida ,  poliomyelitis  and  Charcot-Marie-Tooth disease . In these patients, knowledge of the strength levels of the large muscle groups is necessary to configure the orthotic  for the necessary functions. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_930", "text": "Paralysis caused by diseases or injuries to the central nervous system (e.g.  cerebral palsy ,  traumatic brain injury ,  stroke , and  multiple sclerosis ) can cause incorrect motor impulses that often result in clearly visible deviations in gait. [ 19 ] [ 20 ]  The usefulness of muscle strength tests is therefore limited, as even with high degrees of strength, disturbances to the gait pattern can occur due to the incorrect control of the central nervous system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_931", "text": "In  ambulatory  patients with paralysis due to  cerebral palsy  or  traumatic brain injury ,  the gait pattern is analysed as part of the  physical examination  in order to determine the necessary functions of an orthosis. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_932", "text": "One way of classifying gait is according to the \"Amsterdam Gait Classification\", which describes five gait types. To assess the gait pattern, the patient is viewed directly, or via a video recording, from the side of the leg being assessed. At the point when the leg is   mid-stance  the knee angle and the contact of the foot with the ground are assessed. [ 21 ]  The five gait types are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_933", "text": "Patients with paralysis due to cerebral palsy or traumatic brain injury are usually treated with an ankle-foot orthosis (AFO). Although in these patients the muscles are not paralyzed but being sent the wrong impulses from the brain, the functional elements used in the orthotics are the same for both groups. The compensatory gait is an unconscious reaction to the lack of security when standing or walking that usually worsens with increasing age; [ 20 ]  if the right functional elements are integrated into the orthosis to counter this, and maintain physiological mobility, the right motor impulses are sent to create new cerebral connections. [ 23 ]  The goal of an orthotic is the best possible approximation of the physiological gait pattern. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_934", "text": "In the case of paralysis after a  stroke , rapid care with an orthosis is necessary. Often areas of the brain are affected that contain \"programs\" for controlling the musculoskeletal system. [ 25 ] [ 26 ] [ 27 ]  With the help of an orthosis, physiological standing and walking can be relearned, preventing long term health consequences caused by an abnormal gait pattern. [ 28 ]  According to Vladimir Janda, when configuring the orthotic it is important to understand that the muscle groups are not paralyzed, but are controlled by the brain with wrong impulses, and this is why a muscle function test can lead to incorrect results when assessing the ability to stand and walk. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_935", "text": "An important basic requirement for regaining the ability to walk is that the patient trains early on to stand on both legs safely and well balanced. An orthosis with functional elements to support balance and safety when standing and walking can be integrated into physical therapy from the first standing exercises, and this makes the work of mobilizing the patient at an early stage easier. With the right functional elements that maintain physiological mobility and provide security when standing and walking, the necessary motor impulses to create new cerebral connections can occur. [ 23 ]  Clinical studies confirm the importance of orthoses in stroke rehabilitation. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_936", "text": "Patients with paralysis after a stroke are often treated with an ankle-foot orthosis (AFO), as after a stroke stumbling can occur if only the  dorsiflexors  are supplied with incorrect impulses from the central nervous system. This can lead to insufficient foot lifting during swing phase of walking, and in these cases, an orthosis that only has functional elements to support the dorsiflexors can be helpful. Such an orthosis is also called drop foot orthosis. When configuring a foot lifter orthosis, adjustable functional elements for setting the resistance can be included, which make it possible to adapt the passive lowering of the forefoot (plantar flexion) to the  eccentric work  of the dorsal flexors during loading response. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_937", "text": "In cases where the muscle group of the  plantar flexors  is supplied with wrong impulses from the central nervous system, which leads to uncertainty when standing and walking, an unconscious compensatory gait can occur. [ 20 ]  When configuring an orthosis functional elements that can restore safety when standing and walking must be used in these cases; a foot lifter orthosis is not suitable as it only compensates for the functional deviations caused by weakness of the dorsiflexors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_938", "text": "Patients with paralysis after stroke who are able to walk have the option of analysing the gait pattern in order to determine the optimal function of an orthosis. One way of assessing is the classification according to the \"N.A.P. Gait Classification\", which is a physiotherapeutic treatment concept. [ 30 ]  According to this classification, the gait pattern is assessed in the mid-stance phase and described as one of four possible gait types."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_939", "text": "This assessment is a two step process; in the first step, the patient is viewed from the side of the leg to be assessed, either directly or via a video recording. In gait type 1 the knee angle is hyperextended, while in type 2, the knee angle is flexed. In the second step, the patient is viewed from the front to determine if the foot is  inverted , if it is the letter \"a\" is added to the gait. This is associated with a  varus deformity  of the knee. If instead the patient stands on the inner edge of the foot (eversion), which is associated with a  valgus deformity  of the knee, the letter \"b\" is added to the gait type. Patients are thus classified as gait types 1a, 1b, 2a or 2b. The goal of orthotic fitting for patients who are able to walk is the best possible approximation of the physiological gait pattern. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_940", "text": "In the case of paralysis due to  multiple sclerosis , the degree of strength of the six major muscle groups of the affected leg should be determined as part of the  physical examination  in order to determine the necessary functions of an orthosis, just as in the case of diseases or injuries to the spinal/peripheral nervous system. However, patients with multiple sclerosis may experience muscular fatigue as well. The fatigue can be more or less pronounced and, depending on the severity, can lead to considerable restrictions in everyday life. Persistent stress, such as from walking, causes a deterioration in muscle function and has a significant effect on the spatial and temporal parameters of walking, for example by significantly reducing the cadence and walking speed. [ 31 ] [ 32 ] [ 33 ]  Fatigue can be measured as  muscle weakness . When determining the strength levels of the six major muscle groups as part of the patient's medical history, fatigue can be taken into account by using a standardized six-minute walking test. [ 34 ]  According to Vladimir Janda the muscle function test is carried out in combination with the six-minute walk test in the following steps:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_941", "text": "This sequence of muscle function test and six-minute walk test is used to determine whether muscular fatigue can be induced. If the test reveals muscular fatigue, the strength levels and measured fatigue should be included in the planning of an orthosis, and when determining the functional elements. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_942", "text": "Paralysis of the dorsiflexors \u00a0\u2013  weakness  of the  dorsiflexors  results in a  drop foot . The patient's foot cannot be sufficiently lifted during the swing phase while walking, as the necessary concentric work of the dorsiflexors can not be activated. [ 35 ]  There is a risk of stumbling, and the patient cannot influence the shock absorption when walking (gait phase, loading response), as the  eccentric work  of the dorsiflexors is limited. [ 35 ]  After initial heel contact the forefoot either slaps too quickly on the floor via the heel rocker, which creates an audible noise, or the foot does touch the floor with forefoot first, which disrupts gait development. [ 36 ] :\u200a178\u2013181\u200a [ 37 ] :\u200a44\u201345,\u200a50\u201354 and 126\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_943", "text": "Paralysis of the plantar flexors \u00a0\u2013 If the  plantar flexors  are weak, the muscles of the forefoot lever are either inadequately activated or not activated at all. The patient has no balance when standing and has to support themself with aids such as  crutches . The forefoot lever required for energy-saving walking in the gait phases from mid-stance to pre-swing cannot be activated by the plantar flexors. This leads to excessive dorsiflexion in the ankle joint in terminal stance and a loss of energy while walking. The center of gravity of the body lowers towards the end of the stance phase and the knee of the contralateral leg is flexed excessively. With each step, the center of gravity must be raised above the leg by straightening the excessively flexed knee. Since the plantar flexors originate above the knee joint, they also have a knee-extension effect in the stance phase. [ 36 ] :\u200a177\u2013210\u200a [ 37 ] :\u200a72\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_944", "text": "Paralysis of the knee extensors \u00a0\u2013 if the  knee extensors  are weak, there is an increased risk of falling when walking, as between loading response to the mid-stance the knee extensors control knee flexion inadequately, or not at all. To control the knee, the patient develops compensatory mechanisms that lead to an incorrect gait pattern, for example by exaggerated activation of the plantar flexors, leading into hyperextension of the knee, or when initial contact is with the forefoot and not the heel in order to prevent the knee-flexing effect of the heel rocker. [ 36 ] :\u200a222,\u200a226\u200a [ 37 ] :\u200a132,\u200a143,\u200a148\u2013149\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_945", "text": "Paralysis of the knee flexors \u00a0\u2013 if the knee flexors are weak, it is more difficult to flex the knee in pre-swing. [ 36 ] :\u200a220\u200a [ 37 ] :\u200a154\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_946", "text": "Paralysis of the hip flexors \u00a0\u2013 if the hip flexors are weak, it is more difficult to flex the knee in pre-swing. [ 36 ] :\u200a221\u200a [ 37 ] :\u200a154\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_947", "text": "Paralysis of the hip extensors \u00a0\u2013 the  hip extensors  help control of the knee against unwanted flexion when walking between loading response and mid-stance. [ 36 ] :\u200a216\u201317\u200a [ 37 ] :\u200a45\u201346\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_948", "text": "The functional elements of an orthosis ensure the flexion and extension movements of the ankle, knee and  hip joints. They correct and control the movements and secure the joints against undesired incorrect movements, and help avoid falls when standing or walking. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_949", "text": "Functional elements in paralysis of the dorsiflexors \u00a0\u2013 if the  dorsiflexors  are weak, an orthosis should lift the forefoot during the swing phase in order to reduce the risk of the patient stumbling. An orthosis that has only one functional element for lifting the forefoot in order to compensate for a weakness in the dorsiflexors is also known as a drop foot orthosis. An AFO of the drop foot orthosis type is therefore not suitable for the care of patients with weakness in other muscle groups, as these patients require additional functional elements to be taken into account. Initial contact with the heel should be achieved by lifting the foot through the orthosis, and if the dorsiflexors are very weak, control of the rapid drop of the forefoot should be taken over by dynamic functional elements that allow for adjustable resistance of  plantar flexion . Orthoses should be adapted to the functional deviation of the dorsiflexors in order to correct the shock absorption of the heel rocker lever during loading response, but should not block plantar flexion of the ankle joint as this leads to excessive flexion in the knee and hip and an increase in the energy needed for walking. This is why static functional elements are not recommended when there are newer technical alternatives. [ 12 ] [ 36 ] :\u200a105\u200a [ 37 ] :\u200a134\u200a [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_950", "text": "Functional elements in paralysis of the plantar flexors \u00a0\u2013 in order to compensate for a  weakness  of the  plantar flexors , the orthosis has to transfer large forces that the strong muscle group would otherwise take over. These forces are transmitted in a similar way to a ski boot during downhill skiing via the functional elements of the foot part, ankle joint and lower leg shell. Dynamic functional elements are preferable for the ankle joint as static functional elements would completely block the dorsiflexion, which would have to be compensated for by the upper body, resulting in an increased energy cost when walking. [ 15 ]  The functional element's resistance to protect against unwanted dorsiflexion should be able to be adapted according to the weakness of the plantar flexors. In the case of very weak plantar flexors, the functional element's resistance against undesired dorsiflexion must be very high in order to compensate for the functional deviations this causes. [ 39 ] [ 16 ]  Adjustable functional elements allow the resistance to be adjusted exactly to the weakness of the muscle, and scientific studies recommend adjustable resistance in patients with paralysis or weakness of the plantar flexors. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_951", "text": "Functional elements in paralysis of knee extensors and hip extensors \u00a0\u2013 in the case of weak  knee extensors  or  hip extensors , the orthosis must take over the stability and stance phase control when walking. Different knee-securing functional elements are needed depending on the weakness of these muscles. In order to compensate for functional deviations with slightly weakness of these muscle groups, a free moving mechanical knee joint with the mechanical pivot point behind the anatomical knee pivot point can be sufficient. In the case of significant weakness, knee flexion when walking must be controlled by functional elements that mechanically secure the knee joint during the early stance phases between loading response and mid stance. Stance phase control knee joints which lock the knee in the early stance phases and release it for knee flexion during the swing phase can be used here, with these joints, a natural gait pattern can be achieved despite mechanically securing against unwanted knee flexion. In these cases, locked knee joints are often used, and while they have a good safety function, the knee joint remains mechanically locked during the swing phase while walking. Patients with locked knee joints have to manage the swing phase with a stiff leg, which only works if the patient develops compensatory mechanisms, such as by raising the body's center of gravity in the swing phase ( Duchenne  limping) or by swinging the orthotic leg to the side ( circumduction ). Stance phase control knee joints and locked joints can both be mechanically \"unlocked\" so the knee can be flexed to sit down. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_952", "text": "AFO is the abbreviation for ankle-foot orthoses, which is the English name for an orthosis that spans the ankle and foot. [ 2 ]  In the treatment of paralyzed patients, they are mainly used when there is a  weakness  of the  dorsiflexors  or  plantar flexors . [ 40 ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_953", "text": "Through the use of modern materials, such as carbon fibers and  aramid  fibers, and new knowledge about processing these materials into composite materials, the weight of orthotics has been reduced significantly. In addition to the weight reduction, these materials and technologies have created the possibility of making some areas of an orthosis so rigid that it can take over the forces of the weakened muscles (e.g. the connection from the ankle joint to the frontal contact surface on the shin), while at the same time leaving areas requiring less support very flexible (e.g. the flexible part of the forefoot). [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_954", "text": "It is now possible to combine the required rigidity of the orthotic shells with the dynamics in the ankle, [ 43 ]  with this, other new technologies, and the possibility of producing lightweight but rigid orthoses, new demands have been made of orthotics: [ 44 ] [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_955", "text": "A custom-made AFO can compensate for functional deviations of muscle groups, it should be configured according to the patient data through a function and load calculation so that it meets the functional and load requirements. In calculating or configuring an AFO, variants are optimally matched to individual requirements for the functional elements of the ankle joint, for the stiffness of the foot shell, and for the shape of the lower leg shell. The size of these components is selected by matching their resilience to the load data. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_956", "text": "An ankle joint based on new technology is the connection between the foot shell and the lower leg shell and at the same time contains all the necessary adjustable functional elements of an AFO. [ clarification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_957", "text": "Depending on the combination of the degree of paralysis of the  dorsiflexors  or  plantar flexors , different functional elements to compensate for their weakness can be integrated into the ankle joint; if both muscle groups are affected, the elements should be integrated into one orthotic joint. The necessary dynamics and resistance to movements in the ankle can be adapted via adjustable functional elements in the ankle joint of the orthosis, which allows it to compensate for muscle weaknesses, provide safety when standing and walking, and still allow as much mobility as possible. For example, adjustable spring units with pre-compression can enable an exact adaptation of both static and dynamic resistance to the measured degree of muscle weakness. Studies show the positive effects of these new technologies. [ 12 ] [ 14 ] [ 15 ] [ 39 ] [ 16 ]  It is of great advantage if the resistances for these two functional elements can be set separately. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_958", "text": "An AFO with functional elements to compensate for a weakness of the  plantar flexors  can also be used for slight weakness of the knee-securing muscle groups, the  knee extensors  and the  hip extensors . [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_959", "text": "A drop foot orthosis is an AFO that only has one functional element for lifting the forefoot in order to compensate for a weakness in the dorsiflexors. [ 46 ]  If other muscle groups, such as the plantar flexors, are weak, additional functional elements must be taken into account, making a drop foot orthosis unsuitable for patients with weakness in other muscle groups."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_960", "text": "In 2006, before these new technologies were available, the  International Committee of the Red Cross  published in its 2006 Manufacturing Guidelines for Ankle-Foot Orthoses, with the aim of providing people with disabilities worldwide standardized processes for the production of high-quality, modern, durable and economical devices. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_961", "text": "Because new technologies are not widely used, AFOs are often made from polypropylene-based plastic, mostly in the shape of a continuous \"L\" shape, with the upright part behind the calf and the lower part under the foot, however, this only offers the rigidity of the material. AFOs made of polypropylene are still called \"DAFO\" (dynamic ankle-foot orthosis), \"SAFO\" (solid ankle-foot orthosis) or \"Hinged AFO\". DAFOs are not stable enough to transfer the high forces required to balance the weak plantar flexors when standing and walking, and SAFOs block the mobility of the ankle joint. A \"Hinged AFO\"  only allowed for the compensation that could be achieved with the orthotic joints of the time, for example, they commonly block plantar flexion, as the joints cannot simultaneously transmit the large forces that are required to compensate for muscle deviations while also  offering the necessary dynamics. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_962", "text": "While there was a multitude of AFOs with differing designs in clinical practice, there was also a clear lack of details regarding the design and the materials used for manufacture, leading Eddison and  Chockalingam  to call for a new standardization of the terminology. [ 48 ] [ 49 ]  With a focus on caring for children with cerebral palsy there is a recommendation to investigate the potential for gait pattern improvement via the design and manufacture of orthotics made of polypropylene. [ 50 ]  On the other hand, integrating orthotic joints with modern functional elements into the  production of older technologies using polypropylene is unusual because the orthotic shells made of polypropylene either could not transfer the high forces or would be too soft. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_963", "text": "New studies now show the better possibilities for improving the gait pattern through the new technologies. [ 12 ] [ 15 ] [ 39 ] [ 16 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_964", "text": "The International Committee of the Red Cross published its manufacturing guidelines for ankle\u2013foot orthoses in 2006, and, unfortunately, today's terminologies are still based those guidelines and therefore require a particularly high level of explanation. [ 47 ]  The intent was to provide standardized procedures for the manufacture of high-quality modern, durable and economical devices to people with disabilities throughout the world. However, with the new technologies available, the main types mentioned are in need of revision today."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_965", "text": "plus the body parts included in the orthosis fitting: ankle and foot, English abbreviation: AFO for ankle-foot orthoses"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_966", "text": "\"SAFO\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_967", "text": "Rigid AFO [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_968", "text": "\"DAFO\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_969", "text": "Flexible AFO [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_970", "text": "\"Hinged-AFO\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_971", "text": "\"Hinged\" simply means a flexible connection between the two parts of the orthosis. The joint itself does not offer any further functional elements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_972", "text": "AFO with Tamarack Flexure Joint"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_973", "text": "\"Posterior Leaf Spring\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_974", "text": "Spring made from flexible material behind (posterior) the ankle"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_975", "text": "A DAFO often also known as \"Posterior Leaf Spring\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_976", "text": "FR for Floor reaction"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_977", "text": "\"FRAFO\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_978", "text": "Designation is misleading as other orthoses also have this function"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_979", "text": "Plus further descriptions, such as:\n - ventral shell with torsionally rigid reinforcement to focus the dynamics on the ankle joint\n - dynamic ankle joint with precompressed spring elements to control plantarflexion and dorsiflexion"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_980", "text": "KAFO is the abbreviation for knee-ankle-foot orthoses, which spans the knee, ankle and foot. [ 51 ]  In the treatment of paralyzed patients, a KAFO is used when there is a  weakness  of the knee  or hip extensors. [ 17 ] [ 40 ] [ 41 ]  They have two orthotic joints: an ankle joint between the foot and lower leg shells and a knee joint between the lower leg and thigh shells. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_981", "text": "KAFOs can be roughly divided into three variants, depending on whether the mechanical knee joint is: locked, unlocked or locked and unlocked. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_982", "text": "KAFO with locked knee joint -  The mechanical knee joint is locked both when standing and also when walking (in both the stance and swing phases) in order to achieve the necessary stability. To sit, the user can unlock the knee joint. When walking with a locked knee joint it is difficult for the user to swing the leg forward and, in order to not stumble, the leg must be swung forward and out in a circular arc (circumduction) or the hip must be raised unnaturally to swing the stiff leg. Each of these incorrect gait patterns can lead to secondary diseases in the bone and muscle system, and such compensatory movement patterns lead to increased energy consumption when walking. The film  Forrest Gump  impressively shows how the main character  Forrest Gump  is additionally hindered in his urge to move by such orthoses. [ relevant? ]  For centuries, KAFOs were built with mechanical knee joints that stiffened the knee of the paralyzed leg, and even today, such orthotic fittings are still common. Typical designations for a KAFO with a locked knee joint include \"KAFO with Swiss lock\" or \"KAFO with drop lock lock\". [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_983", "text": "KAFO with unlocked knee joint -  An unlocked knee joint can move freely both when standing and when walking, both in the stance phase and in the swing phase. In order for the leg to swing through without stumbling, knee flexion of approximately 60\u00b0 is allowed; the user does not need to unlock the knee joint to sit. As a KAFO with an unlocked knee joint can provide only minor compensation for paralysis-related issues while standing and walking, an orthotic knee joint with a rearward displacement of the pivot point can be installed in order to increase safety. However, even with this, a KAFO with a non-locked knee joint should only be used in cases of minor paralysis of the knee and hip extensors. With more severe paralysis and low levels of strength in these muscle groups, there is a significant risk of falling. A typical designation for a KAFO with a unlocked knee joint is, among other things, \"KAFO with knee joint for movement control\". [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_984", "text": "KAFO with locked and unlocked knee joint -  The mechanical knee joint of a KAFO with locked and unlocked knee joint is locked when walking in the stance phase, [ 52 ]  providing the necessary stability and security for the user. The knee joint is then automatically unlocked in the swing phase, allowing the leg to be swung through without stumbling. In order to be able to walk efficiently, without stumbling, and without compensating mechanisms, the joint should allow  knee flexion of approximately 60\u00b0 in the swing phase. The first promising developments of automatic knee joints, or stance phase locking knee joints, emerged in the 1990s. In the beginning there were automatic mechanical constructions that took over the locking and unlocking, now [ when? ]  automatic electromechanical and automatic  electrohydraulic  systems are available that make standing and walking safer and more comfortable. Various terms are used for a KAFO with a locked and unlocked knee joint. Typical designations are \"KAFO with automatic knee joint\" or \"KAFO with stance phase control knee joint\". In scientific articles, the English term Stance Control Orthoses SCO is often used, but as this term differs from the ICS classification, one of the first two terms is preferable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_985", "text": "Different functional elements to compensate for weakness of the  dorsiflexors  or  plantar flexors  can be integrated into the ankle joint of the orthosis depending on the degree of paralysis of the two muscle groups. It is of great advantage if the resistances for these two functional elements can be set separately. [ 13 ]  The functional elements to compensate for paralysis of the knee-securing muscle groups of the  knee  and  hip extensors  are integrated into the knee joint of the orthosis via knee-securing functional elements. A KAFO can use a variety of combinations of different variants in the stiffness of the foot shell, the different variants of the functional elements of a dynamic ankle joint, the variants in the shape of the lower leg shell, and the functional elements of a knee joint to compensate for the user's limitations. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_986", "text": "HKAFO is the abbreviation for hip-knee-ankle-foot orthoses; which is the English name for an orthosis that spans the hip, the knee, the ankle and the foot. [ 51 ]  In the treatment of paralyzed patients, a HKAFO is used when there is a  weakness  of the pelvic stabilizing trunk muscles. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_987", "text": "Relief Orthoses are used when there is degeneration to a joint (from \"wear and tear\" for example) or after an injury such as a torn ligament. [ 53 ]  Relief orthoses are also used after operations such as operations on the joint ligaments, other bony, muscular structures, or after a complete replacement of a joint. [ 54 ] [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_988", "text": "Relief orthosis may also be used to: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_989", "text": "A custom-made ankle/foot orthosis can be used for the treatment of patients with foot ulcers, it is a rigid L-shaped support member with a rigid anterior support shell on an articulated hinge. The plantar portion of the L-shaped member has at least one ulcer-protecting hollow to allow the user to transfer their weight away from the ulcer to facilitate treatment. The anterior support shell is designed with a lateral hinged attachment to take advantage of the medial tibial flare structure to enhance the weight-bearing properties of the orthosis. A flexible, polyethylene hinge attaches the support shell to the L-shaped member and straps securely attach the anterior support shell to the user's lower leg. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_990", "text": "Foot orthoses (commonly called  orthotics ) are devices inserted into shoes to provide support for the foot by redistributing  ground reaction forces  acting on the foot joints while standing, walking or running. They may be either pre-moulded (also called pre-fabricated) or custom made according to a cast or impression of the foot. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue conditions. Foot orthoses are effective at reducing pain for people with painful  high-arched feet , and may be effective for people with  rheumatoid arthritis ,  plantar fasciitis , first  metatarsophalangeal  (MTP) joint pain [ 57 ]  or  hallux valgus  (bunions). For children with  juvenile idiopathic arthritis  (JIA) custom-made and pre-fabricated foot orthoses may also reduce foot pain. [ 58 ]  Foot orthoses may also be used in conjunction with properly fitted orthopedic footwear in the prevention of  diabetic foot ulcers . [ 59 ] [ 60 ]  A real-time weight bearing orthotic can be created using a neutral position casting device and the Vertical Foot Alignment System VFAS. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_991", "text": "An AFO can also be used to immobilize the ankle and lower leg in the presence of arthritis or a fracture. Ankle\u2013foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States. [ 61 ]  According to a review of Medicare payments from 2001 to 2006, the base cost of an AFO was about $500 to $700. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_992", "text": "A knee orthosis (KO) or knee brace extends above and below the knee joint and is generally worn to support or align the knee. In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion, extension, or instability of the knee. If the ligaments or cartilage of the knee are affected, a KO can provide stabilization to the knee by replacing their functions. For instance, knee braces can be used to relieve pressure from diseases such as  arthritis  or  osteoarthritis  by realigning the knee joint. In this way a KO may help reduce osteoarthritis pain, [ 63 ]  however, there is no clear evidence about the most effective orthosis or the best approach to rehabilitation. [ 64 ]  A knee brace is not meant to treat an injury or disease on its own, but is used as a component of treatment along with drugs, physical therapy and possibly surgery. When used properly, a knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_993", "text": "Prophylactic braces are used primarily by athletes participating in contact sports. Evidence indicates that prophylactic knee braces, like the ones football linemen wear that are often rigid with a knee hinge, are ineffective in reducing anterior cruciate ligament tears, but may be helpful in resisting medial and lateral collateral ligament tears. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_994", "text": "Functional braces are designed for use by people who have already experienced a knee injury and need support while recovering from it, or to help people who have pain associated with arthritis. They are intended to reduce the rotation of the knee, support stability, reduce the chance of hyperextension, and increase the agility and strength of the knee. The majority of these are made of elastic. They are the least expensive of all braces and are easily found in a variety of sizes. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_995", "text": "Rehabilitation braces are used to limit the movement of the knee in both medial and lateral directions, these braces often have an adjustable range of motion, and can be used to limit flexion and extension following ACL reconstruction. They are primarily used after injury or surgery to immobilize the leg and are larger in size than other braces, due to their function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_996", "text": "A soft brace, sometimes called soft support or a bandage, belong to the field of orthoses and are supposed to protect the joints from excessive loads.\nSoft braces are also classified according to regions of the body. In sport, bandages are used to protect bones and joints, and prevent and protect injuries. [ 66 ]  Bandages should also allow  proprioception . They mostly consist of textiles, some of which have supportive elements. The supporting functions are low compared to paralysis and relief orthoses, though they are sometimes used  prophylactically  or to optimize performance in sport. [ 67 ]  At present, the scientific literature does not provide sufficient high quality research to allow for strong conclusions on their effectiveness and cost-effectiveness. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_997", "text": "Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices applied externally to the arm, or segments of it, in order to restore or improve function or structural characteristics of the arm segments enclosed in the device. In general, musculoskeletal problems that may be alleviated by the use of upper limb orthoses include those resulting from trauma [ 69 ]  or disease (arthritis for example). They may also benefit individuals who have a neurological impairment from a stroke, spinal cord injury, or peripheral neuropathy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_998", "text": "Scoliosis , a condition describing an abnormal curvature of the spine, may in certain cases be treated with spinal orthoses, [ 70 ]  such as the  Milwaukee brace ,  Boston brace ,  Charleston bending brace , or  Providence brace . As scoliosis most commonly develops in adolescent females who are undergoing their  adolescent growth spurt , compliance is hampered by patient concerns about appearance and movement restrictions caused by the brace. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_999", "text": "Spinal orthoses may also be used in the treatment of spinal fractures. A Jewett brace, for instance, may be used to aid healing of an anterior  wedge fracture  involving the T10 to L3 vertebrae, and a body jacket may be used to stabilize more involved fractures of the spine. There are several types of orthoses for managing cervical spine pathology. [ 71 ]  The halo brace is the most restrictive cervical thoracic orthosis in use; it is used to immobilize the cervical spine, usually following fracture, and was developed by Vernon L. Nickel at  Rancho Los Amigos National Rehabilitation Center  in 1955. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1000", "text": "Helmets  such as a cranial molding orthoses is an example of orthoses for the head. [ 73 ]  These devices are often suggested for infants with  positional plagiocephaly . [ 74 ] [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1001", "text": "An  orthotist  is a healthcare professional who specializes in the provision of  orthoses . An orthotist has an overall responsibly of  orthotics  treatment, who can supervise and mentor the practice of other personnel. [ 1 ]  They are clinicians trained to assess the needs of the user, prescribe treatment, determine the precise technical specifications of orthotic devices, take measurements and image of body segments, prepare model of the evaluation, fit devices and evaluate treatment outcome. [ 1 ]  In the United States, orthotists work by prescription from a licensed healthcare provider. Physical therapists are not legally authorized to prescribe orthoses in the U.S. In the U.K., orthotists will often accept open referrals for orthotic assessment without a specific prescription from doctors or other healthcare professionals. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1002", "text": "The scope of an orthotist includes the design and application of  orthoses  (braces or  orthotic devices ). The definition of an orthosis is an \u201cexternally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system\u201d. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1003", "text": "In Canada, a Certified Orthotist CO(c) provides clinical assessment, treatment plan development, patient management, technical design, and fabrication of custom orthoses to maximize patient outcomes. To become CBCPO certified through Orthotics Prosthetics Canada (OPC) an applicant must successfully meet the following requirements:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1004", "text": "Upon successful completion of the national certification exams, candidates are conferred the designation of Canadian Certified Orthotist CO(c). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1005", "text": "In the UK orthotists assess patients, and where appropriate design and fit orthoses for any part of the body. Registration is with the  Health and Care Professions Council  and BAPO - the British Association of Prosthetists and Orthotists. The training is a B.Sc.(Hons) in Prosthetics and Orthotics at either the  University of Salford  or  University of Strathclyde . New graduates are therefore eligible to work as an orthotist and/or  prosthetist ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1006", "text": "Podiatrists are the other profession involved with foot orthotic provision. [ 5 ]  They are also registered with the  Health and Care Professions Council  . Podiatrists assess gait to provide orthotics to improve foot function and alignment or may use orthoses to redistribute stress on pressure areas for those with diabetes or rheumatoid arthritis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1007", "text": "A licensed orthotist is an orthotist who is recognized by the particular state in which they are licensed to have met basic standards of proficiency, as determined by examination and experience to adequately and safely contribute to the health of the residents of that state. An American Board of Certification certified orthotist has met certain standards; these include a degree in orthotics, completion of a one-year residency at an approved clinical site, and passing a rigorous three-part exam. [ 6 ]  A certified orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics, Prosthetics and Pedorthics. Other credentialing bodies who are involved in orthotics include the Board for Orthotic Certification, the pharmaceutical industry, the Pedorthic Footcare Association, and various of the professional associations who work with athletic trainers, physical and occupational therapists, and orthopedic technologists/cast technicians."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1008", "text": "Four universities including the  Iran University of Medical Science ,  Isfahan University of Medical Science ,  University of Social Welfare and Rehabilitation Sciences  and Iran Red Crescent University confer bachelor of science in the Prosthetics and Orthotics. Three universities including Isfahan University of Medical Science, the Iran University of Medical Science and University of Social Welfare and Rehabilitation Science also confer  M.Sc.  and  Ph.D . New bachelor graduates are eligible to work as an orthotist and  prosthetist  after registration in the  Medical Council of Iran . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1009", "text": "Lars Peterson  (born 1936 in  Vansbro ,  Sweden ) is an  orthopedist , known as \"the father of autologous cell implantation\". [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1010", "text": "Beginning in 1987, Peterson co-pioneered, with colleague  Mats Brittberg  and others,  autologous chondrocyte implantation , a method of repairing  cartilage  using a patient's own cartilage cells. [ 2 ]  He was honored for his work at  Genzyme  in 2009. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1011", "text": "He is also a professor and sports physician, and has been a Swedish national league football and ice hockey player, active in both  \u00d6rgryte IS  and  Fr\u00f6lunda HC ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1012", "text": "Peterson's sports career started early in most sports, ending up playing in the Swedish National League in both soccer and hockey with \u00d6rgryte IS, ending on fourth place and  V\u00e4stra Fr\u00f6lunda IF , ending first place, respectively. Along with playing soccer and football, he studied medicine at the  University of Gothenburg  and graduated in 1966.\nHe served his Residency in General Surgery in Kung\u00e4lvs Hospital, his orthopaedic residency in  Sahlgrenska University Hospital  from 1967 to 1974, and became specialist in General Surgery 1972 and in Orthopaedic Surgery 1974. In 1974, Peterson defended his doctoral thesis: Fracture of the Neck of the Talus, An Experimental and Clinical Study."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1013", "text": "In 1980, Peterson was approved associate professor of Orthopaedic Surgery at the University of Gothenburg and in 2000, appointed professor of Orthopaedic Surgery. Peterson had a long and broad experience in treating athletes in his University practice and as team physician in soccer and ice hockey and since 1987 in his clinic, Gothenburg Medical Center. He has served as head physician of the Swedish National Team in ice hockey and in soccer"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1014", "text": "For over 25 years, Peterson has been a member of the Sports Medical Committee of  FIFA , The International Football Federation and a founding member of F-Marc (FIFA Medical Assessment and Research Center). He has served as a Medical Officer at six World Cups in Football.\nPeterson has been President of the  Swedish Society of Sports Medicine  and is an honorary member. He was president and one of the founding members of the  International Society of Cartilage Repair  (ICRS). He has served as Godfather for ICRS Traveling Fellows in 2001. He also has served as Goodfather in the Herodicus Society."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1015", "text": "In 2010, Peterson received \u201cThe Duke of Edinburgh Prize\u201c for \u201cOutstanding contribution to international education in Sports Medicine\u201d. In 2010 awarded \u201cDoctor Honoris Causa\u201d at the  University of Helsinki , Finland. In 2011, he was awarded \u201cDoctor Honoris Causa\u201d at  Universidad Cat\u00f3lica San Antonio de Murcia , Spain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1016", "text": "Peterson has lectured extensively, nationally and internationally and served as visiting professor several times. His publication list includes more than 200 originals, reviews books, book chapters in the fields of Orthopaedic Surgery, Sports Traumatology and Sports Medicine, Biomechanics, and Rehabilitation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1017", "text": "This Swedish biographical article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1018", "text": "This biographical article related to medicine is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1019", "text": "Prosthetic joint infection  (PJI), also known as  peri-prosthetic joint infection , is an acute, sub-acute or chronic infection of a  prosthetic joint . It may occur in the period after the joint replacement or many years later. It usually presents as joint pain,  erythema  (redness of the joint or adjacent area),  joint swelling  and sometimes formation of a  sinus tract  ( a tract connecting the joint space to the outer environment). PJI is estimated to occur in approximately 2% of hip and knee replacements, and up to 4% of revision hip or knee replacements. Other estimates indicate that 1.4-2.5% of all joint replacements worldwide are complicated by PJIs. [ 1 ]  The incidence is expected to rise significantly in the future as  hip replacements  and  knee replacements  become more common. It is usually caused by  aerobic   gram positive  bacteria, such as  Staph epidermidis  or  Staphylococcus aureus  but  enterococcus  species,  gram negative  organisms and  Cutibacterium  are also known causes with  fungal  infections being a rare culprit. The definitive diagnosis is isolation of the causative organism from the  synovial fluid  (joint fluid), but signs of inflammation in the joint fluid and imaging may also aid in the diagnosis. The treatment is a combination of systemic  antibiotics ,  debridement  of infectious and  necrotic  tissue and local antibiotics applied to the joint space. The bacteria that usually cause prosthetic joint infections commonly form a  biofilm , or a thick slime that is adherent to the artificial joint surface, thus making treatment challenging."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1020", "text": "The most common symptom of periprosthetic joint infections is  joint pain . [ 2 ]  Other local symptoms are also present, including  erythema  (redness of the joint),  joint swelling , warmth of the joint, and loosening of the prosthetic joint. [ 2 ]  A  sinus tract , or a tract connecting the joint space to the external environment, is more common in chronic PJI, and is definitively diagnostic of PJI. [ 3 ]  Fever may be present in PJI, but is uncommon. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1021", "text": "Prosthetic joint infections can occur any time after a joint replacement. Early infections (occurring within 4 weeks of a joint replacement) are usually due to Staph aureus,  streptococci  or  enterococci . [ 4 ]  Whereas late infections (occurring 3 months or later after the joint replacement) are usually due to coagulase negative staphylococcus or  cutibacterium . [ 4 ]  The highest risk of PJI is in the immediate post-operative period, when direct inoculation of bacteria into the joint space may occur during surgery. [ 4 ]  The risk of PJI is highest in this early period; within 2 years of the joint replacement. [ 1 ]   Hematogenous spread , or infection of a prosthetic joint via direct seeding from a bloodstream infection, may occur at any time after a joint replacement, with the risk being as high as 34% in staph aureus  bacteremia . [ 4 ]  An additional possible cause of PJI is from direct spread to the joint from a nearby skin or soft tissue infection, a bone infection ( osteomyelitis ), or from more distal spread to the joint from a respiratory tract infection,  gastroenteritis ,or  urinary tract infection . [ 4 ]  Dental procedures may cause a transient bacteremia which can lead to inoculation of the artificial joint and PJI, with  strep viridans  being the most common causative organism. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1022", "text": "The most common causes of PJIs are aerobic, gram positive bacteria, including staph aureus and coagulase negative staphylococcus (such as  staph epidermidis ), which make up greater than 50% of all causes of hip and knee PJIs. [ 3 ]  With regards to acute PJIs, the most common causative organism is staph aureus (comprising 38% of acute infections) followed by aerobic gram negative bacilli (making up 24% of acute infections). [ 3 ]  70% of PJIs are monomicrobial (with a single causative organism identified), whereas 25% of cases are polymicrobial (with multiple causative organisms identified). [ 2 ]  3% of PJIs are due to fungal organisms. [ 2 ]   Propionibacterium acnes  is the most common cause of shoulder PJIs. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1023", "text": "Risk factors for PJI include  diabetes ,  immunosuppression ,  smoking ,  obesity ,  chronic kidney disease , the presence of a soft tissue infection, or an infection in another part of the body or increased fat tissue around the replaced joint. [ 1 ]  Surgical factors that may lead to an increased risk of PJIs include  wound dehiscence  (unplanned opening of the surgical wound after the surgery) and  hematoma  (collection of blood) formation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1024", "text": "The presence of multiple artificial joints,  MRSA  PJIs,  rheumatoid arthritis  or bacteremia place people at risk for multiple PJIs (either concurrent or subsequent infections). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1025", "text": "Prolonged operative times, in which the joint is left open to the external environment, determined as greater than 90 minutes in a single study, also increases the risk for PJIs. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1026", "text": "Prosthetic joint infections are generally difficult to treat as most causative organisms form a biofilm, or a thickly adherent membrane, against the artificial joint surface. The bacteria secrete  adhesion proteins  which help them attach to each other and to the joint surface. [ 1 ]  The bacteria then secrete  autoinducer  proteins that act as bacterial signals which facilitate the secretion of an intricate extracellular matrix, the biofilm. [ 1 ]  Biofilms greatly decrease antibiotic penetrance thereby shielding bacteria from the  bacteriocidal  effects of antibiotics. [ 2 ] [ 1 ]  Biofilms usually take 4 weeks to fully mature. [ 4 ]   Granulocytes  have decreased  phagocytic  activity encountering the biofilm, also allowing the bacteria to persist. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1027", "text": "The presence of a PJI is confirmed when one of the proposed major diagnostic criteria are met: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1028", "text": "Polymerase chain reaction  testing of the joint fluid or sonification fluid may aid in the diagnosis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1029", "text": "Skin swabs, sinus tract swabs, swabbing of the artificial joint surface during surgery is not recommended due to the high risk of contaminants and low diagnostic yield (including the risk of contaminants rather than the pathologic organism being cultured). [ 4 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1030", "text": "Blood cultures are positive in approximately 25% of cases of PJIs, especially in acute PJI, however, the organism isolated from blood culture does not always correlate to the organisms isolated from the joint fluid, and therefore blood cultures are not diagnostic of PJIs. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1031", "text": "Routine blood work attempting to identify infection including elevated white blood cells on a  complete blood count , elevated inflammatory markers ( erythrocyte sedimentation rate  and  C-reactive protein ) or  procalcitonin  are not sensitive nor specific in diagnosis PJIs. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1032", "text": "Plain radiography  (X-ray) has a low sensitivity and specificity for diagnosing PJI but it may show radiolucent lines around the prosthetic joint, bone breakdown, loosening or migration of the prosthetic joint. [ 2 ] [ 4 ]   Functional imaging  tests such as white blood cell  Scintigraphy  or  PET scan  may help to identify hypermetabolic areas consistent with infection and aid with the diagnosis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1033", "text": "Magnetic resonance imaging  is specific to soft tissue infections, with metal artifact reduction sequence (MARS) MRIs having great utility to aid in the diagnosis of PJIs. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1034", "text": "Antibiotic treatment alone, without surgical debridement, usually results in treatment failure. [ 2 ]  Acute infections (in which the biofilm is thought to be immature) are usually treated using the DAIR technique;  debridement , systemic and local antibiotics, and implant retention (the implant is not removed). [ 4 ] [ 2 ]  However, the mobile, easily interchangeable components of the implant are often replaced in the DAIR approach. [ 4 ]  DAIR is contraindicated if there is a sinus tract, loosening of the prosthesis, or the surgical wound cannot be closed. [ 2 ]  The microbial cure rate of DAIR is 74%, 49% and 44% in early, sub-acute and late infections respectively. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1035", "text": "Antibiotic loaded  polymethylmethacrylate  (PMMA) which are placed in the joint are helpful, however these non-resorbable beads may themselves be colonized by bacteria with an associated  biofilm , therefore bio-absorbable local antibiotic carriers (calcium sulfate beads, resorbable  gentamicin  sponges) are preferred. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1036", "text": "Chronic PJIs may be treated using 1 stage revisions, where the artificial joint is replaced with a new one during the same surgical procedure, or with a 2-stage revision; in which the infected joint is removed and an antibiotic spacer is placed, this is followed by a second surgery in which a new artificial joint is placed. [ 4 ]  Two step revisions are associated with increased morbidity, longer hospital stays, longer immobilization time, worse functional outcomes and higher costs. [ 4 ]  Therefore, for intact, or mostly intact bone and soft tissue, and without a history of joint replacement revisions; a 1 step exchange is the treatment of choice. [ 4 ]  In the case of hip PJIs both kinds of surgery are equally effective but one-stage surgery results in faster recovery. [ 5 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1037", "text": "Negative pressure wound therapy  is not recommended as the sponges used are often themselves colonized by the biofilm or by new organisms from the environment (including  multi-drug resistant organisms ). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1038", "text": "An extended course of antibiotics is required in PJIs, usually 6\u201312 weeks of antibiotic therapy. [ 2 ] [ 4 ]  Intravenous antibiotics are initially used and then transitioned to oral antibiotics. A strategy of surgical debridement to decrease the bacterial load prior to starting systemic antibiotics is sometimes employed. [ 4 ]  Common practice involves switching to oral antibiotics after 14 days. [ 4 ]  Intravenous  ampicillin-sulbactam  or  amoxicillin with clavulanic acid  with  vancomycin  added in cases of MRSA is a commonly employed empiric antibiotic treatment strategy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1039", "text": "If surgery fails or the PJI persists despite optimal antibiotic therapy, resection arthroplasty of the hip with a pseudarthrosis ( Femoral head ostectomy ) is sometimes done. [ 2 ]  Or in cases of knee PJIs failing treatment; an  arthrodesis  (artificial induction of ossification of the knee joint) is done. [ 2 ]  These are considered last line therapies due to significant disability. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1040", "text": "Antibiotic prophylaxis , or giving small doses of antibiotics as a preventative measure, during the perioperative period (usually less than 60 minutes prior to the start of joint replacements)(usually using second generation  cephalosporins ) is believed to reduce the risk of acute PJIs. [ 2 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1041", "text": "Screening for and eradication of MRSA carriage and  chlorhexidine  wipes or soap and water skin cleansing prior to surgery may possibly decrease the risk of PJIs. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1042", "text": "According to the  American Dental Association : in patients with prosthetic joint implants, prophylactic antibiotics prior to routine dental procedures are generally not recommended in the prevention of PJI. However specific circumstances placing patients at higher risk, as determined by the dentist or other physicians, may warrant antibiotic prophylaxis. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1043", "text": "The 5-year mortality after hip PJIs is 21%, which is 4 times that of age adjusted controls. [ 2 ]  And the 10 year mortality after hip PJIs was 45%, as compared to 29% in people with non-infected hip replacements. [ 2 ]  25% of people with PJIs have an unplanned re-operation within 1 year of PJI treatment. [ 2 ]  Hospital stays are longer in those with knee and hip PJIs as compared to un-infected knee and hip replacement controls; at 5.3 vs 3 days (knee) and 7.6 vs 3.3 days (hip). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1044", "text": "PJIs are the most common cause of knee replacement failures, and the third most common cause of hip replacement failures. [ 1 ]  As of 2017, 2.1% of hip and 2.3% of knee replacements will at some time develop a PJI. [ 2 ]  The incidence of PJIs have more than tripled in the last 20 years, with the incidence expected to further increase in the future. This increase is believed to be due to the much greater number of hip and knee arthroplasties being performed presently. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1045", "text": "Shoulder reduction  is the process of returning the shoulder to its normal position following a  shoulder dislocation . Normally, closed reduction, in which the relationship of bone and  joint  is manipulated externally without surgical intervention, is used. A variety of techniques exist, but some are preferred due to fewer  complications  or easier execution. [ 1 ]  In cases where closed reduction is not  successful , open (surgical) reduction may be needed. [ 2 ]   X-rays  are often used to confirm success and absence of associated  fractures . The arm should be kept in a sling or immobilizer for several days, prior to supervised recovery of motion and strength."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1046", "text": "Various non-operative reduction techniques are employed. They have certain principles in common, including gentle in-line traction, reduction or abolition of muscle spasm, and gentle external rotation. They all strive to avoid inadvertent injury. Two of them, the Milch and Stimson techniques, have been compared in a randomized trial. [ 3 ]  Pain can be managed during the procedures either by  procedural sedation and analgesia  or by injecting  lidocaine  into the shoulder joint. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1047", "text": "The person's arm is brought against their side. [ 2 ]  The elbow is then bent to 90 degrees and the forearm is slowly and gently externally rotated. [ 2 ]  Any discomfort or spasm interrupts the process until the person is able to relax. Reduction usually takes place by the time full external rotation has been achieved. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1048", "text": "This is an extension of the external rotation technique. The externally rotated arm is gently abducted (brought away from the body into an overhead position) while external rotation is maintained. Gentle in-line traction is applied to the arm while some pressure is applied to the humeral head via the operator's thumb in the armpit to keep the head from moving inferiorly. [ 2 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1049", "text": "In the Stimson technique, also known as prone technique, the person lies on their stomach on a bed or bench and the arm hangs off the side, being allowed to drop toward the ground. A 5\u201310\u00a0kg weight is suspended from the wrist to overcome spasm and to permit reduction by the force of gravity; [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1050", "text": "The person is on their back and gentle upward traction is applied to the extremity coupled with external rotation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1051", "text": "The  Cunningham technique  was originally published in 2003 and is an anatomically based method of shoulder reduction that utilizes positioning (analgesic position), voluntary scapular retraction, and bicipital massage. [ 7 ]  If performed correctly most patients do not require analgesia for the performance of this technique. Inappropriate use of traction will result in pain for the patient with subsequent spasm and failure to reduce. If the patient is unable to adduct the humerus or unable to cooperate with positioning the technique should not be attempted. The patient may require analgesia or sedation if they are in pain or unable to relax spasming muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1052", "text": "FARES stands for fast, reliable, and safe. With the person lying on their back, the operator holds the person's hand on the affected side while the arm is at the side and the elbow is fully extended. The forearm is in neutral position. Next, the operator gently applies longitudinal traction and slowly the arm is abducted. At the same time, continuous vertical oscillating movement at a rate of 2\u20133 \"cycles\" per second is applied throughout the whole reduction process. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1053", "text": "Traction countertraction involves pulling the dislocated arm down and outwards while an assistant pulls the body upwards. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1054", "text": "Kocher's method was described in 1870 and has been incorrectly associated with neuromuscular complications and humeral fractures due to the inappropriate addition of traction by later users. It was designed for subcoracoid dislocations.\n\"This method: Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward.\" [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1055", "text": "A  sling , also known as  arm sling , is a device to limit movement of the shoulder or elbow while it heals. [ 1 ]  A sling can be created from a  triangular bandage . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1056", "text": "This  health -related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1057", "text": "The  Spurling test  is a medical maneuver used to assess nerve root pain (also known as  radicular pain )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1058", "text": "The patient rotates their head to the affected side and extends their neck, while the examiners applies downward pressure to the top of the patient's head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1059", "text": "A positive  Spurling's sign  is when the pain arising in the neck radiates in the direction of the corresponding  dermatome  ipsilaterally. [ 1 ]  It is a type of cervical compression test."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1060", "text": "Patients with a positive Spurling's sign can present with a variety of symptoms, including pain, numbness and weakness. In addition to the clinical history, the neurological examination may show signs suggesting a cervical  radiculopathy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1061", "text": "The Spurling test is used during a spinal or neck examination to aid in the diagnosis and assessment of cervical radiculopathy. It should be used to assess patients with radicular symptoms. The results of this test can guide a clinician when considering further imaging and necessary steps needed to make a proper diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1062", "text": "However, caution should be used when assessing patients with acute cervical injuries, critically ill patients, and those with other neoplastic or infectious processes. Cervical instability is also a reason to avoid performing this medical maneuver."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1063", "text": "Spurling's test is somewhat specific when used for individuals with an abnormal  electromyogram study  and is a relatively sensitive physical examination maneuver in diagnosing  cervical spondylosis  or acute cervical radiculopathy. It is not a very sensitive test when used for individuals without classic radicular signs suggestive of cervical radiculopathy. [ citation needed ]   In 2011, one study evaluated 257 patients with clinical cervical radiculopathy and correlated  CT scan  findings with clinical exam findings using the Spurling's test. The Spurling's test was 95% sensitive and 94% specific for diagnosing nerve root pathology. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1064", "text": "In another study done in the late 1900s, 255 patients were examined using a Spurling test and afterwards received an electrodiagnostic examination. The study results showed the Spurling test was 30% sensitive, and 93% specific for finding cervical radiculopathy diagnosed by electrodiagnostic examination. The conclusions drawn from this study demonstrate clinical utility of the Spurling test to confirm cervical radiculopathy rather than for screening purposes. Overall, there continues to be limited data on the specificity and sensitivity of the Spurling test. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1065", "text": "The  sulcus sign  is an  orthopedic  evaluation test for  glenohumeral  instability of the shoulder.  With the arm straight and relaxed to the side of the patient, the elbow is grasped and traction is applied in an  inferior  direction.  With excessive inferior translation, a depression occurs just below the  acromion .  The appearance of this sulcus is a positive sign. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1066", "text": "This  medical sign  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1067", "text": "Tenodesis grasp and release  is an  orthopedic  observation of a passive  hand grasp  and release mechanism, affected by  wrist extension  or  flexion , respectively.   It is caused by the manner of attachment of the finger tendons to the bones and the passive tension created by two-joint muscles used to produce a functional movement or task (tenodesis). [ 1 ]   Moving the wrist in extension or flexion will cause the fingers to curl or grip when the wrist is extended, and to straighten or release when the wrist is flexed. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1068", "text": "The tenodesis grip and release mechanism is used in occupational therapy, [ 4 ]  physical therapy [ 5 ] [ 4 ]  and rehabilitation of fine motor impairment, typically various levels of spinal paralysis, [ 6 ] [ 7 ]  and in kinesiology and sports mechanics that are concerned with efficient grasp and release mechanics.  Wrist extension is noted for bat grip in baseball. [ 8 ]    Wrist extension is also noted in the form of grip used in most schools of Japanese swordsmanship or  kenjutsu ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1069", "text": "This particular function serves to enhance gripping capabilities for individuals with tetraplegia exhibiting wrist extension against gravity but lacking active finger functionality (C6 Motor Level). The active wrist extension, when initiated, draws the fingers and thumb into a flexed position passively. Acquiring tenodesis function is crucial for enabling task execution, as it allows for the passive holding of objects between the thumb and index finger or within the palm. [ 9 ]  People with tetraplegia devise adaptive approaches to optimize the utility of their hands. Many individuals create alternative techniques to carry out their daily activities. One such strategy involves leveraging the impact of gravity to enhance grasping capabilities. This adjustment is inherent in the tenodesis grasp, where the hand is often opened through wrist flexion assisted by gravity, reflecting a reliance on this natural force. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1070", "text": "The tenodesis grasp entails extending the wrist (specifically the extensor carpi radialis longus and brevis), leading to two distinct types of grips: a passive whole hand grasp attributed to the shortening of finger flexors and a passive lateral grip resulting from the shortening of the flexor pollicis longus. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1071", "text": "There are a number of ways that a patient in a rehabilitation or healthcare setting can optimize their tenodesis Grasp to boost their independence after a spinal cord injury. A physical therapy or occupational therapy professional may guide the patient in the following ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1072", "text": "The use of an effective tenodesis grasp after a spinal cord injury can have a substantial impact on the activities of daily living for a patient after suffering a spinal cord injury. The majority of individuals with tetraplegia opt against undergoing surgical reconstruction for hand function, relying instead on the inherent passive properties of their musculoskeletal system to carry out functional tasks. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1073", "text": "The following  outline  is provided as an overview of and topical guide to trauma and orthopaedics:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1074", "text": "Orthopedic surgery  \u2013 branch of  surgery  concerned with conditions involving the  musculoskeletal system .  Orthopedic surgeons  use both surgical and nonsurgical means to treat  musculoskeletal injuries ,  sports injuries , degenerative diseases, infections,  bone tumours , and  congenital limb deformities .   Trauma surgery  and  traumatology  is a sub-specialty dealing with the operative management of  fractures ,  major trauma  and the multiply-injured patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1075", "text": "History of trauma and orthopaedics"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1076", "text": "Pet orthotics  refers to the use of  orthotics  for  pets .  Orthotics  is an allied health care field concerned with the design, development, fitting, and manufacture of orthoses. Orthoses, sometimes called braces or splints, are devices that support or correct musculoskeletal deformities and/or abnormalities of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1077", "text": "Animals that might benefit from the use of an orthosis commonly have an injury to a lower limb or paw, such as a fracture, torn  meniscus , ruptured  Achilles tendon , or injured  cruciate ligament  (ACL or CCL). They may also have an orthopedic condition due to arthritis, spinal cord injury, or a  congenital abnormality . Animals that have used orthoses and  prostheses  (artificial limbs) include dogs, cats, horses, llamas, and an orangutan. Each animal's situation is unique and should be evaluated by a  veterinarian . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1078", "text": "Orthoses can decrease pain and increase stability in an  unstable joint , as well as prevent potential progression or development of a deformity or contracture. An orthosis will prevent, control or even assist the motion of a joint, depending upon how it is made. An orthosis can be made for short-term use during a post-operative healing period, for example, or for long-term chronic use. [ 2 ]  They can provide a good quality of life for an animal that might otherwise have to be euthanized. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1079", "text": "With a few exceptions, orthoses for animals are custom-made from a  cast . They are typically formed from lightweight plastic or carbon fiber material with a comfort liner inside and velcro to hold them in place. They may have solid joints or hinged joints. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1080", "text": "An orthotic differs from a prosthetic in that a prosthetic completely replaces a missing limb or body part, whereas an orthotic is an external device that is meant to help support or protect a limb or body part."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1081", "text": "The most common orthotic, especially for dogs, are  booties . They have a wide range of uses for the dog, including traction while getting up or walking on slippery surfaces such as hardwood or tile flooring. They can especially help dogs with hip issues and dogs with neurological conditions who are less aware of their self-movement ( proprioception ). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1082", "text": "Another form of orthotic is a leg brace that can improve stabilization for issues caused by age, worn-out bones in the foot, or  ectrodactyly . This is the deficiency of one or more central digits of the foot, causing the animal's foot to become deformed. Proper support is necessary or more serious health issues can arise in the future. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1083", "text": "Malpositions should be corrected as early as possible. The sooner the problem is resolved, and the younger the animal, the easier and faster a correction using dog  braces  or other methods is possible since the bones are still remodeled due to the growth. The misaligned teeth are often congenital, i.e., the causes are genetic. They are already visible in the young dog, e.g., excess teeth,  deciduous teeth  that have not failed, or jaw malformations. As with humans, there are also braces or other appliances for orthodontic treatment in dogs. With the help of these methods, teeth in the jaw, for example, can be realigned and thus integrated into the healthy row of teeth. There are different systems of dog braces. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1084", "text": "When looking at purchasing or constructing an orthotic for a pet, several factors must be taken into consideration to ensure the animal's health and wellness. These include how the orthotic sits on the body, the material being used, and the functionality of the product. The fit is also important for prosthetics for the area of attachment so it is comfortable and does not cause irritation to the skin. Material is also a consideration: if the skin is irritated or damaged, it can have a greater impact on the animal than if it were not wearing the orthotic at all, in some cases. The functionality of the orthotic affects both owner and pet. An orthotic or a prosthetic needs to be monitored regularly. Orthotics need to be removed several times daily to check the condition of the skin. For this reason, it is better if they are easier to take on and off, both in terms of ease and in avoiding irritation to the skin by removing or putting on the orthotic in a cumbersome way. It also helps the pet to stay calm if it is not such a laborious task. For functionality, the product itself and how it will serve the pet are important considerations. An orthotic that interferes with the pet's daily life and  range of motion  is problematic. Even if the pet wears it while standing, it might not function well enough when trying to get up from lying down. The orthotic must also be kept clean, both from dirt from everyday activities and sweat build-up, and if the pet gets dirty. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1085", "text": "Depending on the orthotic, they can be expensive.  3D printing  can be a cost-effective alternative. 3D printing is an additive manufacturing process where filament is layered on top of itself to create a three-dimensional object. This differs from more traditional subtractive manufacturing processes, like drilling, where the material is taken away to form a whole. Free online versions of different orthotics are available to print if a more general model is suitable; they can also be adapted to fit the owner and pet's needs. Libraries may be a source of complimentary or donation-based printing for the public. Custom orthotics can also be designed in  3D modeling  software. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1086", "text": "Otology  is a branch of  medicine  which studies normal,  pathological   anatomy  and  physiology  of the  ear  ( hearing ). Otology also studies  vestibular   sensory systems , related structures and functions, as well as their  diseases ,  diagnosis  and treatment. [ 1 ] [ 2 ]  Otologic surgery generally refers to surgery of the  middle ear  and  mastoid  related to chronic  otitis media , such as  tympanoplasty  (ear drum surgery), ossiculoplasty (surgery of the hearing bones) and  mastoidectomy .  Otology also includes surgical treatment of conductive hearing loss, such as  stapedectomy  surgery for  otosclerosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1087", "text": "Neurotology  (a related field of medicine and subspecialty of  otolaryngology ) is the study of diseases of the inner ear, which can lead to hearing and balance disorders.  Neurotologic surgery generally refers to surgery of the inner ear, or surgery that involves entering the inner ear with risk to the hearing and balance organs, including  labyrinthectomy , cochlear implant surgery, and surgery for tumors of the temporal bone, such as intracanalicular  acoustic neuromas .  Neurotology is expanded to include surgery of the lateral skull base to treat intracranial tumors related to the ear and surrounding nerve and vascular structures, such as large cerebellar pontine angle  acoustic neuromas ,  glomus jugulare  tumors and facial nerve tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1088", "text": "Some of the concerns of otology include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1089", "text": "Related concerns of neurotology include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1090", "text": "Otorhinolaryngology  ( / o\u028a t o\u028a \u02cc r a\u026a n o\u028a \u02cc l \u00e6r \u026a n \u02c8 \u0261 \u0252 l \u0259 d\u0292 i /   oh-toh- RY -noh- LARR -in- GOL -\u0259-jee , abbreviated  ORL  and also known as  otolaryngology ,  otolaryngology \u00a0 \u2013 \u00a0 head and neck surgery  ( ORL\u2013H&N  or  OHNS ), or  ear, nose, and throat  ( ENT )\u200a) is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1091", "text": "Patients seek treatment from an otorhinolaryngologist for diseases of the  ear ,  nose ,  throat ,  base of the skull , head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of  cancers  and  benign tumors  and reconstruction of the head and neck as well as  plastic surgery  of the face, scalp, and neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1092", "text": "The term is a combination of  Neo-Latin   combining forms  ( oto-  +  rhino-  +  laryngo-  +  -logy ) derived from four  Ancient Greek  words: [ 1 ]  ( cf.  Greek  \u03c9\u03c4\u03bf\u03c1\u03b9\u03bd\u03bf\u03bb\u03b1\u03c1\u03c5\u03b3\u03b3\u03bf\u03bb\u03cc\u03b3\u03bf\u03c2   ' otorhinolaryngologist ' )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1093", "text": "Otorhinolaryngologists are  physicians  ( MD ,  DO ,  MBBS ,  MBChB , etc.) who complete both medical school and an average of five\u2013seven years of post-graduate surgical training in ORL-H&N. In the United States, trainees complete at least five years of surgical residency training. [ 2 ]  This comprises three to six months of  general surgical  training and four and a half years in ORL-H&N specialist surgery. In Canada and the United States, practitioners complete a five-year residency training after medical school."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1094", "text": "Following residency training, some otolaryngologist-head & neck surgeons complete an advanced sub-specialty fellowship, where training can be one to two years in duration. Fellowships include head and neck surgical oncology, facial plastic surgery,  rhinology  and sinus surgery,  neuro-otology , pediatric otolaryngology, and laryngology. In the United States and Canada, otorhinolaryngology is one of the most competitive specialties in medicine in which to obtain a residency position following medical school. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1095", "text": "In the United Kingdom, entrance to higher surgical training is competitive and involves a rigorous national selection process. [ 5 ]  The training programme consists of 6 years of higher surgical training after which trainees frequently undertake fellowships in a sub-speciality prior to becoming a consultant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1096", "text": "The typical total length of education, training and post-secondary school is 12\u201314 years. Otolaryngology is among the more highly compensated surgical specialties in the United States. In 2022, the average annual income was $469,000. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1097", "text": "reconstruction"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1098", "text": "(*Currently recognized by  American Board of Medical Subspecialties )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1099", "text": "Study of diseases of the outer ear, middle ear and mastoid, and inner ear, and surrounding structures (such as the facial nerve and lateral skull base)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1100", "text": "Rhinology includes nasal dysfunction and sinus diseases."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1101", "text": "Facial plastic and reconstructive surgery is a one-year fellowship open to otorhinolaryngologists who wish to begin learning the aesthetic and reconstructive surgical principles of the head, face, and neck pioneered by the specialty of Plastic and Reconstructive Surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1102", "text": "Sleep surgery encompasses any surgery that helps alleviate obstructive sleep apnea and can anatomically include any part of the upper airway."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1103", "text": "Microvascular reconstruction repair is a common operation that is done on patients who see an otorhinolaryngologist. It is a surgical procedure that involves moving a composite piece of tissue from the patient's body and to the head and/or neck. Microvascular head-and-neck reconstruction is used to treat head-and-neck cancers, including those of the larynx and pharynx, oral cavity, salivary glands, jaws, calvarium, sinuses, tongue and skin. The tissue that is most commonly moved during this procedure is from the arms, legs, and back, and can come from the skin, bone, fat, and/or muscle. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1104", "text": "When performing this procedure, the decision on which is moved is determined on the reconstructive needs. Transfer of the tissue to the head and neck allows surgeons to rebuild the patient's jaw, optimize tongue function, and reconstruct the throat. When the pieces of tissue are moved, they require their own blood supply for a chance of survival in their new location. After the surgery is completed, the blood vessels that feed the tissue transplant are reconnected to new blood vessels in the neck. These blood vessels are typically no more than 1 to 3\u00a0millimeters in diameter, which means that these connections need to be made with a microscope, which is why the procedure is called \"microvascular surgery\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1105", "text": "Instruments used specially in  Otolaryngology  ( Otorhinolaryngology, head and neck surgery ) i.e. ENT are as follows: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1106", "text": "The  abducens nerve  or  abducent nerve , also known as the  sixth cranial nerve ,  cranial nerve VI , or simply  CN VI , is a  cranial nerve  in humans and various other animals that controls the movement of the  lateral rectus muscle , one of the  extraocular muscles  responsible for outward  gaze . It is a  somatic   efferent nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1107", "text": "The  abducens nucleus  is located in the pons, on the floor of the  fourth ventricle , at the level of the  facial colliculus . Axons from the facial nerve loop around the abducens nucleus, creating a slight bulge (the facial colliculus) that is visible on the dorsal surface of the floor of the fourth ventricle.  The abducens nucleus is close to the midline, like the other motor nuclei that control eye movements (the  oculomotor  and  trochlear nuclei ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1108", "text": "Motor axons leaving the abducens nucleus run ventrally and caudally through the pons. They pass lateral to the  corticospinal tract  (which runs longitudinally through the pons at this level) before exiting the brainstem at the pontomedullary junction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1109", "text": "The abducens nerve emerges from the  brainstem  at the junction of the  pons  and the  medulla , [ 1 ]  superior to the  medullary pyramid , [ 2 ]  and medial to the  facial nerve . It runs upwards and forwards from this position to reach the eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1110", "text": "The nerve enters the  subarachnoid space  (more precisely, the  pontine cistern [ 2 ] ) when it emerges from the brainstem. It runs upward between the pons and the  clivus , and then pierces the  dura mater  to run between the dura and the skull through  Dorello's canal . [ 3 ] [ 4 ]  At the apex of the  petrous part of the temporal bone , it makes a sharp turn forward to enter the  cavernous sinus . [ 1 ]  In the cavernous sinus, it runs anterior-ward alongside (inferolateral to) the  internal carotid artery . It enters the orbit through (medial end of) the  superior orbital fissure , passing through the  common tendinous ring  to reach and innervate the  lateral rectus muscle  of the eye. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1111", "text": "The human abducens nerve is derived from the  basal plate  of the  embryonic   pons ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1112", "text": "The abducens nerve supplies the  lateral rectus muscle  of the  human eye . This muscle is responsible for outward gaze. [ 1 ]  The abducens nerve carries axons of type GSE,  general somatic efferent ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1113", "text": "Damage to the peripheral part of the abducens nerve will cause double vision ( diplopia ), due to the unopposed muscle tone of the  medial rectus muscle . The affected eye is pulled to look towards the midline. In order to see without double vision, patients will rotate their heads so that both eyes are toward the temple. [ citation needed ]  Partial damage to the abducens nerve causes weak or incomplete abduction of the affected eye. The diplopia is worse on attempts at looking laterally."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1114", "text": "The long course of the abducens nerve between the brainstem and the eye makes it vulnerable to injury at many levels.  For example, fractures of the petrous temporal bone can selectively damage the nerve, as can  aneurysms  of the intracavernous carotid artery.  Mass lesions that push the brainstem downward can damage the nerve by stretching it between the point where it emerges from the pons and the point where it hooks over the petrous temporal bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1115", "text": "The central anatomy of the sixth nerve predicts (correctly) that infarcts affecting the dorsal pons at the level of the abducens nucleus can also affect the facial nerve,  producing an ipsilateral facial palsy together with a lateral rectus palsy.  The anatomy also predicts (correctly) that infarcts involving the ventral pons can affect the sixth nerve and the corticospinal tract simultaneously, producing a lateral rectus palsy associated with a contralateral hemiparesis. These rare syndromes are of interest primarily as useful summaries of the anatomy of the brainstem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1116", "text": "Complete interruption of the peripheral sixth nerve causes  diplopia  (double vision), due to the unopposed action of the  medial rectus muscle . The affected eye is pulled medially. In order to see without double vision, patients will turn their heads sideways so that both eyes are looking sideways. On formal testing, the affected eye cannot abduct past the midline \u2013 it cannot look sideways, toward the temple. Partial damage to the sixth nerve causes weak or incomplete abduction of the affected eye.  The diplopia is worse on attempted lateral gaze, as would be expected (since the lateral gaze muscle is impaired)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1117", "text": "Peripheral sixth nerve damage can be caused by tumors, aneurysms, or fractures \u2013 anything that  directly compresses or stretches the nerve.  Other processes that can damage the sixth nerve include strokes (infarctions), demyelination, infections (e.g.  meningitis ), cavernous sinus diseases and various neuropathies. Perhaps the most common overall cause of sixth nerve impairment is  diabetic neuropathy .  Iatrogenic injury is also known to occur, with the abducens nerve being the most commonly injured cranial nerve in halo orthosis placement. [ 5 ]  The resultant palsy is identified through loss of lateral gaze after application of the orthosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1118", "text": "Rare causes of isolated sixth nerve damage include  Wernicke\u2013Korsakoff syndrome  and  Tolosa\u2013Hunt syndrome . Wernicke\u2013Korsakoff syndrome is caused by thiamine deficiency, classically due to alcoholism.  The characteristic ocular abnormalities are nystagmus and lateral rectus weakness.  Tolosa-Hunt syndrome is an idiopathic granulomatous disease that causes painful oculomotor (especially sixth nerve) palsies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1119", "text": "Indirect damage to the sixth nerve can be caused by any process ( brain tumor ,  hydrocephalus ,  pseudotumor cerebri , hemorrhage, edema) that exerts downward pressure on the brainstem, causing the nerve to stretch along the clivus. This type of traction injury can affect either side first. A right-sided brain tumor can produce either a right-sided or a left-sided sixth nerve palsy as an initial sign.  Thus a right-sided sixth nerve palsy does not necessarily imply a right-sided cause.  Sixth nerve palsies are infamous as \"false localizing signs.\" Neurological signs are described as \"false localizing\" if they reflect dysfunction distant or remote from the expected anatomical location of pathology. Isolated sixth nerve palsies in children are assumed to be due to brain tumors until proven otherwise."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1120", "text": "Damage to the abducens nucleus does not produce an isolated  sixth nerve palsy , but rather a horizontal  gaze palsy  that affects both eyes simultaneously.  The abducens nucleus contains two types of cells: motor neurons that control the lateral rectus muscle on the same side, and interneurons that cross the midline and connect to the contralateral oculomotor nucleus (which controls the medial rectus muscle of the opposite eye).  In normal vision, lateral movement of one eye (lateral rectus muscle) is precisely coupled to medial movement of the other eye (medial rectus muscle), so that both eyes remain fixed on the same object."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1121", "text": "The control of  conjugate gaze  is mediated in the brainstem by the  medial longitudinal fasciculus  (MLF), a nerve tract that connects the three extraocular motor nuclei (abducens, trochlear and oculomotor) into a single functional unit.  Lesions of the abducens nucleus and the MLF produce observable sixth nerve problems, most notably  internuclear ophthalmoplegia  (INO)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1122", "text": "The sixth nerve is one of the final common pathways for numerous cortical systems that control eye movement in general.  Cortical control of eye movement ( saccades , smooth pursuit,  accommodation ) involves  conjugate gaze , not unilateral eye movement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1123", "text": "15\u201340% of people with tuberculosis have some resulting cranial nerve deficit.  The sixth nerve is the most commonly affected cranial nerve in immunocompetent people with tuberculosis. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1124", "text": "The Latin name for the sixth cranial nerve is \"nervus abducens\".  The  Terminologia Anatomica  officially recognizes two different English translations: \"abducent nerve\" and \"abducens nerve\". [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1125", "text": "\"Abducens\" is more common in recent literature, while \"abducent\" predominates in the older literature.  The  United States National Library of Medicine  uses \"abducens nerve\" in its Medical Subject Heading ( MeSH ) vocabulary to index the vast  MEDLINE  and  PubMed  biomedical databases.  The 39th edition of  Gray's Anatomy  (2005) also prefers \"abducens nerve.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1126", "text": "The abducens nerve controls the movement of a single muscle, the  lateral rectus muscle  of the eye.  In most other  mammals  it also innervates the  musculus retractor bulbi , which can retract the eye for protection.  Homologous abducens nerves are found in all  vertebrates  except  lampreys  and  hagfishes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1127", "text": "The  accessory nerve , also known as the  eleventh cranial nerve ,  cranial nerve XI , or simply  CN XI , is a  cranial nerve  that supplies the  sternocleidomastoid  and  trapezius muscles . It is classified as the eleventh of twelve pairs of cranial nerves because part of it was formerly believed to originate in the brain. The sternocleidomastoid muscle tilts and rotates the head, whereas the trapezius muscle, connecting to the  scapula , acts to shrug the shoulder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1128", "text": "Traditional descriptions of the accessory nerve divide it into a spinal part and a cranial part. [ 1 ]  The cranial component rapidly joins the  vagus nerve , and there is ongoing debate about whether the cranial part should be considered part of the accessory nerve proper. [ 2 ] [ 1 ]  Consequently, the term \"accessory nerve\" usually refers only to nerve supplying the sternocleidomastoid and trapezius muscles, also called the  spinal accessory nerve . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1129", "text": "Strength testing of these muscles can be measured during a  neurological examination  to assess function of the spinal accessory nerve. Poor strength or limited movement are suggestive of damage, which can result from a variety of causes. Injury to the spinal accessory nerve is most commonly caused by medical procedures that involve the head and neck. [ 4 ]  Injury can cause wasting of the  shoulder  muscles,  winging of the scapula , and weakness of shoulder abduction and  external rotation . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1130", "text": "The accessory nerve is derived from the  basal plate  of the  embryonic  spinal segments C1\u2013C6. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1131", "text": "The fibres of the spinal accessory nerve originate solely in  neurons  situated in the upper  spinal cord , from where the spinal cord begins at the junction with the  medulla oblongata , to the level of about C6. [ 1 ] [ 7 ]  These fibres join to form rootlets, roots, and finally the spinal accessory nerve itself. The formed nerve enters the skull through the  foramen magnum , the large opening at the skull's base. [ 1 ]  The nerve travels along the inner wall of the skull towards the  jugular foramen . [ 1 ]  Leaving the skull, the nerve travels through the jugular foramen with the  glossopharyngeal  and  vagus nerves . [ 8 ]  The spinal accessory nerve is notable for being the only cranial nerve to both enter and exit the skull. This is due to it being unique among the cranial nerves in having neurons in the spinal cord. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1132", "text": "After leaving the skull, the cranial component detaches from the spinal component. The spinal accessory nerve continues alone and heads backwards and downwards. In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of digastric muscle. As it courses downwards, the nerve pierces through the  sternocleidomastoid muscle  (approximately 1\u00a0cm above  Erb's point ) while sending it  motor  branches, then continues down until it reaches the  trapezius muscle  (entering at the junction of the middle and lower third of the anterior border of the  trapezius ) to provide motor innervation to its upper part. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1133", "text": "The fibres that form the spinal accessory nerve are formed by  lower motor neurons  located in the upper segments of the  spinal cord . This  cluster of neurons , called the  spinal accessory nucleus , is located in the lateral aspect of the anterior horn of the spinal cord, and stretches from where the spinal cord begins (at the junction with the medulla) through to the level of about C6. [ 1 ]  The lateral horn of high cervical segments appears to be continuous with the  nucleus ambiguus  of the  medulla oblongata , from which the cranial component of the accessory nerve is derived. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1134", "text": "In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of  digastric muscle , in front of the vein in about 80% of people, and behind it in about 20%, [ 9 ]  and in one reported case, piercing the vein. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1135", "text": "Traditionally, the accessory nerve is described as having a small cranial component that descends from the  medulla  and briefly connects with the spinal accessory component before branching off of the nerve to join the vagus nerve. [ 1 ]  A study, published in 2007, of twelve subjects suggests that in the majority of individuals, this cranial component does not make any distinct connection to the spinal component; the roots of these distinct components were separated by a fibrous sheath in all but one subject. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1136", "text": "The accessory nerve is derived from the  basal plate  of the embryonic spinal segments C1\u2013C6. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1137", "text": "The spinal component of the accessory nerve provides motor control of the  sternocleidomastoid  and  trapezius   muscles . [ 8 ]  The trapezius muscle controls the action of shrugging the shoulders, and the sternocleidomastoid the action of turning the head. [ 8 ]  Like most muscles, control of the trapezius muscle arises from the opposite side of the brain. [ 8 ]   Contraction of the upper part of the trapezius muscle elevates the scapula. [ 13 ]  The nerve fibres supplying sternocleidomastoid, however, are thought to change sides ( Latin :  decussate ) twice. This means that the sternocleidomastoid is controlled by the brain on the same side of the body. Contraction of the stenocleidomastoid fibres turns the head to the opposite side, the net effect meaning that the head is turned to the side of the brain receiving visual information from that area. [ 8 ]  The cranial component of the accessory nerve, on the other hand, provides motor control to the muscles of the soft palate, larynx and pharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1138", "text": "Among researchers there is disagreement regarding the terminology used to describe the type of information carried by the accessory nerve. As the trapezius and sternocleidomastoid muscles are derived from the  pharyngeal arches , some researchers believe the spinal accessory nerve that innervates them must carry specific  special visceral efferent  (SVE) information. [ 14 ]  This is in line with the observation that the spinal accessory nucleus appears to be continuous with the  nucleus ambiguus  of the medulla. Others consider the spinal accessory nerve to carry  general somatic efferent  (GSE) information. [ 15 ]  Still others believe it is reasonable to conclude that the spinal accessory nerve contains both SVE and GSE components. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1139", "text": "The accessory nerve is tested by evaluating the function of the  trapezius  and  sternocleidomastoid muscles . [ 8 ]  The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance. The sternocleidomastoid muscle is tested by asking the patient to turn their head to the left or right against resistance. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1140", "text": "One-sided weakness of the trapezius may indicate injury to the nerve on the same side of an injury to the spinal accessory nerve on the same side (Latin:  ipsilateral ) of the body being assessed. [ 8 ]  Weakness in head-turning suggests injury to the contralateral spinal accessory nerve: a weak leftward turn is indicative of a weak right sternocleidomastoid muscle (and thus right spinal accessory nerve injury), while a weak rightward turn is indicative of a weak left sternocleidomastoid muscle (and thus left spinal accessory nerve). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1141", "text": "Hence, weakness of shrug on one side and head-turning on the other side may indicate damage to the accessory nerve on the side of the shrug weakness, or damage along the nerve pathway at the other side of the brain. Causes of damage may include trauma, surgery, tumours, and compression at the jugular foramen. [ 8 ]  Weakness in both muscles may point to a more general disease process such as  amyotrophic lateral sclerosis ,  Guillain\u2013Barr\u00e9 syndrome  or  poliomyelitis . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1142", "text": "Injury to the spinal accessory nerve commonly occurs during neck surgery, including  neck dissection  and  lymph node  excision. It can also occur as a result of blunt or penetrating trauma, and in some causes spontaneously. [ 17 ] [ 5 ]  Damage at any point along the nerve's course will affect the function of the nerve. [ 10 ]  The nerve is intentionally removed in \"radical\" neck dissections, which are attempts at exploring the neck surgically for the presence and extent of cancer. Attempts are made to spare it in other forms of less aggressive dissection. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1143", "text": "Injury to the accessory nerve can result in neck pain and weakness of the trapezius muscle. Symptoms will depend on at what point along its length the nerve was severed. [ 5 ]  Injury to the nerve can result in shoulder girdle depression, atrophy, abnormal movement, a protruding scapula, and weakened  abduction . [ 5 ]  Weakness of the shoulder girdle can lead to traction injury of the  brachial plexus . [ 10 ]  Because diagnosis is difficult,  electromyogram  or  nerve conduction studies  may be needed to confirm a suspected injury. [ 5 ]  Outcomes with surgical treatment appear to be better than conservative management, which entails physiotherapy and pain relief. [ 17 ]  Surgical management includes  neurolysis , nerve end-to-end suturing, and surgical replacement of affected trapezius muscle segments with other muscle groups, such as the  Eden-Lange procedure . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1144", "text": "Damage to the nerve can cause  torticollis . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1145", "text": "English anatomist  Thomas Willis  in 1664 first described the accessory nerve, choosing to use \"accessory\" (described in  Latin  as  nervus accessorius ) meaning in association with the vagus nerve. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1146", "text": "In 1848,  Jones Quain  described the nerve as the \"spinal nerve accessory to the vagus\", recognizing that while a minor component of the nerve joins with the larger vagus nerve, the majority of accessory nerve fibres originate in the spinal cord. [ 3 ] [ 20 ]  In 1893 it was recognised that the heretofore named nerve fibres \"accessory\" to the vagus originated from the same nucleus in the  medulla oblongata , and it came to pass that these fibres were increasingly viewed as part of the vagus nerve itself. [ 3 ]  Consequently, the term \"accessory nerve\" was and is increasingly used to denote only fibres from the spinal cord; the fact that only the spinal portion could be tested clinically lent weight to this opinion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1147", "text": "In  anatomy , the  pharyngeal tonsil , also known as the  nasopharyngeal tonsil  or  adenoid , is the  superior -most of the  tonsils . It is a mass of  lymphoid tissue  located behind the  nasal cavity , in the roof and the posterior wall of the  nasopharynx , [ 1 ]  where the  nose  blends into the  throat . In  children , it normally forms a soft mound in the roof and back wall of the nasopharynx, just above and behind the  uvula ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1148", "text": "The term  adenoid  is also used to represent  adenoid hypertrophy , the abnormal growth of the pharyngeal tonsils. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1149", "text": "The adenoid is a mass of  lymphoid tissue  located behind the nasal cavity, in the roof and the posterior wall of the  nasopharynx , [ 1 ]  where the nose blends into the throat. The adenoid, unlike the  palatine tonsils , has  pseudostratified epithelium . [ 3 ]   The adenoids are part of the so-called  Waldeyer ring  of lymphoid tissue which also includes the palatine tonsils, the  lingual tonsils  and the  tubal tonsils ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1150", "text": "Adenoids develop from a subepithelial infiltration of  lymphocytes  after the 16th week of embryonic life. After birth, enlargement begins and continues until ages 5 to 7 years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1151", "text": "Part of the immune system, adenoids trap and recognize pathogens such as bacteria and viruses. In response, the adenoid produces  T cells  and  B cells  to combat infection, contributing to the synthesis of IgA  immunoglobulins , assisting in the body's immunologic memory. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1152", "text": "Species of bacteria such as  lactobacilli , anaerobic streptococci,  actinomycosis ,  Fusobacterium  species, and  Nocardia  are normally present by 6 months of age. Normal flora found in the adenoid consists of  alpha-hemolytic streptococci  and  enterococci ,  Corynebacterium  species,  coagulase-negative staphylococci ,  Neisseria  species,  Haemophilus  species,  Micrococcus  species, and  Stomatococcus  species. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1153", "text": "An enlarged adenoid, or  adenoid hypertrophy , can become nearly the size of a  ping pong ball  and completely block airflow through the nasal passages. Even if the enlarged adenoid is not substantial enough to physically block the back of the nose, it can obstruct airflow enough so that breathing through the nose requires an uncomfortable amount of work, and inhalation occurs instead through an open mouth. The enlarged adenoid would also obstruct the nasal airway enough to affect the voice without actually stopping nasal airflow altogether."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1154", "text": "Symptomatic enlargement between 18 and 24 months of age is not uncommon, meaning that snoring, nasal airway obstruction and obstructed breathing may occur during sleep. However, this may be reasonably expected to decline when children reach school age, and progressive shrinkage may be expected thereafter. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1155", "text": "Enlargement of the adenoid, especially in children, causes an atypical appearance of the face, often referred to as  adenoid facies . [ 5 ]  Features of adenoid facies include  mouth breathing , an elongated face, prominent incisors,  hypoplastic   maxilla , short upper lip, elevated nostrils, and a high arched palate. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1156", "text": "Surgical removal of the adenoid is a procedure called  adenoidectomy . Adenoid infection may cause symptoms such as excessive  mucus  production, which can be treated by its removal. Studies have shown that adenoid regrowth occurs in as many as 19% of the cases after removal. [ 7 ]  Carried out through the mouth under a  general anaesthetic  (or less commonly a  topical ), adenoidectomy involves the adenoid being  curetted ,  cauterized ,  lasered , or otherwise  ablated . The adenoid is often removed along with the  palatine tonsils . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1157", "text": "Adenoid hypertrophy , also known as  enlarged adenoids  refers to an enlargement\u00a0of the  adenoid  (pharyngeal  tonsil ) that is linked to nasopharyngeal mechanical blockage and/or chronic inflammation. [ 1 ]  Adenoid hypertrophy is a characterized by  hearing loss , recurrent  otitis media , mucopurulent  rhinorrhea , chronic  mouth breathing , nasal  airway obstruction , increased infection susceptibility, and dental malposition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1158", "text": "The exact cause of adenoid hypertrophy in children remains unclear, but it is likely linked to immunological responses, hormonal factors, or genetic components. Adenoid hypertrophy is an immunological abnormality characterized by altered  cytokine  production, with children experiencing higher levels of proinflammatory cytokines. Adenoid hypertrophy can also be caused by gastric juice exposure during  gastroesophageal reflux disease , passive smoking, and recurrent bacterial and viral infections. Pathogen colonization can disrupt the  immune system 's equilibrium with the adenoid's natural flora. Genetic factors, such as variations in  TLR2  and  TLR4  genes, also contribute to the condition. Adenoids naturally undergo  hypertrophy  between 6-10 and atrophy around 16 years old."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1159", "text": "A clinical examination and  nasoendoscopy  are the gold standard for diagnosing adenoid hypertrophy. Visual examinations should be conducted to identify adenoid facies,  eczema , and similar signs in diseases like partial  choanal atresia , significant palatine tonsil hyperplasia, nasal airway blockage, endonasal foreign bodies, nasal concha hyperplasia, and allergic or viral  rhinitis .  Neoplasms , benign or malignant ones, should be ruled out. Screening for  juvenile nasopharyngeal angiofibroma  is crucial in male adolescents, while adult patients should be evaluated for  carcinoma  and  lymphoma .  Thornwaldt cysts  should also be considered in differential diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1160", "text": "Patients with adenoid hyperplasia alone should follow conservative therapy and off-label intranasal  corticosteroids . Patients with significant symptoms and unsatisfactory responses to conservative measures may be candidates for  adenoidectomy . An  adenoidectomy  can shrink and reduce nasal obstruction in patients. Patients usually experience improved eustachian tube function, reduced obstruction, and decreased nasal discharge. The prevalence of adenoid hypertrophy in the pediatric population is estimated to be 34%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1161", "text": "Enlarged adenoids can become nearly the size of a  ping pong ball  and completely block airflow through the nasal passages. Even if enlarged adenoids are not substantial enough to physically block the back of the nose, they can obstruct airflow enough so that  nasal breathing  requires an uncomfortable amount of work, and inhalation occurs instead through  mouth breathing . Adenoids can also obstruct the nasal airway enough to affect the voice without actually stopping nasal airflow altogether. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1162", "text": "Adenoid hypertrophy is characterized by a number of typical signs and symptoms, including  conductive hearing loss , recurrent  otitis media  (including  cholesteatoma ), mucopurulent  rhinorrhea , chronic  mouth breathing , nasal  airway obstruction , increased susceptibility to infection, and occasionally dental malposition. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1163", "text": "If left untreated, adenoid hypertrophy\u00a0can cause  pulmonary hypertension , ear issues,  obstructive sleep apnea ,\u00a0 failure to thrive , and  craniofacial abnormalities . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1164", "text": "It's unclear what exactly causes adenoid hypertrophy in children. Most likely, immunological responses, hormonal factors, or genetic components have some relationship. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1165", "text": "One of the immunological abnormalities described is altered  cytokine  production. For instance, it was demonstrated that  interleukin (IL)-32  was upregulated in  adenoid  tissue. This could potentially impact the progression of adenoid hypertrophy by inducing the production of proinflammatory cytokines and inducing  pyroptosis  in human nasal  epithelial cells , which is mediated by the  NOD1 / 2 / TLR4 / NLRP3  pathway. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1166", "text": "Furthermore, it has been discovered that children with adenoid hypertrophy had higher levels of proinflammatory cytokines, including  interferon-\u03b3  (IFN-\u03b3), high-sensitivity  C reactive protein ,  IL-1  and  IL-10 ,  TNF-\u03b1  (tumor necrosis factor \u03b1), and  intercellular adhesion molecule-1 . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1167", "text": "Adenoid hypertrophy may also be brought on by gastric juice exposure during  gastro-oesophageal reflux disease , particularly in infants and early toddlers. [ 8 ]  An additional risk factor for adenoid hypertrophy is passive smoking. [ 9 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1168", "text": "Recurrent bacterial and viral infections as well as pathogen colonization might upset the normally stable equilibrium between the  immune system  and the natural flora of the adenoid. [ 10 ]  Hypertrophic processes are frequently brought on by recurrent  upper respiratory tract infections  or  allergies . [ 9 ] [ 11 ]  The bacteria  Haemophilus influenza ,  Streptococcus pneumoniae ,  Streptococcus pyogenes , and  Staphylococcus aureus  are most frequently isolated from adenoid tissue. Pathogens that are  anaerobic bacteria  are also found in chronic infections. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1169", "text": "Genetic factors include, for example, variations in the genes encoding  TLR2  and  TLR4 , SCGB1D4, and other genes. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1170", "text": "The clinical and anatomic basis of hypertrophy is the enlargement of the germinal centers of  lymphoid tissue  and lymphoid follicles. The fundamental reason is thought to be a vicious cycle of  inflammation ,  hypertrophy  and/or  hyperplasia , secretory retention, and recurrent inflammation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1171", "text": "Adenoid  is a lymphoid tissue condensation at the back of the nose or on the nasopharyngeal postrosuperior wall.  Adenoid is part of  Waldeyer's Ring . [ 15 ]  In younger children, it seems to play a significant part in the establishment of a \" immunological memory .\" [ 16 ]  Adenoids naturally undergo  hypertrophy  between the ages of 6 and 10 and  atrophy  around the age\u00a016. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1172", "text": "The  tonsils  in the back of the mouth, the  adenoid , and the tonsilar tissue at the base of the tongue combine to form  Waldeyer's ring , a tissue ring that helps keep toxins,  bacteria , and  viruses  out of the body.  B lymphocytes , a kind of blood cell that produces  antibodies , make up the majority of the tissues found in the tonsils and adenoid glands. This antibody binds to toxins, germs, and viruses to render them inactive, preventing disease-causing agents from entering the body. The adenoid is situated toward the rear of the  nasal cavity  and up behind the  soft palate , in contrast to the tonsils, which are visible when one looks straight through the mouth. Similar to tonsilar tissue, the adenoid can be affected by both acute and long-term  infections . A persistent infection or inflammation may cause the adenoid to gradually get larger. Because of its location at the rear of the nasal cavity, its primary symptoms have an impact on nasal function. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1173", "text": "During the early years of life, the adenoids expand quickly due to their immunological roles. Its size and form change dramatically during childhood, with dynamic growth occurring between the ages of 3 and 6 years. This may be due to the nasopharyngeal cavity growing more slowly than expected. [ 10 ]  Under normal circumstances, the adenoid grows less after the age of six, and the nasopharyngeal cavity expands and widens the  respiratory tract . [ 5 ]  Due to the proliferation of fibrous tissue and fatty  atrophy , the lymphoid tissue experiences  involution  later in life. [ 5 ]  As a result, in the majority of people, adenoid tissue exists in a residual form but never totally vanishes. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1174", "text": "Microscopic and functional changes within are accompanied by macroscopic changes. [ 10 ]  In humans, these adenoids are most immunologically active between the ages of 4 and 10, and after puberty, they start to involute. [ 19 ]  The population of  B cells  declines and the ratio of  T cells  to  B cells  rises as a result. Inflammation of the crypts caused by infection of the adenoids causes immunologically active cells to become inactive, reducing their capacity to transfer antigens. This, in turn, causes the cells to  metaplasia  into a multilayered squamous epithelium. [ 10 ]  Such alterations result in poor cell functioning and ineffective  antigen  uptake. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1175", "text": "Currently, a thorough clinical examination combined with  nasoendoscopy  (NE), notably  nasopharyngoscopy , is the gold standard for diagnosing adenoid hypertrophy. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1176", "text": "Visual examination should be conducted primarily to determine whether adenoid facies are present. The mouth is usually open and the tip of the tongue is visible in a patient with an adenoid facies. Furthermore,  eczema  is frequently seen at the nose's opening. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1177", "text": "Similar signs and symptoms can be found in diseases such partial  choanal atresia  and significant palatine tonsil hyperplasia. Nasal airway blockage can also result from endonasal foreign bodies, nasal concha hyperplasia, and allergic or viral  rhinitis .\u00a0 Neoplasms  that are benign or malignant in particular need to be ruled out. It is important to screen for  juvenile nasopharyngeal angiofibroma  in male adolescents in particular. Adult patients, on the other hand, need to be evaluated particularly for  carcinoma  and  lymphoma , which typically present with symptoms including  ulceration , bleeding, slimy coatings, size increases, and  conductive hearing loss .\u00a0A spherical tumor of the nasopharynx coated in smooth mucosa called a  Thornwaldt cyst  should also be considered in the differential diagnosis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1178", "text": "In patients with adenoid hyperplasia alone without accompanying indications or symptoms, conservative therapy, i.e., cautious waiting, is advised. [ 1 ]  Furthermore, there is data indicating that people with adenoid hyperplasia may benefit from off-label intranasal  corticosteroids . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1179", "text": "Patients exhibiting significant symptoms (such as repeated  fever  and infections, persistent ear problems) and/or unsatisfactory response to conservative measures (such as topical  cortisone , anti-allergic therapy, and watchful waiting) are candidates for  adenoidectomy . Individuals with long-term serous or mucous  otitis media  frequently have an  adenoidectomy ,  myringotomy , and/or tube insertions performed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1180", "text": "The  adenoid  will shrink back to a smaller size and cause less nasal obstruction if it is acutely swollen and responds well to antibiotic and steroid therapy. After undergoing an  adenoidectomy , patients usually experience improvements in their eustachian tube function, a reduction in nasal obstruction, and a decrease in excessive nasal discharge. Of children who undergo  adenoidectomy  for chronic sinus disease, 25% will experience a resolution of their sinus disease. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1181", "text": "In the pediatric population, the estimated prevalence of adenoid hypertrophy is 34%. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1182", "text": "The structure that is today known as the  adenoid  was initially described by the German anatomist Conrad Victor Schneider in 1661. But it wasn't until 1868 that the Danish physician Meyer coined the term\u00a0\"adenoid vegetations.\" [ 10 ]  In an original research report, Meyer characterized these adenoid vegetations as \"soft tumour masses of the nasopharynx that fill the room above the soft palate.\" [ 24 ]  He also realized the connection between adenoid hypertrophy, mouth breathing, snoring, nasal obstruction, and hearing loss. [ 10 ]  In addition, Meyer suggested using a specific knife that is put into the  nasopharynx  through the anterior nostrils in order to surgically treat adenoid hyperplasia. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1183", "text": "Adenoidectomy  is the  surgical  removal of the  adenoid  for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches. The effectiveness of removing the adenoids in children to improve recurrent nasal symptoms and/or nasal obstruction has not been well studied. [ 1 ]  The surgery is less commonly performed in adults in whom the adenoid is much smaller and less active than it is in children. It is most often done on an  outpatient  basis under general  anesthesia . Post-operative pain is generally minimal and reduced by icy or cold foods. The procedure is often combined with  tonsillectomy  (this combination is usually called an \"adenotonsillectomy\" or \"T&A\"), for which the recovery time is an estimated 10\u201314 days, sometimes longer, mostly dependent on age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1184", "text": "Adenoidectomy is not often performed under one year of age as adenoid function is part of the body's immune system, but its contribution to this decreases progressively beyond this age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1185", "text": "The indications for adenoidectomy are still controversial. [ 2 ] [ 3 ] [ 4 ]  Widest agreement surrounds the removal of the adenoid for obstructive sleep apnea, usually combined with tonsillectomy. [ 5 ]  Even then, it has been observed that a significant percentage of the study population (18%) did not respond.\nThere is also support for adenoidectomy in recurrent  otitis media  in children previously treated with  tympanostomy tubes . [ 6 ] \nFinally, the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections, common cold, otitis media and moderate nasal obstruction has been questioned with the outcome, [ 1 ]  in some studies, being no better than watchful waiting. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1186", "text": "In 1971, more than one million Americans underwent tonsillectomies and/or adenoidectomies, of which 50,000 consisted of adenoidectomy alone. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1187", "text": "By 1996, roughly a half million children underwent some surgery on their adenoid and/or tonsils in both outpatient and inpatient settings. This included approximately 60,000 tonsillectomies, 250,000 combined tonsillectomies and adenoidectomies,  and 125,000 adenoidectomies. By 2006, the total number had risen to over 700,000 but when adjusted for population changes, the tonsillectomy \"rate\" had dropped from 0.62 per thousand children to 0.53 per thousand. A larger decline for combined tonsillectomy and adenoidectomy was noted - from 2.20 per thousand to 1.46. There was no significant change in adenoidectomy rates for chronic infectious reasons (0.25 versus 0.21 per 1000). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1188", "text": "Adenoidectomy was first performed using a ring forceps through the  nasal cavity  by William Meyer in 1867. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1189", "text": "In the early 1900s, adenoidectomies began to be routinely combined with tonsillectomy. [ 12 ]  Initially, the procedures were performed by  otolaryngologists , general surgeons, and general practitioners but over the past 30 years have been performed almost exclusively by otolaryngologists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1190", "text": "Then, adenoidectomies were performed as treatment of  anorexia nervosa ,  mental retardation , and  enuresis  or to promote 'good health'. By current standards, these indications seem odd but may be explained by the  hypothesis  that children might have failed to thrive if they had chronically  sore throats  or  severe obstructive sleep apnea  (OSA). Also, children who heard poorly because of chronic  otitis media  might have had unrecognized  speech delay  mistaken for intellectual disability. Adenoidectomy might have helped to resolve ear fluid problems, speech delays, and consequent perceptions of low  intelligence ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1191", "text": "The relationship between enuresis and obstructive apnea, and the benefit of adenoidectomy by implication, is complex and controversial. On one hand, the frequency of enuresis declines as children grow older. On the other, the size of the adenoid, and again by implication, any obstruction that they might be causing, also declines with increasing age. These two factors make it difficult to distinguish the benefits of adenoidectomy from age-related spontaneous improvement. Further, most of the studies in the medical literature which appear to show benefit from adenoidectomy have been case reports or case series. Such studies are prone to unintentional bias. Finally, a recent study of six thousand children has not shown an association between enuresis and obstructive sleep in general but an increase with advancing severity of obstructive sleep apnea, observed only in girls. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1192", "text": "A decline in the frequency of the procedure started in the 1930s as its use became controversial. Tonsillitis and adenoiditis requiring surgery became less frequent with the development of antimicrobial agents and a decline in upper respiratory infections among older school-aged children. Also, several studies had shown that adenoidectomy and tonsillectomy were ineffective for many of the indications used at that time as well as the suggestion of an increased risk of developing  poliomyelitis  after the procedure, later disproved. [ 14 ]  Prospective clinical trials, performed over the last 2 decades, have redefined the appropriate indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1193", "text": "The  angular artery  is an  artery  of the  face . It is the terminal part of the  facial artery . It ascends to the medial angle of the eye's  orbit . It is accompanied by the  angular vein . It ends by anastomosing with the  dorsal nasal branch  of the  ophthalmic artery . It supplies the  lacrimal sac , the  orbicularis oculi muscle , and the outer side of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1194", "text": "The angular artery is the terminal part of the  facial artery . [ 1 ] [ 2 ]  It ascends to the medial angle of the eye's  orbit  (the medial canthus). [ 2 ]  It is embedded in the fibers of the angular head of the  levator labii superioris muscle . [ citation needed ]  It is accompanied by the  angular vein . On the cheek, it distributes branches which anastomose with the  infraorbital artery . [ 2 ]  It ends by anastomosing with the  dorsal nasal branch  of the  ophthalmic artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1195", "text": "The angular artery supplies the  lacrimal sac , [ 2 ]  most of the outer side of the  nose , [ 3 ]  part of the  lower eyelid , [ 2 ]  and the  orbicularis oculi muscle . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1196", "text": "The angular artery is important in a nasolabial skin flap for  reconstructive surgery . [ 4 ]  It can be put at risk during acupuncture of  skin  around the inner side of the  eye . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1197", "text": "This article incorporates text in the  public domain  from  page 556  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1198", "text": "ocular group:   central retinal"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1199", "text": "The  anterior ethmoidal artery  is a branch of the  ophthalmic artery  in the orbit. [ 1 ]  It exits the orbit through the  anterior ethmoidal foramen  alongside the  anterior ethmoidal nerve . It contributes blood supply to the  ethmoid sinuses ,  frontal sinuses , the  dura mater , lateral nasal wall, and  nasal septum . It issues a meningeal branch, and nasal branches. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1200", "text": "The anterior ethmoidal artery branches from the ophthalmic artery distal to the posterior ethmoidal artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1201", "text": "It travels with the  anterior ethmoidal nerve  to exit the medial wall of the orbit at the anterior ethmoidal foramen. It then travels through the anterior ethmoidal canal and gives branches which supply the  frontal sinus  and anterior and middle  ethmoid air cells . Following which, it enters the  anterior cranial fossa  where it bifurcates into a meningeal branch and nasal branch. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1202", "text": "The nasal branch travels through  cribriform plate  to enter the  nasal cavity  and runs in a groove on the deep surface of the  nasal bone . Here it bifurcates into a medial and lateral branch. The lateral branch supplies blood to the lateral wall of the nasal cavity and the medial branch to the  nasal septum . A terminal branch of the lateral branch, called the external nasal branch passes between the nasal bone and the nasal cartilage to supply the skin of the  nose . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1203", "text": "The  anterior ethmoidal nerve  is a nerve of the head. It is a branch of the  nasociliary nerve  (itself a branch of the  ophthalmic nerve (V 1 ) ). It arises in the orbit, and enters first the cranial cavity and then the nasal cavity. It provides sensory innervation to part of the meninges, parts of the  nasal cavity , and part of the skin of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1204", "text": "The anterior ethmoidal nerve is a terminal branch of the  nasociliary nerve , a branch of the  ophthalmic nerve  (CN V 1 ), itself a branch of the  trigeminal nerve  (CN V). [ 1 ]  It branches near the medial wall of the  orbit ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1205", "text": "It passes through the  anterior ethmoidal canal  alongside the  anterior ethmoidal artery [ 2 ] :\u200a780\u200a  and vein [ 2 ] :\u200a566\u200a  to emerge in  anterior cranial fossa  through the  anterior ethmoidal foramen [ 2 ] :\u200a1464.e13\u200a  (at the junction of the cribiform plate of ethmoid bone and  orbital part of frontal bone [ 2 ] :\u200a566\u200a )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1206", "text": "Within the cranial cavity, it passes anterior-ward (external to the dura mater) along a groove upon the superior surface of the  cribriform plate . It descends through an aperture situated lateral to the  crista galli  to reach the  nasal cavity . [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1207", "text": "In the nasal cavity, it passes along a groove upon the internal aspect of the nasal bone, and issuing the medial and lateral internal nasal branches. [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1208", "text": "It is continued as the  external nasal nerve  beyond the inferior margin of the nasal bone. [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1209", "text": "Within the anterior cranial fossa, it gives sensory fibers to the  meninges  to provide sensory innervation to part of the meninges. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1210", "text": "Its medial internal nasal branch innervates the superior and anterior portions of the nasal septum. [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1211", "text": "Its lateral internal nasal branch innervates the anterior portion of the lateral nasal wall. [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1212", "text": "It gives off branches to the roof of the nasal cavity, and bifurcates into a lateral internal nasal branch and medial internal nasal branch. It sends sensory fibers to the  anterior ethmoid air cells  and the  middle ethmoidal air cells . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1213", "text": "Its terminal branch - the  external nasal nerve  - innervates skin of the nose between the nasal bones superiorly and the tip of the nose inferiorly, except the alar portionsurrounding the external nares. [ 2 ] :\u200a1464.e13"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1214", "text": "It is involved in the  diving reflex . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1215", "text": "This  neuroanatomy  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1216", "text": "Antral lavage  is a  largely obsolete [ citation needed ]  surgical procedure in which a  cannula   is inserted into the  maxillary sinus  via the  inferior meatus  to allow irrigation and drainage of the sinus. [ 1 ] \nIt is also called proof puncture, as the presence of an  infection  can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture. [ 2 ]  Often, multiple repeated lavages are subsequently required to allow for full washout of infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1217", "text": "In contemporary practice,  endoscopic sinus surgery  has largely replaced antral lavage and as such, it is rarely performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1218", "text": "It can be used as therapeutic procedure for:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1219", "text": "It can be also used as diagnostic procedure for:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1220", "text": "Age: Below the age of 3 years, as the size of the sinus is small due to underdeveloped  Maxillary Sinus . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1221", "text": "Bleeding disorders: May lead to  epistaxis . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1222", "text": "Fracture of  maxilla : Antral Lavage may result in escape of the fluid through fracture lines. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1223", "text": "Febrile  stage of acute maxillary sinusitis: May cause  osteomyelitis  of Maxilla. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1224", "text": "Procedure is contraindicated in diabetic and hypertensive patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1225", "text": "Acute maxillary sinusitis not resolving on medical treatment. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1226", "text": "The following instruments are used in the procedure: [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1227", "text": "The following difficulties may arise during antral lavage: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1228", "text": "If the returning fluid is purulent, one repeats the puncture after a week. If more than three successive puncture shows returning fluid to be persistently purulent, the patient may require  functional endoscopic sinus surgery  (FESS) and occasionally may need  Caldwell-Luc operation . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1229", "text": "As antral Washout is a much simpler procedure compared to FESS, it may be done on an  outpatient basis for Subacute Maxillary Sinusitis.  However, FESS remains gold standard in treatment of Chronic Maxillary Sinusitis. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1230", "text": "The  arcuate eminence  is a rounded [ 3 ] [ 4 ] :\u200a567\u200a  prominence [ 3 ]  upon the superior surface of [ 3 ] [ 5 ] :\u200a420\u200a  the  petrous part of the temporal bone [ 3 ]  forming the lateral part of the posterior wall of [ 5 ] :\u200a509\u200a  the  middle cranial fossa . [ 4 ] :\u200a566-567\u200a [ 5 ] :\u200a420, 509\u200a  The arcuate eminence indicates the position of the [ 3 ]  underlying [ 4 ] :\u200a567\u200a [ 5 ] :\u200a420\u200a   superior semicircular canal (anterior semicircular canal) . [ 3 ] [ 4 ] :\u200a567\u200a [ 5 ] :\u200a420, 509"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1231", "text": "The groove for the  greater petrosal nerve  is situated anteromedially to the arcuate eminence. [ 5 ] :\u200a509"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1232", "text": "Auricular hypertrichosis  ( hypertrichosis lanuginosa acquisita ,  hypertrichosis pinnae auris ) is a genetic condition expressed as long and strong hairs growing from the  helix  of the  pinna . [ 1 ] [ page\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1233", "text": "Ear hair   generally refers to the  terminal hair  arising from  follicles  inside the  external auditory meatus  in humans. [ 2 ]  In its broader sense,  ear hair  may also include the fine  vellus hair  covering much of the ear, particularly at the prominent parts of the anterior ear, or even the abnormal hair growth as seen in  hypertrichosis  and  hirsutism . Medical research on the function of ear hair is currently very scarce."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1234", "text": "Hair growth within the ear canal is often observed to increase in older men, [ 3 ]  together with increased growth of  nose hair . [ 4 ]  Excessive hair growth within or on the ear is known medically as  auricular  hypertrichosis . [ 5 ]  Some men, particularly in the male population of India, have coarse hair growth along the lower portion of the helix, a condition referred to as \"having  hairy  pinnae \" ( hypertrichosis lanuginosa acquisita ). [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1235", "text": "The genetic basis of auricular hypertrichosis has not been settled. Some researchers have proposed a Y-linked pattern of inheritance and others have suggested an autosomal gene is responsible. A third hypothesis predicts the  phenotype  results from the interaction of two loci, one on the homologous part of the X and Y and one on the nonhomologous sequence of the Y. [ 7 ]  These hypotheses are not mutually exclusive, and there may be a variety of genetic mechanisms underlying this phenotype."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1236", "text": "Lee et al. (2004), using Y-chromosomal DNA binary-marker haplotyping, suggested that a cohort of southern Indian hairy-eared males carried Y chromosomes from many  haplogroup . [ 8 ]  The hypothesis of Y- linkage would require multiple independent mutations within a single  population . No significant difference between the Y-haplogroup frequencies of hairy-eared males and those of a geographically matched control sample of unaffected males was established. The study concluded that auricular hypertrichosis is not Y-linked in southern India, though this result may not apply to all to all populations. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1237", "text": "Autoinflation  is a minimally invasive procedure to treat  serous  non-infectious  otitis media , in which a nasal balloon is inserted into the  nasopharynx , followed by the application of pressure to the  sinus cavities  by forcibly contracting the  diaphragm  against the closed nasal passageways. [ 1 ] [ 2 ]  It can also be performed by manually pinching the nasal passages and closing the back of the  pharynx , followed by forceful contraction of the diaphragm. It is not recommended in cases of bacterial, or  suppurative , otitis media, but rather serous non-infectious cases, colloquially referred to as ' glue ear '. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1238", "text": "This  medical treatment \u2013related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1239", "text": "Balloon Eustachian tuboplasty  (BET) [ 1 ]  is a minimally invasive procedure for the causal treatment of  Eustachian tube dysfunction  (ETD), an often-chronic disorder in which the regulation of  middle ear  pressure and the removal of secretions are impaired. The dysfunction often causes significant discomfort in affected patients and can trigger additional pathologies. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1240", "text": "During dilatation of the  Eustachian tube , a purpose built dilatation catheter is inserted into the cartilaginous part of the Eustachian tube under anesthesia [ 3 ] [ 4 ]  as well as endoscopic control. Access is either contralateral or ipsilateral through the nose. If necessary, the endoscope can also be inserted through the oral cavity. An appropriate introducer is used to guide the flexible catheter safely to the tube opening. Once in position, the balloon is dilated by applying a pressure of 10 bar for 2 minutes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1241", "text": "The method was first used in 2009 in both Finland [ 5 ]  and Germany [ 6 ]  and has since become an established procedure worldwide. Prospective studies and numerous scientific publications now confirm the high treatment success of the procedure, both in adults [ 1 ] [ 7 ] [ 8 ] [ 9 ]  and in children. [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1242", "text": "The  base of skull , also known as the  cranial base  or the  cranial floor , is the most  inferior  area of the  skull . It is composed of the  endocranium  and the lower parts of the  calvaria ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1243", "text": "Structures found at the base of the skull are for example:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1244", "text": "There are five bones that make up the base of the skull:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1245", "text": "Bell's palsy  is a type of  facial paralysis  that results in a temporary inability to control the  facial muscles  on the affected side of the face. [ 1 ]  In most cases, the weakness is temporary and significantly improves over weeks. [ 4 ]  Symptoms can vary from mild to severe. [ 1 ]  They may include muscle twitching, weakness, or total loss of the ability to move one or, in rare cases, both sides of the face. [ 1 ]  Other symptoms include drooping of the eyebrow, [ 5 ]  a change in  taste , and pain around the ear. Typically symptoms come on over 48 hours. [ 1 ]  Bell's palsy can trigger an increased sensitivity to sound known as  hyperacusis . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1246", "text": "The cause of Bell's palsy is unknown [ 1 ]  and it can occur at any age. [ 4 ]  Risk factors include  diabetes , a recent  upper respiratory tract infection , and  pregnancy . [ 1 ] [ 7 ]  It results from a dysfunction of  cranial nerve VII  (the facial nerve). [ 1 ]  Many believe that this is due to a viral infection that results in swelling. [ 1 ]  Diagnosis is based on a person's appearance and ruling out other possible causes. [ 1 ]  Other conditions that can cause facial weakness include  brain tumor ,  stroke ,  Ramsay Hunt syndrome type 2 ,  myasthenia gravis , and  Lyme disease . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1247", "text": "The condition normally gets better by itself, with most achieving normal or near-normal function. [ 1 ]   Corticosteroids  have been found to improve outcomes, while  antiviral medications  may be of a small additional benefit. [ 8 ]  The eye should be protected from drying up with the use of  eye drops  or an  eyepatch . [ 1 ]  Surgery is generally not recommended. [ 1 ]  Often signs of improvement begin within 14 days, with complete recovery within six months. [ 1 ]  A few may not recover completely or have a recurrence of symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1248", "text": "Bell's palsy is the most common cause of one-sided facial nerve paralysis (70%). [ 2 ] [ 9 ]  It occurs in 1 to 4 per 10,000 people per year. [ 2 ]  About 1.5% of people are affected at some point in their lives. [ 10 ]  It most commonly occurs in people between ages 15 and 60. [ 1 ]  Males and females are affected equally. [ 1 ]  It is named after Scottish surgeon  Charles Bell  (1774\u20131842), who first described the connection of the facial nerve to the condition. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1249", "text": "Although defined as a  mononeuritis  (involving only one nerve), people diagnosed with Bell's palsy may have \"myriad neurological symptoms\", including \"facial tingling, moderate or severe headache/neck pain, memory problems, balance problems, ipsilateral limb paresthesias, ipsilateral limb weakness, and a sense of clumsiness\" that are \"unexplained by facial nerve dysfunction\". [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1250", "text": "Bell's palsy is characterized by a one-sided facial droop that comes on within 72 hours. [ 12 ]  In rare cases (<1%), it can occur on both sides resulting in total facial paralysis. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1251", "text": "The facial nerve controls many functions, such as blinking and closing the  eyes ,  smiling ,  frowning ,  lacrimation ,  salivation , flaring  nostrils  and raising  eyebrows . It also carries  taste  sensations from the anterior two thirds of the  tongue , through the  chorda tympani nerve  (a branch of the facial nerve). Because of this, people with Bell's palsy may present with  loss of taste sensation  in the anterior two thirds of the tongue on the affected side. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1252", "text": "Although the facial nerve innervates the  stapedius muscle  of the  middle ear  (through the  tympanic branch ),  sound sensitivity , causing normal sounds to be perceived as very loud ( hyperacusis ), and  dysacusis  is possible but hardly ever clinically evident. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1253", "text": "The cause of Bell's palsy is unknown. [ 1 ]  Risk factors include  diabetes , a recent  upper respiratory tract infection , and  pregnancy . [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1254", "text": "Some viruses are thought to establish a persistent (or  latent ) infection without symptoms, e.g., the  varicella zoster virus [ 17 ]  and the  Epstein\u2013Barr virus , both of the  herpes family . Reactivation of an existing (dormant) viral infection has been suggested as a cause of acute Bell's palsy. [ 18 ]  As the facial nerve swells and becomes inflamed in reaction to the infection, it causes pressure within the  Fallopian canal , resulting in the restriction of blood and oxygen to the nerve cells. [ 19 ]  Other viruses and bacteria that have been linked to the development of Bell's palsy include  HIV ,  sarcoidosis  and  Lyme disease . [ medical citation needed ]  This new activation could be triggered by trauma, environmental factors, and metabolic or emotional disorders. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1255", "text": "Familial inheritance has been found in 4\u201314% of cases. [ 21 ]  There may also be an association with  migraines . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1256", "text": "In December 2020, the U.S.  FDA  recommended that recipients of the  Pfizer  and  Moderna COVID-19 vaccines  should be monitored for symptoms of Bell's palsy after several cases were reported among clinical trial participants, though the data were not sufficient to determine a causal link. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1257", "text": "A meta-analysis of genome-wide association study (GWAS) identified the first unequivocal association with Bell's palsy. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1258", "text": "Bell's palsy is the result of a malfunction of the  facial nerve  ( cranial nerve  VII), which controls the  muscles  of the face. Facial palsy is typified by an inability to move the muscles of facial expression. The paralysis is of the infranuclear/lower motor neuron type."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1259", "text": "It is thought that as a result of  inflammation  of the facial nerve, pressure is produced on the nerve where it exits the skull within its bony canal (the  stylomastoid foramen ), blocking the transmission of neural signals or damaging the nerve. Patients with facial palsy for which an underlying cause can be found are not considered to have Bell's palsy  per se . Possible causes of facial paralysis include  tumor ,  meningitis ,  stroke ,  diabetes mellitus ,  head trauma  and inflammatory diseases of the cranial nerves ( sarcoidosis ,  brucellosis , etc.). In these conditions, the neurologic findings are rarely restricted to the facial nerve. Babies can be born with facial palsy. [ 25 ]  In a few cases, bilateral facial palsy has been associated with  acute HIV infection ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1260", "text": "In some research, the  herpes simplex virus  type 1 (HSV-1) has been identified in a majority of cases diagnosed as Bell's palsy through endoneurial fluid sampling. [ 26 ]  Other research, however, identified, out of a total of 176 cases diagnosed as Bell's palsy, HSV-1 in 31 cases (18%) and  herpes zoster  in 45 cases (26%). [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1261", "text": "In addition, HSV-1 infection is associated with  demyelination  of nerves. This nerve damage mechanism is different from the above-mentioned\u2014that edema, swelling, and compression of the nerve in the narrow bone canal are responsible for nerve damage. Demyelination may not even be directly caused by the virus but by an unknown  immune  response."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1262", "text": "Bell's palsy is a  diagnosis of exclusion , meaning it is diagnosed by the elimination of other reasonable possibilities. By definition, no specific cause can be determined. There are no routine lab or imaging tests required to make the diagnosis. [ 12 ]  The degree of nerve damage can be assessed using the  House-Brackmann score ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1263", "text": "One study found that 45% of patients are not referred to a specialist, which suggests that Bell's palsy is considered by physicians to be a straightforward diagnosis that is easy to manage. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1264", "text": "Other conditions that can cause similar symptoms include  herpes zoster ,  Lyme disease ,  sarcoidosis ,  stroke , and  brain tumors . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1265", "text": "Once the facial paralysis sets in, many people may mistake it as a symptom of a stroke; however, there are a few subtle differences. A stroke will usually cause a few additional symptoms, such as numbness or weakness in the arms and legs. And unlike Bell's palsy, a stroke will usually let patients control the upper part of their faces. A person with a stroke will usually have some wrinkling on their forehead. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1266", "text": "In areas where  Lyme disease  is common, it accounts for about 25% of cases of facial palsy. [ 28 ]  In the U.S., Lyme is most common in the  New England  and  Mid-Atlantic  states and parts of  Wisconsin  and  Minnesota . [ 29 ]  The first sign of about 80% of Lyme infections, typically one or two weeks after a tick bite, is usually an  expanding rash  that may be accompanied by headaches, body aches, fatigue, or fever. [ 30 ]  In up to 10\u201315% of Lyme infections, facial palsy appears several weeks later, and may be the first sign of infection that is noticed as the Lyme rash typically does not itch and is not painful. [ 31 ] [ 32 ]  The likelihood that the facial palsy is caused by Lyme disease should be estimated, based on the recent history of outdoor activities in likely tick habitats during warmer months, a recent history of rash or symptoms such as headache and fever, and whether the palsy affects both sides of the face (much more common in Lyme than in Bell's palsy). If that likelihood is more than negligible, a serological test for Lyme disease should be performed, and if it exceeds 10%,  empiric therapy  with antibiotics should be initiated, without  corticosteroids , and reevaluated upon completion of laboratory tests for Lyme disease. [ 28 ]  Corticosteroids have been found to harm outcomes for facial palsy caused by Lyme disease. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1267", "text": "One disease that may be difficult to exclude in the  differential diagnosis  is the involvement of the facial nerve in infections with the  herpes zoster  virus. The major differences in this condition are the presence of small blisters, or  vesicles , on the external ear, significant pain in the jaw, ear, face, and/or neck, and hearing disturbances, but these findings may occasionally be lacking ( zoster sine herpete ). Reactivation of existing  herpes zoster  infection leading to facial paralysis in a Bell's palsy type pattern is known as  Ramsay Hunt syndrome type 2 . The prognosis for Bell's palsy patients is generally much better than for Ramsay Hunt syndrome type 2 patients. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1268", "text": "Steroids are effective at improving recovery in Bell's palsy while antivirals have not. [ 12 ]  In those who are unable to close their eyes, eye-protective measures are required. [ 12 ]  Management during pregnancy is similar to management in the non-pregnant. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1269", "text": "Corticosteroids  such as  prednisone  improve recovery at 6 months and are thus recommended. [ 3 ]  Early treatment (within 3 days after the onset) is necessary for benefit [ 34 ]  with a 14% greater probability of recovery. [ 35 ]  There is some debate regarding the optimal dosing strategy which is generally physician dependent. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1270", "text": "One review found that  antivirals  (such as  aciclovir ) are ineffective in improving recovery from Bell's palsy beyond steroids alone in mild to moderate disease. [ 37 ]  Another review found a benefit when combined with corticosteroids but stated the evidence was not very good to support this conclusion. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1271", "text": "In severe disease, it is also unclear. One 2015 review found no effect regardless of severity. [ 37 ]  Another review found a small benefit when added to steroids. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1272", "text": "They are commonly prescribed due to a theoretical link between Bell's palsy and the  herpes simplex  and  varicella zoster virus . [ 38 ]  There is still the possibility that they might result in a benefit less than 7% as this has not been ruled out. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1273", "text": "When Bell's palsy affects the blink reflex and stops the eye from closing completely, frequent use of tear-like eye drops or eye ointments is recommended during the day, and protecting the eyes with patches or taping them shut is recommended for sleep and rest periods. [ 28 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1274", "text": "Physiotherapy  can be beneficial to some individuals with Bell's palsy as it helps to maintain  muscle tone  of the affected  facial muscles  and stimulate the  facial nerve . [ 40 ]  It is important that muscle re-education exercises and  soft tissue techniques  be implemented before recovery to help prevent permanent  contractures  of the  paralyzed  facial muscles. [ 40 ]  To reduce  pain , heat can be applied to the affected side of the face. [ 41 ]  There is no high-quality evidence to support the role of electrical stimulation for Bell's palsy. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1275", "text": "Surgery may be able to improve outcomes in facial nerve palsy that has not recovered. [ 34 ]  A number of different techniques exist. [ 34 ]   Smile surgery  or smile reconstruction is a surgical procedure that may restore the smile for people with facial nerve paralysis. Adverse effects include hearing loss which occurs in 3\u201315% of people. [ 43 ]  A Cochrane review (updated in 2021), after reviewing applicable  randomized and quasi-randomized controlled trials  was unable to determine if early surgery is beneficial or harmful. [ 44 ]  As of 2007 the  American Academy of Neurology  did not recommend surgical decompression. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1276", "text": "The efficacy of  acupuncture  remains unknown because the available studies are of low quality (poor primary study design or inadequate reporting practices). [ 45 ]  There is very tentative evidence for  hyperbaric oxygen therapy  in severe disease. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1277", "text": "Most people with Bell's palsy start to regain normal facial function within three weeks\u2014even those who do not receive treatment. [ 47 ]  In a 1982 study, when no treatment was available, of 1,011 patients, 85% showed first signs of recovery within three weeks after onset. For the other 15%, recovery occurred 3\u20136 months later."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1278", "text": "After a follow-up of at least one year or until restoration, complete recovery had occurred in more than two-thirds (71%) of all patients. Recovery was judged moderate in 12% and poor in only 4% of patients. [ 48 ]  Another study found that incomplete palsies disappear entirely, nearly always in one month. The patients who regain movement within the first two weeks nearly always remit entirely. When remission does not occur until the third week or later, a significantly greater part of the patients develop  sequelae . [ 49 ]  A third study found a better prognosis for young patients, aged below 10 years old, while the patients over 61 years old presented a worse prognosis. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1279", "text": "Major possible complications of the condition are chronic loss of taste ( ageusia ), chronic facial  spasm , facial pain, and corneal infections. Another complication can occur in case of incomplete or erroneous regeneration of the damaged facial nerve. The nerve can be thought of as a bundle of smaller individual nerve connections that branch out to their proper destinations. During regrowth, nerves are generally able to track the original path to the right destination\u2014but some nerves may sidetrack leading to a condition known as  synkinesis . For instance, the regrowth of nerves controlling muscles attached to the eye may sidetrack and also regrow connections reaching the muscles of the mouth. In this way, the movement of one also affects the other. For example, when the person closes the eye, the corner of the mouth lifts involuntarily."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1280", "text": "Around 9% of people have some sort of ongoing problems after Bell's palsy, typically the synkinesis already discussed, or spasm, contracture,  tinnitus , or hearing loss during facial movement or crocodile-tear syndrome. [ 50 ]  This is also called gustatolacrimal reflex or  Bogorad's syndrome  and results in shedding tears while eating. This is thought to be due to  faulty regeneration  of the facial nerve, a branch of which controls the lacrimal and salivary glands. Gustatorial sweating can also occur."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1281", "text": "The number of new cases of Bell's palsy ranges from about one to four cases per 10,000 population per year. [ 51 ]  The rate increases with age. [ 2 ] [ 51 ]  Bell's palsy affects about 40,000 people in the United States every year. It affects approximately 1 person in 65 during a lifetime."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1282", "text": "A range of annual incidence rates have been reported in the literature: 15, [ 21 ]  24, [ 52 ]  and 25\u201353 [ 11 ]  (all rates per 100,000 population per year). Bell's palsy is not a  reportable disease , and there are no established registries for people with this diagnosis, [ 53 ]  which complicates precise estimation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1283", "text": "About 40,000 people are affected by Bell's Palsy in the United States every year. It can affect anyone of any gender and age, but its incidence seems to be highest in those in the 15- to 45-year-old age group. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1284", "text": "The Persian physician  Muhammad ibn Zakariya al-Razi  (865\u2013925) detailed the first known description of peripheral and central facial palsy. [ 54 ] [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1285", "text": "Cornelis Stalpart van der Wiel (1620\u20131702) in 1683 gave an account of Bell's palsy and credited the Persian physician  Ibn Sina  (980\u20131037) for describing this condition before him.  James Douglas  (1675\u20131742) and  Nicolaus Anton Friedreich \u00a0[ de ]  (1761\u20131836) also described it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1286", "text": "Scottish neurophysiologist Sir  Charles Bell  read his paper to the  Royal Society of London  on July 12, 1821, describing the role of the facial nerve. He became the first to detail the neuroanatomical basis of facial paralysis. Since then, idiopathic peripheral facial paralysis has been referred to as Bell's palsy, named after him. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1287", "text": "A notable person with Bell's palsy is former  Prime Minister of Canada   Jean Chr\u00e9tien . [ 57 ]  During the  1993 Canadian federal election , Chr\u00e9tien's first as leader of the  Liberal Party of Canada , the opposition  Progressive Conservative Party of Canada  ran  an attack ad  in which voice actors criticized him over images that seemed to highlight his abnormal facial expressions. The ad was interpreted as an attack on Chr\u00e9tien's physical appearance and garnered widespread anger among the public, while Chr\u00e9tien used the ad to make himself more sympathetic to voters. The ad had the adverse effect of increasing Chr\u00e9tien's lead in the polls and the subsequent backlash clinched the election for the Liberals, which the party  won in a landslide ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1288", "text": "On April 25, 2024,  Joel Hans Embiid  of the Philadelphia 76ers scored 50 points in Game 3 of the 76ers' first-round playoff series versus the New York Knicks while suffering from a mild case of Bell's Palsy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1289", "text": "A  bone-anchored hearing aid  ( BAHA ) [ 2 ]  is a type of  hearing aid  based on  bone conduction . It is primarily suited for people who have  conductive hearing losses ,  unilateral hearing loss , single-sided deafness and people with mixed hearing losses who cannot otherwise wear 'in the ear' or 'behind the ear' hearing aids. They are more expensive than conventional hearing aids, and their placement involves invasive surgery which carries a risk of complications, [ 1 ]  although when complications do occur, they are usually minor. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1290", "text": "Two of the causes of  hearing loss  are lack of function in the  inner ear  ( cochlea ) and when the sound has problems in reaching the nerve cells of the inner ear.  Examples of the first include age-related hearing loss and hearing loss due to noise exposure. A patient born without external  ear canals  is an example of the latter for which a conventional hearing aid with a mould in the ear canal opening would not be effective. Some with this condition have normal inner ear function, as the external ear canal and the inner ear are developed at different stages during pregnancy. With normal inner anatomy, sound conducted by the skull bone improves hearing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1291", "text": "A vibrator with a steel spring over the head or in heavy frames of eyeglasses pressed towards the bone behind the ear has been used to bring sound to the inner ear.  This has, however, several disadvantages, such as discomfort and pain due to the pressure needed. [ 4 ]  The sound quality is also impaired as much of the sound energy is lost in the soft tissue over the skull bone, [ 5 ]  particularly for the higher sound frequencies important for speech understanding in noise."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1292", "text": "Bone-anchored hearing aids use a surgically implanted  abutment  to transmit sound by direct  conduction through bone  to the inner ear, bypassing the external auditory canal and middle ear. A titanium prosthesis is surgically embedded into the skull with a small abutment exposed outside the skin. A sound processor sits on this abutment and transmits sound vibrations to the titanium implant. The implant vibrates the skull and inner ear, which stimulate the nerve fibers of the inner ear, allowing hearing. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1293", "text": "The surgery is often performed under local anesthesia and as an outpatient procedure. An important piece of information for patients is that if they for whatever reason are not satisfied with the BAHA solution, removing the implant is easy. No other ear surgical procedure is reversible like this. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1294", "text": "By bypassing the outer or middle ear, BAHA can increase hearing in noisy situations and help localise sounds. In addition to improved speech understanding, it results in a natural sound with less distortion and feedback compared with conventional hearing aids. [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ]  The ear canal is left open for comfort, and helps to reduce any problems caused by chronic ear infections or allergies. In patients with single-sided sensorineural deafness, BAHA sends the sound by the skull bone from the deaf side to the inner ear of the hearing side. This transfer of sound gives a 360\u00b0 sound awareness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1295", "text": "BAHAs may facilitate normal speech development. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1296", "text": "This fairly common condition is often associated with continuous or intermittent drainage from the ear canal. These patients may also have a hearing loss and need amplification. A conventional air conduction aid with a mold placed in the ear canal opening may not be appropriate due to the drainage, and may even provoke drainage. If the hearing loss is significant an air conduction aid may have difficulty overcoming the dysfunction of the eardrum and middle ear bones. Bone conduction hearing device bypassing the middle ear may be a more appropriate treatment for these patients. Good transmission of sound in the bone, with reduced attenuation and distortion may be possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1297", "text": "A person with  unilateral hearing loss  may have functional difficulty hearing even when the other ear is normal, particularly in demanding situations such as noisy environments and when several people are speaking the same time. A complication in single-sided deafness is hearing impairment in the hearing ear. Conventional ear surgery involves a risk of hearing loss due to the surgical procedure. Ear surgeons may be reluctant to perform surgery on an only hearing ear. [ 13 ]  The BAHA surgery avoids this risk and may be an appropriate treatment. An extended trial of a BAHA system with a headband prior to surgery led to more realistic expectations. In the trial, 50% of the candidates wished to proceed to surgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1298", "text": "Irritation in the  external ear canal  due to inflammation or eczema may be a condition for which a conventional air conduction aid is not an appropriate treatment. Direct bone conduction may be an option."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1299", "text": "Patients with malformations are not always suitable for reconstructive surgery.  Treacher Collins syndrome  patients may have significant malformations with  ossicular  defects and an abnormal route of the facial nerve. These structures, as well as the inner ear, could be in danger at surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1300", "text": "Patients with  Down syndrome  may have a narrow ear canal and middle ear malformation leading to impaired hearing. Some part of the cognitive delay seen in these children may be partly due to their poor hearing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1301", "text": "The surgery can only take place once the skull is at least 2.5\u00a0mm thick. [ 15 ] [ 16 ] [ needs update ]  Children with certain syndromes may have a slighter build, thinner bone, or unusual anatomy. Other children may have a thicker skull at a younger age, so it is difficult to give a specific age for surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1302", "text": "In the U.S., the  Food and Drug Administration  only approves BAHA implantation of children aged five years or older."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1303", "text": "For infants and young children prior to surgery, the sound processor can be worn on a head band or soft band which the infant wears to hold it against the skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1304", "text": "Complications of BAHA systems can be considered as either related to the bone (hard tissue) or the  soft tissue . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1305", "text": "Soft-tissue complications are much more common, and most are managed with topical treatments. Children are more likely to develop both kinds of complications than adults. Sometimes, a second surgical procedure is required. Complications are less likely with good wound hygiene. [ 3 ]  Other drawbacks of BAHA include accidental or spontaneous loss of the bone implant, and patient refusal for treatment due to stigma. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1306", "text": "The bone behind the ear is exposed through a U-shaped or straight incision or with the help of a specially designed BAHA  dermatome . A hole, 3 or 4\u00a0mm deep depending on the thickness of the bone, is drilled. The hole is widened and the implant with the mounted coupling is inserted under generous cooling to minimize surgical trauma to the bone. In a single stage procedure, the fixture and abutment are placed simultaneously. For children or patients who may damage the abutment prior to  osseointegration  of the fixture, a two stage procedure may be performed in which the fixture is placed first, and after  osseointegration  roughly 6 months later, the abutment is attached. In children, a sleeper implant may be placed to serve as a backup in case the main implant is damaged."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1307", "text": "Some surgeons perform a reduction of the subcutaneous  soft tissue . The rationale for this is to reduce the mobility between implant and skin to avoid inflammation at the penetration site. This reduction of the soft tissue has been questioned and some surgeons do not perform any or a minimum of it. The rationale for this is that any surgery will result in some scar tissue that could be the focus of infection. The infections seen early during the development of the surgical procedure could perhaps be explained by the lack of seal between implant and abutment allowing bacteria to enter the space. A new helium tight seal may be advantageous and prevent  biofilm  formation. This will also allow the surgeon to use longer abutments should a need exist. Three to six weeks later or even earlier, the  audiologist  will fit and adjust the hearing processor according to the patient's  hearing level . The fitting will be made using a special program in a computer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1308", "text": "The original surgical procedure has been described in detail by Tjellstr\u00f6m et al. 2001. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1309", "text": "An area where skin is penetrated requires care and cleaning because of the risk of inflammation around the abutment. Daily cleaning is required. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1310", "text": "Hearing is of importance for a normal speech development. [ 19 ]  The skull bone in children is often very thin and softer than in the adult. Surgery is thus often delayed until the age of four to five years. In the meantime, the child with bilateral atresia can be fitted with a band around the head with a coupling for a BAHA. This may be done at the age of one month. Infants at this age may tolerate this well. [ 16 ]  As described above, for children who may be at risk of damaging the abutment prior to  osseointegration  of the fixture, a two stage procedure may be performed in which the fixture is placed first, and after  osseointegration  roughly 6 months later, the abutment is attached. In children, a sleeper implant may be placed to serve as a backup in case the main implant is damaged."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1311", "text": "Patients with chronic ear infection where the drum and/or the small bones in the middle ear are damaged often have hearing loss, but difficulties in using a hearing aid fitted in the ear canal. Direct bone conduction through a vibrator attached to a skin-penetrating implant addresses these disadvantages."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1312", "text": "In 1977, the first three patients were implanted with a bone-conduction hearing solution by Anders Tjellstr\u00f6m at the Ear, Nose, and Throat Department at  Sahlgrenska University Hospital  in Gothenburg, Sweden. A 4-mm-long titanium screw with a diameter of 3.75\u00a0mm was inserted in the bone behind the ear, and a bone conduction hearing aid was attached."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1313", "text": "The term osseointegration was coined by Professor Br\u00e5nemark. During animal studies, he found the bone tissue attached to the titanium implant without any soft tissue in between. He also showed an such an implant could take a heavy load. His definition of osseointegration was \"direct contact between living bone and an implant that can take a load\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1314", "text": "The first clinical application of titanium was in oral surgery, where implants were used for retention of dentures. Br\u00e5nemark sought an acoustic way to evaluate osseointegration. A patient with implants in the jaws was fitted with a bone vibrator on one of his implants. When tested, the patient experienced very loud sound even at low stimulation levels, indicating sound could propagate very well in the bone. It has later been shown by H\u00e5kansson that the sound transmission in bone is linear, indicating low distortion of the sound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1315", "text": "The implant in the bone is made of titanium and will osseointegrate. The hearing instrument is impedance-matched.  Osseointegration  has been defined as the direct contact between living bone and an implant that can take a load, with no soft tissue at the interface."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1316", "text": "There are several models of bone-anchored hearing aids available. Most common are the BAHA from Australian company  Cochlear , and the Ponto from Danish manufacturers  Oticon Medical . [ 20 ]  There are also other types of  bone conduction hearing aids , such as implants and non-surgical devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1317", "text": "In the US, the cost of the Baha device is about $4,000. In the Netherlands, the cost of the device is around \u20ac3000 (in 2008). The cost of the titanium implant, surgery, and aftercare from surgeon and audiologist must also be considered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1318", "text": "The  buccal  branches of the  facial nerve  (infraorbital branches), are of larger size than the rest of the branches, pass horizontally forward to be distributed below the  orbit  and around the  mouth ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1319", "text": "The  superficial branches  run beneath the  skin  and above the superficial muscles of the face, which they supply: some are distributed to the  procerus , joining at the medial angle of the orbit with the  infratrochlear  and  nasociliary  branches of the  ophthalmic ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1320", "text": "The  deep branches  pass beneath the  zygomaticus  and the  quadratus labii superioris , supplying them and forming an  infraorbital plexus  with the infraorbital branch of the  maxillary nerve . These branches also supply the small muscles of the  nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1321", "text": "The  lower deep branches  supply the  buccinator  and  orbicularis oris , and join with filaments of the  buccinator branch  of the  mandibular nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1322", "text": "The facial nerve innervates the muscles of facial expression. The buccal branch supplies these muscles"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1323", "text": "\u2022 Puff up cheeks (buccinator)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1324", "text": "i. Tap with finger over each cheek to detect ease of air expulsion on the affected side"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1325", "text": "\u2022 Smile and show teeth (orbicularis oris)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1326", "text": "This article incorporates text in the  public domain  from  page 905  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1327", "text": "The  buccal space  (also termed the  buccinator space ) is a  fascial space of the head and neck  (sometimes also termed  fascial  tissue spaces or tissue spaces). It is a  potential space  in the  cheek , and is paired on each side. The buccal space is superficial to the  buccinator muscle  and deep to the  platysma muscle  and the skin. The buccal space is part of the  subcutaneous  space, which is continuous from head to toe. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1328", "text": "The boundaries of each buccal space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1329", "text": "In health, the space contains:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1330", "text": "A  hematoma  may create the buccal space, e.g. due to  hemorrhage  following  wisdom teeth  surgery. Buccal space abscesses typically cause a facial swelling over the cheek that may extend from the zygomatic arch above to the inferior border of the mandible below, and from the anterior border the masseter muscle posteriorly to the angle of the mouth anteriorly. [ 1 ]  Unless another space is also involved, the tissues around the eye are not swollen. It is usually treated by surgical  incision and drainage , and the incision is located inside the mouth to avoid a scar on the face. [ 2 ]  The incision are placed below the  parotid papilla  to avoid damage to the duct, and forceps are used to divide buccinator and insert a surgical drain into the buccal space. The drain is kept in place for a variable period of time following the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1331", "text": "Long standing buccal abscesses tend to spontaneously drain via a  cutaneous sinus  at the inferior of the space, near the inferior border of the mandible and the angle of the mouth. [ 1 ]  An untreated cutaneous sinus can cause disfiguring soft tissue  fibrosis , and the tract can become  epithelial  lined. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1332", "text": "Sometimes the buccal space is reported to be the most commonly involved fascial space by  dental abscesses , [ 2 ]  although other sources report it is the submandibular space. [ 1 ]  Infections originating in either maxillary or mandibular teeth can spread into the buccal space, usually maxillary molars (most commonly) and premolars or mandibular premolars. [ 1 ]  Odontogenic infections which erode through the buccal cortical plate of the mandible or maxilla will either spread into the buccal vestibule (sulcus) and drain intra-orally, or into the buccal space, depending upon the level of the perforation in relation to the attachment of buccinator to the maxilla above and the mandible below (see diagrams). Frequently infection spreads in both directions as the buccinator is only a partial barrier. [ 3 ]  Infections associated with mandibular teeth with apices at a level inferior to the attachment, and maxillary teeth with apices at a level superior to the attachment are more likely to drain into the buccal space."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1333", "text": "The  canine space  (also termed the  infra-orbital space ) [ 1 ]  is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a thin  potential space  on the face, and is paired on either side. It is located between the  levator anguli oris muscle  inferiorly and the  levator labii superioris muscle  superiorly. [ 1 ] [ 2 ]  The term is derived from the fact that the space is in the region of the  canine fossa , and that infections originating from the  maxillary canine tooth  may spread to involve the space.  Infra-orbital  is derived from  infra-  meaning below and  orbit  which refers to the eye socket."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1334", "text": "The boundaries of the canine space are: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1335", "text": "The canine space communicates with the buccal space posteriorly. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1336", "text": "The contents of the canine space are: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1337", "text": "Canine space infections may occur by spread of infection from the buccal space. [ 2 ]   Signs and symptoms of a canine space abscess might include swelling that obliterates the  nasolabial fold . If left untreated, infections of this space will eventually spontaneously drain via the  medial or lateral canthus  of the eye, as this is the path of least resistance. [ 2 ]  Treatment is usually by surgical  incision and drainage , and the incision is placed inside the mouth to avoid a facial scar."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1338", "text": "Rarely, when infections of the canine space erode into the  infra-orbital vein  or the  inferior ophthalmic vein  (via the  sinuses ), there can be spread via the common ophthalmic vein through the  superior orbital fissure  and into the  cavernous sinus . This can result in septic  cavernous sinus thrombosis , which is a rare, but life-threatening condition. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1339", "text": "Odontogenic infections  may spread to involve the canine space. The most likely causative tooth is the maxillary canine or maxillary first premolar. [ 1 ]  This occurs when pus (e.g. from a  periapical abscess ), perforates the buccal cortical plate of the maxilla above the level of attachment of the levator anguli oris muscle. This is more likely if the tooth root is long (the maxillary canine has the longest root of all the teeth), and its apex lies at a level above the muscle attachment. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1340", "text": "The  carotid canal  is a passage in the  petrous part  of the  temporal bone  of the  skull  through which the  internal carotid artery  and its  internal carotid (nervous) plexus  pass from the neck into (the  middle cranial fossa  of) the  cranial cavity ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1341", "text": "Observing the trajectory of the canal from exterior to interior, the canal is initially directed vertically before curving anteromedially to reach its internal opening. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1342", "text": "The carotid canal has two openings, namely internal and external openings. [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1343", "text": "It is divided in three parts, namely, ascending petrous, transverse petrous, and ascending cavernous parts. [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1344", "text": "The carotid canal opens into the  middle cranial fossa , at the  petrous part of the temporal bone . Anteriorly, it is limited by posterior margin of the  greater wing of sphenoid bone . Posteromedially, it is limited by  basilar part of occipital bone . [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1345", "text": "The external opening of carotid canal (Latin: \" apertura externa canalis carotici \") is located upon the inferior aspect of the  petrous part of the temporal bone . It is situated anterior to the  jugular fossa  (the two being separated by a ridge upon which the  tympanic canaliculus  opens inferiorly), [ 3 ]  and posterolateral to the foramen lacerum. [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1346", "text": "The internal opening of carotid canal (Latin: \" apertura interna canalis carotici \") opens into the  middle cranial fossa  at the  apex of petrous part of temporal bone . [ 4 ]  It is situated lateral to  foramen lacerum . [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1347", "text": "Both internal and external openings of the carotid canal lie anterior to the  jugular foramen  (which opens into the  posterior cranial fossa ). [ 2 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1348", "text": "The carotid canal is separated from  middle ear  and  inner ear  by a thin plate of bone. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1349", "text": "The canal transmits  internal carotid artery  together with its associated  nervous plexus  and  venous plexus . [ 1 ] [ 2 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1350", "text": "Any skull fractures that damage the carotid canal can put the  internal carotid artery  at risk. [ 7 ]   Angiography  can be used to ensure that there is no damage, and to aid in treatment if there is. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1351", "text": "The carotid canal starts on the inferior surface of the  temporal bone  of the  skull  at the external opening of the carotid canal (also referred to as the carotid foramen). The canal ascends at first superiorly, and then, making a bend, runs anteromedially. Its internal opening is near the  foramen lacerum , above which the internal carotid artery passes on its way anteriorly to the  cavernous sinus . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1352", "text": "The carotid canal allows the  internal carotid artery  to pass into the  cranium , [ 8 ] [ 9 ]  as well as the  carotid plexus  traveling on the artery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1353", "text": "The carotid plexus contains  sympathetics  to the head from the  superior cervical ganglion . [ 8 ]  They have several motor functions: raise the  eyelid  ( superior tarsal muscle ), dilate  pupil  (pupillary dilator muscle), innervate  sweat glands  of face and  scalp  and constricts  blood vessels  in the head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1354", "text": "This article incorporates text in the  public domain  from  page 143  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1355", "text": "Catarrh  ( / k \u0259 \u02c8 t \u0251\u02d0r /   k\u0259- TAR ) is an inflammation of  mucous membranes  in one of the  airways  or cavities of the body, [ 1 ] [ 2 ]  usually with reference to the  throat  and  paranasal sinuses . It can result in a thick exudate of  mucus  and  white blood cells  caused by the swelling of the  mucous membranes  in the  head  in response to an infection. It is a  symptom  usually associated with the  common cold ,  pharyngitis , and chesty  coughs , but it can also be found in patients with  adenoiditis ,  otitis media ,  sinusitis  or  tonsillitis .  The  phlegm  produced by catarrh may either discharge or cause a blockage that may become  chronic ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1356", "text": "The word \"catarrh\" was widely used in  medicine  since before the era of medical science, which explains why it has various  senses  and in older texts may be synonymous with, or vaguely indistinguishable from, common cold, nasopharyngitis, pharyngitis,  rhinitis , or sinusitis. The word is no longer as widely used in American medical practice, mostly because more precise words are available for any particular disease. Indeed, to the extent that it is still used, it is no longer viewed  nosologically  as a  disease  entity but instead as a  symptom , a  sign , or a  syndrome  of both. The term \"catarrh\" is found in medical sources from the United Kingdom. [ 3 ]  The word has also been common in the  folk medicine  of  Appalachia , where medicinal plants have been used to treat the inflammation and drainage associated with the condition. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1357", "text": "Because of the human ear's function of regulating the pressure within the head region, catarrh blockage may also cause discomfort during changes in atmospheric pressure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1358", "text": "The word \"catarrh\" comes from 15th-century French  catarrhe , Latin catarrhus, and Greek  Ancient Greek :  \u03ba\u03b1\u03c4\u03b1\u03c1\u03c1\u03b5\u1fd6\u03bd [ 5 ]  ( katarrhein ):  kata-  meaning \"down\" and  rhein  meaning \"to flow.\" The  Oxford English Dictionary  quotes Thomas Bowes' translation of Pierre de la Primaudaye's  The [second part of the] French academic  (1594): \"Sodainely choked by catarrhs, which like to floods of waters, runner downwards.\" [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1359", "text": "Causes of  hearing loss  include  ageing ,  genetics ,  perinatal problems ,  loud sounds , and  diseases . For some kinds of hearing loss the cause may be classified as of  unknown cause ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1360", "text": "There is a progressive loss of ability to hear high frequencies with ageing known as  presbycusis . For men, this can start as early as 25 and for women at 30. Although genetically variable, it is a normal concomitant of ageing and is distinct from hearing loss caused by noise exposure, toxins, or disease agents. [ 1 ]  Common conditions that can increase the risk of hearing loss in elderly people are high blood pressure, diabetes, or the use of certain medications harmful to the ear. [ 2 ] [ 3 ]  While everyone loses hearing with age, the amount and type of hearing loss is variable. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1361", "text": "Noise exposure is the cause of approximately half of all cases of hearing loss, causing some degree of problems in 5% of the population globally. [ 5 ]  The  National Institute for Occupational Safety and Health  (NIOSH) recognizes that the majority of hearing loss is not due to age, but due to noise exposure. By correcting for age in assessing hearing, one tends to overestimate the hearing loss due to noise for some and underestimate it for others. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1362", "text": "Hearing loss due to noise may be temporary, called a 'temporary threshold shift', a reduced sensitivity to sound over a wide frequency range resulting from exposure to a brief but very loud noise like a gunshot, firecracker, jet engine, jackhammer, etc. or exposure to loud sound over a few hours such as during a pop concert or nightclub session. [ 7 ]  Recovery of hearing is usually within 24 hours but may take up to a week. [ 8 ]  Both constant exposure to loud sounds (85\u00a0dB(A) or above) and one-time exposure to extremely loud sounds (120\u00a0dB(A) or above) may cause permanent hearing loss. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1363", "text": "Noise-induced hearing loss  (NIHL) typically manifests as elevated hearing thresholds (i.e. less sensitivity or muting) between 3000 and 6000\u00a0 Hz, centred at 4000\u00a0 Hz. As noise damage progresses, damage spreads to affect lower and higher frequencies. On an  audiogram , the resulting configuration has a distinctive notch, called a 'noise' notch. As ageing and other effects contribute to higher frequency loss (6\u20138\u00a0kHz on an audiogram), this notch may be obscured and entirely disappear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1364", "text": "Various governmental, industry, and standards organizations set noise standards. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1365", "text": "The  U.S. Environmental Protection Agency  has identified the level of 70\u00a0dB(A) (40% louder to twice as loud as normal conversation; typical level of TV, radio, stereo; city street noise) for 24\u2011hour exposure as the level necessary to protect the public from hearing loss and other disruptive effects from noise, such as sleep disturbance, stress-related problems, learning detriment, etc. [ 11 ]  Noise levels are typically in the 65 to 75\u00a0dB (A) range for those living near airports or freeways and may result in hearing damage if sufficient time is spent outdoors. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1366", "text": "Louder sounds cause damage in a shorter period of time. Estimation of a \"safe\" duration of exposure is possible using an  exchange rate  of 3\u00a0dB. As 3\u00a0dB represents a doubling of the intensity of sound, the duration of exposure must be cut in half to maintain the same energy dose. For workplace noise regulation, the \"safe\" daily exposure amount at 85\u00a0dB A, known as an  exposure action value , is 8 hours, while the \"safe\" exposure at 91\u00a0dB(A) is only 2 hours. [ 13 ]  Different standards use exposure action values between 80 dBA and 90 dBA. Note that for some people, sound may be damaging at even lower levels than 85\u00a0dB A. Exposures to other ototoxicants (such as pesticides, some medications including chemotherapy agents, solvents, etc.) can lead to greater susceptibility to noise damage, as well as causing its own damage. This is called a  synergistic  interaction. Since noise damage is cumulative over long periods, persons who are exposed to non-workplace noise, like recreational activities or environmental noise, may have compounding damage from all sources."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1367", "text": "Some national and international organizations and agencies use an exchange rate of 4\u00a0dB or 5\u00a0dB. [ 14 ]  While these exchange rates may indicate a wider zone of comfort or safety, they can significantly underestimate the damage caused by loud noise. For example, at 100\u00a0dB (nightclub music level), a 3\u00a0dB exchange rate would limit exposure to 15 minutes; the 5\u00a0dB exchange rate allows an hour."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1368", "text": "Many people are unaware of the presence of environmental sound at damaging levels, or of the level at which sound becomes harmful. Common sources of damaging noise levels include car stereos, children's toys, motor vehicles, crowds, lawn and maintenance equipment, power tools, gun use, musical instruments, and even hair dryers. Noise damage is cumulative; all sources of damage must be considered to assess risk. If one is exposed to loud sound (including music) at high levels or for extended durations (85\u00a0dB A or greater), then hearing loss will occur. Sound intensity (sound energy or propensity to cause damage to the ears) increases dramatically with proximity according to an inverse square law: halving the distance to the sound quadruples the sound intensity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1369", "text": "In the US, 12.5% of children aged 6\u201319 years have permanent hearing damage from excessive noise exposure. [ 15 ]  The World Health Organization estimates that half of those between 12 and 35 are at risk from using  personal audio devices  that are too loud. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1370", "text": "Hearing loss due to noise has been described as primarily a condition of modern society. [ 17 ]  In preindustrial times, humans had far less exposure to loud sounds. Studies of primitive peoples indicate that much of what has been attributed to age-related hearing loss may be long-term cumulative damage from all sources, especially noise. People living in preindustrial societies have considerably less hearing loss than similar populations living in modern society. Among primitive people who have migrated into modern society, hearing loss is proportional to the number of years spent in modern society. [ 18 ] [ 19 ] [ 20 ]  Military service in  World War II , the  Korean War , and the  Vietnam War , has likely also caused hearing loss in large numbers of men from those generations, though proving that hearing loss was a direct result of military service is problematic without entry and exit audiograms. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1371", "text": "Hearing loss in adolescents may be caused by loud noises from toys, music by headphones, and concerts or events. [ 22 ]  In 2017, the  Centers for Disease Control and Prevention  brought their researchers together with experts from the  World Health Organization  and academia to examine the risk of hearing loss from excessive noise exposure in and outside the workplace in different age groups, as well as actions being taken to reduce the burden of the condition. A summary report was published in 2018. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1372", "text": "In the United States, hearing loss may be more likely among members of the  Republican Party  due to greater firearm ownership, according to  The Washington Post  in February 2024. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1373", "text": "Hearing loss can be inherited. Around 75\u201380% of all these cases are inherited by  recessive genes , 20\u201325% are inherited by  dominant genes , 1\u20132% are inherited by  X-linked  patterns, and fewer than 1% are inherited by  mitochondrial inheritance . [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1374", "text": "When looking at the genetics of deafness, there are 2 different forms, syndromic and  nonsyndromic . Syndromic deafness occurs when there are other signs or medical problems aside from deafness in an individual. This accounts for around 30% of deaf individuals who are deaf from a genetic standpoint. [ 25 ]  Nonsyndromic deafness occurs when there are no other signs or medical problems associated with an individual other than deafness. From a genetic standpoint, this accounts for the other 70% of cases and represents the majority of hereditary hearing loss. [ 25 ]  Syndromic cases occur with disorders such as  Usher syndrome ,  Stickler syndrome ,  Waardenburg syndrome ,  Chudley-Mccullough syndrome ,  Alport's syndrome , and  neurofibromatosis type 2 . These are diseases that have deafness as one of the symptoms or as a common feature associated with it. Many of the genetic mutations giving rise to syndromic deafness have been identified. In nonsyndromic cases, where deafness is the only finding, it is more difficult to identify the genetic mutation although some have been discovered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1375", "text": "A 2023 systematic review and meta-analysis found that alcohol consumption is associated with an increased risk of hearing loss. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1376", "text": "Some medications may reversibly affect hearing. These medications are considered  ototoxic . This includes  loop diuretics  such as furosemide and bumetanide,  non-steroidal anti-inflammatory drugs  (NSAIDs) both over-the-counter (aspirin, ibuprofen, naproxen) as well as prescription (celecoxib, diclofenac, etc.), paracetamol,  quinine , and  macrolide antibiotics . The link between NSAIDs and hearing loss tends to be greater in women, especially those who take ibuprofen six or more times a week. [ 36 ]  Others may cause permanent hearing loss. [ 37 ]  The most important group is the  aminoglycosides  (main member  gentamicin ) and platinum based chemotherapeutics such as  cisplatin  and  carboplatin . [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1377", "text": "In 2007, the  U.S. Food and Drug Administration  (FDA) warned about possible sudden hearing loss from  PDE5 inhibitors , which are used for erectile dysfunction. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1378", "text": "Audiologic monitoring for ototoxicity allows for the early detection of changes to hearing status presumably attributed to a drug/treatment regime so that changes in the drug regimen may be considered, and audiologic intervention when handicapping hearing impairment has occurred. [ 41 ]   Co-administration of anti-oxidants and ototoxic medications may limit the extent of the ototoxic damage. [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1379", "text": "In addition to medications, hearing loss can also result from specific chemicals in the environment: metals, such as  lead ;  solvents , such as  toluene  (found in  crude oil ,  gasoline , [ 44 ]  and  automobile exhaust , [ 44 ]  for example); and  asphyxiants . [ 45 ]  Combined with noise, these  ototoxic  chemicals have an additive effect on a person's hearing loss. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1380", "text": "Hearing loss due to chemicals starts in the high-frequency range and is irreversible. It damages the  cochlea  with lesions and degrades central portions of the  auditory system . [ 45 ]  For some ototoxic chemical exposures, particularly styrene, [ 46 ]  the risk of hearing loss can be higher than being exposed to  noise  alone. The effects are greatest when the combined exposure includes  impulse noise . [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1381", "text": "A 2018 informational bulletin by the US  Occupational Safety and Health Administration  (OSHA) and the  National Institute for Occupational Safety and Health  (NIOSH) introduces the issue, provides examples of ototoxic chemicals, lists the industries and occupations at risk and provides prevention information. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1382", "text": "Audiologic monitoring for ototoxicity allows for the early detection of changes to hearing status presumably attributed to a drug/treatment regime so that changes in the drug regimen may be considered, and audiologic intervention when handicapping hearing impairment has occurred. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1383", "text": "Co-administration of anti-oxidants and ototoxic medications may limit the extent of the ototoxic damage. [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1384", "text": "There can be damage either to the ear, whether the external or middle ear, to the cochlea, or to the brain centres that process the aural information conveyed by the ears. Damage to the middle ear may include fracture and discontinuity of the ossicular chain. Damage to the inner ear (cochlea) may be caused by  temporal bone fracture . People who sustain head injury are especially vulnerable to hearing loss or tinnitus, either temporary or permanent. [ 51 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1385", "text": "The  cervical branch of the facial nerve  is a nerve in the  neck . It is a branch of the  facial nerve  (VII). It supplies the  platysma muscle , among other functions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1386", "text": "The cervical branch of the facial nerve is a branch of the  facial nerve  (VII). It runs forward beneath the  platysma muscle , and forms a series of arches across the side of the neck over the  suprahyoid  region. One branch descends to join the  cervical cutaneous nerve  from the  cervical plexus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1387", "text": "The lateral part of the cervical branch of the facial nerve supplies the  platysma muscle . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1388", "text": "The  choanae  ( sg. :  choana ),  posterior nasal apertures  or  internal nostrils  are two openings found at the back of the nasal passage between the  nasal cavity  and the  pharynx , in humans and other mammals (as well as  crocodilians  and most  skinks ). They are considered one of the most important  synapomorphies  of  tetrapodomorphs , that allowed the passage from water to land. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1389", "text": "In animals with secondary palates, they allow breathing when the mouth is closed. [ 2 ]  In tetrapods without secondary palates their function relates primarily to olfaction (sense of smell)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1390", "text": "The choanae are separated in two by the  vomer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1391", "text": "A choana is the opening between the  nasal cavity  and the  nasopharynx ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1392", "text": "It is therefore not a structure but a space bounded as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1393", "text": "The term is a latinization from the Greek \u03c7\u03bf\u03ac\u03bd\u03b7, \"choan\u0113\" meaning  funnel ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1394", "text": "Early bony fishes (~420 mya) had two pairs of  nostrils , one pair for incoming water (known as the anterior or incurrent nostrils), and a second pair for outgoing water (the posterior or excurrent nostrils), with the olfactory apparatus (for sense of smell) in between. In the first  tetrapodomorphs  (~415 mya) the excurrent nostrils migrated to the edge of the mouth, occupying a position between the maxillary and premaxillary bones, directly below the lateral rostral (a bone that vanished in early tetrapods). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1395", "text": "In all but the most basal (primitive) tetrapodomorphs (or \"choanates\"), the excurrent nostrils have migrated from the edge of the mouth to the interior of the mouth. In tetrapods that lack a secondary palate (basal tetrapods and amphibians), the choanae are located forward in the roof of the mouth, just inside the upper jaw. These internal nasal passages evolved while the vertebrates still lived in water. [ 3 ]  In animals with complete secondary palates (mammals, crocodilians, most skinks) the space between the primary and secondary palates contain the nasal passages, with the choanae located above the posterior end of the secondary palate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1396", "text": "In animals with partial secondary palates (most birds and reptiles), the median  choanal slit  separates the two halves of the posterior half of the palate, connecting the nasal cavity with the buccal cavity (mouth) and the pharynx (throat). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1397", "text": "Most  fish  do not have choanae, instead they have two pairs of external nostrils: each with two tubes whose frontal openings lie close to the upper jaw, and the posterior openings further behind near the eyes. A 395-million-year-old fossil lobe-finned fish called  Kenichthys   campbelli  has something between a choana and the external nostrils seen on other fish. The posterior opening of the external nostrils has migrated into the mouth. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1398", "text": "In lungfish, the inner nostrils are regarded as an example of  parallel evolution . The fossil lungfish  Diabolepis  shows an intermediate stage between posterior and interior nostril and supports the independent origin of internal nostrils in the lungfish. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1399", "text": "Hagfishes  have a single internal nostril that opens inside the mouth cavity, while  chimaeras  have open canals that leads water from their external nostrils into their mouths and through their gills."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1400", "text": "Cholesteatoma  is a destructive and expanding growth consisting of keratinizing  squamous epithelium  in the middle ear and/or  mastoid process . [ 1 ] [ 2 ]  Cholesteatomas are not cancerous as the name may suggest, but can cause significant problems because of their erosive and expansile properties. This can result in the destruction of the bones of the middle ear ( ossicles ), as well as growth through the  base of the skull  into the brain. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1401", "text": "Other more common conditions (e.g.  otitis externa ) may also present with these symptoms, but cholesteatoma is much more serious and should not be overlooked. If a patient presents to a doctor with ear discharge and hearing loss, the doctor should consider cholesteatoma until the disease is definitely excluded. [ 4 ]  Other less common symptoms (all less than 15%) of cholesteatoma may include pain,  balance disruption ,  tinnitus ,  earache ,  headaches  and bleeding from the ear. [ 2 ]  There can also be  facial nerve  weakness. Balance symptoms in the presence of a cholesteatoma raise the possibility that the cholesteatoma is eroding the balance organs in the  inner ear . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1402", "text": "Doctors' initial inspections may only reveal an ear canal full of discharge. Until the doctor has cleaned the ear and inspected the entire  tympanic membrane , cholesteatoma cannot be diagnosed. [ 2 ]  Once the debris is cleared, cholesteatoma can give rise to a number of appearances. If there is significant inflammation, the tympanic membrane may be partially obscured by an aural  polyp . If there is less inflammation, the cholesteatoma may present the appearance of 'semolina' discharging from a defect in the tympanic membrane. The posterior and superior parts of the tympanic membrane are most commonly affected. If the cholesteatoma has been dry, the cholesteatoma may present the appearance of ' wax  over the attic'. The attic is just above the  eardrum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1403", "text": "If untreated, a cholesteatoma can eat or cause erosion of the three small bones located in the middle ear (the  malleus ,  incus  and  stapes , collectively called  ossicles ). [ 5 ]  This can result in nerve deterioration, imbalance,  vertigo , and  deafness  early in the disease. [ 6 ]  It can also affect and erode, through the  enzymes  it produces, the thin bone structure that isolates the top of the ear from the brain, as well as lay the covering of the brain open to infection with serious complications (rarely even death due to  brain abscess  and  sepsis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1404", "text": "Both the acquired as well as the congenital types of the disease can affect the  facial nerve  that extends from the brain to the face and passes through the inner and middle ear and leaves at the anterior tip of the  mastoid bone , and then rises to the front of the ear and extends into the upper and lower face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1405", "text": "Cholesteatomas occur in two basic classifications: Acquired cholesteatomas, which are more common, are usually caused by pathological alteration of the  ear drum  leading to accumulation of keratin within the  middle ear . [ 7 ]  Congenital cholesteatomas are usually middle ear epidermal cysts that are identified deep within an intact ear drum often in the superior anterior portion. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1406", "text": "Cholesteatomas do not contain cholesterol or fat and should not be confused with  cholesterol granulomas . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1407", "text": "Keratin-filled cysts that grow medial to the tympanic membrane are considered to be congenital if they fulfill the following criteria (Levenson's criteria): [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1408", "text": "Congenital cholesteatomas occur at three important sites: the middle ear, the petrous apex, and the cerebropontinio angle. They are most often found deep to the anterior aspect of the ear drum, and a vestigial structure, the  epidermoid  formation, from which congenital cholesteatoma may originate, has been identified in this area. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1409", "text": "Not all middle ear epidermal cysts are congenital, as they can be acquired either by metaplasia of the middle ear mucosa or by traumatic implantation of ear canal or tympanic membrane skin. In addition, cholesteatoma inadvertently left by a surgeon usually regrows as an epidermal cyst. Some authors have also suggested hereditary factors. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1410", "text": "More commonly, keratin accumulates in a pouch of tympanic membrane which extends into the middle ear space. This abnormal folding or 'retraction' of the tympanic membrane arises in one of the following ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1411", "text": "Cholesteatoma may also arise as a result of  metaplasia  of the middle ear mucosa  [ 15 ]  or implantation following trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1412", "text": "Cholesteatoma is diagnosed by a medical doctor by physical examination of the ear. A  CT scan  may help to rule out other, often more serious causes for the patient's clinical presentation. Non-ionizing radiation imaging techniques ( MRI ) may be suitable to replace a CT scan, if determined necessary by a physician. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1413", "text": "Cholesteatoma is a persistent disease. Once the diagnosis of cholesteatoma is made in a patient who can tolerate a general anesthetic, the standard treatment is to surgically remove the growth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1414", "text": "The challenge of cholesteatoma surgery is to permanently remove the cholesteatoma whilst retaining or reconstructing the normal functions of the structures housed within the  temporal bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1415", "text": "The general objective of cholesteatoma surgery has two parts. It is both directed against the underlying  pathology  and directed towards maintaining the normal functions of the temporal bone. These aims are conflicting and this makes cholesteatoma surgery extremely challenging."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1416", "text": "Sometimes, the situation results in a clash of surgical aims. The need to fully remove a progressive disease like cholesteatoma is the surgeon's first priority. Preservation of hearing is secondary to this primary aim. If the disease can be removed easily so that there is no increased risk of residual disease, then the ossicles may be preserved. If the disease is difficult to remove, so that there is an increased risk of residual disease, then removal of involved ossicles in order to fully clear cholesteatoma has generally been regarded as necessary and reasonable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1417", "text": "In other words, the aims of cholesteatoma treatment form a hierarchy. The paramount objective is the complete removal of cholesteatoma. The remaining objectives, such as hearing preservation, are subordinate to the need for complete removal of cholesteatoma. This hierarchy of aims has led to the development of a wide range of strategies for the treatment of cholesteatoma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1418", "text": "The variation in technique in cholesteatoma surgery results from each surgeon's judgment whether to retain or remove certain structures housed within the temporal bone in order to facilitate the removal of cholesteatoma. This typically involves some form of  mastoidectomy  which may or may not involve removing the posterior ear canal wall and the ossicles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1419", "text": "Removal of the canal wall facilitates the complete clearance of cholesteatoma from the temporal bone in three ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1420", "text": "Thus removal of the canal wall provides one of the most effective strategies for achieving the primary aim of cholesteatoma surgery, the complete removal of cholesteatoma. However, there is a trade-off, since the functional impact of canal wall removal is also important."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1421", "text": "The removal of the ear canal wall results in:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1422", "text": "The formation of a mastoid cavity by removal of the canal wall is the simplest and most effective procedure for facilitating the removal of cholesteatoma, but may bestow the most lasting infirmity due to loss of ear function upon the patient treated in this way."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1423", "text": "The following strategies are employed to mitigate the effects of canal wall removal:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1424", "text": "Clearly, preservation and restoration of ear function at the same time as total removal of cholesteatoma requires a high level of surgical expertise."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1425", "text": "Traditionally, ear surgery has been performed using the surgical microscope. The direct line of view dictated by that approach necessitates using the mastoid as the access port to the middle ear. It has long been recognized that failure in cholesteatoma surgery occurs in some of the out of view spaces of the tympanic cavity like the  sinus tympani  and facial recess that are out of view using the traditional microscopic technique. [ 23 ]  More recently, the endoscope has been increasingly utilized in the surgical management of cholesteatoma in one of two ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1426", "text": "There are multiple advantages for the use of the endoscope in cholesteatoma surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1427", "text": "It is important that the patient attend periodic follow-up checks, because even after careful microscopic surgical removal, cholesteatomas may recur. Such recurrence may arise many years, or even decades, after treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1428", "text": "A 'residual cholesteatoma' may develop if the initial surgery failed to completely remove the original; residual cholesteatomas typically become evident within the first few years after the initial surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1429", "text": "A 'recurrent cholesteatoma' is a new cholesteatoma that develops when the underlying causes of the initial cholesteatoma are still present. Such causes can include, for example, poor  Eustachian tube  function, which results in retraction of the ear drum, and failure of the normal outward migration of skin. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1430", "text": "In a retrospective study of 345 patients with middle ear cholesteatoma operated on by the same surgeon, the overall 5-year recurrence rate was 11.8%. [ 28 ]  In a different study with a mean follow-up period of 7.3 years, the recurrence rate was 12.3%, with the recurrence rate being higher in children than in adults. [ 29 ]  The use of the endoscope as an ancillary instrument has been shown to reduce the incidence of residual cholesteatoma. [ 30 ]  Although more studies are needed, so far, new techniques addressing underlying Eustachian tube dysfunction such as transtympanic dilatation of the Eustachian tube has not been shown to change outcomes of chronic ear surgery. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1431", "text": "Recent findings indicate that the keratinizing  squamous epithelium  of the middle ear could be subjected to  human papillomavirus  infection. [ 32 ]  Indeed, DNA belonging to oncogenic HPV16 has been detected in cholesteatoma tissues, thereby underlining that keratinizing squamous epithelia could potentially be a target tissue for HPV infection. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1432", "text": "In one study, the number of new cases of cholesteatoma in  Iowa  was estimated in 1975\u201376 to be just under one new case per 10,000 citizens per year. [ 33 ]  Cholesteatoma affects all age groups, from infants through to the elderly. The peak incidence occurs in the second decade. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1433", "text": "Submandibular gland"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1434", "text": "Chorda tympani  is a branch of the  facial nerve  that carries  gustatory  ( taste ) sensory innervation from the front of the tongue and  parasympathetic  ( secretomotor ) innervation to the  submandibular  and  sublingual   salivary glands . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1435", "text": "Chorda tympani has a complex course from the  brainstem , through the  temporal bone  and  middle ear , into the  infratemporal fossa , and ending in the  oral cavity . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1436", "text": "Chorda tympani  fibers emerge from the  pons  of the  brainstem  as part of the  intermediate nerve  of the  facial nerve . The facial nerve exits the  cranial cavity  through the  internal acoustic meatus  and enters the  facial canal . Within the facial canal, chorda tympani branches off the  facial nerve  and enters the lateral wall of the  tympanic cavity  within the  middle ear , where it runs across the  tympanic membrane  (from posterior to anterior) and medial to the  neck of the malleus . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1437", "text": "Chorda tympani then exits the skull by descending through the  petrotympanic fissure  into the  infratemporal fossa . Here it joins the  lingual nerve , a branch of the  mandibular nerve  (CN V 3 ). Traveling with the  lingual nerve , the fibers of chorda tympani enter the  sublingual space  to reach the  anterior 2/3 of the tongue  and  submandibular ganglion . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1438", "text": "The chorda tympani carries two types of nerve fibers from their origin from the facial nerve to the  lingual nerve  that carries them to their destinations:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1439", "text": "The chorda tympani is one of three cranial nerves that are involved in  taste . The taste system involves a complicated  feedback  loop, with each nerve acting to inhibit the signals of other nerves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1440", "text": "There are similarities between the tastes the chorda tympani picks up in sweeteners between mice and  primates , but not rats. Relating research results to humans is therefore not always consistent. [ 5 ] \n Sodium chloride  is detected and recognized most by the chorda tympani nerve. [ 5 ]  The recognition and responses to sodium chloride in the chorda tympani is mediated by  amiloride -sensitive sodium channels. [ 6 ]  \nThe chorda tympani has a relatively low response to  quinine  and varied responses to  hydrochloride . The chorda tympani is less responsive to  sucrose  than is the  greater petrosal nerve . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1441", "text": "The chorda tympani nerve carries its information to the  nucleus of solitary tract , and shares this area with the  greater petrosal ,  glossopharyngeal , and  vagus  nerves. [ 8 ]  When the greater petrosal and glossopharyngeal nerves are cut, regardless of age, the chorda tympani nerve takes over the space in the terminal field. This takeover of space by the chorda tympani is believed to be the nerve reverting to its original state before competition and pruning. [ 9 ]  \nThe chorda tympani, as part of the  peripheral nervous system , is not as plastic in early ages. In a study done by Hosley et al. and a study done by Sollars, it has been shown that when the nerve is cut at a young age, the related  taste buds  are not likely to grow back to full strength. [ 10 ] [ 11 ]   \nIn a bilateral transection of the chorda tympani in mice, the preference for sodium chloride increases compared to before the transection. Also avoidance of higher concentrations of sodium chloride is eliminated. [ 5 ]  The amiloride-sensitive channels responsible for salt recognition and response is functional in adult rats but not neonatal rats. This explains part of the change in preference of sodium chloride after a chorda tympani transection. [ 6 ] \nThe chorda tympani innervates the  fungiform papillae  on the tongue. [ 11 ]  According to a study done by Sollars et al. in 2002, when the chorda tympani has been transected early in postnatal development some of the fungiform papillae undergo a structural change to become more \u201cfiliform-like\u201d. [ 12 ]   When some of the other papillae grow back, they do so without a pore. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1442", "text": "Injury to the chorda tympani nerve leads to loss or distortion of taste from anterior 2/3 of  tongue . [ 13 ]   However, taste from the posterior 1/3 of tongue (supplied by the glossopharyngeal nerve) remains intact."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1443", "text": "The chorda tympani appears to exert a particularly strong inhibitory influence on other taste nerves, as well as on pain fibers in the tongue. When the chorda tympani is damaged, its inhibitory function is disrupted, leading to less inhibited activity in the other  nerves . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1444", "text": "A  cleft lip  contains an opening in the  upper lip  that may extend into the nose. [ 1 ]  The opening may be on one side, both sides, or in the middle. [ 1 ]  A  cleft palate  occurs when the  palate  (the roof of the mouth) contains an opening into the  nose . [ 1 ]  The term  orofacial cleft  refers to either condition or to both occurring together. These disorders can result in feeding problems, speech problems, hearing problems, and frequent  ear infections . [ 1 ]  Less than half the time the condition is associated with other disorders. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1445", "text": "Cleft lip and palate are the result of tissues of the face not joining properly during  development . [ 1 ]  As such, they are a type of  birth defect . [ 1 ]  The cause is unknown in most cases. [ 1 ]   Risk factors  include  smoking during pregnancy ,  diabetes ,  obesity ,  an older mother , and certain  medications  (such as some used to treat  seizures ). [ 1 ] [ 2 ]  Cleft lip and cleft palate can often be diagnosed during pregnancy with an  ultrasound exam . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1446", "text": "A cleft lip or palate can be successfully treated with surgery. [ 1 ]  This is often done in the first few months of life for cleft lip and before eighteen months for cleft palate. [ 1 ]   Speech therapy  and dental care may also be needed. [ 1 ]  With appropriate treatment, outcomes are good. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1447", "text": "Cleft lip and palate occurs in about 1 to 2 per 1000 births in the  developed world . [ 2 ]  Cleft lip is about twice as common in males as females, while cleft palate without cleft lip is more common in females. [ 2 ]  In 2017, it resulted in about 3,800 deaths globally, down from 14,600 deaths in 1990. [ 3 ] [ 4 ]  Cleft lips are commonly known as  hare-lips  because of their resemblance to the lips of  hares  or rabbits. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1448", "text": "If the cleft does not affect the palate structure of the mouth, it is referred to as cleft lip.  Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft), or it continues into the nose (complete cleft). Lip cleft can occur as a one-sided (unilateral) or two-sided (bilateral) condition. It is due to the failure of fusion of the  maxillary prominence  and  medial nasal processes  (formation of the primary palate)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1449", "text": "A mild form of a cleft lip is a microform cleft. [ 6 ]  A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. [ 7 ]  In some cases  muscle tissue in the lip  underneath the scar is affected and might require reconstructive surgery. [ 8 ]  It is advised to have newborn infants with a microform cleft checked with a  craniofacial team  as soon as possible to determine the severity of the cleft. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1450", "text": "Cleft palate is a condition in which the two plates of the  skull  that form the  hard palate  (roof of the mouth) are not completely joined. The  soft palate  is in these cases cleft as well. In most cases, cleft lip is also present."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1451", "text": "Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the  uvula  is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, or the median palatine processes (formation of the  secondary palate )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1452", "text": "The hole in the roof of the mouth caused by a cleft connects the mouth directly to the  inside of the nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1453", "text": "Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1454", "text": "A result of an open connection between the  mouth  and inside the nose is called  velopharyngeal insufficiency  (VPI). Because of the gap, air leaks into the nasal cavity resulting in a  hypernasal  voice  resonance  and nasal emissions while talking. [ 10 ]  Secondary effects of VPI include speech  articulation  errors (e.g.,  distortions , substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g.,  glottal stops  and posterior nasal  fricatives ). [ 11 ]  Possible treatment options include  speech therapy , prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and  surgical procedures . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1455", "text": "Submucous cleft palate can also occur, which is a cleft of the soft palate with a split  uvula , a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate. [ 12 ]  The diagnosis of submucous cleft palate often occurs late in children as a result of the nature of the cleft. [ 13 ]  While the muscles of the soft palate are not joined, the mucosal membranes covering the roof of the mouth appear relatively normal and intact. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1456", "text": "Tooth development can be delayed with increasing severity of CLP. Some of the dental problems affect the  primary teeth , but most of the problems arise after the permanent teeth erupt. Problems may include fused teeth, missing teeth, and extra teeth erupting behind normal teeth. Missing teeth or extra teeth are both normal occurrences. Typically, the lateral incisors are missing. The  enamel  (outermost layer of the tooth) is commonly found to be hypomineralized and hypoplastic, making the teeth more likely to decay. As CLP can make oral hygiene more difficult, there is an increased rate of cavities. [ 15 ]  In addition, abnormal positioning of individual teeth may affect occlusion, which can create an open bite or cross bite. This in turn can then affect the patient's speech. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1457", "text": "Cleft may cause problems with feeding, ear disease, speech, socialization, and cognition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1458", "text": "Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the  Haberman Feeder . Another equipment commonly used for gravity feeding is a customized bottle with a combination of nipples and bottle inserts. A large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1459", "text": "Individuals with cleft also face many middle ear infections which may eventually lead to hearing loss. The  Eustachian tubes  and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self-cleaning. Hearing is related to learning to speak.  Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1460", "text": "Tentative evidence has found that those with clefts perform less well at language. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1461", "text": "There is research dedicated to the  psychosocial development  of individuals with cleft palate. A cleft palate/lip may impact an individual's  self-esteem ,  social skills  and  behavior . Self-concept may be adversely affected by the presence of a cleft lip or cleft palate, particularly among girls. [ 19 ]  Negative outcomes can also be associated with the long durations of hospitalization. Psychological issues could extend not just to the individual with CLP but also to their families, particularly their mothers, that experience varying levels of depression and anxiety. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1462", "text": "Research has shown that during the early preschool years (ages 3\u20135), children with cleft lip or cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of  social anxiety . Experts conclude that this is probably due to the associated stigma of visible deformities and possible  speech impediments . Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip or cleft palate. [ 22 ]  Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to \"how well they liked themselves.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1463", "text": "The relationship between parental attitudes and a child's self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. [ 23 ]  Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. [ 24 ]  In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip or cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip or cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1464", "text": "As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft lip or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self-esteem, dating and social acceptance. [ 26 ] [ 27 ] [ 28 ]  Adolescents, however, view appearance as the most important characteristic, above intelligence and humor. [ 29 ]  This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to withdrawal, attention, thought, and  internalizing  problems, and may possibly develop anxiousness-depression and aggressive behaviors. [ 28 ]  Adolescent girls are more likely to develop problems relating to self-concept and appearance. Individuals with cleft lip or cleft palate often deal with threats to their  quality of life  for multiple reasons including unsuccessful social relationships, deviance in social appearance, and multiple surgeries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1465", "text": "Most clefts are polygenic and multifactorial in origin with many genetic and environmental factors contributing. Genetic factors cause clefts in 20% to 50% of the cases and the remaining clefts are attributable to either environmental factors (such as  teratogens ) or gene-environment interactions. The polygenic/multifactorial inheritance model predicts that most individuals will be born without clefts; however with a number of genetic or environmental factors, it can result in cleft formation. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1466", "text": "The development of the face is coordinated by complex  morphogenetic events  and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed.  Five primitive tissue lobes grow:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1467", "text": "If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1468", "text": "The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle. [ 30 ]  This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite complex and obscure despite intensive scientific research. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1469", "text": "Orofacial clefts may be associated with a syndrome (syndromic) or may not be associated with a syndrome (nonsyndromic). Syndromic clefts are part of syndromes that are caused by a variety of factors such as environment and genetics or an unknown cause. Nonsyndromic clefts, which are not as common as syndromic clefts, also have a genetic cause. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1470", "text": "Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases. Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome present. [ 32 ]  A number of genes are involved including  cleft lip and palate transmembrane protein 1  and  GAD1 , [ 33 ]  One study found an association between mutations in the  HYAL2  gene and cleft lip and cleft palate formation. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1471", "text": "In some cases, cleft palate is caused by syndromes that also cause other problems:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1472", "text": "Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes  IRF6 ,  PVRL1  and  MSX1 . [ 45 ]  The understanding of the genetic complexities involved in the  morphogenesis  of the midface, including molecular and cellular processes, has been greatly aided by research on animal models, including of the genes  BMP4 ,  SHH ,  SHOX2 ,  FGF10  and  MSX1 . [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1473", "text": "Environmental influences may also cause, or interact with genetics to produce, orofacial clefts. An example of the link between environmental factors and genetics comes from a research on mutations in the gene  PHF8 . The research found that  PHF8  encodes for a  histone  lysine demethylase, [ 46 ]  and is involved in  epigenetic regulation . The catalytic activity of  PHF8  depends on molecular  oxygen , [ 46 ]  a factor considered important from reports on increased incidence of cleft lip/palate in mice that have been exposed to  hypoxia  early during pregnancy. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1474", "text": "Cleft lip and other  congenital abnormalities  have also been linked to maternal hypoxia caused by  maternal smoking , [ 48 ]  with the estimated attributable fraction of orofacial clefts due to smoking in early pregnancy being 6.1%. Orofacial clefts occur very early in pregnancy and so smoking cessation right after recognition of pregnancy is unlikely to reduce the exposure during the critical time period. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1475", "text": "Maternal  alcohol use  has also been linked to cleft lip and palate due to the effects on the cranial  neural crest  cells. The degree of the effect, however, is unknown and requires further research. [ 50 ]  Some forms of maternal  hypertension  treatment have been linked to cleft lip and palate. [ 51 ]  Other environmental factors that have been studied include seasonal causes (such as pesticide exposure); maternal diet and vitamin intake;  retinoids  (members of the vitamin A family);  anticonvulsant  drugs; nitrate compounds; organic solvents; parental exposure to lead; alcohol; cigarette use; and a number of other psychoactive drugs (e.g.  cocaine ,  crack cocaine ,  heroin )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1476", "text": "Current research continues to investigate the extent to which  folic acid  can reduce the incidence of clefting. [ 52 ]  Folic acid alone or in combination with vitamins and minerals prevents neural tube defects but does not have a clear effect on cleft lip palate incidence. [ 53 ]  The mechanism behind beneficial folate supplementation is due to folate playing a pivotal role in DNA synthesis and methylation and contributes to both development and gene expression. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1477", "text": "Traditionally, the diagnosis is made at the time of birth by physical examination. Recent advances in  prenatal diagnosis  have allowed  obstetricians  to diagnose facial clefts  in utero  with  ultrasonography . [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1478", "text": "Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976,  Paul Tessier  described fifteen lines of cleft.  Most of these  craniofacial clefts  are even rarer and are frequently described as Tessier clefts using the numerical locator devised by Tessier. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1479", "text": "Cleft lip and cleft palate is an \"umbrella term\" for a collection of orofacial clefts. It includes clefting of the upper lip, the  maxillary alveolus  (dental arch), and the  hard  or  soft palate , in various combinations. Proposed anatomic combinations include: [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1480", "text": "Cleft lip with or without palate is classified as the most common congenital birth defect. It has been noted that the prevalence of orofacial clefts varies by race. The highest number of cases have been recorded among Asians and Native Americans, followed by Europeans, Hispanics and African-Americans. The critical period for cleft development ranges from the 4th to the 12th week of intrauterine life. Clefts of the primary palate develop between the 4th and 7th weeks of intrauterine life, while clefts of the secondary palate develop between the 8th and 12th embryonic weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1481", "text": "Accurate evaluation of craniofacial malformations is usually possible with the ultrasound scan performed during pregnancy. This is however not a routine procedure according to the American Institute of Ultrasound in Medicine. The accuracy of ultrasonography for prenatal diagnosis of cleft lip +/- palate is dependent on the experience of the sonologist, maternal body type, foetal position, the amount of amniotic fluid and the type of cleft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1482", "text": "Prenatal diagnosis enables appropriate and timely education and discussion with parents by the cleft team. This helps improve the quality of treatment received by the child and improves quality of life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1483", "text": "An accurate prenatal diagnosis of the CLP anomaly is critical for establishing long-term treatment planning, prediction of treatment outcome, and discussion and education of the parent. Although there is no intrauterine treatment for CLP, both mother and child benefit from early diagnosis and education. A multidisciplinary team approach is now accepted as the standard of care in dealing with CLP patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1484", "text": "The time period immediately after the diagnosis and the first year after the birth is most challenging for parents. A systematically planned treatment plan and support system will help assist parents. The ultimate aim is to help educate parents and create awareness so as to improve care provided for the child. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1485", "text": "Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1486", "text": "Most children with a form of clefting are monitored by a  cleft palate team  or  craniofacial team  through young adulthood. [ 59 ]  Care can be lifelong and are looked after by craniofacial cleft teams often consist of: cleft surgeons,  orthodontists , speech and language therapists,  restorative dentists ,  psychologists , ENT surgeons and audio-logical physicians. [ 60 ] :\u200a255\u200a  Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as  deciduous teeth  are replaced by  permanent teeth , thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1487", "text": "Within the first 2\u20133 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the \" rule of 10s \" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g/dL hemoglobin). [ 61 ] [ 62 ]  If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the  Millard procedure  pioneered by  Ralph Millard . Millard performed the first procedure at a  Mobile Army Surgical Hospital  (MASH) unit in Korea. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1488", "text": "Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of  muscles  required to purse the lips run through the upper lip. To restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the  philtrum ) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1489", "text": "In some cases of a severe bilateral complete cleft, the premaxillary segment will be protruded far outside the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1490", "text": "Nasoalveolar molding  prior to surgery can improve long-term nasal symmetry where there is complete unilateral cleft lip\u2013cleft palate, compared to correction by surgery alone, according to a retrospective  cohort study . [ 64 ]  In this study, significant improvements in nasal symmetry were observed in multiple areas including measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. \"The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group,\" this study concluded. A  systematic review  found in conclusion that nasoalveolar molding had a positive effect on the primary surgery of cleft lip/or palate treatment and aesthetics. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1491", "text": "Often a cleft palate is temporarily covered by a  palatal obturator  (a prosthetic device made to fit the roof of the mouth covering the gap). This device re-positions displaced alveolar segments and helps reduce the cleft lip separation. The obturator will improve speech as there's now proper airflow and improve feeding and breathing as the gap in the hard and soft palate is closed over so cannot affect it. [ 60 ] :\u200a257"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1492", "text": "Cleft palate can also be corrected by  surgery , usually performed between 6 and 12 months. Approximately 20\u201325% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non- hypernasal speech . However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the  Latham appliance . [ 66 ]  The Latham is surgically inserted by use of pins during the child's fourth or fifth month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip or palate repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1493", "text": "If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the individual's own chin, rib or hip."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1494", "text": "At age 1\u20137 years the child is regularly reviewed by the cleft team. [ 60 ] :\u200a257"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1495", "text": "Age 7\u201312 years, for the children born with alveolar clefts, they may need to have a secondary alveolar bone graft. This is where autogenous  cancellous bone  from a donor site (often the pelvic bone) is transplanted into the alveolar cleft region. This transplant of bone will close the osseous cleft of the alveolus, close any oro-nasal  fistulae  and will become integrated with the  maxillary bone . It provides bone for teeth to erupt into and to allow implants to be placed as a possible future treatment option. The procedure should be carried out before the upper canine has erupted. Ideally the root of the canine should be one to two-thirds formed and that there is a space available to place the bone graft.  Radio-graphs  are taken to determine the quantity of missing bone in the cleft area. [ 60 ] :\u200a258"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1496", "text": "Orthognathic surgery  \u2013 surgical cutting of bone to realign the upper jaw ( osteotomy ). The bone is cut then re-positioned and held together by wires or rigid fixation plates to ensure there's no anterior-posterior discrepancy, also to reduce scarring as it reduces growth. Single piece or multi-piece osteotomy exist. Single piece osteotomy is carried out where there is sufficient alveolar continuity achieved from a successful bone graft. Multi piece osteotomy is performed when there is a notable residual alveolar defect with a dental gap and oronasal fistula (communication between the oral and nasal cavities). The goal of both single and multi piece osteotomy is to displace the maxilla forward to obtain adequate occlusion as well to provide better support for upper lip and the nose and to close any  fistulae . [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1497", "text": "Distraction osteogenesis  \u2013 bone lengthening by gradual distraction. This involves cutting bone and moving ends apart incrementally to allow new bone to form in the gap. This consists of several phases. After attachment of the distracting device and the bone cuts, there is a latency phase of 3\u20137 days when a  callus  forms. In the activation phase distraction of the callus induces bony ingrowth which can last up to 15 days depending on the required distraction. Once the required bone length is reached, the distraction device is left to remain in situ as it acts as a rigid skeletal fixation device until the new bone has matured (known as the consolidation period). [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1498", "text": "Velopharyngeal insufficiency  (VPI) can occur as a result of an unrepaired or repaired cleft lip and palate. VPI is the inability of the soft palate to close tightly against the back of the throat during speech, resulting in incomplete velopharyngeal closure. In turn, this results in speech abnormalities. Velopharyngeal closure is necessary during speech because it forms a seal between the nose and mouth, allowing the production of normal speech sounds. VPI can cause  hypernasality  (excessive nasal resonance),  hyponasality  (reduced nasal resonance), or a mixed nasal resonance, which is when hypernasality and hyponasality occur simultaneously. [ 68 ]  In addition, CLP may cause abnormal positioning of individual teeth, which can in turn affect the patient's ability to make certain sounds when speaking such as the \"f\" or \"v\" sound and can also result in a lisp. The changes in speech may also be a manifestation on CLP's effects on the patient's occlusion. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1499", "text": "Children with cleft palate have a very high risk of developing a middle ear infection, specifically  otitis media . This is due to the immature development of the different bones and muscles in the ear. Otitis media is caused by the obstruction of the  Eustachian tube , negative middle ear pressure and fluid build-up in the normally air-filled space of the middle ear. [ 69 ]  This is associated with hearing impairment or loss. The insertion of a ventilation tube into the eardrum is a surgical treatment option commonly used to improve hearing in children with otitis media. [ 70 ]  In addition, breast milk has been proven to decrease the incidence of otitis media in infants with clefts. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1500", "text": "There are different options on how to feed a baby with cleft lip or cleft palate which include:  breast-feeding , bottle feeding, spoon feeding and syringe feeding. Although breast-feeding is challenging, it improves weight-gain compared to spoon-feeding. [ 71 ]  Nasal regurgitation is common due to the open space between the oral cavity and the nasal cavity. Bottle feeding can help (with squeezable bottles being easier to use than rigid bottles). In addition, maxillary plates can be added to aid in feeding. Whatever feeding method is established, it is important to keep the baby's weight gain and hydration monitored. Infants with cleft lip or palate may require supplemental feeds for adequate growth and nutrition. Breast feeding position as suggested by specialists can also improve success rate. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1501", "text": "Babies with cleft lip are more likely to breastfeed successfully than those with cleft palate and cleft lip and palate. Larger clefts of the soft or hard palate may not be able to generate suction as the oral cavity cannot be separated from the nasal cavity when feeding which leads to fatigue, prolonged feeding time, impaired growth and nutrition. Changes in swallowing mechanics may result in coughing, choking, gagging and nasal regurgitation. Even after cleft repair, the problem may still persist as significant motor learning of swallowing and sucking was absent for many months before repair. [ 73 ]  These difficulties in feeding may result in secondary problems such as poor weight gain, excessive energy expenditure during feeding, lengthy feeding times, discomfort during feeding, and stressful feeding interactions between the infant and the mother. A potential source of discomfort for the baby during or after feeding is bloating or frequent \"spit up\" which is due to the excessive air intake through the nose and mouth in the open cleft. [ 16 ]  Babies with cleft lip and or palate should be evaluated individually taking into account the size and location of the cleft and the mother's previous experience with breastfeeding. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1502", "text": "Another option is feeding breast milk via bottle or syringe. Since babies with clip lip and cleft palate generate less section when breastfeeding, their nutrition, hydration and weight gain may be affected. This may result in the need for supplemental feeds. Modifying the position of holding the baby may increase the effectiveness and efficiency of breastfeeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1503", "text": "Preoperative feeding \u2013 using a squeezable bottle instead of a rigid bottle can allow a higher volume of food intake and less effort to extract food. Using a syringe is practical, easy to perform and allows greater administered volume of food. It also means there will be weight gain and less time spent feeding. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1504", "text": "Post-operative feeding (isolated lip repair, or lip repair associated or not with  palatoplasty ) \u2013 post  palatoplasty , some studies believe that inappropriate negative pressure on the suture line may affect results. Babies can be fed by a  nasogastric tube  instead. Studies suggest babies required less analgesics and shorter hospital stay with nasogastric feeding post-surgery. With bottle-feeding, there was higher feeding rejection and pain and required more frequent and prolonged feeding times. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1505", "text": "Each person's treatment schedule is individualized. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases, this is usually one procedure, for example lip repair. In other cases, it is an ongoing therapy, for example speech therapy. In most cases of cleft lip and palate that involve the alveolar bone, patients will need a treatment plan including the prevention of cavities, orthodontics, alveolar bone grafting, and possibly jaw surgery. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1506", "text": "People with CLP present with a multiplicity of problems. Therefore, effective management of CLP involves a wide range of specialists. The current model for delivery of this care is the multidisciplinary cleft team. This is a group of individuals from different specialist backgrounds who work closely together to provide patients with comprehensive care from birth through adolescence. This system of delivery of care enables the individuals within the team to function in an interdisciplinary way, so that all aspects of care for CLP patients can be provided in the best way possible. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1507", "text": "Measuring the outcomes of CLP treatment has been laden with difficulty due to the complexity and longitudinal nature of cleft care, which spans birth through young adulthood. Prior attempts to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards for outcomes assessment in cleft care. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1508", "text": "The International Consortium for Health Outcome Measurement (ICHOM) has proposed the Standard Set of Outcome Measures for Cleft Lip and Palate. [ 77 ] [ 78 ]  The ICHOM Standard Set includes measures for many of the important outcome domains in cleft care (hearing, breathing, eating/drinking, speech, oral health, appearance and psychosocial well-being). It includes clinician-reported, patient-reported, and family-reported outcome measures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1509", "text": "Cleft lip and palate occurs in about 1 to 2 per 1000 births in the  developed world . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1510", "text": "Rates for cleft lip with or without cleft palate and cleft palate alone varies within different  ethnic  groups."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1511", "text": "According to CDC, the prevalence of cleft palate in the United States is 6.35/10000 births and the prevalence of cleft lip with or without cleft palate is 10.63/10000 births. [ 79 ]  The highest prevalence  rates  for cleft lip, either with or without cleft palate are reported for Native Americans and  Asians .  Africans  have the lowest prevalence rates. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1512", "text": "Cleft lip and cleft palate caused about 3,800 deaths globally in 2017, down from 14,600 deaths in 1990. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1513", "text": "Prevalence of \"cleft  uvula \" has varied from 0.02% to 18.8% with the highest numbers found among  Chippewa  and  Navajo  and the lowest generally in Africans. [ 81 ] [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1514", "text": "In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform an abortion beyond the legal  fetal  age limit, even though the  fetus  is not in jeopardy of life or limb. [ 83 ] [ 84 ]  Some political opponents contend this practice amounts to  eugenics  based on cosmetic defects rather than practical definitions of a  disability . [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1515", "text": "The eponymous hero of  J. M. Coetzee 's 1983 novel  Life & Times of Michael K  has a cleft lip that is never corrected. In the 1920 novel  Growth of the Soil ,  by Norwegian writer  Knut Hamsun , Inger (wife of the main character) has an uncorrected cleft lip which puts heavy limitations on her life, even causing her to kill her own child, who is also born with a cleft lip. The protagonist of the 1924 novel  Precious Bane , by English writer  Mary Webb , is a young woman living in 19th-century rural  Shropshire  who eventually comes to feel that her deformity is the source of her spiritual strength. The book was later adapted for television by both the  BBC  and  ORTF  in France. Similarly, the main character in  Graham Greene 's 1936 crime noir novel  A Gun for Sale , Raven, has a cleft lip which he is sensitive about, and is described as \"an ugly man dedicated to ugly deeds\". In the 1976  Patricia A. McKillip  novel  The Night Gift , one of the high-school aged protagonists is shy because she has a cleft lip, but learns to have more confidence in herself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1516", "text": "In the first edition of  Harry Potter and the Chamber of Secrets , one of the people Gilderoy Lockhart stole credit from was a witch with a harelip who banished the Bandon Banshee. In later editions, this was changed to a witch with a hairy chin. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1517", "text": "In chapter 26 of  Mark Twain 's  The Adventures of Huckleberry Finn , Huck Finn meets the three Wilks sisters, Mary Jane, Susan, and Joanna. Joanna is described as, \"the one who gives herself to good works and has a hare-lip.\" As a form of offensive  synecdoche , Huck Finn refers to Joanna as \"the hare-lip\" rather than by her name."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1518", "text": "Cleft lip and cleft palate are often portrayed negatively in popular culture. Examples include  Oddjob , the secondary villain of the  James Bond  novel  Goldfinger  by  Ian Fleming  ( the film adaptation  does not mention this but leaves it implied) and serial killer  Francis Dolarhyde  in the novel  Red Dragon  and its screen adaptations,  Manhunter ,  Red Dragon , and  Hannibal . [ 87 ]  The portrayal of enemy characters with cleft lips and cleft palates, dubbed mutants, in the 2019 video game  Rage 2  left Chris Plante of  Polygon  wondering if the condition would ever be portrayed positively. [ 88 ] [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1519", "text": "Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in goats, sheep, cats, horses,  pandas  and  ferrets . Most commonly, the defect involves the lip,  rhinarium , and  premaxilla . Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary.   Brachycephalic  dogs such as  Boxers  and  Boston Terriers  are most commonly affected. [ 107 ]  An inherited disorder with incomplete  penetrance  has also been suggested in  Shih tzus ,  Swiss Sheepdogs ,  Bulldogs , and  Pointers . [ 108 ]  In horses, it is a rare condition usually involving the caudal soft palate. [ 109 ]  In  Charolais cattle , clefts are seen in combination with  arthrogryposis , which is inherited as an  autosomal recessive  trait.  It is also inherited as an autosomal recessive trait in  Texel sheep .  Other contributing factors may include maternal nutritional deficiencies, exposure  in utero  to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain  lupines  by cattle during the second or third month of  gestation . [ 110 ]  The use of  corticosteroids  during pregnancy in dogs and the ingestion of  Veratrum californicum  by pregnant sheep have also been associated with cleft formation. [ 111 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1520", "text": "Difficulty with nursing is the most common problem associated with clefts, but  aspiration pneumonia ,  regurgitation , and  malnutrition  are often seen with cleft palate and is a common cause of death.  Providing nutrition through a  feeding tube  is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks. [ 107 ]  For cleft palate, there is a high rate of surgical failure resulting in repeated surgeries. [ 112 ]  Surgical techniques for cleft palate in dogs include  prosthesis , mucosal flaps, and microvascular  free flaps . [ 113 ]  Affected animals should [ opinion ]  not be bred due to the hereditary nature of this condition. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1521", "text": "The  cochlea  is the part of the  inner ear  involved in  hearing . It is a spiral-shaped cavity in the  bony labyrinth , in humans making 2.75 turns around its axis, the  modiolus . [ 2 ] [ 3 ]  A core component of the cochlea is the  organ of Corti , the sensory organ of hearing, which is distributed along the partition separating the fluid chambers in the coiled tapered tube of the cochlea."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1522", "text": "The name 'cochlea' is derived from the Latin word for  snail shell , which in turn is from the  Ancient Greek  \u03ba\u03bf\u03c7\u03bb\u03af\u03b1\u03c2  kokhlias  (\"snail, screw\"), and from \u03ba\u03cc\u03c7\u03bb\u03bf\u03c2  kokhlos  (\"spiral shell\") [ 4 ]  in reference to its coiled shape; the cochlea is coiled in mammals with the exception of  monotremes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1523", "text": "The cochlea ( pl. : cochleae) is a spiraled, hollow, conical chamber of bone, in which waves propagate from the base (near the middle ear and the  oval window ) to the apex (the top or center of the spiral). The spiral canal of the cochlea is a section of the bony labyrinth of the inner ear that is approximately 30\u00a0mm long and makes 2 3 \u2044 4  turns about the modiolus. The cochlear structures include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1524", "text": "The cochlea is a portion of the inner ear that looks like a snail shell ( cochlea  is Greek for snail). [ 5 ]  The cochlea receives sound in the form of vibrations, which cause the stereocilia to move. The stereocilia then convert these vibrations into nerve impulses which are taken up to the brain to be interpreted. Two of the three fluid sections are canals and the third is the 'organ of Corti' which detects pressure impulses that travel along the auditory nerve to the brain. The two canals are called the vestibular canal and the tympanic canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1525", "text": "The walls of the hollow cochlea are made of bone, with a thin, delicate lining of  epithelial tissue . This coiled tube is divided through most of its length by an inner membranous partition. Two fluid-filled outer spaces (ducts or  scalae ) are formed by this dividing membrane. At the top of the snailshell-like coiling tubes, there is a reversal of the direction of the fluid, thus changing the vestibular duct to the tympanic duct. This area is called the helicotrema. This continuation at the helicotrema allows fluid being pushed into the vestibular duct by the oval window to move back out via movement in the tympanic duct and deflection of the round window; since the fluid is nearly incompressible and the bony walls are rigid, it is essential for the conserved fluid volume to exit somewhere."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1526", "text": "The lengthwise partition that divides most of the cochlea is itself a fluid-filled tube, the third 'duct'. This central column is called the cochlear duct. Its fluid, endolymph, also contains electrolytes and proteins, but is chemically quite different from perilymph. Whereas the perilymph is rich in sodium ions, the endolymph is rich in potassium ions, which produces an  ionic , electrical potential."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1527", "text": "The hair cells are arranged in four rows in the organ of Corti along the entire length of the cochlear coil. Three rows consist of outer hair cells (OHCs) and one row consists of inner hair cells (IHCs). The inner hair cells provide the main neural output of the cochlea. The outer hair cells, instead, mainly 'receive' neural input from the brain, which influences their  motility  as part of the cochlea's mechanical \"pre-amplifier\". The input to the OHC is from the  olivary body  via the medial olivocochlear bundle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1528", "text": "The cochlear duct is almost as complex on its own as the ear itself.  The cochlear duct is bounded on three sides by the  basilar membrane , the  stria vascularis , and Reissner's membrane.  The  stria vascularis  is a rich bed of capillaries and secretory cells; Reissner's membrane is a thin membrane that separates endolymph from perilymph; and the basilar membrane is a mechanically somewhat stiff membrane, supporting the receptor organ for hearing, the organ of Corti, and determines the mechanical wave propagation properties of the cochlear system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1529", "text": "Between males and females, there are differences in the shape of the human cochlea. The variation is in the twist at the end of the spiral. Because of this difference, and because the cochlea is one of the more durable bones in the skull, it is used in ascertaining the sexes of human remains found at archaeological sites. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1530", "text": "The cochlea is filled with a watery liquid, the  endolymph , which moves in response to the vibrations coming from the middle ear via the oval window. As the fluid moves, the cochlear partition (basilar membrane and organ of Corti) moves; thousands of  hair cells  sense the motion via their  stereocilia , and convert that motion to electrical signals that are communicated via neurotransmitters to many thousands of nerve cells. These primary auditory neurons transform the signals into electrochemical impulses known as  action potentials , which travel along the auditory nerve to structures in the brainstem for further processing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1531", "text": "The  stapes  (stirrup) ossicle bone of the middle ear transmits vibrations to the  fenestra ovalis  (oval window) on the outside of the cochlea, which vibrates the perilymph in the  vestibular duct  (upper chamber of the cochlea). The ossicles are essential for efficient coupling of sound waves into the cochlea, since the cochlea environment is a fluid\u2013membrane system, and it takes more pressure to move sound through fluid\u2013membrane waves than it does through air. A pressure increase is achieved by reducing the area ratio from the tympanic membrane (drum) to the oval window ( stapes  bone) by 20. As pressure = force/area, results in a pressure gain of about 20 times from the original sound wave pressure in air. This gain is a form of  impedance matching  \u2013 to match the soundwave travelling through air to that travelling in the fluid\u2013membrane system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1532", "text": "At the base of the cochlea, each 'duct' ends in a membranous portal that faces the middle ear cavity: The  vestibular duct  ends at the  oval window , where the footplate of the  stapes  sits. The footplate vibrates when the pressure is transmitted via the ossicular chain. The wave in the perilymph moves away from the footplate and towards the  helicotrema . Since those fluid waves move the cochlear partition that separates the ducts up and down, the waves have a corresponding symmetric part in perilymph of the tympanic duct, which ends at the round window, bulging out when the oval window bulges in."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1533", "text": "The perilymph in the vestibular duct and the  endolymph  in the cochlear duct act mechanically as a single duct, being kept apart only by the very thin  Reissner's membrane .\nThe vibrations of the endolymph in the cochlear duct displace the basilar membrane in a pattern that peaks a distance from the oval window depending upon the soundwave frequency. The  organ of Corti  vibrates due to  outer hair cells  further amplifying these vibrations.  Inner hair cells  are then displaced by the vibrations in the fluid, and depolarise by an influx of K+ via their  tip-link -connected channels, and send their signals via neurotransmitter to the primary auditory neurons of the  spiral ganglion . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1534", "text": "The hair cells in the organ of Corti are tuned to certain sound frequencies by way of their location in the cochlea, due to the degree of stiffness in the basilar membrane. [ 9 ]  This stiffness is due to, among other things, the thickness and width of the basilar membrane, [ 10 ]  which along the length of the cochlea is stiffest nearest its beginning at the oval window, where the stapes introduces the vibrations coming from the eardrum. Since its stiffness is high there, it allows only high-frequency vibrations to move the basilar membrane, and thus the hair cells.  The farther a wave travels towards the cochlea's apex (the  helicotrema ), the less stiff the basilar membrane is; thus lower frequencies travel down the tube, and the less-stiff membrane is moved most easily by them where the reduced stiffness allows: that is, as the basilar membrane gets less and less stiff, waves slow down and it responds better to lower frequencies. In addition, in mammals, the cochlea is coiled, which has been shown to enhance low-frequency vibrations as they travel through the fluid-filled coil. [ 11 ]   This spatial arrangement of sound reception is referred to as  tonotopy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1535", "text": "For very low frequencies (below 20\u00a0Hz), the waves propagate along the complete route of the cochlea \u2013 differentially up vestibular duct and tympanic duct all the way to the  helicotrema . Frequencies this low still activate the organ of Corti to some extent but are too low to elicit the perception of a  pitch .  Higher frequencies do not propagate to the  helicotrema , due to the stiffness-mediated tonotopy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1536", "text": "A very strong movement of the basilar membrane due to very loud noise may cause hair cells to die. This is a common cause of partial hearing loss and is the reason why users of firearms or heavy machinery often wear  earmuffs  or  earplugs ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1537", "text": "To transmit the sensation of sound to the brain, where it can be processed into the perception of  hearing , hair cells of the cochlea must convert their mechanical stimulation into the electrical signaling patterns of the nervous system. Hair cells are modified  neurons , able to generate action potentials which can be transmitted to other nerve cells. These action potential signals travel through the  vestibulocochlear nerve  to eventually reach the anterior  medulla , where they  synapse  and are initially processed in the  cochlear nuclei . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1538", "text": "Some processing occurs in the cochlear nuclei themselves, but the signals must also travel to the  superior olivary complex  of the  pons  as well as the  inferior colliculi  for further processing. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1539", "text": "Not only does the cochlea \"receive\" sound, a healthy cochlea  generates  and amplifies sound when necessary.  Where the organism needs a mechanism to hear very faint sounds, the cochlea amplifies by the reverse  transduction  of the OHCs, converting electrical signals back to mechanical in a positive-feedback configuration.  The OHCs have a protein motor called  prestin  on their outer membranes; it generates additional movement that couples back to the fluid\u2013membrane wave. This \"active amplifier\" is essential in the ear's ability to amplify weak sounds. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1540", "text": "The active amplifier also leads to the phenomenon of soundwave vibrations being emitted from the cochlea back into the ear canal through the middle ear (otoacoustic emissions)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1541", "text": "Otoacoustic emissions  are due to a wave exiting the cochlea via the oval window, and propagating back through the middle ear to the eardrum, and out the ear canal, where it can be picked up by a microphone.  Otoacoustic emissions are important in some types of tests for  hearing impairment , since they are present when the cochlea is working well, and less so when it is suffering from loss of OHC activity. Otoacoustic emissions also exhibit sex dimorphisms, since females tend to display higher magnitudes of otoacoustic emissions. Males tend to experience a reduction in otoacoustic emission magnitudes as they age. Women, on the other hand, do not experience a change in otoacoustic emission magnitudes with age. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1542", "text": "Gap-junction proteins, called  connexins , expressed in the cochlea play an important role in auditory functioning. [ 16 ]  Mutations in gap-junction genes have been found to cause syndromic and nonsyndromic deafness. [ 17 ]   Certain connexins, including  connexin 30  and  connexin 26 , are prevalent in the two distinct gap-junction systems found in the cochlea.  The epithelial-cell gap-junction network couples non-sensory epithelial cells, while the connective-tissue gap-junction network couples connective-tissue cells. [ 18 ]   Gap-junction channels recycle potassium ions back to the endolymph after  mechanotransduction  in  hair cells . [ 19 ]   Importantly, gap junction channels are found between cochlear supporting cells, but not auditory  hair cells . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1543", "text": "Damage to the cochlea can result from different incidents or conditions like a severe head injury, a  cholesteatoma , an infection, and/or exposure to loud noise which could kill hair cells in the cochlea."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1544", "text": "Hearing loss associated with the cochlea is often a result of outer hair cells and inner hair cells damage or death. Outer hair cells are more susceptible to damage, which can result in less sensitivity to weak sounds. Frequency sensitivity is also affected by cochlear damage which can impair the patient's  ability to distinguish between spectral differences of vowels. The effects of cochlear damage on different aspects of hearing loss like temporal integration, pitch perception, and frequency determination are still being studied, given that multiple factors must be taken into account in regard to cochlear research. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1545", "text": "In 2009, engineers at the  Massachusetts Institute of Technology  created an  electronic chip  that can quickly analyze a very large range of  radio frequencies  while using only a fraction of the power needed for existing technologies; its design specifically mimics a cochlea. [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1546", "text": "The coiled form of cochlea is unique to  mammals . In birds and in other non-mammalian  vertebrates , the compartment containing the sensory cells for hearing is occasionally also called \"cochlea,\" despite not being coiled up. Instead, it forms a blind-ended tube, also called the cochlear duct. This difference apparently  evolved  in parallel with the differences in  frequency range of hearing  between mammals and non-mammalian vertebrates. The superior  frequency range  in mammals is partly due to their unique mechanism of pre-amplification of sound by active cell-body vibrations of outer  hair cells . Frequency resolution is, however, not better in mammals than in most lizards and birds, but the upper frequency limit is \u2013 sometimes much \u2013 higher. Most bird species do not hear above 4\u20135\u00a0kHz, the currently known maximum being ~ 11\u00a0kHz in the barn owl. Some marine mammals hear up to 200\u00a0kHz. A long coiled compartment, rather than a short and straight one, provides more space for additional octaves of hearing range, and has made possible some of the highly derived behaviors involving mammalian hearing. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1547", "text": "As the study of the cochlea should fundamentally be focused at the level of hair cells, it is important to note the anatomical and physiological differences between the hair cells of various species.  In birds, for instance, instead of outer and inner hair cells, there are tall and short hair cells.  There are several similarities of note in regard to this comparative data.  For one, the tall hair cell is very similar in function to that of the inner hair cell, and the short hair cell, lacking afferent auditory-nerve fiber innervation, resembles the outer hair cell.  One unavoidable difference, however, is that while all hair cells are attached to a  tectorial membrane  in birds, only the outer hair cells are attached to the tectorial membrane in mammals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1548", "text": "The  cochlear duct  (a.k.a. the  scala media ) is an  endolymph  filled cavity inside the  cochlea , located between the  tympanic duct  and the  vestibular duct , separated by the  basilar membrane  and the  vestibular membrane  (Reissner's membrane) respectively. The cochlear duct houses the  organ of Corti . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1549", "text": "The cochlear duct is part of the  cochlea . It is separated from the  tympanic duct  (scala tympani) by the  basilar membrane . [ 2 ]  It is separated from the  vestibular duct  (scala vestibuli) by the  vestibular membrane  (Reissner's membrane). [ 2 ]  The  stria vascularis  is located in the wall of the cochlear duct. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1550", "text": "The cochlear duct develops from the ventral  otic vesicle  (otocyst). [ 3 ]  It grows slightly flattened between the middle and outside of the body. [ 3 ]  This development may be regulated by the genes  EYA1 ,  SIX1 ,  GATA3 , and  TBX1 . [ 3 ]  The  organ of Corti  develops inside the cochlear duct. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1551", "text": "The cochlear duct contains the  organ of Corti . [ 2 ] [ 5 ]  This is attached to the basilar membrane. [ 5 ]  It also contains  endolymph , which contains high concentrations of K +  for the function of  inner hair cells  and  outer hair cells  in the organ of Corti. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1552", "text": "Drugs delivered directly to the  tympanic duct  will spread to all of the  cochlea  except for the cochlear duct. [ 6 ]  Rarely, the cochlear duct may develop to have the wrong shape. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1553", "text": "A  cochlear implant  ( CI ) is a surgically implanted  neuroprosthesis  that provides a person who has moderate-to-profound  sensorineural hearing loss  with sound perception. With the help of therapy, cochlear implants may allow for improved speech understanding in both quiet and noisy environments. [ 1 ] [ 2 ]  A CI bypasses acoustic hearing by direct electrical stimulation of the auditory nerve. [ 2 ]  Through everyday listening and auditory training, cochlear implants allow both children and adults to learn to interpret those signals as speech and sound. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1554", "text": "The implant has two main components. The outside component is generally worn behind the ear, but could also be attached to clothing, for example, in young children. This component, the sound processor, contains microphones, electronics that include  digital signal processor  (DSP) chips, battery, and a coil that transmits a signal to the implant across the skin. The inside component, the actual implant, has a coil to receive signals, electronics, and an array of  electrodes  which is placed into the  cochlea , which stimulate the  cochlear nerve . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1555", "text": "The surgical procedure is performed under  general anesthesia . Surgical risks are minimal and most individuals will undergo  outpatient surgery  and go home the same day. However, some individuals will experience  dizziness , and on rare occasions,  tinnitus  or facial nerve bruising."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1556", "text": "From the early days of implants in the 1970s and the 1980s, speech perception via an implant has steadily increased. More than 200,000 people in the  United States  had received a CI through 2019. Many users of modern implants gain reasonable to good hearing and speech perception skills post-implantation, especially when combined with lipreading. [ 7 ] [ 8 ]  One of the challenges that remain with these implants is that hearing and speech understanding skills after implantation show a wide range of variation across individual implant users. Factors such as age of implantation, parental involvement and education level, duration and cause of hearing loss, how the implant is situated in the cochlea, the overall health of the cochlear nerve, and individual capabilities of re-learning are considered to contribute to this variation. [ 9 ] [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1557", "text": "Andr\u00e9 Djourno and Charles Eyri\u00e8s invented the original cochlear implant in 1957. Their design distributed stimulation using a single channel. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1558", "text": "William House  also invented a cochlear implant in 1961. [ 14 ]  In 1964, Blair Simmons and  Robert L. White  implanted a single-channel electrode in a patient's cochlea at Stanford University. [ 15 ]  However, research indicated that these single-channel cochlear implants were of limited usefulness because they cannot stimulate different areas of the cochlea at different times to allow differentiation between low and mid to high frequencies as required for detecting speech. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1559", "text": "The next step in the development of the CI was its clinical trial on a cohort of patients. In the late 1960's Robin Michelson and colleague Melvin Bartz construct a cochlear device with biocompatible materials that can be implanted in human patients. This system is implanted in 4 patients, and the report of the hearing results represent a watershed for clinically applicable cochlear implants. [ 17 ]  Robin Michelson, Robert Schindler, and Michael Merzenich at the University of California, San Francisco, conducted these experiments in 1970 and 1971. Michelson, a clinical pioneer, and Merzenich, a talented basic scientist with a solid foundation in neurophysiology, was an integral element in the development of the UCSF cochlear implant team. Michelson was recognized for implanting a single-channel device into a congenitally deaf woman. She demonstrated auditory sensations from stimulation, as well as pitch perception for stimulus frequencies less that 600 Hz. Unfortunately, This patient had no word recognition. His pioneering work was presented, but not well-received at the 1971 annual meeting of the American Otological Society (Michelson, 1971 and Merzenich et al., 1973). [ 18 ]  In 1973, the first international conference on the \"electrical stimulation of the acoustic nerve as a treatment for profound sensorineural deafness in man\" was organized in San Francisco.  [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1560", "text": "NASA  engineer Adam Kissiah started working in the mid-1970s on what would become the modern cochlear implant. Kissiah used his knowledge learned while working as an electronics instrumentation engineer for NASA. This work took place over three years, when Kissiah would spend his lunch breaks and evenings in  Kennedy Space Center's  technical library, studying the impact of engineering principles on the inner ear. In 1977, NASA helped Kissiah obtain a patent for the cochlear implant; Kissiah later sold the patent rights. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1561", "text": "The modern multi-channel cochlear implant was independently developed and commercialized by two separate teams\u2014one led by  Graeme Clark  in Australia and another by  Ingeborg Hochmair  and her future husband,  Erwin Hochmair  in Austria, with the Hochmairs' device first implanted in a person in December 1977 and Clark's in August 1978. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1562", "text": "Cochlear implants bypass most of the  peripheral auditory system  which receives sound and converts that sound into movements of  hair cells  in the  cochlea ; the deflection of  stereocilia  causes an influx of  potassium ions  into the hair cells, and the depolarisation in turn stimulates calcium influx, which increases release of the  neurotransmitter   glutamate . Excitation of the  cochlear nerve  by the neurotransmitter sends signals to the brain, which creates the  experience  of sound. With an implant, instead, the devices pick up sound and digitize it, convert that digitized sound into electrical signals, and transmit those signals to electrodes embedded in the cochlea. The electrodes electrically stimulate the cochlear nerve, causing it to send signals to the brain. [ 22 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1563", "text": "There are several systems available, but generally they have the following components: [ 22 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1564", "text": "External:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1565", "text": "Internal:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1566", "text": "A  totally implantable cochlear implant (TICI)  is currently in development. This new type of cochlear implant incorporates all the current external components of an audio processor into the internal implant. The lack of external components makes the implant invisible from the outside and also means it is less likely to be damaged or broken. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1567", "text": "Most modern cochlear implants can be used with a range of  assistive listening devices  (ALDs), which help people to hear better in challenging listening situations. These situations could include talking on the phone, watching TV or listening to a speaker or teacher. With an ALD, the sound from devices including mobile phones or from an external microphone is sent to the audio processor directly, rather than being picked up by the audio processor's microphone. This direct transmission improves the sound quality for the user, making it easier to talk on the phone or stream music."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1568", "text": "ALDs come in many forms, such as neckloops, [ 26 ]  pens, [ 27 ]  and specialist battery pack covers. [ 28 ]  Modern ALDs are usually able to receive sound from any Bluetooth device, including phones and computers, before transmitting it wirelessly to the audio processor. Most cochlear implants are also compatible with older ALD technology, such as a telecoil. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1569", "text": "Implantation of children and adults can be done safely with few surgical complications and most individuals will undergo outpatient surgery and go home the same day. [ 30 ] [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1570", "text": "Occasionally, the very young, the very old, or patients with a significant number of medical diseases at once may remain for overnight observation in the hospital. The procedure can be performed in an ambulatory surgery center in healthy individuals. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1571", "text": "The surgical procedure most often used to implant the device is called  mastoidectomy  with facial recess approach (MFRA). [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1572", "text": "The procedure is usually done under general anesthesia. Complications of the procedure are rare, but include  mastoiditis ,  otitis media  (acute or with effusion), shifting of the implanted device requiring a second procedure, damage to the  facial nerve , damage to the  chorda tympani , and wound infections. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1573", "text": "Cochlear implantation surgery is considered a clean procedure with an infection rate of less than 3%. [ 35 ]  Guidelines suggest that routine prophylactic antibiotics are not required. [ 36 ]  However, the potential cost of a postoperative infection is high (including the possibility of implant loss); therefore, a single preoperative intravenous injection of antibiotics is recommended. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1574", "text": "The rate of complications is about 12% for minor complications and 3% for major complications; major complications include infections, facial paralysis, and device failure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1575", "text": "Although up to 20 new cases of post-CI bacterial meningitis occur annually worldwide, data demonstrates a reducing incidence. [ 38 ]  To avoid the risk of bacterial meningitis, the CDC recommends that adults and children undergoing CI receive age-appropriate vaccines that generate antibodies to Streptococcus pneumoniae. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1576", "text": "The rate of transient facial nerve palsy is estimated to be approximately 1%. Device failure requiring reimplantation is estimated to occur 2.5\u20136% of the time. Up to one-third of people experience disequilibrium, vertigo, or vestibular weakness lasting more than one week after the procedure; in people under 70 these symptoms generally resolve over weeks to months, but in people over 70 the problems tend to persist. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1577", "text": "In the past, cochlear implants were only approved for people who were deaf in both ears; as of 2014 [update]  a cochlear implant had been used experimentally in some people who had acquired deafness in one ear after they had learned how to speak, and none who were deaf in one ear from birth; clinical studies as of 2014 [update]  had been too small to draw generalizations. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1578", "text": "Other approaches, such as going through the  suprameatal triangle , are used. A systematic literature review published in 2016 found that studies comparing the two approaches were generally small, not randomized, and retrospective so were not useful for making generalizations; it is not known which approach is safer or more effective. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1579", "text": "With the increased utilization of  endoscopic ear surgery  as popularized by professor Tarabichi, there have been multiple published reports on the use of endoscopic technique in cochlear implant surgery. [ 41 ]  However, this has been motivated by marketing and there is clear indication of increased morbidity associated with this technique as reported by the pioneer of  endoscopic ear surgery . [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1580", "text": "As cochlear implant surgical techniques have advanced over the last four decades, the global complication rate for CI surgery in both children and adults has decreased from more than 35% in 1991 to less than 10% at present. [ 43 ] [ 44 ] [ 45 ]  The risk of postoperative facial nerve injury has also decreased over the last several decades to less than 1%, most of which demonstrated complete return of function within six months. The rate of permanent paralysis is approximately 1 per 1,000 surgeries and likely less than that in experienced CI centers. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1581", "text": "The majority of complications following CI surgery are minor requiring only conservative medical management or prolongation of hospital stay. Less than 5% of all complications are major resulting in surgical intervention or readmission to the hospital. [ 45 ]  Reported rates of revision cochlear implant surgery vary in adults and children from 3.8% to 8% with the most common indications being device failure, infection, and migration of the implant or electrode. [ 46 ]  Disequilibrium and vertigo after CI surgery can occur but the symptoms tend to be mild and short-lived. [ 47 ]  CI rarely results in significant or persistent adverse effects on the vestibular system when hearing conservation surgical techniques are practiced. Moreover, gait and postural stability may actually improve post-implantation. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1582", "text": "Cochlear implant outcomes can be measured using  speech recognition  ability and functional improvements measured using patient reported outcome measures. [ 49 ] [ 50 ]  While the degree of improvement after cochlear implantation may vary, the majority of patients who receive cochlear implants demonstrate a significant improvement in speech recognition ability compared to their preoperative condition. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1583", "text": "Multiple meta-analyses of the literature from 2018 showed that CI users have large improvements in quality of life after cochlear implantation. [ 51 ] [ 52 ]  This improvement occurs in many different facets of life that extends beyond communication including improved ability to engage in social activities; decreased mental effort from listening; and improved environmental sound awareness. [ 53 ] [ 54 ] [ 50 ]  Deaf adolescents with cochlear implants attending mainstream educational settings report high levels of scholastic self-esteem, friendship self-esteem, and global self-esteem. [ 55 ]  They also tend to hold mostly positive attitudes towards their cochlear implants, [ 56 ]  and as a part of their identity, a majority either do \"not really think about\" their hearing loss, or are \"proud of it.\" [ 57 ]  Though advancements in cochlear implant technology have helped patients in their understanding of language, users are still unable to understand suprasegmental portions of language, which includes pitch. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1584", "text": "A study by  Johns Hopkins University  determined that for a three-year-old child who receives them, cochlear implants can save $30,000 to $50,000 in special-education costs for elementary and secondary schools as the child is more likely to be mainstreamed in school and thus use fewer support services than similarly deaf children. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1585", "text": "A 2019 study found that bilateral cochlear implantation was widely regarded as the most beneficial hearing intervention for acceptable candidates, although it is more likely to be performed and reimbursed in children than adults. The study also found that the efficacy of bilateral implantation could be improved by enhancing communication between the two implants and by developing sound coding strategies specifically for bilateral users. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1586", "text": "Early research reviews found that the ability to communicate in spoken language was better the earlier the implantation was performed. The reviews also found that, overall, while cochlear implants provide open-set speech understanding for the majority of implanted profoundly hearing-impaired children, it was not possible to accurately predict the specific outcome of the given implanted child. [ 61 ] [ 62 ] [ 63 ]  Research since then has reported long-term socio-economic benefits for children as well as audiological outcomes including improved sound localization and speech perception. [ 64 ]  A consensus statement from the European Bilateral Pediatric Cochlear Implant Forum also confirmed the importance of bilateral cochlear implantation in children. [ 65 ]  In adults, new research shows that bilateral implantation can improve quality of life and speech intelligibility in quiet and noise. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1587", "text": "A 2015 review examined whether CI implantation to treat people with bilateral hearing loss had any effect on  tinnitus . This review found the quality of evidence to be poor and the results variable: overall total tinnitus suppression rates for patients who had tinnitus prior to surgery varied from 8% to 45% of people who received CI; decrease of tinnitus was seen in 25% to 72%, of people; for 0% to 36% of the people there was no change; increase of tinnitus occurred in between 0% to 25% of patients; and, in between 0 and 10% of cases, people who did not have tinnitus before the procedure, got it. [ 67 ]  Further research found that the electrical stimulation of the CI is at least partly responsible for the general reduction in symptoms. A 2019 study found that although tinnitus suppression in patients with CIs is multifactorial, simply having the CI switched on without any audiological input (while standing alone in a soundproof booth) reduced the symptoms of tinnitus. This would suggest that it is the electrical stimulation that explains the decrease in tinnitus symptoms for many patients, and not only the increased access to sound. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1588", "text": "A 2015 literature review on the use of CI for people with  auditory neuropathy spectrum disorder  found that, as of that date, description and diagnosis of the condition was too heterogeneous to make clear claims about whether CI is a safe and effective way to manage it. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1589", "text": "The data for cochlear implant outcomes in older adults differs. A 2016 research study found that age at implantation was highly correlated with post-operative speech understanding performance for various test measures. In this study, people who were implanted at age 65 or older performed significantly worse on speech perception testing in quiet and in noisy conditions compared to younger CI users. [ 70 ]  Other studies have shown different outcomes, with some reporting that adults implanted at the age of 65 and older showed audiological and speech discrimination outcomes similar to younger adults. [ 71 ]  While cochlear implants demonstrate substantial benefit across all age groups, results will depend on cognitive factors that are ultimately highly age dependent. However, studies have documented the benefit of cochlear implants in octogenarians. [ 72 ] [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1590", "text": "The effects of aging on central auditory processing abilities are thought to play an important role in impacting an individual's speech perception with a cochlear implant. The Lancet reported that untreated hearing loss in adults is the number one modifiable risk factor for dementia. [ 74 ]  In 2017, a study also reported that adults using a cochlear implant had significantly improved cognitive outcomes including working memory, reaction time, and cognitive flexibility compared to people who were waiting to receive a cochlear implant. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1591", "text": "Prolonged duration of deafness is another factor that is thought to have a negative impact on overall speech understanding outcomes for CI users. However, a study found no statistical difference in the speech understanding abilities of CI patients over 65 who had been hearing impaired for 30 years or more prior to implantation. [ 70 ]  In general, outcomes for CI patients are dependent upon the individual's level of motivation, expectations, exposure to speech stimuli and consistent participation in aural rehabilitation programs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1592", "text": "A 2016 systematic review of CI for people with  unilateral hearing loss  (UHL) found that of the studies conducted and published, none were randomized, only one evaluated a control group, and no study was blinded. After eliminating multiple uses of the same subjects, the authors found that 137 people with UHL had received a CI. [ 76 ]  While acknowledging the weakness of the data, the authors found that CI in people with UHL improves  sound localization  compared with other treatments in people who lost hearing after they learned to speak; in the one study that examined this, CI did improve sound localization in people with UHL who lost hearing before learning to speak. [ 76 ]  It appeared to improve  speech perception  and to reduce  tinnitus . [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1593", "text": "In terms of quality of life, several studies have shown that cochlear implants are beneficial in many aspects of quality of life, including communication improvements and positive effects on social, emotional, psychological and physical well-being.\u00a0A 2017 narrative review also concluded that the quality of life scores of children using cochlear implants were comparable to those of children without hearing loss. Studies involving adults of all ages reported significant improvement in QoL after implantation when compared to adults with  hearing aids . This was often independent of audiological performance. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1594", "text": "As of October\u00a02010, [update]  approximately 188,000 individuals had been fitted with cochlear implants. [ 78 ]  As of December\u00a02012, [update]  the same publication cited approximately 324,000 cochlear implant devices having been surgically implanted. In the U.S., roughly 58,000 devices were implanted in adults and 38,000 in children. [ 23 ]  As of 2016, [update]  the Ear Foundation in the United Kingdom, estimates the number of cochlear implant recipients in the world to be about 600,000. [ 79 ]  The American Cochlear Implant Alliance estimates that 217,000 people received CIs in the United States through the end of 2019. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1595", "text": "Cochlear implantation includes the medical device as well as related services and procedures including pre-operative testing, the surgery, and aftercare that includes audiology and speech language pathology services. These are provided over time by a team of clinicians with specialized training. All of these services, as well as the cochlear implant device and related peripherals, are part of the medical intervention and are typically covered by health insurance in the United States and many areas of the world. These medical services and procedures include candidacy evaluation, hospital services inclusive of supplies and medications used during surgery, surgeon and other physicians such as anesthesiologists, the cochlear implant device and system kit, and programming and (re)habilitation following the surgery. [ citation needed ]  In many countries around the world, the cost of cochlear implantation and aftercare is covered by health insurance. [ 81 ] [ 82 ]  However, financial factors impact the evaluation selection process. Children with public health insurance or no health insurance are less likely to receive the implant before 2 years old. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1596", "text": "In the US, as cochlear implants have become more commonplace and accepted as a valuable and cost effective health intervention, insurance coverage has expanded to include private insurance,  Medicare ,  Tricare , the VA System, other federal health plans, and  Medicaid . In September 2022 the  Centers for Medicare & Medicaid Services  expanded coverage of cochlear implants for appropriate candidates under Medicare. Candidates must demonstrate limited benefit with appropriately fit hearing aids but with criteria now defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. [ 84 ]  Just as there is with any medical procedure, there are typically co-pays which vary depending upon the insurance plan. [ 81 ] [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1597", "text": "In the  United Kingdom , the  NHS  covers cochlear implants in full, as does Medicare in  Australia , and the Department of Health [ 85 ]  in  Ireland , Seguridad Social in  Spain , Sistema Sanitario Nazionale in  Italy , S\u00e9curit\u00e9 Sociale in France [ 86 ]  and  Israel , and the Ministry of Health or  ACC  (depending on the cause of deafness) in  New Zealand . In  Germany  and  Austria , the cost is covered by most health insurance organizations. [ 87 ] [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1598", "text": "6.1% of the world population live with hearing loss, and it is predicted that by 2050, more than 900 million people around the globe will have a disabling hearing loss. [ 89 ]  According to a WHO report, unaddressed hearing loss costs the world 980 billion dollars annually. Particularly hard hit are the healthcare and educational sectors, as well as societal costs. 53% of these costs are attributable to low- and middle-income countries. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1599", "text": "The WHO reports that cochlear implants have been shown to be a cost-effective way to mitigate the challenges of hearing loss. In a low-to-middle-income setting, every dollar invested in unilateral cochlear implants has a return on investment of 1.46 dollars. This rises to a return on investment of 4.09 dollars in an upper-middle-income setting. A study in Colombia assessed the lifetime investments made in 68 children who received cochlear implants at an early age. Taking into account the cost of the device and any other medical costs, follow-up, speech therapy, batteries and travel, each child required an average investment of US$99 000 over the course of their life (assuming a life span of 78 years for women and 72 years for men). The study concluded that for every dollar invested in rehabilitation of a child with a cochlear implant, there was a return on investment of US$2.07. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1600", "text": "As of 2021, four cochlear implant devices approved for use in the United States are manufactured by  Cochlear Limited , the  Advanced Bionics  division of  Sonova ,  MED-EL , and  Oticon Medical . [ 91 ] [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1601", "text": "In Europe, Africa, Asia, South America, and Canada, an additional device manufactured by  Neurelec  (later acquired by Oticon Medical) was available. A device made by  Nurotron  (China) was also available in some parts of the world. Each manufacturer has adapted some of the successful innovations of the other companies to its own devices. There is no consensus that any one of these implants is superior to the others. Users of all devices report a wide range of performance after implantation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1602", "text": "Much of the strongest objection to cochlear implants has come from within the  deaf community , some of whom are pre-lingually deaf people whose first language is a  sign language . Some in the deaf community call cochlear implants  audist  and an affront to their culture, which, as they view it, is a minority threatened by the hearing majority. [ 93 ]  This is an old problem for the deaf community, going back as far as the 18th century with the argument of  manualism vs. oralism . This is consistent with medicalisation and the standardisation of the \"normal\" body in the 19th century when differences between normal and abnormal began to be debated. [ 94 ]  It is important to consider the sociocultural context, particularly in regards to the deaf community, which has its own unique language and culture. [ 95 ]  This accounts for the cochlear implant being seen as an affront to their culture, as many do not believe that deafness is something that needs to be cured. However, it has also been argued that this does not necessarily have to be the case: the cochlear implant can act as a tool deaf people can use to access the \"hearing world\" without losing their deaf identity. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1603", "text": "Cochlear implants for congenitally deaf children are most effective when implanted at a young age. [ 96 ]  Children who have had confirmed severe hearing loss can receive the implant as young as 9 months old. [ 97 ]  Evidence shows that deaf children of deaf parents (or with fluent signers as daily caregivers) learn signed language as effectively as hearing peers. Some deaf-community advocates recommend that all deaf children should learn sign language from birth, [ 98 ]  but more than 90% of deaf children are born to hearing parents. Since it takes years to become fluent in sign language, deaf children who grow up without amplification such as hearing aids or cochlear implants will not have daily access to fluent language models in households without fluent signers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1604", "text": "Critics of cochlear implants from deaf cultures also assert that the cochlear implant and the subsequent therapy often become the focus of the child's identity at the expense of language acquisition and ease of communication in sign language and deaf identity. They believe that measuring a child's success only by their mastery of speech will lead to a poor self-image as \"disabled\" (because the implants do not produce normal hearing) rather than having the healthy self-concept of a proudly deaf person. [ 99 ]  However, these assertions are not supported by research. The first children to receive cochlear implants as infants are only in their 20s (as of 2020), and anecdotal evidence points to a high level of satisfaction in this cohort, most of whom don't consider their deafness their primary identity. [ 55 ] [ 56 ] [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1605", "text": "Children with cochlear implants are most likely to be educated with listening and spoken language, without  sign language  and are often not educated with other deaf children who use sign language. [ 101 ]  Cochlear implants have been one of the technological and social factors implicated in the decline of sign languages in the developed world. [ 102 ]  Some Deaf activists have labeled the widespread implantation of children as a  cultural genocide . [ 103 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1606", "text": "As the trend for cochlear implants in children grows, deaf-community advocates have tried to counter the \"either or\" formulation of  oralism  vs.  manualism  with a \"both and\" or \"bilingual-bicultural\" [ 104 ]  approach; some schools are now successfully integrating cochlear implants with sign language in their educational programs. [ 105 ]  However, there is disagreement among researchers about the effectiveness of methods using both sign and speech as compared to sign or speech alone. [ 106 ] [ 107 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1607", "text": "Another point of controversy made by advocates are that there are racial disparities in the cochlear implantation evaluation process. Data taken from 2010-2020 at one academic tertiary care institution showed that 68.5% of patients referred for evaluation were White, 18.5% were Black, and 12.3% were Asian, however the institution's main service area was 46.9% White, 42.3% Black, and 7.7% Asian. It was also shown that the Black patients who were referred for evaluation to receive the implants had greater hearing loss compared to White patients who were also referred. Based on this study, it is shown that Black patients receive cochlear implants at a disproportionately lower rate than White patients. [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1608", "text": "Biderman, Beverly.   Wired for Sound: A Journey into Hearing Rev. 2016  Briar Hill Publishing"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1609", "text": "Craniofacial surgery  is a surgical  subspecialty  that deals with  congenital  and acquired  deformities  of the  head ,  skull ,  face ,  neck ,  jaws  and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific; craniofacial  surgeons  deal with bone, skin, nerve, muscle, teeth, and other related anatomy. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1610", "text": "Defects typically treated by craniofacial surgeons include  craniosynostosis  (isolated and syndromic), rare  craniofacial clefts , acute and chronic sequelae of facial fractures,  cleft lip and palate , micrognathia,  Treacher Collins Syndrome ,  Apert's Syndrome ,  Crouzon's Syndrome , Craniofacial microsomia, microtia and other congenital ear anomalies, and many others. Training in craniofacial surgery requires completion of a Craniofacial surgery fellowship. Such fellowships are available to individuals who have completed residency in  oral and maxillofacial surgery ,  plastic  and  reconstructive surgery , or  ear, nose, and throat surgery . Those who have completed residency in oral and maxillofacial surgery may be either single degree or dual-degree surgeons with no differences. There is no specific board for craniofacial surgery. In the US, cleft and craniofacial centers are found in many major academic centers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1611", "text": "The bones of the human skull are joined by cranial  sutures  (see figure 1). The anterior fontanelle is where the metopic, sagittal and coronal sutures meet. Normally the sutures gradually fuse within the first few years after birth. In infants where one or more of the sutures fuses too early the growth of the skull is restricted, resulting in compensation mechanisms which cause irregular growth patterns. Growth in the skull is perpendicular to the sutures. When a suture fuses too early, the growth perpendicular to that suture will be restricted, and the bone growth near the other sutures will be stimulated, causing an abnormal head shape. The expanding brain is the main stimulus for the rapid growth of the skull in the first years of life. Inhibited growth potential of the skull can restrict the volume, needed by the brain. In cases in which the compensation does not effectively provide enough space for the growing brain,  craniosynostosis  results in increased intracranial pressure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1612", "text": "Craniosynostosis is called simple when one suture is involved, and complex when two or more sutures are involved. It can occur as part of a syndrome or as an isolated defect (nonsyndromic). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1613", "text": "In scaphocephaly, the sagittal suture is prematurely fused. The sagittal suture runs from the front to the back of the head. The shape of this deformity is a long narrow head, formed like a boat (Greek  skaphe , \"light boat or skiff\"). The compensatory head-growth forward at the coronal suture gives a prominent forehead, frontal bossing and a prominent back of the head, called coning. [ 5 ]  The incidence of scaphocephaly is 2.8 per 10,000 births in the Netherlands; therefore, it is the most common form of craniosynostosis. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1614", "text": "In trigonocephaly, the metopic suture is prematurely fused. The metopic suture is situated in the medial line of the forehead. Premature fusion of this suture causes the forehead to become pointed, giving the head a triangular shape when viewed from above (Greek  trigono , \"triangle\"). The incidence of trigonocephaly is 1 - 1.9 per 10,000 births in the Netherlands. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1615", "text": "In plagiocephaly, one of the coronal sutures is prematurely fused. The coronal sutures run over the top of the head, just in front of the ears. The shape of this deformity is an asymmetrical distortion (flattening of one side of the head) as you can see in figure 2. The incidence is 1 in 10,000 births. [ 6 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1616", "text": "In brachycephaly, both of the coronal sutures are prematurely fused. The shape of this deformity is a wide and high head. The incidence at birth is 1/20,000. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1617", "text": "Craniofacial surgery and follow-up care are usually conducted by a multidisclinary team of doctors, surgeons, nurses, and various therapists. [ 10 ]  As of 2016, there is a new multidisciplinary care team of Neuroplastic Surgeons working with Neurosurgeons to prevent and/or correct neurosurgical-related deformities and to maximize outcomes in adult patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1618", "text": "In cases where the forehead is involved (trigonocephaly and plagiocephaly), a technique called fronto-supraorbital advancement is used to correct the shape of the head. The procedure is performed at a young age in order to provide the brain with enough space to grow and prevent further abnormal growth of the skull. Fronto-orbital advancement literally means moving the front of the skull including the eye sockets forward. A section of the skull, ranging from the coronal sutures to the eye sockets is cut loose in order to correct the shape of the skull. The incision is cut in a zigzag shape from ear to ear so that the hair will cover the scar and make it less visible. The incision is made to the bone only, leaving the underlying meninges intact. The top half of the eye sockets is cut loose. Once the eye socket section has been cut loose, a vertical incision is made in the midline, and the whole section of the eye socket is bent outwards in order to correct the pointed shape of the forehead. Because the section is now too wide, a wedge needs to be cut on either side to allow the section to fit into the skull. Figure 4 shows the sections that are loosened and adjusted, and Figure 3 shows the location of the vertical incision (arrow A) and the two wedges (arrow B). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1619", "text": "In scaphocephaly, the sagittal suture is prematurely fused, preventing the skull from growing perpendicular to the suture. Thus, the head becomes very narrow and long. If a scaphocephaly is diagnosed within 4 to 5 months after birth, it can be corrected with a relatively simple procedure whereby the sagittal suture is surgically reopened. Once the suture has been opened the bone segments will be able to grow again, and the head can regain its normal shape. This operation is only performed on patients younger than five months old with a scaphocephaly. This is due to the fact that the bone segments only have the ability to adapt so severely when the operation is performed at this young age. A scaphocephaly that is diagnosed and treated later in life requires a more extensive secondary operation than one that is treated before five months. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1620", "text": "A major focus in craniosynostosis reconstruction is maintaining normalized aesthetics of temporal region, and avoiding temporal hollowing. Despite using overcorrection methods, autologous fat transfer, and bone grafts to prevent temporal hollowing, up to 50% of patients still experience post-operative depression in the temporal fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1621", "text": "Cranioplasty, or skull reconstruction, is the main concentration of a new field for adult neurosurgical patients known as Neuroplastic Surgery. There are now several centers around the world, including the United States and Israel. The first center of Neuroplastic Surgery was started at Johns Hopkins by Dr. Chad Gordon and the Department of Neurosurgery, which is where this new craniofacial subspecialty was born ( c. \u20092016 ). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1622", "text": "Some of the surgical complications in craniofacial surgery may include Death, Shock, Haemorrhage, visual loss, Intracranial collection of air/fluid, Epileptic seizures, Unexpected respiratory complications, etc. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1623", "text": "In  mammalian  anatomy, the  cribriform plate  ( Latin  for  lit.   sieve -shaped ),  horizontal lamina  or  lamina cribrosa  is part of the  ethmoid bone . It is received into the  ethmoidal notch  of the  frontal bone  and roofs in the  nasal cavities . It supports the  olfactory bulb , and is perforated by  olfactory foramina  for the passage of the  olfactory nerves  to the roof of the  nasal cavity  to convey smell to the brain. The foramina at the  medial  part of the groove allow the passage of the nerves to the upper part of the  nasal septum  while the foramina at the lateral part transmit the nerves to the  superior nasal concha ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1624", "text": "A fractured cribriform plate can result in  olfactory dysfunction ,  septal hematoma ,  cerebrospinal fluid rhinorrhoea  (CSF rhinorrhoea), and possibly infection which can lead to  meningitis . CSF rhinorrhoea (clear fluid leaking from the nose) is very serious and considered a  medical emergency . Aging can cause the openings in the cribriform plate to close, pinching olfactory nerve fibers. A reduction in olfactory receptors, loss of blood flow, and thick nasal mucus can also cause an impaired sense of smell. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1625", "text": "The cribriform plate is part of the  ethmoid bone , which has a low density, and is spongy. [ 2 ]  It is narrow, with deep grooves supporting the  olfactory bulb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1626", "text": "Its anterior border, short and thick, articulates with the  frontal bone . It has two small projecting alae (wings), which are received into corresponding depressions in the frontal bone to complete the  foramen cecum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1627", "text": "Its sides are smooth, and sometimes bulging due to the presence of a small  air sinus  in the interior."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1628", "text": "The  crista galli  projects upwards from the middle line of the cribriform plate. The long thin posterior border of the crista galli serves for the attachment of the  falx cerebri . On either side of the crista galli, the cribriform plate is narrow and deeply grooved. At the front part of the cribriform plate, on either side of the crista galli, is a small fissure that is occupied by a process of  dura mater ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1629", "text": "Lateral to this fissure is a notch or foramen which transmits the  nasociliary nerve ; from this notch a groove extends backward to the anterior ethmoidal foramen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1630", "text": "The cribriform plate is formed from the fetal age to the end of the first year, completing ossification. Deriving from the nasal capsule, formation begins specifically during the 5th week of gestation. Ossification begins at its most anterior part and proceeds in a posterior manner. The position also shifts from vertical during the 1st postnatal month to horizontal at the age of 6 months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1631", "text": "The Keros classification is a method of classifying the depth of the olfactory fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1632", "text": "The depth of the olfactory fossa is determined by the height of the lateral lamella of the cribriform plate.  Keros  in 1962, classified the depth into three categories. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1633", "text": "The cribriform plate is perforated by  olfactory foramina , which allow for the passage of the  olfactory nerves  to the roof of the  nasal cavity . [ 4 ]  This conveys information from smell receptors to the  brain . The foramina at the  medial  part of the groove allow the passage of the nerves to the upper part of the  nasal septum  while the foramina at the lateral part transmit the nerves to the  superior nasal concha ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1634", "text": "A fractured cribriform plate (anterior skull trauma) can result in leaking of  cerebrospinal fluid  into the nose and  loss of sense of smell . The tiny apertures of the plate transmitting the olfactory nerve become the route of ascent for a pathogen,  Naegleria fowleri . This  amoeba  tends to destroy the olfactory bulb and the adjacent inferior surface of the frontal lobe of the brain. This surface initially becomes the site of proliferation of the  trophozoites  of  Naegleria fowleri  and their subsequent spread to the rest of the brain and CSF. Because of its initial involvement and trophozoite presence in early phases of  Naegleria fowleri  infection, flushing of this region with saline using a device, to obtain  Naegleria fowleri  for diagnostic PCR and microscopic viewing, has been proposed for patients affected by  naegleriasis , by (Baig AM., et al.) in a recent publication. [ 5 ]  Researchers have suggested the same route to administer drugs at an early phase of infection by using a \"Transcribrial Device\" [ 6 ]  that has been proposed to kill this pathogen at the place of its maximum proliferation. In 2017 the inventor of this device suggested that after slight modifications this method could be effective in delivery of stem cells to the brain as well. [ 7 ]  A recent Australian study has shown that the bacterium causing the tropical disease  melioidosis ,  Burkholderia pseudomallei , can also invade the brain via the olfactory nerve within 24 h by traversing the cribriform plate. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1635", "text": "The cribriform plate is named after its resemblance to a sieve (from Latin  cribrum , \"sieve\" + -form). [ 2 ]  It is also known as the horizontal lamina, and the lamina cribrosa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1636", "text": "The cribriform plate is found in every  mammal  that has been studied. [ 9 ]  It serves the same function of allowing passage of the  olfactory nerves . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1637", "text": "This article incorporates text in the  public domain  from  page 153  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1638", "text": "Croup  ( / k r u\u02d0 p /   KROOP ), also known as  croupy cough , is a type of  respiratory infection  that is usually caused by a  virus . [ 2 ]  The infection leads to swelling inside the  trachea , which interferes with normal breathing and produces the classic symptoms of \"barking/brassy\"  cough , inspiratory  stridor  and a  hoarse voice . [ 2 ]   Fever  and  runny nose  may also be present. [ 2 ]  These symptoms may be mild, moderate, or severe. [ 3 ]  Often it starts or is worse at night and normally lasts one to two days. [ 6 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1639", "text": "Croup can be caused by a number of viruses including  parainfluenza  and  influenza virus . [ 2 ]  Rarely is it due to a  bacterial infection . [ 5 ]  Croup is typically diagnosed based on signs and symptoms after potentially more severe causes, such as  epiglottitis  or an  airway foreign body , have been ruled out. [ 4 ]  Further investigations, such as blood tests,  X-rays  and cultures, are usually not needed. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1640", "text": "Many cases of croup are preventable by  immunization  for  influenza  and  diphtheria . [ 5 ]  Most cases of croup are mild and the patient can be treated at home with supportive care. Croup is usually treated with a single dose of  steroids  by mouth. [ 2 ] [ 7 ]  In more severe cases inhaled  epinephrine  may also be used. [ 2 ] [ 8 ]  Hospitalization is required in one to five percent of cases. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1641", "text": "Croup is a relatively common condition that affects about 15% of children at some point. [ 4 ]  It most commonly occurs between six months and five years of age but may rarely be seen in children as old as fifteen. [ 3 ] [ 4 ] [ 9 ]  It is slightly more common in males than females. [ 9 ]  It occurs most often in autumn. [ 9 ]  Before  vaccination , croup was frequently caused by  diphtheria  and was often fatal. [ 5 ] [ 10 ]  This cause is now very rare in the  Western world  due to the success of the  diphtheria vaccine . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1642", "text": "Croup is characterized by a \"barking\"  cough ,  stridor ,  hoarseness , and  difficult breathing  which usually worsens at night. [ 2 ]  The \"barking\" cough is often described as resembling the call of a  sea lion . [ 5 ]   The stridor is worsened by agitation or  crying , and if it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens, stridor may decrease considerably. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1643", "text": "Other symptoms include  fever ,  coryza  (symptoms typical of the  common cold ), and indrawing of the  chest wall \u2013known as  Hoover's sign . [ 2 ] [ 12 ]   Drooling  or a very sick appearance can indicate other medical conditions, such as  epiglottitis  or  tracheitis . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1644", "text": "Croup is usually deemed to be due to a viral infection. [ 2 ] [ 4 ]  Others use the term more broadly, to include acute laryngotracheitis ( laryngitis  and  tracheitis  together), spasmodic croup, laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis. The first two conditions involve a viral infection and are generally milder with respect to symptomatology; the last four are due to bacterial infection and are usually of greater severity. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1645", "text": "Viral croup or acute laryngotracheitis is most commonly caused by  parainfluenza virus  (a member of the  paramyxovirus  family), primarily types 1 and 2, in 75% of cases. [ 3 ]  Other viral causes include  influenza  A and B,  measles ,  adenovirus  and  respiratory syncytial virus  (RSV). [ 5 ]  Spasmodic croup is caused by the same group of viruses as acute laryngotracheitis, but lacks the usual signs of infection (such as fever, sore throat, and increased  white blood cell count ). [ 5 ]   Treatment, and response to treatment, are also similar. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1646", "text": "Croup caused by a bacterial infection is rare. [ 13 ]  Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis. [ 5 ]   Laryngeal diphtheria is due to  Corynebacterium diphtheriae  while bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis are usually due to a primary viral infection with secondary bacterial growth.  The most common cocci implicated are  Staphylococcus aureus  and  Streptococcus pneumoniae , while the most common bacteria are  Haemophilus influenzae , and  Moraxella catarrhalis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1647", "text": "The viral infection that causes croup leads to swelling of the  larynx ,  trachea , and large  bronchi [ 4 ]  due to infiltration of  white blood cells  (especially  histiocytes ,  lymphocytes ,  plasma cells , and  neutrophils ). [ 5 ]  Swelling produces airway obstruction which, when significant, leads to dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as  stridor . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1648", "text": "Croup is typically diagnosed based on signs and symptoms. [ 4 ]  The first step is to exclude other obstructive conditions of the upper airway, especially  epiglottitis , an airway  foreign body ,  subglottic stenosis ,  angioedema ,  retropharyngeal abscess , and  bacterial tracheitis . [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1649", "text": "A frontal  X-ray  of the neck is not routinely performed, [ 4 ]  but if it is done, it may show a characteristic narrowing of the trachea, called the  steeple sign , because of the subglottic stenosis, which resembles a  steeple  in shape.  The steeple sign is suggestive of the diagnosis, but is absent in half of cases. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1650", "text": "Other investigations (such as  blood tests  and  viral culture ) are discouraged, as they may cause unnecessary agitation and thus worsen the stress on the compromised airway. [ 4 ]  While viral cultures, obtained via  nasopharyngeal  aspiration, can be used to confirm the exact cause, these are usually restricted to research settings. [ 2 ]  Bacterial infection should be considered if a person does not improve with standard treatment, at which point further investigations may be indicated. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1651", "text": "The most commonly used system for classifying the severity of croup is the Westley score. It is primarily used for research purposes rather than in clinical practice. [ 5 ]  It is the sum of points assigned for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions. [ 5 ]  The points given for each factor is listed in the adjacent table, and the final score ranges from 0 to 17. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1652", "text": "85% of children presenting to the emergency department have mild disease; severe croup is rare (<1%). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1653", "text": "Croup is contagious during the first few days of the infection. [ 13 ]  Basic hygiene including hand washing can prevent transmission. [ 13 ]  There are no vaccines that have been developed to prevent croup, [ 13 ]  however, many cases of croup have been prevented by  immunization  for  influenza  and  diphtheria . [ 5 ]  At one time, croup referred to a diphtherial disease, but with vaccination, diphtheria is now rare in the developed world. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1654", "text": "Most children with croup have mild symptoms and supportive care at home is effective. [ 13 ]  For children with moderate to severe croup, treatment with corticosteroids and nebulized epinephrine may be suggested. Steroids are given routinely, with  epinephrine  used in severe cases. [ 4 ]  Children with  oxygen saturation  less than 92% should receive oxygen, [ 5 ]  and those with severe croup may be hospitalized for observation. [ 12 ]  In very rare severe cases of croup that result in respiratory failure, emergency intubation and ventilation may be required. [ 15 ]  With treatment, less than 0.2% of children require  endotracheal intubation . [ 14 ]  Since croup is usually a viral disease,  antibiotics  are not used unless secondary bacterial infection is suspected. [ 2 ]  The use of  cough medicines , which usually contain  dextromethorphan  or  guaifenesin , are also discouraged. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1655", "text": "Supportive care for children with croup includes resting and keeping the child hydrated. [ 13 ]  Infections that are mild are suggested to be treated at home. Croup is contagious so washing hands is important. [ 13 ]  Children with croup should generally be kept as calm as possible. [ 4 ]  Over the counter medications for pain and fever may be helpful to keep the child comfortable. [ 13 ]  There is some evidence that cool or warm mist may be helpful, however, the effectiveness of this approach is not clear. [ 4 ] [ 5 ] [ 13 ]  If the child is showing signs of distress while breathing ( inspiratory stridor , working hard to breathe, blue (or blue-ish) coloured lips, or decrease in the level of  alertness ), immediate medical evaluation by a doctor is required. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1656", "text": "Corticosteroids , such as  dexamethasone  and  budesonide , have been shown to improve outcomes in children with all severities of croup, however, the benefits may be delayed. [ 7 ]  Significant relief may be obtained as early as two hours after administration. [ 7 ]  While effective when given  by injection , or by inhalation, giving the medication by mouth is preferred. [ 4 ]  A single dose is usually all that is required, and is generally considered to be quite safe. [ 4 ]  Dexamethasone at doses of  0.15, 0.3 and 0.6\u00a0mg/kg appear to be all equally effective. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1657", "text": "Moderate to severe croup (for example, in the case of severe stridor) may be improved temporarily with  nebulized   epinephrine . [ 4 ]  While epinephrine typically produces a reduction in croup severity within 10\u201330 minutes, the benefits are short-lived and last for only about 2 hours. [ 2 ] [ 4 ]  If the condition remains improved for 2\u20134 hours after treatment and no other complications arise, the child is typically discharged from the hospital. [ 2 ] [ 4 ]  Epinephrine treatment is associated with potential adverse effects (usually related to the dose of epinephrine) including  tachycardia ,  arrhythmias , and  hypertension . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1658", "text": "More severe cases of croup may require treatment with oxygen. If oxygen is needed, \"blow-by\" administration (holding an oxygen source near the child's face) is recommended, as it causes less agitation than use of a  mask . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1659", "text": "While other treatments for croup have been studied, none has sufficient evidence to support its use.  There is tentative evidence that breathing  heliox  (a mixture of  helium  and  oxygen ) to decrease the work of breathing is useful in those with severe disease, however, there is uncertainty in the effectiveness and the potential adverse effects and/or side effects are not well known. [ 15 ]   In cases of possible secondary bacterial infection, the antibiotics  vancomycin  and  cefotaxime  are recommended. [ 5 ]  In severe cases associated with  influenza\u00a0A  or  B  infections, the  antiviral   neuraminidase inhibitors  may be administered. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1660", "text": "Viral croup is usually a  self-limiting  disease, [ 2 ]  with half of cases resolving in a day and 80% of cases in two days. [ 6 ]  It can very rarely result in death from  respiratory failure  and/or  cardiac arrest . [ 2 ]   Symptoms usually improve within two days, but may last for up to seven days. [ 3 ]  Other uncommon complications include  bacterial tracheitis ,  pneumonia , and  pulmonary edema . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1661", "text": "Croup affects about 15% of children, and usually presents between the ages of 6 months and 5\u20136 years. [ 4 ] [ 5 ]  It accounts for about 5% of hospital admissions in this population. [ 3 ]  In rare cases, it may occur in children as young as 3 months and as old as 15 years. [ 3 ]  Males are affected 50% more frequently than are females, and there is an increased  prevalence  in autumn. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1662", "text": "The word  croup  comes from the  Early Modern English  verb  croup , meaning \"to cry hoarsely.\" The noun describing the disease originated in southeastern Scotland and became widespread after  Edinburgh  physician  Francis Home  published the 1765 treatise  An Inquiry into the Nature, Cause, and Cure of the Croup . [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1663", "text": "Diphtheritic croup  has been known since the time of  Homer 's  ancient Greece , and it was not until 1826 that viral croup was differentiated from croup due to  diphtheria  by  Bretonneau . [ 11 ] [ 19 ]  Viral croup was then called \"faux-croup\" by the French and often called \"false croup\" in English, [ 20 ] [ 21 ]  as \"croup\" or \"true croup\" then most often referred to the disease caused by the  diphtheria bacterium . [ 22 ] [ 23 ]  False croup has also been known as pseudo croup or spasmodic croup. [ 24 ]  Croup due to diphtheria has become nearly unknown in affluent countries in modern times due to the advent of effective  immunization . [ 11 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1664", "text": "One famous fatality of croup was  Napoleon 's designated heir,  Napol\u00e9on Charles Bonaparte . His death in  1807  left Napoleon without an heir and contributed to his decision to divorce from his wife, the Empress  Josephine de Beauharnais . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1665", "text": "A  cystic hygroma  is a form of  lymphatic malformation . It is an abnormal growth that usually appears on a baby's neck or head. It consists of one or more  cysts  and tends to grow larger over time. The disorder usually develops while the fetus is still in the uterus, but can also appear after birth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1666", "text": "Also known as  cystic lymphangioma  and  macrocystic lymphatic malformation , the growth is often a  congenital   lymphatic   lesion  of many small cavities (multiloculated) that can arise anywhere, but is classically found in the left  posterior triangle  of the  neck  and armpits. The malformation contains large  cyst -like cavities containing  lymph , a watery fluid that circulates throughout the  lymphatic system . Microscopically, cystic hygroma consists of multiple  locules  filled with lymph. Deep locules are quite big, but they decrease in size towards the surface."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1667", "text": "Cystic hygromas are  benign , but can be  disfiguring . It is a condition which usually affects children; very rarely it can be present in adulthood. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1668", "text": "Currently, the medical field prefers to use the term  lymphatic malformation , because the term cystic hygroma means water tumor. [ 3 ]  Lymphatic malformation is more commonly used now because it is a  sponge -like collection of abnormal growth that contains clear lymphatic fluid. The fluid collects within the cysts or channels, usually in the soft tissue. Cystic hygromas occur when the  lymphatic vessels  that make up the lymphatic system are not formed properly. The two types of lymphatic malformations are macrocystic  (large cysts) and microcystic (small cysts) lymphatic malformations. A person may have only one kind of the malformation or can have a mixture of both macro- and microcysts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1669", "text": "Cystic hygroma can be associated with a  nuchal   lymphangioma  or a  fetal hydrops . [ 4 ]  Additionally, it can be associated with  Down syndrome ,  Turner syndrome , [ 5 ]  or  Noonan syndrome . If it is diagnosed in the third trimester, then chances of association with Down syndrome are increased, but if diagnosed in the second trimester, then it is associated with Turner syndrome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1670", "text": "A lethal version [ 6 ]  of this condition exists, known as  Cowchock\u2013Wapner\u2013Kurtz syndrome , that, in addition to cystic hygroma, includes  cleft palate  and  lymphedema , a condition of localized  edema  and tissue swelling caused by a compromised lymphatic system. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1671", "text": "Cystic hygromas are increasingly diagnosed by  prenatal   ultrasonography . A common sign is a neck growth. It may be found at birth, or discovered later in an infant after an  upper respiratory tract infection . [ 8 ]  Cystic hygromas can grow very large and may affect breathing and swallowing. Some symptoms may include a mass or lump in the mouth, neck, cheek, or tongue. It feels like a large, fluid-filled sac. In addition, cystic hygromas can be found in other body parts, such as the arms, chest, legs, groin, and buttocks. Cystic hygromas are also often seen in Turner's syndrome, although a patient who does not have the syndrome can present with this condition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1672", "text": "Lymphatic malformations may be detected in the human fetus by ultrasound if they are of sufficient size. Detection of a cystic malformation may prompt further investigation, such as  amniocentesis , to evaluate for genetic abnormalities in the fetus. Lymphatic malformations may be discovered postnatally or in older children/adults, and most commonly present as a mass or as an  incidental finding  during  medical imaging ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1673", "text": "Verification of the diagnosis may require more testing, as multiple cystic masses can arise in children. [ 9 ]  Imaging, such as ultrasound or MRI, may provide more information as to the size and extent of the lesion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1674", "text": "A baby with a prenatally diagnosed cystic hygroma should be delivered in a major medical center equipped to deal with neonatal complications, such as a  neonatal intensive care unit . An  obstetrician  usually decides the method of delivery. If the cystic hygroma is large, a  cesarean section  may be performed. After birth, infants with a persistent cystic hygroma must be monitored for airway obstruction. A thin needle may be used to reduce the volume of the cystic hygroma to prevent facial deformities and airway obstruction. Close observation of the baby by a  neonatologist  after birth is recommended. If resolution of the cystic hygroma does not occur before birth, a  pediatric surgeon  should be consulted. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1675", "text": "Cystic hygromas that develop in the third trimester, after 30 weeks' gestation, or in the  postnatal period  are usually not associated with  chromosome abnormalities . A chance exists of recurrence after  surgical  removal of the cystic hygroma. The chance depends on the extent of the cystic hygroma and whether its wall was completely removed. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1676", "text": "Treatments for removal of cystic hygroma are surgery or  sclerosing agents , which include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1677", "text": "The  deep temporal space   is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a  potential space  in the side of the head, and is paired on either side. It is located deep to the  temporalis muscle"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1678", "text": "The inferior portion of the deep temporal space is also termed the  infratemporal space . The deep temporal space is one of the four  compartments  of the  masticator space , along with the  pterygomandibular space , the  submasseteric space  and the  superficial temporal space . [ 1 ]  The deep temporal space is separated from the pterygomandibular space by the  lateral pterygoid muscle  inferiorly and from the superficial temporal space by the temporalis muscle laterally. The deep temporal space and the superficial temporal space together make up the temporal spaces. [ 1 ] [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1679", "text": "The boundaries of the deep temporal space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1680", "text": "Superior :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1681", "text": "Superior and Inferior temporal lines"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1682", "text": "Inferior :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1683", "text": "Infratemporal crest and Zygomatic arch"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1684", "text": "The communications of the deep temporal space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1685", "text": "The contents of the deep temporal space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1686", "text": "Temporalis muscle"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1687", "text": "Identification of a  hearing loss  is usually conducted by a general practitioner  medical doctor ,  otolaryngologist , certified and licensed  audiologist , school or industrial  audiometrist , or other audiometric technician. Diagnosis of the cause of a hearing loss is carried out by a specialist physician (audiovestibular physician) or  otorhinolaryngologist ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1688", "text": "Difference between subjective and objective hearing test ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1689", "text": "Subjective:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1690", "text": "Objective:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1691", "text": "A case history (usually a written form, with questionnaire) can provide valuable information about the context of the hearing loss, and indicate what kind of diagnostic procedures to employ. Case history will include such items as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1692", "text": "In case of infection or inflammation, blood or other body fluids may be submitted for laboratory analysis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1693", "text": "Hearing loss is generally measured by playing generated or recorded sounds, and determining whether the person can hear them. Hearing sensitivity varies according to the  frequency  of sounds. To take this into account, hearing sensitivity can be measured for a range of frequencies and plotted on an  audiogram ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1694", "text": "Other method for quantifying hearing loss is a  hearing test  using a mobile application or  hearing aid application , which includes a  hearing test . [ 1 ] [ 2 ]  Hearing diagnosis using mobile application is similar to the  audiometry  procedure. As a result of  hearing test ,  hearing thresholds  at different frequencies ( audiogram ) are determined. Despite the errors in the measurements, application can help to diagnose hearing loss. [ 1 ]   Audiogram , obtained using mobile application, can be used to adjust  hearing aid application . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1695", "text": "An alternative approach to assessing hearing impairment is through the utilization of a speech-in-noise test. This evaluation method assesses an individual's ability to comprehend speech amidst background noise. Individuals with hearing loss typically experience difficulty in understanding speech, particularly in environments with high levels of noise. This is especially true for people who have a sensorineural loss \u2013 which is by far the most common type of hearing loss. As such, speech-in-noise tests can provide valuable information about a person's hearing ability, and can be used to detect the presence of a sensorineural hearing loss. A recently developed digit-triple speech-in-noise test may be a more efficient screening test. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1696", "text": "Otoacoustic emissions test is an objective hearing test that may be administered to toddlers and children too young to cooperate in a conventional hearing test. The test is also useful in older children and adults and is an important measure in diagnosing auditory neuropathy described above."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1697", "text": "Auditory brainstem response testing is an electrophysiological test used to test for hearing deficits caused by pathology within the ear, the cochlear nerve and also within the brainstem. This test can be used to identify delay in the conduction of neural impulses due to tumours or inflammation but can also be an objective test of hearing thresholds. Other electrophysiological tests, such as cortical evoked responses, can look at the hearing pathway up to the level of the auditory cortex."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1698", "text": "MRI and CT scans can be useful to identify the pathology of many causes of hearing loss. They are only needed in selected cases. [ vague ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1699", "text": "Hearing loss is categorized by type, severity, and configuration. Furthermore, a hearing loss may exist in only one ear (unilateral) or in both ears (bilateral).  Hearing loss can be temporary or permanent, sudden or progressive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1700", "text": "The severity of a hearing loss is ranked according to ranges of nominal thresholds in which a sound must be so it can be detected by an individual. It is measured in  decibels  of hearing loss, or dB HL. The measurement of hearing loss in an individual is conducted over several  frequencies , mostly 500\u00a0Hz, 1000\u00a0Hz, 2000\u00a0Hz and 4000\u00a0Hz. The hearing loss of the individual is the average of the hearing loss values over the different frequencies. Hearing loss can be ranked differently according to different organisations; and so, in different countries different systems are in use."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1701", "text": "Hearing loss may be ranked as slight, mild, moderate, moderately severe, severe or profound as defined below: [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1702", "text": "The 'Audiometric Classifications of Hearing Impairment' according to the International Bureau Audiophonology (BIAP) in Belgium is as follows: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1703", "text": "Hearing loss may affect one or both ears. If both ears are affected, then one ear may be more affected than the other.  Thus it is possible, for example, to have normal hearing in one ear and none at all in the other, or to have mild hearing loss in one ear and moderate hearing loss in the other."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1704", "text": "For certain legal purposes such as insurance claims, hearing loss is described in terms of percentages. Given that hearing loss can vary by frequency and that audiograms are plotted with a logarithmic scale, the idea of a percentage of hearing loss is somewhat arbitrary, but where decibels of loss are converted via a legally recognized formula, it is possible to calculate a standardized \"percentage of hearing loss\", which is suitable for legal purposes only."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1705", "text": "There are three main types of hearing loss,  conductive hearing loss ,  sensorineural hearing loss . Combinations of conductive and sensorineural hearing losses are called a mixed hearing loss. [ 4 ]  An additional problem which is increasingly recognised is  auditory processing disorder  which is not a hearing loss as such but a difficulty perceiving sound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1706", "text": "Conductive hearing loss is present when the sound is not reaching the inner ear, the  cochlea . This can be due to external ear canal malformation, dysfunction of the eardrum or malfunction of the bones of the middle ear. The eardrum may show defects from small to total resulting in hearing loss of different degree.  Scar tissue  after ear infections may also make the eardrum dysfunction as well as when it is retracted and adherent to the medial part of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1707", "text": "Dysfunction of the three small bones of the  middle ear  \u2013 malleus, incus, and stapes \u2013 may cause conductive hearing loss. The mobility of the  ossicles  may be impaired for different reasons including a boney disorder of the ossicles called  otosclerosis  and disruption of the ossicular chain due to trauma, infection or  ankylosis  may also cause hearing loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1708", "text": "Sensorineural hearing loss is one caused by dysfunction of the inner ear, the cochlea or the nerve that transmits the impulses from the cochlea to the hearing centre in the brain. The most common reason for sensorineural hearing loss is damage to the  hair cells  in the cochlea. Depending on the definition it could be estimated that more than 50% of the population over the age of 70 has impaired hearing. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1709", "text": "Damage to the brain can lead to a central deafness. The peripheral ear and the auditory nerve may function well but the central connections are damaged by tumour, trauma or other disease and the patient is unable to process speech information."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1710", "text": "Mixed hearing loss is a combination of conductive and sensorineural hearing loss. Chronic ear infection (a fairly common diagnosis) can cause a defective  ear drum  or middle-ear ossicle damages, or both.  In addition to the conductive loss, a sensory component may be present."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1711", "text": "This is not an actual hearing loss but gives rise to significant difficulties in hearing. One kind of auditory processing disorder is  King-Kopetzky syndrome , which is characterized by an inability to process out background noise in noisy environments despite normal performance on traditional hearing tests. An  auditory processing disorders  is sometimes linked to language disorders in persons of all ages."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1712", "text": "The shape of an audiogram shows the relative configuration of the hearing loss, such as a  Carhart notch  for otosclerosis, 'noise' notch for noise-induced damage, high frequency rolloff for presbycusis, or a flat audiogram for conductive hearing loss. In conjunction with speech audiometry, it may indicate central auditory processing disorder, or the presence of a  schwannoma  or other tumor. There are four general configurations of hearing loss:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1713", "text": "People with  unilateral hearing loss  or single-sided deafness (SSD) have difficulty in:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1714", "text": "In quiet conditions, speech discrimination is approximately the same for normal hearing and those with unilateral deafness; however, in noisy environments speech discrimination varies individually and ranges from mild to severe."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1715", "text": "One reason for the hearing problems these patients often experience is due to the  head shadow effect . Newborn children with no hearing on one side but one normal ear could still have problems. [ 7 ]  Speech development could be delayed and difficulties to concentrate in school are common. More children with unilateral hearing loss have to repeat classes than their peers. Taking part in social activities could be a problem. Early aiding is therefore of utmost importance. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1716", "text": "The  digastric muscle  (also  digastricus ) (named  digastric  as it has two 'bellies') is a bilaterally paired  suprahyoid muscle  located under the  jaw . Its posterior belly is attached to the  mastoid notch of temporal bone , and its anterior belly is attached to the  digastric fossa of mandible ; the two bellies are united by an intermediate tendon which is held in a loop that attaches to the hyoid bone. The anterior belly is innervated via the  mandibular nerve (cranial nerve V) , and the posterior belly is innervated via the  facial nerve (cranial nerve VII) . It may act to depress the mandible or elevate the hyoid bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1717", "text": "The term \"digastric muscle\" refers to this specific muscle even though there are other muscles in the body to feature two bellies. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1718", "text": "The digastric muscle consists of two muscular bellies united by an intermediate tendon. The posterior belly is longer than the anterior belly. The two bellies of the digastric muscle have different  embryological  origins - the anterior belly is derived from the first brachial arch and the posterior belly from the second brachial arch - and consequently differ in their innervation (the former being innervated via CN V and the latter via CN VII). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1719", "text": "The posterior belly attaches at the  mastoid notch of the temporal bone [ 1 ]  (which is located upon the inferior surface of the skull, medial to the  mastoid process  of the  temporal bone  - between the mastoid process and the  styloid process  of the temporal bone). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1720", "text": "It extends anteroinferiorly from its osseous attachment toward the intermediate tendon. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1721", "text": "The anterior belly attaches at the  digastric fossa of mandible  (situated at the base of the mandible near the midline). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1722", "text": "It extends inferoposteriorly from its origin toward the intermediate tendon. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1723", "text": "The two bellies meet at the intermediate  tendon  which perforates the  stylohyoideus  muscle. The tendon is embraced by a fibrous sling which attaches the body and  greater cornu  of  hyoid bone . The tendon occasionally features a  synovial sheath . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1724", "text": "The anterior belly receives motor innervation from the  mylohyoid nerve  (a branch of the  inferior alveolar nerve , which is in turn a branch of the  mandibular division of the trigeminal nerve (CN V 3 ) ). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1725", "text": "The posterior belly is supplied by the  digastric branch of facial nerve . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1726", "text": "The posterior belly is situated posterior to the parotid gland [ 2 ]  and the facial nerve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1727", "text": "The digastric muscle divides the  anterior triangle of the neck  into four smaller triangles: the  submandibular triangle (digastric triangle) , the  carotid triangle , the  submental triangle (suprahyoid triangle) , and the  inferior carotid triangle (muscular triangle) . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1728", "text": "The intermediate tendon may be absent. The posterior belly may arise partly (by an supplemental strip of muscle) or entirely from the styloid process of the temporal bone. [ 1 ]  It may be connected by a  muscle slip  to the middle or inferior constrictor. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1729", "text": "The anterior belly may be double, or extra slips from this belly may pass to the jaw or mylohyoideus or decussate with a similar slip on opposite side. It may be absent and posterior belly inserted into the middle of the jaw or hyoid bone. [ citation needed ]  It may fuse with the  mylohyoid muscle . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1730", "text": "The tendon may pass in front, more rarely behind the stylohyoideus. The mentohyoideus muscle passes from the body of hyoid bone to chin. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1731", "text": "The muscle depresses the mandible, and may elevate the hyoid bone. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1732", "text": "It depresses the  mandible  when the hyoid bone is held in place (by the  infrahyoid muscles ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1733", "text": "The digastric muscle is involved in any complex jaw action such as speaking, swallowing, chewing, and breathing. [ citation needed ]  The posterior belly is particularly functionally involved in swallowing and chewing. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1734", "text": "The digastric muscles are present in a variety of animals, specific attachment sites may vary. For example, in the  orangutan , the posterior digastric attaches to the  mandible  rather than the hyoid. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1735", "text": "This article incorporates text in the  public domain  from  page 391  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1736", "text": "A  direct acoustic cochlear implant  - also  DACI  - is an  acoustic   implant  which converts  sound  in  mechanical  vibrations that stimulate directly the  perilymph  inside the  cochlea . The hearing function of the external and middle  ear  is being taken over by a little  motor  of a  cochlear implant , directly stimulating the cochlea. With a DACI, people with no or almost no residual hearing but with a still functioning inner ear, can again perceive speech, sounds and music.\nDACI is an official product category, as indicated by the nomenclature of  GMDN . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1737", "text": "A DACI tries to provide an answer for people with hearing problems for which no solution exists today. People with some problems at the level of the cochlea can be helped with a  hearing aid . A hearing aid will absorb the incoming sound from a microphone, and offer enhanced through the natural way. For larger reinforcements, this may cause problems with  feedback  and  distortion . A hearing aid also simply provides more loudness, no more resolution. Users will view this often as, \"all sounds louder, but I understand nothing more than before.\"\nOnce a hearing aid offers no solution anymore, one can switch to a  cochlear implant . A Cochlear implant captures the sound and sends it electrically, through the cochlea, to the auditory nerve. In this way, completely deaf patients can perceive sounds again.\nHowever, As soon as there are problems not only at the level of the cochlea, but also in the middle ear (the so-called  conductive  losses), then there are more efficient ways to get sound to the partially functioning cochlea.\nThe most obvious solution is a  BAHA , which brings the sound to the cochlea via bone conduction.\nHowever, patients who have both problems with the cochlea, as with the middle ear (i.e. patients with mixed losses), none of the above solutions is ideal.\nTo this end, the direct acoustic cochlear implant was developed. A DACI brings the sound directly to the cochlea, and provides the most natural way of sound amplification."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1738", "text": "The first DACI was implanted in Hannover. In Belgium, the first DACI was implanted at the Catholic University Hospital of Leuven. [ 2 ]   In the Netherlands, the Radboud clinic in Nijmegen was the first while in Poland it was first implanted at the Institute of Physiology and Pathology of Hearing in Warsaw. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1739", "text": "The  dorsal nasal artery  is an  artery  of the  face . [ citation needed ]  It is one of the two terminal branches of the  ophthalmic artery . It contributes arterial supply to the  lacrimal sac , and outer surface of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1740", "text": "The dorsal nasal artery is one of the two terminal branches of the  ophthalmic artery  (the other being the  supratrochlear artery ). [ 1 ]  It arises in the superomedial orbit. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1741", "text": "It passes anteriorly [ citation needed ]  to exit the orbit between the  trochlea  (superiorly [ citation needed ] ), the  medial palpebral ligament  (inferiorly [ citation needed ] ). [ 1 ]  It gives a branch to the  lacrimal sac  before bifurcating into two branches: one branch anastomoses with the terminal (angular) part of the  facial artery [ 1 ]  and is important for the blood supply of the  face ; [ citation needed ]  the other travels along the dorsum of the nose to supply the outer surface of the nose, and forms anastomoses with its contralateral fellow, and with the  lateral nasal branch  of the  facial artery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1742", "text": "The dorsal nasal artery contributes arterial supply to the  lacrimal sac , [ 1 ] [ 3 ]  and the outer surface of the nose. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1743", "text": "In around 20% of individuals, it also supplies the tip of the nose. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1744", "text": "This  cardiovascular system  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1745", "text": "Dysgeusia , also known as  parageusia , is a distortion of the sense of taste. Dysgeusia is also often associated with  ageusia , which is the complete lack of taste, and  hypogeusia , which is a decrease in taste sensitivity. [ 1 ]  An alteration in taste or smell may be a secondary process in various disease states, or it may be the primary  symptom . The distortion in the sense of taste is the only symptom, and  diagnosis  is usually complicated since the sense of taste is tied together with other  sensory systems . Common causes of dysgeusia include  chemotherapy , asthma treatment with  albuterol , and  zinc deficiency . Liver disease,  hypothyroidism , and rarely, certain types of  seizures  can also lead to dysgeusia. Different drugs can also be responsible for altering taste and resulting in dysgeusia. Due to the variety of causes of dysgeusia, there are many possible treatments that are effective in alleviating or terminating the symptoms. These include artificial saliva, pilocarpine, zinc supplementation, alterations in drug therapy, and alpha lipoic acid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1746", "text": "The alterations in the sense of  taste , usually a metallic taste, and sometimes  smell  are the only symptoms. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1747", "text": "A major cause of dysgeusia is  chemotherapy  for cancer. Chemotherapy often induces damage to the oral cavity, resulting in  oral mucositis , oral infection, and salivary gland dysfunction. Oral mucositis consists of  inflammation  of the mouth, along with sores and  ulcers  in the tissues. [ 3 ]  Healthy individuals normally have a diverse range of microbial  organisms  residing in their oral cavities; however, chemotherapy can permit these typically non- pathogenic  agents to cause serious infection, which may result in a decrease in  saliva . In addition, patients who undergo  radiation therapy  also lose salivary tissues. [ 4 ]  Saliva is an important component of the taste mechanism. Saliva both interacts with and protects the taste receptors in the mouth. [ 5 ]  Saliva mediates sour and sweet tastes through bicarbonate ions and glutamate, respectively. [ 6 ]  The salt taste is induced when sodium chloride levels surpass the concentration in the saliva. [ 6 ]  It has been reported that 50% of chemotherapy patients have had either dysgeusia or another form of taste impairment. [ 3 ]  Examples of chemotherapy treatments that can lead to dysgeusia are  cyclophosphamide ,  cisplatin ,  vismodegib , [ 7 ]  and  etoposide . [ 3 ]  The exact mechanism of chemotherapy-induced dysgeusia is unknown. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1748", "text": "Distortions in the  taste buds  may give rise to dysgeusia. In a study conducted by Masahide Yasuda and Hitoshi Tomita from Nihon University of Japan, it has been observed that patients with this taste disorder have fewer  microvilli  than normal. In addition, the  nucleus  and  cytoplasm  of the taste bud cells have been reduced. Based on their findings, dysgeusia results from loss of microvilli and the reduction of Type III intracellular vesicles, all of which could potentially interfere with the gustatory pathway.  Radiation to head and neck also results in direct destruction of taste buds, apart from effects of altered salivary output. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1749", "text": "Another primary cause of dysgeusia is  zinc  deficiency. While the exact role of zinc in dysgeusia is unknown, it has been cited that zinc is partly responsible for the repair and production of taste buds. Zinc somehow directly or indirectly interacts with  carbonic anhydrase VI , influencing the concentration of gustin, which is linked to the production of taste buds. [ 9 ]  It has also been reported that patients treated with zinc experience an elevation in  calcium  concentration in the saliva. [ 9 ]  In order to work properly, taste buds rely on calcium receptors. [ 10 ]  Zinc \"is an important cofactor for  alkaline phosphatase , the most abundant  enzyme  in taste bud membranes; it is also a component of a parotid salivary protein important to the development and maintenance of normal taste buds\". [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1750", "text": "Miraculin  Found in miracle berries, sweetens nonsweet food and beverages."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1751", "text": "Gymnema sylvestre  Blocks the ability to taste sweetness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1752", "text": "There are also a wide variety of drugs that can trigger dysgeusia, including  zopiclone , [ 11 ]  H 1 - antihistamines , such as  azelastine  and  emedastine . [ 12 ]  Approximately 250 drugs affect taste, including  Paxlovid , a drug used to treat  COVID-19 . [ 13 ]  Some describe so-called \"Paxlovid mouth\" as like a \"mouthful of dirty pennies and rotten soymilk\", according to the  Wall Street Journal . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1753", "text": "The  sodium  channels linked to taste receptors can be inhibited by  amiloride , and the creation of new taste buds and saliva can be impeded by  antiproliferative  drugs. [ 13 ]  Saliva can have traces of the drug, giving rise to a metallic flavor in the mouth; examples include  lithium carbonate  and  tetracyclines . [ 13 ]  Drugs containing  sulfhydryl  groups, including  penicillamine  and  captopril , may react with zinc and cause deficiency. [ 10 ]   Metronidazole  and  chlorhexidine  have been found to interact with metal ions that associate with the  cell membrane . [ 15 ]  Drugs that act by blocking the  renin\u2013angiotensin\u2013aldosterone system , for example by  antagonizing the angiotensin II receptor  (as  eprosartan  does), have been linked to dysgeusia. [ 16 ]  There are few case reports claiming calcium channel blockers like  Amlodipine  also cause dysgeusia by blocking calcium sensitive taste buds. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1754", "text": "Changes in hormone levels during pregnancy, such as estrogen, can affect the sense of taste. [ 18 ]  A study found that 93 percent of pregnant women reported some change in taste during pregnancy. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1755", "text": "Xerostomia , also known as dry mouth syndrome, can precipitate dysgeusia because normal salivary flow and concentration are necessary for taste. Injury to the  glossopharyngeal nerve  can result in dysgeusia. In addition, damage done to the  pons ,  thalamus , and  midbrain , all of which compose the gustatory pathway, can be potential factors. [ 19 ]  In a case study, 22% of patients who were experiencing a bladder obstruction were also experiencing dysgeusia. Dysgeusia was eliminated in 100% of these patients once the obstruction was removed. [ 19 ]  Although it is uncertain what the relationship between bladder relief and dysgeusia entails, it has been observed that the areas responsible for  urinary system  and taste in the pons and  cerebral cortex  in the brain are close in proximity. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1756", "text": "Dysgeusia can be a symptom of  head and neck cancer . In this case it often present together with having dry mouth. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1757", "text": "Dysgeusia often occurs for unknown reasons. A wide range of miscellaneous factors may contribute to this taste disorder, such as  gastric reflux ,  lead poisoning , and  diabetes mellitus . [ 21 ]  A minority of  pine nuts  can apparently cause taste disturbances, for reasons which are not entirely proven. Certain pesticides can have damaging effects on the taste buds and nerves in the mouth. These  pesticides  include  organochloride  compounds and  carbamate  pesticides. Damage to the  peripheral nerves , along with injury to the  chorda tympani  branch of the facial nerve, also cause dysgeusia. [ 21 ]  A surgical risk for  laryngoscopy  and  tonsillectomy  include dysgeusia. [ 21 ]  Patients with  burning mouth syndrome , primarily  menopausal  women, often have dysgeusia as well. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1758", "text": "The sense of taste is based on the detection of chemicals by specialized taste cells in the mouth. The mouth, throat, larynx, and esophagus all have  taste buds , which are replaced every ten days. Each taste bud contains receptor cells. [ 21 ]  Afferent nerves make contact with the receptor cells at the base of the taste bud. [ 23 ]  A single taste bud is innervated by several afferent nerves, while a single efferent fiber innervates several taste buds. [ 24 ]   Fungiform papillae  are present on the anterior portion of the tongue while  circumvallate papillae  and  foliate papillae  are found on the posterior portion of the tongue. The  salivary glands  are responsible for keeping the taste buds moist with saliva. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1759", "text": "A single taste bud is composed of four types of cells, and each taste bud has between 30 and 80 cells. Type I cells are thinly shaped, usually in the periphery of other cells. They also contain high amounts of  chromatin . Type II cells have prominent  nuclei  and nucleoli with much less chromatin than Type I cells. Type III cells have multiple  mitochondria  and large  vesicles . Type I, II, and III cells also contain  synapses . Type IV cells are normally rooted at the posterior end of the taste bud. Every cell in the taste bud forms  microvilli  at the ends. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1760", "text": "In general,  gustatory  disorders are challenging to diagnose and evaluate. Because gustatory functions are tied to the sense of  smell , the  somatosensory system , and the perception of  pain  (such as in tasting spicy foods), it is difficult to examine sensations mediated through an individual system. [ 26 ]  In addition, gustatory dysfunction is rare when compared to  olfactory  disorders. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1761", "text": "Diagnosis of dysgeusia begins with the patient being questioned about  salivation , swallowing, chewing, oral pain, previous  ear infections  (possibly indicated by hearing or balance problems),  oral hygiene , and stomach problems. [ 28 ]  The initial history assessment also considers the possibility of accompanying diseases such as  diabetes mellitus ,  hypothyroidism , or  cancer . [ 28 ]  A clinical examination is conducted and includes an inspection of the tongue and the oral cavity. Furthermore, the  ear canal  is inspected, as lesions of the  chorda tympani  have a predilection for this site. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1762", "text": "In order to further classify the extent of dysgeusia and clinically measure the sense of taste, gustatory testing may be performed. Gustatory testing is performed either as a whole-mouth procedure or as a regional test. In both techniques, natural or electrical stimuli can be used. In regional testing, 20 to 50 \u03bcL of liquid stimulus is presented to the  anterior  and  posterior  tongue using a pipette, soaked filter-paper disks, or cotton swabs. [ 27 ]  In whole mouth testing, small quantities (2-10 mL) of solution are administered, and the patient is asked to swish the solution around in the mouth. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1763", "text": "Threshold  tests for  sucrose  (sweet),  citric acid  (sour),  sodium chloride  (salty), and  quinine  or  caffeine  (bitter) are frequently performed with natural stimuli. One of the most frequently used techniques is the \"three-drop test\". [ 29 ]  In this test, three drops of liquid are presented to the subject. One of the drops is of the taste stimulus, and the other two drops are pure water. [ 29 ]  Threshold is defined as the concentration at which the patient identifies the taste correctly three times in a row. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1764", "text": "Suprathreshold tests, which provide intensities of taste stimuli above threshold levels, are used to assess the patient's ability to differentiate between different intensities of taste and to estimate the magnitude of suprathreshold loss of taste. From these tests, ratings of pleasantness can be obtained using either the direct scaling or magnitude matching method and may be of value in the diagnosis of dysgeusia. Direct scaling tests show the ability to discriminate among different intensities of stimuli and whether a stimulus of one quality (sweet) is stronger or weaker than a stimulus of another quality (sour). [ 30 ]  Direct scaling cannot be used to determine if a taste stimulus is being perceived at abnormal levels. In this case, magnitude matching is used, in which a patient is asked to rate the intensities of taste stimuli and stimuli of another  sensory system , such as the loudness of a tone, on a similar scale. [ 30 ]  For example, the Connecticut Chemosensory Clinical Research Center asks patients to rate the intensities of NaCl, sucrose, citric acid and quinine-HCl stimuli, and the loudness of 1000\u00a0Hz tones. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1765", "text": "Other tests include identification or discrimination of common taste substances.  Topical anesthesia  of the tongue has been reported to be of use in the diagnosis of dysgeusia as well, since it has been shown to relieve the symptoms of dysgeusia temporarily. [ 27 ]  In addition to techniques based on the administration of chemicals to the tongue,  electrogustometry  is frequently used. It is based on the induction of gustatory sensations by means of an anodal electrical  direct current . Patients usually report sour or metallic sensations similar to those associated with touching both poles of a live battery to the tongue. [ 31 ]  Although electrogustometry is widely used, there seems to be a poor correlation between electrically and chemically induced sensations. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1766", "text": "Certain diagnostic tools can also be used to help determine the extent of dysgeusia.  Electrophysiological  tests and simple reflex tests may be applied to identify abnormalities in the  nerve -to- brainstem  pathways. For example, the  blink reflex  may be used to evaluate the integrity of the  trigeminal nerve \u2013 pontine brainstem \u2013 facial nerve  pathway, which may play a role in gustatory function. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1767", "text": "Structural imaging is routinely used to investigate  lesions  in the taste pathway.  Magnetic resonance imaging  allows direct visualization of the  cranial nerves . [ 34 ]  Furthermore, it provides significant information about the type and cause of a lesion. [ 34 ]  Analysis of  mucosal   blood flow  in the oral cavity in combination with the assessment of  autonomous   cardiovascular  factors appears to be useful in the diagnosis of  autonomic nervous system  disorders in  burning mouth syndrome  and in patients with inborn disorders, both of which are associated with gustatory dysfunction. [ 35 ]   Cell cultures  may also be used. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1768", "text": "In addition, the analysis of  saliva  should be performed, as it constitutes the environment of  taste receptors , including transport of tastes to the receptor and protection of the taste receptor. [ 37 ]  Typical clinical investigations involve sialometry and sialochemistry. [ 37 ]  Studies have shown that  electron micrographs  of taste receptors obtained from saliva samples indicate  pathological  changes in the taste buds of patients with dysgeusia and other gustatory disorders. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1769", "text": "Because medications have been linked to approximately 22% to 28% of all cases of dysgeusia, researching a treatment for this particular cause has been important. [ 39 ]   Xerostomia , or a decrease in saliva flow, can be a side effect of many drugs, which, in turn, can lead to the development of taste disturbances such as dysgeusia. [ 39 ]  Patients can lessen the effects of xerostomia with breath mints, sugarless gum, or lozenges; or physicians can increase saliva flow with artificial saliva or oral  pilocarpine . [ 39 ]  Artificial saliva mimics the characteristics of natural saliva by lubricating and protecting the mouth, but does not provide any digestive or enzymatic benefits. [ 40 ]  Pilocarpine is a  cholinergic  drug, meaning it has the same effects as the  neurotransmitter   acetylcholine . Acetylcholine has the function of stimulating the  salivary glands  to actively produce saliva. [ 41 ]  The increase in saliva flow is effective in improving the movement of tastants to the  taste buds . [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1770", "text": "Approximately one half of drug-related taste distortions are caused by a  zinc deficiency . [ 39 ]  Many medications are known to  chelate , or bind,  zinc , preventing the element from functioning properly. [ 39 ]  Due to the causal relationship of insufficient zinc levels to taste disorders, research has been conducted to test the efficacy of zinc supplementation as a possible treatment for dysgeusia. In a randomized clinical trial, fifty patients with  idiopathic  dysgeusia were given either zinc or a lactose  placebo . [ 9 ]  The patients prescribed the zinc reported experiencing improved taste function and less severe symptoms compared to the control group, suggesting that zinc may be a beneficial treatment. [ 9 ]  The efficacy of zinc, however, has been ambiguous in the past. In a second study, 94% of patients who were provided with zinc supplementation did not experience any improvement in their condition. [ 39 ]  This ambiguity is most likely due to small sample sizes and the wide range of causes of dysgeusia. [ 9 ]  A recommended daily oral dose of 25\u2013100\u00a0mg, as  zinc gluconate , appears to be an effective treatment for taste dysfunction provided that there are low levels of zinc in the  blood serum . [ 42 ]  There is not a sufficient amount of evidence to determine whether or not zinc supplementation is able to treat dysgeusia when low zinc concentrations are not detected in the blood. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1771", "text": "A Cochrane Review in 2017 assessed the effects of different interventions for the management of taste disturbances. There was very low-quality evidence to support the role of zinc supplementation in the improvement of taste acuity and taste discrimination in patients with zinc deficiency or idiopathic taste disorders. Further research is required to improve the quality of evidence for zinc supplementation as an effective intervention for the management of dysgeusia. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1772", "text": "It has been reported that approximately 68% of cancer patients undergoing  chemotherapy  experience disturbances in sensory perception such as dysgeusia. [ 44 ]  In a pilot study involving twelve lung cancer patients, chemotherapy drugs were infused with zinc in order to test its potential as a treatment. [ 45 ]  The results indicated that, after two weeks, no taste disturbances were reported by the patients who received the zinc-supplemented treatment while most of the patients in the control group who did not receive the zinc reported taste alterations. [ 45 ]  A multi-institutional study involving a larger sample size of 169 patients, however, indicated that zinc-infused chemotherapy did not have an effect on the development of taste disorders in cancer patients. [ 44 ]  An excess amount of zinc in the body can have negative effects on the  immune system , and physicians must use caution when administering zinc to  immunocompromised  cancer patients. [ 44 ]  Because taste disorders can have detrimental effects on a patient's quality of life, more research needs to be conducted concerning possible treatments such as zinc supplementation. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1773", "text": "The effects of drug-related dysgeusia can often be reversed by stopping the patient's regimen of the taste altering medication. [ 47 ]  In one case, a forty-eight-year-old woman who had  hypertension  was being treated with  valsartan . [ 48 ]  Due to this drug's inability to treat her condition, she began taking a regimen of  eprosartan , an  angiotensin II receptor antagonist . [ 48 ]  Within three weeks, she began experiencing a metallic taste and a burning sensation in her mouth that ceased when she stopped taking the medication. [ 48 ]  When she began taking eprosartan on a second occasion, her dysgeusia returned. [ 48 ]  In a second case, a fifty-nine-year-old man was prescribed  amlodipine  in order to treat his hypertension. [ 49 ]  After eight years of taking the drug, he developed a loss of taste sensation and numbness in his tongue. [ 49 ]  When he ran out of his medication, he decided not to obtain a refill and stopped taking amlodipine. [ 49 ]  Following this self-removal, he reported experiencing a return of his taste sensation. [ 49 ]  Once he refilled his prescription and began taking amlodipine a second time, his taste disturbance reoccurred. [ 49 ]  These two cases suggest that there is an association between these drugs and taste disorders. This link is supported by the \"de-challenge\" and \"re-challenge\" that took place in both instances. [ 49 ]  It appears that drug-induced dysgeusia can be alleviated by reducing the drug's dose or by substituting a second drug from the same class. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1774", "text": "Alpha lipoic acid  (ALA) is an  antioxidant  that is made naturally by human cells. [ 50 ]  It can also be administered in capsules or can be found in foods such as red meat, organ meats, and yeast. [ 50 ]  Like other antioxidants, it functions by ridding the body of harmful  free radicals  that can cause damage to tissues and organs. [ 50 ]  It has an important role in the  Krebs cycle  as a  coenzyme  leading to the production of antioxidants, intracellular  glutathione , and nerve-growth factors. [ 51 ]  Animal research has also uncovered the ability of ALA to improve  nerve conduction velocity . [ 51 ]  Because flavors are perceived by differences in  electric potential  through specific nerves innervating the tongue, idiopathic dysgeusia may be a form of a  neuropathy . [ 51 ]  ALA has proven to be an effective treatment for  burning mouth syndrome , spurring studies in its potential to treat dysgeusia. [ 51 ]  In a study of forty-four patients diagnosed with the disorder, one half was treated with the drug for two months, while the other half, the control group, was given a placebo for two months, followed by a two-month treatment of ALA. [ 51 ]  The results showed that 91% of the group initially treated with ALA reported an improvement in their condition compared to only 36% of the control group. [ 51 ]  After the control group was treated with ALA, 72% reported an improvement. [ 51 ]  This study suggests that ALA may be a potential treatment for patients, and supports that full double blind randomized studies should be performed. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1775", "text": "In addition to the aforementioned treatments, there are also many management approaches that can alleviate the symptoms of dysgeusia. These include using non-metallic silverware, avoiding metallic- or bitter-tasting foods, increasing the consumption of foods high in protein, flavoring foods with spices and seasonings, serving foods cold in order to reduce any unpleasant taste or odor, frequently brushing one's teeth and utilizing mouthwash, or using  sialogogues  such as sugar-free gum or sour-tasting drops that stimulate the production of saliva. [ 44 ]  When taste is impeded, the food experience can also be improved through means other than taste, such as texture, aroma, temperature, and color. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1776", "text": "People with dysgeusia are also forced to manage the impact that the disorder has on their quality of life. An altered sense of taste has effects on food choice and intake, and can lead to  weight loss ,  malnutrition , impaired immunity, and a decline in health. [ 47 ]  Patients diagnosed with dysgeusia must use caution when adding sugar and salt to food, and must be sure not to overcompensate for their lack of taste with excess amounts. [ 47 ]  Since the elderly are often on multiple medications, they are at risk for taste disturbances, increasing the chances of developing  depression , loss of appetite, and extreme weight loss. [ 52 ]  This is cause for evaluation and management of their dysgeusia. In patients undergoing chemotherapy, taste distortions can often be severe, and make compliance with cancer treatment difficult. [ 45 ]  Other problems that may arise include  anorexia , and behavioral changes that can be misinterpreted as psychiatric delusions regarding food. [ 53 ]  Symptoms including  paranoia ,  amnesia , cerebellar malfunction, and  lethargy  can also manifest when undergoing  histidine  treatment. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1777", "text": "Every year, more than 200,000 individuals see their physicians concerning  chemosensory  problems, and many more taste disturbances are never reported. [ 54 ]  Due to the large number of persons affected by taste disorders, basic and clinical research are both receiving support at different institutions and chemosensory research centers across the United States. [ 54 ]  These taste and smell clinics are focusing their research on better understanding the mechanisms involved in gustatory function and taste disorders such as dysgeusia. For example, the  National Institute on Deafness and Other Communication Disorders  is looking into the mechanisms underlying the key receptors on taste cells, and applying this knowledge to the future of medications and artificial food products. [ 54 ]  Meanwhile, the Taste and Smell Clinic at the  University of Connecticut Health Center  is integrating behavioral, neurophysiological, and genetic studies involving stimulus concentrations and intensities, in order to better understand taste function. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1778", "text": "Dysphagia  is difficulty in swallowing. [ 1 ] [ 2 ]  Although classified under \" symptoms and signs \" in  ICD-10 , [ 3 ]  in some contexts it is classified as a  condition  in its own right. [ 4 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1779", "text": "It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, [ 7 ]  a lack of  pharyngeal  sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including  odynophagia , which is defined as painful swallowing, [ 8 ]  and  globus , which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A  psychogenic  dysphagia is known as  phagophobia . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1780", "text": "Dysphagia is classified into the following major types: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1781", "text": "Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease. [ 11 ]  When dysphagia goes undiagnosed or untreated, patients are at a high risk of  pulmonary aspiration  and subsequent  aspiration pneumonia  secondary to food or liquids going the wrong way into the lungs. Some people present with \"silent aspiration\" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and kidney failure. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1782", "text": "Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent  pneumonia , unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and patient complaint of swallowing difficulty. [ 11 ]  When asked where the food is getting stuck, patients will often point to the cervical ( neck ) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1783", "text": "The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated. Pain on swallowing or  odynophagia  is a distinctive symptom that can be highly indicative of  carcinoma , although it also has numerous other causes that are not related to cancer.  Achalasia  is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the  Auerbach's (Myenteric) plexus  of the entire esophagus, which results in functional narrowing of the lower  esophagus , and peristaltic failure throughout its length. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1784", "text": "Complications of dysphagia may include  aspiration ,  pneumonia ,  dehydration , and weight loss. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1785", "text": "The following table enumerates possible causes of dysphagia:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1786", "text": "Difficulty with or inability to swallow may be caused or exacerbated by usage of opiate and/or opioid drugs. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1787", "text": "All causes of dysphagia are considered as differential diagnoses. Some common ones are: [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1788", "text": "Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially, only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from  thickened fluids  if the person is more comfortable with those liquids, although, so far, there is no scientific study that proves that those thickened liquids are beneficial. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1789", "text": "Dysphagia may manifest as the result of  autonomic nervous system  pathologies including stroke [ 23 ]  and  ALS , [ 24 ]  or due to rapid iatrogenic correction of an electrolyte imbalance. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1790", "text": "In older adults,  presbyphagia  - the normal healthy changes in swallowing associated with age - should be considered as an alternative explanation for symptoms. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1791", "text": "There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders (swallowing therapist), primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist. [ 11 ]  The role of the members of the multidisciplinary team will differ depending on the type of swallowing disorder present. For example, the swallowing therapist will be directly involved in the treatment of a patient with  oropharyngeal dysphagia , while a gastroenterologist will be directly involved in the treatment of an esophageal disorder. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1792", "text": "The implementation of a treatment strategy should be based on a thorough evaluation by the multidisciplinary team. Treatment strategies will differ on a patient to patient basis and should be structured to meet the specific needs of each individual patient. Treatment strategies are chosen based on a number of different factors including diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation and interest. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1793", "text": "Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). [ 11 ]  If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy. [ 11 ]  Some people with dysphagia, especially those nearing the  end of life , may choose to continue eating and drinking orally even when it has been deemed unsafe. This is known as \"risk feeding\". [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1794", "text": "A 2018 Cochrane review found no certain evidence about the immediate and long-term effects of modifying the thickness of fluids for swallowing difficulties in people with dementia. [ 28 ]  While thickening fluids may have an immediate positive effect on swallowing and improving oral intake, the long-term impact on the health of the person with dementia should also be considered. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1795", "text": "Compensatory treatment procedures are designed to change the flow of the food/liquids and eliminate symptoms but do not directly change the physiology of the swallow. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1796", "text": "Therapeutic treatment procedures \u2013 designed to change and/or improve the physiology of the swallow. [ 11 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1797", "text": "Patients may need a combination of treatment procedures to maintain a safe and nutritionally adequate swallow. For example, postural strategies may be combined with swallowing maneuvers to allow the patient to swallow in a safe and efficient manner. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1798", "text": "The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are rehabilitation of the swallow through oral motor exercises, texture modification of foods, thickening fluids and positioning changes during swallowing. [ 30 ]  The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. [ 31 ]  Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures.\u00a0 However, in 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0\u20137), where drinks are measured from Levels 0 \u2013 4, while foods are measured from Levels 3 \u2013 7. [ 32 ]   It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with carers and will lead to greater standardisation of modified diets [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1799", "text": "Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. [ 11 ]  Swallowing problems are a common complaint among older individuals, and the  incidence  of dysphagia is higher in the elderly, [ 33 ] [ 34 ]  and in patients who have had strokes. [ 35 ] \nDysphagia affects about 3% of the population. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1800", "text": "The word \"dysphagia\" is derived from the  Greek   dys  meaning bad or disordered, and the root  phag-  meaning \"eat\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1801", "text": "Ear clearing ,  clearing the ears  or  equalization   is any of various maneuvers to equalize the pressure in the  middle ear  with the  outside pressure , by letting air enter along the  Eustachian tubes , as this does not always happen automatically when the pressure in the middle ear is lower than the outside pressure. This need can arise in  scuba diving ,  freediving / spearfishing ,  skydiving , fast descent in an  aircraft , fast descent in a  mine cage , and being put into pressure in a  caisson  or similar internally pressurised enclosure, or sometimes even simply travelling at fast speeds in an  automobile . [ 1 ] [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1802", "text": "Normally the ears will clear automatically during a reduction in ambient pressure, but if they do not, a reverse squeeze may occur, which can also require clearing to avoid causing injury to the eardrum or inner ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1803", "text": "People who do intense weight lifting, such as squats, may experience sudden conductive hearing loss due to air pressure building up inside the ear. [ citation needed ] [ clarification needed ]  An ear clearing maneuver will often relieve pressure in the middle ear, or pain if any."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1804", "text": "The ears can be cleared by various methods, [ 2 ]  some of which pose a distinct risk of  barotrauma  including perforation of the eardrum:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1805", "text": "No single method but the last is considered safest or most successful in equalization of the middle ear pressure. Using alternative techniques may improve the success individually when a technique fails. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1806", "text": "The pressure difference between the middle ear and the outside, if not released, can result in a burst  eardrum . [ 10 ]  This damages hearing, [ 11 ]  and if this occurs underwater, cold water in the middle ear chills the  inner ear , causing  vertigo . [ 12 ]  The pressure difference can also cause damage to other body air spaces, such as the  paranasal sinuses . [ 13 ]  This can also be caused by damaged  sinus  ducts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1807", "text": "To allow successful equalization when diving, it is important that the  diving suit  hood not make an airtight seal over the outside ear hole, and that earplugs not be worn. [ 2 ]  Diving is proscribed when a eustachian tube is congested or blocked, such as can occur with the  common cold , as this may cause what is known as a  reverse block ,  whereby descent is uninhibited as the Valsalva maneuver may still clear the eustachian tubes temporarily by force, but during ascent a blockage may stop the air in the middle ear (which is now at depth pressure) from escaping as the diver ascends. The eardrum then bursts outwards, causing the same hazards as with an ordinary burst eardrum, such as cold water in the middle ear deranging the working of the sense organs of balance in the inner ear. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1808", "text": "Nasal congestion may affect the sinus openings and the eustachian tubes and may lead to difficulty or inability to clear the ears.\nTo prevent congestion, allergies can be treated by the use of  antihistamines ,  decongestants  and  nasal sprays , and  allergy desensitization . Recently developed antihistamines do not cross the  blood\u2013brain barrier  and do not produce drowsiness. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1809", "text": "Decongestants can have side effects such as speeding up heart rate which may have adverse effects in cases where there is underlying cardiovascular disease. Over-the-counter nasal sprays can produce a rebound effect causing greater congestion when the effect wears off, which can lead to reversed ear blockage on ascent. Some steroid nasal sprays do not have this side effect and can be very effective, but may also only be available by prescription."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1810", "text": "Combinations of the same drugs are useful in non-allergic rhinitis. These medications can be very useful in controlling the nasal congestion problem. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1811", "text": "Divers get training in clearing the ears before being allowed to dive. [ 2 ]  Because of the potential for side effects of the valsalva maneuver, scuba divers and free-divers may train to exercise the muscles that open the Eustachian tubes in a gentler manner. The French underwater association ( F\u00e9d\u00e9ration Fran\u00e7aise d'\u00c9tudes et de Sports Sous-Marins ) has produced a series of exercises using the tongue and  soft palate  to assist a diver in clearing their ears by these techniques. These recommendations were based on work done at the M\u00e9decine du sport, Bd st Marcel, Paris. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1812", "text": "With practice it is possible for some people to close the nostrils hands-free by contracting the  compressor naris  muscles. Some people are able to voluntarily hold their Eustachian tubes open continuously for a period of several seconds to minutes. The 'clicking your ears' can actually be heard if one puts one's ear to another person's ear for them to hear the clicking sound. Those that are borderline on learning this voluntary control first discover this via yawning or swallowing or other means; which after practice can be done deliberately without force even when there are no pressure issues involved. When the Eustachian tubes are deliberately held open, one's voice sounds louder in one's head than when they are closed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1813", "text": "Ear hair  is the  terminal hair  arising from  folliculary  cartilage inside the  external auditory meatus  in humans. [ 1 ]   In its broader sense,  ear hair  may also include the fine  vellus hair  covering much of the ear, particularly at the prominent parts of the anterior ear, or even the abnormal hair growth as seen in  hypertrichosis  and  hirsutism . Medical research on the function of ear hair is currently very scarce."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1814", "text": "Hair growth within the ear canal is often observed to increase in older men, [ 2 ] :\u200a206\u200a  together with increased growth of  nasal hair . [ 3 ]   Visible hair that protrudes from the ear canal is sometimes trimmed for cosmetic reasons. [ 4 ] :\u200a97\u200a   Excessive hair growth within or on the ear is known medically as  auricular hypertrichosis . [ 5 ] :\u200a125\u200a   Some men, particularly in the male population of India, have coarse hair growth along the lower portion of the helix, a condition referred to as \"having  hairy  pinnae \" ( hypertrichosis lanuginosa acquisita ). [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1815", "text": "Hair is a  protein filament  that grows from  follicles  in the  dermis , or skin. With the exception of areas of  glabrous skin , the human body is covered in follicles which produce thick  terminal  and fine  vellus hair . It is an important  biomaterial  primarily composed of protein, notably  keratin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1816", "text": "Radhakant Bajpai, an Indian grocer, was recognized by  Guinness  in 2003 as having the longest ear hair in the world, measuring 13.2 cm. In a 2009 interview, when his hair had reached 25 cm, he said that he considered the long ear hair to be a symbol of luck and prosperity. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1817", "text": "Ear pain , also known as  earache  or  otalgia , is  pain  in the  ear . [ 1 ] [ 2 ]  Primary ear pain is pain that originates from the ear. Secondary ear pain is a type of  referred pain , meaning that the source of the pain differs from the location where the pain is felt."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1818", "text": "Most causes of ear pain are non-life-threatening. [ 3 ] [ 4 ]  Primary ear pain is more common than secondary ear pain, [ 5 ]  and it is often due to infection or injury. [ 3 ]  The conditions that cause secondary (referred) ear pain are broad and range from temporomandibular joint syndrome to inflammation of the throat. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1819", "text": "In general, the reason for ear pain can be discovered by taking a thorough history of all symptoms and performing a physical examination, without need for imaging tools like a CT scan. [ 3 ]  However, further testing may be needed if red flags are present like hearing loss, dizziness, ringing in the ear or unexpected weight loss. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1820", "text": "Management of ear pain depends on the cause. If there is a bacterial infection,  antibiotics  are sometimes recommended and over the counter pain medications can help control discomfort. [ 7 ]  Some causes of ear pain require a procedure or surgery. [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1821", "text": "83 percent of children have at least one episode of a middle ear infection by three years of age. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1822", "text": "Ear pain can present in one or both ears. It may or may not be accompanied by other symptoms such as  fever ,  sensation of the world spinning , ear itchiness, or a sense of fullness in the ear. The pain may or may not worsen with chewing. [ 3 ]  The pain may also be continuous or intermittent. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1823", "text": "Ear pain due to an infection is the most common in children and can occur in babies. [ 10 ]  Adults may need further evaluation if they have hearing loss, dizziness or ringing in the ear. [ 6 ]  Additional red flags include diabetes, a weakened immune system, swelling seen on the outer ear, or swelling along the jaw. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1824", "text": "Ear pain has a variety of causes, the majority of which are not  life-threatening . [ 3 ] [ 4 ]  Ear pain can originate from a part of the ear itself, known as primary ear pain, or from an anatomic structure outside the ear that is perceived as pain within the ear, known as secondary ear pain. [ 3 ]  Secondary ear pain is a type of  referred pain , meaning that the source of the pain differs from the location where the pain is felt. Primary ear pain is more common in children, whereas secondary (referred) pain is more common in adults. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1825", "text": "Primary ear pain is most commonly caused by  infection  or injury to one of the parts of the ear. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1826", "text": "Many conditions involving the external ear will be visible to the naked eye. \u00a0Because the external ear is the most exposed portion of the ear, it is vulnerable to trauma or environmental exposures. [ 14 ]  \u00a0Blunt trauma, such as a blow to the ear, can result in a  hematoma , or collection of blood between the cartilage and  perichondrium  of the ear. This type of injury is particularly common in contact sports such as wrestling and boxing. [ 15 ]  Environmental injuries include  sunburn ,  frostbite , or  contact dermatitis . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1827", "text": "Less common causes of external ear pain include: [ 14 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1828", "text": "Otitis externa , also known as \"swimmer's ear\", is a  cellulitis  of the external ear canal. In North America, 98% of cases are caused by bacteria, and the most common causative organisms are  Pseudomonas  and  Staph aureus . [ 18 ]  Risk factors include exposure to excessive moisture (e.g. from swimming or a warm climate) and disruption of the protective  cerumen  barrier, which can result from aggressive ear cleaning or placing objects in the ear. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1829", "text": "Malignant otitis externa is a rare and potentially life-threatening complication of otitis externa in which the infection spreads from the ear canal into the surrounding skull base, hence becoming an  osteomyelitis . [ 16 ]  It occurs largely in diabetic patients. [ 20 ]  It is very rare in children, though can be seen in  immunocompromised  children and adults. [ 19 ]   Pseudomonas  is the most common causative organism. [ 20 ]  The pain tends to be more severe than in uncomplicated otitis externa, and laboratory studies often reveal elevated inflammatory markers ( ESR  and/or  CRP ). The infection may extend to  cranial nerves , or rarely to the  meninges  or brain. [ 20 ]  Examination of the ear canal may reveal  granulation tissue  in the inferior canal. It is treated with several weeks of IV and oral antibiotics, usually  fluoroquinolones . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1830", "text": "Acute  otitis media  is an infection of the middle ear. More than 80% of children experience at least one episode of otitis media by age 3 years. [ 23 ]   Acute otitis media is also most common in these first 3 years of life, though older children may also experience it. [ 19 ]  The most common causative bacteria are  Streptococcus pneumoniae ,  Haemophilus influenzae , and  Moraxella catarrhalis . [ 19 ]   Otitis media often occurs with or following  cold  symptoms. [ 14 ]  The diagnosis is made by the combination of symptoms and examination of the  tympanic membrane  for redness, bulging, and/or a middle ear effusion (collection of fluid within the middle ear). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1831", "text": "Complications of otitis media include  hearing loss , facial nerve paralysis, or extension of infection to surrounding anatomic structures, including: [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1832", "text": "A variety of conditions can cause irritation of one of the nerves that provides sensation to the ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1833", "text": "Conditions causing irritation the trigeminal nerve (cranial nerve V): [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1834", "text": "Conditions causing irritation of the facial nerve (cranial nerve VII) or glossopharyngeal nerve (cranial nerve IX): [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1835", "text": "Conditions causing irritation of the vagus nerve (cranial nerve X): [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1836", "text": "Conditions causing irritation of cervical nerves C2-C3: [ 3 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1837", "text": "The ear can be anatomically divided into the  external ear , the  external auditory canal , the middle ear, and the  inner ear . [ 30 ]  These three are indistinguishable in terms of the pain experienced. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1838", "text": "Many different nerves provide sensation to the various parts of the ear, including cranial nerves V ( trigeminal ), VII ( facial ), IX ( glossopharyngeal ), and X ( vagus ), and the  great auricular nerve  (cervical nerves C2-C3). [ 30 ] [ 32 ]  These nerves also supply other parts of the body, from the mouth to the chest and abdomen. Irritation of these nerves in another part of the body has the potential to produce pain in the ear. [ 30 ]  This is called referred pain. Irritation of the trigeminal nerve (cranial nerve V) is the most common cause of referred ear pain. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1839", "text": "While some disorders may require specific imaging or testing, most etiologies of ear pain are diagnosed clinically. Because the differential for ear pain is so broad, there is no consensus on the best diagnostic framework to use. One approach is to differentiate by time course, as primary causes of ear pain are typically more acute in nature, while secondary causes of ear pain are more chronic."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1840", "text": "Acute causes may be further distinguished by the presence of fever (indicating an underlying infection) or the absence of fever (suggesting a structural problem, such as such as trauma or other injury to the ear). Etiologies leading to chronic pain may be broken down by the presence or absence of worrisome clinical features, also known as red flags."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1841", "text": "One red flag is the presence of one or multiple risk factors including smoking, heavy alcohol use (greater than 3.5 drinks per day), diabetes, coronary artery disease, and older age (greater than 50). [ 3 ]  These factors increase the risk of having a serious cause of ear pain, like cancer or a serious infection. In particular, second hand smoke may increase risk of acute otitis media in children. [ 33 ]  In addition, swimming is the most significant risk factor for otitis externae, though other risk factors include high humidity in the ear canal,  eczema  and/or ear trauma. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1842", "text": "If red flags are present it may be necessary to do additional workup such as a  CT scan  or  biopsy  to rule out a more dangerous diagnosis. Such diagnoses include malignant (or necrotizing) otitis externa, mastoiditis,  temporal arteritis , and cancer. While the presence of a red flag does raise suspicion for one of these four disease, it does not guarantee a diagnosis as any one symptom can be seen in a variety of situations. For example, jaw claudication can be seen in temporal arteritis, but also in  TMJ dysfunction . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1843", "text": "If there are no red flags, other sources of referred ear pain become more likely and are reasonable to pursue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1844", "text": "(otitis media with effusion)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1845", "text": "otitis externa*"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1846", "text": "*Indicates a \"Can't Miss\" diagnosis or a red flag."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1847", "text": "Management of ear pain depends on the underlying cause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1848", "text": "While not all causes of ear pain are treated with antibiotics, those caused by bacterial infections of the ear are usually treated with antibiotics known to cover the common bacterial organisms for that type of infection. Many bacterial ear infections are treated with cleaning of the area, topical or systemic antibiotics, and oral analgesics for comfort. [ 7 ] [ 35 ] [ 9 ]  Some types of bacterial ear infections can benefit from warm compresses included in the treatment. [ 7 ]  Some of the causes of ear pain that are typically treated with either a topical or systemic antibiotic include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1849", "text": "Some bacterial infections may require a more advanced treatment with evaluation by  otorhinolaryngology , IV antibiotics, and hospital admission."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1850", "text": "Some causes of ear pain require procedural management alone, by a health professional, or in addition to antibiotic therapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1851", "text": "Given the variety of causes of ear pain, some causes require treatment other than antibiotics and procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1852", "text": "2/3 of people presenting with ear pain were diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1853", "text": "A common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum. [ 3 ]  The peak age for children to get acute otitis media is ages 6\u201324 months. One review paper wrote that 83% of children had at least one episode of acute otitis media by 3 years of age. [ 10 ]  Worldwide, there are 709 millions cases of acute otitis media every year. [ 36 ]  Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000. [ 36 ]  Around the world there is around 21,000 to 28,000 deaths due to complications from ear infections. [ 36 ]  These complications include brain abscesses and meningitis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1854", "text": "Otitis externae peaks at age 7\u201312 years of age and around 10% of people has had it at least once in their lives. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1855", "text": "Cerumen impaction occurs in 1 out of every 10 children, 1 in every 20 adults and 1 in every 3 elderly citizens. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1856", "text": "Barotrauma occurs around 1 in every 1000 people. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1857", "text": "Of people presenting with ear pain, only 3% was diagnosed with eustachian tube dysfunction. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1858", "text": "Not much was known about ear pain and acute otitis media before the 17th century. It was a common phenomenon with no treatment. [ 37 ]  That changed when the  otoscope  was invented in the 1840s by  Anton von Troeltsh  in Germany. [ 37 ] \u00a0 Another shift came with the invention of antibiotics. Before antibiotics was introduced there used to be a high rate of ear infections spreading to the bone around the ear, but that is now considered a rare complication. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1859", "text": "There was previously a strong tradition of treating acute otitis media with amoxicillin. [ 5 ]  One quote from the 1980s shows this sentiment by saying \"any child with an earache has an acute amoxicillin deficiency\". [ 5 ]  However, people started realizing that using antibiotics too much can cause bacteria to gain resistance. [ 38 ]  Increasing resistance makes antibiotics less effective. The term  antibiotic stewardship  is then used to describe the systematic effort to educate antibiotic prescribers to only give these medications when they are warranted. In particular to children, most ear pain resolves by itself with no complications. [ 36 ]  There are  guidelines  in place to help determine when antibiotics for ear pain are needed in children."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1860", "text": "The ear itself played a role in treatment via  acupuncture , also known as  auriculotherapy . It was believed that acupuncture of the ear could be used to correct other pain or disorders in the body. Such practices may have started as far back as the  Stone Age . The first documentation of auriculotherapy in Europe was in the 1600s. One physician described stimulating the ear by burning or scarring to treat sciatic pain, while another physician applied this treatment for toothache. Paul Nogier is known as the father of ear acupuncture for his theory that parts of the ear corresponds to other areas of the body in a reliable fashion. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1861", "text": "There are currently studies going on delivering antibiotics directly into the middle ear. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1862", "text": "In the  anatomy  of humans and various other  tetrapods , the  eardrum , also called the  tympanic membrane  or  myringa , is a thin, cone-shaped  membrane  that separates the  external ear  from the  middle ear . Its function is to transmit changes in  pressure  of  sound  from the air to the  ossicles  inside the middle ear, and thence to the  oval window  in the fluid-filled  cochlea . The ear thereby converts and amplifies vibration in the air to vibration in cochlear fluid. [ 1 ]  The  malleus  bone bridges the gap between the eardrum and the other ossicles. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1863", "text": "Rupture or  perforation of the eardrum  can lead to  conductive hearing loss . Collapse or  retraction  of the eardrum can cause conductive hearing loss or  cholesteatoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1864", "text": "The tympanic membrane is oriented obliquely in the  anteroposterior , mediolateral, and superoinferior planes. Consequently, its superoposterior end lies lateral to its anteroinferior end. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1865", "text": "Anatomically, it relates superiorly to the  middle cranial fossa , posteriorly to the  ossicles  and  facial nerve , inferiorly to the  parotid gland , and anteriorly to the  temporomandibular joint . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1866", "text": "The eardrum is divided into two general regions: the  pars flaccida  and the  pars tensa . [ 3 ]  The relatively fragile pars flaccida lies above the lateral  process  of the  malleus  between the  Notch of Rivinus  and the anterior and posterior malleal folds. Consisting of two layers and appearing slightly pinkish in hue, it is associated with [ vague ]   Eustachian tube  dysfunction and  cholesteatomas . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1867", "text": "The larger pars tensa consists of three layers:  skin ,  fibrous tissue , and  mucosa . Its thick periphery forms a  fibrocartilaginous ring  called the  annulus tympanicus  or Gerlach's ligament. [ 5 ]  while the central  umbo  tents inward at the level of the tip of malleus. The middle fibrous layer, containing radial, circular, and parabolic fibers, encloses the handle of malleus. Though comparatively robust, the pars tensa is the region more commonly associated with [ vague ]  perforations. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1868", "text": "The manubrium (Latin for \"handle\") of the  malleus  is firmly attached to the medial surface of the membrane as far as its center, drawing it toward the  tympanic cavity . The lateral surface of the membrane is thus concave. The most depressed aspect of this concavity is termed the umbo (Latin for \" shield boss \"). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1869", "text": "Sensation of the outer surface of the tympanic membrane is supplied mainly by the  auriculotemporal nerve , a branch of the  mandibular nerve  ( cranial nerve   V 3 ), with contributions from the  auricular branch of the vagus nerve  ( cranial nerve X ), the  facial nerve  (cranial nerve VII), and possibly the  glossopharyngeal nerve  (cranial nerve IX). The inner surface of the tympanic membrane is innervated by the glossopharyngeal nerve. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1870", "text": "When the eardrum is illuminated during a  medical examination , a  cone of light  radiates from the tip of the malleus to the periphery in the anteroinferior quadrant, this is what is known clinically as 5 o'clock. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1871", "text": "Unintentional  perforation  (rupture) has been described in  blast injuries [ 9 ]  and  air travel , typically in patients experiencing  upper respiratory   congestion  or general  Eustachian tube dysfunction  that prevents equalization of pressure in the middle ear. [ 10 ]  It is also known to occur in  swimming ,  diving  (including  scuba diving ), [ 11 ]  and  martial arts . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1872", "text": "Patients with tympanic membrane rupture may experience bleeding,  tinnitus ,  hearing loss , or disequilibrium ( vertigo ). However, they rarely require medical intervention, as between 80 and 95 percent of ruptures recover completely within two to four weeks. [ 13 ] [ 14 ] [ 15 ]  The prognosis becomes more guarded as the force of injury increases. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1873", "text": "In some cases, the pressure of fluid in an infected middle ear is great enough to cause the eardrum to rupture naturally. Usually, this consists of a small hole (perforation), from which fluid can drain out of the middle ear. If this does not occur naturally, a  myringotomy  (tympanotomy, tympanostomy) can be performed. A myringotomy is a  surgical  procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain  pus  from the  middle ear . The fluid or pus comes from a middle ear infection ( otitis media ), which is a common problem in children. A  tympanostomy tube  is inserted into the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid.  Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks.  Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1874", "text": "Those requiring myringotomy usually have an obstructed or dysfunctional  Eustachian tube  that is unable to perform drainage or ventilation in its usual fashion.  Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1875", "text": "The  Bajau  people of the  Pacific  intentionally rupture their eardrums at an early age to facilitate diving and hunting at sea. Many older Bajau therefore have difficulties hearing. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1876", "text": "This article incorporates text in the  public domain  from  page 1039  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1877", "text": "Epiglottitis  is the  inflammation  of the  epiglottis \u2014the flap at the base of the  tongue  that prevents food entering the  trachea  (windpipe). [ 7 ]  Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate. [ 1 ] [ 2 ]  As the epiglottis is in the  upper airway , swelling can interfere with  breathing . [ 7 ]  People may  lean forward  in an effort to open the airway. [ 1 ]  As the condition worsens,  stridor  and  bluish skin  may occur. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1878", "text": "Epiglottitis was historically mostly caused by infection by  H. influenzae type b  (commonly referred to as \"Hib\"). [ 1 ]  With vaccination, it is now more often caused by other bacteria, most commonly  Streptococcus pneumoniae ,  Streptococcus pyogenes , or  Staphylococcus aureus . [ 1 ]  Predisposing factors include  burns  and trauma to the area. [ 1 ]  The most accurate way to make the diagnosis is to look directly at the epiglottis. [ 3 ]  X-rays of the neck from the side may show a \"thumbprint sign\" but the lack of this sign does not mean the condition is absent. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1879", "text": "An effective vaccine, the  Hib vaccine , has been available since the 1980s. [ 4 ]  The  antibiotic   rifampicin  may also be used to prevent the disease among those who have been exposed to the disease and are at high risk. [ 5 ]  The most important part of treatment involves securing the airway, which is often done by  endotracheal intubation . [ 1 ]  Intravenous antibiotics such as  ceftriaxone  and possibly  vancomycin  or  clindamycin  is then given. [ 2 ] [ 4 ]   Corticosteroids  are also typically used. [ 1 ]  With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1880", "text": "With the use of the Hib vaccine, the number of cases of epiglottitis has decreased by more than 95%. [ 8 ]  Historically, young children were mostly affected, but it is now more common among older children and adults. [ 4 ]  In the United States, it affects about 1.3 per 100,000 children a year. [ 1 ]  In adults, between 1 and 4 per 100,000 are affected a year. [ 6 ]  It occurs more commonly in the  developing world . [ 9 ]  In children the risk of death is about 6%; however, if they are  intubated  early, it is less than 1%. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1881", "text": "Epiglottitis is associated with  fever , throat pain,  difficulty in swallowing , drooling, hoarseness of voice, and  stridor . [ 10 ]  Onset is typically over a day. [ 10 ]  The throat itself may appear normal. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1882", "text": "Stridor is a sign of upper airway obstruction and is a surgical emergency. The child often appears acutely ill, anxious, and will have very quiet shallow breathing often keeping the head held forward and insisting on sitting up in bed, commonly called the \" tripod position .\" [ 11 ]  The early symptoms are usually insidious but rapidly progressive, and swelling of the throat may lead to  cyanosis  and  asphyxiation . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1883", "text": "Adults commonly present with less dramatic breathing symptoms than children due to them having wider airways to begin with, so their main symptoms are usually a severe sore throat and difficulty swallowing. [ 11 ]  The back of the throat appears normal in 90% of adult patients, so epiglottitis should considered when there is pain out of proportion to exam or when pain is caused by pressing on the external windpipe. [ 11 ]  Adult epiglottitis is often referred to as supraglottitis. In contrast to children, the symptoms are non-specific, sub-acute and can be unpredictable.  [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1884", "text": "Epiglottitis is primarily caused by an acquired  bacterial   infection  of the epiglottis. [ 1 ]  Historically it was most often caused by  Haemophilus influenzae type B , but with the availability of immunization this is no longer the case. [ 1 ]   H. influenzae type B  contains a  capsule  which helps it avoid being destroyed by  macrophages  and also contains surface proteins that allow it to stick to the lining of the upper respiratory tract. [ 14 ]  Presently, the bacteria most often causing infection are other encapsulated organisms including  Streptococcus pneumoniae ,  Streptococcus pyogenes , and  Staphylococcus aureus . [ 1 ]  These bacteria spread in  respiratory droplets  or  aerosols  produced from coughing and sneezing. [ 15 ] [ 16 ]  While the overall incidence of epiglottitis has decreased, the incidence of cases caused by Streptococcus pneumoniae has increased in adults. [ 17 ]  The exact  strains  of  Streptococcus pneumoniae  are often those that are covered by the  PPV-23 vaccine , [ 17 ]  but there is no evidence that this vaccine prevents epiglottitis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1885", "text": "There have been many cases of epiglottitis reported in  immunocompromised  patients, including those undergoing cancer treatment and those who are  HIV  positive. [ 18 ]  While a variety of different bacteria can cause disease in these patients, cases often involve the  Candida  species of fungus, though it is unknown if the fungus causes significant disease on its own. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1886", "text": "Alternate risk factors and causes associated with infection include  burns  and other trauma to the area. [ 1 ]  Medical research has also identified a link between epiglottitis and  crack cocaine  usage. [ 19 ]   Underlying disorders of the immune system, such as  graft-versus-host disease  and  lymphoproliferative disorders , have also been identified as contributors of increased risk for developing the infection . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1887", "text": "Diagnosis may be confirmed by direct inspection using a  laryngoscope , although this may provoke airway  spasm . [ 20 ]  If epiglottitis is suspected, attempts to visualize the epiglottis using a  tongue depressor  are discouraged for this reason; therefore, diagnosis is made on basis of  indirect fiberoptic laryngoscopy  carried out in a controlled environment like an operating room. [ 20 ]  An infected epiglottis appears swollen and is described as having a \"cherry-red\" appearance. [ 21 ]  Imaging is rarely useful, and treatment should not be delayed for this test to be carried out. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1888", "text": "On  lateral   C-spine   X-ray , the  thumbprint sign  describes a swollen, enlarged epiglottis. [ 10 ]  A normal X-ray, however, does not exclude the diagnosis. [ 10 ]  An  ultrasound  may be helpful if specific changes are present, but its use (as of 2018) is in the early stages of study. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1889", "text": "On  CT imaging , the \"Halloween sign\" describes an epiglottis of normal thickness. It can safely exclude the acute epiglottitis. Furthermore, CT imaging can help to diagnose other conditions such as  peritonsillar abscess  or  retropharyngeal abscess  which have similar clinical features. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1890", "text": "If there is visual or radiologic evidence that the infection has caused tissue destruction, the disease is called \"necrotizing epiglottitis\" (NE). [ 23 ]  The feared complication of NE is the bacteria spreading to the surrounding neck muscles and causing cervical  necrotizing fasciitis  which is a surgical emergency. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1891", "text": "The differential diagnosis includes other infectious causes of acute airway obstruction, as well as acute or subacute mechanical causes. It includes, but is not limited to, the conditions below. [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1892", "text": "An effective vaccine, the  Hib vaccine , has been available since the 1980s. [ 4 ]  Modern Hib vaccines are mainly  conjugate vaccines , with the key component being the  polysaccharide  found in the bacteria's  capsule  which is its primary  virulence factor . [ 26 ]  Currently, the CDC recommends that children receive a two or three-dose primary series with an additional booster dose. [ 27 ]  The countries of the world who have included the Hib vaccine in their immunization schedules typically begin the series at the age of two or three months with subsequent doses administered at four or eight week intervals. [ 28 ]  Routine vaccination in these nations has led to a dramatic decrease in the  incidence  of invasive diseases caused by  H. influenzae type b  such as epiglottitis,  meningitis  and  pneumonia . [ 28 ]  It has been reported that epiglottitis cases have decreased by 95% since the 1980s following the introduction of the first Hib vaccine. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1893", "text": "The  antibiotic   rifampicin  may also be used to prevent the disease among those who have been exposed to the disease and are at high risk. [ 5 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1894", "text": "The most important part of treatment involves securing the airway. [ 1 ]  Nebulized  epinephrine  may be useful to improve the situation temporarily. [ 10 ]   Corticosteroids  are also typically used. [ 1 ]  However, there is poor evidence for whether steroids actually improve patient outcomes. [ 10 ]  Epiglottitis may require urgent  tracheal intubation  to protect the airway. [ 1 ]  Tracheal intubation can be difficult due to distorted anatomy and profuse secretions. Spontaneous respiration is ideally maintained until tracheal intubation is successful. [ 10 ]  A surgical airway opening ( cricothyrotomy ) may be required if intubation is not possible. [ 10 ]  The management of epiglottitis is different in adults compared to children. [ 13 ]  Emergent tracheal intubation with general anesthesia (inhalational induction to preserve spontaneous ventilation) in the operating theater is standard. [ 13 ]  However only 10% of adults require airway intervention, which means a selective approach is required. [ 13 ]  Tracheal intubation is a high risk scenario with a 1 in 25 failure rate in adults. [ 13 ]  Multiple airway management techniques have described for adults and include: awake tracheostomy, awake fibreoptic intubation, general anesthesia with spontaneous breathing preserved or ablated with paralysis. [ 13 ]  The optimal technique is controversial and likely determined by contextual factors such as the severity of epiglottitis and the clinical location (ie emergency department or intensive care or the operating room). [ 13 ]  Ideally airway intervention should occur in the operating room with an otolaryngology surgeon present to perform an emergency tracheostomy in the event of complete airway obstruction or failed intubation. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1895", "text": "Intravenous antibiotics such as  ceftriaxone  and possibly  vancomycin  or  clindamycin  are given once the airway is secure. [ 2 ] [ 4 ]  A  third-generation cephalosporin  such as ceftriaxone is usually sufficient since it is usually effective against  H. influenzae  and  S. pneumoniae . [ 29 ]  If  S. aureus  is suspected to be causing the disease, then the treatment should include  ceftaroline  or clindamycin as these would provide coverage against antibiotic resistant strains of that bacteria ( MRSA ). [ 29 ]  Vancomycin can also be considered for its MRSA coverage, but it may be less safe than ceftaroline in children older than two months. [ 29 ]  If the patient has a penicillin allergy,  trimethoprim/sulfamethoxazole ,  clindamycin , or  levofloxacin  may be appropriate choices. [ 29 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1896", "text": "Necrotizing epiglottitis is treated similarly to uncomplicated epiglottitis, but usually requires intubation in addition to standard IV antibiotic therapy. [ 23 ]  If the tissue damage continues to spread and necrotizing fasciitis of the neck is suspected, patients are taken to the operating room for emergency  debridement . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1897", "text": "With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent. [ 3 ]  Elsewhere, it has been reported that only one percent of adults diagnosed with epiglottitis die from the disease. [ 11 ]  Some people may develop  pneumonia ,  lymphadenopathy , or  septic arthritis . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1898", "text": "Between 1998 and 2006, there were an average of 36 deaths per year in the United States attributed to epiglottitis, giving a case-fatality rate of 0.89% during that time period. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1899", "text": "Patients who recover from necrotizing epiglottitis often regain their ability to swallow foods and liquids despite the tissue damage. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1900", "text": "While, historically, young children were mostly affected, it is now more common among older children and adults. [ 4 ]  Before  Haemophilus influenzae  (Hib) immunization children of two to four were most commonly affected. [ 1 ]  With immunization about 1.3 per 100,000 children are affected a year. [ 1 ]  It has been reported that only 0.5 per 100,000 American children are diagnosed every year, while the incidence in American adults is about 1 to 4 per 100,000. [ 11 ]  A 2010 retrospective study revealed the average age of patients admitted to American hospitals for epiglottitis was about 45, but patients under the age of 1 and over the age of 85 are also particularly vulnerable. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1901", "text": "Bill Bixby 's 6-year-old son Christopher died of the condition in 1981. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1902", "text": "Jeannie Mai  spent some time in an  ICU  with epiglottitis. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1903", "text": "Sarah Silverman  spent a week in the ICU at  Cedars Sinai Hospital  with epiglottitis. [ 34 ] [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1904", "text": "George Washington  is thought to have died of epiglottitis. [ 37 ]  The treatments given to Washington, such as severe  bloodletting , an  enema , vinegar, sage, molasses, butter, blistering his throat with  Spanish fly , requiring him to swallow mercurous chloride and antimony potassium tartrate, and applying wheat poultices to various parts of the body, are no longer used. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1905", "text": "Jin  announced in a 2022 video that he had been diagnosed with epiglottitis. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1906", "text": "Wes Moore 's father died of epiglottitis when Moore was four years old. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1907", "text": "Epignathus  is a rare  teratoma  of the  oropharynx . [ 1 ]  Epignathus is a form of oropharyngeal teratoma that arises from the  palate  and, in most cases, results in death. The pathology is thought to be due to unorganized and uncontrolled differentiation of  somatic cells  leading to formation of the teratoma; sometimes it is also referred to as  fetus  in fetu , which is an extremely rare occurrence of an incomplete but  parasitic  fetus located in the body of its twin. [ 2 ] [ 3 ]  This tumor is considered benign (non- cancerous ) but life-threatening because of its atypical features (size, location, and rate of development) and high risk of  airway obstruction , which is the cause of death in 80-100% of the cases at the time of delivery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1908", "text": "Despite the high mortality rate, the most important factor in improving survival probability is to detect and diagnose the lesion before birth using  ultrasound  and  MRI  scans. [ 4 ]  If undetected prenatally, the epignathus will be apparent immediately after birth, but prognosis will be poor due to lack of preparation and treatment plans. [ 1 ]  Most babies with epignathus have a poor prognosis due to late diagnosis and, subsequently, complications in securing the airway. [ 2 ]  However, with early detection and multidisciplinary healthcare teams, an adequate treatment plan to secure the baby's airway and surgically remove the lesion may improve the prognosis. [ 2 ]  Treatment options for this rare condition prioritize managing the risk of  asphyxiation  prior to deciding on an appropriate plan for the teratoma resection. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1909", "text": "Teratomas , which are generally benign tumors, originate from  stem cells , with the oropharynx (epignathus) region being the second most common location for head and neck teratomas. [ 2 ]  The tumor arises from the palato-pharyngeal region around the  basisphenoid  ( Rathke's pouch ), or most commonly the base of the skull. [ 6 ]  Epignathi are present from birth and has been shown to affect all three germ layers (ectodermal, mesodermal, and endodermal layers) and can include cartilage, bone, and fat. [ 1 ] [ 2 ]  Case reports describe the possibility for an epignathus to present as an incompletely formed and parasitic fetal twin, which is called fetus  in fetu . [ 7 ]  Many case reports about babies with epignathus have reported common malformations of  cleft palate , and bifid tongue and/or  nose . [ 1 ] [ 2 ]  The tumor can grow within the oral cavity and protrude out of the mouth, causing obstruction of the airway and therefore mortality. [ 8 ]  This lesion may be associated with  polyhydramnios  \u2013 excessive amniotic fluid around the fetus \u2013 and typically prevents the fetus from swallowing the amniotic fluid. In rare cases, the tumor may extend into the  cranial cavity , including into the brain, or it may become encapsulated in the cranial cavity and not enter the brain at all. [ 9 ]  Most neonates and young children who present with epignathus have exhibited benign tumors, in comparison to older children and adults who have presented with more malignant teratomas. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1910", "text": "Recent findings have shown some genetic abnormalities associated with epignathi. [ 9 ]  There have been case reports noting chromosomal irregularities such as a  49,XXXXY  karyotype, [ 10 ]  duplication of 1q and 19p, [ 11 ]  and ring X chromosome mosaicism. [ 12 ]  However, this theory is still inconclusive, as there have been other studies that have shown no chromosomal abnormalities. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1911", "text": "Teratomas develop in the head and neck region with a  live birth  (fetus shows signs of life after leaving mother's womb) incidence of 1:20,000 to 40,000. [ 14 ]  Due to the rarity of epignathus, the information gathered regarding incidence and prevalence is sourced from case reports. The occurrence of epignathus, a teratoma of the oropharynx, is extremely rare, with a live birth incidence found to be 1:35,000 to 1:200,000. [ 1 ]  Of the reported cases, epignathus was found to be more common in females than in males (3:1 ratio); however, there is a lack of evidence demonstrating that an individual's genetic makeup will increase the likelihood of developing this form of teratoma. [ 15 ]  The studies have shown having one child with epignathus does not increase the chances of having pregnancies with this disease in the future. [ 16 ]  An estimated 10% of most epignathus diagnoses also report various epignathus-related abnormalities and deformities, such as the formation of a  cleft palate  (split in the mouth's roof due to abnormal fusing of the hard palate during fetal development),  hemangiomas  (pathological development of extra blood vessels). [ 17 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1912", "text": "Epignathus occurs at a critical location, which makes this tumor extremely dangerous and not resectable in newborn children. One of the primary modalities that can be used for diagnosing teratoma and epignathus is  ultrasound . Diagnosis of epignathus may be made before the birth of the child by using ultrasound. Sonography evaluation is essential during pregnancy for diagnosing epignathus and, in some cases, surgically removing the teratoma while the child is still in the womb. [ 3 ]  One of the main characteristics of epignathus in the sonography evaluation is a relatively large mass that can be seen in the anterior or front side of the neck. [ 3 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1913", "text": "For diagnosing epignathus,  radiography , which is an imaging tool for bones and skeleton, might not be beneficial, as no skeletal abnormalities have been noted in several cases of epignathus. Microscopic examination of the tumor may be of benefit. The microscopic examination focuses on the pattern of cell growth ( histology ). Because epignathus is a type of teratoma, it has a unique histological structure. Hence, the pattern found in microscopic examination can show a growth pattern consistent with teratoma. [ 4 ]  Another method that can be used to diagnose epignathus is  karyotyping , which shows genetic abnormalities in the fetus. However, the parents' chromosomes are healthy, and there is no evidence of it being inherited genetically. [ clarification needed ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1914", "text": "Epiganthus is a very rare condition that results in the studies on it to primarily be  case studies . In some of these case reports, it was seen that the diagnosis of epignathus occurred as early as 17 weeks from conception. [ 16 ]  However, in other case studies, the ultrasound was normal at 17 weeks. If the tumor is small enough, it might appear at the delivery unpredicted or even later on, in a child. [ 16 ]  For example, in one case, epignathus was detected at week 28, which caused change in the structure of the face and airways, and the child was born in week 34 with Caesarean section and needed assistance for breathing. [ 18 ]  If the diagnosis of epignathus does not happen during pregnancy, and the baby survives to birth, even though it becomes immediately apparent, there is a low chance for survival. [ 8 ]  Other clinical features include  dyspnoea ,  cyanosis , and difficulty in breathing, sucking and swallowing due to the presence of the tumor. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1915", "text": "The main priority for treating epignathus is to establish a usable airway free of obstruction, and then to feed the baby. [ 19 ] [ 20 ]  This is frequently difficult because there are often complications due to the large mass of the tumor, its location, the complex progression and required corrective modifications. [ 1 ]  These tumors, characterized as unusual masses or lumps of tissue, are often the result of abnormal tissue growth and may remain localized in one area or spread to other parts of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1916", "text": "However, diagnostic imaging tools such as 3-D ultrasonography and magnetic resonance imaging (MRI) have been essential in early detection of tumors in the head and neck region of the fetus. [ 2 ]  Although few cases have been treated successfully, early prenatal detection and intervention prior to birth has proven to be key in order to have a chance to save the baby's life. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1917", "text": "3-D ultrasonography  works to create an image by producing high frequency sound waves throughout the body in order to detect and receive echo sound. These echoes are then interpreted to form an image depending on how strong the echo was and how long the echo was received after the sound waves were transmitted. Compared to other imaging techniques that use radioactive dyes or ionizing radiation, ultrasounds have been considered safe. [ 21 ]  The use of 3-D ultrasonography has allowed surgeons to pinpoint the exact position of organs and tissues within the body and has been proven vital for surgical guidance especially when treating transplant and cancer. [ 22 ]  Magnetic resonance imaging (MRI) is another medical imaging technique that uses strong magnetic fields and radio waves to create images of organs and tissues within the body. [ 23 ]  MRI does not involve  x-rays  or  ionizing radiation , which makes it a better and safer choice for medical imaging compared to  CT  and  PET  scans. [ 23 ]  The use of these diagnostic tools during fetal development are important for early detection of any abnormal masses that may turn out to be tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1918", "text": "If tumors are detected early using the featured diagnostic tools, the baby should be stabilized before surgical removal is conducted to repair the abnormalities. [ 5 ]  In order to stabilize the baby, the umbilical cord is kept intact to provide oxygen to the fetus in case of airway obstruction. [ 5 ]  This is important in the case that a  tracheostomy  \u2013 operation required to allow air to enter the lungs \u2013 is required in order to save the baby's life. [ 5 ]  Only after the airway is secured should the umbilical cord be clamped and the baby can proceed with surgery. [ 5 ]  During surgery, a complete repair and removal procedure of the diseased tissues, especially those that may spread throughout the body, is necessary in order to prevent any chance of reoccurrence after a period of improvement. [ 2 ]  Following surgery,  chemotherapy  may be used to promote residual tumor regression. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1919", "text": "In some cases, because of the complications of the epignathus tumor, termination of the pregnancy might be an option that needs to get discussed. [ 16 ] [ why? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1920", "text": "Epignathus diagnoses have a very poor prognosis or outcome with a death rate of 80\u2013100% in newborn babies (either before delivery or shortly after delivery), primarily due to  asphyxiation  or suffocation from the tumor blocking the baby's airway. [ 15 ] [ 3 ]  The course of the disease and outcome are dependent on many factors including size, location, and rate of development of the teratoma, all of which affect the magnitude of airway obstruction. [ 24 ]  Other complications such as the deformation of facial structure or deformation of jaw structure may impact the baby's ability to swallow and breathe, which may also negatively impact the prognosis as well. [ 15 ]  If the tumors are large, they might cause changes in the structure of face, nose and upper lips, to the point that they cannot be identified. [ 16 ]  Factors that may improve survival rates include early diagnosis of epignathus before birth, multidisciplinary management in preventing obstruction in the airways, and feasibility in surgical removal of the teratoma. [ 25 ] [ 26 ]  The prognosis can result in broad range of outcomes. In some cases, pregnancies were terminated after the fetus was diagnosed with epignathus for different complications. The most common reason was that the tumor was continuing to spread even further in the head and mouth area. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1921", "text": "Very few long term survivors have been reported, so the prognosis past the neonatal period is unclear. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1922", "text": "The  epitympanic recess  is the portion of the  tympanic cavity  (of the middle ear) situated superior to the  tympanic membrane . [ 1 ] :\u200a414\u200a  The recess lodges the  head of malleus , and the  body of incus . [ 1 ] :\u200a416"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1923", "text": "The  mastoid antrum  is situated posterior to the recess and opens into the recess at the posterior wall of the recess via the  aditus to mastoid antrum . [ 1 ] :\u200a416\u200a  The  ampulla  of the  lateral semicircular canal  creates a prominence upon the medial wall of the recess. [ 1 ] :\u200a420"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1924", "text": "This recess is a possible route of spread of infection to the  mastoid air cells  located in the  mastoid process  of the  temporal bone  of the skull.  Inflammation  which has spread to the mastoid air cells is very difficult to drain and causes considerable pain. Before the advent of  antibiotics , it could only be drained by drilling a hole in the mastoid bone, a process known as  mastoidectomy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1925", "text": "This  anatomy  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1926", "text": "The  ethmoid bone  ( / \u02c8 \u025b \u03b8 m \u0254\u026a d / ; [ 1 ] [ 2 ]  from  Ancient Greek :  \u1f21\u03b8\u03bc\u03cc\u03c2 ,  romanized :\u00a0 h\u0113thm\u00f3s ,  lit. \u2009 'sieve') is an unpaired  bone  in the  skull  that separates the  nasal cavity  from the  brain . It is located at the roof of the  nose , between the two  orbits . The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that make up the orbit of the eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1927", "text": "The ethmoid bone is an anterior cranial bone located between the eyes. [ 3 ]  It contributes to the medial wall of the orbit, the nasal cavity, and the nasal septum. [ 3 ]  The ethmoid has three parts:  cribriform plate ,  ethmoidal labyrinth , and  perpendicular plate . The cribriform plate forms the roof of the nasal cavity and also contributes to formation of the  anterior cranial fossa , [ 4 ]  the ethmoidal labyrinth consists of a large mass on either side of the perpendicular plate, and the perpendicular plate forms the superior two-thirds of the nasal septum. [ 3 ]  Between the  orbital plate  and the  nasal conchae  are the  ethmoidal sinuses  or ethmoidal air cells, which are a variable number of small cavities in the lateral mass of the ethmoid. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1928", "text": "The ethmoid  articulates  with thirteen bones:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1929", "text": "The ethmoid is  ossified  in the cartilage of the nasal capsule by three centers: one for the perpendicular plate, and one for each labyrinth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1930", "text": "The labyrinths are first developed, ossific granules making their appearance in the region of the  lamina papyracea  between the fourth and fifth months of  fetal  life, and extending into the  conch\u00e6 ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1931", "text": "At birth, the bone consists of the two labyrinths, which are small and ill-developed. During the first year after birth, the perpendicular plate and  crista galli  begin to ossify from a single center, and are joined to the labyrinths about the beginning of the second year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1932", "text": "The  cribriform plate  is ossified partly from the perpendicular plate and partly from the labyrinths."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1933", "text": "The development of the ethmoidal cells begins during fetal life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1934", "text": "Some  birds  and other migratory animals have deposits of biological  magnetite  in their ethmoid bones which allow them to sense the direction of the Earth's  magnetic field . Humans have a similar magnetite deposit (ferric iron), but it is believed to be  vestigial . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1935", "text": "Fracture of the  lamina papyracea , the lateral plate of the ethmoid labyrinth bone, permits communication between the  nasal cavity  and the orbit on the same side of the body through the inferomedial orbital wall, resulting in  orbital emphysema .  Increased pressure within the nasal cavity, as seen during sneezing, for example, leads to temporary  exophthalmos ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1936", "text": "The porous fragile nature of the ethmoid bone makes it particularly susceptible to fractures.  The ethmoid is usually fractured from an upward force to the nose. This could occur by hitting the dashboard in a car crash or landing on the ground after a fall.  The ethmoid fracture can produce bone fragments that penetrate the  cribriform plate .  This trauma can lead to a leak of  cerebrospinal fluid  into the nasal cavity.  These openings let opportunistic bacteria in the nasal cavity enter the sterile environment of the central nervous system (CNS).  The CNS is usually protected by the  blood\u2013brain barrier , but holes in the cribriform plate let bacteria get through the barrier.  The blood\u2013brain barrier makes it extremely difficult to treat such infections, because only certain drugs can cross into the CNS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1937", "text": "An ethmoid fracture can also sever the olfactory nerve.  This injury results in  anosmia  (loss of smell).  A reduction in the ability to taste is also a side effect because it is based so heavily on smell.  This injury is not fatal, but can be dangerous, as when a person fails to smell smoke, gas, or spoiled food. [ 3 ]  In fact, people with anosmia were more than four times as likely to die in five years compared to those with a healthy sense of smell. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1938", "text": "The  ethmoid bulla  (or  ethmoidal bulla ) is a rounded elevation upon the lateral wall of the  middle nasal meatus [ 1 ] [ 2 ] :\u200a377\u200a  ( nasal cavity  inferior to the  middle nasal concha ) produced by one or more of the underlying middle  ethmoidal air cells  (which open into the nasal cavity upon or superior to the ethmoidal bulla [ 2 ] :\u200a374\u200a [ 3 ] ). [ 2 ] :\u200a377\u200a  It varies significantly based on the size of the underlying air cells. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1939", "text": "The ethmoid bulla is formed by is the largest and least variable of the middle ethmoidal air cells. [ 3 ]  The size of the bulla varies with that of its contained cells. The bulla may be a pneumatised cell or a bony prominence found in middle meatus. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1940", "text": "The  hiatus semilunaris  is situated (sources differ) inferior [ 5 ] [ 6 ] [ 1 ] /anterior [ 2 ] :\u200a374\u200a  to the ethmoid bulla. The  maxillary sinus  also opens below the bulla. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1941", "text": "The ethmoid bulla begins to develop between 8 weeks and 12 weeks of  gestation . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1942", "text": "The  ethmoid sinuses  or  ethmoid air cells  of the  ethmoid bone  are one of the four paired  paranasal sinuses . [ 1 ]  Unlike the other three pairs of paranasal sinuses which consist of one or two large cavities, the ethmoidal sinuses entail a number of small air-filled cavities (\"air cells\"). [ 2 ]  The cells are located within the  lateral mass (labyrinth)  of each ethmoid bone and are variable in both size and number. [ 1 ]  The cells are grouped into anterior, middle, and posterior groups; the groups differ in their drainage modalities, [ 2 ]  though all ultimately drain into either the  superior  or the  middle nasal meatus [ 3 ]  of the lateral wall of the nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1943", "text": "The ethmoid air cells consist of numerous thin-walled cavities in the  ethmoidal labyrinth [ 4 ]  that represent invaginations of the mucous membrane of the nasal wall into the ethmoid bone. [ 3 ]  They are situated between the superior parts of the  nasal cavities  and the  orbits , and are separated from these cavities by thin bony lamellae. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1944", "text": "There are 5-15 air cells in either ethmoid bone in the adult, with a combined volume of 2-3mL. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1945", "text": "The ethmoidal cells (sinuses) and  maxillary sinuses  are present at birth. [ 6 ]  At birth, 3-4 air cells are present, with the number increasing to 5-15 by adulthood. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1946", "text": "The ethmoidal labyrinth is divided by multiple obliquely oriented, parallel lamellae. The first lamellae is equivalent to the  uncinate process of ethmoid bone , the second corresponds the  ethmoid bulla , and the third is the basal lamella, and the fourth is equivalent to the  superior nasal concha . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1947", "text": "The anterior and posterior ethmoid cells are separated by the  basal lamella [ 7 ] [ 5 ]  (also known as the  ground lamella ). [ 5 ]  It is one of the bony divisions of the ethmoid bone and is mostly contained inside the  ethmoid labyrinth . The basal lamella is continuous medially with the bony  middle nasal concha . [ 7 ]  Anteriorly, it vertically inserts into the  ethmoid crest ; the middle part attaches obliquely into the  orbital lamina of ethmoid bone (lamina papyricea)  while the posterior part attaches into the orbital lamina horizontally. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1948", "text": "The ethmoidal air cells receive sensory innervation from the  anterior  and the  posterior ethmoidal  nerve (which are ultimately derived from the  ophthalmic branch (CN V 1 )  of the  trigeminal nerve (CN V) ), [ 3 ]   and the orbital branches of the  pterygopalatine ganglion , which carry the postganglionic parasympathetic nerve fibers for mucous secretion from the  facial nerve . [ clarification needed ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1949", "text": "Haller cells are air cells situated beneath the  ethmoid bulla  along the roof of the  maxillary sinus  and the most inferior portion of the  lamina papyracea , including air cells located within the  ethmoid infundibulum . [ 8 ]  These may arise from the anterior or posterior ethmoidal sinuses. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1950", "text": "Also known as a sphenoethmoidal air cell, an Onodi cell is a posterior ethmoidal air cell that lies superolateral to the  sphenoid sinus , often extending into the  anterior clinoid process . [ 9 ]  Onodi cells are clinically significant because they lie in close proximity to the  optic nerve  and  internal carotid artery , so surgeons should be aware of their existence when performing surgery on the sphenoid sinus so as not to damage these important structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1951", "text": "A central Onodi air cell is a variation in which a posterior ethmoid cell lies superior to the sphenoid sinus in a midline position with at least one optic canal bulge. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1952", "text": "Acute ethmoiditis in childhood and ethmoidal carcinoma may spread superiorly causing meningitis and cerebrospinal fluid leakage or it may spread laterally into the orbit causing  proptosis  and  diplopia . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1953", "text": "This article incorporates text in the  public domain  from  page 154  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1954", "text": "The  ethmoidal infundibulum  is a funnel-shaped [ 1 ] /slit-like [ 2 ] :\u200a690\u200a /curved [ 3 ]  opening [ 1 ] /passage [ 4 ] /space [ 2 ] :\u200a690\u200a /cleft [ 3 ]  upon the anterosuperior portion of the  middle nasal meatus [ 1 ]  (and thus of the lateral wall of [ 2 ]  the  nasal cavity [ 1 ] ) at the  hiatus semilunaris [ 3 ] [ 5 ]  (which represents the medial extremity of the infundibulum [ 2 ] ). The  anterior ethmoidal air cells , [ 4 ] [ 2 ] :\u200a612\u200a  and (usually [ 2 ] :\u200a612, 690\u200a ) the  frontonasal duct  (which drains the  frontal sinus [ 1 ] [ 4 ] ) [ 1 ] [ 4 ] [ 2 ] :\u200a690\u200a  open into the ethmoidal infundibulum. [ 1 ]  The ethmoidal infundibulum extends anterosuperiorly from its opening into the nasal cavity. [ 3 ] [ 2 ] :\u200a612"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1955", "text": "The ethmoidal infundibulum is bordered medially by the  uncinate process of the ethmoid bone , and laterally by the orbital plate of the ethmoid bone. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1956", "text": "The ethmoid infundibulum leads towards the  maxillary hiatus . [ 2 ] :\u200a690\u200a The  anterior ethmoidal cells  open into the anterior part of the infundibulum. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1957", "text": "The frontonasal duct may or may not drain into the ethmoidal infundibulum - this is determined by the place of attachment of the  uncinate process of the ethmoid bone : if the uncinate process is attached to the lateral nasal wall, the frontonasal duct will open directly into the middle nasal meatus; if otherwise, it will drain into the infundibulum. [ 2 ] :\u200a690\u200a  In slightly over 50% of subjects, it is directly continuous with the frontonasal duct. When the anterior end of the uncinate process fuses with the anterior part of the bulla, however, this continuity is interrupted and the frontonasal duct then drains directly into the anterior end of the  middle meatus . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1958", "text": "The  ethmoidal labyrinth  or  lateral mass  of the  ethmoid bone  consists of a number of thin-walled cellular cavities, the  ethmoid air cells , arranged in three groups, anterior, middle, and posterior, and interposed between two vertical plates of bone; the lateral plate forms part of the orbit, the medial plate forms part of the  nasal cavity . In the disarticulated bone many of these cells are opened into, but when the bones are articulated, they are closed in at every part, except where they open into the nasal cavity. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1959", "text": "The upper surface of the labyrinth presents a number of half-broken cells, the walls of which are completed, in the articulated skull, by the edges of the  ethmoidal notch  of the frontal bone. Crossing this surface are two grooves, converted into two openings by articulation with the frontal; they are the  anterior  and  posterior ethmoidal foramina , and open on the inner wall of the orbit. The posterior surface presents large irregular cellular cavities, which are closed in by articulation with the  sphenoidal concha  and  orbital process of palatine bone . The lateral surface is formed of a thin, smooth, oblong plate, the  lamina papyracea  (os planum), which covers in the middle and posterior ethmoidal cells and forms a large part of the medial wall of the orbit; it articulates above with the orbital plate of the frontal bone, below with the maxilla and orbital process of the palatine, in front with the lacrimal, and behind with the sphenoid. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1960", "text": "In front of the lamina papyracea are some broken air cells which are overlapped and completed by the lacrimal bone and the frontal process of the maxilla. A curved lamina, the  uncinate process , projects downward and backward from this part of the labyrinth; it forms a small part of the medial wall of the  maxillary sinus , and articulates with the ethmoidal process of the inferior  nasal concha . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1961", "text": "The medial surface of the labyrinth forms part of the lateral wall of the corresponding nasal cavity. It consists of a thin  lamella , which descends from the under surface of the cribriform plate, and ends below in a free, convoluted margin, the middle nasal concha. It is rough, and marked above by numerous grooves, directed nearly vertically downward from the cribriform plate; they lodge branches of the olfactory nerves, which are distributed to the  mucous membrane  covering the superior nasal concha. The back part of the surface is subdivided by a narrow oblique fissure, the superior meatus of the nose, bounded above by a thin, curved plate, the superior nasal concha; the posterior ethmoidal cells open into this meatus. Below, and in front of the  superior meatus , is the convex surface of the middle nasal concha; it extends along the whole length of the medial surface of the labyrinth, and its lower margin is free and thick. The lateral surface of the middle concha is concave, and assists in forming the middle meatus of the nose. The middle ethmoidal cells open into the central part of this  meatus , and a sinuous passage, termed the  infundibulum , extends upward and forward through the labyrinth and communicates with the anterior ethmoidal cells, and in about 50% of skulls is continued upward as the frontonasal duct into the frontal sinus. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1962", "text": "The  ethmoidal nerves , which arise from the  nasociliary nerve , supply the  ethmoidal cells ; the posterior branch leaves the  orbital cavity  through the  posterior ethmoidal foramen  and gives some filaments to the  sphenoidal sinus . There are two ethmoidal nerves on each side of the face:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1963", "text": "This article incorporates text in the  public domain  from  page 888  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1964", "text": "The  Eustachian tube  ( / j u\u02d0 \u02c8 s t e\u026a \u0283 \u0259n / ), also called the  auditory tube  or  pharyngotympanic tube , [ 1 ]  is a tube that links the  nasopharynx  to the  middle ear , of which it is also a part.  In adult humans, the Eustachian tube is approximately 35\u00a0mm (1.4\u00a0in) long and 3\u00a0mm (0.12\u00a0in) in diameter. [ 2 ]  It is named after the sixteenth-century Italian anatomist  Bartolomeo Eustachi . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1965", "text": "In humans and other  tetrapods , both the middle ear and the  ear canal  are normally filled with air. Unlike the air of the ear canal, however, the air of the middle ear is not in direct contact with the atmosphere outside the body; thus, a pressure difference can develop between the atmospheric pressure of the ear canal and the middle ear. Normally, the Eustachian tube is collapsed, but it gapes open with  swallowing  and with  positive pressure , allowing the middle ear's pressure to adjust to the atmospheric pressure. When taking off in an aircraft, the ambient air pressure goes from higher (on the ground) to lower (in the sky). The air in the middle ear  expands  as the plane gains altitude, and pushes its way into the back of the nose and mouth; on the way down, the volume of air in the middle ear shrinks, and a slight vacuum is produced. Active opening of the Eustachian tube (through actions like swallowing or the  Valsalva maneuver ) is required to equalize the pressure between the middle ear and the ambient atmosphere as the plane descends. A  diver  also experiences this change in pressure, but with greater rates of pressure change;  active opening of the Eustachian tube  is required more frequently to  equalize pressure  as the diver goes deeper, into higher pressure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1966", "text": "The Eustachian tube extends from the anterior wall of the middle ear to the lateral wall of the  nasopharynx , approximately at the level of the  inferior nasal concha . It consists of a bony part and a  cartilaginous  part."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1967", "text": "The bony part ( 1 \u2044 3 ) nearest to the middle ear is made of  bone  and is about 12\u00a0mm in length. It begins in the  anterior wall of the tympanic cavity , below the  septum canalis musculotubarius , and, gradually narrowing, ends at the angle of junction of the  squamous  and the  petrous parts  of the  temporal bone , its extremity presenting a jagged margin which serves for the attachment of the cartilaginous part. [ 5 ] \nThe vestibule of the Eustachian tube is known as the  protympanum , [ 6 ]  The protympanum is also known as the anterior part of the bony part of the tube. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1968", "text": "The cartilaginous part of the Eustachian tube is about 24\u00a0mm in length and is formed of a triangular plate of  elastic fibrocartilage , the apex of which is attached to the margin of the medial end of the bony part of the tube, while its base lies directly under the  mucous membrane  of the nasal part of the  pharynx , where it forms an elevation, the  torus tubarius  or cushion, behind the pharyngeal opening of the auditory tube."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1969", "text": "The upper edge of the  cartilage  is curled upon itself, being bent laterally so as to present on  transverse section  the appearance of a hook; a groove or furrow is thus produced, which is open below and laterally, and this part of the canal is completed by fibrous membrane. The cartilage lies in a groove between the  petrous part of the temporal bone  and the  great wing of the sphenoid ; this groove ends opposite the middle of the  medial pterygoid plate . The cartilaginous and bony portions of the tube are not in the same plane, the former inclining downward a little more than the latter. The diameter of the tube is not uniform throughout, being greatest at the pharyngeal opening, least at the junction of the bony and cartilaginous portions, and again increased toward the  tympanic cavity ; the narrowest part of the tube is termed the isthmus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1970", "text": "The position and relations of the pharyngeal opening are described with the  nasal part of the pharynx . The mucous membrane of the tube is continuous in front with that of the nasal part of the pharynx, and behind with that of the tympanic cavity; it is covered with  ciliated pseudostratified columnar epithelia  and is thin in the osseous portion, while in the cartilaginous portion it contains many  mucous glands  and near the pharyngeal orifice a considerable amount of  adenoid  tissue, which has been named by Gerlach the tube tonsil."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1971", "text": "There are four muscles associated with the function of the Eustachian tube:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1972", "text": "The tube is opened during swallowing by contraction of the tensor veli palatini and levator veli palatini, muscles of the  soft palate . [ 1 ]  The tensor veli palatini makes the largest contribution to active opening of the tube. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1973", "text": "Since 2015, two developments have enhanced our understanding of the anatomy of the eustachian tube: Valsalva computerized tomography and endoscopic ear surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1974", "text": "The Eustachian tube is derived from the dorsal part of the first  pharyngeal pouch  and second endodermal pouch, which during  embryogenesis  forms the  tubotympanic recess . The distal part of the tubotympanic sulcus gives rise to the  tympanic cavity , while the proximal tubular structure becomes the Eustachian tube. It helps transformation of sound waves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1975", "text": "Under normal circumstances, the human Eustachian tube is closed, but it can open to let a small amount of air through to prevent damage by equalizing pressure between the middle ear and the atmosphere. Pressure differences cause temporary  conductive hearing loss  by decreased motion of the  tympanic membrane  and  ossicles  of the ear. [ 13 ]  Various methods of  ear clearing  such as  yawning , swallowing, or  chewing gum  may be used to intentionally open the tube and equalize pressures. When this happens, humans hear a small popping sound, an event familiar to aircraft passengers, scuba divers, or drivers in mountainous regions. Devices assisting in pressure equalization include an  ad hoc  balloon applied to the nose, creating inflation by positive air pressure. [ 14 ] \nSome people learn to voluntarily 'click' their ears, together or separately, performing a pressure equalizing routine by opening their Eustachian tubes when pressure changes are experienced, as in ascending/descending in aircraft, mountain driving, elevator lift/drops, etc. Some are even able to deliberately keep their Eustachian tubes open for a brief period, and even increase or decrease air pressure in the middle ear. The 'clicking' can actually be heard by putting one's ear to another's while performing the clicking sound. This voluntary control may be first discovered when yawning or swallowing, or by other means (above). Those who develop this ability may discover that it can be done deliberately without force even when there are no pressure issues involved."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1976", "text": "The Eustachian tube also drains mucus from the middle ear. Upper respiratory tract infections or allergies can cause the Eustachian tube, or the membranes surrounding its opening to become swollen, trapping fluid, which serves as a growth medium for bacteria, causing  ear infections . This swelling can be reduced through the use of decongestants such as  pseudoephedrine ,  oxymetazoline , and  phenylephrine . [ 15 ]  Ear infections are more common in children because the tube is horizontal and shorter, making bacterial entry easier, and it also has a smaller diameter, making the movement of fluid more difficult. In addition, children's developing immune systems and poor hygiene habits make them more prone to upper respiratory infections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1977", "text": "Otitis media , or  inflammation  of the  middle ear , commonly affects the Eustachian tube.  Children under 7 are more susceptible to this condition, one theory being that this is because the Eustachian tube is shorter and at more of a horizontal angle than in the adult ear.  Others argue that susceptibility in this age group is related to immunological factors and not Eustachian tube anatomy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1978", "text": "Barotitis, a form of  barotrauma , may occur when there is a substantial difference in air or water pressure between the outer and the middle ear \u2013 for example, during a rapid ascent while  scuba diving , or during sudden decompression of an aircraft at high altitude."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1979", "text": "Some people are born with a dysfunctional Eustachian tube [ 16 ]  that is much slimmer than usual. The cause may be genetic, but it has also been posited as a condition in which the patient did not fully recover from the effects of pressure on the middle ear during birth (retained birth compression). [ 17 ] [ unreliable medical source ]  It is suggested that Eustachian tube dysfunction can result in a large amount of mucus accumulating in the middle ear, often impairing hearing to a degree. This condition is known as  otitis media with effusion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1980", "text": "A  patulous Eustachian tube  is a rare condition in which the Eustachian tube remains intermittently open, causing an echoing sound of the person's own heartbeat, breathing, and speech. This may be temporarily relieved by holding the head upside down."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1981", "text": "Smoking can also cause damage to the  cilia  that protect the Eustachian tube from mucus, which can result in the clogging of the tube and a buildup of bacteria in the ear, leading to a middle ear infection. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1982", "text": "Recurring and chronic cases of  sinus infection  can result in Eustachian tube dysfunction caused by excessive mucus production which, in turn, causes obstruction to the openings of the Eustachian tubes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1983", "text": "In severe cases of childhood middle ear infections and Eustachian tube blockage, ventilation can be provided by a surgical puncturing of the eardrum to permit air equalization, known as  myringotomy . The eardrum would normally naturally heal and close the hole, so a tiny plastic rimmed grommet is inserted into the hole to hold it open. This is known as a  tympanostomy tube . As a child grows, the tube is eventually naturally expelled by the body. Longer-lasting vent grommets with larger flanges have been researched, but these can lead to permanent perforation of the eardrum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1984", "text": "More recently, dilation of the eustachian tube using balloon catheter has gained attention as a method of treating eustachian tube obstruction. There are two methods of performing this procedure depending on the route of the catheter introduction and the area of the Eustachian tube to be dilated. Dennis Poe popularized the transnasal introduction and the dilation  of the nose side of the eustachian tube. [ 19 ]  Muaaz Tarabichi pioneered the transtympanic (ear) introduction of the balloon catheter and the dilatation of the proximal part (the ear side) of the cartilaginous eustachian tube. [ 20 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1985", "text": "In the  equids  (horses) and some rodent-like species such as the desert  hyrax , an  evagination  of the Eustachian tube is known as the  guttural pouch  and is divided into medial and lateral compartments by the stylohyoid bone of the  hyoid  apparatus. This is of great importance in equine medicine as the pouches are prone to infections, and, due to their intimate relationship to the cranial nerves (VII, IX, X, XI) and the internal and external carotid artery, various syndromes may arise relating to which is damaged.  Epistaxis  (nosebleed) is a very common presentation to veterinary surgeons and this may often be fatal unless a balloon catheter can be placed in time to suppress bleeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1986", "text": "The  external carotid artery  is the major  artery  of the head and upper neck. It arises from the  common carotid artery . It terminates by splitting into the  superficial temporal  and  maxillary artery  within the  parotid gland . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1987", "text": "The external carotid artery arises from the  common carotid artery  just inferior to the upper border of the  thyroid cartilage . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1988", "text": "At its origin, this artery is closer to the skin and more medial than the internal carotid, and is situated within the  carotid triangle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1989", "text": "It curves to pass anterosuperiorly before inclining posterior-ward to reach the space posterior the neck of the  mandible , where it divides into the  superficial temporal  and  maxillary artery  within the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1990", "text": "It rapidly diminishes in size as it travels up the neck, owing to the number and large size of its branches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1991", "text": "At the origin, external carotid artery is more medial than  internal carotid artery . When external carotid artery ascends the neck, it lies more lateral than internal carotid artery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1992", "text": "The external carotid artery is covered by the skin, superficial fascia,  platysma muscle , deep fascia, and anterior margin of the  sternocleidomastoid ; it is crossed by the  hypoglossal nerve , by the  lingual ,  ranine ,  common facial , and  superior thyroid veins ; and by the  digastricus  and  stylohyoideus muscles ; higher up it passes deeply into the substance of the  parotid gland , where it lies deep to the  facial nerve  and the junction of the temporal and internal maxillary veins."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1993", "text": "Medial to it are the  hyoid bone , the wall of the  pharynx , the  superior laryngeal nerve , and a portion of the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1994", "text": "Posterior to it, near its origin, is the  superior laryngeal nerve ; and higher up, it is separated from the  internal carotid  by the  styloglossus  and  stylopharyngeus muscles , the  glossopharyngeal nerve , the pharyngeal branch of the  vagus , and part of the parotid gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1995", "text": "As the artery travels upwards, it gives the following branches:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1996", "text": "The external carotid artery terminates as two branches:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1997", "text": "The superior thyroid artery anastomoses with  inferior thyroid artery , where the latter arises from  thyrocervical trunk  of the  subclavian artery . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1998", "text": "Terminal branch of facial artery anastomose with  ophthalmic artery  of  internal carotid artery . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_1999", "text": "Posterior auricular artery anastomose with occipital artery, another branch of external carotid artery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2000", "text": "One of the branches of superficial temporal artery anastomose with lacrimal and palpebral branches of ophthalmic artery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2001", "text": "In children, the external carotid artery is smaller than the  internal carotid ; but in the adult, the two vessels are of nearly equal size."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2002", "text": "The condition and health of the external carotid arteries is usually evaluated using  Doppler ultrasound ,  CT angiogram  or  phase contrast magnetic resonance imaging  (PC-MRI). Typically, blood flow velocities in the external carotid artery are measured as peak systolic velocity (PSV) and end diastolic velocity (EDV). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2003", "text": "PSV values greater than 200 cm/s are considered to be predictive of more than 50% of external  carotid artery stenosis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2004", "text": "The  facial artery , formerly called the  external maxillary artery,  is a branch of the  external carotid artery  that supplies blood to superficial structures of the medial regions of the face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2005", "text": "The facial artery arises in the  carotid triangle  from the  external carotid artery , [ 1 ] [ 2 ]  a little above the  lingual artery , and sheltered by the  ramus of the mandible . It passes obliquely up beneath the  digastric  and  stylohyoid  muscles, over which it arches to enter a groove on the posterior surface of the  submandibular gland . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2006", "text": "It then curves upward over the body of the mandible at the antero-inferior angle of the  masseter  ( the antegonial notch ); [ 1 ] [ 2 ] [ 4 ]  passes forward and upward across the cheek to the angle of the mouth, then ascends along the side of the nose, and ends at the medial commissure of the eye, under the name of the  angular artery . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2007", "text": "The facial artery is remarkably tortuous.  This is to accommodate itself to neck movements such as those of the  pharynx  in  swallowing ; and facial movements such as those of the  mandible ,  lips , and  cheeks ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2008", "text": "In the neck, its origin is superficial, being covered by the integument,  platysma , and fascia; it then passes beneath the  digastric  and  stylohyoid  muscles and part of the  submandibular gland , but superficial to the  hypoglossal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2009", "text": "It lies upon the  middle pharyngeal constrictor  and the  superior pharyngeal constrictor , the latter of which separates it, at the summit of its arch, from the lower and back part of the tonsil."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2010", "text": "On the face, where it passes over the body of the mandible, it is comparatively superficial, lying immediately beneath the dilators of the mouth. In its course over the face, it is covered by the integument, the fat of the cheek, and, near the angle of the mouth, by the  platysma ,  risorius , and  zygomaticus major . It rests on the  buccinator  and  levator anguli oris , and passes either over or under the infraorbital head of the  levator labii superioris ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2011", "text": "The  anterior facial vein  lies lateral/posterior to the artery, [ 2 ]  and takes a more direct course across the face, where it is separated from the artery by a considerable interval. In the neck it lies superficial to the artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2012", "text": "The branches of the  facial nerve  cross the artery from behind forward."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2013", "text": "The facial artery anastomoses with (among others) the  dorsal nasal artery  of the  internal carotid artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2014", "text": "The branches of the facial artery are: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2015", "text": "Muscles supplied by the facial artery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2016", "text": "The facial artery may be punctured during  maxillofacial surgery , and is likely to  haemorrhage  significantly. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2017", "text": "This article incorporates text in the  public domain  from  page 553  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2018", "text": "The  facial canal  (also known as the  Fallopian canal ) is a Z-shaped canal in the  temporal bone  of the  skull . It extends between the  internal acoustic meatus  and  stylomastoid foramen . It transmits the  facial nerve (CN VII)  (after which it is named)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2019", "text": "The facial canal gives passage to the  facial nerve (CN VII)  (hence the name). [ 1 ] [ verification needed ] [ better\u00a0source\u00a0needed ]  Its proximal opening is at the  internal auditory meatus ; its distal opening is the  stylomastoid foramen . In humans, the canal is approximately 3\u00a0cm long, making it the longest bony canal of a nerve in the human body. [ 2 ] [ verification needed ] [ better\u00a0source\u00a0needed ]  It is located within the middle ear region. [ verification needed ] [ better\u00a0source\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2020", "text": "The facial nerve gives rise to three nerves while passing through the canal: the  greater petrosal nerve ,  nerve to stapedius , and the  chorda tympani . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2021", "text": "The proximal portion of the facial canal is termed the  horizontal part . It commences at the  introitus of facial canal  at the distal end of the internal auditory meatus. The horizontal part is further subdivided into two crura: the proximal/medial [ 4 ]  anteriolaterally [ 5 ]  directed  medial crus  (or  labyrinthine segment [ 5 ] ), and the distal/lateral [ 4 ]  posteriolaterally [ 5 ]  directed  lateral crus  (or  tympanic segment [ 5 ] ); the two crura meet at a sharp angle at the  genu of facial canal  ( geniculum canalis facialis [ 6 ] ) where the  geniculate ganglion  is situated (at the genu, the  greater petrosal nerve  leaves the facial canal through the hiatus of the facial canal). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2022", "text": "The lateral crus of horizontal part ends by turning sharply inferior-ward, commencing the distal-most  descending part  (or  mastoid segment [ 5 ] ) of facial canal which passes vertically inferior-ward, ending distally at the  stylomastoid foramen . The descending part presents two openings through each of which a branch of the facial nerve passes: the  nerve to stapedius  enters the  canaliculus for nerve to stapedius , and the  chorda tympani  enters the  posterior canaliculus of chorda tympani  ( canaliculus chordae tympani , or  iter chordae posterius [ 7 ] ). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2023", "text": "The labyrinthine segment is situated superior to  cochlea . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2024", "text": "The canal traverses the  medial wall  of the  tympanic cavity  superior to the  oval window ; [ citation needed ]  here, the  prominence of the facial canal  (or  prominence of the aqueduct of Fallopius ) upon the medial wall indicates the position of the superior portion of the facial canal. [ 9 ] :\u200a745\u200a  The canal then curves nearly vertically inferior-ward along the  posterior wall . [ citation needed ]  The tympanic segment is closely related to the posterior and medial walls of the  tympanic cavity ; it passes superior to the  oval window  and inferior to the  lateral semicircular canal . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2025", "text": "The facial canal may be interrupted in some people. This may lead to the  facial nerve  being split into 2 or 3 fibres, or it may be poorly formed or congenitally absent on one side. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2026", "text": "The facial canal was first described by  Gabriele Falloppio . [ 10 ]  This is why it may also be known as the Fallopian canal. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2027", "text": "Facial feminization surgery  ( FFS ) is a set of reconstructive [ 1 ]   surgical procedures  that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue procedures such as  brow lift ,  rhinoplasty ,  cheek implantation , and  lip augmentation . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2028", "text": "Faces contain  secondary sex characteristics  that make male and female faces readily distinguishable, including the shape of the forehead, nose, lips, cheeks, chin, and jawline; the features in the upper third of the face seem to be the most important, and subtle changes in the lips can have a strong effect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2029", "text": "For some  transgender  women and non binary people, FFS is medically necessary to treat  gender dysphoria . [ 3 ] [ 4 ]  It can be just as important or even more important than genital forms of  sex reassignment surgery  (SRS) in reducing gender dysphoria and helping trans women integrate socially as women; data on these sorts of outcomes are limited by small study size and confounding variables like other feminization procedures. [ 5 ] [ 6 ]  While most FFS patients are transgender women, some  cisgender  women who feel that their faces are too masculine will also undergo FFS. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2030", "text": "FFS candidates should wait until the bones of their skull have stopped growing before undergoing FFS. The way to determine if the bones of the skull have stopped growing is to take successive  radiographs  of the  mandible  and wrist bones to make sure that bone growth has stopped. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2031", "text": "The surgical procedures most frequently performed during FFS include the following. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2032", "text": "Some studies have shown that the shape of the forehead is one of the key differences between cisgender males and cisgender females. [ 5 ] [ 10 ]  Hairline correction, forehead recontouring, eye socket recontouring, and brow lift are procedures often performed at the same time, with rhinoplasty in mind. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2033", "text": "In males, the hairline is often higher than in females and usually has receded corners above the temples that give it an \"M\" shape. The hairline can be moved forward and given a more rounded shape, either with a procedure called a \" scalp advance \" wherein the scalp is lifted and repositioned, or with  hair transplantation . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2034", "text": "Cisgender males tend to have a horizontal ridge of bone running across the forehead just above eyebrow level called the  brow ridge  (or \"brow bossing\"), which includes the \"supraorbital rims\" (the lower edge, on which the eyebrows sit). Cisgender males also tend to have indented temples and a flatter forehead than females. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2035", "text": "The brow ridge is usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the  glabella ) sits over a hollow area called the  frontal sinus . The frontal sinus is hollow, and thus it can be more difficult to remove bossing there. If the bone over the frontal sinus is thick enough the bossing can be removed by simply grinding down the bone. However, in some people, the wall of bone is so thin that it is not possible to grind the bossing away completely without breaking through the wall into the frontal sinus. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2036", "text": "FFS surgeons have taken two main approaches to resolving this problem. The most conservative approach is to grind down the wall of bone as far as possible without breaking through, and then build up the area around any remaining bossing with  hydroxyapatite  bone cement which can smooth out any visible step between remaining bossing and the rest of the forehead. In these cases, some additional reduction in the bossing can sometimes be achieved by thinning the soft tissues that sit over it. Alternatively, FFS surgeons can perform a procedure called a forehead reconstruction or  cranioplasty  where the  glabella  bone is taken apart, thinned and re-shaped, and reassembled in the new feminine position with small titanium wires or titanium  orthopedic plate  and screws. [ 5 ]  The data on which approach is better is limited and does not provide guidance. [ 5 ]  The risks of cranioplasty include the skull not healing properly, movement of the bone fragments, and the formation of cysts; these can usually be corrected by another procedure. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2037", "text": "Cisgender men tend to have lower eyebrows relative to the position of their  brow ridges  when compared to cisgender women. Cis men's eyebrows tend to be below their brow ridges while cis women's eyebrows tend to be above their brow ridges. Accordingly, FFS to raise the eyebrows results in a face with a more womanly appearance. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2038", "text": "In some studies, the eye shape has been shown to be the key differentiating feature between cis males and females. [ 5 ] [ 10 ]  Cis female eye sockets tend to be smaller, located higher on the face, to have more sharply angled outer edges, and to be closer together at their inner edges (the  intercanthal distance ). [ 5 ]   Some FFS alter the orbit shape; data on outcomes is limited. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2039", "text": "Cis males tend to have larger, longer, and wider noses than cis females; also, the tip of the female nose will more often visibly point slightly upwards than that of a male. Hence, the procedure involves removing bone and cartilage and remodelling what remains. [ 5 ] [ 10 ]  In most cases this is performed in an open procedure, but endonasal procedures have been used; in all cases when reducing the nose there is a risk of interfering with  nasal valve  function. [ 5 ]  Standard rhinoplasty procedures are generally used. [ 11 ]  There is limited data on outcomes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2040", "text": "Cis females often have more forward projection in their cheekbones as well as fuller cheeks overall, with a triangle formed by the  cheekbones  and the point of the chin. Planning of cheek contouring is done while planning reshaping of the chin. [ 5 ]  The cheeks are reshaped by  cutting away bone  and repositioning the facial bones. [ 5 ]  Augmenting the cheeks with implants or with fat harvested from other parts of the body is common. Risks of implants include infection, and the implant moving and becoming asymmetrical; fat can eventually be absorbed. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2041", "text": "Subtle changes to the shape and structure of lips can have a strong influence on feminization. [ 5 ]  The distance between the base of the nose and the top of the upper lip tends to be longer in males than in females and the upper lip is longer; when a female mouth is open and relaxed, the upper incisors are often exposed by a few millimeters. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2042", "text": "An incision is usually made just under the base of the nose and a section of skin is removed. When the gap is closed it has the effect of lifting the top lip, placing it in a more feminine position and often exposing a little of the upper incisors. The surgeon can also use a lip lift to roll the top lip out a little, making it appear fuller. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2043", "text": "Cis females often have fuller lips than cis males, so  lip filling  is often used in feminization. Injectable fillers are low-risk but tend to be absorbed after six months or so, and many implants have higher complication rates like infection or rejection. [ 5 ]  Use of fat harvested from the person can result in lumps and does not last long. [ 5 ]  The longest lasting and least risky results appear to arise from use of  acellular dermis  products. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2044", "text": "The chins of cis males tend to be longer and wider than those of cis females, with a more square base, and to project outward more than female chins. [ 10 ]  Cis male jawlines tend to extend outward from the chin at a wider angle than those of cis females, and to have a sharp corner at the back. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2045", "text": "The  chin can be reduced  in length either by bone shaving or with a procedure called a \" sliding genioplasty \", where a section of bone is removed. The jaw can be reshaped through  jaw reduction  surgery; sometimes this is done through the mouth. The  chewing muscles  can also be reduced to make the jaw appear narrower. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2046", "text": "The biggest risk in these procedures is damage to the  mental nerve  that runs through the chin and jaw; other risks include damage to tooth roots, infection, nonunion, and damage to the  mentalis muscle  that controls the lower lip and is at the edges of the chin. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2047", "text": "Males tend to have a much more prominent  Adam's apple  than females following puberty. [ 5 ] [ 10 ]  The Adam's apple can be reduced with a procedure called a  chondrolaryngoplasty ; the goal of the procedure is to reduce the size without leaving a scar. [ 5 ]  There are risks of damage to the vocal cords and destabilization of the  epiglottis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2048", "text": "Beautification and rejuvenation procedures are often performed at the same time as facial feminisation. For example, it is common for eye bags and sagging eyelids to be corrected with a procedure called \" blepharoplasty \" and many feminization patients undergo a  face and neck lift . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2049", "text": "FFS techniques are derived from  maxillofacial ,  otolaryngology , and  plastic aesthetic and reconstructive surgery . [ 5 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2050", "text": "FFS began in 1982 when Darrell Pratt, a plastic surgeon who performed  sex reassignment surgeries , approached  Douglas Ousterhout  with a request from a transgender woman patient of Pratt's; the patient wanted plastic surgery to make her face appear more feminine, since people still reacted to her as though she were a man. [ 12 ]  Ousterhout's prior practice had involved reconstructing faces and skulls of people who had had birth defects, accidents, or other trauma. [ 12 ]  Ousterhout was interested in helping but knew that he did not know what a \"female face\" was, so he investigated by first reading the  physical anthropology  from the early 20th century to identify what features were \"female\", then deriving measurements defining those features from a series of  cephalograms  taken in the 1970s, and then working with a set of several hundred skulls to see if he could reliably differentiate which were females and which were males using those measurements. [ 6 ] [ 12 ]  Ousterhout then began working out what surgical techniques and materials he already used could be applied in order to transform a male face into a female face. He pioneered most of the procedures involved in FFS and was involved in their subsequent improvements as well. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2051", "text": "The  facial motor nucleus  is a  collection of neurons  in the  brainstem  that belong to the  facial nerve  ( cranial nerve  VII). [ 1 ]  These  lower motor neurons  innervate the  muscles of facial expression  and the  stapedius . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2052", "text": "The  nucleus  is situated in the caudal portion of the ventrolateral  pontine tegmentum . Its axons take an unusual course, traveling dorsally and looping around the  abducens nucleus , then traveling ventrally to exit the  ventral pons  medial to the  spinal trigeminal nucleus . These axons form the motor component of the  facial nerve , with  parasympathetic  and  sensory  components forming the  intermediate nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2053", "text": "The nucleus has a dorsal and ventral region, with neurons in the dorsal region innervating muscles of the upper face and neurons in the ventral region innervating muscles of the lower face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2054", "text": "Because it innervates muscles derived from  pharyngeal arches , the facial motor nucleus is considered part of the  special visceral efferent  (SVE) cell column, which also includes the  trigeminal motor nucleus ,  nucleus ambiguus , and (arguably) the  spinal accessory nucleus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2055", "text": "Like all lower motor neurons, cells of the facial motor nucleus receive  cortical input  from the  primary motor cortex  in the  frontal lobe  of the  brain .  Upper motor neurons  of the cortex send axons that descend through the  internal capsule  and synapse on neurons in the facial motor nucleus. This pathway from the cortex to the brainstem is called the  corticobulbar tract ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2056", "text": "The neurons in the dorsal aspect of the facial motor nucleus receive inputs from both sides of the cortex, while those in the ventral aspect mainly receive contralateral inputs (i.e. from the opposite side of the cortex). The result is that both sides of the brain control the muscles of the upper face, while the right side of the brain controls the lower left side of the face, and the left side of the brain controls the lower right side of the face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2057", "text": "As a result of the corticobulbar input to the facial motor nucleus, an upper motor neuron lesion to fibers innervating the facial motor nucleus results in  central seven . The syndrome is characterized by spastic paralysis of the contralateral lower face. For example, a left corticobulbar lesion results in paralysis of the muscles that control the lower right quadrant of the face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2058", "text": "By contrast, a lower motor neuron lesion to the facial motor nucleus results in  paralysis of facial muscles  on the same side of the injury. If a cause, such as trauma or infection, cannot be identified (this situation is called  idiopathic  palsy) this condition is known as  Bell's palsy .  Otherwise it is described by its cause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2059", "text": "Any lesion occurring within or affecting the corticobulbar tract is known as an upper motor neuron lesion.  Any lesion affecting the individual branches (temporal, zygomatic, buccal, mandibular and cervical) is known as a lower motor neuron lesion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2060", "text": "Branches of the facial nerve leaving the facial motor nucleus (FMN) for the muscles do so via both left and right posterior (dorsal) and anterior (ventral) routes.  In other words, this means lower motor neurons of the facial nerve can leave either from the left anterior, left posterior, right anterior or right posterior facial motor nucleus.  The temporal branch travels out from the left and right posterior components.  The inferior four branches do so via the left and right anterior components.  The left and right branches supply their respective sides of the face (ipsilateral innervation).  Accordingly, the posterior components receive motor input from both hemispheres of the cerebral cortex (bilaterally), whereas the anterior components receive strictly contralateral input.  This means that the temporal branch of the facial nerve receives motor input from both hemispheres of the cerebral cortex whereas the zygomatic, buccal, mandibular and cervical branches receive information from only contralateral hemispheres."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2061", "text": "Now, because the anterior FMN receives only contralateral cortical input whereas the posterior receives that which is bilateral, a corticobulbar lesion (UMN lesion) occurring in the left hemisphere would eliminate motor input to the right anterior FMN component, thus removing signaling to the inferior four facial nerve branches, thereby paralyzing the right mid- and lower-face.  The posterior component, however, although now only receiving input from the right hemisphere, is still able to allow the temporal branch to sufficiently innervate the entire forehead.  This means that the forehead will not be paralyzed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2062", "text": "The same mechanism applies for an upper motor neuron lesion in the right hemisphere.  The left anterior FMN component no longer receives cortical motor input due to its strict contralateral innervation, whereas the posterior component is still sufficiently supplied by the left hemisphere.  The result is paralysis of the left mid- and lower-face with an unaffected forehead."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2063", "text": "On the other hand, a lower motor neuron lesion is a bit different."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2064", "text": "A lesion on either the left or right side would affect both the anterior and posterior routes on that side because of their close physical proximity to one another.  So, a lesion on the left side would inhibit muscle innervation from both the left posterior and anterior routes, thus paralyzing the whole left side of the face ( Bell\u2019s palsy ).  With this type of lesion, the bilateral and contralateral inputs of the posterior and anterior routes, respectively, become irrelevant because the lesion is below the level of the medulla and the facial motor nucleus.  Whereas at a level above the medulla a lesion occurring in one hemisphere would mean that the other hemisphere could still sufficiently innervate the posterior facial motor nucleus, a lesion affecting a lower motor neuron would eliminate innervation altogether because the nerves no longer have a means to receive compensatory contralateral input at a downstream decussation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2065", "text": "Thus, the main distinction between an UMN and LMN lesion is that in the former, there is hemiplegia of the contralateral mid- and lower-face, whereas in the latter, there is complete hemiplegia of the ipsilateral face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2066", "text": "2\u00b0 ( Spinomesencephalic tract  \u2192  Superior colliculus  of  Midbrain tectum )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2067", "text": "The  facial muscles  are a group of striated  skeletal muscles  supplied by the  facial nerve  (cranial nerve VII) that, among other things, control facial expression.  These muscles are also called  mimetic muscles . They are only found in  mammals , although they derive from  neural crest  cells found in all vertebrates. They are the only muscles that attach to the  dermis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2068", "text": "The facial muscles are just under the skin ( subcutaneous ) muscles that control facial expression.  They generally  originate  from the surface of the  skull  bone (rarely the fascia), and insert on the skin of the face. When they contract, the skin moves. These muscles also cause wrinkles at right angles to the muscles\u2019 action line. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2069", "text": "The facial muscles are supplied by the facial nerve (cranial nerve VII), with each nerve serving one side of the face. [ 2 ]   In contrast, the nearby  masticatory muscles  are supplied by the  mandibular nerve , a branch of the  trigeminal nerve  (cranial nerve V)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2070", "text": "The facial muscles include: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2071", "text": "The  platysma  is supplied by the facial nerve. Although it is mostly in the neck and can be grouped with the neck muscles by location, it can be considered a muscle of facial expression due to its common nerve supply."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2072", "text": "The  stylohyoid muscle ,  stapedius  and posterior belly of the  digastric muscle  are also supplied by the facial nerve, but are not considered muscles of facial expression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2073", "text": "The facial muscles are derived from the second branchial/ pharyngeal arch . They, like the branchial arches, originally derive from neural crest cells. In humans, they typically begin forming around the eighth week of embryonic development. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2074", "text": "An inability to form facial expressions on one side of the face may be the first sign of damage to the nerve of these muscles. Damage to the facial nerve results in  facial paralysis  of the muscles of facial expression on the involved side. Paralysis is the loss of voluntary muscle action; the facial nerve has become damaged permanently or temporarily. This damage can occur with a  stroke ,  Bell palsy , or parotid salivary gland cancer (malignant neoplasm) because the facial nerve travels through the gland. The  parotid gland  can also be damaged permanently by surgery or temporarily by trauma. These situations of paralysis not only inhibit facial expression but also seriously impair the patient\u2019s ability to speak, either permanently or temporarily. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2075", "text": "The  facial nerve , also known as the  seventh cranial nerve ,  cranial nerve VII , or simply  CN VII , is a  cranial nerve  that emerges from the  pons  of the  brainstem , controls the  muscles of facial expression , and functions in the conveyance of  taste  sensations from the anterior two-thirds of the  tongue . [ 1 ] [ 2 ]  The nerve typically travels from the pons through the  facial canal  in the  temporal bone  and exits the skull at the  stylomastoid foramen . [ 3 ]  It arises from the brainstem from an area posterior to the  cranial nerve VI  (abducens nerve) and anterior to  cranial nerve VIII  (vestibulocochlear nerve)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2076", "text": "The facial nerve also supplies preganglionic  parasympathetic  fibers to several head and neck  ganglia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2077", "text": "The facial and  intermediate nerves  can be collectively referred to as the  nervus intermediofacialis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2078", "text": "The path of the facial nerve can be divided into six segments:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2079", "text": "The motor part of the facial nerve arises from the  facial nerve nucleus  in the  pons , while the sensory and parasympathetic parts of the facial nerve arise from the  intermediate nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2080", "text": "From the brain stem, the motor and sensory parts of the facial nerve join and traverse the  posterior cranial fossa  before entering the  petrous temporal bone  via the  internal auditory meatus .  Upon exiting the internal auditory meatus, the nerve then runs a tortuous course through the  facial canal , which is divided into the labyrinthine, tympanic, and mastoid segments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2081", "text": "The labyrinthine segment is the shortest and narrowest segment of the facial nerve and ends where the facial nerve forms a bend known as the geniculum of the facial nerve ( genu  meaning knee), which contains the  geniculate ganglion  for sensory nerve bodies.  The first branch of the facial nerve, the  greater petrosal nerve , arises here from the geniculate ganglion. The greater petrosal nerve runs through the  pterygoid canal  and synapses at the  pterygopalatine ganglion .  Postsynaptic fibers of the greater petrosal nerve innervate the  lacrimal gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2082", "text": "In the tympanic segment, the facial nerve runs through the  tympanic cavity , medial to the  incus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2083", "text": "The  pyramidal eminence  is the second bend in the facial nerve, where the nerve runs downward as the mastoid segment, the longest segment of the facial nerve.  In the temporal part of the facial canal, the nerve gives branch to the  stapedius muscle  and  chorda tympani . The chorda tympani supplies taste fibers to the anterior two thirds of the tongue, and also synapses with the  submandibular ganglion . Postsynaptic fibers from the submandibular ganglion supply the  sublingual  and  submandibular glands ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2084", "text": "Upon emerging from the  stylomastoid foramen , the facial nerve gives rise to the  posterior auricular branch .  It then gives rise to the branch to the posterior belly of the digastric, and then the branch to the stylohyoid.  The facial nerve then passes through the  parotid gland , which it does not innervate, to form the  parotid plexus . The nerve then bifurcates at the  pes anserinus  to become the upper and lower divisions of the facial nerve. [ 4 ]  It then splits into five branches (temporal, zygomatic, buccal, marginal mandibular and cervical), innervating the  muscles of facial expression . [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2085", "text": "The  greater petrosal nerve  arises at the  superior salivatory nucleus  of the pons and provides parasympathetic innervation to several glands, including the  nasal glands , the  palatine glands , the  lacrimal gland , and the  pharyngeal gland . It also provides parasympathetic innervation to the  sphenoid sinus ,  frontal sinus ,  maxillary sinus ,  ethmoid sinus , and  nasal cavity . This nerve also includes taste fibers for the  palate  via the  lesser palatine nerve  and  greater palatine nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2086", "text": "The communicating branch to the  otic ganglion  arises at the  geniculate ganglion  and joins the  lesser petrosal nerve  to reach the otic ganglion. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2087", "text": "The  nerve to stapedius  provides motor innervation for the  stapedius muscle  in middle ear"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2088", "text": "The  chorda tympani  provides parasympathetic innervation to the sublingual and submandibular glands, as well as special sensory taste fibers for the anterior two thirds of the tongue. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2089", "text": "Distal to  stylomastoid foramen , the following nerves branch off the facial nerve:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2090", "text": "Intra operatively the facial nerve is recognized at 3 constant landmarks: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2091", "text": "The  cell bodies  for the facial nerve are grouped in anatomical areas called  nuclei  or  ganglia . The cell bodies for the afferent nerves are found in the  geniculate ganglion  for taste sensation.  The cell bodies for muscular efferent nerves are found in the  facial motor nucleus  whereas the cell bodies for the parasympathetic efferent nerves are found in the  superior salivatory nucleus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2092", "text": "The facial nerve is developmentally derived from the second  pharyngeal arch , or branchial arch.  The second arch is called the hyoid arch because it contributes to the formation of the lesser horn and upper body of the  hyoid bone  (the rest of the hyoid is formed by the third arch).  The facial nerve supplies motor and sensory innervation to the muscles formed by the second pharyngeal arch, including the muscles of facial expression, the posterior belly of the digastric, stylohyoid, and stapedius.  The motor division of the facial nerve is derived from the  basal plate  of the embryonic pons, while the sensory division originates from the  cranial neural crest . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2093", "text": "Although the anterior two thirds of the tongue are derived from the first pharyngeal arch, which gives rise to the trigeminal nerve, not all innervation of the tongue is supplied by it.  The lingual branch of the  mandibular division  (V3) of the  trigeminal nerve  supplies non-taste sensation (pressure, heat, texture) to the anterior part of the tongue via  general somatic afferent fibers .  Nerve fibers for taste are supplied by the chorda tympani branch of the facial nerve via  special visceral afferent  fibers. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2094", "text": "The main function of the facial nerve is motor control of all the  muscles of facial expression . It also innervates the posterior belly of the  digastric muscle , the  stylohyoid muscle , and the  stapedius muscle  of the  middle ear . These  skeletal muscles  are developed from the  second pharyngeal arch ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2095", "text": "In addition, the facial nerve receives  taste  sensations from the anterior two-thirds of the  tongue  via the  chorda tympani . Taste sensation is sent to the gustatory portion (superior part) of the  solitary nucleus . General sensation from the anterior two-thirds of tongue are supplied by afferent fibers of the third division of the fifth cranial nerve ( CN V -3). These sensory ( CN V3 ) and taste (VII) fibers travel together as the lingual nerve briefly before the chorda tympani leaves the lingual nerve to enter the tympanic cavity (middle ear) via the petrotympanic fissure. It joins the rest of the facial nerve via the canaliculus for chorda tympani. The facial nerve then forms the  geniculate ganglion , which contains the cell bodies of the taste fibers of chorda tympani and other taste and sensory pathways. From the geniculate ganglion, the taste fibers continue as the intermediate nerve which goes to the upper anterior quadrant of the fundus of the  internal acoustic meatus  along with the motor root of the facial nerve. The intermediate nerve reaches the posterior cranial fossa via the internal acoustic meatus before synapsing in the  solitary nucleus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2096", "text": "The facial nerve also supplies a small amount of afferent innervation to the  oropharynx  below the  palatine tonsil . There is also a small amount of cutaneous sensation carried by the  nervus intermedius  from the skin in and around the  auricle  (outer ear)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2097", "text": "The facial nerve also supplies  parasympathetic  fibers to the  submandibular gland  and  sublingual glands  via  chorda tympani . Parasympathetic innervation serves to increase the flow of saliva from these glands. It also supplies parasympathetic innervation to the nasal mucosa and the  lacrimal gland  via the  pterygopalatine ganglion . The parasympathetic fibers that travel in the facial nerve originate in the  superior salivatory nucleus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2098", "text": "The facial nerve also functions as the efferent limb of the  corneal reflex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2099", "text": "The facial nerve carries axons of type GSA,  general somatic afferent , to skin of the posterior ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2100", "text": "The facial nerve also carries axons of type GVE,  general visceral efferent , which innervate the sublingual, submandibular, and lacrimal glands, also mucosa of nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2101", "text": "Axons of type SVE,  special visceral efferent , innervate muscles of facial expression, stapedius, the posterior belly of digastric, and the stylohyoid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2102", "text": "The axons of type SVA,  special visceral afferent , provide taste to the anterior two-thirds of tongue via  chorda tympani ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2103", "text": "People may suffer from  acute facial nerve paralysis , which is usually manifested by facial paralysis. [ 11 ]   Bell's palsy  is one type of  idiopathic  acute facial nerve paralysis, which is more accurately described as a multiple cranial nerve ganglionitis that involves the facial nerve, and most likely results from viral infection and also sometimes as a result of  Lyme disease . Iatrogenic Bell's palsy may also be as a result of an incorrectly placed dental local-anesthetic ( inferior alveolar nerve block ). Although giving the appearance of a hemiplegic stroke, effects dissipate with the drug. When the facial nerve is permanently damaged due to a birth defect, trauma, or other disorder, surgery including a cross facial nerve graft or masseteric facial nerve transfer may be performed to help regain facial movement. [ citation needed ]   Facial nerve decompression  surgery is also sometimes carried out in certain cases of facial nerve compression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2104", "text": "Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly (inability to do so is called  lagophthalmos ), [ 12 ]  pursing the lips and puffing out the cheeks, all test the facial nerve. There should be no noticeable asymmetry."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2105", "text": "In an  upper motor neuron  lesion, called  central seven , only the lower part of the face on the contralateral side will be affected, due to the bilateral control to the upper facial muscles ( frontalis  and  orbicularis oculi )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2106", "text": "Lower motor neuron  lesions can result in a CN VII palsy (Bell's palsy is the idiopathic form of facial nerve palsy), manifested as both upper and lower facial weakness on the same side of the lesion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2107", "text": "Taste can be tested on the anterior two-thirds of the tongue. This can be tested with a swab dipped in a flavored solution, or with electronic stimulation (similar to putting your tongue on a battery)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2108", "text": "Corneal reflex . The afferent arc is mediated by the general sensory afferents of the trigeminal nerve.  The efferent arc occurs via the facial nerve. The reflex involves consensual blinking of both eyes in response to stimulation of one eye. This is due to the facial nerves' innervation of the muscles of facial expression, namely orbicularis oculi, responsible for blinking. Thus, the corneal reflex effectively tests the proper functioning of both cranial nerves V and VII."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2109", "text": "This article incorporates text in the  public domain  from  page 901  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2110", "text": "Facial nerve paralysis  is a common problem that involves the  paralysis  of any structures innervated by the  facial nerve . The pathway of the facial nerve is long and relatively convoluted, so there are a number of causes that may result in facial nerve paralysis. [ 2 ]  The most common is  Bell's palsy , [ 3 ] [ 4 ]  a disease of unknown cause that may only be diagnosed by exclusion of identifiable serious causes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2111", "text": "Facial nerve paralysis is characterised by facial weakness, usually only in one side of the face, with other symptoms possibly including  loss of taste ,  hyperacusis  and  decreased salivation  and tear secretion [ ambiguous ] . Other signs may be linked to the cause of the paralysis, such as  vesicles  in the ear, which may occur if the facial palsy is due to  shingles . Symptoms may develop over several hours. [ 5 ]   :\u200a1228\u200a  Acute facial pain radiating from the ear may precede the onset of other symptoms. [ 6 ]   :\u200a2585"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2112", "text": "Bell's palsy is the most common cause of acute facial nerve paralysis. [ 3 ] [ 4 ]  There is no known cause of Bell's palsy, [ 5 ] [ 6 ]  although it has been associated with  herpes simplex  infection. Bell's palsy may develop over several days, and may last several months, in the majority of cases recovering spontaneously. It is typically diagnosed clinically, in patients with no risk factors for other causes, without vesicles in the ear, and with no other  neurological signs . Recovery may be delayed in the elderly, or those with a complete paralysis. Bell's palsy is often treated with  corticosteroids . [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2113", "text": "Lyme disease , an infection caused by  Borrelia burgdorferi  bacteria and spread by  ticks , can account for about 25% of cases of facial palsy in areas where Lyme disease is common. [ 7 ]  In the U.S., Lyme is most common in the  New England  and  Mid-Atlantic  states and parts of  Wisconsin  and  Minnesota , but it is expanding into other areas. [ 8 ]  The first sign of about 80% of Lyme infections, typically one or two weeks after a tick bite, is usually an  expanding rash  that may be accompanied by headaches, body aches, fatigue, or fever. [ 9 ]  In up to 10-15% of Lyme infections, facial palsy appears several weeks later, and may be the first sign of infection that is noticed, as the Lyme rash typically does not itch and is not painful. Lyme disease is treated with antibiotics. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2114", "text": "Reactivation of  varicella zoster virus , as well as being associated with Bell's palsy, may also be a direct cause of facial nerve palsy. Reactivation of latent virus within the  geniculate ganglion  is associated with vesicles affecting the ear canal, and termed  Ramsay Hunt syndrome type 2 . [ 6 ]  In addition to facial paralysis, symptoms may include ear pain and vesicles,  sensorineural hearing loss , and  vertigo . Management includes  antiviral drugs  and oral  steroids ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2115", "text": "Otitis media  is an infection in the middle ear, which can spread to the facial nerve and inflame it, causing compression of the nerve in its canal.  Antibiotics  are used to control the otitis media, and other options include a wide  myringotomy  (an incision in the  tympanic membrane ) or decompression if the patient does not improve. \nChronic otitis media usually presents in an ear with chronic discharge ( otorrhea ), or hearing loss, with or without ear pain ( otalgia ). Once suspected, there should be immediate surgical exploration to determine if a  cholesteatoma  has formed as this must be removed if present.  Inflammation from the middle ear can spread to the canalis facialis of the temporal bone - through this canal travels the facial nerve together with the statoacoustisus nerve. In the case of inflammation the nerve is exposed to edema and subsequent high pressure, resulting in a periferic type palsy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2116", "text": "In  blunt trauma , the facial nerve is the most commonly injured  cranial nerve . [ 12 ]   Physical trauma , especially  fractures  of the  temporal bone , may also cause acute facial nerve paralysis. Understandably, the likelihood of facial paralysis after trauma depends on the location of the trauma. Most commonly, facial paralysis follows temporal bone fractures, though the likelihood depends on the type of fracture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2117", "text": "Transverse fractures  in the horizontal plane present the highest likelihood of facial paralysis (40-50%). Patients may also present with blood behind the tympanic membrane, sensory deafness, and  vertigo ; the latter two symptoms due to damage to  vestibulocochlear nerve  and the inner ear.  Longitudinal fracture  in the vertical plane present a lower likelihood of paralysis (20%). Patients may present with blood coming out of the  external auditory meatus ),  tympanic membrane  tear, fracture of  external auditory canal , and  conductive hearing loss . In patients with mild injuries, management is the same as with Bell's palsy \u2013 protect the  eyes  and wait. In patients with severe injury, progress is followed with nerve conduction studies. If nerve conduction studies show a large (>90%) change in nerve conduction, the nerve should be decompressed. The facial paralysis can follow immediately the trauma due to direct damage to the facial nerve, in such cases a surgical treatment may be attempted. In other cases the facial paralysis can occur a long time after the trauma due to oedema and inflammation. In those cases steroids can be a good help."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2118", "text": "A  tumor  compressing the facial nerve anywhere along its complex pathway can result in facial paralysis. Common culprits are  facial neuromas , congenital  cholesteatomas ,  hemangiomas ,  acoustic neuromas ,  parotid gland   neoplasms , or  metastases  of other tumours. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2119", "text": "Often, since facial neoplasms have such an intimate relationship with the facial nerve, removing tumors in this region becomes perplexing as the physician is unsure how to manage the tumor without causing even more palsy. Typically, benign tumors should be removed in a fashion that preserves the facial nerve, while malignant tumors should always be resected along with large areas of tissue around them, including the facial nerve.  While this will inevitably lead to facial paralysis, safe removal of a malignant neoplasm is vital for patient survival. After tumor removal, the facial nerve can be reinnervated with techniques such as cross-facial nerve grafting, nerve transfers and end-to-end nerve repair. [ 15 ]  Alternative treatment methods include muscle transfer techniques, such as the gracilis free muscle transfer [ 16 ]  or static procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2120", "text": "Patients with facial nerve paralysis resulting from tumours usually present with a progressive, twitching paralysis, other neurological signs, or a recurrent Bell's palsy-type presentation.\nThe latter should always be suspicious, as Bell's palsy should not recur. A chronically discharging ear must be treated as a cholesteatoma until proven otherwise; hence, there must be immediate  surgical  exploration. Computed tomography (CT) or magnetic resonance (MR) imaging should be used to identify the location of the tumour, and it should be managed accordingly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2121", "text": "Other neoplastic causes include  leptomeningeal carcinomatosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2122", "text": "Central facial palsy  can be caused by a  lacunar infarct  affecting fibers in the  internal capsule  going to the nucleus. The  facial nucleus  itself can be affected by infarcts of the  pontine arteries . Unlike peripheral facial palsy, central facial palsy does not affect the forehead, because the forehead is served by nerves coming from both motor cortexes. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2123", "text": "Other causes may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2124", "text": "A  medical history  and  physical examination , including a  neurological examination , are needed for diagnosis. The first step is to observe what parts of the face do not move normally when the person tries to smile, blink, or raise the eyebrows. If the forehead wrinkles normally, a diagnosis of  central facial palsy  is made, and the person should be evaluated for  stroke . [ 7 ]  Otherwise, the diagnosis is peripheral facial palsy, and its cause needs to be identified, if possible. Ramsey Hunt's syndrome causes pain and small blisters in the ear on the same side as the palsy. Otitis media, trauma, or post-surgical complications may alternatively become apparent from history and physical examination. If there is a history of trauma, or a tumour is suspected, a  CT scan  or  MRI  may be used to clarify its impact. Blood tests or  x-rays  may be ordered depending on suspected causes. [ 6 ]  The likelihood that the facial palsy is caused by  Lyme disease  should be estimated, based on recent history of outdoor activities in likely tick habitats during warmer months, recent history of rash or symptoms such as headache and fever, and whether the palsy affects both sides of the face (much more common in Lyme than in Bell's palsy). If that likelihood is more than negligible, a serological test for Lyme disease should be performed. If the test is positive, the diagnosis is Lyme disease. If no cause is found, the diagnosis is Bell's Palsy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2125", "text": "Facial nerve paralysis may be divided into supranuclear and infranuclear lesions. In a clinical setting, other commonly used classifications include: intra-cranial and extra-cranial; acute, subacute and chronic duration. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2126", "text": "Central facial palsy  can be caused by a  lacunar infarct  affecting fibers in the  internal capsule  going to the nucleus. The  facial nucleus  itself can be affected by infarcts of the  pontine arteries . These are corticobulbar fibers travelling in internal capsule."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2127", "text": "Infranuclear lesions refer to the majority of causes of facial palsy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2128", "text": "If an underlying cause has been found for the facial palsy, it should be treated. If it is estimated that the likelihood that the facial palsy is caused by  Lyme disease  exceeds 10%,  empiric therapy  with antibiotics should be initiated, without  corticosteroids , and reevaluated upon completion of laboratory tests for Lyme disease. [ 7 ]  All other patients should be treated with corticosteroids and, if the palsy is severe,  antivirals . Facial palsy is considered severe if the person is unable to close the affected eye completely or the face is asymmetric even at rest. Corticosteroids initiated within three days of Bell's palsy onset have been found to increase chances of recovery, reduce time to recovery, and reduce residual symptoms in case of incomplete recovery. [ 7 ]  However, for facial palsy caused by Lyme disease, corticosteroids have been found in some studies to harm outcomes. [ 7 ]  Other studies have found antivirals to possibly improve outcomes relative to corticosteroids alone for severe Bell's palsy. [ 7 ]  In those whose blinking is disrupted by the facial palsy, frequent use of artificial tears while awake is recommended, along with ointment and a patch or taping the eye closed when sleeping. [ 7 ] [ 18 ]  Several surgical treatment options exist to restore symmetry to the paralyzed face in patients where function does not return (see section Tumors above)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2129", "text": "A study followed thirty individuals with facial paralysis following a stroke. Six months after the onset of paralysis, two-thirds of the patients had fully recovered or only had mild facial paralysis. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2130", "text": "In the case of Bell's palsy, 71% of individuals fully recover without any  sequelae . Additionally, the majority of individuals begin to recover within seven days after the onset of paralysis. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2131", "text": "Facial rejuvenation  is a cosmetic treatment (or series of cosmetic treatments), which aims to restore a youthful appearance to the human  face . Facial rejuvenation can be achieved through either  surgical  and/or non-surgical options. Procedures can vary in  invasiveness  and depth of treatment. Surgical procedures can restore  facial symmetry  through targeted procedures and facial restructuring and skin alterations. Non-surgical procedures can target specific depths of facial structures and treat localized facial concerns such as  wrinkles , skin laxity,  hyperpigmentation  and  scars ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2132", "text": "Surgical (invasive) facial rejuvenation procedures can include a  brow lift  (forehead lift), eye lift ( blepharoplasty ),  facelift  (rhytidectomy), chin lift and  neck lift . Non-surgical (non-invasive) facial rejuvenation treatments can include  chemical peels , neuromodulator (such as  botox ),  dermal fillers ,  laser resurfacing ,  photorejuvenation ,  radiofrequency  and  Ultrasound ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2133", "text": "Human  visual perception  is notable for its sensitivity and accuracy in estimating our perceived age by instant  pattern recognition  of facial features. Often, human faces with no measurable difference in  facial geometry  and appearance are perceived as having different ages. This mechanism is not yet entirely understood, but there may be a relation to the subtle changes in facial bone structure related below. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2134", "text": "Facial symmetry  has a direct relationship to perceived beauty. A guiding approach to facial rejuvenation and balancing facial symmetry is through an application of the  golden ratio . [ 2 ]  Artists and architects have been using this ratio to create works that are pleasing to the eye for centuries. [ 3 ]   Aesthetic medicine  and facial rejuvenation techniques has adopted this mathematical approach to facial restoration and enhancement. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2135", "text": "More recent research has pointed out the influence of changes in the facial  skeleton  with age on the appearance of aging, especially in the mid-face area and the lower part of the  orbits  around the  nose . Quantitative study with  CAT scans  of the faces of men and women in several age brackets has revealed that there is an appreciable amount of   bone  tissue loss in these regions with age, leading to changes in angles, lengths and volumes, and also decreasing the distance between the  eyes . [ 4 ]  It has been hypothesized that skin sagging and wrinkles may occur not only because of loss of soft tissue and fat, but also because bone retraction creates an excess of skin which is no longer flexible. Many of the facial manifestations of aging reflect the combined effects of gravity, progressive  bone resorption , decreased tissue elasticity, and redistribution of subcutaneous fullness. [ 5 ]  Future facial rejuvenation techniques may take into account these findings and restore bone lost by aging processes. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2136", "text": "According to the  American Society of Plastic Surgeons , more than 133,000 facelifts and nearly 216,000 eyelid surgeries were performed in the US in 2013, a six per cent increase from 2012. Facial rejuvenation procedures experienced the most growth, as 2013 marked the highest number of botulinum toxin type A injections to date, with 6.3 million injections. [ 7 ]  A significant upward trend on the number of facial rejuvenation procedures is predicted, [ 5 ]  and could be due to the following factors:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2137", "text": "However, while surgical procedures are still preferred to achieve a more dramatic improvement, the current trend is towards less invasive procedures, such as injectables (Botox, fillers) and laser skin treatments. While these treatments achieve temporary results, they tend to be preferred because of their reduced cost and less intensive recovery period. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2138", "text": "Facial rejuvenation procedures can include (but are not limited to):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2139", "text": "A  forehead lift , also known as a browlift or browplasty, is a  cosmetic surgery  procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep \"worry\" lines that run across the  forehead ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2140", "text": "The first documented medical discussion about a forehead lift was written in 1910 by the famous German surgeon  Erich Lexer . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2141", "text": "Since the advent of the hugely popular wrinkle remover,  Botox  (Dysport in the United Kingdom and Europe) many consumers have eschewed the invasive surgery altogether, opting for Botox injections every four to six months to get the same results. Botox is also used after some forehead lift procedures to increase the effects of the surgeries. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2142", "text": "Endoscopic  surgery is often employed in forehead lifts. [ 3 ]  An endoscope is a surgical system with thin, pencil-sized arms that are inserted through three to five incisions about 3/8 of an inch long. One of the instrument's arms is a lighted camera that displays what it sees under the patient's skin on a television monitor. [ 4 ]  Other arms on the Endoscope carry actual surgical tools that perform cutting, or grasping functions. The surgeon watches the television monitor to guide his movements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2143", "text": "Another type of surgical technique is the coronal brow lift, in which a bicoronal incision is made. This technique was popularized in the 1980s and 1990s, but has fallen out of favor compared to the endoscopic technique. [ 5 ]  Other techniques include the direct brow lift, [ 6 ]  mid-forehead brow lift, [ 7 ]  pretrichial brow lift, [ 8 ]  temporal brow lift, and internal (transblepharoplasty) brow lift."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2144", "text": "When surgeons have problems with an endoscopic forehead lift, \u2013 in about one percent of cases \u2013 they finish the procedure by switching to the open forehead lift method."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2145", "text": "Complications are said to be rare and minor when a forehead lift is performed by a surgeon trained in the technique. However, it is possible for the surgical process to damage the nerves that control eyebrow and forehead movements. Hair loss can also occur along the scar edges in the scalp when an incision is made through the hairline.  Moreover, infection and bleeding are possible with any surgical procedure. [ 9 ]  Compared to endoscopic techniques, coronal brow lift techniques have a higher risk of elevating the frontal hairline and decreasing scalp sensation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2146", "text": "Patients who have Endotine implants in their foreheads risk moving their newly adjusted tissues with relatively small movements just after the operation and before complete healing takes place. While the implant absorbs into the body, the Endotine generally does not support the very thick forehead flesh and heavy brows often seen in some overweight males. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2147", "text": "Foreign body aspiration  occurs when a foreign body enters the  airway  which can cause difficulty breathing or  choking . [ 1 ]  Objects may reach the respiratory tract and the digestive tract from the mouth and nose, but when an object enters the respiratory tract it is termed aspiration. The foreign body can then become lodged in the trachea or further down the respiratory tract such as in a bronchus. [ 2 ]  Regardless of the type of object, any aspiration can be a life-threatening situation and requires timely recognition and action to minimize risk of complications. [ 3 ]  While advances have been made in management of this condition leading to significantly improved clinical outcomes, there were still 2,700 deaths resulting from foreign body aspiration in 2018. [ 4 ]   Approximately one child dies every five days due to choking on food in the United States, highlighting the need for improvements in education and prevention. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2148", "text": "Signs and symptoms of foreign body aspiration vary based on the site of obstruction, the size of the foreign body, and the severity of obstruction. [ 2 ]  20% of foreign bodies become lodged in the upper airway, while 80% become lodged in a  bronchus . [ 6 ]  Signs of foreign body aspiration are usually abrupt in onset and can involve coughing, choking, and/or  wheezing ; however, symptoms can be slower in onset if the foreign body does not cause a large degree of obstruction of the airway. [ 2 ]  With this said, aspiration can also be asymptomatic on rare occasions. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2149", "text": "Classically, patients present with acute onset of choking. [ 2 ]  In these cases, the obstruction is classified as a partial or complete obstruction. [ 2 ]  Signs of partial obstruction include choking with drooling,  stridor , and the patient maintains the ability to speak. [ 2 ]  Signs of complete obstruction include choking with inability to speak or absence of bilateral breath sounds among other signs of respiratory distress such as  cyanosis . [ 2 ]  A fever may be present. When this is the case, it is possible the object may be chemically irritating or contaminated. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2150", "text": "Foreign bodies above the  larynx  often present with stridor, while objects below the larynx present with wheezing. [ 6 ]  Foreign bodies above the vocal cords often present with difficulty and pain with swallowing and excessive drooling. [ 8 ]  Foreign bodies below the vocal cords often present with pain and difficulty with speaking and breathing. [ 8 ]  Increased respiratory rate may be the only sign of foreign body aspiration in a child who cannot verbalize or report if they have swallowed a foreign body. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2151", "text": "If the foreign body does not cause a large degree of obstruction, patients may present with chronic cough, asymmetrical breath sounds on exam, or recurrent  pneumonia  of a specific lung lobe. [ 2 ]  If the aspiration occurred weeks or even months ago, the object may lead to an obstructive pneumonia or even a lung abscess. Therefore, it is important to consider chronic foreign body aspiration in patients whose histories include unexplained recurrent pneumonia or lung abscess with or without fever. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2152", "text": "In adults, the right lower lobe of the lung is the most common site of recurrent pneumonia in foreign body aspiration. [ 2 ]  This is due to the fact that the anatomy of the right main bronchus is wider and steeper than that of the left main bronchus, allowing objects to enter more easily than the left side. [ 2 ]  Unlike adults, there is only a slight propensity towards objects lodging in the right bronchus in children. [ 7 ]  This is likely due to the bilateral bronchial angles being symmetric until about 15 years of age when the  aortic knob  fully develops and displaces the  left main bronchus . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2153", "text": "Signs and symptoms of foreign body aspiration in adults may also mimic other lung disorders such as  asthma ,  COPD , and  lung cancer . [ 9 ] \n{"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2154", "text": "Most cases of foreign body aspiration are in children ages 6 months to 3 years due to the tendency for children to place small objects in the mouth and nose. Children of this age usually lack molars and cannot grind up food into small pieces for proper swallowing. [ 8 ]  Small, round objects including nuts, hard candy, popcorn kernels, beans, and berries are common causes of foreign body aspiration. [ 2 ]  Latex balloons are also a serious choking hazard in children that can result in death. A latex balloon will conform to the shape of the  trachea , blocking the airway and making it difficult to expel with the  Heimlich maneuver . [ 10 ]  In addition, if the foreign body is able to absorb water, such as a bean, seed, or corn, among other things, it may swell over time leading to a more severe obstruction. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2155", "text": "In adults, foreign body aspiration is most prevalent in populations with impaired swallowing mechanisms such as the following: neurological disorders, alcohol use, advanced age leading to senility (most common in the 6th decade of life), and loss of consciousness. [ 11 ]  This inadequate airway protection may also be attributed to poor dentition, seizure, general anesthesia, or  sedative  drug use. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2156", "text": "The most important aspect of the assessment for a clinician is an accurate history provided by an event witness. [ 7 ]  Unfortunately, this is not always available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2157", "text": "A physical examination by a clinician should include, at a minimum, a general assessment in addition to cardiac and pulmonary exams. Auscultation of breath sounds may give additional information regarding object location and the degree of airway obstruction. [ 7 ]  The presence of drooling and dysphagia (drooling) should always be noted alongside the classic signs of airway obstruction as these can indicate involvement of the esophagus and impact management. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2158", "text": "Radiography is the most common form of imaging used in the initial assessment of a foreign body presentation. Most patients receive a  chest x-ray  to determine the location of the foreign body. [ 2 ]  Lateral neck, chest, and bilateral decubitus end-expiratory chest x-rays should be obtained in patients suspected of having aspirated a foreign body. [ 6 ]  However, the presence of normal findings on chest radiography should not rule out foreign body aspiration as not all objects can be visualized. [ 2 ]  In fact, up to 50% of cases can have normal findings on radiography. [ 7 ]  This is because visibility of an object depends on many factors, such as the object's material, size, anatomic location and surrounding structures, as well as the patient's body habitus. [ 13 ]  X-ray beams only show an object if that object's composition blocks the rays from traveling through, making it  radiopaque  and appearing lighter or white on the image. This also requires it to not be stuck behind something that blocks the beams first. [ 13 ]  Objects that are radiopaque include items made of most metals except aluminum, bones except most fish bones, and glass. If the material does not block the x-ray beams it is considered  radiolucent  and will appear dark which prevents visualization. [ 13 ]  This includes material such as most plastics, most fish bones, wood, and most aluminum objects. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2159", "text": "Other diagnostic imaging modalities, such as  magnetic resonance imaging ,  computed tomography , and  ventilation perfusion scans  play a limited role in the diagnosis of foreign body aspiration. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2160", "text": "Signs on x-ray that are more commonly seen than the object itself and can be indicative of foreign body aspiration include visualization of the foreign body or hyperinflation of the affected lung. [ 13 ]  Other x-ray findings that can be seen with foreign body aspiration include obstructive  emphysema ,  atelectasis , and consolidation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2161", "text": "While, x-ray can be used to visualize the location and identity of a foreign body,  rigid bronchoscopy  under general anesthesia is the gold-standard for diagnosis since the foreign body can be visualized and removed with this intervention. [ 2 ]  Rigid bronchoscopy is indicated when two of the three following criteria are met: report of foreign body aspiration by the patient or a witness, abnormal lung exam findings, or abnormal chest x-ray findings. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2162", "text": "See also:   Choking \u00a7 Treatment ,  Basic Life Support ,  Advanced Cardiovascular Life Support"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2163", "text": "Treatment of foreign body aspiration is determined by the age of the patient and the severity of obstruction of the airway involved. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2164", "text": "An airway obstruction can be partial or complete. In partial obstruction, the patient can usually clear the foreign body with coughing. [ 2 ]  In complete obstruction, acute intervention is required to remove the foreign body. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2165", "text": "If foreign body aspiration is suspected, finger sweeping in the mouth is not recommended due to the increased risk of displacing the foreign object further into the airway. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2166", "text": "For choking children less than 1 year of age, the child should be placed face down over the rescuer's arm. [ 2 ]  Back blows should be delivered with the heel of the hand, then the patient should be turned face-up and chest thrusts should be administered. [ 2 ]  The rescuer should alternate five back blows followed by five chest thrusts until the object is cleared. [ 2 ]  The  Heimlich maneuver  should be used in choking patients older than 1 year of age to dislodge a foreign body. [ 2 ]  If the patient becomes unresponsive during physical intervention,  cardiopulmonary resuscitation  (CPR) should be started. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2167", "text": "In the event that the basic measures do not remove the foreign body, and adequate ventilation cannot be restored, need for treatment by trained personnel becomes necessary. [ 2 ]   Laryngoscopy  should be performed in unresponsive patients if non-invasive airway clearance techniques are unsuccessful. [ 6 ]  Laryngoscopy involves placing a device in the mouth to visualize the back of the airway. [ 6 ]  If the foreign body can be seen, it can be removed with  forceps . [ 6 ]  An  endotracheal tube  should then be placed in order to prevent airway compromise from resulting inflammation after the procedure. [ 6 ]  If the foreign body cannot be visualized, intubation,  tracheotomy , or needle  cricothyrotomy  can be done to restore an airway for patients who have become unresponsive due to airway compromise. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2168", "text": "If non-invasive measures do not dislodge the foreign body, and the patient can maintain adequate ventilation,  rigid bronchoscopy  under general anesthesia should be performed. [ 2 ]  Supplemental oxygen,  cardiac monitoring , and a  pulse oximeter  should be applied to the patient. [ 6 ]  Efforts should be made to keep the patient calm and avoid agitating the patient to prevent further airway compromise. [ 6 ]  Flexible rather than rigid bronchoscopy might be used when the diagnosis or object location are unclear. When  flexible bronchoscope  is used, rigid bronchoscope is typically on standby and readily available as this is the preferred approach for removal. [ 14 ]  Rigid bronchoscopy allows good airway control, ready bleeding management, better visualization, and ability to manipulate the aspirated object with a variety of forceps. [ 14 ]  Flexible bronchoscopy may be used for extraction when distal access is needed and the operator is experienced in this technique. [ 14 ]  Potential advantages include avoidance of  general anesthesia  as well as the ability to reach subsegmental bronchi which are smaller in diameter and further down the respiratory tract than the main bronchi. [ 14 ]  The main disadvantage of using a flexible scope is the risk of further dislodging the object and causing airway compromise. [ 14 ]  Bronchoscopy is successful in removing the foreign body in approximately 95% of cases with a complication rate of only 1%. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2169", "text": "After the foreign body is removed, patients should receive nebulized beta-adrenergic medication and  chest physiotherapy  to further protect the airway. [ 2 ]   Steroidal anti-inflammatories  and antibiotics are not routinely administered except in certain scenarios. [ 2 ]  These include situations such as when the foreign body is difficult or impossible to extract, when there is a documented respiratory tract infection, and when swelling within the airway occurs after removal of the object. [ 14 ]   Glucocorticoids  may be administered when the foreign body is surrounded by inflamed tissue and extraction is difficult or impossible. [ 14 ]  In such cases, extraction may be delayed for a short course of glucocorticoids so that the inflammation may be reduced before subsequent attempts. [ 14 ]  These patients should remain under observation in the hospital until successful extraction as this practice can result in dislodgement of the foreign body. [ 14 ]  Antibiotics are appropriate when an infection has developed but should not delay extraction. [ 14 ]  In fact, removal of the object may improve infection control by removing the infectious source as well as using cultures taken during the bronchoscopy to guide antibiotic choice. [ 14 ]  When airway  edema  or swelling occur, the patient may have  stridor . In these cases, glucocorticoids, aerosolized  epinephrine , or helium oxygen therapy may be considered as part of the management plan. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2170", "text": "Patients who are clinically stable with no need for supplemental oxygen after extraction may be discharged from the hospital the same day as the procedure. [ 4 ]  Routine imaging such as a follow-up chest x-ray are not needed unless symptoms persist or worsen, or if the patient had imaging abnormalities previously to verify return to normal. [ 4 ]  Most children are discharged within 24 hours of the procedure. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2171", "text": "Many complications can develop if a foreign body remains in the airway. There are also complications that may occur after removal of the object depending on the timeline of events. [ 2 ]   Cardiac arrest and death are possible complications if a sudden complete obstruction occurs and immediate medical care is not performed. [ 7 ]  The most common complication from a foreign body aspiration is a pulmonary infection, such as  pneumonia  or a lung  abscess . [ 7 ]  This can be more difficult to overcome in the elderly population and lead to even further complications. Patients may develop inflammation of the airway walls from a foreign body remaining in the airway. [ 2 ]  Airway secretions can be retained behind the obstruction which creates an ideal environment for subsequent bacterial overgrowth. [ 7 ]  Hyperinflation of the airway distal to the obstruction can also occur if the foreign body is not removed. [ 9 ]  Episodes of recurrent pneumonia in the same lung field should prompt evaluation for a possible foreign body in the airway. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2172", "text": "Whether or not the foreign body is removed, complications such as chemical  bronchitis , mucosal reactions, and the development of granulation tissue are possible. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2173", "text": "Complications can also arise from interventions used to remove a foreign body from the airway. [ 15 ]  Rigid bronchoscopy is the gold standard for removal of a foreign body, however this intervention does have potential risks. [ 15 ]  The most common complication from rigid bronchoscopy is damage to the patient's teeth. [ 15 ]  Other less common complications include cuts to the mouth or esophagus, perforation of the bronchial tree, damage to the vocal cords, pneumothorax, atelectasis, stricture, and perforation. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2174", "text": "There are many factors to consider when determining how to decrease the likelihood of aspiration, especially in the extremely young and elderly populations. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2175", "text": "The major considerations in children are their developmental level in terms of swallowing and protecting their airway via mechanisms such as coughing and the gag reflex. [ 5 ]  Also, certain object characteristics such as size, shape, and material can increase their potential to cause choking among children. [ 5 ]  When there are multiple children in a shared environment, toys and foods that are acceptable for older children often pose a choking risk to the younger children. [ 5 ]  Education for parents and caretakers should continue to be prioritized when possible. This can be through positions such as pediatricians, dentists, and school teachers as well as media advertisements and printed materials. This education should include educating caretakers on how to recognize choking and perform first aid and cardiopulmonary resuscitation, check for warning labels and toy recalls, and avoid high risk objects and foods. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2176", "text": "Thanks to numerous public advancements, such as the  Child Safety Protection Act  and the  Federal Hazardous Substance Act  (FHSA), warning labels for choking hazards are required on packaging for small balls, marbles, balloons, and toys with small parts when these are intended for use by children in at-risk age groups. [ 5 ]  Also, the  Consumer Product Safety Improvement Act  of 2008 amended the FHSA to also require advertisements on websites, catalogues, and other printed materials to include the choking hazard warnings. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2177", "text": "The  frontal sinuses  are one of the four pairs of  paranasal sinuses  that are situated behind the  brow ridges .  Sinuses  are  mucosa -lined airspaces within the bones of the face and skull. Each opens into the anterior part of the corresponding  middle nasal meatus  of the nose through the  frontonasal duct  which traverses the anterior part of the labyrinth of the  ethmoid . These structures then open into the  semilunar hiatus  in the  middle meatus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2178", "text": "Each frontal sinus is situated between the external and internal plates of the frontal bone. [ 1 ] [ 2 ]  Their average measurements are as follows: height 28\u00a0mm, breadth 24\u00a0mm, depth 20\u00a0mm, creating a space of 6-7 ml. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2179", "text": "Each frontal sinus extends into the  squamous part of the frontal bone  superiorly, and into the  orbital part of frontal bone  posteriorly to come to occupy the medial part of the roof of the orbit. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2180", "text": "Each sinus drains through an opening in its inferomedial part into the  frontonasal duct . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2181", "text": "The mucous membrane of [ citation needed ]  the frontal sinus receives arterial supply from the  supraorbital artery , and  anterior ethmoidal artery . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2182", "text": "Venous drainage is provided by the  superior ophthalmic vein . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2183", "text": "Lymph is drained into the  submandibular lymph nodes . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2184", "text": "The mucous membrane of [ citation needed ]  the sinus is innervated by the  supraorbital nerve , [ 2 ]  which contains the  postganglionic   parasympathetic  nerve fibers for  mucous   secretion  from the  ophthalmic nerve . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2185", "text": "Frontal sinuses are rarely symmetrical as the  septum  between them frequently deviates to either side of the midline. [ 3 ] [ 1 ]  The two sinuses also vary in extent compared to one another. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2186", "text": "Their size of the frontal sinuses is highly variable. [ 2 ]  Rarely, one or both sinuses is hypoplastic [ 1 ]  or even absent. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2187", "text": "Prominence of frontal sinuses is  sexual dimorphic ; they are more prominent in males, whereas less so in children and in females, resulting in an oblique forehead in males that is a male  sexual characteristic . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2188", "text": "The frontal sinuses are the only sinuses that are [ 2 ]  absent at birth. [ 2 ] [ 4 ]  They begin to appear during the second year of life as excavations in the  diplo\u00eb . [ 2 ]  The development of these sinuses accounts for the suddenly increased mucus production at this age. [ citation needed ]  They are generally well developed, and functional between the sixth and eighth years, though they continue to grow slower until reaching their maximum size after  puberty . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2189", "text": "Through its copious mucus production, the sinus is an essential part of the immune defense/air filtration carried out by the nose. Nasal and sinal mucosae are  ciliated  and move mucus to the  choanae  and finally to the stomach.  The thick upper layers of nasal mucus trap bacteria and small particles in tissue abundantly provided with  immune cells ,  antibodies , and antibacterial proteins.  The layers beneath are thinner and provide a substrate in which the cilia are able to beat and move the upper layer with its debris through the  ostia  toward the  choanae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2190", "text": "Infection of the frontal sinus causing sinusitis can give rise to serious complications, as it is in close proximity to the orbit and cranial cavity ( orbital cellulitis ,  epidural  and  subdural abscess ,  meningitis ). [ 4 ] \nEndonasal approach into the frontal sinus in children with acute and chronic frontal sinusitis without the usage of surgical optics is not successful, because in this case the operation is performed almost blindly and technically difficult even in adults. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2191", "text": "Frontal sinus fractures occur from trauma to the part of the frontal bone that overlies the sinus, often from motor vehicle accidents and falls. The hallmarks of a frontal sinus fracture is a frontal depression in the anterior table of the bone. Additionally, clear fluid leaking from the nose may indicate that fractures to the posterior table have torn into the  dura mater , creating a  cerebrospinal fluid  leak. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2192", "text": "Goals in management are to protect the intracranial structure, control any existing CSF leakage, prevent late complications, and aesthetically correct the deformity caused, if any. In anterior table fractures, if the table is minimally displaced, there will be no treatment necessary, only observation. If largely displaced, the correction is open reduction and internal fixation. If inhibiting the nasofrontal outflow tract, procedure is to undergo open reduction and internal fixation of the anterior table and osteoplastic flap with obliteration. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2193", "text": "In posterior table fractures, a nondiplaced fracture with no CSF leak will only be observed. Those with a CSF leak will undergo sinus exploration if the CSF leak is not internally resolved within 4 to 7 days. With more dramatic displacements, sinus exploration will be required to determine the required level of cranialization, obliteration, and reparation to the dura. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2194", "text": "In the case of  facial feminization surgery , modifications to the frontal sinus can be made to make the face more feminine, alongside softening the orbital rims. The forehead operations for feminization were first described by Dr.  Douglas Ousterhout  in the 1980s. Those operations consisted of four different techniques based on the anatomy of the patient. They were named arbitrarily by number (Type 1, Type 2, Type 3 and Type 4), with no particular relevance to their level of difficulty or frequency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2195", "text": "The Type I forehead describes a forehead with an absent frontal sinus or alternatively with sufficiently thick bone overlaying the frontal sinus so that burring alone is enough to correct the forehead. This type of forehead tends to occur in approximately 3% to 5% of the population. In these situations, the operation consists of using rotary instruments to shape and contour the bone to the desired level, while observing the thickness of the bone to avoid penetrating the intracranial space. The main risks associated with this operation tend to be bleeding. There are often venous lakes present throughout the frontal bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2196", "text": "The Type II forehead describes another uncommon situation. This describes a patient with brow bossing; however, the bossing is at the correction position in terms of prominence. Therefore, the problem lies primarily above the bossing. We see this forehead type at about the same frequency as we see the Type I forehead. The Type II forehead is corrected by using a filling material such as methyl methacrylate.7 Other materials may be more ideal at this point; however, none are superior in terms of cost to methyl methacrylate. Although many surgeons do not consider the cost of the materials they are using, hydroxyapatite and calcium phos-phate bone cements cost approximately 1000 times that of methyl methacrylate. The advantage of bone cement is its adherence to the underlying bone, and the more analogous nature to native bone substrate. The material is applied to fill in the area above the bossing, and then gently contoured to blend with the transverse forehead bossing thereby-creating a uniformly round forehead"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2197", "text": "The Type III forehead is the most common situation and occurs in more than 90% of patients. The forehead, in this situation, has a prominent bossing across the top of the brows, and that bossing is overly projected. A frontal sinus is present. The thinness of the sinus precludes using exclusively rotary instruments to thin the bone. An osteotomy and reconstruction are the only operations to provide the proper round shape to the forehead with the decreased prominence that is necessary for a soft forehead, which involves a setback of the anterior table of the frontal sinus. This procedure is described as Type 3 Forehead Cranioplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2198", "text": "This operation can be described as an extended Type II operation. In this situation, the entire forehead is diminutive, including the area underlying the brows, and the entire forehead requires augmentation. Regardless of the material type, care should be taken to avoid having the implant sit directly underneath the incision as this leads to a higher rate of infection and removal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2199", "text": "Treatment of the orbital rim is almost always necessary in all these various forehead operations, regardless of what is done with the frontal bossing. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2200", "text": "This article incorporates text in the  public domain  from  page 998  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2201", "text": "Functional endoscopic sinus surgery  ( FESS ) is a procedure that is used to treat  sinusitis  and other conditions that affect the  sinuses . Sinusitis is an  inflammation  of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2202", "text": "FESS is a minimally invasive procedure that is performed using an  endoscope , a thin, rigid tube with a camera on the end. The endoscope is inserted through the nostrils, allowing the surgeon to visualize the inside of the  nasal passages  and sinuses. The surgeon can then remove any tissue or obstruction that is blocking the sinuses, such as swollen or infected tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2203", "text": "FESS is generally considered to be a safe and effective treatment for sinusitis and other conditions that affect the sinuses. It can help to alleviate symptoms and improve the overall functioning of the sinuses. However, as with any medical procedure, there are potential risks and complications that should be discussed with a healthcare provider."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2204", "text": "The first recorded instance of endoscopy being used to visualize the nasal passage took place in  Berlin  in 1901. [ 1 ]  Alfred Hirschmann, a designer and maker of medical instruments, modified a  cystoscope  for use in the nasal cavity. In October 1903, Hirschmann published \"Endoscopy of the nose and its accessory sinuses.\" [ 2 ]  In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7\u00a0mm endoscope."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2205", "text": "In 1925,  Maxwell Maltz  created the term \"sinuscopy,\" referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2206", "text": "In the 1960s,  Harold Hopkins , then a PhD at the  University of Reading , used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy. [ 1 ]  Utilizing Hopkins' rod optic system, Walter Messenklinger visualized, recorded, and mapped the anatomy of the paranasal sinuses and the lateral nasal walls - specifically, the mucociliary routes - in cadavers. [ 3 ]  In 1978, Messerklinger published the book titled \"Endoscopy of the Nose\" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2207", "text": "Heinz Stammberger, [ 5 ]  a  head and neck surgeon  who worked at the University of Graz with Messerklinger was captivated by the technique and the implications for pathophysiology and treatment of sinus disease. He adopted the technique and became identified with it. He traveled the world advocating and popularizing the technique and he carried out multiple courses both at University of Graz and around the world. He later met David Kennedy, a physician at  Johns Hopkins University , and together, they worked with the surgical instrument maker  Karl Storz  to develop instruments for use in endoscopic sinus surgery, and coined the term  Functional Endoscopic Sinus Surgery . [ 3 ]  Stammberger and Kennedy published multiple papers on FESS use and technique, and in 1985 the first North American course on FESS was taught at  Johns Hopkins Hospital  in  Baltimore . [ 1 ]  Stammberger, the chair of  otolaryngology  at University of Graz, and Kennedy, refined the techniques and provided hands-on courses on the techniques throughout the world. Stammberger retired from his position as the chair of the department in Graz and moved to  Dubai , where he worked with  Muaaz Tarabichi , also known as \"the father of  endoscopic ear surgery \", to establish the Tarabichi Stammberger Ear and Sinus Institute (TSESI), a center dedicated to the advancement of endoscopic ear and sinus surgery. [ 6 ]  Stammberger died in 2018. [ 5 ]  There was a rise in the overall number of endoscopic sinus surgery procedures performed between 2010 - 2019 in the UK which coincided with a reduction in the number of open procedures performed over the same period. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2208", "text": "Functional endoscopic sinus surgery is most commonly used to treat chronic rhinosinusitis (CRS), [ 8 ]  only after all non-surgical treatment options such as antibiotics,  topical   nasal   corticosteroids , and  nasal lavage  with  saline solutions [ 9 ]  have been exhausted. CRS is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage. [ 9 ]  It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping. [ 10 ]  CRS is a common condition in children and young adults. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2209", "text": "The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the ethmoid air cells and Haller cells [ 12 ]  as well as the  maxillary ostium , if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed. [ 8 ]  In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngologist can perform FESS to remove the growths, sometimes with the help of a  neurosurgeon , depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2210", "text": "In the thyroid disorder known as  Graves' ophthalmopathy , inflammation and fat accumulation in the orbitonasal region cause severe  proptosis . [ 14 ]  In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed. [ 1 ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2211", "text": "The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which innervate the teeth. [ 8 ]  Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2212", "text": "It has been suggested that one of the main objectives in FESS surgery is to allow for the introduction of local therapeutic agents (such as steroids) to the sinuses. Research has shown that a special modification of the nozzle of the nasal spray in patients who had FESS allows for better delivery of local therapeutic agents into the ethmoid sinuses. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2213", "text": "Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1\u20132 month postoperative healing period. [ 8 ] [ 16 ] [ 17 ]  Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery. [ 18 ] [ 16 ]  The success rate of FESS in treating adults with CRS has been reported as 80-90%, [ 19 ]  and the success rate in treating children with CRS has been reported as 86\u201397%. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2214", "text": "The most common complication of FESS is  cerebrospinal fluid leak  (CSFL), which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include  infection , bleeding, double vision usually lasting a few hours, numbness of the front teeth,  orbital hematoma , decreased sense of smell, and blindness. [ 20 ] [ 21 ]  The  medial rectus muscle  may be damaged. [ 22 ]  Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2215", "text": "A  Cochrane review  in 2006 based on three  randomized control trials  concluded that FESS has not been shown to provide significantly better results than medical treatment for chronic rhinosinusitis. [ 23 ]  Another Cochrane review looked at postoperative care of patients after FESS using debridement (removal of blood clots, crusts, and secretions from the nasal and sinus cavities under local anaesthetic), but the evidence from the available clinical trials was uncertain. The debridement procedure after FESS may make little or no difference to health\u2010related quality of life or disease severity. There may be a lower risk of adhesions but whether this has any impact on long\u2010term outcomes is unknown. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2216", "text": "Functional sinus surgery had been grossly overutilized as a way of treating headache based on an assumption of a sinus etiology of the different types of primary headache. Many patients, primary care providers, and even specialists confuse any frontal migraine for sinus disease. Multiple attempts at further definition of primary headache and or sinus headache has been suggested by the International Headache Society and the American Academy of Otolaryngology\u2013Head and Neck Surgery. [ 25 ]  It has been suggested early on that such a confusion might be  a cause of failure of functional endoscopic sinus surgery. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2217", "text": "The  geniculate ganglion  (from  Latin   genu , for \"knee\" [ 1 ] ) is a bilaterally paired special sense ganglion [ 2 ]  of the  intermediate nerve  component of the  facial nerve (CN VII) . [ 3 ]  It is situated within  facial canal  of the  head . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2218", "text": "It contains cell bodies of first-order  unipolar   sensory neurons  which convey  gustatory (taste)  afferents from  taste receptors  of the anterior two-thirds of the tongue by way of the  chorda tympani , and of the  palate  by way of the  greater petrosal nerve , From the ganglion, the proximal fibres proceed to the gustatory (i.e. superior/rostral [ 3 ] ) part of the  solitary nucleus  where they synapse with second-order neurons. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2219", "text": "The geniculate ganglion is conical in shape. The  greater petrosal nerve  diverges from CNVII and the  lesser petrosal nerve  diverges from CN IX at the geniculate ganglion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2220", "text": "It is located close to the  internal auditory meatus . [ 4 ]  It is covered superiorly by the  petrous part of the temporal bone  (which is sometimes absent over the ganglion). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2221", "text": "The geniculate ganglion is an important  surgical landmark  near the  internal auditory meatus . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2222", "text": "The geniculate ganglion may become  inflamed  due  herpes zoster virus  virus infection. Swelling of the ganglion may result in facial palsy ( Ramsay Hunt syndrome ). The syndrome presents with intense pain in one ear that is followed by a vesicular rash around the  ear canal . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2223", "text": "The  glossopharyngeal nerve  ( / \u02cc \u0261 l \u0252 s o\u028a f \u0259 \u02c8 r \u026a n ( d ) \u0292 i \u0259 l ,   - \u02cc f \u00e6r \u0259n \u02c8 d\u0292 i\u02d0 \u0259 l / [ 1 ] ), also known as the  ninth cranial nerve ,  cranial nerve IX , or simply  CN IX , [ 2 ]  is a  cranial nerve  that exits the  brainstem  from the sides of the upper  medulla , just anterior (closer to the  nose ) to the  vagus nerve . Being a mixed nerve (sensorimotor), it carries afferent sensory and efferent motor information. The motor division of the glossopharyngeal nerve is derived from the  basal plate  of the  embryonic   medulla oblongata , whereas the sensory division originates from the  cranial neural crest ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2224", "text": "From the anterior portion of the  medulla oblongata , the glossopharyngeal nerve passes laterally across or below the  flocculus , and leaves the skull through the central part of the  jugular foramen . From the superior and inferior ganglia in jugular foramen, it has its own sheath of  dura mater . The inferior ganglion on the inferior surface of petrous part of temporal is related with a triangular depression into which the aqueduct of cochlea opens. On the inferior side, the glossopharyngeal nerve is lateral and anterior to the  vagus nerve  and  accessory nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2225", "text": "In its passage through the foramen (with X and XI), the glossopharyngeal nerve passes between the  internal jugular vein  and  internal carotid artery . [ 3 ]  It descends in front of the latter vessel and beneath the  styloid process  and the muscles connected with it, to the posterior lower border of the  stylopharyngeus muscle . [ 4 ]  It then curves forward, forming an arch on the side of the neck and lying upon the  stylopharyngeus  and  middle pharyngeal constrictor  muscle. From there, it passes under cover of the  hyoglossus  muscle and is finally distributed to the  palatine tonsil , the  mucous membrane  of the  fauces  and base of the  tongue , and the serous glands of the  mouth ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2226", "text": "Note: The glossopharyngeal nerve contributes in the formation of the  pharyngeal plexus  along with the vagus nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2227", "text": "The glossopharyngeal nerve has five distinct general functions:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2228", "text": "The glossopharyngeal nerve as noted above is a mixed nerve consisting of both sensory and motor nerve fibers. The sensory fibers' origin include the pharynx, middle ear, posterior one-third of the tongue (including taste buds); and the carotid body and sinus. These fibers terminate at the  medulla oblongata . The motor fibers' origin is the medulla oblongata, and they terminate at the parotid salivary gland, the glands of the posterior tongue, and the  stylopharyngeus  muscle (which dilates the pharynx during swallowing)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2229", "text": "The  branchial motor  component of CN IX provides voluntary control of the stylopharyngeus muscle, which elevates the pharynx during swallowing and speech."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2230", "text": "Origin and central course"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2231", "text": "The branchial motor component originates from the  nucleus ambiguus  in the reticular formation of the rostral  medulla . Fibers leaving the nucleus ambiguus travel anteriorly and laterally to exit the medulla, along with the other components of CN IX, between the olive and the  inferior cerebellar peduncle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2232", "text": "Intracranial course"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2233", "text": "Upon emerging from the lateral aspect of the medulla the branchial motor component joins the other components of CN IX to exit the skull via the jugular foramen. The glossopharyngeal fibers travel just anterior to the cranial nerves X and XI, which also exit the skull via the  jugular foramen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2234", "text": "Extra-cranial course and final innervation"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2235", "text": "Upon exiting the skull the branchial motor fibers descend deep to the  temporal styloid process  and wrap around the posterior border of the  stylopharyngeus muscle  before innervating it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2236", "text": "Voluntary control of the stylopharyngeus muscle"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2237", "text": "Signals for the voluntary movement of  stylopharyngeus muscle  originate in the pre-motor and motor cortex (in association with other cortical areas) and pass via the  corticobulbar  tract in the genu of the internal capsule to synapse bilaterally on the ambiguus nuclei in the medulla."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2238", "text": "Parasympathetic component of the glossopharyngeal nerve that innervates the ipsilateral parotid gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2239", "text": "The  preganglionic  nerve fibers originate in the  inferior salivatory nucleus  of the rostral medulla and travel anteriorly and laterally to exit the brainstem between the  medullary olive  and the  inferior cerebellar peduncle  with the other components of CN IX.  Note: These neurons do not form a distinct nucleus visible on cross-section of the brainstem. The position indicated on the diagram is representative of the location of the cell bodies of these fibers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2240", "text": "Upon emerging from the lateral aspect of the medulla, the  visceral motor  fibers join the other components of CN IX to enter the  jugular foramen . Within the jugular foramen, there are two glossopharyngeal ganglia that contain nerve cell bodies that mediate general, visceral, and special sensation. The visceral motor fibers pass through both ganglia without synapsing and exit the inferior ganglion with CN IX general sensory fibers as the  tympanic nerve . Before exiting the jugular foramen, the tympanic nerve enters the  petrous portion of the temporal bone  and ascends via the  inferior tympanic canaliculus  to the  tympanic cavity . Within the tympanic cavity the tympanic nerve forms a  plexus  on the surface of the  promontory of the middle ear  to provide general sensation. The visceral motor fibers pass through this plexus and merge to become the  lesser petrosal nerve . The lesser petrosal nerve re-enters and travels through the temporal bone to emerge in the  middle cranial fossa  just lateral to the  greater petrosal nerve . It then proceeds anteriorly to exit the skull via the  foramen ovale  along with the  mandibular nerve  component of CN V (V3)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2241", "text": "Extra-cranial course and final innervations"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2242", "text": "Upon exiting the skull, the lesser petrosal nerve synapses in the  otic ganglion , which is suspended from the  mandibular nerve  immediately below the  foramen ovale . Postganglionic fibers from the otic ganglion travel with the  auriculotemporal branch  of CN V3 to enter the substance of the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2243", "text": "Hypothalamic Influence"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2244", "text": "Fibers from the  hypothalamus  and  olfactory system  project via the  dorsal longitudinal fasciculus  to influence the output of the  inferior salivatory nucleus . Examples include: 1) dry mouth in response to fear (mediated by the hypothalamus); 2) salivation in response to smelling food (mediated by the olfactory system)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2245", "text": "This component of CN IX innervates the baroreceptors of the  carotid sinus  and chemoreceptors of the  carotid body ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2246", "text": "Clinical correlation  \nThe visceral sensory fibers of CN IX mediate the afferent limb of the pharyngeal reflex in which touching the back of the pharynx stimulates the patient to gag (i.e., the gag reflex). The efferent signal to the musculature of the pharynx is carried by the branchial motor fibers of the vagus nerve.  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2247", "text": "This component of CN IX carries general sensory information (pain, temperature, and touch) from the skin of the external ear, internal surface of the tympanic membrane, the walls of the upper pharynx, and the posterior one-third of the tongue, anterior surface of the epiglottis, vallecula."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2248", "text": "The special sensory component of CN IX provides taste sensation from the posterior one-third of the tongue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2249", "text": "Damage to the glossopharyngeal nerve can result in loss of taste sensation to the posterior one third of the tongue, and impaired  swallowing ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2250", "text": "The clinical tests used to determine if the glossopharyngeal nerve has been damaged include testing the  gag reflex  of the mouth, asking the patient to  swallow  or  cough , and evaluating for speech impediments. The clinician may also test the posterior one-third of the tongue with bitter and sour substances to evaluate for impairment of taste."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2251", "text": "The integrity of the glossopharyngeal nerve may be evaluated by testing the patient's general sensation and that of taste on the posterior third of the tongue. The gag reflex can also be used to evaluate the glossopharyngeal nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2252", "text": "Saladin, Anatomy and Physiology: The Unity of Form and Function, 6th edition"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2253", "text": "The  greater palatine artery  is a branch of the descending palatine artery (a terminal branch of the  maxillary artery ) and contributes to the blood supply of the  hard palate  and  nasal septum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2254", "text": "The  descending palatine artery  branches off of the maxillary artery in the  pterygopalatine fossa  and descends through the  greater palatine canal  along with the  greater palatine nerve  (from the  pterygopalatine ganglion ).  Once emerging from the  greater palatine foramen , it changes names to the greater palatine artery and begins to supply the  hard palate . [ 1 ]  As it terminates it travels through the  incisive canal  to  anastomose  with the  sphenopalatine artery  to supply the  nasal septum . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2255", "text": "The  greater palatine nerve  is a branch of the  pterygopalatine ganglion . This nerve is also referred to as the  anterior palatine nerve , due to its location anterior to the   lesser palatine nerve . It carries both general sensory fibres from the  maxillary nerve , and parasympathetic fibers from the  nerve of the pterygoid canal . It may be anaesthetised for  procedures  of the  mouth  and maxillary (upper)  teeth ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2256", "text": "The greater palatine nerve is a branch of the  pterygopalatine ganglion . It descends through the  greater palatine canal , moving anteriorly and inferiorly. [ 1 ] [ 2 ]  Here, it is accompanied by the  descending palatine artery . [ 1 ]  It emerges upon the  hard palate  through the  greater palatine foramen . It then passes forward in a groove in the hard palate, nearly as far as the  incisor  teeth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2257", "text": "While in the  pterygopalatine canal , it gives off  lateral posterior inferior nasal branches , which enter the nasal cavity through openings in the  palatine bone , and ramify over the  inferior nasal concha  and middle and inferior meatuses. At its exit from the canal, a palatine branch is distributed to both surfaces of the  soft palate ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2258", "text": "The greater palatine nerve carries both general sensory fibres from the  maxillary nerve , and parasympathetic fibers from the  nerve of the pterygoid canal . It supplies the gums, the  mucous membrane  and glands of the hard palate, and communicates in front with the terminal filaments of the  nasopalatine nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2259", "text": "The greater palatine nerve may be  anaesthetised  to perform  dental procedures  on the maxillary (upper)  teeth , and sometimes for  cleft lip and cleft palate   surgery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2260", "text": "This article incorporates text in the  public domain  from  page 893  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2261", "text": "The  greater petrosal nerve  (or  greater superficial petrosal nerve ) is a  nerve  of the head mainly containing pre-ganglionic parasympathetic fibres [ 1 ] :\u200a370\u200a  which ultimately synapse in the  pterygopalatine ganglion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2262", "text": "It branches from the  facial nerve (CN VII)  and is derived from the parasympathetic part of the  nervus intermedius  component of CN VII, with its cell bodies located in the  superior salivary nucleus . [ 2 ]  In the connective tissue substance of the  foramen lacerum , [ citation needed ]  the greater petrosal nerve unites with the ( sympathetic )  deep petrosal nerve  to form the  nerve of the pterygoid canal  (vidian nerve) which proceeds to the pterygopalatine ganglion. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2263", "text": "It forms part of a chain of nerves that provide secretomotor innervation to the  lacrimal gland  and mucosal glands of nasal cavity and palate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2264", "text": "Preganglionic  parasympathetic  fibres arise in the  superior salivary nucleus  of the  pontine tegmentum . They join with general somatic sensory and special sensory fibres to form the  nervus intermedius . The nervus intermedius exits the cranial cavity at the  internal auditory meatus , and joins with the motor root of the facial nerve at the  geniculate ganglion . While preganglionic parasympathetic fibres pass through the geniculate ganglion, they neither synapse, nor have their cell bodies located there. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2265", "text": "Preganglionic parasympathetic fibres exit the geniculate ganglion as the greater petrosal nerve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2266", "text": "The greater petrosal nerve also conveys some special sensory nerve fibres which carry gustatory (taste) sensory information from the  palate [ 1 ] :\u200a22\u200a  that are relayed to the pterygopalatine ganglion by the  lesser palatine nerves  and are in turn conveyed to the geniculate ganglion by the greater petrosal nerve to synapse in the ganglion. [ 1 ] :\u200a370"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2267", "text": "The greater petrosal nerve enters the  petrous part of the temporal bone  and travels anteromedially through it at a 45\u00b0 angle. It emerges into the  middle cranial fossa  upon the anterosuperior surface of the bone [ 1 ] :\u200a498\u200a  through the  hiatus for greater petrosal nerve  alongside the  petrosal branch  of the  middle meningeal artery . [ 3 ] :\u200a842"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2268", "text": "In the middle cranial fossa, the nerve is situated between the two layers of the dura mater [ 1 ] :\u200a450, 498\u200a  and passes obliquely anterior-ward [ 1 ] :\u200a450\u200a  along a groove upon the floor of the fossa [ 1 ] :\u200a509\u200a  - the  groove for the greater petrosal nerve  - that is situated upon the anterosuperior aspect of the  petrous part of the temporal bone [ 3 ] :\u200a842\u200a  and anteromedial to the  arcuate eminence , and adjacent and parallel to the  lesser petrosal nerve  and its own groove. [ 1 ] :\u200a509\u200a  The nerve passes deep to the  trigeminal ganglion  to reach the  foramen lacerum . [ 1 ] :\u200a498, 509"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2269", "text": "At the foramen lacerum, it unites with the (sympathetic)  deep petrosal nerve , forming the  nerve of the pterygoid canal  (which continues anterior-ward through the  pterygoid canal  to reach the  pterygopalatine fossa  and form the  pterygopalatine ganglion ). [ 1 ] :\u200a498"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2270", "text": "During surgery of the middle cranial fossa, manipulation of the dura mater may damage the greater petrosal nerve, [ 1 ] :\u200a450, 498\u200a  causing bleeding [ 1 ] :\u200a498\u200a  or swelling at the geniculate ganglion; this can compress the facial nerve and cause facial paralysis. [ 1 ] :\u200a450, 498"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2271", "text": "Head and neck cancer  is a general term encompassing multiple  cancers  that can develop in the head and neck region. These include cancers of the mouth, tongue, gums and lips ( oral cancer ), voice box ( laryngeal ), throat ( nasopharyngeal ,  oropharyngeal , [ 1 ]   hypopharyngeal ),  salivary glands ,  nose and sinuses . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2272", "text": "Head and neck cancer can present a wide range of symptoms depending on where the cancer developed. These can include an  ulcer in the mouth  that does not heal,  changes in the voice ,  difficulty swallowing ,  red or white patches in the mouth , and a  neck lump . [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2273", "text": "The majority of head and neck cancer is caused by the use of  alcohol  or  tobacco  (including  smokeless tobacco ). An increasing number of cases are caused by the  human papillomavirus  (HPV). [ 8 ] [ 2 ]  Other risk factors include the  Epstein\u2013Barr virus , chewing  betel quid  (paan),  radiation exposure , poor nutrition and workplace exposure to certain toxic substances. [ 8 ]  About 90% are pathologically classified as  squamous cell cancers . [ 9 ] [ 2 ]  The diagnosis is confirmed by a  tissue biopsy . [ 8 ]  The degree of surrounding tissue invasion and distant spread may be determined by  medical imaging  and  blood tests . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2274", "text": "Not using tobacco or alcohol can reduce the risk of head and neck cancer. [ 2 ]  Regular dental examinations may help to identify signs before the cancer develops. [ 1 ]  The  HPV vaccine  helps to prevent  HPV-related oropharyngeal cancer . [ 10 ]  Treatment may include a combination of surgery,  radiation therapy ,  chemotherapy , and  targeted therapy . [ 8 ]  In the early stage head and neck cancers are often curable but 50% of people see their doctor when they already have an advanced disease. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2275", "text": "Globally, head and neck cancer accounts for 650,000 new cases of cancer and 330,000 deaths annually on average. In 2018, it was the seventh most common cancer worldwide, with 890,000 new cases documented and 450,000 people dying from the disease. [ 12 ]  The usual age at diagnosis is between 55 and 65 years old. [ 13 ]  The average  5-year survival  following diagnosis in the  developed world  is 42\u201364%. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2276", "text": "Head and neck cancers can cause a broad range of symptoms, many of which occur together. These can be categorised local (head and neck cancer-specific), general and  gastrointestinal  symptoms. Local symptoms include changes in taste and voice, inflammation of the mouth or throat ( mucositis ), dry mouth ( xerostomia ), and difficulty swallowing ( dysphagia ). General symptoms include difficulty sleeping, tiredness, depression, nerve damage ( peripheral neuropathy ). Gastrointestinal symptoms are typically nausea and vomiting. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2277", "text": "Symptoms predominantly include a sore on the face or oral cavity that does not heal, trouble swallowing, or a change in voice. In those with advanced disease, there may be unusual bleeding, facial pain, numbness or swelling, and visible lumps on the outside of the neck or oral cavity. [ 15 ]  Head and neck cancer often begins with benign signs and symptoms of the disease, like an enlarged  lymph node  on the outside of the neck, a  hoarse-sounding voice , or a progressive worsening cough or sore throat. In the case of head and neck cancer, these symptoms will be notably persistent and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficulty or pain in swallowing. Speaking may become difficult. There may also be a persistent  earache . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2278", "text": "Other symptoms can include: a lump in the lip, mouth, or gums; ulcers or mouth sores that do not heal; bleeding from the mouth or numbness; bad breath; discolored patches that persist in the mouth; a sore tongue; and slurring of speech if the cancer is affecting the tongue. There may also be congested sinuses, weight loss, and some numbness or paralysis of  facial muscles . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2279", "text": "Oral cancer affects the areas of the mouth, including the inner lip,  tongue ,  floor of the mouth ,  gums , and  hard palate . Cancers of the mouth are strongly associated with  tobacco  use, especially the use of  chewing tobacco  or  dipping tobacco , as well as heavy  alcohol  use. Cancers of this region, particularly the tongue, are more frequently treated with  surgery  than other head and neck cancers. Lip and oral cavity cancers are the most commonly encountered types of head and neck cancer. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2280", "text": "Surgeries for oral cancers include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2281", "text": "The defect is typically covered or improved by using another part of the body and/or skin grafts and/or wearing a  prosthesis . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2282", "text": "Paranasal sinus and nasal cavity cancer  affects the  nasal cavity  and the  paranasal sinuses . Most of these cancers are  squamous cell carcinomas . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2283", "text": "Nasopharyngeal cancer arises in the  nasopharynx , the region in which the  nasal cavities  and the  Eustachian tubes  connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common head and neck cancers, \"poorly differentiated\" nasopharyngeal carcinoma is  lymphoepithelioma , which is distinct in its  epidemiology , biology, clinical behavior, and treatment and is treated as a separate disease by many experts. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2284", "text": "Most  oropharyngeal cancers  begin in the  oropharynx  (throat), the middle part of the throat that includes the  soft palate , the base of the  tongue , and the  tonsils . [ 1 ]  Cancers of the tonsils are more strongly associated with  human papillomavirus  infection than are cancers of other regions of the head and neck.  HPV-positive oropharyngeal cancer  generally has a better outcome than HPV-negative disease, with a 54% better survival rate, [ 18 ]  but this advantage for HPV-associated cancer applies only to oropharyngeal cancers. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2285", "text": "People with oropharyngeal carcinomas are at high risk of developing a second primary head and neck cancer. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2286", "text": "The  hypopharynx  includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis and have the most adverse prognoses of pharyngeal tumors. They tend to  metastasize  early due to the extensive lymphatic network around the  larynx . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2287", "text": "Laryngeal cancer begins in the  larynx , or \"voice box\", and is the second most common type of head and neck cancer encountered. [ 5 ]  Cancer may occur on the  vocal folds  themselves (\"glottic\" cancer) or on tissues above and below the true cords (\"supraglottic\" and \"subglottic\" cancers, respectively). Laryngeal cancer is strongly associated with  tobacco smoking . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2288", "text": "Surgery can include laser excision of small vocal cord lesions, partial laryngectomy (removal of part of the larynx), or total laryngectomy (removal of the whole larynx). If the whole larynx has been removed, the person is left with a permanent tracheostomy. Voice rehabilitation in such patients can be achieved in three important ways: esophageal speech, tracheoesophageal puncture, or electrolarynx. One would likely require intensive teaching, speech therapy, and/or an electronic device. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2289", "text": "Cancer of the trachea  is a rare cancer usually classified as a  lung cancer . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2290", "text": "Most  tumors of the salivary glands  differ from the common head and neck cancers in cause,  histopathology , clinical presentation, and therapy. Other uncommon tumors arising in the head and neck include  teratomas ,  adenocarcinomas ,  adenoid cystic carcinomas , and  mucoepidermoid carcinomas . [ 22 ]  Rarer still are  melanomas  and  lymphomas  of the upper aerodigestive tract. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2291", "text": "Alcohol  and  tobacco  use are major risk factors for head and neck cancer.  72% of head and neck cancer cases are caused by using both alcohol and tobacco. [ 23 ]  This rises to 89% when looking specifically at laryngeal cancer. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2292", "text": "There is thought to be a dose-dependent relationship between alcohol use and development of head and neck cancer where higher rates of alcohol consumption contribute to an increased risk of developing head and neck cancer. [ 25 ] [ 26 ]  Alcohol use following a diagnosis of head and neck cancer also contributes to other negative outcomes. These include physical effects such as an increased risk of developing a second primary cancer or other malignancies, [ 27 ] [ 28 ]  cancer recurrence, [ 29 ]  and worse prognosis [ 30 ]  in addition to an increased chance of having a future  feeding tube  placed and  osteoradionecrosis  of the jaw. Negative social factors are also increased with sustained alcohol use after diagnosis including unemployment and work disability. [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2293", "text": "The way in which alcohol contributes to cancer development is not fully understood. It is thought to be related to permanent damage of DNA strands by a metabolite of alcohol called  acetaldehyde . Other suggested mechanisms include nutritional deficiencies and genetic variations. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2294", "text": "Tobacco smoking  is one of the main risk factors for head and neck cancer. Cigarette smokers have a lifetime increased risk for head and neck cancer that is 5 to 25 times higher than the general population. [ 33 ]  The ex-smoker's risk of developing head and neck cancer begins to approach the risk in the general population 15 years after  smoking cessation . [ 34 ]  In addition, people who smoke have a worse prognosis than those who have never smoked. [ 35 ]  Furthermore, people who continue to smoke after diagnosis of head and neck cancer have the highest probability of dying compared to those who have never smoked. [ 36 ] [ 37 ]  This effect is seen in patients with HPV-positive head and neck cancer as well. [ 38 ] [ 39 ] [ 40 ]  It has also been demonstrated that  passive smoking , both at work and at home, increases the risk of head and neck cancer. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2295", "text": "A major carcinogenic compound in  tobacco smoke  is  acrylonitrile . [ 41 ]  Acrylonitrile appears to indirectly cause  DNA damage  by increasing  oxidative stress , leading to increased levels of  8-oxo-2'-deoxyguanosine  (8-oxo-dG) and  formamidopyrimidine  in DNA. [ 42 ]  (see image). Both 8-oxo-dG and formamidopyrimidine are  mutagenic . [ 43 ] [ 44 ]   DNA glycosylase   NEIL1  prevents  mutagenesis  by 8-oxo-dG [ 45 ]  and removes formamidopyrimidines from DNA. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2296", "text": "Smokeless tobacco  (including products where tobacco is  chewed ) is a cause of  oral cancer . Increased risk of oral cancer caused by smokeless tobacco is present in countries such as the United States but particularly prevalent in  Southeast Asian countries  where the use of smokeless tobacco is common. [ 5 ] [ 47 ] [ 48 ]  Smokeless tobacco is associated with a higher risk of developing head and neck cancer  due to the presence of the tobacco-specific carcinogen  N'-nitrosonornicotine . [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2297", "text": "Cigar  and  pipe smoking  are also important risk factors for oral cancer. [ 49 ]  They have a dose dependent relationship with more consumption leading to higher chances of developing cancer. [ 23 ]  The use of  electronic cigarettes  may also lead to the development of head and neck cancers due to the substances like  propylene glycol ,  glycerol ,  nitrosamines , and metals contained therein, which can cause damage to the airways. [ 50 ] [ 5 ]  Exposure to e-vapour has been shown to reduce cell viability and increase the rate of  cell death  via  apoptosis  or  necrosis  with or without nicotine. [ 51 ]  This area of study requires more research, however. [ 50 ] [ 5 ]  Similarly, additional research is needed to understand how  marijuana  possibly promotes head and neck cancers. [ 52 ]  A 2019 meta-analysis did not conclude that marijuana was associated with head and neck cancer risk. [ 53 ]  Yet individuals with cannabis use disorder were more likely to be diagnosed with such cancers in a large study published 2024. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2298", "text": "Many dietary nutrients are associated with cancer protection and its development. Generally, foods with a protective effect with respect to oral cancer demonstrate  antioxidant  and  anti-inflammatory effects  such as fruits, vegetables,  curcumin  and  green tea . Conversely, pro-inflammatory food substances such as  red meat ,  processed meat  and fried food can increase the risk of developing head and neck cancer. [ 23 ] [ 54 ]  An increased adherence to the  Mediterranean diet  is also related to a lower risk of cancer mortality and a reduced risk of developing multiple cancers including head and neck cancer. [ 55 ]  Elevated levels of  nitrites  in preserved meats and  salted fish  have been shown to increase the risk of nasopharyngeal cancer. [ 56 ] [ 57 ]  Overall, a poor nutritional intake (often associated with alcoholism) with subsequent  vitamin deficiencies  is a risk factor for head and neck cancer. [ 56 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2299", "text": "In terms of nutritional supplements, antioxidants such as  vitamin E  and  beta-carotene  might reduce the toxic effect of radiotherapy in people with head and neck cancer but they can also increase recurrence rates, especially in smokers. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2300", "text": "Betel nut chewing  is associated with an increased risk of head and neck cancer. [ 1 ] [ 59 ]  When chewed with additional tobacco in its preparation (like in  gutka ), there is an even higher risk, especially for oral and oropharyngeal cancers. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2301", "text": "People who develop head and neck cancer may have a  genetic predisposition  for the condition.  There are seven known genetic variations ( loci ) which specifically increase the chances of developing oral and pharyngeal cancer. [ 60 ] [ 61 ]  Family history, that is having a first-degree relative with head and neck cancer, is also a risk factor. In addition, genetic variations in pathways involved in  alcohol metabolism  (for example  alcohol dehydrogenase ) have been associated with an increased head and neck cancer risk. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2302", "text": "It is known that prior exposure to  radiation  of the head and neck is associated with an increased risk of cancer, particularly thyroid, salivary gland and squamous cell carcinomas, although there is a time-delay of many years and the overall risk is still low. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2303", "text": "Some head and neck cancers, and in particular oropharyngeal cancer, are caused by the  human papillomavirus  (HPV), [ 1 ] [ 62 ]  and 70% of all head and neck cancer cases are related to HPV. [ 62 ]  Risk factors for HPV-positive oropharyngeal cancer include multiple sexual partners, anal and oral sex and a weak immune system. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2304", "text": "The incidence of HPV-related head and neck cancer is increasing, especially in the Western world. In the United States, the incidence of  HPV-positive oropharyngeal cancer  has overtaken HPV-positive  cervical cancer  as the leading HPV related cancer type. [ 63 ]  An increased incidence has particularly affected males. As a result, recent changes have resulted in the  HPV vaccine  being offered to adolescent boys between 12-13 (previously only offered to girls between this age due to cervical cancer risks) and men under 45  who have sex with men  in the UK. [ 64 ] [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2305", "text": "Over 20 different high-risk HPV subtypes have been implicated in causing head and neck cancer. In particular, HPV-16 is responsible for up to 90% of oropharyngeal cancer in North America. [ 56 ]   Approximately 15\u201325% of head and neck cancers contain genomic DNA from HPV, [ 66 ]  and the association varies based on the site of the tumor. [ 67 ]  In the case of  HPV-positive oropharyngeal cancer , the highest distribution is in the  tonsils , where HPV DNA is found in 45\u201367% of the cases, [ 68 ]  and it is less often in the hypopharynx (13\u201325%), and least often in the oral cavity (12\u201318%) and larynx (3\u20137%). [ 69 ] [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2306", "text": "Positive HPV16 status is associated with a improved prognosis over HPV-negative oropharyngeal cancer due to better response to  radiotherapy  and  chemotherapy . [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2307", "text": "HPV can induce tumors by several mechanisms: [ 71 ] [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2308", "text": "There are observed biological differences between HPV-positive and HPV-negative head and neck cancer, for example in terms of  mutation  patterns. In HPV-negative disease, genes frequently mutated include  TP53 ,  CDKN2A  and  PIK3CA . [ 73 ]  In HPV-positive disease, these genes are less frequently mutated, and the tumour suppressor gene p53 and  pRb  (protein retinoblastoma) are commonly inactivated by HPV oncoproteins E6 and E7 respectively. [ 74 ]  In addition, viral infections such as HPV can cause aberrant  DNA methylation  during cancer development. HPV-positive head and neck cancers demonstrate higher levels of such DNA methylation compared to HPV-negative disease. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2309", "text": "E6 sequesters p53 to promote p53 degradation, while E7 inhibits pRb. Degradation of p53 results in cells being unable to respond to checkpoint signals that are normally present to activate  apoptosis  when DNA damage is signalled. Loss of pRb leads to deregulation of  cell proliferation  and apoptosis. Both mechanisms therefore leave cell proliferation unchecked and increase the chance of  carcinogenesis . [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2310", "text": "Epstein\u2013Barr virus  (EBV) infection is associated with  nasopharyngeal cancer . Nasopharyngeal cancer caused by EBV commonly occurs in some countries of the Mediterranean and Asia, where EBV  antibody titers  can be measured to screen high-risk populations. [ 77 ] [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2311", "text": "The presence of  gastroesophageal reflux disease  (GERD) or laryngeal reflux disease can also be a major factor.  Stomach acids  that flow up through the  esophagus  can damage its lining and raise susceptibility to throat cancer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2312", "text": "People after  hematopoietic stem cell transplantation  (HSCT) are at a higher risk for oral cancer. Post-HSCT oral cancer may have more aggressive behavior and a poorer prognosis when compared to oral cancer in non-HSCT patients. [ 79 ]  This effect is supposed to be due to continuous, lifelong  immune  suppression and chronic oral  graft-versus-host disease . [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2313", "text": "Several other risk factors have been identified in the development of head and neck cancer. These include occupational environmental  carcinogen  exposure such as  asbestos ,  wood dust ,  mineral acid ,  sulfuric acid mists  and metal dusts. In addition, weakened immune systems, age greater than 55 years, poor  socioeconomic factors  such as lower incomes and occupational status, and low  body mass index  (<18.5 kg/m2) are also risk factors. [ 56 ] [ 80 ] [ 23 ]  Poor  oral hygiene  and chronic  oral cavity inflammation  (for example secondary to  chronic gum inflammation ) are also linked to an increased head and neck cancer risk. [ 81 ] [ 82 ]  The presence of  leukoplakia , which is the appearance of white patches or spots in the mouth, can develop into cancer in about 1\u20443 of cases. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2314", "text": "A significant proportion of people with head and neck cancer will present to their physicians with an already advanced stage disease. [ 11 ]  This can either be down to patient factors (delays in seeking medical attention), or physician factors (such as delays in referral from primary care, or non-diagnostic investigation results). [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2315", "text": "A person usually presents to the physician complaining of one or more of the typical symptoms. These symptoms may be site specific (such as a laryngeal cancer causing  hoarse voice ), or not site specific (earache can be caused by multiple types of head and neck cancers). [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2316", "text": "The physician will undertake a thorough history to determine the nature of the symptoms and the presence or absence of any risk factors. The physician will also ask about other illnesses such as heart or lung diseases as they may impact their fitness for potentially curative treatment. Clinical examination will involve examination of the neck for any masses, examining inside the mouth for any abnormalities and assessing the rest of the pharynx and larynx with a  nasendoscope . [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2317", "text": "Further investigations will be directed by the symptoms discussed and any abnormalities identified during the exam. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2318", "text": "Neck masses  typically undergo assessment with  ultrasound  and a  fine-needle aspiration  (FNA, a type of needle biopsy). Concerning  lesions  that are readily accessible (such as in the mouth) can be biopsied with a  local anaesthetic . Lesions less readily available can be biopsied either with the patient awake or under a  general anaesthetic  depending on local expertise and availability of specialist equipment. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2319", "text": "The cancer will also need to be  staged  (accurately determine its size, association with nearby structures, and spread to distant sites). This is typically done by scanning the patient with a combination of  magnetic resonance imaging  (MRI),  computed tomography  (CT) and/or  positron emission tomography  (PET). Exactly which investigations are required will depend on a variety of factors such as the site of concern and the size of the tumour. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2320", "text": "Some people will present with a neck lump containing cancer cells (identified by  FNA ) that have spread from elsewhere, but with no identifiable primary site on initial assessment. In such cases people will undergo additional testing to attempt to find the initial site of cancer, as this has significant implications for their treatment. These patients undergo MRI scanning,  PET-CT  and then  panendoscopy  and  biopsies  of any abnormal areas. If the scans and panendoscopy still do not identify a primary site for the cancer, affected people will undergo a bilateral  tonsillectomy  and tongue base  mucosectomy  (as these are the most common subsites of cancer that spread to the neck). This procedure can be done with or without  robotic assistance . [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2321", "text": "Once a diagnosis is confirmed, a multidisciplinary discussion of the optimal treatment strategy will be undertaken between the  radiation oncologist ,  surgical oncologist , and  medical oncologist . A  histopathologist  and a  radiologist  will also be present to discuss the biopsy and imaging findings. [ 86 ]  Most (90%) cancers of the head and neck are  squamous cell -derived, termed \"head-and-neck squamous-cell carcinomas\". [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2322", "text": "Throat cancers are classified according to their  histology  or cell structure and are commonly referred to by their location in the oral cavity and neck. This is because where the cancer appears in the throat affects the prognosis; some throat cancers are more aggressive than others, depending on their location. The stage at which the cancer is diagnosed is also a critical factor in the prognosis of throat cancer. Treatment guidelines recommend routine testing for the presence of HPV for all oropharyngeal squamous cell carcinoma tumors. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2323", "text": "Squamous-cell carcinoma  is a  cancer  of the  squamous cell , a kind of  epithelial  cell found in both the  skin  and  mucous membranes . It accounts for over 90% of all head and neck cancers, [ 89 ]  including more than 90% of throat cancer. [ 22 ]  Squamous cell carcinoma is most likely to appear in males over 40 years of age with a history of heavy alcohol use coupled with smoking. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2324", "text": "All squamous cell carcinomas arising from the oropharynx, and all neck node  metastases  of unknown primary should undergo testing for HPV status. This is essential to adequately stage the tumour and adequately plan treatment. Due to the different biology of HPV positive and negative cancers, differentiating HPV status is also important for ongoing research to determine the best treatments. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2325", "text": "Nasopharyngeal carcinomas , or neck node metastases possibly arising from the nasopharynx will also be tested for Ebstein Barr virus. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2326", "text": "The tumor marker Cyfra 21-1 may be useful in diagnosing squamous cell carcinoma of the head and neck (SCCHN). [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2327", "text": "Adenocarcinoma  is a cancer of the epithelial tissue that has  glandular  characteristics. Several head and neck cancers are adenocarcinomas (either of intestinal or non-intestinal cell types). [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2328", "text": "Avoidance of risk factors (such as smoking and alcohol) is the single most effective form of prevention. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2329", "text": "Regular dental examinations may identify pre-cancerous lesions in the oral cavity. [ 1 ]  While  screening  in the general population does not appear to be useful, screening high-risk groups by examination of the throat might be useful. [ 2 ]  Head and neck cancer is often curable if it is diagnosed early; however, outcomes are typically poor if it is diagnosed late. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2330", "text": "When diagnosed early, oral, head, and neck cancers can be treated more easily, and the chances of survival increase tremendously. [ 1 ]  The  HPV vaccine  helps to prevent the development of HPV-related oropharyngeal cancer. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2331", "text": "Improvements in diagnosis and local management, as well as  targeted therapy , have led to improvements in quality of life and survival for people with head and neck cancer. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2332", "text": "After a histologic diagnosis has been established and tumor extent determined, such as with the use of PET-CT, [ 94 ]  the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, concomitant health problems, social and logistic factors, previous primary tumors, and the person's preference. Treatment planning generally requires a multidisciplinary approach involving specialist surgeons, medical oncologists, and radiation oncologists.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2333", "text": "Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. For more extensive primary tumors or those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. More recently, as historical survival and control rates have been recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2334", "text": "Surgery  as a treatment is frequently used for most types of head and neck cancer. Usually, the goal is to remove the cancerous cells entirely. This can be particularly tricky if the cancer is near the  larynx  and can result in the person being unable to speak. Surgery is also commonly used to resect (remove) some or all of the cervical lymph nodes to prevent further spread of the disease.  Transoral robotic surgery  (TORS) is gaining popularity worldwide as the technology and training become more accessible. It now has an established role in the treatment of early stage oropharyngeal cancer. [ 95 ]  There is also a growing trend worldwide towards TORS for the surgical treatment of laryngeal and hypopharyngeal tumours. [ 96 ] [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2335", "text": "CO 2  laser surgery  is also another form of treatment.  Transoral laser microsurgery  allows surgeons to remove tumors from the voice box with no external incisions. It also allows access to tumors that are not reachable with robotic surgery. During the surgery, the surgeon and pathologist work together to assess the adequacy of excision (\"margin status\"), minimizing the amount of normal tissue removed or damaged. [ 98 ]  This technique helps give the person as much speech and swallowing function as possible after surgery. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2336", "text": "Radiation therapy  is the most common form of treatment. There are different forms of radiation therapy, including 3D conformal radiation therapy, intensity-modulated radiation therapy,  particle beam therapy , and brachytherapy, which are commonly used in the treatment of cancers of the head and neck. Most people with head and neck cancer who are treated in the United States and Europe are treated with intensity-modulated radiation therapy using high-energy photons. At higher doses, head and neck radiation is associated with  thyroid  dysfunction and  pituitary  axis dysfunction. [ 100 ]  Radiation therapy for head and neck cancers can also cause acute skin reactions of varying severity, which can be treated and managed with topically applied creams or specialist films. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2337", "text": "Chemotherapy  for throat cancer is not generally used to  cure  the cancer as such. Instead, it is used to provide an inhospitable environment for metastases so that they will not establish themselves in other parts of the body. Typical chemotherapy agents are a combination of  paclitaxel  and  carboplatin .  Cetuximab  is also used in the treatment of throat cancer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2338", "text": "Docetaxel -based chemotherapy has shown a very good response in locally advanced head and neck cancer. Docetaxel is the only  taxane  approved by the FDA for head and neck cancer, in combination with cisplatin and fluorouracil for the induction treatment of inoperable, locally advanced head and neck cancer. [ 102 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2339", "text": "While not specifically a chemotherapy,  amifostine  is often administered  intravenously  by a chemotherapy clinic prior to  IMRT  radiotherapy sessions. Amifostine protects the gums and  salivary glands  from the effects of radiation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2340", "text": "There is no evidence that  erythropoietin  should be routinely given with radiotherapy. [ 103 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2341", "text": "Photodynamic therapy  may have promise for treating mucosal dysplasia and small head and neck tumors. [ 22 ]   Amphinex  is showing good results in early clinical trials for the treatment of advanced head and neck cancer. [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2342", "text": "Targeted therapy , according to the  National Cancer Institute , is \"a type of treatment that uses drugs or other substances, such as monoclonal antibodies, to identify and attack specific cancer cells without harming normal cells.\" Some  targeted therapies  used in head and neck cancers include  cetuximab ,  bevacizumab , and  erlotinib . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2343", "text": "Cetuximab  is used for treating people with advanced-stage cancer who cannot be treated with conventional chemotherapy ( cisplatin ). [ 105 ] [ 106 ]  However, cetuximab's efficacy is still under investigation by researchers. [ 107 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2344", "text": "Gendicine  is a  gene therapy  that employs an  adenovirus  to deliver the  tumor suppressor gene   p53  to cells. It was approved in China in 2003 for the treatment of head and neck cancer. [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2345", "text": "The mutational profiles of  HPV + and HPV- head and neck cancer have been reported, further demonstrating that they are fundamentally distinct diseases.\n [ 109 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2346", "text": "Immunotherapy  is a type of treatment that activates the immune system to fight cancer. One type of immunotherapy, immune checkpoint blockade, binds to and blocks inhibitory signals on immune cells to release their anti-cancer activities. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2347", "text": "In 2016, the FDA granted accelerated approval to  pembrolizumab  for the treatment of people with recurrent or metastatic head and neck cancer with disease progression on or after platinum-containing chemotherapy. [ 110 ]  Later that year, the FDA approved  nivolumab  for the treatment of recurrent or metastatic head and neck cancer with disease progression on or after platinum-based chemotherapy. [ 111 ]  In 2019, the FDA approved  pembrolizumab  for the first-line treatment of metastatic or unresectable recurrent head and neck cancer. [ 112 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2348", "text": "Depending on the treatment used, people with head and neck cancer may experience the following symptoms and treatment side effects: [ 22 ] [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2349", "text": "Programs to support the emotional and social well-being of people who have been diagnosed with head and neck cancer may be offered. [ 113 ]  There is no clear evidence on the effectiveness of these interventions or any particular type of psychosocial program or length of time that is most helpful for those with head and neck cancer. [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2350", "text": "Although early-stage head and neck cancers (especially laryngeal and oral cavity) have high cure rates, up to 50% of people with head and neck cancer present with advanced disease. [ 114 ] \nCure rates decrease in locally advanced cases, whose probability of cure is inversely related to tumor size and even more so to the extent of regional node involvement.  [ citation needed ]  HPV-associated oropharyngeal cancer has been shown to respond better to chemoradiation and, subsequently, have a better prognosis compared to non-associated HPV head and neck cancer. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2351", "text": "Consensus panels in America ( AJCC ) and Europe ( UICC ) have established staging systems for head and neck cancers. These staging systems attempt to standardize clinical trial criteria for research studies and define prognostic categories of disease. Head and neck cancers are staged according to the  TNM  classification system, where T is the size and configuration of the tumor, N is the presence or absence of lymph node metastases, and M is the presence or absence of distant metastases. The T, N, and M characteristics are combined to produce a \"stage\" of the cancer, from I to IVB. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2352", "text": "Survival advantages provided by new treatment modalities have been undermined by the significant percentage of people cured of head and neck cancer who subsequently develop second  primary tumors . The incidence of second primary tumors ranges in studies from 9% [ 116 ] \nto 23% [ 117 ] \nat 20 years. Second primary tumors are the major threat to long-term survival after successful therapy of early-stage head and neck cancer. [ 118 ]  Their high incidence results from the same carcinogenic exposure responsible for the initial primary process, called  field cancerization . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2353", "text": "Many people with head and neck cancer are also not able to eat sufficiently. A tumor may impair a person's ability to swallow and eat, and throat cancer may affect the  digestive system . The difficulty in swallowing can cause a person to  choke  on their food in the early stages of digestion and interfere with the food's smooth travel down into the  esophagus  and beyond. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2354", "text": "The treatments for throat cancer can also be harmful to the digestive system as well as other body systems. Radiation therapy can lead to  nausea  and  vomiting , which can deprive the body of vital fluids (although these may be obtained through intravenous fluids if necessary). Frequent vomiting can lead to an electrolyte imbalance, which has serious consequences for the proper functioning of the heart. Frequent vomiting can also upset the balance of stomach acids, which has a negative impact on the digestive system, especially the lining of the stomach and esophagus. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2355", "text": "Enteral feeding , a method that adds nutrients directly into a person's stomach using a  nasogastric  feeding tube or a  gastrostomy tube , may be necessary for some people. [ 119 ]  Further research is required to determine the most effective method of enteral feeding to ensure that people undergoing radiotherapy or chemoradiation treatment are able to stay nourished during their treatment. [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2356", "text": "Cancer in the head or neck may impact a person's mental well-being and can sometimes lead to social isolation. [ 113 ]  This largely results from a decreased ability or inability to eat, speak, or effectively communicate. Physical appearance is often altered by the cancer itself and/or as a consequence of treatment side effects. Psychological distress may occur, and feelings such as uncertainty and fear may arise. [ 113 ]  Some people may also have a changed physical appearance, differences in swallowing or breathing, and residual pain to manage. [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2357", "text": "Caregiver stress"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2358", "text": "Caregivers for people with head and neck cancer show higher rates of  caregiver stress  and poorer mental health compared to both the general population and those caring for non-head and neck cancer patients. [ 120 ]  The high symptom burden patients' experience necessitates complex caregiver roles, often requiring hospital staff training, which caregivers can find distressing when asked to do so for the first time. It is becoming increasingly apparent that caregivers (most often spouses, children, or close family members) might not be adequately informed about, prepared for, or trained for the tasks and roles they will encounter during the treatment and recovery phases of this unique patient population, which span both technical and emotional support. [ 121 ]  Of note, caregivers of patients who report lower quality of life demonstrate increased burden and fatigue that extend beyond the treatment phase."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2359", "text": "Examples of technically difficult caregiver duties include tube feeding, oral suctioning, wound maintenance, medication delivery safe for tube feeding, and troubleshooting home medical equipment. If the cancer affects the mouth or larynx, caregivers must also find a way to effectively communicate among themselves and with their healthcare team. This is in addition to providing emotional support for the person undergoing cancer therapy. [ 121 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2360", "text": "Like any  cancer ,  metastasis  affects many areas of the body as the cancer spreads from cell to cell and  organ  to organ. For example, if it spreads to the  bone marrow , it will prevent the body from producing enough  red blood cells  and affect the proper functioning of the  white blood cells  and the body's  immune system ; spreading to the  circulatory system  will prevent oxygen from being transported to all the cells of the body; and throat cancer can throw the  nervous system  into chaos, making it unable to properly regulate and control the body. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2361", "text": "Globally, head and neck cancer accounts for 650,000 new cases of cancer and 330,000 deaths annually on average. In 2018, it was the seventh most common cancer worldwide, with 890,000 new cases documented and 450,000 people dying from the disease. [ 12 ]   The risk of developing head and neck cancer increases with age, especially after 50 years. Most people who do so are between 50 and 70 years old. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2362", "text": "In North America and Europe, the tumors usually arise from the oral cavity, oropharynx, or larynx, whereas nasopharyngeal cancer is more common in the Mediterranean countries and in the Far East. In Southeast China and Taiwan, head and neck cancer, specifically  nasopharyngeal cancer , is the most common cause of death in young men. [ 123 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2363", "text": "In the United States, head and neck cancer makes up 3% of all cancer cases (averaging 53,000 new diagnoses per year) and 1.5% of cancer deaths. [ 124 ]  The 2017 worldwide figure cites head and neck cancers as representing 5.3% of all cancers (not including non-melanoma skin cancers). [ 125 ] [ 5 ]   Notably, head and neck cancer secondary to chronic alcohol or tobacco use has been steadily declining as less of the population chronically smokes tobacco. [ 12 ]  However, HPV-associated oropharyngeal cancer is rising, particularly in younger people in westernized nations, which is thought to be reflective of changes in oral sexual practices, specifically with regard to the number of oral sexual partners. [ 5 ] [ 12 ]  This increase since the 1970s has mostly affected wealthier nations and male populations. [ 126 ] [ 127 ] [ 5 ]  This is due to evidence suggesting that transmission rates of HPV from women to men are higher than from men to women, as women often have a higher immune response to infection. [ 5 ] [ 128 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2364", "text": "Immunotherapy with immune checkpoint inhibitors is being investigated in head and neck cancers. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2365", "text": "A  head mirror  is a simple diagnostic device,  stereotypically  worn by  physicians , but less so in recent decades as they have become somewhat obsolete. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2366", "text": "A head mirror is mostly used for examination of the  ear, nose and throat  (ENT). It comprises a circular  concave mirror , with a small hole in the middle, and is attached to a headband. The mirror is worn over the physician's eye of choice, with the concave mirror surface facing outwards and the hole directly over the physician's eye, providing illumination like a  ring light ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2367", "text": "In use, the patient sits and faces the physician. A bright lamp is positioned adjacent to the patient's head, pointing toward the physician's face and hence towards the head mirror. The light from the lamp reflects off the mirror, along the line of sight of the user, with the light being somewhat concentrated by the curvature of the mirror. When used properly, the head mirror thus provides excellent shadow-free illumination."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2368", "text": "Because they were  once in common use , notably by  general practitioners  and  otorhinolaryngologists , head mirrors are often used as a stereotypical part of a physician's uniform by costumers and as props in comic routines. The main drawback to head mirrors was that they required some skill to use well. [ 1 ]  They are rarely seen outside of the ENT setting, having been largely replaced by pen lights among  general practitioners . They are still used by some otolaryngologists, particularly for examinations and procedures involving the oral cavity, although many are switching to fiber optic headlights. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2369", "text": "Hearing loss  is a partial or total inability to  hear . [ 5 ]  Hearing loss may be present at birth or acquired at any time afterwards. [ 6 ] [ 7 ]   Hearing loss may occur in one or both ears. [ 2 ]  In children, hearing problems can affect the ability to  acquire  spoken  language , and in adults it can create difficulties with social interaction and at work. [ 8 ]  Hearing loss can be temporary or permanent.  Hearing loss related to age  usually affects both ears and is due to  cochlear hair cell  loss. [ 9 ]  In some people, particularly older people, hearing loss can result in loneliness. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2370", "text": "Hearing loss may be caused by a number of factors, including:  genetics ,  ageing ,  exposure to noise , some  infections , birth complications, trauma to the ear, and certain medications or toxins. [ 2 ]  A common condition that results in hearing loss is  chronic ear infections . [ 2 ]  Certain infections during pregnancy, such as  cytomegalovirus ,  syphilis  and  rubella , may also cause hearing loss in the child. [ 2 ] [ 10 ]  Hearing loss is diagnosed when  hearing testing  finds that a person is unable to hear 25  decibels  in at least one ear. [ 2 ]  Testing for poor hearing is recommended for all newborns. [ 8 ]  Hearing loss can be categorized as mild (25 to 40  dB ), moderate (41 to 55\u00a0dB), moderate-severe (56 to 70\u00a0dB), severe (71 to 90\u00a0dB), or profound (greater than 90\u00a0dB). [ 2 ]  There are three main types of hearing loss:  conductive hearing loss ,  sensorineural hearing loss , and mixed hearing loss. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2371", "text": "About half of hearing loss globally is preventable through public health measures. [ 2 ]  Such practices include  immunization , proper care around  pregnancy , avoiding loud noise, and avoiding certain medications. [ 2 ]  The  World Health Organization  recommends that young people limit exposure to loud sounds and the use of  personal audio players  to an hour a day in an effort to limit exposure to noise. [ 11 ]  Early identification and support are particularly important in children. [ 2 ]  For many,  hearing aids ,  sign language ,  cochlear implants  and  subtitles  are useful. [ 2 ]   Lip reading  is another useful skill some develop. [ 2 ]  Access to hearing aids, however, is limited in many areas of the world. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2372", "text": "As of 2013 hearing loss affects about 1.1 billion people to some degree. [ 12 ]  It causes disability in about 466 million people (5% of the global population), and moderate to severe disability in 124 million people. [ 2 ] [ 13 ] [ 14 ]  Of those with moderate to severe disability 108 million live in low and middle income countries. [ 13 ]  Of those with hearing loss, it began during childhood for 65 million. [ 15 ]  Those who use sign language and are members of  Deaf culture  may see themselves as having a difference rather than a  disability . [ 16 ]  Many members of Deaf culture oppose attempts to cure deafness [ 17 ] [ 18 ] [ 19 ]  and some within this community view cochlear implants with concern as they have the potential to eliminate their culture. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2373", "text": "Use of the terms \"hearing impaired\", \"deaf-mute\", or \"deaf and dumb\" to describe deaf and hard of hearing people is discouraged by many in the deaf community as well as advocacy organizations, as they are offensive to many deaf and hard of hearing people. [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2374", "text": "Human hearing extends in frequency from 20 to 20,000\u00a0Hz, and in intensity from 0\u00a0dB to 120\u00a0dB HL or more. 0\u00a0dB does not represent absence of sound, but rather the softest sound an average unimpaired human ear can hear; some people can hear down to \u22125 or even \u221210\u00a0dB.  Sound is generally uncomfortably loud above 90\u00a0dB and 115\u00a0dB represents the  threshold of pain . The ear does not hear all frequencies equally well: hearing sensitivity peaks around 3,000\u00a0Hz.  There are many qualities of human hearing besides frequency range and intensity that cannot easily be measured quantitatively. However, for many practical purposes, normal hearing is defined by a frequency versus intensity graph, or audiogram, charting sensitivity thresholds of hearing at defined frequencies.  Because of the cumulative impact of age and exposure to noise and other acoustic insults, 'typical' hearing may not be normal. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2375", "text": "The presentation is as follows: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2376", "text": "Hearing loss is sensory, but may have accompanying symptoms: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2377", "text": "There may also be accompanying secondary symptoms: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2378", "text": "Hearing loss is associated with  Alzheimer's disease  and  dementia . [ 27 ]  The risk increases with the hearing loss degree. There are several hypotheses including cognitive resources being redistributed to hearing and social isolation from hearing loss having a negative effect. [ 28 ]  According to preliminary data,  hearing aid  usage can slow down the decline in  cognitive functions . [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2379", "text": "Hearing loss is responsible for causing  thalamocortical dysrthymia  in the brain which is a cause for several neurological disorders including  tinnitus  and  visual snow syndrome . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2380", "text": "Hearing loss is an increasing concern especially in aging populations. The prevalence of hearing loss increases about two-fold for each decade increase in age after age 40. [ 30 ]  While the secular trend might decrease individual level risk of developing hearing loss, the prevalence of hearing loss is expected to rise due to the aging population in the US. Another concern about aging process is cognitive decline, which may progress to  mild cognitive impairment  and eventually dementia. [ 31 ]  The association between hearing loss and cognitive decline has been studied in various research settings. Despite the variability in study design and protocols, the majority of these studies have found consistent association between age-related hearing loss and cognitive decline, cognitive impairment, and dementia. [ 32 ]  The association between age-related hearing loss and Alzheimer's disease was found to be nonsignificant, and this finding supports the hypothesis that hearing loss is associated with dementia independent of Alzheimer pathology. [ 32 ]  There are several hypotheses about the underlying causal mechanism for age-related hearing loss and cognitive decline. One hypothesis is that this association can be explained by common etiology or shared neurobiological pathology with decline in other physiological system. [ 33 ]  Another possible cognitive mechanism emphasize on individual's  cognitive load . As people developing hearing loss in the process of aging, the cognitive load demanded by auditory perception increases, which may lead to change in brain structure and eventually to dementia. [ 34 ]  One other hypothesis suggests that the association between hearing loss and cognitive decline is mediated through various psychosocial factors, such as decrease in  social contact  and increase in  social isolation . [ 33 ]  Findings on the association between hearing loss and dementia have significant public health implication, since about 9% of dementia cases are associated with hearing loss. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2381", "text": "People with hearing loss are at a higher risk of falling. There is also a potential  dose\u2013response relationship  between hearing loss and falls\u2014greater severity of hearing loss is associated with increased difficulties in postural control and increased prevalence of falls. [ 36 ]  The underlying causal link between the association of hearing loss and falls is yet to be elucidated. There are several hypotheses that indicate that there may be a common process between decline in  auditory system  and increase in incident falls, driven by physiological, cognitive, and behavioral factors. [ 36 ]  This evidence suggests that treating hearing loss has potential to increase  health-related quality of life  in older adults. [ 36 ] Falls  have important health implications, especially for an aging population where they can lead to significant morbidity and mortality. Elderly people are particularly vulnerable to the consequences of injuries caused by falls, since older individuals typically have greater bone fragility and poorer protective reflexes. [ 37 ]  Fall-related injury can also lead to burdens on the financial and health care systems. [ 37 ]  In literature, age-related hearing loss is found to be significantly associated with incident falls. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2382", "text": "Hearing loss can contribute to decrease in health-related quality of life, increase in social isolation and decline in social engagement, which are all risk factors for increased risk of developing depression symptoms. [ 39 ]   Depression  is one of the leading causes of morbidity and mortality worldwide. In older adults, the suicide rate is higher than it is for younger adults, and more suicide cases are attributable to depression. [ 40 ]  Some chronic diseases are found to be significantly associated with risk of developing depression, such as  coronary heart disease ,  pulmonary disease ,  vision loss  and hearing loss. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2383", "text": "Prelingual deafness  is profound hearing loss that is sustained before the acquisition of language, which can occur due to a  congenital  condition or through hearing loss before birth or in early infancy. Prelingual deafness impairs an individual's ability to acquire a  spoken  language in children, but deaf children can acquire spoken language through support from cochlear implants (sometimes combined with hearing aids). [ 42 ] [ 43 ]  Non-signing (hearing) parents of deaf babies (90\u201395% of cases) usually go with oral approach without the support of sign language, as these families lack previous experience with  sign language  and cannot competently provide it to their children without learning it themselves. This may in some cases (late implantation or not sufficient benefit from cochlear implants) bring the risk of  language deprivation  for the deaf baby [ 44 ]  because the deaf baby would not have a sign language if the child is unable to acquire spoken language successfully. The 5\u201310% of cases of deaf babies born into signing families have the potential of age-appropriate development of language due to early exposure to a  sign language  by sign-competent parents, thus they have the potential to meet language milestones, in sign language in lieu of spoken language. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2384", "text": "Post-lingual deafness  is hearing loss that is sustained after the  acquisition of language , which can occur due to  disease ,  trauma , or as a side-effect of a medicine. Typically, hearing loss is gradual and often detected by family and friends of affected individuals long before the patients themselves will acknowledge the disability. [ 46 ]  Post-lingual deafness is far more common than pre-lingual deafness. Those who lose their hearing later in life, such as in late adolescence or adulthood, face their own challenges, living with the adaptations that allow them to live independently. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2385", "text": "Hearing loss has multiple causes, including ageing, genetics, perinatal problems and acquired causes like noise and disease.  For some kinds of hearing loss the cause may be classified as  of unknown cause . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2386", "text": "There is a progressive loss of ability to hear high frequencies with aging known as  presbycusis . For men, this can start as early as 25 and women at 30. Although genetically variable, it is a normal concomitant of ageing and is distinct from hearing losses caused by noise exposure, toxins or disease agents. [ 47 ]  Common conditions that can increase the risk of hearing loss in elderly people are  high blood pressure ,  diabetes  ( hearing loss in diabetes ), [ 48 ]  or the use of certain medications harmful to the ear. [ 49 ] [ 50 ]  While everyone loses hearing with age, the amount and type of hearing loss is variable. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2387", "text": "Noise-induced hearing loss  (NIHL), also known as  acoustic trauma , typically manifests as elevated hearing thresholds (i.e. less sensitivity or muting). Noise exposure is the cause of approximately half of all cases of hearing loss, causing some degree of problems in 5% of the population globally. [ 52 ]  The majority of hearing loss is not due to age, but due to noise exposure. [ 53 ]  Various governmental, industry and standards organizations set noise standards. [ 54 ]  Many people are unaware of the presence of environmental sound at damaging levels, or of the level at which sound becomes harmful. Common sources of damaging noise levels include car stereos, children's toys, motor vehicles, crowds, lawn and maintenance equipment, power tools, gun use, musical instruments, and even hair dryers. Noise damage is cumulative; all sources of damage must be considered to assess risk. In the US, 12.5% of children aged 6\u201319 years have permanent hearing damage from excessive noise exposure. [ 55 ]   The World Health Organization estimates that half of those between 12 and 35 are at risk from using  personal audio devices  that are too loud. [ 11 ]  Hearing loss in adolescents may be caused by loud noise from toys, music by headphones, and concerts or events. [ 56 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2388", "text": "Hearing loss can be inherited. Around 75\u201380% of all these cases are inherited by  recessive genes , 20\u201325% are inherited by  dominant genes , 1\u20132% are inherited by  X-linked  patterns, and fewer than 1% are inherited by  mitochondrial inheritance . [ 58 ]   Syndromic deafness occurs when there are other signs or medical problems aside from deafness in an individual, [ 58 ]  such as  Usher syndrome ,  Stickler syndrome ,  Waardenburg syndrome ,  Alport's syndrome , and  neurofibromatosis type 2 .  Nonsyndromic deafness  occurs when there are no other signs or medical problems associated with the deafness in an individual. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2389", "text": "Fetal alcohol spectrum disorders  are reported to cause hearing loss in up to 64% of infants born to  alcoholic  mothers, from the ototoxic effect on the developing fetus plus malnutrition during pregnancy from the excess  alcohol  intake.  Premature birth  can be associated with sensorineural hearing loss because of an increased risk of  hypoxia ,  hyperbilirubinaemia , ototoxic medication and infection as well as noise exposure in the neonatal units. Also, hearing loss in premature babies is often discovered far later than a similar hearing loss would be in a full-term baby because normally babies are given a hearing test within 48 hours of birth, but doctors must wait until the premature baby is medically stable before testing hearing, which can be months after birth. [ 59 ]  The risk of hearing loss is greatest for those weighing less than 1500\u00a0g at birth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2390", "text": "Disorders responsible for hearing loss include  auditory neuropathy , [ 60 ] [ 61 ]   Down syndrome , [ 62 ]   Charcot\u2013Marie\u2013Tooth disease  variant 1E, [ 63 ]   autoimmune disease ,  multiple sclerosis ,  meningitis ,  cholesteatoma ,  otosclerosis ,  perilymph fistula ,  M\u00e9ni\u00e8re's disease , recurring ear infections, strokes,  superior semicircular canal dehiscence ,  Pierre Robin ,  Treacher-Collins ,  Usher Syndrome ,  Pendred Syndrome , and  Turner  syndrome,  syphilis ,  vestibular schwannoma , and  viral infections  such as  measles ,  mumps , congenital  rubella  (also called German measles) syndrome, several varieties of  herpes viruses , [ 64 ] [ 65 ]   HIV/AIDS , [ 66 ]  and  West Nile virus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2391", "text": "Some medications may reversibly or irreversibly affect hearing. These medications are considered  ototoxic . This includes  loop diuretics  such as furosemide and bumetanide,  non-steroidal anti-inflammatory drugs  (NSAIDs) both over-the-counter (aspirin, ibuprofen, naproxen) as well as prescription (celecoxib, diclofenac, etc.), paracetamol,  quinine , and  macrolide antibiotics . [ 67 ]  Others may cause permanent hearing loss. [ 68 ]  The most important group is the  aminoglycosides  (main member  gentamicin ) and platinum based chemotherapeutics such as  cisplatin  and  carboplatin . [ 69 ] [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2392", "text": "In addition to medications, hearing loss can also result from specific chemicals in the environment: metals, such as  lead ;  solvents , such as  toluene  (found in  crude oil ,  gasoline [ 71 ]  and  automobile exhaust , [ 71 ]  for example); and  asphyxiants . [ 72 ]  Combined with noise, these ototoxic chemicals have an additive effect on a person's hearing loss. [ 72 ]  Hearing loss due to chemicals starts in the high frequency range and is irreversible. It damages the  cochlea  with lesions and degrades central portions of the  auditory system . [ 72 ]  For some ototoxic chemical exposures, particularly styrene, [ 73 ]  the risk of hearing loss can be higher than being exposed to  noise  alone. The effects is greatest when the combined exposure include  impulse noise . [ 74 ] [ 75 ]  A 2018 informational bulletin by the US  Occupational Safety and Health Administration  (OSHA) and the  National Institute for Occupational Safety and Health  (NIOSH) introduces the issue, provides examples of ototoxic chemicals, lists the industries and occupations at risk and provides prevention information. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2393", "text": "There can be damage either to the ear, whether the external or middle ear, to the cochlea, or to the brain centers that process the aural information conveyed by the ears.  Damage to the middle ear may include fracture and discontinuity of the ossicular chain. [ 77 ] [ 78 ]   Damage to the inner ear (cochlea) may be caused by  temporal bone fracture .  People who sustain head injury are especially vulnerable to hearing loss or tinnitus, either temporary or permanent. [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2394", "text": "Sound waves reach the outer ear and are conducted down the ear canal to the  eardrum , causing it to vibrate. The vibrations are transferred by the 3 tiny ear bones of the  middle ear  to the fluid in the inner ear. The fluid moves hair cells ( stereocilia ), and their movement generates nerve impulses which are then taken to the brain by the  cochlear nerve . [ 81 ] [ 82 ]   The auditory nerve takes the impulses to the brainstem, which sends the impulses to the midbrain. Finally, the signal goes to the auditory cortex of the temporal lobe to be interpreted as sound. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2395", "text": "Hearing loss is most commonly caused by long-term exposure to loud noises, from recreation or from work, that damage the hair cells, which do not grow back on their own. [ 84 ] [ 85 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2396", "text": "Older people may lose their hearing from long exposure to noise, changes in the inner ear, changes in the middle ear, or from changes along the nerves from the ear to the brain. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2397", "text": "Identification of a hearing loss is usually conducted by a general practitioner  medical doctor ,  otolaryngologist , certified and licensed  audiologist , school or industrial  audiometrist , or other audiometric technician. Diagnosis of the cause of a hearing loss is carried out by a specialist physician (audiovestibular physician) or  otorhinolaryngologist ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2398", "text": "Hearing loss is generally measured by playing generated or recorded sounds, and determining whether the person can hear them. Hearing sensitivity varies according to the  frequency  of sounds. To take this into account, hearing sensitivity can be measured for a range of frequencies and plotted on an  audiogram . Other method for quantifying hearing loss is a  hearing test  using a mobile application or hearing aid application, which includes a hearing test. [ 87 ] [ 88 ]  Hearing diagnosis using mobile application is similar to the  audiometry  procedure. [ 87 ]  Audiograms, obtained using mobile applications, can be used to adjust hearing aid applications. [ 88 ]  Another method for quantifying hearing loss is a speech-in-noise test. which gives an indication of how well one can understand speech in a noisy environment. [ 89 ]  Otoacoustic emissions test is an objective hearing test that may be administered to toddlers and children too young to cooperate in a conventional hearing test. Auditory brainstem response testing is an electrophysiological test used to test for hearing deficits caused by pathology within the ear, the cochlear nerve and also within the brainstem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2399", "text": "A case history (usually a written form, with questionnaire) can provide valuable information about the context of the hearing loss, and indicate what kind of diagnostic procedures to employ. Examinations include  otoscopy ,  tympanometry , and differential testing with the  Weber ,  Rinne , Bing and Schwabach tests. In case of infection or inflammation, blood or other body fluids may be submitted for laboratory analysis.  MRI and CT scans can be useful to identify the pathology of many causes of hearing loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2400", "text": "Hearing loss is categorized by severity, type, and configuration. Furthermore, a hearing loss may exist in only one ear (unilateral) or in both ears (bilateral).  Hearing loss can be temporary or permanent, sudden or progressive. The  severity  of a hearing loss is ranked according to ranges of nominal thresholds in which a sound must be so it can be detected by an individual. It is measured in  decibels  of hearing loss, or dB HL. There are three main  types  of hearing loss:  conductive hearing loss ,  sensorineural hearing loss , and mixed hearing loss. [ 15 ]  An additional problem which is increasingly recognised is  auditory processing disorder  which is not a hearing loss as such but a difficulty perceiving sound. The shape of an audiogram shows the relative  configuration  of the hearing loss, such as a  Carhart notch  for otosclerosis, 'noise' notch for noise-induced damage, high frequency rolloff for presbycusis, or a flat audiogram for conductive hearing loss. In conjunction with speech audiometry, it may indicate central auditory processing disorder, or the presence of a  schwannoma  or other tumor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2401", "text": "People with  unilateral hearing loss  or single-sided deafness (SSD) have difficulty in hearing conversation on their impaired side, localizing sound, and understanding speech in the presence of background noise.  One reason for the hearing problems these patients often experience is due to the  head shadow effect . [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2402", "text": "Idiopathic sudden hearing loss is a condition where a person as an immediate decrease in the sensitivity of their  sensorineural hearing  that does not have a known cause. [ 91 ]  This type of loss is usually only on one side (unilateral) and the severity of the loss varies. A common threshold of a \"loss of at least 30 dB in three connected frequencies within 72 hours\" is sometimes used, however there is no universal definition or international consensus for diagnosing idiopathic sudden hearing loss. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2403", "text": "It is estimated that half of cases of hearing loss are preventable. [ 92 ]  About 60% of hearing loss in children under the age of 15 can be avoided. [ 93 ] [ 2 ]  There are a number of effective preventative strategies, including: immunization against  rubella  to prevent  congenital rubella syndrome , immunization against  H. influenza  and  S. pneumoniae  to reduce cases of  meningitis , and avoiding or protecting against excessive noise exposure. [ 15 ]  The  World Health Organization  also recommends immunization against  measles ,  mumps , and  meningitis , efforts to prevent  premature birth , and avoidance of certain medication as prevention. [ 94 ]   World Hearing Day  is a yearly event to promote actions to prevent hearing damage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2404", "text": "Avoiding exposure to loud noise can help prevent noise-induced hearing loss. [ 95 ]  18% of adults exposed to loud noise at work for five years or more report hearing loss in both ears as compared to 5.5% of adults who were not exposed to loud noise at work. [ 96 ]  Different programs exist for specific populations such as school-age children, adolescents and workers. [ 97 ]   But the HPD (without individual selection, training and  fit testing ) does not significantly reduce the risk of hearing loss. [ 98 ] [ 99 ]  The use of  antioxidants  is being studied for the prevention of noise-induced hearing loss, particularly for scenarios in which noise exposure cannot be reduced, such as during military operations. [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2405", "text": "Noise is widely recognized as an  occupational hazard . In the United States, the  National Institute for Occupational Safety and Health  (NIOSH) and the  Occupational Safety and Health Administration  (OSHA) work together to provide standards and enforcement on workplace noise levels. [ 101 ] [ 102 ]  The  hierarchy of hazard controls  demonstrates the different levels of controls to reduce or eliminate exposure to noise and prevent hearing loss, including  engineering controls  and  personal protective equipment  (PPE). [ 103 ]  Other programs and initiative have been created to prevent hearing loss in the workplace. For example, the  Safe-in-Sound Award  was created to recognize organizations that can demonstrate results of successful noise control and other interventions. [ 104 ]  Additionally, the  Buy Quiet  program was created to encourage employers to purchase quieter machinery and tools. [ 105 ]  By purchasing less noisy power tools like those found on the  NIOSH Power Tools Database  and limiting exposure to ototoxic chemicals, great strides can be made in preventing hearing loss. [ 106 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2406", "text": "Companies can also provide personal hearing protector devices tailored to both the worker and type of employment. Some hearing protectors universally block out all noise, and some allow for certain noises to be heard. Workers are more likely to wear hearing protector devices when they are properly fitted. [ 107 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2407", "text": "Often interventions to prevent noise-induced hearing loss have many components. A 2017 Cochrane review found that stricter legislation might reduce noise levels. [ 108 ]   Providing workers with information on their  sound exposure levels  was not shown to decrease exposure to noise. Ear protection, if used correctly, can reduce noise to safer levels, but often, providing them is not sufficient to prevent hearing loss. Engineering noise out and other solutions such as proper maintenance of equipment can lead to noise reduction, but further field studies on resulting noise exposures following such interventions are needed. Other possible solutions include improved enforcement of existing legislation and better implementation of well-designed prevention programmes, which have not yet been proven conclusively to be effective. The conclusion of the Cochrane Review was that further research could modify what is now regarding the effectiveness of the evaluated interventions. [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2408", "text": "The  Institute for Occupational Safety and Health of the German Social Accident Insurance  has created a hearing impairment calculator based on the ISO 1999 model for studying  threshold shift  in relatively homogeneous groups of people, such as workers with the same type of job.  The ISO 1999 model estimates how much hearing impairment in a group can be ascribed to age and  noise exposure .  The result is calculated via an  algebraic equation  that uses the A-weighted sound exposure level, how many years the people were exposed to this noise, how old the people are, and their sex. The model's estimations are only useful for people without hearing loss due to non-job related exposure and can be used for prevention activities. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2409", "text": "The  United States Preventive Services Task Force  recommends  neonatal hearing screening  for all newborns, as the first three years of life are believed to be the most important for language development. [ 8 ] [ 110 ]  Universal neonatal hearing screenings have now been widely implemented across the U.S., with rates of newborn screening increasing from less than 3% in the early 1990s to 98% in 2009. [ 111 ] [ 112 ]  Newborns whose screening reveals a high index of suspicion of hearing loss are referred for additional diagnostic testing with the goal of providing early intervention and access to language. [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2410", "text": "The  American Academy of Pediatrics  advises that children should have their hearing tested several times throughout their schooling: [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2411", "text": "While the American College of Physicians indicated that there is not enough evidence to determine the utility of screening in adults over 50 years old who do not have any symptoms, [ 114 ]  the  American Language, Speech Pathology and Hearing Association  recommends that adults should be screened at least every decade through age 50 and at three-year intervals thereafter, to minimize the detrimental effects of the untreated condition on quality of life. [ 115 ]  For the same reason, the US Office of Disease Prevention and Health Promotion included as one of  Healthy People 2020  objectives: to increase the proportion of persons who have had a hearing examination. [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2412", "text": "Management depends on the specific cause if known as well as the extent, type and configuration of the hearing loss. Sudden hearing loss due to an underlying nerve problem may be treated with  corticosteroids . [ 117 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2413", "text": "Most hearing loss, that result from age and noise, is progressive and irreversible, and there are currently no approved or recommended treatments.  A few specific kinds of hearing loss are amenable to surgical treatment.  In other cases, treatment is addressed to underlying pathologies, but any hearing loss incurred may be permanent. Some management options include  hearing aids ,  cochlear implants ,  middle ear implants ,  assistive technology , and  closed captioning ; [ 9 ]  in  movie theaters , a Hearing Impaired (HI) audio track may be available via headphones to better hear dialog. [ 118 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2414", "text": "This choice depends on the level of hearing loss, type of hearing loss, and personal preference. Hearing aid applications are one of the options for hearing loss management. [ 88 ] [ 119 ]  For people with bilateral hearing loss, it is not clear if bilateral hearing aids (hearing aids in both ears) are better than a unilateral hearing aid (hearing aid in one ear). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2415", "text": "For people with idiopathic sudden hearing loss, different treatment approaches have been suggested that are usually based on the suspected cause of the sudden hearing loss. Treatment approaches may include corticosteroid medications, rheological drugs, vasodilators, anesthetics, and other medications chosen based on the suspected underlying pathology that caused the sudden hearing loss. [ 91 ]  The evidence supporting most treatment options for idiopathic sudden hearing loss is very weak and adverse effects of these different medications is a consideration when deciding on a treatment approach. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2416", "text": "Globally, hearing loss affects about 10% of the population to some degree. [ 52 ]  It caused moderate to severe disability in 124.2\u00a0million people as of 2004 (107.9\u00a0million of whom are in low and middle income countries). [ 13 ]  Of these 65\u00a0million acquired the condition during childhood. [ 15 ]  At birth ~3 per 1000 in  developed countries  and more than 6 per 1000 in  developing countries  have hearing problems. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2417", "text": "Hearing loss increases with age. In those between 20 and 35 rates of hearing loss are 3% while in those 44 to 55 it is 11% and in those 65 to 85 it is 43%. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2418", "text": "A 2017 report by the World Health Organization estimated the costs of unaddressed hearing loss and the cost-effectiveness of interventions, for the health-care sector, for the education sector and as broad societal costs. [ 120 ]   Globally, the annual cost of unaddressed hearing loss was estimated to be in the range of $750\u2013790 billion  international dollars ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2419", "text": "The  International Organization for Standardization  (ISO) developed the ISO 1999 standards for the estimation of hearing thresholds and noise-induced hearing impairment. [ 121 ]  They used data from two noise and hearing study databases, one presented by Burns and Robinson ( Hearing and Noise in Industry,  Her Majesty's Stationery Office,  London, 1970) and by Passchier-Vermeer (1968). [ 122 ]  As race are some of the factors that can affect the expected distribution of pure-tone hearing thresholds several other national or regional datasets exist, from Sweden, [ 123 ]   Norway, [ 124 ]  South Korea, [ 125 ]  the United States [ 126 ]  and Spain. [ 127 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2420", "text": "In the United States hearing is one of the health outcomes measure by the  National Health and Nutrition Examination Survey  (NHANES), a  survey   research  program conducted by the  National Center for Health Statistics . It examines  health  and  nutritional  status of adults and children in the  United States .  Data from the United States in 2011\u20132012 found that rates of hearing loss has declined among adults aged 20 to 69 years, when compared with the results from an earlier time period (1999\u20132004). It also found that adult hearing loss is associated with increasing age, sex, ethnicity, educational level, and noise exposure. [ 128 ]   Nearly one in four adults had audiometric results suggesting noise-induced hearing loss. Almost one in four adults who reported excellent or good hearing had a similar pattern (5.5% on both sides and 18% on one side). Among people who reported exposure to loud noise at work, almost one third had such changes. [ 129 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2421", "text": "People with extreme hearing loss may communicate through  sign languages . Sign languages convey meaning through manual communication and body language instead of acoustically conveyed sound patterns. This involves the simultaneous combination of hand shapes, orientation and movement of the hands, arms or body, and facial expressions to express a speaker's thoughts. \"Sign languages are based on the idea that vision is the most useful tool a deaf person has to communicate and receive information\". [ 130 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2422", "text": "Deaf culture  refers to a tight-knit  cultural group  of people whose  primary language  is signed, and who practice social and cultural norms which are distinct from those of the surrounding hearing community. This community does not automatically include all those who are clinically or legally deaf, nor does it exclude every hearing person. According to Baker and Padden, it includes any person or persons who \"identifies him/herself as a member of the Deaf community, and other members accept that person as a part of the community,\" [ 131 ]  an example being  children of deaf adults  with normal hearing ability.  It includes the set of social beliefs, behaviors, art, literary traditions, history, values, and shared institutions of communities that are influenced by deafness and which use sign languages as the main means of communication. [ 132 ] [ 133 ]   Members of the Deaf community tend to view deafness as a difference in human experience rather than a  disability  or  disease . [ 134 ] [ 135 ]   When used as a cultural label especially within the culture, the word  deaf  is often written with a capital  D  and referred to as \"big\u00a0D Deaf\" in speech and sign. When used as a label for the  audiological  condition, it is written with a lower case  d . [ 132 ] [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2423", "text": "There also multiple educational institutions for both deaf and Deaf people, that usually use sign language as the main language of instruction. Famous institutions include  Gallaudet University  and the  National Technical Institute for the Deaf  in the US, [ 136 ]  and the  National University Corporation of Tsukuba University of Technology  in Japan. [ 137 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2424", "text": "A 2005 study achieved successful  regrowth of cochlea cells  in guinea pigs. [ 138 ]  However, the regrowth of cochlear hair cells does not imply the restoration of hearing sensitivity, as the sensory cells may or may not make connections with neurons that carry the signals from hair cells to the brain. A 2008 study has shown that gene therapy targeting  Atoh1  can cause hair cell growth and attract neuronal processes in embryonic mice. Some hope that a similar treatment will one day ameliorate hearing loss in humans. [ 139 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2425", "text": "Recent research, reported in 2012 achieved growth of cochlear nerve cells resulting in hearing improvements in gerbils, [ 140 ]  using stem cells. Also reported in 2013 was regrowth of hair cells in deaf adult mice using a drug intervention resulting in hearing improvement. [ 141 ]  The  Hearing Health Foundation  in the US has embarked on a project called the Hearing Restoration Project. [ 142 ]  Also Action on Hearing Loss in the UK is also aiming to restore hearing. [ 143 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2426", "text": "Researchers reported in 2015 that genetically deaf mice which were treated with  TMC1  gene therapy recovered some of their hearing. [ 144 ] [ 145 ]  In 2017, additional studies were performed to treat  Usher syndrome [ 146 ]  and here, a recombinant adeno-associated virus seemed to outperform the older vectors. [ 147 ] [ 148 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2427", "text": "Besides research studies seeking to improve hearing, such as the ones listed above, research studies on the deaf have also been carried out in order to understand more about audition. Pijil and Shwarz (2005) conducted their study on the deaf who lost their hearing later in life and, hence, used cochlear implants to hear. They discovered further evidence for rate coding of pitch, a system that codes for information for frequencies by the rate that neurons fire in the auditory system, especially for lower frequencies as they are coded by the frequencies that neurons fire from the basilar membrane in a synchronous manner. Their results showed that the subjects could identify different pitches that were proportional to the frequency stimulated by a single electrode. The lower frequencies were detected when the basilar membrane was stimulated, providing even further evidence for rate coding. [ 149 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2428", "text": "Tracheal intubation  (usually simply referred to as  intubation ), an  invasive medical procedure , is the placement of a flexible plastic  catheter  into the  trachea . For millennia,  tracheotomy  was considered the most reliable (and most risky) method of tracheal intubation. By the late 19th century, advances in the sciences of  anatomy  and  physiology , as well as the beginnings of an appreciation of the  germ theory of disease , had reduced the  morbidity  and  mortality  of this operation to a more acceptable rate. Also in the late 19th century, advances in  endoscopic  instrumentation had improved to such a degree that direct  laryngoscopy  had finally become a viable means to secure the  airway  by the non-surgical orotracheal route. Nasotracheal intubation was not widely practiced until the early 20th century. The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of  anesthesia ,  critical care medicine ,  emergency medicine ,  gastroenterology ,  pulmonology  and  surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2429", "text": "The earliest known depiction of a tracheotomy is found on two  Egyptian   tablets  dating back to circa 3600 BC. [ 1 ]  The 110-page  Ebers Papyrus , an  Egyptian medical papyrus  that dates to around 1550 BC, also refers to the tracheotomy. [ 1 ] [ 2 ]  Tracheotomy was described in an ancient Indian scripture, the  Rigveda : the text mentions \"the bountiful one who, without a ligature, can cause the windpipe to re-unite when the cervical cartilages are cut across, provided they are not entirely severed.\" [ 2 ] [ 3 ] [ 4 ]  The  Sushruta Samhita  ( c. \u2009400 BC ) is another text from the  Indian subcontinent  on ayurvedic medicine and surgery that mentions tracheotomy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2430", "text": "The  Greek  physician  Hippocrates  ( c. \u2009460 \u2013 c. \u2009370 BC ) condemned the practice of tracheotomy. Warning against the unacceptable risk of death from inadvertent laceration of the  carotid artery  during tracheotomy, Hippocrates also cautioned that \"The most difficult  fistulas  are those that occur in the cartilaginous areas.\" [ 6 ]   Homerus of Byzantium  is said to have written of  Alexander the Great  (356\u2013323 BC) saving a soldier from  asphyxiation  by making an incision with the tip of his sword in the man's trachea. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2431", "text": "Despite the concerns of Hippocrates,  Galen  of  Pergamon  (129\u2013199) and  Aretaeus  of  Cappadocia  (both of whom lived in  Rome  in the 2nd century AD) credit  Asclepiades of Bithynia  ( c. \u2009124 \u201340 BC) as being the first physician to perform a non-emergency tracheotomy. [ 8 ] [ 9 ]  However, Aretaeus warned against the performance of tracheotomy because he believed that incisions made into the tracheal  cartilage  were prone to secondary  wound infections  and therefore would not heal. He wrote that \"The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite\". [ 10 ] [ 11 ]   Antyllus , another Greek surgeon who lived in Rome in the 2nd century AD, was reported to have performed tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a  transverse  incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. [ 10 ]  Antyllus wrote that tracheotomy was not effective however in cases of severe  laryngotracheobronchitis  because the  pathology  was distal to the operative site. Antyllus' original writings were lost, but they were preserved by  Oribasius  ( c. \u2009320 \u2013400) and  Paul of Aegina  ( c. \u2009625 \u2013690), both of whom were Greek physicians as well as historians. [ 10 ]  Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. [ 12 ] [ 13 ]  Galen may have understood the importance of artificial ventilation, because in one of his experiments he used bellows to inflate the lungs of a dead animal. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2432", "text": "Circa 1020,  Ibn S\u012bn\u0101  (980\u20131037) described the use of tracheal intubation in  The Canon of Medicine  to facilitate  breathing . [ 16 ]  In the 12th century medical textbook  Al-Taisir ,  Ibn Zuhr  (1091\u20131161) of Al-Andalus (also known as Avenzoar) provided an anatomically correct description of the tracheotomy operation. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2433", "text": "The  Renaissance  saw significant advances in anatomy and surgery, and surgeons became increasingly open to surgery on the trachea. Despite this, the mortality rate failed to improve. [ 10 ]  From 1500 through 1832 there are only 28 known descriptions of successful tracheotomy in the literature. [ 10 ]  The first detailed descriptions on tracheal intubation and subsequent  artificial respiration  of animals were from  Andreas Vesalius  (1514\u20131564) of Brussels. In his landmark book published in 1543,  De humani corporis fabrica , he described an experiment in which he passed a  reed  into the trachea of a dying animal whose  thorax  had been opened and maintained ventilation by blowing into the reed intermittently. [ 15 ] [ 19 ]  Vesalius wrote that the technique could be life-saving.  Antonio Musa Brassavola  (1490\u20131554) of  Ferrara  treated a patient with  peritonsillar abscess  by tracheotomy after the patient had been refused by  barber surgeons . The patient apparently made a complete recovery and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2434", "text": "Towards the end of the 16th century, anatomist and surgeon  Hieronymus Fabricius  (1533\u20131619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short  cannula  that incorporated wings to prevent the tube from advancing too far into the trachea. Fabricius' description of the tracheotomy procedure is similar to that used today.  Julius Casserius  (1561\u20131616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy, recommending a curved silver tube with several holes in it.  Marco Aurelio Severino  (1580\u20131656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a  diphtheria   epidemic  in  Naples  in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2435", "text": "In 1620 the French surgeon  Nicholas Habicot  (1550\u20131624), surgeon of the  Duke of Nemours  and anatomist, published a report of four successful \"bronchotomies\" he had performed. [ 21 ]  One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first known tracheotomy performed on a  pediatric  patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a  highwayman . The object became lodged in his  esophagus , obstructing his trachea. Habicot suggested that the operation might also be effective for patients with inflammation of the larynx. He developed equipment for this surgical procedure that are similar in many ways to modern designs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2436", "text": "Sanctorius  (1561\u20131636) is believed to be the first to use a trocar in the operation. He recommended leaving the cannula in place for a few days following the operation. [ 22 ]  Early tracheostomy devices are illustrated in Habicot's  Question Chirurgicale [ 21 ]  and Julius Casserius' posthumous  Tabulae anatomicae  in 1627. [ 23 ]  Thomas Fienus (1567\u20131631), Professor of Medicine at the  University of Louvain , was the first to use the word \"tracheotomy\" in 1649, but this term was not commonly used until a century later. [ 24 ]  Georg Detharding (1671\u20131747), professor of anatomy at the  University of Rostock , treated a drowning victim with tracheostomy in 1714. [ 25 ] [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2437", "text": "Fearful of complications, most surgeons delayed the potentially life-saving tracheotomy until a patient was moribund, despite the knowledge that irreversible organ damage would have already occurred by that time. This began to change in the early 19th century, when the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician  Pierre Bretonneau  (1778\u20131862) employed tracheotomy as a last resort to treat a case of  diphtheria . [ 28 ]  In 1852, Bretonneau's student  Armand Trousseau  (1801\u20131867) presented a series of 169 tracheotomies (158 of which were for  croup  and 11 for \"chronic maladies of the larynx\"). [ 29 ]  In 1871, the German surgeon  Friedrich Trendelenburg  (1844\u20131924) published a paper describing the first successful elective human tracheotomy performed to administer general anesthesia. [ 30 ] [ 31 ] [ 32 ] [ 33 ]  After the death of German Emperor  Frederick III  from  laryngeal cancer  in 1888, Sir  Morell Mackenzie  (1837\u20131892) and the other treating physicians collectively wrote a book discussing the then-current  indications  for tracheotomy and when the operation is absolutely necessary. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2438", "text": "In the early 20th century, physicians began to use the tracheotomy in the treatment of patients affected by paralytic  poliomyelitis  who required mechanical ventilation. The currently used surgical tracheotomy technique was described in 1909 by  Chevalier Jackson  (1865\u20131958), a professor of laryngology at  Jefferson Medical College  in Philadelphia. [ 35 ]  However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the \"high tracheotomy\" or the \"low tracheotomy\" was more beneficial. Ironically, the newly developed  inhalational anesthetic agents  and techniques of general anesthesia actually seemed to increase the risks, with many patients with fatal postoperative complications. Jackson emphasised the importance of postoperative care, which dramatically reduced the mortality rate. By 1965, the surgical anatomy was thoroughly and widely understood,  antibiotics  were widely available and useful for treating postoperative infections and other major complications of tracheotomy had also become more manageable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2439", "text": "While all these surgical advances were taking place, many important developments were also taking place in the science of  optics . Many new  optical instruments  with medical applications were invented during the 19th century. In 1805, a German army surgeon named  Philipp von Bozzini  (1773\u20131809) invented a device he called the  lichtleiter  (or light-guiding instrument). This instrument, the ancestor of the modern endoscope, was used to examine the  urethra , the human  urinary bladder ,  rectum , oropharynx and nasopharynx. [ 36 ] [ 37 ] [ 38 ] [ 39 ]  The instrument consisted of a candle within a metal chimney; a mirror on the inside reflected light from the candle through attachments into the relevant body cavity. [ 40 ]  The practice of gastric endoscopy in humans was pioneered by United States Army surgeon  William Beaumont  (1785\u20131853) in 1822 with the cooperation of his patient  Alexis St. Martin  (1794\u20131880), a victim of an accidental gunshot wound to the stomach. [ 41 ]  In 1853,  Antonin Jean Desormeaux  (1815\u20131882) of Paris modified Bozzini's lichtleiter such that a mirror would reflect light from a  kerosene lamp  through a long metal channel. [ 40 ]  Referring to this instrument as an  endoscope  (he is credited with coining this term), Desormeaux employed it to examine the urinary bladder. However, like Bozzini's lichtleiter, Desormeaux's endoscope was of limited utility due to its propensity to become very hot during use. [ 40 ]  In 1868,  Adolph Kussmaul  (1822\u20131902) of Germany performed the first  esophagogastroduodenoscopy  (a  diagnostic  procedure in which an endoscope is used to visualize the esophagus, stomach and  duodenum ) on a living human. The subject was a  sword-swallower , who swallowed a metal tube with a length of 47 centimeters and a diameter of 13 millimeters. [ 42 ] [ 43 ] [ 44 ] [ 45 ]  On 2 October 1877,  Berlin   urologist   Maximilian Carl-Friedrich Nitze  (1848\u20131906) and  Viennese  instrument maker Josef Leiter (1830\u20131892) introduced the first practical  cystourethroscope  with an electric light source. [ 46 ]  The instrument's biggest drawback was the  tungsten  filament  incandescent light bulb  (invented by  Alexander Lodygin , 1847\u20131923), which became very hot and required a complicated  water cooling  system. [ 40 ]  In 1881, Polish physician  Jan Mikulicz-Radecki  (1850\u20131905) created the first rigid gastroscope for practical applications. [ 47 ] [ 48 ] [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2440", "text": "In 1932,  Rudolph Schindler  (1888\u20131968) of Germany introduced the first semi-flexible gastroscope. [ 50 ]  This device had numerous  lenses  positioned throughout the tube and a miniature light bulb at the distal tip. The tube of this device was 75 centimeters long and 11 millimeters in diameter, and the distal portion was capable of a certain degree of flexion. Between 1945 and 1952,  optical engineers  (particularly Karl Storz (1911\u20131996) of the  Karl Storz GmbH  company of Germany,  Harold Hopkins  (1918\u20131995) of England and  Mutsuo Sugiura  of the Japanese  Olympus Corporation ) built upon this early work, leading to the development of the first \"gastrocamera\". [ 51 ] [ 52 ]  In 1964, Fernando Alves Martins (born 17 June 1927) of Portugal applied  optical fiber  technology to one of these early gastrocameras to produce the first gastrocamera with a flexible fiberscope. [ 53 ] [ 54 ]  Initially used in esophagogastroduodenoscopy, newer devices were developed in the late 1960s for use in  bronchoscopy ,  rhinoscopy  and laryngoscopy. The concept of using a fiberoptic endoscope for tracheal intubation was introduced by Peter Murphy, an English anesthetist, in 1967. [ 55 ]  By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the  pulmonology  and anesthesia communities. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2441", "text": "In 1854, a Spanish  vocal pedagogist  named  Manuel Garc\u00eda  (1805\u20131906) became the first man to view the functioning glottis in a living human. Garc\u00eda developed a tool that used two mirrors for which the Sun served as an external  light source . [ 57 ]  Using this device, he was able to observe the function of his own glottic apparatus and the uppermost portion of his trachea. He presented his observations at the  Royal Society of London  in 1855. [ 57 ] [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2442", "text": "In 1858,  Eug\u00e8ne Bouchut  (1818\u20131891), a  pediatrician  from Paris, developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria-related pseudomembrane. His method involved introducing a small straight metal tube into the larynx, securing it by means of a silk thread and leaving it there for a few days until the pseudomembrane and airway obstruction had resolved sufficiently. [ 59 ]  Bouchut presented this experimental technique along with the results he had achieved in the first seven cases at the  French Academy of Sciences  conference on 18 September 1858. [ 60 ]  The members of the academy rejected Bouchut's ideas, largely as a result of highly critical and negative remarks made by the influential Armand Trousseau. [ 61 ]  Undaunted, Bouchut later introduced a set of tubes (\"Bouchut's tubes\") for intubation of the trachea, as an alternative to tracheotomy in cases of diphtheria."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2443", "text": "In March 1878, Wilhelm Hack of  Freiburg  published a paper describing the use of non-surgical orotracheal intubation in the removal of  vocal cord polyps . [ 62 ]  In November of that year, he published another study, this time on the use of orotracheal intubation to secure the airway of a patient with acute  glottic edema , progressively introducing sizes 3 through 11 of \"Schrotter's graduated triangular  vulcanite  bougies\" into the larynx. [ 63 ] [ 64 ]  In 1880, the  Scottish  surgeon  William Macewen  (1848\u20131924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with  chloroform . [ 64 ] [ 65 ] [ 66 ]  All previous observations of the glottis and larynx (including those of Garc\u00eda, Hack and Macewen) had been performed under indirect vision (using mirrors) until 23 April 1895, when  Alfred Kirstein  (1863\u20131922) of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose; he called this device an  autoscope . [ 67 ]  The death in 1888 of  Emperor Frederick III [ 34 ]  may have motivated Kirstein to develop the autoscope. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2444", "text": "Until 1913,  oral and maxillofacial surgery  was performed by mask  inhalation anesthesia , topical application of  local anesthetics  to the  mucosa , rectal anesthesia, or  intravenous  anesthesia. While otherwise effective, these techniques did not protect the airway from obstruction and also exposed patients to the risk of pulmonary aspiration of blood and  mucus  into the tracheobronchial tree. In 1913,  Chevalier Jackson  was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea. [ 69 ]  Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than the proximal light source used by Kirstein. [ 70 ]  This new blade incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2445", "text": "That same year,  Henry H. Janeway  (1873\u20131921) published results he had achieved using a laryngoscope he had recently developed. [ 72 ]  While practicing at  Bellevue Hospital  in  New York City , Janeway was of the opinion that direct intratracheal  insufflation  of  volatile anesthetics  would provide improved conditions for  otolaryngologic  surgery. With this in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson's device, Janeway's instrument incorporated a distal light source. Unique however was the inclusion of  batteries  within the handle, a central notch in the blade for maintaining the tracheal tube in the midline of the oropharynx during intubation and a slight curve to the distal tip of the blade to help guide the tube through the glottis. The success of this design led to its subsequent use in other types of surgery. Janeway was thus instrumental in popularizing the widespread use of direct laryngoscopy and tracheal intubation in the practice of anesthesiology. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2446", "text": "After  World War I , further advances were made in the field of intratracheal anesthesia. Among these were those made by Sir  Ivan Whiteside Magill  (1888\u20131986). Working at the  Queen's Hospital for Facial and Jaw Injuries  in  Sidcup  with plastic surgeon Sir  Harold Gillies  (1882\u20131960) and anesthetist E. Stanley Rowbotham (1890\u20131979), Magill developed the technique of awake blind nasotracheal intubation. [ 73 ] [ 74 ] [ 75 ] [ 76 ] [ 77 ] [ 78 ]  Magill devised a new type of angulated forceps (the Magill forceps) that are still used today to facilitate nasotracheal intubation in a manner that is little changed from Magill's original technique. [ 79 ]  Other devices invented by Magill include the Magill laryngoscope blade, [ 80 ]  as well as several apparati for the administration of volatile anesthetic agents. [ 81 ] [ 82 ] [ 83 ]  The Magill curve of an endotracheal tube is also named for Magill."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2447", "text": "Sir  Robert Macintosh  (1897\u20131989) also achieved significant advances in techniques for tracheal intubation when he introduced his new curved laryngoscope blade in 1943. [ 84 ]  The Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation. [ 85 ]  In 1949, Macintosh published a case report describing the novel use of a  gum elastic   urinary catheter  as an endotracheal tube introducer to facilitate difficult tracheal intubation. [ 86 ]  Inspired by Macintosh's report, P. Hex Venn (who was at that time the anesthetic advisor to the British firm Eschmann Brothers & Walsh, Ltd.) set about developing an endotracheal tube introducer based on this concept. Venn's design was accepted in March 1973, and what became known as the Eschmann endotracheal tube introducer went into production later that year. [ 87 ]  The material of Venn's design was different from that of a gum elastic bougie in that it had two layers: a core of tube woven from  polyester  threads and an outer  resin  layer. This provided more stiffness but maintained the flexibility and the slippery surface. Other differences were the length (the new introducer was 60\u00a0cm (24\u00a0in), which is much longer than the gum elastic bougie) and the presence of a 35\u00b0 curved tip that let it be steered around obstacles. [ 88 ] [ 89 ]  The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a  central venous catheter . [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2448", "text": "The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia,  critical care medicine ,  emergency medicine ,  gastroenterology , pulmonology and surgery. The  \"digital revolution\"  of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed  video laryngoscopes  that use  digital technology  such as the  CMOS   active pixel sensor  (CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The Glidescope video laryngoscope is one example of such a device. [ 91 ] [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2449", "text": "A  hoarse voice , also known as  dysphonia  or  hoarseness , [ 1 ]  is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. [ 2 ] [ 3 ] [ clarification needed ]  A hoarse voice can be associated with a feeling of unease or scratchiness in the throat. [ 2 ]  Hoarseness is often a symptom of problems in the vocal folds of the larynx. [ 2 ]  It may be caused by  laryngitis , which in turn may be caused by an  upper respiratory infection , a  cold , or  allergies . [ 2 ]  Cheering at sporting events, speaking loudly in noisy environments, talking for too long without resting one's voice, singing loudly, or speaking with a voice that is too high or too low can also cause temporary hoarseness. [ 2 ]  A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. [ 2 ]  If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2450", "text": "It appears to occur more commonly in females and the elderly. [ 4 ]  Furthermore, certain occupational groups, such as teachers and singers, are at an increased risk. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2451", "text": "Long-term hoarseness, or hoarseness that persists over three weeks, especially when not associated with a cold or  flu  should be assessed by a medical doctor. [ 2 ]  It is also recommended to see a doctor if hoarseness is associated with coughing up blood,  difficulties swallowing , a lump in the neck, pain when speaking or swallowing,  difficulty breathing , or  complete loss of voice  for more than a few days. [ 2 ]  For voice to be classified as \"dysphonic\", abnormalities must be present in one or more vocal parameters: pitch, loudness, quality, or variability. [ 7 ]  Perceptually, dysphonia can be characterised by hoarse, breathy, harsh, or rough vocal qualities, but some kind of  phonation  remains. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2452", "text": "Dysphonia can be categorized into two broad main types: organic and functional, and classification is based on the underlying pathology. While the causes of dysphonia can be divided into five basic categories, all of them result in an interruption of the ability of the  vocal folds  to vibrate normally during exhalation, which affects the voice. The assessment and diagnosis of dysphonia is done by a multidisciplinary team, and involves the use of a variety of subjective and objective measures, which look at both the quality of the voice as well as the physical state of the  larynx . [ citation needed ]  Multiple treatments have been developed to address organic and functional causes of dysphonia. Dysphonia can be targeted through direct therapy, indirect therapy, medical treatments, and surgery. Functional dysphonias may be treated through direct and indirect voice therapies, whereas surgeries are recommended for chronic, organic dysphonias. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2453", "text": "Voice disorders can be divided into two broad categories: organic and functional. [ 9 ]  The distinction between these broad classes stems from their cause, whereby organic dysphonia results from some sort of physiological change in one of the subsystems of speech (for voice, usually respiration, laryngeal anatomy, and/or other parts of the vocal tract are affected). Conversely, functional dysphonia refers to hoarseness resulting from vocal use (i.e. overuse/abuse). [ 10 ]  Furthermore, according to  ASHA , organic dysphonia can be subdivided into structural and neurogenic; neurogenic dysphonia is defined as impaired functioning of the vocal structure due to a neurological problem (in the  central nervous system  or  peripheral nervous system ); in contrast, structural dysphonia is defined as impaired functioning of the vocal mechanism that is caused by some sort of physical change (e.g. a lesion on the vocal folds). [ 10 ]  Notably, an additional subcategory of functional dysphonia recognized by professionals is psychogenic dysphonia, which can be defined as a type of voice disorder that has no known cause and can be presumed to be a product of some sort of psychological stressors in one's environment. [ 10 ] [ 11 ]  It is important to note that these types are not mutually exclusive and much overlap occurs. For example,  Muscle Tension Dysphonia  (MTD) has been found to be a result of many different causes including the following: MTD in the presence of an organic pathology (i.e. organic type), MTD stemming from vocal use (i.e. functional type), and MTD as a result of personality and/or psychological factors (i.e. psychogenic type). [ 10 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2454", "text": "The most common causes of hoarseness is  laryngitis  (acute 42.1%; chronic 9.7%) and functional dysphonia (30%). [ 13 ]  Hoarseness can also be caused by laryngeal  tumours  (benign 10.7 - 31%; malignant 2.2 - 3.0%). [ 13 ]  Causes that are overall less common include  neurogenic  conditions (2.8 - 8.0%), psychogenic conditions (2.0 - 2.2%), and aging (2%). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2455", "text": "A variety of different causes, which result in abnormal vibrations of the vocal folds, can cause dysphonia. These causes can range from vocal abuse and misuse to  systemic diseases . Causes of dysphonia can be divided into five basic categories, although overlap may occur between categories. [ 14 ] [ 15 ] [ 16 ] [ 17 ]  (Note that this list is not exhaustive):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2456", "text": "It has been suggested that certain occupational groups may be at increased risk of developing dysphonia [ 5 ] [ 6 ]  due to the excessive or intense vocal demands of their work. [ 19 ]  Research on this topic has primarily focused on teachers and singers, although some studies have examined other groups of heavy voice users (e.g. actors, cheerleaders, aerobic instructors, etc.). [ 5 ] [ 20 ]  At present, it is known that teachers and singers are likely to report dysphonia. [ 19 ] [ 21 ]  Moreover, physical education teachers, teachers in noisy environments, and those who habitually use a loud speaking voice are at increased risk. [ 19 ]  The term  clergyman's throat  or  dysphonia clericorum  was previously used for painful dysphonia associated with public speaking, particularly among preachers. [ 22 ]  However, the exact prevalence rates for occupational voice users are unclear, as individual studies have varied widely in the methodologies used to obtain data (e.g. employing different  operational definitions  for \"singer\"). [ 19 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2457", "text": "Located in the anterior portion of the neck is the  larynx  (also known as the voice box), a structure made up of several supporting cartilages and ligaments, which houses the  vocal folds . [ 23 ]  In normal voice production, exhaled air moves out of the lungs and passes upward through the  vocal tract . [ 23 ]  At the level of the larynx, the exhaled air causes the vocal folds to move toward the midline of the tract (a process called adduction). The adducted vocal folds do not close completely but instead remain partially open. The narrow opening between the folds is referred to as the  glottis . [ 23 ] [ 7 ]  As air moves through the glottis, it causes a distortion of the air particles which sets the vocal folds into vibratory motion. It is this vibratory motion that produces phonation or voice. [ 7 ]  In dysphonia, there is an impairment in the ability to produce an appropriate level of phonation. More specifically, it results from an impairment in vocal fold vibration or the nerve supply of the larynx. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2458", "text": "The assessment and diagnosis of a dysphonic voice is completed by a multidisciplinary team, such as an otolaryngologist (ear, nose and throat doctor) and Speech-Language Pathologist, involving the use of both objective and subjective measures to evaluate the quality of the voice as well as the condition of the vocal fold  tissue  and  vibration  patterns. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2459", "text": "Dysphonia is a broad clinical term which refers to abnormal functioning of the voice. [ 23 ] [ 7 ]  More specifically, a voice can be classified as \"dysphonic\" when there are abnormalities or impairments in one or more of the following parameters of voice: pitch, loudness, quality, and variability. [ 7 ]  For example, abnormal pitch can be characterized by a voice that is too high or low whereas abnormal loudness can be characterized by a voice that is too quiet or loud. [ 7 ]  Similarly, a voice that has frequent, inappropriate breaks characterizes abnormal quality while a voice that is monotone (i.e., very flat) or inappropriately fluctuates characterizes abnormal variability. [ 7 ]  While hoarseness is used interchangeably with the term dysphonia, it is important to note that the two are not synonymous. Hoarseness is merely a subjective term to explain the perceptual quality (or sound) of a dysphonic voice. [ 25 ]  While hoarseness is a common symptom (or complaint) of dysphonia, [ 23 ]  there are several other signs and symptoms that can be present such as: breathiness, roughness, and dryness. Furthermore, a voice can be classified as dysphonic when it poses problems in the functional or occupational needs of the individual or is inappropriate for their age or sex. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2460", "text": "Auditory-perceptual measures are the most commonly used tool by clinicians to evaluate the voice quality due to its quick and non-invasive nature. [ 26 ]  Additionally, these measures have been proven to be reliable in a clinical setting. [ 27 ]  Ratings are used to evaluate the quality of a patient's voice for a variety of voice features, including overall severity, roughness, breathiness, strain, loudness and pitch. These evaluations are done during spontaneous speech, sentence or passage reading or sustained vowel productions. [ 17 ]  The GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) and the CAPE-V (Consensus Auditory Perceptual Evaluation\u2014Voice) are two formal voice rating scales commonly used for this purpose. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2461", "text": "Vocal fold imaging techniques are used by clinicians to examine the vocal folds and allows them to detect vocal  pathology  and assess the quality of the vocal fold vibrations. Laryngeal  stroboscopy  is the primary clinical tool used for this purpose. Laryngeal stroboscopy uses a synchronized flashing light passed through either a rigid or flexible  laryngoscope  to provide an image of the vocal fold motion; the image is created by averaging over several vibratory cycles and is thus not provided in real-time. [ 28 ]  As this technique relies on  periodic  vocal fold vibration, it cannot be used in patients with moderate to severe dysphonia. [ 17 ]  High speed digital imaging of the vocal folds ( videokymography ), another imaging technique, is not subject to the same limitations as laryngeal stroboscopy. A rigid endoscope is used to take images at a rate of 8000 frames per second, and the image is displayed in real time. As well, this technique allows imaging of aperiodic vibrations [ 17 ]  and can thus be used with patients presenting with all severities of dysphonia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2462", "text": "Acoustic measures can be used to provide objective measures of vocal function. Signal processing  algorithms  are applied to voice recordings made during sustained  phonation  or during spontaneous speech. [ 29 ]  The acoustic parameters which can then be examined include  fundamental frequency , signal  amplitude , jitter, shimmer, and noise-to-harmonic ratios. [ 17 ]  However, due to limitations imposed by the algorithms employed, these measures cannot be used with patients who exhibit severe dysphonia. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2463", "text": "Aerodynamic  measures of voice include measures of  air volume , air flow and sub glottal air pressure. The normal aerodynamic parameters of voice vary considerably among individuals, which leads to a large overlapping range of values between dysphonic and non-dysphonic patients. This limits the use of these measures as a diagnostic tool. [ 17 ]  Nonetheless, they are useful when used in adjunct with other voice assessment measures, or as a tool for monitoring therapeutic effects over time. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2464", "text": "Given that certain occupations are more at risk for developing dysphonia (e.g., teachers) research into prevention studies have been conducted. [ 30 ]  Research into the effectiveness of prevention strategies for dysphonia have yet to produce definitive results, however, research is still ongoing. [ 9 ] [ 30 ]  Primarily, there are two types of vocal training recognized by professionals to help with prevention: direct and indirect. Direct prevention describes efforts to reduce conditions that may serve to increase vocal strain (such as patient education, relaxation strategies, etc.), while indirect prevention strategies refer to changes in the underlying physiological mechanism for voice production (e.g., adjustments to the manner in which vocal fold adduction occurs, respiratory training, shifting postural habits, etc.). [ 9 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2465", "text": "Although there is no universal classification of voice problems, voice disorders can be separated into certain categories: organic (structural or neurogenic), functional, neurological (psychogenic) or iatrogenic, for example. [ 31 ]  Depending on the diagnosis and severity of the voice problem, and depending on the category that the voice disorder falls into, there are various treatment methods that can be suggested to the patient. The professional has to keep in mind there is not one universal treatment, but rather the clinical approach must find what  the optimal effective course of action for that particular patient is. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2466", "text": "There are three main type of treatments: medical treatments, voice therapy and surgical treatments. [ 32 ]  When necessary, certain voice disorders use a combination of treatment approaches. [ 9 ]  A medical treatment involves the use of botulinum toxin (botox) or anti-reflux medicines, for example. Botox is a key treatment for voice disorders such as Spasmodic Dysphonia. [ 33 ]  Voice therapy is mainly used with patients who have an underlying cause of voice misuse or abuse. [ 34 ]  Laryngologists also recommend this type of treatment to patients who have an organic voice disorder - such as vocal fold nodules, cysts or polyps as well as to treat functional dysphonia. [ 9 ]  Certain surgical treatments can be implemented as well - phono microsurgery (removal of vocal fold lesions performed with a microscope), laryngeal framework surgery (the manipulation of the voice box), as well as injection augmentation (injection of substance to vocal folds to improve closure). Surgical treatments may be recommended for patients having an organic dysphonia. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2467", "text": "A combination of both an indirect treatment method (an approach used to change external factors affecting the vocal folds) [ 37 ]  and a direct  treatment  method (an approach used where the mechanisms functioning during the use of the vocal folds, such as phonation or respiration, are the main focus) [ 37 ]  may be used to treat dysphonia. [ 9 ] [ 12 ] [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2468", "text": "Direct therapies address the physical aspects of vocal production. [ 9 ]  Techniques work to either modify vocal fold contact, manage breathing patterns, and/or change the tension at level of the larynx. [ 9 ]  Notable techniques include, but are not limited to, the  yawn-sigh method ,  optimal pitch ,  laryngeal manipulation , humming, the  accent method , and the  Lee Silverman Voice Treatment . [ 9 ] [ 38 ]  An example of a direct therapy is circumlaryngeal manual therapy, which has been used to reduce tension and massage hyoid-laryngeal muscles. [ 12 ]  This area is often tense from chronic elevation of the larynx. [ 12 ]  Pressure is applied to these areas as the patient hums or sustains a vowel. [ 12 ]  Traditional voice therapy is often used to treat muscular tension dysphonia. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2469", "text": "Indirect therapies take into account external factors that may influence vocal production. [ 9 ]  This incorporates maintenance of vocal hygiene practices, as well as the prevention of harmful vocal behaviours. [ 40 ]  Vocal hygiene includes adequate hydration of the vocal folds, monitoring the amount of voice use and rest, avoidance of vocal abuse (e.g., shouting, clearing of the throat), and taking into consideration lifestyle choices that may affect vocal health (e.g., smoking, sleeping habits). [ 40 ]  Vocal warm-ups and cool-downs may be employed to improve muscle tension and decrease risk of injury before strenuous vocal activities. [ 40 ]  It should be taken into account that vocal hygiene practices alone are minimally effective in treating dysphonia, and thus should be paired with other therapies. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2470", "text": "Medical and surgical treatments have been recommended to treat organic dysphonias. An effective treatment for  spasmodic dysphonia  (hoarseness resulting from periodic breaks in phonation due to hyperadduction of the vocal folds) is  botulinum toxin  injection. [ 8 ] [ 41 ]  The toxin acts by blocking  acetylcholine  release at the thyro-arytenoid muscle. Although the use of botulinum toxin injections is considered relatively safe, patients' responses to treatment differ in the initial stages; some have reported experiencing swallowing problems and breathy voice quality as a side-effect to the injections. [ 8 ] [ 41 ]  Breathiness may last for a longer period of time for males than females. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2471", "text": "Surgeries involve myoectomies of the laryngeal muscles to reduce voice breaks, and laryngoplasties, in which laryngeal cartilage is altered to reduce tension. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2472", "text": "Dysphonia is a general term for voice impairment that is sometimes used synonymously with the  perceptual  voice quality of hoarseness. [ 13 ]  It is the reason for 1% of all visits to primary care providers. [ 13 ]  The  lifetime risk  of hoarse voice complaints among primary care patients is 30%. [ 13 ]  Since hoarseness is a general symptom, it is associated with a number of laryngeal diagnoses. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2473", "text": "There is an interplay of sex and age differences associated with dysphonia. The  point prevalence  of dysphonia in adults under the age of 65 is 6.6%. [ 20 ]  Dysphonia is more common in adult females than males, [ 20 ] [ 42 ]  possibly due to sex-related anatomical differences of the vocal mechanism. [ 4 ]  In childhood, however, dysphonia is more often found in boys than girls. [ 43 ]  As there are no anatomical differences in larynges of boys and girls prior to puberty, it has been proposed that the higher rate of voice impairment found in boys arises from louder social activities, personality factors, or more frequent inappropriate vocal use. [ 43 ]  The most common laryngeal diagnosis among children is  vocal fold nodules , [ 20 ]  a condition known to be associated with vocally damaging behaviours. [ 44 ]  However, a causal relationship has not yet been definitively proven. [ 43 ]  The overall prevalence of dysphonia in children ranges from 3.9% - 23.4%, most commonly affecting children between the ages of 8 - 14. [ 20 ]  Among the elderly, dysphonia is associated with both naturally occurring anatomical and physiological changes as well as higher rates of pathological conditions. [ 42 ]  The point prevalence of dysphonia among the elderly is 29%. [ failed verification ] [ 20 ]  Findings regarding the prevalence of geriatric dysphonia in the general population are very variable, ranging from 4 - 29.1%. [ 42 ]  This variability is likely due to different  methodology  used in obtaining information from participants. [ 20 ]  The most common laryngeal diagnoses among the elderly are polyps,  laryngopharyngeal reflux , muscle tension dysphonia,  vocal fold paresis  or  paralysis , vocal fold mass, glottic insufficiency,  malignant lesions , and neurologic conditions affecting the larynx. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2474", "text": "The  House\u2013Brackmann score  is a score to grade the degree of  nerve  damage in a  facial nerve palsy . The measurement is determined by measuring the upwards (superior) movement of the mid-portion of the top of the  eyebrow , and the outwards (lateral) movement of the angle of the mouth. Each reference point scores 1 point for each 0.25\u00a0cm movement, up to a maximum of 1\u00a0cm. The scores are then added together, to give a number out of 8. [ 1 ]  The score predicts recovery in those with  Bell's palsy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2475", "text": "The score carries the name of the Dr John W. House and Dr Derald E. Brackmann, otolaryngologists in Los Angeles, California, who first described the system in 1985. [ 1 ]  It is one of a number of facial nerve scoring systems, such as Burres-Fisch, Nottingham, Sunnybrook, [ 3 ]  and Yanagihara. [ 4 ]  Of these, the Nottingham scale has been identified as possibly being easier and more reproducible. [ 3 ]  A modification of the original House\u2013Brackmann score, called the \"Facial Nerve Grading Scale 2.0\" (FNGS2.0) was proposed in 2009. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2476", "text": "Human papillomavirus-positive oropharyngeal cancer  ( HPV-positive OPC  or  HPV+OPC ), is a  cancer  ( squamous cell carcinoma ) of the throat caused by the  human papillomavirus  type 16 virus (HPV16). In the past, cancer of the  oropharynx  (throat) was associated with the use of alcohol or tobacco or both, but the majority of cases are now associated with the HPV  virus , acquired by having oral contact with the  genitals  ( oral-genital sex ) of a person who has a genital HPV infection.  Risk factors include having a large number of sexual partners, a history of oral-genital sex or  anal\u2013oral sex , having a female partner with a history of either an abnormal  Pap smear  or  cervical dysplasia , having chronic  periodontitis , and, among men, younger age at first intercourse and a history of  genital warts . HPV-positive OPC is considered a separate disease\nfrom HPV-negative  oropharyngeal cancer  (also called HPV negative-OPC and  HPV-OPC)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2477", "text": "HPV-positive OPC presents in one of four ways: as an asymptomatic abnormality in the mouth found by the patient or a health professional such as a dentist; with local symptoms such as pain or infection at the site of the tumor; with difficulties of speech, swallowing, and/or breathing; or as a swelling in the neck if the cancer has spread to local lymph nodes. Detection of a  tumour suppressor protein , known as  p16 , is commonly used to diagnose an HPV-associated OPC. The extent of disease is described in the standard cancer  staging system , using the  AJCC   TNM  system, based on the T stage (size and extent of tumor), N stage (extent of involvement of regional  lymph nodes ) and M stage (whether there is  spread of the disease  outside the region or not), and combined into an overall stage from I\u2013IV. In 2016, a separate staging system was developed for HPV+OPC, distinct from HPV-OPC."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2478", "text": "Whereas most  head and neck cancers  have been declining as smoking rates have declined, HPV-positive OPC has been increasing. Compared to HPV-OPC patients, HPV-positive patients tend to be younger, have a higher  socioeconomic status  and are less likely to smoke. In addition, they tend to have smaller tumours, but are more likely to have involvement of the cervical lymph nodes. In the United States and other countries, the number of cases of oropharyngeal cancer has been increasing steadily, with the incidence of HPV-positive OPC increasing faster than the decline in HPV-negative OPC. The increase is seen particularly in young men in  developed  countries, and HPV-positive OPC now accounts for the majority of all OPC cases. Efforts are being made to reduce the incidence of HPV-positive OPC by introducing  vaccination  that includes HPV types 16 and 18, found in 95% of these cancers, before exposure to the virus. Early data suggest a reduction in infection rates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2479", "text": "In the past, the treatment of OPC was radical surgery, with an approach through the neck and splitting of the  jaw bone , which resulted in morbidity and poor survival rates. Later,  radiotherapy  with or without the addition of  chemotherapy , provided a less disfiguring alternative, but with comparable poor outcomes. Now, newer  minimally invasive  surgical techniques through the mouth have improved outcomes; in high-risk cases, this surgery is often followed by radiation and/or chemotherapy. In the absence of   high-quality evidence  regarding which treatment provides the best outcomes, management decisions are often based on one or more of the following: technical factors, likely functional loss, and patient preference. The presence of HPV in the tumour is associated with a better response to treatment and a better outcome, independent of the treatment methods used, and a nearly 60% reduced risk of dying from the cancer. Most recurrence occurs locally and within the first year after treatment. The use of tobacco decreases the chances of survival."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2480", "text": "HPV+OPC presents in one of four ways: as an asymptomatic abnormality in the mouth found by the patient or a health professional such as a dentist; with local symptoms such as pain or infection at the site of the tumor; with difficulties of speech, swallowing, and/or breathing; or as a swelling in the neck (if the cancer has spread to lymph nodes). These may be accompanied by more general symptoms such as loss of appetite, weight loss, and weakness. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2481", "text": "Most  mucosal   squamous cell   head and neck cancers , including  oropharyngeal cancer  (OPC), have historically been attributed to tobacco and alcohol use. However, this pattern has changed considerably since the 1980s. It was realised that some cancers occur in the absence of these risk factors and\nan association between  human papillomavirus  (HPV) and various squamous cell cancers, including OPC, was first described in 1983. [ 4 ] [ 5 ]  Since then both  molecular  and  epidemiological  evidence has been accumulating, with the  International Agency for Research on Cancer  (IARC) stating that high-risk HPV types 16 and 18 are carcinogenic in humans, in 1995, [ 6 ]  and In 2007 that HPV was a cause for oral cancers. [ 7 ] [ 8 ]   Human papillomavirus  (HPV)-positive cancer (HPV+OPC)  incidence  has been increasing while HPV-negative (HPV-OPC) cancer incidence is declining, a trend that is estimated to increase further in coming years. [ 9 ]  Since there are marked differences in  clinical presentation  and  treatment   relative to HPV status, HPV+OPC is now viewed as a distinct biologic and clinical condition. [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2482", "text": "Human HPV has long been implicated in the  pathogenesis  of several anogenital cancers including those of the  anus ,  vulva ,  vagina ,  cervix , and  penis . [ 13 ]  In 2007 it was also implicated by both  molecular  and  epidemiological  evidence in cancers arising outside of the anogenital tract, namely oral cancers. HPV infection is common among healthy individuals and is acquired through  oral sex . Although less data is available, the prevalence of HPV infection is at least as common among men as among women, with 2004 estimates of about 27% among US women aged 14\u201359. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2483", "text": "HPV oral infection precedes the development of HPV+OPC. [ 8 ] [ 5 ]  Slight injuries in the  mucous membrane  serve as an entry gate for HPV, which thus works into the  basal layer  of the  epithelium . [ 14 ] [ 15 ]   People testing positive for HPV type 16 virus (HPV16) oral infection have a 14 times increased risk of developing HPV+OPC. [ 14 ]   Immunosuppression  seems to be an increased risk factor for HPV+OPC. [ 5 ]  Individuals with  TGF-\u03b21  genetic variations, specially T869C, are more likely to have HPV16+OPC. [ 16 ]  TGF-\u03b21 plays an important role in controlling the immune system. In 1993 it was noted that patients with human papillomavirus (HPV)-associated anogenital cancers had a 4-fold increased risk of tonsillar squamous-cell carcinoma. [ 17 ]  Although evidence suggests that HPV16 is the main cause of OPC in humans not exposed to smoking and alcohol, the degree to which tobacco and/or alcohol use may contribute to increasing the risk of HPV+OPC has not always been clear [ 5 ]  but it appears that both smoking and HPV infection are independent and additive risk factors for developing OPC. [ 18 ]  The connection between HPV-infection and oropharyngeal cancer is stronger in regions of lymphoepithelial tissue (base of tongue and palatine tonsils) than in regions of stratified squamous epithelium (soft palate and uvula). [ 19 ]   Human herpesvirus-8  infection can potentiate the effects of HPV-16. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2484", "text": "Risk factors  include a high number of sexual partners (25% increase >= 6 partners), a history of  oral-genital sex  (125% >= 4 partners), or  anal\u2013oral sex , a female partner with a history of either an abnormal  Pap smear  or  cervical dysplasia , [ 21 ]  chronic  periodontitis , [ 22 ] [ 23 ]  and, among men, decreasing age at first intercourse and history of  genital warts . [ 24 ] [ 25 ] [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2485", "text": "Cancers of the oropharynx primarily arise in lingual and palatine tonsil  lymphoid  tissue that is lined by respiratory  squamous   mucosal epithelium, which may be  invaginated  within the lymphoid tissue. Therefore, the tumour first arises in hidden crypts. OPC is graded based on the degree of squamous and  keratin  differentiation into well, moderate, or poorly (high) differentiated grades. Other pathological features include the presence of finger-like invasion,  perineural invasion , depth of invasion, and distance of the tumour from resection margins. Phenotypic variants include  basaloid squamous carcinoma , a high-grade form ( see  Chung Fig. 35-3(C) [ 28 ]  and illustration here). They are most commonly non-keratinising. HPV+OPC also differs from HPV-OPC in being focal rather than multifocal and not being associated with pre-malignant  dysplasia . HPV+OPC patients are therefore at less risk of developing other malignancies in the head and neck region, unlike other head and neck primary tumours that may have associated second neoplasms, that may occur at the same time (synchronous) or a distant time (metachronous), both within the head and neck region or more distantly. This suggests that the oncogenic alterations produced by the virus are spatially limited rather than related to a field defect. [ 29 ] [ 28 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2486", "text": "The  oropharynx , at the back of the  mouth , forms a circle and includes the  base of the tongue  (posterior third) below, the  tonsils  on each side, and the  soft palate  above, together with the walls of the  pharynx , including the anterior  epiglottis ,  epiglottic valleculae  and  branchial cleft  at its base.  The oropharynx is one of three divisions of the interior of the pharynx based on their relation to adjacent structures (nasal pharynx ( nasopharynx ), oral pharynx (oropharynx) and laryngeal pharynx ( laryngopharynx  \u2013 also referred to as the hypopharynx), from top to bottom). The pharynx is a semicircular fibromuscular tube joining the  nasal cavities  above to the  larynx  (voice box) and  oesophagus  (gullet), below, where the larynx is situated in front of the oesophagus. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2487", "text": "The oropharynx lies between the mouth (oral cavity) to the front, and the laryngopharynx below, which separates it from the larynx. The upper limit of the oropharynx is marked by the soft palate and its lower limit by the epiglottis and root of the tongue. The oropharynx communicates with the mouth, in front through what is known as the oropharyngeal isthmus, or  isthmus of the fauces . The  isthmus  (i.e. connection) is formed above by the soft palate, below by the posterior third of the tongue, and at the sides by the  palatoglossal arches . The posterior third of the tongue or tongue base contains numerous  follicles  of  lymphatic tissue  that form the  lingual tonsils . Adjacent to the tongue base, the lingual surface of the epiglottis, which curves forward, is attached to the tongue by median and lateral  glossoepiglottic folds . The folds form small troughs known as the epiglottic valleculae. The lateral walls are marked by two vertical pillars on each side, the pillars of the fauces, or palatoglossal arches. More properly they are separately named the palatoglossal arch anteriorly and the  palatopharyngeal arch  posteriorly. The anterior arch is named from the  palatoglossal muscle  within, running from the soft palate to the  tongue   ( glossus ), while the posterior arch similarly contains the  palatopharyngeal muscle  running from the soft palate to the lateral pharynx. Between the arches lies a triangular space, the  tonsillar fossa  in which lies the  palatine tonsil , another lymphoid organ.  [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2488", "text": "The external pharyngeal walls consisting of the four constrictor muscles form part of the mechanism of  swallowing . The microscopic anatomy is composed of four layers, being from the  lumen  outwards, the  mucosa ,  submucosa , muscles, and the fibrosa, or fibrous layer. The mucosa consists of stratified squamous epithelium, that is generally non-keratinised, except when exposed to chronic irritants such as tobacco smoke. The submucosa contains aggregates of lymphoid tissue. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2489", "text": "Cancers arising in the tonsillar fossa spread to the  cervical lymph nodes , primarily the subdigastric (upper jugular) lymph nodes (level II), with secondary involvement of the mid (level III) and low (level IV)  jugular nodes  and sometimes the posterior cervical nodes (level V). Base of tongue cancers spread to the subdigastric and mid jugular nodes, and occasionally posterior cervical nodes but being closer to the midline are more likely to have bilateral nodal disease. Tonsillar cancers rarely spread to the contralateral side unless involving the midline. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2490", "text": "HPV-associated cancers are caused by high-risk strains of HPV, mainly HPV-16 and HPV-18. [ 35 ]  HPV is a small  non-enveloped   DNA virus  of the  papillomavirus  family. Its  genome  encodes the early (E)  oncoproteins  E5, E6 and E7 and the late (L)  capsid  proteins L1 and L2. The virus gains access to the mucosa through microlesions, where it infects the  basal layer  of cells, which are still able to proliferate. While the virus does not replicate in these cells,  expression  of its early genes stimulates proliferation and lateral expansion of the basal cells. As this moves the virus particles into the overlying suprabasal layers, late viral gene expression occurs, enabling replication of the circular viral genome ( see  figure) and structural proteins. As these are pushed into the most superficial mucosal layers, complete viral particles are assembled and released. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2491", "text": "An increased risk of HPV+OPC is observed more than 15 years after HPV exposure, [ 8 ]  pointing to a slow development of the disease, similar to that seen in cervical cancer. Relative to HPV-OPC, the  oncogenic  molecular progression of HPV+OPC is poorly understood. [ 28 ]   The two main viral  oncoproteins  of the high risk HPV types are E6 and E7. These are consistently expressed in malignant cell lines, and if their expression is inhibited the malignant  phenotype  of the cancer cells is blocked. Either of these oncoproteins can  immortalise  cell lines, [ 37 ]  but are more efficient when both are expressed since their separate molecular roles are  synergistic . [ 35 ] [ 36 ]  The E6 and E7  oncogenes  become integrated into host-cell DNA, and the oncoproteins they express interfere with a variety of predominantly  antiproliferative   cellular regulatory mechanisms . They bind to and inactivate the best known of these mechanisms, the  tumor suppressor proteins   p53  and  retinoblastoma protein  pRB (pRb) leading to genomic instability and then  cell cycle  deregulation ( see  Chung et al., 2016 Fig. 35.2). [ 28 ]  Further, yet to be elicited, mechanisms are required for the final steps of  malignant transformation  of HPV infected cells. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2492", "text": "HPV- and HPV+OPC are distinguishable at the molecular level. The naturally occurring ( wild type ) p53 is widely involved in  cellular processes , including  autophagy , response to DNA damage, cell cycle regulation, and  senescence ,  apoptosis  and the generation of  adenosine triphosphate  (ATP) through  oxidative phosphorylation . [ 38 ]  The gene encoding p53 is inactivated by E6 at the protein level and is found as the wild type in HPV+OPC but mutated in HPV-OPC. In HPV+OPC  p53  protein undergoes accelerated degradation by E6, drastically reducing its levels, while in HPV-OPC it undergoes  genetic mutation , which may result in  synthesis  of an abnormal p53 protein, that may not only be inactive as a tumour suppressor but can also bind and inactivate any non-mutated wild type p53, with an increase in oncogenic activity. [ 39 ]  Although p53 mutations occur in HPV+OPC, they are far less common than in HPV-OPC (26%  vs  48%), and do not appear to affect clinical outcome. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2493", "text": "The pRb protein is inactivated by E7 in HPV+OPC, but in HPV-OPC it is the p16 tumour suppressor part of the pRb tumour suppressor network that is inactivated. Also the pRb pathway is inactivated by E7 instead of  Cyclin D1  amplification. [ 8 ] [ 41 ]   CDKN2A  is a  tumour suppressor gene  that encodes a tumor suppressor protein,  p16  (cyclin-dependent kinase inhibitor 2A) and inhibits the  kinase  activity of the cyclin-dependent kinases  CDK4  and  CDK6 , which in turn induce cell cycle arrest. [ 38 ]  p16 expression is cell cycle-dependent and is expressed focally in only about 5\u201310% of normal squamous epithelium. Like most HPV+ cancers, HPV+OPC express p16 but the latter does not function as a tumour-suppressor, because the mechanism by which this is achieved, pRb, has been inactivated by E7. p16 is  upregulated  (over-expressed) due to E7-related loss of pRB with reduced negative feedback, [ 39 ] [ 42 ]  whereas it is downregulated in up to 90% of HPV-OPC. [ 43 ]  This diffuse over-expression in the tumour cells provides a diagnostic marker for HPV involvement. [ 44 ] [ 45 ]  Although HPV E6 and E7 reduce tumour suppressor activity, they do so less than genetic and  epigenetic  processes do in HPV-OPC. [ 46 ] [ 47 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2494", "text": "The tonsillar epithelia ( palatine  and  lingual ) share similar  nonkeratinization  characteristics with the  cervix , where HPV infection plays the major role in cases of  cervical cancer . [ 14 ] [ 48 ]  Also E6 and E7 may make HPV+OPC more  immunogenic  than HPV-OPC, since anti-E6 and E7  antibodies  may be detected in these patients. This, in turn, could restrict the malignant behaviour of HPV+OPC and the presence of antibodies has been associated with a better prognosis, while treatment may enhance the immunogenicity of the tumour, and hence improve response, although to what extent is not clear. [ 49 ] [ 11 ]  Outcomes are also associated with improved  adaptive immunity . [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2495", "text": "Initial diagnosis requires visualisation of the tumour either through the mouth or  endoscopically  through the nose using a  rhinoscope , illustrated to the right, followed by  biopsy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2496", "text": "HPV+OPC is usually diagnosed at a more advanced  stage  than HPV-OPC, [ 8 ]  with 75\u201390% having involvement of regional lymph nodes. [ 51 ]  Furthermore, HPV+OPC is more likely to be poorly differentiated with nonkeratinized or basaloid cells. [ 52 ] [ 53 ]   [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2497", "text": "Genetic signatures of HPV+ and HPV- OPC are different. [ 55 ] [ 56 ] [ 57 ] [ 58 ] [ 59 ]  HPV+OPC is associated with expression level of the  E6/E7 mRNAs  and of  p16 . [ 60 ]   HPV16 E6/E7-positive cases are  histopathologically  characterized by their  verrucous  or papillary ( nipple  like) structure and  koilocytosis  of the adjacent mucosa. Approximately 15% of HNSCCs are caused by HPV16 infection and the subsequent constitutive expression of E6 and E7, and some HPV-initiated tumors may lose their original characteristics during  tumor progression . [ 61 ]  High-risk HPV types may be associated with oral carcinoma, by  cell-cycle  control dysregulation, contributing to oral  carcinogenesis  and the overexpression of mdm2, p27 and cathepsin B. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2498", "text": "HPV+OPC is not merely characterized by the presence of HPV-16: only the expression of viral oncogenes within the tumor cells plus the serum presence of E6 or E7 antibodies is unambiguously conclusive for HPV+OPC. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2499", "text": "There is not a standard HPV testing method in head and neck cancers, [ 63 ]  both  in situ hybridization  (ISH) and  polymerase chain reaction  (PCR) are commonly used. [ 44 ] [ 64 ]  Both methods have comparable performance for HPV detection, however, it is important to use appropriate  sensitivity  controls. [ 65 ]   Immunohistochemistry  (IHC)  staining  of the tissue for p16 is frequently used as a cost-effective surrogate for HPV in OPC, compared to ISH or PCR [ 66 ] [ 67 ] [ 68 ]  but there is a small incidence of HPV-negative p16-positive disease accounting for about 5% of HPV-OPC. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2500", "text": "Staging  is generally by the  UICC / AJCC   TNM  (Tumour, Nodes, Metastases) system. [ 68 ]  Staging is based on  clinical examination ,  diagnostic imaging , and pathology. On imaging, involved lymph nodes may appear  cystic , a characteristic of HPV+OPC. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2501", "text": "HPV+OPC has been treated similarly to stage-matched and site-matched HPV-unrelated OPC, but its unique features, which contrast smoking-related HPV-OPC head and neck cancers, for which patients' demographics, comorbidities, risk factors, and carcinogenesis differ markedly, suggest that a distinct staging system be developed to more appropriately represent the severity of the disease and its prognosis. [ 70 ]  Standard AJCC TNM staging, such as the seventh edition (2009) [ 71 ]  while predictive for HPV-OPC has no prognostic value in HPV+OPC. [ 72 ] [ 73 ] [ 67 ] [ 70 ]  The 8th edition of the  AJCC  TNM Staging Manual (2016) [ 74 ]  incorporates this specific staging for HPV+OPC. [ 75 ]  As of 2018, treatment  guidelines  are evolving to account for the different outcomes observed in HPV+OPC. Consequently, less intensive (de-intensification) use of radiotherapy or chemotherapy, [ 76 ]  as well as specific therapy, is under investigation, enrolling HPV+OPC in  clinical trials  to preserve disease control and minimise  morbidity  in selected groups based on modified TNM staging and smoking status. [ 77 ] [ 78 ] [ 79 ] [ 80 ] [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2502", "text": "HPV+ cancer of the oropharynx are staged as (AJCC 8th ed. 2016): [ 75 ] \nTumour stage"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2503", "text": "Nodal stage"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2504", "text": "Clinical stage"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2505", "text": "However, the published literature and ongoing clinical trials use the older seventh edition that does not distinguish between HPV+OPC and HPV-OPC \u2013 see  Oropharyngeal Cancer \u2013 Stages . [ 82 ] [ 83 ]  The T stages are essentially similar between AJCC 7 and AJCC 8. with two exceptions. Tis ( carcinoma in situ ) has been eliminated and the division of T4 into substages (e.g. T4a) has been removed. The major changes are in the N stages, and hence the overall clinical stage. N0 remains the same, but as with the T stage, substages such as N2a have been eliminated. Extracapsular extension (ECE), also referred to as extranodal extension (ENE), which is invasion by the tumour beyond the capsule of the lymph node has been eliminated as a staging criterion. [ a ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2506", "text": "This results in an HPV+OPC tumour being given a lower stage than if it were HPV-OPC. For instance, a 5\u00a0cm tumour with one ipsilateral node involved that is 5\u00a0cm in size but has ECE would be considered T3N3bM0 Stage IVB if HPV- but T3N1M0 Stage II if HPV+. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2507", "text": "Prevention of HPV+OPC involves avoiding or reducing exposure to risk factors where possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2508", "text": "About 90% of HPV+OPC carry HPV 16, and another 5% type 18. These two types are both targets of available vaccines.  HPV vaccines  given before exposure can prevent persistent genital infection and the consequent precancerous state. [ 11 ]  Therefore, they have a theoretical potential to prevent oral HPV infection. [ 8 ]  A 2010 review study has found that HPV16 oral infection was rare (1.3%) among the 3,977 healthy subjects analyzed. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2509", "text": "The goals of treatment are to optimise survival and locoregional disease control, and prevent spread to distant areas of the body ( metastasis ), while minimising short- and long-term  morbidity . [ 85 ]  There is no high quality  Level I evidence  from prospective clinical trials in HPV+OPC, therefore treatment guidelines must rely on data from treatment of OPC in general and from some retrospective unplanned  subsetting  of those studies, together with data for head and neck cancer in general. [ 68 ]  Treatment for OPC has traditionally relied on  radiotherapy ,  chemotherapy  and/or other systemic treatments, and surgical resection. Depending on the stage and other factors treatment may include a combination of  modalities . [ 86 ]  The mainstay has been radiotherapy in most cases. [ 67 ]  a pooled analysis of published studies suggested comparable disease control between radiation and surgery, but higher complication rates for surgery +/\u2212 radiation. [ 86 ] [ 87 ]  Ideally a single modality approach is preferred since triple modality is associated with much more toxicity and a multidisciplinary team in a large centre with high patient volumes is recommended. [ 68 ] [ 88 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2510", "text": "Differences in response to treatment between HPV-OPC and HPV+OPC may include differences in the extent and manner in which cellular growth-regulatory pathways are altered in the two forms of OPC. For instance, in HPV+OPC the HPV E6 and E7 oncogenes merely render the p53 and pRb pathways dormant, leaving open the possibility of reactivation of these pathways by  down-regulating  (reducing) expression of the oncogenes. This is in contrast to the mutant form of p53 found in HPV-OPC which is associated with treatment resistance. [ 11 ]  Furthermore, it is suggested that the effects of E6 and E7 on these pathways render the tumour more radiosensitive, possibly by interference with mechanisms such as  DNA repair , repopulation signalling, and cell-cycle redistribution. [ 89 ] [ 90 ]  The microenvironment is also important, with radiation increasing host  immune response  to viral  antigens  expressed on the tumour. [ 50 ] [ 49 ]  Also, there is an association between an increase in  tumour-infiltrating lymphocytes  and in circulating  white blood cells  in HPV+OPC patients and better prognosis. This implies a role for an  adaptive immune system  in suppressing  tumour progression . [ 91 ] [ 92 ] [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2511", "text": "Historically, surgery provided a single approach to head and neck cancer. Surgical management of OPC carried significant morbidity with a transcervical (through the neck) approach, often involving mandibulotomy, in which the jawbone ( mandible ) is split. This is referred to as an open surgical technique. Consequently, surgical approaches declined in favour of radiation. In the United States, the use of surgery declined from 41% of cases in 1998 to 30% by 2009, the year that the  Food and Drug Administration  approved the use of the newer techniques. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2512", "text": "These improvements in surgical techniques have allowed many tumours to be  resected  (removed)  by transoral (through the mouth) surgical approaches (TOS), using transoral  endoscopic  head and neck surgery (HNS). [ 94 ]  Consequently, surgery became used more, increasing to 35% of cases by 2012. [ 93 ]  This approach has proven safety, efficacy and tolerability, and includes two main  minimally invasive  techniques,  transoral robotic surgery  (TORS) [ 95 ] [ 96 ] [ 97 ] [ 98 ] [ 99 ] [ 100 ]  and  transoral laser microsurgery  (TLM). [ 101 ] [ 102 ] [ 103 ]  No direct comparisons of these two techniques have been conducted, and clinical trials in head and neck cancer such as ECOG 3311 allow either. They are associated with substantial postoperative morbidity, depending on the extent of resection but compared to older techniques have a shorter hospital stay, faster recovery, less pain, and less need for  gastrostomy  or  tracheostomy , and less long-term effects, which are minimal in the absence of postoperative radiation (RT), or chemoradiation (CRT). [ 104 ] [ 105 ]  TORS has the practical advantage that angled telescopes and rotating robotic surgical arms provide better line of sight. Outcomes of minimally invasive procedures also compare favourably with more invasive ones. In early-stage disease, including involvement of neck nodes, TORS produces a 2-year survival of 80\u201390%. [ 106 ]  TLM similarly, is reported to have a five-year survival of 78% and local control rates of 85\u201397%. [ 107 ] [ 108 ]  In addition to early disease, minimally invasive surgery has been used in advanced cases, with up to 90% local control and disease-specific survival. [ 95 ] [ 108 ]  Postoperative swallowing was excellent in 87%, but long-term dysphagia was associated with larger (T4) cancers, especially if involving the base of the tongue. [ 108 ]   [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2513", "text": "The details of the surgical approach depend on the location and size of the primary tumour and its N stage.  Neck dissection  to examine the draining lymph nodes may be carried out simultaneously or as a second staging procedure. For tumours of the tonsil and lateral pharyngeal wall, and clinically node-negative (N0) disease, dissection of the neck typically involves levels 2\u20134 ( see  diagram in Dubner 2017 )  ipsilaterally . Where nodes are involved clinically, dissection will depend on the location and size of the node or nodes. In the case of tongue base primaries, close to the  midline , bilateral dissection is recommended. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2514", "text": "An advantage of a primary surgical approach is the amount of  pathological  information made available, including grade,  margin status , and degree of involvement of lymph nodes. This may change the staging, as up to 40% of patients may have a different postoperative pathological stage compared to their preoperative clinical stage. In one study, 24% had their stage reduced (downstaged), which may impact subsequent decision making, including a reduction in intensity and morbidity. [ 109 ] [ 12 ]  In the United Kingdom, the  Royal College of Pathologists  (1998) [ 110 ] [ b ]  has standardised the reporting of surgical margins, with two categories, \"mucosal\" and \"deep\", and for each created groups based on the microscopic distance from invasive cancer to the margin, as follows: more than 5\u00a0mm (clear), 1\u20135\u00a0mm (close) and less than 1\u00a0mm (involved). [ 111 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2515", "text": "Data on the use of postoperative  radiation therapy  (PORT) is largely confined to historical or retrospective studies rather than high quality  randomized clinical trials  and are based on the overall population of patients with head and neck cancer, rather than specific studies of HPV+OPC, which would have formed a very small proportion of the population studied. [ 12 ]  Despite surgical excision, in the more advanced cases local and regional recurrence of the cancer, together with spread outside of the head and neck region ( metastases ) are frequent. The risk of subsequent recurrent disease has been considered highest in those tumours where the pathology shows tumour at the margins of the resection (positive margins), multiple involved regional lymph nodes, and extension of the tumour outside of the capsule of the lymph node (extracapsular extension), based on historical experience with head and neck cancer. [ 112 ]  PORT was introduced in the 1950s in an attempt to reduce treatment failure from surgery alone. [ 113 ]  Although never tested in a controlled setting, PORT has been widely adopted for this purpose. [ 114 ]  In an analysis of surgical treatment failure at  Memorial Sloan-Kettering Cancer Center , patients treated with surgery alone between 1960 and 1970 had failure rates of 39 and 73% for those with negative and positive surgical margins respectively. These were compared to those who received PORT (with or without chemotherapy) from 1975 to 1980. The latter group had lower failure rates of 2% and 11% respectively. [ 115 ]  In addition, one randomised study from the 1970s (RTOG 73\u201303) compared preoperative radiation to PORT, and found lower failure rates with the latter. [ 114 ] [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2516", "text": "The addition of another modality of treatment is referred to as  adjuvant  (literally helping) therapy, compared to its use as the initial (primary) therapy, also referred to as radical therapy. Consequently, many of these patients have been treated with adjuvant radiation, with or without chemotherapy. In the above series of reports of minimally invasive surgery, many (30\u201380%) patients received adjuvant radiation. However, functional outcomes were worse if radiation was added to surgery and even worse if both radiation and chemotherapy were used. [ 12 ]  Radiation dosage has largely followed that derived for all head and neck cancers, in this setting, based on risk. Historically only one randomised clinical trial has addressed optimal dosage, allocated patients to two dosage levels, stratified by risk, but showed no difference in cancer control between the low and high doses (63 and 68.4\u00a0Gy), but a higher incidence of complications at the higher doses. Consequently, the lower dose of 57.6\u00a0 Gy  was recommended. [ 117 ] [ 118 ]  Because the authors used a fractionation scheme of 1.8\u00a0Gy per treatment, this dosage was not widely adopted, practitioners preferring a larger fraction of 2\u00a0Gy to produce a shorter treatment time, and a slightly higher dose of 60\u00a0Gy in 2\u00a0Gy fractions (30 daily treatments). [ 41 ]  Yet 57.6\u00a0Gy in 1.8\u00a0Gy fractions is equivalent (iso-effective dose) to only 56\u00a0Gy in 2\u00a0Gy fractions. [ 119 ]  60\u00a0Gy corresponds to the 63\u00a0Gy used as the low dose in the high-risk group. 60\u00a0Gy was also the dose used in RTOG 73\u201303. Subsequently, there was a tendency to intensify treatment in head and neck cancer, and many centres adopted a dose of 66\u00a0Gy, at least for those patients with adverse tumour features. [ 120 ]  The effectiveness of PORT in HPV+OPC receives some support from a  cohort study  (Level 2b), although the number of patients was low, and the number of events (recurrent disease or death) only 7%. [ 121 ]  Another retrospective population-level study (Level 4) of the  SEER  database (1998\u20132011) concluded that there was an overall survival but not disease-specific survival effect of radiation in 410 patients with a single lymph node involved, but used only  univariate  statistical analysis and contained no information on HPV status. [ 122 ]  A subsequent much larger study on a similar population in the National Cancer Database (2004\u20132013) of over 9,000 patients found a survival advantage but this was only in HPV-OPC, not in 410 HPV+OPC patients, [ 123 ]  and a subsequent study of 2,500 low and intermediate risk HPV+OPC patients showed similar overall survival whether PORT was given or not. [ 124 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2517", "text": "While less studies have been completed examining deintensification (de-escalation) in this setting, than in primary radical radiation for this cancer (see below), it is an area of active investigation. [ 125 ]  In one single institution study, a decision was made to reduce the radiation dose in high-risk patients with HPV+OPC from 66 to 60\u00a0Gy, corresponding to the actual evidence, and follow-up has shown no decrease in cancer control. [ 120 ]  Current trials, both in North America and Europe (such as ECOG 3311 [ c ]  and PATHOS [ d ] ) use 50\u00a0Gy as the comparison arm. [ 127 ]  The comparator of 50\u00a0Gy was chosen on the grounds of (i) the exquisite sensitivity of HPV+OPC to radiation, both  in vitro  and  in vivo ; ECOG 1308 showing excellent disease control at 54\u00a0Gy; and data [ 128 ]  suggesting that 50\u00a0Gy in 1.43\u00a0Gy (iso-effective dose 43\u00a0Gy in 2.0\u00a0Gy) was sufficient to electively treat the neck. [ 126 ]  Other studies, such as MC1273 and DART-HPV have evaluated doses as low as 30\u201336\u00a0Gy. [ 129 ]  Lowering the radiation dose to 54\u00a0Gy was identified as one of the important Clinical Cancer Advances of 2018 by the\n American Society of Clinical Oncology , under the general theme of \"Less Is More: Preserving Quality of Life With Less\nTreatment\". [ 130 ] \nChemotherapy has been used concurrently with radiation in this setting, as in primary treatment with radical radiation, particularly where pathological features indicated a higher risk of cancer recurrence. Several studies have suggested that this does not improve local control, but adds toxicity. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2518", "text": "Concerns over the morbidity associated with traditional open surgical en-bloc resection led to exploring alternative approaches using radiation. [ 121 ]  Intensity-modulated radiation therapy ( IMRT ) can provide good control of primary tumours while preserving excellent control rates, with reduced toxicity to salivary and pharyngeal structures relative to earlier technology. HPV+OPC has shown increased sensitivity to radiation with more rapid regression, compared to HPV-OPC. [ 132 ]  Generally, radiation can safely be delivered to the involved side alone (ipsilateral), due to the low rate of recurrent cancer on the opposite side (contralateral), and significantly less toxicity compared to bilateral treatment. [ e ] [ 134 ] [ 133 ]  IMRT has a two-year disease-free survival between 82 and 90%, and a two-year disease-specific survival up to 97% for stage I and II. [ 135 ] [ 136 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2519", "text": "Reported  toxicities  include dry mouth ( xerostomia ) from  salivary gland  damage, 18% (grade 2); [ f ]  difficulty swallowing ( dysphagia ) from damage to the constrictor muscles, larynx and oesophageal sphincter, 15% (grade 2);  subclinical   aspiration  up to 50% (reported incidence of aspiration pneumonia approximately 14%);  hypothyroidism  28\u201338% at three years (may be up to 55% depending on amount of the thyroid gland exposed to over 45\u00a0 Gy  radiation;  esophageal stenosis  5%;  osteonecrosis  of the  mandible  2.5%; and need for a  gastrostomy  tube to be placed at some point during or up to one year after treatment 4% (up to 16% with longer follow up). [ 12 ] [ 138 ] [ 136 ] [ 139 ] [ 140 ]  Concerns have been expressed regarding excessive short- and long-term toxicity, especially dysphagia, and xerostomia, [ 141 ] [ 142 ] [ 143 ]  and hence whether standard doses expose patients with better prognoses are being exposed to overtreatment and unnecessary side effects. [ 144 ] [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2520", "text": "The probability of xerostomia at one year increases by 5% for every 1Gy increase in dose to the  parotid gland . Doses above 25\u201330\u00a0Gy are associated with moderate to severe xerostomia. Similar considerations apply to the  submandibular gland , but xerostomia is less common if only one parotid gland is included in the radiated field [ 145 ]  and the contralateral submandibular gland is spared (less than 39\u00a0Gy) [ 146 ]  In the same manner, the radiation dose to the  pharyngeal constrictor muscles ,  larynx , and  cricopharyngeal inlet  determine the risk of dysphagia (and hence the dependence on  gastrostomy  tube feeds). The threshold for this toxicity is volume-dependent at 55\u201360\u00a0Gy, [ 147 ] [ 148 ] [ 149 ] [ 90 ]  with moderate to severe impairment of swallowing, including aspiration, stricture and feeding tube dependence above a mean dose of 47\u00a0Gy, with a recommended dose to the inferior constrictor of less than 41\u00a0Gy. [ 150 ] [ 151 ]  Dose-toxicity relationships for the superior and middle constrictors are steep, with a 20% increase in the probability of dysphagia for each 10\u00a0Gy. [ 152 ]  For late dysphagia, threshold mean total constrictor doses, to limit rates of greater than or equal to grade 2 and 3 below 5% were 58 and 61\u00a0Gy respectively. For grade 2 dysphagia, the rate increased by 3.4% per Gy. [ 153 ]  Doses above 30\u00a0Gy to the thyroid are associated with moderate to severe hypothyroidism. [ 154 ]  Subjective, patient-reported outcomes of  quality of life  also correlate with radiation dose received. [ 142 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2521", "text": "Altered  fractionation  schemes, such as RTOG 9003   [ g ] [ 141 ]  and RTOG 0129 [ h ]  have not conferred additional benefit. [ 155 ] [ 156 ]  Radiation dose recommendations were largely determined  empirically  in clinical studies with few HPV+OPC patients, and have remained unchanged for half a century, [ 90 ]  making it difficult to determine the optimum dose for this subgroup. A common approach uses 70\u00a0Gy bilaterally and anteriorly, such as RTOG 9003 (1991\u20131997) [ 141 ] [ 155 ]  and RTOG 0129 (2002\u20132005). [ 157 ] [ 156 ]  For lateralized tonsil cancer unilateral neck radiation is usually prescribed, but for tongue base primaries bilateral neck radiation is more common, but unilateral radiation may be used where tongue base lesions are lateralised. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2522", "text": "Concerns have been expressed regarding excessive short- and long-term toxicity, especially dysphagia and xerostomia, [ 141 ] [ 142 ] [ 143 ]  and hence whether standard doses expose patients with better prognoses to overtreatment and unnecessary side effects. [ 144 ] [ 90 ]  Current toxicities have been described as \"not tolerable\", [ 158 ]  and hence an intense interest in de-escalation. [ 127 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2523", "text": "While comparison with historical controls has limited value compared to randomised clinical trials ( phase III ),  phase II  studies using reduced doses of radiation compared to the historical standard of 70\u00a0Gy have been carried out. A study using 54\u201360\u00a0Gy (a 15\u201320% reduction, stratified by response to initial induction chemotherapy) demonstrated comparable levels of disease control with much lower complication rates, [ 90 ]  when compared to similar studies, using 70\u00a0Gy, such as ECOG 2399. [ 159 ] [ 160 ]  The percentage of patients alive after 2 years was 95% at the higher dose and 98% at the lower dose. Similarly for the percentage free of disease (86 and 92%). Toxicities were greatly reduced from an incidence of grade 3 or greater dysphagia and mucositis of 54 and 53% respectively, to 9%. A lower incidence and severity of dysphagia also means that fewer patients require gastrostomy feeding. [ 90 ]  A similar comparison can be made with the pooled data from two RTOG studies which utilized 70\u00a0Gy (0129 and 0522). [ 161 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2524", "text": "No new guidelines dealing specifically with HPV+OPC have yet been developed, outside of clinical trials. Indirect data suggests the efficacy of less intense treatment. A retrospective analysis of advanced (N+) HPV+OPC suggested 96% 5-year local control with de-intensified radiation of 54\u00a0Gy and concurrent  cisplatin  based chemotherapy. [ 162 ]  The conclusions of the above pair of similar phase II trials have been supported by several other phase II trials. A prospective trial ( ECOG  1308) demonstrated similar locoregional control with 54\u00a0Gy, [ 144 ]  and another study, a high pathological complete response rate at 60\u00a0Gy. [ 163 ]  The Quarterback trial [ i ]  showed comparable outcomes between 56 and 70\u00a0Gy. [ 164 ]  and was followed by Quarterback 2, comparing 50 to 56\u00a0Gy. [ j ]  Similarly, the Optima trial showed good disease control with doses between 45 and 50\u00a0Gy. [ 165 ]  Ongoing studies, following the experience of the  Mayo Clinic  trial (MC1273), [ 129 ]  such as that the  Memorial Sloan Kettering Cancer Center  are exploring doses as low as 30Gy. [ k ]  These studies all used well below the previous standard dose of 70\u00a0Gy. Since long-term toxicity is associated with radiation dose, determining the efficacy of lower and hence less morbid doses of radiation is a priority, since many HPV+ patients can be expected to have long-term survival. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2525", "text": "Radiation is commonly utilised in combination with chemotherapy but also may be used as a single modality, especially in earlier stages, e.g. T1-T2, N0-1, and its use in later stages is being explored in clinical trials such as RTOG 1333 which compares radiation alone to radiation with reduced chemotherapy, in non or light smokers. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2526", "text": "As with the radiotherapy data, most of the available knowledge on the efficacy of chemotherapy derives from the treatment of advanced head and neck cancer rather than specific studies of HPV+OPC. Since 1976, many clinical studies have compared CRT to RT alone in the primary management of locally advanced head and neck cancers and have demonstrated an advantage to CRT in both survival and locoregional control. [ 166 ] [ 167 ]  Cisplatin is considered the standard agent, and a survival advantage was seen for those patients who received radiation with concurrent cisplatin. [ 168 ]  Despite this no trials directly comparing cisplatin with other agents in this context have been conducted. The other agent that is widely used is  Cetuximab , a  monoclonal antibody  directed at the  epidermal growth factor receptor  (EGFR). A 10% survival advantage at three years was noted when cetuximab was given concurrently with radiation (bioradiation). [ 169 ]  Cetuximab trials were completed before knowledge of HPV status. [ 170 ]  Laboratory and clinical studies on the utility of cetuximab in this context are conflicting.  The main toxicity is an  acneiform  rash, but it had not been compared directly to cisplatin in HPV+OPC, until RTOG 1016 ( see Talk ) addressed this question. [ 12 ] [ 164 ]  Analysis of the results three years after the trial was completed demonstrates that cetuximab is inferior to cisplatin. [ 171 ]  Concurrent chemotherapy is also superior to chemotherapy alone ( induction chemotherapy ) followed by radiation. [ 166 ] [ 12 ]  Cetuximab shows no advantage when added to cisplatin in combination with radiation. [ 143 ]  Although chemoradiation became a treatment standard based on clinical trials and in particular,  meta-analyses , a subsequent  population-based study  of patients with OPC, indicated no advantage to the addition of chemotherapy to radiation in either HPV+OPC or HPV-OPC, [ 172 ]  and significant concerns about added toxicity. [ 173 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2527", "text": "Chemotherapy also has a role, combined with radiation, in the postoperative setting (adjuvant therapy). [ 174 ]  Generally it is used where the  pathology  of the resected specimen indicates features associated with a high risk of locoregional recurrence (e.g. extracapsular extension through involved lymph nodes or very close margins). It has shown improved disease-free survival and locoregional control in two very similar clinical trials in such high-risk patients,  EORTC  22931 (1994\u20132000) [ 112 ]  and RTOG 9501 (1995\u20132000). [ l ] [ m ] [ n ] [ 175 ] [ 176 ] [ 177 ]  However, for HPV+OPC patients, such extracapsular spread does not appear to be an adverse factor [ 178 ] [ 179 ] [ 180 ]  and the addition of chemotherapy to radiation in this group provided no further advantage. [ 179 ]  Since the  sample size  to detect a survival advantage is large, given the small number of events in this group, these studies may have been  underpowered  and the question of the utility of adding chemotherapy is being addressed in a randomized clinical trial (ADEPT) with two-year locoregional control and disease-free survival as the endpoint. [ o ]  The addition of chemotherapy to radiation increases acute and late toxicity. In the GORTEC trial, chemotherapy with  docetaxel  provided improved survival and locoregional control in locally advanced OPC but was associated with increased mucositis and need for feeding by gastrostomy. [ 181 ]  Chemotherapy and radiation are associated with a risk of death of 3\u20134% in this context. [ 182 ]  It is unclear whether the added toxicity of adding chemotherapy to radiation is offset by significant clinical benefits in disease control and survival. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2528", "text": "It is thought that HPV+OPC patients benefit better from radiotherapy and concurrent  cetuximab  treatment than HPV-OPC patients receiving the same treatment, [ 183 ]  and that radiation and cisplatin induce an immune response against an  antigenic  tumour which enhances their effect on the cancer cells. [ 49 ]  Although the incidence of HPV positivity is low (10\u201320%), an advantage for HPV+OPC was seen in trials of both cetuximab and  panitumumab , a similar anti-EGFR agent, but not a consistent interaction with treatment, although HPV+OPC appears not to benefit to the same extent as HPV-OPC to second line anti-EGFR therapy, possibly due to lower EGFR expression in HPV+OPC. [ 170 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2529", "text": "In the absence of high-quality evidence comparing a primary surgical approach to other modalities, decisions are based on consideration of factors such as adequate surgical exposure and anatomically favourable features for adequate resection, post-treatment function, and  quality of life . Such patient selection may enable them to avoid the morbidity of additional adjuvant treatment. In the absence of favourable surgical features, the primary treatment of choice remains radiation with or without chemotherapy. Tumor characteristics that favour a non-surgical approach include invasion of the base of the tongue to the extent of requiring resection of 50% or more of the tongue, pterygoid muscle involvement, extension into the  parapharyngeal fat  abutting the  carotid , involvement of the mandible or  maxilla  or invasion of the  prevertebral space . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2530", "text": "The adequacy of surgical  resection  is a major factor in determining the role of postoperative adjuvant therapy. In the presence of a  positive margin  on pathological examination, most radiation oncologists recommend radiation to the primary site, and concurrent chemotherapy. A negative margin is more likely to be treated with lower doses and a smaller treatment volume. Also, the removal of a bulky tumour may allow reduced dosage to adjacent uninvolved pharyngeal structures and hence less effect on normal  swallowing . [ 76 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2531", "text": "The cancer outcomes (local control, regional control, and survival) for transoral resection followed by adjuvant therapy are comparable to primary chemoradiation, [ 102 ] [ 98 ] [ 139 ]  so that treatment decisions depend more on treatment-related morbidity, functional outcome, and quality of life. Patient factors also need to be taken into account, including general baseline functionality, smoking history, anesthesia risk, oropharyngeal function, swallowing and airway protection, and potential for rehabilitation. Patient preference is equally important. Many clinical trials are underway focussing on deintensification, often with risk  stratification , e.g. Low, Intermediate and High Risk ( see Fundakowski and Lango, Table I ). [ 12 ] [ p ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2532", "text": "Clinical decisions also take into account morbidities, particularly if cancer outcomes are comparable for instance surgery is associated with a risk of bleeding between 5\u201310%, and a 0.3% risk of fatal postoperative haemorrhage. [ 103 ] [ 184 ] [ 99 ] [ 100 ]  Surgery may also be complicated by  dysphagia , and while most patients can tolerate a diet on the first postoperative day, long-term use of a feeding tube has been reported as high as 10%. [ 108 ] [ 99 ] [ 100 ]  Patients with larger tumours, involvement of base of the tongue and requiring postoperative adjuvant therapy are more likely to require a long-term feeding tube. [ 185 ] [ 186 ]  Overall, function and quality of life appear relatively similar between surgery with postoperative radiation, and primary chemoradiation, [ 187 ] [ 188 ] [ 12 ]  but HPV+OPC patients tend to have a better quality of life at diagnosis than HPV-OPC but may sustain greater loss following treatment. [ 189 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2533", "text": "Anatomical considerations may also dictate a preference for surgical or non-surgical approaches. For instance  trismus , a bulky tongue, limited extension of the neck, prominent teeth,  torus mandibularis  (a bony growth on the mandible), or limited width of the mandible would all be relative contraindications to surgery. [ 101 ]  Tumour-related considerations include invasion of the mandible,  base of the skull , and extensive involvement of the larynx or more than half of the base of the tongue. [ 102 ]  Technical considerations in offering surgery as a primary modality include the presumed ability to achieve adequate margins in the resected specimen and the degree of resulting defect, since close or positive margins are likely to result in subsequent adjuvant therapy to achieve disease control, with resultant increased morbidity. Costs are difficult to estimate but one US study, based on estimates of 25% of all OPC patients receiving surgery alone and 75% surgery followed by adjuvant therapy, using the criteria of the  NCCN , found that this approach was less expensive than primary chemoradiation. [ 190 ] [ 191 ] [ 192 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2534", "text": "Early stage disease [ q ]  is associated with a relatively favourable outcome, for which single modality therapy is recommended, the choice depending on tumour location and accessibility. For instance, unilateral tonsil or tongue base tumours will generally be treated with transoral resection and selective ipsilateral neck dissection. On the other hand, a large midline tongue lesion would require bilateral neck dissection, but in the absence of what are considered adverse pathology (positive margins, extracapsular extension) will likely be treated by surgery alone or radiation including ipsilateral or bilateral neck radiation fields, with surgery for those instances where the likelihood of adjuvant therapy is low. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2535", "text": "But many HPV+OPC present with involvement of the lymph nodes in the neck, and hence a higher stage of disease, generally referred to as locally advanced disease. This group is mostly treated with multimodality therapy, except one of the more favourable subgroups with small primary tumours and lymph node involvement confined to a single node no larger than 3\u00a0cm in size, which as noted are considered early-stage disease. The three main options for locally advanced but operable disease are resection, neck dissection, and adjuvant therapy; chemoradiation (with possible  salvage surgery ); induction chemotherapy followed by radiation or chemoradiation. However, the last option has not been supported in clinical trials that tested it. [ r ]  The primary consideration of surgery for locally advanced disease is to obtain adequate negative margins and spare the patient postoperative chemoradiation. But this must be balanced against the morbidity and functional loss from extensive resection, particularly where the tongue base is involved. To avoid such morbidity, primary chemoradiation is preferred. The management of disease within the cervical lymph nodes has to be taken into account in treating locally advanced disease. Guidelines for all OPC dictate that extracapsular extension be given postoperative chemoradiation. Where gross neck disease is evident initially primary chemoradiation is usually given. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2536", "text": "Current guidelines are based on data for OPC as a whole so that patients are generally being treated regardless of HPV status, yet many clinicians and researchers are considering deintensification. [ 195 ]  Treatment of this condition will likely continue to evolve in the direction of deintensification, to minimize loss of function but maintain disease control. [ 196 ]  In the absence of specific clinical trials and guidelines, patient preferences need to be taken into consideration to minimise short- and long-term toxicity and functional loss and optimize quality of life, given the prolonged survival frequently seen. [ 12 ]  This may involve exploring patients' values regarding  trade-offs  of disease control against adverse effects of treatment. Patients who have received CRT as primary treatment for OPC place a high value on survival, and although agreeing that deintensification is desirable, were reluctant to trade off much survival advantage for lower toxicity, though would be more likely to forgo chemotherapy than accept reduced radiation. [ 197 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2537", "text": "In some situations, HPV+OPC may present with cervical lymph nodes but no evident disease of a primary tumour (T0 N1\u20133) and is therefore classed as  Squamous Cell Carcinoma of Unknown Primary Origin . This occurs in 2\u20134% of patients presenting with metastatic cancer in the cervical nodes. The incidence of HPV positivity is increasing at a similar rate to that seen in OPC. In such situations, resection of the lingual and palatine tonsils together with neck dissection may be diagnostic and constitute sufficient intervention, since recurrence rates are low. [ 198 ] [ 199 ] [ 200 ] [ 201 ] [ 202 ] [ 12 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2538", "text": "The presence of HPV within the tumour has been realised to be an important factor for predicting survival since the 1990s. [ 203 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2539", "text": "Tumor HPV status is strongly associated with positive therapeutic response and survival compared with HPV-negative cancer, independent of the treatment modality chosen and even after adjustment for the stage. [ 204 ]  While HPV+OPC patients have some favourable  demographic  features compared to HPV-OPC patients, such differences account for only about ten percent of the survival difference seen between the two groups. [ 11 ]  Response rates of over 80% are reported in HPV+ cancer and three-year progression-free survival has been reported as 75\u201382% and 45\u201357%, respectively, for HPV+ and HPV- cancer, and improving over increasing time. [ 12 ] [ 205 ] [ 206 ] [ 207 ]  It is likely that HPV+OPC is inherently less malignant than HPV-OPC since patients treated by surgery alone have better survival after adjustment for stage. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2540", "text": "HPV is tested for by the presence of the  biomarker   p16 , which normally increases in the presence of HPV. Some people can have elevated levels of p16 but test negative for HPV and vice versa. This is known as discordant cancer. The 5-year survival for people who test positive for HPV and p16 is 81%, for discordant cancer it is 53 \u2013 55%, and 40% for those who test negative for p16 and HPV. [ 208 ] [ 209 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2541", "text": "In  RTOG  clinical trial 0129, [ s ]  in which all patients with advanced disease received radiation and chemotherapy, a retrospective analysis ( recursive-partitioning analysis , or RPA) at three years identified three risk groups for survival (low, intermediate, and high) based on HPV status, smoking, T stage, and N stage ( see  Ang et al., Fig. 2). [ 157 ]  HPV status was the major determinant of survival, followed by smoking history and stage. 64% were HPV+ and all were in the low and intermediate-risk groups, with all non-smoking HPV+ patients in the low-risk group. 82% of the HPV+ patients were alive at three years compared to 57% of the HPV- patients, a 58% reduction in the risk of death. [ t ] [ 157 ]  Locoregional failure is also lower in HPV+, being 14% compared to 35% for HPV-. [ 160 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2542", "text": "HPV positivity confers a 50\u201360% lower risk of disease progression and death, but the use of tobacco is an independently negative prognostic factor. [ 157 ] [ 210 ]  A pooled analysis of HPV+OPC and HPV-OPC patients with disease progression in RTOG trials 0129 and 0522 showed that although less HPV+OPC experienced disease progression (23 v. 40%), the  median  time to disease progression following treatment was similar (8 months). The majority (65%) of recurrences in both groups occurred within the first year after treatment and were locoregional. Although the rate of failure in the opposite neck following treatment of only one side, is 2.4%, the rate of an isolated recurrence in the opposite neck is 1.7%, and these were mainly where the primary tumour involved the midline. However, the rate of failure in the contralateral neck is also greater for HPV+. [ 211 ]  Of those that recur in this site, nearly all were successfully treated (salvaged) by further local treatment to the opposite neck. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2543", "text": "HPV+ did not reduce the rate of metastases (about 45% of patients experiencing progression), which are predominantly to the lungs (70%), although some studies have reported a lower rate. [ 212 ] [ 161 ]  with 3-year distant recurrence rates of about 10% for patients treated with primary radiation or chemoradiation. [ 213 ]  Even if recurrence or metastases occur, HPV positivity still confers an advantage. [ 12 ] [ 212 ] [ 214 ] \nBy contrast tobacco usage is an independently negative prognostic factor, with decreased response to therapy, [ 157 ] [ 210 ]  increased disease recurrence rates and decreased survival. [ 215 ]  The negative effects of smoking, increases with the amount smoked, particularly\nif greater than 10  pack-years . [ 157 ] [ 210 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2544", "text": "For patients such as those treated on RTOG 0129 with primary chemoradiation, detailed  nomograms  have been derived from that  dataset  combined with RTOG 0522, enabling prediction of outcome based on a large number of  variables . For instance, a 71-year-old married non-smoking high school graduate with a  performance status  (PS) of 0, and no weight loss or  anaemia  and a T3N1 HPV+OPC would expect to have a  progression-free survival  of 92% at 2 years and 88% at 5 years. A 60-year-old unmarried nonsmoking high school graduate with a PS of 1, weight loss and anaemia, and a T4N2 HPV+OPC  would expect to have a survival of 70% at two years and 48% at five years. [ 216 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2545", "text": "Less detailed information is available for those treated primarily with surgery, for whom fewer patients are available, [ 121 ]  as well as low rates of recurrence (7\u201310%), but features that have traditionally been useful in predicting prognosis in other head and neck cancers, appear to be less useful in HPV+OPC. [ 51 ]  These patients are frequently stratified into three risk groups: [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2546", "text": "HPV+OPC patients are less likely to develop other cancers, compared to other head and neck cancer patients. [ 30 ]  A possible explanation for the favourable impact of HPV+ is \"the lower probability of occurrence of 11q13 gene amplification, which is considered to be a factor underlying faster and more frequent recurrence of the disease\" [ 14 ]  Presence of TP53 mutations, a marker for HPV- OPC, is associated with worse prognosis. [ 8 ]  High grade of p16 staining is thought to be better than HPV PCR analysis in predicting radiotherapy response. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2547", "text": "The risk of regional cancer recurrence after neck dissection is often estimated [ 164 ]  from a large series based on all upper aerodigestive squamous cell cancers. In this series, the overall risks at three years by pathological stage (AJCC 7) were: [ 217 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2548", "text": "In 2015, squamous cell cancer of the head and neck region was the fifth most common cancer other than skin cancer, globally, with an annual incidence of 600,000 cases and about 60,000 cases annually in the United States and Europe. [ 218 ]  The global  incidence  of pharyngeal cancer in 2013 was estimated at 136,000 cases. [ 12 ] [ 219 ] [ 220 ]  For 2008 the  Global Burden of Disease  for OPC in 2008 is estimated at 85,000 cases, of which 22,000 were attributable to HPV, a  population attributable fraction  (PAF) of 26%. Of these, 17,000 were males and 4,400 females, 13,000 (60%) were aged between 50 and 69 years of age, and the majority of cases (15,000) were in  developed regions  compared to  developing regions  (6,400). [ 221 ] [ 2 ]   Age Standardised Incidence Rates  (ASR) differ considerably by region and country ( see  de Martel et al., 2017 Fig. 2b). [ 221 ]  ASRs for 2012 were highest in  Europe (Hungary 3.0) and North America (United States 1.7) but much lower in Africa (\u2264 0.3), Asia (\u2264 0.6), Latin America (\u2264 0.4) and  Oceania  (\u2264 0.2) (other than  Australasia , Australia 0.9). [ 222 ] [ 221 ]  Estimated average numbers of cases and ASR for the US in the period 2008\u20132012 were 15,738 and 4.5 respectively. HPV+OPC was much more common in males than females (12,638, 7.6 and 3,100, 1.7). The highest incidence age group was 60\u201369 and was higher in  Caucasians  than in other races. [ 223 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2549", "text": "HPV+OPC patients tend to be younger than HPV- patients in general. [ 224 ]  The clinical presentation is also changing from the \"typical\" head and neck cancer patient with advanced age and major  substance usage . [ 12 ]  By contrast patients with HPV+ cancer are younger (4th\u20136th decades), male (ratio 8:1) with no or only a minimum history of smoking, generally Caucasian, reached higher education levels, are married, and have higher income. [ 225 ]  The risk factors for HPV-OPC and HPV+OPC tend to be independent, except for smoking which adversely affects both. [ 11 ]  The presenting features are also different between HPV+ and HPV- OPC. HPV+ tumours have smaller primary lesions (less than 4\u00a0cm) but more advanced nodal disease resulting in higher TNM staging. This, in turn, may overestimate the severity of the disease status. [ 226 ] [ 227 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2550", "text": "There has been a global trend in increasing OPC incidence, particularly in North America and northern Europe, but even in Taiwan, which has a very high rate for all cancers of the head and neck region, OPC rates increased more rapidly between 1995 and 2009 than any other cancer site. [ 228 ] [ 229 ]  The Global Burden of HPV+OPC increased from 22,000 in 2008 to 29,000 by 2012, and the PAF from 26% to 31%, [ 221 ]  and is considered an  epidemic . [ 44 ]  In the United States the estimated number of cases was 12,410 in 2008, [ 230 ]  13,930 in 2013 [ 231 ]  and 17,000 for 2017. [ 232 ]  Of these cases, HPV+ cancer has been increasing compared to HPV- cancer, but the increase in HPV+OPC exceeds the decline in HPV-OPC resulting an overall increase in OPC. [ 11 ]  The rise in pharyngeal cancer incidence contrasts with a marginal decline in other head and neck cancers. [ 233 ]  As a result, the commonest head and neck cancer has shifted from  larynx  to oropharynx. [ 121 ]  A survey of 23 countries between 1983 and 2002 showed an increase in oropharyngeal squamous cell carcinoma that was particularly noticeable in young men in economically  developed  countries. [ 220 ] [ 12 ]  In the United Kingdom the incidence of oral and oropharyngeal cancer in men rose 51%, from 7/100,000 to 11/100,000 between 1989 and 2006. [ 233 ]  In the US there is a growing incidence of HPV associated oropharyngeal cancers, [ 234 ]  In the early 1980s HPV+ accounted for only 7.5% of cases in the US but by 2016 this was 70%, [ 12 ] [ 235 ] [ 236 ] [ 237 ]  perhaps as a result of changing sexual behaviors, decreased popularity of tonsillectomies, improved radiologic and pathologic evaluation, and changes in classification. [ 238 ] [ 239 ] [ 240 ]  Tonsil and oropharyngeal cancers increased in male predominance between 1975 and 2004, despite reductions in smoking. [ 241 ]  HPV-OPC decreased with decreasing smoking rates from 1988 to 2004, while HPV+OPC increased by almost 7.5% per year from about 16% of all cases of OPC in the early 1980s to almost 70% in 2004. [ 225 ] [ 242 ]  The decline in smoking may be linked to the decreasing proportion of HPV negative cancers, while changes in sexual activity may be reflected in increasing proportion of HPV positive cancers. [ 225 ]  Recently, in the US, HPV associated OPC represent about 60% of OPC cases [ 160 ] [ 243 ]  compared with 40% in the previous decade. [ 233 ]  By 2007, in the US,  incidence of general OPC, including non-HPV associated, is 3.2 cases per 100,000 males/year and 1.9 per 100,000 all-sexes/year. [ 244 ]  This makes HPV+OPC one of only five cancers that have increased in incidence in the US since 1975. [ 245 ]  The largest increase in incidence has occurred in patients under age 50. [ 246 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2551", "text": "The increase in incidence of HPV-associated OPC is also seen in other countries, like  Sweden , with a 2007 incidence of over 80% for cancer in the tonsils, [ 247 ] [ 248 ]   Finland [ 249 ]  and the  Czech Republic . [ 250 ]  Partners of patients with HPV-positive oropharyngeal cancer do not seem to have elevated oral HPV infection compared with the general population. [ 251 ]  In Australia the incidence of HPV-associated OPC was 1.56 cases per 100,000 males/year (2001\u20132005), rising from 19% (1987\u201390) to 47% (2001\u201305) and 63.5% (2006\u20132010). [ 252 ] [ 253 ]  In Canada the percentage of cases of OPC attributable to HPV increased from 47% in 2000 to 74% in 2012. [ 254 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2552", "text": "The  hyoid bone  ( lingual bone  or  tongue-bone ) ( / \u02c8 h a\u026a \u0254\u026a d / [ 2 ] [ 3 ] ) is a  horseshoe-shaped   bone  situated in the anterior midline of the  neck  between the  chin  and the  thyroid cartilage .  At rest, it lies between the base of the  mandible  and the third  cervical vertebra ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2553", "text": "Unlike other bones, the hyoid is only distantly  articulated  to other bones by muscles or ligaments. It is the only bone in the human body that is not connected to any other bones. The hyoid is anchored by muscles from the anterior, posterior and inferior directions, and aids in tongue movement and swallowing. The hyoid bone provides attachment to the muscles of the  floor of the mouth  and the tongue above, the  larynx  below, and the  epiglottis  and  pharynx  behind. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2554", "text": "Its name is derived from  Greek    hyoeides \u00a0'shaped like the letter  upsilon  (\u03c5)'. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2555", "text": "The hyoid bone is classed as an  irregular bone  and consists of a central part called the body, and two pairs of horns, the greater and lesser horns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2556", "text": "The body of the hyoid bone is the central part of the hyoid bone. [ clarification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2557", "text": "The greater and lesser horns ( Latin :  cornua ) are two sections of bone that project from each side of the hyoid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2558", "text": "The greater horns project backward from the outer borders of the body; they are flattened from above downward and taper to their end, which is a bony  tubercle  connecting to the  lateral thyrohyoid ligament . The upper surface of the greater horns are rough and close to its lateral border, and facilitates muscular attachment. The largest of muscles that attach to the upper surface of the greater horns are the  hyoglossus  and the  middle pharyngeal constrictor , which extend along the whole length of the horns; the  digastric muscle  and  stylohyoid muscle  have small insertions in front of these near the junction of the body with the horns. To the medial border, the  thyrohyoid membrane  is attached, while the anterior half of the lateral border gives insertion to the  thyrohyoid muscle . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2559", "text": "The lesser horns are two small, conical eminences, attached by their bases to the angles of junction between the body and greater horns of the hyoid bone. They are connected to the body of the bone by fibrous tissue, and occasionally to the greater horns by distinct diarthrodial  joints , which usually persist throughout life, but occasionally become  ankylosed . The lesser horns are situated in the line of the transverse ridge on the body and appear to be continuations of it. The apex of each horn gives attachment to the  stylohyoid ligament ; the  chondroglossus  rises from the medial side of the base. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2560", "text": "The second  pharyngeal arch , also called the hyoid arch, gives rise to the lesser cornu of the hyoid and the upper part of the body of the hyoid. The cartilage of the third pharyngeal arch forms the greater cornu of the hyoid and the lower portion of the body of the hyoid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2561", "text": "The hyoid is  ossified  from six centers: two for the body, and one for each cornu.  Ossification commences in the greater cornua toward the end of  fetal development , in the hyoid body shortly afterward, and in the lesser cornua during the first or second year after birth.  Until middle age, the connection between the body and greater cornu is  fibrous ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2562", "text": "In early life, the outer borders of the body are connected to the greater horns by synchondroses; after middle life, usually by bony union."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2563", "text": "Blood is supplied to the hyoid bone via the  lingual artery , which runs down from the  tongue  to the greater horns of the bone. The suprahyoid branch of the lingual artery runs along the upper border of the hyoid bone and supplies blood to the attached muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2564", "text": "The hyoid bone is present in many  mammals . It allows a wider range of tongue, pharyngeal and laryngeal movements by bracing these structures alongside each other in order to produce variation. [ 6 ]  Its descent in living creatures is not unique to  Homo sapiens , [ 7 ]  and does not allow the production of a wide range of sounds: with a lower larynx, men do not produce a wider range of sounds than women and two-year-old babies. Moreover, the larynx position of Neanderthals was not a handicap to producing speech sounds. [ 8 ]    The discovery of a modern-looking hyoid bone of a  Neanderthal  man in the  Kebara Cave  in  Israel  led its discoverers to argue that the Neanderthals had a descended  larynx , and thus human-like  speech  capabilities. [ 9 ]   However, other researchers have claimed that the morphology of the hyoid is not indicative of the larynx's position. Recent research has indicated that the hyoid bone may have significant involvement in the ability to swallow. It has been hypothesized that the mammalian hyoid bone evolved in conjunction with the development of  lactation , thus allowing babies to suckle milk. [ 10 ]  It is necessary to take into consideration the skull base, the mandible and the cervical vertebrae and a cranial reference plane. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2565", "text": "A large number of muscles attach to the hyoid: [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2566", "text": "The hyoid bone is important to a number of physiological functions, including breathing, swallowing and speech. It is also thought to play a key role in keeping the upper airway open during sleep, [ 14 ] [ 15 ]  and as such, the development and treatment of  obstructive sleep apnea  (OSA; characterized by repetitive collapse of the upper airway during sleep). A mechanistic involvement of the hyoid bone in OSA is supported by numerous studies demonstrating that a more inferiorly positioned hyoid bone is strongly associated with the presence and severity of the disorder. [ 16 ] [ 17 ]  Movement of the hyoid bone is also thought to be important in modifying upper airway properties, which was recently demonstrated in computer model simulations. [ 18 ]  A  surgical procedure  that aims to potentially increase and improve the airway is called  hyoid suspension ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2567", "text": "Due to its position, the hyoid bone is not easily susceptible to fracture. In a suspected case of murder or physical abuse of an adult, a  fractured hyoid  strongly indicates throttling or  strangulation . In children and adolescents (in whom the hyoid bone is still flexible because  ossification  is yet to be completed) fracture may not occur even after serious trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2568", "text": "The hyoid bone is derived from the lower half of the second  gill arch  in  fish , which separates the first gill slit from the  spiracle , and is often called the  hyoid arch . In many vertebrates, it also incorporates elements of other gill arches, and has a correspondingly greater number of cornua.  Amphibians  and non-avian  reptiles  may have many cornua, while mammals (including humans) have two pairs, and  birds  only one. In birds, and some reptiles, the body of the hyoid is greatly extended forward, creating a solid bony support for the  tongue . [ 19 ]   The howler monkey  Alouatta  has a  pneumatized  hyoid bone, one of the few cases of postcranial pneumatization of bones outside  Saurischia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2569", "text": "In  woodpeckers , the hyoid bone is elongated, with the horns wrapping around the back of the skull. This is part of the system that keeps the brain cushioned and undamaged by the pecking action."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2570", "text": "In  mammals , the hyoid often determines whether one can  roar . If the hyoid is incompletely  ossified  (for example:  lions ), it allows the animal to roar, but not purr. If the hyoid is completely ossified (for example:  cheetahs ), it does not allow the animal to roar, but instead will allow the animal to purr and meow, as seen in  house cats  (lions, cheetahs and house cats all belong to the family  Felidae ). [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2571", "text": "In veterinary anatomy, the term  hyoid apparatus  is the collective term used to refer to the  bones  of the  tongue \u2014a pair of  stylohyoidea , a pair of  thyrohyoidea , and unpaired  basihyoideum [ 21 ] \u2014and associated, upper- gular  connective tissues. [ 22 ]  In humans, the single hyoid bone is an equivalent of the hyoid apparatus. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2572", "text": "This article incorporates text in the  public domain  from  page 177  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2573", "text": "The  hypoglossal nerve , also known as the  twelfth cranial nerve ,  cranial nerve XII , or simply  CN XII , is a  cranial nerve  that innervates all the  extrinsic and intrinsic muscles  of the  tongue  except for the  palatoglossus , which is innervated by the  vagus nerve . [ a ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2574", "text": "CN XII is a  nerve with a sole motor function . The nerve arises from the  hypoglossal nucleus  in the  medulla [ 1 ] [ 2 ]  as a number of small rootlets, pass through the  hypoglossal canal  and down through the neck, and eventually passes up again over the tongue muscles it supplies into the tongue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2575", "text": "The nerve is involved in controlling tongue movements required for speech and  swallowing , including sticking out the tongue and moving it from side to side. Damage to the nerve or the neural pathways which control it can affect the ability of the tongue to move and its appearance, with the most common sources of damage being injury from trauma or surgery, and  motor neuron disease . The first recorded description of the nerve was by  Herophilos  in the third century BC. The name hypoglossus springs from the fact that its passage is below the  tongue , from  hypo  ( Greek :  \"under\" ) and  glossa  ( Greek :  \"tongue\" )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2576", "text": "The hypoglossal nerve arises as a number of small rootlets from the front of the  medulla , the bottom part of the  brainstem , [ 1 ] [ 2 ]  in the  anterolateral sulcus  which separates the  olive  and the  pyramid . [ 3 ]  The nerve passes through the  subarachnoid space  and pierces the  dura mater  near the  hypoglossal canal , an opening in the  occipital bone  of the skull. [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2577", "text": "After emerging from the hypoglossal canal, the hypoglossal nerve gives off a meningeal branch and picks up a branch from the  anterior   ramus  of  C1 .  It then travels close to the  vagus nerve   and spinal division of the  accessory nerve , [ 2 ]  spirals downwards behind the vagus nerve and passes between the  internal carotid artery  and  internal jugular vein  lying on the  carotid sheath . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2578", "text": "At a point at the level of the  angle of the mandible , the hypoglossal nerve emerges from behind the   posterior  belly of the  digastric muscle . [ 4 ]  It then loops around a branch of the  occipital artery  and travels forward into the region beneath the mandible. [ 4 ]  The hypoglossal nerve moves forward lateral to the  hyoglossus  and medial to the  stylohyoid muscles  and  lingual nerve . [ 5 ]  It continues deep to the  genioglossus muscle  and continues forward to the tip of the tongue. It distributes branches to the intrinsic and extrinsic muscle of the tongue innervates as it passes in this direction, and supplies several muscles (hyoglossus, genioglossus and styloglossus) that it passes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2579", "text": "The rootlets of the hypoglossal nerve arise from the  hypoglossal nucleus  near the bottom of the  brain stem . [ 1 ]  The hypoglossal nucleus receives input from both the  motor cortices  but the contralateral input is dominant; innervation of the tongue is essentially lateralized. [ 6 ]  Signals from muscle spindles on the tongue travel through the hypoglossal nerve, moving onto the  lingual nerve  which synapses on the  trigeminal   mesencephalic nucleus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2580", "text": "Neurons of the hypoglossal nucleus are derived from the  basal plate  of the embryonic  medulla oblongata . [ 7 ] [ 8 ]  The musculature they supply develops as the  hypoglossal cord  from the  myotomes  of the first four pairs of occipital somites. [ 9 ] [ 10 ]  The nerve is first visible as a series of roots in the fourth week of development, which have formed a single nerve and link to the tongue by the fifth week. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2581", "text": "The hypoglossal nerve provides motor control of the extrinsic muscles of the tongue:  genioglossus ,  hyoglossus ,  styloglossus , and the intrinsic muscles of the  tongue . [ 2 ]  These represent all muscles of the tongue except the  palatoglossus muscle , which is innervated by the  vagus nerve . [ 2 ]   The hypoglossal nerve is of a  general somatic efferent  (GSE) type. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2582", "text": "These muscles are involved in moving and manipulating the tongue. [ 2 ]  The left and right genioglossus muscles in particular are responsible for protruding the tongue. The muscles, attached to the underside of the top and back parts of the tongue, cause the tongue to protrude and deviate towards the opposite side. [ 13 ]  The hypoglossal nerve also supplies movements including clearing the mouth of saliva and other involuntary activities. The hypoglossal nucleus interacts with the  reticular formation , involved in the control of several reflexive or automatic motions, and several corticonuclear originating fibers supply innervation aiding in unconscious movements relating to speech and articulation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2583", "text": "Reports of damage to the hypoglossal nerve are rare. [ 14 ]  The most common causes of injury in one case series were compression by tumours and gunshot wounds. [ 15 ]  A wide variety of other causes can lead to damage of the nerve. These include surgical damage, medullary stroke, multiple sclerosis, Guillain-Barre syndrome, infection, sarcoidosis, and presence of an ectatic vessel in the hypoglossal canal. [ 15 ] [ 16 ]  Damage can be on one or both sides, which will affect symptoms that the damage causes. [ 2 ]  Because of the close proximity of the nerve to other structures including nerves, arteries, and veins, it is rare for the nerve to be damaged in isolation. [ 16 ]  For example, damage to the left and right hypoglossal nerves may occur with damage to the facial and trigeminal nerves as a result of damage from a clot following  arteriosclerosis  of the  vertebrobasilar artery . Such a stroke may result in tight oral musculature, and difficulty speaking, eating and chewing. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2584", "text": "Progressive bulbar palsy , a form of  motor neuron disease , is associated with combined lesions of the hypoglossal nucleus and  nucleus ambiguus  with wasting ( atrophy ) of the motor nerves of the  pons  and medulla. This may cause difficulty with tongue movements, speech, chewing and swallowing caused by dysfunction of several cranial nerve nuclei. [ 2 ]  Motor neuron disease is the most common disease affecting the hypoglossal nerve. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2585", "text": "The hypoglossal nerve is tested by examining the tongue and its movements. At rest, if the nerve is injured a tongue may appear to have the appearance of a \"bag of worms\" ( fasciculations ) or wasting ( atrophy ). The nerve is then tested by sticking the tongue out. If there is damage to the nerve or its pathways, the tongue will usually but not always deviate to one side, due to the  genioglossus  muscle receiving nerve signals on one side but not the other. [ 6 ] [ 19 ]  When the nerve is damaged, the tongue may feel \"thick,\" \"heavy,\" or \"clumsy.\" Weakness of tongue muscles can result in slurred speech, affecting sounds particularly dependent on the tongue for generation (i.e.,  lateral approximants ,  dental stops ,  alveolar stops ,  velar nasals ,  rhotic consonants  etc.). [ 17 ]  Tongue strength may be tested by poking the tongue against the inside of their cheek, while an examiner feels or presses from the cheek. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2586", "text": "The hypoglossal nerve carries lower motor neurons that  synapse  with upper motor neurons at the  hypoglossal nucleus . Symptoms related to damage will depend on the position of damage in this pathway. If the damage is to the nerve itself (a  lower motor neuron lesion ), the tongue will curve toward the damaged side, owing to weakness of the genioglossus muscle of affected side which action is to deviate the tongue in the contralateral side . [ 19 ] [ 20 ]  If the damage is to the nerve pathway (an  upper motor neuron lesion ) the tongue will curve away from the side of damage, due to action of the affected genioglossus muscle, and will occur without fasciculations or wasting, [ 19 ]  with speech difficulties more evident. [ 6 ]  Damage to the hypoglossal nucleus will lead to wasting of muscles of the tongue and deviation towards the affected side when it is stuck out. This is because of the weaker genioglossal muscle. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2587", "text": "The hypoglossal nerve may be connected ( anastomosed ) to the  facial nerve  to attempt to restore function when the facial nerve is damaged. Attempts at repair by either wholly or partially connecting nerve fibres from the hypoglossal nerve to the facial nerve may be used when there is focal facial nerve damage (for example, from trauma or cancer). [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2588", "text": "The hypoglossal nerve has also been clinically implicated in the treatment of  obstructive sleep apnea . [ 23 ] [ 24 ]  Certain patients with  obstructive sleep apnea  who are deemed eligible candidates (e.g., failed  continuous positive airway pressure  therapy, underwent appropriate testing with  drug induced sleep endoscopy , and meet other criteria as outlined by the  FDA ) [ 25 ]  may be offered the  hypoglossal nerve stimulator  as an alternative. The purpose of the  hypoglossal nerve stimulator  is to relieve  tongue  base obstruction during sleep by stimulating the  tongue  to protrude during inspiration (i.e., inhale)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2589", "text": "In this procedure, an electrical stimulator lead is placed around branches of the hypoglossal nerve that control tongue protrusion (e.g.,  genioglossus ) via an incision in the neck. [ 26 ]  A sensor lead is then placed in the chest between the ribs in the layer between the  internal intercostal muscles  and  external intercostal muscles . The stimulator and sensory lead are then connected via a tunneled wire to an implantable pulse generator. When turned on during sleep, the sensory lead in the chest detects the respiratory cycle. During inspiration (i.e., inhale), an electrical signal is fired via the stimulator lead in the neck, stimulating the hypoglossal nerve, and causing the tongue to protrude, thereby alleviating obstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2590", "text": "The first recorded description of the hypoglossal nerve was by  Herophilos  (335\u2013280 BC), although it was not named at the time. The first use of the name  hypoglossal  in Latin as  nervi hypoglossi externa  was used by  Winslow  in 1733. This was followed though by several different namings including  nervi indeterminati ,  par lingual ,  par gustatorium ,  great sub-lingual  by different authors, and  gustatory nerve  and  lingual nerve  (by Winslow). It was listed in 1778 as  nerve hypoglossum magnum  by Soemmering. It was then named as the  great hypoglossal nerve  by  Cuvier  in 1800 as a translation of Winslow and finally named in English by  Knox  in 1832. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2591", "text": "The hypoglossal nerve is one of twelve cranial nerves found in  amniotes  including  reptiles ,  mammals  and birds. [ 28 ]  As with humans, damage to the nerve or nerve pathway will result in difficulties moving the tongue or  lap ping water, decreased tongue strength, and generally cause deviation away from the affected side initially, and then to the affected side as contractures develop. [ 29 ]  The evolutionary origins of the nerve have been explored through studies of the nerve in rodents and reptiles. [ 30 ]  The nerve is regarded as arising evolutionarily from nerves of the cervical spine, [ 2 ]  which has been incorporated into a separate nerve over the course of evolution. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2592", "text": "The size of the hypoglossal nerve, as measured by the size of the hypoglossal canal, has been hypothesised to be associated with the progress of evolution of  primates , with reasoning that larger nerves would be associated with improvements in speech associated with evolutionary changes. This hypothesis has been refuted. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2593", "text": "The  hypoglossal nerve stimulator  is a novel strategy for the treatment of  obstructive sleep apnea . [ 1 ] [ 2 ]  It has been gaining popularity over the last few decades and was approved in Europe in 2013 and the  Food and Drug Administration  (FDA) in April 2014. [ 3 ] \nThe purpose of the hypoglossal nerve stimulator is to relieve  tongue  base obstruction during sleep by stimulating the  tongue  to protrude during inspiration (i.e., inhale). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2594", "text": "Certain patients with  obstructive sleep apnea  who are deemed eligible candidates may be offered the hypoglossal nerve stimulator as an alternative.  FDA -approved hypoglossal nerve neurostimulation is considered medically reasonable and necessary for the treatment of moderate to severe  obstructive sleep apnea  when all of the following criteria are met: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2595", "text": "In this procedure, an electrical stimulator lead is placed around branches of the  hypoglossal nerve  that control tongue protrusion (e.g.,  genioglossus ) via an incision in the neck. [ 5 ]  A sensor lead is then placed in the chest between the  ribs  in the layer between the  internal intercostal muscles  and  external intercostal muscles . The stimulator and sensory lead are then connected via a tunneled wire to an implantable pulse generator. When turned on during sleep, the sensory lead in the chest detects the respiratory cycle. During inspiration (i.e., inhale), an electrical signal is fired via the stimulator lead in the neck, stimulating the hypoglossal nerve, and causing the tongue to protrude, thereby alleviating obstruction. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2596", "text": "Once implanted, the hypoglossal nerve stimulator is typically activated in clinic approximately 4 weeks afterwards. [ 7 ]  The implant may be configured to best accommodate the patient's comfort and sleeping habits (e.g., set a delay based on sleep latency)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2597", "text": "The hypoglossal nerve stimulator implantable pulse generator battery life typically lasts 8\u201312 years, after which the implantable pulse generator may be safely replaced with another surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2598", "text": "In the  human mouth , the  incisive foramen  (also known as: \" anterior palatine foramen \", or \" nasopalatine foramen \") is the opening of the  incisive canals  on the  hard palate  immediately behind the  incisor teeth . It gives passage to blood vessels and nerves. The incisive foramen is situated within the incisive fossa of the  maxilla ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2599", "text": "The incisive foramen is used as an  anatomical landmark  for defining the severity of  cleft lip and cleft palate ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2600", "text": "The incisive foramen exists in a variety of species."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2601", "text": "The incisive foramen is a funnel-shaped opening in the bone of the oral  hard palate  representing the inferior termination of the  incisive canal . [ citation needed ]  An oral prominence - the incisive papilla - overlies the incisive fossa. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2602", "text": "The incisive foramen is situated immediately behind the  incisor teeth , and in between the two  premaxillae . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2603", "text": "The incisive foramen allows for blood vessels and nerves to pass. These include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2604", "text": "As many nerves exit the  incisive canal  at the incisive foramen, it may be used for injection of  local anaesthetic . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2605", "text": "When  plain radiographs  are taken of the  mouth , the incisive foramen may be mistaken for a periapical lesion. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2606", "text": "The incisive foramen can be used as a landmark when describing  cleft lip and cleft palate , which can either extend in front of (primary) or behind (secondary) the foramen. [ 6 ] [ 7 ]  It is also important as a  surgical  landmark to avoid damaging its nerves and vascular structures. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2607", "text": "The incisive foramen is also known as the anterior palatine foramen, [ 5 ]  the nasopalatine foramen, and the incisive fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2608", "text": "In many other species, the incisive foramina allow for passage of ducts to the  vomeronasal organ . [ 2 ]  It can be found in  cats , [ 6 ]  and  alligators . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2609", "text": "This article incorporates text in the  public domain  from  page 162  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2610", "text": "The  incus  ( pl. :  incudes ) or  anvil  in the  ear  is one of three small  bones  ( ossicles ) in the  middle ear . The incus receives vibrations from the  malleus , to which it is connected laterally, and transmits these to the  stapes  medially. The incus is named for its resemblance to an  anvil  ( Latin :  incus )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2611", "text": "The incus is the second of three  ossicles , very small bones in the  middle ear  which act to transmit sound. It is shaped like an  anvil , and has a long and short crus extending from the body, which articulates with the  malleus . [ 2 ] :\u200a862\u200a  The short crus attaches to the  posterior ligament of the incus . The long crus articulates with the  stapes  at the lenticular process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2612", "text": "The  superior ligament of the incus  attaches at the body of the incus to the roof of the  tympanic cavity ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2613", "text": "The incus is  homologous  to the  quadrate bone  found in other tetrapods. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2614", "text": "Vibrations in the  middle ear  are received via the  tympanic membrane . The malleus, resting on the membrane, conveys vibrations to the incus. This in turn conveys vibrations to the  stapes . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2615", "text": "\"Incus\" means \"anvil\" in Latin. Several sources  attribute the discovery of the incus to the anatomist and philosopher  Alessandro Achillini . [ 4 ] [ 5 ]  The first brief written description of the  incus  was by  Berengario da Carpi  in his  Commentaria super anatomia Mundini  (1521). [ 6 ]   Andreas Vesalius , in his  De humani corporis fabrica , [ 7 ]  was the first to compare the second element of the ossicles to an anvil, thereby giving it the name  incus . [ 8 ]  The final part of the long limb was once described as a \"fourth ossicle\" by  Pieter Paaw  in 1615. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2616", "text": "The  inferior nasal concha  ( inferior turbinated bone  or  inferior turbinal/turbinate ) is one of the three paired  nasal conchae  in the  nose . It extends horizontally along the lateral wall of the  nasal cavity  and consists of a  lamina  of spongy  bone , curled upon itself like a scroll, ( turbinate  meaning inverted cone). [ 1 ]   The inferior nasal conchae are considered a pair of facial bones. As the air passes through the turbinates, the air is churned against these mucosa-lined bones in order to receive warmth, moisture and cleansing. Superior to inferior nasal concha are the  middle nasal concha  and  superior nasal concha  which both arise from the  ethmoid bone , of the cranial portion of the skull. [ 2 ]  Hence, these two are considered as a part of the cranial bones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2617", "text": "It has two surfaces, two borders, and two extremities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2618", "text": "The  medial surface  is  convex , perforated by numerous apertures, and traversed by longitudinal grooves for the lodgement of vessels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2619", "text": "The  lateral surface  is  concave , and forms part of the  inferior meatus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2620", "text": "Its  upper border  is thin, irregular, and connected to various bones along the lateral wall of the nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2621", "text": "It may be divided into three portions: of these,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2622", "text": "The  inferior border  is free, thick, and cellular in structure, more especially in the middle of the bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2623", "text": "Both extremities are more or less pointed, the posterior being the more tapering."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2624", "text": "The inferior nasal concha is ossified from a single center, which appears about the fifth month of fetal life in the lateral wall of the  cartilaginous nasal capsule . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2625", "text": "The entire inferior concha may be absent in some people. This is a consequence of embryologic  agenesis  and is a normal anatomic variant. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2626", "text": "Large, swollen inferior turbinates may lead to blockage of nasal breathing.  Allergies , exposure to environmental  irritants , or a persistent  inflammation  within the sinuses can lead to turbinate swelling. Deformity of the  nasal septum  can also result in enlarged turbinates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2627", "text": "Treatment of the underlying allergy or irritant may reduce turbinate swelling. In cases that do not resolve, or for treatment of  deviated septum , turbinate surgery may be required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2628", "text": "Inferior  turbinate reduction  is a surgery to reduce the size of the inferior turbinates. There are different techniques, including bipolar  radiofrequency ablation  (also known as  somnoplasty ),  electrocautery , and use of cold steel instruments (eg, microdebrider).  Inferior turbinectomy  is a surgery to remove the  inferior turbinates ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2629", "text": "In the case of  turbinate reduction , only small amounts of turbinate tissue are removed because the turbinates are essential for respiration.  Turbinectomy  is usually reserved for patients who have persistent symptoms despite previous  turbinate reduction  surgery. Risks of reduction of the inferior or middle turbinates include  empty nose syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2630", "text": "This article incorporates text in the  public domain  from  page 169  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2631", "text": "The  infratemporal space  (also termed the  infra-temporal space  or the  infra-temporal portion of the deep temporal space ) [ 1 ]  is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a  potential space  in the side of the head, and is paired on either side. It is located posterior to the  maxilla , between the  lateral pterygoid plate  of the  sphenoid bone  medially and by the  base of skull  superiorly. [ 2 ]  The term is derived from  infra-  meaning below and  temporal  which refers to the  temporalis muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2632", "text": "The infratemporal space is the inferior portion of the  deep temporal space , which is one of the four  compartments  of the  masticator space , along with the  pterygomandibular space , the  submasseteric space  and the  superficial temporal space . [ 2 ]  The deep temporal space is separated from the pterygomandibular space by the  lateral pterygoid muscle  inferiorly and from the superficial temporal space by the temporalis muscle laterally. The deep temporal space and the superficial temporal space together make up the temporal spaces. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2633", "text": "The boundaries of the infratemporal space are: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2634", "text": "The communications of the infratemporal space are: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2635", "text": "The contents of the infratemporal space are: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2636", "text": "Infections of the infratemporal space are rare. They may be significant however, as it is possible for infection to spread via emissary veins from the pterygoid plexus to the cavernous sinus, which may result in  cavernous sinus thrombosis , a rare but life-threatening condition. [ 2 ]  \nThe signs and symptoms of an infratemporal space infection are swelling of the face in the region of the  sigmoid notch , swelling of the mouth in the region of the maxillary tuberosity and marked  trismus  (difficulty opening the mouth), since some of the  muscles of mastication  are restricted by the swelling. [ 4 ]  Treatment of an abscess of this space is usually by surgical  incision and drainage , with the incision being placed on the face (a small horizontal incision posterior to the junction of the temporal and frontal process of the  zygomatic bone . or both on the face and inside the mouth. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2637", "text": "The spread of  odontogenic infections  may sometimes involve the infratemporal space. The most likely causative tooth is the maxillary third molar (upper  wisdom tooth )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2638", "text": "The  inner ear  ( internal ear ,  auris interna ) is the innermost part of the vertebrate  ear . In  vertebrates , the inner ear is mainly responsible for sound detection and balance. [ 1 ]  In  mammals , it consists of the  bony labyrinth , a hollow cavity in the  temporal bone  of the skull with a system of passages comprising two main functional parts: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2639", "text": "The inner ear is found in all vertebrates, with substantial variations in form and function. The inner ear is innervated by the eighth  cranial nerve  in all vertebrates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2640", "text": "The labyrinth can be divided by layer or by region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2641", "text": "The  bony labyrinth , or osseous labyrinth, is the network of passages with bony walls lined with  periosteum . The three major parts of the bony labyrinth are the  vestibule of the ear , the  semicircular canals , and the  cochlea . The  membranous labyrinth  runs inside of the bony labyrinth, and creates three parallel fluid filled spaces. The two outer are filled with  perilymph  and the inner with endolymph. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2642", "text": "In the  middle ear , the energy of  pressure waves  is translated into mechanical vibrations by the three auditory ossicles. Pressure waves move the tympanic membrane which in turns moves the malleus, the first bone of the middle ear. The malleus articulates to incus which connects to the stapes. The footplate of the stapes connects to the oval window, the beginning of the inner ear. When the stapes presses on the oval window, it causes the perilymph, the liquid of the inner ear to move. The middle ear thus serves to convert the energy from sound pressure waves to a force upon the perilymph of the inner ear. The oval window has only approximately 1/18 the area of the tympanic membrane and thus produces a higher  pressure . The cochlea propagates these mechanical signals as waves in the fluid and membranes and then converts them to nerve impulses which are transmitted to the brain. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2643", "text": "The vestibular system is the region of the inner ear where the semicircular canals converge, close to the cochlea. The vestibular system works with the visual system to keep objects in view when the head is moved. Joint and muscle receptors are also important in maintaining balance. The brain receives, interprets, and processes the information from all these systems to create the sensation of balance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2644", "text": "The vestibular system of the inner ear is responsible for the sensations of balance and motion.  It uses the same kinds of fluids and detection cells ( hair cells ) as the cochlea uses, and sends information to the brain about the attitude, rotation, and linear motion of the head.  The type of motion or attitude detected by a hair cell depends on its associated mechanical structures, such as the curved tube of a semicircular canal or the calcium carbonate crystals ( otolith ) of the  saccule  and  utricle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2645", "text": "The human inner ear develops during week 4 of  embryonic development  from the  auditory placode , a thickening of the  ectoderm  which gives rise to the  bipolar neurons  of the  cochlear  and  vestibular ganglions . [ 5 ]  As the auditory placode invaginates towards the embryonic  mesoderm , it forms the auditory vesicle or  otocyst ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2646", "text": "The  auditory vesicle  will give rise to the utricular and saccular components of the  membranous labyrinth . They contain the sensory hair cells and  otoliths  of the  macula of utricle  and  of the saccule , respectively, which respond to  linear acceleration  and the force of  gravity . The utricular division of the auditory vesicle also responds to  angular acceleration , as well as the  endolymphatic sac  and  duct  that connect the saccule and utricle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2647", "text": "Beginning in the fifth week of development, the auditory vesicle also gives rise to the  cochlear duct , which contains the spiral  organ of Corti  and the  endolymph  that accumulates in the membranous labyrinth. [ 6 ]  The  vestibular wall  will separate the cochlear duct from the perilymphatic  scala vestibuli , a cavity inside the cochlea. The  basilar membrane  separates the cochlear duct from the  scala tympani , a cavity within the cochlear labyrinth. The lateral wall of the cochlear duct is formed by the  spiral ligament  and the  stria vascularis , which produces the  endolymph . The  hair cells  develop from the lateral and medial ridges of the cochlear duct, which together with the  tectorial membrane  make up the organ of Corti. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2648", "text": "Rosenthal's canal or the spiral canal of the cochlea is a section of the bony labyrinth of the inner ear that is approximately 30\u00a0mm long and makes 2\u00be turns about the  modiolus , the central axis of the cochlea that contains the  spiral ganglion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2649", "text": "Specialized inner ear cell include: hair cells, pillar cells, Boettcher's cells, Claudius' cells, spiral ganglion neurons, and Deiters' cells (phalangeal cells)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2650", "text": "The hair cells are the primary auditory receptor cells and they are also known as auditory sensory cells, acoustic hair cells, auditory cells or cells of Corti. The  organ of Corti  is lined with a single row of inner hair cells and three rows of outer hair cells. The hair cells have a hair bundle at the apical surface of the cell. The hair bundle consists of an array of actin-based stereocilia. Each stereocilium inserts as a rootlet into a dense filamentous actin mesh known as the cuticular plate. Disruption of these bundles results in hearing impairments and balance defects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2651", "text": "Inner and outer pillar cells in the organ of Corti support hair cells. Outer pillar cells are unique because they are free standing cells which only contact adjacent cells at the bases and apices. Both types of pillar cell have thousands of cross linked  microtubules  and  actin  filaments in parallel orientation. They provide mechanical coupling between the  basement membrane  and the  mechanoreceptors  on the hair cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2652", "text": "Boettcher's cells  are found in the organ of Corti where they are present only in the lower turn of the cochlea. They lie on the basilar membrane beneath Claudius' cells and are organized in rows, the number of which varies between species. The cells interdigitate with each other, and project  microvilli  into the intercellular space. They are supporting cells for the auditory hair cells in the organ of Corti. They are named after German pathologist  Arthur B\u00f6ttcher  (1831\u20131889)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2653", "text": "Claudius' cells  are found in the organ of Corti located above rows of Boettcher's cells. Like Boettcher's cells, they are considered supporting cells for the auditory hair cells in the organ of Corti. They contain a variety of  aquaporin  water channels and appear to be involved in ion transport. They also play a role in sealing off endolymphatic spaces. They are named after the German anatomist  Friedrich Matthias Claudius  (1822\u20131869)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2654", "text": "Deiters' cells  (phalangeal cells) are a type of  neuroglial  cell found in the organ of Corti and organised in one row of inner phalangeal cells and three rows of outer phalangeal cells. They are the supporting cells of the hair cell area within the cochlea. They are named after the German pathologist Otto Deiters (1834\u20131863) who described them."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2655", "text": "Hensen's cells  are high columnar cells that are directly adjacent to the third row of Deiters' cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2656", "text": "Hensen's stripe  is the section of the tectorial membrane above the inner hair cell."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2657", "text": "Nuel's spaces  refer to the fluid-filled spaces between the outer pillar cells and adjacent hair cells and also the spaces between the outer hair cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2658", "text": "Hardesty's membrane  is the layer of the tectoria closest to the reticular lamina and overlying the outer hair cell region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2659", "text": "Reissner's membrane  is composed of two cell layers and separates the scala media from the scala vestibuli."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2660", "text": "Huschke's teeth  are the tooth-shaped ridges on the spiral limbus that are in contact with the tectoria and separated by interdental cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2661", "text": "The bony labyrinth receives its blood supply from three arteries:\n1 \u2013 Anterior tympanic branch (from maxillary artery).\n2 \u2013 Petrosal branch (from middle meningeal artery).\n3 \u2013 Stylomastoid branch (from posterior auricular artery).\nThe  membranous labyrinth  is supplied by the  labyrinthine artery .\nVenous drainage of the inner ear is through the labyrinthine vein, which empties into the  sigmoid sinus  or  inferior petrosal sinus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2662", "text": "Neurons within the ear respond to simple tones, and the brain serves to process other increasingly complex sounds. An average adult is typically able to detect sounds ranging between 20 and 20,000\u00a0Hz. The ability to detect higher pitch sounds decreases in older humans."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2663", "text": "The human ear has evolved with two basic tools to encode sound waves; each is separate in detecting high and low-frequency sounds.  Georg von B\u00e9k\u00e9sy  (1899\u20131972) employed the use of a microscope in order to examine the basilar membrane located within the inner-ear of cadavers. He found that movement of the basilar membrane resembles that of a traveling wave; the shape of which varies based on the frequency of the pitch. In low-frequency sounds, the tip (apex) of the membrane moves the most, while in high-frequency sounds, the base of the membrane moves most. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2664", "text": "Interference with or infection of the labyrinth can result in a syndrome of ailments called  labyrinthitis .  The symptoms of labyrinthitis include temporary nausea, disorientation, vertigo, and dizziness. Labyrinthitis can be caused by viral infections, bacterial infections, or physical blockage of the inner ear. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2665", "text": "Another condition has come to be known as autoimmune inner ear disease (AIED). It is characterized by idiopathic, rapidly progressive, bilateral sensorineural hearing loss. It is a fairly rare disorder while at the same time, a lack of proper diagnostic testing has meant that its precise incidence cannot be determined. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2666", "text": "Birds have an auditory system similar to that of mammals, including a cochlea. Reptiles, amphibians, and fish do not have cochleas but hear with simpler auditory organs or vestibular organs, which generally detect lower-frequency sounds than the cochlea.  The cochlea of birds is also similar to that of crocodiles, consisting of a short, slightly curved bony tube within which lies the basilar membrane with its sensory structures. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2667", "text": "In  reptiles , sound is transmitted to the inner ear by the  stapes  (stirrup) bone of the middle ear. This is pressed against the  oval window , a membrane-covered opening on the surface of the vestibule. From here, sound waves are conducted through a short  perilymphatic duct  to a second opening, the  round window , which equalizes pressure, allowing the incompressible fluid to move freely. Running parallel with the perilymphatic duct is a separate blind-ending duct, the  lagena , filled with  endolymph . The lagena is separated from the perilymphatic duct by a  basilar membrane , and contains the sensory hair cells that finally translate the vibrations in the fluid into nerve signals. It is attached at one end to the saccule. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2668", "text": "In most reptiles the perilymphatic duct and lagena are relatively short, and the sensory cells are confined to a small  basilar papilla  lying between them. However, in  mammals ,  birds , and  crocodilians , these structures become much larger and somewhat more complicated. In birds, crocodilians, and  monotremes , the ducts are simply extended, together forming an elongated, more or less straight, tube. The endolymphatic duct is wrapped in a simple loop around the lagena, with the basilar membrane lying along one side. The first half of the duct is now referred to as the  scala vestibuli , while the second half, which includes the basilar membrane, is called the  scala tympani . As a result of this increase in length, the basilar membrane and papilla are both extended, with the latter developing into the  organ of Corti , while the lagena is now called the  cochlear duct . All of these structures together constitute the cochlea. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2669", "text": "In  therian  mammals, the lagena is extended still further, becoming a coiled structure (cochlea) in order to accommodate its length within the head. The organ of Corti also has a more complex structure in mammals than it does in other  amniotes . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2670", "text": "The arrangement of the inner ear in living  amphibians  is, in most respects, similar to that of reptiles. However, they often lack a basilar papilla, having instead an entirely separate set of sensory cells at the upper edge of the saccule, referred to as the  papilla amphibiorum , which appear to have the same function. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2671", "text": "Although many fish are capable of hearing, the lagena is, at best, a short diverticulum of the saccule, and appears to have no role in sensation of sound. Various clusters of hair cells within the inner ear may instead be responsible; for example,  bony fish  contain a sensory cluster called the  macula neglecta  in the utricle that may have this function. Although fish have neither an outer nor a middle ear, sound may still be transmitted to the inner ear through the bones of the skull, or by the  swim bladder , parts of which often lie close by in the body. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2672", "text": "By comparison with the  cochlear  system, the  vestibular system  varies relatively little between the various groups of  jawed vertebrates . The central part of the system consists of two chambers, the saccule and utricle, each of which includes one or two small clusters of sensory hair cells. All jawed vertebrates also possess three semicircular canals arising from the utricle, each with an  ampulla  containing sensory cells at one end. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2673", "text": "An  endolymphatic duct  runs from the saccule up through the head and ending close to the brain. In  cartilaginous fish , this duct actually opens onto the top of the head, and in some  teleosts , it is simply blind-ending. In all other species, however, it ends in an  endolymphatic sac . In many reptiles, fish, and amphibians this sac may reach considerable size. In amphibians the sacs from either side may fuse into a single structure, which often extends down the length of the body, parallel with the  spinal canal . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2674", "text": "The primitive  lampreys  and  hagfish , however, have a simpler system. The inner ear in these species consists of a single vestibular chamber, although in lampreys, this is associated with a series of sacs lined by  cilia . Lampreys have only two semicircular canals, with the horizontal canal being absent, while hagfish have only a single, vertical, canal. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2675", "text": "The inner ear is primarily responsible for balance, equilibrium and orientation in three-dimensional space. The inner ear can detect both static and dynamic equilibrium. Three  semicircular ducts  and two chambers, which contain the  saccule  and  utricle , enable the body to detect any deviation from equilibrium. The macula sacculi detects vertical acceleration while the  macula utriculi  is responsible for horizontal acceleration. These microscopic structures possess stereocilia and one kinocilium which are located within the gelatinous otolithic membrane. The membrane is further weighted with otoliths. Movement of the stereocilia and kinocilium enable the hair cells of the saccula and utricle to detect motion. The semicircular ducts are responsible for detecting rotational movement. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2676", "text": "The  internal auditory meatus  (also  meatus acusticus internus ,  internal acoustic meatus ,  internal auditory canal , or  internal acoustic canal ) is a canal within the  petrous part of the temporal bone  of the  skull  between the  posterior cranial fossa  and the  inner ear ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2677", "text": "The opening to the meatus is called the  porus acusticus internus  or  internal acoustic opening . It is located inside the  posterior cranial fossa  of the skull, near the center of the posterior surface of the petrous part of the temporal bone.  The size varies considerably. Its outer margins are smooth and rounded."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2678", "text": "The canal which comprises the internal auditory meatus is short (about 1\u00a0cm) and runs laterally into the bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2679", "text": "The lateral (outer) aspect of the canal is known as the  fundus . [ 1 ]  The fundus is subdivided by two thin crests of bone to form three separate canals, through which course the  facial  and  vestibulocochlear nerve  branches. [ citation needed ]  The falciform crest first divides the meatus into superior and inferior sections; a vertical crest (Bill's bar, named by  William F. House ) then divides the upper passage into anterior and posterior sections. [ 2 ]  Although there are three osseous canals, the fundus is conceptually divided more commonly into four quadrant areas according to the four major nerve branches of the inner ear:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2680", "text": "The cochlear and vestibular branches of cranial nerve VIII separate according to this schema and terminate in the inner ear. The facial nerve continues traveling through the  facial canal , eventually exiting the skull at the  stylomastoid foramen . A common mnemonic to remember the anterior quadrants of the inner ear is: \"seven up, coke down\" (seventh nerve superior, cochlear nerve inferior)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2681", "text": "The internal auditory meatus provides a passage through which the  vestibulocochlear nerve  (CN VIII), the  facial nerve  (CN VII), and the  labyrinthine artery  (an internal auditory branch of the  anterior inferior cerebellar artery  in 85% of people) can pass from inside the skull to structures of the inner ear and face. It also contains the  vestibular ganglion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2682", "text": "The  internal carotid artery  is an  artery  in the  neck  which supplies the  anterior  and  middle   cerebral circulation . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2683", "text": "In human anatomy, the internal and  external  carotid arise from the  common carotid artery , where it bifurcates at  cervical vertebrae  C3 or C4. The internal carotid artery supplies the  brain , including the eyes, [ 2 ]  while the external carotid nourishes other portions of the head, such as the  face ,  scalp ,  skull , and  meninges ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2684", "text": "Terminologia Anatomica  in 1998 subdivided the artery into four parts: \"cervical\", \"petrous\", \"cavernous\", and \"cerebral\". [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2685", "text": "In clinical settings, however, usually the classification system of the internal carotid artery follows the 1996 recommendations by Bouthillier, [ 5 ]  describing seven anatomical segments of the internal carotid artery, each with a corresponding alphanumeric identifier: C1 cervical; C2 petrous; C3 lacerum; C4 cavernous; C5 clinoid; C6 ophthalmic; and C7 communicating. The Bouthillier nomenclature remains in widespread use by neurosurgeons, neuroradiologists and neurologists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2686", "text": "The segments are subdivided based on anatomical and microsurgical landmarks and surrounding anatomy, more than  angiographic  appearance of the artery. An alternative  embryologic  classification system proposed by  Pierre Lasjaunias [ 6 ]  and colleagues is invaluable when it comes to explanation of many internal carotid artery variants. An older clinical classification, based on pioneering work by Fischer, [ 7 ]  is mainly of historical significance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2687", "text": "The segments of the internal carotid artery are as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2688", "text": "The internal carotid artery is a terminal branch of the  common carotid artery ; it arises around the level of the fourth cervical  vertebra  when the common carotid bifurcates into this artery and its more superficial counterpart, the  external carotid artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2689", "text": "The  cervical segment , or C1, or  cervical part of the internal carotid , extends from the carotid bifurcation until it enters the  carotid canal  in the skull anterior to the  jugular foramen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2690", "text": "At its origin, the internal carotid artery is somewhat dilated. This part of the artery is known as the  carotid sinus  or the carotid bulb. The ascending portion of the cervical segment occurs distal to the bulb when the vessel walls are again parallel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2691", "text": "The internal carotid runs vertically upward in the  carotid sheath  and enters the  skull  through the  carotid canal . During this part of its course, it lies in front of the  transverse processes  of the upper three cervical vertebrae."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2692", "text": "It is relatively superficial at its start, where it is contained in the  carotid triangle  of the neck, and lies behind and medial to the external carotid, overlapped by the  sternocleidomastoid  muscle, and covered by the deep fascia, the  platysma , and integument: it then passes beneath the  parotid gland , being crossed by the  hypoglossal nerve , the  digastric muscle  and the  stylohyoid muscle , the  occipital artery  and the  posterior auricular artery . Higher up, it is separated from the external carotid by the  styloglossus  and  stylopharyngeus  muscles, the tip of the  styloid process  and the  stylohyoid ligament , the  glossopharyngeal nerve  and the pharyngeal branch of the  vagus nerve . It is in relation, behind, with the  longus capitis , the  superior cervical ganglion  of the  sympathetic trunk , and the  superior laryngeal nerve ; laterally, with the  internal jugular vein  and  vagus nerve , the nerve lying on a plane posterior to the artery; medially, with the  pharynx ,  superior laryngeal nerve , and  ascending pharyngeal artery . At the base of the skull the  glossopharyngeal , vagus,  accessory , and  hypoglossal  nerves lie between the artery and the  internal jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2693", "text": "Unlike the  external carotid artery , the internal carotid normally has no branches in the  neck ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2694", "text": "The  petrous segment , or C2, of the internal carotid, is that which is inside the petrous part of the  temporal bone . This segment extends until the  foramen lacerum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2695", "text": "The petrous portion classically has three sections:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2696", "text": "When the internal carotid artery enters the canal in the  petrous portion of the temporal bone , it first ascends a short distance and then curves anteriorly and medially. The artery lies at first in front of the  cochlea  and  tympanic cavity ; from the latter cavity it is separated by a thin, bony lamella, which is cribriform in the young subject, and often partly absorbed in old age. Farther forward, it is separated from the  trigeminal ganglion  by a thin plate of bone, which forms the floor of the fossa for the ganglion and the roof of the horizontal portion of the canal. Frequently this bony plate is more or less deficient, and then the ganglion is separated from the artery by fibrous membrane. The artery is separated from the bony wall of the  carotid canal  by a prolongation of  dura mater  and is surrounded by a number of small veins and by filaments of the  carotid plexus , derived from the ascending branch of the  superior cervical ganglion  of the sympathetic trunk."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2697", "text": "The named branches of the petrous segment of the internal carotid artery are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2698", "text": "The  lacerum segment , or C3, is a short segment that begins above the  foramen lacerum  and ends at the  petrolingual ligament , a reflection of  periosteum  between the lingula and petrous apex (or petrosal process) of the  sphenoid bone . The lacerum portion is still considered \"extradural\" since it is surrounded by periosteum and fibrocartilage along its course. It is erroneously stated in several anatomy textbooks that the internal carotid artery passes through the foramen lacerum. This at best has only ever been a partial truth in that it passes through the superior part of the foramen on its way to the cavernous sinus. As such it does not traverse the skull through it. The inferior part of the foramen is actually filled with fibrocartilage. The broad consensus is that the internal carotid artery should not be described as travelling through the foramen lacerum. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2699", "text": "The  cavernous segment , or C4, of the internal carotid artery begins at the petrolingual ligament and extends to the proximal dural ring, which is formed by the medial and inferior periosteum of the anterior clinoid process. The cavernous segment is surrounded by the  cavernous sinus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2700", "text": "In this part of its course, the artery is situated between the layers of the  dura mater  forming the  cavernous sinus , but covered by the lining membrane of the sinus. It at first ascends toward the  posterior clinoid process , then passes forward by the side of the  body of the sphenoid bone , again curves upward on the medial side of the  anterior clinoid process , and perforates the dura mater forming the roof of the sinus. The curve in the cavernous segment is called the  carotid siphon . This portion of the artery is surrounded by filaments of the sympathetic trunk, and on its lateral side is the  abducent nerve , or cranial nerve VI."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2701", "text": "The named branches of the cavernous segment are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2702", "text": "The cavernous segment also gives rise to small capsular arteries that supply the wall of the cavernous sinus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2703", "text": "The  clinoid segment , or C5, is another short segment of the internal carotid that begins after the artery exits the  cavernous sinus  at the proximal dural ring and extends distally to the distal dural ring, after which the carotid artery is considered \"intra-dural\" and has entered the  subarachnoid space ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2704", "text": "The clinoid segment normally has no named branches, though the  ophthalmic artery  may arise from the clinoid segment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2705", "text": "The  ophthalmic segment , or C6, extends from the distal dural ring, which is continuous with the falx cerebri, to the origin of the  posterior communicating artery . The ophthalmic segment courses roughly horizontally, parallel to the  optic nerve , which runs superomedially to the carotid at this point."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2706", "text": "The named branches of the ophthalmic segment are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2707", "text": "The  communicating segment , or terminal segment, or C7, of the internal carotid artery passes between the optic and oculomotor nerves to the anterior perforated substance at the medial extremity of the lateral cerebral fissure. Angiographically, this segment extends from the origin of the  posterior communicating artery  to the bifurcation of the internal carotid artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2708", "text": "The named branches of the communicating segment are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2709", "text": "The internal carotid then divides to form the  anterior cerebral artery  and  middle cerebral artery . The  circle of Willis  provides a  collateral pathway  for blood supply to the brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2710", "text": "The following are the branches of the internal carotid artery, listed by segment: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2711", "text": "The  sympathetic trunk  forms a plexus of nerves around the artery known as the  carotid plexus . The  internal carotid nerve  arises from the  superior cervical ganglion , and forms this plexus, which follows the internal carotid into the skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2712", "text": "The state and health of internal carotid arteries is usually evaluated using  doppler ultrasound ,  CT angiogram  or  phase contrast magnetic resonance imaging  (PC-MRI)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2713", "text": "Typically internal carotid artery blood flow velocities are measured in peak systolic velocity (PSV) and end diastolic velocity (EDV) and according to Society of Radiologists in Ultrasound in healthy subjects without stenosis must be below 125 cm/sec at PSV and below 40 cm/sec at EDV. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2714", "text": "One study found that for  normative  males in the 20-39 age group, PSV averaged 82 cm/sec and EDV 34 cm/sec. In the male 80+ age group, PSV averaged 76 cm/sec and EDV 18 cm/sec. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2715", "text": "This article incorporates text in the  public domain  from  page 566  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2716", "text": "The  internal jugular vein  is a paired  jugular vein  that collects blood from the  brain  and the superficial parts of the  face  and  neck . This vein runs in the  carotid sheath  with the  common carotid artery  and  vagus nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2717", "text": "It begins in the posterior compartment of the  jugular foramen , at the base of the  skull . It is somewhat dilated at its origin, which is called the  superior bulb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2718", "text": "This vein also has a common trunk into which drains the anterior branch of the  retromandibular vein , the  facial vein , and the  lingual vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2719", "text": "It runs down the side of the neck in a vertical direction, being at one end lateral to the  internal carotid artery , and then lateral to the  common carotid artery , and at the root of the neck, it unites with the  subclavian vein  to form the  brachiocephalic vein  (innominate vein); a little above its termination is a second dilation, the  inferior bulb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2720", "text": "Above, it lies upon the  rectus capitis lateralis , behind the  internal carotid artery  and the nerves passing through the  jugular foramen . Lower down, the vein and artery lie upon the same plane, the  glossopharyngeal  and  hypoglossal  nerves passing forward between them. The  vagus nerve  descends between and behind the  vein  and the  artery  in the same sheath (the  carotid sheath ), and the  accessory  runs obliquely backward,  superficial  or deep to the vein."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2721", "text": "At the root of the neck, the  right internal jugular vein  is a little distance from the  common carotid artery , and crosses the first part of the  subclavian artery , while the  left internal jugular vein  usually overlaps the common carotid artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2722", "text": "The left vein is generally smaller than the right, and each contains a pair of  valves , which exist about 2.5\u00a0cm above the termination of the vessel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2723", "text": "In 9\u201312% of the Western population, the size, shape or course of the internal jugular vein is abnormal. [ 1 ]  Variants identified including veins markedly smaller, or not functionally present. [ 2 ]  The mean diameter is 10\u00a0mm, but may range between 5 and 35\u00a0mm. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2724", "text": "The jugular veins are relatively superficial and not protected by tissues such as  bone  or  cartilage . This makes them susceptible to damage. Due to the large volumes of blood that flow through the jugular veins, damage to the jugulars can quickly cause significant blood loss, which can lead to hypovol\u00e6mic shock and then death if not treated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2725", "text": "As there is one pair of valves between the  right atrium  of the heart and the internal jugular, blood can flow back into the internal jugular when the pressure in the atrium is sufficiently high. This can be seen from the outside, and allows one to estimate the pressure in the atrium. The pulsation seen is called the  jugular venous pressure , or JVP. This is normally viewed with the patient at 45 degrees turning his/her head slightly away from the observer. The JVP can be raised in a number of conditions: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2726", "text": "The JVP can also be artificially raised by applying pressure to the liver (the  hepatojugular reflux ). This method is used to locate the JVP and distinguish it from the carotid pulse. Unlike the carotid pulse, the JVP is impalpable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2727", "text": "As the internal jugular is large, central and relatively superficial, it is often used to place  central venous lines . Such a line may be inserted for several reasons, such as to accurately measure the central venous pressure or to administer fluids when a line in a peripheral vein would be unsuitable (such as during resuscitation when peripheral veins are hard to locate). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2728", "text": "Because the internal jugular rarely varies in its location, it is easier to find than other veins. However, sometimes when a line is inserted the jugular is missed and other structures such as the  carotid artery , lung or the  vagus nerve  (CN X) are punctured, and damage is caused to these structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2729", "text": "This article incorporates text in the  public domain  from  page 648  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2730", "text": "A  jugular foramen  is one of the two (left and right) large  foramina  (openings) in the  base of the skull , located behind the  carotid canal . It is formed by the  temporal bone  and the  occipital bone . It allows many structures to pass, including the  inferior petrosal sinus , three  cranial nerves , the  sigmoid sinus , and meningeal arteries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2731", "text": "The jugular foramen is formed in front by the  petrous  portion of the  temporal bone , and behind by the  occipital bone . [ 1 ]  It is generally slightly larger on the right side than on the left side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2732", "text": "The jugular foramen may be subdivided into three compartments, each with their own contents."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2733", "text": "An alternative imaging based subclassification exists, delineated by the  jugular spine  which is a bony ridge partially separating the jugular foramen into two parts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2734", "text": "Obstruction of the jugular foramen can result in  jugular foramen syndrome . [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2735", "text": "This article incorporates text in the  public domain  from  page 181  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2736", "text": "The  jugular fossa  is a deep depression ( fossa ) in the inferior part of the  temporal bone  at the  base of the skull . It lodges the bulb of the  internal jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2737", "text": "The jugular fossa is located in the  temporal bone , posterior to the  carotid canal  and the  cochlear aqueduct ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2738", "text": "In the bony ridge dividing the carotid canal from the jugular fossa is the small inferior tympanic canaliculus for the passage of the tympanic branch of the  glossopharyngeal nerve . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2739", "text": "In the lateral part of the jugular fossa is the  mastoid canaliculus  for the entrance of the  auricular branch  of the  vagus nerve . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2740", "text": "Behind the jugular fossa is a quadrilateral area, the jugular surface, covered with cartilage in the fresh state, and articulating with the jugular process of the  occipital bone . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2741", "text": "The jugular fossa has variable depth and size in different skulls."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2742", "text": "The jugular fossa lodges the bulb of the  internal jugular vein . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2743", "text": "Abnormally shaped jugular fossae may cause ear problems. [ 2 ]  If it lies close to the  cochlea , it may cause  tinnitus . [ 2 ]  A high jugular fossa may be linked to  M\u00e9ni\u00e8re's disease . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2744", "text": "The  jugular process  is a quadrilateral or triangular bony plate projecting lateralward from the posterior half of the  occipital condyle ; it is a part of the  lateral part of the occipital bone . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2745", "text": "The jugular process is excavated in front by the jugular notch of occipital bone (which forms the posterior part of the  jugular foramen ). The posterolateral side of the jugular formanen is divided from the anteromedial side by the  intrajugular process of occipital bone . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2746", "text": "The jugular process serves as the insertion of the  rectus capitis lateralis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2747", "text": "Killian's dehiscence  (also known as  Killian's triangle ) is a triangular area in the wall of the  pharynx  between the cricopharyngeus and thyropharyngeus which are the two parts of the inferior constrictors(also see  Pharyngeal pouch ). It can be seen as a locus minoris resistentiae.\nA similar triangular area between circular fibres of the cricopharyngeus and longitudinal fibres of the esophagus is  Lamier's   triangle  or  Lamier-hackermann's area ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2748", "text": "It represents a potentially weak spot where a pharyngoesophageal diverticulum ( Zenker's diverticulum ) is more likely to occur. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2749", "text": "It is named after the German ENT surgeon  Gustav Killian . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2750", "text": "The  lacrimal glands  are paired  exocrine glands , one for each  eye , found in most terrestrial vertebrates and some marine mammals, that secrete the aqueous layer of the  tear  film. [ 1 ]  In humans, they are situated in the upper lateral region of each  orbit , in the  lacrimal fossa  of the orbit formed by the frontal bone. [ 2 ]  Inflammation of the lacrimal glands is called  dacryoadenitis . The lacrimal gland produces tears which are secreted by the lacrimal ducts, and flow over the ocular surface, and then into canals that connect to the  lacrimal sac . From that sac, the tears drain through the  lacrimal duct  into the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2751", "text": "Anatomists divide the gland into two sections, a palpebral lobe, or portion, and an orbital lobe or portion. [ 3 ]  The smaller  palpebral lobe  lies close to the eye, along the inner surface of the eyelid; if the upper  eyelid  is everted, the palpebral portion can be seen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2752", "text": "The orbital lobe of the gland, contains fine  interlobular ducts  that connect the orbital lobe and the palpebral lobe. [ 4 ]  They unite to form three to five main secretory ducts, joining five to seven ducts in the palpebral portion before the secreted fluid may enter on the surface of the eye.  Tears secreted collect in the fornix conjunctiva of the upper lid, and pass over the eye surface to the  lacrimal puncta , small holes found at the inner corner of the eyelids.  These pass the tears through the  lacrimal canaliculi  on to the  lacrimal sac , in turn to the  nasolacrimal duct , which dumps them out into the nose. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2753", "text": "Lacrimal glands are also present in other  mammals , such as horses."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2754", "text": "The lacrimal gland is a compound  tubuloacinar gland , it is made up of many  lobules  separated by  connective tissue , each lobule contains many  acini . The acini composed of large serous cells which, produce a watery serous secretion, serous cells are filled with lightly stained secretory granules and surrounded by well-developed myoepithelial cells and a sparse, vascular stroma.\nEach acinus consists of a grape-like mass of  lacrimal gland cells  with their apices pointed to a central  lumen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2755", "text": "The central lumen of many of the units converge to form  intralobular ducts , and then they unite to form interlobular ducts. The gland lacks  striated ducts ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2756", "text": "The lacrimal gland receives blood from the  lacrimal artery , which is a branch of the  ophthalmic artery . Blood from the gland drains to the  superior ophthalmic vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2757", "text": "No lymphatic vessels have been observed draining the lacrimal gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2758", "text": "The lacrimal gland is innervated by the  lacrimal nerve , which is the smallest branch of the  ophthalmic nerve , itself a branch of the  trigeminal nerve  (CN V). After the lacrimal nerve branches from the ophthalmic nerve it receives a communicating branch from the  zygomatic nerve . This communicating branch carries postganglionic parasympathetic axons from the  pterygopalatine ganglion . The lacrimal nerve passes anteriorly in the orbit and through the lacrimal gland providing parasympathetic and sympathetic innervation to it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2759", "text": "The parasympathetic innervation to the lacrimal gland is a complex pathway which traverses through numerous structures in the head. Ultimately this two-neuron pathway involving both a preganglionic and postganglionic parasympathetic neuron increases the secretion of lacrimal fluid from the lacrimal gland. The preganglionic parasympathetic neurons are located in the  superior salivatory nucleus . They project axons which exit the brainstem as part of the  facial nerve  (CN VII). Within the  facial canal  at the  geniculate ganglion  the axons branch from the facial nerve forming the  greater petrosal nerve . This nerve exits the facial canal through the  hiatus for the greater petrosal nerve  in the  petrous part of the temporal bone . It emerges to the  middle cranial fossa  and travels anteromedially to enter the  foramen lacerum . Within the foramen lacerum it joins to the  deep petrosal nerve  to form the  nerve of the pterygoid canal  and then passes through this canal. It emerges in the pterygopalatine fossa and enters the pterygopalatine ganglion where the preganglionic parasympathetic axons synapse with the postganglionic parasympathetic neurons. The postganglionic neurons then send axons which travel with the zygomatic nerve to enter the inferior orbital fissure. As the zygomatic nerve travels anteriorly in the orbit it sends a communicating branch to the lacrimal nerve which carries the postganglionic parasympathetic axons. The lacrimal nerve completes this long pathway by travelling through the lacrimal gland and sending branches to which it provides parasympathetic innervation to increase the secretion of lacrimal fluid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2760", "text": "Sympathetic innervation to the lacrimal gland is of less physiologic importance than the parasympathetic innervation, however there are noradrenergic axons found within the lacrimal gland. Their cell bodies are located in the superior cervical ganglion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2761", "text": "In contrast to the normal moisture of the eyes or even crying, there can be persistent dryness, scratching, itchiness and burning in the eyes, which are signs of dry eye syndrome (DES) or keratoconjunctivitis sicca (KCS). With this syndrome, the lacrimal glands produce less lacrimal fluid, which mainly occurs with aging or certain medications. The Schirmer test, conducted by placing a thin strip of filter paper at the edge of the eye, can be used to determine the level of dryness of the eye. Many medications or diseases that cause dry eye syndrome can also cause hyposalivation with xerostomia. Treatment varies according to aetiology and includes avoidance of exacerbating factors, tear stimulation and supplementation, increasing tear retention, eyelid cleansing, and treatment of eye inflammation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2762", "text": "In addition, the following can be associated with lacrimal gland pathology:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2763", "text": "The  lacrimal sac  or  lachrymal sac [ 1 ]  is the upper dilated end of the  nasolacrimal duct , [ 2 ]  and is lodged in a deep groove formed by the  lacrimal bone  and  frontal process of the maxilla . It connects the  lacrimal canaliculi , which drain tears from the eye's surface, and the  nasolacrimal duct , which conveys this fluid into the nasal cavity. [ 3 ]  Lacrimal sac occlusion leads to  dacryocystitis .\n [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2764", "text": "It is oval in form and measures from 12 to 15\u00a0mm. in length; its upper end is closed and rounded; its lower is continued into the nasolacrimal duct."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2765", "text": "Its superficial surface is covered by a fibrous expansion derived from the  medial palpebral ligament , and its deep surface is crossed by the lacrimal part of the  orbicularis oculi , which is attached to the crest on the lacrimal bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2766", "text": "Like the nasolacrimal duct, the sac is lined by  stratified columnar epithelium  with mucus-secreting  goblet cells , with surrounding connective tissue. The Lacrimal Sac also drains the eye of debris and microbes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2767", "text": "It serves as a reservoir for overflow of tears, in which the lacrimal sac pumps inward and outward driven by the  orbicularis  muscle during blinking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2768", "text": "The lacrimal sac can be imaged by  dacrocystography , in which  radiocontrast  is injected, followed by  X-ray imaging ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2769", "text": "This article incorporates text in the  public domain  from  page 1028  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2770", "text": "Laryngitis  is  inflammation  of the  larynx  (voice box). [ 1 ]  Symptoms often include a  hoarse voice  and may include  fever , cough, pain in the front of the neck, and  trouble swallowing . [ 1 ] [ 2 ]  Typically, these last under 2 weeks. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2771", "text": "Laryngitis is categorized as  acute  if it lasts less than 3 weeks and  chronic  if symptoms last more than 3 weeks. [ 1 ]  Acute cases usually occur as part of a  viral upper respiratory tract infection , [ 1 ]  other infections, and trauma such as from coughing or other causes. [ 1 ]  Chronic cases may occur due to  smoking ,  tuberculosis ,  allergies ,  acid reflux ,  rheumatoid arthritis , or  sarcoidosis . [ 1 ] [ 3 ]  The underlying mechanism involves irritation of the  vocal cords . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2772", "text": "Concerning signs that may require further investigation include  stridor , history of  radiation therapy  to the neck, trouble swallowing, duration of more than 3 weeks, and a history of smoking. [ 1 ]  If concerning signs are present. the vocal cords should be examined via  laryngoscopy . [ 1 ]  Other conditions that can produce similar symptoms include  epiglottitis ,  croup , inhaling a  foreign body , and  laryngeal cancer . [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2773", "text": "The acute form of the infection, or acute laryngitis, generally resolves without specific treatment. [ 1 ]  Resting the voice and sufficient fluids may help. [ 1 ]   Antibiotics  generally do not appear to be useful in the acute form. [ 5 ]  The acute form is common while the chronic form of the infection, or chronic laryngitis, is not. [ 1 ]  Chronic laryngitis occurs most often in middle age and is more common in men than women. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2774", "text": "The primary symptom of laryngitis is a hoarse voice. [ 7 ] :\u200a108\u200a  Because laryngitis can have various causes, other signs and symptoms may vary. [ 8 ]  They can include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2775", "text": "Aside from a hoarse-sounding voice, changes to pitch and volume may occur with laryngitis. Speakers may experience a lower or higher pitch than normal, depending on whether their vocal folds are swollen or stiff. [ 1 ] [ 9 ]  They may also have breathier voices, as more air flows through the space between the vocal folds (the  glottis ), quieter volume, [ 10 ]  and a reduced range. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2776", "text": "Laryngitis can be infectious as well as noninfectious in origin. The resulting inflammation of the vocal folds results in a distortion of the sound produced there. [ 1 ]  It normally develops in response to either an infection, trauma to the vocal folds, or allergies. [ 3 ]  Chronic laryngitis may also be caused by more severe problems, such as nerve damage, sores, and polyps, or hard and thick lumps  (nodules ) on the vocal cords. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2777", "text": "Diagnosis of different forms of acute laryngitis include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2778", "text": "The larynx itself will often show  erythema  (reddening) and  edema  (swelling). This can be seen with  laryngoscopy  or  stroboscopy  (method depends on the type of laryngitis). [ 7 ]  Stroboscopy may be relatively normal or may reveal asymmetry, aperiodicity, and reduced mucosal wave patterns. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2779", "text": "Other features of the laryngeal tissues may include [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2780", "text": "Some signs and symptoms indicate the need for early referral. [ 1 ]  These include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2781", "text": "Treatment is often supportive in nature, and depends on the severity and type of laryngitis (acute or chronic). [ 1 ]  General measures to relieve symptoms of laryngitis include behavior modification, hydration, and humidification. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2782", "text": "Vocal hygiene (care of the voice) is very important to relieve symptoms of laryngitis. Vocal hygiene involves measures such as resting the voice, drinking sufficient water, reducing caffeine and alcohol intake, stopping smoking, and limiting throat clearing. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2783", "text": "In general, acute laryngitis treatment involves vocal hygiene, painkillers ( analgesics ), humidification, and antibiotics. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2784", "text": "The suggested treatment for viral laryngitis involves vocal rest,  pain medication , and mucolytics for frequent coughing. [ 7 ]  Home remedies such as tea and honey may also be helpful. [ 1 ]  Antibiotics are not used for treatment of viral laryngitis. [ 1 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2785", "text": "Antibiotics  may be prescribed for bacterial laryngitis, especially when symptoms of upper respiratory infection are present. [ 7 ]  However, the use of antibiotics is highly debated for acute laryngitis. This relates to issues of effectiveness, side effects, cost, and possibility of antibiotic resistance patterns. Overall, antibiotics do not appear to be very effective in the treatment of acute laryngitis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2786", "text": "In severe cases of bacterial laryngitis, such as supraglottitis or epiglottitis, there is a higher risk of the airway becoming blocked. [ 7 ]  An urgent referral to a physician should be made to manage the airway. [ 1 ]  Treatment may involve humidification,  corticosteroids , intravenous antibiotics, and nebulised adrenaline. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2787", "text": "Fungal laryngitis can be treated with oral antifungal tablets and antifungal solutions. [ 1 ] [ 7 ]  These are typically used for up to 3 weeks and treatment may need to be repeated if the fungal infection returns. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2788", "text": "Laryngitis caused by excessive use or misuse of the voice can be managed through vocal hygiene measures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2789", "text": "Laryngopharyngeal reflux  treatment primarily involves behavioral management and medication. [ 1 ] [ 7 ]  Behavioral management involves aspects such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2790", "text": "Anti-reflux medications may be prescribed for patients with signs of chronic laryngitis and hoarse voice. [ 24 ]  If anti-reflux treatment does not result in a decrease of symptoms, other possible causes should be examined. [ 1 ]  Over-the-counter medications for neutralizing acids ( antacids ) and acid suppressants ( H-2 blockers ) may be used. [ 7 ]  Antacids are often short-acting and may not be sufficient for treatment. [ 7 ]   Proton pump inhibitors  are an effective type of medication. [ 7 ]  These should only be prescribed for a set period of time, after which the symptoms should be reviewed. [ 1 ]  Proton pump inhibitors do not work for everyone. A physical reflux barrier (e.g., Gaviscon Liquid) may be more appropriate for some. [ 1 ]  Antisecretory medications (i.e., ulcers) can have several side-effects. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2791", "text": "When appropriate, anti-reflux surgery may benefit some individuals. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2792", "text": "When treating allergic laryngitis, topical nasal steroids and  immunotherapy  have been found to be effective for  allergic rhinitis . [ 7 ]   Antihistamines  may also be helpful, but can create a dryness in the larynx. [ 7 ]  Inhaled steroids that are used for a long period can lead to problems with the larynx and voice. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2793", "text": "Mucous membrane pemphigoid  may be managed with medication ( cyclophosphamide  and  prednisolone ). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2794", "text": "Sarcoidosis  is typically treated with  systemic corticosteroids . Less frequently used treatments include intralesional injections or laser resection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2795", "text": "Acute laryngitis may persist, but will typically resolve on its own within 2 weeks. [ 1 ]  Recovery is likely to be quick if the patient follows the treatment plan. [ 25 ]  In viral laryngitis, symptoms can persist for an extended period, even when upper respiratory tract inflammation has been resolved. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2796", "text": "Laryngitis that continues for more than 3 weeks is considered  chronic . [ 1 ]  If laryngeal symptoms last for more than 3 weeks, a referral to a physician should be made for further examination, including direct  laryngoscopy . [ 1 ]  The prognosis for chronic laryngitis varies depending on the cause of the laryngitis. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2797", "text": "Laryngology  is a branch of  medicine  that deals with disorders,  diseases  and  injuries  of the  larynx , colloquially known as the voice box. Laryngologists treat disorders of the larynx, including diseases that affects the voice, swallowing, or upper airway. Common conditions addressed by laryngologists include  vocal fold nodules  and  cysts ,  laryngeal cancer ,  spasmodic dysphonia ,  laryngopharyngeal reflux ,  papillomas , and voice misuse/abuse/overuse syndromes.  Dysphonia /hoarseness;  laryngitis  (including  Reinke's edema ,  Vocal cord nodules  and  polyps ); * Spasmodic dysphonia ;  dysphagia ;  Tracheostomy ;  Cancer of the larynx ; and  vocology  (the science and practice of voice habilitation) are included in laryngology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2798", "text": "The word \"laryngology\" is derived from:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2799", "text": "Laryngospasm  is an uncontrolled or involuntary muscular contraction ( spasm ) of the  vocal folds . [ 1 ]  It may be triggered when the  vocal cords  or the area of the  trachea  below the vocal folds detects the entry of water, mucus, blood, or other substance.  It may be associated with  stridor  or  retractions ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2800", "text": "Laryngospasm is characterized by involuntary spasms of the laryngeal muscles. It is associated with difficulty or inability to breathe or speak,  retractions , a feeling of suffocation, which may be followed by hypoxia-induced loss of consciousness. [ 2 ]  It may be followed by paroxysmal coughing and in partial laryngospasms, a stridor may be heard. [ 3 ]  It requires prompt identification to avoid possibly fatal complications. It may present with loss of end-tidal carbon dioxide (for mechanically ventilated patients), chest or neck retractions and paradoxical chest wall movements. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2801", "text": "The condition typically lasts less than 60 seconds, but in cases of partial blocking it may last 20 to 30 minutes and hinder  inspiration , while  exhalation  remains easier. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2802", "text": "Laryngospasm is a primitive protective airway reflex that functions to protect against  aspiration . However, it may be detrimental if there is sustained closure of the  glottis  resulting in blockage of respiration that hinders the free flow of air. It may be triggered when the  vocal cords  or the area of the  trachea  below the vocal folds detects the entry of water, mucus, blood, or other substance.   [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2803", "text": "It is most often reported 1) post-operatively after endotracheal extubation or 2) after sudden reflux of gastric contents. [ 2 ]   [ 4 ] [ 1 ]   It is common in drowning. It is estimated that in 10% of cases of drowning as a response to inhalation of water, death occurs due to asphyxia due to laryngospasm without any water in the lungs. [ 5 ]  It is also a symptom of  hypoparathyroidism . [ 6 ]  It can sometimes occur during sleep, waking up the affected person. These episodic interruptions of sleep have been attributed to acute irritation due to gastro-oesophageal reflux. [ 2 ] [ 7 ]  Laryngospasm is also an unlikely but possible side effect of  ketamine  administration. [ 8 ]  Laryngospasm may happen in people with neurological disease. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2804", "text": "In children, rapid detection and management are imperative to prevent deadly complications such as cardiac arrest, hypoxia and bradycardia. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2805", "text": "Patients with a history of significant aspiration, asthma, exposure to airway irritants (smoke, dust, mold, fumes, use of  Desflurane ), upper respiratory infections, airway anomalies, light anesthesia and patients with acute mental status depression may be at increased risk. [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2806", "text": "When gastroesophageal reflux disease (GERD) is the trigger, treatment of GERD can help manage laryngospasm. Proton pump inhibitors such as  Dexlansoprazole  (Dexilant),  Esomeprazole  (Nexium), and  Lansoprazole  (Prevacid) reduce the production of stomach acids, making reflux fluids less irritant.  Prokinetic agents  reduce the amount of acid available by stimulating movement in the digestive tract. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2807", "text": "Patients who are prone to laryngospasm during illness can take measures to prevent irritation such as antacids to avoid acid reflux. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2808", "text": "For acute context, making an upright position of the upper part of the body has been shown to shorten the spasm episodes.  Fixation  of  the arms  on  stabilization  of  the  body  and  slowing  of  breathing is also recommended. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2809", "text": "Incidence has been estimated at approximately 1% in both adult and pediatric populations. Its incidence is reported to be more than triple in the very young (birth to 3 months of age), increasing to 10% in those with  reactive airways . Other sub-populations with high incidence of laryngospams include patients undergoing tonsillectomy and adenoidectomy (25%). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2810", "text": "It is likely that more than 10% of  drownings  involve laryngospasm, but the evidence suggests that it is not usually effective at preventing water from entering the trachea. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2811", "text": "Most minor laryngospasm get better on its own for most people. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2812", "text": "Laryngospasm is one of the most common intraoperative complications. It may be life-threatening as it involves reflex closure of the laryngeal muscles and thus results in inability to ventilate the patient. [ 13 ]  Treatment requires clearing secretions from the  oropharynx , applying  continuous positive airway pressure  with 100%  oxygen , followed by deepening the plane of anaesthesia with  propofol , and/or paralyzing with  succinylcholine . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2813", "text": "The  lesser palatine nerves  ( posterior palatine nerve ) are branches of the  maxillary nerve  (CN V 2 ). They descends through the  greater palatine canal  alongside the greater palatine nerve, and emerge (separately) through the  lesser palatine foramen  to pass posteriorward. [ 1 ]  They supply the  soft palate ,  tonsil , [ 1 ] [ 2 ]  and  uvula . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2814", "text": "The  lesser petrosal nerve  (also known as the  small superficial petrosal nerve ) is the  general visceral efferent  (GVE) nerve conveying pre-ganglionic  parasympathetic  secretomotor fibers for the  parotid gland  from the  tympanic plexus  to the  otic ganglion  (where they synapse). It passes out of the tympanic cavity through the petrous part of the temporal bone into the middle cranial fossa of the cranial cavity, then exits the cranial cavity through its own canaliculus to reach the infratemporal fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2815", "text": "Cell bodies of the lesser petrosal nerve are situated in the  inferior salivatory nucleus , and are conveyed first by the  glossopharyngeal nerve (CN IX)  and then by the  tympanic nerve  to the tympanic plexus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2816", "text": "The nucleus of the lesser petrosal nerve is the  inferior salivatory nucleus . [ citation needed ]  The lesser petrosal nerve may be considered a continuation of the  tympanic nerve . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2817", "text": "After arising in the  tympanic plexus , the lesser petrosal nerve passes anterior-ward, then through the  hiatus for lesser petrosal nerve  on the anterior surface of the  petrous part  of the  temporal bone  into the  middle cranial fossa . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2818", "text": "It runs across the floor of this fossa [ 2 ]  along a groove oriented in the direction the  foramen ovale  and situated parallel and anterolateral to the groove for the  greater petrosal nerve  and its groove. [ 3 ] :\u200a509"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2819", "text": "It exits the skull via canaliculus innominatus [ 4 ]  and enters the  infratemporal fossa . In the fossa, its fibres synapse at the  otic ganglion . Post-ganglionic fibres then exit the ganglion to briefly travel along with the  auriculotemporal nerve  (a branch of the  mandibular nerve (CN V 3 ) ) before entering the substance of the  parotid gland . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2820", "text": "The lesser petrosal nerve distributes its post-ganglionic parasympathetic (GVE) fibers to the parotid gland via the intraparotid plexus (or  parotid plexus ), the branches from the facial nerve in the parotid gland. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2821", "text": "This article incorporates text in the  public domain  from the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2822", "text": "The  levator labii superioris  ( pl. :  levatores labii superioris , also called  quadratus labii superioris ,  pl. :  quadrati labii superioris ) is a  muscle  of the  human body  used in  facial expression .  It is a broad sheet, the origin of which extends from the side of the  nose  to the  zygomatic bone . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2823", "text": "Its medial fibers form the  angular head  (also known as the  levator labii superioris alaeque nasi muscle [ 2 ] ) which arises by a pointed extremity from the upper part of the  frontal process  of the  maxilla  and passing obliquely downward and lateralward divides into two slips."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2824", "text": "One of these is inserted into the  greater alar cartilage  and skin of the nose; the other is prolonged into the lateral part of the  upper lip , blending with the infraorbital head and with the  orbicularis oris ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2825", "text": "The intermediate portion or  infraorbital head  arises from the lower margin of the  orbit  immediately above the infraorbital foramen, some of its fibers being attached to the  maxilla , others to the  zygomatic bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2826", "text": "Its fibers converge, to be inserted into the muscular substance of the upper lip between the angular head and the  levator anguli oris ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2827", "text": "The lateral fibers, forming the  zygomatic head  (also known as the  zygomaticus minor muscle [ 3 ] ) arise from the malar surface of the  zygomatic bone  immediately behind the  zygomaticomaxillary suture  and pass downward and medialward to the upper lip."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2828", "text": "Its main function is to elevate the upper lip. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2829", "text": "This article incorporates text in the  public domain  from  page 383  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2830", "text": "The  major alar cartilage  ( greater alar cartilage ) ( lower lateral cartilage ) is a thin, flexible plate, situated immediately below the  lateral nasal cartilage , and bent upon itself in such a manner as to form the  medial wall  and lateral wall of the  nostril  of its own side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2831", "text": "The portion which forms the  medial wall  (crus mediale) is loosely connected with the corresponding portion of the opposite cartilage, the two forming, together with the thickened  integument  and subjacent tissue, the  nasal septum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2832", "text": "The part which forms the lateral wall (crus laterale) is curved to correspond with the  ala of the nose ; it is oval and flattened, narrow behind, where it is connected with the  frontal process of the maxilla  by a tough fibrous membrane, in which are found three or four small cartilaginous plates, the  lesser alar cartilages  (cartilagines alares minores; sesamoid cartilages)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2833", "text": "Above, it is connected by fibrous tissue to the lateral cartilage and front part of the  cartilage of the septum ; below, it falls short of the margin of the nostril, the ala being completed by fatty and fibrous tissue covered by  skin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2834", "text": "In front, the greater alar cartilages are separated by a notch which corresponds with the apex of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2835", "text": "This article incorporates text in the  public domain  from  page 993  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2836", "text": "The  malleus , or  hammer , is a hammer-shaped small bone or  ossicle  of the  middle ear . It connects with the  incus , and is attached to the inner surface of the  eardrum . The word is Latin for 'hammer' or 'mallet'. It transmits the sound vibrations from the eardrum to the  incus  (anvil)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2837", "text": "The malleus is a bone situated in the middle ear. It is the first of the three  ossicles , and attached to the  eardrum  (tympanic membrane). The head of the malleus is the large protruding section, which attaches to the  incus . The head connects to the neck of malleus. The bone continues as the handle (or manubrium) of malleus, which connects to the tympanic membrane. [ 1 ]  Between the neck and handle of the malleus, lateral and anterior processes emerge from the bone. [ 2 ] [ 3 ]  The bone is oriented so that the head is superior and the handle is inferior. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2838", "text": "Embryologically, the malleus is derived from the first  pharyngeal arch  along with the  incus . [ 3 ]  In humans it grows from  Meckel's cartilage . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2839", "text": "The malleus is one of three  ossicles  in the  middle ear  which transmit sound from the  tympanic membrane (ear drum)  to the  inner ear . The malleus receives vibrations from the tympanic membrane and transmits this to the incus. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2840", "text": "The malleus may be  palpated  by  surgeons  during  ear surgery . [ 1 ]  It may become fixed in place due to surgical complications, causing hearing loss. [ 1 ]  This may be corrected with further surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2841", "text": "Several sources  attribute the discovery of the malleus to the  anatomist  and  philosopher   Alessandro Achillini . [ 4 ] [ 5 ]  The first brief written description of the malleus was by  Berengario da Carpi  in his  Commentaria super anatomia Mundini  (1521). [ 6 ]   Niccolo Massa 's  Liber introductorius anatomiae [ 7 ]  described the malleus in slightly more detail and likened both it and the  incus  to little hammers terming them  malleoli . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2842", "text": "The  malleus  is unique to mammals, and  evolved from a lower jaw bone  in basal  amniotes  called the  articular , which still forms part of the jaw joint in reptiles and birds. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2843", "text": "In  neuroanatomy , the  mandibular nerve  ( V 3 ) is the largest of the three divisions of the  trigeminal nerve , the fifth  cranial nerve  (CN V). Unlike the other divisions of the trigeminal nerve ( ophthalmic nerve ,  maxillary nerve ) which contain only  afferent fibers , the mandibular nerve contains both afferent and  efferent fibers . These nerve fibers innervate structures of the  lower jaw  and face, such as the  tongue ,  lower lip , and  chin . The mandibular nerve also innervates the  muscles of mastication . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2844", "text": "The large sensory root of mandibular nerve emerges from the lateral part of the  trigeminal ganglion  and exits the  cranial cavity  through the  foramen ovale . The motor root (Latin:  radix motoria  s.  portio minor ), the small motor root of the  trigeminal nerve , passes under the trigeminal ganglion and through the  foramen ovale  to unite with the sensory root just outside the  skull . [ 2 ] [ better\u00a0source\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2845", "text": "The mandibular nerve immediately passes between  tensor veli palatini , which is medial, and  lateral pterygoid , which is lateral, and gives off a  meningeal branch  (nervus spinosus) and the  nerve to medial pterygoid  from its medial side. The nerve then divides into a small anterior division and a large posterior division."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2846", "text": "The mandibular nerve gives off the following branches:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2847", "text": "Anterior Division"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2848", "text": "(Motor Innervation -  Muscles of mastication )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2849", "text": "(Sensory Innervation)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2850", "text": "Posterior Division"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2851", "text": "Lingual Split \n(general sensory innervation ( not  special sensory for taste))"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2852", "text": "Inferior Alveolar Split \n(Motor Innervation)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2853", "text": "Auriculotemporal Split"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2854", "text": "Mandibular setback surgery  is a  surgical procedure  performed along the  occlusal plane  to prevent bite opening on the anterior or posterior teeth and retract the lower jaw for both functional and aesthetic effects in patients with  mandibular prognathism . [ 1 ] [ 2 ]  It is an orthodontic surgery that is a form of  reconstructive plastic surgery. [ 3 ]  There are three main types of procedures for mandibular setback surgery: Bilateral Sagittal Split Osteotomy (BSSO), Intraoral Vertical Ramus Osteotomy (IVRO) and Extraoral Ramus Osteotomy (EVRO), depending on the magnitude of mandibular setback for each patient. Postoperative care aims to minimise postoperative complications, complications includes  bite  changes,  relapse  and  nerve injury ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2855", "text": "The origin of orthognathic surgery was introduced by  Simon P. Hullihen  in 1849. [ 4 ]  Upon Hullihen's discovery of the procedure, many surgeons further investigated and modified approaches to correct mandibular prognathism. [ 5 ]  Vilray Blair and Edward H. Angle collaborated to introduce osteotomy to the mandibular body with a horizontal incision, marking the beginning of orthognathic surgery. [ 6 ]  With these notable modifications in surgical procedures for prognathism, BSSO, IVRO and EVRO are procedures used in practise to treat individuals with dentofacial deformities. VRO was first introduced as EVRO by Caldwell and Letterman and further modified into IVRO by Moose in 1964. [ 7 ] [ 8 ] [ 9 ] [ 10 ]  BSSO was then introduced by Obwegeser in 1959. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2856", "text": "Mandible  is a movable solitary bone forming the lower jaw. [ 12 ]  It is composed of a mandibular body and two mandibular rami (singular: ramus [ 13 ] ) on bilateral sides of the face. [ 14 ]  The mandibular ramus contains the  mandibular foramen , which is where the  inferior alveolar nerve  and  artery  enters. [ 14 ]  Each end of the ramus has a projection that articulates with the  temporal bones  via  temporomandibular joint  called  mandibular condyle . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2857", "text": "Lingula  is superior to mandibular foramen on the mandibular ramus, which often acts as a recognisable feature for surgical procedures. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2858", "text": "BSSO and IVRO are the two most common types of procedures used for mandibular setback surgery while EVRO is carried out for specific cases."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2859", "text": "A vertical incision is performed on the inferior and lateral sides of the soft tissue in the mouth at a distance from the adjacent  gums . [ 17 ]  The cut is performed from the mandibular ramus to the mandibular body along the external oblique line, down to the mandibular  first molar  region, and further down the  buccal vestibule  of the mandible. [ 16 ]  A precise cut allows sufficient tissues remained for closing the suture. [ 17 ]   The surrounding soft tissue from the bone is dissected and elevated in a subperiosteal plane to see the mandibular ramus clearly. The mandibular foramen and the lingula must also be exposed without damaging the inferior alveolar nerve. A clamp is used to hold the layers in a fixed position for mandibular osteotomy to be carried out."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2860", "text": "The BSSO technique requires two cuts of the mandible utilising an osteotome that is inclined to one side. [ 17 ]  Firstly, the lateral osteotomy starts at the buccal cortex, the bone in the buccal space. This split is done vertically down to the first or second molar region. [ 18 ]  Then the medial osteotomy is done on the lingual cortical bone, which extends to the anterior border of the ramus posterior and to the inferior alveolar canal. [ 16 ]  Subsequently, the fractures of the ramus are split by applying slight force."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2861", "text": "Mobilisation of the segments are done to the pre-arranged position and fixed internally with screws and plates. [ 19 ]  BSSO allows rigid fixation and increases stability of mandibular setbacks. However, as the nerve is manipulated to a large extent during the surgery, it increases the chance of patients experiencing neurosensory loss. [ 20 ]  Studies have shown statistically that another type of method, IVRO, can reduce the chance of neurosensory disturbance. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2862", "text": "Firstly, a horizontal incision through the  oral mucosa  along the anterior border of the ramus of mandible within the mouth allows surgeons to reach the underlying bone and tissue of the lower jaw. [ 16 ]  Once the cut opens near the coronoid process and mandibular first molar region, a deeper dissection is done so the  mandibular notch , inferior and posterior of the ramus are visible. [ 16 ]  Then, the IVRO can be performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2863", "text": "A pair of  retractors  are positioned properly and carefully for clear exposure of the ramus. [ 16 ]  The cutting of the bone is done by surgical  oscillating saw , [ 22 ]  at an angle of 105\u00b0 precisely behind the body prominence of antilingula, superior to the  sigmoid notch  and inferior to the  mandibular angle . The bone fragment is adjusted to the preoperative planned position, which sets the lower jaw backwards. [ 23 ]  Stabilisation of the jaw at its modified position is then done through wiring. The inter-maxillary fixation is usually kept for around six weeks. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2864", "text": "The IVRO procedure can be performed if the magnitude of the mandibular setback is within 10mm. [ 24 ]  The limitation of the specific range of setback is to prevent postoperative forward relapse and the dislocation of mandibular condylar head. [ 24 ]  When the required adjustment of the jaw exceeds 10mm, patients will most likely undertake the EVRO procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2865", "text": "The incision for EVRO is made on the most superficial layer of the skin, approximately 1 to 2\u00a0cm below the mandibular angle. [ 25 ] [ 26 ]  The dissection cuts the  platysma  and the  masseter muscle . As the skin dissection is done, a small protrude of the ramus could be observed. This allows the mandible osteotomy to be done safely by avoiding damaging the adjacent nerves. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2866", "text": "The bony cut is made from the sigmoid notch to the mandibular angle with an osteotome. The bony fragment at the proximal end is rearranged and stabilized using screws, plates, or wires. The closure of the wound is done layer by layer. The intermaxillary fixation is usually kept for a week to ten days. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2867", "text": "Compared to BSSO and IVRO, this technique takes the least surgical time as it is performed on the external surface, which allows the surgeons to have easier access and clearer vision. However, the surgical scar that is left behind could be a concern to certain patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2868", "text": "The mandibular setback surgery can improve masticatory function and facial aesthetics by repositioning the jaw and mouth, which can have a positive effect on the patient's psychosocial well-being. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2869", "text": "Patients with mandibular prognathism may have difficulty chewing, speaking, and breathing, which can affect their quality of life. [ 17 ]  The mandibular setback surgery improves one's  masticatory muscle  activity and  speech intelligibility . [ 29 ]  The mandibular setback surgery improves functional difficulties caused by mandibular prognathism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2870", "text": "Aesthetic correction is second positive effect of mandibular setback surgery. In particular, it improves the asymmetry of the upper and lower lip in patients with  mandibular prognathism . Patients after the surgery may result in a more pronounced and defined chin by repositioning the jaw. [ 30 ] [ 31 ]  Ultimately, it allows for a more balanced and harmonious facial profile. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2871", "text": "Post-surgery questionnaires results indicated improved psychosocial well-being, self-esteem and social functioning in patients after the mandibular setback surgery. [ 32 ]  There is also a high patient satisfaction rate for the surgery. [ 33 ]  These show how the mandibular setback surgery improves well-being of patients with mandibular prognathism. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2872", "text": "After the setback surgery, a 2-week recovery period is needed for the wires to be closed and inter-maxillary fixation to stabilise the position of the mandible. [ 34 ]  Patients would stay for a minimum of 1 to 2 days and exception may occur if a complication has occurred. Post-operative assessments need to be done for the 2 weeks after the operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2873", "text": "Gum chewing and patient education exercise post-surgery can improve masticatory function in patient and minimise the risk of complications. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2874", "text": "More than 40% of patients have complications after mandibular setback surgery. [ 31 ]  Complications include bite changes, nerve injuries and relapse."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2875", "text": "Bite changes occur in 20.3% of the cases post-setback surgery. [ 37 ]  Change in pharyngeal airway space and tongue position can have a significant effect on bite changes after mandibular setback surgery and cause obstructive sleep apnea. [ 1 ] [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2876", "text": "The tongue is normally positioned against the roof of the mouth, supporting the upper jaw. After surgery, the change in the position of the tongue affects the position of the jaw, leading to bite changes. [ 40 ]  Bite changes can narrow the pharyngeal airway space after surgery can lead obstructive sleep apnea. [ 41 ]  Incorrect jaw positioning requires additional surgery to reposition the jaw and open up the airway. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2877", "text": "9.2% of the patients who underwent the mandibular setback surgery has found post-surgery relapse. [ 43 ]  This is caused by actions of the condyle resorption. [ 44 ]  Condyle resorption is when the bone tissue is lost in the condyle. Condyle resorption reduces stability of the mandible and cause long term skeletal relapse. [ 45 ] [ 46 ]  When the mandible is not stabilised, it allows movement of the mandible into its pre-operative position, contributing to early relapse. [ 47 ]  Bone fixation procedures will be needed due to the lack of bone healing. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2878", "text": "Nerve injuries occur in 3.7% of the patients after the mandibular setback surgery. [ 49 ]  Cutting and repositioning of the mandible in the surgery can potentially damage nerves in the mandible that is responsible for sensation and movement. Specifically, the inferior alveolar nerve are the commonly affected nerve in the surgery. [ 50 ]  Less common nerves injuries are on the lingual nerve and mental nerve, which are responsible for tongue and chin sensation respectively. The lingual nerve is affected by the wire placement in the molar region. [ 51 ]  The mental nerve injury can be caused by the presence of  bony spurs . A damage in the nerve may require additional therapy to repair the loss of ability in the nerves. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2879", "text": "The  marginal mandibular branch of the facial nerve  arises from the  facial nerve (CN VII)  in the parotid gland at the  parotid plexus . It passes anterior-ward deep to the  platysma  and  depressor anguli oris  muscles. It provides motor innervation to muscles of the  lower lip  and  chin : the  depressor labii inferioris muscle ,  depressor anguli oris muscle , and  mentalis muscle . [ 1 ]  It communicates with the mental branch of the  inferior alveolar nerve . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2880", "text": "The marginal mandibular nerve may be injured during surgery in the neck region, especially during excision of the submandibular salivary gland or during neck dissections due to lack of accurate knowledge of variations in the course, branches and relations. An injury to this nerve during a surgical procedure can distort the expression of the smile as well as other facial expressions. The marginal mandibular branch of the facial nerve is found superficial to the facial artery and (anterior) facial vein. Thus the facial artery can be used as an important landmark in locating the marginal mandibular nerve during surgical procedures. [ 2 ]  Damage can cause paralysis of the three muscles it supplies, which can cause an asymmetrical smile due to lack of contraction of the  depressor labii inferioris muscle . [ 3 ]  This may be corrected with resection of the muscle, which tends to be successful. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2881", "text": "The  mastoid antrum  ( tympanic antrum ,  antrum mastoideum ,  Valsalva's antrum ) is an air space in the petrous portion of the  temporal bone , communicating posteriorly with the  mastoid cells  and anteriorly with the  epitympanic recess  of the  middle ear  via the  aditus to mastoid antrum  (entrance to the mastoid antrum). These air spaces function as sound receptors, provide voice resonance, act as acoustic insulation and dissipation, provide protection from physical damage and reduce the mass of the cranium. [ citation needed ] \nThe roof is formed by the tegmen antri which is a continuation of the  tegmen tympani  and separates it from the  middle cranial fossa .\nThe lateral wall of the antrum is formed by a plate of bone which is an average of 1.5\u00a0cm in adults.\nThe  mastoid air cell   system is a major contributor to middle ear inflammatory diseases. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2882", "text": "In the lateral part of the  jugular fossa  of the  temporal bone  is the  mastoid canaliculus  for the entrance of the  auricular branch  of the  vagus nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2883", "text": "This article incorporates text in the  public domain  from  page 144  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2884", "text": "The  mastoid cells  (also called  air cells of Lenoir  or  mastoid cells of Lenoir ) are air-filled cavities within the  mastoid process  of the  temporal bone  of the  cranium . The mastoid cells are a form of  skeletal pneumaticity . Infection in these cells is called  mastoiditis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2885", "text": "The term  cells  here refers to enclosed spaces, not  cells  as living, biological units."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2886", "text": "The mastoid air cells vary greatly in number, shape, and size; they may be extensive or minimal or even absent. [ 1 ] :\u200a746"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2887", "text": "The cells are typically interconnected and their walls lined by mucosa that is continuous with that of the mastoid antrum and tympanic cavity. [ 1 ] :\u200a746"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2888", "text": "They may excavate the mastoid process to its tip, and be separated from the  posterior cranial fossa  and  sigmoid sinus  by a mere slip of bone or not at all. They may extend into the  squamous part of temporal bone ,  petrous part of the temporal bone   zygomatic process of temporal bone , and - rarely - the  jugular process of occipital bone ; they may thus come to adjoin many important structures (including the bony labyrinth, tympanic cavity, external acoustic meatus, pharyngotympanic tube, superior jugular bulb, posterior cranial fossa, middle cranial fossa, carotid canal, abducens nerve, sigmoid sinus) to which they may disseminate infection in case of infective mastoiditis. [ 1 ] :\u200a746"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2889", "text": "The cells receive  innervation [ clarify ]  from the posterior branch of the  meningeal branch of the mandibular nerve (nervus spinosus) , [ 1 ] :\u200a400.e2\u200a [ 2 ] :\u200a364\u200a  and branches of the  tympanic plexus . [ 1 ] :\u200a749\u200a [ 2 ] :\u200a366"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2890", "text": "The cells receive arterial supply from the stylomastoid branch of the  occipital artery  or  posterior auricular artery , and (sometimes) a mastoid branch of the  occipital artery . [ 1 ] :\u200a749"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2891", "text": "The  superior petrosal sinus  receives venous drainage from the mastoid air cells (mastoid infection may thus lead to a cerebellar abscess). [ 2 ] :\u200a443"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2892", "text": "At birth, the mastoid is not pneumatized, but becomes aerated before age six. [ 3 ]  At birth, the mastoid antrum is well developed but the air cells are represented only by small diverticula from the antrum. The air cells then gradually extend into the bone of the mastoid during the first years of life. Their most significant enlargements takes place during puberty. [ 1 ] :\u200a746"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2893", "text": "The air cells are hypothesised to protect the temporal bone and the inner and middle ear against trauma and to regulate air pressure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2894", "text": "Infections in the middle ear  easily spread into the mastoid air cells through the  aditus ad antrum , resulting in  mastoiditis , a potentially dangerous and life-threatening condition. Infection may then further spread into the middle cranial fossa or posterior cranial fossa, causing meningitis or abscess of adjacent brain tissue. Infection may also spread to muscles of the neck, causing pain and  torticollis . [ 1 ] :\u200a746"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2895", "text": "The  mastoid foramen  is a hole in the posterior border of the  temporal bone . It transmits an  emissary vein  between the  sigmoid sinus  and the  suboccipital venous plexus , and a small branch of the  occipital artery , the  posterior meningeal artery  to the  dura mater ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2896", "text": "The mastoid foramen is a hole in the posterior border of the  temporal bone  of the  skull . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2897", "text": "The opening of the mastoid foramen is an average of 18 mm from the  asterion , [ 2 ]  and around 34 mm from the  external auditory meatus . [ 3 ]  It is typically very narrow. [ 1 ] [ 3 ]  This may be around 2 mm. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2898", "text": "The position and size of this foramen are very variable. [ 1 ] [ 3 ]  It is not always present. [ 1 ] [ 3 ]  Sometimes, it is duplicated on one side or both sides. [ 1 ]  Sometimes, it is situated in the  occipital bone , or in the  suture  between the temporal bone and the occipital bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2899", "text": "The mastoid foramen transmits:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2900", "text": "This article incorporates text in the  public domain  from  page 141  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2901", "text": "The  mastoid part of the temporal bone  is the posterior (back) part of the  temporal bone , one of the  bones  of the  skull . Its rough surface gives attachment to various  muscles  (via  tendons ) and it has  openings  for  blood vessels . From its borders, the mastoid part  articulates  with two other bones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2902", "text": "The word \"mastoid\" is derived from the Greek word for \" breast \", a reference to the shape of this bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2903", "text": "Its outer surface is rough and gives attachment to the  occipitalis  and  posterior auricular muscles . It is perforated by numerous  foramina  (holes); for example, the  mastoid foramen  is situated near the posterior border and transmits a vein to the  transverse sinus  and a small branch of the  occipital artery  to the  dura mater . The position and size of this foramen are very variable; it is not always present; sometimes it is situated in the occipital bone, or in the suture between the temporal and the occipital."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2904", "text": "The mastoid process is located posterior and inferior to the  ear canal , lateral to the  styloid process , and appears as a conical or pyramidal projection. It forms a bony prominence behind and below the ear. [ 1 ]  It has variable size and form (e.g. it is larger in the  male  than in the  female ). It is also filled with  sinuses , or  mastoid cells . The mastoid process serves for the attachment of the  sternocleidomastoid , the posterior belly of the  digastric muscle ,  splenius capitis , and  longissimus capitis . On the medial side of the process is a deep groove, the mastoid notch, for the attachment of the  digastric muscle ; medial to this is a shallow furrow, the  occipital groove , which lodges the  occipital artery . The  facial nerve  passes close to the mastoid process. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2905", "text": "The inner surface of the mastoid portion presents a deep, curved groove, the  sigmoid sulcus , which lodges part of the  transverse sinus ; in it may be seen in the opening of the  mastoid foramen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2906", "text": "The groove for the transverse sinus is separated from the innermost of the mastoid cells by a very thin lamina of bone, and even this may be partly deficient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2907", "text": "The  superior border  of the mastoid part is broad and serrated, for articulation with the mastoid angle of the parietal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2908", "text": "The  posterior border , also serrated, articulates with the inferior border of the occipital between the lateral angle and  jugular process ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2909", "text": "Anteriorly, the mastoid portion is fused with the descending process of the  squama  above; below, it enters into the formation of the  ear canal  and the  tympanic cavity ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2910", "text": "A section of the mastoid process shows it to be hollowed out into a number of spaces, the  mastoid cells , which exhibit the greatest possible variety as to their size and number. At the upper and front part of the process, they are large and irregular and contain air, but toward the lower part, they diminish in size, while those at the apex of the process are frequently quite small and contain marrow; occasionally, they are entirely absent, and the mastoid is then solid throughout."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2911", "text": "In addition to these a large irregular cavity is situated at the upper and front part of the bone. It is called the  tympanic antrum  and must be distinguished from the mastoid cells, though it communicates with them. Like the mastoid cells, it is filled with air and lined by a prolongation of the mucous membrane of the tympanic cavity, with which it communicates. The tympanic antrum is bounded above by a thin plate of bone, the  tegmen tympani , which separates it from the middle fossa of the  base of the skull , below by the mastoid process, laterally by the squama just below the  temporal line , and medially by the  lateral semicircular canal  of the  internal ear , which projects into its cavity. It opens in front into that portion of the tympanic cavity which is known as the attic or  epitympanic recess . The tympanic antrum is a cavity of some considerable size at the time of birth; the mastoid air cells may be regarded as diverticula from the antrum and begin to appear at or before birth. By the fifth year, they are well-marked, but their development is not completed until toward  puberty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2912", "text": "The mastoid process is absent or rudimentary in the neonatal skull. It forms postnatally (starts to develop after 1 year old), [ citation needed ]  as the sternocleidomastoid muscle develops and pulls on the bone. It usually finishes structural development by 2 years old. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2913", "text": "Because of the late  postnatal development  of the mastoid process, antenatal injuries to the region often recover spontaneously. [ 3 ]  The largest size is found in  South Africans  and least found in North American Indians. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2914", "text": "Rarely, lesions can develop on the mastoid process. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2915", "text": "A  mastoidectomy  is a procedure performed to remove the  mastoid air cells [ 1 ]  near the middle ear. The procedure is part of the treatment for  mastoiditis ,  chronic suppurative otitis media  or  cholesteatoma . [ 2 ]  Additionally, it is sometimes performed as part of other procedures, such as  cochlear implants , [ 3 ]  or to access the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2916", "text": "Historically,  trephination  was used to potentially relieve intracranial pressures or build-up of pus, with records dating back to pre-historic times. [ 4 ]  Over time, these became formalized as mastoidectomies. Mastoidectomies were used to treat infections such as otitis media, or abnormal skin cell growth near the middle ear. [ 2 ]  Over time, they were adapted to help treat hearing issues such as  tinnitus . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2917", "text": "Mastoidectomies have also been used in the modern practice of placing cochlear implants. [ 6 ]  Additionally, mastoidectomies are occasionally performed with  tympanoplasties  to fix the tympanic membrane. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2918", "text": "The following are possible complications from mastoidectomy procedures: [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2919", "text": "In 2018, the International Otology Outcome Group agreed on guidelines defining different mastoidectomies. [ 8 ]  Before this, there was discourse on the proper classifications of the procedure. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2920", "text": "Under the 2018 guidelines, there are the following types of mastoidectomy: [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2921", "text": "Also known as  schwartze procedure  or  cortical mastoidectomy  or  canal wall up"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2922", "text": "Also known as  canal wall down"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2923", "text": "Used for"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2924", "text": "Additionally, there are mixed categories, such as M 1a+2a  and M 1b+2a . There is a slight distinction between M 2c  and M 3a  in that M 3a  removes the eardrum before pre auricular pit and cavity closure and blocks the tympanic opening of the  Eustachian tube . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2925", "text": "After the invention of  endoscopic transcanal ear surgery  by  Muaaz Tarabichi , the usage of this procedure has decreased significantly. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2926", "text": "Greek physician  Galen  (AD 129-217) was the first to write in his treatise Hygiene (Italian:  De Sanitate Tuenda ,  English:  On the Preservation of Health ) about ear discharge being a natural secretion form the brain, and the importance of permitting drainage of such fluid. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2927", "text": "The first potential documented case of a mastoidectomy procedure was recorded in 1524 by  Lucas van Leyden  as an incision behind the right ear. Abscess drainage was popularized by  Adam Politzer , considered to be one of the founders of  otology  and initially interpreted Galen's writings on ear discharge to mean that Galen removed infected mastoid regions. [ 16 ]  However, this may have been deliberately misrepresented to justify mastoidectomy procedures to more conservative audiences. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2928", "text": "Additionally, there is controversy whether French physician  Ambroise Par\u00e9  was the first to describe a surgical procedure draining an infected ear of  Francis II of France  in 1560. [ 18 ]  Recent studies have shown how there is lack of documentation of this event by French historian Louis R\u00e9gnier de la Planch, and also lack of mention in Par\u00e9's own writings. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2929", "text": "Credit for the first mastoidectomy to remove abscesses is attributed to  Jean-Louis Petit  in the 18th century. [ 19 ]  However soon after this, the procedure fell out of popularity in the 18th century after the death of Justus von Berger in 1791. [ 20 ]  von Berger, the court physician of  Christian VII , died 13 days after a mastoidectomy attempt to fix his right-sided deafness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2930", "text": "The mastoidectomy was revitalized in 1873 following the publication,  Ueber die k\u00fcnstliche Er\u00f6ffnung des Warzenfortsatzes  (English:  \u201cOn the artificial opening of the mastoid process\u201d ), written by  Hermann Schwartze  and his assistant Adolf Eysell. [ 21 ]  In the publication, Schwartze made several recommendations on modernizing the procedure, including replacing older instruments and a new surgical technique. This procedure, using a chisel and gouge, [ 4 ]  is now credited as the \"modern mastoid operation\" or Schwartze operation. [ 22 ]  Published in the oldest and most known otolaryngology journal of the time,  Archiv f\u00fcr Ohrenheilkunde , the publication became widely disseminated and referenced. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2931", "text": "Mastoiditis  is the result of an infection that extends to the  air cells  of the  skull  behind the ear.  Specifically, it is an inflammation of the  mucosal lining  of the  mastoid antrum  and  mastoid air cell  system inside [ 1 ]  the  mastoid process . The mastoid process is the portion of the  temporal bone  of the skull that is behind the ear. The mastoid process contains open,  air-containing spaces . [ 2 ] [ 3 ]  Mastoiditis is usually caused by untreated acute  otitis media  (middle ear infection) and used to be a leading cause of child mortality. With the development of  antibiotics , however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2932", "text": "There is no evidence that the drop in antibiotic prescribing for otitis media has increased the incidence of mastoiditis, raising the possibility that the drop in reported cases is due to a confounding factor such as childhood immunizations against  Haemophilus  and  Streptococcus . Untreated, the infection can spread to surrounding structures, including the brain, causing serious complications. [ 4 ]  While the use of antibiotics has reduced the incidence of mastoiditis, the risk of masked mastoiditis, a subclinical infection without the typical findings of mastoiditis has increased with the inappropriate use of antibiotics and the emergence of  multidrug-resistant bacteria . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2933", "text": "Some common  symptoms  and  signs  of mastoiditis include  pain , tenderness, and swelling in the mastoid region. There may be ear pain ( otalgia ), and the ear or mastoid region may be red (erythematous). Fever or headaches may also be present. Infants usually show  nonspecific symptoms , including  anorexia ,  diarrhea , or  irritability . Drainage from the ear occurs in more serious cases often manifests as brown discharge on the pillowcase upon waking. [ 4 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2934", "text": "The pathophysiology of mastoiditis is straightforward: bacteria spread from the middle ear to the  mastoid air cells , where the inflammation causes damage to the bony structures.  Streptococcus pneumoniae ,  Streptococcus pyogenes ,  Staphylococcus aureus ,  Haemophilus influenzae ,  and  Moraxella catarrhalis  are the most common organisms recovered in acute mastoiditis. Organisms that are rarely found are  Pseudomonas aeruginosa  and other Gram-negative aerobic bacilli, and anaerobic bacteria. [ 7 ]   P. aeruginosa,  Enterobacteriaceae,  S. aureus  and  anaerobic bacteria  ( Prevotella ,  Bacteroides ,  Fusobacterium , and  Peptostreptococcus  spp.) are the most common isolates in chronic mastoiditis. [ 8 ]  Rarely,  Mycobacterium  species can also cause the infection. Some mastoiditis is caused by  cholesteatoma , which is a sac of keratinizing squamous epithelium in the middle ear that usually results from repeated middle-ear infections. If left untreated, the cholesteatoma can erode into the mastoid process, producing mastoiditis, as well as other complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2935", "text": "The diagnosis of mastoiditis is clinical\u2014based on the  medical history  and  physical examination . Imaging studies provide additional information; The standard method of diagnosis is via  MRI scan  although a  CT scan  is a common alternative as it gives a clearer and more useful image to see how close the damage may have gotten to the brain and facial nerves. Planar (2-D)  X-rays  are not as useful. If there is drainage, it is often sent for  culture , although this will often be negative if the patient has begun taking antibiotics.  Exploratory surgery  is often used as a last resort method of diagnosis to see the mastoid and surrounding areas. [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2936", "text": "If ear infections are treated in a reasonable amount of time, the antibiotics will usually cure the infection and prevent its spread. For this reason, mastoiditis is rare in developed countries. Most ear infections occur in infants as the eustachian tubes are not fully developed and don't drain readily. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2937", "text": "In all developed countries with up-to-date modern healthcare the primary treatment for mastoiditis is administration of  intravenous  antibiotics. Initially, broad-spectrum antibiotics are given, such as  ceftriaxone . As culture results become available, treatment can be switched to more specific antibiotics directed at the eradication of the recovered aerobic and  anaerobic bacteria . [ 8 ]  Long-term antibiotics may be necessary to completely eradicate the infection. [ 4 ]  If the condition does not quickly improve with antibiotics, surgical procedures may be performed (while continuing the medication). The most common procedure is a  myringotomy , a small incision in the  tympanic membrane  (eardrum), or the insertion of a  tympanostomy tube  into the eardrum. [ 9 ]  These serve to drain the pus from the middle ear, helping to treat the infection. The tube is extruded spontaneously after a few weeks to months, and the incision heals naturally. If there are complications, or the mastoiditis does not respond to the above treatments, it may be necessary to perform a  mastoidectomy : a procedure in which a portion of the bone is removed and the infection drained. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2938", "text": "With prompt treatment, it is possible to cure mastoiditis. Seeking medical care early is important. However, it is difficult for antibiotics to penetrate to the interior of the mastoid process and so it may not be easy to cure the infection; it also may recur. Mastoiditis has many possible complications, all connected to the infection spreading to surrounding structures.  Hearing loss  is likely, or inflammation of the  labyrinth  of the  inner ear  ( labyrinthitis ) may occur, producing  vertigo  and an ear ringing may develop along with the hearing loss, making it more difficult to communicate. The infection may also spread to the  facial nerve  (cranial nerve VII), causing  facial-nerve palsy , producing weakness or paralysis of some muscles of facial expression, on the same side of the face. Other complications include  Bezold's abscess , an abscess (a collection of pus surrounded by inflamed tissue) behind the  sternocleidomastoid muscle  in the neck, or a  subperiosteal abscess , between the periosteum and mastoid bone (resulting in the typical appearance of a protruding ear). Serious complications result if the infection spreads to the brain. These include  meningitis  (inflammation of the protective membranes surrounding the brain),  epidural abscess  (abscess between the skull and outer membrane of the brain), dural venous  thrombophlebitis  (inflammation of the  venous  structures of the brain), or  brain abscess . [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2939", "text": "In the United States and other developed countries, the  incidence  of mastoiditis is quite low, around 0.004%, although it is higher in developing countries.  The condition most commonly affects children aged from two to thirteen months, when ear infections most commonly occur. Males and females are equally affected. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2940", "text": "In  vertebrates , the  maxilla  ( pl. :  maxillae   / m \u00e6 k \u02c8 s \u026a l i\u02d0 / ) [ 2 ]  is the upper fixed (not fixed in  Neopterygii )  bone  of the  jaw  formed from the fusion of two maxillary bones. In humans, the upper jaw includes the  hard palate  in the front of the  mouth . [ 3 ] [ 4 ]  The two maxillary bones are fused at the intermaxillary suture, forming the  anterior nasal spine . This is similar to the  mandible  (lower jaw), which is also a fusion of two mandibular bones at the  mandibular symphysis . The mandible is the movable part of the jaw."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2941", "text": "The maxilla is a paired bone - the two maxillae unite with each other at the intermaxillary suture. The maxilla consists of: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2942", "text": "It has three surfaces: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2943", "text": "Features of the maxilla include: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2944", "text": "Each maxilla articulates with nine bones:  frontal ,  ethmoid ,  nasal ,  zygomatic ,  lacrimal , and  palatine  bones, the  vomer , the  inferior nasal concha , as well as the maxilla of the other side. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2945", "text": "Sometimes it articulates with the orbital surface, and sometimes with the  lateral pterygoid plate  of the  sphenoid ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2946", "text": "The maxilla is ossified in membrane.  Mall  and Fawcett maintain that it is ossified from  two  centers only, one for the maxilla proper and one for the premaxilla. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2947", "text": "These centers appear during the sixth week of  prenatal development  and unite in the beginning of the third month, but the suture between the two portions persists on the palate until nearly middle life. Mall states that the frontal process is developed from both centers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2948", "text": "The maxillary sinus appears as a shallow groove on the nasal surface of the bone about the fourth month of development, but does not reach its full size until after the second dentition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2949", "text": "The maxilla was formerly described as ossifying from six centers, viz.:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2950", "text": "At birth the transverse and antero-posterior diameters of the bone are each greater than the vertical."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2951", "text": "The frontal process is well-marked and the body of the bone consists of little more than the alveolar process, the teeth sockets reaching almost to the floor of the orbit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2952", "text": "The maxillary sinus presents the appearance of a furrow on the lateral wall of the nose. In the adult the vertical diameter is the greatest, owing to the development of the alveolar process and the increase in size of the sinus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2953", "text": "The  alveolar process  of the maxillae holds the upper teeth, and is referred to as the maxillary arch. Each maxilla attaches laterally to the  zygomatic bones  (cheek bones)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2954", "text": "Each maxilla assists in forming the boundaries of three cavities:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2955", "text": "Each maxilla also enters into the formation of two fossae: the  infratemporal  and  pterygopalatine , and two  fissures , the  inferior orbital  and  pterygomaxillary .\n-When the tender bones of the upper jaw and lower nostril are severely or repetitively damaged, at any age the surrounding cartilage can begin to deteriorate just as it does after death. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2956", "text": "A  maxilla fracture  is a form of  facial fracture . A maxilla fracture is often the result of  facial trauma  such as  violence ,  falls  or  automobile accidents . Maxilla fractures are classified according to the  Le Fort classification ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2957", "text": "Sometimes (e.g. in bony fish), the maxilla is called \"upper maxilla\", with the mandible being the \"lower maxilla\". Conversely, in birds the upper jaw is often called \"upper mandible\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2958", "text": "In most vertebrates, the foremost part of the upper jaw, to which the  incisors  are attached in mammals consists of a separate pair of bones, the  premaxillae . These fuse with the maxilla proper to form the bone found in humans, and some other mammals. In  bony fish ,  amphibians , and  reptiles , both maxilla and premaxilla are relatively plate-like bones, forming only the sides of the upper jaw, and part of the face, with the premaxilla also forming the lower boundary of the  nostrils . However, in mammals, the bones have curved inward, creating the palatine process and thereby also forming part of the roof of the mouth. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2959", "text": "Birds  do not have a maxilla in the strict sense; the corresponding part of their  beaks  (mainly consisting of the premaxilla) is called \"upper mandible\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2960", "text": "Cartilaginous fish , such as sharks, also lack a true maxilla. Their upper jaw is instead formed from a  cartilaginous  bar that is not  homologous  with the bone found in other vertebrates. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2961", "text": "This article incorporates text in the  public domain  from  page 157  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2962", "text": "The  maxillary artery  (eg, internal maxillary artery) supplies deep structures of the face. It branches from the  external carotid artery  just deep to the neck of the mandible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2963", "text": "The maxillary artery, the larger of the two terminal branches of the  external carotid artery , arises behind the neck of the  mandible , and is at first imbedded in the substance of the  parotid gland ; it passes forward between the  ramus of the mandible  and the  sphenomandibular ligament , and then runs, either superficial or deep to the  lateral pterygoid muscle , to the  pterygopalatine fossa ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2964", "text": "It supplies the deep structures of the face, and may be divided into  mandibular ,  pterygoid , and  pterygopalatine  portions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2965", "text": "The  first  or  mandibular   or  bony  portion passes horizontally forward, between the neck of the mandible and the sphenomandibular ligament, where it lies parallel to and a little below the  auriculotemporal nerve ; it crosses the  inferior alveolar nerve , and runs along the lower border of the  lateral pterygoid muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2966", "text": "Branches include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2967", "text": "The  second  or  pterygoid  or  muscular  portion runs obliquely forward and upward under cover of the ramus of the mandible and insertion of the  temporalis , on the superficial (very frequently on the deep) surface of the  lateral pterygoid muscle ; it then passes between the two heads of origin of this muscle and enters the fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2968", "text": "The  third  or  pterygopalatine [ 1 ]  or  pterygomaxillary portion  lies in the  pterygopalatine fossa  in relation with the  pterygopalatine ganglion .  This is considered the terminal branch of the maxillary artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2969", "text": "This article incorporates text in the  public domain  from  page 559  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2970", "text": "The  maxillary hiatus  (also known as  maxillary sinus ostium ,  maxillary ostium , or  opening from the  maxillary sinus ) [ citation needed ]  is the opening of a  maxillary sinus  into the  middle nasal meatus  of the nasal cavity. It is situated superoposteriorly upon the lateral nasal wall, opening into the nasal cavity at the posterior portion of the  ethmoidal infundibulum . [ 1 ]  Its opening in the maxillary sinus is present upon the superior part of the medial wall of the sinus [ 2 ] [ 3 ]  near the roof of the  sinus ; [ 4 ]  because of the position, gravity cannot drain the maxillary sinus contents when the head is erect. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2971", "text": "An accessory maxillary hiatus may be present either anterior or posterior to the inferior portion of the  uncinate process of ethmoid bone . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2972", "text": "It measures 2\u20134 mm in diameter [ 1 ]  with an average diameter of 2.4\u00a0mm. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2973", "text": "It opens into the nasal cavity inferior to the  bulla ethmoidalis , and is partly obscured by the inferior end of the  uncinate process of ethmoid bone . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2974", "text": "The bone window of this aperture itself is much larger, but the actual opening is much reduced [ 3 ]  by the following: the uncinate process of the ethmoid superiorly, the  ethmoidal process of inferior nasal concha  inferiorly, the  perpendicular plate of palatine bone  posteriorly, and a small part of the lacrimal bone anteriorly and superiorly, [ 4 ]  as well as by the adjacent soft tissues. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2975", "text": "This article incorporates text in the  public domain  from  page 995  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2976", "text": "In  neuroanatomy , the  maxillary nerve  ( V 2 ) is one of the three branches or divisions of the  trigeminal nerve , the fifth (CN V)  cranial nerve .  It comprises the principal functions of  sensation  from the  maxilla ,  nasal cavity ,  sinuses , the  palate  and subsequently that of the mid-face, [ 1 ]  and is intermediate, both in position and size, between the  ophthalmic nerve  and the  mandibular nerve . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2977", "text": "It begins at the middle of the  trigeminal ganglion  as a flattened plexiform band then it passes through the lateral wall of the cavernous sinus. It leaves the skull through the  foramen rotundum , where it becomes more cylindrical in form, and firmer in texture. After leaving foramen rotundum it gives two branches to the pterygopalatine ganglion. It then crosses the  pterygopalatine fossa , inclines lateralward on the back of the  maxilla , and enters the orbit through the  inferior orbital fissure . It then runs forward on the floor of the orbit, at first in the infraorbital groove and then in the infraorbital canal remaining outside the periosteum of the orbit. It then emerges on the face through the  infraorbital foramen  and terminates by dividing into inferior palpebral, lateral nasal and superior labial branches. The nerve is accompanied by the infraorbital branch of (the third part of) the maxillary artery and the accompanying vein."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2978", "text": "Its branches may be divided into four groups, depending upon where they branch off: in the cranium, in the pterygopalatine fossa, in the infraorbital canal, or on the face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2979", "text": "The Maxillary nerve gives cutaneous branches to the face. It also carries parasympathetic preganglionic fibers (sphenopalatine) and postganglionic fibers (zygomatic, greater and lesser palatine and nasopalatine) to and from the pterygopalatine ganglion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2980", "text": "This article incorporates text in the  public domain  from  page 889  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2981", "text": "The pyramid-shaped  maxillary sinus  (or antrum of  Highmore ) is the largest of the  paranasal sinuses , located in the  maxilla . It drains into the  middle meatus  of the nose [ 1 ] [ 2 ]  through the  semilunar hiatus . It is located to the side of the  nasal cavity , and below the orbit. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2982", "text": "It is the largest air sinus in the body. [ 1 ] [ 3 ]  It has a mean volume of about 10 ml. [ 1 ] [ verification needed ]  It is situated within the  body of the maxilla , [ 1 ] [ 3 ] [ 4 ]  but may extend into its  zygomatic  and  alveolar processes  when large. It is pyramid-shaped, with the apex at the maxillary  zygomatic process , and the base represented by the lateral nasal wall. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2983", "text": "It has three recesses: an alveolar recess pointed inferiorly, bounded by the  alveolar process  of the maxilla; a zygomatic recess pointed laterally, bounded by the  zygomatic bone ; and an infraorbital recess pointed superiorly, bounded by the inferior  orbital surface of the maxilla . The medial wall is composed primarily of  cartilage . [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2984", "text": "The nasal wall of the maxillary sinus, or base, presents, in the disarticulated bone, a large, irregular aperture that communicates with the  nasal cavity . [ citation needed ]  In the articulated skull this aperture is much reduced in size by the following bones:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2985", "text": "The sinus communicates through an opening into the  semilunar hiatus  on the lateral nasal wall. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2986", "text": "The medial wall is composed primarily of  cartilage . [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2987", "text": "On the posterior wall are the  alveolar canals , transmitting the  posterior superior alveolar vessels  and  nerves  to the  molar  teeth. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2988", "text": "The floor is formed by the  alveolar process , and, if the sinus is of an average size, is on a level with the floor of the nose; if the sinus is large it reaches below this level. [ citation needed ]  Projecting into the floor of the antrum are several conical processes, corresponding to the roots of the first and second maxillary  molar teeth ; in some cases the floor can be perforated by the apices of the teeth. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2989", "text": "The roof is formed by the floor of the orbit. It is traversed by infraorbital nerves and vessels. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2990", "text": "The  infraorbital canal  forms a ridge at the junction of the roof and anterior wall of the sinus; [ 4 ]  additional ridges are sometimes seen in the posterior wall of the cavity and are caused by the  alveolar canals . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2991", "text": "The mucous membranes receive their mucomotor  postganglionic   parasympathetic  nerve fibres from the  pterygopalatine ganglion . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2992", "text": "The superior alveolar (anterior, middle, and posterior) nerves, branches of the  maxillary nerve  provide  sensory innervation . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2993", "text": "The sinus is lined with  mucoperiosteum , with cilia that beat toward the ostia. This  membranous  lining is also referred to as the  Schneiderian membrane , which is  histologically  a bilaminar membrane with  pseudostratified ciliated columnar epithelial cells  on the internal (or cavernous) side and  periosteum  on the  osseous  side. The size of the sinuses varies in different  skulls , and even on the two sides of the same skull. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2994", "text": "The roof of the sinus is also the floor of the  orbit . Posterior to the sinus and its wall are the  pterygopalatine fossa  and the  infratemporal fossa . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2995", "text": "After puberty, the maxillary sinus rapidly increases in size. Its size is variable in the adult; if large, it may extend into the  zygomatic process  and  alveolar process  of the maxilla. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2996", "text": "Extension into the maxillary alveolar process may cause the roots of the molars and even premolars to lie just beneath the floor of the sinus or even project through the floor and into the sinus; in such cases, the roots of the teeth are typically surrounded by a thin layer of bone, but may sometimes lie directly underneath the mucous membrane of the sinus. Projection of the roots into the maxillary sinus is more common in advanced age due to  bone resorption . In such cases, tooth extraction can create a  fistula  between the  oral cavity  and the sinus that nevertheless usually resolves spontaneously. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2997", "text": "Maxillary sinus is the first  paranasal sinuses  to form. At birth, it is about 6 to 8\u00a0cm 3  in volume, elongated, as is orientated in antero-posterior direction, located at the next to the medial orbital wall of the eye. The lateral wall of the maxillary sinus goes beneath the medial orbital wall during the first year of life, extends laterally pass the  infraorbital groove  by the age of four years, and reach the  maxilla  by the age of nine years. [ 5 ]  After the first  permanent tooth  erupted at the age of six to seven, aeration of maxillary sinus is the main growth feature. [ 5 ] [ 6 ]  At the final phase of aeration, the floor of maxillary sinus is four to five milimetres below the floor of  nasal cavity . However, timing of maxillary sinus growth is variable in different people. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2998", "text": "Maxillary  sinusitis  is  inflammation  of the maxillary sinuses. The  symptoms  of sinusitis are headache, usually near the involved sinus, and foul-smelling nasal or pharyngeal discharge, possibly with some systemic signs of infection such as fever and weakness. The skin over the involved sinus can be tender, hot, and even reddened due to the inflammatory process in the area. On radiographs, there is opacification (or cloudiness) of the usually translucent sinus due to retained mucus. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_2999", "text": "Maxillary sinusitis is common due to the close anatomic relation of the frontal sinus, anterior  ethmoidal sinus  and the maxillary teeth, allowing for easy spread of infection. Differential diagnosis of dental problems needs to be done due to the close proximity to the teeth since the pain from sinusitis can seem to be dentally related. [ 1 ]   Furthermore, the drainage orifice lies near the roof of the sinus, and so the maxillary sinus does not drain well, and infection develops more easily. The maxillary sinus may drain into the   mouth  via an abnormal opening, an oroantral  fistula , a particular risk after tooth extraction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3000", "text": "An OAC is an abnormal physical communication between the maxillary sinus and the mouth. This opening is only present when the structures that normally separates the mouth and sinus into 2 separate compartments are lost. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3001", "text": "There are many causes of an OAC. The most common reason is following extraction of a posterior maxillary (upper)  premolar  or  molar  tooth. Other causes include trauma, pathology (e.g. tumours or cysts), infection or iatrogenic damage during surgery. Iatrogenic damage during dental treatment accounts for nearly half of the incidence of dental-related maxillary sinusitis. [ 9 ]  There is always a thin layer of mucous membrane ( Schneiderian membrane ) and usually bone between the roots of the upper back teeth and the floor of the maxillary sinus. However, the bone can vary in thickness in different individuals, ranging from complete absence to 12mm thick. [ 9 ]  Therefore, in certain individuals the membrane +/- the bony floor of the sinus can be perforated easily, creating an opening into the mouth when a tooth is extracted. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3002", "text": "An OAC that is smaller than 2mm can heal spontaneously i.e. closure of the opening. [ 11 ]  Those that are larger than 2mm have a higher chance of developing into  oro-antral fistula (OAF) . [ 11 ]  The passage is only defined as an OAF if it is persistent and lined by  epithelium . [ 11 ]  Epithelialisation happens when an OAC persist for at least 2\u20133 days and oral epithelial cells proliferate to line the defect. Large defects (more than 2mm) should be surgically closed as soon as possible to avoid accumulation of food and saliva which could contaminate the maxillary sinus, leading to infection (sinusitis). [ 11 ]  Various surgical techniques can be employed to manage an OAF but the most common involves pulling and stitching some soft tissue from the gum to cover the opening (i.e. soft tissue flap). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3003", "text": "Traditionally the treatment of acute maxillary sinusitis is usually prescription of a broad-spectrum  cephalosporin  antibiotic resistant to beta-lactamase, administered for 10 days. Recent studies have found that the cause of chronic sinus infections lies in the nasal mucus, not in the nasal and sinus tissue targeted by standard treatment. This suggests a beneficial effect in treatments that target primarily the underlying and presumably damage-inflicting nasal and sinus membrane inflammation, instead of the secondary bacterial infection that has been the primary target of past treatments for the disease. Also, surgical procedures with chronic sinus infections are now changing with the direct removal of the mucus, which is loaded with toxins from the inflammatory cells [ citation needed ] , rather than the inflamed tissue during surgery. Leaving the mucus behind might predispose early recurrence of the chronic sinus infection. If any surgery is performed, it is to enlarge the ostia in the lateral walls of the nasal cavity, creating adequate drainage. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3004", "text": "Carcinoma  of the maxillary sinus may invade the palate and cause dental pain. It may also block the nasolacrimal duct. Spread of the tumor into the orbit causes  proptosis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3005", "text": "With age, the enlarging maxillary sinus may even begin to surround the roots of the maxillary posterior teeth and extend its margins into the body of the zygomatic bone. If the maxillary posterior teeth are lost, the maxillary sinus may expand even more, thinning the bony floor of the alveolar process so that only a thin shell of bone is present. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3006", "text": "The maxillary sinus was first discovered and illustrated by  Leonardo da Vinci , but the earliest attribution of significance was given to  Nathaniel Highmore , the British surgeon and anatomist who described it in detail in his 1651 treatise. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3007", "text": "M\u00e9ni\u00e8re's disease  ( MD ) is a disease of the  inner ear  that is characterized by potentially severe and incapacitating episodes of  vertigo ,  tinnitus ,  hearing loss , and a feeling of fullness in the ear. [ 3 ] [ 4 ]  Typically, only one ear is affected initially, but over time, both ears may become involved. [ 3 ]  Episodes generally last from 20 minutes to a few hours. [ 5 ]  The time between episodes varies. [ 3 ]  The hearing loss and ringing in the ears can become constant over time. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3008", "text": "The cause of M\u00e9ni\u00e8re's disease is  unclear , but likely involves both genetic and environmental factors. [ 1 ] [ 3 ]  A number of theories exist for why it occurs, including constrictions in blood vessels, viral infections, and autoimmune reactions. [ 3 ]  About 10% of cases run in families. [ 4 ]  Symptoms are believed to occur as the result of increased fluid buildup in the  labyrinth  of the inner ear. [ 3 ]  Diagnosis is based on the symptoms and a  hearing test . [ 3 ]  Other conditions that may produce similar symptoms include  vestibular migraine  and  transient ischemic attack . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3009", "text": "No cure is known. [ 3 ]  Attacks are often treated with medications to help with the  nausea  and  anxiety . [ 4 ]  Measures to prevent attacks are overall poorly supported by the evidence. [ 4 ]  A low-salt diet,  diuretics , and  corticosteroids  may be tried. [ 4 ]   Physical therapy  may help with balance and  counselling  may help with anxiety. [ 3 ] [ 4 ]  Injections into the ear or surgery may also be tried if other measures are not effective, but are associated with risks. [ 3 ] [ 5 ]  The use of  tympanostomy tubes  (ventilation tubes) to improve vertigo and hearing in people with M\u00e9ni\u00e8re's disease is not supported by definitive evidence. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3010", "text": "M\u00e9ni\u00e8re's disease was identified in the early 1800s by  Prosper Meni\u00e8re . [ 5 ]  It affects between 0.3 and 1.9 per 1,000 people. [ 1 ]  The onset of M\u00e9ni\u00e8re's disease is usually around 40 to 60 years old. [ 3 ] [ 6 ]  Females are more commonly affected than males. [ 1 ]  After 5-15 years of symptoms, episodes that include dizziness or a sensation of spinning sometimes stop and the person is left with loss of balance, poor hearing in the affected ear, and ringing or other sounds in the affected ear or ears. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3011", "text": "M\u00e9ni\u00e8re's is characterized by recurrent episodes of vertigo, fluctuating hearing loss, and tinnitus; episodes may be preceded by a headache and a feeling of fullness in the ears. [ 4 ]  People may also experience additional symptoms related to irregular reactions of the  autonomic nervous system . These symptoms are not symptoms of M\u00e9ni\u00e8re's disease per se, but rather are side effects resulting from failure of the organ of hearing and balance, and include nausea,  vomiting , and  sweating , which are typically symptoms of vertigo, and not of M\u00e9ni\u00e8re's. [ 1 ]  This includes a sensation of being pushed sharply to the floor from behind. [ 5 ]  Sudden falls without loss of consciousness ( drop attacks ) may be experienced by some people. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3012", "text": "The cause of M\u00e9ni\u00e8re's disease is unclear, but likely involves both genetic and environmental factors. [ 1 ] [ 3 ] [ 7 ]  A number of theories exist including constrictions in blood vessels, viral infections, and autoimmune reactions. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3013", "text": "The initial triggers of M\u00e9ni\u00e8re's disease are not fully understood, with a variety of potential inflammatory causes that lead to  endolymphatic hydrops , a distension of the  endolymphatic  spaces in the inner ear.  Endolymphatic hydrops  (EH) is strongly associated with developing M\u00e9ni\u00e8re's disease, [ 1 ]  but not everyone with EH develops M\u00e9ni\u00e8re's disease: \"The relationship between endolymphatic hydrops and Meniere's disease is not a simple, ideal correlation.\" [ 8 ]  Notably, mild EH can also occur in  vestibular migraine  which is an important differential diagnosis for M\u00e9ni\u00e8re's disease. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3014", "text": "Additionally, in fully developed M\u00e9ni\u00e8re's disease, the balance system ( vestibular system ) and the hearing system ( cochlea ) of the inner ear are affected, but some cases occur where EH affects only one of the two systems enough to cause symptoms. The corresponding subtypes of the disease are called vestibular M\u00e9ni\u00e8re's disease, showing symptoms of vertigo, and cochlear M\u00e9ni\u00e8re's disease, showing symptoms of hearing loss and tinnitus. [ 10 ] [ 11 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3015", "text": "The mechanism of M\u00e9ni\u00e8re's disease is not fully explained by EH, but fully developed EH may mechanically and chemically interfere with the sensory cells for balance and hearing, which can lead to temporary dysfunction and even to death of the sensory cells, which in turn can cause the typical symptoms of MD \u2013 vertigo, hearing loss, and tinnitus. [ 8 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3016", "text": "An estimated 30% of people with M\u00e9ni\u00e8re's disease have  Eustachian tube dysfunction . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3017", "text": "The diagnostic criteria as of 2015 define definite MD and probable MD as: [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3018", "text": "Definite"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3019", "text": "Probable"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3020", "text": "A common and important symptom of MD is  hypersensitivity to sounds . [ 16 ]  This hypersensitivity is easily diagnosed by measuring the loudness discomfort levels (LDLs). [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3021", "text": "Symptoms of MD overlap with  migraine-associated vertigo  (MAV) in many ways, but when hearing loss develops in MAV, it is usually in both ears, and this is rare in MD, and hearing loss generally does not progress in MAV as it does in MD. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3022", "text": "People who have had a  transient ischemic attack  (TIA) or  stroke  can present with symptoms similar to MD, and in people at risk  magnetic resonance imaging   should be conducted to exclude TIA or stroke. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3023", "text": "Other vestibular conditions that should be excluded include  vestibular paroxysmia ,  recurrent unilateral vestibulopathy ,  vestibular schwannoma , or a tumor of the  endolymphatic sac . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3024", "text": "No cure for M\u00e9ni\u00e8re's disease is known, but medications, diet, physical therapy, counseling, and some surgical approaches can be used to manage it. [ 4 ]  More than 85% of patients with M\u00e9ni\u00e8re's disease get better from changes in lifestyle, medical treatment, or minimally invasive surgical procedures. Those procedures include intratympanic steroid therapy, intratympanic gentamicin therapy or  endolymphatic sac surgery . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3025", "text": "During MD episodes,  medications to reduce nausea  are used, as are  drugs to reduce the anxiety  caused by vertigo. [ 4 ] [ 19 ]  For longer-term treatment to stop progression, the evidence base is weak for all treatments. [ 4 ]  Although a causal relation between allergy and M\u00e9ni\u00e8re's disease is uncertain,  medication to control allergies  may be helpful. [ 20 ]  To assist with vertigo and balance problems,  glycopyrrolate  has been found to be a useful vestibular suppressant in patients with M\u00e9ni\u00e8re's disease. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3026", "text": "Diuretics , such as the thiazide-like diuretic  chlortalidone , are widely used to manage MD on the theory that it reduces fluid buildup (pressure) in the ear. [ 22 ]  Based on evidence from multiple but small clinical trials, diuretics appear to be useful for reducing the frequency of episodes of dizziness but do not seem to prevent hearing loss. [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3027", "text": "In cases where hearing loss and continuing severe episodes of vertigo occur, a  chemical labyrinthectomy , in which a medication such as  gentamicin  is injected into the middle ear and kills parts of the vestibular apparatus, may be prescribed. [ 4 ] [ 25 ] [ 26 ]  This treatment has the risk of worsening hearing loss. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3028", "text": "People with MD are often advised to reduce their sodium intake. [ 19 ] [ 27 ]  Reducing salt intake, however, has not been well studied. [ 27 ]  Based on the assumption that MD is similar in nature to a migraine, some advise eliminating \"migraine triggers\" such as caffeine, but the evidence for this is weak. [ 19 ]  There is no high-quality evidence that changing diet by restricting salt, caffeine or alcohol improves symptoms. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3029", "text": "While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term. [ 4 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3030", "text": "The psychological distress caused by the vertigo and hearing loss may worsen the condition in some people. [ 30 ]  Counseling may be useful to manage the distress, [ 4 ]  as may education and  relaxation techniques . [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3031", "text": "If symptoms do not improve with less invasive approaches and for cases where the condition is uncontrolled or persistent and affecting both ears, surgery may be considered. [ 4 ] [ 19 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3032", "text": "Surgery to decompress the  endolymphatic sac  is one surgical approach that is sometimes suggested. Three methods of surgical endolymphatic sac decompression are sometimes suggested \u2013 simple decompression, insertion of a shunt, or removal of the sac. [ 33 ]  There is some very weak evidence that all three methods may be useful for reducing dizziness, but that the level of evidence supporting these surgical procedures is low with further higher quality investigations being suggested. [ 33 ]  There is a risk in these types of surgical procedures that the shunts used in these surgeries are at risk of becoming displaced or misplaced. [ 19 ]  For those with severe cases who are eligible for endolymphatic sac decompression, a 2014 systematic review reported that in at least 75% of people, EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months). [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3033", "text": "Surgical implantation of eustachian tubes (ventilation tubes) is not strongly supported by medical studies. There are some tentative evidence of benefit from  tympanostomy tubes  for improvement in the unsteadiness associated with the disease, [ 14 ]  conclusions about how effective this surgery is and the potential for side effects and harms is not clear. [ 5 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3034", "text": "Destructive surgeries such as vestibular nerve  labyrinthectomy  are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013, almost no evidence existed with which to judge whether these surgeries are effective. [ 35 ]  The inner ear itself can be surgically removed via labyrinthectomy, although hearing is always completely lost in the affected ear with this operation. [ 35 ]  The surgeon can also cut the nerve to the balance portion of the inner ear in a  vestibular   neurectomy . The hearing is often mostly preserved; however, the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring is required. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3035", "text": "M\u00e9ni\u00e8re's disease usually starts confined to one ear; it extends to both ears in about 30% of cases. [ 5 ]  People may start out with only one symptom, but in M\u00e9ni\u00e8re's disease all three appear with time. [ 5 ]  Hearing loss usually fluctuates in the beginning stages and becomes more permanent in later stages. M\u00e9ni\u00e8re's disease has a course of 5\u201315 years, and people generally end up with mild disequilibrium, tinnitus, and moderate hearing loss in one ear. [ 5 ] \nAs of 2020, there has been no recent major breakthrough in the pathogenesis research of M\u00e9ni\u00e8re's disease. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3036", "text": "From 3 to 11% of diagnosed dizziness in neuro-otological clinics are due to M\u00e9ni\u00e8re's disease. [ 46 ]  The annual incidence rate is estimated to be about 15 cases per 100,000 people and the prevalence rate is about 218 per 100,000, and around 15% of people with M\u00e9ni\u00e8re's disease are older than 65. [ 46 ]  In around 9% of cases, a relative also had M\u00e9ni\u00e8re's disease, indicating a genetic predisposition in some cases. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3037", "text": "The odds of M\u00e9ni\u00e8re's disease are greater for people of white ethnicity, with severe obesity, and women. [ 1 ]  Several conditions are often comorbid with M\u00e9ni\u00e8re's disease, including  arthritis ,  psoriasis ,  gastroesophageal reflux disease ,  irritable bowel syndrome , and  migraine . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3038", "text": "The condition is named after the French physician  Prosper Meni\u00e8re , who in an 1861 article described the main symptoms and was the first to suggest a single disorder for all of the symptoms, in the combined organ of balance and hearing in the inner ear. [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3039", "text": "The  American Academy of Otolaryngology \u00a0\u2013 Head and Neck Surgery Committee on Hearing and Equilibrium set criteria for diagnosing MD, as well as defining two subcategories \u2013 cochlear (without vertigo) and vestibular (without deafness). [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3040", "text": "In 1972, the academy defined criteria for diagnosing MD as: [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3041", "text": "In 1985, this list changed to alter wording, such as changing \"deafness\" to \"hearing loss associated with tinnitus, characteristically of low frequencies\" and requiring more than one attack of vertigo to diagnose. [ 49 ]  Finally in 1995, the list was again altered to allow for degrees of the disease: [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3042", "text": "In 2015, the International Classification for Vestibular Disorders Committee of the Barany Society published consensus diagnostic criteria in collaboration with the American Academy of Otolaryngology\u2013Head and Neck Surgery, the European Academy of Otology and Neurootology, the Japan Society for Equilibrium Research, and the Korean Balance Society. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3043", "text": "The  mental space  is a  fascial space of the head and neck  (also termed  fascial  spaces or tissue spaces). It is a  potential space , bilaterally located in the chin, between the  mentalis muscle   superiorly  and the  platysma muscle   inferiorly . These spaces may be created by  pathology , e.g., the spread of  odontogenic infection . Commonly the origin of the infection is an  anterior   mandibular  tooth with associated  periapical abscess  which erodes through the buccal cortical plate of the mandibular at a level below the attachment of the mentalis muscle. The mental space also has the mental foramen located laterally on both the right and left sides. This is important as many mandibular nerves pass through these foremens.  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3044", "text": "Microsurgery  is a general term for  surgery  requiring an  operating microscope . The most obvious developments have been procedures developed to allow  anastomosis  of successively smaller blood vessels and nerves (typically 1\u00a0mm in diameter) which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Microsurgical techniques are utilized by several specialties today, such as  general surgery ,  ophthalmology ,  orthopedic surgery ,  gynecological surgery ,  otolaryngology ,  neurosurgery ,  oral and maxillofacial surgery ,  endodontic microsurgery ,  plastic surgery ,  podiatric surgery   and  pediatric surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3045", "text": "Otolaryngologists were the first physicians to use microsurgical techniques. A Swedish  otolaryngologist , Carl-Olof Siggesson Nyl\u00e9n (1892\u20131978), was the father of microsurgery. In 1921, in the University of Stockholm, he built the first surgical microscope, a modified monocular Brinell-Leitz microscope. At first he used it for operations in animals. In November of the same year he used it to operate on a patient with chronic otitis who had a labyrinthine fistula. Nylen's microscope was soon replaced by a binocular microscope, developed in 1922 by his colleague Gunnar Holmgren (1875\u20131954). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3046", "text": "Gradually the  operating microscope  began to be used for ear operations. In the 1950s many otologists began to use it in the  fenestration  operation, usually to perfect the opening of the  fenestra  in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, although it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950s. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3047", "text": "Today  neurosurgeons  are very proud to use microscopes in their procedures. But it was not always so: many prestigious centers did not accept that idea and it had to be developed in relative isolation. In the late 1950s  William House  began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors. The first neurosurgeon to make use of the surgical microscope was a Turkish emigrant,  Gazi Yasargil . In 1953 he studied neurovascular surgery during work with Prof. Hugo Krayenb\u00fchl in Switzerland. His ideas interested Dr. Pete Donaghy, who invited Yasargil to his microvascular laboratory in  Burlington, Vermont . After his return to  Z\u00fcrich  in 1967 Yasargil concentrated on discovering clinical applications to their novel inventions. [ 1 ]  Publications on that topic:  Micro-Vascular Surgery [ 2 ]  and  Microsurgery Applied to Neurosurgery [ 3 ]  won him international recognition. His lifelong experiences with microsurgery were recapitulated in the four-volume textbook entitled simply  Microneurosurgery . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3048", "text": "Advances in the techniques and technology that popularized microsurgery began in the early 1960s to involve other medical areas. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by vascular surgeon, Julius H. Jacobson II of the University of Vermont in 1960. Using an operating microscope, he performed coupling of vessels as small as 1.4\u00a0mm and coined the term  microsurgery .  [ 5 ]  Hand surgeons at the  University of Louisville , Drs. Harold Kleinert and Mort Kasdan, performed the first revascularization of a partial digital amputation in 1963. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3049", "text": "Nakayama, a Japanese cardiothoracic surgeon, reported the first true series of microsurgical free-tissue transfers using vascularized intestinal segments to the neck for esophageal reconstruction after cancer resections using 3\u20134\u00a0mm vessels. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3050", "text": "Contemporary reconstructive microsurgery was introduced by an American  plastic surgeon , Dr.  Harry J. Buncke . In 1964, Buncke reported a  rabbit  ear replantation, famously using a garage as a lab/operating theatre and home-made instruments [ 8 ] \nThis was the first report of successfully using blood vessels 1 millimeter in size. In 1966, Buncke used microsurgery to transplant a primate's great toe to its hand. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3051", "text": "During the late sixties and early 1970s,  plastic surgeons  ushered in many new microsurgical innovations that were previously unimaginable. The first human microsurgical transplantation of the second toe to thumb was performed in February 1966 by Dr. Dong-yue Yang and Yu-dong Gu, in Shanghai, China. [ 10 ]  Great toe (big toe) to thumb was performed in April 1968 by Dr. John Cobbett, in England. [ 11 ]  In Australia work by Dr. Ian Taylor [ 12 ]  saw new techniques developed to reconstruct head and neck cancer defects with living bone from the hip or the  fibula ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3052", "text": "A number of surgical specialties use microsurgical techniques. Otolaryngologists (ear, nose, throat and head and neck surgeons) perform microsurgery on structures of the inner ear and the vocal cords. Otolaryngologists and maxillofacial surgeons use microsurgical techniques when reconstructing defects from resection of head and neck cancers. Cataract surgery, corneal transplants, and treatment of conditions like glaucoma are performed by ophthalmologists. Urologists and gynecologists frequently now reverse vasectomies and tubal ligations to restore fertility."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3053", "text": "Free tissue transfer is a  surgical reconstructive procedure  using microsurgery. A region of \"donor\" tissue is selected that can be isolated on a feeding artery and vein; this tissue is usually a composite of several tissue types (e.g.,  skin ,  muscle ,  fat ,  bone ). Common donor regions include the  rectus abdominis muscle ,  latissimus dorsi muscle ,  fibula , radial  forearm  bone and skin, and lateral arm skin. The composite tissue is transferred (moved as a  free flap  of tissue) to the region on the patient requiring reconstruction (e.g.,  mandible  after  oral cancer  resection,  breast  after cancer resection, traumatic tissue loss, congenital tissue absence). The vessels that supply the free flap are anastomosed with microsurgery to matching vessels ( artery  and  vein ) in the reconstructive site. The procedure was first done in the early 1970s and has become a popular \"one-stage\" (single operation) procedure for many surgical reconstructive applications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3054", "text": "Replantation  is the reattachment of a completely detached body part.  Fingers  and  thumbs  are the most common but the  ear ,  scalp ,  nose ,  face ,  arm  and  penis  have all been replanted. Generally replantation involves restoring blood flow through  arteries  and  veins , restoring the bony skeleton and connecting tendons and nerves as required.\nRobert Malt and Charles Mckhann reported the first replantation of two human upper extremities by microvascular means in 1964, with the first arm replanted in a child after a train injury in 1962 in Boston. [ 13 ] \nInitially, when the techniques were developed to make replantation possible, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons specializing in replantation began to understand that survival of the amputated piece was not enough to ensure success of the replant. In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted. Additional concerns about the patient's ability to tolerate the long rehabilitation process that is necessary after replantation both on physical and psychological levels also became important. So, when fingers are amputated, for instance, a replantation surgeon must seriously consider the contribution of the finger to the overall function of the hand. In this way, every attempt will be made to salvage an amputated thumb, since a great deal of hand function is dependent on the thumb, while an index finger or small finger might not be replanted, depending on the individual needs of the patient and the ability of the patient to tolerate a long surgery and a long course of rehabilitation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3055", "text": "However, if an amputated specimen is not able to be replanted to its original location entirely, this does not mean that the specimen is unreplantable. In fact, replantation surgeons have learned that only a piece or a portion may be necessary to obtain a functional result, or especially in the case of multiple amputated fingers, a finger or fingers may be transposed to a more useful location to obtain a more functional result. This concept is called \"spare parts\" surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3056", "text": "Microsurgical techniques have played a crucial role in the development of transplantation immunological research because it allowed the use of rodent models, which are more appropriate for transplantation research (there are more reagents, monoclonal antibodies, knockout animals, and other immunological tools for mice and rats than other species). Before it was introduced, transplant immunology was studied in rodents using the skin transplantation model, which is limited by the fact that it is not vascularized. Thus, microsurgery represents the link between surgery and transplant immunological research.\nThe first microsurgical experiments (porto-caval anastomosis in the rat) were performed by Dr. Sun Lee (pioneer of microsurgery) at the University of Pittsburgh in 1958. After a short time, many models of organ transplants in rat and mice have been established. Today, virtually every rat or mouse organ can be transplanted with relative high success rate.\nMicrosurgery was also important to develop new techniques for transplantation, that would be later performed in humans. In addition, it allows reconstruction of small arteries in clinical organ transplantation (e.g. accessory arteries in cadaver liver transplantation, polar arteries in renal transplantation and in living liver donor transplantation)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3057", "text": "Microsurgery has been used to treat several pathologic conditions leading to infertility such as tubal obstructions, vas deferens obstructions, and  varicocele , which is one of the most frequent cause of male infertility. Microsurgical drainages by placing microvascular bypasses between spermatic and inferior epigastric veins as proposed by  Flati  et al. have been successfully performed in treating male infertility due to varicocele. Microsurgical treatment has been shown to significantly improve fertility rate also in patients with recurrent varicocele who had previously undergone non-microsurgical treatments. [ 14 ] \n [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3058", "text": "The  middle ear  is the portion of the  ear  medial to the  eardrum , and distal to the  oval window  of the cochlea (of the  inner ear )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3059", "text": "The mammalian middle ear contains three  ossicles  (malleus, incus, and stapes), which transfer the vibrations of the eardrum into waves in the fluid and membranes of the  inner ear .  The hollow space of the middle ear is also known as the  tympanic cavity  and is surrounded by the  tympanic part of the temporal bone . The  auditory tube  (also known as the Eustachian tube or the pharyngotympanic tube) joins the tympanic cavity with the nasal cavity ( nasopharynx ), allowing pressure to equalize between the middle ear and throat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3060", "text": "The primary function of the middle ear is to efficiently transfer acoustic energy from  compression waves  in air to fluid\u2013membrane waves within the  cochlea ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3061", "text": "The middle ear contains three tiny bones known as the  ossicles :  malleus ,  incus , and  stapes .  The ossicles were given their Latin names for their distinctive shapes; they are also referred to as the  hammer ,  anvil , and  stirrup , respectively. The ossicles directly couple sound energy from the eardrum to the  oval window  of the cochlea.  While the stapes is present in all  tetrapods , the malleus and incus  evolved from lower and upper jaw bones present in reptiles ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3062", "text": "The ossicles are classically supposed to mechanically convert the vibrations of the  eardrum  into amplified pressure waves in the fluid of the  cochlea  (or  inner ear ), with a lever arm factor of 1.3. Since the effective vibratory area of the eardrum is about 14 fold larger than that of the oval window, the sound pressure is concentrated, leading to a pressure gain of at least 18.1. The eardrum is merged to the malleus, which connects to the incus, which in turn connects to the stapes. Vibrations of the stapes footplate introduce pressure waves in the  inner ear . There is a steadily increasing body of evidence that shows that the lever arm ratio is actually variable, depending on frequency. Between 0.1 and 1\u00a0kHz it is approximately 2, it then rises to around 5 at 2\u00a0kHz and then falls off steadily above this frequency. [ 1 ]  The measurement of this lever arm ratio is also somewhat complicated by the fact that the ratio is generally given in relation to the tip of the malleus (also known as the  umbo ) and the level of the middle of the stapes. The eardrum is actually attached to the malleus handle over about a 0.5\u00a0cm distance. In addition, the eardrum itself moves in a very chaotic fashion at frequencies >3\u00a0kHz. The linear attachment of the eardrum to the malleus actually smooths out this chaotic motion and allows the ear to respond linearly over a wider frequency range than a point attachment. The auditory ossicles can also reduce sound pressure (the inner ear is very sensitive to overstimulation), by uncoupling each other through particular muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3063", "text": "The middle ear efficiency peaks at a frequency of around 1\u00a0kHz. The combined  transfer function  of the outer ear and middle ear gives humans a peak sensitivity to frequencies between 1\u00a0kHz and 3\u00a0kHz."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3064", "text": "The movement of the ossicles may be stiffened by two muscles. The  stapedius muscle , the smallest skeletal muscle in the body, connects to the stapes and is controlled by the  facial nerve ; the  tensor tympani muscle  is attached to the upper end of the medial surface of the handle of malleus [ 2 ]  and is under the control of the  medial pterygoid nerve  which is a branch of the  mandibular nerve  of the  trigeminal nerve . These muscles contract in response to loud sounds, thereby reducing the transmission of sound to the inner ear. This is called the  acoustic reflex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3065", "text": "Of surgical importance are two branches of the  facial nerve  that also pass through the middle ear space.  These are the horizontal portion of the facial nerve and the  chorda tympani .  Damage to the horizontal branch during ear surgery can lead to  paralysis of the face (same side of the face as the ear).  The chorda tympani is the branch of the facial nerve that carries taste from the  ipsilateral  half (same side) of the tongue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3066", "text": "Ordinarily, when sound waves in air strike liquid, most of the energy is reflected off the surface of the liquid.  The middle ear allows the  impedance matching  of sound traveling in air to acoustic waves traveling in a system of fluids and membranes in the inner ear.  This system should not be confused, however, with the propagation of sound as compression waves in liquid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3067", "text": "The  acoustic impedance  of air is about  \n \n \n \n \n Z \n \n 1 \n \n \n = \n 400 \n \n \n P \n a \n \u22c5 \n s \n \n / \n \n m \n \n \n \n {\\displaystyle Z_{1}=400\\;\\mathrm {Pa\\cdot s/m} } \n \n , while the impedance of cochlear fluids ( \n \n \n \n \n Z \n \n 2 \n \n \n = \n 1.5 \n \u00d7 \n \n 10 \n \n 6 \n \n \n \n \n P \n a \n \u22c5 \n s \n \n / \n \n m \n \n \n \n {\\displaystyle Z_{2}=1.5\\times 10^{6}\\;\\mathrm {Pa\\cdot s/m} } \n \n ) is approximately equal to that of sea water. Because of this high impedance, only  \n \n \n \n \n \n \n 2 \n \n Z \n \n 1 \n \n \n \n \n \n Z \n \n 1 \n \n \n + \n \n Z \n \n 2 \n \n \n \n \n \n = \n 0.05 \n % \n \n \n {\\displaystyle {\\frac {2Z_{1}}{Z_{1}+Z_{2}}}=0.05\\%} \n \n  of incident energy could be directly transmitted from the air to cochlear fluids."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3068", "text": "The middle ear's impedance matching mechanism increases the efficiency of sound transmission. Two processes are involved:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3069", "text": "Together, they amplify pressure by 26 times, or about 30 dB. The actual value is around 20 dB across 200 to 10000 Hz. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3070", "text": "The middle ear couples sound from air to the fluid via the  oval window , using the principle of \"mechanical advantage\" in the form of the \"hydraulic principle\" and the \"lever principle\". [ 5 ]   The vibratory portion of the tympanic membrane (eardrum) is many times the surface area of the footplate of the  stapes  (the third ossicular bone which attaches to the oval window); furthermore, the shape of the articulated ossicular chain is a complex  lever , the long arm being the long process of the  malleus , the fulcrum being the body of the  incus , and the short arm being the lenticular process of the  incus .  The collected pressure of sound vibration that strikes the tympanic membrane is therefore concentrated down to this much smaller area of the footplate, increasing the force but reducing the velocity and displacement, and thereby coupling the acoustic energy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3071", "text": "The middle ear is able to dampen sound conduction substantially when faced with very loud sound, by noise-induced reflex contraction of the middle-ear muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3072", "text": "The middle ear is hollow in the tympanic cavity and Eustachian tube. In a high-altitude environment or on diving into water, there will be a pressure difference between the middle ear and the outside environment.  This pressure will pose a risk of bursting or otherwise damaging the tympanum (eardrum) if it is not relieved. If middle ear pressure remains low, the  eardrum  (tympanic membrane) may become  retracted  into the middle ear. [ citation needed ]   One of the functions of the  Eustachian tubes  that connect the middle ear to the  nasopharynx  is to help keep middle ear pressure the same as air pressure. The Eustachian tubes are normally pinched off at the nose end, to prevent being clogged with  mucus , but they may be opened by lowering and protruding the jaw; this is why  yawning  or chewing helps relieve the pressure felt in the ears when on board an aircraft.  Eustachian tube  obstruction may result in fluid build up in the middle ear, which causes a  conductive hearing loss .  Otitis media  is an inflammation of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3073", "text": "The middle ear is well protected from most minor external injuries by its internal location, but is vulnerable to pressure injury ( barotrauma )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3074", "text": "Recent findings indicate that the middle ear mucosa could be subjected to  human papillomavirus  infection. [ 6 ]  Indeed, DNAs belonging to oncogenic HPVs, i.e., HPV16 and HPV18, have been detected in normal middle ear specimens, thereby indicating that the normal middle ear mucosa could potentially be a target tissue for HPV infection. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3075", "text": "The middle ear of  tetrapods  is  analogous  with the  spiracle  of fishes, an opening from the  pharynx  to the side of the head in front of the main gill slits. In fish embryos, the spiracle forms as a pouch in the pharynx, which grows outward and breaches the skin to form an opening; in most tetrapods, this breach is never quite completed, and the final vestige of tissue separating it from the outside world becomes the eardrum. The inner part of the spiracle, still connected to the pharynx, forms the eustachian tube. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3076", "text": "In  reptiles ,  birds , and early fossil tetrapods, there is a single auditory ossicle, the  columella  which is homologous with the stapes, or \"stirrup\" of mammals. This is connected indirectly with the eardrum via a mostly cartilaginous extracolumella and medially to the inner-ear spaces via a widened footplate in the fenestra ovalis. [ 7 ]  The columella is an evolutionary derivative of the bone known as the hyomandibula in fish ancestors, a bone that supported the skull and braincase."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3077", "text": "The structure of the middle ear in living  amphibians  varies considerably and is often degenerate. In most  frogs and toads , it is similar to that of reptiles, but in other amphibians, the middle ear cavity is often absent. In these cases, the stapes either is also missing or, in the absence of an eardrum, connects to the  quadrate bone  in the skull, although, it is presumed, it still has some ability to transmit vibrations to the inner ear. In many amphibians, there is also a second auditory ossicle, the  operculum  (not to be confused with the  structure of the same name  in fishes). This is a flat, plate-like bone, overlying the fenestra ovalis, and connecting it either to the stapes or, via a special muscle, to the  scapula . It is not found in any other vertebrates. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3078", "text": "Mammals are unique in having  evolved a three-ossicle middle-ear  independently of the various single-ossicle middle ears of other land vertebrates, all during the Triassic period of geological history. Functionally, the mammalian middle ear is very similar to the single-ossicle ear of non-mammals, except that it responds to sounds of higher frequency, because these are better taken up by the inner ear (which also responds to higher frequencies than those of non-mammals). The malleus, or \"hammer\", evolved from the  articular  bone of the lower jaw, and the incus, or \"anvil\", from the quadrate. In other vertebrates, these bones form the primary jaw joint, but the expansion of the  dentary  bone in mammals led to the evolution of an entirely new jaw joint, freeing up the old joint to become part of the ear. For a period of time, both jaw joints existed together, one medially and one laterally. The evolutionary process leading to a three-ossicle middle ear was thus an \"accidental\" byproduct of the simultaneous evolution of the new, secondary jaw joint. In many mammals, the middle ear also becomes protected within a cavity, the  auditory bulla , not found in other vertebrates. A bulla evolved late in time and independently numerous times in different mammalian clades, and it can be surrounded by membranes, cartilage or bone. The bulla in humans is part of the  temporal bone . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3079", "text": "Recently found fossils such as  Morganucodon  show intermediary steps of middle ear evolution. A new morganucodontan-like species,  Dianoconodon youngi , shows parts of the  mandible  (= dentary) that permit an auditory function, although these bones are still attached to the mandible. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3080", "text": "Minimal-access cranial suspension  is a form of facial surgery or  rhytidectomy  used to reduce wrinkles and lift sagging facial tissue and originally developed in Belgium. [ 1 ]  Facial tissues are accessed via an incision before the ear. Sutures are then used to lift the underlying tissue. These sutures are then anchored to the deep  temporal   fascia  with  purse-string sutures . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3081", "text": "The  nasal mucosa  lines the  nasal cavity . It is part of the  respiratory mucosa , the  mucous membrane  lining the  respiratory tract . [ 1 ] [ 2 ]  The nasal mucosa is intimately adherent to the  periosteum  or  perichondrium  of the  nasal conchae . It is continuous with the skin through the  nostrils , and with the  mucous membrane  of the nasal part of the  pharynx  through the  choanae . From the nasal cavity its continuity with the  conjunctiva  may be traced, through the  nasolacrimal  and  lacrimal ducts ; and with the  frontal ,  ethmoidal ,  sphenoidal , and  maxillary sinuses , through the several openings in the  nasal meatuses . The mucous membrane is thickest, and most vascular, over the  nasal conchae . It is also thick over the  nasal septum  where increased numbers of goblet cells produce a greater amount of  nasal mucus . It is very thin in the meatuses on the floor of the nasal cavities, and in the various  sinuses .  It is one of the most commonly infected tissues in adults and children. Inflammation of this tissue may cause significant impairment of daily activities, with symptoms such as stuffy nose, headache, mouth breathing, etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3082", "text": "Owing to the thickness of the greater part of this  membrane , the nasal cavities are much narrower, and the middle and inferior nasal conch\u00e6 appear larger and more prominent than in the  skeleton ; also the various apertures communicating with the meatuses are considerably narrowed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3083", "text": "The  epithelium  of the nasal mucosa is of two types \u2013  respiratory epithelium , and  olfactory epithelium  differing according to its functions. In the respiratory region it is columnar and ciliated. [ 3 ] [ 4 ]  Interspersed among the  columnar cells  are  goblet  or mucin cells, while between their bases are found smaller  pyramidal cells . Beneath the epithelium and its  basement membrane  is a fibrous layer infiltrated with lymph corpuscles, so as to form in many parts a diffuse  adenoid  tissue, and under this a nearly continuous layer of small and larger  glands , some mucous and some serous, the ducts of which open upon the surface. In the olfactory region the mucous membrane is yellowish in color and the  epithelial cells  are columnar and non-ciliated; they are of two kinds, supporting cells and  olfactory cells . The supporting cells contain oval nuclei, which are situated in the deeper parts of the cells and constitute the zone of oval nuclei; the superficial part of each cell is columnar, and contains granules of yellow  pigment , while its deep part is prolonged as a delicate process which ramifies and communicates with similar processes from neighboring cells, so as to form a net-work in the mucous membrane. Lying between the deep processes of the supporting cells are a number of  bipolar nerve cells , the olfactory cells, each consisting of a small amount of granular  protoplasm  with a large spherical  nucleus , and possessing two processes\u2014a superficial one which runs between the columnar epithelial cells, and projects on the surface of the mucous membrane as a fine, hair-like process, the olfactory hair; the other or deep process runs inward, is frequently beaded, and is continued as the  axon  of an olfactory nerve fiber. Beneath the epithelium, and extending through the thickness of the mucous membrane, is a layer of tubular, often branched, glands, the  glands of Bowman , identical in structure with  serous glands . The epithelial cells of the  nose ,  fauces  and respiratory passages play an important role in the maintenance of an equable temperature, by the moisture with which they keep the surface always slightly lubricated. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3084", "text": "A  myringotomy  is a surgical procedure in which an incision is created in the  eardrum  (tympanic membrane) to relieve pressure caused by excessive buildup of fluid, or to drain  pus  from the  middle ear . A  tympanostomy tube  may be inserted through the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously within two to three weeks.  Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3085", "text": "Those requiring myringotomy usually have an obstructed or dysfunctional  eustachian tube  that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe  acute otitis media  (middle ear infection). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3086", "text": "The words  myringotomy ,  tympanotomy ,  tympanostomy , and  tympanocentesis  overlap in meaning. The first two are always synonymous, and the third is often used synonymously. [ 2 ]  The core idea with each is cutting a hole in the eardrum to allow fluid to pass through it. Sometimes a distinction is drawn between myringotomy/tympanotomy and tympanostomy, in parallel with the general distinction between an  -otomy  (cutting) and an  -ostomy  (creating a  stoma  with some degree of permanence or semipermanence). In this distinction, only a tympanostomy involves  tympanostomy tubes  and creates a semipermanent stoma. This distinction in usage is not always made. The word  tympanocentesis  specifies that  centesis  (the removal of fluid [ 3 ] ) is being done."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3087", "text": "Etymologically,  myringotomy  ( myringo- , from Latin  myringa  \"eardrum\", [ 4 ]  +  -tomy ) and  tympanotomy  ( tympano-  +  -tomy ) both mean \"eardrum cutting\", and  tympanostomy  ( tympano-  +  -stomy  means \"making an eardrum stoma\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3088", "text": "In 1649,  Jean Riolan the Younger  accidentally pierced a patient's eardrum while cleaning it with an  ear spoon .  Surprisingly, the patient's hearing improved. There are also reports from the 17th and 18th centuries describing separate experiments exploring the function of the eardrum. [ 5 ]   In particular, the animal experiments of  Thomas Willis  were expanded upon by Sir  Astley Cooper , who presented two papers to the  Royal Society  in 1801 on his observations that myringotomy could improve hearing. [ 6 ]   First, he showed that two patients with perforations of both eardrums could hear perfectly well, despite conventional wisdom that this would result in deafness. Second, he demonstrated that deafness caused by obstruction of the Eustachian tube could be relieved by myringotomy, which equalized the pressure on each side of the tympanic membrane. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3089", "text": "Widespread inappropriate use of the procedure later led to it falling out of use.  However, it was reintroduced by  Hermann Schwartze  in the 19th century.  An inherent problem became recognized, namely the tendency of the tympanic membrane to heal spontaneously and rapidly, reversing the beneficial effects of the perforation.  In order to prevent this, a tympanostomy tube, initially made of gold foil, was placed through the incision to prevent it from closing. In 1819 the French physician Antoine Saissy (1756\u20131822) tried to keep the myringotomy unsuccessfully open with Catgut. [ 7 ] [ 8 ]   \u00c1d\u00e1m Politzer , a Hungarian-born  otologist  practicing in Vienna, experimented with rubber in 1886.  The German otologist Rudolf Voltolini (1819\u20131889) created in 1874 a grommet made of gold and later on one made of aluminium. [ 8 ] [ 9 ]  The vinyl tube used today was introduced by Beverly Armstrong in 1954. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3090", "text": "There are numerous indications for tympanostomy in the pediatric age group, [ 1 ] [ 10 ]  the most frequent including chronic  otitis media with effusion (OME)  which is unresponsive to antibiotics, and recurrent  otitis media .  Adult indications [ 1 ] [ 11 ] [ 12 ]  differ somewhat and include Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss,  vertigo ,  tinnitus , and a severe retraction pocket in the  tympanic membrane .  Recurrent episodes of  barotrauma , especially with flying, diving, or  hyperbaric chamber treatment , may merit consideration. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3091", "text": "Myringotomy is usually performed as an outpatient procedure.  General anesthesia  is preferred in children, while  local anesthesia  suffices for adults.  The ear is washed and a small incision made in the eardrum.  Any fluid that is present is then aspirated, the tube of choice inserted, and the ear packed with cotton to control any slight bleeding that might occur.  This is known as conventional (or  cold knife ) myringotomy and usually heals in one to two days. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3092", "text": "A new variation (called  tympanolaserostomy  or  laser-assisted tympanostomy ) uses a  CO 2  laser , and is performed with a computer-driven laser and a video monitor to pinpoint a precise location for the hole.  The laser takes one-tenth of a second to create the opening, without damaging surrounding skin or other structures.  This perforation remains  patent  for several weeks and provides ventilation of the middle ear without the need for tube placement. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3093", "text": "Though laser myringotomies maintain patency slightly longer than cold-knife myringotomies (two to three weeks for laser and two to three days for cold knife without tube insertion), [ 15 ]  they have not proven to be more effective in the management of effusion.  One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME. [ 16 ]   Multiple occurrences in children, a strong history of allergies in children, the presence of thick  mucoid  effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3094", "text": "Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes.  More recent ones are coated with antibiotics and  phosphorylcholine . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3095", "text": "There is little scientific evidence to guide the care of the ear after tubes have been inserted.  A single, randomized trial found statistical benefit to using ear protective devices when swimming although the size of the benefit was quite small. [ 17 ]   In the absence of strong evidence, general opinion has been against the use of ear protection devices.  However, protection such as cotton covered with petroleum jelly, ear plugs, or ear putty is recommended for swimming in dirty water (lakes, rivers, oceans, or non-chlorinated pools) to prevent ear infections.  For bathing, shampooing, or surface-water swimming in chlorinated pools, no ear protection is recommended."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3096", "text": "The placement of tubes is not a cure.  If middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection.  There may be early drainage through the tube ( tube otorrhea ) in about 15% of patients in the first two weeks after placement, and developing in 25% more than three months after insertion, although usually not a longterm problem. [ 18 ]   Otorrhea is considered to be secondary to bacterial colonization.  The most commonly isolated organism is  Pseudomonas aeruginosa , while the most troublesome is  Methicillin-resistant  Staphylococcus aureus  (MRSA) . Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial  biofilm . [ 1 ]   A laboratory study showed that tubes covered in the antibiotic  vancomycin  prevented in-vitro formation of MRSA biofilm as compared to noncoated ones, [ 19 ]  although no study has been conducted on humans yet.  Comparing phosphorylcholine-coated fluoroplastic tympanostomy tubes to uncoated fluoroplastic tympanostomy tubes showed no statistically significant difference in the incidence of post-operative otorrhea, tube blockage, or extrusion. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3097", "text": "Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have no other serious medical problems.  No effect on speech and language development has yet been shown. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3098", "text": "A retrospective study of success rates in 96 adults and 130 children with otitis media treated with CO 2  laser myringotomy showed about a 50% cure rate at six months in both groups. [ 13 ]   To date, there have been no published systematic reviews."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3099", "text": "Balloon dilation  eustachian tuboplasty (BDET), a new treatment, has proven to be effective in treating OME secondary to  eustachian tube  dysfunction. [ 22 ] [ 23 ] [ 24 ]  However, the number of patients in the studies cited, 22 and 8 respectively and 18 in the tympanometric study, is extremely small and simply points to the need for large, well-controlled studies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3100", "text": "The  nasal bones  are two small oblong  bones , varying in size and form in different individuals; they are placed side by side at the middle and upper part of the  face  and by their junction, form the  bridge  of the upper one third of the  nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3101", "text": "Each has two surfaces and four borders."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3102", "text": "There is heavy  variation  in the structure of the nasal bones, accounting for the differences in sizes and shapes of the nose seen across different people. Angles, shapes, and configurations of both the bone and cartilage are heavily varied between individuals. Broadly, most nasal bones can be categorized as \"V-shaped\" or \"S-shaped\" but these are not  scientific  or medical categorizations. When viewing  anatomical drawings  of these bones, consider that they are unlikely to be accurate for a majority of people. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3103", "text": "The two nasal bones are joined at the midline  internasal suture  and make up the  bridge of the nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3104", "text": "The  outer surface  is  concavo-convex  from above downward, convex from side to side; it is covered by the  procerus  and  nasalis  muscles, and perforated about its center by the  nasal foramen , a small passageway for the transmission of a small  vein  from the overlying soft tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3105", "text": "The  inner surface  is concave from side to side, and is traversed from above downward, by a groove for the passage of a branch of the  nasociliary nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3106", "text": "The nasal articulates with four bones: two of the cranium, the  frontal  and  ethmoid , and two of the face, the opposite nasal and the  maxilla ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3107", "text": "In primitive  bony fish  and  tetrapods , the nasal bones are the most anterior of a set of four paired bones forming the  roof of the skull , being followed in sequence by the frontals, the  parietals , and the  postparietals . Their form in living species is highly variable, depending on the shape of the head, but they generally form the roof of the snout or beak, running from the nostrils to a position short of the orbits. In most animals, they are generally therefore proportionally larger than in humans or great apes, because of the shortened faces of the latter.  Turtles , unusually, lack nasal bones, with the  prefrontal bones  of the orbit reaching all the way to the nostrils. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3108", "text": "The  nasal cartilages  are structures within the nose that provide form and support to the nasal cavity. [ 1 ]  The nasal cartilages are made up of a flexible material called  hyaline cartilage  (packed collagen) in the distal portion of the nose. [ 2 ]  There are five individual cartilages that make up the nasal cavity:  septal nasal cartilage ,  lateral nasal cartilage ,  major alar cartilage  (greater alar cartilage, or cartilage of the aperture),  minor alar cartilage  (lesser alar cartilage, sesamoid, or accessory cartilage), and  vomeronasal cartilage  (Jacobson's cartilage)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3109", "text": "The nasal cartilages associate with other cartilage structures of the nose or with bones of the facial skeleton. These associations create vent-like structures within the nose so that air can flow from the nasal cavity to the lungs or vice versa. Therefore, the nasal cartilages are structures that aid the body in respiratory functions to intake oxygen or expire carbon dioxide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3110", "text": "Abnormalities or defects in the nasal cartilages affect airflow through the nasal cavity, resulting in respiratory issues. Surgical techniques have been produced to adjust the position or repair the nasal cartilages so that maximal airflow is once again accomplished. Some of these surgical techniques include:  septoplasty  (restructuring the septal nasal cartilage), upper lateral cartilage repositioning (restructuring the lateral nasal cartilage), and sliding alar cartilage (restructuring the major alar cartilage).  Rhinoplasty , which is the surgical reconstruction of the nose, has increased in recent popularity for functional and social purposes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3111", "text": "Other mammals also contain nasal cartilages in order to maintain structure and function for the nasal cavity. The orientation of the nasal cartilages can produce different shapes and sizes of the nostrils and nasal cavities. For the most part, animals contain similar cartilage structures within the nose but vary in the number of different cartilage structures they have. Donkeys, buffalo, and camels have a variety of cartilage structures that are analogous to humans but they all lack septal nasal cartilages. Instead, they have multiple components merging together to form the  nasal septum . Even though nasal cartilages differ between species, they all aid in the function of the  respiratory system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3112", "text": "The  septal nasal cartilage  is a flat, quadrilateral piece of hyaline cartilage that separates both nasal cavities from one another. [ 3 ]  The septal nasal cartilage fits in a place between the perpendicular plate of the ethmoid and vomer bones while also being covered by an internal  mucous membrane . The superior portion of the septal nasal cartilage attaches to the nasal bones, while the inferior portion attaches to the alar cartilages via fibrous tissues. The septal nasal cartilage separates both right and left nasal cavities, which allows air to pass through them. Providing two cavities generates turbulence within the tight spaces, allowing air to flow quicker bidirectionally. The septal nasal cartilage is also the main structure that provides the orientation of the nose, being the midline structure of the organ. With an offset septal nasal cartilage, the nose will appear crooked to the viewer. A crooked nose can block airflow coming from the nares to the lungs or vice versa. [ 4 ]  This can lead to respiratory issues due to low oxygen but high carbon dioxide counts within the body. A surgical procedure to correct this issue is called  septoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3113", "text": "The  lateral nasal cartilage  is a wing-like expansion extending out from the septal nasal cartilage. [ 5 ]  The lateral nasal cartilage lies inferiorly to the nasal bones while sitting superiorly to the major alar cartilage, separated by a narrow fissure. The lateral nasal cartilage and major alar cartilage curl up upon interaction with one another, forming a tight connection through fibrous tissues. Like the septal nasal cartilage, the lateral nasal cartilage is composed of hyaline cartilage. Hyaline cartilage provides form and flexibility within a specific structure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3114", "text": "The superior portion of the lateral nasal cartilage fuses with the septum to provide support within the nasal cavities. With a collapse of the lateral nasal cartilage, the inner nasal valve could become obstructed and prevent the movement of airflow throughout. [ 6 ]  A new surgical technique to reposition the lateral nasal cartilage has been constructed to relieve the site of obstruction within the inner nasal valve and regain maximal airflow throughout the nose (upper lateral cartilage repositioning)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3115", "text": "The  major alar cartilages  are positioned with one structure on each side of the nasal tip. [ 7 ]  Superiorly, the major alar cartilages are connected to the lateral nasal cartilage via fibrous tissues. Composed of hyaline cartilage, these structures are very thin and folded to form the lateral and medial crus. The medial crus is the inner portion of the major alar cartilages that are situated perpendicularly to the septal nasal cartilage. The lateral crus is the outer portion of the major alar cartilages that associate with the  ala of the nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3116", "text": "Both crus come together to form an oval tip at each nostril. Both sides of the major alar cartilages merge together to form a notch at the tip, which is referred to as the apex of the nose. With the formation of the medial and lateral walls within the nares, the major alar cartilages function to hold open each naris. This allows maximal airflow to reach the nasal valve, allowing optimal respiration. Due to weakness corresponding with the lateral crus in certain individuals, a technique called sliding alar cartilage (SAC) has been a procedure practiced to restructure and support the nasal tip. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3117", "text": "The  minor alar cartilages  are 3 to 4 small hyaline cartilage pieces on both sides of the nose that sit between the lateral nasal cartilage and the major alar cartilage. [ 9 ]  Associated within the ala of the nose, these small structures are contained within the most dorsal part of the ala. Also known by its other name, \"accessory cartilage\", these structures aid to provide form and strength at the base of the nares in conjunction with the major alar cartilage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3118", "text": "The  vomeronasal cartilage  is a thin piece of hyaline cartilage that attaches to the vomer and extends to the septal nasal cartilage. [ 10 ]  This structure is associated with the  vomeronasal organ , which is part of the accessory olfactory system. This associated organ plays an important role in the sense of smell by being lined with similar epithelium to that of the olfactory region of the nose. The vomeronasal cartilage is another small component of the nose that provides strength and structure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3119", "text": "With emerging technological advancements, reconstruction and surgical techniques have been developed to adjust the lifestyle and health of individuals.  Rhinoplasty  is one of the surgical practices that has become more common in the modern era. Some rhinoplastic procedures include septoplasty, sliding alar cartilage, and upper lateral cartilage repositioning. These procedures aid in cosmetic as well as functional issues involving the nose. Other reconstruction procedures are being produced and tested as the knowledge for nasal cartilages increase."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3120", "text": "Septoplasty  is a surgical procedure that straightens the septal nasal cartilage within the center of the nose. [ 11 ]  With a crooked septum, it is more difficult for an individual to breathe and the risk for getting a sinus infection increases. Also called a  deviated septum , a crooked nose will block one or both sides of the nose, affecting the quality of life. [ 4 ]  However, a deviated septum is very common and does not always create respiratory issues. Respiratory issues usually occur in more severe cases, requiring surgery to repair. [ 11 ]  Surgery is also permitted to individuals that seek cosmetic changes due to moderate cases of a deviated septum. Surgery may require a surgeon to cut and remove parts of the septal nasal cartilages, replacing them later in a reconstructed format. This will allow the individual to receive more airflow through the nostrils when the surgery fully heals after 3 to 6 months. However, there are some risks correlated with this surgical procedure. These risks include a change in the shape of the nose, excessive bleeding, vacant space in the septum, trouble smelling, blood clots that need to be removed, and numbness by the facial region. Smoking can also cause further damage during the healing process of septoplastic surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3121", "text": "The upper lateral cartilage repositioning procedure is done to move the lateral nasal cartilage from blocking the nasal valve. [ 6 ]  The nasal valve is the smallest airway within the nose and is a common site for obstruction. Other surgical procedures open up this air way by employing grafts to separate the septal nasal and lateral nasal cartilages from one another. Grafts need to be used permanently due to the complications of removing such a device. The upper lateral cartilage repositioning technique deploys a temporary stint that repositions the lateral nasal cartilage, lets it heal/be stationary due to scar tissue formation, then is removed. This open rhinoplastic procedure allows the nose to heal to an optimal position without the permanent use of man-made hardware. This procedure is just one way to resolve issues involving lateral nasal cartilage deformities. Other procedures are being produced and improved upon in order to generate the simplest and most safe surgical procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3122", "text": "The sliding alar cartilage is a procedure to strengthen and support the nasal tip. [ 8 ]  This medical practice is completed on the greater alar cartilage in order to reshape this structure. The greater alar cartilages can become very weak or have deformities, creating respiratory issues. Other medical procedures that reshape the greater alar cartilages use grafts or cartilage re-sectioning. The SAC procedure is completed within two to three minutes. In that timeframe, the tip of the nose is cut open, the greater alar cartilage is manipulated to preserve the scroll area, providing strength and structure, then the incision is sutured back up. [ 12 ]  This simple technique creates tip definition while maintaining airway function. While there are other procedures to strengthen the greater alar cartilage, the SAC procedure is gaining momentum into common rhinoplastic operations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3123", "text": "The  nasal cavity  is a large, air-filled space above and behind the  nose  in the middle of the  face . The  nasal septum  divides the cavity into two cavities, [ 1 ]  also known as  fossae . [ 2 ]  Each cavity is the continuation of one of the two  nostrils . The nasal cavity is the uppermost part of the  respiratory system  and provides the  nasal passage  for inhaled air from the  nostrils  to the  nasopharynx  and rest of the  respiratory tract ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3124", "text": "The  paranasal sinuses  surround and drain into the nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3125", "text": "The term \"nasal cavity\" can refer to each of the two cavities of the nose, or to the two sides combined."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3126", "text": "The lateral wall of each nasal cavity mainly consists of the  maxilla . However, there is a deficiency that is compensated for by the perpendicular plate of the  palatine bone , the  medial pterygoid plate , the  labyrinth of ethmoid  and the  inferior concha .  The  paranasal sinuses  are connected to the nasal cavity through small orifices called  ostia . Most of these ostia communicate with the nose through the lateral nasal wall, via a semi-lunar depression in it known as the  semilunar hiatus . The hiatus is bound laterally by a projection known as the  uncinate process . This region is called the  ostiomeatal complex . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3127", "text": "The roof of each nasal cavity is formed in its upper third to one half by the  nasal bone  and more inferiorly by the junctions of the upper lateral cartilage and nasal septum.  Connective tissue and skin cover the bony and cartilaginous components of the  nasal dorsum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3128", "text": "The floor of the nasal cavities, which also form the roof of the mouth, is made up by the bones of the hard palate: the horizontal plate of the palatine bone posteriorly and the palatine process of the maxilla anteriorly. The most anterior part of the nasal cavity is the  nasal vestibule . [ 4 ]  The vestibule is enclosed by the  nasal cartilages  and lined by the same  epithelium  of the  skin  (stratified squamous, keratinized). Within the vestibule, this changes into the typical respiratory epithelium that lines the rest of the nasal cavity and  respiratory tract . Inside the  nostrils  of the vestibule are the  nasal hair , which filter dust and other matter that are breathed in. The back of the cavity blends, via the  choanae , into the  nasopharynx ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3129", "text": "The nasal cavity is divided in two by the vertical  nasal septum . On the side of each nasal cavity are three horizontal outgrowths called  nasal conchae  (singular \"concha\") or turbinates. These turbinates disrupt the airflow, directing air toward the  olfactory epithelium  on the surface of the turbinates and the septum. The  vomeronasal organ  is located at the back of the  septum  and has a role in  pheromone  detection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3130", "text": "The nasal cavity has a  nasal valve area  that includes an  external nasal valve  and an  internal nasal valve . The external nasal valve is bounded medially by the  columella , laterally by the  lateral nasal cartilage , and posteriorly by the nasal sill. [ 5 ]  The internal nasal valve is bounded laterally by the caudal border of the lateral nasal cartilage, medially by the dorsal  nasal septum , and inferiorly by the anterior border of the  inferior turbinate . [ 6 ]  The internal nasal valve is the narrowest region of the nasal cavity and is the primary site of nasal resistance. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3131", "text": "The nasal cavity is divided into two segments: the respiratory segment and the olfactory segment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3132", "text": "There is a rich blood supply to the nasal cavity.\nBlood supply comes from branches of both the  internal  and  external carotid artery , including branches of the  facial artery  and  maxillary artery . The named arteries of the nose are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3133", "text": "Innervation  of the nasal cavity responsible for the  sense of smell  is via the  olfactory nerve , which sends microscopic fibers from the  olfactory bulb  through the  cribriform plate  to reach the top of the nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3134", "text": "General sensory innervation is by branches of the  trigeminal nerve  (V 1  and V 2 ):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3135", "text": "The nasal cavity is innervated by autonomic fibers.  Sympathetic  innervation to the blood vessels of the mucosa causes them to  constrict , while the control of secretion by the  mucous glands  is carried on  postganglionic   parasympathetic  nerve fibers originating from the  facial nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3136", "text": "The two nasal cavities condition the air to be received by the other areas of the  respiratory tract . Owing to the large surface area provided by the  nasal conchae  (also known as turbinates), the air passing through the nasal cavity is warmed or cooled to within 1 degree of  body temperature . In addition, the air is humidified, and dust and other particulate matter is removed by  nasal hair  in the nostrils. The entire mucosa of the nasal cavity is covered by a blanket of mucus, which lies superficial to the microscopic cilia and also filters inspired air. The  cilia  of the  respiratory epithelium  move the secreted mucus and particulate matter posteriorly towards the  pharynx  where it passes into the  esophagus  and is digested in the stomach. The nasal cavity also houses the sense of smell and contributes greatly to taste sensation through its posterior communication with the mouth via the  choanae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3137", "text": "Diseases of the nasal cavity include  viral ,  bacterial  and  fungal  infections, nasal cavity  tumors , both benign and much more often malignant, as well as inflammations of the  nasal mucosa .\nMany problems can affect the nose, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3138", "text": "The  nasal  glands  are the  seromucous glands  in the  respiratory  region of the  nasal mucous membrane . [ 2 ]  The three major types of nasal glands are anterior serous glands, seromucous glands, and Bowman glands. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3139", "text": "The anterior nasal glands help moisturize the nasal mucosa. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3140", "text": "The seromucous glands are found primarily in the anterior nasal cavity, and they are also found within the nasal cavity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3141", "text": "The Bowman glands are serous glands that help the olfactory region with smelling. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3142", "text": "In  anatomy , the term  nasal meatus [ 1 ]  can refer to any of the three  meatuses  (passages) through the  skull ' s  nasal cavity : the  superior meatus  ( meatus nasi superior ),  middle meatus  ( meatus nasi medius ), and  inferior meatus  ( meatus nasi inferior )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3143", "text": "The nasal meatuses are the spaces beneath each of the corresponding  nasal conchae . In the case where a fourth,  supreme nasal concha  is present, there is a fourth  supreme nasal meatus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3144", "text": "The superior meatus is the smallest of the three. It is a narrow cavity located obliquely below the  superior concha . This meatus is short, lies above and extends from the middle part of the  middle concha  below. From behind, the  sphenopalatine foramen  opens into the cavity of the superior meatus and the meatus communicates with the posterior  ethmoidal cells . Above and at the back of the  superior concha  is the  sphenoethmoidal recess  which the  sphenoidal sinus  opens into. The superior meatus occupies the middle third of the  nasal cavity\u2019s  lateral wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3145", "text": "The middle meatus is the middle-sized and located nasal opening, lying underneath the middle concha and above the  inferior concha  where the meatus extends along its length. On it is a curved fissure, the  hiatus semilunaris , limited below by the edge of the  uncinate process of the ethmoid  and above by an elevation named the  bulla ethmoidalis ; the middle  ethmoidal cells  are contained within this bulla and open on or near to it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3146", "text": "Through the hiatus semilunaris the meatus communicates with a curved passage termed the  infundibulum , which communicates in front with the anterior ethmoidal cells and in rather more than fifty percent of skulls is continued upward as the frontonasal duct into the frontal air-sinus; when this continuity fails, the frontonasal duct opens directly into the anterior part of the meatus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3147", "text": "Below the bulla ethmoidalis and hidden by the uncinate process of the ethmoid is the opening of the  maxillary sinus  (ostium maxillare); an accessory opening is frequently present above the posterior part of the inferior nasal concha."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3148", "text": "The inferior meatus is the largest of the three. It lies below the inferior concha and above the nasal cavity. It extends most of the length of the nasal cavity\u2019s lateral wall. It is broader in the front than at the back, and presents anteriorly the lower orifice of the  nasolacrimal canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3149", "text": "Nasal polyps  are  noncancerous growths  within the  nose  or  sinuses . [ 1 ]  Symptoms include trouble breathing through the nose,  loss of smell , decreased taste,  post nasal drip , and a  runny nose . [ 1 ]  The growths are  sac-like , movable, and nontender, though face pain may occasionally occur. [ 1 ]  They typically occur in both nostrils in those who are affected. [ 1 ]  Complications may include  sinusitis  and broadening of the nose. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3150", "text": "The exact cause is unclear. [ 1 ]  They may be related to chronic  inflammation  of the lining of the sinuses. [ 1 ]  They occur more commonly among people who have  allergies ,  cystic fibrosis ,  aspirin sensitivity , or certain infections. [ 1 ]  The polyp itself represents an overgrowth of the mucous membranes. [ 1 ]  Diagnosis may be accomplished by looking up the nose. [ 1 ]  A  CT scan  may be used to determine the number of polyps and help plan surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3151", "text": "Treatment is typically with  steroids , often in the form of a  nasal spray . [ 1 ]  If this is not effective,  surgery  may be considered. [ 1 ]  The condition often recurs following surgery; thus, continued use of a steroid nasal spray is often recommended. [ 1 ]   Antihistamines  may help with symptoms but do not change the underlying disease. [ 1 ]   Antibiotics  are not required for treatment unless an infection occurs. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3152", "text": "About 4% of people currently have nasal polyps while up to 40% of people develop them at some point in their life. [ 1 ]  They most often occur after the age of 20 and are more frequent in males than females. [ 1 ]  Nasal polyps have been described since the time of the  Ancient Egyptians . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3153", "text": "Symptoms of polyps include  nasal congestion ,  sinusitis ,  loss of smell , thick nasal discharge, facial pressure, nasal speech, and mouth breathing. [ 5 ]  Recurrent  sinusitis  can result from polyps. [ 2 ]  Long-term, nasal polyps can cause destruction of the nasal bones and broadening of the nose. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3154", "text": "As polyps grow larger, they eventually prolapse into the  nasal cavity , resulting in symptoms. [ 6 ]  The most prominent symptoms of nasal polyps is blockage of the nasal passage. [ 7 ]  People with nasal polyps due to  aspirin intolerance  often have a disease known as  aspirin-exacerbated respiratory disease , which consists of asthma and chronic nasal polyps along with a hypersensitivity reaction to aspirin. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3155", "text": "The exact cause of nasal polyps is unclear. [ 1 ]  They are, however, commonly associated with conditions that cause long term  inflammation  of the sinuses. [ 8 ]  This includes  chronic rhinosinusitis ,  asthma ,  aspirin  sensitivity, and  cystic fibrosis . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3156", "text": "Various additional diseases associated with polyp formation include: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3157", "text": "Chronic rhinosinusitis  is a common medical condition characterized by symptoms of sinus inflammation lasting at least 12 weeks. The cause is unknown and the role of microorganisms remains unclear. It can be classified as either with or without nasal polyposis. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3158", "text": "Cystic fibrosis  (CF) is the most common cause of nasal polyps in children. Therefore, any child under 12 to 20 years old with nasal polyps should be tested for CF. [ 7 ] [ 10 ]  Half of people with CF will experience extensive polyps leading to nasal obstruction and requiring aggressive management. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3159", "text": "The true cause of nasal polyps is unknown, but they are thought to be due to recurrent infection or inflammation. [ 2 ]  Polyps arise from the lining of the sinuses. Nasal mucosa, particularly in the region of  middle meatus  becomes swollen due to collection of extracellular fluid. This extracellular fluid collection causes polyp formation and protrusion into the nasal cavity or sinuses. Polyps which are sessile in the beginning become  pedunculated  due to gravity. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3160", "text": "In people with nasal polyps due to  aspirin  or  NSAID  sensitivity, the underlying mechanism is due to disorders in the metabolism of  arachidonic acid . Exposure to  cycloxygenase inhibitors  such as aspirin and NSAIDs leads to shunting of products through the lipoxygenase pathway leading to an increased production of products that cause inflammation. In the airway, these inflammatory products lead to symptoms of asthma such as wheezing as well as nasal polyp formation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3161", "text": "Nasal polyps can be seen on physical examination inside of the nose and are often detected during the evaluation of symptoms. On examination, a polyp will appear as a visible mass in the nostril. [ 5 ]  Some polyps may be seen with anterior rhinoscopy (looking in the nose with a nasal speculum and a light), but frequently, they are farther back in the nose and must be seen by nasal  endoscopy . [ 12 ]  Nasal endoscopy involves passing a small, rigid camera with a light source into the nose. An image is projected onto a screen in the office so the doctor can examine the nasal passages and sinuses in greater detail. The procedure is not generally painful, but the person can be given a spray decongestant and local anesthetic to minimize discomfort. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3162", "text": "Attempts have been made to develop scoring systems to determine the severity of nasal polyps. Proposed staging systems take into account the extent of polyps seen on endoscopic exam and the number of sinuses affected on CT imaging. This staging system is only partially validated, but in the future, may be useful for communicating the severity of disease, assessing treatment response, and planning treatment. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3163", "text": "There are two primary types of nasal polyps: ethmoidal and antrochoanal. Ethmoidal polyps arise from the  ethmoid sinuses  and extend through the  middle meatus  into the nasal cavity. Antrochoanal polyps usually arise in the  maxillary sinus  and extend into the nasopharynx and represent only 4\u20136% of all nasal polyps. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3164", "text": "However, antrochoanal polyps are more common in children comprising one-third of all polyps in this population. Ethmoidal polyps are usually smaller and multiple while antrochoanal polyps are usually single and larger. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3165", "text": "CT scan can show the full extent of the polyp, which may not be fully appreciated with physical examination alone. Imaging is also required for planning surgical treatment. [ 7 ]  On a  CT scan , a nasal polyp generally has an attenuation of 10\u201318  Hounsfield units , which is similar to that of  mucus . Nasal polyps may have  calcification . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3166", "text": "On histologic examination, nasal polyps consist of hyperplastic edematous (excess fluid)  connective tissue  with some  seromucous glands  and cells representing inflammation (mostly  neutrophils  and  eosinophils ). Polyps have virtually no neurons. Therefore, the tissue that makes up the polyp does not have any tissue sensation and the polyp itself will not be painful. [ 6 ]  In early stages, the surface of the nasal polyp is covered by normal respiratory epithelium, but later it undergoes  metaplastic  change to squamous type epithelium with the constant irritation and inflammation. The submucosa shows large intercellular spaces filled with serous fluid. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3167", "text": "Other disorders can mimic the appearance of nasal polyps and should be considered if a mass is seen on exam. [ 16 ]  Examples include  encephalocele ,  glioma ,  inverted papilloma , and cancer. [ 10 ]  Early biopsy is recommended for unilateral nasal polyps to rule out more serious conditions such as cancer,  inverted papilloma , or  fungal sinusitis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3168", "text": "The first line of treatment for nasal polyps is topical  steroids . [ 12 ]  Steroids decrease the inflammation of the sinus mucosa to decrease the size of the polyps and improve symptoms. [ 12 ]  Topical preparations are preferred in the form of a nasal spray but are often ineffective for people with many polyps. Steroids by mouth often provide drastic symptom relief, but should not be taken for long periods of time due to their side effects. Because steroids only shrink the size and swelling of the polyp, people often have recurrence of symptoms once the steroids are stopped. [ 12 ]  Decongestants do not shrink the polyps, but can decrease swelling and provide some relief. [ 7 ]  Antibiotics are only recommended if the person has a co-occurring  bacterial infection . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3169", "text": "In people with nasal polyps caused by aspirin or NSAIDs, avoidance of these medications will help with symptoms. Aspirin desensitization has also been shown to be beneficial. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3170", "text": "Endoscopic sinus surgery , advocated and popularized by Professor Stammberger, is often very effective for most people, providing rapid symptom relief. Endoscopic sinus surgery is minimally-invasive and is done entirely through the nostril with the help of a camera. Surgery should be considered for those with complete nasal obstruction, uncontrolled runny nose, nasal deformity caused by polyps or continued symptoms despite medical management. [ 7 ]  Surgery serves to remove the polyps as well as the surrounding inflamed mucosa, open obstructed nasal passages, and clear the sinuses. This not only removes the obstruction caused by the polyps themselves, but allows medications such as saline irrigations and topical steroids to become more effective. [ 19 ]  It has been suggested that one of the main objectives in sinus surgery for polyps is to allow delivery of the steroids into those areas of the sinuses where polyps develop, namely, the ethmoid sinuses. Specially designed long nozzles had been developed to use postoperatively to deliver steroids into those areas after sinus surgery for polyps. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3171", "text": "Surgery lasts approximately 45 to 60 minutes and can be done under general or local anesthesia. [ 19 ]  Most people tolerate the surgery without much pain, though this can vary from person to person. The person should expect some discomfort, congestion, and drainage from the nose in the first few days after surgery, but this should be mild. [ 21 ]  Complications from endoscopic sinus surgery are rare, but can include bleeding and damage to other structures in the area including the eye or brain. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3172", "text": "Many physicians recommend a course of oral steroids prior to surgery to reduce mucosal inflammation, decrease bleeding during surgery, and help with visualization of the polyps. [ 12 ]  Nasal steroid sprays should be used preventatively after surgery to delay or prevent recurrence. [ 7 ]  People often have recurrence of polyps even following surgery. Therefore, continued follow up with a combination of medical and surgical management is preferred for the treatment of nasal polyps. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3173", "text": "Nasal polyps resulting from chronic rhinosinusitis affect approximately 4.3% of the population. [ 6 ]  Nasal polyps occur more frequently in men than women and are more common as people get older, increasing drastically after the age of 40. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3174", "text": "Of people with chronic rhinosinusitis, 10% to 54% also have allergies. An estimated 40% to 80% of people with sensitivity to aspirin will develop nasal polyposis. [ 6 ]  In people with cystic fibrosis, nasal polyps are noted in 37% to 48%. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3175", "text": "The  nasal septum  ( Latin :  septum nasi ) separates the left and right airways of the  nasal cavity , dividing the two  nostrils ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3176", "text": "It is  depressed  by the  depressor septi nasi muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3177", "text": "The fleshy external end of the nasal septum is called the  columella  or columella nasi, and is made up of  cartilage  and soft tissue. [ 2 ]  The nasal septum contains bone and  hyaline cartilage . [ 3 ]  It is normally about 2\u00a0mm thick. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3178", "text": "The nasal septum is composed of four structures:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3179", "text": "The lowest part of the septum is a narrow strip of bone that projects from the maxilla and the  palatine bones , and is the length of the septum. This strip of bone is called the maxillary crest; it articulates in front with the septal nasal cartilage, and at the back with the vomer. [ 5 ]  The maxillary crest is described in the anatomy of the nasal septum as having a maxillary component and a palatine component."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3180", "text": "At an early period, the septum of the nose consists of a plate of cartilage, known as the  ethmovomerine cartilage ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3181", "text": "The posterosuperior part of this cartilage is  ossified  to form the perpendicular plate of the  ethmoid ; its anteroinferior portion persists as the septal cartilage, while the  vomer  is ossified in the membrane covering its posteroinferior part."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3182", "text": "Two  ossification centers , one on either side of the middle line, appear about the eighth week of  fetal development  in this part of the membrane, and hence the vomer consists primarily of two lamellae."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3183", "text": "About the third month, these unite below, and thus a deep groove is formed in which the cartilage is lodged."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3184", "text": "As growth proceeds, the union of the lamellae extends upward and forward, and at the same time, the intervening plate of cartilage undergoes absorption."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3185", "text": "By the onset of  puberty  the lamellae are almost completely united to form a median plate, but evidence of the bilaminar origin of the bone is seen in the everted alae of its upper border and in the groove on its anterior margin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3186", "text": "The nasal septum can depart from the centre line of the nose in a condition that is known as a  deviated septum  caused by trauma. However, it is normal to have a slight deviation to one side. The septum generally stays in the midline until about the age of seven, at which point it will frequently deviate to the right. An  operation  to straighten the nasal septum is known as a  septoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3187", "text": "A  perforated nasal septum  can be caused by an  ulcer , trauma due to an inserted object, long-term exposure to  welding fumes , [ 6 ]  or  cocaine  use. There is a procedure that can be of help to those suffering from the perforated septum. A  silicone  button can be inserted in the hole to close the open sore."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3188", "text": "The nasal septum can be affected by both  benign tumors  such as  fibromas , and  hemangiomas , and  malignant tumors  such as  squamous cell carcinoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3189", "text": "A  nasal septum piercing  is usually carried out through the fleshy columella close to the end of the nasal septum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3190", "text": "Nasal septum deviation  is a physical disorder of the nose, involving a displacement of the  nasal septum . Some displacement is common, affecting 80% of people, mostly without their knowledge. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3191", "text": "The  nasal septum  is the bone and  cartilage  in the nose that separates the  nasal cavity  into the two  nostrils . The cartilage is called the  quadrangular cartilage  and the bones comprising the septum include the  maxillary crest ,  vomer , and the  perpendicular plate of the ethmoid . Normally, the septum lies centrally, and thus the nasal passages are symmetrical. [ 2 ]  A deviated septum is an abnormal condition in which the top of the cartilaginous ridge leans to the left or the right, causing obstruction of the affected nasal passage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3192", "text": "It is common for nasal septa to depart from the exact centerline; the septum is only considered deviated if the shift is substantial or causes problems. [ 3 ]  By itself, a deviated septum can go undetected for years and thus be without any need for correction. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3193", "text": "Symptoms of a deviated septum include infections of the  sinus  and  sleep apnea ,  snoring , repetitive  sneezing , facial pain,  nosebleeds ,  mouth breathing , difficulty with  breathing , mild to severe loss of the ability to  smell , [ 1 ] [ 4 ]  and possibly headaches. [ 5 ]  Only more severe cases of a deviated septum will cause symptoms of difficulty breathing and require treatment. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3194", "text": "It is most frequently caused by  impact trauma , such as by a blow to the face. [ 3 ]  It can also be a  congenital disorder , caused by compression of the nose during childbirth. [ 3 ]  Deviated septum is associated with genetic connective tissue disorders such as  Marfan syndrome ,  homocystinuria  and  Ehlers\u2013Danlos syndrome . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3195", "text": "Nasal septum deviation is the most common cause of nasal obstruction. [ 7 ]  A history of trauma to the nose is often present including trauma from the process of birth or microfractures. [ 7 ]  A medical professional, such as an  otorhinolaryngologist  (ears, nose, and throat doctor), typically makes the diagnosis after taking a thorough history from the affected person and performing a physical examination. [ 7 ]  Imaging of the nose is sometimes used to aid in making the diagnosis as well. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3196", "text": "Medical therapy with nasal sprays including  decongestants ,  antihistamines , or nasal  corticosteroid  sprays is typically tried first before considering a surgical approach to correct nasal septum deviation. [ 7 ]  Medication temporarily relieves symptoms, but does not correct the underlying condition. Non-medical relief can also be obtained using  nasal strips ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3197", "text": "A minor surgical procedure known as  septoplasty  can cure symptoms related to septal deviations. The surgery lasts roughly one hour and does not result in any cosmetic alteration or external scars. Nasal congestion, pain, [ 8 ]  drainage or swelling may occur within the first few days after the surgery. [ 9 ]  Recovery from the procedure may take anywhere from two days to four weeks to heal completely. [ citation needed ]  Septal bones never regrow. If symptoms reappear they are not related to deviations. Reappearance of symptoms may be due to  mucosal   metaplasia  of the nose. [ citation needed ]  There are times also when the surgery also may be unsuccessful, leading to a continuation of the symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3198", "text": "A randomised controlled trial found that people who had septoplasty had a greater improvement in their symptoms and quality of life after 6 months than people who managed their nasal airway obstruction with nasal sprays. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3199", "text": "The  nasociliary nerve  is a branch of the  ophthalmic nerve (CN V 1 )  (which is in turn a branch of the  trigeminal nerve (CN V) ). It is intermediate in size between the other two branches of the ophthalmic nerve, the  frontal nerve  and  lacrimal nerve . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3200", "text": "The nasociliary nerve enters the orbit via the superior orbital fissure, [ citation needed ]  through the  common tendinous ring , [ 1 ]  and between the two heads of the  lateral rectus muscle  and between the superior and inferior rami of the  oculomotor nerve . [ citation needed ]  It passes across the  optic nerve (CN II)  along with the  ophthalmic artery . It then runs obliquely beneath (inferior to) the  superior rectus muscle  and  superior oblique muscle  to the medial wall of the  orbital cavity  whereupon it emits the  posterior ethmoidal nerve , and the  anterior ethmoidal nerve . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3201", "text": "Branches of the nasociliary nerve include: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3202", "text": "The branches of the nasociliary nerve provide sensory innervation to structures surrounding the eye such as the cornea, eyelids, conjunctiva, ethmoid air cells and mucosa of the nasal cavity. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3203", "text": "Since both the short and long ciliary nerves carry the afferent limb of the  corneal reflex , one can test the integrity of the nasociliary nerve (and, ultimately, the  trigeminal nerve ) by examining this reflex in the patient. Normally both eyes should blink when either cornea (not the conjunctiva, which is supplied by the adjacent cutaneous nerves) is irritated. If neither eye blinks, then either the ipsilateral nasociliary nerve is damaged, or the  facial nerve  (CN VII, which carries the efferent limb of this reflex) is bilaterally damaged. If only the contralateral eye blinks, then the ipsilateral facial nerve is damaged. If only the ipsilateral eye blinks, then the contralateral facial nerve is damaged. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3204", "text": "The  neck dissection  is a  surgical procedure  for control of neck  lymph node   metastasis  from  squamous cell carcinoma  ( SCC ) of the head and neck. [ 1 ]  The aim of the procedure is to remove lymph nodes from one side of the neck into which cancer cells may have migrated.  Metastasis of squamous cell carcinoma into the lymph nodes of the neck reduce survival and is the most important factor in the spread of the disease. The metastases may originate from SCC of the upper aerodigestive tract, including the oral cavity, tongue,  nasopharynx ,  oropharynx ,  hypopharynx , and  larynx , as well as the  thyroid ,  parotid  and posterior scalp. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3205", "text": "To describe the lymph nodes of the neck for neck dissection, the neck is divided into 6 areas called  Levels . The levels are identified by Roman numeral, increasing towards the chest. A further Level VII to denote lymph node groups in the superior  mediastinum  is no longer used. Instead, lymph nodes in other non-neck regions are referred to by the name of their specific nodal groups."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3206", "text": "The 2001 revisions proposed by the American Head and Neck Society (AHNS) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) are as follows."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3207", "text": "The  nerve to the stapedius  is a branch of the  facial nerve (CN VII)  which innervates the  stapedius muscle . [ 1 ]  It arises from the CN VII within the  facial canal , [ 2 ]  opposite the  pyramidal eminence . It passes through a small canal in this eminence to reach the  stapedius muscle . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3208", "text": "Neurotology  or  neuro-otology  is a subspecialty of  otolaryngology\u2014head and neck surgery , also known as ENT (ear, nose, and throat) medicine. [ 1 ]  Neuro-otology is closely related to  otology ,  clinical neurology [ 2 ]  and  neurosurgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3209", "text": "Otology may refer to ENT  physicians  who \"... [study] normal and pathological anatomy and physiology of the ear (hearing and vestibular sensory systems and related structures and functions) ...\", and who treat diseases of the ear with medicine or surgery. [ 3 ]  In some instances, otology and neurotology are considered together\u2014as so closely related that a clear demarcation between the subspecialties might not exist. For example, the  University of Maryland Medical Center  uses the term, \"otologist/neurotologist\". [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3210", "text": "Otologists and neurotologists have specialized in otolaryngology and then further specialized in pathological conditions of the ear and related structures. Many general otolaryngologists are trained in otology or middle ear surgery, performing surgery such as a  tympanoplasty , or a reconstruction of the eardrum, when a hole remains from a prior ear tube or infection. Otologic surgery includes treatment of  conductive hearing loss  by reconstructing the hearing bones, or  ossicles , as a result of infection, or by replacing the stapes bone with a  stapedectomy  for  otosclerosis . Otology and neurotology encompass more complex surgery of the inner ear not typically performed by general otolaryngologists, such as removal of vestibular schwannoma,  cholesteatoma ,  labyrinthectomy , surgery of the  endolymphatic sac  for  M\u00e9ni\u00e8re's disease  and  cochlear implant  surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3211", "text": "It is more and more common in the United States as well as around the world for  otolaryngologists  to obtain additional advanced training in neurotology, which requires an additional one or two years of fellowship training after the usual five years of  residency ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3212", "text": "Conditions treated by neurotologists include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3213", "text": "A  nosebleed , also known as  epistaxis , is an instance of  bleeding  from the  nose . [ 1 ]   Blood  can flow down into the stomach, and cause  nausea  and  vomiting . [ 8 ]  In more severe cases, blood may come out of both  nostrils . [ 9 ]  Rarely, bleeding may be so significant that  low blood pressure  occurs. [ 1 ]  Blood may also be forced to flow up and through the  nasolacrimal duct  and out of the eye, producing  bloody tears . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3214", "text": "Risk factors include trauma, including putting the finger in the nose,  blood thinners ,  high blood pressure ,  alcoholism ,  seasonal allergies , dry weather, and  inhaled corticosteroids . [ 3 ]  There are two types: anterior, which is more common; and posterior, which is less common but more serious. [ 3 ]  Anterior nosebleeds generally occur from  Kiesselbach's plexus  while posterior bleeds generally occur from the  sphenopalatine artery  or  Woodruff's plexus . [ 3 ]  The diagnosis is by direct observation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3215", "text": "Prevention may include the use of  petroleum jelly  in the nose. [ 4 ]  Initially, treatment is generally the application of pressure for at least five minutes over the lower half of the nose. [ 5 ]  If this is not sufficient,  nasal packing  may be used. [ 5 ]   Tranexamic acid  may also be helpful. [ 6 ]  If bleeding episodes continue,  endoscopy  is recommended. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3216", "text": "About 60% of people have a nosebleed at some point in their life. [ 7 ]  About 10% of nosebleeds are serious. [ 7 ]  Nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. [ 11 ]  Nosebleeds most commonly affect those younger than 10 and older than 50. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3217", "text": "Nosebleeds can occur due to a variety of reasons. Some of the most common causes include trauma from  nose picking , blunt trauma (such as a motor vehicle accident), or insertion of a foreign object (more likely in children). [ 4 ]  Low  relative humidity  (such as in centrally heated buildings),  respiratory tract infections ,  chronic sinusitis ,  rhinitis  or environmental  irritants  can cause inflammation and thinning of the tissue in the nose, leading to a greater likelihood of bleeding from the nose. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3218", "text": "Most causes of nose bleeding are self-limiting and do not require medical attention. However, if nosebleeds are recurrent or do not respond to home therapies, an underlying cause may need to be investigated. Some rarer causes are listed below: [ 2 ] [ 4 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3219", "text": "Coagulopathy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3220", "text": "Dietary"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3221", "text": "Inflammatory"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3222", "text": "Medications/Drugs"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3223", "text": "Neoplastic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3224", "text": "Traumatic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3225", "text": "Vascular"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3226", "text": "The nasal  mucosa  contains a rich blood supply that can be easily ruptured and cause bleeding. Rupture may be spontaneous or initiated by trauma. Nosebleeds are reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50 and appear to occur in males more than females. [ 15 ]  An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis. [ 16 ]   Anticoagulant  medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nosebleeds as their blood vessels are less able to constrict and control the bleeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3227", "text": "The vast majority of nosebleeds occur in the front  anterior  (front) part of the nose from the  nasal septum . This area is richly endowed with blood vessels ( Kiesselbach's plexus ). This region is also known as  Little's area . Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from  Woodruff's plexus , a venous plexus situated in the posterior part of inferior meatus. [ 17 ]  Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3228", "text": "Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Such bleeding is called \"pseudoepistaxis\" ( pseudo  +  epistaxis ). Examples include  blood coughed up  through the  airway  and ending up in the nasal cavity, then dripping out."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3229", "text": "People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying  petroleum jelly  to the nasal  nares . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3230", "text": "Individuals who suffer from nosebleeds regularly, especially children, are encouraged to use over-the-counter nasal saline sprays and avoid vigorous nose-blowing as preventative measures. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3231", "text": "Most anterior nosebleeds can be stopped by applying  direct pressure , which helps by promoting blood  clots . [ 4 ]  Those who have a nosebleed should first attempt to blow out any blood  clots  and then apply pressure to the soft anterior part of the nose (by pinching the  nasal ala ; not the bony  nasal bridge ) for at least five minutes and up to 30 minutes. [ 4 ]  Pressure should be firm and tilting the head forward helps decrease the chance of nausea and airway obstruction due to blood dripping into the airway. [ 15 ]  When attempting to stop a nosebleed at home, the head should not be tilted back. [ 2 ]  Swallowing excess blood can irritate the stomach and cause vomiting.  Vasoconstrictive  medications such as  oxymetazoline  (Afrin) or  phenylephrine  are widely available over the counter for treatment of  allergic rhinitis  and may also be used to control benign cases of epistaxis. [ 19 ]  For example, a few sprays of  oxymetazoline  may be applied into the bleeding side(s) of the nose followed by application of direct pressure. Those with nosebleeds that last longer than 30 minutes (despite use of direct pressure and vasoconstrictive medications such as  oxymetazoline ) should seek medical attention. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3232", "text": "This method involves applying a chemical such as  silver nitrate  to the nasal mucosa, which burns and seals off the bleeding. [ 12 ]  Eventually the nasal tissue to which the chemical is applied will undergo  necrosis . [ 12 ]  This form of treatment is best for mild bleeds, especially in children, that are clearly visible. [ 12 ]  A topical anesthetic (such as  lidocaine ) is usually applied prior to cauterization. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time. [ 20 ]  Once the  silver nitrate  is deposited,  saline  may be used to neutralize any excess  silver nitrate  via formation of  silver chloride  precipitate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3233", "text": "If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment. [ 21 ]  Nasal packing is typically categorized into anterior nasal packing and posterior nasal packing. [ 22 ]  Nasal packing may also be categorized into dissolvable and non-dissolvable types."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3234", "text": "Dissolvable nasal packing materials stop bleeding through use of thrombotic agents that promote blood clots, such as  surgicel  and  gelfoam . [ 4 ]  The thrombogenic foams and gels do not require removal and dissolve after a few days. Typically, dissolvable nasal packing is first attempted; if the bleeding persists, non-dissolvable nasal packing is the next option."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3235", "text": "Traditionally, nasal packing was accomplished by packing gauze into the nose, thereby placing pressure on the vessels in the nose and stopping the bleeding. Traditional gauze packing has been replaced with other non-dissolvable nasal packing products such as  Merocel  and the Rapid Rhino. [ 21 ]  The Merocel nasal tampon is similar to gauze packing except it is a synthetic foam polymer (made of polyvinyl alcohol and expands in the nose after application of water) that provides a less hospitable medium for bacteria. [ 4 ]  The Rapid Rhino stops nosebleeds using a balloon catheter, made of  carboxymethylcellulose , which has a cuff that is inflated by air to stop bleeding through extra pressure in the nasal cavity. [ 21 ]  Systematic review articles have demonstrated that the efficacy in stopping nosebleeds is similar between the Rapid Rhino and  Merocel  packs; however, the Rapid Rhino has been shown to have greater ease of insertion and reduced discomfort. [ 21 ]  Posterior nasal packing can be achieved by using a  Foley catheter , blowing up the balloon when it is in the back of the throat, and applying anterior traction so that the inflated balloon occludes the  choanae . [ 22 ]  Patients who receive non-dissolvable nasal packing need to return to a medical professional in 24\u201372 hours in order to have packing removed. [ 4 ] [ 3 ]  Complications of non-dissolvable nasal packing include  abscesses ,  septal hematomas ,  sinusitis , and pressure necrosis. [ 2 ]  In rare cases  toxic shock syndrome  can occur with prolonged nasal packing. As a result, any patient who has non-dissolvable nasal packing should be given prophylactic antibiotic medication to be taken as long as the nasal packing remains in the nose. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3236", "text": "Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the  sphenopalatine , anterior and posterior ethmoidal arteries. More rarely the maxillary or a branch of the external  carotid artery  can be ligated. The bleeding can also be stopped by intra-arterial  embolization  using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an  interventional radiologist . [ 23 ]  There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive. [ 24 ]  Continued bleeding may be an indication of more serious underlying conditions. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3237", "text": "Tranexamic acid  helps promote blood clotting. [ 6 ]  For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3238", "text": "The utility of local cooling of the head and neck is controversial. [ 25 ]  Some state that applying ice to the nose or forehead is not useful. [ 26 ] [ 27 ]  Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful. [ 28 ]  In Indonesian traditional medicine, betel leaf is used to stop nosebleeds as it contains tannin which causes blood to coagulate, thus stopping active bleeding. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3239", "text": "In the visual language of Japanese  manga  and  anime , nosebleeding often indicates that the bleeding person is sexually aroused. [ 30 ] [ 31 ] [ 32 ]  In  Western fiction , nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers. [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3240", "text": "In American and Canadian usage, \" nosebleed section \" and \"nosebleed seats\" are common slang for seating at sporting or other spectator events that are the highest up and farthest away from the event. The reference alludes to the propensity for nasal hemorrhage at high altitudes, usually owing to lower barometric pressure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3241", "text": "The oral history of the Native American  Sioux  tribe includes reference to women who experience nosebleeds as a result of a lover's playing of music, implying sexual arousal. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3242", "text": "In the  Finnish language , \"picking blood from one's nose\" and \"begging for a nosebleed\" are commonly used in abstract meaning to describe self-destructive behaviour, for example ignoring safety procedures or deliberately aggravating stronger parties. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3243", "text": "In  Filipino  slang, to \"have a nosebleed\" is to have serious difficulty conversing in English with a fluent or native English speaker. It can also refer to anxiety brought on by a stressful event such as an  examination  or a  job interview . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3244", "text": "In the  Dutch language , \"pretending to have a nosebleed\" is a saying that means pretending not to know anything about something. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3245", "text": "The word  epistaxis  is from  Ancient Greek :  \u1f10\u03c0\u03b9\u03c3\u03c4\u03ac\u03b6\u03c9   epistazo , \"to bleed from the nose\" from  \u1f10\u03c0\u03af   epi , \"above, over\" and  \u03c3\u03c4\u03ac\u03b6\u03c9   stazo , \"to drip [from the nostrils]\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3246", "text": "A  nostril  (or  naris   / \u02c8 n \u025b\u0259r \u026a s / ,  pl. :  nares   / \u02c8 n \u025b\u0259r i\u02d0 z / ) is either of the two  orifices  of the  nose . They enable the entry and exit of air and other gasses through the  nasal cavities .  In  birds  and  mammals , they contain branched bones or cartilages called  turbinates , whose function is to warm air on inhalation and remove moisture on exhalation.  Fish  do not breathe through noses, but they do have two small holes used for  smelling , which can also be referred to as nostrils (with the exception of  Cyclostomi , which have just one nostril)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3247", "text": "In  humans , the  nasal cycle  is the normal  ultradian cycle  of each nostril's blood vessels becoming engorged in swelling, then shrinking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3248", "text": "The nostrils are separated by the  septum . The septum can sometimes be  deviated , causing one nostril to appear larger than the other.  With extreme damage to the septum and columella, the two nostrils are no longer separated and form a single larger external opening."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3249", "text": "Like other  tetrapods , humans have two external nostrils (anterior nares) and two additional nostrils at the back of the nasal cavity, inside the head (posterior nares, posterior nasal apertures or  choanae ). They also connect the nose to the throat (the nasopharynx), aiding in respiration. Though all four nostrils were on the outside of the head of the aquatic ancestors of modern tetrapods, the nostrils for outgoing water (excurrent nostrils) migrated to the inside of the mouth, as evidenced by the discovery of  Kenichthys campbelli , a 395-million-year-old fossilized  lobe-finned fish  which shows this migration in progress. It has two nostrils between its front teeth, similar to human  embryos  at an early stage. If these fail to join up, the result is a  cleft palate . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3250", "text": "Each external nostril contains approximately 1,000 strands of  nasal hair , which function to filter foreign particles such as pollen and dust. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3251", "text": "It is possible for humans to smell different  olfactory  inputs in the two nostrils and experience a perceptual rivalry akin to that of  binocular rivalry  when there are two different inputs to the two eyes. [ 3 ]  Furthermore, scent information from the two nostrils leads to two types of neural activity [ 4 ]  with the first cycle corresponding to the ipsilateral and the second cycle corresponding to the contralateral odor representations.  In some cultures the extreme wide flaring of the nostrils accompanied by the baring of the upper teeth is often referred to as \"doing the nostrils.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3252", "text": "The  Procellariiformes  are distinguished from other birds by having tubular extensions of their nostrils."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3253", "text": "Widely-spaced nostrils, like those of the  hammerhead shark , may be useful in determining the direction of an odour's source. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3254", "text": "The  occipital artery  is a branch of the  external carotid artery  that provides arterial supply to the back of the scalp,  sternocleidomastoid  muscles, and deep muscles of the back and neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3255", "text": "The occipital artery arises from (the posterior aspect of) the  external carotid artery  (some 2 cm distal to the origin of the external carotid artery). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3256", "text": "At its origin, the  hypoglossal nerve (CN XII)  crosses artery superficially as the nerve passes posteroanteriorly. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3257", "text": "The artery passes superoposteriorly deep to the posterior belly of the  digastricus muscle . It crosses the  internal carotid artery  and  vein , the  vagus nerve (CN X) ,  accessory nerve (CN XI) , and  hypoglossal nerve (CN XII) . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3258", "text": "It next ascends to the interval between the transverse process of the  atlas  and the  mastoid process  of the  temporal bone , and passes horizontally backward, grooving the surface of the latter bone, being covered by the  sternocleidomastoideus ,  splenius capitis ,  longissimus capitis , and  digastricus , and resting upon the  rectus capitis lateralis , the  obliquus superior , and  semispinalis capitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3259", "text": "It then changes its course and runs vertically upward, pierces the fascia connecting the cranial attachment of the  trapezius  with the  sternocleidomastoideus , and ascends in a tortuous course in the superficial fascia of the scalp, where it divides into numerous branches, which reach as high as the  vertex of the skull  and  anastomose  with the  posterior auricular  and  superficial temporal  arteries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3260", "text": "Its terminal portion is accompanied by the  greater occipital nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3261", "text": "The  occipitalis muscle  ( occipital belly ) is a  muscle  which covers parts of the  skull . Some sources consider the occipital muscle to be a distinct muscle. However,  Terminologia Anatomica  currently classifies it as part of the  occipitofrontalis muscle  along with the  frontalis muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3262", "text": "The occipitalis muscle is thin and quadrilateral in form. It arises from tendinous fibers from the lateral two-thirds of the  superior nuchal line  of the  occipital bone  and from the  mastoid process  of the  temporal  and ends in the  epicranial aponeurosis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3263", "text": "The occipitalis muscle is innervated by the  posterior auricular nerve  (a branch of the  facial nerve ) and its function is to move the  scalp  back. [ 2 ]  The muscles receives blood from the  occipital artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3264", "text": "This article incorporates text in the  public domain  from  page 379  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3265", "text": "The  oculomotor nerve , also known as the  third cranial nerve ,  cranial nerve III , or simply  CN III ,  is a  cranial nerve  that enters the  orbit  through the  superior orbital fissure  and innervates  extraocular muscles  that enable most  movements of the eye  and that raise the eyelid.  The nerve also contains fibers that innervate the  intrinsic eye muscles  that enable pupillary constriction and accommodation (ability to focus on near objects as in reading). The oculomotor nerve is derived from the  basal plate  of the  embryonic   midbrain . Cranial nerves  IV  and  VI  also participate in control of  eye movement . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3266", "text": "The oculomotor nerve originates from the third nerve  nucleus  at the level of the  superior colliculus  in the midbrain. The third nerve nucleus is located ventral to the  cerebral aqueduct , on the pre-aqueductal  grey matter . The fibers from the two third nerve nuclei located laterally on either side of the cerebral aqueduct then pass through the  red nucleus . From the red nucleus fibers then pass via the  substantia nigra [ citation needed ]  to emerge from the substance of the brainstem at the oculomotor sulcus (a groove on the lateral wall of the  interpeduncular fossa ). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3267", "text": "On emerging from the  brainstem , the nerve is invested with a sheath of  pia mater , and enclosed in a prolongation from the  arachnoid . It passes between the  superior cerebellar  (below) and  posterior cerebral  arteries (above), and then pierces the dura mater anterior and lateral to the  posterior clinoid process , passing between the free and attached borders of the  tentorium cerebelli . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3268", "text": "It traverses the  cavernous sinus , above the other orbital nerves receiving in its course one or two filaments from the  cavernous plexus  of the sympathetic nervous system, and a communicating branch from the  ophthalmic division  of the  trigeminal  nerve. As the oculomotor nerve enters the orbit via the  superior orbital fissure  it then divides into a superior and an inferior branch. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3269", "text": "The  superior branch  of the oculomotor nerve or the  superior division , the smaller, passes medially over the  optic nerve . It supplies the  superior rectus  and  levator palpebrae superioris ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3270", "text": "The  inferior branch  of the oculomotor nerve or the  inferior division , the larger, divides into three branches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3271", "text": "All these branches enter the muscles on their ocular surfaces, with the exception of the nerve to the inferior oblique, which enters the muscle at its posterior border."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3272", "text": "The oculomotor nerve (CN III) arises from the anterior aspect of the  mesencephalon  (midbrain). There are two nuclei for the oculomotor nerve:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3273", "text": "Sympathetic postganglionic fibres also join the nerve from the plexus on the internal carotid artery in the wall of the cavernous sinus and are distributed through the nerve, e.g., to the smooth muscle of superior tarsal (Mueller's) muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3274", "text": "The oculomotor nerve includes axons of type GSE,  general somatic efferent , which innervate skeletal muscle of the levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique muscles. (Innervates all the extrinsic muscles except superior oblique and lateral rectus.)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3275", "text": "The nerve also includes axons of type GVE,  general visceral efferent , which provide preganglionic parasympathetics to the ciliary ganglion. From the ciliary ganglion postganglionic fibers pass through the short ciliary nerve to the constrictor pupillae of the iris and the ciliary muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3276", "text": "Paralysis of the oculomotor nerve, i.e.,  oculomotor nerve palsy , can arise due to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3277", "text": "In people with  diabetes  and older than 50 years of age, an oculomotor nerve palsy, in the classical sense, occurs with sparing (or preservation) of the pupillary reflex.  This is thought to arise due to the anatomical arrangement of the  nerve fibers  in the oculomotor nerve; fibers controlling the pupillary function are superficial and spared from  ischemic  injuries typical of diabetes.  On the converse, an aneurysm which leads to compression of the oculomotor nerve affects the superficial fibers and manifests as a third nerve palsy with loss of the pupillary reflex (in fact, this third nerve finding is considered to represent an aneurysm\u2014until proven otherwise\u2014and should be investigated). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3278", "text": "Cranial nerves III, IV, and VI are usually tested together as part of the  cranial nerve examination . The examiner typically instructs the patient to hold his head still and follow only with the eyes a finger or penlight that circumscribes a large \"H\" in front of the patient. By observing the  eye movement  and  eyelids , the examiner is able to obtain more information about the  extraocular muscles , the  levator palpebrae superioris muscle , and cranial nerves III, IV, and VI. Loss of function of any of the eye muscles results in  ophthalmoparesis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3279", "text": "Since the oculomotor nerve controls most of the eye muscles, it may be easier to detect damage to it.  Damage to this nerve, termed  oculomotor nerve palsy , is known by its  down and out  symptoms, because of the position of the affected eye (lateral, downward deviation of gaze)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3280", "text": "The oculomotor nerve also controls the constriction of the  pupils  and thickening of the lens of the eye. This can be tested in two main ways. By moving a finger toward a person's face to induce  accommodation , their pupils should constrict."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3281", "text": "Shining a light into one eye should result in equal constriction of the other eye. Fibers from the optic nerves  cross over  in the optic chiasm with some fibers passing to the contralateral optic nerve tract. This is the basis of the \" swinging-flashlight test \"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3282", "text": "Loss of  accommodation  and continued pupillary dilation can indicate the presence of a lesion on the oculomotor nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3283", "text": "This article incorporates text in the  public domain  from  page 884  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3284", "text": "The  olfactory bulb  ( Latin :  bulbus olfactorius ) is a  neural structure  of the  vertebrate   forebrain  involved in  olfaction , the sense of  smell . It sends olfactory information to be further processed in the  amygdala , the  orbitofrontal cortex  (OFC) and the  hippocampus  where it plays a role in emotion, memory and learning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3285", "text": "The bulb is divided into two distinct structures: the main olfactory bulb and the accessory olfactory bulb. The main olfactory bulb connects to the amygdala via the  piriform cortex  of the  primary olfactory cortex  and directly projects from the main olfactory bulb to specific amygdala areas. The accessory olfactory bulb resides on the dorsal-posterior region of the main olfactory bulb and forms a parallel pathway."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3286", "text": "Destruction of the olfactory bulb results in  ipsilateral   anosmia , while irritative  lesions  of the  uncus  can result in olfactory and  gustatory  hallucinations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3287", "text": "In most vertebrates, the olfactory bulb is the most  rostral  (forward) part of the brain, as seen in rats. In humans, however, the olfactory bulb is on the  inferior  (bottom) side of the brain. The olfactory bulb is supported and protected by the  cribriform plate  of the  ethmoid bone , which in mammals separates it from the  olfactory epithelium , and which is perforated by  olfactory nerve  axons. The bulb is divided into two distinct structures: the main olfactory bulb and the accessory olfactory bulb."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3288", "text": "The main olfactory bulb has a multi-layered  cellular architecture . In order from surface to the center the layers are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3289", "text": "The olfactory bulb transmits smell information from the nose to the brain, and is thus necessary for a proper sense of smell. As a  neural circuit , the glomerular layer receives direct input from  afferent nerves , made up of the axons from approximately ten million  olfactory receptor neurons  in the  olfactory mucosa , a region of the  nasal cavity . The ends of the axons cluster in spherical structures known as  glomeruli  such that each glomerulus receives input primarily from olfactory receptor neurons that express the same  olfactory receptor . The glomeruli layer of the olfactory bulb is the first level of  synaptic processing . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3290", "text": "The glomeruli layer represents a spatial odor map organized by chemical structure of  odorants  like  functional group  and carbon chain length.  This spatial map is divided into zones and clusters, which represent similar glomeruli and therefore similar odors.  One cluster in particular is associated with rank, spoiled smells which are represented by certain chemical characteristics.  This classification may be evolutionary to help identify food that is no longer good to eat. The spatial map of the glomeruli layer may be used for perception of odor in the olfactory cortex. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3291", "text": "The next level of synaptic processing in the olfactory bulb occurs in the external plexiform layer, between the glomerular layer and the mitral cell layer.  The external plexiform layer contains  astrocytes ,  interneurons  and some mitral cells.  It does not contain many  cell bodies , rather mostly  dendrites  of mitral cells and GABAergic granule cells  [ 3 ]  are also permeated by dendrites from neurons called  mitral cells , which in turn output to the  olfactory cortex . Numerous interneuron types exist in the olfactory bulb including  periglomerular cells  which synapse within and between glomeruli, and granule cells which synapse with mitral cells.  The granule cell layer is the deepest layer in the olfactory bulb.  It is made up of dendrodendritic granule cells that synapse to the mitral cell layer. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3292", "text": "This part of the brain receives sensations of smell.\nAs a neural circuit, the olfactory bulb has one source of sensory input (axons from olfactory receptor neurons of the olfactory epithelium), and one output (mitral cell axons).  As a result, it is generally assumed that it functions as a  filter , as opposed to an associative circuit that has many inputs and many outputs. However, the olfactory bulb also receives \"top-down\" information from such brain areas as the  olfactory cortex ,   amygdala ,  neocortex ,  hippocampus ,  locus coeruleus , and  substantia nigra . [ 5 ] \nIts potential functions can be placed into four non-exclusive categories: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3293", "text": "While all of these functions could theoretically arise from the olfactory bulb's circuit layout, it is unclear which, if any, of these functions are performed exclusively by the olfactory bulb. By analogy to similar parts of the brain such as the  retina , many researchers have focused on how the olfactory bulb filters incoming information from receptor neurons in space, or how it filters incoming information in time.  At the core of these proposed filters are the two classes of interneurons; the periglomerular cells, and the granule cells.  Processing occurs at each level of the main olfactory bulb, beginning with the spatial maps that categorize odors in the glomeruli layer. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3294", "text": "Interneurons in the external plexiform layer are responsive to pre-synaptic action potentials and exhibit both  excitatory postsynaptic potentials  and  inhibitory postsynaptic potentials .  Neural firing varies temporally, there are periods of fast, spontaneous firing and slow modulation of firing.  These patterns may be related to sniffing or change in intensity and concentration of odorant. [ 3 ]  Temporal patterns may have effect in later processing of spatial awareness of odorant. [ citation needed ]  For example, synchronized mitral cell spike trains appear to help to discriminate similar odors better than when those spike trains are not synchronized. [ 6 ]  A well known model [ 7 ]  is that the bulbar neural circuit transforms the odor information in the receptors to a population pattern of neural oscillatory activities [ 8 ]  in the mitral cell population, [ 7 ]  and this pattern is then recognized by the associative memories of olfactory objects in the olfactory cortex. [ 9 ] [ 10 ]  Top-down feedback from the olfactory cortex to the olfactory bulb modulates the bulbar responses, so that, for example, the bulb can adapt to a pre-existing olfactory background to single out a foreground odor from an odor mixture for recognition, [ 10 ] [ 11 ]  or can enhance sensitivity to a target odor during odor search. [ 12 ] [ 10 ]   Destruction to the olfactory bulb results in  ipsilateral   anosmia  while irritative  lesion  of the  uncus  can result in olfactory and  gustatory  hallucinations. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3295", "text": "The interneurons in the external plexiform layer perform feedback inhibition on the mitral cells to control  back propagation .  They also participate in  lateral inhibition  of the mitral cells. This inhibition is an important part of olfaction as it aids in odor discrimination by decreasing firing in response to background odors and differentiating the responses of olfactory nerve inputs in the mitral cell layer. [ 1 ]   Inhibition of the mitral cell layer by the other layers contributes to odor discrimination and higher level processing by modulating the output from the olfactory bulb.  These hyperpolarizations during odor stimulation shape the responses of the mitral cells to make them more specific to an odor. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3296", "text": "There is a lack of information regarding the function of the internal plexiform layer which lies between the mitral cell layer and the granule cell layer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3297", "text": "The basal  dendrites  of  mitral cells  are connected to interneurons known as  granule cells , which by some theories produce  lateral inhibition  between mitral cells.  The synapse between mitral and granule cells is of a rare class of synapses that are \"dendro-dendritic\" which means that both sides of the synapse are dendrites that release neurotransmitter.  In this specific case, mitral cells release the excitatory neurotransmitter  glutamate , and granule cells release the inhibitory neurotransmitter  Gamma-aminobutyric acid  (GABA).  As a result of its bi-directionality, the dendro-dendritic synapse can cause mitral cells to inhibit themselves (auto-inhibition), as well as neighboring mitral cells (lateral inhibition).  More specifically, the granule cell layer receives excitatory glutamate signals from the basal dendrites of the mitral and tufted cells.  The granule cell in turn releases GABA to cause an inhibitory effect on the mitral cell.  More neurotransmitter is released from the activated mitral cell to the connected dendrite of the granule cell, making the inhibitory effect from the granule cell to the activated mitral cell stronger than the surrounding mitral cells. [ 4 ]   It is not clear what the functional role of lateral inhibition would be, though it may be involved in boosting the signal-to-noise ratio of odor signals by silencing the basal firing rate of surrounding non-activated neurons.  This in turn aids in odor discrimination. [ 1 ]   Other research suggest that the lateral inhibition contributes to differentiated odor responses, which aids in the processing and perception of distinct odors. [ 4 ]  There is also evidence of cholinergic effects on granule cells that enhance depolarization of granule cells making them more excitable which in turn increases inhibition of mitral cells.  This may contribute to a more specific output from the olfactory bulb that would closer resemble the glomerular odor map. [ 13 ] [ 14 ] \nOlfaction is distinct from the other  sensory systems  where peripheral  sensory receptors  have a relay in the  diencephalon . Therefore, the olfactory bulb plays this role for the   olfactory system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3298", "text": "In vertebrates, the accessory olfactory bulb (AOB), which resides on the dorsal-posterior region of the main olfactory bulb, forms a parallel pathway independent from the main olfactory bulb. The  vomeronasal organ  sends projections to the accessory olfactory bulb [ 15 ] [ 16 ]  making it the second processing stage of the  accessory olfactory system . As in the main olfactory bulb, axonal input to the accessory olfactory bulb forms synapses with mitral cells within glomeruli. The accessory olfactory bulb receives axonal input from the  vomeronasal organ , a distinct sensory epithelium from the main  olfactory epithelium  that detects chemical stimuli relevant for social and reproductive behaviors, but probably also generic odorants. [ 17 ]  It has been hypothesized that, in order for the vomernasal pump to turn on, the main olfactory epithelium must first detect the appropriate odor. [ 18 ]  However, the possibility that the vomeronasal system works in parallel or independently from generic olfactory inputs has not been ruled out yet."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3299", "text": "Vomeronasal sensory neurons provide direct excitatory inputs to AOB principle neurons called mitral cells [ 19 ]  which are transmitted to the  amygdala  and  hypothalamus  and therefore are directly involved in sex hormone activity and may influence aggressiveness and mating behavior. [ 20 ]  Axons of the vomeronasal sensory neurons express a given receptor type which, differently from what occurs in the main olfactory bulb, diverge between 6 and 30 AOB glomeruli. Mitral cell dendritic endings go through a dramatic period of targeting and clustering just after presynaptic unification of the sensory neuron axons. The connectivity of the vomernasal sensorglomery neurons to mitral cells is precise, with mitral cell dendrites targeting the  glomeruli . [ 19 ]  There is evidence against the presence of a functional accessory olfactory bulb in humans and other higher primates. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3300", "text": "The AOB is divided into two main subregions, anterior and posterior, which receive segregated synaptic inputs from two main categories of vomeronasal sensory neurons, V1R and V2R, respectively. This appears as a clear functional specialization, given the differential role of the two populations of sensory neurons in detecting chemical stimuli of different type and molecular weight. Although it doesn't seem to be maintained centrally, where mitral cell projections from both sides of the AOB converge. A clear difference of the AOB circuitry, compared to the rest of the bulb, is its heterogeneous connectivity between mitral cells and vomeronasal sensory afferents within neuropil glomeruli. AOB mitral cells indeed contact through apical dendritic processes glomeruli formed by afferents of different receptor neurons, thus breaking the one-receptor-one-neuron rule which generally holds for the main olfactory system. This implies that stimuli sensed through the VNO and elaborated in the AOB are subjected to a different and probably more complex level of elaboration. Accordingly, AOB mitral cells show clearly different firing patterns compared to other bulbar projection neurons. [ 22 ]  Additionally, top down input to the olfactory bulb differentially affects olfactory outputs. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3301", "text": "The olfactory bulb sends olfactory information to be further processed in the  amygdala , the  orbitofrontal cortex  (OFC) and the  hippocampus  where it plays a role in emotion, memory and learning.  The main olfactory bulb connects to the amygdala via the  piriform cortex  of the  primary olfactory cortex  and directly projects from the main olfactory bulb to specific amygdala areas. [ 24 ]  The amygdala passes olfactory information on to the  hippocampus .  The orbitofrontal cortex, amygdala, hippocampus,  thalamus , and olfactory bulb have many interconnections directly and indirectly through the cortices of the primary olfactory cortex.  These connections are indicative of the association between the olfactory bulb and higher areas of processing, specifically those related to emotion and memory. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3302", "text": "Associative learning  between odors and behavioral responses takes place in the  amygdala .  The odors serve as the reinforcers or the punishers during the associative learning process; odors that occur with positive states reinforce the behavior that resulted in the positive state while odors that occur with negative states do the opposite. Odor cues are coded by neurons in the amygdala with the behavioral effect or emotion that they produce.  In this way odors reflect certain emotions or physiological states. [ 25 ]  Odors become associated with pleasant and unpleasant responses, and eventually the odor becomes a cue and can cause an emotional response.  These odor associations contribute to emotional states such as fear.  Brain imaging shows amygdala activation correlated with pleasant and unpleasant odors, reflecting the association between odors and emotions. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3303", "text": "The  hippocampus  aids in olfactory memory and learning as well.  Several olfaction-memory processes occur in the hippocampus.  Similar to the process in the amygdala, an odor is associated with a particular reward, i.e. the smell of food with receiving sustenance. [ 26 ]   Odor in the hippocampus also contributes to the formation of  episodic memory ; the memories of events at a specific place or time.  The time at which certain neurons fire in the hippocampus is associated by neurons with a stimulus such as an odor.  Presentation of the odor at a different time may cause recall of the memory, therefore odor aids in recall of episodic memories. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3304", "text": "In lower vertebrates (lampreys and teleost fishes), mitral cell (principal olfactory neurons) axons project exclusively to the right hemisphere of Habenula in an asymmetric manner. It is reported that dorsal Habenula (Hb) are functional asymmetric with predominant odor responses in right hemisphere. It was also shown that Hb neurons are spontaneous active even in absence of olfactory stimulation. These spontaneous active Hb neurons are organized into functional clusters which were proposed to govern olfactory responses. (Jetti, SK. et al. 2014, Current Biology)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3305", "text": "Further evidence of the link between the olfactory bulb and emotion and memory is shown through  animal depression models . Olfactory bulb removal in rats effectively causes structural changes in the amygdala and hippocampus and behavioral changes similar to that of a person with depression. Researchers use rats with olfactory bulbectomies to research antidepressants. [ 27 ]  Research has shown that removal of the olfactory bulb in rats leads to  dendrite  reorganization, disrupted cell growth in the hippocampus, and decreased  neuroplasticity  in the hippocampus. These hippocampal changes due to olfactory bulb removal are associated with behavioral changes characteristic of depression, demonstrating the correlation between the olfactory bulb and emotion. [ 28 ]  The hippocampus and amygdala affect odor perception. During certain physiological states such as hunger a food odor may seem more pleasant and rewarding due to the associations in the amygdala and hippocampus of the food odor stimulus with the reward of eating. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3306", "text": "Olfactory information is sent to the primary olfactory cortex, where projections are sent to the  orbitofrontal cortex . The OFC contributes to this odor-reward association as well as it assesses the value of a reward, i.e. the nutritional value of a food.  The OFC receives projections from the  piriform cortex , amygdala, and parahippocampal cortices. [ 25 ]  Neurons in the OFC that encode food reward information activate the reward system when stimulated, associating the act of eating with reward.  The OFC further projects to the  anterior cingulate cortex  where it plays a role in appetite. [ 29 ]   The OFC also associates odors with other stimuli, such as taste. [ 25 ]  Odor perception and discrimination also involve the OFC.  The spatial odor map in the glomeruli layer of the olfactory bulb may contribute to these functions.  The odor map begins processing of olfactory information by spatially organizing the glomeruli.  This organizing aids the olfactory cortices in its functions of perceiving and discriminating odors. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3307", "text": "The olfactory bulb is, along with both the  subventricular zone  and the subgranular zone of the dentate gyrus of the hippocampus, one of only three structures in the brain observed to undergo continuing  neurogenesis  in adult mammals. [ citation needed ]  In most mammals, new neurons are born from neural stem cells in the sub-ventricular zone and migrate rostrally towards the main  [ 30 ]  and accessory [ 31 ]    olfactory bulbs. Within the olfactory bulb these immature neuroblasts develop into fully functional granule cell interneurons and periglomerular cell interneurons that reside in the granule cell layer and glomerular layers, respectively.  The olfactory sensory neuron axons that form synapses in olfactory bulb glomeruli are also capable of regeneration following regrowth of an olfactory sensory neuron residing in the olfactory epithelium.  Despite dynamic turnover of sensory axons and interneurons, the projection neurons (mitral and tufted neurons) that form synapses with these axons are not structurally plastic. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3308", "text": "The function of adult neurogenesis in this region remains a matter of study.  The survival of immature neurons as they enter the circuit is highly sensitive to olfactory activity and in particular associative learning tasks.  This has led to the hypothesis that new neurons participate in learning processes. [ 32 ]   No definitive behavioral effect has been observed in loss-of-function experiments suggesting that the function of this process, if at all related to olfactory processing, may be subtle. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3309", "text": "The olfactory lobe is a structure of the vertebrate forebrain involved in olfaction, or sense of smell. Destruction of the olfactory bulb results in ipsilateral  anosmia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3310", "text": "Comparing the structure of the olfactory bulb among vertebrate species, such as the  leopard frog  and the  lab mouse , reveals that they all share the same fundamental layout (five layers containing the nuclei of three major cell types; see \"Anatomy\" for details), despite being dissimilar in shape and size.  A similar structure is shared by the analogous olfactory center in the fruit fly  Drosophila melanogaster , the  antennal lobe .  One possibility is that vertebrate olfactory bulb and insect antennal lobe structure may be similar because they contain an optimal solution to a  computational problem  experienced by all olfactory systems and thus may have evolved independently in different phyla \u2013 a phenomenon generally known as  convergent evolution . [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3311", "text": "\"The increase of brain size relative to body size\u2014 encephalization \u2014is intimately linked with human evolution. However, two genetically different evolutionary lineages,  Neanderthals  and  modern humans , have produced similarly large-brained human species. Thus, understanding human brain evolution should include research into specific cerebral reorganization, possibly reflected by brain shape changes. Here we exploit developmental integration between the brain and its underlying skeletal base to test hypotheses about brain evolution in  Homo . Three-dimensional geometric morphometric analyses of endobasicranial shape reveal previously undocumented details of evolutionary changes in  Homo sapiens . Larger olfactory bulbs, relatively wider orbitofrontal cortex, relatively increased and forward projecting temporal lobe poles appear unique to modern humans. Such brain reorganization, beside physical consequences for overall skull shape, might have contributed to the evolution of  H. sapiens'  learning and social capacities, in which higher olfactory functions and its cognitive, neurological behavioral implications could have been hitherto underestimated factors.\" [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3312", "text": "The  olfactory epithelium  is a specialized  epithelial  tissue inside the  nasal cavity  that is involved in  smell . In humans, it measures\n5\u00a0cm 2  (0.78\u00a0sq\u00a0in) [ 1 ]  and lies on the roof of the nasal cavity about 7\u00a0cm (2.8\u00a0in) above and behind the nostrils. [ 2 ]  The olfactory epithelium is the part of the  olfactory system  directly responsible for detecting  odors ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3313", "text": "Olfactory epithelium consists of four distinct cell types: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3314", "text": "The  olfactory receptor neurons  are sensory neurons of the olfactory epithelium. They are  bipolar neurons  and their apical poles express odorant receptors on  non-motile cilia  at the ends of the  dendritic knob ,  [ 4 ]  which extend out into the airspace to interact with odorants. Odorant receptors bind odorants in the airspace, which are made soluble by the serous secretions from  olfactory glands  located in the lamina propria of the mucosa. [ 5 ]  The axons of the olfactory sensory neurons congregate to form the  olfactory nerve  (CN I). Once the axons pass through the  cribriform plate , they terminate and synapse with the dendrites of  mitral cells  in the  glomeruli  of the  olfactory bulb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3315", "text": "Analogous to neural  glial cells , the supporting cells are non-neural cells in the olfactory epithelium that are located in the apical layer of the pseudostratified ciliated columnar epithelium. There are two types of supporting cells in the olfactory epithelium:  sustentacular cells  and microvillar cells. The sustentacular cells function as metabolic and physical support for the olfactory epithelium. Microvillar cells are another class of supporting cells that are morphologically and biochemically distinct from the sustentacular cells, and arise from a basal cell population that expresses the  c-KIT  cell surface protein. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3316", "text": "Resting on or near the  basal lamina  of the olfactory epithelium, basal cells are stem cells capable of division and differentiation into either supporting or olfactory cells.  While some of these basal cells divide rapidly, a significant proportion remain relatively quiescent and replenish olfactory epithelial cells as needed. This leads to the olfactory epithelium being replaced every 6\u20138 weeks. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3317", "text": "Basal cells  can be divided on the basis of their cellular and histological features into two populations: the horizontal basal cells, which are slowly dividing reserve cells that express p63; and globose basal cells, which are a heterogeneous population of cells consisting of reserve cells, amplifying progenitor cells, and immediate precursor cells. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3318", "text": "A  brush cell  is a microvilli-bearing columnar cell with its basal surface in contact with afferent nerve endings of the  trigeminal nerve  (CN V) and is specialized for transduction of general sensation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3319", "text": "Tubuloalveolar serous secreting glands lying in the lamina propria of the  olfactory mucosa .  These glands deliver a proteinaceous secretion via ducts onto the surface of the mucosa.  The role of the secretions are to trap and dissolve odiferous substances for the bipolar neurons.  Constant flow from the olfactory glands allows old odors to be constantly washed away. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3320", "text": "The olfactory epithelium derives from two structures during  embryonic development : the  nasal placodes , which were long believed to be its sole origin; and  neural crest cells , whose contributions have been identified more recently through  fate mapping  studies. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3321", "text": "The embryonic olfactory epithelium consists of fewer cell types than in the adult, including apical and basal  progenitor cells , as well as immature  olfactory sensory neurons . [ 9 ]  Early embryonic neurogenesis relies mostly on the apical cells, while later stage embryonic  neurogenesis  and secondary neurogenesis in adults relies on basal stem cells. [ 10 ]   The  axons  of the immature  olfactory sensory neurons , along with a mixed population of  migratory cells , including immature  olfactory ensheathing cells  and  gonadotropin-releasing hormone neurons  form a \"migratory mass\" that travels towards the  olfactory bulb . [ 9 ] [ 10 ]  At the end of the embryonic stage, the epithelium develops into a  pseudostratified columnar epithelium  and begins secondary neurogenesis. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3322", "text": "Neurogenic placodes  are transient, focal aggregations of  ectoderm  located in the developmental region of the future  vertebrate   head , and give rise to  sensory organs . [ 11 ]  Early cranial sensory placodes are marked by expression of  Six1 , part of the Six family of transcription factors that regulate the  preplacodal  specification. [ 12 ]  The  olfactory placode  forms as two thickenings of non-neural region of  embryonic ectoderm . [ 13 ]  In mice, the olfactory placode derives from an anterior portion of the  neural tube , ~9-9.5 days into development and not long after the closure of the  neural plate . [ 9 ]  Development of the olfactory placode requires the presence underlying  neural crest -derived  mesenchymal  tissue. [ 12 ]  The specification of the olfactory placode tissue involves signaling of multiple  gene networks , beginning with signals from  bone morphogenetic proteins  (BMP),  retinoic acid  (RA), and  fibroblast growth factor  (FGF), specifically  FGF8 . [ 14 ]  The resulting regulated downstream expression of  transcription factors , such as  Pax6 ,  Dlx3 ,  Sox2 , and others, within the presumptive olfactory placode are crucial for sub-regionalization within the future olfactory epithelium and is responsible for the diversity of cells that compose the future epithelium. [ 9 ] [ 12 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3323", "text": "Similar to the other embryonic placodes, the olfactory placode gives rise to both neural and non-neural structures, ultimately resulting in the formation of the nasal epithelium. [ 16 ]  The specification of neural versus non-neural tissue involves signals both within the olfactory placode, and between the olfactory placode and the underlying  mesenchymal  compartment. [ 12 ]  Continued signaling by BMP, FGF, and RA, the  morphogens  that initially induced placode formation, collectively coordinate the patterning of olfactory placode tissue into the future distinct cell types that make up the olfactory epithelium. [ 16 ]  The cell types derived from the olfactory placode include: [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3324", "text": "However, there is significant evidence for an additional  neural crest -origin for many of these cell types as well. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3325", "text": "Olfaction  results from the proper development and interaction of the two components of the primary  olfactory pathway : the olfactory epithelium and the  olfactory bulb . [ 18 ]  The olfactory epithelium contains  olfactory sensory neurons , whose  axons   innervate  the olfactory bulb. In order for olfactory sensory neurons to function properly, they must express  odorant receptors  and the proper  transduction proteins  on  non-motile cilia  that extend from the  dendritic knob  in addition to projecting their axons to the olfactory bulb. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3326", "text": "The cells of the olfactory epithelium, including olfactory sensory neurons, begin to  differentiate  soon after the induction of the  olfactory placode . Once the olfactory sensory neurons differentiate, they express odorant receptors, which transduce  odorant  information from the environment to the  central nervous system  and aids in the development of the odorant map. [ 20 ]  The differentiated olfactory sensory neurons extend  pioneering axons , which follow  guidance cues  released by the underlying  mesenchyme , as well as other  chemotrophic cues  released from the  telencephalon . [ 10 ]  As development of the olfactory pathway progresses, more axons innervate the olfactory bulb, which develops from the rostral-most region of telencephalon. The organization and subsequent processing of odorant information is possible due to the convergence of olfactory sensory neuron axons expressing the same odorant receptors onto the same  glomerulus  at the olfactory bulb. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3327", "text": "The olfactory epithelium can be damaged by inhalation of toxic fumes, physical injury to the interior of the nose, and possibly by the use of some nasal sprays.  Because of its regenerative capacity, damage to the olfactory epithelium can be temporary but in extreme cases, injury can be permanent, leading to  anosmia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3328", "text": "The  olfactory nerve ,  also known as the  first cranial nerve ,  cranial nerve I , or simply  CN I , is a  cranial nerve  that contains sensory nerve fibers relating to  the sense of smell ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3329", "text": "The  afferent nerve fibers  of the  olfactory receptor neurons  transmit  nerve impulses  about  odors  to the  central nervous system  ( olfaction ). Derived from the  embryonic   nasal placode , the olfactory nerve is somewhat unusual among cranial nerves because it is capable of some regeneration if damaged. The olfactory nerve is sensory in nature and originates on the  olfactory mucosa  in the upper part of the  nasal cavity . [ 1 ]  From the olfactory mucosa, the nerve (actually many small nerve fascicles) travels up through the  cribriform plate  of the  ethmoid bone  to reach the surface of the brain. Here the fascicles enter the  olfactory bulb  and synapse there; from the bulbs (one on each side) the olfactory information is transmitted into the brain via the  olfactory tract . [ 2 ]  The fascicles of the olfactory nerve are not visible on a cadaver brain because they are severed upon removal. [ 3 ]   :\u200a548"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3330", "text": "The specialized  olfactory receptor neurons  of the olfactory nerve are located in the olfactory  mucosa  of the upper parts of the  nasal cavity . The olfactory nerves consist of a collection of many sensory nerve fibers that extend from the olfactory epithelium to the  olfactory bulb , passing through the many openings of the  cribriform plate , a  sieve -like structure of the  ethmoid bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3331", "text": "The sense of  smell  arises from the stimulation of  receptors  by small molecules in inspired air of varying spatial, chemical, and electrical properties that reach the nasal epithelium in the nasal cavity during inhalation. These stimulants are transduced into electrical activity in the olfactory neurons, which then transmit these impulses to the olfactory bulb and from there they reach the olfactory areas of the brain via the  olfactory tract ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3332", "text": "The olfactory nerve is the shortest of the twelve cranial nerves and, similar to the optic nerve, does not emanate from the  brainstem . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3333", "text": "The olfaction system works to ensure that people can successfully identify an extensive range of odorants and distinguish odors from one another. [ 4 ] [ 5 ]  Odorants interact with the  olfactory receptor neurons (ORNs)  at the periphery and transmit olfactory information to the  central nervous system  via  axons  at the basal surface. [ 4 ] [ 5 ]  These axons aggregate, forming the olfactory nerve. [ 4 ] [ 5 ] [ 6 ]  Therefore, the olfactory nerve works to transduce  sensory stimuli  in the form of odorants and encode them into electrical signals, which are relayed to higher-order centers through  synaptic transmission . [ 4 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3334", "text": "Odorants bind to specific  odorant receptor proteins  contained to the outer surface of  olfactory cilia  within the  olfactory epithelium . [ 4 ] [ 5 ]  Odorant binding to the cilia of an ORN evokes an electrical response, kickstarting odor transduction. [ 4 ]  An individual ORN contains several  microvilli , olfactory cilia, which protrude from a knoblike structure at the  apical surface  involved in  dendritic processes . [ 4 ]  The olfactory cilia lack the  cytoskeletal  features of  motile cilia  and are, therefore, more similar to microvilli like that found in the lungs or gut. [ 4 ]  Olfactory cilia are  actin -rich protrusions supported by  scaffolding proteins  which help to localize odorant receptors and provide an increased cellular surface for odorant binding. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3335", "text": "Homologous  to  G-protein-coupled receptors (GPCRs) , olfactory receptor molecules consist of seven trans-membrane,  hydrophobic  domains and a cytoplasmic domain with a  carboxyl terminal  region that interacts with  G-proteins  and odorants. [ 4 ] [ 5 ]  Once an odorant is bound to an odor receptor protein, the alpha subunit of an olfactory-specific heterotrimeric G-protein, G olf , dissociates and activates olfactory-specific  adenylate cyclase , adenylyl cyclase III (ACIII). [ 4 ] [ 5 ]  Activation of ACIII leads to an increase in  cyclic AMP  (cAMP), which  depolarizes  the neuron due to an influx of Na+ and Ca2+ by opening  cyclic nucleotide-gated ion channels . [ 4 ] [ 5 ]  The neuron is further depolarized by a Ca2+-activated Cl- current travelling from the cilia, where the depolarization first occurred, to the  axon hillock  of the ORN. [ 4 ] [ 5 ]  At the axon hillock,  voltage-gated Na+ channels  open and generate an  action potential  that is transmitted to the  olfactory bulb . [ 4 ] [ 5 ]  After transmission, the ORN membrane is repolarized by  calcium/calmodulin kinase  II-mediated mechanisms that work to extrude Ca2+ and transport Na+ via an Na+/Ca2+ exchanger, diminish cAMP levels by activating  phosphodiesterases , and restore heterotrimeric G olf. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3336", "text": "ORN axons are responsible for relaying odorant information to CNS through action potentials. [ 4 ] [ 6 ]  The ORN axons leave the olfactory epithelium and travel  ipsilaterally  to the olfactory bulb where the ORN axons coalesce into multiple clusters, called  glomeruli , which together form the olfactory nerve. [ 4 ] [ 5 ] [ 6 ]  The ORN axons of each glomerulus synapse with apical dendrites of  mitral cells , the primary projection neurons of the olfactory bulb, which create and send action potentials further into the CNS. [ 4 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3337", "text": "ORNs directly interact with odorants inhaled into the olfactory epithelium which can also subject the ORNs to damage through continuous exposure to harmful substances such as  airborne pollutants ,  microorganisms , and  allergens . [ 4 ] [ 6 ] [ 7 ]  Therefore, ORNs maintain a normal cycle of degeneration and regeneration. [ 4 ] [ 7 ]  The olfactory epithelium consists of three main cell types: supporting cells, mature ORNs, and basal cells. [ 4 ] [ 7 ]  Regeneration of ORNs requires the division of basal cells,  neural stem cells , to produce new receptor neurons. [ 4 ] [ 6 ] [ 7 ]  This regeneration process makes ORNs unique when compared to other neurons. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3338", "text": "In the nasal passages, inhaled odorant molecules interact with receptor proteins on localized neuronal cilia of ORNs. [ 5 ] [ 6 ]  These dendritic extensions, cilia, express one type of protein receptor, although individual odorants can interact with multiple different receptor proteins. [ 5 ] [ 6 ]  As new ORNs mature, they have decreased expression levels of multiple olfactory receptor  genes , contrasting with mature ORNs firm rule of one neuron\u2014one expressed olfactory receptor gene. [ 4 ] [ 6 ]  Moreover, different odors activate specific ORNs in a molecular and spatial manner due to receptor specificity. [ 4 ]  Some ORNs contain receptor proteins with high affinity for some odorants, with distinct odor selectivity to a specific chemical structure, while other receptor proteins are less selective. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3339", "text": "Damage to this nerve leads to impairment or total loss of the sense of smell ( anosmia ). To simply test the function of the olfactory nerve, each  nostril  is tested with a pungent odor. If the odor is smelled, the olfactory nerve is likely functioning. On the other hand, the nerve is only one of several reasons that could explain if the odor is not smelled. There are olfactory testing packets in which strong odors are embedded into cards and the responses of the patient to each odor can be determined. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3340", "text": "Lesions to the olfactory nerve can occur because of \"blunt trauma\", such as  coup-contrecoup  damage, meningitis, and tumors of the  frontal lobe  of the brain. These injuries often lead to a reduced ability to taste and smell. Lesions of the olfactory nerve do not lead to a reduced ability to sense pain from the nasal epithelium. This is because pain from the nasal epithelium is not carried to the central nervous system by the olfactory nerve - it is carried to the central nervous system by the  trigeminal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3341", "text": "A decrease in the ability to smell is a normal consequence of human  aging , and usually is more pronounced in men than in women. It is often unrecognized in patients except that they may note a decreased ability to taste (much of taste is actually based on reception of food odor). Some of this decrease results from repeated damage to the olfactory nerve receptors due likely to repeated upper respiratory infections. Patients with  Alzheimer's disease  almost always have an abnormal sense of smell when tested. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3342", "text": "Some  nanoparticles  entering the nose are transported to the brain via olfactory nerve. This can be useful for  nasal administration  of medications. [ 8 ]  It can be harmful when the particles are soot [ 9 ]  or magnetite [ 10 ]  in  air pollution . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3343", "text": "In  naegleriasis , \"brain-eating\" amoeba enter through the olfactory mucosa of the nasal tissues and follow the olfactory nerve fibers into the olfactory bulbs and then the brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3344", "text": "The  ophthalmic artery  ( OA ) is an artery of the head. It is the first branch of the  internal carotid artery  distal to the  cavernous sinus . Branches of the ophthalmic artery supply all the structures in the  orbit  around the  eye , as well as some structures in the  nose ,  face , and  meninges . Occlusion of the ophthalmic artery or its branches can produce sight-threatening conditions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3345", "text": "The ophthalmic artery emerges from the  internal carotid artery . [ 1 ]  This is usually just after the internal carotid artery emerges from the  cavernous sinus . In some cases, the ophthalmic artery branches just before the internal carotid exits the cavernous sinus. The ophthalmic artery emerges along the medial side of the  anterior clinoid process . It runs anteriorly, passing through the  optic canal  inferolaterally to the  optic nerve . [ 1 ]  It can also pass superiorly to the optic nerve in a minority of cases. [ 2 ]  In the posterior third of the cone of the orbit, the ophthalmic artery turns sharply and medially to run along the medial wall of the orbit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3346", "text": "Because of the obvious importance of the ocular globe, branches of the ophthalmic artery often are subdivided into two groups: those that supply the eyeball (ocular group) and those that supply non-ocular orbital structures (orbital group). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3347", "text": "The orbital group, distributing vessels to the orbit and surrounding parts, includes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3348", "text": "The ocular group, distributing vessels to the eye and its muscles, includes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3349", "text": "The  central retinal artery  is the first, and one of the smaller branches of the ophthalmic artery and runs in the dura mater inferior to the optic nerve. About 12.5mm (0.5 inch) posterior to the globe, the central retinal artery turns superiorly and penetrates the  optic nerve , continuing along the center of the optic nerve, entering the eye to supply the inner retinal layers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3350", "text": "The next branch of the ophthalmic artery is the  lacrimal artery , one of the largest, arises just as the OA enters the orbit and runs along the superior edge of the  lateral rectus muscle  to supply the  lacrimal gland ,  eyelids  and  conjunctiva ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3351", "text": "The ophthalmic artery then turns medially, giving off 1 to 5  posterior ciliary arteries  (PCA) that subsequently branch into the long and short posterior ciliary arteries (LPCA and SPCA respectively) which perforate the sclera posteriorly in the vicinity of the optic nerve and macula to supply the posterior uveal tract. In the past, anatomists made little distinction between the posterior ciliary arteries and the short and long posterior ciliary arteries often using the terms synonymously. However, recent work by Hayreh has shown that there is both an anatomic and clinically useful distinction. [ 4 ]   The PCAs arise directly from the OA and are end arteries which is to say no PCA or any of its branches anastomose with any other artery. Consequently, sudden occlusion of any PCA will produce an infarct in the region of the choroid supplied by that particular PCA. Occlusion of a short or long PCA will produce a smaller choroidal infarct, within the larger area supplied by the specific parent PCA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3352", "text": "The ophthalmic artery continues medially the superior and inferior muscular branches arise either from the ophthalmic artery directly or a single trunk from the ophthalmic artery subsequently divides into superior and inferior branches to supply the  extraocular muscles ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3353", "text": "The  supraorbital artery  branches from the ophthalmic artery as it passes over the optic nerve. The supraorbital artery passes anteriorly along the medial border of the  superior rectus  and  levator palpebrae  and through the  supraorbital foramen  to supply muscles and skin of the forehead."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3354", "text": "After reaching the medial wall of the orbit, the ophthalmic artery again turns anteriorly. The  posterior ethmoidal artery  enters the nose via the posterior ethmoidal canal and supplies the posterior ethmoidal sinuses and enters the skull to supply the meninges."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3355", "text": "The OA continues anteriorly, giving off the  anterior ethmoidal artery  which enters the nose after traversing the anterior ethmoidal canal and supplies the anterior and middle ethmoidal sinuses, as well as the frontal sinus and also enters the cranium to supply the meninges."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3356", "text": "The OA continues anteriorly to the trochlea, where the medial palpebral arteries (superior and inferior) arise and supply the eyelids."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3357", "text": "The OA terminates in two branches, the supratrochlear (or frontal) artery and the dorsal nasal artery. Both exit the orbit medially to supply the forehead and scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3358", "text": "Branches of the ophthalmic artery supply:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3359", "text": "Severe occlusion of the ophthalmic artery causes  ocular ischemic syndrome . As with  central retinal artery  occlusions, ophthalmic artery occlusions may result from systemic  cardiovascular diseases ; however, a  cherry-red spot  is typically absent and the vision is usually worse.  Amaurosis fugax  is a temporary loss of vision that occurs in two conditions which cause a temporary reduction in ophthalmic artery pressure:  orthostatic hypotension  and positive acceleration. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3360", "text": "Even complete occlusion of the ophthalmic artery may possibly leave the eye without symptoms, probably because of  circulatory anastomoses [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3361", "text": "The  ophthalmic nerve  ( CN V 1 ) is a sensory nerve of the head. It is one of three divisions of the  trigeminal nerve (CN V) , a  cranial nerve . It has three major branches which provide sensory innervation to the  eye , and the  skin  of the upper face and anterior  scalp , as well as other structures of the head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3362", "text": "It measures about 2.5\u00a0cm in length. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3363", "text": "The ophthalmic nerve is the first branch of the  trigeminal nerve (CN V) , the first and smallest of its three divisions. [ 1 ]  It arises from the superior part of the  trigeminal ganglion . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3364", "text": "It passes anterior-ward along the lateral wall of the  cavernous sinus  inferior to the  oculomotor nerve (CN III)  and  trochlear nerve (N IV) . [ 1 ]  It exits the skull into the orbit through the  superior orbital fissure . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3365", "text": "Within the skull, the ophthalmic nerve produces: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3366", "text": "The ophthalmic nerve divides into three major branches which pass through the superior orbital fissure: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3367", "text": "The ophthalmic nerve provides sensory innervation to the  cornea ,  ciliary body , and  iris ; to the  lacrimal gland  and  conjunctiva ; to the part of the  mucous membrane  of the  nasal cavity ; and to the skin of the  eyelids ,  eyebrow ,  forehead  and  nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3368", "text": "It carries sensory branches from the eyes, conjunctiva, lacrimal gland, nasal cavity, frontal sinus, ethmoidal cells, falx cerebri, dura mater in the anterior cranial fossa, superior parts of the tentorium cerebelli, upper eyelid, dorsum of the nose, and anterior part of the scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3369", "text": "Roughly speaking, the ophthalmic nerve supplies general somatic afferents to the upper face, head, and eye:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3370", "text": "In comparison, the  maxillary nerve (CN V2)  provides general somatic afferents to the mid-face and mid-head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3371", "text": "Damage to the ophthalmic nerve can cause loss of sensation of the structures it supplies in the face. [ 3 ]  The  corneal reflex  may be lost, which can increase the risk of damage to the  cornea . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3372", "text": "This article incorporates text in the  public domain  from  page 887  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3373", "text": "In  neuroanatomy , the  optic nerve , also known as the  second cranial nerve ,  cranial nerve II , or simply  CN II , is a paired  cranial nerve  that transmits  visual  information from the  retina  to the  brain . In humans, the optic nerve is derived from  optic stalks  during the seventh week of development and is composed of  retinal ganglion cell  axons and  glial cells ; it extends from the  optic disc  to the  optic chiasma  and continues as the  optic tract  to the  lateral geniculate nucleus ,  pretectal nuclei , and  superior colliculus . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3374", "text": "The optic nerve has been classified as the second of twelve paired  cranial nerves , but it is technically a myelinated tract of the  central nervous system , rather than a classical nerve of the  peripheral nervous system  because it is derived from an out-pouching of the  diencephalon  ( optic stalks ) during embryonic development. As a consequence, the fibers of the optic nerve are covered with  myelin  produced by  oligodendrocytes , rather than  Schwann cells  of the peripheral nervous system, and are encased within the  meninges . [ 3 ]   Peripheral neuropathies  like  Guillain\u2013Barr\u00e9 syndrome  do not affect the optic nerve. However, most typically, the optic nerve is grouped with the other eleven cranial nerves and is considered to be part of the peripheral nervous system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3375", "text": "The optic nerve is ensheathed in all three meningeal layers ( dura ,  arachnoid , and  pia mater ) rather than the  epineurium ,  perineurium , and  endoneurium  found in peripheral nerves.  Fiber tracts  of the mammalian central nervous system have only limited regenerative capabilities compared to the peripheral nervous system. [ 4 ]  Therefore, in most mammals, optic  nerve damage  results in irreversible  blindness . The fibers from the  retina  run along the optic nerve to nine primary visual nuclei in the brain, from which a major relay inputs into the  primary visual cortex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3376", "text": "The optic nerve is composed of  retinal ganglion cell  axons and  glia . Each human optic nerve contains between 770,000 and 1.7 million nerve fibers, [ 5 ]  which are axons of the retinal ganglion cells of one retina. In the  fovea , which has high acuity, these ganglion cells connect to as few as 5  photoreceptor cells ; in other areas of the retina, they connect to thousands of photoreceptors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3377", "text": "The optic nerve leaves the  orbit  (eye socket) via the  optic canal , running postero-medially towards the  optic chiasm , where there is a partial decussation (crossing) of fibers from the temporal  visual fields  (the nasal hemi-retina) of both eyes. The proportion of decussating fibers varies between species, and is correlated with the degree of  binocular vision  enjoyed by a species. [ 6 ]  Most of the  axons  of the optic nerve terminate in the  lateral geniculate nucleus  from where information is relayed to the  visual cortex , while other axons terminate in the  pretectal area [ 7 ]  and are involved in reflexive  eye movements . Other axons terminate in the  suprachiasmatic nucleus  and are involved in regulating the  sleep-wake cycle . Its diameter increases from about 1.6\u00a0mm within the eye to 3.5\u00a0mm in the orbit to 4.5\u00a0mm within the cranial space. The optic nerve component lengths are 1\u00a0mm in the globe, 24\u00a0mm in the orbit, 9\u00a0mm in the optic canal, and 16\u00a0mm in the cranial space before joining the optic chiasm. There, partial decussation occurs, and about 53% of the fibers cross to form the optic tracts. Most of these fibers terminate in the lateral geniculate body. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3378", "text": "Based on this anatomy, the optic nerve may be divided into four parts as indicated in the image at the top of this section (this view is from above as if you were looking into the orbit after the top of the skull had been removed): 1. the optic head (which is where it begins in the eyeball (globe) with fibers from the retina); 2. orbital part (which is the part within the orbit); 3. intracanicular part (which is the part within a bony canal known as the optic canal); and, 4. cranial part (the part within the cranial cavity, which ends at the optic chiasm). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3379", "text": "From the lateral geniculate body, fibers of the  optic radiation  pass to the  visual cortex  in the  occipital lobe  of the brain. In more specific terms, fibers carrying information from the contralateral superior visual field traverse Meyer's loop to terminate in the  lingual gyrus  below the  calcarine fissure  in the occipital lobe, and fibers carrying information from the contralateral inferior visual field terminate more superiorly, to the  cuneus . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3380", "text": "The optic nerve transmits all visual information including  brightness  perception,  color perception  and  contrast  ( visual acuity ). It also conducts the visual impulses that are responsible for two important neurological reflexes: the  light reflex  and the  accommodation reflex . The light reflex refers to the constriction of both  pupils  that occurs when light is shone into either eye. The accommodation reflex refers to the swelling of the  lens of the eye  that occurs when one looks at a near object (for example: when reading, the lens adjusts to near vision). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3381", "text": "The eye's  blind spot  is a result of the absence of photoreceptors in the area of the retina where the optic nerve leaves the eye. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3382", "text": "Damage to the optic nerve typically causes permanent and potentially severe loss of  vision , as well as an abnormal pupillary reflex, which is important for the diagnosis of nerve damage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3383", "text": "The type of  visual field  loss will depend on which portions of the optic nerve were damaged. In general, the location of the damage in relation to the optic chiasm (see diagram above) will affect the areas of vision loss. Damage to the optic nerve that is  anterior , or in front of the optic chiasm (toward the face) causes loss of vision in the eye on the same side as the damage. Damage at the optic chiasm itself typically causes loss of vision laterally in both visual fields or  bitemporal hemianopsia  (see image to the right). Such damage may occur with large  pituitary  tumors, such as  pituitary adenoma . Finally, damage to the  optic tract , which is posterior to, or behind the chiasm, causes loss of the entire visual field from the side opposite the damage, e.g. if the left optic tract were cut, there would be a loss of vision from the entire right visual field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3384", "text": "Injury to the optic nerve can be the result of  congenital  or inheritable problems like  Leber's hereditary optic neuropathy ,  glaucoma , trauma,  toxicity ,  inflammation ,  ischemia ,  infection  (very rarely), or compression from  tumors  or  aneurysms . By far, the three most common injuries to the optic nerve are from glaucoma;  optic neuritis , especially in those younger than 50 years of age; and anterior  ischemic optic neuropathy , usually in those older than 50."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3385", "text": "Glaucoma  is a group of diseases involving loss of retinal ganglion cells causing  optic neuropathy  in a pattern of  peripheral vision  loss, initially sparing central vision.  Glaucoma is frequently associated with increased intraocular pressure that damages the optic nerve as it exits the eyeball. The  trabecular meshwork  assists the drainage of  aqueous humor  fluid. The presence of excess aqueous humor, increases IOP, yielding the diagnosis and symptoms of glaucoma. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3386", "text": "Optic neuritis  is inflammation of the optic nerve. It is associated with a number of diseases, the most notable one being  multiple sclerosis .  The patient will likely experience varying vision loss and eye pain.  The condition tends to be episodic."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3387", "text": "Anterior ischemic optic neuropathy  is commonly known as a \"stroke of the optic nerve\" and affects the optic nerve head (where the nerve exits the eyeball). There is usually a sudden loss of blood supply and nutrients to the optic nerve head. Vision loss is typically sudden and most commonly occurs upon waking up in the morning. This condition is most common in diabetic patients 40\u201370 years old."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3388", "text": "Other optic nerve problems are less common.  Optic nerve hypoplasia  is the underdevelopment of the optic nerve resulting in little to no vision in the affected eye. Tumors, especially those of the pituitary gland, can put pressure on the optic nerve causing various forms of visual loss. Similarly,  cerebral aneurysms , a swelling of  blood vessel(s) , can also affect the nerve. Trauma can cause serious injury to the nerve. Direct optic nerve injury can occur from a penetrating injury to the orbit, but the nerve can also be injured by indirect trauma in which severe head impact or movement stretches or even tears the nerve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3389", "text": "Ophthalmologists  and  optometrists  can detect and diagnose some optic nerve diseases but  neuro-ophthalmologists  are often best suited to diagnose and treat diseases of the optic nerve. The International Foundation for Optic Nerve Diseases (IFOND) sponsors research and provides information on a variety of optic nerve disorders."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3390", "text": "Oral allergy syndrome  ( OAS ) or  pollen-food allergy syndrome  ( PFAS ) is a type of  allergy  classified by a cluster of allergic reactions in the mouth and throat in response to eating certain (usually fresh)  fruits ,  nuts , and  vegetables . It typically develops in adults with  hay fever . [ 1 ]  It is not usually serious. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3391", "text": "OAS is the result of  cross-reactivity  between  antigens  of tree or weed pollen and antigens found in certain fruits and vegetables.  Therefore, OAS is only seen in people with seasonal pollen allergies, and mostly people who are allergic to tree  pollen . [ 3 ]   It is usually limited to ingestion of uncooked fruits or vegetables. [ 3 ] \nIn adults, up to 60% of all food allergic reactions are due to cross-reactions between foods and inhalative allergens. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3392", "text": "OAS is a class II allergy where the body's immune system produces IgE  antibodies  against pollen; in OAS, these antibodies also bind to (or cross-react with) other structurally similar proteins found in botanically related plants. This differs from class 1  food allergy  where sensitisation to the protein occurs in the GI tract, and is produced as a result of exposure to the food itself. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3393", "text": "OAS can occur any time of the year, but is most prevalent during the pollen season. Individuals with OAS usually develop symptoms within minutes of eating the food. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3394", "text": "Individuals with OAS may have any of a number of allergic reactions that usually occur very rapidly, within minutes of eating a trigger food.  The most common reaction is an itching or burning sensation in the lips, mouth, ear canal, or  pharynx . Sometimes other reactions can be triggered in the eyes, nose, and skin.  Swelling of the lips, tongue, and  uvula , and a sensation of tightness in the throat may be observed. Once the allergen reaches the\nstomach, it is broken down by the acid, and the allergic reaction does not progress further. [ 7 ] :\u200a405\u200a  The natural course of the disease is that it usually persists. [ 7 ] :\u200a407"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3395", "text": "If an affected person swallows the raw food, and the allergen is not destroyed by the stomach acids, it is likely that there will be a reaction from histamine release later in the  gastrointestinal tract .  Vomiting ,  diarrhea , severe  indigestion , or  cramps  may occur. [ 6 ]  Rarely, OAS may be severe and present as wheezing, vomiting, hives,  low blood pressure , [ 8 ]  or  anaphylaxis . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3396", "text": "A person with an allergic disposition is sensitized to allergenic pollen proteins through the respiratory route can develop an allergy to heat labile food proteins (for example  profilins ) in certain fruits and vegetables, which cross-react with pollen proteins. [ 7 ] :\u200a409"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3397", "text": "OAS produces symptoms when an affected person eats certain fruits, vegetables, and nuts. Some individuals may only show allergy to one particular food, and others may show an allergic response to many foods. [ 1 ] [ dead link \u200d ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3398", "text": "Individuals with an allergy to tree pollen may develop OAS to a variety of foods. While the tree pollen allergy has been worked out, the grass pollen is not well understood. Furthermore, some individuals have severe reactions to certain fruits and vegetables that do not fall into any particular allergy category. When tropical foods initiate OAS, allergy to  latex  may be the underlying cause. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3399", "text": "Because the allergenic proteins associated with OAS are usually destroyed by cooking, most reactions are caused by eating raw foods. [ 7 ]  The main exceptions to this are celery and nuts, which may cause reactions even after being cooked. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3400", "text": "Allergies to a specific pollen are usually associated with OAS reactions to other certain foods.  For instance, an allergy to  ragweed  is associated with OAS reactions to  banana ,  watermelon ,  cantaloupe ,  honeydew ,  zucchini ,  kiwifruit , and  cucumber . This does not mean that everyone with an allergy to ragweed will experience adverse effects from all or even any of these foods. Reactions may be associated with one type of food, with new reactions to other foods developing later. However, reaction to one or more foods in any given category does not necessarily mean a person is allergic to all foods in that group. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3401", "text": "The person typically already has a history of  atopy  and an atopic family history. Eczema, otolaryngeal symptoms of hay fever or asthma will often dominate leading to the food allergy being unsuspected. Often well-cooked, canned, pasteurized, or frozen food offenders cause little to no reaction due to  denaturation  of the cross-reacting proteins, [ 9 ]  causing delay and confusion in diagnosis as the symptoms are elicited only to the raw or fully ripened fresh foods. Correct diagnosis of the allergen types involved is critical. Those with OAS may be allergic to more than just pollen. Oral reactions to food are often mistakenly self-diagnosed by patients as caused by pesticides or other contaminants. Other reactions to food\u2014such as  lactose intolerance  and intolerances which result from a patient being unable to metabolize naturally occurring chemicals (e.g., salicylates and proteins) in food\u2014need to be distinguished from the systemic symptoms of OAS. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3402", "text": "Many people are unaware that they have OAS. However, if  swelling ,  tingling  or pain develops while eating certain foods, it is wise to see an allergy specialist. Before a diagnosis can be made, it is best to keep a food diary. This is important as the  physician  can then perform an allergy test. A comprehensive history is obtained so that random testing is avoided. The diagnosis of OAS may involve skin prick tests, blood tests, patch tests or oral challenges. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3403", "text": "To confirm OAS, the suspected food is consumed in a normal way. The period of observation after ingestion and symptoms are recorded. If other factors such as combined foods are required, this is also replicated in the test. For example, if the individual always develops symptoms after eating followed by exercise, then this is replicated in the laboratory. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3404", "text": "OAS must be managed in conjunction with the patient's other allergies, primarily the allergy to pollen.  The symptom severity may wax and wane with the pollen levels. Published pollen counts and seasonal charts are useful but may be ineffective in cases of high wind or unusual weather, as pollen can travel hundreds of kilometers from other areas. In addition, patients are advised to avoid the triggering foods, particularly nuts. Peeling or cooking the foods has been shown to eliminate the effects of some allergens such as  mal d 1  (apple), but not others such as celery or strawberry.  In the case of foods such as hazelnut, which have more than one allergen, cooking may eliminate one allergen but not the other. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3405", "text": "Antihistamines  may also relieve the symptoms of the allergy by blocking the immune pathway.  Persons with a history of severe anaphylactic reaction may carry an injectable emergency dose of  epinephrine  (such as an EpiPen).  Oral steroids may also be helpful.  Allergy immunotherapy  has been reported to improve or cure OAS in some patients.  Immunotherapy with extracts containing birch pollen may benefit those with apple or hazelnut related to birch pollen-allergens. Even so, the increase in the amount of apple/hazelnut tolerated was small (from 12.6 to 32.6 g apple), and as a result, a patient's management of OAS would be limited. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3406", "text": "Oropharyngeal cancer , [ 1 ] [ 2 ] [ 3 ]  also known as  oropharyngeal squamous cell carcinoma  and  tonsil cancer , [ 1 ]  is a disease in which abnormal cells with the potential to both grow locally and spread to other parts of the body are found in the  oral cavity , in the tissue of the part of the throat ( oropharynx ) that includes the  base of the tongue , the  tonsils , the soft  palate , and the walls of the  pharynx . [ 1 ] [ 2 ] [ 3 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3407", "text": "The two types of oropharyngeal cancers are  HPV-positive oropharyngeal cancer , which is caused by an oral  human papillomavirus infection ; [ 1 ] [ 2 ] [ 3 ] [ 4 ]  and HPV-negative oropharyngeal cancer, which is linked to  use of alcohol ,  tobacco , or both. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3408", "text": "Oropharyngeal cancer is diagnosed by  biopsy  of observed abnormal tissue in the throat. Oropharyngeal cancer  is staged according to the appearance of the abnormal cells on the biopsy coupled with the dimensions and the extent of the abnormal cells found. Treatment is with surgery, chemotherapy, or radiation therapy; or some combination of those treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3409", "text": "The signs and symptoms of oropharyngeal cancer may include: [ 5 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3410", "text": "The risk factors that can increase the risk of developing oropharyngeal cancer are: [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3411", "text": "The cancer can spread three ways: [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3412", "text": "Diagnosis is by  biopsy  of observed abnormal tissue in the oropharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3413", "text": "The  National Cancer Institute  (2016) provides the following definition: [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3414", "text": "Abnormal cells are found in the lining of the  oropharynx . These may become cancer and spread into nearby normal tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3415", "text": "Cancer has formed and is 20\u00a0mm or smaller and has not spread outside the oropharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3416", "text": "Cancer has formed and is larger than 20\u00a0mm, but not larger than 40\u00a0mm. Also, it has not yet spread outside the oropharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3417", "text": "Cancer has spread to other parts of the body; the  tumor  may be any size and may have spread to lymph nodes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3418", "text": "Regarding the primary prevention of  HPV-positive oropharyngeal cancer ,  HPV vaccines  show more than 90% efficacy in preventing vaccine-type HPV infections and their correlated anogenital  precancerous lesions . [ 1 ]  A research conducted in 2017 demonstrated that HPV vaccination induces HPV antibodies levels at the  oral cavity  that correlate with circulating levels. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3419", "text": "Regarding the primary prevention of HPV-positive oropharyngeal cancer,  safe oral sex habits  should be advised [ 1 ]  (see  Sex education ). Regarding the primary prevention of HPV-negative oropharyngeal cancer, educating people on the risks of chewing  betel quid ,  alcohol use , and  tobacco smoking  is of the prime importance in the control and prevention of oropharyngeal cancers. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3420", "text": "People with  HPV-positive oropharyngeal cancer  tend to have higher survival rates. [ 1 ] [ 6 ]  However, HPV is tested for by the presence of the  biomarker   p16 , which normally increases in the presence of HPV. Some people can have elevated levels of p16 but test negative for HPV and vice versa. This is known as discordant cancer. The five-year survival for people who test positive for HPV and p16 is 81%, for discordant cancer it is 53 \u2013 55%, and 40% for those who test negative for p16 and HPV. [ 15 ] [ 16 ]  The  prognosis  for people with oropharyngeal cancer depends on the age and health of the person and the stage of the disease. [ 1 ]  It is important for people with oropharyngeal cancer to have follow-up exams for the rest of their lives, as cancer can occur in nearby areas. In addition, it is important to eliminate risk factors such as smoking and drinking alcohol, which increase the risk for second cancers. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3421", "text": "Traditionally, oropharyngeal cancer has been managed through combination of surgery and radiotherapy. Other treatments have been developed including a combination of surgery, radiotherapy, chemotherapy and immunotherapy, but with limited improvement in survival rates. [ 17 ]  Studies comparing different combinations of treatment on patient outcomes have shown insufficient evidence that any treatment combination is superior to others. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3422", "text": "Oral cancer , also known as  oral cavity cancer ,  tongue cancer  or  mouth cancer , is a  cancer  of the lining of the lips, mouth, or upper throat. [ 6 ]  In the mouth, it most commonly starts as a painless  red  or  white patch , that thickens, gets ulcerated and continues to grow. When on the lips, it commonly looks like a persistent crusting ulcer that does not heal, and slowly grows. [ 7 ]  Other symptoms may include difficult or painful swallowing, new lumps or bumps in the neck, a swelling in the mouth, or a feeling of numbness in the mouth or lips. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3423", "text": "Risk factors include  tobacco  and  alcohol use . [ 9 ] [ 10 ]  Those who use both alcohol and tobacco have a 15 times greater risk of oral cancer than those who use neither. [ 11 ]  Other risk factors include  betel nut chewing [ 12 ]  and  sun exposure  on the lip. [ 13 ]   HPV  infection may play a limited role in some oral cavity cancers. [ 14 ]  Oral cancer is a subgroup of  head and neck cancers . [ 6 ]  Diagnosis is made by sampling ( biopsy ) of the lesion, followed by an imaging workup (called staging) which can include  CT scan ,  MRI ,  PET scan  to determine the local extension of the tumor, and if the disease has spread to distant parts of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3424", "text": "Oral cancer can be prevented by avoiding tobacco products, limiting alcohol use, sun protection on the lip, HPV vaccination, and avoidance of  betel nut chewing . Treatments used for oral cancer can include a combination of  surgery  (to remove the tumor and  regional lymph nodes ),  radiation therapy ,  chemotherapy , or  targeted therapy . The types of treatments will depend on the size, locations, and spread of the cancer taken into consideration with the general health of the person. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3425", "text": "In 2018, oral cancer occurred globally in about 355,000 people, and resulted in 177,000 deaths. [ 5 ]  Between 1999 and 2015 in the United States, the rate of oral cancer increased 6% (from 10.9 to 11.6 per 100,000). Deaths from oral cancer during this time decreased 7% (from 2.7 to 2.5 per 100,000). [ 15 ]  Oral cancer has an overall 5 year survival rate of 65% in the United States as of 2015. [ 4 ]  This varies from 84% if diagnosed when localized, compared to 66% if it has spread to the lymph nodes in the neck, and 39% if it has spread to distant parts of the body. [ 4 ]  Survival rates also are dependent on the location of the disease in the mouth. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3426", "text": "The signs and symptoms of oral cancer depend on the location of the  tumor  but are generally thin, irregular, red and/or white patches in the mouth. The classic warning sign is a persistent rough patch with  ulceration , and a raised border that is minimally painful. On the lip, the ulcer is more commonly crusting and dry, and in the  pharynx  it is more commonly a mass. It can also be associated with loose teeth, bleeding gums, persistent  ear ache , a feeling of numbness in the lip and chin, or swelling. [ 17 ]  When the cancer extends to the  oropharynx  (back of the throat), there can also be  difficulty swallowing ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3427", "text": "Typically, the lesions cause very little pain until they become larger and then are associated with a local pain, burning sensation or ear ache (referred otalgia). [ 18 ]  As the lesion spreads to the  lymph nodes  of the neck, a painless, hard mass will develop. If it spreads elsewhere in the body, general aches can develop, most often due to  bone metastasis . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3428", "text": "The main causes of oral cancer are alcohol and tobacco (smoked or  chewed ). The risk is especially high when a person regularly uses both. The more is consumed of either the higher the risk of developing oral cancer. Like all environmental factors, the rate at which cancer will develop is dependent on the dose, frequency and method of application of the  carcinogen  (the substance that is causing the cancer). [ 19 ] [ 20 ]  Aside from tobacco and alcohol, other carcinogens for oral cancer include viruses (particularly  HPV  16 and 18),  radiation , and  UV light . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3429", "text": "Tobacco  is the greatest single cause of oral and pharyngeal cancer. Using tobacco increases the risk of oral cancer by 3 to 6 times [ 20 ] [ 9 ]  and is responsible for around 40% of all oral cancers. [ 21 ]   Smokeless tobacco  (including  chewing tobacco ,  snuff ,  snus ) also causes oral cancer. [ 22 ] [ 23 ] [ 24 ]   Cigar  and  pipe smoking  are also important risk factors. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3430", "text": "The use of  electronic cigarettes  may also lead to the development of head and neck cancers due to the substances like  propylene glycol ,  glycerol ,  nitrosamines , and metals contained therein, which can cause damage to the airways. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3431", "text": "Use of  marijuana  has currently not been shown to be associated with head and neck cancer risk. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3432", "text": "Drinking  alcohol  is a major cause of oral cancer. [ 28 ] [ 29 ]  It was responsible for 20% of global oral cancer cases in 2020. [ 30 ]  The more alcohol is consumed regularly the higher the risk, but light to moderate drinking still somewhat increases the chances of getting oral cancer. [ 31 ]  The risk is especially high when both alcohol and tobacco are used. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3433", "text": "It has been controversial if the use of alcohol-based  mouthwashes  increases oral cancer risk. [ 33 ]  As of 2024, there is some limited evidence supporting that the use of mouthwashes containing alcohol can increase the occurrence of oral cancer in some cases. [ 34 ]  There are complex interactions between alcohol content, usage patterns, reduction of oral pathogens, poor oral hygiene, smoking, and drinking which make any broad conclusion very tenuous in the absence of rigorously controlled studies. [ 35 ] [ 34 ]  In subgroup analyses, various combinations of smoking, drinking alcohol, poor oral hygiene, and using mouthwash several times a day for 35 years or more significantly increased risk. [ 36 ]  Although alcohol is necessary to dissolve some active antimicrobial agents, Rao et al. advise reducing the alcohol content of mouthwashes if possible. [ 34 ] \nAccording to a 2024 IARC report, drinking alcohol is the primary cause of around 20% of the nearly 75,000 lip and mouth cancers diagnosed worldwide annually. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3434", "text": "Infection with  human papillomavirus  (HPV), particularly type 16, is a cause of oropharyngeal cancer (tonsils, base of tongue). [ 38 ]  However, its role in the genesis of oral cavity cancers is a matter of debate. [ 14 ]  A 2023 meta-analysis observed that the HPV was present 6% of all oral cavity cancer cases, however without establishing a role of this virus in the oncogenesis of these tumors. The authors even reported that some base of tongue tumors may have been misclassified as oral cavity tumors, therefore mistakenly increasing the rate of HPV-positive oral cavity cancers. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3435", "text": "Chewing  betel quid  (paan) and  Areca nut -based products is known to be a strong risk factor for developing oral cancer even in the absence of tobacco. It doubles the risk of oral cancer 2.1 times [ 20 ]  and when chewed with additional tobacco in its preparation (like in  gutka ), there is an even higher risk. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3436", "text": "In  India  where such practices are common, oral cancer represents up to 40% of all cancers, compared to just 4% in the  UK ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3437", "text": "People after  hematopoietic stem cell transplantation  (HSCT) are at a higher risk for oral cancer. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in people not treated with HSCT. [ 41 ]  This effect is supposed to be owing to the continuous lifelong  immune  suppression and chronic oral  graft-versus-host disease . [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3438", "text": "This HPV16 (along with HPV18) is the same virus responsible for the vast majority of all  cervical cancers  and is the most common sexually transmitted infection. Risk factors for developing HPV-positive oropharyngeal cancer include multiple sexual partners, anal and oral sex and a weak immune system. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3439", "text": "A  premalignant  (or precancerous) lesion is defined as \"a benign, morphologically altered tissue that has a greater than normal risk of malignant transformation.\" There are several different types of premalignant lesion that occur in the mouth. Some oral cancers begin as white patches ( leukoplakia ), red patches ( erythroplakia ) or mixed red and white patches (erythroleukoplakia or \"speckled leukoplakia\"). Other common premalignant lesions include  oral submucous fibrosis  and  actinic cheilitis . [ 43 ]  In the Indian subcontinent oral submucous fibrosis is very common due to  betel nut  chewing. This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3440", "text": "Oral  squamous cell carcinoma  is the end product of an unregulated proliferation of mucous basal cells. A single precursor cell is transformed into a clone consisting of many daughter cells with an accumulation of altered genes called  oncogenes . What characterizes a malignant tumor over a benign one is its ability to metastasize. This ability is independent of the size or grade of the tumor (often seemingly slow growing cancers like the adenoid cystic carcinoma can metastasis widely). It is not just rapid growth that characterizes a  cancer , but their ability to secrete enzymes, angiogeneic factors, invasion factors, growth factors and many other factors that allow it to spread. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3441", "text": "The full causal relation between alcohol consumption and the elevated risk of cancer remains unclear, but  acetaldehyde  plays a major role. [ 44 ]  Immediately after alcohol consumption, there are elevated levels of acetaldehyde in saliva, peaking after about 2 minutes. Acetaldehyde is produced by the oral microbiome, and also by enzymes in the oral mucosa, saliva glands, and liver. It is also naturally present in alcoholic beverages. Of these, the microbiome is the major contributor, accounting for at least half of the acetaldehyde present. Poor oral hygiene, smoking, and heavy drinking induce an increase in acetaldehyde-producing bacteria in the mouth. Many species of bacteria contribute to acetaldehyde production and their epidemiological significance is not known. The acetaldehyde reacts with oral epithelial cells, inducing DNA modifications, which can lead to mutations and cancer development. The ability to metabolize acetaldehyde in the mouth is limited, so it may remain in the saliva for hours. L-cysteine tablets may be used to decrease acetaldehyde exposure in the oral cavity. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3442", "text": "Diagnosis of oral cancer is completed for (1) initial diagnosis, (2)  staging , and (3) treatment planning. A complete history, and clinical examination is first completed, then a  wedge of tissue  is cut from the suspicious lesion for  tissue diagnosis . This might be done with scalpel biopsy,  punch biopsy ,  fine or core needle biopsy . In this procedure, the  surgeon  cuts all, or a piece of the tissue, to have it examined under a microscope by a  pathologist . [ 46 ]  Brush biopsies are not considered accurate for the diagnosis of oral cancer. [ 47 ]  Salivary biomarkers are also being under investigation with emerging outcomes and could potentially be used as a non-invasive diagnostic tool in the future. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3443", "text": "With the first biopsy, the  pathologist  will provide a  tissue diagnosis  (e.g.  squamous cell carcinoma ), and  classify  the cell structure. They may add additional information that can be used in staging, and treatment planning, such as the  mitotic rate , the  depth of invasion , and the  HPV  status of the tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3444", "text": "After the tissue is confirmed cancerous, other tests will be completed to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3445", "text": "Other, more invasive tests, may also be completed such as  fine needle aspiration ,  biopsy  of  lymph nodes , and  sentinel node biopsy . When the cancer has spread to lymph nodes, their exact location, size, and spread beyond the capsule (of the lymph nodes) needs to be determined, as each can have a significant impact on treatment and prognosis. Small differences in the pattern of lymph node spread, can have a significant impact on treatment and prognosis. Panendoscopy may be recommended, because the tissues of the entire upper  aerodigestive tract  are generally affected by the same  carcinogens , so other primary cancers are a common occurrence. [ 49 ] [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3446", "text": "From these collective findings, taken in consideration with the health and desires of the person, the cancer team develops a plan for treatment. Since most oral cancers require surgical removal, a second set of  histopathologic  tests will be completed on any tumor removed to determine the prognosis, need for additional surgery, chemotherapy, radiation, immunotherapy, or other interventions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3447", "text": "Oral cancer is a subgroup of  head and neck cancers  which includes those of the  oropharynx ,  larynx ,  nasal cavity  and  paranasal sinuses ,   salivary glands , and  thyroid gland . Oral  melanoma , while part of head and neck cancers is considered separately. [ 6 ]  Other cancers can occur in the mouth (such as  bone cancer ,  lymphoma , or  metastatic cancers  from distant sites) but are also considered separately from oral cancers. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3448", "text": "Oral  cancer staging  is an assessment of the degree of spread of the cancer from its original source. [ 51 ]  It is one of the factors affecting both the  prognosis  and the potential treatment of oral cancer. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3449", "text": "The evaluation of squamous cell carcinoma of the mouth and pharynx staging uses the  TNM classification  (tumor, node, metastasis). This is based on the size of the primary tumor, lymph node involvement, and distant metastasis. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3450", "text": "TMN evaluation allows the person to be classified into a prognostic staging group; [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3451", "text": "The  US Preventive Services Task Force  (USPSTF) in 2013 stated evidence was insufficient to determine the balance of benefits and harms of screening for oral cancer in adults without symptoms by primary care providers. [ 53 ]  The  American Academy of Family Physicians  comes to similar conclusions while the  American Cancer Society  recommends that adults over 20 years who have periodic health examinations should have the oral cavity examined for cancer. [ 53 ]  The  American Dental Association  recommends that providers remain alert for signs of cancer during routine examinations. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3452", "text": "There are a variety of screening devices such as  toluidine blue , brush biopsy, or  fluorescence imaging , however, there is no evidence that routine use of these devices in general dental practice is helpful. [ 54 ]  Potential risks of using screening devices include false positives, unnecessary surgical biopsies, and a financial burden. [ 54 ]  Micronuclei assays can help in early detection of pre-malignant and malignant lesions, thereby improving survival and reducing morbidity associated with treatment. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3453", "text": "There has also been research showing potential in using oral cytology as a diagnostic test for oral cancer instead of traditional biopsy techniques. In oral cytology, a brush is used to take some cells from the suspected lesion/area and these are sent to a laboratory for examination. [ 55 ]  This can be much less invasive and painful than a scalpel biopsy for the patient, however, there needs to be further research before oral cytology can be considered as an effective routine screening tool when compared to biopsies. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3454", "text": "Oral cancer (squamous cell carcinoma) is usually treated with surgery alone, or in combination with adjunctive therapy, including radiation, with or without chemotherapy. [ 46 ] :\u200a602\u200a  With small lesions (T1), surgery or radiation have similar control rates, so the decision about which to use is based on functional outcome, and complication rates. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3455", "text": "In most centres, removal of  squamous cell carcinoma  from the oral cavity and neck is achieved primarily through surgery. This also allows a detailed examination of the tissue for  histopathologic  characteristics, such as depth, and spread to lymph nodes that might require radiation or chemotherapy. For small lesions (T1\u20132), access to the oral cavity is through the mouth. When the lesion is larger, involves the bone of the  maxilla  or  mandible , or access is limited due to mouth opening, the upper or lower lip is split, and the cheek pulled back to give greater access to the mouth. [ 46 ]  When the tumor involves the jaw bone, or when surgery or radiation will cause severe limited mouth opening, part of the bone is also removed with the tumor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3456", "text": "Spread of cancer from the oral cavity to the  lymph nodes  of the neck has a significant effect on  survival . Between 60 and 70% of people with early stage oral cancer will have no lymph node involvement of the neck  clinically , but 20\u201330% of those people (or up to 20% of all those affected) will have clinically undetectable spread of cancer to the lymph nodes of the neck (called occult disease)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3457", "text": "The management of the neck is crucial, since spread to it reduces the chance of survival by 50%. [ 56 ]  If there is evidence of lymph node involvement of the neck, during the diagnostic phase, then a modified radical  neck dissection  is generally performed. Where the neck lymph nodes have no evidence of involvement clinically, but the oral cavity lesion is high risk for spread (e.g. T2 or above lesions), then a neck dissection of the lymph nodes above the level of the  omohyoid muscle  may be completed. T1 lesions that are 4\u00a0mm or greater in thickness have a significant risk of spread to neck nodes. When disease if found in the nodes after removal (but not seen clinically) the recurrence rates is 10\u201324%. If post-operative radiation is added, the failure rate is 0\u201315%. When lymph nodes are clinically found during the diagnosis phase, and radiation is added post-operative, disease control is >80%. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3458", "text": "Chemotherapy and  radiotherapy  are most often used, as an adjunct to surgery, to control oral cancer that is greater than stage 1, or has spread to either regional lymph nodes or other parts of the body. [ 46 ]  Radiotherapy alone can be used instead of surgery, for very small lesions, but is generally used as an adjunct when lesions are large, cannot be completely removed, or have spread to the lymph nodes of the neck.  Chemotherapy  is useful in oral cancers when used in combination with other treatment modalities such as radiation therapy but it is not used alone as a monotherapy. When a cure is unlikely, it can also be used to extend life and can be considered palliative but not  curative care . [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3459", "text": "Monoclonal antibody therapy  (with agents such as  cetuximab ) have been shown to be effective in the treatment of squamous cell head and neck cancers, and are likely to have an increasing role in the future management of this condition when used in conjunction with other established treatment modalities, although it is not a replacement for chemotherapy in head and neck cancers. [ 59 ] [ 58 ]  Likewise, molecularly targeted therapies and immunotherapies may be effective for the treatment of oral and oropharyngeal cancers. Adding epidermal growth factor receptor monoclonal antibody (EGFR mAb) to standard treatment may increase survival, keeping the cancer limited to that area of the body and may decrease reappearance of the cancer. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3460", "text": "Following treatment,  rehabilitation  may be necessary to improve movement, chewing, swallowing, and speech.  Speech and language pathologists  may be involved at this stage. Treatment of oral cancer will usually be by a multidisciplinary team, with treatment professionals from the realms of radiation, surgery, chemotherapy, nutrition, dentistry, and even psychology all possibly involved with diagnosis, treatment, rehabilitation, and care. Due to the location of oral cancer, there may be a period where the person requires a  tracheotomy  and  feeding tube ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3461", "text": "Survival rates for oral cancer depend on the precise site and the stage of the cancer at diagnosis. Overall, 2011 data from the SEER database shows that survival is around 57% at five years when all stages of initial diagnosis, all genders, all ethnicities, all age groups, and all treatment modalities are considered. Survival rates for stage 1 cancers are approximately 90%, hence the emphasis on early detection to increase survival outcome for people. Similar survival rates are reported from other countries, such as Germany. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3462", "text": "Globally, it newly occurred in about 355,000 people and resulted in 177,000 deaths in 2018. [ 5 ]  Of these 355,000, about 246,000 are males and 108,000 are females. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3463", "text": "In 2013, oral cancer resulted in 135,000 deaths, up from 84,000 deaths in 1990. [ 61 ]  Oral cancer occurs more often in people from lower and middle income countries. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3464", "text": "Europe places second-highest after Southeast Asia among all continents for age-standardised rate (ASR) specific to oral and oropharyngeal cancer. It is estimated that there were 61,400 cases of oral and lip cancer within Europe in 2012. Hungary recorded the highest number of mortality and morbidity due to oral and pharyngeal cancer among all European countries while Cyprus reported the lowest numbers\u00a0 [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3465", "text": "British Cancer Research found 2,386 deaths due to oral cancer in 2014; while most oral cancer cases are diagnosed in older adults between 50 and 74 years old, this condition can affect the young as well; [ 64 ]  6% of people affected by oral cancer are under 45 years of age. [ 65 ]  The United Kingdom is 16th-lowest for males and 11th-highest for females for oral cancer incidence among Europe. Additionally, there is a regional variability within the United Kingdom, with Scotland and northern England having higher rates than southern England. The same analysis applies to lifetime risk of developing oral cancer, as in Scotland it is 1.84% in males and 0.74% in females, higher than the rest of the UK, being 1.06% and 0.48%, respectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3466", "text": "Oral cancer is the sixteenth most-common cancer in the United Kingdom (around 6,800 people were diagnosed with oral cancer in the United Kingdom in 2011), and it is the 19th most-common cause of cancer death (around 2,100 people died from the disease in 2012). [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3467", "text": "The highest incidence of oral and pharyngeal cancer was recorded in Denmark, with age-standardised rates per 100,000 of 13.0, followed by Lithuania (9.9) and the United Kingdom (9.8). [ 63 ]  Lithuania reported the highest incidence in men while Denmark reported the highest in women. The highest rates for mortality in 2012 were reported in Lithuania (7.5), Estonia (6.0), and Latvia (5.4). [ 63 ]  Incidence of oral cancer in young adults (ages 20\u201339 years old) in Scandinavia has reportedly risen approximately 6-fold between 1960 and 1994 [ 66 ]  The high incidence rate of oral and pharyngeal cancer in Denmark could be attributed to their higher alcohol intake than citizens of other Scandinavian countries and low intake of fruits and vegetables in general."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3468", "text": "Hungary (23.3), Slovakia (16.4), and Romania (15.5) reported the highest incidences of oral and pharyngeal cancer. [ 63 ]  Hungary also recorded the highest incidence in both genders as well as the highest mortality rates in Europe. [ 63 ]  It is ranked third globally for cancer mortality rates. [ 67 ]  Cigarette smoking, excessive alcohol consumption, inequalities in the care received by people with cancer, and gender-specific systemic risk factors have been determined as the leading causes for the high morbidity and mortality rates in Hungary. [ 68 ] [ 69 ] [ 70 ] [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3469", "text": "The incidence rates of oral cancer in western Europe found France, Germany and Belgium to be highest. The ASRs (per 100,000) were 15.0, 14.6, and 14.1, respectively. When filtered by gender category, the same countries rank top 3 for male, however, in different order of Belgium (21.9), Germany (23.1), and France (23.1). France, Belgium, and the Netherlands rank highest for females, with ASRs 7.6, 7.0, and 7.0, respectively. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3470", "text": "Incidence of oral and oropharyngeal cancers were recorded, finding Portugal, Croatia and Serbia to have highest rates (ASR per 100,000). These values are 15.4, 12, and 11.7, respectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3471", "text": "It is the eleventh-most-common cancer in the United States among males while in Canada and Mexico it is the twelfth and thirteenth-most-common cancer respectively. The ASIR for lip and oral cavity cancer among men in Canada and Mexico is 4.2 and 3.1, respectively. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3472", "text": "Of all the cancers, oral cancer attributes to 3% in males, opposed to 2% in women. New cases of oral cancer in US as of 2013, approximated almost 66,000 with almost 14000 attributed from tongue cancer, and nearly 12000 from the mouth, and the remainder from the oral cavity and pharynx. In the previous year, 1.6% of lip and oral cavity cancers were diagnosed, where the age-standardised incidence rate (ASIR) across all geographic regions of United States of America estimates at 5.2 per 100,000 population. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3473", "text": "In 2022, close to 54,000 Americans are projected to be diagnosed with oral or oropharyngeal cancer. 66% of the time, these will be found as late stage three and four disease. It will cause over 8,000 deaths. Of those newly diagnosed, only slightly more than half will be alive in five years. Similar survival estimates are reported from other countries. For example, five-year relative survival for oral cavity cancer in Germany is about 55%. [ 60 ]  In the US oral cancer accounts for about 8 percent of all malignant growths."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3474", "text": "Oral cancers overall risk higher in black males opposed to white males, however specific oral cancers-such as of the lip, have a higher risk in white males opposed to black males. Overall, rates of oral cancer between gender groups (male and female) seem to be decreasing, according to data from 3 studies. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3475", "text": "The ASIR across all geographic regions of South America as of 2012 sits at 3.8 per 100,000 population where approximately 6,046 deaths have occurred due to lip and oral cavity cancer, where the age-standardized mortality rate remains at 1.4. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3476", "text": "In Brazil, however, lip and oral cavity cancer is the 7th most common cancer, with an estimated 6,930 new cases diagnosed in the year 2012. This number is rising and has an overall higher ASIR at 7.2 per 100,000 population whereby an approx 3000 deaths have occurred  [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3477", "text": "Rates are increasing across both males and females. As of 2017, almost 50000 new cases of oropharyngeal cancers will be diagnosed, with incidence rates being more than twice as high in men than women. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3478", "text": "Oral cancer is one of the most-common types of cancer in Asia due to its association with smoking (tobacco, bidi), betel quid and alcohol consumption. Regionally incidence varies with highest rates in South Asia, particularly India, Bangladesh, Sri Lanka, Pakistan, and Afghanistan. [ 75 ]  In South East Asia and Arab countries, although the prevalence is not as high, estimated incidences of oral cancer ranged from 1.6 to 8.6/ 100,000 and 1.8 to 2.13/ 100,000 respectively. [ 76 ] [ 77 ]  According to GLOBOCAN 2012, the estimated age-standardised rates of cancer incidence and mortality was higher in males than females. However, in some areas, specifically South East Asia, similar rates were recorded for both genders. [ 76 ]  The average age of those diagnosed with oral squamous cell carcinoma is approximately 51\u201355. [ 75 ]  In 2012, there were 97,400 deaths recorded due to oral cancer. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3479", "text": "Oral cancer is the third-most-common form of cancer in India with over 77 000 new cases diagnosed in 2012 (2.3:1 male to female ratio). [ 79 ]  Studies estimate over five deaths per hour. [ 80 ]  One of the reasons behind such high incidence might be popularity of betel and areca nuts, which are considered to be risk factors for development of oral cavity cancers. [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3480", "text": "There is limited data for the prevalence of oral cancer in Africa. The following rates describe the number of new cases (for incidence rates) or deaths (for mortality rates) per 100 000 individuals per year. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3481", "text": "The incidence rate of oral cancer is 2.6 for both sexes. The rate is higher in males at 3.3 and lower in females at 2.0. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3482", "text": "The mortality rate is lower than the incidence rate at 1.6 for both sexes. The rate is again higher for males at 2.1 and lower for females at 1.3. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3483", "text": "The following rates describe the number of new cases or deaths per 100 000 individuals per year. The incidence rate of oral cancer is 6.3 for both sexes; this is higher in males at 6.8\u20138.8 and lower in females at 3.7\u20133.9. [ 82 ]  The mortality rate is significantly lower than the incidence rate at 1.0 for both sexes. The rate is higher in males at 1.4 and lower in females at 0.6. [ 83 ]  Table 1 provides age-standardised incidence and mortality rates for oral cancer based on the location in the mouth. The location 'other mouth' refers to the buccal mucosa, the vestibule and other unspecified parts of the mouth. The data suggests lip cancer has the highest incidence rate while gingival cancer has the lowest rate overall. In terms of mortality rates, oropharyngeal cancer has the highest rate in males and tongue cancer has the highest rate in females. Lip, palatal and gingival cancer have the lowest mortality rates overall. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3484", "text": "Oral cancers are the fourth most common type seen in other animals in veterinary medicine, with older animals having higher chances of developing it. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3485", "text": "Dogs that are a breed that is at higher risk of developing oral cancer are more susceptible. Tumors that are found early in development can be removed by surgery, however some cases involve removing a part of the jaw. Chemotherapy is used following surgeries or to remove a tumor that cannot be accessed. Tumors that are caught when the cancer has already spread to other places of the body will result in the dog living for only 6-12 more months. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3486", "text": "The most common type of oral cancer seen in cats is squamous cell carcinoma. Due to tumors developing in hidden spots such as beneath the tongue, when the tumors in the cats mouth are caught it is often untreatable. [ 86 ]  Risk factors include secondhand smoke, as the smoke settles on the fur which is ingested when cats groom, and potentially the over consumption of canned food and use of flea collars. [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3487", "text": "In  anatomy , the  orbit [ a ]  is the  cavity  or socket/hole of the  skull  in which the  eye  and  its appendages  are situated. \"Orbit\" can refer to the bony socket, [ 1 ]  or it can also be used to imply the contents. [ 2 ]  In the adult human, the volume of the orbit is about 28 millilitres (0.99\u00a0imp\u00a0fl\u00a0oz; 0.95\u00a0US\u00a0fl\u00a0oz), [ 3 ]  of which the eye occupies 6.5\u00a0ml (0.23\u00a0imp\u00a0fl\u00a0oz; 0.22\u00a0US\u00a0fl\u00a0oz). [ 4 ]  The orbital contents comprise the eye, the  orbital  and  retrobulbar  fascia,  extraocular muscles ,  cranial nerves   II ,  III ,  IV ,  V , and  VI , blood vessels, fat, the  lacrimal gland  with its  sac  and  duct , the  eyelids ,  medial  and  lateral palpebral ligaments , cheek ligaments, the  suspensory ligament ,  septum ,  ciliary ganglion  and  short ciliary nerves ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3488", "text": "The orbits are conical or four-sided pyramidal cavities, which open into the midline of the face and point back into the head. Each consists of a base, an apex and four walls. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3489", "text": "There are two important  foramina , or windows, two important  fissures , or grooves, and one  canal  surrounding the  globe  in the orbit. There is a  supraorbital foramen , an  infraorbital foramen , a  superior orbital fissure , an  inferior orbital fissure  and the  optic canal , each of which contains structures that are crucial to normal eye functioning. The supraorbital foramen contains the supraorbital nerve, the first division of the  trigeminal nerve  or V1 and lies just lateral to the  frontal sinus . The infraorbital foramen contains the second division of the trigeminal nerve, the  infraorbital nerve  or V2, and sits on the anterior wall of the  maxillary sinus . Both foramina are crucial as potential pathways for cancer and infections of the orbit to spread  into the brain  or other deep facial structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3490", "text": "The  optic canal  contains the ( cranial nerve II ) and the  ophthalmic artery , and sits at the junction of the sphenoid sinus with the  ethmoid air cells , superomedial and  posterior  to structures at the orbital apex. It provides a pathway between the orbital contents and the  middle cranial fossa . The superior orbital fissure lies just  lateral  and  inferior  to the optic canal, and is formed at the junction of the  lesser  and  greater wing  of the  sphenoid bone . It is a major pathway for intracranial communication, containing cranial nerves  III ,  IV ,  VI  which control eye movement via the  extraocular muscles , and the ophthalmic branches of  cranial nerve V , or V1. The second division of the trigeminal nerve enters the skull base at the  foramen rotundum , or V2. The inferior orbital fissure lies inferior and lateral to the ocular globe at the lateral wall of the maxillary sinus. It is not as important in function, though it does contain a few branches of the maxillary nerve and the infraorbital artery and vein. [ 6 ]  Other minor structures in the orbit include the  anterior  and  posterior ethmoidal foramen  and  zygomatic orbital foramen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3491", "text": "The bony walls of the orbital canal in humans do not derive from a single bone, but a mosaic of seven  embryologically  distinct structures: the  zygomatic bone   laterally , the  sphenoid bone , with its lesser wing forming the optic canal and its greater wing forming the lateral posterior portion of the bony orbital process, the  maxillary bone   inferiorly  and  medially  which, along with the  lacrimal  and  ethmoid bones , forms the medial wall of the  orbital canal . The ethmoid air cells are extremely thin, and form a structure known as the  lamina papyracea , the most delicate bony structure in the skull, and one of the most commonly fractured bones in orbital trauma. The lacrimal bone also contains the  nasolacrimal duct . The superior bony margin of the orbital rim, otherwise known as the  orbital process , is formed by the frontal bone. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3492", "text": "The roof (superior wall) is formed primarily by the orbital plate  frontal bone , and also the lesser wing of  sphenoid  near the apex of the orbit. The orbital surface presents medially by trochlear fovea and laterally by lacrimal fossa. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3493", "text": "The floor (inferior wall) is formed by the orbital surface of  maxilla , the orbital surface of  zygomatic bone  and the minute orbital process of  palatine bone . Medially, near the orbital margin, is located the groove for  nasolacrimal duct . Near the middle of the floor, located infraorbital groove, which leads to the infraorbital foramen. The floor is separated from the lateral wall by  inferior orbital fissure , which connects the orbit to  pterygopalatine  and  infratemporal fossa ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3494", "text": "The medial wall is formed primarily by the orbital plate of  ethmoid , as well as contributions from the frontal process of maxilla, the  lacrimal bone , and a small part of the body of the sphenoid. It is the thinnest wall of the orbit, evidenced by pneumatized ethmoidal cells. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3495", "text": "The lateral wall is formed by the frontal process of zygomatic and more posteriorly by the orbital plate of the greater wing of sphenoid. The bones meet at the zygomaticosphenoid suture. The lateral wall is the thickest wall of the orbit, important because it is the most exposed surface, highly vulnerable to blunt force trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3496", "text": "The base, orbital margin, which opens in the face, has four borders. The following bones take part in their formation:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3497", "text": "The orbit holds and protects the  eyes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3498", "text": "The movement of the eye is controlled by six distinct extraocular muscles, a  superior , an  inferior , a  medial  and a  lateral  rectus, as well as a  superior  and an  inferior oblique . The superior ophthalmic vein is a sigmoidal vessel along the superior margin of the orbital canal that drains deoxygenated blood from surrounding musculature. The  ophthalmic artery  is a crucial structure in the orbit, as it is often the only source of collateral blood to the brain in cases of large  internal carotid   infarcts , as it is a collateral pathway to the  circle of Willis . In addition, there is the  optic canal , which contains the optic nerve, or cranial nerve II, and is formed entirely by the lesser wing of the sphenoid, separated from the supraorbital fissure by the  optic strut . Injury to any one of these structures by infection, trauma or neoplasm can cause temporary or permanent visual dysfunction, and even blindness if not promptly corrected. [ 9 ]  The orbits also protect the eye from mechanical injury. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3499", "text": "In the orbit, the surrounding fascia allows for smooth rotation and protects the orbital contents. If excessive tissue accumulates behind the ocular globe, the eye can protrude, or become  exophthalmic . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3500", "text": "Enlargement of the  lacrimal gland , located superotemporally within the orbit, produces protrusion of the eye inferiorly and medially (away from the location of the lacrimal gland). Lacrimal gland may be enlarged from  inflammation  (e.g.  sarcoid ) or  neoplasm  (e.g.  lymphoma  or  adenoid cystic carcinoma ). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3501", "text": "Tumors (e.g.  glioma  and  meningioma  of the  optic nerve ) within the cone formed by the horizontal rectus muscles produce axial protrusion (bulging forward) of the eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3502", "text": "Graves disease  may also cause axial protrusion of the eye, known as  Graves' ophthalmopathy , due to buildup of  extracellular matrix   proteins  and  fibrosis  in the rectus muscles. Development of Graves' ophthalmopathy may be independent of thyroid function. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3503", "text": "The  ossicles  (also called  auditory ossicles ) are three  irregular bones  in the  middle ear  of  humans  and other  mammals , and are among the smallest  bones  in the human body. Although the term \"ossicle\" literally means \"tiny bone\" (from  Latin   ossiculum ) and may refer to any small bone throughout the body, it typically refers specifically to the  malleus ,  incus  and  stapes  (\"hammer, anvil, and stirrup\") of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3504", "text": "The auditory ossicles serve as a  kinematic chain  to transmit and amplify ( intensify )  sound  vibrations collected from the air by the  ear drum  to the fluid-filled  labyrinth  ( cochlea ). The absence or pathology of the auditory ossicles would constitute a moderate-to-severe  conductive hearing loss ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3505", "text": "The ossicles are, in order from the eardrum to the inner ear (from superficial to deep): the  malleus ,  incus , and  stapes , terms that in  Latin  are translated as \"the  hammer ,  anvil , and  stirrup \". [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3506", "text": "Studies have shown that ear bones in mammal embryos are attached to the  dentary , which is part of the lower  jaw . These are ossified portions of  cartilage \u2014called  Meckel's cartilage \u2014that are attached to the jaw. As the embryo develops, the cartilage hardens to form bone. Later in development, the bone structure breaks loose from the jaw and migrates to the inner ear area. The structure is known as the middle ear, and is made up of the  stapes ,  incus ,  malleus , and  tympanic membrane . These correspond to the  columella ,  quadrate ,  articular , and  angular  structures in the amphibian, bird or reptile jaw. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3507", "text": "As sound waves vibrate the tympanic membrane (eardrum), it in turn moves the nearest ossicle, the malleus, to which it is attached. The malleus then transmits the vibrations, via the incus, to the stapes, and so ultimately to the membrane of the fenestra ovalis (oval window), the opening to the vestibule of the inner ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3508", "text": "Sound traveling through the air is mostly reflected when it comes into contact with a liquid medium; only about 1/30 of the sound energy moving through the air would be transferred into the liquid. [ 4 ]  This is observed from the abrupt cessation of sound that occurs when the head is submerged underwater. This is because the relative incompressibility of a liquid presents resistance to the force of the sound waves traveling through the air. The ossicles give the eardrum a  mechanical advantage  via lever action and a reduction in the area of force distribution; the resulting vibrations are stronger but don't move as far. This allows more efficient coupling than if the sound waves were transmitted directly from the outer ear to the oval window. This reduction in the area of force application allows a large enough increase in  pressure  to transfer most of the sound energy into the liquid. The increased pressure will compress the fluid found in the cochlea and transmit the stimulus. Thus, the lever action of the ossicles changes the vibrations so as to improve the transfer and reception of sound, and is a form of  impedance matching ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3509", "text": "However, the extent of the movements of the ossicles is controlled (and constricted) by two muscles attached to them (the  tensor tympani  and the  stapedius ). It is believed that these muscles can contract to dampen the vibration of the ossicles, in order to protect the inner ear from excessively loud noise (theory 1) and that they give better frequency resolution at higher frequencies by reducing the transmission of low frequencies (theory 2) (see  acoustic reflex ). These muscles are more highly developed in  bats  and serve to block outgoing cries of the bats during  echolocation  (SONAR)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3510", "text": "Occasionally the joints between the ossicles become rigid. One condition,  otosclerosis , results in the fusing of the stapes to the oval window. This reduces  hearing  and may be treated surgically using a passive  middle ear implant . [ further explanation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3511", "text": "There is some doubt as to the discoverers of the auditory ossicles and several anatomists from the early 16th century have the discovery attributed to them with the two earliest being  Alessandro Achillini  and  Jacopo Berengario da Carpi . [ 5 ]  Several sources, including  Eustachi  and  Casseri , [ 6 ]  attribute the discovery of the malleus and incus to the anatomist and philosopher  Achillini . [ 7 ]  The first written description of the malleus and incus was by  Berengario da Carpi  in his  Commentaria super anatomia Mundini  (1521), [ 8 ]  although he only briefly described two bones and noted their theoretical association with the transmission of sound. [ 9 ]   Niccolo Massa 's  Liber introductorius anatomiae [ 10 ]  described the same bones in slightly more detail and likened them both to little hammers. [ 9 ]  A much more detailed description of the first two ossicles followed in  Andreas Vesalius '  De humani corporis fabrica [ 11 ]  in which he devoted a chapter to them. Vesalius was the first to compare the second element of the ossicles to an anvil although he offered the molar as an alternative comparison for its shape. [ 12 ]  The first published description of the stapes came in  Pedro Jimeno 's  Dialogus de re medica  (1549) [ 13 ]  although it had been previously described in public lectures by  Giovanni Filippo Ingrassia  at the  University of Naples  as early as 1546. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3512", "text": "The term  ossicle  derives from  ossiculum , a  diminutive  of \"bone\" ( Latin :  os ;  genitive   ossis ). [ 15 ]  The malleus gets its name from Latin  malleus , meaning \"hammer\", [ 16 ]  the incus gets its name from Latin  incus  meaning \"anvil\" from incudere meaning \"to forge with a hammer\", [ 17 ]  and the stapes gets its name from Modern Latin \"stirrup\", probably an alteration of Late Latin  stapia  related to stare \"to stand\" and pedem, an accusative of pes \"foot\", so called because the bone is shaped like a stirrup \u2013 this was an invented Modern Latin word for \"stirrup\", for which there was no classical Latin word, as the ancients did not use stirrups. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3513", "text": "The  otic ganglion  is a small   parasympathetic ganglion  located immediately below the  foramen ovale  in the  infratemporal fossa  and on the medial surface of the  mandibular nerve . It is functionally associated with the  glossopharyngeal nerve  and innervates the  parotid gland  for salivation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3514", "text": "It is one of four parasympathetic ganglia of the head and neck. The others are the  ciliary ganglion , the  submandibular ganglion  and the  pterygopalatine ganglion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3515", "text": "The otic ganglion is a small (2\u20133\u00a0mm), oval shaped, flattened  parasympathetic ganglion  of a reddish-grey color, located immediately below the  foramen ovale  in the  infratemporal fossa  and on the medial surface of the  mandibular nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3516", "text": "It is in relation, laterally, with the trunk of the mandibular nerve at the point where the motor and sensory roots join; medially, with the cartilaginous part of the  auditory tube , and the origin of the  tensor veli palatini ; posteriorly, with the  middle meningeal artery . It surrounds the origin of the nerve to the  medial pterygoid ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3517", "text": "The preganglionic  parasympathetic  fibres originate in the  inferior salivatory nucleus  of the  glossopharyngeal nerve . They leave the glossopharyngeal nerve by its  tympanic  branch and then pass via the  tympanic plexus  and the  lesser petrosal nerve  to the otic ganglion.  Here, the fibers synapse and the postganglionic fibers pass by communicating branches to the  auriculotemporal nerve , which conveys them to the  parotid gland . They produce vasodilator and secretomotor effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3518", "text": "Its sympathetic root is derived from the plexus on the  middle meningeal artery . It contains post-ganglionic fibers arising in the  superior cervical ganglion . The fibers pass through the ganglion without relay and reach the  parotid gland  via the  auriculotemporal nerve . They are vasomotor in function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3519", "text": "The sensory root comes from the  auriculotemporal nerve  and is sensory to the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3520", "text": "The motor fibers supplying the  medial pterygoid  and the  tensor veli palatini  and the  tensor tympani  pass through the ganglion without relay."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3521", "text": "Frey's syndrome  is caused by re-routing of parasympathetic and sympathetic fibres of the auriculotemporal nerve (V3) within the otic ganglion. It is a complication of surgery involving the parotid gland whereby injury to these branches, which innervate the parotid gland and sweat glands of the face respectively, form abnormal connections. Salivation leads to perspiration and flushing of the pre-auricular region and is called 'gustatory sweating'."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3522", "text": "This article incorporates text in the  public domain  from  page 897  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3523", "text": "Otitis media  is a group of  inflammatory  diseases of the  middle ear . [ 2 ]  One of the two main types is  acute otitis media  ( AOM ), [ 3 ]  an  infection  of rapid onset that usually presents with ear pain. [ 1 ]  In young children this may result in pulling at the ear, increased crying, and poor sleep. [ 1 ]  Decreased eating and a  fever  may also be present. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3524", "text": "The other main type is  otitis media with effusion  ( OME ), typically not associated with symptoms, [ 1 ]  although  occasionally a feeling of fullness is described; [ 4 ]  it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. [ 4 ]   Chronic suppurative otitis media  ( CSOM ) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. [ 7 ]  It may be a complication of acute otitis media. [ 4 ]  Pain is rarely present. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3525", "text": "All three types of otitis media may be associated with  hearing loss . [ 2 ] [ 3 ]  If children with hearing loss due to OME do not learn  sign language , it may affect their ability to learn. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3526", "text": "The cause of AOM is related to childhood  anatomy  and  immune function . [ 4 ]  Either bacteria or viruses may be involved. [ 4 ]  Risk factors include exposure to smoke, use of  pacifiers , and attending  daycare . [ 4 ]  It occurs more commonly among  indigenous Australians  and those who have  cleft lip and palate  or  Down syndrome . [ 4 ] [ 9 ]  OME frequently occurs following AOM and may be related to  viral upper respiratory infections , irritants such as smoke, or  allergies . [ 3 ] [ 4 ]  Looking at the eardrum is important for making the correct diagnosis. [ 10 ]  Signs of AOM include bulging or a lack of movement of the  tympanic membrane  from a puff of air. [ 1 ] [ 11 ]  New discharge not related to  otitis externa  also indicates the diagnosis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3527", "text": "A number of measures decrease the risk of otitis media including  pneumococcal  and  influenza vaccination ,  breastfeeding , and avoiding tobacco smoke. [ 1 ]  The use of  pain medications  for AOM is important. [ 1 ]  This may include  paracetamol  (acetaminophen),  ibuprofen ,  benzocaine  ear drops, or  opioids . [ 1 ]  In AOM, antibiotics may speed recovery but may result in side effects. [ 12 ]  Antibiotics are often recommended in those with severe disease or under two years old. [ 11 ]  In those with less severe disease they may only be recommended in those who do not improve after two or three days. [ 11 ]  The initial antibiotic of choice is typically  amoxicillin . [ 1 ]  In those with frequent infections, surgical placement of  tympanostomy tubes  may decrease recurrence. [ 1 ]  In children with otitis media with effusion  antibiotics  may increase resolution of symptoms, but may cause diarrhoea, vomiting and skin rash. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3528", "text": "Worldwide AOM affects about 11% of people a year (about 325 to 710\u00a0million cases). [ 14 ] [ 15 ]  Half the cases involve children less than five years of age and it is more common among males. [ 4 ] [ 14 ]  Of those affected about 4.8% or 31\u00a0million develop chronic suppurative otitis media. [ 14 ]  The total number of people with CSOM is estimated at 65\u2013330 million people. [ 16 ]  Before the age of ten OME affects about 80% of children at some point. [ 4 ]  Otitis media resulted in 3,200 deaths in 2015 \u2013 down from 4,900 deaths in 1990. [ 6 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3529", "text": "The primary symptom of acute otitis media is  ear pain ; other possible symptoms include  fever , reduced hearing during periods of illness, tenderness on touch of the skin above the ear, purulent discharge from the ears,  irritability , ear blocking sensation and diarrhea (in infants). Since an episode of otitis media is usually precipitated by an  upper respiratory tract infection  (URTI), there are often accompanying symptoms like a  cough  and  nasal discharge . [ 1 ]   One might also experience a feeling of fullness in the ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3530", "text": "Discharge from the ear can be caused by acute otitis media with perforation of the eardrum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a  basilar skull fracture , can also lead to cerebrospinal fluid otorrhea (discharge of CSF from the ear) due to cerebral spinal drainage from the brain and its covering (meninges). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3531", "text": "The common cause of all forms of otitis media is dysfunction of the  Eustachian tube . [ 18 ]  This is usually due to inflammation of the  mucous membranes  in the  nasopharynx , which can be caused by a viral  upper respiratory tract infection  (URTI),  strep throat , or possibly by  allergies . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3532", "text": "By reflux or aspiration of unwanted secretions from the nasopharynx into the normally sterile middle-ear space, the fluid may then become infected \u2013 usually with  bacteria . The virus that caused the initial upper respiratory infection can itself be identified as the  pathogen  causing the infection. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3533", "text": "As its typical symptoms overlap with other conditions, such as acute external otitis, symptoms alone are not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the  tympanic membrane . [ 20 ] [ 21 ]  Examiners may use a pneumatic  otoscope  with a rubber bulb attached to assess the mobility of the tympanic membrane. Other methods to diagnose otitis media is with a  tympanometry ,  reflectometry , or hearing test."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3534", "text": "In more severe cases, such as those with associated hearing loss or high  fever ,  audiometry ,  tympanogram ,  temporal bone   CT  and  MRI  can be used to assess for associated complications, such as  mastoid effusion ,  subperiosteal   abscess  formation,  bony destruction ,  venous thrombosis  or  meningitis . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3535", "text": "Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum. To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum (called  myringitis  or tympanitis) have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum. [ 1 ]  It is important to attempt to differentiate between acute otitis media and otitis media with effusion (OME), as antibiotics are not recommended for OME. [ 1 ]  It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME, with a bulging of the membrane suggesting AOM rather than OME. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3536", "text": "Viral otitis may result in blisters on the external side of the tympanic membrane, which is called  bullous myringitis  ( myringa  being Latin for \"eardrum\"). [ 24 ]  However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. An upset young child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3537", "text": "The most common bacteria isolated from the middle ear in AOM are  Streptococcus pneumoniae ,  Haemophilus influenzae ,  Moraxella catarrhalis , [ 1 ]  and  Staphylococcus aureus . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3538", "text": "Otitis media with  effusion  (OME), also known as serous otitis media (SOM) or secretory otitis media (SOM), and colloquially referred to as 'glue ear', [ 27 ]  is fluid accumulation that can occur in the  middle ear  and  mastoid air cells  due to negative pressure produced by dysfunction of the Eustachian tube. This can be associated with a viral upper respiratory infection (URI) or bacterial infection such as otitis media. [ 28 ]  An effusion can cause  conductive hearing loss  if it interferes with the transmission of vibrations of  middle ear bones  to the  vestibulocochlear nerve complex  that are created by  sound waves . [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3539", "text": "Early-onset OME is associated with feeding of infants while lying down, early entry into group  child care , parental  smoking , lack or too short a period of  breastfeeding , and greater amounts of time spent in group child care, particularly those with a large number of children. These risk factors increase the incidence and duration of OME during the first two years of life. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3540", "text": "Chronic suppurative otitis media (CSOM) is a long-term middle ear inflammation causing persistent ear discharge due to a perforated eardrum. It often follows an unresolved upper respiratory infection leading to acute otitis media. Prolonged inflammation leads to middle ear swelling, ulceration, perforation, and attempts at repair with granulation tissue and polyps. This can worsen discharge and inflammation, potentially developing into CSOM, often associated with cholesteatoma. Symptoms may include ear discharge or pus seen only on examination. Hearing loss is common. Risk factors include poor eustachian tube function, recurrent ear infections, crowded living, daycare attendance, and certain craniofacial malformations. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3541", "text": "Worldwide approximately 11% of the human population is affected by AOM every year, or 709 million cases. [ 14 ] [ 15 ]  About 4.4% of the population develop CSOM. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3542", "text": "According to the  World Health Organization , CSOM is a primary cause of hearing loss in children. [ 31 ]  Adults with recurrent episodes of CSOM have a higher risk of developing permanent conductive and sensorineural hearing loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3543", "text": "In Britain, 0.9% of children and 0.5% of adults have CSOM, with no difference between the sexes. [ 31 ]  The incidence of CSOM across the world varies dramatically where high income countries have a relatively low prevalence while in low income countries the prevalence may be up to three times as great. [ 14 ]  Each year 21,000 people worldwide die due to complications of CSOM. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3544", "text": "Adhesive otitis media occurs when a thin  retracted ear drum  becomes sucked into the middle-ear space and stuck (i.e., adherent) to the  ossicles  and other bones of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3545", "text": "AOM is far less common in breastfed infants than in formula-fed infants, [ 32 ]  and the greatest protection is associated with exclusive breastfeeding (no formula use) for the first six months of life. [ 1 ]  A longer duration of breastfeeding is correlated with a longer protective effect. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3546", "text": "Pneumococcal conjugate vaccines  (PCV) in early infancy decrease the risk of acute otitis media in healthy infants. [ 33 ]  PCV is recommended for all children, and, if implemented broadly, PCV would have a significant  public health  benefit. [ 1 ]   Influenza vaccination  in children appears to reduce rates of AOM by 4% and the use of antibiotics by 11% over 6 months. [ 34 ]  However, the vaccine resulted in increased adverse-effects such as fever and runny nose. [ 34 ]  The small reduction in AOM may not justify the side effects and inconvenience of influenza vaccination every year for this purpose alone. [ 34 ]  PCV does not appear to decrease the risk of otitis media when given to high-risk infants or for older children who have previously experienced otitis media. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3547", "text": "Risk factors such as season, allergy predisposition and presence of older siblings are known to be determinants of recurrent otitis media and persistent middle-ear effusions (MEE). [ 35 ]  History of recurrence, environmental exposure to tobacco smoke, use of daycare, and lack of breastfeeding have all been associated with increased risk of development, recurrence, and persistent MEE. [ 36 ] [ 37 ]  Pacifier use has been associated with more frequent episodes of AOM. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3548", "text": "Long-term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long-term outcomes such as  hearing loss . [ 39 ]  This method of prevention has been associated with emergence of undesirable  antibiotic-resistant otitic bacteria . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3549", "text": "There is moderate evidence that the sugar substitute  xylitol  may reduce infection rates in healthy children who go to daycare. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3550", "text": "Evidence does not support  zinc  supplementation as an effort to reduce otitis rates except maybe in those with severe  malnutrition  such as  marasmus . [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3551", "text": "Probiotics  do not show evidence of preventing acute otitis media in children. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3552", "text": "Oral and topical  pain killers  are the mainstay for the treatment of pain caused by otitis media. Oral agents include  ibuprofen ,  paracetamol  (acetaminophen), and  opiates . A 2023 review found evidence for the effectiveness of single or combinations of oral pain relief in acute otitis media is limited. [ 43 ]  Topical agents shown to be effective include  antipyrine and benzocaine ear drops . [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3553", "text": "A 2008 review found reason to not recommend  decongestants  and  antihistamines , either nasal or oral, due to the lack of benefit and concerns regarding side effects, but this review was withdrawn from publication for being outdated. [ 45 ]  Half of cases of  ear pain  in children resolve without treatment in three days and 90% resolve in seven or eight days. [ 46 ]  The use of steroids is not supported by the evidence for acute otitis media. [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3554", "text": "Use of antibiotics for acute otitis media has benefits and harms. As over 82% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one  perforation , and 11 children to prevent one opposite-side ear infection. For every 14 children treated with antibiotics, one child has an episode of vomiting, diarrhea or a rash. [ 49 ]   Analgesics  may relieve pain, if present. For people requiring surgery to treat otitis media with effusion, preventative antibiotics may not help reduce the risk of post-surgical complications. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3555", "text": "For bilateral acute otitis media in infants younger than 24 months, there is evidence that the benefits of antibiotics outweigh the harms. [ 12 ]  A 2015 Cochrane review concluded that watchful waiting is the preferred approach for children over six months with non severe acute otitis media. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3556", "text": "Most children older than 6 months of age who have acute otitis media do not benefit from treatment with antibiotics. If antibiotics are used, a  narrow-spectrum antibiotic  like  amoxicillin  is generally recommended, as  broad-spectrum antibiotics  may be associated with more adverse events. [ 1 ] [ 51 ]  If there is  resistance  or use of amoxicillin in the last 30 days then  amoxicillin-clavulanate  or another penicillin derivative plus beta lactamase inhibitor is recommended. [ 1 ]  Taking amoxicillin once a day may be as effective as twice [ 52 ]  or three times a day. While less than 7 days of antibiotics have fewer side effects, more than seven days appear to be more effective. [ 53 ]  If there is no improvement after 2\u20133\u00a0days of treatment a change in therapy may be considered. [ 1 ]  Azithromycin appears to have less side effects than either high dose amoxicillin or amoxicillin/clavulanate. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3557", "text": "Tympanostomy tubes  (also called \"grommets\") are recommended with three or more episodes of acute otitis media in 6 months or four or more in a year, with at least one episode or more attacks in the preceding 6 months. [ 1 ]  There is tentative evidence that children with recurrent acute otitis media (AOM) who receive tubes have a modest improvement in the number of further AOM episodes (around one fewer episode at six months and less of an improvement at 12 months following the tubes being inserted). [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3558", "text": "Evidence does not support an effect on long-term hearing or language development. [ 56 ] [ 57 ]  A common complication of having a tympanostomy tube is otorrhea, which is a discharge from the ear. [ 58 ]  The risk of persistent  tympanic membrane perforation  after children have grommets inserted may be low. [ 55 ]  It is still uncertain whether or not grommets are more effective than a course of antibiotics. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3559", "text": "Oral antibiotics should not be used to treat uncomplicated acute tympanostomy tube otorrhea. [ 58 ]  They are not sufficient for the bacteria that cause this condition and have side effects including increased risk of opportunistic infection. [ 58 ]  In contrast, topical antibiotic eardrops are useful. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3560", "text": "The decision to treat is usually made after a combination of physical exam and laboratory diagnosis, with additional testing including  audiometry ,  tympanogram ,  temporal bone   CT  and  MRI . [ 59 ] [ 60 ] [ 61 ]  Decongestants, [ 62 ]  glucocorticoids, [ 63 ]  and topical antibiotics are generally not effective as treatment for non-infectious, or  serous , causes of mastoid effusion. [ 59 ]  Moreover, it is recommended against using  antihistamines  and decongestants in children with OME. [ 62 ]  In less severe cases or those without significant hearing impairment, the effusion can resolve spontaneously or with more conservative measures such as  autoinflation . [ 64 ] [ 65 ]  In more severe cases,  tympanostomy tubes  can be inserted, [ 57 ]  possibly with  adjuvant   adenoidectomy [ 59 ]  as it shows a significant benefit as far as the resolution of middle ear effusion in children with OME is concerned. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3561", "text": "Topical antibiotics are of uncertain benefit as of 2020. [ 67 ]  Some evidence suggests that topical antibiotics may be useful either alone or with antibiotics by mouth. [ 67 ]  Antiseptics are of unclear effect. [ 68 ]  Topical antibiotics (quinolones) are probably better at resolving ear discharge than antiseptics. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3562", "text": "Complementary and alternative medicine  is not recommended for otitis media with effusion because there is no evidence of benefit. [ 28 ]   Homeopathic  treatments have not been proven to be effective for acute otitis media in a study with children. [ 70 ]   An  osteopathic manipulation technique  called the Galbreath technique [ 71 ]  was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3563", "text": "Complications of acute otitis media consists of perforation of the ear drum, infection of the mastoid space behind the ear ( mastoiditis ), and more rarely intracranial complications can occur, such as  bacterial meningitis ,  brain abscess , or  dural sinus thrombosis . [ 73 ]  It is estimated that each year 21,000 people die due to complications of otitis media. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3564", "text": "In severe or untreated cases, the tympanic membrane may  perforate , allowing the  pus  in the middle-ear space to drain into the  ear canal . If there is enough, this drainage may be obvious. Even though the perforation of the tympanic membrane suggests a highly painful and traumatic process, it is almost always associated with a dramatic relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the  infection  and the ear drum nearly always heals.\nAn option for severe acute otitis media in which analgesics are not controlling ear pain is to perform a tympanocentesis, i.e., needle aspiration through the tympanic membrane to relieve the ear pain and to identify the causative organism(s)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3565", "text": "Children with recurrent episodes of acute otitis media and those with otitis media with effusion or chronic suppurative otitis media have higher risks of developing  conductive  and  sensorineural hearing loss . Globally approximately 141\u00a0million people have mild hearing loss due to otitis media (2.1% of the population). [ 74 ]  This is more common in males (2.3%) than females (1.8%). [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3566", "text": "This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications and, together with persistent tympanic membrane perforation, contributes to the severity of the disease and hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3567", "text": "Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children. [ 76 ] [ 77 ] [ 78 ]  Some studies have linked otitis media to learning problems, attention disorders, and problems with social adaptation. [ 79 ]  Furthermore, it has been demonstrated that individuals with otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing. [ 80 ]  Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea. [ 81 ]  More research on the importance of screening all children under 4 years old for otitis media with effusion needs to be performed. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3568", "text": "Acute otitis media is very common in childhood. It is the most common condition for which medical care is provided in children under five years of age in the US. [ 19 ]  Acute otitis media affects 11% of people each year (709\u00a0million cases) with half occurring in those below five years. [ 14 ]  Chronic suppurative otitis media affects about 5% or 31\u00a0million of these cases with 22.6% of cases occurring annually under the age of five years. [ 14 ]  Otitis media resulted in 2,400 deaths in 2013\u00a0\u2013 down from 4,900 deaths in 1990. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3569", "text": "Australian Aboriginals  experience a high level of  conductive hearing loss  largely due to the massive incidence of middle ear disease among the young  in Aboriginal communities . Aboriginal children experience middle ear disease for two and a half years on average during childhood compared with three months for non indigenous children. If untreated it can leave a permanent legacy of hearing loss. [ 82 ]  The higher incidence of deafness in turn contributes to poor social, educational and emotional outcomes for the children concerned. Such children as they grow into adults are also more likely to experience employment difficulties and find themselves caught up in the criminal justice system. Research in 2012 revealed that nine out of ten Aboriginal prison inmates in the  Northern Territory  suffer from significant hearing loss. [ 83 ] \nAndrew Butcher speculates that the lack of  fricatives  and the unusual  segmental  inventories of  Australian languages  may be due to the very high presence of otitis media ear infections and resulting hearing loss in their populations. People with hearing loss often have trouble distinguishing different vowels and hearing fricatives and  voicing  contrasts. Australian Aboriginal languages thus seem to show similarities to the speech of people with hearing loss, and avoid those sounds and distinctions which are difficult for people with early childhood hearing loss to perceive. At the same time, Australian languages make full use of those distinctions, namely place of articulation distinctions, which people with otitis media-caused hearing loss can perceive more easily. [ 84 ]  This hypothesis has been challenged on historical, comparative, statistical, and medical grounds. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3570", "text": "The term  otitis media  is composed of  otitis ,  Ancient Greek  for \"inflammation of the ear\", and  media ,  Latin  for \"middle\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3571", "text": "Oxybuprocaine  ( INN ), also known as  benoxinate  or  BNX , is an ester-type  local anesthetic , which is used especially in  ophthalmology  and  otolaryngology . Oxybuprocaine is sold by  Novartis  under the brand names  Novesine  or  Novesin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3572", "text": "Safety for use in pregnancy and lactation has not been established."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3573", "text": "Anaesthesia starts with a latency of 30 to 50 seconds and lasts for about 10 to 30 minutes, depending on  perfusion . The drug is metabolised by  esterases  in blood plasma and liver. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3574", "text": "When used excessively, oxybuprocaine like any other topical anesthetic used in the eye and on mucous membranes (like for example  tetracaine ,  proxymetacaine  and  proparacaine ) can cause irritation,  hypersensitivity ,  anaphylaxis , irreversible corneal damage and even complete destruction of the cornea. [ 2 ] [ 4 ]  (Excessive use means several times a day during several days or even weeks.)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3575", "text": "Oxybuprocaine is incompatible with  silver  and  mercury  salts, as well as  alkaline  substances. It also reduces the antimicrobial action of  sulfonamides . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3576", "text": "The nitration of 3-hydroxybenzoic acid [99-06-9] (0) gives 3-hydroxy-4-nitrobenzoic acid [619-14-7] ( 1 ).  Fischer esterification with ethanol gives ethyl 3-hydroxy-4-nitrobenzoate [717-01-1] ( 2 ). The phenoxide ion was then prepared from potash ( 3 ). Alkylation with  1-bromobutane   supplied ethyl 3-butoxy-4-nitrobenzoate,  CID:13346201  ( 4 ). The product is crystallized from hydrochloric acid, and then halogenation with thionyl chloride gives 3-butoxy-4-nitrobenzoyl chloride [23442-21-9] ( 5 ). Esterification with diethylaminoethanol [100-37-8] ( 6 ) gives 2-(diethylamino)ethyl 3-butoxy-4-nitrobenzoate,  CID:13346204  ( 7 ) Lastly, catalytic hydrogenation over Raney-Nickel completes the synthesis of Oxybuprocaine ( 8 )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3577", "text": "The  palate  ( / \u02c8 p \u00e6 l \u026a t / ) is the roof of the  mouth  in humans and other  mammals . It separates the  oral cavity  from the  nasal cavity . [ 1 ]  A similar structure is found in  crocodilians , but in most other  tetrapods , the oral and nasal cavities are not truly separated. The palate is divided into two parts, the anterior, bony  hard palate  and the posterior, fleshy  soft palate  (or velum). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3578", "text": "The  maxillary nerve  branch of the  trigeminal nerve  supplies  sensory innervation  to the palate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3579", "text": "The hard palate forms before birth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3580", "text": "If the fusion is incomplete,  a  cleft palate  results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3581", "text": "When functioning in conjunction with other parts of the mouth, the palate produces certain sounds, particularly  velar ,  palatal ,  palatalized ,  postalveolar ,  alveolopalatal , and  uvular   consonants . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3582", "text": "The  English   synonyms  palate and palatum, and also the related adjective palatine (as in  palatine bone ), are all from the  Latin   palatum  via  Old French   palat , words that like their English  derivatives , refer to the \"roof\" of the mouth. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3583", "text": "The Latin word  palatum  is of unknown (possibly  Etruscan ) ultimate origin and served also as a source to the Latin word meaning palace,  palatium , from which other senses of  palatine  and the English word palace derive, and not the other way round. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3584", "text": "As the roof of the mouth was once considered the seat of the sense of  taste , palate can also refer to this sense itself, as in the phrase \"a discriminating palate\". By further extension, the flavor of a food (particularly beer or wine) may be called its palate, as when a wine is said to have an  oaky  palate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3585", "text": "In  anatomy , the  palatine bones  ( / \u02c8 p \u00e6 l \u0259 t a\u026a n / ; [ 1 ] [ 2 ]  derived from the Latin  palatum ) are two  irregular bones  of the  facial skeleton  in many animal species, located above the  uvula  in the  throat . Together with the  maxilla , they comprise the  hard palate ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3586", "text": "The palatine bones are situated at the back of the  nasal cavity  between the  maxilla  and the  pterygoid process of the sphenoid bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3587", "text": "They contribute to the walls of three cavities: the floor and lateral walls of the nasal cavity, the roof of the mouth, and the floor of the orbits. They help to form the  pterygopalatine  and  pterygoid fossae , and the  inferior orbital fissures ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3588", "text": "Each palatine bone somewhat resembles the letter L, and consists of a  horizontal plate , a  perpendicular plate , and three projecting processes\u2014the  pyramidal process , which is directed backward and lateral from the junction of the two parts, and the  orbital  and  sphenoidal processes , which surmount the vertical part, and are separated by a deep notch, the sphenopalatine notch. The two plates form the posterior part of the hard palate and the floor of the nasal cavity; anteriorly, they join with the maxillae. The two horizontal plates articulate with each other at the posterior part of the median palatine suture and more anteriorly with the maxillae at the transverse palatine suture. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3589", "text": "The human palatine articulates with six bones: the  sphenoid ,  ethmoid ,  maxilla ,  inferior nasal concha ,  vomer  and opposite palatine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3590", "text": "There are two important foramina in the palatine bones that transmit nerves and blood vessels to this region: the greater and lesser palatine. The larger  greater palatine foramen  is located in the posterolateral region of each of the palatine bones, usually at the apex of the maxillary third molar. The greater palatine foramen transmits the greater palatine nerve and blood vessels. A smaller opening nearby, the  lesser palatine foramen , transmits the lesser palatine nerve and blood vessels to the soft palate and tonsils. Both foramina are openings of the pterygopalatine canal that carries the descending palatine nerves and blood vessels from the pterygopalatine fossa to the palate. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3591", "text": "The  sphenopalatine foramen  is the opening between the sphenoid bone and orbital processes of the palatine bone; it opens into the nasal cavity and gives passage to branches from the pterygopalatine ganglion and the  sphenopalatine artery  from the maxillary artery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3592", "text": "In  bony fish , the palatine bone consists of the perpendicular plate only, lying on the inner edge of the maxilla. The lower surface of the bone may bear several teeth, forming a second row behind those of the maxilla; in many cases, these are actually larger than the maxillary teeth. Although a similar pattern was present in primitive  tetrapods , the palatine bone is reduced in most living  amphibians , forming, in  frogs  and  salamanders , only a narrow bar between the vomer and maxilla. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3593", "text": "Early fossil  reptiles  retained the arrangement seen in more primitive vertebrates, but in  mammals , the lower surface of the palatine became folded over during evolution, forming the horizontal plate, and meeting in the midline of the mouth. This forms the rear of the  hard palate , separating the oral and nasal cavities, and making it easier to breathe while eating. A  parallel  development has occurred to varying degrees in many living reptiles, reaching its greatest extent in  crocodilians . In  birds , the palatine bones remain separate, long the sides of the rear part of the upper jaw, and typically have a mobile articulation with the  cranium . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3594", "text": "There are numerous variations amongst mammals, amphibians and other species. For example, the palatine bone in many amphibians such as the  rough-skinned newt  manifests as a distinct V-shaped structure. [ 5 ]  In the case of cat species, the horizontal and a vertical elements join at a 45-degree angle. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3595", "text": "This article incorporates text in the  public domain  from  page 166  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3596", "text": "The  palatine glands  form a continuous layer on the posterior surface of the  mucous membrane  of the  soft palate  and around the  uvula . They are pure mucous glands."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3597", "text": "This article incorporates text in the  public domain  from  page 1141  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3598", "text": "Palatine tonsils , commonly called the  tonsils  and occasionally called the  faucial tonsils , [ 1 ]  are  tonsils  located on the left and right sides at the back of the  throat  in humans and other mammals, which can often be seen as flesh-colored, pinkish lumps. Tonsils only present as \"white lumps\" if they are inflamed or infected with symptoms of exudates (pus drainage) and severe swelling."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3599", "text": "Tonsillitis  is an  inflammation  of the tonsils and will often, but not necessarily, cause a sore throat and  fever . [ 2 ]  In  chronic  cases,  tonsillectomy  may be indicated. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3600", "text": "The palatine tonsils are located in the  isthmus of the fauces , between the  palatoglossal arch  and the  palatopharyngeal arch  of the  soft palate ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3601", "text": "The palatine tonsil is one of the  mucosa-associated lymphoid tissues  (MALT), located at the entrance to the upper respiratory and  gastrointestinal  tracts to protect the body from the entry of exogenous material through mucosal sites. [ 4 ] [ 5 ]  In consequence it is a site of, and potential focus for, infections, and is one of the chief immunocompetent tissues in the  oropharynx . It forms part of the  Waldeyer's ring , which comprises the  adenoid , the paired  tubal tonsils , the paired palatine tonsils and the  lingual tonsils . [ 6 ]  From the pharyngeal side, they are covered with a  stratified squamous epithelium , whereas a fibrous capsule links them to the wall of the pharynx. Through the capsule pass trabecules that contain small blood vessels, nerves and lymphatic vessels. These trabecules divide the tonsil into lobules."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3602", "text": "The nerves supplying the palatine tonsils come from the  maxillary division  of the  trigeminal nerve  via the lesser palatine nerves, and from the tonsillar branches of the  glossopharyngeal nerve . The glossopharyngeal nerve continues past the palatine tonsil and innervates the posterior 1/3 of the tongue to provide general and taste sensation. [ 6 ]  This nerve is most likely to be damaged during a  tonsillectomy , which leads to reduced or lost general sensation and taste sensation to the posterior third of the tongue. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3603", "text": "Blood supply is provided by tonsillar branches of five arteries: the  dorsal lingual artery  (of the  lingual artery ),  ascending palatine artery  (of the  facial artery ), tonsillar branch (of the facial artery),  ascending pharyngeal artery  (of the  external carotid artery ), and the  lesser palatine artery  (a branch of the  descending palatine artery , itself a branch of the  maxillary artery ).\nThe tonsils venous drainage is by the  peritonsillar plexus , which drain into the lingual and pharyngeal veins, which in turn drain into the  internal jugular vein . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3604", "text": "Palatine tonsils consist of approximately 15 crypts, which result in a large internal surface. The tonsils contain four lymphoid compartments that influence immune functions, namely the reticular crypt  epithelium , the  extrafollicular  area, the mantle zones of  lymphoid  follicles, and the follicular germinal centers. In human palatine tonsils, the very first part exposed to the outside environment is tonsillar epithelium. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3605", "text": "Tonsillar (relating to palatine tonsil) B cells can mature to produce all the five major  immunoglobulin  (Ig, aka antibody) classes. [ 5 ]  Furthermore, when incubated in vitro with either  mitogens  or specific  antigens , they produce specific antibodies against  diphtheria toxoid ,  poliovirus ,  Streptococcus pneumoniae ,  Haemophilus influenzae ,  Staphylococcus aureus , and the  lipopolysaccharide  of  E. coli . Most  Immunoglobulin A  produced by tonsillar B cells in vitro appears to be 7S monomers, although a significant proportion may be l0S dimeric IgA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3606", "text": "In addition to humoral immunity elicited by tonsillar and  adenoidal  B cells following antigenic stimulation, there is considerable T-cell response in palatine tonsils. [ 5 ]  Thus, natural infection or intranasal immunization with live,  attenuated   rubella  virus vaccine has been reported to prime tonsillar  lymphocytes  much better than  subcutaneous  vaccination. Also, natural infection with  varicella zoster virus  has been found to stimulate tonsillar lymphocytes better than lymphocytes from  peripheral blood ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3607", "text": "Cytokines  are humoral  immunomodulatory  proteins or  glycoproteins  which control or modulate the activities of target cells, resulting in gene activation, leading to mitotic division, growth and differentiation, migration, or  apoptosis . They are produced by wide range of cell types upon antigen-specific and non-antigen specific stimuli. It has been reported by many studies that the clinic outcome of many infectious,  autoimmune , or malignant diseases appears to be influenced by the overall balance of production (profiles) of pro-inflammatory and anti-inflammatory cytokines. Therefore, determination of cytokine profiles in tonsil study will provide key information for further in-depth analysis of the cause and underlying mechanisms of these disorders, as well as the role and possible interactions between the T- and B-lymphocytes and other immunocompetent cells. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3608", "text": "The cytokine network represents a very sophisticated and versatile regulatory system that is essential to the immune system for overcoming the various defense strategies of microorganisms. Through several studies, the  Th1  and  Th2  cytokines and cytokine mRNA are both detectable in tonsillar hypertrophy (or  obstructive sleep apnea , OSA) and recurrent  tonsillitis  groups. It showed that human palatine tonsil is an active immunological organ containing a wide range of cytokine-producing cells. Both Th1 and Th2 cells are involved in the  pathophysiology  of TH and RT conditions. Indeed, human tonsils persistently harbor  microbial  antigens even when the subject is asymptomatic of ongoing infection. It could also be an effect of ontogeny of the immune system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3609", "text": "The pathogenesis of infectious/inflammatory disease in the tonsils most likely has its basis in their anatomic location and their inherent function as organ of immunity, processing infectious material, and other antigens and then becoming, paradoxically, a focus of infection/inflammation. No single theory of pathogenesis has yet been accepted, however. Viral infection with secondary bacterial invasion may be one mechanism of the initiation of chronic disease, [ 11 ]  but the effects of the environment, host factors, the widespread use of antibiotics, ecological considerations, and diet all may play a role. [ 12 ]  A recent cross-sectional study revealed a high rate of prevalent virus infections in non-acutely ill patients undergoing routine tonsillectomy. However, none of the 27 detected viruses showed positive association to the tonsillar disease. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3610", "text": "In children, the tonsils are common sites of infections that may give rise to acute or chronic tonsillitis. However, it is still an open question whether tonsillar hypertrophy is also caused by a persistent infection. Tonsillectomy is one of the most common major operations performed on children. The indications for the operation have been complicated by the controversy over the benefits of removing a chronically infected tissue and the possible harm caused by eliminating an important immune inductive tissue. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3611", "text": "The information that is necessary to make a rational decision to resolve this controversy can be obtained by understanding the immunological potential of the normal palatine tonsils and comparing these functions with the changes that occur in the chronically diseased counterparts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3612", "text": "Tonsillitis  is the inflammation of tonsils. Acute tonsillitis is the most common manifestation of tonsillar disease. It is associated with sore throat, fever and  difficulty swallowing . [ 16 ]  The tonsils may appear normal sized or enlarged but are usually erythematous. Often, but not always,  exudates  can be seen. Not all these signs and symptoms are present in every patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3613", "text": "Recurrent infection has been variably defined as from four to seven episodes of acute tonsillitis in one year, five episodes for two consecutive years or three episodes per year for 3 consecutive years. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3614", "text": "Tonsillar hypertrophy is the enlargement of the tonsils, but without the history of inflammation. Obstructive tonsillar hypertrophy is currently the most common reason for tonsillectomy. [ 14 ]  These patients present with varying degrees of disturbed sleep which may include symptoms of loud snoring, irregular breathing, nocturnal choking and coughing, frequent awakenings,  sleep apnea ,  dysphagia  and/or daytime hypersomnolence. These may lead to behavioral/mood changes in patients and facilitate the need for a  polysomnography  in order to determine the degree to which these symptoms are disrupting their sleep. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3615", "text": "The  palatopharyngeus  ( palatopharyngeal  or  pharyngopalatinus )  muscle  is a small  muscle  in the  roof of the mouth ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3616", "text": "It is a long, fleshy fasciculus, narrower in the middle than at either end, forming, with the mucous membrane covering its surface, the  palatopharyngeal arch ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3617", "text": "It is separated from the  palatoglossus muscle  by an angular interval, in which the  palatine tonsil  is lodged. It arises from the soft palate, where it is divided into two fasciculi by the  levator veli palatini  and  musculus uvulae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3618", "text": "Passing laterally and downward behind the palatine tonsil, the palatopharyngeus joins the  stylopharyngeus  and is inserted with that muscle into the posterior border of the thyroid cartilage, some of its fibers being lost on the side of the  pharynx  and others passing across the middle line posteriorly to decussate with the muscle of the opposite side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3619", "text": "Motor innervation of this muscle is provided through the pharyngeal plexus of the CN X (vagal nerve), SVE (special visceral efferent) fibers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3620", "text": "The  palatine velum  is slightly raised by the  levator veli palatini  and made tense by the  tensor veli palatini ; the palatopharyngeus muscles, by their contraction, pull the  pharynx  upward over the  bolus  of food and nearly come together, the  uvula  filling up the slight interval between them."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3621", "text": "By these means the bolus is prevented from passing into the  nasopharynx ; at the same time, the palatopharyngeus muscles form an inclined plane, directed obliquely downward and backward, along the under surface of which the bolus descends into the lower part of the pharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3622", "text": "This article incorporates text in the  public domain  from  page 1140  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3623", "text": "Paranasal sinus and nasal cavity cancer  is a type of  cancer  that is caused by the appearance and spread of malignant cells into the  paranasal sinus  and  nasal cavity . The cancer most commonly occurs in people between 50 and 70 years old, and occurs twice as often in males as in females. [ 3 ]  During early phases of the cancer, symptoms may include  nasal obstruction  and  hyposmia , as well as other symptoms. [ 3 ]  More symptoms may develop as  malignant cells  further grow and spread into other nearby tissue such as the  palate  or orbital floor.  X-rays  of the head and  MRI  can aid in diagnosis of the cancer while tumor resection surgery,  radiation therapy  and  chemotherapy  can be used for treatment of the cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3624", "text": "People with early stage nasal cavity or paranasal sinus cancer often do not show any symptoms, therefore, these types of cancer are usually diagnosed in the later stages. Nasal cavity or paranasal sinus cancer is often discovered when a person is being treated for a seemingly benign, inflammatory disease of the sinuses, such as  sinusitis . [ 4 ]  The signs and symptoms of later stage cancer are generally caused by the spread of malignant cells into the neighbouring structures of the paranasal sinus and nasal cavity. [ 5 ]  There are often no obvious signs and symptoms before tumor cells spread into bone tissue. During the progress of the cancer, the overall signs and symptoms may include sinus pressure and pain, blocked sinus, headaches, nosebleeds, pain and pressure in the ears, among other symptoms. [ 1 ]  Different symptoms may appear as the tumor starts to spread into other body structures. Symptoms such as  proptosis ,  diplopia  and other eye problems may appear if the tumor spreads into the  orbit . [ 5 ]  Symptoms such as  trismus  (lockjaw), facial swelling,  toothache , mid-face or jaw numbness may occur if the tumor spreads into the  infratemporal fossa ,  pterygopalatine fossae  or masseteric space. [ 5 ]  The spread of the cancer into the cranial cavity may lead to  headaches ,  nerve damage , and  cerebrospinal fluid leak ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3625", "text": "Cigarette smoking is strongly related to the risk of developing nasal cancer. Smokers have an excess 20% risk of developing nasal cancer.[2] There is a positive relationship between the quantity of cigarettes smoked and time period of smoking, and an increased risk of developing nasal cancer. Quitting smoking decreases the risk. There is also a positive relationship between having a spouse that smokes and developing nasal cancer.[2]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3626", "text": "Direct contact of tobacco powder with the gums and the mucous membranes of the mouth can largely increase the risk of developing nasal or paranasal sinus cancer. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3627", "text": "Environmental factors are likely one of the main causes of paranasal sinus and nasal cavity cancer.[2] Exposure to wood dust and nickel dust may cause paranasal sinus and nasal cavity tumors. [ 3 ]  Exposure to radium fumes,  formaldehyde  fumes and other substances used in the production of leather and other textiles may also increase the risk. [ 7 ]  Exposure to air pollution may also increase the risk of getting the cancer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3628", "text": "Alcohol consumption  may increase the risk  of cancer.[2] There is no evidence that alcohol increases the risk of any specific histological type of paranasal sinus and nasal cavity cancer. [ 6 ]  Consumption of large amounts of salted and smoked food may also increase the risk of developing paranasal sinus and nasal cavity cancer.[2]  Human papillomavirus infection  is likely a major cause of paranasal sinus and nasal cavity cancer. [ 1 ]  Other chronic nasal conditions may also increase the risk. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3629", "text": "Physical examination can performed to find physical signs of cancer such as swollen lymph nodes, lumps, or other abnormalities. [ 1 ]  Past medical records can also provide essential information for diagnosis. [ 1 ]  There are no blood or urine tests that can diagnose paranasal sinus and nasal cavity cancer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3630", "text": "X-rays can be used to identify abnormalities in the patient's sinus. [ 7 ]  MRI technology is typically a more efficient method to identify a tumor located in soft tissue and fluid, while CT scans serve to detect damage to bone tissue, especially in the  cribriform plate . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3631", "text": "A  biopsy  can be used to examine an excised sample of tissue with the help of a microscope. Biopsy results often determine the final diagnosis of paranasal sinus and nasal cavity cancer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3632", "text": "When used for diagnosing paranasal sinus and nasal cancer, the main goal of a  bone scan  is to investigate whether the cancer cells have spread into the bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3633", "text": "A nasoscopy is a type of  endoscopy  that can be used as a diagnosis method for paranasal sinus and nasal cavity cancer. [ 1 ]  A nasoscopy is performed by the insertion of a nasoscope into the patient\u2019s nose to search for abnormal areas in the nasal cavity. The tissue may be extracted with tools attached to the nasoscope and later examined with a microscope for signs of cancer. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3634", "text": "A  PET scan  can also be implemented to detect cancer cells inside the body. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3635", "text": "Various treatments can be implemented to treat paranasal sinus and nasal cavity cancer. Generally, treatment uses methods such as surgery, radiation therapy, chemotherapy and proton therapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3636", "text": "Surgery is often implemented in all stages of paranasal sinus and nasal cavity cancer. [ 1 ]  The main goal of surgery is to remove cancerous tissue. [ 1 ]  Surgery is typically followed by chemotherapy and radiation therapy, to kill off any remaining cancer cells. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3637", "text": "The type of surgery performed depends on the extent to which cancerous tissue has spread. If the cancer has significantly spread into neighboring structures, large portions of tissue may have to be removed. If necessary, a maxillectomy could be used to remove all or part of the  maxilla , which includes the  hard palate .  [ 7 ]  More extensive craniofacial surgery can be also used in the treatment of paranasal sinus and nasal cavity cancer, with more extensive tissue removal. The vacancy created by the removal of tissue can be filled by  prostheses  or soft tissue. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3638", "text": "If the cancer may have spread to the neck, a  neck dissection  might be performed in order to remove the lymph nodes in the neck area, in order to remove any cancerous cells there. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3639", "text": "Radiation therapy  aims to destroy cancer cells by using high energy radiation. [ 7 ]  Radiation therapy is an effective method for paranasal sinus and nasal cavity cancer after implementation of surgery. [ 8 ]  Radiation therapy can also be used as an alternative method for a patient who is unable to undergo surgery. [ 7 ]  For paranasal sinus and nasal cavity cancer, Volumetric Modulated Arc Therapy (VMAT) more consistently and accurately irradiated the target area than Intensity Modulated Radiation Therapy (IMRT). [ 9 ]  Tooth decay may be caused by radiation therapy. [ 7 ]  Tooth decay from radiation therapy may can be prevented by receiving dental treatment before radiation therapy. [ 7 ]  Radiation therapy may cause skin redness and irritation. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3640", "text": "Chemotherapy  is usually used before or after surgery or radiation therapy. [ 7 ]  Chemotherapy can be used in the treatment of paranasal sinus and nasal cavity cancer. [ 10 ]  Infections and hair loss might occur after the implementation of chemotherapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3641", "text": "Paranasal sinuses  are a group of four paired  air-filled spaces  that surround the  nasal cavity . [ 1 ]  The  maxillary sinuses  are located under the  eyes ; the  frontal sinuses  are above the eyes; the  ethmoidal sinuses  are between the eyes and the  sphenoidal sinuses  are behind the eyes. The  sinuses  are named for the  facial bones and sphenoid bone  in which they are located. Their role is disputed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3642", "text": "Humans possess four pairs of paranasal sinuses, divided into subgroups that are named according to the  bones  within which the sinuses lie. They are all innervated by branches of the  trigeminal nerve  (CN V)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3643", "text": "The paranasal sinuses are lined with  respiratory epithelium  (ciliated pseudostratified columnar epithelium)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3644", "text": "One known function of the paranasal sinuses is the production of  nitric oxide , which also functions as a facilitator of oxygen uptake. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3645", "text": "Paranasal sinuses form developmentally through excavation of bone by air-filled sacs ( pneumatic diverticula ) from the  nasal cavity . This process begins prenatally (intrauterine life), and it continues through the course of an organism's lifetime."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3646", "text": "The results of experimental studies suggest that the natural ventilation rate of a sinus with a single  sinus ostium  (opening) is extremely slow. Such limited ventilation may be protective for the sinus, as it would help prevent drying of its mucosal surface and maintain a near-sterile environment with high  carbon dioxide  concentrations and minimal  pathogen  access. Thus composition of gas content in the maxillary sinus is similar to  venous blood , with high carbon dioxide and lower  oxygen  levels compared to breathing air. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3647", "text": "At birth, only the  maxillary sinus  and the  ethmoid sinus  are developed but not yet pneumatized; only by the age of seven are they fully aerated. The  sphenoid sinus  appears at the age of three, and the  frontal sinuses  first appear at the age of six, and fully develop during adulthood. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3648", "text": "The, paranasal sinuses are joined to the  nasal cavity  via small orifices called  ostia . These become blocked easily by allergic inflammation, or by swelling in the nasal lining that occurs with a  cold . If this happens, normal drainage of  mucus  within the sinuses is disrupted, and  sinusitis  may occur. Because the maxillary posterior teeth are close to the maxillary sinus, this can also cause clinical problems if any disease processes are present, such as an infection in any of these teeth. These clinical problems can include secondary sinusitis, the inflammation of the sinuses from another source such as an infection of the adjacent teeth. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3649", "text": "These conditions may be treated with drugs such as  decongestants , which cause  vasoconstriction  in the sinuses; reducing inflammation; by traditional techniques of  nasal irrigation ; or by  corticosteroid . [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3650", "text": "Malignancies of the paranasal sinuses comprise approximately 0.2% of all malignancies. About 80% of these malignancies arise in the maxillary sinus. Men are much more often affected than women. They most often occur in the age group between 40 and 70 years.  Carcinomas  are more frequent than  sarcomas . Metastases are rare.  Tumours  of the sphenoid and frontal sinuses are extremely rare."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3651", "text": "Sinus  is a  Latin  word meaning a fold, curve, or bay. Compare  sine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3652", "text": "Paranasal sinuses occur in many other animals, including most  mammals ,  birds , non-avian  dinosaurs , and  crocodilians . The bones occupied by sinuses are quite variable in these other species."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3653", "text": "A  parapharyngeal abscess  is a deep  neck space   abscess  of the  parapharyngeal space  (or pharyngomaxillary space), which is lateral to the  superior pharyngeal constrictor muscle  and medial to the  masseter muscle .  [ 1 ]  This space is divided by the  styloid process  into anterior and posterior compartments. The posterior compartment contains the  carotid artery ,  internal jugular vein , and many nerves. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3654", "text": "Symptoms include fever, sore throat,  painful swallowing , and swelling in the neck. [ 2 ] \nAn anterior space abscess can cause  lockjaw  (spasm of jaw muscle), and hard mass formation along the angle of the  mandible , with medial bulging of the tonsil and lateral pharyngeal wall. A posterior space abscess causes swelling in the posterior pharyngeal wall, and lockjaw is minimal. Other structures within the carotid sheath may be involved, causing rigors, high fever, bacteremia, neurologic deficit, or a massive haemorrhage caused by carotid artery rupture. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3655", "text": "Infection can occur from:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3656", "text": "Parapharyngeal abscess is more common in male than the female gender. [ 4 ] [ 5 ]   Any age group can develop a parapharyngeal abscess but it is most commonly seen in children and adolescents. [ 6 ]  Adults who are  immunocompromised  are also at high risk. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3657", "text": "The  parotid gland  is a major  salivary gland  in many animals. In humans, the two parotid glands are present on either side of the  mouth  and in front of both  ears . They are the largest of the salivary glands. Each parotid is wrapped around the  mandibular ramus , and secretes serous  saliva  through the  parotid duct  into the mouth, to facilitate  mastication  and  swallowing  and to begin the digestion of  starches . There are also two other types of  salivary  glands; they are  submandibular  and  sublingual  glands. [ 1 ]  Sometimes  accessory parotid glands  are found close to the main parotid glands. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3658", "text": "The word  parotid  literally means \" beside the ear \". From Greek \u03c0\u03b1\u03c1\u03c9\u03c4\u03af\u03c2 (stem \u03c0\u03b1\u03c1\u03c9\u03c4\u03b9\u03b4-)\u00a0: (gland) behind the ear < \u03c0\u03b1\u03c1\u03ac - par\u00e1\u00a0: in front, and \u03bf\u1f56\u03c2 - ous (stem \u1f60\u03c4-, \u014dt-)\u00a0: ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3659", "text": "The parotid glands are a pair of mainly  serous  salivary glands located below and in front of each  ear canal , draining their secretions into the vestibule of the mouth through the  parotid duct . [ 3 ]  Each gland lies behind the mandibular ramus and in front of the  mastoid process  of the  temporal bone . The gland can be  felt  on either side, by feeling in front of each ear, along the cheek, and below the  angle of the mandible . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3660", "text": "The parotid duct, a long excretory duct, emerges from the front of each gland, superficial to the  masseter muscle . The duct pierces the  buccinator muscle , then opens into the mouth on the inner surface of the cheek, usually opposite the  maxillary second molar . The parotid papilla is a small elevation of tissue that marks the opening of the parotid duct on the inner surface of the cheek. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3661", "text": "The gland has four surfaces\u00a0\u2013 superficial or lateral, superior, anteromedial, and posteromedial. The gland has three borders\u00a0\u2013 anterior, medial, and posterior. The parotid gland has two ends\u00a0\u2013 a superior end in the form of a small superior surface and an inferior end (apex)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3662", "text": "A number of different structures pass through the gland. From  lateral to medial , these are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3663", "text": "Sometimes accessory parotid glands are found as an  anatomic variation . These are close to the main glands and consist of  ectopic  salivary gland tissue. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3664", "text": "Capsule of parotid gland"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3665", "text": "A capsule of the parotid gland is formed from the investing layer of the deep cervical fascia. It is supplied by the great auricular nerve. The fascia splits to enclose the gland. This splitting occurs between the angle of the mandible and the mastoid process. The  superficial lamina (parotidomassetric fascia)  is thick and is attached to the zygomatic arch. The deep lamina is thin and is attached to the styloid process, tympanic plate, and the ramus of the mandible. The part of the deep lamina extending between the styloid process and the mandible is thickened to form a  stylomastoid ligament.  The stylomandibular ligament separates the parotid gland from the superficial lobe of the submandibular gland.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3666", "text": "The  facial nerve (CN VII)  splits into its branches within the parotid gland, thus forming its  parotid plexus . Nerves of this plexus then pass through the parotid gland without innervating the gland itself. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3667", "text": "Arterial supply"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3668", "text": "The external carotid artery and its terminal branches within the gland, namely, the superficial temporal and the maxillary artery, also the posterior auricular artery supply the parotid gland. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3669", "text": "Venous drainage"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3670", "text": "Venous return is to the retromandibular veins. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3671", "text": "Lymphatic drainage"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3672", "text": "The gland is mainly drained into the preauricular or parotid lymph nodes which ultimately drain to the deep cervical chain. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3673", "text": "The parotid gland receives both sensory and autonomic innervation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3674", "text": "Sympathetic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3675", "text": "The cell bodies of the preganglionic sympathetic fibres that supply the gland usually lie in the lateral horns of upper thoracic spinal segments (T1-T3).  [ citation needed ]  Postganglionic sympathetic fibers from  superior cervical ganglion  reach the gland by passing along the  external carotid artery  and  middle meningeal artery . They act to cause vasoconstriction. [ 6 ] :\u200a359\u2013360"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3676", "text": "Parasympathetic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3677", "text": "Preganglionic parasympathetic fibers for the parotid gland arise in the brainstem in the  inferior salivatory nucleus , and leave the brain in the  glossopharyngeal nerve (CN IX) , then pass in the  tympanic nerve  to the  tympanic plexus , then from the tympanic plexus in the  lesser petrosal nerve  to the  otic ganglion  where they synapse. Postganglionic (post-synaptic) fibers from the ganglion then \"hitch-hike\" along the  auriculotemporal nerve  to reach the parotid gland. [ 7 ] [ 8 ] :\u200a255"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3678", "text": "Sensory"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3679", "text": "General sensory innervation to the parotid gland and its  capsule  is provided by the  auriculotemporal nerve . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3680", "text": "The gland has a capsule of its own of dense connective tissue but is also provided with a false capsule by the investing layer of the deep cervical fascia. The fascia at the imaginary line between the angle of the mandible and the mastoid process splits into a superficial and a deep lamina to enclose the gland. The  risorius  is a small muscle embedded with this capsule substance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3681", "text": "The gland has short, striated ducts and long, intercalated ducts. [ 10 ]  The intercalated ducts are also numerous and lined with cuboidal epithelial cells and have lumina larger than those of the acini. The striated ducts are also numerous and consist of simple columnar epithelium, having striations that represent the infolded basal cell membranes and mitochondria. [ 8 ] :\u200a273"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3682", "text": "Though the parotid gland is the largest, it provides only 25% of the total salivary volume. The serous cell predominates in the parotid, making the gland secrete a mainly serous secretory product. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3683", "text": "The parotid gland also secretes salivary alpha-amylase ( sAA ), which is the first step in the decomposition of starches during mastication. It is the main exocrine gland to secrete this. It breaks down amylose (straight chain starch) and amylopectin (branched starch) by hydrolyzing alpha 1,4 bonds. Additionally, the alpha amylase has been suggested to prevent bacterial attachment to oral surfaces and to enable bacterial clearance from the mouth. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3684", "text": "The parotid salivary glands appear early in the sixth week of the prenatal development and are the first major salivary glands formed. The epithelial buds of these glands are located on the inner part of the cheek, near the labial commissures of the primitive mouth (from ectodermal lining near angles of the  stomodeum  in the 1st/2nd pharyngeal arches; the stomodeum itself is created from the rupturing of the oropharyngeal membrane at about 26 days. [ 12 ] ) These buds grow up posteriorly toward the otic placodes of the ears and branch to form solid cords with rounded terminal ends near the developing facial nerve. Later, at around 10 weeks of prenatal development, these cords are canalized and form ducts, with the largest becoming the parotid duct for the parotid gland. The rounded terminal ends of the cords form the acini of the glands. Secretion by the parotid glands via the parotid duct begins at about 18 weeks of gestation. Again, the supporting connective tissue of the gland develops from the surrounding  mesenchyme . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3685", "text": "Inflammation of one or both parotid glands is known as  parotitis . The most common cause of parotitis is  mumps . Widespread vaccination against mumps has markedly reduced the incidence of mumps parotitis. The pain of mumps is due to the swelling of the gland within its fibrous capsule. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3686", "text": "Apart from viral infection, other infections, such as bacterial, can cause parotitis (acute suppurative parotitis or chronic parotitis). These infections may cause blockage of the duct by  salivary duct calculi  or external compression. Parotid gland swellings can also be due to benign lymphoepithelial lesions [ clarification needed ]  caused by  Mikulicz disease  and  Sj\u00f6gren syndrome . Swelling of the parotid gland may also indicate the eating disorder  bulimia nervosa , creating the look of a heavy jaw line. With the inflammation of mumps or obstruction of the ducts, increased levels of the salivary alpha amylase secreted by the parotid gland can be detected in the blood stream."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3687", "text": "Mumps  is seen to be a common cause of parotid gland swelling\u00a0\u2013 85% of cases occur in children younger than 15 years. The disease is highly contagious and spreads by airborne droplets from salivary, nasal, and urinary secretions. [ 13 ]  Symptoms include oedema in the area,  trismus  as well as otalgia. The lesion tends to begin on one side of the face and eventually becomes bilateral. [ 13 ]  The transmission of the  paramyxovirus  is by contact with the infected persons saliva. [ 13 ]  Initial symptoms tend to be a headache and fever. Mumps is not fatal, however further complications can include swelling of the ovaries or the testes. [ 13 ]  Diagnosis of mumps is confirmed through viral serology, management of the condition includes hydration and good oral hygiene of the patient [ 13 ]  requiring excellent motivation. However, since the development of the mumps vaccine, given at the age of between 4\u20136 years, the incidence of this viral infection has greatly reduced. This vaccine has reduced the incidence by 99%. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3688", "text": "Tuberculosis  and  syphilis  can cause  granuloma  formation in the parotid glands."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3689", "text": "Salivary stones  mainly occur within the main confluence of the ducts and within the main parotid duct. The patient usually complains of intense  pain  when salivating and tends to avoid foods which produce this symptom. In addition, the parotid gland may become enlarged upon trying to eat. The pain can be reproduced in clinic by squirting lemon juice into the mouth. Surgery depends upon the site of the stone: if within the anterior aspect of the duct, a simple incision into the buccal mucosa with sphinterotomy [ clarification needed ]  may allow removal; however, if situated more posteriorly [ clarification needed ]  within the main duct, complete gland excision may be necessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3690", "text": "The parotid salivary gland can also be pierced and the facial nerve temporarily traumatized when an inferior alveolar local anesthesia nerve block is incorrectly administered, causing transient facial paralysis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3691", "text": "About 80% of tumors of the parotid gland are benign. [ 14 ]  The most common of these include  pleomorphic adenoma  (70% of tumors, [ 14 ]  of which 60% occur in females [ 14 ] ) and  Warthin tumor  (i.e.  adenolymphoma , which is more common in males than in females). Their importance is in relation to their anatomical position and tendency to grow over time. The tumorous growth can also change the consistency of the gland and cause facial pain on the involved side. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3692", "text": "Around 20% of parotid tumors are malignant, with the most common tumors being  mucoepidermoid carcinoma  and  adenoid cystic carcinoma . Other malignant tumors of the parotid gland include acinic cell carcinoma, carcinoma expleomorphic adenoma, adenocarcinoma (arising from ductal epithelium of parotid gland), squamous cell carcinoma (arising from parenchyma of parotid gland), and undifferentiated carcinoma. Metastasis from other sites like  phyllodes tumour  of breast presenting as parotid swelling have also been described. [ 15 ]  Critically, the relationship of the tumor to the branches of the  facial nerve  ( CN  VII) must be defined because resection may damage the nerves, resulting in paralysis of the muscles of facial expression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3693", "text": "Neoplastic  lesions of the parotid salivary gland can either be benign or malignant. Within the parotid gland, nearly 80% of tumours are  benign . [ 17 ]  Benign lesions tend to be painless,  asymptomatic  and slow-growing. The most common salivary gland neoplasms in children are  hemangiomas , lymphatic malformations, and  pleomorphic adenomas . [ 13 ]  Diagnosis of benign lesions require a fine-needle-like  aspiration biopsy . [ 13 ]  With various benign lesions, most commonly the pleomorphic adenoma, there is a risk of developing  malignancy  over time. [ 13 ]  As a result, these lesions are typically resected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3694", "text": "Pleomorphic adenoma is seen to be a common benign neoplasm of the salivary gland and has an overall incidence of 54\u201368%. [ 13 ]  The Warthin tumour has a lower incidence of 6\u201310%; this tumour is associated with smoking and is more common in older men. [ 13 ]  Benign lesions of the parotid gland have a significantly higher incidence than malignant lesions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3695", "text": "Malignant  salivary gland lesions are rare. However, when a tumour extends to the  submandibular ,  sublingual  and the minor salivary glands, they tend to be malignant. [ 13 ]  Distinguishing a malignant lesion from a benign one may be difficult as they both present as painless lesions. [ 13 ]  A  biopsy  is crucial in aiding diagnosis. There are common signs that can highlight the presence of a malignant lesion. These include facial nerve weakness, rapid increase of the size of the lump as well as ulceration of the mucosa of the skin. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3696", "text": "Mucoepidermoid carcinoma  is a common malignant tumour of the salivary glands and has a low incidence of 4\u201313%. [ 13 ]   Adenoid cystic carcinoma  is also a common malignant salivary gland lesion and has an incidence of 4\u20138%. This carcinoma tends to invade nerves and can re-occur post-treatment. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3697", "text": "A developmental polycystic disease of the salivary gland is seen to be extremely rare and is seen to be independent of recurrent  parotitis . [ 18 ]  The cause is thought to be a defect in the interactions between  activin ,  follistatin  and  TGF-\u03b2 , leading to a developmental disorder of glandular tissue. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3698", "text": "Surgical treatment of parotid gland tumors is sometimes difficult because of the anatomical relations of the facial nerve parotid lodge, as well as the increased potential for postoperative relapse. Thus, detection of early stages of a parotid tumor is extremely important in terms of postoperative prognosis. [ 14 ]  Operative technique is laborious, because of relapses and incomplete previous treatment made in other border specialties. [ 14 ]  Surgical techniques in parotid surgery have evolved in the last years with the use of neuromonitoring of the facial nerve and have become safer and less invasive. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3699", "text": "After surgical removal of the parotid gland ( parotidectomy ), the  auriculotemporal  nerve is liable to damage and upon recovery it fuses with sweat glands. This can cause sweating on the cheek on the side of the face of the affected gland. This condition is known as  Frey's syndrome . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3700", "text": "Commonly caused by a retrograde bacterial infection as a result of illness,  sepsis , trauma, surgery, reduced salivary flow due to medications,  diabetes , malnutrition and dehydration. Classically symptoms of painful swelling in the parotid region when eating seen. Management is based upon antibacterials, rehydration combined with gentle massage to encourage salivary flow. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3701", "text": "A latent infection despite clinical resolution of the disease resulting in impaired function. Histologically glandular duct dilation, abscess formation and atrophy may be seen. Parotid secretions are viscous. Disease course shows pain and swelling, waxing and waning. Radiographic screening should be undertaken to rule out  sialolith . Management with  palliative care  with parotidectomy as a last resort. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3702", "text": "Acute non-suppurative disease that often occurs in epidemics. Prevented by  MMR vaccine . Caused by  paramyxovirus  that is transmitted by infected saliva and urine. A prodromal period of 24\u201328 hours is experienced, followed by rapid and painful swelling of the parotid gland. Treatment is supportive (bedrest, hydration) as spontaneous resolution occurs within 5\u201310 days. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3703", "text": "Diffuse gland enlargement is seen, and may affect patients throughout all stages of the infection. Lymphoepithelial cysts [ 22 ]  seen via imaging help aid diagnosis. Pathogenic process occurs due to circulating  CD8  lymphocytes within the salivary gland. Medical management via use of  antiretrovirals , excellent oral hygiene measures and sialogogues. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3704", "text": "Most commonly seen in fourth and fifth decades in women, and can affect any salivary gland. Presentation is a slowly enlarging gland, with diagnosis made by identification of the underlying systemic disorder and measurements of salivary chemical levels. Sodium and chloride ion levels will be elevated two or three times normal levels. Treatment is by addressing the underlying systemic condition. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3705", "text": "Sarcoidosis is a chronic systemic disease characterised by the production of non-caseating granulomas of unknown aetiology. It can affect any organ of the body, depressing cellular immunity and enhancing humoral immunity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3706", "text": "Salivary gland involvement primarily involves both parotid glands, causing enlargement and swelling. Salivary gland biopsy with histopathologic examination is needed to make the distinction between whether Sjoren's syndrome or sarcoidosis is the cause of this. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3707", "text": "Salivary gland enlargement occurs in up to 30% of patients with Sjogren's syndrome, with the parotid gland being most often enlarged, and bilateral parotid gland enlargement seen in 25\u201360% of patients. However, the parotid glands have a longer-lasting secretory capacity in Sjogren's syndrome patient and therefore are the last glands to manifest hyposalivation in the disease. Histopathology shows clustering of lymphocytic infiltrates and epimyoepithelial islands. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3708", "text": "The most common head and neck manifestation of tuberculosis mycobacterial disease is infection of cervical lymph nodes. The infection is thought to originate in the tonsils or gingiva, ascending to the parotid gland. Two clinical forms; acute and chronic lesions. Acute lesions have diffuse glandular edema, easily confused with acute sialdentitis or abscess. The chronic lesions occur as slow growing masses mimicking tumors. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3709", "text": "A patient with parotid swelling may complain of swelling, pain,  xerostomia , bad taste and sometimes  sialorrhoea . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3710", "text": "The most common presenting symptom of  neoplasms  (both benign and malignant) is an asymptomatic swelling. Pain is more common in patients with parotid cancer (10\u201329% feel pain) than those with benign neoplasms (only 2.5\u20134%), [ 23 ]  but pain itself it not diagnostic of malignancy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3711", "text": "Episodic swelling of major salivary glands accompanied by pain and related to salivary stimuli suggests duct obstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3712", "text": "Also need to assess the facial nerve. The facial nerve passes through the parotid so may be affected if there is a change in the parotid gland. Facial nerve paralysis in a previously untreated patient usually indicates that a tumour is malignant. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3713", "text": "The superficial location of the salivary glands allows palpation and visual inspection. The inspection must be systematic, both intraorally and extraorally, so no area is missed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3714", "text": "For extraoral examination the patients head should be inclined forwards in order to maximally expose the parotid and submandibular glands. A normal parotid gland is barely palpable and a normal sublingual gland is not palpable. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3715", "text": "Intra-oral examination should include observations for asymmetry, discolouration, pulsation and obstructions in the duct orifices. Swelling of the deep lobe of the parotid gland may be seen intra-orally, and may also displace the tonsil. The minor salivary glands should be examined. The labial, buccal and posterior palatal mucosa should be dried with an air blower or tissue and pressed to assess the flow of saliva. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3716", "text": "Salivary stimulation"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3717", "text": "Sialography"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3718", "text": "Sialochemistry"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3719", "text": "Radioisotope scintigraphy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3720", "text": "The  parotid plexus  or  plexus parotideus  is the branch point of the  facial nerve  (extratemporal) after it leaves the  stylomastoid foramen . This division takes place within the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3721", "text": "Commonly, it divides into the following branches (several variations):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3722", "text": "Patient registration  is used to correlate the reference position of a  virtual   3D   dataset  gathered by computer  medical imaging  with the reference position of the patient. This procedure is crucial in  computer assisted surgery , in order to insure the reproducitibility of the preoperative registration and the clinical situation during surgery.\nThe use of the term \"patient registration\" out of this context can lead to a confusion with the procedure of registering a patient into the files of a medical institution."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3723", "text": "In  computer assisted surgery , the first step is to gather a 3D dataset that reproduces with great accuracy the geometry of the normal and pathological tissues in the region that has to be operated on. This is mainly obtained by using  CT  or  MRI  scans of that region. The role of patient registration is to obtain a close-to-ideal reference reproducibility of the dataset \u2013 in order to correlate the position (offset) of the gathered dataset with the patient's position during the surgical intervention. Patient registration (1) eliminates the necessity of maintaining the same strict position of the patient during both preoperative scanning and surgery, and (2) provides the surgical robot the necessary reference information to act accurately on the patient, even if he has (been) moved during the intervention."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3724", "text": "Patient registration was used mostly in head surgery \u2013 oral and maxillofacial surgery, neurosurgery, otolaryngology. With the advent of marker- and markerless-registration, the concept has been extended for abdominal surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3725", "text": "The first attempts in 3D mapping of human tissues were made by  V. Horsley  and R. Clarke in 1906. [ 1 ]  They have built a rectangular  stereotactic  headframe that had to be fixed to the head. It was based on cartesian principles and allowed them to accurately and reproductibly guide needle-like electrodes for neurophysiological experiments. They have experimented animals and were able to contribute to the mapping of the cerebellum. Improved versions of the  Horsley\u2013Clarke apparatus  are still in used today in experimental neurosurgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3726", "text": "The first stereotactic device for humans was also developed in neurosurgery, by E. Spiegel and H. Wycis in 1947. [ 2 ]  It was used for surgical treatment of  Parkinson's disease  and, during time, its applicability was extended for the surgical treatment of tumors, vascular malformations, functional neurosurgery etc. The system was based both on headframes and X-ray images taken for all three planes of space."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3727", "text": "Further development of stereotactic surgery was made by Brown, Roberts and Wells in 1980. [ 3 ]  They have developed a halo ring that was applied on the skull, during a  CT  scan and neurosurgical interventions. This method provided improved surgical guidance and was in fact the first development of computer guided surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3728", "text": "Patient registration for the head area has developed for nearly two decades on the same principle of combining CT scans with mechanical reference devices such as headframes or halo rings. But the clinical experience showed that headgear is very uncomfortable to wear and even impossible to apply on little children, because their lack of cooperation; furthermore, the headframes can create  artifacts  in preoperative data gathering, or during surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3729", "text": "In 1986, a different approach was developed by Roberts und Strohbehn. [ 4 ]  They have used as landmarks several markers on the patient's skin both preoperative CT registration, and intraoperatively. This was a new current of the time in patient registration. Still, the method is time-consuming, and the exact reproducitibility of the marker positions is questionable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3730", "text": "The bony structures can provide a much better stability and reproducibility of the landmarks for patient registration. Based on this concept, a further technique was used: to implant temporary markers into bone structures that are superficial to the skin, under local anestesia. [ 5 ]  This was also combined with surface markers and CT registration. [ 6 ]  The technique has the disadvantage of a further minimal surgical procedure of placing the bone implants, with some risk of infection for the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3731", "text": "Dental splints have been traditionally used for transferring and reproducing 3D reference landmarks for positioning cast models in  articulators  \u2013 in  dental prosthetics ,  orthodontics  and orthognathic surgery. By applying several infrared markers on the splints and using an infrared camera, a better registration was obtained. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3732", "text": "The first attempts, based on the identification of anatomical landmarks were made by Caversaccio and Zulliger. [ 8 ]  The method was based on identifying certain antropometrical points and other anatomical landmarks on the skull, in correlation with the CT registration. But the landmarks cannot be exactly pointed out and reproduced during patient dataset registration and surgery, therefore the method is not precise enough."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3733", "text": "Since 1998, new procedures have been developed by Marmulla and co-workers, using a different approach to the problem. [ 9 ] [ 10 ]  Both during CT dataset gathering and surgical intervention, the patient registration was made by registering complete areas and surfaces, instead of distinctive surface markers. This was achieved by using laser scanners and a small guiding transmitter. The precision of the patient registration was significantly improved with this method."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3734", "text": "Based on this concept, several registration and navigation systems were built by the same team. The  Surgical Segment Navigator (SSN and SSN++)  is such a system, developed for the first time for  oral and maxillofacial surgery . This system correlates three different coordinate sets: CT data set, surface laser scan data set and the dataset produced by a small guiding transmitter, placed on the patient's head. The Laboratory Unit for Computer-Assisted Surgery (LUCAS) is used for planning surgery in the laboratory. This technological and surgical advance has permitted the elimination of mechanical guidance systems and improved the accuracy of the determinations, and thus the surgical act."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3735", "text": "A research group at  Ryerson University (now Toronto Metropolitan University)  developed a method to use optical topographical imaging (OTI) to create a 3D model of the surface of open surgical sites and perform surface registration to  CT  and  MRI  data sets for  neurosurgical   navigation . [ 11 ] [ 12 ]  The OTI technology is being licensed by  7D Surgical  for their navigation platform. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3736", "text": "A  perforated eardrum  ( tympanic membrane perforation ) is a prick in the  eardrum . It can be caused by  infection  ( otitis media ),  trauma ,  overpressure  (loud  noise ), inappropriate  ear clearing , and changes in middle ear pressure. An  otoscope  can be used to view the eardrum to diagnose a perforation. Perforations may heal naturally or require surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3737", "text": "A perforated eardrum leads to  conductive hearing loss , which is usually temporary. Other symptoms may include  tinnitus ,  ear pain ,  vertigo , or a discharge of  mucus . [ 1 ]   Nausea  and/or  vomiting  secondary to vertigo may occur. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3738", "text": "A perforated eardrum can have one of many causes, such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3739", "text": "An  otoscope  can be used to look at the  ear canal . This gives a view of the  ear canal  and  eardrum , so that a perforated eardrum can be seen.  Tympanometry  may also be used. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3740", "text": "A perforated eardrum often heals naturally. [ 2 ] [ 7 ]  It may heal in a few weeks or may take up to a few months. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3741", "text": "Some perforations require surgical intervention. [ 3 ]  This may take the form of a paper patch to promote healing (a simple procedure by an  ear, nose and throat specialist ), or surgery ( tympanoplasty ). [ 2 ]  However, in some cases, the perforation can last several years and will be unable to heal naturally. For patients with persistent perforation, surgery is usually undertaken to close the perforation. The objective of the surgery is to provide a platform of sort to support the regrowth and healing of the tympanic membrane in the two weeks post-surgery period. There are two ways of doing the surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3742", "text": "The success of surgery is variable based on the cause of perforation and the technique being used. Predictors of success include traumatic perforation, dry ear, and central perforations. Predictors of failure includes young age and poor Eustachian tube function. [ 9 ]   The use of minimally invasive endoscopic technique does not reduce the chance of successful outcome. [ 10 ]  Hearing is usually recovered fully, but chronic infection over a long period may lead to permanent hearing loss. Those with more severe ruptures may need to wear an  ear plug  to prevent water contact with the ear drum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3743", "text": "Periodic fever, aphthous stomatitis, pharyngitis and adenitis  syndrome is a medical condition, typically occurring in young children, in which high  fever  occurs periodically at intervals of about 3\u20135 weeks, frequently accompanied by  aphthous-like ulcers ,  pharyngitis  and cervical adenitis ( cervical lymphadenopathy ). The syndrome was described in 1987 and named two years later. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3744", "text": "The key symptoms of PFAPA are those in its name: periodic high  fever  at intervals of about 3\u20135 weeks, as well as  aphthous ulcers ,  pharyngitis  and  adenitis . In between episodes, and even during the episodes, the children appear healthy. At least 6 months of episodes. Diagnosis requires recurrent negative throat cultures and that other causes (such as  EBV ,  CMV ,  FMF ) be excluded. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3745", "text": "The cause of PFAPA is unknown. [ 4 ]  It is frequently discussed together with other  periodic fever syndromes . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3746", "text": "Possible causes include primarily  genetic  factors or it may be due to an initial  infection ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3747", "text": "The condition appears to be the result of a disturbance of innate immunity. [ 5 ]  The changes in the immune system are complex and include increased expression of complement related genes ( C1QB ,  C2 ,  SERPING1 ), interleukin-1-related genes ( interleukin-1\u03b2 ,  interleukin 1 RN ,  CASP1 ,  interleukin 18 RAP ) and  interferon  induced ( AIM2 , IP-10/ CXCL10 ) genes.  T cell  associated  genes  ( CD3 ,  CD8B ) are down regulated. Flares are accompanied by increased serum levels of activated T lymphocyte chemokines (IP-10/CXCL10, MIG/ CXCL9 ),  G-CSF  and proinflammatory  cytokines  ( interleukin 6 ,  interleukin 18 ). Flares also manifest with a relative  lymphopenia . Activated  CD4 + / CD25 +  T-lymphocyte counts correlated negatively with serum concentrations of IP-10/CXCL10, whereas CD4 + / HLA-DR +  T lymphocyte counts correlated positively with serum concentrations of the counterregulatory IL-1 receptor antagonist. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3748", "text": "PFAPA syndrome typically resolves spontaneously. Treatment options are used to lessen the severity of episodes. [ 6 ]  These treatments are either medical or surgical:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3749", "text": "One treatment often used is a dose of a  corticosteroid  at the beginning of each fever episode. [ 4 ]  A single dose usually ends the fever within several hours. [ 4 ]  However, in some children, they can cause the fever episodes to occur more frequently. [ 4 ]   Interleukin-1  inhibition appears to be effective in treating this condition. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3750", "text": "There has been some evidence for the use of medications to reduce the frequency of flare-ups, including  colchicine  and  cimetidine . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3751", "text": "Surgical removal of the tonsils appears to be beneficial compared to no surgery in symptom resolution and number of future episodes. [ 6 ]  The evidence to support surgery is; however, of moderate quality. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3752", "text": "Children with PFAPA have an impaired quality of life, which may be treated via individual  counseling . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3753", "text": "According to present research, PFAPA does not lead to other diseases and spontaneously resolves as the child gets older, with no long term physical effects. [ 2 ] \n [ 9 ] \n [ 10 ] \nHowever, PFAPA has been found in adults and may not spontaneously resolve. [ 11 ] [ non-primary source needed ]  Children with PFAPA experience lower physical, emotional, and psychosocial functioning. [ 8 ]  Their performance in school is also substantially impacted. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3754", "text": "A  peritonsillar abscess  ( PTA ), also known as a  quinsy , is an accumulation of  pus  due to an  infection  behind the  tonsil . [ 2 ]  Symptoms include  fever , throat pain,  trouble opening the mouth , and a change to the voice. [ 1 ]  Pain is usually worse on one side. [ 1 ]  Complications may include blockage of the airway or  aspiration pneumonitis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3755", "text": "PTA is typically due to infection by a number of types of  bacteria . [ 1 ]  Often it follows  streptococcal pharyngitis . [ 1 ]  They do not typically occur in those who have had a  tonsillectomy . [ 1 ]  Diagnosis is usually based on the symptoms. [ 1 ]   Medical imaging  may be done to rule out complications. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3756", "text": "Treatment is by removing the pus,  antibiotics , sufficient fluids, and  pain medication . [ 1 ]   Steroids  may also be useful. [ 1 ]  Admission to hospital is generally not needed. [ 1 ]  In the United States about 3 per 10,000 people per year are affected. [ 1 ]  Young adults are most commonly affected. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3757", "text": "Physical signs of a peritonsillar abscess include  redness  and  swelling  in the tonsillar area of the affected side and swelling of the  jugulodigastric lymph nodes . The  uvula  may be displaced towards the unaffected side. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3758", "text": "Unlike  tonsillitis , which is more common in children, PTA has a more even age spread, from children to adults. Symptoms start appearing two to eight days before the formation of an  abscess . A progressively severe sore throat on one side and pain during swallowing ( odynophagia ) usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area,  fever ,  a general sense of feeling unwell , headache, and a distortion of vowels informally known as \"hot potato voice\" may appear. Neck pain associated with  tender, swollen lymph nodes , referred ear pain and  foul breath  are also common. While these signs may be present in tonsillitis itself, a PTA should be specifically considered if there is limited ability to open the mouth ( trismus ). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3759", "text": "While most people recover uneventfully, there is a wide range of possible complications. [ 4 ]  These may include: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3760", "text": "Difficulty swallowing can lead to decreased oral intake and  dehydration ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3761", "text": "PTA usually arises as a complication of an untreated or partially treated episode of acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis).  This region comprises loose connective tissue and is hence susceptible to formation of an abscess.  PTA can also occur  de novo . Both aerobic and anaerobic bacteria can be causative. Commonly involved aerobic pathogens include  Streptococcus ,  Staphylococcus  and  Haemophilus . The most common anaerobic species include  Fusobacterium necrophorum ,    Peptostreptococcus ,  Prevotella species , and  Bacteroides . [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3762", "text": "Diagnosis is usually based on the symptoms. [ 1 ]   Medical imaging  may be done to rule out complications. [ 1 ]  Medical imaging may include  CT scan ,  MRI , or  ultrasound  is also useful in diagnosis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3763", "text": "Medical treatment with antibiotics, volume repletion with fluids, and pain medication is usually adequate, although in cases where airway obstruction or systemic sepsis occurs, surgical drainage may be necessary. [ 1 ] [ 11 ]   Corticosteroids  may also be useful. [ 1 ]  Admission to hospital is generally not needed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3764", "text": "The infection is frequently penicillin resistant. [ 1 ]  There are a number of antibiotics options including  amoxicillin/clavulanate ,  ampicillin/sulbactam ,  clindamycin , or  metronidazole  in combination with  benzylpenicillin  (penicillin G) or  penicillin V . [ 1 ] [ 12 ]   Piperacillin/tazobactam  may also be used. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3765", "text": "The pus can be removed by a number of methods including  needle aspiration ,  incision and drainage , and  tonsillectomy . [ 1 ]  Incision and drainage may be associated with a lower chance of recurrence than needle aspiration but the evidence is very uncertain. Needle aspiration may be less painful but again the evidence is very uncertain. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3766", "text": "Treatment can also be given while a patient is under anesthesia, but this is usually reserved for children or anxious patients.  Tonsillectomy  can be indicated if a patient has recurring peritonsillar abscesses or a history of tonsillitis. For patients with their first peritonsillar abscess most ENT-surgeons prefer to \"wait and observe\" before recommending tonsillectomy. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3767", "text": "It is a commonly encountered  otorhinolaryngological (ENT)  emergency. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3768", "text": "The number of new cases per year of peritonsillar abscess in the  United States  has been estimated approximately at 30 cases per 100,000 people. [ 15 ]  In a study in  Northern Ireland , the number of new cases was 10 cases per 100,000 people per year. [ 16 ] \nIn  Denmark , the number of new cases is higher and reaches 41 cases per 100,000 people per year. [ 17 ]  Younger children who develop a peritonsillar abscess are often immunocompromised and in them, the infection can cause airway obstruction. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3769", "text": "The condition is often referred to as \"quincy\", \"quinsy\", [ 19 ]  or \"quinsey\", anglicised versions of the French word  esquinancie  which was originally rendered as squinsey and subsequently quinsy. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3770", "text": "The ancient Roman goddess  Angerona  was claimed to cure quinsy (Latin  angina ) in humans and sheep. [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3771", "text": "The  petrous part  of the  temporal bone  is pyramid-shaped and is wedged in at the base of the  skull  between the  sphenoid  and  occipital bones . Directed medially, forward, and a little upward, it presents a base, an apex, three surfaces, and three angles, and houses in its interior the components of the  inner ear . The petrous portion is among the most basal elements of the skull and forms part of the  endocranium . Petrous comes from the Latin word  petrosus , meaning \"stone-like, hard\". It is one of the densest bones in the body. In other mammals, it is a separate bone, the  petrosal bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3772", "text": "The petrous bone is important for studies of ancient DNA from skeletal remains, as it tends to contain extremely well-preserved DNA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3773", "text": "The base is fused with the internal surfaces of the  squamous ,  tympanic , and  mastoid parts . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3774", "text": "The apex, which is rough and uneven, is received into the angular interval between the posterior border of the  great wing  of the  sphenoid bone  and the  basilar part  of the  occipital bone ; it presents the anterior or internal opening of the  carotid canal , and forms the postero-lateral boundary of the  foramen lacerum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3775", "text": "The anterior surface forms the posterior part of the  middle cranial fossa  of the base of the skull, and is continuous with the inner surface of the squamous portion, to which it is united by the  petrosquamous suture , remains of which are distinct even at a late period of life. It is marked by depressions for the convolutions of the brain, and presents six notable points:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3776", "text": "The  posterior surface  forms the anterior part of the  posterior cranial fossa  of the base of the skull, and is continuous with the inner surface of the mastoid portion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3777", "text": "Near the center is a large orifice, the  internal acoustic opening , the size of which varies considerably; its margins are smooth and rounded, and it leads into the  internal auditory meatus  a short canal, about 1\u00a0cm. in length, which runs lateralward. It transmits the facial and acoustic nerves and the internal auditory branch of the  basilar artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3778", "text": "The lateral end of the canal is closed by a vertical plate, which is divided by a horizontal crest, the  falciform crest , into two unequal portions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3779", "text": "Each portion is further subdivided by a vertical ridge into an anterior and a posterior part."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3780", "text": "Behind the internal acoustic meatus is a small slit almost hidden by a thin plate of bone, leading to a canal, the aqu\u00e6ductus vestibuli, which transmits the ductus endolymphaticus together with a small artery and vein."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3781", "text": "Above and between these two openings is an irregular depression that lodges a process of the dura mater and transmits a small vein; in the infant, this depression is represented by a large fossa, the  subarcuate fossa , which extends backward as a blind tunnel under the  superior semicircular canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3782", "text": "The  inferior surface  is rough and irregular, and forms part of the exterior of the base of the skull. It presents eleven points for examination:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3783", "text": "The  superior angle , the longest, is grooved for the  superior petrosal sinus , and gives attachment to the  tentorium cerebelli ; at its medial extremity is a notch, in which the  trigeminal nerve  lies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3784", "text": "The  posterior angle  is intermediate in length between the superior and the anterior. Its medial half is marked by a sulcus, which forms, with a corresponding sulcus on the occipital bone, the channel for the inferior petrosal sinus. Its lateral half presents an excavation \u2014 the jugular fossa \u2014 which, with the jugular notch on the occipital, forms the jugular foramen; an eminence occasionally projects from the center of the fossa, and divides the foramen into two."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3785", "text": "The  anterior angle  is divided into two parts\u2014a lateral joined to the squamous part by a suture (petrosquamous), the remains of which are more or less distinct; a medial, free, which articulates with the spinous process of the sphenoid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3786", "text": "At the angle of junction of the petrous and the squamous parts are two canals, one above the other, and separated by a thin plate of bone, the septum canalis musculotubarii; both canals lead into the tympanic cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3787", "text": "In ancient DNA studies, scientists extract and sequence DNA from ancient skeletal remains of humans and other species. In many cases the DNA is highly degraded, and contaminated by DNA from soil microbes. In 2015 it was found that the petrous bone has remarkably well-preserved DNA. [ 2 ]  A 2017 study [ 3 ]  comparing DNA from different skeletal sites concluded that \"The inner part of petrous bones and the cementum layer in teeth roots are currently recognized as the best substrates for (ancient DNA) research ... Both substrates display significantly higher endogenous DNA content (average of 16.4% and 40.0% for teeth and petrous bones, respectively) than parietal skull bone (average of 2.2%).\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3788", "text": "Consequently, petrous bones are now the most widely-used skeletal site for the study of ancient DNA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3789", "text": "This article incorporates text in the  public domain  from  page 142  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3790", "text": "The  pharyngeal arches , also known as  visceral arches ,  are transient structures seen in the  embryonic development  of  humans  and other  vertebrates , that are recognisable precursors for many structures. [ 1 ]  In  fish , the arches support the  gills  and are known as the  branchial arches , or gill arches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3791", "text": "In the  human embryo , the arches are first seen during the fourth week of  development . They appear as a series of outpouchings of  mesoderm  on both sides of the developing  pharynx . The  vasculature  of the pharyngeal arches are the  aortic arches  that arise from the  aortic sac ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3792", "text": "In  humans  and other  vertebrates , the pharyngeal arches are derived from all three  germ layers  (the primary layers of cells that form during  embryonic development ). [ 2 ]   Neural crest cells  enter these arches where they contribute to features of the  skull  and  facial skeleton  such as bone and cartilage. [ 2 ]  However, the existence of pharyngeal structures before neural crest cells evolved is indicated by the existence of neural crest-independent mechanisms of pharyngeal arch development. [ 3 ]  The first, most anterior  pharyngeal arch  gives rise to the  mandible .  The second arch becomes the  hyoid  and jaw support. [ 2 ]   In fish, the other posterior arches contribute to the branchial skeleton, which support the gills; in tetrapods the anterior arches develop into components of the ear, tonsils, and thymus. [ 4 ]  The genetic and developmental basis of pharyngeal arch development is well characterized.  It has been shown that  Hox genes  and other developmental genes such as  DLX  are important for patterning the anterior/posterior and dorsal/ventral axes of the  branchial arches . [ 5 ]  Some fish species have a second set of jaws in their throat, known as  pharyngeal jaws , which develop using the same genetic pathways involved in oral jaw formation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3793", "text": "During  embryonic development , a series of pharyngeal arch pairs form. These project forward from the back of the embryo toward the front of the face and neck. Each arch develops its own artery, nerve that controls a distinct muscle group, and skeletal tissue. The arches are numbered from 1 to 6, with 1 being the arch closest to the head of the embryo, and arch 5 existing only transiently. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3794", "text": "These grow and join in the ventral midline. The first arch, as the first to form, separates the mouth pit or  stomodeum  from the  pericardium .  By differential growth the neck elongates and new arches form, so the pharynx has six arches ultimately."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3795", "text": "Each pharyngeal arch has a  cartilaginous  stick, a  muscle  component that differentiates from the cartilaginous tissue, an artery, and a  cranial nerve . Each of these is surrounded by  mesenchyme . Arches do not develop simultaneously but instead possess a \"staggered\" development."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3796", "text": "Pharyngeal pouches  form on the  endodermal  side between the arches, and  pharyngeal grooves  (or clefts) form from the lateral  ectodermal  surface of the  neck  region to separate the arches. [ 8 ]  In fish, the pouches line up with the clefts, and these thin segments become  gills . In mammals the  endoderm  and  ectoderm  not only remain intact but also continue to be separated by a  mesoderm  layer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3797", "text": "The development of the pharyngeal arches provides a useful landmark with which to establish the precise stage of embryonic development.  Their formation and development corresponds to  Carnegie stages  10 to 16 in  mammals , and  Hamburger\u2013Hamilton stages  14 to 28 in the  chicken . Although there are six pharyngeal arches, in humans the fifth arch exists only transiently during  embryogenesis . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3798", "text": "The  first pharyngeal arch , also  mandibular arch  (corresponding to the first branchial arch of fish), is the first of six pharyngeal arches that develops during the fourth week of  development . [ 10 ]   It is located between the  stomodeum  and the  first pharyngeal groove ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3799", "text": "This arch divides into a  maxillary process  and a  mandibular process , giving rise to structures including the  bones  of the lower two-thirds of the face and the jaw.  The maxillary process becomes the  maxilla  (or  upper jaw , although there are large differences among animals [ 11 ] ), and  palate  while the mandibular process becomes the  mandible  or  lower jaw . This arch also gives rise to the  muscles of mastication ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3800", "text": "Meckel's cartilage  forms in the  mesoderm  of the mandibular process and eventually regresses to form the  incus  and  malleus  of the  middle ear , the anterior ligament of the malleus and the  sphenomandibular ligament . The  mandible  or lower jaw forms by perichondral  ossification  using Meckel's cartilage as a 'template', but the maxillary does  not  arise from direct ossification of Meckel's cartilage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3801", "text": "The skeletal elements and muscles are derived from mesoderm of the pharyngeal arches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3802", "text": "Skeletal"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3803", "text": "Muscles"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3804", "text": "Other"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3805", "text": "Mucous membrane  and glands of the  anterior two thirds of the tongue  are derived from  ectoderm  and  endoderm  of the arch."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3806", "text": "The mandibular and maxillary branches of the  trigeminal nerve  ( CN V ) innervate the structures derived from the corresponding processes of the first arch. In some lower animals, each arch is supplied by two cranial nerves. The nerve of the arch itself runs along the cranial side of the arch and is called post-trematic nerve of the arch. Each arch also receives a branch from the nerve of the succeeding arch called the pre-trematic nerve which runs along the caudal border of the arch. In human embryo, a double innervation is seen only in the first pharyngeal arch. The mandibular nerve is the post-trematic nerve of the first arch and  chorda tympani  (branch of facial nerve) is the pre-trematic nerve. This double innervation is reflected in the nerve supply of anterior two-thirds of  tongue  which is derived from the first arch. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3807", "text": "The artery of the first arch is the first  aortic arch , [ 13 ]  which partially persists as the  maxillary artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3808", "text": "The  second pharyngeal arch  or  hyoid arch , is the second of fifth pharyngeal arches that develops in  fetal life  during the fourth week of development [ 10 ]  and assists in forming the side and front of the  neck ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3809", "text": "Cartilage in the second pharyngeal arch is referred to as Reichert's cartilage and contributes to many structures in the fully developed adult. [ 14 ]  In contrast to the  Meckel's cartilage  of the  first pharyngeal arch  it does not constitute a continuous element, and instead is composed of two distinct cartilaginous segments joined by a faint layer of  mesenchyme . [ 15 ]   Dorsal ends of Reichert's cartilage  ossify  during development to form the  stapes  of the  middle ear  before being incorporated into the middle ear cavity, while the ventral portion ossifies to form the lesser cornu and upper part of the body of the  hyoid bone . Caudal to what will eventually become the  stapes , Reichert's cartilage also forms the  styloid process  of the  temporal bone . The cartilage between the  hyoid bone  and  styloid process  will not remain as development continues, but its  perichondrium  will eventually form the  stylohyoid ligament ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3810", "text": "From the cartilage of the second arch arises"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3811", "text": "Facial nerve  (CN VII)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3812", "text": "The artery of the second arch is the second  aortic arch , [ 13 ]  which gives origin to the  stapedial artery  in some mammals but atrophies in most humans."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3813", "text": "Pharyngeal muscles or Branchial muscles  are  striated muscles  of the head and neck. Unlike  skeletal muscles  that developmentally come from  somites , pharyngeal muscles are developmentally formed from the pharyngeal arches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3814", "text": "Most of the skeletal musculature supplied by the cranial nerves ( special visceral efferent ) is pharyngeal. Exceptions include, but are not limited to, the  extraocular muscles  and some of the muscles of the tongue. These exceptions receive  general somatic efferent  innervation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3815", "text": "All of the  pharyngeal muscles  that come from the first pharyngeal arch are innervated by the mandibular divisions of the  trigeminal nerve . [ 16 ]   These muscles include all the  muscles of mastication , the anterior belly of the  digastric , the  mylohyoid ,  tensor tympani , and  tensor veli palatini ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3816", "text": "All of the pharyngeal muscles of the second pharyngeal arch are innervated by the  facial nerve .  These muscles include the  muscles of facial expression , the posterior belly of the  digastric , the  stylohyoid  muscle, the auricular muscle [ 16 ]  and the  stapedius  muscle of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3817", "text": "There is only one muscle of the third pharyngeal arch, the  stylopharyngeus . The stylopharyngeus and other structures from the third pharyngeal arch are all innervated by the  glossopharyngeal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3818", "text": "All the pharyngeal muscles of the fourth and sixth arches are innervated by the superior laryngeal and the recurrent laryngeal branches of the  vagus nerve . [ 16 ]  These muscles include all the muscles of the palate (exception of the  tensor veli palatini  which is innervated by the  trigeminal nerve ), all the muscles of the pharynx (except  stylopharyngeus  which is innervated by the  glossopharyngeal nerve ), and all the muscles of the larynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3819", "text": "It has been proposed that the five arches in amniotes numbered 1\u20134 and 6, be re-named as simply 1\u20135. [ 17 ]  The fifth arch is seen to be a transient structure and becomes the sixth arch, (the fifth being absent). More is known about the fate of the first arch than the remaining four. The first three contribute to structures above the larynx, whereas the last two contribute to the  larynx  and  trachea ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3820", "text": "The  recurrent laryngeal nerves  are produced from the nerve of arch 5, and the laryngeal cartilages from arches 4 and 5. The superior laryngeal branch of the vagus nerve arises from arch 4. Its arteries, which project between the nerves of the fourth and fifth arches, become the left-side arch of the aorta and the right  subclavian artery . On the right side, the artery of arch 5 is obliterated while, on the left side, the artery persists as the  ductus arteriosus ; circulatory changes immediately following birth cause the vessel to close down, leaving a remnant, the  ligamentum arteriosum . During growth, these arteries descend into their ultimate positions in the chest, creating the elongated recurrent paths. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3821", "text": "Left 4th aortic arch:  aortic arch"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3822", "text": "Left 5th aortic arch:  pulmonary artery  and  ductus arteriosus"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3823", "text": "It has been proposed that the arches be re-named simply as 1\u20135. The argument is the existence of the fifth arch (and pouch), held to be a transient structure in the embryo. [ 17 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3824", "text": "Pharyngitis  is  inflammation  of the back of the  throat , known as the  pharynx . [ 2 ]  It typically results in a  sore throat  and  fever . [ 2 ]  Other symptoms may include a  runny nose ,  cough ,  headache , difficulty swallowing, swollen  lymph nodes , and a  hoarse voice . [ 1 ] [ 6 ]  Symptoms usually last 3\u20135 days, but can be longer depending on cause. [ 2 ] [ 3 ]  Complications can include  sinusitis  and  acute otitis media . [ 2 ]  Pharyngitis is a type of  upper respiratory tract infection . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3825", "text": "Most cases are caused by a  viral infection . [ 2 ]   Strep throat , a  bacterial infection , is the cause in about 25% of children and 10% of adults. [ 2 ]  Uncommon causes include other bacteria such as  gonococcus ,  fungi , irritants such as  smoke ,  allergies , and  gastroesophageal reflux disease . [ 2 ] [ 4 ]  Specific testing is not recommended in people who have clear symptoms of a viral infection, such as a  cold . [ 2 ]  Otherwise, a  rapid antigen detection test  or  throat swab  is recommended. [ 2 ]   PCR  testing has become common as it is as good as taking a throat swab but gives a faster result. [ 8 ]  Other conditions that can produce similar symptoms include  epiglottitis ,  thyroiditis ,  retropharyngeal abscess , and occasionally  heart disease . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3826", "text": "NSAIDs , such as  ibuprofen , can be used to help with the pain. [ 2 ]  Numbing medication, such as topical  lidocaine , may also help. [ 4 ]  Strep throat is typically treated with  antibiotics , such as either  penicillin  or  amoxicillin . [ 2 ]  It is unclear whether  steroids  are useful in acute pharyngitis, other than possibly in severe cases, but a recent (2020) review found that when used in combination with antibiotics they moderately reduced pain and the likelihood of resolution. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3827", "text": "About 7.5% of people have a sore throat in any 3-month period. [ 5 ]  Two or three episodes in a year are not uncommon. [ 1 ]  This resulted in 15 million physician visits in the United States in 2007. [ 4 ]  Pharyngitis is the most common cause of a sore throat. [ 11 ]  The word comes from the  Greek word   pharynx  meaning \"throat\" and the suffix  -itis  meaning \"inflammation\". [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3828", "text": "Pharyngitis is a type of inflammation caused by an  upper respiratory tract infection . It may be classified as acute or chronic. Acute pharyngitis may be  catarrhal ,  purulent , or  ulcerative , depending on the  causative agent  and the  immune capacity  of the affected individual. Chronic pharyngitis may be catarrhal,  hypertrophic , or  atrophic . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3829", "text": "Tonsillitis  is a subtype of pharyngitis. [ 14 ]  If the inflammation includes both the  tonsils  and other parts of the throat, it may be called  pharyngotonsillitis  or  tonsillopharyngitis . [ 15 ]  Another subclassification is  nasopharyngitis  (the common cold). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3830", "text": "Clergyman's sore throat  or  clergyman's throat  is an archaic term formerly used for chronic pharyngitis associated with overuse of the voice as in public speaking. It was sometimes called  dysphonia clericorum  or chronic  folliculitis  sore throat. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3831", "text": "Most cases are due to an  infectious organism  acquired from close contact with an infected individual. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3832", "text": "These comprise about 40\u201380% of all infectious cases and can be a feature of many different types of viral infections. [ 11 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3833", "text": "A number of different bacteria can infect the human throat. The most common is  group A streptococcus  ( Streptococcus pyogenes ), but others include  Streptococcus pneumoniae ,  Haemophilus influenzae ,  Bordetella pertussis ,  Bacillus anthracis ,  Corynebacterium diphtheriae ,  Neisseria gonorrhoeae ,  Chlamydophila pneumoniae ,  Mycoplasma pneumoniae ,  and  Fusobacterium necrophorum . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3834", "text": "Streptococcal pharyngitis or strep throat is caused by a  group A beta-hemolytic streptococcus  (GAS). [ 20 ]  It is the most common bacterial cause of cases of pharyngitis (15\u201330%). [ 19 ]  Common symptoms include  fever ,  sore throat , and large lymph nodes. It is a contagious infection, spread by close contact with an infected individual. A definitive diagnosis is made based on the results of a  throat culture .  Antibiotics  are useful to both prevent complications (such as  rheumatic fever ) and speed recovery. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3835", "text": "Fusobacterium necrophorum  is a normal inhabitant of the oropharyngeal  flora  and can occasionally create a  peritonsillar abscess . In one out of 400 untreated cases,  Lemierre's syndrome  occurs. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3836", "text": "Diphtheria  is a potentially life-threatening upper respiratory infection caused by  Corynebacterium diphtheriae , which has been largely eradicated in developed nations since the introduction of childhood  vaccination  programs, but is still reported in the  Third World  and increasingly in some areas in  Eastern Europe . Antibiotics are effective in the early stages, but recovery is generally slow. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3837", "text": "A few other causes are rare, but possibly fatal, and include  parapharyngeal space  infections:  peritonsillar abscess  (\"quinsy abscess\"),  submandibular space infection  (Ludwig's angina), and  epiglottitis . [ 23 ] [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3838", "text": "Some cases of pharyngitis are caused by  fungal infection , such as  Candida albicans , causing  oral thrush . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3839", "text": "Pharyngitis may also be caused by mechanical, chemical, or thermal irritation, for example cold air or  acid reflux . Some medications may produce pharyngitis, such as  pramipexole  and  antipsychotics . [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3840", "text": "Differentiating a viral and a bacterial cause of a sore throat based on symptoms alone is difficult. [ 29 ]  Thus, a throat swab often is done to rule out a bacterial cause. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3841", "text": "The modified  Centor criteria  may be used to determine the management of people with pharyngitis. Based on five clinical criteria, it indicates the probability of a streptococcal infection. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3842", "text": "One point is given for each of the criteria: [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3843", "text": "The  Infectious Disease Society of America  recommends against  empirical treatment  and considers antibiotics only appropriate following positive testing. [ 29 ]  Testing is not needed in children under three, as both group A strep and  rheumatic fever  are rare, except if they have a sibling with the disease. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3844", "text": "The majority of the time, treatment is symptomatic. Specific treatments are effective for bacterial, fungal, and  herpes simplex  infections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3845", "text": "Gargling  salt water  is often suggested, but there is no evidence to support or discourage this practice. [ 4 ]   Alternative medicines  are promoted and used for the treatment of sore throats. [ 37 ]  However, they are poorly supported by evidence. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3846", "text": "Acute pharyngitis is the most common cause of a  sore throat  and, together with cough, it is diagnosed in more than 1.9 million people a year in the United States. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3847", "text": "The  pharynx  ( pl. :  pharynges ) is the part of the  throat  behind the  mouth  and  nasal cavity , and above the  esophagus  and  trachea  (the tubes going down to the  stomach  and the  lungs  respectively). It is found in vertebrates and invertebrates, though its structure varies across species. The pharynx carries food to the esophagus and air to the  larynx . The flap of cartilage called the  epiglottis  stops food from entering the larynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3848", "text": "In humans, the pharynx is part of the  digestive system  and the  conducting zone  of the  respiratory system . (The conducting zone\u2014which also includes the  nostrils  of the  nose , the  larynx ,  trachea ,  bronchi , and  bronchioles \u2014filters, warms and moistens air and conducts it into the  lungs ). [ 1 ]  The human pharynx is conventionally divided into three sections: the  nasopharynx ,  oropharynx , and  laryngopharynx ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3849", "text": "In humans, two sets of  pharyngeal muscles  form the pharynx and determine the shape of its  lumen . They are arranged as an inner layer of longitudinal muscles and an outer circular layer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3850", "text": "The upper portion of the pharynx, the nasopharynx, extends from the base of the  skull  to the upper surface of the  soft palate . [ 2 ]  It includes the space between the  internal nares  and the soft palate and lies above the oral cavity. The  adenoids , also known as the pharyngeal tonsils, are  lymphoid tissue  structures located in the posterior wall of the nasopharynx.  Waldeyer's tonsillar ring  is an annular arrangement of lymphoid tissue in both the nasopharynx and oropharynx. The nasopharynx is lined by  respiratory epithelium  that is pseudostratified, columnar, and ciliated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3851", "text": "Polyps  or  mucus  can obstruct the nasopharynx, as can congestion due to an upper respiratory infection. The  auditory tube , which connects the middle ear to the pharynx, opens into the nasopharynx at the pharyngeal opening of the auditory tube. The opening and closing of the auditory tubes serves to equalize the barometric pressure in the middle ear with that of the ambient atmosphere."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3852", "text": "The anterior aspect of the nasopharynx communicates through the  choanae  with the nasal cavities. On its lateral wall is the  pharyngeal opening of the auditory tube , somewhat triangular in shape and bounded behind by a firm prominence, the  torus tubarius  or cushion, caused by the medial end of the cartilage of the tube that elevates the  mucous membrane .\nTwo folds arise from the cartilaginous opening:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3853", "text": "The oropharynx lies behind the oral cavity, extending from the  uvula  to the level of the  hyoid bone . It opens anteriorly, through the  isthmus faucium , into the mouth, while in its lateral wall, between the  palatoglossal arch  and the  palatopharyngeal arch , is the  palatine tonsil . [ 4 ]  The anterior wall consists of the base of the tongue and the  epiglottic vallecula ; the lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars; the superior wall consists of the inferior surface of the soft palate and the uvula. Because both food and air pass through the pharynx, a flap of connective tissue called the  epiglottis  closes over the  glottis  when food is swallowed to prevent  aspiration . The oropharynx is lined by non-keratinized squamous stratified epithelium."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3854", "text": "The  HACEK  organisms ( H aemophilus ,  A ctinobacillus actinomycetemcomitans ,  C ardiobacterium hominis ,  E ikenella corrodens ,  K ingella ) are part of the normal oropharyngeal flora, which grow slowly, prefer a carbon dioxide-enriched atmosphere, and share an enhanced capacity to produce  endocardial  infections, especially in young children. [ 5 ]   Fusobacterium  is a pathogen. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3855", "text": "The laryngopharynx, ( Latin :  pars laryngea pharyngis ), also known as  hypopharynx , is the  caudal  part of the pharynx; it is the part of the throat that connects to the esophagus. It lies inferior to the epiglottis and extends to the location where this common pathway diverges into the respiratory ( laryngeal ) and digestive ( esophageal ) pathways. At that point, the laryngopharynx is continuous with the esophagus posteriorly. The esophagus conducts food and fluids to the stomach; air enters the larynx anteriorly. During swallowing, food has the \"right of way\", and air passage temporarily stops. Corresponding roughly to the area located between the 4th and 6th  cervical vertebrae , the superior boundary of the laryngopharynx is at the level of the  hyoid bone . The laryngopharynx includes three major sites: the  pyriform sinus , postcricoid area, and the posterior pharyngeal wall. Like the oropharynx above it, the laryngopharynx serves as a passageway for food and air and is lined with a  stratified squamous epithelium . It is innervated by the  pharyngeal plexus  and by the  recurrent laryngeal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3856", "text": "The vascular supply to the laryngopharynx includes the  superior thyroid artery , the  lingual artery  and the  ascending pharyngeal artery . The primary neural supply is from both the  vagus  and  glossopharyngeal  nerves. The vagus nerve provides an  auricular branch  also termed \"Arnold's nerve\" which also supplies the external auditory canal, thus laryngopharyngeal cancer can result in referred  ear pain . This nerve is also responsible for the  ear-cough reflex  in which stimulation of the ear canal results in a person coughing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3857", "text": "The pharynx moves food from the mouth to the esophagus. It also moves air from the  nasal  and  oral  cavities to the  larynx . It is also used in human speech, as  pharyngeal consonants  are articulated here, and it acts as a  resonating chamber  during phonation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3858", "text": "Inflammation of the pharynx, or  pharyngitis , is the painful inflammation of the throat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3859", "text": "Pharyngeal cancer  is a cancer that originates in the neck and/or throat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3860", "text": "Waldeyer's tonsillar ring  is an anatomical term collectively describing the annular arrangement of lymphoid tissue in the pharynx. Waldeyer's ring circumscribes the naso- and oropharynx, with some of its tonsillar tissue located above and some below the soft palate (and to the back of the oral cavity). It is believed that Waldeyer's ring prevents the invasion of microorganisms from going into the air and food passages and this helps in the defense mechanism of the respiratory and alimentary systems. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3861", "text": "The word  pharynx  ( / \u02c8 f \u00e6r \u026a \u014b k s / [ 8 ] [ 9 ] ) is derived from the  Greek  \u03c6\u03ac\u03c1\u03c5\u03b3\u03be  ph\u00e1rynx , meaning \"throat\". Its plural form is  pharynges   / f \u0259 \u02c8 r \u026a n d\u0292 i\u02d0 z /  or  pharynxes   / \u02c8 f \u00e6r \u026a \u014b k s \u0259 z / , and its adjective form is  pharyngeal  ( / \u02cc f \u00e6 r \u026a n \u02c8 d\u0292 i\u02d0 \u0259l /   or   / f \u0259 \u02c8 r \u026a n d\u0292 i \u0259l / )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3862", "text": "All vertebrates have a pharynx, used in both feeding and respiration. The pharynx arises during development in all vertebrates through a series of six or more outpocketings on the lateral sides of the head. These outpocketings are  pharyngeal arches , and they give rise to a number of different structures in the skeletal, muscular, and circulatory systems. The structure of the pharynx varies across the vertebrates. It differs in dogs, horses, and ruminants. In dogs, a single duct connects the nasopharynx to the nasal cavity. The tonsils are a compact mass that points away from the lumen of the pharynx. In the horse, the auditory tube opens into the guttural pouch and the tonsils are diffuse and raised slightly. Horses are unable to breathe through the mouth as the free apex of the rostral epiglottis lies dorsal to the soft palate in a normal horse. In  ruminants , the tonsils are a compact mass that points towards the lumen of the pharynx."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3863", "text": "Pharyngeal arches are characteristic features of vertebrates whose origin can be traced back through  chordates  to basal  deuterostomes  who also share endodermal outpocketings of the pharyngeal apparatus. Similar patterns of gene expression can be detected in the developing pharynx of  amphioxi  and  hemichordates . However, the vertebrate pharynx is unique in that it gives rise to  endoskeletal  support through the contribution of  neural crest  cells. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3864", "text": "Pharyngeal jaws  are a \"second set\" of  jaws  contained within the pharynx of many species of fish, distinct from the primary (oral) jaws. Pharyngeal jaws have been studied in  moray eels  where their specific action is noted. When the moray bites  prey , it first bites normally with its oral jaws, capturing the prey. Immediately thereafter, the pharyngeal jaws are brought forward and bite down on the prey to grip it; they then retract, pulling the prey down the eel's esophagus, allowing it to be swallowed. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3865", "text": "Invertebrates  also have a pharynx. Invertebrates with a pharynx include the  tardigrades , [ 12 ]   annelids  and  arthropods , [ 13 ]  and the  priapulids  (which have an eversible pharynx). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3866", "text": "The \"pharynx\" of the  nematode  worm is a muscular food pump in the head, triangular in cross-section, that grinds food and transports it directly to the intestines. A one-way valve connects the pharynx to the excretory canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3867", "text": "General"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3868", "text": "The  posterior auricular muscle  is a  muscle  behind the  auricle  of the  outer ear . It arises from the mastoid part of the temporal bone, and inserts into the lower part of the cranial surface of the  auricle  of the  outer ear . It draws the auricle backwards, usually a very slight effect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3869", "text": "The posterior auricular muscle is found behind the  auricle  of the  outer ear . [ 1 ]  It consists of two or three fleshy  fasciculi . These arise from the  mastoid part  of the  temporal bone  by short aponeurotic fibers. [ 1 ]  They insert into the lower part of the cranial surface of the  auricle  of the  outer ear . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3870", "text": "The posterior auricular muscle is supplied by branches of the  posterior auricular artery , which continues deep to the muscle. [ 2 ]  It is drained by the  posterior auricular vein  that accompanies the artery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3871", "text": "The posterior auricular muscle is supplied by the  posterior auricular nerve , a branch of the  facial nerve  (VII). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3872", "text": "The posterior auricular nerve draws the auricle of the outer ear backwards. [ 2 ]  This effect is usually very slight, although some people can wiggle their ears due to a more significant muscle movement. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3873", "text": "The  postauricular reflex  is a  vestigial  myogenic [ 4 ]  muscle response in humans that acts to pull the ear upward and backward. [ 5 ]  Research suggests neural circuits for  auricle  orienting have survived in a vestigial state for over 25 million years. It is often assumed the reflex is a vestigial  Preyer reflex  (also known as the  pinna reflex ). [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3874", "text": "A study on auriculomotor activity found that in the presence of sudden, surprising sounds, the muscles around the ear closest to the direction of the sound would respond by moving involuntarily, causing the pinna to be pulled backwards and flatten. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3875", "text": "If the posterior auricular muscle inserts into an unusual part of the  auricle  of the  outer ear , this can cause  protruding ears . [ 1 ]  In one study, the muscle was found to be absent in 5% of people. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3876", "text": "The  posterior auricular nerve  is a  nerve  of the  head . It is a branch of the  facial nerve  (CN VII). It communicates with branches from the  vagus nerve , the  great auricular nerve , and the  lesser occipital nerve . Its auricular branch supplies the  posterior auricular muscle , the intrinsic muscles of the  auricle , and gives sensation to the auricle. Its occipital branch supplies the  occipitalis muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3877", "text": "The posterior auricular nerve arises from the  facial nerve  (CN VII). [ 1 ]  It is the first branch outside of the  skull . [ 2 ]  This origin is close to the  stylomastoid foramen . It runs upward in front of the  mastoid process . It is joined by a branch from the  auricular branch  of the  vagus nerve  (CN X). It communicates with the posterior branch of the  great auricular nerve , as well as with the  lesser occipital nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3878", "text": "As it ascends between the  external acoustic meatus  and mastoid process it divides into auricular and occipital branches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3879", "text": "The posterior auricular nerve supplies the  posterior auricular muscle , and the intrinsic muscles of the  auricle . [ 1 ]  It gives sensation to the auricle. [ 1 ]  It also supplies the  occipitalis muscle . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3880", "text": "The posterior auricular nerve can be tested by contraction of the  occipitalis muscle , and by sensation in the  auricle . [ 1 ]  This testing is rarely performed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3881", "text": "The posterior auricular nerve can be biopsied. [ 3 ]  This can be used to test for  leprosy , which can be important in diagnosis. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3882", "text": "1:  Dorsum sellae  of the  sphenoid bone \n2: Superior borders of the  petrous part of the temporal bone"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3883", "text": "The  posterior cranial fossa  is the part of the  cranial cavity  located between the  foramen magnum , and  tentorium cerebelli . It is formed by the   sphenoid bones ,  temporal bones , and  occipital bone . It lodges the  cerebellum , and parts of the  brainstem ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3884", "text": "The posterior cranial fossa is formed by the  sphenoid bones ,  temporal bones , and  occipital bone . [ 1 ]  It is the most inferior of the  fossae . [ citation needed ]  It houses the  cerebellum ,  medulla oblongata , and  pons . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3885", "text": "Anteriorly, the posterior cranial fossa is bounded by the  dorsum sellae , posterior aspect of the  body of sphenoid bone , and the  basilar part of occipital bone / clivus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3886", "text": "Laterally, it is bounded by the  petrous parts  and  mastoid parts  of the  temporal bones , and the  lateral parts of occipital bone . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3887", "text": "Posteriorly, it is bounded by the  squamous part of occipital bone . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3888", "text": "The foramen magnum is a large opening of the floor of the posterior cranial fossa, its most conspicuous feature. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3889", "text": "Lies in the anterior wall of the posterior cranial fossa. It transmits the facial (VII) and  vestibulocochlear  (VIII)  cranial nerves  into a canal in the  petrous temporal bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3890", "text": "Lies between the inferior edge of the petrous temporal bone and the adjacent  occipital bone  and transmits the  internal jugular vein  (actually begins here), the  glossopharyngeal nerve (CN IX) ,  vagus nerve (CN X) , and  accessory nerve (CN XI) ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3891", "text": "Lies at the anterolateral margins of the  foramen magnum  and transmits the  hypoglossal nerve (CN XII) ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3892", "text": "Also visible in the posterior cranial fossa are depressions caused by the venous sinuses returning blood from the brain to the venous circulation:\nRight and left transverse sinuses which meet at the confluence of sinuses (marked by the internal occipital protuberance)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3893", "text": "The transverse sinuses pass horizontally from the most posterior point of the occiput."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3894", "text": "Where the apex of the petrous temporal meets the squamous temporal, the transverse sinuses lead into sigmoid (S-shaped) sinuses (one on each side)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3895", "text": "These pass along the articulation between the posterior edge of the petrous temporal bone and the anterior edge of the occipital bones to the  jugular foramen , where the  sigmoid sinus  becomes the  internal jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3896", "text": "Note that a superior petrosal sinus enters the junction of the transverse and sigmoid sinuses. Also an inferior petrosal sinus enters the sigmoid sinus near the jugular foramen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3897", "text": "The posterior cranial fossa is formed in the  endocranium , and holds the most basal parts of the  brain ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3898", "text": "An underdeveloped posterior cranial fossa can cause  Arnold\u2013Chiari malformation .  These can be either acquired or congenital disorders. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3899", "text": "The  posterior ethmoidal artery  is an  artery  of the head which arises from the  ophthalmic artery  to supply the  posterior ethmoidal air cells , and the  meninges . [ 1 ]  It is smaller than the  anterior ethmoidal artery . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3900", "text": "The posterior ethmoidal artery is an orbital branch of the  ophthalmic artery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3901", "text": "After branching from the  ophthalmic artery , the posterior ethmoidal artery passes between the upper border of the  medial rectus muscle  and  superior oblique muscle [ citation needed ]  to reach, enter and traverse the  posterior ethmoidal canal . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3902", "text": "Meningeal branch"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3903", "text": "It emits a meningeal branch to the  dura mater  after entering the cranium. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3904", "text": "Nasal branches"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3905", "text": "It emits nasal branches that pass through the  cribriform plate  to reach the nasal cavity. The nasal branches form  anastomoses  with the  sphenopalatine artery . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3906", "text": "This artery supplies the posterior  ethmoidal air sinuses , the dura mater [ 2 ]  of the  anterior cranial fossa , and the upper part of the  nasal mucosa  of the  nasal septum . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3907", "text": "This article incorporates text in the  public domain  from  page 570  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3908", "text": "The  pterion  is the region where the  frontal ,  parietal ,  temporal , and  sphenoid  bones join. [ 1 ]  It is located on the side of the  skull , just behind the  temple . It is also considered to be the weakest part of the skull, which makes it clinically significant, as if there is a  fracture  around the pterion it could be accompanied by an  epidural hematoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3909", "text": "The pterion is located in the  temporal fossa , approximately 2.6\u00a0cm behind and 1.3\u00a0cm above the posterolateral margin of the  frontozygomatic suture . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3910", "text": "It is the junction between four bones:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3911", "text": "These bones are typically joined by five  cranial sutures :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3912", "text": "The pterion is known as the weakest part of the skull. [ 3 ]   The anterior division of the  middle meningeal artery  runs underneath the pterion. [ 4 ]  Consequently, a traumatic blow to the pterion may rupture the middle meningeal artery causing an  epidural haematoma . The pterion may also be fractured indirectly by blows to the top or back of the head that place sufficient force on the skull to fracture the pterion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3913", "text": "The pterion is a structural landmark for  neurosurgical  approach to middle cerebral artery  aneurysms . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3914", "text": "The pterion receives its name from the Greek root  pteron , meaning  wing . In  Greek mythology ,  Hermes , messenger of the gods, was enabled to fly by winged sandals, and wings on his head, which were attached at the pterion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3915", "text": "This article incorporates text in the  public domain  from  page 182  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3916", "text": "The  pterygoid canal  (also  vidian canal ) is a passage in the sphenoid bone of the  skull  leading from just  anterior  to the  foramen lacerum  in the  middle cranial fossa  to the  pterygopalatine fossa . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3917", "text": "It transmits the  nerve of pterygoid canal (Vidian nerve) , the  artery of the pterygoid canal (Vidian artery) , and the vein of the pterygoid canal (Vidian vein)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3918", "text": "The pterygoid canal runs through the  medial pterygoid plate  of the  sphenoid bone  to the back wall of the  pterygopalatine fossa ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3919", "text": "The  pterygoid processes of the sphenoid  (from Greek   pteryx ,  pterygos , \"wing\"), one on either side, descend perpendicularly from the regions where the  body  and the  greater wings  of the  sphenoid bone  unite."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3920", "text": "Each process consists of a  medial pterygoid plate  and a  lateral pterygoid plate , the latter of which serve as the origins of the  medial  and  lateral pterygoid muscles . The medial pterygoid, along with the  masseter  allows the jaw to move in a vertical direction as it contracts and relaxes. The lateral pterygoid allows the jaw to move in a horizontal direction during mastication (chewing). Fracture of either plate are used in clinical medicine to distinguish the  Le Fort fracture classification  for high impact injuries to the  sphenoid  and  maxillary bones ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3921", "text": "The superior portion of the pterygoid processes are fused anteriorly; a vertical groove, the  pterygopalatine fossa , descends on the front of the line of fusion. The plates are separated below by an angular cleft, the  pterygoid notch , the margins of which are rough for articulation with the pyramidal process of the  palatine bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3922", "text": "The two plates diverge behind and enclose between them a V-shaped fossa, the  pterygoid fossa , which contains the  medial pterygoid muscle  and the  tensor veli palatini ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3923", "text": "Above this fossa is a small, oval, shallow depression, the  scaphoid fossa , which gives origin to the tensor veli palatini."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3924", "text": "The anterior surface of the pterygoid process is broad and triangular near its root, where it forms the posterior wall of the pterygopalatine fossa and presents the anterior orifice of the  pterygoid canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3925", "text": "In many mammals it remains as a separate bone called the  pterygoid bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3926", "text": "Its name is Greek for \"resembling a fin or wing\", from its shape."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3927", "text": "The  medial pterygoid plate  (or  medial pterygoid lamina ) of the  sphenoid bone  is a horse-shoe shaped  process  that arises from its underside."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3928", "text": "It is narrower and longer than the  lateral pterygoid plate  and curves lateralward at its lower extremity into a hook-like process, the  pterygoid hamulus , around which the tendon of the  tensor veli palatini  glides."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3929", "text": "The lateral surface of this plate forms part of the  pterygoid fossa , the medial surface constitutes the lateral boundary of the  choana  or posterior aperture of the corresponding nasal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3930", "text": "Superiorly the medial plate is prolonged on to the under surface of the body as a thin lamina, named the vaginal process, which articulates in front with the  sphenoidal process  of the palatine and behind this with the  ala  (wing) of the  vomer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3931", "text": "The angular prominence between the posterior margin of the vaginal process and the medial border of the  scaphoid fossa  is named the  pterygoid tubercle , and immediately above this is the posterior opening of the  pterygoid canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3932", "text": "On the under surface of the vaginal process is a furrow, which is converted into a canal by the sphenoidal process of the  palatine bone , for the transmission of the pharyngeal branch of the  internal maxillary artery  and the pharyngeal nerve from the  sphenopalatine ganglion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3933", "text": "The  pharyngeal aponeurosis  is attached to the entire length of the posterior edge of the medial plate, and the  constrictor pharyngis superior  takes origin from its lower third."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3934", "text": "Projecting backward from near the middle of the posterior edge of this plate is an angular process, the processus tubarius, which supports the pharyngeal end of the Eustachian tube."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3935", "text": "The anterior margin of the plate articulates with the posterior border of the vertical part of the palatine bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3936", "text": "In many animals it is a separate bone called the  pterygoid bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3937", "text": "The  lateral  pterygoid  plate  of the  sphenoid  (or  lateral lamina of pterygoid process ) is broad, thin, and everted and forms the lateral part of a horseshoe like process that extends from the inferior aspect of the sphenoid bone, and serves as the origin of the lateral pterygoid muscle, which functions in allowing the mandible to move in a lateral and medial direction, or from side-to-side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3938", "text": "Its lateral surface forms part of the medial wall of the infratemporal fossa, and gives attachment to the  lateral pterygoid muscle ; its medial surface forms part of the pterygoid fossa, and gives attachment to the  medial pterygoid muscle . Posterior edge is sharp, and often has sharp projection -  pterygospinous process  (Civinini process)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3939", "text": "This article incorporates text in the  public domain  from  page 151  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3940", "text": "The  pterygomandibular space  is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a  potential space  in the head and is paired on each side. It is located between the  medial pterygoid muscle  and the medial surface of the  ramus of the mandible . The pterygomandibular space is one of the four  compartments  of the  masticator space . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3941", "text": "The boundaries of each pterygomandibular space are: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3942", "text": "The communications of each pterygomandibular space are: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3943", "text": "The pterygomandibular space is the area where  local anesthetic  solution is deposited during an  inferior alveolar nerve block , a common procedure used to anesthetize the distribution of the inferior alveolar nerve. Rarely,  pathogenic  micro-organisms from the mouth may be seeded into the pterygomandibular space during this injection and cause a  needle tract infection  of the space. [ 1 ]  It is also occasionally reported that the needle breaks off and is retained in the pterygomandibular space during this injection. [ 3 ]  Minor oral surgery is then required to remove the fractured needle. [ 3 ]  Due to its high vascularity, injections into the pterygomandibular space carry a high risk of  intravascular injection  (injecting into a blood vessel). [ 4 ]  Another possible complication of an inferior alveolar nerve block occurs when the needle is placed too deep, passing through the pterygomandibular space and into the parotid gland behind. Branches of the  facial nerve  (which gives the motor supply to the  muscles of facial expression ) run through the substance of the parotid gland and so this is manifest as a transient  facial palsy . The pterygomandibular space is one of the possible spaces into which a tooth may be displaced into during  dental extraction , e.g. of a maxillary  wisdom tooth . [ 5 ]  A  mandibular fracture  in the angle region may also be the cause of a pterygomandibular space infection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3944", "text": "The signs and symptoms of an isolated pterygomandiublar infection may include  trismus  (difficulty opening the mouth), however there is not usually any externally visible facial swelling. [ 1 ]  Intra-orally, there may be swelling and  erythema  (redness) of the anterior tonsillar pillar (the  Palatoglossal arch ) and deviation of the  uvula  to the unaffected side. [ 1 ]  The airway may be compressed. Treatment is by surgical  incision and drainage , and the incision may be placed inside the mouth or two incisions may be used, one inside the mouth and one outside. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3945", "text": "Odontogenic infections  may spread to involve the pterygomandibular space, and the most common teeth responsible for this are the mandibular second and third molar teeth. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3946", "text": "The  pterygopalatine ganglion  (aka  Meckel's ganglion ,  nasal ganglion , or  sphenopalatine ganglion ) is a  parasympathetic ganglion  in the  pterygopalatine fossa . It is one of four parasympathetic ganglia of the head and neck, (the others being the  submandibular ,  otic , and  ciliary ganglion )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3947", "text": "It is innervated by the  Vidian nerve  (formed by the  greater superficial petrosal nerve  branch of the  facial nerve  and  deep petrosal nerve ) and  maxillary division  of the  trigeminal nerve . Its postsynaptic axons project to the  lacrimal glands  and nasal mucosa. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3948", "text": "The flow of blood to the  nasal mucosa , in particular the venous plexus of the conchae, is regulated by the pterygopalatine ganglion and heats or cools the air in the  nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3949", "text": "The pterygopalatine ganglion (of  Meckel ), the largest of the parasympathetic ganglia associated with the branches of the  maxillary nerve , is deeply placed in the  pterygopalatine fossa , close to the  sphenopalatine foramen . It is triangular or heart-shaped, of a reddish-gray color, and is situated just below the maxillary nerve as it crosses the fossa."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3950", "text": "The pterygopalatine ganglion supplies the  lacrimal gland ,  paranasal sinuses , glands of the mucosa of the  nasal cavity  and  pharynx , the  gingiva , and the mucous membrane and  glands  of the  hard palate . It communicates anteriorly with the  nasopalatine nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3951", "text": "It receives a sensory, a parasympathetic, and a sympathetic root."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3952", "text": "Its sensory root is derived from two  sphenopalatine  branches of the  maxillary nerve  of the  trigeminal nerve ; their fibers, for the most part, pass directly into the  palatine nerves ; a few, however, enter the ganglion, constituting its sensory root."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3953", "text": "Its parasympathetic root is derived from the  nervus intermedius  (a part of the  facial nerve ) through the  greater petrosal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3954", "text": "In the pterygopalatine ganglion, the preganglionic parasympathetic fibers from the greater petrosal branch of the facial nerve synapse with neurons whose postganglionic axons, vasodilator, and secretory fibers are distributed with the deep branches of the  trigeminal nerve  to the mucous membrane of the  nose ,  soft palate ,  tonsils ,  uvula , roof of the mouth, upper lip and gums, and upper part of the  pharynx .  It also sends postganglionic parasympathetic fibers to the  lacrimal nerve  (a branch of the  ophthalmic nerve , also part of the trigeminal nerve) via the  zygomatic nerve , a branch of the  maxillary nerve  (from the trigeminal nerve), which then arrives at the lacrimal gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3955", "text": "The  nasal glands  are innervated with secretomotor fibers from the nasal branches. Likewise, the  palatine glands  are innervated by the  nasopalatine ,  greater palatine nerve  and  lesser palatine nerves . The  pharyngeal nerve  innervates pharyngeal glands. These are all branches of  maxillary nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3956", "text": "The ganglion also consists of sympathetic efferent (postganglionic) fibers from the  superior cervical ganglion .  These fibers, from the superior cervical ganglion, travel through the  carotid plexus , and then through the  deep petrosal nerve . The deep petrosal nerve (carrying postganglionic sympathetics) joins with the  greater petrosal nerve  (carrying preganglionic parasympathetics) to form the  nerve of the pterygoid canal , which passes through the pterygoid canal before entering the ganglion. The stellate ganglion is at the bottom of the cervical sympathetic chain.  Fibers from the stellate ganglion pass up the chain to the superior cervical sympathetic ganglion and into and through the sphenopalatine ganglion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3957", "text": "Blockade of the ganglion with local anesthetic, clinically referred to as a 'sphenopalatine ganglion block' may be performed transcutaneously with a small needle, or topically via the nose with local anesthetic soaked swabs. The topical sphenopalatine ganglion block is used for  treatment of persistent migraines and cluster headaches , demonstrating relief within 10\u201320 minutes. Sphenopalatine ganglion block has been used to treat  post-dural-puncture headache , [ 2 ]  though a 2020 trial comparing local anaesthetic sphenopalatine ganglion block to sham injection with saline failed to show difference in pain scores for those receiving local anaesthetic vs placebo, suggesting any efficacy is unrelated to local anaesthetic blockade. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3958", "text": "Self-administration of sphenopalatine ganglion blocks with cotton-tipped catheters and continual capillary feed is the most cost-effective method of treatment and has the benefit of allowing patients to avoid visits to physicians and emergency rooms.  After initial visit self-administered sphenopalatine ganglion blocks are less than $1.00 per application. Frequent repeated administration of sphenopalatine ganglion blocks seems to increase effectiveness initially, after which decreased frequency is required.  Self-administered sphenopalatine ganglion blocks can be used to treat acute pain symptoms, and prophylactically to reduce the onset of painful conditions and anxiety."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3959", "text": "Self-administered sphenopalatine ganglion blocks are extremely helpful for treatment of migraines, chronic daily headaches, anxiety and temporomandibular joint disorders.  Neuromuscular dentistry and the role of the autonomic nervous system: Sphenopalatine ganglion blocks and neuromodulation. An International College of Cranio Mandibular Orthopedics (ICCMO) position paper  They are also effective in about  1 \u2044 3  of cases of essential hypertension. Bilateral sphenopalatine ganglion block reduces blood pressure in never treated patients with essential hypertension. A randomized controlled single-blinded study"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3960", "text": "The sphenopalatine ganglion block has been called \"The Miracle Block\" after publication of Albert Bengamin Gerber's book  Miracles on Park Avenue , the story of octogenerian otorhinolargyngologist Dr. Milton Reder, whose entire medical practice was based on that procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3961", "text": "There are multiple new devices utilized for neuromodulation of the sphenopalatine ganglion.  There is one non-invasive device, a myomonitor, an ultra low frequency transcutaneous electrical nerve stimulation that has been utilized safely for more than 50 years by neuromuscular dentists in the diagnosis and treatment of temporomandibular joint disorders and orofacial pain conditions.  Spenopalatine ganglion neuromodulation (possibly via the vagal nerve) is a secondary effect making it extremely effective for TMD. Neuromuscular dentistry and the role of the autonomic nervous system: Sphenopalatine ganglion blocks and neuromodulation. An International College of Cranio Mandibular Orthopedics (ICCMO) position paper"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3962", "text": "This article incorporates text in the  public domain  from  page 891  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3963", "text": "Reconstructive surgery  is  surgery  performed to restore normal appearance and function to body parts malformed by a disease or medical condition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3964", "text": "Reconstructive surgery is a term with training, clinical, and reimbursement implications. It has historically been referred to as synonymous with  plastic surgery . [ 1 ]  In regard to training,  plastic surgery  is a recognized medical specialty and a surgeon can be a \"board-certified\" plastic surgeon by the  American Board of Plastic Surgery . [ 2 ]  However, reconstructive surgery is not a specialty and there are no board-certified reconstructive surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3965", "text": "More accurately, reconstructive surgery should be contrasted with  cosmetic surgery . Reconstructive surgery is performed to"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3966", "text": "Separately, the patient must be healthy enough so that the benefits of the procedure outweigh the risks of complications or death. A procedure could be considered reconstructive but not medically necessary due to the risk to the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3967", "text": "In addition, Section 1862(a) (1) (A) of the Social Security Act directs the following:\n\"No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.\" [ 4 ]  Therefore, outside clinical interpretation and carrier guidelines, there is a federal statute that \"improving functionality and restoring appearance\" are covered as reconstructive and medically necessary. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3968", "text": "This definition is contrasted with cosmetic surgery performed to improve aesthetics or the appearance of a body part. [ 6 ]  A plastic surgeon can perform both reconstructive and cosmetic procedures. Some procedures, such as a panniculectomy (aka tummy tuck) can be considered as cosmetic by one insurance company and reconstructive by another. The surgeon may not be using the Medicare or reimbursement criteria when referring to a procedure as reconstructive or cosmetic. Plastic surgeons,  maxillo-facial surgeons  and  otolaryngologists  do reconstructive surgery on faces to correct congenital defects, after trauma and to reconstruct the head and neck after cancer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3969", "text": "Another good example is repair of a cleft palate, or cheiloplasty, which surgically corrects abnormal development, restores function to the lips and mouth and produces a more normal appearance. [ 8 ]  This meets the definition of reconstructive surgery and is mandated by state laws in at least 31 states, but could be denied as cosmetic by individual insurance companies in the remaining  states. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3970", "text": "Other branches of surgery ( e.g. ,  general surgery ,  gynecological surgery ,  pediatric surgery ,  plastic surgery ,  podiatric surgery ) also perform some reconstructive procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3971", "text": "Reconstructive surgery represents a small but critical component of the comprehensive care of cancer patients. Its primary role in the treatment of cancer patients is to extend the ability of other surgeons and specialists to more radically treat cancer, offering patients the best opportunity for cure. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3972", "text": "Reconstructive surgeons use the concept of a  reconstructive ladder  to manage increasingly complex wounds. This ranges from very simple techniques such as primary closure and dressings to more complex skin grafts, tissue expansion, and free flaps. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3973", "text": "Reconstructive surgery procedures include breast implant removal, reduction mammoplasty, breast reconstruction, surgical correction of birth anomalies, congenital nevi surgery, and liposuction for  lipedema . [ 11 ] [ 12 ] \nCosmetic surgery procedures include  breast enhancement , reduction and lift,  face lift ,  forehead lift , upper and lower eyelid surgery ( blepharoplasty ), laser skin resurfacing ( laser resurfacing ),  chemical peel , nose reshaping ( rhinoplasty ), reconstruction  liposuction ,  Nasal reconstruction using a paramedian forehead flap , as well as  tummy tuck  ( abdominoplasty ). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3974", "text": "Recent literature in  medline  also has noted implementation of  barbed suture  in these procedures. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3975", "text": "Biomaterials are, in their simplest form, plastic implants used to correct or replace damaged body parts. Biomaterials were not used for reconstructive purposes until after  World War II  due to the new and improved technology and the tremendous need for the correction of damaged body parts that could replace  transplantation . The process involves scientific and medical research to ensure that the biomaterials are  biocompatible  and that they can assume the mechanical and functioning roles of the components they are replacing. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3976", "text": "A successful implantation can best be achieved by a team that understands not only the  anatomical ,  physiological ,  biochemical , and  pathological  aspects of the problem, but also comprehends  bioengineering . Cellular and tissue engineering is crucial to know for reconstructive procedures. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3977", "text": "An overview of the standardization and control of  biomedical  devices has recently been gathered by D. G. Singleton. Papers have covered in depth the U.S.  Food and Drug Administration  (FDA) Premarket Approval Process (J. L. Ely) and FDA regulations governing Class III devices. Two papers have described how the  National Institute of Standards and Technology ,  American Dental Association ,  National Institute of Dental and Craniofacial Research , and private dental companies have collaborated in a number of important advances in dental materials, devices, and analytical systems. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3978", "text": "Restylane  is the trade name for a range of  injectable fillers  with a specific formulation of  hyaluronic acid  (HA)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3979", "text": "In the  United States , Restylane was the first hyaluronic acid filler to be approved by the  U.S. Food and Drug Administration  (FDA) for cosmetic injection into subdermal facial tissues. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3980", "text": "Restylane is produced by  Galderma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3981", "text": "Restylane is most commonly used for  lip enhancement  (volume and contouring). It is used to diminish  wrinkles  and aging lines of the face such as the  nasolabial folds  (nose to mouth lines) and melomental folds (sad mouth corners).  It may also be used for filling aging-related facial hollows and \"orbital troughs\" (under and around the eyes), as well as for cheek volume and contouring of the chin, lips and nose. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3982", "text": "A treatment with a dermal filler like Restylane can cause some temporary bruising in addition to\nswelling and numbness for a few days. In rare cases there has been reports of lumps or granulomas. These side effects can be easily reversed with a treatment of  hyaluronidase , which is an enzyme that speeds up the natural degradation of the injected hyaluronic acid filler. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3983", "text": "Several studies have been done to understand the long-term side effects of restylane and other hyaluronic acid fillers. [ 4 ]  In certain cases, the filler results in a granulomatous foreign body reaction. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3984", "text": "Even though side effects are rare Restylane should not be used in or near areas where there is or has been skin disease, inflammation or related conditions. Restylane has not been tested in pregnant or breast-feeding women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3985", "text": "Restylane dermal fillers are generally considered safe, there are certain contraindications and safety rules that online licensed providers should be aware of before buying and injecting Restylane fillers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3986", "text": "Contraindications for Restylane dermal fillers:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3987", "text": "Most injectors inject the filler with a small needle under the skin. Numbing creams or injections decrease pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3988", "text": "A new way to use Restylane was described in the August 2007 issue of the  Journal of Drugs in Dermatology  by  Dutch  cosmetic doctor Tom van Eijk, whose \"fern pattern\" injection technique aims to restore dermal elasticity rather than to fill underneath the wrinkles. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3989", "text": "Mimic wrinkles are inextricably linked to the skin and affect the formation of fine wrinkles. Muscles woven into the dermis, contracting, tighten the skin, which provides mimic facial mobility. Their constant movement stretches the skin and leads to its sagging. This drug helps to restore weakened tissue and increase its volume without external damage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3990", "text": "The  retromandibular vein  ( temporomaxillary vein ,  posterior facial vein ) is a major vein of the face. It is formed within the parotid gland by the confluence of the  maxillary vein , and  superficial temporal vein . It descends in the gland and splits into two branches upon emerging from the gland. Its  anterior branch  then joins the  (anterior) facial vein  forming the  common facial vein , while its  posterior branch  joins the  posterior auricular vein  forming the  external jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3991", "text": "The retromandibular vein is formed within the  parotid gland [ 1 ]  by the confluence of the  maxillary vein , and  superficial temporal vein . [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3992", "text": "It descends inside  parotid gland , [ 1 ] [ 4 ]  superficial to the  external carotid artery  (but beneath the  facial nerve ), [ 4 ]  between the  sternocleidomastoideus  muscle and  ramus of mandible . [ citation needed ]  It emerges from the parotid gland inferiorly, then immediately divides into two branches: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3993", "text": "The retromandibular vein provides venous drainage to the superior  cranium , and significant drainage to the  ear . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3994", "text": "Parrot's sign  is a sensation of pain when pressure is applied to the retromandibular region. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3995", "text": "This article incorporates text in the  public domain  from  page 646  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3996", "text": "Retropharyngeal abscess  ( RPA ) is an  abscess  located in the tissues in the back of the throat behind the posterior pharyngeal wall (the  retropharyngeal space ).  Because RPAs typically occur in deep tissue, they are difficult to diagnose by  physical examination  alone. RPA is a relatively uncommon illness, and therefore may not receive early diagnosis in children presenting with  stiff neck ,  malaise ,  difficulty swallowing , or other symptoms listed below. Early diagnosis is key, while a delay in diagnosis and treatment may lead to death.  Parapharyngeal space  communicates with retropharyngeal space and an infection of retropharyngeal space can pass down behind the  esophagus  into the  mediastinum . [ 1 ]  RPAs can also occur in adults of any age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3997", "text": "RPA can lead to  airway obstruction  or  sepsis  \u2013 both life-threatening emergencies. [ 2 ]  Fatalities normally occur from patients not receiving treatment immediately and suffocating prior to knowing that anything serious was wrong."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3998", "text": "Signs and symptoms may include the following  stiff neck  (limited neck mobility or  torticollis ), [ 3 ]  some form of  palpable  neck pain (may be in \"front of the neck\" or around the  Adam's apple ),  malaise , difficulty swallowing,  fever ,  stridor , drooling,  croup -like cough or enlarged cervical  lymph nodes . Any combination of these symptoms should arouse suspicion of RPA. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_3999", "text": "RPA is usually caused by a bacterial infection originating from the  nasopharynx ,  tonsils ,  sinuses ,  adenoids ,  molar teeth  or  middle ear . Any  upper respiratory infection  (URI) can be a cause. RPA can also result from a direct infection due to penetrating injury or a  foreign body . RPA can also be linked to young children who do not have adequate dental care or brush their teeth properly. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4000", "text": "A computed tomography (CT) scan is the definitive diagnostic imaging test. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4001", "text": "X-ray of the neck often (80% of the time) shows swelling of the retropharyngeal space in affected individuals. If the  retropharyngeal space  is more than half of the size of the C2 vertebra, it may indicate retropharyngeal abscess. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4002", "text": "RPA's frequently require surgical intervention. A  tonsillectomy  approach is typically used to access/drain the abscess, and the outcome is usually positive. Surgery in adults may be done without general anesthesia because there is a risk of abscess rupture during tracheal intubation. This could result in  pus  from the abscess aspirated into the lungs. In complex cases, an emergency tracheotomy may be required to prevent upper airway obstruction caused by edema in the neck. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4003", "text": "High-dose intravenous  antibiotics  are required in order to control the infection and reduce the size of the abscess prior to surgery. Chronic retropharyngeal abscess is usually secondary to  tuberculosis  and the patient needs to be started on anti-tubercular therapy as soon as possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4004", "text": "Rhinitis , also known as  coryza , [ 3 ]  is irritation and  inflammation  of the  mucous membrane  inside the  nose . Common symptoms are a  stuffy nose ,  runny nose ,  sneezing , and  post-nasal drip . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4005", "text": "The inflammation is caused by  viruses ,  bacteria , irritants or  allergens . The most common kind of rhinitis is  allergic rhinitis , [ 5 ]  which is usually triggered by airborne  allergens  such as  pollen  and  dander . [ 6 ]  Allergic rhinitis may cause additional symptoms, such as sneezing and nasal itching,  coughing ,  headache , [ 7 ]   fatigue ,  malaise , and  cognitive impairment . [ 8 ] [ 9 ]  The allergens may also affect the eyes, causing watery, reddened, or itchy eyes and puffiness around the eyes. [ 7 ]  The inflammation results in the generation of large amounts of  mucus , commonly producing a runny nose, as well as a stuffy nose and post-nasal drip. In the case of allergic rhinitis, the inflammation is caused by the  degranulation  of  mast cells  in the nose. When mast cells degranulate, they release  histamine  and other chemicals, [ 10 ]  starting an inflammatory process that can cause symptoms outside the nose, such as fatigue and malaise. [ 11 ]  In the case of infectious rhinitis, it may occasionally lead to  pneumonia , either  viral  or  bacterial . Sneezing also occurs in infectious rhinitis to expel bacteria and viruses from the respiratory tract."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4006", "text": "Rhinitis is very common. Allergic rhinitis is more common in some countries than others; in the United States, about 10\u201330% of adults are affected annually. [ 12 ]  Mixed rhinitis (MR) refers to patients with nonallergic rhinitis and allergic rhinitis. MR is a specific rhinitis subtype. It may represent between 50 and 70% of all AR patients. However, true prevalence of MR has not been confirmed yet. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4007", "text": "Rhinitis is categorized into three types (although infectious rhinitis is typically regarded as a separate clinical entity due to its transient nature): (i) infectious rhinitis includes acute and chronic  bacterial infections ; (ii)  nonallergic rhinitis [ 14 ]  includes vasomotor, idiopathic,  hormonal ,  atrophic , occupational, and  gustatory rhinitis , as well as  rhinitis medicamentosa  (rebound congestion); (iii)  allergic rhinitis , triggered by  pollen ,  mold , animal  dander , dust,  Balsam of Peru , and other inhaled allergens. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4008", "text": "Rhinitis is commonly caused by a  viral  or  bacterial  infection, including the common cold, which is caused by  Rhinoviruses ,  Coronaviruses , and  influenza viruses , others caused by  adenoviruses ,  human parainfluenza viruses ,  human respiratory syncytial virus ,  enteroviruses  other than rhinoviruses,  metapneumovirus , and  measles virus , or bacterial  sinusitis , which is commonly caused by  Streptococcus pneumoniae ,  Haemophilus influenzae , and  Moraxella catarrhalis . Symptoms of the common cold include  rhinorrhea , sneezing, sore throat ( pharyngitis ),  cough ,  congestion , and slight  headache . [ 16 ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4009", "text": "Nonallergic rhinitis refers to rhinitis that is not due to an allergy. The category was formerly referred to as vasomotor rhinitis, as the first cause discovered was vasodilation due to an overactive parasympathetic nerve response. As additional causes were identified, additional types of nonallergic rhinitis were recognized. Vasomotor rhinitis is now included among these under the more general classification of nonallergic rhinitis. [ 17 ]  The diagnosis is made upon excluding allergic causes. [ 18 ]  It is an umbrella term of rhinitis of multiple causes, such as occupational (chemical), smoking, gustatory, hormonal, senile (rhinitis of the elderly), atrophic, medication-induced (including rhinitis medicamentosa), local allergic rhinitis, non-allergic rhinitis with eosinophilia syndrome (NARES) and idiopathic (vasomotor or non-allergic, non-infectious perennial allergic rhinitis (NANIPER), or non-infectious non-allergic rhinitis (NINAR). [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4010", "text": "In vasomotor rhinitis, [ 20 ] [ 21 ]  certain nonspecific stimuli, including changes in environment (temperature, humidity,  barometric pressure , or weather), airborne irritants (odors, fumes), dietary factors (spicy food, alcohol), sexual arousal, exercise, [ 22 ]  and emotional factors trigger rhinitis. [ 23 ]  There is still much to be learned about this, but it is thought that these non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling and drainage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4011", "text": "Non-allergic rhinitis can co-exist with allergic rhinitis, and is referred to as \"mixed rhinitis\". [ 24 ]  The pathology of vasomotor rhinitis appears to involve  neurogenic inflammation [ 25 ]  and is as yet not very well understood. The role of transient receptor potential ion channels on the non-neuronal nasal epithelial cells has also been suggested. Overexpression of these receptors have influence the nasal airway hyper-responsiveness to non-allergic irritant environmental stimuli (e.g., extremes of temperature, changes in osmotic or barometric pressure). [ 26 ]  Vasomotor rhinitis appears to be significantly more common in women than men, leading some researchers to believe that  hormone  imbalance plays a role. [ 27 ] [ 28 ]  In general, age of onset occurs after 20 years of age, in contrast to allergic rhinitis which can be developed at any age. Individuals with vasomotor rhinitis typically experience symptoms year-round, though symptoms may be exacerbated in the spring and autumn when rapid weather changes are more common. [ 17 ]  An estimated 17 million United States citizens have vasomotor rhinitis. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4012", "text": "Drinking alcohol may cause rhinitis as well as worsen  asthma  (see  alcohol-induced respiratory reactions ). In certain populations, particularly those of East Asian countries such as Japan, these reactions have a nonallergic basis. [ 29 ]  In other populations, particularly those of European descent, a genetic variant in the gene that metabolizes ethanol to acetaldehyde, ADH1B, is associated with alcohol-induced rhinitis. It is suggested that this variant metabolizes ethanol to acetaldehyde too quickly for further processing by ALDH2 and thereby leads to the accumulation of acetaldehyde and rhinitis symptoms. [ 30 ]  In these cases, alcohol-induced rhinitis may be of the  mixed rhinitis  type and, it seems likely, most cases of alcohol-induced rhinitis in non-Asian populations reflect true allergic response to the non-ethanol and/or contaminants in alcoholic beverages, particularly when these beverages are wines or beers. [ 29 ]  Alcohol-exacerbated rhinitis is more frequent in individuals with a history of rhinitis exacerbated by aspirin. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4013", "text": "Aspirin and other  non-steroidal anti-inflammatory drugs  (NSAIDs), particularly those that inhibit  cyclooxygenase 1  ( COX1 ), can worsen rhinitis and asthma symptoms in individuals with a history of either one of these diseases. [ 32 ]  These exacerbations most often appear due to  NSAID hypersensitivity reactions  rather than NSAID-induced allergic reactions. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4014", "text": "The antihistamine  azelastine , applied as a nasal spray, may be effective for vasomotor rhinitis. [ 34 ]   Fluticasone propionate  or  budesonide  (both are  steroids ) in nostril spray form may also be used for symptomatic treatment. The antihistamine  cyproheptadine  is also effective, probably due to its  antiserotonergic  effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4015", "text": "A systematic review on non-allergic rhinitis reports improvement of overall function after treatment with  capsaicin  (the active component of chili peppers). The quality of evidence is low, however. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4016", "text": "Allergic rhinitis or hay fever may follow when an allergen such as  pollen , dust, or  Balsam of Peru [ 36 ]  is inhaled by an individual with a sensitized immune system, triggering  antibody  production. These antibodies mostly bind to  mast cells , which contain  histamine . When the mast cells are stimulated by an allergen, histamine (and other chemicals) are released. This causes itching, swelling, and mucus production."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4017", "text": "Symptoms vary in severity between individuals. Very sensitive individuals can experience  hives  or other  rashes . Particulate matter in polluted air and chemicals such as  chlorine  and detergents, which can normally be tolerated, can greatly aggravate the condition. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4018", "text": "Characteristic physical findings in individuals who have allergic rhinitis include  conjunctival  swelling and  erythema , eyelid swelling, lower eyelid  venous stasis , lateral crease on the nose, swollen nasal  turbinates , and  middle ear   effusion . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4019", "text": "Even if a person has negative  skin-prick, intradermal  and  blood tests  for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called  local allergic rhinitis . [ 38 ]  Many people who were previously diagnosed with nonallergic rhinitis may actually have local allergic rhinitis. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4020", "text": "A  patch test  may be used to determine if a particular substance is causing the rhinitis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4021", "text": "Rhinitis medicamentosa is a form of drug-induced nonallergic rhinitis which is associated with  nasal congestion  brought on by the use of certain oral medications (primarily  sympathomimetic amine  and  2-imidazoline  derivatives) and  topical decongestants  (e.g.,  oxymetazoline ,  phenylephrine ,  xylometazoline , and  naphazoline   nasal sprays ) that constrict the blood vessels in the lining of the nose. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4022", "text": "Chronic rhinitis is a form of  atrophy  of the mucous membrane and glands of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4023", "text": "Chronic form of dryness of the mucous membranes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4024", "text": "Chronic rhinitis associated with  polyps in the nasal cavity ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4025", "text": "Most prominent pathological changes observed are nasal airway  epithelial  metaplasia  in which  goblet cells  replace  ciliated columnar epithelial cells  in the nasal mucous membrane. [ 26 ]  This results in mucin hypersecretion by goblet cells and decreased mucociliary activity. Nasal secretion are not adequately cleared with clinical manifestation of nasal congestion, sinus pressure, post-nasal dripping, and headache. Over-expression of transient receptor potential  (TRP) ion channels , such as TRPA1 and TRPV1, may be involved in the pathogenesis of non-allergic rhinitis. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4026", "text": "Neurogenic inflammation produced by neuropeptides released from sensory nerve endings to the airways is a proposed common mechanism of association between both allergic and non-allergic rhinitis with asthma. This may explain higher association of rhinitis with asthma developing later in life. [ 42 ]  Environmental irritants acts as modulators of airway inflammation in these contiguous airways. Development of  occupational asthma  is often preceded by occupational rhinitis. Among the causative agents are flours, enzymes used in processing food, latex, isocyanates, welding fumes, epoxy resins, and formaldehyde. Accordingly, prognosis of  occupational asthma  is contingent on early diagnosis and the adoption of protective measures for rhinitis. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4027", "text": "The different forms of rhinitis are essentially diagnosed clinically. [ clarification needed ]  Vasomotor rhinitis is differentiated from viral and bacterial infections by the lack of purulent exudate and crusting. It can be differentiated from allergic rhinitis because of the absence of an identifiable allergen. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4028", "text": "Evidence has been published from a few health  apps for mobile devices  that show potential to assist in the diagnosis of rhinitis and rhinosinusitis and to evaluate management and treatment adherence. While this shows promise for clinical management, as of 2022 [update]  few had been validated in the scientific literature, and even fewer included considerations for  multimorbidity . [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4029", "text": "The management of rhinitis depends on the underlying cause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4030", "text": "For allergic rhinitis, intranasal  corticosteroids  are recommended. [ 47 ]  For severe symptoms intranasal  antihistamines  may be added. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4031", "text": "Rhinitis is pronounced  / r a\u026a \u02c8 n a\u026a t \u026a s / , [ 48 ]  while coryza is pronounced  / k \u0259 \u02c8 r a\u026a z \u0259 / . [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4032", "text": "Rhinitis  comes from the  Ancient Greek   \u1fe5\u03af\u03c2   rhis ,  gen .:  \u1fe5\u03b9\u03bd\u03cc\u03c2   rhinos , \"nose\".  Coryza  comes through Latin from Ancient Greek  \u03ba\u03cc\u03c1\u03c5\u03b6\u03b1 . According to physician Andrew Wylie, \"we use the term [ coryza ] for a cold in the head, but the two are really synonymous. The  ancient Romans  advised their patients to clean their nostrils and thereby sharpen their wits.\" [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4033", "text": "A  facelift , technically known as a  rhytidectomy  (from the  Ancient Greek   \u1fe5\u03c5\u03c4\u03af\u03c2  ( rhytis ) 'wrinkle', and  \u1f10\u03ba\u03c4\u03bf\u03bc\u03ae  ( ektome ) 'excision', the surgical removal of wrinkles), is a type of  cosmetic surgery  procedure intended to give a more youthful facial appearance. There are multiple surgical techniques and exercise routines. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the  skin  on the  patient 's  face  and  neck . Exercise routines tone underlying facial muscles without surgery. Surgical facelifts are effectively combined with eyelid surgery ( blepharoplasty ) and other facial procedures and are typically performed under general anesthesia or deep  twilight sleep ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4034", "text": "According to the most recent American Society for Aesthetic Plastic Surgery facelifts were the third most popular aesthetic surgery in 2019, surpassed only by  rhinoplasty  and  blepharoplasty . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4035", "text": "Cost varies by country where surgery is performed. Prices were quoted ranging from US$2,500 ( India  and  Panama ) to US$15,000 ( United States  and  Canada ) as of 2008 [update] . [ 2 ]  Costs in Europe mostly ranged \u00a34,000\u2013\u00a39,000 as of 2009 [update] . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4036", "text": "In the first 70 years of the 20th century, facelifts were performed by pulling on the skin on the face and cutting the loose parts off. The first facelift was reportedly performed by  Eugen Holl\u00e4nder  in 1901 in  Berlin . [ 4 ]  An elderly Polish female aristocrat asked him to:  \"lift her cheeks and corners of the mouth\". After much debate, he finally proceeded to excise an elliptical piece of skin around the ears. The first textbook about facial cosmetic surgery (1907) was written by  Charles Miller  (Chicago) entitled  The Correction of Featural Imperfections . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4037", "text": "In the First World War (1914\u20131918), the Dutch surgeon  Johannes Esser  made one of the most famous discoveries in the field of plastic surgery to date, namely the \" skin graft inlay technique ,\" [ 6 ]  the technique was soon used on both English and German sides in the war. At the same time, the British plastic surgeon  Harold Delfs Gillies  used the Esser-graft to school all those who flocked towards him who wanted to study under him. That's how he earned the name \"Father of 20th Century Plastic Surgery\". In 1919, Dr Passot was known to publish one of the first papers on face-lifting, this consisted mainly of the elevating and redraping of the facial skin. After this, many others began to write papers on face-lifting in the 1920s. From then, the esthetic surgery was being performed on a large scale, form the basis of the reconstructive surgery. The first female plastic surgeon,  Suzanne No\u00ebl , played a large role in its development and she wrote one of the first books about esthetic surgery named  Chirurgie Esthetique, son r\u00f4le social . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4038", "text": "In 1968,  Tord Skoog  introduced the concept of subfacial dissection, therefore providing suspension of the stronger deeper layer rather than relying on skin tension to achieve his facelift (he publishes his technique in 1974, with subfacial dissection of the  platysma  without detaching the skin in a posterior direction). [ 7 ]  In 1976, Mitz and Peyronie described the anatomical Superficial Musculoaponeurotic System, or SMAS, [ 8 ]  a term coined by  Paul Tessier , Mitz and Peyronie's tutor in  craniofacial surgery , after he had become familiar with Skoog's technique. After Skoog died of a heart attack, the  superficial muscular aponeurotic system  (SMAS) concept rapidly emerged to become the standard face-lifting technique, which was the first innovative change in facelift surgery in over 50 years. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4039", "text": "Tessier, who had his background in the craniofacial surgery, made the step to a  subperiosteal   dissection  via a coronal incision. [ 10 ]  In 1979, Tessier demonstrated that the subperiosteal undermining of the superior and lateral orbital rims allowed the elevation of the soft tissue and eyebrows with better results than the classic face-lifting. The objective was to elevate the soft tissue over the underlying skeleton to re-establish the patient's youthful appearance. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4040", "text": "At the start of this period in the history of the facelift, there was a change in conceptual thinking, surgeons started to care more about minimizing scars, restoring the  subcutaneous  volume that was lost during the ageing process and they started making use of a  cranial  direction of the \"lift\" instead of posterior. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4041", "text": "The technique for performing a facelift went from simply pulling on the skin and sewing it back to aggressive SMAS and deep plane surgeries to a more refined facelift where variable options are considered to have an aesthetically good and a more long-lasting effect. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4042", "text": "A facelift is performed to  rejuvenate  the appearance of the face. Aging of the face is most shown by a change in position of the deep anatomical structures, notably the  platysma muscle , cheek fat and the  orbicularis oculi muscle . [ 11 ]   These lead up to three landmarks namely, an appearance of the jowl (a broken jaw line by  ptosis  of the platysma muscle), increased redundancy of the  nasolabial fold  (caused by a descent of cheek fat) and the increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle (caused by decreasing tone of the orbicularis oculi muscle). [ 11 ]   The skin is a fourth component in the aging of the face. The ideal age for face-lifting is at age 50 or younger, as measured by patient satisfaction. [ 12 ] [ 13 ] [ 14 ]  Some areas, such as the nasolabial folds or  marionette lines , in some cases can be treated more suitably with  Botox  or  liposculpture . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4043", "text": "Contraindications to facelift surgery include severe  concomitant  medical problems, both physical and psychological. While not absolute contraindications, the risk of postoperative complications is increased in cigarette smokers and patients with hypertension and diabetes. [ 15 ]  These strong relative contraindications consist primarily of diseases predisposing to poor wound healing. Patients are typically asked to abstain from taking aspirin or other blood thinners for at least one week prior to surgery. Patients motivations and expectations are an important factor in order to determine the patient's medical status. A psychiatric illness leading to unreasonable expectations for the surgical outcome, such as a distorted perception of reality, can be a contraindication to surgery. Some kinds of  hypersensitivity  to  anesthesia  are a contraindication. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4044", "text": "Many different procedures are used for rhytidectomy. [ 20 ]  The differences are mostly the type of incision, the invasiveness and the area of the face that is treated. Each surgeon practices multiple different types of facelift surgery. At a consultation the procedure with the best outcome is chosen for every patient. Expectations of the patient, the age, possible recovery time and areas to improve are some of the many factors taken in consideration before choosing a technique of rhytidectomy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4045", "text": "In the traditional facelift, an incision is made in front of the ear extending up into the hairline. The incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. After the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors (also called undermining) over the cheeks and neck. At this point, the deeper tissues (SMAS, the fascial suspension system of the face) can be tightened with sutures, with or without removing some of the excess deeper tissues. The skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgement and experience. The excess skin is then removed, and the skin incisions are closed with  sutures  and  staples ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4046", "text": "The SMAS (Superficial Musculo Aponeurotic System) layer consists of suspensory ligaments that encase the cheek fat, thereby causing them to remain in their normal position. This procedure is often performed in tandem with blepharoplasty as an ancillary procedure. [ 21 ] [ 22 ]  Resuspension and securing the SMAS anatomical layer can lead to rejuvenation of the face, by counteracting aging and gravity caused  laxity . [ 22 ]  Modifications to this technique led to development of the \"Composite Facelift\" and \"Deep plane Facelift.\" [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4047", "text": "In order to correct the deepening of the nasolabial fold more accurately, the deep plane facelift was developed. Differing from the SMAS lift by freeing cheek fat and some muscles from their bone implement. This technique has a higher risk at damaging the facial nerve. The SMAS lift is an effective procedure to reposition the platysma muscle; however, the nasolabial fold is according to some surgeons better addressed by a deep plane facelift or composite facelift."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4048", "text": "As well as in the deep plane facelift, in the composite facelift a deeper layer of tissue is mobilised and repositioned. The difference between these operating techniques is the extra repositioning and fixation of the orbicularis oculi muscle in the composite facelift procedure. The malar crescent caused by the orbicularis oculi ptosis can be addressed in a composite facelift. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4049", "text": "The mid face area, the area between the cheeks, flattens and makes a woman's face look slightly more masculine. The mid face-lift is suggested to people where these changes occur, yet without a significant degree of  jowling  or sagging of the neck. In these cases a mid face-lift is sufficient to rejuvenate the face opposed to a full facelift, which is a more drastic surgery.\nThe ideal candidates for a mid face-lift is when a person is in his 40s, or if the cheeks appear to be sagging and the nasolabial area has laxity or skin folds.\nTo achieve a younger appearance the surgeon makes several small incisions along the hairline and inside the mouth, this way the fatty tissue layers can be lifted and repositioned. This way there are practically no scars. The fatty layer that lies over the cheekbones is also lifted and repositioned. This improves the nose-to-mouth lines and the roundness over the cheekbones. The recovery time is rather short and this procedure is often combined with a blepharoplasty (eyelid surgery)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4050", "text": "The mini-facelift is the least invasive type of facelift which is similar to a full facelift, the only difference is the omission of the  neck lift  in the mini lift procedure. It is also called the \u2018S\u2019 lift because of the shape of the incision that is used or the \u2018short-scar\u2019 facelift. This lift is a more temporary solution to the ageing of the face which also has less downtime and is done on people who have deep nasolabial folds, sagging facial structures, yet still have a firm and well-contoured neck. The position of the incision is usually made from the hairline around the ear with scars hidden in the natural crease of the skin. The mini lift can be performed with an  endoscope , which is used to reposition the soft tissues. After this, the skin is repositioned by the surgeon with small sutures. [ 24 ]  This type of lift is a good alternative to the full facelift to people with premature ageing. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4051", "text": "The subperiosteal facelift technique is done by vertically lifting the soft tissues of the face, completely separating it from the underlying facial bones and elevating it to a more esthetically pleasing position, correcting deep nasolabial folds and sagging cheeks. The technique is often combined with standard techniques, which provide a long-lasting rejuvenation of the face and is done in all age groups. The difference between this and other lifts is that the subperiosteal facelift has a longer period of facial swelling after the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4052", "text": "With the skin-only facelift only the skin of the face is lifted and not the underlying SMAS, muscles or other structures. As the elastin fibers disintegrate, the skin itself loses elasticity in older patients. A skin only face lift requires skill in understanding the extent of safe removal of skin and the Vector of pull to get an optimal result. It can be done with a simple ellipse of skin removed with minimal undermining of skin flaps or more extensively with large skin flaps. It can last 5 to 10 years but some patients may want a touch-up at  6 to 12 months after the procedure. The reason that this option is considered is that it has fewer complications and quicker recovery. One of the father's of plastic surgery Sir Harold Gilles described a simple ellipse of skin excision in a socialite who was pleased with her quick recovery and outcome. Can be done for a simple jowl lift in a 35 to 45-year-old patient. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4053", "text": "A technique called thread lift or non-surgical face lift simplifies the operation. Silicone threads with barbs are used to pull the face and neck skin upwards without the need of skin excision. These are non-absorbable threads and combination of these threads with other methods of facial rejuvenation reveals even better results. [ 25 ]  One such procedure is thread-lift with anti- ptosis  (APTOS) sutures. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4054", "text": "In the UK aesthetic practitioners\u2014who administer thread lifts and other treatments\u2014are not required to have any mandatory qualifications, although some treatments can cause serious complications. In  Liverpool  the  BBC  found 26 cosmetic training academies offering courses ranging in price from \u00a3150 to \u00a35,000 in 2021, lasting from a couple of hours  online  to a couple of days of face-to-face training. A professionally trained cosmetic doctor, Vincent Wong, said that a thread lift is the most dangerous procedure an aesthetic practitioner can do. A great many things can go wrong, more so than any injectable treatment, because threads stay in the skin and cannot be pulled out; while the results can be very good, the procedure can also cause irreversible damage. The professional training of Wong\u2014already a physician with a degree in surgery\u2014in this procedure involved four courses over three months. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4055", "text": "A nurse sent undercover by the BBC to take and secretly film a course teaching thread lifting was shocked at the unprofessionalism and unsafe practices she was taught. While exceptional sterility is required to avoid possible long-term infection, there was no attempt to control infection. The tutor touched various objects and then the patient's face, and the procedure was carried out on a chair instead of a clean bed. Several blood vessels were accidentally punctured, and the patient was clearly in severe pain. Patients drank alcohol before the treatment and  vaped  during it. Ashton Collins, the director of Save Face,  a national register of accredited medical practitioners that provide non-surgical cosmetic treatments, said that \"there's no doubt that if people following that course go on to do treatments [it] will cause a lot of complications\". [ 27 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4056", "text": "The term MACS-lift \u2013 or Minimal Access Cranial Suspension lift \u2013 allows for the correction of sagging facial features through a short, minimal incision, elevating them vertically by suspending them from above. There are many advantages to having a MACS facelift versus a traditional facelift. For starters, the MACS-lift uses a shorter scar that is in front of the ear, instead of behind, which is much easier to hide. Overall, the MACS-lift surgery is safer because less skin is raised. This means that there is less risk of bleeding and nerve damage. The operation also takes less time, lasting 2.5 hours instead of the 3.5 hours that the traditional facelift requires. There is also a shorter recovery period, 2\u20133 weeks instead of 3\u20134 weeks. Finally, the results of the MACS-lift are very natural while the traditional facelift will often result in a \"windswept\" look. The MACS lift has been successfully used for to correct complication after thread-lift with APTOS. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4057", "text": "The most common complication is bleeding which usually requires a return to the operating room. Less common, but potentially serious, complications may include damage to the facial nerves and necrosis of the skin flaps or  infection . Although the facial plastic surgeon attempts to prevent and minimise the risk of complications, a rhytidectomy can have complications. As a risk to every operation, complications can be derived as a reaction to the anesthetics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4058", "text": "Hematoma  is the most seen complication after rhytidectomy. [ 17 ] [ 18 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ]  Arterial bleeding can cause the most dangerous hematomas, as they can lead to  dyspnea . Almost all of the hematomas occur within the first 24 hours after the rhytidectomy. [ 17 ] [ 18 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4059", "text": "Nerve injury  can be sustained during rhytidectomy. This kind of injury can be temporary or permanent and harm can be done to either  sensory  or  motor  nerves of the face. As a sensory nerve, the  great auricular nerve  is the most common nerve to get injured at a facelift procedure. [ 18 ] [ 28 ]  The most injured motor nerve is the facial nerve. [ 18 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4060", "text": "Skin necrosis can occur after a facelift operation.  Smoking  increases the risk of skin necrosis 12-fold. [ 15 ]  Scarring is considered a complication of facelift surgery.  Hypertrophic  scars can appear. A facelift requires skin incisions; however, the incisions in front of and behind the ear are usually inconspicuous."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4061", "text": "Hair loss  in the portions of the incision within the hair-bearing scalp can rarely occur. A distortion of the hairline\u2014and facial hair in men\u2014can result after a rhytidectomy. There is a high incidence of  alopecia  after rhytidectomy. [ 34 ] [ 35 ]  The permanent hair loss is mostly seen at the incision site in the temporal areas. In men, the sideburns can be pulled backwards and upwards, resulting in an unnatural appearance if appropriate techniques are not employed to address this issue. Achieving a natural appearance following surgery in men can be more challenging due to their hair-bearing preauricular skin.\nIn both men and women, one of the signs of having had a facelift can be an earlobe which is pulled forwards and/or distorted. If too much skin is removed, or a more vertical vector not employed, the face can assume a pulled-back, \"windswept\" appearance. This appearance can also be due to changes in bone structure that generally happen with age.[2]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4062", "text": "One of the most often overlooked (or not discussed) areas of a traditional facelift procedure is the effects on the anatomical positioning and angles of the ears. Most patients are, in many cases, not made aware that the vector forces in a facelift will lower the ears as well as change the angle of the ears. Ear lowering can be as much as 1\u00a0cm and change in the angle as much as 10 degrees."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4063", "text": "Infection is a rare complication for patients who have undergone a rhytidectomy. [ 36 ]  Staphylococcus is the most usual causative organism for an infection after facelift surgery. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4064", "text": "The  salivatory nuclei  are two  general visceral efferent   nuclei  located in the caudal  pons , dorsal and lateral to the  facial nucleus . Their neurons give rise to  preganglionic   parasympathetic  nerve fibers in the control of  salivation . [ 1 ] [ 2 ]  The superior salivatory nucleus supplies fibers to the  intermediate nerve  (part of the  facial nerve  (CN VII). The inferior salivatory nucleus supplies fibers to the  glossopharyngeal nerve  (CN IX). [ 2 ]  The nuclei may also be involved in parasympathetic control of (extracranial and intracranial) head vasculature. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4065", "text": "The  superior salivatory nucleus  (or  nucleus salivatorius superior ) is a visceral motor  cranial nerve nucleus  of the  facial nerve (CN VII) . It is located in the  pontine tegmentum . [ citation needed ]  It projects  pre-ganglionic  visceral motor parasympathetic efferents (via  CN VII ) to the  pterygopalatine ganglion , and  submandibular ganglion . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4066", "text": "The term \"lacrimal nucleus\" is sometimes used to refer to a portion of the superior salivatory nucleus. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4067", "text": "Preganglionic  fibers en route to the pterygopalatine ganglion (destined to ultimately innervate the lacrimal gland and the mucosal glands of the nose, palate, and pharynx) subsequently form the  greater petrosal nerve , whereas those en route to the submandibular ganglion (destined to ultimately innervate the  submandibular  and  sublingual   salivary glands ) subsequently form the  chorda tympani . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4068", "text": "The nucleus receives cortical stimuli from the  nucleus of solitary tract  via the  dorsal longitudinal fasciculus  and reflex connections. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4069", "text": "The  inferior salivatory nucleus  (or  nucleus salivatorius inferior ) is a cluster of  neurons  in the  medulla . It is the  general visceral efferent  (GVE) component of the  glossopharyngeal nerve  supplying the  parasympathetic  input to the  parotid gland  for  salivation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4070", "text": "It lies immediately caudal to the  superior salivatory nucleus  and just above the upper end of the  dorsal nucleus of the vagus nerve  in the medulla."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4071", "text": "The preganglionic  parasympathetic  fibres originate in the inferior salivatory nucleus of the  glossopharyngeal nerve . They leave the glossopharyngeal nerve by its  tympanic  branch and then pass via the  tympanic plexus  and the  lesser petrosal nerve  to the  otic ganglion . Here, the fibres synapse, and the postganglionic fibers pass by communicating branches to the  auriculotemporal nerve , which conveys them to the  parotid gland . They produce vasodilator and secretomotor effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4072", "text": "Parasympathetic input from fibers of the inferior salivatory nucleus stimulates the parotid gland to produce  vasodilation  and secrete  saliva ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4073", "text": "The  semicircular canals  are three  semicircular  interconnected tubes located in the innermost part of each  ear , the  inner ear . The three canals are the lateral, anterior and posterior semicircular canals. They are the part of the  bony labyrinth , a  periosteum -lined cavity on the  petrous part  of the  temporal bone  filled with  perilymph ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4074", "text": "Each semicircular canal contains its respective  semicircular duct , i.e. the lateral, anterior and posterior semicircular ducts, which provide the  sensation  of  angular acceleration  and are part of the  membranous labyrinth \u2014therefore filled with  endolymph ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4075", "text": "The semicircular canals are a component of the  bony labyrinth  that are at right angles from each other and contain their respective semicircular duct. At one end of each of the semicircular ducts is a dilated sac called a  membranous ampulla , which is more than twice the diameter of the ducts. Each ampulla contains an ampullary crest, the  crista ampullaris  which consists of a thick gelatinous cap called a  cupula  and many  hair cells . The superior and posterior semicircular ducts are oriented vertically at right angles to each other. The lateral semicircular duct is about a 30-degree angle from the horizontal plane. The orientations of the ducts cause a different duct to be stimulated by movement of the head in different planes, and more than one duct is stimulated at once if the movement is off those planes. The lateral semicircular duct detects angular acceleration of the head when the head is turned and the anterior and posterior semicircular ducts detect vertical head movements when the head is moved up or down. [ 1 ]  When the head changes position, the  endolymph  in the ducts lags behind due to inertia and this acts on the cupula which bends the cilia of the hair cells. The stimulation of the hair cells sends the message to the brain that acceleration is taking place. The semicircular canals open into the vestibule by five orifices, one of the apertures being common to two of them."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4076", "text": "Among species of mammals, the size of the semicircular canals is correlated with their type of locomotion. Specifically, species that are agile and have fast, jerky locomotion have larger canals relative to their body size than those that move more cautiously. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4077", "text": "The  lateral semicircular canal  (also known as  horizontal  or  external semicircular canal ) is the shortest of the three canals. Movement of fluid within its duct corresponds to rotation of the head around a vertical axis (i.e. the neck), or in other words, rotation in the  transverse plane . This occurs, for example, when one turns the head from side to side (yaw axis)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4078", "text": "It measures from 12 to 15\u00a0mm (0.47 to 0.59\u00a0in), and its arch is directed horizontally backward and laterally; thus each semicircular canal stands at right angles to the other two. Its ampullated end corresponds to the upper and lateral angle of the  vestibule , just above the  oval window , where it opens close to the ampullated end of the anterior semicircular canal; its opposite end opens at the upper and back part of the vestibule. The lateral canal of one ear is very nearly in the same plane as that of the other."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4079", "text": "The  anterior semicircular canal  (also known as  superior semicircular canal ) contains the part of the  vestibular system  that detects rotations of the head in around the lateral axis, that is, rotation in the  sagittal plane . This occurs, for example, when nodding one's head (pitch axis)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4080", "text": "It is 15 to 20\u00a0mm (0.59 to 0.79\u00a0in) in length, is vertical in direction, and is placed transversely to the long axis of the  petrous part  of the  temporal bone , on the anterior surface of which its arch forms a round projection. It describes about two-thirds of a circle. Its lateral extremity is ampullated, and opens into the upper part of the vestibule; the opposite end joins with the upper part of the posterior semicircular canal to form the  crus osseum commune , which opens into the upper and medial part of the vestibule."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4081", "text": "The  posterior semicircular canal  contains the part of the vestibular system that detects rotation of the head around the antero-posterior (sagittal) axis, or in other words, rotation in the  coronal plane . This occurs, for example, when one moves the head to touch the shoulders, or when doing a  cartwheel  (roll axis)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4082", "text": "It is directed superiorly and posteriorly, as per its nomenclature, nearly parallel to the posterior surface of the petrous part of the temporal bone. The  vestibular aqueduct  is immediately medial to it. The posterior semicircular canal is part of the bony labyrinth and its duct is used by the vestibular system to detect rotations of the head in the coronal plane. It is the longest of the three semicircular canals, measuring from 18 to 22\u00a0mm (0.71 to 0.87\u00a0in). Its lower or ampullated end opens into the lower and back part of the vestibule, its upper into the  crus osseum commune ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4083", "text": "Findings from a 2009 study demonstrated a critical late role for  bone morphogenetic protein 2  (BMP-2) in the morphogenesis of semicircular canals in the  zebrafish  inner ear. It is suspected that the role of BMP-2 in semicircular canal duct outgrowth is likely to be conserved between different  vertebrate  species. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4084", "text": "Additionally, it has been found that the two semicircular canals found in the  lamprey  inner ear are developmentally similar to the superior and posterior canals found in humans, as the canals of both organisms arise from two depressions in the  otic vesicle  during early development. These depressions first form in lampreys between the 11 and 42 millimeter larval stages and form in zebrafish 57 hours post-fertilization   [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4085", "text": "The semicircular ducts provide sensory input for experiences of rotary movements. They are oriented along the  pitch, roll, and yaw axes . The lateral semicircular canal is oriented in the yaw axis, the anterior semicircular canal is oriented in the pitch axis, and the posterior semicircular canal is oriented in the roll axis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4086", "text": "Each duct is filled with a fluid called  endolymph  and contains motion sensors within the fluids. The base of each duct is enlarged, opening into the  utricle , and has a dilated sac at one end called the membranous ampulla. Within the ampulla is a mound of hair cells and supporting cells called  crista ampullaris . These hair cells have many cytoplasmic projections on the apical surface called  stereocilia  which are embedded in a gelatinous structure called the  cupula . As the head rotates, the duct moves, but the endolymph lags behind owing to  inertia . This deflects the cupula and bends the stereocilia within. The bending of these stereocilia alters an electric signal that is transmitted to the brain. Within approximately 10 seconds of achieving constant motion, the endolymph catches up with the movement of the duct and the cupula is no longer affected, stopping the sensation of acceleration. [ 1 ]  The specific gravity of the cupula is comparable to that of the surrounding endolymph. Consequently, the cupula is not displaced by gravity, unlike the  otolithic membranes  of the utricle and  saccule . As with macular hair cells, hair cells of the crista ampullaris will depolarise when the stereocilia deflect towards the  kinocilium . Deflection in the opposite direction results in hyperpolarisation and inhibition. In the lateral semicircular duct, ampullopetal flow is necessary for hair-cell stimulation, whereas ampullofugal flow is necessary for the anterior and posterior semicircular ducts. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4087", "text": "This adjustment period is in part the cause of an illusion known as \" the leans \" often experienced by pilots. As a pilot enters a turn, hair cells in the semicircular ducts are stimulated, telling the brain that the aircraft, and the pilot, are no longer moving in a straight line but rather making a banked turn. If the pilot were to sustain a constant rate turn, the endolymph would eventually catch up with the ducts and cease to deflect the cupula. The pilot would no longer feel as if the aircraft was in a turn. As the pilot exits the turn, the semicircular ducts are stimulated to make the pilot think that they are now turning in the opposite direction rather than flying straight and level. In response to this, the pilot will often lean in the direction of the original turn in an attempt to compensate for this illusion. A more serious form of this is called a  graveyard spiral . Rather than the pilot leaning in the direction of the original turn, they may actually re-enter the turn. As the endolymph stabilizes, the semicircular ducts stop registering the gradual turn and the aircraft slowly loses altitude until impact with the ground.  [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4088", "text": "Jean Pierre Flourens , by destroying the horizontal semicircular canal of  pigeons , noted that they continue to fly in a circle, showing the purpose of the semicircular canals. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4089", "text": "This article incorporates text in the  public domain  from  page 1049  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4090", "text": "The  sense of smell , or  olfaction , [ nb 1 ]  is the  special sense  through which smells (or  odors ) are perceived. [ 2 ]  The sense of smell has many functions, including detecting desirable foods, hazards, and  pheromones , and plays a role in  taste ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4091", "text": "In humans, it occurs when an  odor  binds to a  receptor  within the  nasal cavity , transmitting a signal through the  olfactory system . [ 3 ]   Glomeruli  aggregate signals from these receptors and transmit them to the  olfactory bulb , where the sensory input will start to interact with parts of the brain responsible for smell identification,  memory , and  emotion . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4092", "text": "There are many different things which can interfere with a normal sense of smell, including damage to the  nose  or smell receptors,  anosmia ,  upper respiratory infections ,  traumatic brain injury , and  neurodegenerative disease . [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4093", "text": "Early scientific study of the sense of smell includes the extensive doctoral dissertation of  Eleanor Gamble , published in 1898, which compared olfactory to other  stimulus modalities , and implied that smell had a lower intensity discrimination. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4094", "text": "As the Epicurean and atomistic Roman philosopher  Lucretius  (1st \u00a0 century BCE) speculated, different odors are attributed to different shapes and sizes of \"atoms\" (odor molecules in the modern understanding) that stimulate the olfactory organ. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4095", "text": "A modern demonstration of that theory was the cloning of olfactory receptor proteins by  Linda B. Buck  and  Richard Axel  (who were awarded the  Nobel Prize  in 2004), and subsequent pairing of odor molecules to specific receptor proteins. [ 9 ]  Each odor receptor molecule recognizes only a particular molecular feature or class of odor molecules.  Mammals  have about a thousand  genes  that code for  odor reception . [ 10 ]  Of the genes that code for odor receptors, only a portion are functional. Humans have far fewer active odor receptor genes than other primates and other mammals. [ 11 ]  In mammals, each  olfactory receptor neuron  expresses only one functional odor receptor. [ 12 ]  Odor receptor nerve cells function like a key\u2013lock system: if the airborne molecules of a certain chemical can fit into the lock, the nerve cell will respond."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4096", "text": "There are, at present, a number of competing theories regarding the mechanism of odor coding and perception. According to the  shape theory , each receptor detects a feature of the odor  molecule . The weak-shape theory, known as the  odotope theory , suggests that different receptors detect only small pieces of molecules, and these minimal inputs are combined to form a larger olfactory perception (similar to the way visual perception is built up of smaller, information-poor sensations, combined and refined to create a detailed overall perception). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4097", "text": "According to a new study, researchers have found that a functional relationship exists between molecular volume of odorants and the olfactory neural response. [ 14 ]  An alternative theory, the  vibration theory  proposed by  Luca Turin , [ 15 ] [ 16 ]  posits that odor receptors detect the frequencies of vibrations of odor molecules in the infrared range by  quantum tunnelling . However, the behavioral predictions of this theory have been called into question. [ 17 ]  There is no theory yet that explains olfactory perception completely."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4098", "text": "Flavor perception is an aggregation of  auditory ,  taste ,  haptic , and smell sensory information. [ 18 ]   Retronasal smell  plays the biggest role in the sensation of flavor. During the process of  mastication , the tongue manipulates food to release odorants. These odorants enter the nasal cavity during exhalation. [ 19 ]  The smell of food has the sensation of being in the mouth because of co-activation of the motor cortex and olfactory epithelium during mastication. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4099", "text": "Smell,  taste , and  trigeminal  receptors (also called  chemesthesis ) together contribute to  flavor . The human  tongue  can distinguish only among five distinct qualities of taste, while the nose can distinguish among hundreds of substances, even in minute quantities. It is during  exhalation  that the smell's contribution to flavor occurs, in contrast to that of proper smell, which occurs during the  inhalation  phase of breathing. [ 19 ]  The olfactory system is the only human sense that bypasses the  thalamus  and connects directly to the  forebrain . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4100", "text": "Smell and  sound  information has been shown to converge in the olfactory tubercles of  rodents . [ 21 ]  This neural convergence is proposed to give rise to a perception termed  smound . [ 22 ]  Whereas a  flavor  results from interactions between smell and taste, a smound may result from interactions between smell and sound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4101", "text": "The  MHC  genes (known as  HLA  in humans) are a group of genes present in many animals and important for the  immune system ; in general, offspring from parents with differing MHC genes have a stronger immune system. Fish, mice, and female humans are able to smell some aspect of the MHC genes of potential sex partners and prefer partners with MHC genes different from their own. [ 23 ] [ 24 ]  However, some research suggests that taking  hormonal contraception  can alter women's preference for partners with dissimilar MHC genes, thus resulting in a greater likelihood to choose partners with relatively similar MHC genes to their own. [ 25 ] [ 26 ]  Sexual orientation can also influence preference for different body odors, and some studies suggest that preference may be influenced by the putative pheromones  AND  and  EST . [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4102", "text": "Humans can detect blood relatives from olfaction. [ 28 ]  Mothers can identify by body odor their biological children but not their stepchildren. Pre-adolescent children can olfactorily detect their full siblings but not half-siblings or step siblings, and this might explain  incest avoidance  and the  Westermarck effect . [ 29 ]  Functional imaging shows that this olfactory kinship detection process involves the frontal-temporal junction, the  insula , and the dorsomedial  prefrontal cortex , but not the primary or secondary olfactory cortices, or the related  piriform cortex  or  orbitofrontal cortex . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4103", "text": "Since  inbreeding  is detrimental, it tends to be avoided. In the house mouse, the  major urinary protein  (MUP) gene cluster provides a highly polymorphic scent signal of genetic identity that appears to underlie  kin recognition  and inbreeding avoidance. Thus, there are fewer matings between mice sharing MUP haplotypes than would be expected if there were random mating. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4104", "text": "Some animals use  scent trails  to guide movement, for example social insects may lay down a trail to a food source, or a  tracking dog  may follow the scent of its target. A number of  scent-tracking strategies  have been studied in different species, including gradient search or  chemotaxis , anemotaxis, klinotaxis, and tropotaxis. Their success is influenced by the  turbulence  of the air plume that is being followed. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4105", "text": "Different people smell different odors, and most of these differences are caused by genetic differences. [ 34 ]  Although  odorant receptor  genes make up one of the largest gene families in the human genome, only a handful of genes have been linked conclusively to particular smells. For instance, the odorant receptor  OR5A1  and its genetic variants (alleles) are responsible for our ability (or failure) to smell \u03b2- ionone , a key aroma in foods and beverages. [ 35 ]  Similarly, the odorant receptor  OR2J3  is associated with the ability to detect the \"grassy\" odor, cis-3-hexen-1-ol. [ 36 ]  The preference (or dislike) of  cilantro  (coriander) has been linked to the olfactory receptor  OR6A2 . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4106", "text": "The importance and sensitivity of smell varies among different organisms; most  mammals  have a good sense of smell, whereas most  birds  do not, except the  tubenoses  (e.g.,  petrels  and  albatrosses ), certain species of new world  vultures , and the  kiwis . Also, birds have hundreds of olfactory receptors.  [ 38 ]  Although, recent analysis of the chemical composition of  volatile organic compounds  (VOCs) from  king penguin  feathers suggest that VOCs may provide olfactory cues, used by the penguins to locate their colony and recognize individuals. [ 39 ]  Among mammals, it is well developed in the  carnivores  and  ungulates , which must always be aware of each other, and in those that smell for their food, such as  moles . Having a strong sense of smell is referred to as  macrosmatic  in contrast to having a weak sense of smell which is referred to as  microsmotic ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4107", "text": "Figures suggesting greater or lesser sensitivity in various species reflect experimental findings from the reactions of animals exposed to aromas in known extreme dilutions. These are, therefore, based on perceptions by these animals, rather than mere nasal function. That is, the brain's smell-recognizing centers must react to the stimulus detected for the animal to be said to show a response to the smell in question. It is estimated that dogs, in general, have an olfactory sense approximately ten thousand to a hundred thousand times more acute than a human's. [ 40 ]  This does not mean they are overwhelmed by smells our noses can detect; rather, it means they can discern a molecular presence when it is in much greater dilution in the carrier, air."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4108", "text": "Scenthounds  as a group can smell one- to ten-million times more acutely than a human, and  bloodhounds , which have the keenest sense of smell of any dogs, [ 41 ]  have noses ten- to one-hundred-million times more sensitive than a human's. They were bred for the specific purpose of tracking humans, and can detect a  scent trail  a few days old. The second-most-sensitive nose is possessed by the  Basset Hound , which was bred to track and hunt rabbits and other small animals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4109", "text": "Grizzly bears  have a sense of smell seven times stronger than that of the bloodhound, essential for locating food underground. Using their elongated claws, bears dig deep trenches in search of burrowing animals and nests as well as roots, bulbs, and insects. Bears can detect the scent of food from up to eighteen miles away; because of their immense size, they often scavenge new kills, driving away the predators (including packs of wolves and human hunters) in the process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4110", "text": "The sense of smell is less developed in the  catarrhine   primates , and nonexistent in  cetaceans , which compensate with a well-developed sense of  taste . [ 41 ]  In some  strepsirrhines , such as the  red-bellied lemur , scent glands occur atop the head. In many species, smell is highly tuned to  pheromones ; a male  silkworm  moth, for example, can sense a single molecule of  bombykol ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4111", "text": "Fish, too, have a well-developed sense of smell, even though they inhabit an aquatic environment. [ citation needed ]  Salmon utilize their sense of smell to identify and return to their home stream waters. Catfish use their sense of smell to identify other individual catfish and to maintain a social hierarchy. Many fishes use the sense of smell to identify mating partners or to alert to the presence of food."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4112", "text": "Although conventional wisdom and lay literature, based on impressionistic findings in the 1920s, have long presented human smell as capable of distinguishing between roughly 10,000 unique odors, recent research has suggested that the average individual is capable of distinguishing over one trillion unique odors. [ 42 ]  Researchers in the most recent study, which tested the psychophysical responses to combinations of over 128 unique odor molecules with combinations composed of up to 30 different component molecules, noted that this estimate is \"conservative\" and that some subjects of their research might be capable of deciphering between a thousand trillion odorants, adding that their worst performer could probably still distinguish between 80 \u00a0 million scents. [ 43 ]  Authors of the study concluded, \"This is far more than previous estimates of distinguishable olfactory stimuli. It demonstrates that the human olfactory system, with its hundreds of different olfactory receptors, far out performs the other senses in the number of physically different stimuli it can discriminate.\" [ 44 ]  However, it was also noted by the authors that the ability to distinguish between smells is not analogous to being able to consistently identify them, and that subjects were not typically capable of identifying individual odor stimulants from within the odors the researchers had prepared from multiple odor molecules. In November 2014 the study was strongly criticized by Caltech scientist Markus Meister, who wrote that the study's \"extravagant claims are based on errors of mathematical logic.\" [ 45 ] [ 46 ]  The logic of his paper has in turn been criticized by the authors of the original paper. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4113", "text": "In humans and other  vertebrates , smells are sensed by  olfactory sensory neurons  in the  olfactory epithelium . The olfactory epithelium is made up of at least six morphologically and biochemically different cell types. [ 20 ]  The proportion of olfactory  epithelium  compared to respiratory epithelium (not innervated, or supplied with nerves) gives an indication of the animal's olfactory sensitivity. Humans have about 10\u00a0cm 2  (1.6\u00a0sq\u00a0in) of olfactory epithelium, whereas some dogs have 170\u00a0cm 2  (26\u00a0sq\u00a0in). A dog's olfactory epithelium is also considerably more densely innervated, with a hundred times more receptors per square centimeter. [ 48 ]  The sensory olfactory system integrates with other senses to form the perception of  flavor . [ 18 ]  Often, land organisms will have separate olfaction systems for smell and taste (orthonasal smell and  retronasal smell ), but water-dwelling organisms usually have only one system. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4114", "text": "Molecules of odorants passing through the  superior nasal concha  of the nasal passages dissolve in the  mucus  that lines the superior portion of the cavity and are detected by  olfactory receptors  on the  dendrites  of the olfactory sensory neurons. This may occur by diffusion or by the binding of the odorant to  odorant-binding proteins . The mucus overlying the epithelium contains  mucopolysaccharides , salts,  enzymes , and  antibodies  (these are highly important, as the olfactory neurons provide a direct passage for infection to pass to the  brain ). This mucus acts as a solvent for odor molecules, flows constantly, and is replaced approximately every ten minutes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4115", "text": "In  insects , smells are sensed by olfactory sensory neurons in the chemosensory  sensilla , which are present in insect antenna, palps, and tarsa, but also on other parts of the insect body. Odorants penetrate into the cuticle pores of chemosensory sensilla and get in contact with insect odorant-binding proteins (OBPs) or  Chemosensory proteins  (CSPs), before activating the sensory neurons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4116", "text": "The binding of the  ligand  (odor molecule or odorant) to the receptor leads to an  action potential  in the receptor neuron, via a  second messenger  pathway, depending on the organism. In mammals, the odorants stimulate  adenylate cyclase  to synthesize  cAMP  via a  G protein  called G olf . cAMP, which is the second messenger here, opens a  cyclic nucleotide-gated ion channel  (CNG), producing an influx of  cations  (largely  Ca 2+  with some  Na + ) into the cell, slightly depolarising it. The Ca 2+  in turn opens a Ca 2+ -activated  chloride channel , leading to efflux of  Cl \u2212 , further depolarizing the cell and triggering an action potential. Ca 2+  is then extruded through a  sodium-calcium exchanger . A calcium- calmodulin  complex also acts to inhibit the binding of cAMP to the cAMP-dependent channel, thus contributing to olfactory adaptation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4117", "text": "The main olfactory system of some mammals also contains small subpopulations of olfactory sensory neurons that detect and transduce odors somewhat differently. Olfactory sensory neurons that use trace amine-associated receptors (TAARs) to detect odors use the same second messenger signaling cascade as do the canonical olfactory sensory neurons. [ 50 ]  Other subpopulations, such as those that express the receptor guanylyl cyclase GC-D (Gucy2d) [ 51 ]  or the soluble guanylyl cyclase Gucy1b2, [ 52 ]  use a cGMP cascade to transduce their odorant ligands. [ 53 ] [ 54 ] [ 55 ]  These distinct subpopulations (olfactory subsystems) appear specialized for the detection of small groups of chemical stimuli."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4118", "text": "This mechanism of transduction is somewhat unusual, in that cAMP works by directly binding to the  ion channel  rather than through activation of  protein kinase A . It is similar to the transduction mechanism for  photoreceptors , in which the second messenger  cGMP  works by directly binding to ion channels, suggesting that maybe one of these receptors was evolutionarily adapted into the other. There are also considerable similarities in the immediate processing of stimuli by  lateral inhibition ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4119", "text": "Averaged activity of the receptor neurons can be measured in several ways. In vertebrates, responses to an odor can be measured by an  electro-olfactogram  or through calcium imaging of receptor neuron terminals in the olfactory bulb. In insects, one can perform  electroantennography  or calcium imaging within the olfactory bulb."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4120", "text": "Olfactory sensory neurons project  axons  to the brain within the  olfactory nerve , ( cranial nerve \u00a0 I). These nerve fibers, lacking  myelin  sheaths, pass to the  olfactory bulb  of the brain through perforations in the  cribriform plate , which in turn projects olfactory information to the  olfactory cortex  and other areas. [ 56 ]  The axons from the  olfactory receptors  converge in the outer layer of the olfactory bulb within small (\u224850  micrometers  in diameter) structures called  glomeruli .  Mitral cells , located in the inner layer of the olfactory bulb, form synapses with the axons of the sensory neurons within glomeruli and send the information about the  odor  to other parts of the olfactory system, where multiple signals may be processed to form a synthesized olfactory perception. A large degree of convergence occurs, with 25,000 axons synapsing on 25 or so mitral cells, and with each of these mitral cells projecting to multiple glomeruli. Mitral cells also project to  periglomerular cells  and  granular cells  that inhibit the mitral cells surrounding it ( lateral inhibition ). Granular cells also mediate inhibition and excitation of mitral cells through pathways from centrifugal fibers and the anterior olfactory nuclei. Neuromodulators like  acetylcholine ,  serotonin  and  norepinephrine  all send axons to the olfactory bulb and have been implicated in gain modulation, [ 57 ]  pattern separation, [ 58 ]  and  memory  functions, [ 59 ]  respectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4121", "text": "The mitral cells leave the olfactory bulb in the  lateral olfactory tract , which synapses on five major regions of the cerebrum: the  anterior olfactory nucleus , the  olfactory tubercle , the  amygdala , the  piriform cortex , and the  entorhinal cortex . The anterior olfactory nucleus projects, via the  anterior commissure , to the contralateral olfactory bulb, inhibiting it. The piriform cortex has two major divisions with anatomically distinct organizations and functions. The anterior piriform cortex (APC) appears to be better at determining the chemical structure of the odorant molecules, and the posterior piriform cortex (PPC) has a strong role in categorizing odors and assessing similarities between odors (e.g. minty, woody, and citrus are odors that can, despite being highly variant chemicals, be distinguished via the PPC in a concentration-independent manner). [ 60 ]  The piriform cortex projects to the  medial dorsal nucleus  of the thalamus, which then projects to the orbitofrontal cortex. The orbitofrontal cortex mediates conscious perception of the odor. [ citation needed ]  The three-layered piriform cortex projects to a number of thalamic and hypothalamic nuclei, the  hippocampus  and amygdala and the orbitofrontal cortex, but its function is largely unknown. The entorhinal cortex projects to the amygdala and is involved in emotional and autonomic responses to odor. It also projects to the hippocampus and is involved in motivation and memory. Odor information is stored in  long-term memory  and has strong connections to  emotional memory . This is possibly due to the olfactory system's close anatomical ties to the  limbic system  and hippocampus, areas of the brain that have long been known to be involved in emotion and place memory, respectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4122", "text": "Since any one receptor is responsive to various odorants, and there is a great deal of convergence at the level of the olfactory bulb, it may seem strange that human beings are able to distinguish so many different odors. It seems that a highly complex form of processing must be occurring; however, as it can be shown that, while many neurons in the olfactory bulb (and even the pyriform cortex and amygdala) are responsive to many different odors, half the neurons in the orbitofrontal cortex are responsive to only one odor, and the rest to only a few. It has been shown through microelectrode studies that each individual odor gives a particular spatial map of excitation in the olfactory bulb. It is possible that the brain is able to distinguish specific odors through spatial encoding, but temporal coding must also be taken into account. Over time, the spatial maps change, even for one particular odor, and the brain must be able to process these details as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4123", "text": "Inputs from the two  nostrils  have separate inputs to the brain, with the result that, when each nostril takes up a different odorant, a person may experience perceptual rivalry in the olfactory sense akin to that of  binocular rivalry . [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4124", "text": "In  insects , smells are sensed by sensilla located on the antenna and maxillary palp and first processed by the  antennal lobe  (analogous to the  olfactory bulb ), and next by the  mushroom bodies  and  lateral horn ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4125", "text": "The process by which olfactory information is coded in the brain to allow for proper perception is still being researched, and is not completely understood. When an odorant is detected by receptors, they in a sense break the odorant down, and then the brain puts the odorant back together for identification and perception. [ 62 ]  The odorant binds to receptors that recognize only a specific functional group, or feature, of the odorant, which is why the chemical nature of the odorant is important. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4126", "text": "After binding the odorant, the receptor is activated and will send a signal to the glomeruli  [ 63 ]  in the  olfactory bulb . Each glomerulus receives signals from multiple receptors that detect similar odorant features. Because several receptor types are activated due to the different chemical features of the odorant, several glomeruli are activated as well. The signals from the glomeruli are transformed to a pattern of oscillations of neural activities [ 64 ]  of the  mitral cells , the output neurons from the olfactory bulb. Olfactory bulb sends this pattern to the  olfactory cortex . Olfactory cortex is thought to have associative memories, [ 65 ]  so that it resonates to this bulbar pattern when the odor object is recognized. [ 66 ]  The cortex sends centrifugal feedback to the bulb. [ 67 ]  This feedback could suppress bulbar responses to the recognized odor objects, causing olfactory adaptation to background odors, so that the newly arrived foreground odor objects could be singled out for better recognition. [ 66 ] [ 68 ]  During odor search, feedback could also be used to enhance odor detection. [ 69 ] [ 66 ]  The distributed code allows the brain to detect specific odors in mixtures of many background odors. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4127", "text": "It is a general idea that the layout of brain structures corresponds to physical features of stimuli (called topographic coding), and similar analogies have been made in smell with concepts such as a layout corresponding to chemical features (called chemotopy) or perceptual features. [ 71 ]  While chemotopy remains a highly controversial concept, [ 72 ]  evidence exists for perceptual information implemented in the spatial dimensions of olfactory networks. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4128", "text": "Many animals, including most mammals and reptiles, but not humans, [ 73 ]  have two distinct and segregated olfactory systems: a main olfactory system, which detects volatile stimuli, and an accessory olfactory system, which detects fluid-phase stimuli. Behavioral evidence suggests that these fluid-phase stimuli often function as  pheromones , although pheromones can also be detected by the main olfactory system. In the accessory olfactory system, stimuli are detected by the  vomeronasal organ , located in the vomer, between the  nose  and the  mouth . Snakes use it to smell prey, sticking their tongue out and touching it to the organ. Some mammals make a facial expression called  flehmen  to direct stimuli to this organ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4129", "text": "The sensory receptors of the accessory olfactory system are located in the vomeronasal organ. As in the main olfactory system, the axons of these sensory neurons project from the vomeronasal organ to the  accessory olfactory bulb , which in the mouse is located on the dorsal-posterior portion of the main  olfactory bulb . Unlike in the main olfactory system, the axons that leave the accessory olfactory bulb do not project to the brain's cortex but rather to targets in the  amygdala  and  bed nucleus of the stria terminalis , and from there to the  hypothalamus , where they may influence aggression and mating behavior."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4130", "text": "Insect olfaction refers to the function of  chemical receptors  that enable  insects  to detect and identify  volatile compounds  for  foraging , predator avoidance, finding  mating  partners (via  pheromones ) and locating  oviposition  habitats. [ 74 ]  Thus, it is the most important sensation for insects. [ 74 ]  Most important insect behaviors must be timed perfectly which is dependent on what they smell and when they smell it. [ 75 ]  For example, smell is essential for hunting in many species of  wasps , including  Polybia sericea ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4131", "text": "The two organs insects primarily use for detecting odors are the  antennae  and specialized mouth parts called the maxillary palps. [ 76 ]  However, a recent study has demonstrated the olfactory role of ovipositor in fig wasps. [ 77 ]  Inside of these olfactory organs there are neurons called olfactory receptor neurons which, as the name implies, house receptors for scent molecules in their cell membranes. The majority of  olfactory receptor neurons  typically reside in the  antenna . These neurons can be very abundant, for example  Drosophila  flies have 2,600 olfactory sensory neurons. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4132", "text": "Insects are capable of smelling and differentiating between thousands of  volatile  compounds both  sensitively  and selectively. [ 74 ] [ 78 ]  Sensitivity is how attuned the insect is to very small amounts of an odorant or small changes in the concentration of an odorant. Selectivity refers to the insects' ability to tell one odorant apart from another. These compounds are commonly broken into three classes: short chain  carboxylic acids ,  aldehydes  and low molecular weight nitrogenous compounds. [ 78 ]  Some insects, such as the moth  Deilephila elpenor , use smell as a means to find food sources."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4133", "text": "The tendrils of plants are especially sensitive to airborne  volatile organic compounds . Parasites such as  dodder  make use of this in locating their preferred hosts and locking on to them. [ 79 ]  The emission of volatile compounds is detected when foliage is browsed by animals. Threatened plants are then able to take defensive chemical measures, such as moving  tannin  compounds to their foliage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4134", "text": "Scientists have devised methods for quantifying the intensity of odors, in particular for the purpose of analyzing unpleasant or objectionable odors released by an industrial source into a community. Since the 1800s industrial countries have encountered incidents where proximity of an industrial source or landfill produced adverse reactions among nearby residents regarding airborne odor. The basic theory of odor analysis is to measure what extent of dilution with \"pure\" air is required before the sample in question is rendered indistinguishable from the \"pure\" or reference standard. Since each person perceives odor differently, an \"odor panel\" composed of several different people is assembled, each  sniffing  the same sample of diluted specimen air. A field  olfactometer  can be utilized to determine the magnitude of an odor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4135", "text": "Many air management districts in the  US  have numerical standards of acceptability for the intensity of odor that is allowed to cross into a residential property. For example, the  Bay Area Air Quality Management District  has applied its standard in regulating numerous industries, landfills, and sewage treatment plants. Example applications this district has engaged are the  San Mateo, California , wastewater treatment plant; the  Shoreline Amphitheatre  in  Mountain View, California ; and the  IT Corporation  waste ponds,  Martinez, California ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4136", "text": "Systems of classifying odors include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4137", "text": "Specific terms are used to describe disorders associated with smelling:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4138", "text": "Viruses can also infect the olfactory epithelium leading to a loss of the sense of olfaction. About 50% of patients with  SARS-CoV-2  (causing COVID-19) experience some type of  disorder associated with their sense of smell , including anosmia and parosmia.  SARS-CoV-1 ,  MERS-CoV  and even the flu ( influenza virus ) can also disrupt  olfaction . [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4139", "text": "Media related to  Smell  at Wikimedia Commons"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4140", "text": "Septoplasty  ( Latin :  saeptum , \"septum\" +  Ancient Greek :  \u03c0\u03bb\u03ac\u03c3\u03c3\u03b5\u03b9\u03bd ,  romanized :\u00a0 plassein , \"to shape\"), or alternatively  submucous septal resection  and  septal reconstruction , [ 1 ]  is a corrective  surgical  procedure done to straighten a  deviated nasal septum  \u2013 the  nasal septum  being the partition between the two  nasal cavities . [ 2 ]  Ideally, the septum should run down the center of the  nose . When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Deviated nasal septum or \u201ccrooked\u201d  internal nose can occur at childbirth or as the result of an injury or other trauma. If the wall that functions as a separator of both sides of the nose is tilted towards one side at a degree greater than 50%, it might cause difficulty breathing. Often the inferior  turbinate  on the opposite side enlarges, which is termed  compensatory hypertrophy . Deviations of the septum can lead to nasal obstruction. Most surgeries are completed in 60 minutes or less, while the recovery time could be up to several weeks. Put simply, septoplasty is a surgery that helps repair the passageways in the nose making it easier to breathe. This surgery is usually performed on patients with a deviated septum, recurrent rhinitis, or sinus issues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4141", "text": "The procedure [ 3 ]  usually involves a judicious excision/realignment of a portion of the bone and/or cartilage in the nasal cavity. Under  general  or  local anesthesia , the surgeon works through the nostrils, making an incision in the lining of the septum to reach the cartilage/bone targeted in the operation. This may be performed using an endoscope or with open techniques. Sufficient cartilage and bone is preserved for structural support. After the septum is straightened, it may then be stabilized temporarily with small plastic tubes, splints, or sutures internally.  Skin grafts  can be placed internally to support the internal structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4142", "text": "Apart from in patients with deviated nasal septum causing airway obstruction leading to difficulty with breathing, recurrent rhinitis, or sinusitis, septoplasty is done as an approach to  hypophysectomy . [ citation needed ]  It is sometimes done as well to cure recurrent   nosebleed (epistaxis)  due to  septal spur ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4143", "text": "Septoplasty should not be done in acute nasal or sinus infection. It should also be avoided if the person has untreated  diabetes , severe  hypertension  or  bleeding diathesis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4144", "text": "Unless there are unusual complications, there is no swelling or discoloration of the external nose or face with septoplasty alone.   Packing  is rare with modern surgical techniques, but  splinting  the inside of the nose for a few days is common; the splints are not visible externally. Patients who have nasal splints should receive prophylactic antibiotics against gram positive organisms to prevent possible toxic shock syndrome. One percent of patients can experience excessive bleeding afterwards\u00a0\u2014 the risk period lasts up to two weeks. This could require packing or  cautery , but is generally handled safely and without compromise of the ultimate surgical result.  Septal perforation and septal hematoma are possible, as is a decrease in the sense of smell. [ 5 ]  Temporary numbness of the front upper teeth after surgery is common. [ 5 ]  Sometimes the numbness extends to the upper jaw and the tip of the nose.  This almost always resolves within several months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4145", "text": "The nasal tissues should mostly stabilize within 3-6 months post-surgery, although shifting is still possible for up to and over a year afterwards. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4146", "text": "A randomised controlled trial found that people who had septoplasty had a greater improvement in their symptoms and quality of life after 6 months than people who managed their nasal airway obstruction with nasal sprays. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4147", "text": "A  sialogogue  (also spelled  sialagogue ,  ptysmagogue  or  ptyalagogue ) is a  substance , especially a  medication , that increases the flow rate of  saliva . [ 1 ]  The definition focuses on substances that promote  production or secretion of saliva  (proximal causation) rather than any food that is  mouthwatering  (distal causation that triggers proximal causation)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4148", "text": "Sialogogues can be used in the treatment of  xerostomia  (the subjective feeling of having a dry mouth), to stimulate any functioning  salivary gland  tissue to produce more saliva. Saliva has a bactericidal effect, so when low levels of it are secreted, the risk of  caries  increases. [ 2 ]  Not only this, but fungal infections such as oral  candidosis  also can be a consequence of low salivary flow rates. The  buffer  effect of saliva is also important, neutralising acids that cause tooth enamel demineralisation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4149", "text": "The following are used in dentistry to treat xerostomia: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4150", "text": "A tincture is prepared from the root of the pyrethrium ( pyrethrum ) or pellitory (a number of plants in the  Chrysanthemum  family). It is found growing in Levant and parts of Limerick and Clare in  Ireland . The root powder was used as flavouring in tooth powders in the past. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4151", "text": "The inner surface of the  mastoid portion  of the  temporal bone  presents a deep, curved groove, the  sigmoid sulcus , which lodges part of the  transverse sinus ; in it may be seen the opening of the  mastoid foramen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4152", "text": "Sleep apnea  ( sleep apnoea  or  sleep apn\u0153a  in  British English ) is a sleep-related breathing disorder in which repetitive  pauses in breathing , periods of shallow breathing, or collapse of the upper airway during  sleep  results in poor ventilation and sleep disruption. [ 10 ] [ 11 ]  Each pause in breathing can last for a few seconds to a few minutes and often occurs many times a night. [ 1 ]  A choking or snorting sound may occur as breathing resumes. [ 1 ]  Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time. [ 12 ]   Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. [ 1 ]  It is often a chronic condition. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4153", "text": "Sleep apnea may be categorized as  obstructive sleep apnea  (OSA), in which breathing is interrupted by a blockage of air flow,  central sleep apnea  (CSA), in which regular unconscious breath simply stops, or a combination of the two. [ 1 ]  OSA is the most common form. [ 1 ]  OSA has four key contributors; these include a narrow, crowded, or collapsible upper airway, an ineffective pharyngeal dilator muscle function during sleep, airway narrowing during sleep, and unstable control of breathing (high loop gain). [ 14 ] [ 15 ]  In CSA, the basic neurological controls for breathing rate malfunction and fail to give the signal to inhale, causing the individual to miss one or more cycles of breathing. If the pause in breathing is long enough, the percentage of oxygen in the circulation can drop to a lower than normal level ( hypoxemia ) and the concentration of carbon dioxide can build to a higher than normal level ( hypercapnia ). [ 16 ]  In turn, these conditions of  hypoxia  and hypercapnia will trigger  additional  effects on the body such as  Cheyne-Stokes Respiration . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4154", "text": "Some people with sleep apnea are unaware they have the condition. [ 1 ]  In many cases it is first observed by a family member. [ 1 ]  An in-lab sleep study overnight is the preferred method for diagnosing sleep apnea. [ 15 ]  In the case of OSA, the outcome that determines disease severity and guides the treatment plan is the apnea-hypopnea index (AHI). [ 15 ]  This measurement is calculated from totaling all pauses in breathing and periods of shallow breathing lasting greater than 10 seconds and dividing the sum by total hours of recorded sleep. [ 10 ] [ 15 ]  In contrast, for CSA the degree of respiratory effort, measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is an important distinguishing factor between OSA and CSA. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4155", "text": "A systemic disorder, sleep apnea is associated with a wide array of effects, including increased risk of  car accidents ,  hypertension ,  cardiovascular disease ,  myocardial infarction ,  stroke ,  atrial fibrillation ,  insulin resistance , higher incidence of  cancer , and  neurodegeneration . [ 19 ]  Further research is being conducted on the potential of using biomarkers to understand which chronic diseases are associated with sleep apnea on an individual basis. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4156", "text": "Treatment may include lifestyle changes, mouthpieces, breathing devices, and surgery. [ 1 ]  Effective lifestyle changes may include avoiding  alcohol , losing weight,  smoking  cessation, and sleeping on one's side. [ 20 ]  Breathing devices include the use of a  CPAP machine . [ 21 ]  With proper use, CPAP improves outcomes. [ 22 ]  Evidence suggests that CPAP may improve sensitivity to insulin, blood pressure, and sleepiness. [ 23 ] [ 24 ] [ 25 ]  Long term compliance, however, is an issue with more than half of people not appropriately using the device. [ 22 ] [ 26 ]  In 2017, only 15% of potential patients in developed countries used CPAP machines, while in developing countries well under 1% of potential patients used CPAP. [ 27 ] [ unreliable source? ]  Without treatment, sleep apnea may increase the risk of  heart attack ,  stroke ,  diabetes ,  heart failure ,  irregular heartbeat ,  obesity , and  motor vehicle collisions . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4157", "text": "OSA is a common sleep disorder. A large analysis in 2019 of the estimated prevalence of OSA found that OSA affects 936 million\u20141 billion people between the ages of 30\u201369 globally, or roughly every 1 in 10 people, and up to 30% of the elderly. [ 28 ]  Sleep apnea is somewhat more common in men than women, roughly a 2:1 ratio of men to women, and in general more people are likely to have it with older age and obesity. Other risk factors include being overweight, [ 19 ]  a family history of the condition, allergies, and enlarged  tonsils . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4158", "text": "The typical screening process for sleep apnea involves asking patients about common symptoms such as snoring, witnessed pauses in breathing during sleep and  excessive daytime sleepiness . [ 19 ]  There is a wide range in presenting symptoms in patients with sleep apnea, from being asymptomatic to falling asleep while driving. [ 19 ]   Due to this wide range in clinical presentation, some people are not aware that they have sleep apnea and are either misdiagnosed or ignore the symptoms altogether. [ 29 ]  A current area requiring further study involves identifying different subtypes of sleep apnea based on patients who tend to present with different clusters or groupings of particular symptoms. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4159", "text": "OSA may increase risk for driving accidents and work-related accidents due to sleep fragmentation from repeated arousals during sleep. [ 19 ]  If OSA is not treated it results in excessive daytime sleepiness and oxidative stress from the repeated drops in oxygen saturation, people are at increased risk of other systemic health problems, such as diabetes, hypertension or cardiovascular disease. [ 19 ]  Subtle manifestations of sleep apnea may include treatment refractory hypertension and cardiac arrhythmias and over time as the disease progresses, more obvious symptoms may become apparent. [ 12 ]  Due to the disruption in daytime cognitive state, behavioral effects may be present. These can include moodiness, belligerence, as well as a decrease in attentiveness and energy. [ 30 ]  These effects may become intractable, leading to depression. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4160", "text": "Obstructive sleep apnea can affect people regardless of sex, race, or age. [ 32 ]  However, risk factors include: [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4161", "text": "Central sleep apnea is more often associated with any of the following risk factors: [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4162", "text": "Obstructive sleep apnea"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4163", "text": "The causes of obstructive sleep apnea are complex and individualized, but typical risk factors include narrow pharyngeal anatomy and craniofacial structure. [ 15 ]  When anatomical risk factors are combined with non-anatomical contributors such as an ineffective pharyngeal dilator muscle function during sleep, unstable control of breathing (high loop gain), and premature awakening to mild airway narrowing, the severity of the OSA rapidly increases as more factors are present. [ 15 ]  When breathing is paused due to upper airway obstruction, carbon dioxide builds up in the bloodstream.  Chemoreceptors  in the bloodstream note the high carbon dioxide levels. The brain is signaled to awaken the person, which clears the airway and allows breathing to resume. Breathing normally will restore oxygen levels and the person will fall asleep again. [ 35 ]  This carbon dioxide build-up may be due to the decrease of output of the brainstem regulating the chest wall or pharyngeal muscles, which causes the pharynx to collapse. [ 36 ]  People with sleep apnea experience reduced or no  slow-wave sleep  and spend less time in  REM sleep . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4164", "text": "Central sleep apnea"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4165", "text": "There are two main mechanism that drive the disease process of CSA, sleep-related hypoventilation and post-hyperventilation hypocapnia. [ 18 ]  The most common cause of CSA is post-hyperventilation hypocapnia secondary to heart failure. [ 18 ]  This occurs because of brief failures of the ventilatory control system but normal alveolar ventilation. [ 18 ]  In contrast, sleep-related hypoventilation occurs when there is a malfunction of the brain's drive to breathe. [ 18 ]  The underlying cause of the loss of the wakefulness drive to breathe encompasses a broad set of diseases from strokes to severe kyphoscoliosis. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4166", "text": "OSA is a serious medical condition with systemic effects; patients with untreated OSA have a greater mortality risk from cardiovascular disease than those undergoing appropriate treatment. [ 37 ]  Other complications include hypertension, congestive heart failure, atrial fibrillation, coronary artery disease, stroke, and type 2 diabetes. [ 37 ]  Daytime fatigue and sleepiness, a common symptom of sleep apnea, is also an important public health concern regarding transportation crashes caused by drowsiness. [ 37 ]  OSA may also be a risk factor of  COVID-19 . People with OSA have a higher risk of developing severe complications of COVID-19. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4167", "text": "Alzheimer's disease  and severe obstructive sleep apnea are connected [ 39 ]  because there is an increase in the protein  beta-amyloid  as well as  white-matter  damage.  These are the main indicators of Alzheimer's, which in this case comes from the lack of proper rest or poorer sleep efficiency resulting in  neurodegeneration . [ 3 ] [ 40 ] [ 41 ]  Having sleep apnea in mid-life brings a higher likelihood of developing Alzheimer's in older age, and if one has Alzheimer's then one is also more likely to have sleep apnea. [ 9 ]  This is demonstrated by cases of sleep apnea even being misdiagnosed as  dementia . [ 42 ]  With the use of treatment through CPAP, there is a reversible risk factor in terms of the amyloid proteins.  This usually restores brain structure and f cognitive impairment. [ 43 ] [ 44 ] [ 45 ]  Evidence continues to be found supporting there is an association between BMI and Alzheimer's. [ 46 ]  There is also evidence of increased risk of developing Alzheimer's for those with a higher BMI in women ages 70 and above. [ 47 ]  While continuous positive airway pressure (CPAP) wasn't found to significantly improve cognitive performance, it was found to benefit other symptoms like depression, anxiety, etc. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4168", "text": "There are three types of sleep apnea. OSA accounts for 84%, CSA for 0.9%, and 15% of cases are mixed. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4169", "text": "In a systematic review of published evidence, the  United States Preventive Services Task Force  in 2017 concluded that there was uncertainty about the accuracy or clinical utility of all potential screening tools for OSA, [ 50 ]  and recommended that evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4170", "text": "The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of partial or complete collapse of the upper airway during sleep resulting in apneas or hypopneas, respectively. [ 52 ]  Criteria defining an apnea or a hypopnea vary. The  American Academy of Sleep Medicine (AASM)  defines an apnea as a reduction in airflow of \u2265\u200990% lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of \u2265\u200930% lasting at least 10 seconds and associated with a \u2265\u20094% decrease in pulse oxygenation, or as a \u2265\u200930% reduction in airflow lasting at least 10 seconds and associated either with a \u2265\u20093% decrease in pulse oxygenation or with an arousal. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4171", "text": "To define the severity of the condition, the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI) are used. While the AHI measures the mean number of apneas and hypopneas per hour of sleep, the RDI adds to this measure the respiratory effort-related arousals (RERAs). [ 54 ]  The OSA syndrome is thus diagnosed if the AHI is >\u20095 episodes per hour and results in daytime sleepiness and fatigue or when the RDI is \u2265\u200915 independently of the symptoms. [ 55 ]  According to the American Association of Sleep Medicine, daytime sleepiness is determined as mild, moderate and severe depending on its impact on social life. Daytime sleepiness can be assessed with the Epworth Sleepiness Scale (ESS), a self-reported questionnaire on the propensity to fall asleep or doze off during daytime. [ 56 ]  Screening tools for OSA itself comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a very powerful tool to detect OSA. [ 57 ] [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4172", "text": "According to the  International Classification of Sleep Disorders , there are 4 types of criteria. [ 59 ] [ 60 ]  The first one concerns sleep \u2013 excessive sleepiness, nonrestorative sleep, fatigue or insomnia symptoms. The second and third criteria are about respiration \u2013 waking with breath holding, gasping, or choking; snoring, breathing interruptions or both during sleep. The last criterion revolved around medical issues as hypertension, coronary artery disease, stroke, heart failure, atrial fibrillation, type 2 diabetes mellitus, mood disorder or cognitive impairment. Two levels of severity are distinguished, the first one is determined by a polysomnography or home sleep apnea test demonstrating 5 or more predominantly obstructive respiratory events per hour of sleep and the higher levels are determined by 15 or more events. If the events are present less than 5 times per hour, no obstructive sleep apnea is diagnosed. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4173", "text": "A considerable night-to-night variability further complicates diagnosis of OSA. In unclear cases, multiple nights of testing might be required to achieve an accurate diagnosis. [ 61 ]  Since sequential nights of testing would be impractical and cost prohibitive in the sleep lab, home sleep testing for multiple nights can not only be more useful, but more reflective of what is typically happening each night. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4174", "text": "Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold standard test for diagnosis. Patients are monitored with EEG leads,  pulse oximetry , temperature and pressure sensors to detect nasal and oral airflow, respiratory impedance plethysmography or similar resistance belts around the chest and abdomen to detect motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin, chest, and legs. A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation or a reduction in airflow of at least 30% for more than 10 seconds associated with at least 3% oxygen desaturation or an arousal from sleep on EEG. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4175", "text": "An \"event\" can be either an apnea, characterized by complete cessation of airflow for at least 10 seconds, or a  hypopnea  in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep. [ 64 ]  To grade the severity of sleep apnea, the number of events per hour is reported as the  apnea-hypopnea index  (AHI). An AHI of less than 5 is considered normal. An AHI of 5\u201315 is mild; 15\u201330 is moderate, and more than 30 events per hour characterizes severe sleep apnea."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4176", "text": "The diagnosis of CSA syndrome is made when the presence of at least 5 central apnea events occur per hour. [ 11 ]  There are multiple mechanisms that drive the apnea events. In individuals with heart failure with Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced during sleep. [ 65 ]   This results in ventilatory instability, caused by chemoreceptors that are hyperresponsive to CO2 fluctuations in the blood, resulting in high respiratory drive that leads to apnea. [ 11 ]  Another common mechanism that causes CSA is the loss of the brain's wakefulness drive to breathe. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4177", "text": "CSA is organized into 6 individual syndromes: Cheyne-Stokes respiration, Complex sleep apnea, Primary CSA, High altitude periodic breathing, CSA from medication, CSA from comorbidity. [ 11 ]  Like in OSA, nocturnal polysomnography is the mainstay of diagnosis for CSA. [ 18 ]   The degree of respiratory effort, measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is an important distinguishing factor between OSA and CSA. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4178", "text": "Some people with sleep apnea have a combination of both types; its prevalence ranges from 0.56% to 18%. The condition, also called treatment-emergent central apnea, is generally detected when obstructive sleep apnea is treated with CPAP and central sleep apnea emerges. [ 18 ]  The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown but is most likely related to incorrect settings of the CPAP treatment and other medical conditions the person has. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4179", "text": "The treatment of obstructive sleep apnea is different than that of central sleep apnea. Treatment often starts with behavioral therapy and some people may be suggested to try a  continuous positive airway pressure  device. Many people are told to avoid alcohol, sleeping pills, and other sedatives, which can relax throat muscles, contributing to the collapse of the airway at night. [ 67 ]  The evidence supporting one treatment option compared to another for a particular person is not clear. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4180", "text": "More than half of people with obstructive sleep apnea have some degree of positional obstructive sleep apnea, meaning that it gets worse when they sleep on their backs. [ 69 ]   Sleeping on their sides is an effective and cost-effective treatment for positional obstructive sleep apnea. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4181", "text": "For moderate to severe sleep apnea, the most common treatment is the use of a  continuous positive airway pressure  (CPAP) or automatic positive airway pressure (APAP) device. [ 67 ] [ 70 ]  These splint the person's airway open during sleep by means of pressurized air. The person typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4182", "text": "Although CPAP therapy is effective in reducing apneas and less expensive than other treatments, some people find it uncomfortable. Some complain of feeling trapped, having chest discomfort, and skin or nose irritation. Other side effects may include dry mouth, dry nose, nosebleeds, sore lips and gums. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4183", "text": "Whether or not it decreases the risk of death or heart disease is controversial with some reviews finding benefit and others not. [ 22 ] [ 72 ] [ 68 ]  This variation across studies might be driven by low rates of compliance\u2014analyses of those who use CPAP for at least four hours a night suggests a decrease in cardiovascular events. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4184", "text": "Excess body weight is thought to be an important cause of sleep apnea. [ 74 ]  People who are overweight have more tissues in the back of their throat which can restrict the airway, especially when sleeping. [ 75 ]  In weight loss studies of overweight individuals, those who lose weight show reduced apnea frequencies and improved apnoea\u2013hypopnoea index (AHI). [ 74 ] [ 76 ]  Weight loss effective enough to relieve obesity hypoventilation syndrome (OHS) must be 25\u201330% of body weight. For some obese people, it can be difficult to achieve and maintain this result without  bariatric surgery . [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4185", "text": "In children, orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical rapid  palatal expansion  is common. The procedure has been found to significantly decrease the AHI and lead to long-term resolution of clinical symptoms. [ 78 ] [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4186", "text": "Since the palatal suture is fused in adults, regular RPE using tooth-borne expanders cannot be performed. Mini-implant assisted rapid palatal expansion (MARPE) has been recently developed as a non-surgical option for the transverse expansion of the maxilla in adults. This method increases the volume of the nasal cavity and nasopharynx, leading to increased airflow and reduced respiratory arousals during sleep. [ 80 ] [ 81 ]  Changes are permanent with minimal complications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4187", "text": "Several surgical procedures ( sleep surgery ) are used to treat sleep apnea, although they are normally a third line of treatment for those who reject or are not helped by CPAP treatment or dental appliances. [ 22 ]  Surgical treatment for obstructive sleep apnea needs to be individualized to address all anatomical areas of obstruction. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4188", "text": "Often, correction of the nasal passages needs to be performed in addition to correction of the  oropharynx  passage.  Septoplasty  and turbinate surgery may improve the nasal airway, [ 82 ]  but has been found to be ineffective at reducing respiratory arousals during sleep. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4189", "text": "Tonsillectomy  and  uvulopalatopharyngoplasty  (UPPP or UP3) are available to address pharyngeal obstruction. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4190", "text": "The \"Pillar\" device is a treatment for snoring and obstructive sleep apnea; it is thin, narrow strips of polyester. Three strips are inserted into the roof of the mouth (the  soft palate ) using a modified syringe and local anesthetic, in order to stiffen the soft palate. This procedure addresses one of the most common causes of snoring and sleep apnea\u00a0\u2014 vibration or collapse of the soft palate. It was approved by the FDA for snoring in 2002 and for obstructive sleep apnea in 2004. A 2013 meta-analysis found that \"the Pillar implant has a moderate effect on snoring and mild-to-moderate obstructive sleep apnea\" and that more studies with high level of evidence were needed to arrive at a definite conclusion; it also found that the polyester strips work their way out of the soft palate in about 10% of the people in whom they are implanted. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4191", "text": "Base-of-tongue advancement by means of advancing the genial tubercle of the mandible, tongue suspension, or  hyoid suspension  (aka hyoid myotomy and suspension or hyoid advancement) may help with the lower pharynx. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4192", "text": "Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat, procedures done at either a doctor's office or a hospital. Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4193", "text": "Maxillomandibular advancement  (MMA) is considered the most effective surgery for people with sleep apnea, because it increases the posterior airway space (PAS). [ 85 ]  However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impedes surgery; or significant craniofacial abnormalities which hinder device use. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4194", "text": "Several inpatient and outpatient procedures use sedation. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient's airways. [ 87 ]  Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4195", "text": "Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period. Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4196", "text": "A person with sleep apnea undergoing any medical treatment must make sure their doctor and  anesthetist  are informed about the sleep apnea. Alternative and emergency procedures may be necessary to maintain the airway of sleep apnea patients. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4197", "text": "Diaphragm pacing , which involves the rhythmic application of electrical impulses to the diaphragm, has been used to treat central sleep apnea. [ 89 ] [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4198", "text": "In April 2014, the U.S. Food and Drug Administration granted pre-market approval for use of an upper airway stimulation system in people who cannot use a continuous positive airway pressure device. The Inspire Upper Airway Stimulation system is a  hypoglossal nerve stimulator  that senses respiration and applies mild electrical stimulation during inspiration, which pushes the tongue slightly forward to open the airway. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4199", "text": "There is currently insufficient evidence to recommend any medication for OSA. [ 92 ]  This may result in part because people with sleep apnea have tended to be treated as a single group in clinical trials. Identifying specific physiological factors underlying sleep apnea makes it possible to test drugs specific to those causal factors: airway narrowing, impaired muscle activity, low arousal threshold for waking, and unstable breathing control. [ 93 ] [ 94 ] \nThose who experience low waking thresholds may benefit from  eszopiclone , a sedative typically used to treat insomnia. [ 93 ] [ 95 ]  The  antidepressant  desipramine  may stimulate upper airway muscles and lessen pharyngeal collapsibility in people who have limited muscle function in their airways. [ 93 ] [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4200", "text": "There is limited evidence for medication, but 2012 AASM guidelines suggested that  acetazolamide  \"may be considered\" for the treatment of central sleep apnea;  zolpidem  and  triazolam  may also be considered for the treatment of central sleep apnea, [ 97 ]  but \"only if the patient does not have underlying risk factors for respiratory depression\". [ 92 ] [ 70 ] \nLow doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects. [ 98 ] [ 99 ] [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4201", "text": "In December 2024, the FDA approved  tirzepatide , an anti-diabetic and weight loss medication, as a component in the combination treatment of adults with obesity suffering from moderate to severe obstructive sleep apnea. Other components of the therapy are a reduced-calorie diet and increased physical activity. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4202", "text": "An oral appliance, often referred to as a  mandibular advancement splint , is a custom-made mouthpiece that shifts the lower jaw forward and opens the bite slightly, opening up the airway. These devices can be fabricated by a general dentist. Oral appliance therapy (OAT) is usually successful in patients with mild to moderate obstructive sleep apnea. [ 102 ] [ 103 ]  While CPAP is more effective for sleep apnea than oral appliances, oral appliances do improve sleepiness and quality of life and are often better tolerated than CPAP. [ 103 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4203", "text": "Nasal EPAP  is a bandage-like device placed over the nostrils that uses a person's own breathing to create positive airway pressure to prevent obstructed breathing. [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4204", "text": "Oral pressure therapy  uses a device that creates a vacuum in the mouth, pulling the soft palate tissue forward. It has been found useful in about 25 to 37% of people. [ 105 ] [ 106 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4205", "text": "Death could occur from untreated OSA due to lack of oxygen to the body. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4206", "text": "There is increasing evidence that sleep apnea may lead to liver function impairment, particularly  fatty liver  diseases (see  steatosis ). [ 107 ] [ 108 ] [ 109 ] [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4207", "text": "It has been revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss. [ 111 ]  Using  magnetic resonance imaging  (MRI), the scientists discovered that people with sleep apnea have  mammillary bodies  that are about 20% smaller, particularly on the left side. One of the key investigators hypothesized that repeated drops in oxygen lead to the brain injury. [ 112 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4208", "text": "The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures. At worst, central sleep apnea may cause sudden death. Short of death, drops in blood oxygen may trigger  seizures , even in the absence of  epilepsy . In people  with  epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medications. [ 113 ]  In other words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with  coronary artery disease , a severe drop in blood oxygen level can cause  angina ,  arrhythmias , or heart attacks ( myocardial infarction ). Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a  respiratory acidosis . [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4209", "text": "The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea. [ 114 ] [ 115 ]  It also estimated that in middle-age as many as 9% of women and 24% of men were affected, undiagnosed and untreated. [ 74 ] [ 114 ] [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4210", "text": "The costs of untreated sleep apnea reach further than just health issues. It is estimated that in the U.S., the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea. This may cause $3.4 billion/year in additional medical costs. Whether medical cost savings occur with treatment of sleep apnea remains to be determined. [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4211", "text": "Sleep disorders including sleep apnea have become an important health issue in the United States. Twenty-two million Americans have been estimated to have sleep apnea, with 80% of moderate and severe OSA cases undiagnosed. [ 117 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4212", "text": "OSA can occur at any age, but it happens more frequently in men who are over 40 and overweight. [ 117 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4213", "text": "A type of CSA was described in the German  myth  of  Ondine's curse  where the person when asleep would forget to breathe. [ 118 ]  The clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process. The term \" Pickwickian syndrome \" that is sometimes used for the syndrome was coined by the famous early 20th-century physician  William Osler , who must have been a reader of  Charles Dickens . The description of Joe, \"the fat boy\" in Dickens's novel  The Pickwick Papers , is an accurate clinical picture of an adult with obstructive sleep apnea syndrome. [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4214", "text": "The early reports of obstructive sleep apnea in the medical literature described individuals who were very severely affected, often presenting with severe  hypoxemia ,  hypercapnia  and  congestive heart failure . [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4215", "text": "The management of obstructive sleep apnea was improved with the introduction of  continuous positive airway pressure  (CPAP), first described in 1981 by Colin Sullivan and associates in  Sydney , Australia. [ 120 ]  The first models were bulky and noisy, but the design was rapidly improved and by the late 1980s, CPAP was widely adopted. The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of  sleep disorders . Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep-disordered breathing. Sleep apnea awareness day is 18 April in recognition of Colin Sullivan. [ 121 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4216", "text": "In  surgery , a  sling  is an implant that is intended to provide additional support to a particular tissue. It usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine or porcine) or the patient\u2019s own tissue. The ends are usually attached to a fixed body part such as the  skeleton ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4217", "text": "In  stress incontinence , a sling is a potential method of treatment, and is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a backboard of support under the urethra."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4218", "text": "For this purpose, Pelvicol (a porcine dermal sling) implant sling had a comparable patient-determined success rate with TVT. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4219", "text": "Slings can also be used in the surgical management of  female genital prolapse ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4220", "text": "A  chin sling  is a  synthetic  lining used in  chin augmentation  to lift the tissues under the  chin  and  neck . The sling is surgically implanted under the skin of the chin and hooked behind the ears, giving a more youthful appearance, and reversing the effects of aging such as accumulated fat, lost skin elasticity and stretched muscle lining, all of which cause the neck to droop and sag."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4221", "text": "Sore throat , also known as  throat pain , is pain or irritation of the  throat . [ 1 ]  The majority of sore throats are caused by a virus, for which  antibiotics  are not helpful. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4222", "text": "For sore throat caused by bacteria (GAS), treatment with antibiotics may help the person get better faster, reduce the risk that the bacterial infection spreads, prevent  retropharyngeal abscesses  and  quinsy , and reduce the risk of other complications such as  rheumatic fever  and  rheumatic heart disease . [ 2 ]  In most  developed countries , post-streptococcal diseases have become far less common. For this reason, awareness and  public health  initiatives to promote minimizing the use of antibiotics for viral infections have become the focus. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4223", "text": "Approximately 35% of childhood sore throats and 5\u201325% of cases in adults are caused by a bacterial infection from group A streptococcus. [ 2 ]  Sore throats that are \"non-group A streptococcus\" are assumed to be caused by a viral infection. Sore throat is a common reason for people to visit their primary care doctors and the top reason for antibiotic prescriptions by primary care practitioners such as family doctors. [ 2 ]  In the United States, about 1% of all visits to the hospital emergency department, physician office and medical clinics, and outpatient clinics are for sore throat (over 7 million visits for adults and 7 million visits for children per year). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4224", "text": "Causes of sore throat include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4225", "text": "A sore throat is pain felt anywhere in the throat. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4226", "text": "Symptoms of sore throat include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4227", "text": "The most common cause (80%) is  acute   viral  pharyngitis, a viral  infection  of the throat. [ 3 ]   Other causes include other bacterial infections (such as group A streptococcus or  streptococcal pharyngitis ), trauma, and  tumors . [ 3 ]   Gastroesophageal (acid) reflux disease  can cause  stomach acid  to back up into the throat and also cause the throat to become sore. [ 5 ]  In children, streptococcal pharyngitis is the cause of 35\u201337% of sore throats. [ 6 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4228", "text": "The symptoms of a viral infection and a bacterial infection may be very similar. Some clinical guidelines suggest that the cause of a sore throat is confirmed prior to prescribing antibiotic therapy and only recommend antibiotics for children who are at high risk of non- suppurative  complications. [ 7 ] [ 8 ]  A group A streptococcus infection can be diagnosed by  throat culture  or a rapid test:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4229", "text": "Clinicians often also make treatment decisions based on the person's signs and symptoms alone. In the US, approximately two-thirds of adults and half of children with sore throat are diagnosed based on symptoms and do not have testing for the presence of GAS to confirm a bacterial infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4230", "text": "Numerous clinical scoring systems ( decision tools ) have also been developed to support clinical decisions. Scoring systems that have been proposed include  Centor's , McIsaac's, and the feverPAIN. [ 2 ]  A clinical scoring system is often used along with a rapid test. [ 2 ]  The scoring systems use observed signs and symptoms in order to determine the likelihood of a bacterial infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4231", "text": "Sore or  scratchy  throat can temporarily be relieved by  gargling  a solution of 1/4 to 1/2 teaspoon (1.3 to 2.5 milliliters)  salt  dissolved in an 8-US-fluid-ounce (240\u00a0ml) glass of water. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4232", "text": "Pain medications such as  non-steroidal anti-inflammatory drugs  (NSAIDs) and  paracetamol  (acetaminophen) help in the  management of pain . [ 10 ] [ 11 ]  The use of  corticosteroids  seems to increase slightly the likelihood of resolution and the reduction of pain, but more analysis is necessary to ensure that  this minimal benefit outweighs the risks. [ 11 ] [ 12 ]  Antibiotics probably reduce pain, diminish headaches and could prevent some sore throat complications, but as these effects are small they must be balanced with the threat of antimicrobial resistance. [ 13 ]   It is not known whether antibiotics are effective for preventing  recurrent  sore throat. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4233", "text": "There is only limited evidence that a hot drink can help alleviate a sore throat, and other  common cold  and  influenza  symptoms. [ 15 ]  If the sore throat is unrelated to a cold and is caused by, for example,  tonsillitis , a cold drink may be helpful. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4234", "text": "There are also other medications such as  lozenges  which can help soothe irritated tissues of the throat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4235", "text": "Without active treatment, symptoms usually last two to seven days. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4236", "text": "In the United States, there are about 2.4 million  emergency department  visits with throat-related complaints per year. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4237", "text": "The  sphenoid bone [ note 1 ]  is an unpaired  bone  of the  neurocranium . It is situated in the middle of the  skull  towards the front, in front of the  basilar part of the occipital bone . The sphenoid bone is one of the seven bones that articulate to form the  orbit . Its shape somewhat resembles that of a  butterfly ,  bat  or  wasp  with its wings extended. The name presumably originates from this shape, since  sphekodes  ( \u03c3\u03c6\u03b7\u03ba\u03ce\u03b4\u03b7\u03c2 ) means  ' wasp-like '  in  Ancient Greek ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4238", "text": "It is divided into the following parts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4239", "text": "Two  sphenoidal conchae  are situated at the anterior and inferior part of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4240", "text": "The more important of these are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4241", "text": "These ligaments occasionally  ossify , though the incidence of ligamentous ossification (both partial and complete) varies according to the ligament type, with the interclinoid ligament being most commonly identified as having ossified and the  pterygoalar ligament  least commonly identified. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4242", "text": "The sphenoid articulates with the  frontal ,  parietal ,  ethmoid ,  temporal ,  zygomatic ,  palatine ,  vomer , and  occipital  bones and helps to connect the  neurocranium  to the  facial skeleton ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4243", "text": "Articulates with  ethmoid bone  anteriorly and basilar part of  occipital bone  posteriorly.\nIt shows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4244", "text": "Sphenoidal crest articulates with the perpendicular plate of  ethmoid  leading to formation of a part of the septum of nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4245", "text": "Basilar part of occipital bone"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4246", "text": "Carotid sulcus  lodging  cavernous sinus  and  internal carotid artery"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4247", "text": "Sphenoidal or  sphenoid sinuses  are asymmetrical air sinuses in the body of the sphenoid, closed by  sphenoidal conchae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4248", "text": "This forms the floor of the  middle cranial fossa .  It presents (starting from the front):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4249", "text": "This is divided into (by  infratemporal crest ):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4250", "text": "Foramen  pierce it:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4251", "text": "This forms the posterior wall of the  orbit [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4252", "text": "These are two triangular wings projecting laterally from anterosuperior part of the body.  Each consists of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4253", "text": "Until the seventh or eighth month of  fetal development , the body of the sphenoid consists of two parts: one in front of the  tuberculum sellae , the presphenoid, with which the small wings are continuous; the other, consisting of the  sella turcica  and  dorsum sellae , the postsphenoid, with which are associated the great wings, and pterygoid processes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4254", "text": "The greater part of the bone is ossified in cartilage. There are fourteen centers in all, six for the presphenoid and eight for the postsphenoid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4255", "text": "By about the ninth week of  fetal development  an ossific center appears for each of the  small wings  (orbito-sphenoids) just lateral to the  optic foramen ; this is followed by the appearance of two nuclei in the  presphenoid  part of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4256", "text": "The sphenoidal conchae are each developed from a center that makes its appearance about the fifth month; at birth they consist of small triangular laminae, and it is not until the third year that they become hollowed out and coneshaped; about the fourth year they fuse with the labyrinths of the  ethmoid bone , and between the ninth and twelfth years they unite with the sphenoid bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4257", "text": "The first ossific nuclei are those for the great wings ( alisphenoids ). One makes its appearance in each wing between the  foramen rotundum  and  foramen ovale  about the eighth week. The orbital plate and that part of the sphenoid, which is found in the temporal fossa, as well as the lateral pterygoid plate, are ossified in membrane (Fawcett)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4258", "text": "Soon after, the centers for the  postsphenoid part of the body  appear, one on either side of the sella turcica, and become blended together about the middle of fetal life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4259", "text": "Each  medial pterygoid plate  (except its hamulus) is ossified in membrane, and its center probably appears about the ninth or tenth week; the hamulus becomes chondrified during the third month, and almost at once ossifies (Fawcett)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4260", "text": "The medial joins the lateral pterygoid plate about the sixth month."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4261", "text": "About the fourth month, a center appears for each lingula and speedily joins the rest of the bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4262", "text": "The  presphenoid  is united to the postsphenoid about the eighth month, and at birth the sphenoid is in three pieces [Fig. 4]: a central, consisting of the body and small wings, and two lateral, each comprising a great wing and pterygoid process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4263", "text": "In the first year after birth the great wings and body unite, and the small wings extend inward above the anterior part of the body, and, meeting with each other in the middle line, form an elevated smooth surface, termed the jugum sphenoidale."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4264", "text": "By the twenty-fifth year the sphenoid and occipital are completely fused."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4265", "text": "Between the pre- and postsphenoid there are occasionally seen the remains of a canal, the canalis cranio-pharyngeus, through which, in early fetal life, the hypophyseal diverticulum of the buccal  ectoderm  is transmitted."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4266", "text": "The sphenoidal sinuses are present as minute cavities at the time of birth (Onodi), but do not attain their full size until after puberty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4267", "text": "This bone assists with the formation of the base and the sides of the skull, and the floors and walls of the orbits. It is the site of attachment for most of the muscles of  mastication . Many foramina and fissures are located in the sphenoid that carry nerves and blood vessels of the head and neck, such as the  superior orbital fissure  (with  ophthalmic nerve ),  foramen rotundum  (with  maxillary nerve ) and  foramen ovale  (with  mandibular nerve ). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4268", "text": "The sphenoid bone of humans is  homologous  with a number of bones that are often separate in other animals, and have a somewhat complex arrangement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4269", "text": "In the early  lobe-finned fishes  and  tetrapods , the pterygoid bones were flat, wing-like bones forming the major part of the roof of the mouth.  Above the pterygoids were the epipterygoid bones, which formed part of a flexible joint between the braincase and the palatal region, as well as extending a vertical bar of bone towards the roof of the skull. Between the pterygoids lay an elongated, narrow parasphenoid bone, which also spread over some of the lower surface of the braincase, and connected, at its forward end, with a  sphenethmoid  bone helping to protect the  olfactory nerves . Finally, the basisphenoid bone formed part of the floor of the braincase and lay immediately above the parasphenoid. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4270", "text": "Aside from the loss of the flexible joint at the rear of the palate, this primitive pattern is broadly retained in  reptiles , albeit with some individual modifications. In  birds , the epipterygoids are absent and the pterygoids considerably reduced. Living  amphibians  have a relatively simplified skull in this region; a broad parasphenoid forms the floor of the braincase, the pterygoids are relatively small, and all other related bones except the sphenethmoid are absent. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4271", "text": "In  mammals , these various bones are often (though not always) fused into a single structure; the sphenoid. The basisphenoid forms the posterior part of the base, while the pterygoid processes represent the pterygoid bones. The epipterygoids have extended into the wall of the cranium; they are referred to as  alisphenoids  when separate in mammals, and form the greater wings of the sphenoid when fused into a larger structure. The sphenethmoid bone forms as three bones: the lesser wings and the anterior part of the base. These two parts of the sphenethmoid may be distinguished as  orbitosphenoids  and  presphenoid , respectively, although there is often some degree of fusion. Only the parasphenoid appears to be entirely absent in mammals. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4272", "text": "In the  dog  the sphenoid is represented by eight bones: basisphenoid, alisphenoids, presphenoid, orbitosphenoids, pterygoids. These bones remain separate and are the:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4273", "text": "This article incorporates text in the  public domain  from  page 147  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4274", "text": "The  sphenoid sinus  is a paired  paranasal sinus  in the  body  of the  sphenoid bone . It is one pair of the four paired paranasal sinuses. [ 1 ]  The two sphenoid sinuses are separated from each other by a septum. Each sphenoid sinus communicates with the  nasal cavity  via the opening of sphenoidal sinus. [ 2 ] :\u200a500\u200a  The two sphenoid sinuses vary in size and shape, and are usually asymmetrical. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4275", "text": "On average, a sphenoid sinus measures 2.2\u00a0cm vertical height, 2\u00a0cm in transverse breadth; and 2.2\u00a0cm antero-posterior depth. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4276", "text": "Each spehoid sinus is in the  body of sphenoid bone , just under the  sella turcica . The sphenoid sinuses are separated from each other medially by the septum of sphenoidal sinuses, which is usually asymmetrical. [ 2 ] :\u200a500"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4277", "text": "An opening of sphenoidal sinus forms a passage between each sphenoidal sinus [ 2 ] :\u200a500\u200a  and the nasal cavity. Posteriorly, an opening of sphenoidal sinus opens into the sphenoidal sinus by an aperture high on the anterior wall the sinus; anteriorly, an opening of sphenoidal sinus opens into the roof of the nasal cavity via an aperture on the posterior wall of the  sphenoethmoidal recess , just over the  choana . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4278", "text": "The mucous membrane receives sensory [ citation needed ]  innervation from the  posterior ethmoidal nerve  (branch of the  ophthalmic nerve (CN V 1 ) ) and from branches of the  maxillary nerve (CN V 2 ) . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4279", "text": "Postganglionic   parasympathetic  fibers of the  facial nerve  that  synapsed  at the  pterygopalatine ganglion  control  mucus   secretion . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4280", "text": "Nearby structures include the  optic canal , the  optic nerve , the  internal carotid artery , the  cavernous sinus , the  trigeminal nerve , the  pituitary gland , and the  anterior ethmoidal cells . [ 2 ] :\u200a500\u200a  One study found that  carotid canal  protrudation into the sphenoid sinus wall was present in 23.9\u201332.1% of males and 35.5\u201336.2% of females, dehiscence in carotid canal was detected more in females (34%) than in males (22%),  optic canal  protrudation was 33.3 and 30.5% in males and females, and optic canal dehiscence was detected in 11.3% of males and 9.9% of females. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4281", "text": "The sphenoid sinuses vary in size and shape; because of the lateral displacement of the intervening  septum  of sphenoid sinuses, the pair rarely is symmetrical. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4282", "text": "When exceptionally large, the sphenoid sinuses may extend into the roots of the  pterygoid processes  or  greater wings of sphenoid bone , and may invade the  basilar part  of the  occipital bone . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4283", "text": "The septum of the sphenoidal sinuses may be partly or completely absent. Other septa also may be incomplete. [ 2 ] :\u200a500"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4284", "text": "The sphenoidal sinuses are minute at birth; [ 3 ] [ 4 ]  their main development takes place after puberty. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4285", "text": "The sphenoid sinuses cannot be palpated on physical examination. [ 1 ]  However, patients with isolated  sphenoid sinusitis  may complain of  occipital  or vertex headache, retro-orbital pain,  otalgia , drowsiness, or  meningitis -like symptoms. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4286", "text": "A potential complication of sphenoidal  sinusitis  is  cavernous sinus thrombosis . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4287", "text": "If a fast-growing tumor erodes the floor of the sphenoidal sinus, the  vidian nerve  may be in danger. [ citation needed ]  If the tumor spreads laterally, the  cavernous sinus  and all its constituent nerves may be in danger. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4288", "text": "Sphenoidotomy, a form of endonasal surgery, may be done to enlarge the sphenoid sinus, usually in order to drain it. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4289", "text": "The sphenoid sinus should be distinguished from an  Onodi cell , an anatomic variant that is the rearmost  ethmoidal air cell . Onodi cells typically extend back to lie superolateral to the sphenoid sinus and thus near the  optic nerve  and  internal carotid artery . [ 9 ]  Failure to recognize an Onodi cell on  CT scan  before surgery may put these structures at risk. One study found that an Onodi cell was present in 26.6% of males and 19.1% of females. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4290", "text": "Because only thin shelves of bone separate the sphenoidal sinuses from the nasal cavities, below, and from the  hypophyseal fossa , above, the  pituitary gland  can be reached surgically through the roof of the nasal cavities by passage through the anterioinferior aspect of the sphenoid bone and into the sinuses, followed by entry through the top of the sphenoid bone into the hypophyseal fossa. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4291", "text": "The  sphenopalatine artery  ( nasopalatine artery ) is an  artery  of the head, commonly known as the  artery of  epistaxis . [ 1 ]  It passes through the  sphenopalatine foramen  to reach the  nasal cavity . It is the main artery of the nasal cavity. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4292", "text": "The sphenopalatine artery is a branch of the  maxillary artery  which passes through the  sphenopalatine foramen  into the cavity of the  nose , at the back part of the  superior meatus . Here it gives off its  posterior lateral nasal branches ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4293", "text": "Crossing the under surface of the sphenoid, the sphenopalatine artery ends on the  nasal septum  as the  posterior septal branches .  Here it will  anastomose  with the branches of the  greater palatine artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4294", "text": "The sphenopalatine artery is the artery commonly responsible for epistaxis (difficult to control bleeding of the nasal cavity, especially the posterior nasal cavity). [ 3 ]  In severe nose bleed cases which do not stop after intense packing of anti-clotting agents, the sphenopalatine artery can be ligated (clipped and then cut) during open surgery or embolized (blocked with surgical glue or tiny microparticles). [ 4 ]  Embolization is typically done under  fluoroscopic  guidance with minimally invasive techniques (e.g. via small  microcatheters  inserted into arteries in the wrist or groin) by interventional radiologists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4295", "text": "This article incorporates text in the  public domain  from  page 562  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4296", "text": "The  splenius capitis  ( / \u02c8 s p l i\u02d0 n i \u0259 s   \u02c8 k \u00e6 p \u026a t \u026a s / ) (from  Greek    spl\u0113n\u00edon \u00a0'bandage' and  Latin    caput \u00a0'head' [ 1 ] [ 2 ] ) is a broad, straplike muscle in the back of the neck. It pulls on the  base of the skull  from the  vertebrae   in the neck  and upper  thorax . It is involved in movements such as shaking the head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4297", "text": "It arises from the lower half of the  nuchal ligament , from the  spinous process  of the  seventh cervical vertebra , and from the spinous processes of the upper three or four  thoracic vertebrae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4298", "text": "The fibers of the muscle are directed upward and laterally and are inserted, under cover of the  sternocleidomastoideus , into the  mastoid process  of the  temporal bone , and into the rough surface on the  occipital bone  just below the lateral third of the  superior nuchal line . The splenius capitis is deep to  sternocleidomastoideus  at the mastoid process, and to the  trapezius  for its lower portion. It is one of the muscles that forms the floor of the posterior triangle of the neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4299", "text": "The splenius capitis muscle is innervated by the  posterior ramus of spinal nerves   C3  and  C4 ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4300", "text": "The splenius capitis muscle is a prime mover for head extension. The splenius capitis can also allow lateral flexion and rotation of the  cervical spine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4301", "text": "This article incorporates text in the  public domain  from  page 397  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4302", "text": "The  stapedius  is the smallest  skeletal muscle  in the  human  body. [ 1 ]  At just over one millimeter in length, its purpose is to stabilize the smallest bone in the body, the  stapes  or stirrup bone of the middle ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4303", "text": "The stapedius emerges from a pinpoint  foramen  or opening in the apex of the  pyramidal eminence  (a hollow, cone-shaped prominence in the posterior wall of the  tympanic cavity ), and inserts into the neck of the stapes. [ 2 ]   :\u200a863"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4304", "text": "The stapedius is supplied by the  nerve to stapedius , a branch of the  facial nerve . [ 2 ]   :\u200a863"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4305", "text": "The stapedius dampens the vibrations of the stapes by pulling on the neck of that bone. [ 2 ]   :\u200a863\u200a  As one of the muscles involved in the  acoustic reflex  it prevents excess movement of the  stapes , helping to control the amplitude of  sound waves  from the general external environment to the inner  ear . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4306", "text": "Paralysis  of the stapedius allows wider  oscillation  of the stapes, resulting in heightened reaction of the  auditory ossicles  to sound vibration. This condition, known as  hyperacusis , causes normal sounds to be perceived as very loud. Paralysis of the stapedius muscle may result when the  nerve to the stapedius , a branch of the  facial nerve , is damaged, or when the facial nerve itself is damaged before the nerve to stapedius branches. In cases of  Bell's palsy , a unilateral paralysis of the facial nerve, the stapedius is paralyzed and hyperacusis may result. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4307", "text": "Like the  stapes  bone to which it attaches, the stapedius muscle shares evolutionary history with other vertebrate structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4308", "text": "The mammalian stapedius evolved from a muscle called the  depressor mandibulae  in other tetrapods, the function of which was to open the jaws (this function was taken over by the  digastric muscle  in mammals). The depressor mandibulae arose from the  levator operculi  in bony fish, and is equivalent to the  epihyoidean  in sharks. Like the stapedius, all of these muscles derive from the  hyoid arch  and are innervated by  cranial nerve VII . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4309", "text": "Rodr\u00edguez-V\u00e1zquez JF. Development of the stapedius muscle and pyramidal eminence in humans. J Anat. 2009 Sep;215(3):292-9. doi: 10.1111/j.1469-7580.2009.01105.x"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4310", "text": "The  stapes  or  stirrup  is a  bone  in the  middle ear  of humans and other tetrapods which is involved in the conduction of sound vibrations to the  inner ear . This bone is connected to the  oval window  by its  annular ligament , which allows the footplate (or base) to transmit sound energy through the  oval window  into the inner ear. The  stapes  is the smallest and lightest bone in the  human body , and is so-called because of its resemblance to a  stirrup  ( Latin :  Stapes )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4311", "text": "The  stapes  is the third bone of the three  ossicles  in the  middle ear  and the smallest in the human body. It measures roughly  2 to 3 mm , greater along the head-base span. [ 1 ]  It rests on the  oval window , to which it is connected by an  annular ligament  and articulates with the  incus , or anvil through the  incudostapedial joint . [ 2 ]  They are connected by anterior and posterior limbs ( Latin :  crura ). [ 3 ] :\u200a862"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4312", "text": "The  stapes  develops from the second  pharyngeal arch  during the sixth to eighth week of  embryological life . The central cavity of the  stapes , the  obturator foramen , is due to the presence embryologically of the  stapedial artery , which usually regresses in humans during normal development. [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4313", "text": "The  stapes  is one of three ossicles in mammals. In non-mammalian  tetrapods , the bone  homologous  to the  stapes  is usually called the  columella ; however, in  reptiles , either term may be used. In fish, the homologous bone is called the  hyomandibular , and is part of the  gill arch  supporting either the  spiracle  or the jaw, depending on the species. The equivalent term in  amphibians  is the  pars media plectra . [ 2 ] [ 5 ] :\u200a481\u2013482"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4314", "text": "The  stapes  appears to be relatively constant in size in different ethnic groups. [ 6 ]  In 0.01\u20130.02% of people, the stapedial artery does not regress, and persists in the central foramen. [ 7 ]  In this case, a pulsatile sound may be heard in the affected ear, or there may be no symptoms at all. [ 8 ]  Rarely, the  stapes  may be completely absent. [ 9 ] [ 10 ] :\u200a262"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4315", "text": "Situated between the incus and the inner ear, the  stapes  transmits sound vibrations from the incus to the oval window, a membrane-covered opening to the inner ear. The  stapes  is also stabilized by the  stapedius  muscle, which is innervated by the  facial nerve . [ 3 ] :\u200a861\u2013863"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4316", "text": "Otosclerosis  is a congenital or spontaneous-onset disease characterized by abnormal  bone remodeling  in the inner ear. Often this causes the  stapes  to adhere to the oval window, which impedes its ability to conduct sound, and is a cause of  conductive hearing loss . Clinical otosclerosis is found in about 1% of people, although it is more common in forms that do not cause noticeable hearing loss. Otosclerosis is more likely in young age groups, and females. [ 11 ]  Two common treatments are  stapedectomy , the surgical removal of the  stapes  and replacement with an artificial prosthesis, and  stapedotomy , the creation of a small hole in the base of the  stapes  followed by the insertion of an artificial prosthesis into that hole. [ 12 ]   :\u200a661\u200a  Surgery may be complicated by a  persistent stapedial artery ,  fibrosis -related damage to the base of the bone, or obliterative otosclerosis, resulting in obliteration of the base. [ 7 ] [ 10 ]   :\u200a254\u2013262"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4317", "text": "The  stapes  is commonly described as having been discovered by the professor  Giovanni Filippo Ingrassia  in 1546 at the  University of Naples , [ 13 ]   although this remains the nature of some controversy, as Ingrassia's description was published posthumously in his 1603 anatomical commentary  In Galeni librum de ossibus doctissima et expectatissima commentaria . Spanish anatomist  Pedro Jimeno  is first to have been credited with a published description, in  Dialogus de re medica  (1549). [ 14 ]  The bone is so-named because of its resemblance to a stirrup ( Latin :  stapes ), an example of a  late Latin  word, probably created in  mediaeval  times from \"to stand\" ( Latin :  stapia ), as stirrups did not exist in the early Latin-speaking world. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4318", "text": "The  sternocleidomastoid muscle  is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and  flexion  of the neck. [ 3 ]  The sternocleidomastoid is innervated by the  accessory nerve . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4319", "text": "It is given the name  sternocleidomastoid  because it originates at the  manubrium  of the  sternum  ( sterno- ) and the  clavicle  ( cleido- ) and has an  insertion  at the  mastoid process  of the  temporal bone  of the  skull . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4320", "text": "The sternocleidomastoid muscle originates from two locations: the  manubrium  of the  sternum  and the  clavicle . [ 4 ]  It travels obliquely across the side of the neck and inserts at the  mastoid process  of the  temporal bone  of the  skull  by a thin  aponeurosis . [ 4 ] [ 5 ]  The sternocleidomastoid is thick and narrow at its center, and broader and thinner at either end."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4321", "text": "The sternal head is a round  fasciculus , tendinous in front, fleshy behind, arising from the upper part of the front of the  manubrium sterni . It travels superiorly, laterally, and posteriorly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4322", "text": "The clavicular head is composed of fleshy and  aponeurotic  fibers, arises from the upper, frontal surface of the medial third of the  clavicle ; it is directed almost vertically upward."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4323", "text": "The two heads are separated from one another at their origins by a triangular interval ( lesser supraclavicular fossa ) but gradually blend, below the middle of the neck, into a thick, rounded muscle which is inserted, by a strong tendon, into the lateral surface of the  mastoid process , from its apex to its superior border, and by a thin  aponeurosis  into the lateral half of the  superior nuchal line  of the  occipital bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4324", "text": "The sternocleidomastoid is innervated by  accessory nerve  of the same side. [ 6 ] [ 7 ]  It supplies only motor fibres. The cervical plexus supplies sensation, including  proprioception , from the  ventral primary rami  of  C2  and  C3 . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4325", "text": "The clavicular origin of the sternocleidomastoid varies greatly: in some cases the clavicular head may be as narrow as the sternal; in others it may be as much as 7.5 millimetres (0.30\u00a0in) in breadth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4326", "text": "When the clavicular origin is broad, it is occasionally subdivided into several slips, separated by narrow intervals. More rarely, the adjoining margins of the sternocleidomastoid and  trapezius  are in contact. This would leave no  posterior triangle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4327", "text": "The  supraclavicularis muscle  arises from the manubrium behind the sternocleidomastoid and passes behind the sternocleidomastoid to the upper surface of the clavicle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4328", "text": "The function of this muscle is to rotate the head to the opposite side or obliquely rotate the head. [ 4 ]  It also flexes the neck. [ 4 ]  When both sides of the muscle act together, it  flexes  the neck and extends the head. When one side acts alone, it causes the head to rotate to the opposite side and flexes laterally to the same side (ipsilaterally)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4329", "text": "It also acts as an  accessory muscle of respiration , along with the  scalene muscles  of the neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4330", "text": "The signaling process to contract or relax the sternocleidomastoid begins in Cranial Nerve XI, the  accessory nerve . The accessory nerve nucleus is in the  anterior horn of the spinal cord  around C1-C3, where lower motor neuron fibers mark its origin. The fibers from the accessory nerve nucleus travel upward to enter the cranium via the foramen magnum. The internal carotid artery to reach both the sternocleidomastoid muscles and the  trapezius . After a signal reaches the accessory nerve nucleus in the anterior horn of the spinal cord, the signal is conveyed to  motor endplates  on the muscle fibers located at the clavicle.  Acetylcholine  (ACH) is released from vesicles and is sent over the synaptic cleft to receptors on the postsynaptic bulb. The ACH causes the resting potential to increase above -55mV, thus initiating an action potential which travels along the muscle fiber. Along the muscle fibers are t-tubule openings which facilitate the spread of the action potential into the muscle fibers. The t-tubule meets with the  sarcoplasmic reticulum  at locations throughout the muscle fiber, at these locations the sarcoplasmic reticulum releases calcium ions that results in the movement of  troponin  and  tropomyosin  on thin filaments. The movement of troponin and tropomyosin is key in facilitating the myosin head to move along the thin filament, resulting in a contraction of the sternocleidomastoid muscle. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4331", "text": "The sternocleidomastoid is within the  investing fascia  of the neck, along with the  trapezius muscle , with which it shares its nerve supply (the  accessory nerve ). It is thick and thus serves as a primary  landmark  of the neck, as it divides the neck into anterior and posterior cervical triangles (in front and behind the muscle, respectively) which helps define the location of structures, such as the lymph nodes for the head and neck. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4332", "text": "Many important structures relate to the sternocleidomastoid, including the  common carotid artery , accessory nerve, and  brachial plexus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4333", "text": "Examination of the sternocleidomastoid muscle forms part of the  examination of the cranial nerves . It can be felt on each side of the neck when a person moves their head to the opposite side. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4334", "text": "The triangle formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid muscle is used as a landmark in identifying the correct location for  central venous catheterization . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4335", "text": "Contraction of the muscle gives rise to a condition called  torticollis  or  wry neck , and this can have a number of causes.  Torticollis gives the appearance of a tilted head on the side involved. Treatment involves physiotherapy exercises to stretch the involved muscle and strengthen the muscle on the opposite side of the neck.  Congenital torticollis  can have an unknown cause or result from  birth trauma  that gives rise to a mass or tumor that can be palpated within the muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4336", "text": "This article incorporates text in the  public domain  from  page 390  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4337", "text": "The  stomatognathic system  is an anatomical system comprising the  teeth ,  jaws , and associated soft tissues. It was formerly called the  stomognathic system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4338", "text": "Stomatognathic diseases  are treated by  dentists ,  maxillofacial surgeons ,  ear, nose, and throat specialists ,  speech therapists ,  occupational therapists ,  myofunctional therapists , and  physical therapists ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4339", "text": "The  stylohyoid muscle  is one of the  suprahyoid muscles . [ 1 ]  Its originates from the styloid process of the  temporal bone ; it inserts onto hyoid bone. It is innervated by a branch of the  facial nerve . It acts draw the  hyoid bone  upwards and backwards."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4340", "text": "The stylohyoid is a  slender   muscle . [ 2 ]  It is directed inferoanteriorly from its origin towards its insertion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4341", "text": "It is perforated near its insertion by the intermediate  tendon  of the  digastric muscle . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4342", "text": "The muscle arises from the posterior surface of the  temporal styloid process ; it arises near the base of the process. It arises by a small tendon of origin. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4343", "text": "The muscle inserts onto the  body of hyoid bone  at the junction of the body and  greater cornu . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4344", "text": "The site of insertion is situated immediately superior to that of the superior belly of  omohyoid muscle . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4345", "text": "The stylohyoid muscle receives arterial supply branches of the  facial artery ,  posterior auricular artery , and  occipital artery . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4346", "text": "The stylohyoid muscle receives motor innervation from the  stylohyoid branch  of  facial nerve (CN VII) . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4347", "text": "The muscle is situated  antero superior  to the posterior belly of the  digastric muscle . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4348", "text": "It may be absent or doubled. It may be situated medial to the  carotid artery . It may insert suprahyoid muscles of infrahyoid muscles. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4349", "text": "The stylohyoid muscle elevates and retracts the hyoid bone (i.e. draws it superiorly and posteriorly). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4350", "text": "The stylohyoid muscle elongates the floor of the mouth. [ 3 ]  It initiates a swallowing. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4351", "text": "This article incorporates text in the  public domain  from  page 392  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4352", "text": "Anatomy figure: 34:02-04  at Human Anatomy Online, SUNY Downstate Medical Center"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4353", "text": "The  stylomastoid foramen  is a  foramen  between the  styloid  and  mastoid  processes of the  temporal bone  of the  skull . It is the termination of the  facial canal , and transmits the  facial nerve , and  stylomastoid artery . Facial nerve  inflammation  in the stylomastoid foramen may cause  Bell's palsy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4354", "text": "The stylomastoid foramen is between the  styloid  and  mastoid  processes of the  temporal bone . The average distance between the opening of the stylomastoid foramen and the styloid process is around 0.7 mm or 0.8 mm in adults, but may decrease to around 0.2 mm during aging. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4355", "text": "The stylomastoid foramen transmits the  facial nerve , [ 2 ] [ 3 ]  and the  stylomastoid artery . [ 3 ]  These 2 structures lie directly next to each other. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4356", "text": "Bell's palsy  can result from  inflammation  of the  facial nerve  where it leaves the skull at the stylomastoid foramen. Patients with Bell's palsy appear with facial drooping on the affected side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4357", "text": "The  sublingual gland  ( glandula sublingualis ) is a seromucous polystomatic  exocrine gland . Located underneath the oral diaphragm ( diaphragma oris ), the sublingual gland is the smallest and most diffuse of the three major salivary glands of the oral cavity, with the other two being the  submandibular  and  parotid . The sublingual gland provides approximately 3-5% of the total salivary volume. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4358", "text": "They lie anterior and superior to the  submandibular gland  and inferior and lateral to the  tongue , as well as beneath the  mucous membrane  of the floor of the mouth. They are bound laterally by the bone of the mandible and inferolaterally by the  mylohyoid muscle .  The glands can be felt behind each mandibular canine. Placing one index finger within the mouth and the fingertips of the opposite hand outside it, the compressed gland is manually palpated between the inner and outer fingers. [ clarification needed ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4359", "text": "The sublingual gland is constituted by 1 major duct and approximately 20 small excretory ducts, with the latter often being referred to as  ducts of Rivinus . [ 4 ]  The largest of all, the  sublingual duct  (of Bartholin) joins the submandibular duct to drain through the  sublingual caruncle . The sublingual caruncle is a small papilla near the midline of the floor of the mouth on each side of the lingual frenum. [ 3 ]  Most of the remaining small sublingual ducts (of Rivinus) open separate into the mouth on an elevated crest of mucous membrane, the  plica sublingualis  (aka  sublingual fold ), formed by the gland and located on either side of the  frenulum linguae ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4360", "text": "The sublingual gland consists mostly of mucous acini capped with  serous demilunes  and is therefore categorized as a mixed mucous gland with a mucous product predominating.  Striated  and  intercalated  ducts are also present. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4361", "text": "The gland receives its blood supply from the sublingual and submental arteries. [ 4 ]  Lymph from the sublingual salivary gland drains into the  submandibular lymph nodes . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4362", "text": "The  chorda tympani  nerve (from the  facial nerve  via the  submandibular ganglion ) is  secretomotor  and provides parasympathetic supply to the sublingual glands. The path of the nerve is as follows: junction between  pons  and  medulla , through  internal acoustic meatus  and  facial canal  to  chorda tympani , through middle ear cavity, out petrotympanic fissure to join the  lingual nerve , travels with lingual nerve to synapse at the  submandibular ganglion , then  postganglionic  fibers travels to the sublingual gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4363", "text": "The sublingual salivary glands appear in the eighth week of prenatal development, two weeks later than the other two major salivary glands. They develop from  epithelial  buds in the sulcus surrounding the sublingual folds on the floor of the mouth, lateral to the developing submandibular gland. These buds branch and form into cords that canalize to form the sublingual ducts associated with the gland. The rounded terminal ends of the cords form  acini . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4364", "text": "Ranulas  are the most common pathologic lesion associated with the sublingual glands. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4365", "text": "The  sublingual space  is a  fascial space of the head and neck  (sometimes also termed fascial spaces or tissue spaces). It is a  potential space [ 1 ]  located below the mouth and above the  mylohyoid muscle , and is part of the suprahyoid group of fascial spaces."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4366", "text": "The sublingual space is V-shaped, with the apex pointing to the anterior. Its boundaries are: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4367", "text": "The sublingual space communicates posteriorly around the posterior free border of the mylohyoid muscle with the  submandibular space . [ 2 ]  Infections of the sublingual space may also erode through the mylohyoid, or spread via the lymphatics to the submandibular and  submental spaces ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4368", "text": "The sublingual space contains: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4369", "text": "This space may be created by pathology, such as the spread of  pus  in an infection, e.g.  odontogenic infections . A  periapical abscess  may spread into the sublingual space if the apex of the tooth is above the level of attachment of mylohyoid, and the infection erodes through the lingual cortical plate of the mandible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4370", "text": "Signs and symptoms of a sublingual space infection might include a firm, painful swelling in the anterior part of the floor of the mouth. A sublingual abscess may elevate the tongue and cause drooling or  dysphagia  (difficulty swallowing). There is usually little swelling visible on the face outside the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4371", "text": "If the space contains pus, the usual treatment is by  incision and drainage . The site of the incision is intra-oral, made lateral to sublingual plica. Incision of the plica itself can result in a  ranula , or an incision placed medial to the plica can damage Wharton's duct, the sublingual artery and veins and the lingual nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4372", "text": "Pathology arising from the sublingual gland is rare, however, sublingual gland  neoplasms  are predominantly  malignant  and thus important to recognize."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4373", "text": "Ludwig's angina  is a serious infection involving the submandibular, sublingual and submental spaces bilaterally. [ 3 ]  Ludwig's angina may extend into the pharyngeal and cervical spaces, and the swelling can compress the airway and cause  dyspnoea  (difficulty breathing). [ 3 ]  Collectively, the submandibular, sublingual and submental spaces are sometimes termed the perimandibular spaces, or the submaxillary space. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4374", "text": "The  submandibular ganglion  (or  submaxillary ganglion  in older texts) is part of the human  autonomic nervous system . It is one of four  parasympathetic ganglia  of the head and neck. (The others are the  otic ganglion ,  pterygopalatine ganglion , and  ciliary ganglion )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4375", "text": "The submandibular ganglion is small and  fusiform  in shape. It is situated above the deep portion of the  submandibular gland , on the  hyoglossus muscle , near the posterior border of the  mylohyoid muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4376", "text": "The ganglion 'hangs' by two nerve filaments from the lower border of the  lingual nerve  (itself a branch of the  mandibular nerve , CN V 3 ). It is suspended from the lingual nerve by two filaments, one anterior and one posterior. Through the posterior of these it receives a branch from the  chorda tympani  nerve which runs in the sheath of the lingual nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4377", "text": "Like other parasympathetic ganglia of the head and neck, the submandibular ganglion is the site of synapse for parasympathetic fibers and carries other types of nerve fiber that do not synapse in the ganglion. In summary, the fibers carried in the ganglion are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4378", "text": "The paired  submandibular glands  (historically known as  submaxillary glands ) are major  salivary glands  located beneath the  floor of the mouth . In adult humans, they each weigh about 15 grams and contribute some 60\u201367% of unstimulated saliva secretion; on stimulation their contribution decreases in proportion as  parotid gland  secretion rises to 50%. [ 1 ]  The average length of the normal adult human submandibular salivary gland is approximately 27\u00a0mm, while the average width is approximately 14.3\u00a0mm. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4379", "text": "Each submandibular gland is divided into a superficial lobe and a deep lobe, the two being separated by the  mylohyoid muscle : [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4380", "text": "Secretions are delivered into the  submandibular duct  on the deep portion after which they hook around the posterior edge of the mylohyoid muscle and proceed on the superior surface laterally. The excretory ducts are then crossed by the  lingual nerve , and ultimately drain into the  sublingual caruncles  \u2013 small prominences on either side of the  lingual frenulum  along with the major  sublingual duct . The gland can be bilaterally  palpated  (felt) inferior and posterior to the body of the mandible, moving inward from the inferior border of the mandible near its angle with the head tilted forwards. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4381", "text": "The terminal part of the submandibular (Wharton's) duct is located in the mouth floor and opens as an orifice of the submandibular duct papilla. The position of the duct and its 0.5\u20131.5\u00a0mm wide ostium is invariably symmetric, but quite unpredictable; consequently, submandibular duct papillae can occasionally be challenging to recognize. Based on the macroscopic appearance of the papillae and a  sialoendoscopic  approach, Anicin et al. described four different types of submandibular gland papillae: types A, B, C, and D. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4382", "text": "Lobes contain smaller lobules, which contain  adenomeres , the secretory units of the gland. Each adenomere contains one or more  acini , or alveoli, which are small clusters of cells that secrete their products into a duct. The acini of each adenomere are composed of either  serous  or  mucous cells , with serous adenomeres predominating. [ 6 ]  Some mucous adenomeres may also be capped with a  serous demilune , a layer of  lysozyme -secreting serous cells resembling a half moon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4383", "text": "Like other  exocrine glands , the submandibular gland can be classified by the microscopic anatomy of its secretory cells and how they are arranged. Because the glands are branched, and because the tubules forming the branches contain secretory cells, submandibular glands are classified as  branched tubuloacinar glands . Further, because the secretory cells are of both serous and mucous types, the submandibular gland is a mixed gland, and though most of the cells are serous, the exudate is chiefly mucous.  It has long striated ducts and short intercalated ducts. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4384", "text": "The secretory acinar cells of the submandibular gland have distinct functions. The mucous cells are the most active and therefore the major product of the submandibular glands is saliva which is mucoid in nature. Mucous cells secrete mucin which aids in the lubrication of the food bolus as it travels through the esophagus. In addition, the serous cells produce salivary amylase, which aids in the breakdown of starches in the mouth. The submandibular gland's highly active acini account for most of the salivary volume. The parotid and sublingual glands account for the remaining."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4385", "text": "The gland receives its blood supply from the facial and lingual arteries. [ 8 ]  The gland is supplied by sublingual and submental arteries and drained by common facial and lingual veins."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4386", "text": "The lymphatics from submandibular gland first drain into submandibular lymph nodes and subsequently into jugulo - digastric lymph nodes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4387", "text": "Their secretions, like the secretions of other salivary glands, are regulated  directly  by the  parasympathetic nervous system  and  indirectly  by the  sympathetic nervous system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4388", "text": "The submandibular gland occurs within the  submandibular triangle . It is situated posteroinferior to the  ramus of mandible , [ 12 ] :\u200a601\u200a  and between the two bellies of the  digastric muscle . [ 12 ] :\u200a601"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4389", "text": "The submandibular salivary glands develop later than the parotid glands and appear late in the sixth week of prenatal development. They develop bilaterally from epithelial buds in the sulcus surrounding the sublingual folds on the floor of the primitive mouth. Solid cords branch from the buds and grow posteriorly, lateral to the developing tongue. The cords of the submandibular gland later branch further and then become canalized to form the ductal part. The submandibular gland acini develop from the cords\u2019 rounded terminal ends at 12 weeks, and secretory activity via the submandibular duct begins at 16 weeks. Growth of the submandibular gland continues after birth with the formation of more acini. Lateral to both sides of the tongue, a linear groove develops and closes over to form the submandibular duct. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4390", "text": "The submandibular gland is one of the major three glands that provide the mouth with  saliva . The\ntwo other types of  salivary  glands are  parotid  and  sublingual  glands. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4391", "text": "The submandibular gland releases a host of factors which regulate systemic inflammatory responses and modulate systemic immune and inflammatory reactions.  Early work in identifying factors that played a role in the cervical sympathetic trunk-submandibular gland (CST-SMG) axis lead to the discovery of a seven  amino acid   peptide , called the submandibular gland peptide-T.  SGP-T was demonstrated to have biological activity and thermoregulatory properties related to  endotoxin  exposure. [ 14 ]  SGP-T, an isolate of the submandibular gland, demonstrated its immunoregulatory properties and potential role in modulating the CST-SMG axis, and subsequently was shown to play an important role in the control of inflammation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4392", "text": "The submandibular gland accounts for 80% of all  salivary duct calculi  (salivary stones or sialolith), possibly due to the different nature of the saliva that it produces and the tortuous travel of the submandibular duct to its ductal opening for a considerable upward distance. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4393", "text": "Benign and malignant tumors can also develop in the submandibular gland (see pie chart)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4394", "text": "The  submandibular space  is a  fascial space of the head and neck  (sometimes also termed fascial spaces or tissue spaces). It is a  potential space , and is paired on either side, located on the superficial surface of the  mylohyoid muscle  between the anterior and posterior bellies of the  digastric muscle . [ 1 ]  The space corresponds to the anatomic region termed the  submandibular triangle , part of the  anterior triangle of the neck ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4395", "text": "The anatomic boundaries of each submandibular space are: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4396", "text": "The communications of the submandibular space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4397", "text": "In health, the contents of the space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4398", "text": "Infections  may spread into the submandibular space, e.g.  odontogenic infections , often related to the  mandibular molar  teeth. This is due to the fact that the attachment of mylohyoid (the  mylohyoid line ) becomes more superior towards the posterior of the mandible, meaning that the roots of the posterior teeth are more likely to be below mylohyoid than above."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4399", "text": "Signs and symptoms of a submandibular space infection might include  trismus  (difficulty opening the mouth), inability to  palpate  (feel) the inferior border of the mandible and swelling of the face over the submandibular region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4400", "text": "If the space contains pus, the usual treatment is by  incision and drainage . The site of the incision is extra-oral, and usually made 2\u20133\u00a0cm below, and parallel to, the inferior border of the mandible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4401", "text": "Ludwig's angina  is a serious infection involving the submandibular, sublingual and submental spaces bilaterally. [ 3 ]  Ludwig's angina may extend into the pharyngeal and cervical spaces, and the swelling can compress the airway and cause  dyspnoea  (difficulty breathing). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4402", "text": "The  submasseterric space  (also termed the  masseteric space ) is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a  potential space  in the face over the angle of the jaw, and is paired on each side. It is located between the lateral aspect of the mandible and the medial aspect of the  masseter muscle  and its  investing fascia . The term is derived from  sub-  meaning \"under\" in Latin and  masseteric  which refers to the masseter muscle. The submasseteric space is one of the four  compartments  of the  masticator space . [ 1 ]  Sometimes the submasseteric space is described as a series of spaces, created because the masseter muscle has multiple insertions that cover most of the lateral surface of the  ramus of the mandible ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4403", "text": "The boundaries of each submasseteric space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4404", "text": "The communications of each submasseteric space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4405", "text": "Submasseteric abscesses are relatively rare, and may be confused with a  parotid abscess  or  parotitis . [ 2 ]  They tend to be chronic. [ 3 ]  The submasseteric space may be involved by infections that spread from the buccal space. [ 1 ]  Sometimes  mandibular fractures  in the region of the angle of the mandible may cause an infection of the submasseteric space. [ 1 ]  The signs and symptoms of a submasseteric abscess may include marked  trismus  (i.e. difficulty opening the mouth, since the masseter elevates the mandible and it becomes restricted) and swelling in the region of the masseter muscle. [ 1 ]  The treatment of a submasseteric space infection is usually by surgical  incision and drainage , and the incision is placed intra-orally (inside the mouth) or both intra and extra-orally if other parts of the masticator space are involved."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4406", "text": "The submasseteric space is sometimes involved by the spread of  odontogenic infections , such as a  pericoronal abscess  associated with an  impacted   mandibular third molar  (lower wisdom tooth) when the apices of the tooth lie very close to or within the space. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4407", "text": "The  submental space  is a  fascial space of the head and neck  (sometimes also termed  fascial  spaces or tissue spaces). It is a  potential space  located between the  mylohyoid muscle   superiorly , the  platysma muscle   inferiorly , [ 1 ]  under the chin in the midline. The space coincides with the  anatomic  region termed the  submental triangle , part of the  anterior triangle of the neck ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4408", "text": "The boundaries of the submental space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4409", "text": "The communications of the submental space are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4410", "text": "Its contents are submental  lymph nodes ,  areolar connective tissue  and the  anterior jugular veins ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4411", "text": "This space may be created by pathology, such as the spread of  pus  in an infection.  Odontogenic infection  of the mandibular anterior teeth may erode through the lingual cortical plate of the mandible. If the level at which the infection breaks out of the mandible is below the attachment of the mylohyoid, then it will spread into the submental space. [ 1 ]  However, it is more usual for odontogenic infections to spread into the submental space via first involving the submandibular space. Cutaneous infections or symphyseal/parasymphyseal  mandibular fractures  may also give rise to a submental space infection. Signs and symptoms of a severe submental  abscess  include a firm swelling below the chin and  dysphagia  (difficulty swallowing). Treatment is by surgical  incision and drainage , with the incision running transversely in a skin crease behind the chin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4412", "text": "Ludwig's angina  is a progressive  cellulitis  involving the submandibular, sublingual and submental spaces bilaterally. Ludwig's angina may extend into the pharyngeal and cervical spaces, and the swelling can compress the airway and cause  dyspnoea  (difficulty breathing). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4413", "text": "Superficial muscular aponeurotic system  (or  superficial musculoaponeurotic system [ 1 ] ) ( SMAS ) is a thin yet tough [ 2 ] :\u200a438\u200a  unitary tissue plane of the face [ 3 ]  formed by facial fasciae, subcutis connective tissue, and facial muscles. [ 2 ] :\u200a438\u200a  Its composition varies, containing muscle fibres in some areas, and fibrous or fibroaponeurotic tissue in others. [ 3 ]  It connects to the dermis via vertical septa. [ citation needed ]  It does not attach to bone. In most areas, a distinct plane can be defined deep to the SMAS (continuous with that formed between the platysma and underlying  investing layer of deep cervical fascia ). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4414", "text": "Superiorly, the SMAS extends to the  galea aponeurotica  of [ citation needed ]  the scalp, [ 2 ] :\u200a438\u200a  becoming continuous with  temporoparietal fascia [ 1 ] [ 1 ]  (at the  zygomatic arch [ 1 ] ) and galea. [ citation needed ]  It becomes continuous with the  platysma muscle  inferiorly (inferior to the inferior border of the mandible), and indistinct laterally (inferior to the  zygomatic arch ). Anteromedially, it blends with the  epimysium  of some facial muscles; [ 3 ]  a link between facial muscles and the skin of the face is thereby established, enabling  facial expression . [ 2 ] :\u200a429\u200a  Over the parotid gland, the SMAS is firmly united with the superficial layer of  parotid fascia . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4415", "text": "The SMAS is clinically important in  facial   plastic surgery  for  rhytidectomy (facelift procedure) . During this procedure, the SMAS is accessed through an arch-shaped incision anterior to the ear; a portion of the SMAS is then excised and the remaining SMAS is stretched by drawing it posterior-ward and suturing it, thus making the skin of the face which overlies the SMAS taut. [ 2 ] :\u200a438"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4416", "text": "This  muscle  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4417", "text": "The  superior labial artery  ( superior labial branch of facial artery ) is larger and more egregious than the  inferior labial artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4418", "text": "It follows a similar course along the edge of the  upper lip , lying between the  mucous membrane  and the  orbicularis oris , and anastomoses with the artery of the opposite side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4419", "text": "It supplies the upper lip, and gives off in its course two or three vessels which ascend to the nose; a septal branch ramifies on the  nasal septum  as far as the point of the  nose , and an alar branch supplies the  ala of the nose ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4420", "text": "This article incorporates text in the  public domain  from  page 555  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4421", "text": "Surgical airway management  ( bronchotomy [ 1 ]  or  laryngotomy ) is the medical procedure ensuring an open  airway  between a patient\u2019s  lungs  and the outside world. Surgical methods for airway management rely on making a surgical incision below the  glottis  in order to achieve direct access to the  lower respiratory tract , bypassing the  upper respiratory tract . Surgical airway management is often performed as a last resort in cases where orotracheal and nasotracheal  intubation  are impossible or  contraindicated . Surgical airway management is also used when a person will need a  mechanical ventilator  for a longer period. The surgical creation of a permanent opening in the  larynx  is referred to as laryngostomy.\nSurgical airway management is a primary consideration in  anaesthesia ,  emergency medicine  and  intensive care medicine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4422", "text": "Surgical methods for airway management include  cricothyrotomy  and  tracheostomy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4423", "text": "Asclepiades of Bithynia  is credited with being the first person who proposed bronchotomy as a surgical procedure, though he never attempted to perform one. [ 2 ]   Aretaeus of Cappadocia  thought the procedure dangerous even as a remedy for  choking , since the resulting incision \" would not heal, as being  cartilaginous \";  Caelius Aurelianus  also rejected its usefulness. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4424", "text": "A cricothyrotomy is an incision made through the skin and  cricothyroid membrane  to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body,  angioedema , or massive facial trauma. [ 3 ]   A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4425", "text": "A needle cricothyrotomy is similar to a cricothyrotomy, but instead of making a scalpel incision, a large over-the-needle catheter is inserted (10- to 14-gauge). This is considerably simpler, particularly if using specially designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called  percutaneous transtracheal ventilation  (PTV)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4426", "text": "A tracheotomy is a surgically created opening from the skin of the neck down to the trachea. [ 5 ]  A tracheotomy may be considered where a person will need to be on a mechanical ventilator for a longer period. [ 5 ]  The advantages of a tracheotomy include less risk of infection and damage to the trachea such as tracheal stenosis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4427", "text": "The  temporal bones  are situated at the sides and base of the  skull , and lateral to the  temporal lobes  of the  cerebral cortex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4428", "text": "The temporal bones are overlaid by the sides of the head known as the  temples  where four of the cranial bones fuse. Each temple is covered by a  temporal muscle . The temporal bones house the structures of the  ears . The lower seven  cranial nerves  and the major vessels to and from the  brain  traverse the temporal bone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4429", "text": "The temporal bone consists of four parts\u2014the  squamous ,  mastoid ,  petrous  and  tympanic  parts. [ 1 ] [ 2 ]  The squamous part is the largest and most superiorly positioned relative to the rest of the bone. The  zygomatic process  is a long, arched process projecting from the lower region of the squamous part and it articulates with the  zygomatic bone . Posteroinferior to the squamous is the mastoid part. Fused with the squamous and mastoid parts and between the  sphenoid  and  occipital bones  lies the  petrous part , which is shaped like a pyramid. The tympanic part is relatively small and lies inferior to the squamous part, anterior to the mastoid part, and superior to the  styloid process . The styloid, from the  Greek   stylos , is a phallic shaped pillar directed inferiorly and anteromedially between the  parotid gland  and  internal jugular vein . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4430", "text": "The temporal bone is  ossified  from eight centers, exclusive of those for the  internal ear  and the  tympanic ossicles : one for the squama including the zygomatic process, one for the tympanic part, four for the petrous and mastoid parts, and two for the styloid process. Just before the end of  prenatal development  [Fig. 6] the temporal bone consists of three principal parts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4431", "text": "Apart from size increase, the chief changes from birth through puberty in the temporal bone are as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4432", "text": "Glomus jugulare tumor:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4433", "text": "Temporal bone fractures were historically divided into three main categories,  longitudinal , in which the vertical axis of the fracture paralleled the petrous ridge,  horizontal , in which the axis of the fracture was perpendicular to the petrous ridge, and  oblique , a mixed type with both longitudinal and horizontal components. Horizontal fractures were thought to be associated with injuries to the  facial nerve , and longitudinal with injuries to the  middle ear ossicles . [ 6 ] \nMore recently, delineation based on disruption of the  otic capsule  has been found as more reliable in predicting complications such as facial nerve injury,  sensorineural hearing loss ,  intracerebral hemorrhage , and  cerebrospinal fluid   otorrhea . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4434", "text": "In many animals some of these parts stay separate through life:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4435", "text": "In evolutionary terms, the temporal bone is derived from the fusion of many bones that are often separate in non-human mammals:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4436", "text": "Its exact etymology is unknown. [ 9 ]  It is thought to be from the Old French  temporal  meaning \"earthly\", which is directly from the Latin  tempus  meaning \"time, proper time or season.\" Temporal bones are situated on the sides of the skull, where grey hairs usually appear early on. Or it may relate to the pulsations of the underlying superficial temporal artery, marking the time we have left here. There is also a probable connection with the Greek verb  temnion , to wound in battle. The skull is thin in this area and presents a vulnerable area for a blow from a battle axe. [ 10 ]  Another possible etymology is described at  Temple (anatomy) ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4437", "text": "This article incorporates text in the  public domain  from  page 138  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4438", "text": "The  temporal branches of the facial nerve  ( frontal branch of the facial nerve ) crosses the  zygomatic arch  to the temporal region, supplying the  auriculares anterior  and superior, and joining with the  zygomaticotemporal branch  of the  maxillary nerve , and with the  auriculotemporal branch  of the  mandibular nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4439", "text": "The more anterior branches supply the  frontalis , the  orbicularis oculi , and  corrugator supercilii , and join the  supraorbital  and  lacrimal branches  of the  ophthalmic . The temporal branch acts as the efferent limb of the  corneal reflex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4440", "text": "The temporal branch of the  facial nerve  is typically found between the  temporoparietal fascia  (i.e., superficial temporal fascia) and  temporal fascia  (i.e., deep temporal fascia). This layer is also known as the innominate fascia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4441", "text": "There are several methods using anatomic landmarks that may be used to find the temporal branch of the  facial nerve . One method is using Pitanguy's line, which is defined as running from 0.5\u00a0cm below the  tragus  to 1.5\u00a0cm above the lateral eyebrow. [ 1 ]  Another method is to recognize that the temporal branch runs between the lines from the earlobe to the hairline and from the earlobe to the lateral eyebrow."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4442", "text": "To test the function of the temporal branches of the facial nerve, a patient is asked to frown and wrinkle their forehead."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4443", "text": "This  neuroscience  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4444", "text": "The  temporal styloid process  is a slender bony  process  of the  temporal bone  extending downward and forward from the undersurface of the  temporal bone [ 1 ]  just below the ear. [ citation needed ]  The styloid process gives attachments to several muscles, and ligaments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4445", "text": "The styloid process is a slender and pointed bony process of the temporal bone projecting anteroinferiorly from the inferior surface of the  temporal bone [ 1 ]  just below the ear. [ citation needed ]  Its length normally ranges from just under 3\u00a0cm to just over 4\u00a0cm. It is usually nearly straight, but may be curved in some individuals. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4446", "text": "Its  proximal  ( tympanohyal )  part  is ensheathed by the  tympanic part of the temporal bone   (vaginal process), whereas  its  distal (stylohyal)   part  gives attachment to several structures. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4447", "text": "The styloid process gives attachments to several muscles, and ligaments. [ 1 ]  It serves as an anchor point for several muscles associated with the  tongue  and  larynx . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4448", "text": "The parotid gland is situated laterally to the styloid process, the external carotid artery passes by its apex, the facial nerve crosses its base, and the attachment of the stylopharyngeus muscle separates it from the internal jugular vein medially. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4449", "text": "The styloid process arises from  endochondral ossification  of the  cartilage  from the second  pharyngeal arch . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4450", "text": "A small percentage of the population will suffer from an elongation of the styloid process and stylohyoid ligament  calcification . This condition is also known as  Eagle syndrome . The tissues in the throat rub on the styloid process during the act of swallowing with resulting pain along the glossopharyngeal nerve. There is also pain upon turning the head or extending the tongue. Other symptoms may include voice alteration, cough, dizziness, migraines, occipital neuralgia, pain in teeth and jaw and sinusitis or bloodshot eyes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4451", "text": "This article incorporates text in the  public domain  from  page 145  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4452", "text": "In  vertebrate anatomy , the  throat  is the front part of the  neck , internally positioned in front of the  vertebrae . It contains the  pharynx  and  larynx . An important section of it is the  epiglottis , separating the  esophagus  from the  trachea  (windpipe), preventing food and drinks being inhaled into the  lungs . The throat contains various  blood vessels ,  pharyngeal muscles , the  nasopharyngeal tonsil , the  tonsils , the  palatine uvula , the trachea, the  esophagus , and the  vocal cords . [ 1 ] [ 2 ]   Mammal  throats consist of two  bones , the  hyoid bone  and the  clavicle . The \"throat\" is sometimes thought to be synonymous for the  fauces . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4453", "text": "It works with the mouth,  ears  and  nose , as well as a number of other parts of the body. Its pharynx is connected to the mouth, allowing speech to occur, and food and liquid to pass down the throat. It is joined to the nose by the  nasopharynx  at the top of the throat, and to the ear by its  Eustachian tube . [ 4 ]  The throat's trachea carries inhaled air to the  bronchi  of the lungs. The esophagus carries food through the throat to the  stomach . [ 5 ]   Adenoids  and tonsils help prevent infection and are composed of lymph tissue. The larynx contains vocal cords, the epiglottis (preventing food/liquid inhalation), and an area known as the subglottic larynx, in children it is the narrowest section of the upper part of the throat. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4454", "text": "The  jugulum  is a low part of the throat, located slightly above the breast. [ 8 ]  The term  jugulum  is reflected both by the internal and external  jugular veins , which pass through the  jugulum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4455", "text": "Thyroplasty  is a phonosurgical technique designed to improve the voice by altering the  thyroid cartilage  of the  larynx  (the voice box), which houses the  vocal cords  in order to change the position or the length of the vocal cords."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4456", "text": "There are four different types of thyroplasty procedures described by Isshiki:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4457", "text": "It is the most commonly used surgical procedure to correct unilateral vocal cord paralysis (a condition where the vocal cord of one side is paralysed)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4458", "text": "In this type of thyroplasty, a rectangular portion of the thyroid cartilage is mobilized and pushed towards the medial side using a piece of silastic block of proper shape under local anesthesia. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4459", "text": "Earlier, the piece of the thyroid cartilage was kept along with implant and the stitches were taken, but nowadays, the piece of the thyroid cartilage is cut and removed to avoid complications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4460", "text": "Currently, there are four types of implant procedures which are used to perform type 1 thyroplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4461", "text": "This system was discovered after years of research and the main advantage of this implant system is that it eliminates the process of customizing the implant at the time of surgery. This system consists of different sizes and shapes of shims made of silastic. It has the most proven success rate and the duration of the procedure is slow in comparison to other implant system. The other advantage is that it does not require suturing. It has reduced incidence of trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4462", "text": "This system consists of different sizes and shapes of implants made from  hydroxyapatite  (a naturally occurring mineral form of calcium  apatite ). It helps in achieving accurate vocal fold medialization. This procedure is technically reversible. But it should be used in candidates of permanent implantation due to its biocompatible clinical use lasting for nearly a decade."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4463", "text": "This system generally consists of two sizes of implants made out of pure titanium. It has a lot of advantages and the main one is that it reduces the operative time. Titanium is safer than other implants. It has great biocompatibility. The implants are available in only two variants and they are designed in such a way that they ensure optimal fixation. The implant can be easily made as the titanium sheet is easy to shape. The technique is relatively simple and does not require expensive instruments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4464", "text": "In this type of implant system, the implant is made of homopolymer of  polytetrafluoroethylene  in form of minute beads arranged in a fine fiber mesh. It is  malleable  and can be inserted through a small window. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4465", "text": "It is a surgical procedure used in conditions like adductor spasmodic dysphonia (a condition in which there is distortion of the voice due to excessively tight closure of the glottis on phonation).\nGenerally, lateralization thyroplasty is intended to prevent this tight closure of the glottis at the terminal stage of phonation by lateralizing the position of the vocal cord.\nThis is a completely mechanical process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4466", "text": "An incision is made at midline of the thyroid cartilage. A silicon wedge is used to fix the incised thyroid cartilage in the newly abducted position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4467", "text": "A specially devised titanium bridge is used instead of silicon wedge. Nowadays, instead of one titanium bridge, two titanium bridges are used for permanent fixation of the thyroid cartilage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4468", "text": "This procedure is generally done to lower the vocal pitch by shortening the thyroid ala."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4469", "text": "In this thyroplasty, the relaxation of the vocal cords is done by antero-posterior shortening of the thyroid ala."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4470", "text": "This procedure is done to elevate the vocal pitch.\nThis procedure consists of lengthening of the thyroid cartilage. It includes  cricothyroid approximation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4471", "text": "In some specific conditions, different types of thyroplasties are combined for the desired results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4472", "text": "The main purpose of this combination is the medialization of the entire vocal cord (anterior and posterior)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4473", "text": "Thyrotomy  (also called  thyroidotomy ,  median laryngotomy ,  laryngofissure  or  thyrofissure ) is an  incision of the  larynx  through the  thyroid cartilage ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4474", "text": "Tonsil stones , also known as  tonsilloliths , are mineralizations of debris within the crevices of the  tonsils . [ 1 ] [ 3 ]  When not mineralized, the presence of debris is known as  chronic caseous tonsillitis  ( CCT ). [ 1 ]  Symptoms may include  bad breath , [ 1 ]  foreign body sensation, sore throat, pain or discomfort with swallowing, and cough. [ 4 ]  Generally there is no pain, though there may be the feeling of something present. [ 1 ]  The presence of tonsil stones may be otherwise undetectable; however, some people have reported seeing white material in the rear of their throat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4475", "text": "Risk factors may include recurrent  throat infections . [ 2 ]  Tonsil stones contain a  biofilm  composed of a number of different  bacteria , and calcium salts, either alone or in combination with other mineral salts. [ 5 ] [ 1 ]  While they most commonly occur in the  palatine tonsils , they may also occur in the  adenoids ,  lingual tonsils  and  tubal tonsil . [ 3 ] [ 6 ] [ 7 ]  Tonsil stones have been recorded weighing from 0.3 \u00a0 g to 42 \u00a0 g, [ 3 ]   and they are typically small in size. However, there are occasional reports of large tonsilloliths. They are often discovered during  medical imaging  for other reasons and more recently, due to the impact and influence of social media platforms such as  TikTok , medical professionals have experienced an increase in patient concern and tonsillolith evaluations. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4476", "text": "They are usually benign, so if tonsil stones do not bother the patient, no treatment is needed. [ 1 ]  However in rare cases, tonsilloliths have presented patients with further complications necessitating surgical extraction. Tonsilloliths that exceed the average size are typically seen in older individuals as the likelihood of developing tonsil stones is linear.  Otherwise,  gargling  with salt water and manual removal may be tried. [ 1 ]   Chlorhexidine  or  cetylpyridinium chloride  may also be tried. [ 1 ]  Surgical treatment may include partial or complete  tonsil removal . [ 1 ] [ 10 ]  Up to 10% of people have tonsil stones. [ 1 ]  Biological sex does not influence the chance of having tonsil stones, [ 1 ]  but older people are more commonly affected. [ 2 ]  Many people opt to extract their own tonsil stones manually or with developments in dental hygiene products.  Water flossers  have become a more common mechanism to extract tonsilloliths and alleviate the discomfort and complications they exacerbate. Tonsil stones can become dislodged on their own while eating, drinking, gargling, and coughing. Additionally, an exhalation technique that vigorously shakes the tonsils may be performed to dislodge them. This involves loudly producing a  voiceless velar fricative  sound, at various pitches to shake both the palatine and lingual tonsils."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4477", "text": "Tonsil stones may produce no symptoms or they may be associated with  bad breath . [ 1 ]  In fact, many dental professionals argue that tonsil stones are the leading cause of bad breath in their patients. The smell may be that of rotting eggs. [ 11 ]  Tonsil stones tend to happen most often in people with longterm inflammation in their tonsils. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4478", "text": "Occasionally there may be pain when swallowing. [ 13 ]  Even when they are large, some tonsil stones are only discovered incidentally on  X-rays  or  CAT scans . Other symptoms include a metallic taste, throat closing or tightening, coughing fits, itchy throat, and choking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4479", "text": "Larger tonsil stones may cause recurrent bad breath, which frequently accompanies a tonsil infection,  sore throat , white debris, a bad taste in the back of the throat, difficulty swallowing,  ear ache , and tonsil swelling. [ 12 ]  A medical study conducted in 2007 found an association between tonsilloliths and bad breath in patients with a certain type of recurrent tonsillitis. Among those with bad breath, 75% of the subjects had tonsilloliths, while only 6% of subjects with normal halitometry values (normal breath) had tonsilloliths. A foreign body sensation may also exist in the back of the throat. The condition may also be an  asymptomatic condition , with detection upon palpating a hard intratonsillar or  submucosal  mass."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4480", "text": "The mechanism by which these calculi form is subject to debate, [ 3 ]  though they appear to result from the accumulation of material retained within the crypts, along with the growth of bacteria and fungi\u2014sometimes in association with persistent chronic purulent  tonsillitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4481", "text": "In 2009, an association between  biofilms  and tonsilloliths was shown. Central to the biofilm concept is the assumption that bacteria form a three dimensional structure, dormant bacteria being in the center to serve as a constant nidus of infection. This impermeable structure renders the biofilm immune to antibiotic treatment. By use of  confocal microscopy  and microelectrodes, biofilms similar to dental biofilms were shown to be present in the tonsillolith, with oxygen respiration at the outer layer of tonsillolith,  denitrification  toward the middle layer, and acidification toward the core. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4482", "text": "Diagnosis is usually made upon inspection. Tonsilloliths are difficult to  diagnose  in the absence of clear manifestations, and often constitute casual findings of routine  radiological  studies. The cause of tonsil stones can include a multitude of sources from bacterial infections,  streptococcus  bacteria, viral infections, adenoviruses, influenza virus, enteroviruses and parainfluenza virus. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4483", "text": "Tonsilloliths or tonsil stones are  calcifications  that form in the crypts of the palatal tonsils. They are also known to form in the throat and on the roof of the mouth. Tonsils are filled with crevices where bacteria and other materials, including dead cells and mucus, can become trapped. When this occurs, the debris can become concentrated in white formations that occur in the pockets. [ 12 ]  Researchers found aerobic bacteria present on the surface of tonsilloliths and anaerobic bacteria at the core of tonsilloliths. They have the potential to cause oral halitosis as they contain volatile sulfur compounds and sulfur derived gases, foul smelling compounds produced during bacterial metabolism. [ 16 ]  Tonsilloliths are formed when this trapped debris accumulates and are expressed from the tonsil. They are generally soft, sometimes rubbery. This tends to occur most often in people who suffer from chronic inflammation in their tonsils or repeated bouts of tonsillitis. [ 12 ]  They are often associated with  post-nasal drip ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4484", "text": "Much rarer than the typical tonsil stones are giant tonsilloliths. Giant tonsilloliths may often be mistaken for other oral maladies, including  peritonsillar abscess , and tumors of the tonsil. [ 17 ]  On average, tonsil stones should appear within a similar range of the image shown here; however, individuals with extenuating cases have been reported. In these instances, extensive care such as extraction by a licensed medical professional may be needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4485", "text": "Imaging diagnostic techniques can identify a  radiopaque  mass that may be mistaken for foreign bodies, displaced teeth or calcified blood vessels.  CT scan  may reveal nonspecific calcified images in the tonsillar zone. The differential diagnosis must be established with acute and chronic tonsillitis, tonsillar  hypertrophy , peritonsillar abscesses, foreign bodies,  phlebolites , ectopic bone or cartilage,  lymph nodes , granulomatous lesions or calcification of the  stylohyoid ligament  in the context of  Eagle syndrome  (elongated styloid process). [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4486", "text": "Differential diagnosis  of tonsilloliths includes foreign body, calcified  granuloma ,  malignancy , an enlarged  temporal styloid process  or rarely, isolated bone which is usually derived from  embryonic rests  originating from the  branchial arches . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4487", "text": "If tonsil stones do not bother a person, no treatment is needed. [ 1 ]  Otherwise  gargling  with saltwater and manual removal may be tried. [ 1 ]   Chlorhexidine  or  cetylpyridinium chloride  may also be tried. [ 1 ]  Surgical treatment may include partial or complete  tonsil removal . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4488", "text": "Some people are able to remove tonsil stones using a cotton swab.  Oral irrigators  are also effective. Most electric oral irrigators are unsuitable for tonsil stone removal because they are too powerful and are likely to cause discomfort and rupture the tonsils, which could result in further complications such as infection. Irrigators that connect directly to the sink tap via a threaded attachment or otherwise are suitable for tonsil stone removal and everyday washing of the tonsils because they can jet water at low-pressure levels that the user can adjust by simply manipulating the sink tap, allowing for a continuous range of pressures to suit each user's requirements. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4489", "text": "There are also manually pressurized tonsil stone removers. A manual pump-type tonsil stone remover can adjust the water pressure depending on the number of pumps, effectively removing tonsil stones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4490", "text": "More simply still, gargling with warm, salty water may help alleviate the discomfort of tonsillitis, which often accompanies tonsil stones. Vigorous gargling each morning can also keep the tonsil crypts clear of all but the most persistent tonsilloliths. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4491", "text": "Larger tonsil stones may require removal by  curettage  (scooping) or otherwise, although thorough irrigation will still be required afterward to effectively wash out smaller pieces. Larger  lesions  may require local  excision , although these treatments may not completely help the bad breath issues that are often associated with this condition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4492", "text": "Another option is to decrease the surface area (crypts, crevices, etc.) of the tonsils via laser resurfacing. The procedure is called a laser  cryptolysis . It can be performed using a  local anesthetic . A scanned  carbon dioxide laser  selectively vaporizes and smooths the surface of the tonsils. This technique flattens the edges of the crypts and crevices that collect the debris, preventing trapped material from forming stones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4493", "text": "Tonsillectomy  may be indicated if bad breath due to tonsillar stones persists despite other measures. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4494", "text": "Tonsilloliths or tonsillar concretions occur in up to 10% of the population, frequently due to episodes of tonsillitis. [ 21 ]  While small concretions in the tonsils are common, true stones are less so. [ 3 ]  They commonly occur in young adults and are rare in children. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4495", "text": "Tonsillectomy  is a  surgical procedure  in which both  palatine tonsils  are fully removed from the back of the  throat . [ 1 ]  The procedure is mainly performed for recurrent  tonsillitis ,  throat infections  and  obstructive sleep apnea  (OSA). [ 1 ]  For those with frequent throat infections, surgery results in 0.6 (95% confidence interval: 1.0 to 0.1) fewer sore throats in the following year, but there is no evidence of long term benefits. [ 1 ] [ 2 ]  In children with OSA, it results in improved  quality of life . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4496", "text": "While generally safe, complications may include  bleeding ,  vomiting ,  dehydration , trouble eating, and trouble talking. [ 1 ]   Throat pain  typically lasts about one to two weeks after surgery. [ 1 ] [ 4 ]  Bleeding occurs in about 1% within the first day and another 2% after that. [ 1 ]  Between 1 in 2,360 and 1 in 56,000 procedures cause death. [ 1 ]  Tonsillectomy does not appear to affect long term  immune function . [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4497", "text": "Following the surgery,  ibuprofen  and  paracetamol  (acetaminophen) may be used to treat postoperative pain. [ 1 ]  The surgery is often done using  metal instruments  or  electrocautery . [ 1 ] [ 6 ]  The  adenoid  may also be removed or shaved down, in which case it is known as an \"adenotonsillectomy\". [ 1 ]  The partial removal of the tonsils is called a \"tonsillotomy\", which may be preferred in cases of OSA. [ 1 ] [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4498", "text": "The surgery has been described since at least as early as 50 AD by  Celsus . [ 10 ]  In the United States, as of 2010, tonsillectomy is performed less frequently than in the 1970s although it remains the second-most common  outpatient surgical procedure  in children. [ 1 ]  The typical cost when done as an  inpatient  in the United States is US$4,400 as of 2013. [ 11 ]  There is some controversy as of 2019 as to when the surgery should be used. [ 1 ] [ 2 ]  There are variations in the rates of tonsillectomy between and within countries. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4499", "text": "Tonsillectomy is mainly undertaken for  sleep apnea  and recurrent or chronic  tonsillitis . [ 1 ]  It is also carried out for  peritonsillar abscess ,  periodic fever, aphthous stomatitis, pharyngitis and adenitis  (PFAPA),  guttate psoriasis , nasal  airway obstruction ,  tonsil cancer  and  diphtheria carrier state . For children, tonsillectomy is usually combined with the  removal of the adenoid . However, it is unclear whether the removal of the adenoid has any additional positive or negative effects for the treatment of recurrent sore throat. [ 2 ]  In cases of chronic tonsillitis in adults, there is strong evidence of increased quality of life, reduction of symptoms, and economic benefit. [ 14 ] [ 15 ] [ 16 ]  A randomised controlled trial of tonsillectomy versus medical treatment (antibiotics and pain killers) in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4500", "text": "Surgery is not recommended for those with fewer than seven documented throat infections in the last year, fewer than five each year for the last two years, or fewer than three each year for three years. [ 1 ]  Severely affected children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not. [ 1 ] [ 2 ] [ 19 ]  Specifically one review of five randomized controlled trials, found a decrease from 3.6 to 3.0 episodes in the year following surgery. [ 2 ]  In less severely affected children, surgery results in an increase, rather than a decrease of sore throats when the sore throat directly following surgery is included. [ 2 ]  Surgery results in a reduction in school absence in the following year, but the strength of evidence is low. [ 19 ]  Surgery does not result in an improvement in the quality of life. [ 19 ]  Benefits of surgery do not persist over time. [ 1 ] [ 19 ]  Those with frequent throat infections often spontaneously improve over a year without surgery. [ 1 ] [ 2 ]  Therefore, a certain number of people who undergo surgery will do so unnecessarily as they would not have had further episodes of tonsillitis had they not had surgery. [ 2 ]  Evidence in adults is unclear. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4501", "text": "In 2019, the  American Academy of Otolaryngology & Head and Neck Surgery  (AAO-HNS) recommended:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4502", "text": "Caregivers and patients who meet the appropriate criteria for tonsillectomy as described here should be advised of only modest anticipated benefits of tonsillectomy, as weighed against the natural history of resolution with watchful waiting, as well as the risk of surgical morbidity and complications and the unknown risk of general anesthesia exposure in children [younger than] four years of age. In considering the potential harms, the guideline panel agreed that there was not a clear preponderance of benefit over harm for tonsillectomy, even for children meeting the Paradise criteria [seven episodes in the past year, five episodes per year in the past two years, or three episodes per year in the past three years].  Instead, the group felt there to be a balance that allows either tonsillectomy or watchful waiting as an appropriate management option for these children and does not imply that all qualifying children should have surgery. The role of tonsillectomy as an option in managing children with recurrent throat infection means that there is a substantial role for shared decision making with the child's caregiver and primary care clinician. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4503", "text": "Many cases of the sore throat have other causes than tonsillitis and tonsillectomy is therefore not indicated for those cases. [ 2 ] [ 19 ]  The diagnosis of tonsillitis is often made without testing for bacteria. [ 19 ]  The  UK National Health Service  states that it is very rare that someone needs to have their tonsils taken out, and it is usually only necessary in case of severe tonsillitis that keeps recurring. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4504", "text": "Tonsillectomy improves obstructive sleep apnea (OSA) in most children. [ 1 ]  A 2015  Cochrane  review found moderate quality evidence for benefits in terms of quality of life and symptoms but no benefit in attention or academic performance. [ 3 ]  It recommended that physicians and parents should weigh the benefits and risks of surgery as OSA symptoms may spontaneously resolve over time. [ 3 ]  An  AHRQ  review however did find improvements at school. [ 1 ]  The procedure is recommended for those who have OSA that has been verified by a  sleep study . [ 1 ]  Studies have shown that treatment success of  uvulopalatopharyngoplasty  with tonsillectomy increases with tonsil size. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4505", "text": "There is no good evidence for other uses such as  tonsil stones ,  bad breath ,  trouble swallowing , and an  abnormal voice  in children. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4506", "text": "While generally safe, tonsillectomy may result in several  complications , some of which are serious. [ 1 ] [ 2 ]  Complications are divided into primary (first 24 hours after surgery), and secondary (after 24 hours), with bleeding being the most common complication. Other common complications are  postoperative nausea and vomiting ,  dehydration , trouble eating,  ear pain ,  taste dysfunction  and trouble talking. [ 1 ] [ 22 ]  In rare cases, tonsillectomy may also cause damage to the  teeth  (because of the clamp that is placed in the mouth during surgery),  larynx  and  pharyngeal wall ,  aspiration ,  respiratory compromise ,  laryngospasm ,  laryngeal edema  and  cardiac arrest . [ 1 ]  Throat pain typically lasts about one to two weeks after surgery. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4507", "text": "Significant post-operative primary bleeding occurs in 0.2\u20132.2% of people, and secondary bleeding in 0.1\u20133.3%. [ 1 ]  \nIn several reported case series, the rate of post tonsillectomy bleeding ranged from 2.0% to 7.0%. [ 23 ] [ 24 ] [ 25 ] \nAlso in veterinary surgery, bleeding was a common complication. [ 26 ]  A meta-analysis reported that frequency of bleeding after tonsillectomy across different techniques did not differ. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4508", "text": "It is estimated 1.3% of people will have a delayed discharge (of 4 to 24 hours) due to a complication, and up to 3.9% will require repeat admission to hospital. The main reasons for either keeping a person in hospital, or readmitting them after tonsillectomy are uncontrolled pain, vomiting, fever, or bleeding. Death occurs as a result in between 1 in 2,360 and 56,000 procedures. [ 1 ]  Bleeding accounts for one-third of deaths. [ 1 ]  As the procedure is done under  general anesthesia , there are anesthesia risks. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4509", "text": "There is no evidence tonsillectomy affects long term  immune function . [ 1 ] [ 5 ]  It does not appear to affect the long term risk of  infections  in other areas of the body. [ 27 ]  Some studies have found small changes in  immunoglobulin  concentrations after tonsillectomy but these are of unclear significance. [ 1 ]  Tonsillectomy is a risk factor for  Crohn's disease . [ 28 ] [ 29 ]  A 2024  meta-analysis  found that tonsillectomy is associated with Crohn's disease and  ulcerative colitis , with an  odds ratio  of 1.93 and 1.24, respectively. [ 29 ]  There is an association suggesting an increase in the risk of developing  multiple sclerosis  if done before the age of 20. [ 30 ]  A meta-analysis published in 2020 indicated a statistically significant association between a history of tonsillectomy and the development of  Hodgkin's disease . [ 31 ]  A meta-analysis from 2022 concluded that a history of tonsillectomy is associated with an increased risk of  breast cancer . [ 32 ]  The relationship between childhood tonsillectomy and the development of other cancer types in adulthood remains unclear. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4510", "text": "For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding  fascia , a so-called total, or extra-capsular tonsillectomy. Problems including pain and bleeding led to a recent resurgence in interest in sub-total tonsillectomy or  tonsillotomy , which was popular 60 to 100 years ago, in an effort to reduce these complications. [ 34 ]  The generally accepted procedure for 'total' tonsillectomy uses a  scalpel  and blunt dissection,  electrocautery , or  diathermy . [ 35 ]   Harmonic scalpels  or  lasers  have also been used. Bleeding is stopped with electrocautery, ligation by  sutures , and the topical use of  thrombin , a protein that induces  blood clotting . The most effective surgical approach has not been well studied. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4511", "text": "It is not known whether the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. But this is also the case for tonsillectomy for sleep apnea. There have been no randomised controlled trials of long term effectiveness of tonsillectomy for sleep apnea. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4512", "text": "The  scalpel  is the preferred surgical instrument of many  ear, nose, and throat specialists .  However, there are other techniques and a brief review of each follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4513", "text": "A single dose of the  corticosteroid  drug  dexamethasone  may be given during surgery to prevent  post-operative vomiting . [ 48 ]  A dose of dexamethasone during surgery prevents vomiting in one out of every five children. A dose of dexamethasone may help children return to a normal diet more quickly and have less post-operative pain. [ 48 ]  Many people are prescribed antibiotics following a tonsillectomy, however, the benefits and potential harms have not been well studied. [ 49 ]  Antibiotics are not suggested to be used routinely following tonsillectomy. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4514", "text": "A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay. [ 50 ]  Recovery can take from 7 to 10 days and proper hydration is very important during this time, since  dehydration  can increase throat pain, leading to a  circle  of poor fluid intake. [ 51 ] [ 52 ]  Tonsillectomy appears to be more painful in adults than children. [ 53 ]  Controlling the pain following tonsillectomy is important to ensure that people can start eating again normally following the procedure. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4515", "text": "At some point, most commonly 7 to 11 days after the surgery (but occasionally as long as two weeks after), bleeding can occur when  scabs  begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1\u20132%. It is higher in adults, especially males over age 70 and three-quarters of bleeding incidents occur on the same day as the surgery. [ 55 ]  Approximately 3% of adults develop bleeding at this time which may sometimes require surgical intervention."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4516", "text": "Recommendations for pain management include  ibuprofen  and  paracetamol  (acetaminophen). [ 1 ]  The  opioid   codeine  is not recommended for those less than 12 years old. [ 1 ]  There is a theoretical concern that  NonSteroidal Anti-Inflammatory Drugs  (NSAIDs) may increase the risk of bleeding but evidence does not support such a risk. [ 56 ]  Further research is required to determine if mouth rinses, mouthwashes and sprays help improve recovery following surgery. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4517", "text": "Some surgeons recommend starting with a soft diet for two weeks before advancing to normal diet. This is to prevent any sharp foods from potentially irritating the tonsillar fossae during the healing stage and provoking a bleed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4518", "text": "There are variations in tonsillectomy rates, both between and within countries. [ 12 ] [ 13 ]  In 2015, tonsillectomy rates in the Netherlands, Belgium, Finland and Norway were at least twice those in the UK but rates in Spain, Italy and Poland were at least a quarter lower. [ 12 ]  Tonsillectomy rates even vary considerably between neighbouring countries. For example, rates in Croatia are three times those in Slovenia. [ 12 ]  Variations between countries may be explained by a lack of or differences between guidelines. [ 9 ]  However differences in guidelines cannot explain the seven-fold variation between local authority areas within England. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4519", "text": "In Germany tonsillectomy rates between regions differ by up to a factor of 8. [ 9 ]  A 2010 study in England found the annual tonsillectomy rate per 100,000 between 2000 and 2005 was 754 in the highest region, the national average was 304 and the lowest region was 102. [ 13 ]  This means there is a seven-fold difference between the region with the highest tonsillectomy rate and the region with the lowest one. [ 13 ]  In 2006, English Chief Medical Officer  Liam Donaldson  revealed that unnecessary tonsillectomies and unnecessary  hysterectomies  combined cost the  British National Health Service  21 million pounds a year. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4520", "text": "The rise in adenotonsillectomies for sleep apnea in the USA has been greater than the decline in tonsillectomies for sore throat. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4521", "text": "In 2018, a study of the medical records of 1.6 million UK children found 15,760 had sufficient sore throats to justify tonsillectomy and 13.6% (2,144) underwent surgery. [ 60 ]  The same study found 18,281 children who had undergone tonsillectomy, and of these only 11.7% (2,144) had evidence-based indications (i.e. frequent enough sore throats to justify surgery). [ 60 ]  The majority of tonsillectomies were undertaken for indications which did not have an evidence-base: five to six sore throats in one year (12.4%), two to four sore throats in one year (44.6%), sleep disordered breathing (12.3%), or obstructive sleep apnea (3.9%). [ 60 ]  In the UK therefore, most children who undergo tonsillectomy probably do not benefit and most children who might benefit do not undergo tonsillectomy. [ 60 ]  The study concluded that 32,500 (close to 90%) out of the 37,000 children who have their tonsils removed annually \"are unlikely to benefit\" and that surgery therefore may do more harm than good to those children. [ 60 ]  Tonsillectomy rates are lower in the UK than in most other western European countries. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4522", "text": "Table: Numbers of children (from 1.6 million children between 2005 and 2016 in the UK) identified with possible indications for tonsillectomy and the numbers who subsequently undergo tonsillectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4523", "text": "Source: \u0160umilo et al. 2018 [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4524", "text": "According to a study from 2009, surgery rates on average increase by 78% when surgeons are paid  fee-for-service  reimbursements instead of a fixed salary. [ 61 ]  Regarding tonsillectomy, a 1968 Canadian study pointed out that ENT specialists working on a fee-for-service programme were twice as likely to perform a tonsillectomy than those who were not. [ 62 ] [ 63 ]  In 2009 then  US President Obama  remarked:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4525", "text": "Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and \u2013 and you come in and you've got a bad sore throat, or your child has a bad sore throat, or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, \"You know what? I make a lot more money if I take this kid's tonsils out.\" Now, that may be the right thing to do. But I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change \u2013 maybe they have allergies. Maybe they have something else that would make a difference. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4526", "text": "Tonsillectomies have been practiced for over 2,000 years, with varying popularity over the centuries. [ 65 ]  The earliest mention of the procedure is in \"Hindu medicine\" from about 1000  BCE . Roughly a millennium later, the  Roman  aristocrat  Aulus Cornelius Celsus  (25 BCE\u201350  CE ) described a  procedure  whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue before being cut out. [ 65 ]   Galen  (121\u2013200 CE) was the first to advocate the use of the surgical instrument known as the  snare , a practice that was to become common until  Aetius  (490 CE) recommended partial removal of the tonsil, writing \"Those who extirpate the entire tonsil remove, at the same time, structures that are perfectly healthy, and, in this way, give rise to serious H\u00e6morrhage\". [ 65 ]  In the 7th century  Paulus Aegineta  (625\u2013690) described a detailed procedure for tonsillectomy, including dealing with the inevitable post-operative bleeding. 1,200 years pass before the procedure is described again with such precision and detail. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4527", "text": "The  Middle Ages  saw tonsillectomy fall into disfavor;  Ambroise Pare  (1509) wrote it to be \"a bad operation\" and suggested a procedure that involved gradual strangulation with a  ligature . This method was not popular with the patients due to the immense pain it caused and the infection that usually followed. Scottish physician  Peter Lowe  in 1600 summarized the three methods in use at the time, including the  snare , the  ligature , and the  excision . [ 65 ]  At the time, the function of the tonsils was thought to be absorption of  secretions  from the nose; it was assumed that removal of large amounts of tonsillar tissue would interfere with the ability to remove these secretions, causing them to accumulate in the  larynx , resulting in  hoarseness . For this reason, physicians like  Dionis  (1672) and  Lorenz Heister  censured the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4528", "text": "In 1828, physician  Philip Syng Physick  modified an existing instrument originally designed by  Benjamin Bell  for removing the  uvula ; the instrument, known as the tonsil guillotine (and later as a  tonsillotome ), became the standard instrument for tonsil removal for over 80 years. [ 65 ]  By 1897, it became more common to perform complete rather than partial removal of the tonsil after American physician Ballenger noted that partial removal failed to completely alleviate symptoms in a majority of cases. His results using a technique involving removal of the tonsil with a scalpel and forceps were much better than partial removal; tonsillectomy using the guillotine eventually fell out of favor in America. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4529", "text": "In the beginning of the 20th century, tonsillectomy became more common in the United Kingdom and the United States and by the 1930s was very common in both countries. [ 66 ]  For example, a study conducted in 1934 found that 61% of 1,000 New York schoolchildren had been tonsillectomized; doctors recommended surgery for all but 65 of the remaining children. [ 67 ]  Complications were often simply accepted. [ 66 ]  The medical community considered enlarged tonsils a disease, attributing their enlargement to infection rather than a  physiologic response . [ 68 ]  Because of the  theory of focal infection , many surgeons believed that not only enlarged tonsils, but all tonsils should be removed. [ 68 ]  In the 1940s tonsillectomy became controversial as several studies linked it to  bulbar poliomyelitis . [ 66 ]  From the 1940s to 1970s, further studies found an association between tonsillectomy and bulbar poliomyelitis with recommendations not to do the operation during outbreaks. [ 69 ] [ 70 ] [ 71 ] [ 72 ]  Controversy surrounding tonsillectomy increased further in the United Kingdom in the 1960s because of the financial costs associated with the number of surgeries being performed and because of unexplainable variations in tonsillectomy rates between geographic regions and between  social classes . [ 66 ]  In the media, tonsillectomy was criticised for being \"fashionable\" or a \" status symbol \". [ 66 ]  There was also an increasing concern regarding the psychological and physical suffering of young children as a result of surgery. [ 68 ]  Furthermore, opponents of surgery argued that the tonsils should be retained whenever possible because of their role in the immune system and that the benefits of surgery were marginal. [ 68 ]  In the 1970s, tonsillectomy rates in the United Kingdom started to decline after several studies concluded that tonsillectomy was not as effective for sore throats and many other indications as previously thought. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4530", "text": "Tonsillectomy rates in the United States have declined since 1978, when experts of the  National Institutes of Health  concluded that there was insufficient evidence that the benefits of tonsillectomy outweighed the risks and therefore recommended more research, which subsequently led to stricter guidelines. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4531", "text": "As doctors took a more conservative approach towards tonsillectomy, parental pressure became one of the most important reasons for surgery. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4532", "text": "Tonsillitis  is  inflammation  of the  tonsils  in the upper part of the  throat . It can be acute or chronic. [ 8 ] [ 9 ] [ 2 ]  Acute tonsillitis typically has a rapid onset. [ 10 ]  Symptoms may include  sore throat ,  fever , enlargement of the tonsils, trouble swallowing, and enlarged  lymph nodes  around the neck. [ 1 ] [ 2 ]  Complications include  peritonsillar abscess (quinsy) . [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4533", "text": "Tonsillitis is most commonly caused by a  viral infection  and about 5% to 40% of cases are caused by a  bacterial infection . [ 1 ] [ 5 ] [ 6 ]  When caused by the bacterium  group A streptococcus , it is classed as  streptococcal tonsillitis [ 11 ]  also referred to as  strep throat . [ 12 ]  Rarely bacteria such as  Neisseria gonorrhoeae ,  Corynebacterium diphtheriae , or  Haemophilus influenzae  may be the cause. [ 5 ]  Typically the infection is spread between people through the air. [ 6 ]  A scoring system, such as the  Centor score , may help separate possible causes. [ 1 ] [ 5 ]  Confirmation may be by a  throat swab  or  rapid strep test . [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4534", "text": "Treatment efforts involve improving symptoms and decreasing complications. [ 5 ]   Paracetamol  (acetaminophen) and  ibuprofen  may be used to help with pain. [ 1 ] [ 5 ]  If strep throat is present the antibiotic  penicillin  by mouth is generally recommended. [ 1 ] [ 5 ]  In those who are allergic to penicillin,  cephalosporins  or  macrolides  may be used. [ 1 ] [ 5 ]  In children with frequent episodes of tonsillitis,  tonsillectomy  modestly decreases the risk of future episodes. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4535", "text": "About 7.5% of people have a sore throat in any three-month period and 2% of people visit a doctor for tonsillitis each year. [ 7 ]    It is most common in school-aged children and typically occurs in the colder months of autumn and winter. [ 5 ] [ 6 ]  The majority of people recover with or without medication. [ 1 ] [ 5 ]  In 82% of people, symptoms resolve within one week, regardless if bacteria or viruses were present. [ 4 ]  Antibiotics probably reduce the number of people experiencing sore throat or headache, but the balance between modest symptom reduction and the potential hazards of  antimicrobial resistance  must be recognised. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4536", "text": "Those with tonsillitis usually experience  sore throat ,  painful swallowing ,  malaise , and fever. [ 1 ] [ 14 ] [ 15 ]  Their tonsils \u2013 and often the back of the throat \u2013 appear  red  and swollen, and sometimes give off a white discharge. [ 1 ] [ 15 ] [ 16 ]  Some also have tender swelling of the  cervical lymph nodes . [ 1 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4537", "text": "Many viral infections that cause tonsillitis will also cause cough,  runny nose ,  hoarse voice , or blistering in the mouth or throat. [ 17 ]   Infectious mononucleosis  can cause the tonsils to swell with red  spots  or white discharge that may extend to the tongue. [ 18 ]  This can be accompanied by fever, sore throat, cervical lymph node swelling, and enlargement of the liver and spleen. [ 18 ]  Bacterial infections that cause tonsillitis can also cause a distinct  \"scarletiniform\" rash , vomiting, and tonsillar spots or discharge. [ 1 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4538", "text": "Tonsilloliths  occur in up to 10% of the population frequently due to episodes of tonsillitis. [ clarification needed ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4539", "text": "Viral infections cause 40 to 60% of cases of tonsillitis. [ 14 ]  Many viruses can cause inflammation of the tonsils (and the rest of throat) including  adenovirus ,  rhinovirus ,  coronavirus ,  influenza virus ,  parainfluenza virus ,  coxsackievirus ,  measles virus ,  Epstein-Barr virus ,  cytomegalovirus ,  respiratory syncytial virus , and  herpes simplex virus . [ 17 ]  Tonsillitis can also be part of the  initial reaction  to  HIV  infection. [ 17 ]  An estimated 1 to 10% of the cases are caused by Epstein-Barr virus. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4540", "text": "Tonsillitis can also stem from infection with bacteria, predominantly Group A \u03b2-hemolytic streptococci ( GABHS ), which causes  strep throat . [ 1 ] [ 14 ]  Bacterial infection of the tonsils usually follows the initial viral infection. [ 15 ]  When tonsillitis recurs after antibiotic treatment for streptococcus bacteria, it is usually due to the same bacteria as the first time, which suggests that the antibiotic treatment was not fully effective. [ 1 ] [ 20 ]   Less common bacterial causes include:   Streptococcus pneumoniae ,  Mycoplasma pneumoniae ,  Chlamydia pneumoniae ,  Bordetella pertussis ,  Fusobacterium  sp.,  Corynebacterium diphtheriae ,  Treponema pallidum , and  Neisseria gonorrhoeae . [ 21 ] [ 22 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4541", "text": "Anaerobic bacteria  have been implicated in tonsillitis, and a possible role in the acute inflammatory process is supported by several clinical and scientific observations. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4542", "text": "Sometimes tonsillitis is caused by an  infection  of  spirochaeta  and  treponema , which is called Vincent's angina or  Plaut -Vincent angina. [ non-primary source needed ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4543", "text": "Within the tonsils,  white blood cells  of the immune system destroy the viruses or bacteria by producing inflammatory  cytokines  like  phospholipase A2 , [ non-primary source needed ] [ 27 ]  which also lead to fever. [ 28 ] [ 29 ]   The infection may also be present in the  throat  and surrounding areas, causing inflammation of the  pharynx . [ 1 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4544", "text": "There is no firm distinction between a sore throat that is specifically tonsillitis and a sore throat caused by inflammation in both the tonsils and also nearby tissues. [ 1 ] [ 31 ]   An  acute sore throat  may be diagnosed as  tonsillitis ,  pharyngitis , or  tonsillopharyngitis  (also called pharyngotonsillitis), depending upon the clinical findings. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4545", "text": "In  primary care  settings, the  Centor criteria  are used to determine the likelihood of group A beta-hemolytic streptococcus (GABHS) infection in an acute tonsillitis and the need of antibiotics for tonsillitis treatment. [ 1 ] [ 15 ]  However, the Centor criteria have their weaknesses in making precise diagnosis for adults. The Centor criteria are also ineffective in diagnosis for tonsillitis in children and in  secondary care  settings (hospitals). [ 15 ]  A modified version of the Centor criteria, which modified the original Centor criteria in 1998, is often used to aid in diagnosis. The original Centor criteria had four major criteria but the modified Centor criteria have five. The five major criteria of the modified Centor score are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4546", "text": "The possibility of GABHS infection increases with increasing score. The probability for getting GABHS is 2 to 23% for the score of 1, and 25 to 85% for the score of 4. [ 15 ] \nThe diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing the throat and plating them on  blood agar  medium.  This small percentage of false-negative results are part of the characteristics of the tests used but are also possible if the person has received antibiotics prior to testing. Identification requires 24 to 48 hours by culture but rapid screening tests (10\u201360 minutes), which have a sensitivity of 85\u201390%, are available. In 40% of the people without any symptoms, the throat culture can be positive. Therefore, throat culture is not routinely used in clinical practice for the detection of GABHS. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4547", "text": "Bacterial culture may need to be performed in cases of a negative rapid streptococcal test. [ 32 ]  An increase in antistreptolysin O ( ASO ) streptococcal antibody titer  following the acute infection can provide retrospective evidence of GABHS infection and is considered definitive proof of GABHS infection, but not necessarily of the tonsils. [ 33 ] \nEpstein Barr virus  serology  can be tested for those who may have  infectious mononucleosis  with a typical  lymphocyte  count in  full blood count  result. [ 15 ]  Blood investigations are only required for those with hospital admission requiring intravenous antibiotics. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4548", "text": "Nasoendoscopy  can be used for those with severe neck pain and inability to swallow any fluids to rule out masked  epiglotitis  and supraglotitis. Routine nasoendscopy is not recommended for children. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4549", "text": "Treatments to reduce the discomfort from tonsillitis include: [ 1 ] [ 22 ] [ 23 ] [ 24 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4550", "text": "There are no antiviral medical treatments for virally caused tonsillitis. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4551", "text": "If the tonsillitis is caused by  group A streptococcus , then  antibiotics  are useful, with  penicillin  or  amoxicillin  being primary choices. [ 1 ] [ 15 ]   Cephalosporins  and  macrolides  are considered good alternatives to penicillin in the acute care setting. [ 1 ] [ 35 ]  A macrolide, such as  azithromycin  or  erythromycin , is used for people allergic to penicillin. [ 1 ]  If penicillin therapy fails, bacterial tonsillitis may respond to treatment effective against beta-lactamase producing bacteria such as  clindamycin  or  amoxicillin-clavulanate . [ 36 ]  Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can \"shield\" group A streptococcus from penicillins. [ 37 ]  There is no significant difference in efficacy of various groups of antibiotics for treating tonsillitis. [ 15 ]  Intravenous antibiotics can be for those who are hospitalized with inability to swallow and presented with complications. [ citation needed ]  Oral antibiotics can be resumed immediately if the person is clinically improved and able to swallow orally. [ 15 ]  Antibiotic treatment is usually taken for seven to ten days. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4552", "text": "Paracetamol  and   nonsteroidal anti-inflammatory drugs  (NSAIDs) can be used to treat throat pain in children and adults. [ 1 ] [ 15 ]   Codeine  is avoided in children under 12 years of age to treat throat pain or following tonsilectomy. [ 38 ] [ 39 ]  NSAIDs (such as  ibuprofen ) and  opioids  (such as codeine and  tramadol ) are equally effective at relieving pain, however, precautions should be taken with these pain medications. NSAIDs can cause  peptic ulcer disease  and kidney damage. [ citation needed ]  Opioids can cause  respiratory depression  in those who are vulnerable. [ 15 ]  Anaesthetic  mouthwash  can also be used for symptomatic relief. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4553", "text": "Corticosteroids  reduce tonsillitis pain and improve symptoms in 24 to 48 hours. Oral corticosteroids are recommended unless the person is unable to swallow medications. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4554", "text": "When tonsillitis recurs frequently, often arbitrarily defined as at least five episodes of tonsillitis in a year, [ 40 ]  or when the palatine tonsils become so swollen that swallowing is difficult as well as painful, a  tonsillectomy  can be performed to surgically remove the tonsils. A randomised controlled trial of tonsillectomy versus medical treatment (antibiotics and pain killers) in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat. [ 41 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4555", "text": "Children have had only a modest benefit from tonsillectomy for repeated cases of tonsillitis. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4556", "text": "Since the advent of penicillin in the 1940s, a major preoccupation in the treatment of streptococcal tonsillitis has been the prevention of  rheumatic fever , and its major effects on the  nervous system  and  heart ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4557", "text": "Complications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and  pharyngitis  due to the spread of infection. [ 22 ] [ 23 ] [ 24 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4558", "text": "An  abscess  may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis. [ citation needed ]  This is termed a  peritonsillar abscess  (or quinsy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4559", "text": "Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the  internal jugular vein  giving rise to a spreading infectious  thrombophlebitis  ( Lemierre's syndrome ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4560", "text": "In  strep throat , diseases like  post-streptococcal glomerulonephritis [ non-primary source needed ] [ 44 ]  can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations. [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4561", "text": "Tonsillitis occurs throughout the world, without racial or ethnic differences. [ 47 ]  Most children have tonsillitis at least once during their childhood, [ 48 ]  although it rarely occurs before the age of two. [ 47 ]  It most typically occurs between the ages of four and five; bacterial infections most typically occur at a later age. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4562", "text": "Tonsillitis is described in the ancient Greek  Hippocratic Corpus . [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4563", "text": "Recurrent tonsillitis can interfere with vocal function and the ability to perform among people who use their voices professionally. [ 50 ] [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4564", "text": "Tracheal intubation , usually simply referred to as  intubation , is the placement of a flexible plastic  tube  into the  trachea  (windpipe) to maintain an open  airway  or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate  ventilation  of the lungs, including  mechanical ventilation , and to prevent the possibility of  asphyxiation  or airway obstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4565", "text": "The most widely used route is orotracheal, in which an  endotracheal tube  is passed through the mouth and  vocal apparatus  into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea. Other methods of intubation involve surgery and include the  cricothyrotomy  (used almost exclusively in emergency circumstances) and the  tracheotomy , used primarily in situations where a prolonged need for airway support is anticipated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4566", "text": "Because it is an  invasive  and uncomfortable  medical procedure , intubation is usually performed after administration of  general anesthesia  and a  neuromuscular-blocking drug . It can, however, be performed in the awake patient with  local  or  topical anesthesia  or in an emergency without any anesthesia at all. Intubation is normally facilitated by using a conventional  laryngoscope ,  flexible fiberoptic bronchoscope , or  video laryngoscope  to identify the  vocal cords  and pass the tube between them into the  trachea  instead of into the esophagus. Other devices and techniques may be used alternatively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4567", "text": "After the trachea has been intubated, a balloon cuff is typically inflated just above the far end of the tube to help secure it in place, to prevent leakage of respiratory gases, and to protect the  tracheobronchial tree  from  receiving undesirable material  such as stomach acid. The tube is then secured to the face or neck and connected to a T-piece, anesthesia breathing circuit,  bag valve mask  device, or a  mechanical ventilator . Once there is no longer a need for ventilatory assistance or protection of the airway, the tracheal tube is removed; this is referred to as extubation of the trachea (or decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4568", "text": "For centuries,  tracheotomy  was considered the only reliable method for intubation of the trachea. However, because only a minority of patients survived the operation, physicians undertook tracheotomy only as a last resort, on patients who were nearly dead. It was not until the late 19th century, however, that advances in understanding of  anatomy  and  physiology , as well an appreciation of the  germ theory of disease , had improved the outcome of this operation to the point that it could be considered an acceptable treatment option. Also at that time, advances in  endoscopic  instrumentation had improved to such a degree that direct laryngoscopy had become a viable means to secure the airway by the non-surgical orotracheal route. By the mid-20th century, the tracheotomy as well as endoscopy and non-surgical tracheal intubation had evolved from rarely employed procedures to becoming essential components of the practices of  anesthesiology ,  critical care medicine ,  emergency medicine , and  laryngology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4569", "text": "Tracheal intubation can be associated with  complications  such as broken teeth or lacerations of the  tissues  of the  upper airway . It can also be associated with potentially fatal complications such as  pulmonary aspiration  of stomach contents which can result in a severe and sometimes fatal chemical  aspiration pneumonitis , or unrecognized intubation of the  esophagus  which can lead to potentially fatal  anoxia . Because of this, the potential for difficulty or complications due to the presence of unusual airway anatomy or other uncontrolled variables is carefully evaluated before undertaking tracheal intubation. Alternative strategies for securing the airway must always be readily available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4570", "text": "Tracheal intubation is  indicated  in a variety of situations when illness or a medical procedure prevents a person from maintaining a clear airway, breathing, and  oxygenating  the blood. In these circumstances,  oxygen supplementation  using a  simple face mask  is inadequate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4571", "text": "Perhaps the most common indication for tracheal intubation is for the placement of a conduit through which  nitrous oxide  or  volatile anesthetics  may be administered.  General anesthetic agents ,  opioids , and neuromuscular-blocking drugs may  diminish  or even  abolish  the  respiratory drive . Although it is not the only means to maintain a patent airway during general anesthesia, intubation of the trachea provides the most reliable means of oxygenation and  ventilation [ 1 ]  and the greatest degree of protection against regurgitation and pulmonary aspiration. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4572", "text": "Damage to the brain (such as from a massive  stroke ,  non-penetrating head injury ,  intoxication  or  poisoning ) may result in a  depressed level of consciousness . When this becomes severe to the point of  stupor  or  coma  (defined as a score on the  Glasgow Coma Scale  of less than 8), [ 3 ]  dynamic collapse of the extrinsic  muscles of the airway  can obstruct the airway, impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such as  coughing  and  swallowing  may be diminished or absent. Tracheal intubation is often required to restore patency (the relative absence of blockage) of the airway and protect the tracheobronchial tree from pulmonary aspiration of gastric contents. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4573", "text": "Intubation may be necessary for a patient with  decreased oxygen content  and  oxygen saturation  of the blood caused when their breathing is inadequate ( hypoventilation ), suspended ( apnea ), or when the lungs are unable to sufficiently  transfer gasses to the blood . [ 5 ]  Such patients, who may be awake and alert, are typically critically ill with a multisystem disease or  multiple severe injuries . [ 1 ]  Examples of such conditions include  cervical spine injury ,  multiple rib fractures , severe  pneumonia ,  acute respiratory distress syndrome  (ARDS), or near- drowning . Specifically, intubation is considered if the  arterial   partial pressure  of oxygen (PaO 2 ) is less than 60\u00a0 millimeters of mercury  (mm Hg) while breathing an inspired O 2  concentration ( FIO 2 ) of 50% or greater. In patients with  elevated arterial carbon dioxide , an arterial partial pressure of CO 2  (PaCO 2 ) greater than 45\u00a0mm Hg in the setting of  acidemia  would prompt intubation, especially if a series of measurements demonstrate a worsening  respiratory acidosis . Regardless of the laboratory values, these guidelines are always interpreted in the clinical context. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4574", "text": "Actual or impending airway obstruction is a common indication for intubation of the trachea. Life-threatening airway obstruction may occur when a  foreign body  becomes lodged in the airway; this is especially common in infants and toddlers. Severe  blunt  or  penetrating  injury to the face or neck may be accompanied by  swelling  and an expanding  hematoma , or injury to the  larynx, trachea or bronchi . Airway obstruction is also common in people who have suffered  smoke inhalation  or burns within or near the airway or  epiglottitis . Sustained  generalized seizure activity  and  angioedema  are other common causes of life-threatening airway obstruction which may require tracheal intubation to secure the airway. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4575", "text": "Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy,  laser therapy  or  stenting  of the  bronchi ) may intermittently interfere with the ability to breathe; intubation may be necessary in such situations. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4576", "text": "Syndromes such as  respiratory distress syndrome ,  congenital heart disease ,  pneumothorax , and  shock  may lead to breathing problems in newborn infants that require endotracheal intubation and mechanically assisted breathing ( mechanical ventilation ). [ 7 ]  Newborn infants may also require endotracheal intubation during surgery while under  general anaesthesia . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4577", "text": "The vast majority of tracheal intubations involve the use of a  viewing instrument  of one type or another. The modern conventional laryngoscope consists of a handle containing batteries that power a light and a set of interchangeable  blades , which are either straight or curved. This device is designed to allow the laryngoscopist to directly view the larynx. Due to the widespread availability of such devices, the technique of blind intubation [ 8 ]  of the trachea is rarely practiced today, although it may still be useful in certain emergency situations, such as natural or man-made disasters. [ 9 ]  In the prehospital emergency setting, digital intubation may be necessitated if the patient is in a position that makes direct laryngoscopy impossible. For example, digital intubation may be used by a paramedic if the patient is entrapped in an inverted position in a vehicle after a motor vehicle collision with a prolonged extrication time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4578", "text": "The decision to use a straight or curved laryngoscope blade depends partly on the specific anatomical features of the airway, and partly on the personal experience and preference of the laryngoscopist. The Miller blade, characterized by its straight, elongated shape with a curved tip, is frequently employed in patients with challenging airway anatomy, such as those with limited mouth opening or a high larynx. Its design allows for direct visualization of the epiglottis, facilitating precise glottic exposure. [ 10 ] \nConversely, the Macintosh blade, with its curved configuration reminiscent of the letters \"C\" or \"J,\" is favored in routine intubations for patients with normal airway anatomy. Its curved design enables indirect laryngoscopy, providing enhanced visualization of the vocal cords and glottis in most adult patients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4579", "text": "The choice between the Miller and Macintosh blades is influenced by specific anatomical considerations and the preferences of the laryngoscopist. While the Macintosh blade is the most commonly utilized curved laryngoscope blade, the Miller blade is the preferred option for straight blade intubation. Both blades are available in various sizes, ranging from size 0 (infant) to size 4 (large adult), catering to patients of different ages and anatomies. Additionally, there exists a myriad of specialty blades with unique features, including mirrors for enhanced visualization and ports for oxygen administration, primarily utilized by anesthetists and otolaryngologists in operating room settings. [ 12 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4580", "text": "Fiberoptic  laryngoscopes have become increasingly available since the 1990s. In contrast to the conventional laryngoscope, these devices allow the laryngoscopist to indirectly view the larynx. This provides a significant advantage in situations where the operator needs to see around an acute bend in order to visualize the glottis, and deal with otherwise difficult intubations.  Video laryngoscopes  are specialized fiberoptic laryngoscopes that use a  digital   video camera sensor  to allow the operator to view the glottis and larynx on a video monitor. [ 13 ] [ 14 ]  Other \"noninvasive\" devices which can be employed to assist in tracheal intubation are the  laryngeal mask airway [ 15 ]  (used as a conduit for endotracheal tube placement) and the  Airtraq . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4581", "text": "An intubating stylet is a malleable metal wire designed to be inserted into the endotracheal tube to make the tube conform better to the upper airway anatomy of the specific individual. This aid is commonly used with a difficult laryngoscopy. Just as with laryngoscope blades, there are also several types of available stylets, [ 17 ]  such as the Verathon Stylet, which is specifically designed to follow the 60\u00b0 blade angle of the GlideScope video laryngoscope. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4582", "text": "The Eschmann tracheal tube introducer (also referred to as a \"gum elastic bougie\") is specialized type of stylet used to facilitate difficult intubation. [ 19 ]  This flexible device is 60\u00a0cm (24\u00a0in) in length, 15  French  (5\u00a0mm diameter) with a small \"hockey-stick\" angle at the far end. Unlike a traditional intubating stylet, the Eschmann tracheal tube introducer is typically inserted directly into the trachea and then used as a guide over which the endotracheal tube can be passed (in a manner analogous to the  Seldinger technique ). As the Eschmann tracheal tube introducer is considerably less rigid than a conventional stylet, this technique is considered to be a relatively atraumatic means of tracheal intubation. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4583", "text": "The tracheal tube exchanger is a hollow  catheter , 56 to 81\u00a0cm (22.0 to 31.9\u00a0in) in length, that can be used for removal and replacement of tracheal tubes without the need for laryngoscopy. [ 22 ]  The Cook Airway Exchange Catheter (CAEC) is another example of this type of catheter; this device has a central  lumen  (hollow channel) through which  oxygen can be administered . [ 23 ]  Airway exchange catheters are long hollow catheters which often have connectors for jet ventilation, manual ventilation, or oxygen insufflation.\u00a0It is also possible to connect the catheter to a capnograph to perform respiratory monitoring."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4584", "text": "The lighted stylet is a device that employs the principle of  transillumination  to facilitate blind orotracheal intubation (an intubation technique in which the laryngoscopist does not view the glottis). [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4585", "text": "A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent (open and unobstructed) airway. Tracheal tubes are frequently used for  airway management  in the settings of general anesthesia, critical care, mechanical ventilation, and emergency medicine. Many different types of tracheal tubes are available, suited for different specific applications. An endotracheal tube is a specific type of tracheal tube that is nearly always inserted through the mouth (orotracheal) or nose (nasotracheal). It is a  breathing  conduit designed to be placed into the airway of critically injured, ill or anesthetized patients in order to perform mechanical  positive pressure ventilation  of the lungs and to prevent the possibility of aspiration or airway obstruction. [ 25 ]  The endotracheal tube has a fitting designed to be connected to a source of pressurized gas such as oxygen. At the other end is an orifice through which such gases are directed into the lungs and may also include a balloon (referred to as a cuff). The tip of the endotracheal tube is positioned above the  carina  (before the trachea divides to each lung) and sealed within the trachea so that the lungs can be ventilated equally. [ 25 ]  A tracheostomy tube is another type of tracheal tube; this 50\u201375-millimetre-long (2.0\u20133.0\u00a0in) curved metal or plastic tube is inserted into a tracheostomy  stoma  or a cricothyrotomy incision. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4586", "text": "Tracheal tubes can be used to ensure the adequate  exchange  of oxygen and  carbon dioxide , to deliver oxygen in higher concentrations than found in air, or to administer other gases such as  helium , [ 27 ]   nitric oxide , [ 28 ]  nitrous oxide,  xenon , [ 29 ]  or certain volatile anesthetic agents such as  desflurane ,  isoflurane , or  sevoflurane . They may also be used as a route for administration of certain medications such as  bronchodilators ,  inhaled corticosteroids , and drugs used in treating  cardiac arrest  such as  atropine ,  epinephrine ,  lidocaine  and  vasopressin . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4587", "text": "Originally made from  latex rubber , [ 30 ]  most modern endotracheal tubes today are constructed of  polyvinyl chloride . Tubes constructed of  silicone rubber , wire-reinforced silicone rubber or  stainless steel  are also available for special applications. For human use, tubes range in size from 2 to 10.5\u00a0mm (0.1 to 0.4\u00a0in) in internal diameter. The size is chosen based on the patient's body size, with the smaller sizes being used for infants and children. Most endotracheal tubes have an inflatable cuff to seal the tracheobronchial tree against leakage of respiratory gases and pulmonary aspiration of gastric contents, blood, secretions, and other fluids. Uncuffed tubes are also available, though their use is limited mostly to children (in small children, the  cricoid cartilage  is the narrowest portion of the airway and usually provides an adequate seal for mechanical ventilation). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4588", "text": "In addition to cuffed or uncuffed, preformed endotracheal tubes are also available. The oral and nasal RAE tubes (named after the inventors Ring, Adair and Elwyn) are the most widely used of the preformed tubes. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4589", "text": "There are a number of different types of  double-lumen endo-bronchial tubes  that have endobronchial as well as endotracheal channels (Carlens, White and Robertshaw tubes). These tubes are typically  coaxial , with two separate channels and two separate openings. They incorporate an endotracheal lumen which terminates in the trachea and an endobronchial lumen, the distal tip of which is positioned 1\u20132\u00a0cm into the right or left mainstem bronchus. There is also the Univent tube, which has a single tracheal lumen and an integrated  endobronchial blocker . These tubes enable one to ventilate both lungs, or either lung independently. Single-lung ventilation (allowing the lung on the operative side to collapse) can be useful during  thoracic surgery , as it can facilitate the surgeon's view and access to other relevant structures within the  thoracic cavity . [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4590", "text": "The \"armored\" endotracheal tubes are cuffed, wire-reinforced silicone rubber tubes. They are much more flexible than polyvinyl chloride tubes, yet they are difficult to compress or kink. This can make them useful for situations in which the trachea is anticipated to remain intubated for a prolonged duration, or if the neck is to remain flexed during surgery. Most armored tubes have a Magill curve, but preformed armored RAE tubes are also available. Another type of endotracheal tube has four small openings just above the inflatable cuff, which can be used for suction of the trachea or administration of intratracheal medications if necessary. Other tubes (such as the Bivona Fome-Cuf tube) are designed specifically for use in laser surgery in and around the airway. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4591", "text": "No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods for confirmation of correct tube placement is now widely considered to be the  standard of care . [ 34 ]  Such methods include direct visualization as the tip of the tube passes through the glottis, or indirect visualization of the tracheal tube within the trachea using a device such as a bronchoscope. With a properly positioned tracheal tube, equal bilateral  breath sounds  will be heard upon  listening to  the chest with a stethoscope, and no sound upon listening to the area  over the stomach . Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. A small amount of  water vapor  will also be evident within the lumen of the tube with each exhalation and there will be no gastric contents in the tracheal tube at any time. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4592", "text": "Ideally, at least one of the methods utilized for confirming tracheal tube placement will be a  measuring instrument . Waveform  capnography  has emerged as the  gold standard  for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of a  colorimetric  end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device. [ 35 ]  The distal tip of a properly positioned tracheal tube will be located in the mid-trachea, roughly 2\u00a0cm (1\u00a0in) above the bifurcation of the carina; this can be confirmed by  chest x-ray . If it is inserted too far into the trachea (beyond the carina), the tip of the tracheal tube is likely to be within the  right main bronchus \u2014a situation often referred to as a \"right mainstem intubation\". In this situation, the left lung may be unable to participate in ventilation, which can lead to  decreased oxygen content  due to  ventilation/perfusion mismatch . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4593", "text": "Tracheal intubation in the emergency setting can be difficult with the fiberoptic bronchoscope due to blood, vomit, or  secretions  in the airway and poor patient cooperation. Because of this, patients with massive facial injury, complete upper airway obstruction, severely diminished ventilation, or profuse upper airway bleeding are poor candidates for fiberoptic intubation. [ 37 ]  Fiberoptic intubation under general anesthesia typically requires two skilled individuals. [ 38 ]  Success rates of only 83\u201387% have been reported using fiberoptic techniques in the emergency department, with significant  nasal bleeding  occurring in up to 22% of patients. [ 39 ] [ 40 ]  These drawbacks limit the use of fiberoptic bronchoscopy somewhat in urgent and emergency situations. [ 41 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4594", "text": "Personnel experienced in direct laryngoscopy are not always immediately available in certain settings that require emergency tracheal intubation. For this reason, specialized devices have been designed to act as bridges to a definitive airway. Such devices include the laryngeal mask airway, cuffed  oropharyngeal  airway and the esophageal-tracheal combitube ( Combitube ). [ 43 ] [ 44 ]  Other devices such as rigid stylets, the lightwand (a blind technique) and indirect fiberoptic rigid stylets, such as the Bullard scope, Upsher scope and the WuScope can also be used as alternatives to direct laryngoscopy. Each of these devices have its own unique set of benefits and drawbacks, and none of them is effective under all circumstances. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4595", "text": "Rapid sequence induction and intubation (RSI) is a particular method of induction of general anesthesia, commonly employed in emergency operations and other situations where patients are assumed to have a full stomach. The objective of RSI is to minimize the possibility of  regurgitation  and pulmonary aspiration of gastric contents during the induction of general anesthesia and subsequent tracheal intubation. [ 34 ]  RSI traditionally involves preoxygenating the lungs with a tightly fitting oxygen mask, followed by the sequential administration of an intravenous  sleep-inducing  agent and a rapidly acting neuromuscular-blocking drug, such as  rocuronium ,  succinylcholine , or  cisatracurium besilate , before intubation of the trachea. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4596", "text": "One important difference between RSI and routine tracheal intubation is that the practitioner does not manually assist the ventilation of the lungs after the onset of general anesthesia and  cessation of breathing , until the trachea has been intubated and the cuff has been inflated. Another key feature of RSI is the application of manual ' cricoid pressure ' to the cricoid cartilage, often referred to as the \"Sellick maneuver\", prior to instrumentation of the airway and intubation of the trachea. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4597", "text": "Named for British anesthetist Brian Arthur Sellick (1918\u20131996) who first described the procedure in 1961, [ 46 ]  the goal of cricoid pressure is to minimize the possibility of regurgitation and pulmonary aspiration of gastric contents. Cricoid pressure has been widely used during RSI for nearly fifty years, despite a lack of compelling evidence to support this practice. [ 47 ]  The initial article by Sellick was based on a small sample size at a time when high  tidal volumes ,  head-down positioning  and  barbiturate  anesthesia were the rule. [ 48 ]  Beginning around 2000, a significant body of evidence has accumulated which questions the effectiveness of cricoid pressure. The application of cricoid pressure may in fact displace the esophagus laterally [ 49 ]  instead of compressing it as described by Sellick. Cricoid pressure may also compress the glottis, which can obstruct the view of the laryngoscopist and actually cause a delay in securing the airway. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4598", "text": "Cricoid pressure is often confused with the \"BURP\" (Backwards Upwards Rightwards Pressure) maneuver. [ 51 ]  While both of these involve digital pressure to the anterior aspect (front) of the laryngeal apparatus, the purpose of the latter is to improve the view of the glottis during laryngoscopy and tracheal intubation, rather than to prevent regurgitation. [ 52 ]  Both cricoid pressure and the BURP maneuver have the potential to worsen laryngoscopy. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4599", "text": "RSI may also be used in prehospital emergency situations when a patient is conscious but respiratory failure is imminent (such as in extreme trauma). This procedure is commonly performed by flight paramedics. Flight paramedics often use RSI to intubate before transport because intubation in a moving fixed-wing or rotary-wing aircraft is extremely difficult to perform due to environmental factors. The patient will be paralyzed and intubated on the ground before transport by aircraft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4600", "text": "A cricothyrotomy is an incision made through the skin and  cricothyroid membrane  to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. [ 54 ]  A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4601", "text": "The easiest method to perform this technique is the needle cricothyrotomy (also referred to as a  percutaneous  dilational cricothyrotomy), in which a large-bore (12\u201314  gauge )  intravenous catheter  is used to puncture the cricothyroid membrane. [ 56 ]  Oxygen can then be administered through this catheter via  jet insufflation . However, while needle cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established. [ 57 ]  While needle cricothyrotomy can provide adequate oxygenation, the small diameter of the cricothyrotomy catheter is insufficient for elimination of carbon dioxide (ventilation). After one hour of  apneic oxygenation  through a needle cricothyrotomy, one can expect a  PaCO 2  of greater than 250\u00a0mm Hg and an arterial  pH  of less than 6.72, despite an oxygen saturation of 98% or greater. [ 58 ]  A more definitive airway can be established by performing a surgical cricothyrotomy, in which a 5 to 6\u00a0mm (0.20 to 0.24\u00a0in) endotracheal tube or tracheostomy tube can be inserted through a larger incision. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4602", "text": "Several manufacturers market prepackaged cricothyrotomy kits, which enable one to use either a wire-guided percutaneous dilational (Seldinger) technique, or the classic surgical technique to insert a polyvinylchloride catheter through the cricothyroid membrane. The kits may be stocked in hospital emergency departments and operating suites, as well as ambulances and other selected  pre-hospital  settings. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4603", "text": "Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea. The resulting  opening  can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his nose or mouth. The opening may be made by a scalpel or a needle (referred to as surgical [ 59 ]  and percutaneous [ 61 ]  techniques respectively) and both techniques are widely used in current practice. In order to limit the risk of damage to the  recurrent laryngeal nerves  (the nerves that control the  voice box ), the tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the patient's voice may be impaired ( dysphonia ); if both of the nerves are damaged, the patient will be unable to speak ( aphonia ). In the acute setting, indications for tracheotomy are similar to those for cricothyrotomy. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and removal of tracheal secretions (e.g., comatose patients, or extensive surgery involving the head and neck). [ 62 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4604", "text": "There are significant differences in airway anatomy and respiratory physiology between children and adults, and these are taken into careful consideration before performing tracheal intubation of any  pediatric  patient. The differences, which are quite significant in infants, gradually disappear as the human body approaches a mature age and  body mass index . [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4605", "text": "For infants and young children, orotracheal intubation is easier than the nasotracheal route. Nasotracheal intubation carries a risk of dislodgement of  adenoids  and nasal bleeding. Despite the greater difficulty, nasotracheal intubation route is preferable to orotracheal intubation in children undergoing intensive care and requiring prolonged intubation because this route allows a more secure fixation of the tube. As with adults, there are a number of devices specially designed for assistance with difficult tracheal intubation in children. [ 65 ] [ 66 ] [ 67 ] [ 68 ]  Confirmation of proper position of the tracheal tube is accomplished as with adult patients. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4606", "text": "Because the airway of a child is narrow, a small amount of glottic or tracheal  swelling  can produce critical obstruction. Inserting a tube that is too large relative to the diameter of the trachea can cause swelling. Conversely, inserting a tube that is too small can result in inability to achieve effective positive pressure ventilation due to retrograde escape of gas through the glottis and out the mouth and nose (often referred to as a \"leak\" around the tube). An excessive leak can usually be corrected by inserting a larger tube or a cuffed tube. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4607", "text": "The tip of a correctly positioned tracheal tube will be in the mid-trachea, between the  collarbones  on an  anteroposterior  chest radiograph. The correct diameter of the tube is that which results in a small leak at a pressure of about 25\u00a0cm (10\u00a0in) of water. The appropriate inner diameter for the endotracheal tube is estimated to be roughly the same diameter as the child's little finger. The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of the child's mouth to the  ear canal . For  premature infants  2.5\u00a0mm (0.1\u00a0in) internal diameter is an appropriate size for the tracheal tube. For infants of normal  gestational age , 3\u00a0mm (0.12\u00a0in) internal diameter is an appropriate size. For normally nourished children 1\u00a0year of age and older, two formulae are used to estimate the appropriate diameter and depth for tracheal intubation. The internal diameter of the tube in mm is (patient's age in years + 16) / 4, while the appropriate depth of insertion in cm is 12 + (patient's age in years / 2). [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4608", "text": "Endotrachael suctioning is often used during intubation in newborn infants to reduce the risk of a blocked tube due to secretions, a collapsed lung, and to reduce pain. [ 7 ]  Suctioning is sometimes used at specifically scheduled intervals, \"as needed\", and less frequently. Further research is necessary to determine the most effective suctioning schedule or frequency of suctioning in intubated infants. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4609", "text": "In newborns free flow  oxygen  used to be recommended during intubation however as there is no evidence of benefit the 2011  NRP guidelines  no longer do. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4610", "text": "Tracheal intubation is not a simple procedure and the consequences of failure are grave. Therefore, the patient is carefully evaluated for potential difficulty or complications beforehand. This involves taking the  medical history  of the patient and performing a  physical examination , the results of which can be scored against one of several classification systems. The proposed surgical procedure (e.g., surgery involving the head and neck, or  bariatric surgery ) may lead one to anticipate difficulties with intubation. [ 34 ]  Many individuals have unusual airway anatomy, such as those who have limited movement of their neck or jaw, or those who have tumors, deep swelling  due to injury  or  to allergy , developmental abnormalities of the jaw, or excess fatty tissue of the face and neck. Using conventional laryngoscopic techniques, intubation of the trachea can be difficult or even impossible in such patients. This is why all persons performing tracheal intubation must be familiar with alternative techniques of securing the airway. Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases. However, these devices require a different skill set than that employed for conventional laryngoscopy and are expensive to purchase, maintain and repair. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4611", "text": "When taking the patient's medical history, the subject is questioned about any significant  signs  or  symptoms , such as  difficulty in speaking  or  difficulty in breathing . These may suggest obstructing  lesions  in various locations within the upper airway,  larynx , or tracheobronchial tree. A history of previous surgery (e.g., previous  cervical fusion ), injury,  radiation therapy , or  tumors  involving the head, neck and  upper chest  can also provide clues to a potentially difficult intubation. Previous experiences with tracheal intubation, especially difficult intubation, intubation for prolonged duration (e.g., intensive care unit) or prior tracheotomy are also noted. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4612", "text": "A detailed  physical examination  of the airway is important, particularly: [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4613", "text": "Many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including the  Cormack-Lehane classification system , [ 74 ]  the Intubation Difficulty Scale (IDS), [ 75 ]  and the  Mallampati score . [ 76 ]  The Mallampati score is drawn from the observation that the size of the  base of the tongue  influences the difficulty of intubation. It is determined by looking at the anatomy of the mouth, and in particular the visibility of the base of  palatine uvula ,  faucial pillars  and the  soft palate . Although such medical scoring systems may aid in the evaluation of patients, no single score or combination of scores can be trusted to specifically detect all and only those patients who are difficult to intubate. [ 77 ] [ 78 ]  Furthermore, one study of experienced anesthesiologists, on the widely used Cormack\u2013Lehane classification system, found they did not score the same patients consistently over time, and that only 25% could correctly define all four grades of the widely used Cormack\u2013Lehane classification system. [ 79 ]  Under certain emergency circumstances (e.g., severe head trauma or suspected cervical spine injury), it may be impossible to fully utilize these the physical examination and the various classification systems to predict the difficulty of tracheal intubation. [ 80 ]  A Cochrane systematic review examined the sensitivity and specificity of various bedside tests commonly used for predicting difficulty in airway management. [ 81 ]  In such cases, alternative techniques of securing the airway must be readily available. [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4614", "text": "Tracheal intubation is generally considered the best method for airway management under a wide variety of circumstances, as it provides the most reliable means of oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration. [ 2 ]  However, tracheal intubation requires a great deal of clinical experience to master [ 83 ]  and serious complications may result even when properly performed. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4615", "text": "Four anatomic features must be present for orotracheal intubation to be straightforward: adequate mouth opening (full range of motion of the temporomandibular joint), sufficient pharyngeal space (determined by examining the  back of the mouth ), sufficient submandibular space (distance between the thyroid cartilage and the chin, the space into which the tongue must be displaced in order for the larygoscopist to view the glottis), and adequate extension of the cervical spine at the atlanto-occipital joint. If any of these variables is in any way compromised, intubation should be expected to be difficult. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4616", "text": "Minor complications are common after laryngoscopy and insertion of an orotracheal tube. These are typically of short duration, such as sore throat, lacerations of the lips or  gums  or other structures within the upper airway, chipped, fractured or dislodged teeth, and nasal injury. Other complications which are common but potentially more serious include  accelerated  or  irregular  heartbeat,  high blood pressure , elevated  intracranial  and  introcular  pressure, and  bronchospasm . [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4617", "text": "More serious complications include  laryngospasm ,  perforation of the trachea  or  esophagus , pulmonary aspiration of gastric contents or other foreign bodies, fracture or dislocation of the cervical spine,  temporomandibular joint  or  arytenoid cartilages , decreased oxygen content,  elevated arterial carbon dioxide , and  vocal cord weakness . [ 84 ]  In addition to these complications, tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding. [ 39 ] [ 40 ]  Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of some of these complications, though the most frequent cause of intubation trauma remains a lack of skill on the part of the laryngoscopist. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4618", "text": "Complications may also be severe and long-lasting or permanent, such as vocal cord damage, esophageal perforation and  retropharyngeal abscess , bronchial intubation, or nerve injury. They may even be immediately life-threatening, such as laryngospasm and negative pressure  pulmonary edema  (fluid in the lungs), aspiration, unrecognized esophageal intubation, or accidental disconnection or dislodgement of the tracheal tube. [ 84 ]  Potentially fatal complications more often associated with prolonged intubation or tracheotomy include abnormal communication between the trachea and nearby structures such as the  innominate artery  (tracheoinnominate  fistula ) or esophagus ( tracheoesophageal fistula ). Other significant complications include airway obstruction due to  loss of tracheal rigidity ,  ventilator-associated pneumonia  and  narrowing  of the glottis or trachea. [ 33 ]  The cuff pressure is monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressure  restricting the blood supply to  the tracheal mucosa. [ 85 ] [ 86 ]  A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10\u201315% and procedural mortality of 0%, [ 61 ]  which is comparable to those of other series reported in the literature from the Netherlands [ 87 ]  and the United States. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4619", "text": "Inability to secure the airway, with subsequent failure of oxygenation and ventilation is a life-threatening complication which if not immediately corrected leads to  decreased oxygen content , brain damage,  cardiovascular collapse , and death. [ 84 ]  When performed improperly, the associated complications (e.g., unrecognized esophageal intubation) may be rapidly fatal. [ 89 ]  Without adequate training and experience, the incidence of such complications is high. [ 2 ]  The case of Andrew Davis Hughes, from Emerald Isle, NC is a widely known case in which the patient was improperly intubated and, due to the lack of oxygen, sustained severe brain damage and died. For example, among  paramedics  in several United States urban communities, unrecognized esophageal or  hypopharyngeal  intubation has been reported to be 6% [ 90 ] [ 91 ]  to 25%. [ 89 ]  Although not common, where basic  emergency medical technicians  are permitted to intubate, reported success rates are as low as 51%. [ 92 ]  In one study, nearly half of patients with misplaced tracheal tubes died in the emergency room. [ 89 ]  Because of this, the  American Heart Association 's  Guidelines for Cardiopulmonary Resuscitation  have de-emphasized the role of tracheal intubation in favor of other airway management techniques such as bag-valve-mask ventilation, the laryngeal mask airway and the Combitube. [ 2 ]   Higher quality studies demonstrate favorable evidence for this shift, as they have shown no survival or neurological benefit with endotracheal intubation over supraglottic airway devices (Laryngeal mask or Combitube). [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4620", "text": "One complication\u2014unintentional and unrecognized intubation of the esophagus\u2014is both common (as frequent as 25% in the hands of inexperienced personnel) [ 89 ]  and likely to result in a deleterious or even fatal outcome. In such cases, oxygen is inadvertently administered to the stomach, from where it cannot be taken up by the  circulatory system , instead of the lungs. If this situation is not immediately identified and corrected, death will ensue from cerebral and cardiac anoxia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4621", "text": "Of 4,460 claims in the  American Society of Anesthesiologists  (ASA) Closed Claims Project database, 266 (approximately 6%) were for airway injury. Of these 266 cases, 87% of the injuries were temporary, 5% were permanent or disabling, and 8% resulted in death. Difficult intubation, age older than 60 years, and female gender were associated with claims for perforation of the esophagus or pharynx. Early signs of perforation were present in only 51% of perforation claims, whereas late  sequelae  occurred in 65%. [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4622", "text": "During the  SARS  and  COVID-19 pandemics , tracheal intubation has been used with a  ventilator  in severe cases where the patient struggles to breathe. Performing the procedure carries a risk of the caregiver becoming infected. [ 95 ] [ 96 ] [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4623", "text": "Although it offers the greatest degree of protection against regurgitation and pulmonary aspiration, tracheal intubation is not the only means to maintain a patent airway. Alternative techniques for airway management and delivery of oxygen, volatile anesthetics or other  breathing gases  include the  laryngeal mask airway , i-gel, cuffed oropharyngeal airway,  continuous positive airway pressure  (CPAP mask), nasal  BiPAP  mask, simple face mask, and nasal cannula. [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4624", "text": "General anesthesia is often administered without tracheal intubation in selected cases where the procedure is brief in duration, or procedures where the depth of anesthesia is not sufficient to cause significant compromise in ventilatory function. Even for longer duration or more invasive procedures, a general anesthetic may be administered without intubating the trachea, provided that patients are carefully selected, and the  risk-benefit ratio  is favorable (i.e., the risks associated with an unprotected airway are believed to be less than the risks of intubating the trachea). [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4625", "text": "Airway management can be classified into closed or open techniques depending on the system of ventilation used. Tracheal intubation is a typical example of a closed technique as ventilation occurs using a closed circuit. Several open techniques exist, such as spontaneous ventilation, apnoeic ventilation or jet ventilation. Each has its own specific advantages and disadvantages which determine when it should be used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4626", "text": "Spontaneous ventilation has been traditionally performed with an inhalational agent (i.e. gas induction or inhalational induction using halothane or sevoflurane) however it can also be performed using intravenous anaesthesia (e.g. propofol, ketamine or dexmedetomidine). SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) is an open airway technique that uses an upwards titration of propofol which maintains ventilation at deep levels of anaesthesia. It has been used in airway surgery as an alternative to tracheal intubation. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4627", "text": "The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600 BC. [ 100 ]  The 110-page  Ebers Papyrus , an  Egyptian medical papyrus  which dates to roughly 1550 BC, also makes reference to the tracheotomy. [ 101 ]  Tracheotomy was described in the  Rigveda , a  Sanskrit  text of  ayurvedic medicine  written around 2000 BC in  ancient India . [ 102 ]  The  Sushruta Samhita  from around 400 BC is another text from the Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy. [ 103 ]   Asclepiades of Bithynia  ( c. \u2009124 \u201340 BC) is often credited as being the first physician to perform a non-emergency tracheotomy. [ 104 ]   Galen  of  Pergamon  (AD 129\u2013199) clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. [ 105 ]  In one of his experiments, Galen used bellows to inflate the lungs of a dead animal. [ 106 ]   Ibn S\u012bn\u0101  (980\u20131037) described the use of tracheal intubation to facilitate breathing in 1025 in his 14-volume medical encyclopedia,  The Canon of Medicine . [ 107 ]  In the 12th century medical textbook  Al-Taisir ,  Ibn Zuhr  (1092\u20131162)\u2014also known as Avenzoar\u2014of  Al-Andalus   provided a correct description of the tracheotomy operation. [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4628", "text": "The first detailed descriptions of tracheal intubation and subsequent  artificial respiration  of animals were from  Andreas Vesalius  (1514\u20131564) of Brussels. In his landmark book published in 1543,  De humani corporis fabrica , he described an experiment in which he passed a  reed  into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently. [ 106 ]   Antonio Musa Brassavola  (1490\u20131554) of  Ferrara  successfully treated a patient with  peritonsillar abscess  by tracheotomy. Brassavola published his account in 1546; this operation has been identified as the first recorded successful tracheotomy, despite the many previous references to this operation. [ 109 ]  Towards the end of the 16th century,  Hieronymus Fabricius  (1533\u20131619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. In 1620 the French surgeon  Nicholas Habicot  (1550\u20131624) published a report of four successful tracheotomies. [ 110 ]  In 1714, anatomist Georg Detharding (1671\u20131747) of the  University of Rostock  performed a tracheotomy on a drowning victim. [ 111 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4629", "text": "Despite the many recorded instances of its use since  antiquity , it was not until the early 19th century that the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1852, French physician  Armand Trousseau  (1801\u20131867) presented a series of 169 tracheotomies to the  Acad\u00e9mie Imp\u00e9riale de M\u00e9decine . 158 of these were performed for the treatment of  croup , and 11 were performed for \"chronic maladies of the larynx\". [ 112 ]  Between 1830 and 1855, more than 350 tracheotomies were performed in Paris, most of them at the  H\u00f4pital des Enfants Malades , a  public hospital , with an overall survival rate of only 20\u201325%. This compares with 58% of the 24 patients in Trousseau's private practice, who fared better due to greater postoperative care. [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4630", "text": "In 1871, the German surgeon  Friedrich Trendelenburg  (1844\u20131924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. [ 114 ]  In 1888, Sir  Morell Mackenzie  (1837\u20131892) published a book discussing the indications for tracheotomy. [ 115 ]  In the early 20th century, tracheotomy became a life-saving treatment for patients affected with paralytic  poliomyelitis  who required mechanical ventilation. In 1909, Philadelphia laryngologist  Chevalier Jackson  (1865\u20131958) described a technique for tracheotomy that is used to this day. [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4631", "text": "In 1854, a Spanish  singing teacher  named  Manuel Garc\u00eda  (1805\u20131906) became the first man to view the functioning glottis in a living human. [ 117 ]  In 1858, French pediatrician  Eug\u00e8ne Bouchut  (1818\u20131891) developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a  diphtheria -related pseudomembrane. [ 118 ]  In 1880, Scottish surgeon  William Macewen  (1848\u20131924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with  chloroform . [ 119 ]  In 1895,  Alfred Kirstein  (1863\u20131922) of Berlin first described direct visualization of the vocal cords, using an esophagoscope he had modified for this purpose; he called this device an autoscope. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4632", "text": "In 1913, Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea. [ 121 ]  Jackson introduced a new laryngoscope blade that incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope. [ 122 ]  Also in 1913, New York surgeon  Henry H. Janeway  (1873\u20131921) published results he had achieved using a laryngoscope he had recently developed. [ 123 ]  Another pioneer in this field was Sir  Ivan Whiteside Magill  (1888\u20131986), who developed the technique of awake blind nasotracheal intubation, [ 124 ] [ 125 ]  the Magill forceps, [ 126 ]  the Magill laryngoscope blade, [ 127 ]  and several apparati for the administration of volatile anesthetic agents. [ 128 ] [ 129 ] [ 130 ]  The Magill curve of an endotracheal tube is also named for Magill. Sir  Robert Macintosh  (1897\u20131989) introduced a curved laryngoscope blade in 1943; [ 131 ]  the Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4633", "text": "Between 1945 and 1952,  optical engineers  built upon the earlier work of  Rudolph Schindler  (1888\u20131968), developing the first gastrocamera. [ 132 ]  In 1964,  optical fiber  technology was applied to one of these early gastrocameras to produce the first flexible fiberoptic endoscope. [ 133 ]  Initially used in  upper GI endoscopy , this device was first used for laryngoscopy and tracheal intubation by Peter Murphy, an English anesthetist, in 1967. [ 134 ]  The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a  central venous catheter . [ 135 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4634", "text": "By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia communities. [ 13 ]  The  digital revolution  of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ  digital technology  such as the  CMOS   active pixel sensor  (CMOS APS) to generate a view of the glottis so that the trachea may be intubated. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4635", "text": "Tracheitis  is an  inflammation  of the  trachea . [ 1 ] \nAlthough the trachea is usually considered part of the  lower respiratory tract , [ 2 ]  in  ICD-10  tracheitis is classified under \"acute upper respiratory infections\". [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4636", "text": "Bacterial tracheitis is a bacterial infection of the  trachea  and is capable of producing airway obstruction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4637", "text": "One of the most common causes is  Staphylococcus aureus  and often follows a recent viral upper respiratory infection.  Bacterial tracheitis is a rare complication of influenza infection. [ 4 ]  It is the most serious in young children, possibly because of the relatively small size of the trachea that gets easily blocked by swelling.  The most frequent sign is the rapid development of  stridor .  It is occasionally confused with  croup .\nIf it is inflamed, a condition known as tracheitis can occur. In this condition there can be inflammation of the linings of the trachea. A condition called tracheo-bronchitis can be caused, when the mucous membrane of the trachea and bronchi swell. A collapsed trachea is formed as a result of defect in the cartilage, that makes the cartilage unable to support the trachea and results in dry hacking cough. In this condition there can be inflammation of the linings of the trachea. If the connective nerve tissues in the trachea degenerate it causes tracheomalacia. Infections to the trachea can cause tracheomegaly. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4638", "text": "The diagnosis of tracheitis requires the direct vision of exudates or pseudomembranes on the trachea. X-ray findings may include subglottic narrowing. The priority is to secure the patient's airway, and to rule out croup and epiglottitis which may be fatal. Suspicion for tracheitis should be high in cases of onset of airway obstruction that do not respond to racemic epinephrine. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4639", "text": "In more severe cases, it is treated by administering intravenous antibiotics and may require admission to an intensive care unit (ICU) for intubation and supportive ventilation if the airway swelling is severe.  During an intensive care admission, various methods of invasive and non-invasive monitoring may be required, which may include ECG monitoring, oxygen saturation, capnography and arterial blood pressure monitoring. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4640", "text": "1 \u2013  Vocal folds \n2 \u2013  Thyroid cartilage \n3 \u2013  Cricoid cartilage \n4 \u2013  Tracheal rings"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4641", "text": "Tracheotomy  ( / \u02cc t r e\u026a k i \u02c8 \u0252 t \u0259 m i / ,  UK also   / \u02cc t r \u00e6 k i -/ ), or  tracheostomy , is a  surgical airway management  procedure which consists of making an incision on the front of the neck to open a direct airway to the  trachea . The resulting  stoma  (hole) can serve independently as an  airway  or as a site for a  tracheal tube  (or tracheostomy tube) to be inserted; [ 1 ]  this tube allows a person to breathe without the use of the nose or mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4642", "text": "The  etymology  of the word  tracheotomy  comes from two  Greek  words: the  root   tom-  (from  Greek  \u03c4\u03bf\u03bc\u03ae  tom\u1e17 ) meaning \"to cut\", and the word  trachea  (from Greek \u03c4\u03c1\u03b1\u03c7\u03b5\u03af\u03b1  trache\u00eda ). [ 2 ]  The word  tracheostomy , including the root  stom-  (from Greek \u03c3\u03c4\u03cc\u03bc\u03b1  st\u00f3ma ) meaning \"mouth\", refers to the making of a semi-permanent or permanent opening and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the  stoma  (hole) at the time it is created. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4643", "text": "There are four main reasons why someone would receive a tracheotomy: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4644", "text": "In the acute (short term) setting, indications for tracheotomy include such conditions as severe  facial trauma , tumors of the head and neck (e.g.,  cancers ,  branchial cleft cysts ), and acute  angioedema  and  inflammation  of the head and neck. In the context of failed  tracheal intubation , either tracheotomy or  cricothyrotomy  may be performed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4645", "text": "In the chronic (long-term) setting, indications for tracheotomy include the need for long-term mechanical ventilation and  tracheal toilet  (e.g.,  comatose  patients, extensive surgery involving the head and neck). Tracheotomy may result in a significant reduction in the administration of  sedatives  and  vasopressors , as well as the duration of stay in the  intensive care unit  (ICU). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4646", "text": "In extreme cases, the procedure may be indicated as a treatment for severe  obstructive sleep apnea  (OSA) seen in patients intolerant of  continuous positive airway pressure  (CPAP) therapy. The reason tracheostomy works well for OSA is because it is the  only  surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the  uvulopalatopharyngoplasty ,  genioglossus advancement , and  maxillomandibular advancement  surgeries were described as alternative surgical modalities for OSA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4647", "text": "If prolonged ventilation is required, tracheostomy is usually considered. The timing of this procedure is dependent on the clinical situation and an individual's preference. An international multicenter study in 2000 determined that the median time between starting mechanical ventilation and receiving a tracheostomy was 11 days. [ 5 ]  Although the definition varies depending on hospital and provider, early tracheostomy can be considered to be less than 10 days (2 to 14 days) and late tracheostomy to be 10 days or more."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4648", "text": "Biphasic cuirass ventilation  is a form of non-invasive mechanical ventilation that can \u2014 in a small subset of cases \u2014 allow people to avoid a tracheostomy. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4649", "text": "A tracheostomy tube may be single or dual lumen, and also cuffed or uncuffed. A dual lumen tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning after use or it may be replaced. Single-lumen tracheostomy tubes do not have a removable inner cannula, suitable for narrower airways. Cuffed tracheostomy tubes have inflatable balloons at the end of the tube to secure them in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the  larynx , allowing speech. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4650", "text": "Special tracheostomy tube valves (such as the Passy-Muir valve [ 8 ] ) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4651", "text": "The typical procedure done is the open surgical tracheotomy (OST) and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse (horizontal) incision is made two fingerbreadths above the  suprasternal notch . Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (a specific group of neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open, either through the space between cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4652", "text": "The first widely accepted percutaneous tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985. [ 12 ]  The next widely used technique was developed in 1989 by  Bill Griggs , an Australian intensive care specialist. [ 13 ]  In 1995, Fantoni developed a translaryngeal approach of percutaneous tracheostomy. [ 14 ]  The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging [ 15 ]  An advantage of PDT over OST is the ability to perform the procedure at the patient's bedside. This significantly decreases costs and time/people-power needed for an operating room (OR) procedure. [ 11 ]  Contraindications for percutaneous tracheostomy include infection at the site of tracheostomy, uncontrolled bleeding disorder, unstable cardiopulmonary status, patient unable to stay still, abnormal anatomy of the tracheolaryngeal structures. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4653", "text": "As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open. [ 16 ]  There are other difficulties with patients with irregular necks, the obese, and those with a large  goitre ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4654", "text": "The many possible complications include  hemorrhage , loss of airway,  subcutaneous emphysema , wound infections, stoma cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and  bronchospasm . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4655", "text": "Early complications include infection, hemorrhage,  pneumomediastinum ,  pneumothorax ,  tracheoesophageal fistula , recurrent laryngeal nerve injury, and tube displacement. Delayed complications include  tracheal-innominate artery fistula ,  tracheal stenosis , delayed tracheoesophageal fistula, and tracheocutaneous fistula. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4656", "text": "A 2013 systematic review (published cases from 1985 to April 2013) studied the complications and risk factors of percutaneous dilatational tracheostomy (PDT), identifying major causes of fatality to be  hemorrhage  (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and  pneumothorax  (5.6%) [ 18 ]  A similar systematic review in 2017 (cases from 1990 to 2015) studying fatality in both open surgical tracheotomy (OST) and PDT identified similar rates of mortality and causes of death between the two techniques. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4657", "text": "Hemorrhage  is rare, but the most likely cause of fatality after a tracheostomy. It usually occurs due to a  tracheoarterial fistula , an abnormal connection between the trachea and nearby blood vessels, and most commonly manifests between 3 days to 6 weeks after the procedure is done. Fistulas can result from incorrectly positioned equipment, high cuff pressures causing pressure sores or mucosal damage, a low surgical trachea site, repetitive neck movement, radiotherapy, or prolonged intubation. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4658", "text": "A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the lack of  bronchoscopic  guidance. Use of the bronchoscope, an instrument inserted through a patient's mouth for internal visualization of the airway, can help with proper placement of instruments and better visualization of anatomical structures. However, this can also be dependent on the skills and familiarity of the surgeon with both the procedure and the patient's anatomy. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4659", "text": "There are a multitude of potential complications related to the airway. The main causes of mortality during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of the tube. [ 18 ]  One of the more urgent complications include displacement or dislodgment of the tracheotomy tube, either spontaneously or during a tube change. Although uncommon (< 1/1000 tracheostomy tube days), the associated fatality is high due to the loss of airway. [ 21 ]  Due to the seriousness of such a situation, individuals with a tracheotomy tube should consult with their healthcare providers to have a specific, written, emergency intubation and tracheostomy recannulation (reinsertion) plan prepared in advance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4660", "text": "Tracheal stenosis , otherwise known as an abnormal narrowing of the airway, is a possible long term complication. The most common symptom of stenosis is gradually-worsening difficulty with breathing ( dyspnea ). However incidence is low, ranging from 0.6 to 2.8% with increased rates if major bleeding or wound infections are present. A 2016 systematic review identified a higher rate of tracheal stenosis in individuals who underwent a surgical tracheostomy, as compared to PDT, however the difference was not statistically significant. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4661", "text": "A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10\u201315% and a procedural mortality of 0%, [ 23 ]  which is comparable to those of other series reported in the literature from the Netherlands [ 24 ] [ 25 ]  and the United States. [ 26 ] [ 27 ]  A 2013 systematic review calculated procedural mortality to be 0.17% or 1 in 600 cases. [ 18 ]  Multiple systematic reviews identified no significant difference in rates of mortality, major bleeding, or wound infection between the percutaneous or open surgical methods. [ 22 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4662", "text": "Specifically a 2017 systematic review calculated the most common causes of death and their frequencies, out of all tracheotomies, to be hemorrhage (OST: 0.26%, PDT: 0.19%), loss of airway (OST: 0.21%, PDT: 0.20%), and misplacement of tube (OST: 0.11%, PDT: 0.20%). [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4663", "text": "A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. [ 28 ]  The comparative study above also identified ring fractures in 9 of 30 live patients [ 15 ]  while another small series identified ring fractures in 5 of their 20 patients. [ 29 ]  The long term significance of tracheal ring fractures is unknown. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4664", "text": "Tracheotomy was first potentially depicted on  Egyptian  artifacts in 3600 BC. [ 30 ]   Hippocrates  condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the  carotid artery . Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of  tracheal intubation . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4665", "text": "Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by  Asclepiades of Bithynia , who lived in Rome around 100 BC. [ 31 ]   Galen  and  Aretaeus , both of whom lived in Rome in the 2nd century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy.  Antyllus , another Roman-era Greek physician of the 2nd century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a  transverse  incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4666", "text": "The 7th century Byzantine physician  Paul of Aegina , an advocate of the procedure, acknowledged previous Greek authors' works on the subject of tracheotomies and provided descriptions of the procedure in his own works. [ 32 ]  In 1000,  Abu al-Qasim al-Zahrawi  (936\u20131013), an Arab who lived in  Arabic Spain , published the 30-volume  Kitab al-Tasrif , the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as  Albucasis ) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa AD 1020,  Avicenna  (980\u20131037) described tracheal intubation in  The Canon of Medicine  in order to facilitate  breathing . [ 33 ]  The first clear description of the tracheotomy operation for treating asphyxiation was given by  Ibn Zuhr  (1091\u20131161) in the 12th century. According to Mostafa Shehata, Ibn Zuhr (also known as Avenzoar) successfully practiced the tracheotomy procedure on a goat, justifying Galen's approval of the operation. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4667", "text": "The European  Renaissance  brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate, [ quantify ]  and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate [ quantify ]  for this operation, which had not improved, supported their position. From the period 1500 to 1832 there are only 28 known reports of tracheotomy. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4668", "text": "In 1543,  Andreas Vesalius  (1514\u20131564) wrote that tracheal intubation and subsequent  artificial respiration  could be life-saving.  Antonio Musa Brassavola  (1490\u20131554) of  Ferrara  treated a patient with  peritonsillar abscess  by tracheotomy after the patient had been refused by  barber surgeons . The patient apparently made a complete recovery, and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. [ 35 ]   Ambroise Par\u00e9  (1510\u20131590) described suture of tracheal lacerations in the mid-16th century. One patient survived despite a concomitant injury to the internal jugular vein. Another sustained wounds to the trachea and esophagus and died."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4669", "text": "Towards the end of the 16th century, anatomist and surgeon  Hieronymus Fabricius  (1533\u20131619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short  cannula  that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of  airway  obstruction by  foreign bodies  or  secretions . Fabricius' description of the tracheotomy procedure is similar to that used today.  Giulio Cesare Casseri  (1552\u20131616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy. Casseri recommended using a curved silver tube with several holes in it.  Marco Aurelio Severino  (1580\u20131656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a  diphtheria   epidemic  in  Naples  in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4670", "text": "In 1620 the French surgeon  Nicholas Habicot  (1550\u20131624), surgeon of the  Duke of Nemours  and anatomist, published a report of four successful \"bronchotomies\" which he had performed. [ 37 ]  One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a  pediatric  patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a  highwayman . The object became lodged in his  esophagus , obstructing his trachea. Habicot suggested that the operation might also be effective for patients with inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4671", "text": "Sanctorius  (1561\u20131636) is believed to be the first to use a trocar in the operation, and he recommended leaving the cannula in place for a few days following the operation. [ 38 ]  Early tracheostomy devices are illustrated in Habicot's  Question Chirurgicale [ 37 ]  and Casseri's posthumous  Tabulae anatomicae  in 1627. [ 39 ]  Thomas Fienus (1567\u20131631), Professor of Medicine at the  University of Louvain , was the first to use the word \"tracheotomy\" in 1649, but this term was not commonly used until a century later. [ 40 ]  Georg Detharding (1671\u20131747), professor of anatomy at the  University of Rostock , treated a drowning victim with tracheostomy in 1714. [ 41 ] [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4672", "text": "In the 1820s, the tracheotomy began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician  Pierre Bretonneau  employed it as a last resort to treat a case of  diphtheria . [ 44 ]  In 1852, Bretonneau's student  Armand Trousseau  reported a series of 169 tracheotomies (158 of which were for  croup , and 11 for \"chronic maladies of the larynx\") [ 45 ]  In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model. [ 46 ]  In 1871, the German surgeon  Friedrich Trendelenburg  (1844\u20131924) published a paper describing the first successful  elective  human tracheotomy to be performed for the purpose of administration of general anesthesia. [ 47 ]  In 1880, the Scottish surgeon  William Macewen  (1848\u20131924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with  chloroform . [ 48 ] [ 49 ]  At last, in 1880  Morell Mackenzie 's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4673", "text": "In the early 20th century, physicians began to use the tracheotomy in the treatment of patients affected by paralytic  poliomyelitis  who required  mechanical ventilation . However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different  surgical instruments  and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the \"high tracheotomy\" or the \"low tracheotomy\" was more beneficial. The currently used surgical tracheotomy technique was described in 1909 by  Chevalier Jackson  of  Pittsburgh ,  Pennsylvania . Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood,  antibiotics  were widely available and useful for treating postoperative infections, and other major complications had also become more manageable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4674", "text": "Notable individuals who have or have had a tracheotomy include  Catherine Zeta-Jones ,  Mika H\u00e4kkinen ,  Stephen Hawking ,  Connie Culp ,  Christopher Reeve , [ 50 ]   Roy Horn ,  William Rehnquist ,  Gabby Giffords ,  George Michael ,  Val Kilmer , [ 51 ]  and many others. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4675", "text": "Across movies and TV shows, there are many situations where an emergency procedure is done on an individual's neck to re-establish an airway. An example is in the 2008 horror film,  Saw V , in which a character being drowned from the neck up performs a manual tracheotomy, stabbing his neck with a pen to create an airway to breathe through. The most common procedure is a  cricothyrotomy  (or \"crike\"), which is an incision through the skin and cricothyroid membrane. This is often confused or misnamed as a tracheotomy (or \"trach\") and vice versa. However, they are quite different based on location of the opening and length of time the alternate airway is needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4676", "text": "Another example of an emergency attempt at this procedure is featured in the 2013 comedy film  The Heat , where  Sandra Bullock \u2019s character, Sarah Ashburn, attempts to perform the operation on a person choking on a pancake in a  Denny's , but fails.  Melissa McCarthy \u2019s character, Detective Mullens, then presses hard on the man's chest, causing the piece of food to be expelled from his mouth. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4677", "text": "The  tragus  is a small pointed eminence of the  external ear , situated in front of the  concha , and projecting backward over the  meatus . It also is the name of hair growing at the entrance of the ear. [ 1 ]  Its name comes from the  Ancient Greek   tragos  ( \u03c4\u03c1\u03ac\u03b3\u03bf\u03c2 ), meaning 'goat', and is descriptive of its general covering on its under surface with a tuft of  hair , resembling a  goat 's  beard . [ 2 ]  The nearby  antitragus  projects forwards and upwards. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4678", "text": "Because the tragus faces rearwards, it aids in collecting sounds from behind.  These sounds are delayed more than sounds arriving from the front, assisting the brain to sense front vs. rear sound sources. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4679", "text": "In a positive  fistula  test (for the presence of a fistula from  cholesteatoma  to the  labyrinth ), pressure on the tragus causes  vertigo  or eye deviation by inducing movement of  perilymph . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4680", "text": "The tragus is a key feature in many bat species. As a piece of skin in front of the ear canal, it plays an important role in directing sounds into the ear for prey location and navigation via  echolocation . [ 6 ]  Because the tragus tends to be prominent in bats, it is an important feature in identifying bat species. [ 7 ] \nThe tragus allows echolocating bat species to vertically discriminate the objects around them, which is key to identifying where prey items and obstacles are in three-dimensional space.\nIn studies where an individual's tragi are temporarily glued out of their normal positions, the bat's navigational acuity is one-fourth as effective as individuals with unmodified tragi.\nBased on this study, the authors concluded that the tragus's function is to create acoustic cues to determine the direction of a target in the vertical plane. [ 8 ] \nNot all echolocating bats possess tragi, however.\n Horseshoe bats  are one such family; the way in which the outer bottom edge of the ear folds in on itself is thought to function in a similar way to the tragus in other families. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4681", "text": "This article incorporates text in the  public domain  from  page 1034  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4682", "text": "Transnasal esophagoscopy  ( TNE ) is a safe and inexpensive way to examine the  esophagus  in patients at risk for  esophageal cancer  and other disorders. [ 1 ] [ 2 ] [ 3 ]  TNE doesn't require sedation, unlike other techniques widely used to look into the esophagus. This is possible because TNE uses a camera that is passed through the  nose , whereas other techniques, such as upper endoscopy, are performed through the  mouth , requiring a patient to be sedated. TNE, as it is used today, was developed by  Jonathan E. Aviv  who published his findings on the first series of TNE that he performed. [ 4 ]   The origins of the idea to pass the camera through the nose date from 1993 as first described by C. A. Prescott, MD, a pediatrician  otolaryngologist  in Cape Town, South Africa  [ 5 ]  and further embellished by Reza Shaker, MD, a  gastroenterologist  in Milwaukee, WI in 1994. [ 6 ]  However, it wasn't until the year 2000 when  Jonathan E. Aviv , MD, published his findings on the first series of TNE he performed, that it began to have a widespread attention by ear, nose, and throat doctors. [ 7 ]  Since that time it has been used by both otolaryngologists and gastroenterologists as a diagnostic tool to detect globus,  dysphagia ,  laryngopharyngeal reflux  (LPR), gastroesophageal reflux disease ( GERD ). TNE may also be useful in detecting  Barrett's , but there is incongruence between TNE findings and biopsy results. [ 8 ]  Experts in the field suggest that TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4683", "text": "Transnasal esophagoscopy  is an office based procedure in which the patient is anesthetized locally in the nose and sometimes the  oropharynx . The scope is advanced into the  ipsilateral   pyriform sinus  and through the esophageal inlet to the stomach, where the esophagus can be examined, with special attention paid to the gastroesophageal (GE) junction. [ 10 ]  An advantage of TNE over other more invasive cancer screening methods that require  conscious sedation  is that it can be performed using topical anesthesia alone with the patient sitting upright in an exam chair unencumbered by cardiac monitoring equipment. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4684", "text": "In  neuroanatomy , the  trigeminal nerve  ( lit.   triplet  nerve), also known as the  fifth cranial nerve ,  cranial nerve V , or simply  CN V , is a  cranial nerve  responsible for  sensation  in the  face  and  motor functions  such as  biting  and  chewing ; it is the most complex of the  cranial nerves . Its name ( trigeminal , from  Latin    tri- \u00a0'three' and   -geminus \u00a0'twin' [ 1 ] ) derives from each of the two nerves (one on each side of the  pons ) having three major branches: the  ophthalmic nerve  (V 1 ), the  maxillary nerve  (V 2 ), and the  mandibular nerve  (V 3 ). The ophthalmic and maxillary nerves are purely sensory, whereas the mandibular nerve supplies motor as well as sensory (or \" cutaneous \") functions. [ 2 ]  Adding to the complexity of this nerve is that  autonomic nerve fibers  as well as special  sensory fibers  ( taste ) are contained within it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4685", "text": "The motor division of the trigeminal nerve derives from the  basal plate  of the  embryonic   pons , and the sensory division originates in the  cranial neural crest . Sensory information from the face and body is processed by parallel pathways in the  central nervous system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4686", "text": "From the trigeminal ganglion, a single, large sensory root  enters the  brainstem  at the level of the  pons . Immediately adjacent to the sensory root, a smaller motor root emerges from the pons [ 3 ]  slightly rostrally and medially to the sensory root. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4687", "text": "Motor fibers pass through the trigeminal ganglion without synapsing on their way to peripheral muscles, their cell bodies being located in the nucleus of the fifth nerve, deep within the pons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4688", "text": "The three major branches of the trigeminal nerve\u2014the  ophthalmic nerve  (V 1 ), the  maxillary nerve  (V 2 ) and the  mandibular nerve  (V 3 )\u2014converge on the  trigeminal ganglion  (also called the semilunar ganglion or gasserian ganglion), located within  Meckel's cave  and containing the cell bodies of incoming sensory-nerve fibers. The trigeminal ganglion is analogous to the  dorsal root  ganglia of the spinal cord, which contain the cell bodies of incoming sensory fibers from the rest of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4689", "text": "The ophthalmic, maxillary and mandibular branches leave the skull through three separate  foramina : the  superior orbital fissure , the  foramen rotundum  and the  foramen ovale , respectively. The ophthalmic nerve (V 1 ) carries sensory information from the scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses and parts of the  meninges  (the  dura  and blood vessels). The maxillary nerve (V 2 ) carries sensory information from the lower eyelid and cheek, the  nares  and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses and parts of the meninges. The mandibular nerve (V 3 ) carries sensory information from the lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw, which is supplied by C2-C3), parts of the external ear and parts of the meninges. The mandibular nerve carries touch-position and pain-temperature sensations from the mouth. Although it does not carry taste sensation (the  chorda tympani  is responsible for taste), one of its branches\u2014the  lingual nerve \u2014carries sensation from the tongue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4690", "text": "The peripheral processes of mesencephalic nucleus of V neurons run in the motor root of the trigeminal nerve and terminate in the muscle spindles in the muscles of mastication. They are proprioceptive fibers, conveying information regarding the location of the masticatory muscles. The central processes of mesencephalic V neurons synapse in the motor nucleus V."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4691", "text": "The areas of cutaneous distribution ( dermatomes ) of the three sensory branches of the trigeminal nerve have sharp borders with relatively little overlap (unlike dermatomes in the rest of the body, which have considerable overlap). The injection of a  local anesthetic , such as  lidocaine , results in the complete loss of sensation from well-defined areas of the face and mouth. For example, teeth on one side of the jaw can be numbed by injecting the mandibular nerve. Occasionally, injury or disease processes may affect two (or all three) branches of the trigeminal nerve; in these cases, the involved branches may be termed:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4692", "text": "Nerves on the left side of the jaw slightly outnumber the nerves on the right side of the jaw."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4693", "text": "The sensory function of the trigeminal nerve is to provide tactile,  proprioceptive , and  nociceptive  afference to the face and mouth. Its motor function activates the  muscles of mastication , the  tensor tympani ,  tensor veli palatini ,  mylohyoid  and the  anterior belly of the digastric ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4694", "text": "The trigeminal nerve carries  general somatic afferent fibers  (GSA), which innervate the skin of the face via ophthalmic (V1), maxillary (V2) and mandibular (V3) divisions. The trigeminal nerve also carries  special visceral efferent  (SVE)  axons , which innervate the muscles of mastication via the mandibular (V3) division."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4695", "text": "The motor component of the mandibular division (V3) of the trigeminal nerve controls the movement of eight muscles, including the four  muscles of mastication : the  masseter , the  temporal muscle , and the  medial  and  lateral pterygoids . The other four muscles are the  tensor veli palatini , the  mylohyoid , the anterior belly of the  digastric  and the  tensor tympani ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4696", "text": "With the exception of the tensor tympani, all these muscles are involved in biting, chewing and swallowing and all have bilateral  cortical  representation.  A unilateral central lesion (for example, a  stroke ), no matter how large, is unlikely to produce an observable deficit. Injury to a peripheral nerve can cause paralysis of muscles on one side of the jaw, with the jaw deviating towards the paralyzed side when it opens. This direction of the mandible is due to the action of the functioning pterygoids on the opposite side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4697", "text": "The two basic types of sensation are touch-position and pain-temperature. Touch-position input comes to attention immediately, but pain-temperature input reaches the level of consciousness after a delay; when a person steps on a pin, the awareness of stepping on something is immediate but the pain associated with it is delayed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4698", "text": "Touch-position information is generally carried by myelinated (fast-conducting) nerve fibers, and pain-temperature information by unmyelinated (slow-conducting) fibers. The primary sensory receptors for touch-position ( Meissner's corpuscles ,  Merkel's receptors ,  Pacinian corpuscles ,  Ruffini's corpuscles ,  hair receptors ,  muscle spindle organs  and  Golgi tendon organs ) are structurally more complex than those for pain-temperature, which are nerve endings."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4699", "text": "Sensation in this context refers to the conscious perception of touch-position and pain-temperature information, rather than the  special senses  (smell, sight, taste, hearing and balance) processed by different cranial nerves and sent to the cerebral cortex through different pathways. The perception of magnetic fields, electrical fields, low-frequency vibrations and infrared radiation by some nonhuman vertebrates is processed by their equivalent of the fifth cranial nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4700", "text": "Touch in this context refers to the perception of detailed, localized tactile information, such as  two-point discrimination  (the difference between touching one point and two closely spaced points) or the difference between coarse, medium or fine sandpaper. People without touch-position perception can feel the surface of their bodies and perceive touch in a broad sense, but they lack perceptual detail."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4701", "text": "Position, in this context, refers to conscious  proprioception . Proprioceptors (muscle spindle and Golgi tendon organs) provide information about joint position and muscle movement. Although much of this information is processed at an unconscious level (primarily by the  cerebellum  and the  vestibular  nuclei), some is available at a conscious level."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4702", "text": "Touch-position and pain-temperature sensations are processed by different pathways in the central nervous system. This hard-wired distinction is maintained up to the cerebral cortex. Within the cerebral cortex, sensations are linked with other cortical areas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4703", "text": "Sensory pathways from the periphery to the cortex are separate for touch-position and pain-temperature sensations. All sensory information is sent to specific nuclei in the  thalamus . Thalamic nuclei, in turn, send information to specific areas in the  cerebral cortex . Each pathway consists of three bundles of nerve fibers connected in series:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4704", "text": "The secondary neurons in each pathway  decussate  (cross the spinal cord or brainstem), because the spinal cord develops in segments. Decussated fibers later reach and connect these segments with the higher centers. The  optic chiasm  is the primary cause of decussation; nasal fibers of the optic nerve cross (so each cerebral hemisphere receives contralateral\u2014opposite\u2014vision) to keep the  interneuronal  connections responsible for processing information short. All sensory and motor pathways converge and diverge to the contralateral hemisphere. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4705", "text": "Although sensory pathways are often depicted as chains of individual neurons connected in series, this is an oversimplification. Sensory information is processed and modified at each level in the chain by interneurons and input from other areas of the nervous system. For example, cells in the main trigeminal nucleus (Main V in the diagram below) receive input from the  reticular formation  and cerebellar cortex. This information contributes to the final output of the cells in Main V to the thalamus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4706", "text": "Touch-position information from the body is carried to the thalamus by the  medial lemniscus , and from the face by the  trigeminal lemniscus  (both the anterior and posterior trigeminothalamic tracts). Pain-temperature information from the body is carried to the thalamus by the  spinothalamic tract , and from the face by the anterior division of the  trigeminal lemniscus  (also called the  anterior trigeminothalamic tract )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4707", "text": "Pathways for touch-position and pain-temperature sensations from the face and body merge in the brainstem, and touch-position and pain-temperature sensory maps of the entire body are projected onto the thalamus. From the thalamus, touch-position and pain-temperature information is projected onto the cerebral cortex."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4708", "text": "The complex processing of pain-temperature information in the thalamus and cerebral cortex (as opposed to the relatively simple, straightforward processing of touch-position information) reflects a  phylogenetically  older, more primitive sensory system. The detailed information received from peripheral touch-position receptors is superimposed on a background of awareness, memory and emotions partially set by peripheral pain-temperature receptors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4709", "text": "Although thresholds for touch-position perception are relatively easy to measure, those for pain-temperature perception are difficult to define and measure. \"Touch\" is an objective sensation, but \"pain\" is an individualized sensation which varies among different people and is conditioned by memory and emotion. Anatomical differences between the pathways for touch-position perception and pain-temperature sensation help explain why pain, especially chronic pain, is difficult to manage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4710", "text": "All sensory information from the face, both touch-position and pain-temperature, is sent to the  trigeminal nucleus . In classical anatomy most sensory information from the face is carried by the fifth nerve, but sensation from parts of the mouth, parts of the ear and parts of the  meninges  is carried by  general somatic afferent fibers  in cranial nerves VII (the  facial nerve ), IX (the  glossopharyngeal nerve ) and X (the  vagus nerve )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4711", "text": "All sensory fibers from these nerves terminate in the trigeminal nucleus. On entering the brainstem, sensory fibers from V, VII, IX and X are sorted and sent to the trigeminal nucleus (which contains a sensory map of the face and mouth). The spinal counterparts of the trigeminal nucleus (cells in the  dorsal horn  and  dorsal column  nuclei of the spinal cord) contain a sensory map of the rest of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4712", "text": "The trigeminal nucleus extends throughout the brainstem, from the midbrain to the medulla, continuing into the cervical cord (where it merges with the dorsal horn cells of the spinal cord). The nucleus is divided into three parts, visible in microscopic sections of the brainstem. From caudal to rostral (ascending from the medulla to the midbrain), they are the  spinal trigeminal , the  principal sensory  and the  mesencephalic  nuclei. The parts of the trigeminal nucleus receive different types of sensory information; the spinal trigeminal nucleus receives pain-temperature fibers, the principal sensory nucleus receives touch-position fibers and the mesencephalic nucleus receives proprioceptor and mechanoreceptor fibers from the jaws and teeth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4713", "text": "The  spinal trigeminal nucleus  represents pain-temperature sensation from the face. Pain-temperature fibers from peripheral  nociceptors  are carried in cranial nerves V, VII, IX and X. On entering the brainstem, sensory fibers are grouped and sent to the spinal trigeminal nucleus. This bundle of incoming fibers can be identified in cross-sections of the pons and medulla as the spinal tract of the trigeminal nucleus, which parallels the spinal trigeminal nucleus. The spinal tract of V is analogous to, and continuous with,  Lissauer's tract  in the spinal cord."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4714", "text": "The spinal trigeminal nucleus contains a pain-temperature sensory map of the face and mouth. From the spinal trigeminal nucleus, secondary fibers cross the midline and ascend in the trigeminothalamic (quintothalamic) tract to the contralateral thalamus. Pain-temperature fibers are sent to multiple thalamic nuclei. The central processing of pain-temperature information differs from the processing of touch-position information."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4715", "text": "Exactly how pain-temperature fibers from the face are distributed to the spinal trigeminal nucleus is disputed. The present general understanding is that pain-temperature information from all areas of the human body is represented in the spinal cord and brainstem in an ascending,  caudal-to-rostral  fashion. Information from the lower extremities is represented in the lumbar cord, and that from the upper extremities in the thoracic cord. Information from the neck and the back of the head is represented in the cervical cord, and that from the face and mouth in the spinal trigeminal nucleus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4716", "text": "Within the spinal trigeminal nucleus, information is represented in a layered, or \"onion-skin\" fashion. The lowest levels of the nucleus (in the upper cervical cord and lower medulla) represent peripheral areas of the face (the scalp, ears and chin). Higher levels (in the upper medulla) represent central areas (nose, cheeks and lips). The highest levels (in the pons) represent the mouth, teeth and pharyngeal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4717", "text": "The onion skin distribution differs from the dermatome distribution of the peripheral branches of the fifth nerve. Lesions which destroy lower areas of the spinal trigeminal nucleus (but spare higher areas) preserve pain-temperature sensation in the nose (V 1 ), upper lip (V 2 ) and mouth (V 3 ) and remove pain-temperature sensation from the forehead (V 1 ), cheeks (V 2 ) and chin (V 3 ). Although analgesia in this distribution is \"nonphysiologic\" in the traditional sense (because it crosses several dermatomes), this analgesia is found in humans after surgical sectioning of the spinal tract of the trigeminal nucleus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4718", "text": "The spinal trigeminal nucleus sends pain-temperature information to the  thalamus  and sends information to the  mesencephalon  and the  reticular formation  of the brainstem. The latter pathways are analogous to the spinomesencephalic and spinoreticular tracts of the spinal cord, which send pain-temperature information from the rest of the body to the same areas. The mesencephalon modulates painful input before it reaches the level of consciousness. The reticular formation is responsible for the automatic (unconscious) orientation of the body to painful stimuli.  Incidentally,  Sulfur -containing compounds found in plants in the  onion  family stimulate receptors found in trigeminal ganglia, bypassing the  olfactory system . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4719", "text": "The  principal nucleus  represents touch-pressure sensation from the face. It is located in the pons, near the entrance for the fifth nerve. Fibers carrying touch-position information from the face and mouth via cranial nerves V, VII, IX, and X are sent to this nucleus when they enter the brainstem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4720", "text": "The principal nucleus contains a touch-position sensory map of the face and mouth, just as the spinal trigeminal nucleus contains a complete pain-temperature map. This nucleus is analogous to the  dorsal column  nuclei (the  gracile  and  cuneate  nuclei) of the spinal cord, which contain a touch-position map of the rest of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4721", "text": "From the principal nucleus, secondary fibers cross the midline and ascend in the  ventral trigeminothalamic tract  to the contralateral  thalamus . The ventral trigeminothalamic tract runs parallel to the  medial lemniscus , which carries touch-position information from the rest of the body to the thalamus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4722", "text": "Some sensory information from the teeth and jaws is sent from the principal nucleus to the  ipsilateral  thalamus via the small  dorsal trigeminal tract . Touch-position information from the teeth and jaws of one side of the face is represented bilaterally in the thalamus and cortex."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4723", "text": "The  mesencephalic nucleus  is not a true  nucleus ; it is a sensory  ganglion  (like the  trigeminal ganglion ) embedded in the brainstem [ citation needed ]  and the sole exception to the rule that sensory information passes through peripheral sensory ganglia before entering the central nervous system. It has been found in all  vertebrates  except  lampreys  and  hagfishes . They are the only vertebrates without jaws and have specific cells in their brainstems. These \"internal ganglion\" cells were discovered in the late 19th century by medical student  Sigmund Freud ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4724", "text": "Two types of sensory fibers have cell bodies in the mesencephalic nucleus:  proprioceptor  fibers from the jaw and mechanoreceptor fibers from the teeth. Some of these incoming fibers go to the motor nucleus of the trigeminal nerve (V), bypassing the pathways for conscious perception. The  jaw jerk reflex  is an example; tapping the jaw elicits a reflex closure of the jaw in the same way that tapping the knee elicits a reflex kick of the lower leg. Other incoming fibers from the teeth and jaws go to the main nucleus of V. This information is projected bilaterally to the thalamus and available for conscious perception."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4725", "text": "Activities such as biting, chewing and swallowing require symmetrical, simultaneous coordination of both sides of the body. They are automatic activities, requiring little conscious attention and involving a sensory component (feedback about touch-position) processed at the unconscious level in the mesencephalic nucleus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4726", "text": "Sensation has been defined as the conscious perception of touch-position and pain-temperature information. With the exception of smell, all sensory input (touch-position, pain-temperature, sight, taste, hearing and balance) is sent to the thalamus and then the cortex. The thalamus is anatomically subdivided into nuclei."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4727", "text": "Touch-position information from the body is sent to the  ventral posterolateral nucleus  (VPL) of the thalamus. Touch-position information from the face is sent to the  ventral posteromedial nucleus  (VPM) of the thalamus. From the VPL and VPM, information is projected to the  primary somatosensory cortex  (SI) in the  parietal lobe ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4728", "text": "The representation of sensory information in the postcentral gyrus is organized  somatotopically . Adjacent areas of the body are represented by adjacent areas in the cortex. When body parts are drawn in proportion to the density of their innervation, the result is a \"little man\": the  cortical homunculus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4729", "text": "Many textbooks have reproduced the outdated  Penfield -Rasmussen diagram [ref?], with the toes and genitals on the  mesial  surface of the cortex when they are actually represented on the convexity. [ 7 ]  The classic diagram implies a single primary sensory map of the body, when there are multiple primary maps. At least four separate, anatomically distinct sensory homunculi have been identified in the postcentral gyrus. They represent combinations of input from surface and deep receptors and rapidly  and slowly adapting peripheral receptors; smooth objects will activate certain cells, and rough objects will activate other cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4730", "text": "Information from all four maps in SI is sent to the secondary sensory cortex (SII) in the parietal lobe. SII contains two more sensory homunculi. Information from one side of the body is generally represented on the opposite side in SI, but on both sides in SII. Functional MRI imaging of a defined stimulus (for example, stroking the skin with a toothbrush) \"lights up\" a single focus in SI and two foci in SII."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4731", "text": "Pain-temperature information is sent to the VPL (body) and VPM (face) of the thalamus (the same nuclei which receive touch-position information). From the thalamus, pain-temperature and touch-position information is projected onto SI."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4732", "text": "Unlike touch-position information, however, pain-temperature information is also sent to other thalamic nuclei and projected onto additional areas of the cerebral cortex. Some pain-temperature fibers are sent to the  medial dorsal thalamic nucleus  (MD), which projects to the anterior  cingulate cortex . Other fibers are sent to the ventromedial (VM) nucleus of the thalamus, which projects to the  insular cortex . Finally, some fibers are sent to the  intralaminar nucleus  (IL) of the thalamus via the  reticular formation . The IL projects diffusely to all parts of the cerebral cortex."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4733", "text": "The insular and cingulate cortices are parts of the brain which represent touch-position and pain-temperature in the context of other simultaneous perceptions (sight, smell, taste, hearing and balance) in the context of memory and emotional state. Peripheral pain-temperature information is channeled directly to the brain at a deep level, without prior processing. Touch-position information is handled differently. Diffuse thalamic projections from the IL and other thalamic nuclei are responsible for a given level of consciousness, with the thalamus and reticular formation \"activating\" the brain; peripheral pain-temperature information also feeds directly into this system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4734", "text": "Lateral medullary syndrome  (Wallenberg syndrome) is a clinical demonstration of the anatomy of the trigeminal nerve, summarizing how it processes sensory information. A stroke usually affects only one side of the body; loss of sensation due to a stroke will be lateralized to the right or the left side of the body. The only exceptions to this rule are certain spinal-cord lesions and the medullary syndromes, of which Wallenberg syndrome is the best-known example. In this syndrome, a stroke causes a loss of pain-temperature sensation from one side of the face and the other side of the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4735", "text": "This is explained by the anatomy of the brainstem. In the medulla, the ascending  spinothalamic tract  (which carries pain-temperature information from the opposite side of the body) is adjacent to the ascending spinal tract of the trigeminal nerve (which carries pain-temperature information from the same side of the face). A stroke which cuts off the blood supply to this area (for example, a clot in the posterior inferior cerebellar artery) destroys both tracts simultaneously. The result is a loss of pain-temperature (but not touch-position) sensation in a \"checkerboard\" pattern (ipsilateral face, contralateral body), facilitating diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4736", "text": "Sensory neuronopathy  (also known as sensory ganglionopathy) is a type of peripheral neuropathy in which sensory nerve cell bodies in the  dorsal root ganglia , commonly including the  trigeminal ganglion  of the trigeminal nerve, are damaged due to a variety of mechanisms leading to sensory symptoms such as  parasthesias ,  dysesthesias , or  hyperalgesia  in the affected nerve distribution including the distribution of the trigeminal nerve. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4737", "text": "Tubomanometry  is a technique for assessing the  eustachian tube  opening function, and sometimes to determine a treatment plan. [ 1 ]  This technique was familiarised by D. Est\u00e8ve  et al  in 2001. [ 2 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4738", "text": "The individual is asked to perform a swallowing maneuver. During this time, the  nasal fossae  and the  nasopharynx  are occluded by the velum. A tympanometry earplug is inserted into the external ear of the studied side to avoid fluctuations in ear pressure due to atmospheric conditions. The tubomanometer then creates a dysbarical situation, where the pressure conditions encountered during a rapid drop in altitude is reproduced. This is done by releasing an air bolus into the nasopharynx through airtight nozzles previously placed on both nostrils. At this point, the tubomanometer is able to make several recordings of the pressure variations in the  rhinopharynx  and on the eardrum as the eustachian tube opens. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4739", "text": "Immediate opening of the eustachian tube was observed in healthy subjects at 30-50 mbar pressure. In patients with chronic eustachian tube dysfunction, this opening could be registered in only 42% of the patients at 30 mbar and 58% at 50 mbar. [ 3 ]  The results are usually interpreted as R values. An R-value less than or equal to one indicates regular eustachian tube function and an R-value greater than 1 indicates a delayed opening of eustachian tube, thereby supporting the diagnosis of chronic  eustachian tube dysfunction . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4740", "text": "The  tympanic cavity  is a small cavity surrounding the  bones  of the  middle ear . Within it sit the ossicles, three small bones that transmit vibrations used in the detection of  sound ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4741", "text": "On its lateral surface, it abuts the  external auditory meatus  (ear canal) from which it is separated by the  tympanic membrane  (eardrum)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4742", "text": "The tympanic cavity is bounded by:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4743", "text": "It is formed from the  tubotympanic recess , an expansion of the first  pharyngeal pouch ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4744", "text": "If damaged, the  tympanic membrane  can be repaired in a procedure called  tympanoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4745", "text": "Should fluid accumulate within the middle ear as the result of infection or for some other reason, it can be drained by puncturing the tympanic membrane with a large bore needle ( tympanocentesis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4746", "text": "This article incorporates text in the  public domain  from  page 1037  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4747", "text": "The  tympanic nerve  ( Jacobson 's nerve ) is a branch of the  glossopharyngeal nerve  passing through the  petrous part of the temporal bone  to reach the  middle ear . It provides sensory innervation for the middle ear, the  Eustachian tube , the  parotid gland , and  mastoid cells . It also carries parasympathetic fibers destined for the  parotid gland ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4748", "text": "The tympanic nerve contains sensory axons to the  middle ear  (including the internal surface of the  tympanic membrane ) whose cell bodies are lodged in the  superior ganglion of the glossopharyngeal nerve . [ 1 ] [ verification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4749", "text": "It also contains parasympathetic axons which continue as the  lesser petrosal nerve  to the  otic ganglion , which itself gives off postganglionic parasympathetic neurons. [ 1 ] [ verification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4750", "text": "The tympanic nerve arises from the  inferior ganglion  of the  glossopharyngeal nerve (CN IX) [ 1 ]  in the  jugular fossa . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4751", "text": "It passes through the  petrous part of the temporal bone  within the  tympanic canaliculus  that is situated within the bony ridge separating the  carotid canal  and the  jugular foramen  to reach the  middle ear . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4752", "text": "In the  tympanic cavity  of the  middle ear , it ramifies upon the  promontory of tympanic cavity  to form the  tympanic plexus . [ 2 ] [ 1 ] [ verification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4753", "text": "The tympanic nerve provides sensation to the  middle ear  ( tympanic cavity ). [ 1 ]  This includes the internal surface of the  tympanic membrane . It also supplies the  Eustachian tube , the  parotid gland , and  mastoid air cells . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4754", "text": "The tympanic nerve is also the parasympathetic root of the  otic ganglion . [ 1 ] [ 3 ]  These neurons then provide secretomotor innervation of the  parotid gland  via the  auriculotemporal nerve . [ 1 ]  It is involved in the salivatory reflex to increase  salivation  during  chewing . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4755", "text": "The tympanic nerve usually arises from the  inferior ganglion  of the  glossopharyngeal nerve . Rarely, it may arise from a higher part. [ 1 ] [ verification needed ]  Rarely, it may provide no parasympathetic fibres to the otic ganglion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4756", "text": "The tympanic nerve is involved in a reflex, where stimulation of the  ear canal  increases  salivation . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4757", "text": "The tympanic nerve may be involved by  paraganglioma , in this location referred to as a glomus tympanicum tumour. [ 5 ]  This causes a soft mass in the  middle ear  ( tympanic cavity ). [ 5 ]  There may also be  pulsatile tinnitus ,  hearing loss  or  hearing problems , and some cardiac abnormalities. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4758", "text": "The tympanic nerve is also known as the nerve of Jacobson, or Jacobson's nerve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4759", "text": "This article incorporates text in the  public domain  from  page 910  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4760", "text": "Tympanostomy tube , also known as a  grommet,   myringotomy tube , or  pressure equalizing tube , is a small tube inserted into the  eardrum  via a surgical procedure called  myringotomy  to keep the  middle ear  aerated for a prolonged period of time, typically to prevent accumulation of fluid in the middle ear. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4761", "text": "The tube itself is made in a variety of designs, most often shaped like a  grommet  for short-term use, or with long  flanges  and sometimes resembling a T-shape for long-term use. [ 2 ]  Materials used to manufacture the tubes are often made from  fluoroplastic  or  silicone , which have largely replaced the use of metal tubes made from stainless steel, titanium, or gold. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4762", "text": "Inserting tympanostomy tubes is one of the most common pediatric surgical procedures in the United States, with 9% of children having had tubes placed sometime in their lives. [ 1 ] [ 3 ]  Tympanostomy tubes are typically placed in one or both eardrums to help children suffering from recurrent acute  otitis media  (ear infection) or persistent  otitis media with effusion  (sometimes called \"glue ear\"). [ 1 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4763", "text": "Tympanostomy tubes work by improving drainage, allowing air to circulate in the middle ear, and offering a direct route for  antibiotics  to enter the middle ear. [ 2 ] [ 6 ]  Tube placement has been shown to increase hearing in children with persistent otitis media with effusion and may lead to fewer ear infections for children with frequent ear infections. [ 1 ] [ 2 ]  Once placed, short-term tubes are designed to stay in the eardrum for 6\u201315 months, whereas long-term tubes are designed to stay for 15\u201318 months. [ 2 ] [ 6 ]  Tympanostomy tubes usually fall out on their own as the eardrum heals over time; however, they can sometimes get stuck in the eardrum and require surgical assistance for removal. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4764", "text": "Guidelines state that tubes are an option in:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4765", "text": "While tympanostomy tubes are commonly used in children, they are seldom used in adults. Options for use in adults include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4766", "text": "Otorrhea  (ear discharge) is the most common complication of tympanostomy tube placement, affecting between 25\u201375% of children receiving this procedure. [ 2 ] [ 6 ] [ 9 ] [ 10 ]  Saline washouts and antibiotic drops at the time of surgery are effective measures to reduce rates of otorrhea, which is why antibiotic ear drops are not routinely prescribed. [ 1 ] [ 6 ] [ 9 ]  If children experience persistent ear drainage or have new discharge two weeks following surgery, antibiotic ear drops are an effective treatment and have been shown to work better than oral antibiotics. [ 1 ] [ 9 ] [ 10 ]  Frequent use of ear drops in children may have an  ototoxic  effect, which is why antibiotic ear drop use following surgery should only be recommended by a trained healthcare professional. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4767", "text": "Potential risks of tympanostomy tube placement in children include going under general anesthesia to have the procedure as well as adverse effects following tube placement. [ 1 ]  Estimates of these other adverse effects from tubes being in the eardrum include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4768", "text": "Long term effects include visible changes to the eardrum such as  tympanosclerosis ,  cholesteatoma , focal  atrophy , or  retraction pockets . [ 1 ] [ 11 ]  These changes usually resolve on their own and do not usually require medical treatment or result in hearing problems that are clinically significant. [ 1 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4769", "text": "Surgical intervention may be required in cases of persistent perforation or retained tympanostomy tubes. Persistent perforations are corrected via  tympanoplasty  with an 80-90% success rate. [ 1 ]  Most tympanostomy tubes fall out on their own as the eardrum heals; however, when tubes remain after 2\u20133 years they are often removed to prevent complications. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4770", "text": "Myringotomy  with insertion of tympanostomy tubes is performed by an ENT doctor ( otolaryngologist ) and is one of the most common pediatric surgical procedures, accounting for more than 20% of all  ambulatory  pediatric surgeries in 2006. [ 1 ]  Although myringotomy with tympanostomy tube insertion can be performed in-office under  local anesthesia  for adolescents and adults, children or any patient who may have difficulty lying still during the procedure require  general anesthesia . [ 6 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4771", "text": "During the procedure, a small incision is made to the eardrum using either a myringotomy knife or a  CO 2  laser . [ 6 ] [ 15 ]  The middle ear is then usually washed out thoroughly with  saline  before the tympanostomy tubes are placed. Antibiotic drops are commonly used during surgery once tubes are placed but are not routinely prescribed for use following surgery unless recommended by a doctor for individual reasons. [ 1 ] [ 6 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4772", "text": "Following surgery, it is suggested that children keep their ears dry for the first two weeks to help prevent complications. After two weeks children do not need to wear earplugs when swimming or to take other measures to prevent water from getting in their ears as there is minimal reduction in adverse effects. [ 1 ] [ 16 ]  It is approximated that a child would need to wear ear plugs for 2.8 years to prevent one additional ear infection. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4773", "text": "Tympanostomy tubes generally remain in the  eardrum  for six months to two years, and about 14% of children will require tympanostomy tubes more than once. [ 1 ]  The eardrum usually closes without a residual hole at the tube site but in a small number of cases a  perforation  can persist. [ 1 ]  For children with otitis media with effusion (glue ear), tympanostomy tubes decrease the prevalence of effusions by 33% and improve hearing by 5-12  decibels , within 1\u20133 months of the procedure. There is no long-term benefit for hearing by 12\u201324 months after the procedure. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4774", "text": "For children with frequent episodes of acute otitis media (ear infection), there is debate about the effectiveness of tympanostomy tubes in reducing rates of infections. There is consensus, however, on the beneficial role of tympanostomy tubes in allowing for drainage of infections and offering direct access to the middle ear with antibiotic drops. [ 1 ]  This aids healthcare providers in identifying the cause of the infection so they can better treat it and decrease the need for systemic antibiotic use. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4775", "text": "The first myringotomy dates back to 1649 when French anatomist  Jean Riolan  noticed an improvement in his hearing after intentionally perforating his eardrum with a spoon. [ 17 ]  For nearly two hundred years, scientists would study and debate the potential benefits of myringotomy before German scientists Martell Frank and Gustav Lincke had the first documented use of tympanostomy tubes in 1845. These scientists used an approximately 6mm long gold tube in an attempt to prevent the eardrum from closing after myringotomy. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4776", "text": "From 1845 to 1875, seven different types of tympanostomy tubes were manufactured and made of materials including rubber, silver, aluminum, and gold. These tubes were not widely used or accepted due to complications including falling into the middle ear, falling out of the ear, and the tubes getting plugged. [ 18 ]  In 1952, tympanostomy tubes would make a return when American otolaryngologist Beverly Armstrong introduced them as a new treatment for  chronic secretory otitis media . This would lead to numerous types of tympanostomy tubes being developed and studied throughout the 20th century. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4777", "text": "Today,  silicone  and  fluoroplastic  tympanostomy tubes are more commonly used than metal tubes made from stainless steel, titanium, or gold. [ 2 ]  Research on ways to reduce  biofilm  formation on tympanostomy tubes, such as coating the tubes with antibiotics before placement to help prevent tube blockage or infection, has been started, but there is not enough data to determine its effectiveness. [ 2 ]  Dissolvable tubes are also being explored as potential alternatives for current tube materials. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4778", "text": "In the  ethmoid bone , a sickle shaped projection, the  uncinate process , projects posteroinferiorly from the  ethmoid labyrinth .\nBetween the posterior edge of this process and the anterior surface of the  ethmoid bulla , there is a two-dimensional space, resembling a crescent shape. This space continues laterally as a three-dimensional slit-like space - the  ethmoidal infundibulum . This is bounded by the uncinate process, medially, the  orbital lamina of ethmoid bone  (lamina papyracea), laterally, and the ethmoidal bulla, posterosuperiorly. This concept is easier to understand if one imagine the infundibulum as a prism so that its medial face is the hiatus semilunaris. The \"lateral face\" of this infundibulum contains the ostium of the maxillary sinus, which, therefore, opens into the infundibulum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4779", "text": "The uncinate process can be attached to either the lateral nasal wall, on the lamina papyracea (50%), the anterior cranial fossa, on the ethmoidal roof (25%), or the middle concha (25%). The superior attachment of the uncinate process determines the drainage pattern of the frontal sinus. In the first case, the infundibulum and the frontal recess are separated from each other, forcing the frontal sinus to drain directly into the middle meatus and not into the ethmoidal infundibulum. With the other configurations, the sinus will drain, firstly, into the infundibulum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4780", "text": "This article incorporates text in the  public domain  from  page 155  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4781", "text": "G., Arun et alli (2017) - Anatomical variations in superior attachment of uncinate process and localization of frontal sinus outflow tract. International Journal of Otorhinolaryngology and Head and Neck Surgery, 3(2):176-179"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4782", "text": "P.S., Hechl et alli (1997) - The hiatus semilunaris and infundibulum. Endoscopic Anatomy of the Paranasal Sinuses. Springer, Vienna"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4783", "text": "Uvulopalatopharyngoplasty  (also known by the  abbreviations   UPPP  and  UP3 ) is a surgical procedure or  sleep surgery  used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4784", "text": "Tissues which may typically be remodeled include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4785", "text": "UPPP involves removal of the tonsils, the posterior surface of the soft palate, and the uvula. The uvula is then folded toward the soft palate and sutured together as demonstrated in the figures. In the US, UPPP is the most commonly performed procedure for obstructive sleep apnea with approximately 33,000 procedures performed per year. The surgery is more successful in patients who are not obese, and there is a limited role in morbidly obese (>40\u00a0kg/m 2 ) individuals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4786", "text": "UPPP is typically administered to patients with obstructive  sleep apnea  in isolation. It is administered as a stand-alone procedure in the hope that the tissue which obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4787", "text": "UPPP is also offered to sleep apnea patients who opt for a more comprehensive surgical procedure known as the \" Stanford Protocol \", first attempted by Doctors  Nelson Powell  and  Robert Riley  of  Stanford University . The Stanford Protocol consists of two phases.  The first involves surgery of the soft tissue ( tonsillectomy , uvulopalatopharyngoplasty) and the second involves skeletal surgeries ( maxillomandibular advancement ). First, Phase 1 or soft tissue surgery is performed and after re-testing with a new sleep study, if there is residual sleep apnea, then Phase 2 surgery would consist of jaw surgery. The goal is to improve the airway and thereby treat (or possibly cure) sleep apnea. It has been found that obstructive sleep apnea usually involves multiple sites where tissue obstructs the airway; the base of the tongue is often involved. The Protocol successively addresses these multiple sites of obstruction. Note that  genioglossus advancement  can be performed either during Phase 1 or Phase 2 surgeries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4788", "text": "Phase 2 involves maxillomandibular advancement, a surgery which moves the jaw top (maxilla) and bottom (mandible) forward.  The tongue muscle is anchored to the chin, and translation of the mandible forward pulls the tongue forward as well.  If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase 2 than for Phase 1 \u2013 approximately 90 percent benefit from the second phase, and the success of the Stanford Protocol Operation therefore is due in large part to this second phase."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4789", "text": "There is debate among surgeons as to the role of Phase 1 surgery. In 2002, an Atlanta-based surgical team, led by Dr. Jeffrey Prinsell, published  results  which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4790", "text": "When UPPP has been administered in isolation, the results are variable. As explained above, sleep apnea is often caused by multiple co-existing obstructions at various locations of the airway such as the  nasal cavity , and particularly the base of the  tongue . The contributing factors in the variability of success include the pre-surgical size of the tonsils, palate, uvula and tongue base. Also, patients who are morbidly obese (body mass index >40\u00a0kg/m 2 ) are significantly less likely to have success from this surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4791", "text": "Over one thousand people have undergone The Stanford Protocol operation and received follow-up sleep study testing. 60 to 70 percent of patients have been entirely cured. [ 1 ]  In approximately ninety percent of patients, a significant improvement can be expected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4792", "text": "In the recent years, many surgeons have tried to address the multiple levels of obstruction by performing multiple procedures on the same surgical day, called the \"multi-level approach\".  Typical surgeries in a multi-level approach may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4793", "text": "Nasal-level surgeries"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4794", "text": "Soft palate-level surgeries"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4795", "text": "Hypopharyngeal-level surgeries"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4796", "text": "UPPP with tonsillectomy improves postoperative results of obstructive sleep apnea depending on tonsil size. The success rate increases with increasing tonsil size. [ 2 ]  This approach improves postoperative results in well-selected patients. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4797", "text": "One of the risks is that by cutting the tissues, excess scar tissue can \"tighten\" the airway and make it even smaller than it was before UPPP."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4798", "text": "After surgery, complications may include these:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4799", "text": "In 2008, Labra,  et al. , from Mexico, published a variation of UP3, by adding a uvulopalatal flap, in order to avoid such complications, with a good rate of success. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4800", "text": "The  vestibulocochlear nerve  or  auditory vestibular nerve , also known as the  eighth cranial nerve ,  cranial nerve VIII , or simply  CN VIII , is a  cranial nerve  that transmits  sound  and  equilibrium (balance)  information from the  inner ear  to the  brain . Through  olivocochlear fibers , it also transmits motor and modulatory information from the  superior olivary complex  in the brainstem to the  cochlea . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4801", "text": "The vestibulocochlear nerve consists mostly of  bipolar neurons  and splits into two large divisions: the  cochlear nerve  and the  vestibular nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4802", "text": "Cranial nerve 8, the vestibulocochlear nerve, goes to the middle portion of the  brainstem  called the  pons  (which then is largely composed of fibers going to the  cerebellum ). \nThe 8th cranial nerve runs between the base of the pons and  medulla oblongata  (the lower portion of the brainstem).  This junction between the pons, medulla, and cerebellum that contains the 8th nerve is called the  cerebellopontine angle .\nThe vestibulocochlear nerve is accompanied by the  labyrinthine artery , which usually branches off from the  anterior inferior cerebellar artery  at the cerebellopontine angle, and then goes with the 7th nerve through the  internal acoustic meatus  to the internal ear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4803", "text": "The cochlear nerve travels away from the  cochlea  of the  inner ear  where it starts as the  spiral ganglia . Processes from the  organ of Corti  conduct afferent transmission to the spiral ganglia. It is the  inner hair cells  of the organ of Corti that are responsible for activation of afferent receptors in response to pressure waves reaching the  basilar membrane  through the transduction of sound. The exact mechanism by which sound is transmitted by the  neurons  of the cochlear nerve is uncertain; the two competing theories are  place theory  and  temporal theory ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4804", "text": "The vestibular nerve travels from the  vestibular system  of the inner ear. The  vestibular ganglion  houses the cell bodies of the  bipolar neurons  and extends processes to five sensory organs. Three of these are the  cristae  located in the ampullae of the  semicircular canals . Hair cells of the cristae activate afferent receptors in response to rotational acceleration. The other two sensory organs supplied by the vestibular neurons are the maculae of the  saccule  and  utricle . Hair cells of the maculae in the utricle activate afferent receptors in response to linear acceleration, while hair cells of the maculae in the saccule respond to vertically directed linear force."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4805", "text": "The vestibulocochlear nerve is derived from the  embryonic   otic placode ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4806", "text": "This is the  nerve  along which the sensory cells (the hair cells) of the inner ear transmit information to the  brain . It consists of the cochlear nerve, carrying details about  hearing , and the vestibular nerve, carrying information about  balance . \nIt emerges from the  pontomedullary junction  and exits the inner  skull  via the internal acoustic meatus in the  temporal bone ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4807", "text": "The vestibulocochlear nerve carries axons of type  special somatic afferent ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4808", "text": "Damage to the vestibulocochlear nerve may cause the following symptoms:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4809", "text": "Examinations that can be done include the  Rinne  and  Weber tests ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4810", "text": "Rinne's test involves Rinne's Right and Left Test, since auditory acuity is equal in both ears. If  bone conduction  (BC) is more than air conduction (AC) (BC>AC) indicates Rinne Test is negative or abnormal. If AC>BC Rinne test is normal or positive. If BC>AC and Weber's test lateralizes to abnormal side then it is Conductive hearing loss. If AC>BC and Weber's test lateralizes to normal side then it concludes Sensorineural hearing loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4811", "text": "After pure-tone testing, if the AC and BC responses at all frequencies 500\u20138000\u00a0Hz are better than 25\u00a0dB HL, meaning 0-24\u00a0dB HL, the results are considered normal hearing sensitivity. If the AC and BC are worse than 25\u00a0dB HL at any one or more frequency between 500 and 8000\u00a0Hz, meaning 25+, and there is a no bigger difference between AC and BC beyond 10\u00a0dB at any frequency, there is a sensori-neural hearing loss present. If the BC responses are normal, 0-24\u00a0dB HL, and the AC are worse than 25\u00a0dB HL, as well as a 10\u00a0dB gap between the air and bone responses, a conductive hearing loss is present.\n{updated March 2019}"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4812", "text": "The modified Hughson\u2013Westlake method is used by many audiologists during testing. A battery of (1) otoscopy, to view the ear canal and tympanic membrane, (2) tympanometry, to assess the  immittance  of the tympanic membrane and how well it moves, (3) otoacoustic emissions, to measure the response of the outer hair cells located in the cochlea, (4) audiobooth pure-tone testing, to obtain thresholds to determine the type, severity, and pathology of the hearing loss present, and (5) speech tests, to measure the patients recognition and ability to repeat the speech heard, is all taken into consideration when diagnosing the pathology of the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4813", "text": "Some older texts call the nerve the  acoustic  or  auditory nerve , [ 3 ]  but these terms have fallen out of widespread use because they fail to recognize the nerve's role in the vestibular system.  Vestibulocochlear nerve  is therefore preferred by most."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4814", "text": "Vocal cord dysfunction  ( VCD ) is a condition affecting the  vocal cords . [ 1 ]  It is characterized by abnormal closure of the vocal folds, which can result in significant difficulties and distress during  breathing , particularly during  inhalation . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4815", "text": "Due to the similarity in symptoms, VCD attacks are often mistaken for  asthma  attacks or  laryngospasms . Symptoms of VCD are not always present. [ 2 ]  Rather, they often occur as episodic \"attacks,\" where the patient will be symptomatic for a short period. [ 1 ]  Although several contributing factors have been identified, the exact cause of VCD is unknown. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4816", "text": "Diagnosis of VCD may include a series of evaluations, including  pulmonary function tests ,  medical imaging , and the evaluation or visualization of the vocal folds during an episode through the use of  videolaryngoscopy . [ 3 ]  Such evaluations can also help to rule out other conditions that can affect the upper and lower airways. [ 3 ]  Treatment of VCD often combines behavioral, medical, and psychological approaches, most often including an  otolaryngologist , a psychologist, and a  speech-language pathologist . [ 1 ]  Although information on the incidence and prevalence of VCD is limited, it is known to occur most frequently in young women. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4817", "text": "Many of the symptoms are not limited to the disorder, as they may resemble a number of conditions that affect the upper and lower airways. Such conditions include  asthma ,  angioedema , vocal cord tumors, and  vocal cord paralysis . [ 5 ] [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4818", "text": "People with vocal cord dysfunction often complain of \"difficulty in breathing in\" or \"fighting for breath\", [ 6 ]  which can lead to subjective respiratory distress, [ 5 ]  and in severe cases, loss of consciousness. [ 4 ]  They may report tightness in the throat or chest, choking, stridor on inhalation and wheezing, which can resemble the symptoms of asthma. [ 5 ] [ 6 ] [ 7 ]  These episodes of  dyspnea  can be recurrent and symptoms can range from mild to severe and prolonged in some cases. [ 5 ]  Agitation and a sense of panic are not uncommon and can result in hospitalization. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4819", "text": "Different subtypes of vocal cord dysfunction are characterized by additional symptoms. For instance, momentary  aphonia  can be caused by laryngospasm, an involuntary spasm of the vocal cords [ 5 ]  and a strained or hoarse voice may be perceived when the vocal cord dysfunction occurs during speech. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4820", "text": "Many of the symptoms are not specific to vocal cord dysfunction and can resemble a number of conditions that affect the upper and lower airways."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4821", "text": "VCD can mimic asthma,  anaphylaxis ,  collapsed lungs ,  pulmonary embolism , or  fat embolism , which can lead to an inaccurate diagnosis and inappropriate, potentially harmful, treatment. [ 9 ]  Some cases of VCD are misdiagnosed as asthma, but are unresponsive to asthma therapy, including bronchodilators and steroids. [ citation needed ]  Among adult patients, women tend to be diagnosed more often. [ 10 ]  Among children and teenage patients, VCD has been linked with high participation in competitive sports and family orientation towards high achievement. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4822", "text": "Vocal cord dysfunction co-occurs with asthma approximately 40% of the time. [ 11 ]  This frequently results in a misdiagnosis of asthma alone. Even young children can tell the difference between an asthma attack (primarily difficulty exhaling) and a VCD attack (primarily difficulty inhaling). [ citation needed ]  Knowing the difference between the two will help those who have both know when to use the rescue inhaler prescribed or when to use the breathing recovery exercises trained by a speech-language pathologist. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4823", "text": "Episodes can be triggered suddenly or develop gradually and triggers are numerous. Primary causes are believed to be  gastroesophageal reflux disease  (GERD),  extra-esophageal reflux  (EERD), exposure to inhaled allergens,  post-nasal drip , exercise, or neurological conditions that can cause difficulty inhaling only during waking. [ 11 ]  Published studies emphasize anxiety or stress as a primary cause while more recent literature indicates a likely physical etiology. [ citation needed ]  This disorder has been observed from infancy through old age, with the observation of its occurrence in infants leading some to believe that a physiological cause such as reflux or allergy is likely. Certain medications, such as antihistamines for allergies, cause drying of the mucous membranes, which can cause further irritation or hypersensitivity of the vocal cords. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4824", "text": "VCD has long been strongly associated with a variety of psychological or psychogenic factors, including\u00a0 conversion disorder ,\u00a0 major depression ,\u00a0 obsessive-compulsive disorder ,\u00a0 anxiety \u00a0(especially in adolescents), stress (particularly stress relating to competitive sports), physical and sexual abuse,\u00a0 post-traumatic stress disorder ,\u00a0 panic attacks ,\u00a0 factitious disorder \u00a0and\u00a0 adjustment disorder . [ 10 ] [ 5 ] [ 6 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4825", "text": "Anxiety and depression may occur in certain patients as a result of having VCD, rather than being the cause of it. [ 10 ] [ 5 ] \u00a0Psychological factors are important precipitating factors for many patients with VCD; although exercise is also a major trigger for episodes of VCD, some patients experience VCD co-occurring with anxiety regardless of whether or not they are physically active at the time of the VCD/anxiety episode. [ 4 ] \u00a0Experiencing or witnessing a traumatic event related to breathing (such as a near-drowning or life-threatening asthma attack, for example), has also been identified as a risk factor for VCD. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4826", "text": "VCD has also been associated with certain\u00a0 neurologic \u00a0diseases including\u00a0 Arnold-Chiari malformation , cerebral aqueduct\u00a0 stenosis , cortical or\u00a0 upper motor neuron \u00a0injury (such as that resulting from\u00a0 stroke ),\u00a0 amyotrophic lateral sclerosis \u00a0(ALS),\u00a0 parkinsonism \u00a0syndromes and other movement disorders. [ 10 ] [ 4 ]  However, this association occurs only rarely. [ 4 ]  In addition, it has been associated with  Ehlers-Danlos Syndromes , a group of  connective tissue  disorders. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4827", "text": "The exact cause of VCD is not known, and it is unlikely that a single underlying cause exists. [ 5 ] [ 6 ] \u00a0Several contributing factors have been identified, which vary widely among VCD patients with different medical histories. [ 10 ] \u00a0Physical exercise (including, but not limited to, competitive athletics) is one of the major triggers for VCD episodes, leading to its frequent misdiagnosis as exercise-induced\u00a0asthma. [ 10 ] [ 5 ] [ 6 ] \u00a0Other triggers include airborne pollutants and irritants such as smoke, dust, gases, soldering fumes, cleaning chemicals such as ammonia, perfumes, and other odors. [ 5 ] [ 4 ]   Gastroesophageal reflux disease \u00a0(GERD) and\u00a0 rhinosinusitis \u00a0(inflammation of the\u00a0 paranasal sinuses \u00a0and\u00a0 nasal cavity ) may also play a role in inflaming the\u00a0 airway \u00a0and leading to symptoms of VCD as discussed below. [ 5 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4828", "text": "Laryngeal hyperresponsiveness is considered the most likely physiologic cause of VCD, brought on by a range of different triggers that cause inflammation and/or irritation of the\u00a0 larynx \u00a0(voice box). [ 10 ] [ 6 ]  The glottic closure\u00a0 reflex \u00a0(or laryngeal adductor reflex) serves to protect the airway, and it is possible that this reflex becomes hyperactive in some individuals, resulting in the paradoxical vocal fold closure seen in VCD. [ 10 ] [ 4 ] \u00a0Two major causes of laryngeal inflammation and hyperresponsiveness are\u00a0gastroesophageal reflux disease\u00a0(GERD) and\u00a0 postnasal drip \u00a0(associated with\u00a0 rhinosinusitis , allergic or nonallergic\u00a0 rhinitis , or a viral\u00a0 upper respiratory tract infection \u00a0(URI)). [ 10 ] [ 5 ] [ 6 ] [ 4 ] \u00a0Rhinosinusitis is very common among patients with VCD and for many patients, VCD symptoms are ameliorated when the rhinosinusitis is treated. [ 5 ] \u00a0GERD is also common among VCD patients, but only some experience an improvement in VCD symptoms when GERD is treated. [ 5 ] [ 6 ] \u00a0Other causes of laryngeal hyperresponsiveness include inhalation of toxins and irritants, cold and dry air, episodic\u00a0 croup \u00a0and\u00a0 laryngopharyngeal reflux \u00a0(LPR). [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4829", "text": "The following increases an individual's chances for acquiring VCD: [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4830", "text": "The most effective diagnostic strategy is to perform  laryngoscopy  during an episode, at which time abnormal movement of the cords, if present, can be observed. If the  endoscopy  is not performed during an episode, it is likely that the vocal folds will be moving normally, a ' false negative ' finding. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4831", "text": "Spirometry  may also be useful to establish the diagnosis of VCD when performed during a crisis or after a  nasal provocation test . [ 14 ]  With spirometry, just as the expiratory loop may show flattening or concavity when expiration is affected in asthma, so may the inspiratory loop show truncation or flattening in VCD. Of course, testing may well be negative when symptoms are absent. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4832", "text": "The symptoms of VCD are often inaccurately attributed to asthma, [ 5 ]  which in turn results in the unnecessary and futile intake of  corticosteroids ,  bronchodilators  and  leukotriene modifiers , [ 7 ]  although there are instances of comorbidity of asthma and VCD. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4833", "text": "The  differential diagnosis  for vocal cord dysfunction includes vocal fold swelling from allergy, asthma, or some obstruction of the vocal folds or throat. Anyone suspected of this condition should be evaluated and the vocal folds (voice box) visualized.  In individuals who experience a persistent difficulty with inhaling, consideration should be given to a neurological cause such as brain stem compression, cerebral palsy, etc. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4834", "text": "The main difference between VCD and asthma is the audible stridor or wheezing that occurs at different stages of the breath cycle: VCD usually causes stridor on the inhalation, while asthma results in wheezing during exhalation. [ 5 ] [ 6 ] [ 7 ]  Patients with asthma usually respond to the usual medication and see their symptoms resolve. [ 6 ] [ 7 ]  Clinical measures that can be done to differentiate VCD from asthma include: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4835", "text": "Once a diagnosis of VCD has been confirmed by a medical professional, a specific treatment plan can be implemented. If vocal cord dysfunction is secondary to an underlying condition, such as asthma, gastroesophageal reflux disease (GERD), or  postnasal drip , it is important to treat the primary condition as this will help control VCD symptoms. [ 4 ] \nConventional treatments for VCD are often multidisciplinary and include speech-language pathology,  psychotherapy ,  behavioral therapy , use of anti-anxiety and anti-depressant medications, medical interventions, and hypnotherapy. [ 4 ] [ 18 ] [ 19 ]  There is no uniform approach. [ 19 ] \nThe information from randomized, blinded studies is limited. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4836", "text": "Speech-language pathologists provide behavioral treatment for VCD. Speech therapy usually involves educating the client on the nature of the problem, what happens when symptoms are present, and then comparing this to what happens during normal breathing and  phonation . [ 1 ]  Intervention goals target teaching a client breathing and relaxation exercises so that they can control their throat muscles and keep the airway open, allowing air to flow in and out. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4837", "text": "Breathing techniques can be taught to reduce tension in the throat, neck, and upper body and bring attention to the flow of air during respiration. [ 20 ]  Diaphragm support during breathing decreases muscle tension in the larynx. [ 20 ]  These techniques are meant to move awareness away from the act of breathing in and focus on the  auditory feedback  provided by the air moving in and out. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4838", "text": "Other techniques can involve breathing through a straw and panting, which widens the opening of the throat by activating the  Posterior cricoarytenoid  (PCA) muscle. [ 4 ] [ 19 ]  Endoscopic feedback can also be used to show a patient what is happening when they are doing simple tasks such as taking a deep breath or speaking on an inspiration. [ 1 ]  This provides the client with visual information so that they can actually see what behaviors help to open the throat and what behaviors constrict the throat. [ 1 ]  Respiratory muscle strength training, a form of increased resistance training using a hand-held breathing device has also been reported to alleviate symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4839", "text": "Speech therapy has been found to eliminate up to 90% of ER visits in patients with VCD. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4840", "text": "Medical often works in conjunction with behavioral approaches. A pulmonary or ENT ( otolaryngologist ) specialist will screen for and address any potential underlying pathology that may be associated with VCD. Managing GERD has also been found to relieve laryngospasm, a spasm of the vocal cords that makes breathing and speaking difficult. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4841", "text": "Non-invasive positive pressure ventilation can be used if a patient's vocal cords adduct (close) during exhalation. [ 4 ]  Mild sedatives have also been employed to reduce anxiety as well as reduce acute symptoms of VCD. [ 4 ] [ 19 ]  Benzodiazepines are an example of one such treatment, though they have been linked to a risk of suppression of the respiratory drive. [ 19 ]  While Ketamine, a dissociative anesthetic, does not suppress respiratory drive, it has been thought to be associated with laryngospasms. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4842", "text": "For more severe VCD cases, physicians may inject  botulinum toxin  into the vocal ( thyroarytenoid ) muscles to weaken or decrease muscle tension. [ 4 ] [ 1 ]  Nebulized Lignocaine can also been used in acute cases and helium-oxygen inhalation given by a face mask has been used in cases of respiratory distress. [ 4 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4843", "text": "Psychological interventions including psychotherapy,  cognitive behavioral therapy  (CBT), Biofeedback, and teaching self-hypnosis are also suggested to treat VCD. [ 18 ]  Intervention is generally targeted at making the client aware of stressors that may trigger VCD symptoms, to implement strategies to reduce stress and anxiety, and to teach techniques for coping with their symptoms. [ 18 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4844", "text": "CBT can focus on bringing awareness to negative thought patterns and help reframe them by focusing on problem solving strategies. [ 18 ]  Psychologists may also use relaxation to reduce distress when a patient is experiencing symptoms. [ 4 ] [ 1 ]   Biofeedback  can be a helpful addition to psychotherapy. The aim of Biofeedback is to educate the client on what happens to the vocal cords during breathing and to help them learn to control their symptoms. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4845", "text": "Choosing an intervention strategy needs to be assessed by a multidisciplinary team and individualized therapy planned carefully, keeping the characteristics of each patient in mind. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4846", "text": "The natural prognosis of VCD in both children and adults are not well described in the literature. [ 7 ]  Additionally, there is currently no research that has studied whether the underlying cause of VCD makes a difference in the resolution of symptoms or in the long-term prognosis of the impairment. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4847", "text": "Information on the prognosis of VCD after acute therapies is also limited. Minimal response has been documented with the continued treatment of asthma in people with VCD using  inhaled bronchodilators ,  corticosteroids  and other asthma medications. [ 23 ]  While using  Botox  in VCD has limited reports, those that are available report successful resolution of exercise-induced VCD symptoms for up to 2 months. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4848", "text": "Outcomes of chronic VCD treatment are similarly limited. When pediatric patients undergoing hypnosis therapy were studied, more than half saw either a reduction or resolution of VCD. [ 23 ]  Even though it is widely used, no long-term studies have been done to study the prognosis of VCD after psychotherapy. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4849", "text": "Speech therapy  is the main course of treatment for long-term management of VCD and includes a variety of techniques such as relaxed-throat breathing, respiratory retraining therapy, and vocal hygiene counseling. [ 5 ]  Most studies agree that symptoms of VCD improve in patients and few continue to require asthma medications six months post speech therapy intervention. [ 7 ] [ 23 ]  Significant improvements were reported for respiratory retraining therapy, including fewer episodes of  dyspnea  per month and decreased respiratory stress severity. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4850", "text": "For those adolescent patients who recovered from VCD, the average time before the symptoms were resolved was 4\u20135 months. [ 7 ]  However, some adolescents had VCD symptoms even 5 years post VCD onset, regardless of intervention. [ 7 ]  It has been noted that some patients do not respond to standard VCD therapies and continue to express recurrent symptoms. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4851", "text": "There is currently a limited amount of information available on the incidence and\u00a0 prevalence \u00a0of VCD, and the various rates reported in the literature are most likely an underestimate. [ 4 ] [ 25 ] \u00a0Although VCD is thought to be rare overall, its prevalence among the population at large is not known. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4852", "text": "However, numerous studies have been conducted on its incidence and prevalence among patients presenting with\u00a0asthma\u00a0and\u00a0 exertional dyspnea . A VCD incidence rate of 2% has been reported among patients whose primary complaint was either asthma or dyspnea; the same incidence rate has also been reported among patients with acute asthma exacerbation. [ 6 ] [ 25 ] \u00a0Meanwhile, much higher VCD incidence rates have also been reported in asthmatic populations, ranging from 14% in children with refractory asthma to 40% in adults with the same complaint. [ 25 ] \u00a0It has also been reported that the VCD incidence rate is as high as 27% in non-asthmatic teenagers and young adults. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4853", "text": "Data on the prevalence of VCD is also limited. An overall prevalence of 2.5% has been reported in patients presenting with asthma. [ 19 ] \u00a0Among adults with asthma considered \"difficult to control\", 10% were found to have VCD while 30% were found to have both VCD and asthma. [ 6 ] \u00a0Among children with severe asthma, a VCD prevalence rate of 14% has been reported. [ 6 ] \u00a0However, higher rates have also been reported; among one group of schoolchildren thought to have exercise-induced asthma, it was found that 26.9% actually had VCD and not asthma. [ 4 ] \u00a0Among intercollegiate athletes with exercise-induced asthma, the VCD rate has been estimated at 3%. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4854", "text": "In patients presenting with symptoms of dyspnea, prevalence rates ranging from 2.8% to 22% have been reported in various studies. [ 6 ] [ 4 ] [ 19 ] \u00a0It has been reported that two to three times more females than males have VCD. [ 6 ] [ 4 ] [ 25 ] \u00a0VCD is especially common in females who have psychological conditions. [ 4 ] \u00a0There is an increased risk associated with being young and female. [ 4 ] \u00a0Among patients with VCD, 71% are over the age of 18. [ 6 ] \u00a0In addition, 73% of those with VCD have a previous psychiatric diagnosis. [ 6 ] \u00a0VCD has also been reported in newborns with\u00a0gastroesophageal reflux disorder\u00a0(GERD). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4855", "text": "In humans, the  vocal cords , also known as  vocal folds , are folds of throat tissues that are key in creating sounds through  vocalization . The length of the vocal cords affects the pitch of voice, similar to a violin string. Open when breathing and vibrating for  speech  or  singing , the folds are controlled via the  recurrent laryngeal branch  of the  vagus nerve . They are composed of twin infoldings of  mucous membrane  stretched horizontally, from back to front, across the  larynx . They  vibrate , modulating the flow of air being expelled from the lungs during  phonation . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4856", "text": "The 'true vocal cords' are distinguished from the 'false vocal folds', known as  vestibular folds  or  ventricular folds , which sit slightly superior to the more delicate true folds. These have a minimal role in normal  phonation , but can produce deep sonorous tones, screams and growls."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4857", "text": "The length of the vocal fold at birth is approximately six to eight millimeters and grows to its adult length of eight to sixteen millimeters by adolescence.  DHT , an  androgen  metabolite of  testosterone  which is secreted by the gonads, causes changes in the cartilages and musculature of the larynx when present in high enough concentrations, such as during an adolescent boy's  puberty : The thyroid prominence appears, the vocal folds lengthen and become rounded, and the epithelium thickens with the formation of three distinct layers in the  lamina propria . [ citation needed ] . These changes are only partially reversible via  reconstructive surgery  such as  chondrolaryngoplasty ,  feminization laryngoplasty , and laser tuning of the vocal cords."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4858", "text": "The vocal folds are located within the larynx at the top of the  trachea . They are attached at the back to the  arytenoid cartilages , and at the front to the  thyroid cartilage  via Broyles ligament. They are part of the  glottis . Their outer edges are attached to muscle in the larynx while their inner edges form an opening called the  rima glottidis . They are constructed from  epithelium , but they have a few muscle-fibres in them, namely the  vocalis muscle  which tightens the front part of the  ligament  near to the thyroid cartilage. They are flat triangular bands and are pearly white in color. Above both sides of the  glottis  are the two  vestibular folds  or false vocal folds which have a small sac between them."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4859", "text": "The vocal folds are sometimes called 'true vocal folds' to distinguish them from the 'false vocal folds' known as  vestibular folds  or  ventricular folds . These are a pair of thick folds of mucous membrane that protect and sit slightly higher to the more delicate true folds.  They have a minimal role in normal  phonation , but are often used to produce deep sonorous tones in  Tibetan chant  and  Tuvan throat singing , [ 2 ]  as well as in musical  screaming  and the  death growl  vocal style. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4860", "text": "The vocal cords are composed of twin infoldings of 3 distinct tissues: an outer layer of flat cells that do not produce  keratin  ( squamous epithelium ). Below this is the superficial layer of the  lamina propria , a gel-like layer, which allows the vocal fold to vibrate and produce sound. The  vocalis  and  thyroarytenoid muscles  make up the deepest portion. These vocal folds are covered with a  mucous membrane  and are stretched horizontally, from back to front, across the  larynx ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4861", "text": "Males and females have different vocal fold sizes. Adult male  voices  are usually lower-pitched due to longer and thicker folds. The male's vocal folds are between 1.75\u00a0cm and 2.5\u00a0cm (approx 0.75\" to 1.0\") in length, [ 3 ]  while females' vocal folds are between 1.25\u00a0cm and 1.75\u00a0cm (approx 0.5\" to 0.75\") in length. The vocal folds of children are much shorter than those of adult males and females. The difference in vocal fold length and thickness between males and females causes a difference in vocal pitch. Additionally, genetic factors cause variations between members of the same sex, with males' and females' voices being categorized into  voice types ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4862", "text": "Newborns have a uniform single layered lamina propria, which appears loose with no vocal ligament. [ 4 ]  The monolayered lamina propria is composed of ground substances such as  hyaluronic acid  and  fibronectin ,  fibroblasts , elastic fibers, and collagenous fibers. While the fibrous components are sparse, making the lamina propria structure loose, the hyaluronic acid (HA) content is high."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4863", "text": "HA is a bulky, negatively charged glycosaminoglycan, whose strong affinity with water procures hyaluronic acid its viscoelastic and shock absorbing properties essential to vocal biomechanics. [ 5 ]  Viscosity and elasticity are critical to voice production. Chan, Gray and Titze, quantified the effect of hyaluronic acid on both the viscosity and the elasticity of vocal folds by comparing the properties of tissues with and without HA. [ 6 ]  The results showed that removal of hyaluronic acid decreased the stiffness of the vocal cords by an average of 35%, but increased their dynamic viscosity by an average of 70% at frequencies higher than 1\u00a0Hz. Newborns have been shown to cry an average of 6.7 hours per day during the first 3 months, with a sustained pitch of 400\u2013600\u00a0Hz, and a mean duration per day of 2 hours. [ 7 ]  Similar treatment on adult vocal cords would quickly result in edema, and subsequently aphonia. Schweinfurth and al. presented the hypothesis that high  hyaluronic acid  content and distribution in newborn vocal cords is directly associated with newborn crying endurance. [ 7 ]  These differences in newborn vocal fold composition would also be responsible for newborns inability to articulate sounds, besides the fact that their lamina propria is a uniform structure with no vocal ligament. The layered structure necessary for phonation will start to develop during the infancy and until the adolescence. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4864", "text": "The  fibroblasts  in the newborn  Reinke's space  are immature, showing an oval shape, and a large nucleus-cytoplasm ratio. [ 4 ]  The rough endoplasmic reticulum and Golgi apparatus, as shown by electron micrographs, are not well developed, indicating that the cells are in a resting phase. The collagenous and reticular fibers in the newborn the vocal cords are fewer than in the adult one, adding to the immaturity of the vocal fold tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4865", "text": "In the infant, many fibrous components were seen to extend from the macula flava towards the Reinke's space. Fibronectin is very abundant in the Reinke's space of newborn and infant. Fibronectin is a glycoprotein that is believed to act as a template for the oriented deposition of the collagen fibers, stabilizing the collagen fibrils. Fibronectin also acts as a skeleton for the elastic tissue formation. [ 4 ]  Reticular and collagenous fibers were seen to run along the edges of the vocal cords throughout the entire lamina propria. [ 4 ]  Fibronectin in the Reinke's space appeared to guide those fibers and orient the fibril deposition. The elastic fibers remained sparse and immature during infancy, mostly made of microfibrils. The fibroblasts in the infant Reinke's space were still sparse but spindle-shaped. Their rough endoplasmic reticulum and Golgi apparatus were still not well developed, indicating that despite the change in shape, the fibroblasts still remained mostly in a resting phase. Few newly released materials were seen adjacent to the fibroblasts. The ground substance content in the infant  Reinke's space  seemed to decrease over time, as the fibrous component content increased, thus slowly changing the vocal fold structure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4866", "text": "The infant lamina propria is composed of only one layer, as compared to three in the adult, and there is no vocal ligament. The vocal ligament begins to be present in children at about four years of age. Two layers appear in the lamina propria between the ages of six and twelve, and the mature lamina propria, with the superficial, intermediate and deep layers, is only present by the conclusion of adolescence. As vocal fold vibration is a foundation for vocal formants, this presence or absence of tissue layers influences a difference in the number of formants between the adult and pediatric populations. In females, the voice is three tones lower than the child's and has five to twelve formants, as opposed to the pediatric voice with three to six.\nThe length of the vocal fold at birth is approximately six to eight millimeters and grows to its adult length of eight to sixteen millimeters by adolescence. The infant vocal fold is half membranous or anterior glottis, and half cartilaginous or posterior glottis. The adult fold is approximately three-fifths membranous and two-fifths cartilaginous."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4867", "text": "Puberty  usually lasts from 2 to 5 years, and typically occurs between the ages of 12 and 17. During puberty, voice change is controlled by  sex hormones . In females during puberty, the vocal muscle thickens slightly, but remains very supple and narrow. The squamous mucosa also differentiates into three distinct layers (the lamina propria) on the free edge of the vocal folds. The sub- and supraglottic glandular mucosa becomes hormone-dependent to estrogens and progesterone. For females, the actions of  estrogens  and  progesterone  produce changes in the extravascular spaces by increasing capillary permeability which allows the passage of intracapillary fluids to the interstitial space as well as modification of glandular secretions. Estrogens have a hypertrophic and proliferative effect on mucosa by reducing the desquamating effect on the superficial layers. The  thyroid hormones  also affect dynamic function of the vocal folds; ( Hashimoto's thyroiditis  affects the fluid balance in the vocal folds). Progesterone has an anti-proliferative effect on mucosa and accelerates desquamation. It causes a menstrual-like cycle in the vocal fold epithelium and a drying out of the mucosa with a reduction in secretions of the glandular epithelium. Progesterone has a diuretic effect and decreases capillary permeability, thus trapping the  extracellular fluid  out of the capillaries and causing tissue congestion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4868", "text": "Testosterone , an androgen secreted by the testes, will cause changes in the cartilages and musculature of the larynx for males during puberty, and to a lesser extent to females  assigned at birth  and others such as  intersex  individuals as well as those who are androgen deficient if they are given  masculinizing hormone therapy . In females, androgens are secreted principally by the  adrenal cortex  and the ovaries and can have irreversible masculinizing effects if present in high enough concentration. In males, they are essential to  male sexuality . In muscles, they cause a hypertrophy of striated muscles with a reduction in the fat cells in  skeletal muscles , and a reduction in the whole body fatty mass. Androgens are the most important hormones responsible for the passage of the boy-child voice to adult male voice, and the change is irreversible without  reconstructive surgery  such as  feminization laryngoplasty . The thyroid prominence, which contains the vocal cords appears, the vocal folds lengthen and become rounded, and the epithelium thickens with the formation of  three distinct layers in the lamina propria. [ 8 ]  These changes are also irreversible without surgery, albeit the thyroid/laryngeal prominence, also known as an  Adam's apple  can be potentially diminished via a  tracheal shave  or  feminization laryngoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4869", "text": "Human vocal cords are paired structures located in the larynx, just above the trachea, which vibrate and are brought in contact during phonation. The human vocal cords are roughly 12 \u2013 24\u00a0mm in length, and 3\u20135\u00a0mm thick. [ 9 ]  Histologically, the human vocal cords are a laminated structure composed of five different layers. The vocalis muscle, main body of the vocal cords, is covered by the mucosa, which consists of the epithelium and the lamina propria. [ 10 ]  The latter is a pliable layer of connective tissue subdivided into three layers: the superficial layer (SL), the intermediate layer (IL), and the deep layer (DL). [ 11 ]  Layer distinction is either made looking at differential in cell content or  extracellular matrix  (extracellular matrix) content. The most common way being to look at the extracellular matrix content. The SLP has fewer elastic and collagenous fibers than the two other layers, and thus is looser and more pliable. The ILP is mostly composed of elastic fibers, while the DLP has fewer elastic fibers, and more collagenous fibers. [ 10 ]  In those two layers, which form what is known as the vocalis ligament, the elastic and collagenous fibers are densely packed as bundles that run almost parallel to the edge of the vocal fold. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4870", "text": "There is a steady increase in the elastin content of the lamina propria as humans age (elastin is a yellow scleroprotein, the essential constituent of the elastic  connective tissue ) resulting in a decrease in the ability of the lamina propria to expand caused by cross-branching of the elastin fibers. Among other things, this leads to the mature voice being better suited to the rigors of opera. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4871", "text": "The extracellular matrix of the vocal cord LP is composed of fibrous proteins such as collagen and elastin, and interstitial molecules such as  HA , a non-sulfated  glycosaminoglycan . [ 11 ]  While the SLP is rather poor in elastic and collagenous fibers, the ILP and DLP are mostly composed of it, with the concentration of elastic fibers decreasing and the concentration of collagenous fibers increasing as the vocalis muscle is approached. [ 10 ]  Fibrous proteins and interstitial molecules play different roles within the extracellular matrix. While collagen (mostly type I) provides strength and structural support to the tissue, which are useful to withstanding stress and resisting deformation when subjected to a force, elastin fibers bring elasticity to the tissue, allowing it to return to its original shape after deformation. [ 11 ]  Interstitial proteins, such as HA, plays important biological and mechanical roles in the vocal cord tissue. [ 5 ]  In the vocal cord tissue, hyaluronic acid plays a role of shear-thinner, affecting the tissue viscosity, space-filler, shock absorber, as well as wound healing and cell migration promoter. The distribution of those proteins and interstitial molecules has been proven to be affected by both age and gender, and is maintained by the  fibroblasts . [ 11 ] [ 12 ] [ 5 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4872", "text": "Vocal fold structure in adults is quite different from that in newborns. Exactly how the vocal cord mature from an immature monolayer in newborns to a mature three layer tissue in adults is still unknown, however a few studies have investigated the subjects and brought some answers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4873", "text": "Hirano et al. previously found that the newborns did not have a true lamina propria, but instead had cellular regions called maculae flavae, located at the anterior and posterior ends of the loose vocal fold tissue. [ 4 ] [ 14 ]  Boseley and Hartnick examined at the development and maturation of pediatric human vocal fold lamina propria. [ 15 ]  Hartnick was the first one to define each layer by a change in their cellular concentration. [ 16 ]  He also found that the lamina propria monolayer at birth and shortly thereafter was hypercellular, thus confirming Hirano's observations. By 2 months of age, the vocal fold started differentiating into a bilaminar structure of distinct cellular concentration, with the superficial layer being less densely populated than the deeper layer. By 11 months, a three-layered structure starts to be noted in some specimens, again with different cellular population densities. The superficial layer is still hypocellular, followed by an intermediate more hypercellular layer, and a deeper hypercellular layer, just above the vocalis muscle. Even though the vocal cords seem to start organizing, this is not representative of the trilaminar structure seen in adult tissues, where the layer are defined by their differential elastin and collagen fiber compositions. By 7 years of age, all specimens show a three-layered vocal fold structure, based on cellular population densities. At this point, the superficial layer was still hypocellular, the middle layer was the hypercellular one, with also a greater content of elastin and collagen fibers, and the deeper layer was less cellularly populated. Again, the distinction seen between the layers at this stage is not comparable to that seen in the adult tissue. The maturation of the vocal cords did not appear before 13 years of age, where the layers could be defined by their differential fiber composition rather than by their differential cellular population. The pattern now show a hypocellular superficial layer, followed by a middle layer composed predominantly of elastin fiber, and a deeper layer composed predominantly of collagen fibers. This pattern can be seen in older specimens up to 17 years of age, and above. While this study offers a nice way to see the evolution from immature to mature vocal cords, it still does not explain what is the mechanism behind it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4874", "text": "Maculae flavae are located at the anterior and posterior ends of the membranous parts of the vocal cords. [ 17 ]  The histological structure of the macula flava is unique, and Sato and Hirano speculated that it could play an important role in growth, development and aging of the vocal cords. The macula flava is composed of  fibroblasts , ground substances, elastic and collagenous fibers. Fibroblasts were numerous and spindle or stellate-shaped. The fibroblasts have been observed to be in active phase, with some newly released amorphous materials present at their surface. From a biomechanical point of view, the role of the macula flava is very important. Hirano and Sato studies suggested that the macula flava is responsible for the synthesis of the fibrous components of the vocal cords. Fibroblasts have been found mostly aligned in the direction of the vocal ligament, along bundles of fibers. It then was suggested that the mechanical stresses during phonation were stimulating the fibroblasts to synthesize those fibers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4875", "text": "The  viscoelastic  properties of human vocal fold lamina propria are essential for their vibration, and depend on the composition and structure of their  extracellular matrix . Adult vocal cords have a layered structure which is based on the layers differential in extracellular matrix distribution. Newborns on the other hand, do not have this layered structure. Their vocal cords are uniform, and immature, making their viscoelastic properties most likely unsuitable for phonation. Hyaluronic acid plays a very important role in the vocal fold biomechanics. In fact, hyaluronic acid has been described as the extracellular matrix molecule that not only contributes to the maintenance of an optimal tissue viscosity that allows phonation, but also of an optimal tissue stiffness that allows frequency control. [ 6 ]   CD44  is a cell surface receptor for HA. Cells such as  fibroblasts  are responsible for synthesizing extracellular matrix molecules. Cell surface matrix receptors in return, feed back to the cells through cell-matrix interaction, allowing the cell to regulate its metabolism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4876", "text": "Sato et al. [ 18 ]  carried out a histopathologic investigation of unphonated human vocal cords. Vocal fold mucosae, which were unphonated since birth, of three young adults (17, 24, and 28 years old) were looked at using light and electron microscopy. The results show that the vocal fold mucosae were hypoplastic, and rudimentary, and like newborns, did not have any vocal ligament, Reinke's space, or layered structure. Like newborns, the lamina propria appeared as a uniform structure. Some  stellate cells  were present in the macula flava, but started to show some signs of degeneration. The stellate cells synthesized fewer extracellular matrix molecules, and the cytoplasmic processes were shown to be short and shrinking, suggesting a decreased activity. Those results confirm the hypothesis that phonation stimulates stellate cells into producing more extracellular matrix."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4877", "text": "Furthermore, using a specially designed bioreactor, Titze et al. showed that fibroblasts exposed to mechanical stimulation have differing levels of extracellular matrix production from fibroblasts that are not exposed to mechanical stimulation. [ 19 ]  The gene expression levels of extracellular matrix constituents such as fibronectin, MMP1, decorin, fibromodulin, hyaluronic acid synthase 2, and  CD44  were altered. All those genes are involved in extracellular matrix remodeling, thus suggesting that mechanical forces applied to the tissue, alter the expression levels of extracellular matrix related genes, which in turn allow the cells present in the tissue to regulate the extracellular matrix constituent synthesis, thus affecting the tissue's composition, structure, and biomechanical properties. In the end, cell-surface receptors close the loop by giving feedback on the surrounding extracellular matrix to the cells, affecting also their gene expression level."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4878", "text": "Other studies suggest that  hormones  play also an important role in vocal fold maturation. Hormones are molecules secreted into the blood stream to be delivered at different targeted sites. They usually promote growth, differentiation and functionality in different organs or tissues. Their effect is due to their ability to bind to intracellular receptors, modulating the gene expression, and subsequently regulating protein synthesis. [ 20 ]  The interaction between the endocrine system and tissues such as breast, brain, testicles, heart, bones, etc., is being extensively studied. It has clearly been seen that the larynx is somewhat affected by hormonal changes, but, very few studies are working on elucidating this relationship. The effect of hormonal changes in voice is clearly seen when hearing male and female voices, or when listening to a teenage voice changing during puberty. Actually, it is believed that the number of hormonal receptors in the pre-pubertal phase is higher than in any other age. [ 20 ]  Menstruation has also been seen to influence the voice. In fact, singers are encouraged by their instructors not to perform during their pre-menstrual period, because of a drop in their voice quality. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4879", "text": "Vocal fold phonatory functions are known to change from birth to old age. The most significant changes occur in development between birth and puberty, and in old age. [ 10 ] [ 21 ]   Hirano et al. previously described several structural changes associated with aging, in the vocal fold tissue. [ 22 ]  Some of those changes are: a shortening of the membranous vocal fold in males, a thickening of the vocal fold mucosa and cover in females, and a development of edema in the superficial lamina propria layer in both sexes. Hammond et al. observed that the hyaluronic acid content in the vocal fold lamina propria was significantly higher in males than in females. [ 12 ]  Although all those studies did show that there are clear structural and functional changes seen in the human vocal cords which are associated with gender and age, none really fully elucidated the underlying cause of those changes. In fact, only a few recent studies started to look at the presence and role of hormone receptors in the vocal cords. Newman et al. found that hormone receptors are indeed present in the vocal cords, and show a statistical distribution difference with respect to age and gender. [ 21 ]  They have identified the presence of  androgen ,  estrogen , and  progesterone  receptors in  epithelial cells ,  granular cells  and  fibroblasts  of the vocal cords, suggesting that some of the structural changes seen in the vocal cords could be due to hormonal influences. [ 21 ]  In this specific study, androgen and progesterone receptors were found more commonly in males than in females. In others studies, it has been suggested that the estrogen/androgen ratio be partly responsible for the voice changes observed at menopause. [ 23 ]  As previously said, Hammond et al. showed than the hyaluronic acid content was higher in male than in female vocal cords. Bentley et al. demonstrated that sex skin swelling seen in monkey was due to an increase in hyaluronic acid content, which was in fact mediated by estrogen receptors in dermal fibroblasts. [ 24 ]  An increase in collagen biosynthesis mediated by the estrogen receptors of dermal fibroblasts was also observed. A connection between hormone levels, and  extracellular matrix  distribution in the vocal cords depending on age and gender could be made. More particularly a connection between higher hormone levels and higher hyaluronic acid content in males could exist in the human vocal fold tissue. Although a relationship between hormone levels and extracellular matrix biosynthesis in vocal fold can be established, the details of this relationship, and the mechanisms of the influence has not been elucidated yet."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4880", "text": "There is a thinning in the superficial layer of the lamina propria in old age. In aging, the vocal fold undergoes considerable sex-specific changes. In the female larynx, the vocal fold cover thickens with aging. The superficial layer of the lamina propria loses density as it becomes more edematous. The intermediate layer of the lamina propria tends to atrophy only in men. The deep layer of the lamina propria of the male vocal fold thickens because of increased collagen deposits. The vocalis muscle atrophies in both men and women. However, the majority of elderly patients with voice disorders have disease processes associated with aging rather than physiologic aging alone. [ 25 ] [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4881", "text": "The larynx is a major (but not the only) source of sound in  speech , generating sound through the rhythmic opening and closing of the vocal folds.  To oscillate, the vocal folds are brought near enough together such that air pressure builds up beneath the larynx.  The folds are pushed apart by this increased subglottal pressure, with the inferior part of each fold leading the superior part. Such a wave-like motion causes a transfer of energy from the airflow to the fold tissues. [ 28 ]  Under the correct conditions, the energy transferred to the tissues is large enough to overcome losses by dissipation and the oscillation pattern will sustain itself.  In essence, sound is generated in the larynx by chopping up a steady flow of air into little puffs of sound waves. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4882", "text": "The perceived pitch of a person's voice is determined by a number of different factors, most importantly the  fundamental frequency  of the sound generated by the larynx.  The fundamental frequency is influenced by the length, size, and tension of the vocal folds.  This frequency averages about 125  Hz  in an adult male, 210\u00a0Hz in adult females, and over 300\u00a0Hz in children.  Depth-kymography [ 30 ]  is an imaging method to visualize the complex horizontal and vertical movements of vocal folds."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4883", "text": "The vocal folds generate a sound rich in  harmonics .  The harmonics are produced by collisions of the vocal folds with themselves, by recirculation of some of the air back through the trachea, or both. [ 31 ]  Some singers can isolate some of those harmonics in a way that is perceived as  singing  in more than one pitch at the same time\u2014a technique called  overtone singing  or throat singing such as in the tradition of  Tuvan throat singing ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4884", "text": "The majority of vocal fold lesions primarily arise in the cover of the folds. Since the basal lamina secures the epithelium to the superficial layer of the lamina propria with anchoring fibers, this is a common site for injury. If a person has a phonotrauma or habitual vocal hyperfunction, also known as pressed phonation, the proteins in the basal lamina can shear, causing vocal fold injury, usually seen as nodules or polyps, which increase the mass and thickness of the cover. The  squamous cell  epithelium of the anterior glottis are also a frequent site of laryngeal cancer caused by smoking."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4885", "text": "A voice pathology called Reinke's edema, swelling due to abnormal accumulation of fluid, occurs in the superficial lamina propria or Reinke's space. This causes the vocal fold mucosa to appear floppy with excessive movement of the cover that has been described as looking like a loose sock. [ 32 ]  The greater mass of the vocal folds due to increased fluid lowers the  fundamental frequency  during phonation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4886", "text": "Wound healing is a natural regeneration process of dermal and epidermal tissue involving a sequence of biochemical events. These events are complex and can be categorized into three stages: inflammation, proliferation and tissue remodeling. [ 33 ]  The study on vocal fold wound healing is not as extensive as that on animal models due to the limited availability of human vocal folds. Vocal fold injuries can have a number of causes including chronic overuse, chemical, thermal and mechanical trauma such as smoking, laryngeal cancer, and surgery. Other benign pathological phenomena like polyps,  vocal fold nodules  and edema will also introduce disordered phonation. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4887", "text": "Any injury to human vocal folds elicits a wound healing process characterized by disorganized collagen deposition and, eventually, formation of scar tissue. [ 35 ] [ 36 ] [ 37 ] [ 38 ]  Verdolini [ 39 ]  and her group sought to detect and describe acute tissue response of injured rabbit vocal cord model. They quantified the expression of two biochemical markers:  interleukin 1  and  prostaglandin E2 , which are associated with acute wound healing. They found the secretions of these inflammatory mediators were significantly elevated when collected from injured vocal cords versus normal vocal cords. This result was consistent with their previous study about the function of IL-1 and PGE-2 in wound healing. [ 39 ] [ 40 ]  Investigation about the temporal and magnitude of inflammatory response in the vocal cords may benefit for elucidating subsequent pathological events in vocal fold wounding, [ 40 ]  which is good for clinician to develop therapeutic targets to minimize scar formation. In the proliferative phase of vocal cord wound healing, if the production of hyaluronic acid and collagen is not balanced, which means the hyaluronic acid level is lower than normal, the fibrosis of collagen cannot be regulated. Consequently, regenerative-type wound healing turns to be the formation of scar. [ 35 ] [ 38 ]  Scarring may lead to the deformity of vocal fold edge, the disruption of lipopolysaccharides viscosity and stiffness. [ 41 ]  Patients suffering from vocal fold scar complain about increased phonatory effort, vocal fatigue, breathlessness, and  dysphonia . [ 35 ]  Vocal fold scar is one of the most challenging problems for otolaryngologists because it is hard to be diagnosed at germinal stage and the function necessity of vocal cords is delicate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4888", "text": "The vocal folds are commonly referred to as  vocal cords , and less commonly as  vocal flaps  or  vocal bands . The term  vocal cords  was coined by the French anatomist  Antoine Ferrein  in 1741. In his violin analogy of the  human voice , he postulated that the moving air acted like a bow on  cordes vocales . [ 42 ]  The alternative spelling in English is  vocal chords , possibly due to the musical connotations or to confusion with the geometrical definition of the word  chord . While both spellings have historical precedents, standard American spelling is  cords . [ 43 ]  According to the  Oxford English Corpus , a database of 21st-century texts that contains everything from academic journal articles to unedited writing and blog entries, contemporary writers opt for the nonstandard  chords  instead of  cords  49% of the time. [ 44 ] [ 45 ]  The  cords  spelling is also standard in the United Kingdom and Australia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4889", "text": "In  phonetics ,  vocal folds  is preferred over  vocal cords , on the grounds that it is more accurate and illustrative. [ 46 ] [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4890", "text": "Xerostomia , also known as  dry mouth , is a subjective complaint of dryness in the  mouth , which may be associated with a change in the composition of  saliva , or reduced salivary flow, or  have no identifiable cause . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4891", "text": "This symptom is very common and is often seen as a  side effect  of many types of medication. It is more common in older people (mostly because this group tend to take several medications) and in people who  breathe through their mouths .  Dehydration ,  radiotherapy  involving the  salivary glands ,  chemotherapy  and several diseases can cause reduced salivation (hyposalivation), or a change in saliva consistency and hence a complaint of xerostomia. Sometimes there is no identifiable cause, and there may sometimes be a  psychogenic  reason for the complaint. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4892", "text": "Xerostomia is the subjective sensation of dry mouth, which is often (but not always) associated with hypofunction of the salivary glands. [ 3 ]  The term is derived from the Greek words \u03be\u03b7\u03c1\u03cc\u03c2 ( xeros ) meaning \"dry\" and \u03c3\u03c4\u03cc\u03bc\u03b1 ( stoma ) meaning \"mouth\". [ 4 ] [ 5 ]  A drug or substance that increases the rate of salivary flow is termed a  sialogogue ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4893", "text": "Hyposalivation  is a clinical diagnosis that is made based on the history and examination, [ 1 ]  but reduced salivary flow rates have been given objective definitions. Salivary gland hypofunction has been defined as any objectively demonstrable reduction in whole and/or individual gland flow rates. [ 6 ]  An unstimulated whole saliva flow rate in a normal person is 0.3\u20130.4 ml per minute, [ 7 ]  and below 0.1 ml per minute is significantly abnormal. A stimulated saliva flow rate less than 0.5 ml per gland in 5\u00a0minutes or less than 1 ml per gland in 10\u00a0minutes is decreased. [ 1 ]  The term subjective xerostomia is sometimes used to describe the symptom in the absence of any clinical evidence of dryness. [ 8 ]  Xerostomia may also result from a change in composition of saliva (from serous to mucous). [ 6 ]   Salivary gland dysfunction  is an  umbrella term  for the presence of xerostomia, salivary gland hyposalivation, [ 6 ]  and  hypersalivation . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4894", "text": "Hyposalivation may give the following signs and symptoms:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4895", "text": "However, sometimes the clinical findings do not correlate with the symptoms experienced. [ 9 ]  For example, a person with signs of hyposalivation may not complain of xerostomia. Conversely a person who reports experiencing xerostomia may not show signs of reduced salivary secretions (subjective xerostomia). [ 8 ]  In the latter scenario, there are often other oral symptoms suggestive of  oral dysesthesia  (\"burning mouth syndrome\"). [ 3 ]  Some symptoms outside the mouth may occur together with xerostomia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4896", "text": "These include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4897", "text": "There may also be other systemic signs and symptoms if there is an underlying cause such as  Sj\u00f6gren's syndrome , [ 1 ]  for example, joint pain due to associated  rheumatoid arthritis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4898", "text": "The differential of hyposalivation significantly overlaps with that of xerostomia. A reduction in saliva production to about 50% of the normal unstimulated level will usually result in the sensation of dry mouth. [ 8 ]  Altered saliva composition may also be responsible for xerostomia. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4899", "text": "Salivary flow rate is decreased during sleep, which may lead to a transient sensation of dry mouth upon waking. This disappears with eating or drinking or with oral hygiene. When associated with halitosis, this is sometimes termed \"morning breath\". Dry mouth is also a common sensation during periods of anxiety, probably owing to enhanced  sympathetic  drive. [ 11 ]  During periods of stress, our body responds in a \u2018fight or flight\u2019 state that will interfere with the saliva flow in the mouth. [ 12 ]  Dehydration is known to cause hyposalivation, [ 1 ]  the result of the body trying to conserve fluid. Physiologic age-related changes in salivary gland tissues may lead to a modest reduction in salivary output and partially explain the increased prevalence of xerostomia in older people. [ 1 ]  However,  polypharmacy  is thought to be the major cause in this group, with no significant decreases in salivary flow rate being likely to occur through aging alone. [ 9 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4900", "text": "Aside from physiological causes of xerostomia,  iatrogenic  effects of medications are the most common cause. [ 1 ]  A medication which is known to cause xerostomia may be termed  xerogenic . [ 3 ]  Over 400 medications are associated with xerostomia. [ 8 ]  Although drug induced xerostomia is commonly reversible, the conditions for which these medications are prescribed are frequently chronic. [ 8 ]  The likelihood of xerostomia increases in relation to the total number of medications taken, whether the individual medications are xerogenic or not. [ 9 ]  The sensation of dryness usually starts shortly after starting the offending medication or after increasing the dose. [ 1 ]   Anticholinergic ,  sympathomimetic , or  diuretic  drugs are usually responsible. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4901", "text": "Xerostomia may be caused by autoimmune conditions which damage saliva-producing cells. [ 8 ]  Sj\u00f6gren's syndrome is one such disease, and it is associated with symptoms including fatigue,  myalgia  and  arthralgia . [ 8 ]  The disease is characterised by inflammatory changes in the moisture-producing glands throughout the body, leading to reduced secretions from glands that produce saliva, tears and other secretions throughout the body. [ 8 ]  Primary Sj\u00f6gren's syndrome is the combination of dry eyes and xerostomia. Secondary Sj\u00f6gren's syndrome is identical to primary form but with the addition of a combination of other connective tissue disorders such as  systemic lupus erythematosus  or  rheumatoid arthritis . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4902", "text": "Xerostomia may be the only symptom of celiac disease, especially in adults, who often have no obvious digestive symptoms. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4903", "text": "Radiation therapy for  cancers of the head and neck  (including  brachytherapy  for  thyroid cancers ) where the salivary glands are close to or within the field irradiated is another major cause of xerostomia. [ 8 ]  A radiation dose of 52 Gy is sufficient to cause severe salivary dysfunction. Radiotherapy for oral cancers usually involves up to 70 Gy of radiation, often given along with chemotherapy which may also have a damaging effect on saliva production. [ 8 ]  This side effect is a result of radiation damage of the parasympathetic nerves. Formation of salivary gland ducts depends on the secretion of a  neuropeptide  from the parasympathetic nerves, while development of the end buds of the salivary gland depends on  acetylcholine  from the parasympathetic nerves. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4904", "text": "\"Sicca\" simply means dryness. Sicca syndrome is not a specific condition, and there are varying definitions, but the term can describe oral and eye dryness that is not caused by autoimmune diseases (e.g., Sj\u00f6gren syndrome)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4905", "text": "Oral dryness may also be caused by mouth breathing, [ 3 ]  usually caused by partial obstruction of the  upper respiratory tract . Examples include  hemorrhage ,  vomiting ,  diarrhea , and  fever . [ 1 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4906", "text": "Alcohol may be involved in the cause of salivary gland disease, liver disease, or dehydration. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4907", "text": "Smoking is another possible cause. [ 9 ]  Other recreational drugs such as  methamphetamine , [ 16 ]   cannabis , [ 17 ]   hallucinogens , [ 18 ]  or  heroin , [ 19 ]  may be implicated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4908", "text": "Hormonal disorders, such as poorly controlled diabetes, chronic graft versus host disease or low fluid intake in people undergoing  hemodialysis  for renal impairment may also result in xerostomia, due to dehydration. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4909", "text": "Nerve damage can be a cause of oral dryness. An injury to the face or surgery can cause nerve damage to the head and neck area which can effect the nerves that are associated with the salivary flow. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4910", "text": "Xerostomia may be a consequence of infection with hepatitis C virus (HCV) and a rare cause of salivary gland dysfunction may be  sarcoidosis . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4911", "text": "Infection with Human Immunodeficiency Virus/Acquired immunodeficiency Syndrome (AIDS) can cause a related salivary gland disease known as Diffuse Infiltrative Lymphocytosis Syndrome (DILS). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4912", "text": "Similar to taste dysfunction, xerostomia is one of the most prevalent and persistent oral symptoms associated with COVID-19. Despite a close association with COVID-19, xerostomia, dry mouth and hyposalivation tend to be overlooked in COVID-19 patients and survivors, unlike ageusia, dysgeusia and hypogeusia. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4913", "text": "A diagnosis of hyposalivation is based predominantly on the clinical signs and symptoms. [ 1 ]  The  Challacombe scale  maybe used to classify the extent of dryness. [ 22 ] [ 23 ]  The rate of the salivary flow in an individual's mouth can also be measured. [ 24 ]  There is little correlation between symptoms and objective tests of salivary flow, [ 25 ]  such as  sialometry . This test is simple and noninvasive, and involves measurement of all the saliva a patient can produce during a certain time, achieved by dribbling into a container. Sialometery can yield measures of stimulated salivary flow or unstimulated salivary flow. Stimulated salivary flow rate is calculated using a stimulant such as 10%  citric acid  dropped onto the tongue, and collection of all the saliva that flows from one of the  parotid papillae  over five or ten minutes. Unstimulated whole saliva flow rate more closely correlates with symptoms of xerostomia than stimulated salivary flow rate. [ 1 ]   Sialography  involves introduction of  radio-opaque  dye such as  iodine  into the duct of a salivary gland. [ 1 ]  It may show blockage of a duct due to a calculus. Salivary  scintiscanning  using  technetium  is rarely used. Other medical imaging that may be involved in the investigation include  chest x-ray  (to exclude sarcoidosis),  ultrasonography  and  magnetic resonance imaging  (to exclude Sj\u00f6gren's syndrome or neoplasia). [ 1 ]  A minor salivary gland  biopsy , usually taken from the lip, [ 26 ]  may be carried out if there is a suspicion of  organic disease  of the salivary glands. [ 1 ]   Blood tests  and  urinalysis  may be involved to exclude a number of possible causes. [ 1 ]  To investigate xerophthalmia, the Schirmer test of lacrimal flow may be indicated. [ 1 ]   Slit-lamp examination  may also be carried out. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4914", "text": "The successful treatment of xerostomia is difficult to achieve and often unsatisfactory. [ 9 ]  This involves finding any correctable cause and removing it if possible, but in many cases it is not possible to correct the xerostomia itself, and treatment is  symptomatic , and also focuses on  preventing tooth decay through improving  oral hygiene . Where the symptom is caused by hyposalivation secondary to underlying chronic disease, xerostomia can be considered permanent or even progressive. [ 8 ]  The management of salivary gland dysfunction may involve the use of saliva substitutes and/or saliva stimulants:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4915", "text": "Saliva substitutes can improve xerostomia, but tend not to improve the other problems associated with salivary gland dysfunction. [ citation needed ]  Parasympathomimetic drugs (saliva stimulants) such as pilocarpine may improve xerostomia symptoms and other problems associated with salivary gland dysfunction, but the evidence for treatment of radiation-induced xerostomia is limited. [ 27 ]  Both stimulants and substitutes relieve symptoms to some extent. [ 28 ]   Salivary stimulants are probably only useful in people with some remaining detectable salivary function. [ 3 ]  A systematic review compromising of 36  randomised controlled trials  for the treatment of dry mouth found that there was no strong evidence to suggest that a specific  topical  therapy is effective. [ 8 ]  This review also states that topical therapies can be expected to provide only short-term effects, which are reversible. [ 8 ]  The review reported limited evidence that oxygenated glycerol triester spray was more effective than electrolyte sprays. [ 8 ]  Sugar free  chewing gum  increases saliva production but there is no strong evidence that it improves symptoms. [ 8 ]   Plus, there is no clear evidence to suggest whether chewing gum is more or less effective as a treatment. [ 8 ]  There is a suggestion that intraoral devices and integrated mouthcare systems may be effective in reducing symptoms, but there was a lack of strong evidence. [ 8 ]  A systematic review of the management of radiotherapy-induced xerostomia with parasympathomimetic drugs found that there was limited evidence to support the use of pilocarpine in the treatment of radiation-induced salivary gland dysfunction. [ 6 ]  It was suggested that, barring any  contraindications , a trial of the drug be offered in the above group (at a dose of five mg three times per day to minimize side effects). [ 6 ]  Improvements can take up to twelve weeks. [ 6 ]  However, pilocarpine is not always successful in improving xerostomia symptoms. [ 6 ]  The review also concluded that there was little evidence to support the use of other parasympathomimetics in this group. [ 6 ]  Another systematic review showed, that there is some low-quality evidence to suggest that amifostine prevents the feeling of dry mouth or reduce the risk of moderate to severe xerostomia in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short- (end of radiotherapy) to medium-term (three months postradiotherapy). But, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4916", "text": "A 2013 review looking at non-pharmacological interventions reported a lack of evidence to support the effects of electrostimulation devices, or acupuncture, on symptoms of dry mouth. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4917", "text": "Xerostomia is a very common symptom. A conservative estimate of prevalence is about 20% in the general population, with increased prevalences in females (up to 30%) and the elderly (up to 50%). [ 8 ]  Estimates of the prevalence of persistent dry mouth vary between 10 and 50%. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4918", "text": "Xerostomia has been used as a test to detect lies, which relied on emotional inhibition of salivary secretions to indicate possible incrimination. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4919", "text": "The  zygomatic branches of the facial nerve  ( malar branches ) are  nerves  of the  face . They run across the  zygomatic bone  to the lateral angle of the  orbit . Here, they supply the  orbicularis oculi muscle , and join with filaments from the  lacrimal nerve  and the  zygomaticofacial branch  of the  maxillary nerve  (CN V 2 )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4920", "text": "The zygomatic branches of the facial nerve are branches of the  facial nerve  (CN VII). [ 1 ]  They run across the  zygomatic bone  to the lateral angle of the  orbit . This is deep to  zygomaticus major muscle . [ 1 ]  They send fibres to orbicularis oculi muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4921", "text": "The zygomatic branches of the facial nerve have many nerve connections. Along their course, there may be connections with the  buccal branches of the facial nerve . [ 2 ]  They join with filaments from the  lacrimal nerve  and the  zygomaticofacial nerve  from the  maxillary nerve  (CN V 2 ). [ 3 ]  They also join with the  inferior palpebral nerve  and the  superior labial nerve , both from the  infraorbital nerve . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4922", "text": "The zygomatic branches of the facial nerve supply part of the  orbicularis oculi muscle . [ 2 ]  This is used to close the eyelid. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4923", "text": "To test the zygomatic branches of the facial nerve, a patient is asked to close their eyes tightly. [ citation needed ]  This uses  orbicularis oculi muscle . [ 2 ]  The zygomatic branches of the facial nerve may be recorded and stimulated with an  electrode . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4924", "text": "Rarely, the zygomatic branches of the facial nerve may be damaged during surgery on the  temporomandibular joint  (TMJ). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4925", "text": "A  cystoprostatectomy  is a  surgical procedure  in which the urinary  bladder  and  prostate  gland are removed. The procedure combines a  cystectomy  and a  prostatectomy . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4926", "text": "A  cystourethrectomy  or  cysto-urethrectomy  is a  surgical procedure  in which the  urinary bladder  and  urethra  are removed. [ 1 ]   The procedure combines a  cystectomy  and a  urethrectomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4927", "text": "Emasculation  is the removal of the external  male sex organs , which includes both the  penis  and the  scrotum , the latter of which contains the  testicles . It is distinct from  castration , where only the testicles are removed. Although the terms are sometimes used interchangeably, the potential  medical consequences  of emasculation are more extensive due to the complications arising from the removal of the penis. [ 1 ]  There are a range of religious, cultural, punitive, and personal reasons why someone may choose to emasculate themselves or another person."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4928", "text": "The term  emasculation  may be used in a  metaphorical  sense, referring to the perceived loss of attributes traditionally associated with  masculinity , such as strength, power, or autonomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4929", "text": "There are several different methods of emasculation. Both the penis and testicles may be removed simultaneously using a sharp instrument, such as a knife or razor or swords. [ 2 ] [ 3 ]  Non-crushing vascular clamps may also be used in medical surgery to cut off blood circulation and reduce bleeding. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4930", "text": "Alternatively, the penis and testicles may be removed during a series of stages. Medical surgeons use this method when performing surgery on  trans women  who want their genitals removed over multiple  sex reassignment surgeries (male-to-female) , rather than in a single operation. [ 5 ]  In these surgeries, the tissue is used and re-shaped into the neo-vagina and vulva."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4931", "text": "Short-term consequences of emasculation include  bleeding [ 6 ]  and infection. [ 7 ]  Historically, death was also a potential complication, although the prevalence is disputed. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4932", "text": "Long term complications include incontinence, [ 9 ]   urethral stricture , [ 10 ]  urine retention, [ 11 ]   urinary tract infection , [ 12 ]   urine extravasation [ 7 ]  and  bladder stones . [ 13 ]  Some studies have found that emasculation may cause a range of physiological changes, such as a shortened torso, [ 14 ]  widened stomach and hips, [ 15 ]  increased height, bowed legs, [ 14 ]  and an elongated skull. [ 14 ]  Additionally, emasculates typically have less or no facial and body hair, [ 16 ]  increased fatty tissue or  gynecomastia , [ 16 ]  and a feminine fat pattern distribution. [ 17 ]  The physiological effects of emasculation are more severe for people who undergo the procedure before the onset of puberty. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4933", "text": "Emasculation was performed in China on men to create palace  eunuchs  for the imperial court. [ 19 ]  The practice dates back to the  Shang dynasty  (1600\u20131046 BC) [ 20 ]  and continued up until 1924, [ 21 ]  when the eunuch system was abolished by the last emperor of China,  Puyi . [ 22 ]  The last living palace eunuch,  Sun Yaoting , died in 1996. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4934", "text": "Originally, palace eunuchs were prisoners who were involuntarily emasculated. In the  Qing dynasty , men began volunteering to undergo the procedure in order to gain employment, although instances of forced emasculation still occurred. [ 24 ]  One reason why recipients willingly underwent emasculation is that they saw employment as a palace eunuch as a way to acquire wealth and power. Alternatively, poverty was a reason why fathers forced their sons to undergo emasculation, and the desire for financial benefit motivated human traffickers to force emasculation on their victims. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4935", "text": "There were several reasons why the Imperial court required its civil servants to be emasculated. Emasculation was thought to ensure a recipient's undivided loyalty to the emperor, as it severs the recipient's existing familial or social bonds and destroys their ability to produce future heirs. [ 26 ]  The choice to hire emasculated eunuchs also ensured the legitimacy of the emperor's lineage. [ 27 ]  The choice to emasculate, rather than merely castrate, was motivated by a desire to protect the chastity of women in the court, as emasculation rendered a recipient physically incapable of having sex. [ 28 ]  While emasculation was a pre-requisite for gaining employment as a palace eunuch, it did not guarantee employment. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4936", "text": "The emasculation procedure was typically performed by a trained 'knifer', or 'knife expert'. [ 30 ]  To prepare for the operation, the recipient was bathed in cold water to numb his senses and, in some instances, his genitals were twisted to reduce blood flow. [ 31 ]  The recipient was then asked if he consented to the procedure, and if he answered yes the knifer excised the genitals with a single cut. [ 32 ]   Styptic powder  was then applied to the wound to stop bleeding, and a  pewter  needle or spigot was inserted into the urethra to prevent stenosis (narrowing). [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4937", "text": "Some Chinese emasculates were the great historian  Sima Qian ,  Cao Teng , the foster grandfather of  Cao Cao ,  Zheng He , a  Ming dynasty  admiral of the imperial navy who sailed to Africa, and the surviving sons and grandson of rebel  Yaqub Beg . [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4938", "text": "To create eunuchs for the  Arab slave trade , young black boys from South East Africa typically had their penis and scrotum amputated. [ 35 ]  White boys, by comparison, were usually only castrated. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4939", "text": "Emasculation was one form of genital mutilation practiced by the Skoptsy, a Russian Christian sect. For males, the other form of mutilation available was castration. Females could remove their nipples, breasts,  labia majora ,  labia minora  or  clitoris . [ 36 ]  These practices may have begun sometime during the 1760s, after the sect was founded by Kondratii Selivanov, although they were only discovered by the broader community in 1772. [ 37 ]  They continued up until the 1930s, when the sect was destroyed and its members sentenced. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4940", "text": "The Skoptsy practiced genital mutilation because they believed the genitals were the source of original sin, and that by removing them, they could attain salvation. [ 39 ]  The aim of removing the offending genitalia was to purify the body. [ 40 ]  Their belief was based on a literal reading of the verse of  Matthew 19:12 , which states: \"There are some eunuchs, which were so born from their mother's womb: and there are some eunuchs, which were made eunuchs of men: and there be eunuchs, which have made themselves eunuchs for the kingdom of heaven's sake.\" [ 41 ]  In addition, the verses of  Matthew 18 :8,9 and  Luke 23 :29 were also cited as support. [ 42 ]  Of the two types of genital mutilation available to men, emasculation was called the Greater Seal. Castration, by comparison, was called the Lesser Seal. [ 43 ]  Emasculation was preferable because it rendered a recipient physically incapable of engaging in sinful sexual conduct, allowing them to attain a higher level of purity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4941", "text": "Originally, the emasculation procedure was performed by burning the testicles off with an iron. [ 44 ]  Later, the genitals were tied at the base and removed using a knife or razor blade. The wound was then cauterised, or a salve was applied, to prevent bleeding. Many Skoptsy were peasants and were familiar with animal husbandry, which meant their emasculation procedures were often performed with \"surgical precision.\" [ 45 ]  In some instances, members of the Skoptsy would perform the emasculation on themselves, in an act of  self-surgery , though it was more typical for the procedure to be performed by an elder during a ceremony. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4942", "text": "Throughout the  Indian subcontinent tradition , including India, Bangladesh and Pakistan, some members of the  Hijra  community reportedly undergo emasculation, or  nirvan. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4943", "text": "Traditionally, emasculation was a  rite of passage  into the Hijra community. [ 47 ]  Today it remains an important ritual, though is not mandatory or universally practiced. [ 48 ]  When it is performed, it typically occurs several years after an individual has already participated within the Hijra community. While some Hijra are emasculated, others are intersex, undeveloped in puberty or impotent. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4944", "text": "Whether or not a Hijra undergoes emasculation is influenced by a range of considerations. Some people are not emasculated because they are fearful of surgical complications, are under financial constraints, or merely as a matter of personal choice. [ 50 ]  For Muslim Hijra, emasculation may be avoided due to the belief that genital mutilation goes against Allah's will. [ 51 ] \nOthers see emasculation as necessary in order to be 'reborn' as a Hijra. In this view, emasculated Hijra are seen as more 'real' than those who are not. [ 52 ]  The decision to be emasculated may also be motivated by personal beliefs about whether a Hijra can have spiritual powers without undergoing the procedure. Amongst members of the Hijra community, this issue is subject to considerable debate. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4945", "text": "In the past, the emasculation procedure was performed by barbers or by the individual themselves (i.e. self-emasculation). [ 53 ]  Nowadays, the operation is performed by a Hijra elder, also called a  dai ma  (midwife). [ 54 ]  They have no medical training, but believe they operate with the power of the patron goddess,  Bahuchara Mata . [ 55 ]  The operation takes place early in the morning, around 3 \u00a0 a.m. or 4 \u00a0 a.m. [ 55 ]  Anesthesia is not administered.   [ 56 ]  The penis and testes are tied together with a string, and the elder then makes two diagonal cuts with a sharp surgical knife to completely excise the organs. [ 57 ]  The elder allows the blood to gush from the wound, which is considered necessary to completely cleanse the recipient of their male parts. This is one reason why the procedure is performed by an elder rather than a medical professional, who might try to stop the haemorrhage, thus interfering with the ritual's cleansing effect. [ 58 ]  Afterwards, no stitches are taken and the wound is left exposed, although a small stick is inserted into the urethra to prevent  urethral stricture . [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4946", "text": "Emasculation was one of the Five Punishments used in ancient  China . [ 60 ]  It was the prescribed punishment for people who engaged in licentious conduct, such as infidelity or rape. [ 61 ]  The first evidence of its use dates to the  Shang dynasty  (1700\u20131100 BC), when the characters for a knife and male genitalia were carved into oracle bones. It continued up until the  Sui dynasty  (581\u2013618 CE), when it was formally abolished. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4947", "text": "There are reports of self-emasculation cases resulting from  mental disorder . Some academics claim that a majority of self-emasculations are a result of psychosis, [ 63 ]  although this finding has been challenged. [ 64 ]  Nonetheless, there are several reported cases of people with  schizophrenia  engaging in self-emasculation.  [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4948", "text": "It has been linked to other mental disorders such as dissociative identity disorder. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4949", "text": "Klingsor syndrome, sometimes known as Skotpic syndrome is a condition where people mutilate their genitals as a result of psychotic  religious delusions .  [ 67 ]  For example, in one case a person is reported to have mutilated his genitals after experiencing  auditory hallucinations  telling him he would only be allowed into the  kingdom of heaven  if he emasculated himself. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4950", "text": "Body integrity dysphoria , or xenomelia, is another mental disorder that may drive a person to seek emasculation. [ 69 ]  People with this disorder are distressed by the presence of a limb that they do not identify as part of their body, including the genitals. Emasculation in this context alleviates their distress, enabling them to become 'whole'. [ 70 ]  However, the amputation of healthy limbs by medical professionals is highly controversial. The inability to acquire medically administered emasculation has driven some to self-emasculation. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4951", "text": "Occasionally, self-emasculation is practiced by those suffering from gender dysphoria. [ 72 ]  When compared with the general population, transgender persons are at a higher risk of engaging in acts of genital self-mutilation, including self-emasculation. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4952", "text": "In some cases, a person with a mental illness has emasculated other people. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4953", "text": "Emasculation occurs voluntarily within the  transgender  community as a form of  gender reassignment surgery , allowing recipients to renounce their masculine characteristics and bring their body into closer alignment with their identified gender. It may be sought by trans women (those assigned male at birth who identify as female), who wish to assume their femininity, or by non-binary transgender individuals (those assigned male at birth who identify as neither male nor female), who want to locate themselves outside of traditional gender categories. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4954", "text": "For trans women, emasculation surgery may be performed with or without the creation of a vagina. When a vagina is created, the procedure is called a  vaginoplasty , [ 76 ]  and where it is not, the procedure is called a  vulvoplasty . [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4955", "text": "For  non-binary  transgender people, the purpose of emasculation is to make the body less congruent with one's assigned sex without the subsequent assumption of femininity.  [ 78 ]  These individuals may identify as non-binary, a third-sex, eunuch, or another gender. Some adopt the term ' nullo ', meaning someone whose gender has been nullified. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4956", "text": "In some circumstances, a person may be emasculated involuntarily as the result of an accident, [ 80 ]  as part of a ritual attack, [ 81 ]  or due to poor circumcision practice. [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4957", "text": "In these cases, the objective of medical treatment is different than for cases of voluntary emasculation. The goals of treatment are to either reattach the severed genitals or to reconstruct an artificial penis and testes. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4958", "text": "From 1960 to 2000, involuntarily emasculated infants were surgically reassigned female, similar to the treatment received by  David Reimer  after his penis was burnt off during a  circumcision  procedure. It is now understood from cases like Reimer's that gender reassignment surgery in infancy can interfere with gender identity formation. Therefore, gender reassignment is no longer the standard practice for involuntarily emasculated infants. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4959", "text": "By extension, the word  emasculation  has also come to mean rendering a male less  masculine , including by humiliation. It can also mean to deprive anything of vigour or effectiveness. This figurative usage has become more common than the literal meaning. For example: \" William Lewis Hughes  voted for Folkestone's amendment to Curwen's emasculated reform  bill , 12 June 1809 ... \" [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4960", "text": "In  horticulture , the removal of male (pollen) parts of a plant, largely for controlled pollination and breeding purposes, is also called emasculation. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4961", "text": "A  frenuloplasty of prepuce of penis  (also known as a  release of frenulum ) is a  frenuloplasty  of the  frenulum of prepuce of penis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4962", "text": "An abnormally short or sensitive  frenulum  of the  penis  can make some types of sexual activity uncomfortable or even painful.  This may be a complication of circumcision or a naturally occurring event.  When it is a naturally occurring event, a short frenulum can restrict normal retraction of the  foreskin  during  erection  (a condition known as  frenulum breve ). The goal of treatment is to allow normal retraction of the foreskin.  Circumcision may relieve this condition but is not indicated solely for treating frenulum breve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4963", "text": "The procedure usually involves the removal of the frenulum or the creation of an incision in the frenulum that is then stretched to lengthen it and stitched closed. The incision can be z-shaped, y-shaped or a single horizontal cut. Once healed, the procedure effectively elongates the frenulum, allowing normal function. Under normal circumstances the incision heals completely in around six to eight weeks, after which time normal sexual activity can resume. Other methods of treatment include horizontal stitches in the frenulum which over the course of a week cut through the tight skin, elongating it. This is generally more painful than the standard procedure, but heals faster. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4964", "text": "Another reason for the treatment is to correct a rare complication of a frenulum breve which presents as scars on the frenulum, these scars cause  pain  and make normal sex very difficult and are caused by the rubbing of the frenulum whilst engaging in sexual activity. These scars only affect those with frenulum breve. The frenuloplasty can be conducted under both general or local anesthesia. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4965", "text": "One study suggests around 15\u201320% of men require additional circumcision after a frenuloplasty, because not all symptoms indicating the surgery improved. [ 3 ]  The British Association of Urological Surgeons (BAUS) estimates this number to be lower at 2\u201310%. [ 4 ]   Frenuloplasty might avoid the need for circumcision even when a clinician felt circumcision to be indicated at presentation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4966", "text": "A swelling of the penis occurs in 10\u201350% of patients after operation, usually lasting a few days. Reduced sensation in the  glans  penis is reported in 2\u201310% of patients. Below 2% of patients experience an infection of the incision requiring antibiotics or further treatment. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4967", "text": "GreenLight Laser Therapy  is a medical procedure for treating  benign prostatic hyperplasia . [ 1 ]  It uses a  laser  beam to remove prostate tissue. The laser treatment is delivered through a thin and flexible fiber, which is inserted into the urethra through a  cystoscope ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4968", "text": "GreenLight Laser Therapy has been increasingly performed as an alternative to  transurethral resection of the prostate  in order to treat benign prostatic hyperplasia, with several studies demonstrating comparable results with fewer side effects and complications. Typically, it is an outpatient procedure which provides immediate relief of lower urinary tract symptoms.  It is a virtually bloodless procedure and may be suitable for patients who cannot undergo traditional surgery. GreenLight has well-documented safety and success data since 1997 and has treated more than 500,000 patients worldwide. Cost analyses have shown GreenLight to be less costly than traditional surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4969", "text": "Inguinal orchiectomy  (also named  orchidectomy ) is a specific method of  orchiectomy  whereby one or both  testicles  and the full  spermatic cord  are  surgically removed [ 1 ]  through an incision in the lower lateral  abdomen  (the \"inguinal region\"). The procedure is generally performed by a  urologist , typically if  testicular cancer  is suspected. Often it is performed as same-day surgery, with the patient returning home within hours of the procedure. Some patients elect to have a prosthetic testicle inserted into their  scrotum . Depending on whether or not a prosthetic testicle is put in place of the original one, operating times run on average from three to six hours."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4970", "text": "A 4\u20136\u00a0cm incision is made above the  pubic bone  on the side corresponding to the testicle to be removed.  This incision runs obliquely midway between the  pubic tubercle  and the  anterior superior iliac spine .  The incision is extended down through the fat until the  external oblique   fascia  is encountered.  It is incised along its fibres and the spermatic cord is identified and isolated.  From there, the testicle is pulled into the field through the  inguinal canal .  The  spermatic cord  is clamped off in two places and cut between the clamps.  Long permanent sutures, usually silk or  polypropylene , are left on the stump of the spermatic cord as a marker in case it needs to be removed in the future during a  retroperitoneal lymph node dissection  (RPLND)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4971", "text": "The inguinal orchiectomy is a necessary procedure if  testicular cancer  is suspected.  While it is possible to remove a testicle through an incision in the scrotum, this is not done when cancer is suspected because it disrupts the natural  lymphatic drainage patterns .  Testicular cancer usually spreads into the lymph nodes inside the abdomen in a predictable manner.  Cutting the skin in the scrotum may disrupt this and cancer may spread to the  inguinal lymph nodes , making surveillance and subsequent operations more difficult."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4972", "text": "Complications from this procedure include bleeding and infection. The  ilioinguinal nerve  which runs anterior to the spermatic cord may be damaged during the operation and cause numbness over the inner thigh or chronic groin and scrotal pain. Other symptoms also include intermittent and chronic back pain and sudden loss of mobility in the lower back."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4973", "text": "If the orchiectomy is performed to diagnose cancer, the testicle and spermatic cord are then sent to a  pathologist  to determine the makeup of the  tumor , and the extent of spread within the testicle and cord.\nThe pathology report, along with pre-surgical imaging studies and  tumor markers , will determine the course of treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4974", "text": "Laparoscopic radical prostatectomy  (LRP) is a form of radical  prostatectomy , an operation for  prostate cancer . Contrasted with the original open form of the  surgery , it does not make a large incision but instead uses  fiber optics  and miniaturization. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4975", "text": "The  laparoscopic  and open forms of radical prostatectomy physically remove the entire  prostate  and reconstruct the  urethra  directly to the bladder. Laparoscopic radical prostatectomy and open radical prostatectomy differ in how they access the deep pelvis and generate operative views. In contrast to open radical prostatectomy, the laparoscopic radical prostatectomy makes no use of  retractors  and does not require that the  abdominal wall  be parted and stretched for the duration of the operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4976", "text": "A few good studies exist looking at open versus laparoscopic versus laparoscopic and robotic radical prostatectomy in cancer as of 2011. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4977", "text": "There is a robotic and non robotic version. [ 2 ]  These two versions have unclear differences in cancer related outcomes [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4978", "text": "The  American Cancer Society  states that success with laparoscopic technique is determined by surgeon experience and focus. There is a long learning curve for the robotic procedure. It is estimated that about 60 cases need to be performed by a surgeon to be comfortable with the procedure and about 250 cases to be an expert."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4979", "text": "The procedure takes at least five hours and as long as eight hours for the average urologist, without a bilateral lymph node dissection, compared to 2.5\u20133 hours when done by an open technique with an incision, with a completed lymph node dissection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4980", "text": "There is a greater risk of accidentally incising into the prostate, resulting in \"margin positivity,\" i.e. leaving cancer within the patient, in otherwise organ confined disease, even in the hands of experts. This is presumed to happen as a result of the lack of tactile sensation.  Margin positivity is strongly correlated with  PSA  recurrences and a fourfold annual increase in cancer recurrence compared to men with negative surgical margins.\nThere was a recent study from the University of Michigan by Hollenbeck et al. (Urology 2007; 70: 96-100) after their first 200 cases that they were able to eliminate extensive positive margins (12% in their first 15 cases versus 2% after performing 81 cases) but they continued to have a positive surgical margin rate of 22%.  Their conclusion was \"It seems that cumulative surgeon volume beyond that which can be obtained in the typical urology practice may be needed to obtain ideal margin rates with this new technology.\"Patrick C. Walsh M.D in an editorial comment in the Journal of Urology, commenting on this article, compared his own experience at Johns Hopkins with organ confined disease with a positive surgical margin rate of only 1.8%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4981", "text": "Another problem in higher-risk cases is that many surgeons using the robotic technique do not perform a lymph node dissection, as it is difficult to perform this adequately, robotically. The rationale usually given is that patient selection is such that most patients with  Gleason score  6 on pathology do not need a  lymphadenectomy . However, a small number of patients with Gleason 6 adenocarcinoma of the prostate are upgraded to Gleason 7 on final pathology. Any  micrometastases  in  lymph nodes  would not be detected, not be removed and would increase the risk of recurrences."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4982", "text": "There has not been any evidence in the urologic literature showing a benefit in regard to  continence ,  potency  or cure rates with the robotic procedure. Interest in the procedure is often patient driven, by patients who have been led to believe by the extensive advertising, that there are significant benefits to be obtained from the procedure.\nThe open radical prostatectomy is still the \"gold standard.\" [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4983", "text": "There was a study in the Journal of Clinical Oncology from Harvard [ 3 ]  using a national random sample of Medicare patients, showing that patients who had a laparoscopic/robotic radical prostatectomy underwent hormonal therapy in more than 25% of cases after the procedure compared to an open radical prostatectomy [this is usually not necessary with open radical prostatectomy if all the cancer has been removed and is usually less than 10% of cases], with a high risk of secondary procedures for bladder neck contracture [40% greater risk] which can result in poorer continence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4984", "text": "In an accompanying editorial in the journal commenting on this article [ 4 ]  (Note: over 9 years ago) Michael L.Blute, M.D. of the Mayo Clinic wrote that \"Patient interest in robotic assisted radical prostatectomy has been the result of a highly successful marketing campaign with the resultant consumer demand. Patients have been led to believe that hospital and recovery times are shorter and outcomes are better, a study has shown this expectation not to be the case.\"\nHe also wrote \"Currently, open technique is the state-of-the-art procedure in experienced hands, as the long-term results for laparoscopic/robotic assisted radical prostatectomy do not exist. The published literature fails to answer the question whether these procedures meet 'quality standards."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4985", "text": "No-scalpel vasectomy  (also called  non-scalpel vasectomy ,  keyhole vasectomy  or  NSV ) is a type of  vasectomy  procedure in which a specifically designed ringed clamp and dissecting  hemostat  is used to puncture the  scrotum [ 1 ]  to access the  vas deferens . This is different from a conventional or incisional vasectomy where the scrotal opening is made with a  scalpel . The NSV approach offers several benefits, including lower risk for bleeding, bruising, infection, and pain. [ 1 ]  The NSV approach also has a shorter procedure time than the conventional scalpel incision technique. [ 1 ]  Both approaches to vasectomy are equally effective. Because of the inherent simplicity of the procedure it affords itself to be used in  public health  programs worldwide. This method is used in over 40 countries for  male sterilisation . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4986", "text": "No-scalpel vasectomy was developed and first performed in China by Dr. Li Shunqiang with the aim of reducing men's fear related to the incision and increasing vasectomy use in China. [ 3 ]  In 1985, a team created by  EngenderHealth  visited his centre to learn the technique. [ 3 ]  One of the team members, Dr. Phaitun Gojaseni, introduced the no-scalpel technique in Thailand upon his return, while another member of the team, Dr.  Marc Goldstein , introduced the technique to the United States at the  NewYork\u2013Presbyterian Hospital . Over time, the technique gained popularity and it is now a preferred method of male sterilization in many countries. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4987", "text": "No-scalpel vasectomy was introduced in India in 1998. A team of Indian surgeons led by Dr RCM Kaza travelled to Chengdu, China, to learn the technique under the aegis of EngenderHealth and the  UN . They then introduced the procedure in India, under the  National Rural Health Mission . The  Government of India  then proceeded to introduce the procedure in every district of India as an alternative to  tubal ligation  offered to women. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4988", "text": "World Vasectomy Day  is celebrated on 7 November in India. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4989", "text": "No-scalpel vasectomy is a day case ( outpatient ) procedure and the patient is fit to go home the same day. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4990", "text": "The eligibility criteria for the no-scalpel vasectomy and the conventional vasectomy procedure are the same, although may vary from clinic to clinic."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4991", "text": "No-scalpel vasectomy is performed under  local anaesthesia . Usually  lidocaine  2 percent is infiltrated into the  vas deferens  and the puncture site on the scrotum. This makes the procedure pain free. Some patients may prefer to receive  regional anaesthesia . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4992", "text": "The vas deferens is isolated by three-finger technique on both sides. The ideal entry point for the needle is midway between the top of the  testes  and the base of the  penis . Usually, 100\u00a0mg  lidocaine  (without  epinephrine ) is injected to create a wheal. The no-scalpel vasectomy uses two specific instruments designed by Dr. Li Shunqiang. One is a ringed clamp and the other is a dissecting forceps. The ringed clamp is used to isolate and encircle the vas. The dissecting forceps is used to puncture the scrotal skin, spread tissues, and pierce the vas deferens to deliver it outside the scrotum. The vas deferens is then occluded. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4993", "text": "The most commonly used methods to occlude the vas deferens include: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4994", "text": "The American Urological Association recommends occlusion by one of the following methods to achieve highest efficacy: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4995", "text": "No-scalpel vasectomy has less pain, bleeding and infection than conventional vasectomy. [ 1 ]  No-scalpel vasectomy can also be done in less time and the individual is able to return to sexual activity sooner than traditional vasectomy surgery. [ 1 ]  However,  sperm  may still be present for 10\u201320 ejaculations, and some doctors may schedule a follow-up visit to confirm the success of the procedure. Additionally, there is approximately a 1 in 2,000 chance of pregnancy following a vasectomy, as some sperm may be able to cross the severed vas deferens. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4996", "text": "Complications are rare and can include: [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4997", "text": "Orchiectomy  (also named  orchidectomy ) is a  surgical procedure  in which one or both  testicles  are removed. The surgery can be performed for various reasons: [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4998", "text": "Less frequently, orchiectomy may be performed following a trauma, or due to wasting away of one or more testicles. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_4999", "text": "A simple orchiectomy is commonly performed as part of  gender-affirming surgery  for  transgender women , or as  palliative treatment  for advanced cases of  prostate cancer . A simple orchiectomy may also be required in the event of  testicular torsion . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5000", "text": "For the procedure, the person lies flat on an operating table with the  penis  taped against the  abdomen . The nurse shaves a small area for the incision. After anesthetic has been administered, the surgeon makes an incision in the midpoint of the  scrotum  and cuts through the underlying tissue. The surgeon removes the testicles and parts of the  spermatic cord  through the incision. The incision is closed with two layers of  sutures  and is covered with a  surgical dressing . If desired,  prosthetic testicles  can be inserted before the incision is closed to present an outward appearance of a pre-surgical scrotum. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5001", "text": "A subcapsular orchiectomy is also commonly performed for treatment of prostate cancer. The operation is similar to that of a simple orchiectomy, with the exception that the  glandular tissue  that surrounds each testicle is removed rather than the entire testis itself. This type of orchiectomy is performed to remove testosterone-producing glandular tissue while maintaining the appearance of an ordinary scrotum. [ 6 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5002", "text": "Inguinal orchiectomy  (named from the Latin  inguen  for \"groin\", and also called  radical orchiectomy ) is performed when an onset of  testicular cancer  is suspected, in order to prevent a possible spread of cancer from the spermatic cord into the lymph nodes near the kidneys. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5003", "text": "An inguinal orchiectomy can be either unilateral (one testicle) or bilateral (both testicles). The surgeon makes an incision in the groin area (in contrast to an incision in the scrotum, as is done in both simple and subcapsular orchiectomies). The entire  spermatic cord  is removed, as well as the testicle(s). A long, non-absorbable suture may be left in the stump of the spermatic cord in case later surgery is deemed necessary. [ 6 ]  After the cord and testicle(s) have been removed, the surgeon washes the area with saline solution and closes the layers of tissues and skin with sutures. The wound is then covered with sterile gauze and bandaged. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5004", "text": "Partial orchiectomy is an option for individuals with testicular masses that want to preserve their testes and their function. During surgery, the testis is exposed in a similar way to inguinal orchiectomy. Once the testis is exposed and the spermatic cord is clamped, there is a current debate as to whether surgeons should deliver  cold ischaemia  which means submitting the organ, in this case the testis, into a cold/freezing environment. Whether or not it is submerged and frozen, the next step is to cut the  tunica vaginalis  and an ultrasound is used to find the tumor. After, the tumor is scraped away from the testis in a process called  enucleation . Following enucleation, biopsies are taken of the tissues surrounding the testicle where the mass once was. Afterwards, each layer or tunica of the testis is sutured up and the testis is placed back in the scrotum. The skin layers are also closed up with sutures. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5005", "text": "Guidelines state that fertility counseling should be offered to all patients undergoing inguinal orchiectomy, as there is a risk of reduced fertility or infertility. Testicular germ cell tumors (TGCT) accounts for 95% of cases of testicular cancer in young men. [ 7 ]  TGCT is associated with abnormal semen parameters. [ 8 ]  Because testicular cancer is commonly diagnosed in young, fertile men, it is critical that these individuals be educated on preserving their semen through freezing ( cryopreservation ) and complete a fertility assessment prior to surgery. In addition, testicular prosthesis placement counseling and education is encouraged to be given before an individual undergoes orchiectomy or before inguinal exploration with possibility of orchiectomy. This is an elective surgery which can be done at the time of orchiectomy. Testicular prosthesic placement has known psychological benefits (see below). Although risks for complications with prosthesis is low, individuals should also be informed of the possibility of infection, rotation, and replacement of prosthesis. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5006", "text": "Following orchiectomy, those who have undergone the procedure are advised to avoid bathing, swimming, and heavy lifting for at least one month. If an individual had previously been taking hormone and/or hormone-blocking medications, modifications to their medication would be needed after the procedure. Any androgen-blocking medications, such as  spironolactone  or  cyproterone , are stopped, and estrogen hormones can be resumed at the doctor's discretion. Post-operative pain management includes icing the surgical site, wearing supportive underwear, and the use of pain relief medications ( analgesics ) such as acetaminophen or ibuprofen; for more severe pain,  narcotic analgesics  may be needed. A follow-up appointment to monitor recovery and healing is routine. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5007", "text": "Risks and complications should be discussed with an individual pre-operatively. Risks and complications for inguinal orchiectomy include scrotal hematoma (accumulation of blood in the scrotum), infection, post-operative pain (60% initially, 1.8% one year after), phantom testis syndrome (pain in the kidney as a result from trauma from the testicle), reduced fertility, and with the more rare complications being inguinal hernia, ilioinguinal nerve injury, tumor spillage, and hypogonadism. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5008", "text": "Unilateral orchiectomy results in decreased sperm count but does not reduce testosterone levels. [ 9 ] [ 4 ]   Bilateral orchiectomy  causes infertility and greatly reduced testosterone levels. This can lead to side effects including loss of sexual interest,  erectile dysfunction , hot flashes, breast enlargement ( gynecomastia ), weight gain, loss of muscle mass, and  osteoporosis . [ 4 ]  It has been discovered that some individuals with a history of prostate cancer who had bilateral orchiectomy had effects on their new bone production, resulting in increased risk of bone fractures due to testosterone deficiency after the procedure. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5009", "text": "Bilateral orchiectomy also reduces the use of exogenous medications for transgender women; the reduction in testosterone eliminates the need for testosterone-blocking medications and can contribute to feminizing features such as breast enlargement. [ 1 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5010", "text": "The loss of one or both testicles from orchiectomy can have severe implications in a male's identity and self-image surrounding masculinity, such that it can lead to an individual having thoughts of hopelessness, inadequacy, and loss. Among testicular cancer survivors who have lost a testicle, there are feelings of shame and loss, which are more evident in young and single men than older and non-single men. [ 13 ]  As many as one third of individuals who will undergo orchiectomy are not offered the option of having a testicular prosthesis. Data shows that simply offering testicular prosthesis to individuals undergoing orchioectomy is psychologically beneficial. While some individuals do not mind losing a testicle, studies have shown that there is a change in body image in testicular cancer survivors who have undergone orchiectomy and an improvement in body image in 50\u201360% of individuals who undergo testicular prosthesis placement. One year after testicular prosthesis placement, there are reports of increase in self-esteem and psychological well-being during sexual activity in a study that followed up on post-orchiectomy individuals including adolescents. [ 14 ]  On the other hand, there is a current debate whether children undergoing orchiectomy should be offered testicular prosthesis to be inserted at the time of orchiectomy procedure. [ 5 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5011", "text": "Bilateral simple orchiectomy is one option of  gender-affirming surgery  for transgender women. [ 1 ]  It may be performed as a standalone procedure or at the same time as a  vaginoplasty . [ 1 ]  Bilateral orchiectomy is considered first before undergoing vaginoplasty. Vaginoplasty can still be administered after undergoing bilateral orchiectomy, as the orchiectomy preserves the penoscrotal skin that can later be transformed into a skin flap. Additionally, it is an option for those who are unable to undergo vaginoplasty due to the risk of complications. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5012", "text": "In addition to alleviating  gender dysphoria , the procedure allows trans women to stop taking testosterone-blocking medications, which may cause unwanted side effects. [ 1 ]  Some common testosterone-blocking medications that most use before undergoing orchiectomy are  spironolactone  and  cyproterone . Common side effects caused by spironolactone are drowsiness, confusion, headache, fatigue, nausea/vomiting,  gastritis ,  polyuria ,  polydipsia , and electrolyte imbalance ( hyperkalemia ). Cyproterone can cause side effects such as fatigue, low mood, and  fulminant hepatitis . Orchiectomy allows individuals to stop taking these medications and avoid these adverse effects. [ 1 ]  It is also an alternative for trans women who have contraindications to antiandrogens and is a minimally invasive procedure to eliminate testosterone levels. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5013", "text": "Criteria from the World Professional Association for Transgender Health (WPATH) are used as a framework to guide health care professionals in approving or denying an orchiectomy. When a transgender individual wants to complete an orchiectomy, they are in a state of gender incongruence and they must meet the criteria before having the procedure done. The criteria are as follows: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5014", "text": "(i) persistent, documented gender dysphoria,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5015", "text": "(ii) capacity to make informed decisions and consent to treatment,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5016", "text": "(iii) well-controlled medical or mental health comorbidities, and"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5017", "text": "(iv) the use of hormone therapy for 12 months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5018", "text": "Additionally, persons wishing to go through with the procedure are required to obtain referrals from two independent qualified mental health professionals. This referral should include \"the individual's demographic information, psychosocial assessment results, duration of the therapeutic relationship, type of evaluation and therapy performed, if the criteria for surgery have been met and if informed consent has been obtained from the patient.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5019", "text": "An individual seeking to undergo orchiectomy is evaluated by a healthcare provider to ensure that the procedure is safe. Many candidates for orchiectomy are on estrogen therapy before the operation, which increases risk of intraoperative  venous thromboembolism  (VTE); thus, the provider must take this risk into account and determine whether  prophylaxis  (prevention) is necessary. [ 11 ]  Current smokers, individuals with limited mobility, individuals older than the age of 40, and individuals who have a medical history of  thrombolytic disorder  are at higher risk of developing VTE. For these high-risk populations, the use of sequential compression devices during the operation is recommended to prevent VTE complications. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5020", "text": "Testicular cancer most commonly occurs in males ages 15 to 34. In 2017, there were 8,850 new cases and 410 deaths in the United States. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5021", "text": "The American Urological Association (AUA) and European Association of Urology (EAU) 2019 guidelines recommend imaging with testicular ultrasound in any individual suspected of having testicular cancer following a physical examination. The ultrasound aids in differentiating diagnoses so that the individual may avoid the need of the surgical approach of inguinal orchiectomy. Inguinal orchiectomy is the gold standard treatment approach for those with confirmed malignancy of testicular cancer. Thus, it is imperative to diagnose the individual as having benign tumor vs. malignant tumor. Benign tumors are cancerous masses typically outside the testicle or surrounding it (extratesticular), whereas the malignant tumors typically lie within/inside the testicle (intratesticular). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5022", "text": "An orchiectomy is used not only as a treatment option, but also as a diagnostic tool for testicular cancer. Before an orchiectomy is deemed necessary, liver function tests, tumor markers, and various blood panels are taken to confirm the presence of testicular cancer. Tumor markers that may be checked include  beta human chorionic gonadotropin ,  lactate dehydrogenase , and  alpha fetoprotein . These markers are rechecked after orchiectomy to stage the testicular cancer. [ 16 ] [ 7 ]  Imaging, including  chest radiography  and an  abdominal/pelvic CT (computed tomography)  are also performed after orchiectomy to evaluate for  metastasis . [ 16 ]  An inguinal orchiectomy is the primary treatment for any cancerous tumor that is found in the testicles; however, in cases where tumors are small, testis- or testes-sparing surgery may be performed instead. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5023", "text": "Partial orchiectomy, also known as testis-sparing surgery, is another treatment option for smaller testicular masses which is becoming widely popular in recent years. This treatment option is an alternative to remove testicular cancer masses which are <20\u00a0mm, have a high probability of being benign, and with negative serum tumor markers. Its benefits include preserving fertility and normal hormone function. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5024", "text": "About half of testicular cancer germ cell tumors are  seminomas . Individuals with seminomas are 80-85% likely to have a stage 1 diagnosis and the individual must undergo surveillance every 3\u20136 months in the first year following their orchiectomy, with an abdominal/pelvic CT at 3, 6 and 12 months. Additional treatment such as chemotherapy may be given if they have risk factors for a relapse. Men with stage 1 seminoma after orchiectomy have been shown to be free from a relapse for five years following orchiectomy. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5025", "text": "Among children and adolescents diagnosed with  testicular torsion , the orchiectomy rate is as high as 42%. [ 3 ]  Though the goal during surgery is to correct the twist of the spermatic cord, orchiectomy is performed if the testicle is examined during the surgery to have dead tissue ( necrosis ) and suspected to no longer be a functioning testicle (no fertility). [ 3 ]  Delays in diagnosis and treatment increase the risk of orchiectomy, with diagnosis in the first four to eight hours of symptoms being critical to prevent permanent  ischemic damage , decreased fertility, and need for orchiectomy. [ 3 ] [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5026", "text": "Prostate cancer, if non-metastatic, is commonly treated with radical prostatectomy or radiation therapy. Less often, orchiectomy is used to treat prostate cancer. Prostate cancer grows in the presence of testosterone. When testosterone is present, \" it is metabolized and converted into  dihydrotestosterone  (DHT) which stimulates the growth of prostate cells. This leads to normal prostate growth in adolescents but contributes to abnormal cell growth in older men.\" [ 19 ]  Reducing the amount of testosterone in a person is one way in which prostate cancer is treated. If the prostate cancer is in fact metastatic, then orchiectomy may be used \"...to abolish the stimulation of cancer cells by inhibiting testicular testosterone production and thereby reducing androgen levels in the blood: so-called androgen deprivation therapy (ADT).\" [ 20 ]  Castration or orchiectomy is a suitable option for androgen deprivation therapy, and it should be used if a very quick reduction in testosterone levels is needed. However, in recent years, orchiectomy is not commonly used since medical castration is a viable option. [ 20 ]  Medical castration means that drugs or medications are used to suppress the production of androgens such as testosterone. Some examples of medications used in medical castration include, euprolide, goserelin (Zoladex), buserelin, and triptorelin (Trelstar). [ 21 ]  Some of the side effects of these medications include but are not limited to \"Reduced sexual desire and libido, Impotence, reduced size of testes and penis, hot flashes, growth of breast tissue (gynaecomastia) and pain across the breasts, thinning of the bones or osteoporosis and risk of fracture, anemia, loss of muscle mass, weight gain, fatigue and memory problems, and depression.\" [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5027", "text": "Until the mid-1980s, pediatric testis tumors were managed in accordance with adult guidelines where the standard therapy was radical inguinal orchiectomy. It was later discovered that this procedure was being overused in the pediatric population, particularly those in pre-puberty, because it was assumed that the tumor was malignant. [ 22 ]  It was discovered that the majority of the pediatric tumor registries over reported malignant tumors and had biased reporting. It has now been found that most tumors are benign lesions and the majority are cases of  teratoma  which act benign in pre-puberty pediatric individuals along with other benign tumors that have been reported such as:  Sertolic cell tumor ,  Leydig cell tumor  and  juvenile granulosa cell tumors . Most malignant tumors found in pre-pubertal individuals are pure yolk sac tumors. [ 22 ]  There is a difference in pre-pubertal, post-pubertal, and adult testis tumors in their histology and their level of malignancy with malignant tumors being rare in the pre-pubertal pediatric population. [ 23 ] [ 24 ]  There has been a consideration to switch to testes sparing surgery (TSS) such as partial orchiectomy specifically for the pre-puberty pediatric populations who lack signs of malignant tumors. [ 22 ]  Partial orchiectomy allows the ability to preserve hormone function and the possibility of reproduction in the future. [ 23 ] [ 24 ]  It has also been found to increase the quality of life. In the case that an individual is pediatric (<18 years of age) and is a post-pubertal with a malignant testes tumor, they must follow the adult recommended standard guidelines and proceed with radical inguinal orchiectomy. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5028", "text": "The post-pubertal pediatric population and adults are at higher risk of malignant tumors and usually have a histology of a mixed germ cell tumor. Their first line of treatment is radical orchiectomy; however, they may be candidates for testis-sparing surgery such as partial orchiectomy, if there is a presence of a benign tumor. Although partial orchiectomy is controversial for this group of individuals, it has been found to be a successful procedure for benign masses such as stromal tumors, epidermoid cysts, and fibrous pseudotumors. [ 22 ]  There is greater use of partial orchiectomy with individuals who have small, benign testicular mass usually < 2\u00a0cm which indicate the tumors being benign. There is limited data on the size of tumors of the pediatric population, therefore, size cannot be used as a predictor of a tumor being benign. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5029", "text": "Orchiopexy  (or  orchidopexy ) is a  surgery  to move and/or permanently fix a  testicle  into the  scrotum . While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve  testicular torsion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5030", "text": "Undescended testicles affect 1% of males and are 10% bilateral. The cause is unknown, with a small percentage associated with developmental abnormalities or chromosomal aberrations. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5031", "text": "Early orchiopexy reduces the risks for cancer and sterility in males with  cryptorchidism , or undescended testes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5032", "text": "Cryptorchidism is definitively diagnosed after 1 year of age, as testicular descent may occur after birth. Surgical placement into the scrotum is recommended by 18 months to decrease the likelihood of testicular cancer, testicular atrophy, and sterility."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5033", "text": "Cryptorchidism is associated with tubular atrophy and sterility. In addition, cryptorchid testes carry a three to five times higher risk for  testicular cancer  (germ cell neoplasia in situ within the atrophic tubules). Patients are at increased risk for the development of cancer and atrophy in the contralateral, normally descended testes as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5034", "text": "There are multiple different orchiopexy techniques used to correct an undescended testicle due to the large variation in location where the testes may present. The procedures have a high overall success rate. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5035", "text": "Orchiopexy is performed in the event of  testicular torsion , a urologic emergency presenting with intense pain and often without inciting injury. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5036", "text": "While neonatal torsion occurs with no anatomic defect to account for its occurrence (occurring in utero or shortly after birth), adult torsion results from a bilateral congenital anomaly often called a \" bell-clapper deformity \", where the testis is abnormally anchored in the scrotal sac, leading to increased mobility. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5037", "text": "Twisting of the spermatic cord results in obstruction of the testicular venous drainage. Intense vascular engorgement and infarction may lead to testicular injury and sterility. If the cord is manually untwisted within approximately six hours the testis has a high chance of remaining viable. One in three cases results in dead testes, requiring  orchiectomy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5038", "text": "Surgical fixation in the form of orchiopexy is indicated to prevent the reoccurrence of torsion, and is usually performed bilaterally, even if only one testicle is affected by torsion. The procedure has a high success rate in preventing reoccurrence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5039", "text": "For the management of palpable undescended testes (over 80% of undescended testes) the standard inguinal approach is the appropriate procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5040", "text": "Approximately 50% of non-palpable testis are high in the  inguinal canal  or abdominal, while the other 50% are atrophic, and usually located in the scrotum. Diagnostic  laparoscopy  is often advised to determine the location of non-palpable testis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5041", "text": "Two distinct techniques used for surgical fixation are the sutured point-fixation and Jaboulay tunica plication. Multiple studies have shown that both are effective techniques for fixation with limited evidence favoring either in acute torsion. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5042", "text": "Sutured fixation  may be performed using either absorbable or non-absorbable sutures, with 3 point fixation sites being preferred. There are concerns regarding potential complications arising from suture fixation (and required breach of the  tunica albuginea ) like infarction and abscess formation, however this is not supported by data. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5043", "text": "The  Jaboulay procedure  was developed later as a non-suture fixation method that avoids trans-parenchymal sutures and instead utilizes eversion, loose plication, and adhesion formation. this technique is criticized for potential security inadequacy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5044", "text": "Overall, there is considerable variation in surgical practice for testicular fixation for testicular torsion, with no significant difference in effectiveness between sutured and Jaboulay fixation in emergency re-presentations, post-operative complications, or returns to operation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5045", "text": "The first attempts at surgical correction of cryptorchidism began in the early 1800s. Before this, inguinal testis were managed with the use of  truss  or  castration , if at all."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5046", "text": "The theory of orchiopexy is attributed to the observations of Baron Albrecht von Haller and  John Hunter  in the 1700s, who began to elucidate the anatomy and mechanism of testicular descent."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5047", "text": "The first recorded attempt for surgical correction of an undescended testis was performed by James Adams in the London Hospital in 1871, although there are reports of attempts by several German doctors (J. F. Rosenmerkel in 1820 and M.J. von Chelius in 1837). The patient died due to infectious complications of the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5048", "text": "Thomas Annandale  completed the first successful orchiopexy in 1887 on a three-year-old boy. He discussed the care of this patient in  The British Medical Journal,  crediting Thomas Curling (who had worked with James Adams) with the idea of anchoring the testis to the bottom of the scrotum. Notably, Annandale was a close acquaintance of  Joseph Lister , and practiced antiseptic techniques that had been absent from previous attempts by other physicians. The postoperative course was reported to be \u201csatisfactory in every way\u201d."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5049", "text": "Max Sch\u00fcller, Arthur Dean Bevan, and  John K. Lattimer  further contributed to the current techniques for orchiopexy between the late 1800s and early 1900s, with the steps for standard orchiopexy being established before the 1960s. At this point, the standard orchiopexy applied to most undescended testes had a high success rate ranging from 89% to 92%- Attention was then turned to the treatment of high undescended testes, which the standard orchiopexy did not adequately treat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5050", "text": "In 1979, Jones and Bagley suggested a high inguinal incision for high canalicular or intra-abdominal testes. Fowler and Stephens devised a means to preserve the blood supply of high undescended testes through collateral circulation. Their technique was modified into a two-staged operation. Later, one-stage laparoscopic orchiopexy was reported first to reveal the location of non-palpable testes and then as a therapeutic treatment. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5051", "text": "Penectomy  is  penis removal  through  surgery , generally for medical or personal reasons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5052", "text": "Cancer , for example, sometimes necessitates removal of part or all of the penis. [ 1 ]  The amount of penis removed depends on the severity of the cancer. Some men have only the tip of their penis removed. For others with more advanced cancer, the entire penis must be removed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5053", "text": "In rare instances, a botched  circumcision  can also result in a full or partial penectomy, as with  David Reimer . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5054", "text": "Fournier gangrene  can also be a reason for penectomy and/or  orchiectomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5055", "text": "Because of the rarity of cancers which require the partial or total removal of the penis, support from people who have had the penis removed can be difficult to find locally. Website support networks are available. [ 2 ]  For instance, the American Cancer Society's Cancer Survivors Network website provides information for finding support networks. [ 4 ]   Phalloplasty  is also an option for surgical reconstruction of a penis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5056", "text": "Patients who have undergone a partial penectomy as a result of a penile cancer diagnosis have reported similar sexual outcomes as prior to surgery. [ 5 ]  Sexual support therapists and specialists are available nationally in the United States and can be accessed through the specialist cancer services. [ 2 ]  Many surgeons or hospitals will also provide this information postoperatively. Local government health services departments may be able to provide advice, names, and contact numbers. [ tone ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5057", "text": "Frenulectomy of the penis  is a surgical procedure for cutting and removal of the  penile frenulum , to correct a condition known as  frenulum breve . This condition prevents the full retraction of the foreskin with or without an erection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5058", "text": "It is a simple and normally painless procedure that is performed in a urologist's office. First the physician applies a local anesthetic, such as  lidocaine/prilocaine  cream on the frenulum and surrounding area. If the patient retains any feeling there after the anesthetic has had time to take effect, the physician may recommend that the procedure be performed in a hospital, with stronger anesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5059", "text": "Once the frenulum is cut, the physician applies stitches to close the wound. The patient may be given a prescription for pain killers to take in case there is pain afterwards, but usually the only discomfort is from the pricking of the stitches on the foreskin. Once the stitches are removed, in about seven days, normal sexual activity can resume."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5060", "text": "A  penile implant  is an  implanted device  intended for the treatment of  erectile dysfunction ,  Peyronie's disease , ischemic  priapism , deformity and any traumatic injury of the penis, and for  phalloplasty  or  metoidioplasty , including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size, which leads some to seek surgical and non-surgical solutions for penis alteration. [ 1 ]  Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5061", "text": "The first modern prosthetic reconstruction of a penis is attributed to NA Borgus, a German physician who performed the first surgical attempts in 1936 on soldiers with traumatic  amputations of the penis . He used  rib cartilages  as prosthetic material and reconstructed the genitals for both  micturition  and  intercourse  purposes. [ 3 ]  Willard E. Goodwin and William Wallace Scott were the first to describe the placement of synthetic penile implants using  acrylic  prosthesis in 1952. [ 4 ]   Silicone -based penile implants were developed by Harvey Lash and the first case series were published in 1964. [ 5 ]  The development of a high-grade silicone that is currently used in penile implants is credited to  NASA . [ 6 ]  The prototypes of the contemporary inflatable and malleable penile implants were presented in 1973 during the annual meeting of the  American Urological Association  by two groups of physicians from  Baylor University  (Gerald Timm, William E. Bradley and F. Brantley Scott) and  University of Miami  (Michael P. Small and Hernan M. Carrion). [ 3 ] [ 7 ] [ 8 ]  Small and Carrion pioneered the popularization of semi-rigid penile implants with the introduction of Small-Carrion prosthesis ( Mentor , USA) in 1975. Brantley Scott described the initial device as composed of two inflatable cylindrical bodies made up of silicone, a reservoir containing  radiopaque  fluid and two pumping units. [ 7 ]  The first generation products were marketed through American Medical Systems (AMS; currently  Boston Scientific ), with which Brantley Scott was associated. [ 6 ] [ 9 ]  Many device updates have been released by AMS since the first generation implants. In 1983, Mentor (currently  Coloplast ) joined the market. [ 6 ]  In 2017, there were more than ten manufacturers of penile implants in the world, however only a few now remain in the market. [ 10 ]  The latest additions to the market are  Zephyr Surgical Implants  and  Rigicon Innovative Urological Solutions . [ 11 ] [ 12 ]  Zephyr Surgical Implants, along with penile implants for biological men, introduced the first line of inflatable and malleable penile implants designed for  sex reassignment  for  trans men . In recent years, Rigicon Innovative Urological Solutions, a US-based company, has made significant advancements in the field of penile implants. In 2017, they released the 'Rigi10,' a malleable implant that expanded the market's options. Following this, in 2019, they introduced both the 'Infla10' series, which includes the Infla10 AX, Infla10 X, and Infla10 models, and the 'Rigi10 Hydrophilic.' These inflatable and hydrophilic-coated malleable models respectively were important additions to the range of penile implant technologies available. These advancements have contributed to the diversity and progress in the development of penile implants, offering patients more varied and tailored treatment solutions. [ 13 ]   [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5062", "text": "According to analysis of the 5% Medicare Public Use Files from 2001 to 2010 approximately 3% of patients diagnosed with erectile dysfunction opt for penile implantation. [ 15 ]  Each year nearly 25,000 inflatable penile prostheses are implanted in the USA. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5063", "text": "The list shows penile implants available in the market in 2020."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5064", "text": "The malleable (also known as non-inflatable or semi-rigid) penile  prosthesis  is a pair of rods implanted into the corpora of the penis. The rods are hard, but 'malleable' in the sense that they can be adjusted manually into the erect position. [ 18 ]  There are two types of malleable implants: one that is made of silicone and does not have a rod inside, also called soft implants, and another with a silver or steel spiral wire core inside coated with silicone. Some of the models have trimmable tails intended for length adjustment. [ 10 ]  Currently, a variety of malleable penile implants are available worldwide. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5065", "text": "The inflatable penile implant (IPP), more recently developed, is a set of inflatable cylinders and a pump system. Based on the differences in structure, there are two types of inflatable penile implants: two-piece and three-piece IPPs. Both types of inflatable devices are filled with sterile  saline solution  which is pumped into cylinders when in process. The cylinders are implanted into the  cavernous body of the penis . The pump system is attached to the cylinders and placed in the  scrotum . [ 10 ]  Three-piece implants have a separate large reservoir connected to the pump. The reservoir is commonly placed in the  retropubic space  (Retzius' space), however other locations have also been described, such as between the  transverse muscle  and  rectus muscle . Three-piece implants provide more desirable rigidity and girth of the penis resembling natural erection. Additionally, due to the presence of a large reservoir, three-piece implants provide full flaccidity of the penis when deflated, thus bringing more comfort than two-piece inflatable and malleable implants. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5066", "text": "The saline solution is pumped manually from the reservoir into bilateral chambers of cylinders implanted in the shaft of the penis, which replaces the non- or minimally-functioning erectile tissue. This produces an erection. The  glans of the penis , however, remains unaffected. Ninety to ninety-five percent of inflatable prostheses produce erections suitable for  sexual intercourse . In the United States, the inflatable prosthesis has largely replaced the malleable one, due to its lower rate of infections, high device survival rate and 80\u201390% satisfaction rate. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5067", "text": "The first IPP prototype presented in 1975 by Scott and colleagues was a three-piece prosthesis (two cylinders, two pumps and a fluid reservoir). Since then, the IPP has undergone multiple modifications and improvements for device reliability and durability, including change in the chemical material used in implant manufacturing, using hydrophilic and antibiotic eluting coatings to reduce the rates of infections, introducing one-touch release etc. [ 10 ]  Surgical techniques used for the implantation of penile prostheses have also improved along with evolution of the device. Inflatable penile implants were one of the first interventions in urology where the \"no-touch\" surgical technique was introduced. This has significantly reduced the rates of post-operative infections. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5068", "text": "In spite of recent rapid and extensive development of non-surgical management options for  erectile dysfunction , especially novel targeted medications and  gene therapy , the penile implants remain the mainstay and the gold standard choice for the treatment of erectile dysfunction refractory to oral medications and injectable therapy. [ 21 ] [ 6 ]  Additionally, penile implants can be a relevant option for those with erectile dysfunction who want to proceed with a permanent solution without medical therapy. Penile implants have been used for the treatment of erectile dysfunction with various etiologies, including vascular,  cavernosal , neurogenic, psychological and post-surgical (e.g.  prostatectomy ). The  American Urological Association  recommends informing all men with erectile dysfunction about penile implants as a choice of treatment and discussing the potential outcomes with them. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5069", "text": "Penile implants can help recover the natural shape of the penis in various conditions that have led to penile deformity. These can be traumatic injuries, penile surgeries, disfiguring and  fibrosing  diseases of the penis, such as  Peyronie's disease . [ 6 ]  In Peyronie's disease, the change in penile curvature affects normal sexual intercourse as well as causing  erectile dysfunction  due to disruption of blood flow in the  cavernous bodies  of the penis. [ 23 ]  Therefore, implantation of penile prosthesis in Peyronie's disease addresses several mechanisms involved in the pathophysiology of the disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5070", "text": "Although different models of penile prostheses have been reported to be implanted after  phalloplasty  procedures, [ 24 ]  with the first case described in 1978 by Pucket and Montie, [ 25 ]  the first penile implants designed and produced specifically for  female-to-male gender reassignment surgery  for  trans men  were introduced in 2015 by  Zephyr Surgical Implants . [ 26 ]  Both malleable and inflatable models are available. These implants have more realistic shape with an ergonomic glans at the tip of the prosthesis. The inflatable model has an attached pump resembling a testicle. The prosthesis is implanted with a sturdy fixation on  pubic bone . Another, thinner malleable implant is intended for  metoidioplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5071", "text": "The overall satisfaction rate with penile implants reaches over 90%. [ 6 ]  Both self- and partner-reported satisfaction rates are evaluated to assess the outcomes. It has been shown that implantation of inflatable penile prosthesis brings more patient and partner satisfaction than medication therapy with  PDE5 inhibitors  or  intracavernosal injections . [ 21 ]  Satisfaction rates are reported to be higher with inflatable rather than malleable implants, but there are no differences between two-piece and three-piece devices. [ 27 ] [ 28 ]  The most frequent reasons for dissatisfaction are reduced penis length and girth, failed expectations and difficulties with device use. [ 21 ] [ 27 ]  Thus, it is vital to provide patients and their partners with detailed preoperative counselling and instructions. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5072", "text": "33% to 90% of cases of patients with Peyronie's disease that have had an inflatable PI procedure have successfully corrected their penile deformity. [ 23 ]  The residual curvature after penile implant placement usually requires intraoperative surgical intervention."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5073", "text": "Dilation of the corpora cavernosa, typically with Hegar sounds, before inserting the device has been a common part of implantation procedures. This dilation destroys erectile tissue. It has been shown that a tissue-sparing technique, i.e.  without  dilation, correlates with superior outcomes\u00a0\u2013 some remaining natural erectile response can be preserved, and post-operative pain is reduced as well. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5074", "text": "The most common complication associated with penile implant placement appears to be infections with reported rates of 1\u20133%. [ 27 ]  Both surgical site and device infections are reported. When the infection involves the penile implant itself, implant removal is required and irrigation of the cavities with  antiseptic  solutions. In this scenario, placement of a new implant is needed to avoid further tissue fibrosis and shortening of the penis. The rate of repeat surgeries or device replacements ranges from 6% to 13%. [ 23 ]  Other reported complications include perforation of the  corpus cavernosum  and  urethra  (0.1\u20133%), commonly occurring in patients with previous  fibrosis , prosthesis erosion or extrusion, change in  glans  shape,  hematoma , shortening of penis length, and device malfunction. Due to continuous improvement of surgical techniques and modifications of implants, complication rates have dramatically decreased over time. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5075", "text": "To overcome post-operative penile shortening and to increase the perceived length of the penis and patient satisfaction, ventral and dorsal  phalloplasty  procedures in combination with penile implants have been described. [ 21 ]  Modified glanulopexy has been proposed to prevent supersonic transporter deformity and glandular hypermobility which are possible complications of penile implants. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5076", "text": "Sliding techniques in which the penis is cut and elongated with penile implants have been performed in cases of severe penile shortening. However, these techniques had higher rates of complications and are currently avoided. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5077", "text": "Penis reduction  or  penis reduction surgery  refers to efforts or an assortment of techniques intended to decrease the girth or length of the  human penis , especially when erect. The motive behind such a procedure can range from complications such as  macropenis , [ 1 ] [ 2 ]  genital  lymphedema , [ 3 ]  or  sex reassignment . [ 4 ]  It may also be motivated by the shape or size of the extant penis being unviable for intercourse and the associated social liabilities of having macrophallic penile dimensions. [ 5 ]  The causes of macrophallism can range from  sickle cell disease  to  priapism . [ 6 ]  The age range of individuals who have undergone treatment or are purported to have considered it vary including a 17 year old, [ 7 ]  a 52 year old, [ 8 ]  a 20 year old [ 9 ]  and a 41 year old named Matt Barr. [ 10 ]  The procedure may involve the removal of tissue beneath the skin of the penis, [ 11 ]  amelioration through simple excision procedures, [ 12 ]  or antihypertensive medication. [ 13 ]  Such procedures have been considered by men with partners who have complained about discomfort of thrusts against the  cervix [ 14 ]  as well as those seeking additional stimulation of the  clitoris . [ 15 ]  In some ancient periods of history, the diminution of penile size was a desired appearance aesthetically, including those observable in surviving works of art, due to an association with unpretentiousness, reticence and timidity; [ 16 ]  artists also wanted to distance themselves from erotic art's obsession with over-sized genitals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5078", "text": "Penis removal  is the act of removing the  human penis . It is not to be confused with the related practice of  castration , in which the testicles are removed or deactivated, or emasculation, which removes both. Penis removal and castration have been used to create a class of servants or slaves called  eunuchs  in many different places and eras, having a notable presence in various societies such as  Imperial China ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5079", "text": "In  Russia , men of a devout group of  Spiritual Christians  known as the  Skoptsy  were castrated, either undergoing \"greater castration\", which entailed removal of the penis, or \"lesser castration\", in which the penis remained in place, while Skoptsy women underwent  mastectomy . These procedures were performed in an effort to eliminate lust and to restore the Christian to a pristine state that existed prior to  original sin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5080", "text": "In the modern era, removing the human penis for any such activity is very rare (with some exceptions listed below), and references to removal of the penis are almost always symbolic. Castration is less rare, and is performed as a last resort in the treatment of  androgen -sensitive  prostate cancer . [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5081", "text": "Some men have penile  amputations , known as  penectomies , for medical reasons.  Cancer , for example, sometimes necessitates removal of all or part of the penis. In some instances, botched childhood  circumcisions  have also resulted in full or partial penectomies. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5082", "text": "Genital surgical procedures for  transgender women  undergoing  sex reassignment surgery  do not usually involve the complete removal of the penis; part or all of the  glans  is usually kept and reshaped as a  clitoris , and the skin of the penile shaft may also be inverted to form the  vagina . When procedures such as this are not possible, other procedures such as  colovaginoplasty  are used which do involve the removal of the penis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5083", "text": "Issues related to the removal of the penis appear in psychology, for example in the condition known as  castration anxiety ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5084", "text": "Some men have undergone penectomies as a voluntary  body modification , thus including it as part of a  body dysmorphic disorder .\nProfessional opinion is divided regarding the desire for penile amputation as a pathology, much as all other forms of treatment by amputation for body dysmorphic disorder. Voluntary  subincision , removal of the  glans penis , and bifurcation of the penis are related topics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5085", "text": "In ancient China, for crimes including adultery, \"licentious\" and \"promiscuous\" activity, males had their penises removed in addition to being  castrated . This was one of the  Five Punishments  that could be legally inflicted on criminals in China. [ 5 ]  The exact crime was called  gong , and referred to \"immoral\" sex between males and females. The punishment stated, \"If a male and female engage in intercourse without morality, their punishments shall be castration and  sequestration  [respectively].\" [ 6 ]  They were designed to permanently disfigure for life. [ 7 ]  \"Castration\", in China, meant the severing of the penis in addition to the testicles, after which male offenders were sentenced to work in the palace as  eunuchs . The punishment was called  g\u014dngx\u00edng  (\u5bab\u5211), which meant \"palace punishment\", since castrated men would be enslaved to work in the harem of the palace. It was also called \" f\u01d4x\u00edng \"(\u8150\u5211). [ 8 ]  Husbands who committed  adultery  were punished with castration as required under this law. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5086", "text": "The removal of the penis was used as a punishment for men in the  Heian period  in Japan, where it replaced execution. It was called  rasetsu  \u7f85\u5207 (\u3089\u305b\u3064), and was separate from castration which was called  ky\u016bkei  \u5bae\u5211 (\u304d\u3085\u3046\u3051\u3044). [ 10 ] [ 11 ]   Rasetsu  was done voluntarily by some Japanese Buddhist priests to ensure celibacy. [ 12 ] [ 13 ]  Rasetsu was also known in  Edo period  Japan. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5087", "text": "The word  rasetsu  was made out of the components \"ra\" from \" mara \" which meant penis, and \" setsu \", which meant cutting. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5088", "text": "The word  rasetsu  was used in Japanese literature. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5089", "text": "Ky\u016bkei  in Japanese law referred to the punishment of castration, which was used for male offenders, and confinement for females. [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5090", "text": "The  Arab slave trade  provided many eunuchs who were more highly prized, and priced. African boys were generally subject to penis removal, as well as castration. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5091", "text": "A study of penis reattachment in China found that in a group of 50 men, all but one reacquired functionality, even though some involved full reconstructive surgery using tissue and bone. Reportedly, some of these men later fathered children. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5092", "text": "If reattachment is not an option (such as the penis not being reattached long after 24 hours), [ 26 ] [ 27 ]  doctors can reconstruct a penis from muscle and skin grafted from another part of the body like the forearm. However, a penile implant is needed for an erection to be possible, as the reconstructed penis would look strange and would either not be able to ejaculate, [ 28 ] [ 29 ]  or ejaculate with less force. [ 26 ]  Patients are often dissatisfied with the reconstructed penis. [ 30 ]  Since 2015,  Zephyr Surgical Implants  produces malleable and inflatable penile implants particularly designed for phalloplasty surgeries. [ 31 ]  Standing during urination is an advantage offered by a reconstructed penis. [ 32 ]  If penis reconstruction is not done, the patient will have to squat in order to urinate since doctors reroute the entrance of the urethra to below the scrotum. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5093", "text": "In the 21st-century, successful  allographic  penis transplantation surgery began."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5094", "text": "Phalloplasty  (also called  penoplasty ) [ 1 ]  is the construction or reconstruction of a  penis  or the artificial modification of the penis by  surgery . The term is also occasionally used to refer to  penis enlargement . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5095", "text": "Russian surgeon Nikolaj Bogoraz performed the first reconstruction of a total penis using rib cartilage in a reconstructed phallus made from a tubed abdominal flap in 1936. [ 3 ] [ 4 ] [ 5 ] \nThe first  gender-affirming surgery  for a  trans man  was performed in 1946 by Sir  Harold Gillies  on fellow physician  Michael Dillon , documented in  Pagan Kennedy 's book  The First Man-Made Man . [ citation needed ]  Gillies' technique remained the standard one for decades. Later improvements in  microsurgery  made more techniques available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5096", "text": "A complete construction or reconstruction of a penis can be performed on patients who: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5097", "text": "There are different techniques for phalloplasty. Construction of a new penis (sometimes called a neophallus or neopenis) [ 6 ]  typically involves taking a tissue flap from a donor site (such as the forearm). Extending the  urethra  through the length of the neophallus is another goal of phalloplasty. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5098", "text": "Temporary lengthening can also be gained by a procedure that releases the suspensory ligament where it is attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. However, scar formation can cause the penis to retract. Therefore, the  American Urological Association  \"considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious.\" [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5099", "text": "Phalloplasty requires an implanted  penile prosthesis  to achieve an erection. Penile prostheses are implanted devices intended to restore the erectile rigidity in  cisgender  men and to build a neophallus (new penis) in  transgender  men. Penile implants have been used in phalloplasty surgeries both in cisgender and transgender patients since 1970s. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5100", "text": "There are two main types of penile implants \u2013 malleable (also known as non-inflatable or semi-rigid) and inflatable implants. Both types have a pair of cylinders implanted into the penis, replacing the non-erectile tissue in cisgender men and serving as the core for the neophallus in the phalloplasty procedure. The cylinder of the inflatable implant is filled with sterile  saline solution . Pumping saline into the chambers of this cylinder produces an erection. The glans of the penis, however, remains unaffected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5101", "text": "In  sex reassignment surgeries , a new penis is formed with the use of a penile implant surrounded with a tissue flap. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5102", "text": "The pump unit of inflatable penile implants resembles a human testicle and can serve as an artificial testicle for concomitant  scrotoplasty . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5103", "text": "Initially, standard penile implants were used in phalloplasty procedures. However, since there is no  corpus cavernosum  in the penis undergoing phalloplasty, and the fact that standard penile implants were designed to be implanted in corpus cavernosum, there were many adverse outcomes. [ 13 ]  Since 2015,  Zephyr Surgical Implants  proposes malleable and inflatable penile implants particularly designed for phalloplasty surgeries. [ 14 ]  Implantation procedures are usually done in a separate surgery to allow time for proper healing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5104", "text": "[ 15 ]  Sensation is retained through the  clitoral tissue  at the base of the neophallus. [ 15 ]  Nerves from the flap and the tissue it has been attached to may eventually connect. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5105", "text": "The disadvantages include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5106", "text": "This phalloplasty method is from  latissimus dorsi  musculocutaneous flap. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5107", "text": "This phalloplasty procedure involves the insertion of a subcutaneous soft silicone implant under the penile skin. [ 18 ] [ 19 ] [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5108", "text": "The no-touch surgical technique for  penile prosthesis  implantation is a surgical procedure developed by J. Francois Eid for the implantation of a  penile implant . [ 22 ]  Implantation through the use of the \"No-Touch\" technique minimizes the risk of infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5109", "text": "As advancements in the design and manufacturing process of the IPP improved its mechanical survival, infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for patients, requiring complete removal of the device and permanent loss of penile size and anatomy. [ 23 ] [ 24 ]  Bacterial contamination of the device can occur during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections occur due to the skin  microbiome 's microorganisms including  Staphylococcus epidermidis ,  Staphylococcus aureus ,  Streptococcus  and  Candida albicans . [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5110", "text": "Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The \"No-Touch\" technique is unique in that it aims to prevent bacterial contamination of the prosthesis by completely eliminating contact of the  device with the skin. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5111", "text": "Paired with the antibiotic-coated implant, the \"No Touch\" technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. [ 27 ]  Eid developed the technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection. [ 25 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5112", "text": "Three days prior to the procedure, a patient is placed on oral  fluoroquinolones , a grouping of antibacterial drugs. During this time, the patient scrubs the lower abdomen and genitals daily with  chlorhexidine  soap. On the day of the surgery,  vancomycin  and  gentamicin  are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a chlorhexidine sponge and prepped with chorhexidine/alcohol applicator. The area is then draped with a  surgical drape  and a Vi Drape over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5113", "text": "A 3\u00a0cm (1.2\u00a0in) scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the  Buck's fascia . A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5114", "text": "Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. [ 29 ]  At this stage of the \"No-Touch\" technique, after the incision has been made, all instruments, including surgical gloves, that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point, new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5115", "text": "Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the \"No-Touch\" drape is removed and the skin closed. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5116", "text": "Penis transplantation  could also become a standardized method. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5117", "text": "Preputioplasty  or  prepuce plasty , also known as  limited dorsal slit with transverse closure , is a plastic surgical operation on the prepuce or  foreskin  of the  penis , [ 1 ]  to widen a narrow non-retractile foreskin which cannot comfortably be drawn back off the head of the penis in erection because of a constriction ( stenosis ) which has not expanded after  adolescence ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5118", "text": "Preputioplasty is a treatment for  phimosis  in the alternative to  circumcision  and radical  dorsal slit"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5119", "text": "Preputioplasty may be performed by  Z-plasty , also used in reconstructive surgery to loosen constricting scar tissue following traumatic burns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5120", "text": "However, Y-plasty and Z-plasty require a degree of surgical sophistication that physicians in general practice may lack."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5121", "text": "More commonly it simply consists of one or more very short longitudinal incisions which release the stenosis\u2013the constricting ring of tissue\u2014in the foreskin and are closed transversely: [\u00a0|\u00a0] is closed and sutured as [\u00a0\u2014\u00a0]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5122", "text": "In the alternative to suturing, \"[h]aemostasis [has been successfully] performed [in children] with a heated probe using the flame of an alcohol lamp or with bipolar electrodiathermy.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5123", "text": "Only one incision is shown in Figure 3; if two or more such incisions are made this will prevent a V-shaped indentation at the opening of the foreskin when the penis is not erect. If incisions are placed on the sides of the phimotic ring, the ultimate cosmetic result is better. It is also recommended that the subcutaneous tissue be  undermined  to ensure a better cosmetic result."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5124", "text": "The opening of the foreskin is now normally wide enough for the foreskin to be easily retracted. The foreskin is also slightly shorter (by half the length of the longitudinal incisions which are now closed transversely) because the widening of the phimotic ring takes up some foreskin length.\nStudies from a large cohort in the Indian Subcontinent show a good acceptance and an interest for foreskin preservation when there is no religious indication to remove the foreskin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5125", "text": "Prostate biopsy  is a procedure in which small hollow needle-core samples are removed from a man's  prostate gland  to be examined for the presence of  prostate cancer . It is typically performed when the result from a  PSA  blood test is high. [ 1 ]  It may also be considered advisable after a  digital rectal exam  (DRE) finds possible abnormality.  PSA screening is controversial  as PSA may become elevated due to non-cancerous conditions such as  benign prostatic hyperplasia  (BPH), by infection, or by manipulation of the prostate during surgery or  catheterization . Additionally many prostate cancers detected by screening develop so slowly that they would not cause problems during a man's lifetime, making the complications due to treatment unnecessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5126", "text": "The most frequent side effect of the procedure is  blood in the urine  (31%). [ 2 ]  Other side effects may include infection (0.9%) and death (0.2%). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5127", "text": "The procedure may be performed transrectally, through the  urethra  or through the  perineum . The most common approach is transrectally, and historically this was done with tactile finger guidance. [ 3 ]  The most common method of prostate biopsy as of 2014 [update]  was transrectal  ultrasound -guided prostate (TRUS) biopsy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5128", "text": "Extended biopsy schemes take 12 to 14 cores from the prostate gland through a thin needle in a systematic fashion from different regions of the prostate. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5129", "text": "A biopsy procedure with a higher rate of cancer detection is template prostate mapping (TPM) or transperineal template-guided mapping biopsy (TTMB), whereby typically 50 to 60 samples are taken of the prostate through the outer skin between the rectum and  scrotum , to thoroughly sample and map the entire prostate, through a template with holes every 5\u00a0mm, usually under a general or spinal  anaesthetic . [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5130", "text": "Antibiotics  are usually prescribed to minimize the risk of infection. [ 4 ] [ 8 ]  A healthcare provider may also prescribe an  enema  to be taken in the morning of the procedure. During the transrectal procedure, an ultrasound probe is inserted into the rectum to assist in guiding the biopsy needles. Following this, a  local anesthetic , such as  lidocaine , is administered into the tissue surrounding the prostate. Subsequently, a spring-loaded  biopsy needle  is inserted into the prostate, resulting in a clicking sound. When the local anesthetic is effective, any discomfort experienced is minimal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5131", "text": "Since the mid-1980s, TRUS biopsy has been used to diagnose prostate cancer in essentially a blind fashion because prostate cancer cannot be seen on ultrasound due to poor soft tissue resolution.  However, multi-parametric  magnetic resonance imaging  (mpMRI) has since about 2005 been used to better identify and characterize prostate cancer. [ 9 ]   A study correlating MRI and surgical pathology specimens demonstrated a  sensitivity  of 59% and  specificity  of 84% in identifying cancer when  T2-weighted ,  dynamic contrast enhanced , and  diffusion-weighted imaging  were used together. [ 10 ]   Many prostate cancers missed by conventional biopsy are detectable by MRI-guided targeted biopsy. [ 11 ]  In fact, a side-by-side comparison of TRUS versus MRI-guided targeted biopsy that was conducted as a prospective, investigator-blinded study demonstrated that MRI-guided biopsy improved detection of significant prostate cancer by 17.7%, and decreased the diagnosis of insignificant or low-risk disease by 89.4%. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5132", "text": "Two methods of MRI-guided, or \"targeted\" prostate biopsy, are available: (1) direct \"in-bore\" biopsy within the MRI tube, and (2) fusion biopsy using a device that fuses stored MRI with real-time ultrasound (MRI-US). Visual or cognitive MRI-US fusion have been described. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5133", "text": "When MRI is used alone to guide prostate biopsy, it is done by an  interventional radiologist . Correlation between biopsy and final pathology is improved between MRI-guided biopsy as compared to TRUS. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5134", "text": "In the fusion MRI-US prostate biopsy, a prostate MRI is performed before biopsy and then, at the time of biopsy, the MRI images are fused to the ultrasound images to guide the  urologist  to the suspicious targets. Fusion MRI-US biopsies can be achieved in an office setting with a variety of devices. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5135", "text": "MRI-guided prostate biopsy appears to be superior to standard TRUS-biopsy in prostate cancer detection. Several groups in the U.S., [ 15 ] [ 16 ]  and Europe, [ 17 ] [ 18 ]  have demonstrated that targeted biopsies obtained with fusion imaging are more likely to reveal cancer than blind systematic biopsies. In 2015, AdMeTech Foundation, American College of Radiology and European Society of Eurogenital Radiology developed Prostate Imaging Reporting and Data System (PI-RADS v2) for global standardization of image acquisition and interpretation, which similarly to BI-RADS standardization of breast imaging, is expected to improve patient selection for biopsies and precisely-targeted tissue sampling. [ 19 ] [ 20 ]   PI-RADS  v2 created standards for optimal mpMRI image reporting and graded the level of suspicion based on the score of one to five, with the goal to improve early detection (and exclusion) of clinically significant (or aggressive) prostate cancer. [ 21 ]  The higher suspicion on mpMRI and the higher PI-RADS v2 score, the greater the likelihood of aggressive prostate cancer on targeted biopsy. Considerable experience and training is required by the reader of prostate mpMRI studies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5136", "text": "Up to 2013, indications for targeted biopsy have included mainly patients for whom traditional TRUS biopsies have been negative despite concern for rising PSA, as well as for patients enrolling in a program of  active surveillance  who may benefit from a confirmatory biopsy and/or the added confidence of more accurate non-invasive monitoring. [ 15 ]  Increasingly, men undergoing initial biopsy are requesting targeted biopsy, and thus, the use of pre-biopsy MRI is growing rapidly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5137", "text": "Clinical trials of mpMRI and PI-RADS v2, including NIH-funded studies are underway to further clarify the benefits of targeted prostate biopsy. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5138", "text": "Side effects of a TRUS or TPM biopsy include: [ 23 ] [ 6 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5139", "text": "The tissue samples are examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or  Gleason score ) of any cancer found. Gleason score, PSA, and digital rectal examination together determine clinical risk, which then dictates treatment options."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5140", "text": "Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of malignant cells that have metastasized. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5141", "text": "Prostate cancer screening  is the  screening  process used to detect undiagnosed  prostate cancer  in men without  signs  or  symptoms . [ 1 ] [ 2 ]  When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early detection reduces mortality rates. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5142", "text": "Screening precedes a diagnosis and subsequent treatment. The  digital rectal examination  (DRE) is one screening tool, during which the prostate is manually assessed through the wall of the rectum. The second screening tool is the measurement of  prostate-specific antigen  (PSA) in the  blood . The evidence remains insufficient to determine whether screening with PSA or DRE reduces mortality from prostate cancer. [ 1 ]  A 2013  Cochrane  review concluded PSA screening results in \"no statistically significant difference in prostate cancer-specific mortality...\". [ 3 ]  The American studies were determined to have a high bias. European studies included in this review were of low bias and one reported \"a significant reduction in prostate cancer-specific mortality.\" PSA screening with DRE was not assessed in this review. DRE was not assessed separately. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5143", "text": "Most recent guidelines have recommended that the decision whether or not to screen should be based on  shared decision-making , [ 4 ]  so that men are informed of the risks and benefits of screening. [ 5 ] [ 6 ]  In 2012, the  American Society of Clinical Oncology  recommends screening be discouraged for those who are expected to live less than ten years, while for those with a longer life expectancy a decision should be made by the person in question. In general, they conclude that based on recent research, \"it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment.\" [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5144", "text": "Prostate biopsies  are used to diagnose prostate cancer but are not done on asymptomatic men and therefore are not used for screening. [ 8 ] [ 9 ]  Infection after prostate biopsy occurs in about 1%, while death occurs as a result of biopsy in 0.2%. [ 10 ] [ 11 ]  Prostate biopsy guided by  magnetic resonance imaging  has improved the diagnostic accuracy of the procedure. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5145", "text": "Prostate-specific antigen  (PSA) is secreted by the  epithelial cells  of the  prostate  gland and can be detected in a sample of blood. [ 14 ]  PSA is present in small quantities in the  serum  of men with healthy prostates, but is often elevated in the presence of  prostate cancer  or other prostate disorders. [ 15 ]  PSA is not a unique indicator of prostate cancer, but may also detect  prostatitis  or  benign prostatic hyperplasia . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5146", "text": "A 2018  United States Preventive Services Task Force  (USPSTF) recommendation adjusted the prior opposition to PSA screening, [ 17 ]  suggesting shared decision-making regarding screening in healthy males 55 to 69 years of age. [ 17 ]  The recommendation for that age group states screening should only be done in those who wish it. [ 18 ]  In those 70 and over, screening remains not recommended. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5147", "text": "Screening with PSA has been associated with a number of harms including  over-diagnosis , increased  prostate biopsy  with associated harms, increased anxiety, and unneeded treatment. [ 19 ]  The evidence surrounding prostate cancer screening indicates that it may cause little to no difference in mortality. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5148", "text": "On the other hand, up to 25% of men diagnosed in their 70s or even 80s die of prostate cancer,  if  they have high-grade (i.e., aggressive) prostate cancer. [ 20 ]  Conversely, some argue against PSA testing for men who are too young, because too many men would have to be screened to find one cancer, and too many men would have treatment for cancer that would not progress. Low-risk prostate cancer does not always require immediate treatment, but may be amenable to active surveillance. [ 21 ]  A PSA test cannot 'prove' the existence of prostate cancer by itself; varying levels of the antigen can be due to other causes. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5149", "text": "During a digital  rectal examination  (DRE), a healthcare provider slides a gloved finger into the  rectum  and presses on the prostate, to check its size and to detect any lumps on the accessible side. If the examination suggests anomalies, a PSA test is performed. If an elevated PSA level is found, a follow-up test is then performed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5150", "text": "A 2018 review recommended against primary care screening for prostate cancer with DRE due to the lack of evidence of the effectiveness of the practice. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5151", "text": "The USPSTF recommends against digital rectal examination as a screening tool due to lack of evidence of benefits. [ 24 ]  Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5152", "text": "The American Urological Association in 2018 stated that for men aged 55 to 69, they could find no evidence to support the continued use of DRE as a first-line screening test; however, in men referred for an elevated PSA, DRE may be a useful secondary test. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5153", "text": "A study by Krilaviciute et al. (2023) [ 28 ]  examined the effectiveness of the DRE as a standalone screening test for prostate cancer in >46,000 young men in Germany (age 45). It was found that DRE has a much lower detection rate for prostate cancer compared to PSA screening. Therefore, the authors recommend not to use DRE as a screening test for prostate cancer in young men, as it does not provide an improvement in detection compared to PSA screening."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5154", "text": "Prostate biopsies  are considered the gold standard in detecting prostate cancer. [ 8 ] [ 9 ]  Infection after the biopsy procedure is a possible risk. [ 10 ]  MRI guided techniques have improved the diagnostic accuracy of the procedure. [ 12 ] [ 13 ]  Biopsies can be done through the  rectum  or  penis . [ 29 ]  The biopsy technique includes factors such as needle angle and prostate mapping method. [ 30 ]  People who have localized cancer and perineural invasion may benefit more from immediate treatment rather than adopting a watchful waiting approach. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5155", "text": "Transrectal ultrasonography  (TRUS) has the advantage of being fast and minimally invasive, and better than MRI for the evaluation of superficial tumor. [ 2 ]  It also gives details about the layers of the rectal wall, accurate and useful for staging primary rectal cancer. While MRI is better in visualization of locally advanced and stenosing cancers, for staging perirectal lymph nodes, both TRUS and MRI are capable. TRUS has a small field of view, but 3D TRUS can improve the diagnosis of anorectal diseases. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5156", "text": "MRI is used when screening suggests a malignancy. [ 32 ]  This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield. [ 33 ] [ dubious  \u2013  discuss ] [ citation needed ]  Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective. [ dubious  \u2013  discuss ] [ citation needed ]  MRI imaging can be used for patients who have had a previous negative biopsy but their PSA continues to increase. [ 34 ]  Consensus has not been determined as to which of the MRI-targeted biopsy techniques is more useful. [ 35 ]  In a study involving 400 men aged 50 \u2013 69, MRI screening identified more men with prostate cancer than PSA tests or ultrasound and did not increase the number of men who needed a biopsy. [ 36 ] [ 37 ]  A large-scale trial of MRI screening, TRANSFORM, began in the UK in spring 2024. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5157", "text": "68 Ga -PSMA PET/CT imaging has become, in a relatively short period of time, the gold standard for restaging recurrent prostate cancer in clinical centers in which this imaging modality is available. [ 39 ]  It is likely to become the standard imaging modality in the staging of intermediate-to-high risk primary prostate cancer. [ 39 ]  The potential to guide therapy, and to facilitate more accurate prostatic biopsy is being explored. [ 39 ]  In the theranostic paradigm,  68 Ga-PSMA PET/CT imaging is critical for detecting prostate specific membrane antigen-avid disease which may then respond to targeted  177 Lu -PSMA or  225 Ac -PSMA therapies. [ 39 ]  For local recurrence,  68 Ga-PSMA PET/MR or PET/CT in combination with mpMR is most appropriate. [ 40 ]  PSMA PET/CT may be potentially helpful for locating the cancer when combined with multiparametric MRI (mpMRI) for primary prostate care. [ 41 ]  Prostate multiparametric MR imaging (mpMRI) is helpful in evaluating recurrence of primary prostate cancer following treatment. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5158", "text": "A number of  biomarkers  (blood, urine and tissue based tests) for screening, diagnosing and determining the prognosis of prostate cancer are supported by evidence and used widely. [ 43 ] [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5159", "text": "Researchers at the Korea Institute of Science and Technology (KIST) developed a urinary multi marker sensor with the ability to measure trace amounts of biomarkers from naturally voided urine. [ 48 ]  The correlation of clinical state with the sensing signals form urinary multi markers was analyzed by two machine learning algorithms, random forest and neural network. Both algorithms provided a monotonic increase in screening performance as the number of biomarkers was increased. With the best combination of biomarkers, the algorithms were able to screen prostate cancer patients with more than 99% accuracy. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5160", "text": "Screening for prostate cancer continues to generate debate among clinicians and broader lay audiences. [ 53 ]  Publications authored by governmental, non-governmental and medical organizations continue the debate and publish recommendations for screening. [ 3 ]  One in six men will be diagnosed with prostate cancer during their lifetime but screening may result in the overdiagnosis and overtreatment of prostate cancer. [ 54 ] [ 55 ]  Though the death rates from prostate cancer continue to decline, 238,590 men were diagnosed with prostate cancer in the United States in 2013 while 29,720 died as a result. Death rates from prostate cancer have declined at a steady rate since 1992. Cancers of the prostate, lung and bronchus, and colorectum accounted for about 50% of all newly diagnosed cancers in American men in 2013, with prostate cancer constituting 28% of cases. Screening for prostate cancer varies by state and indicates differences in the use of screening for prostate cancer as well as variations between locales. Out of all cases of prostate cancer, African American men have an incidence of 62%. African American men are less likely to receive standard therapy for prostate cancer. This discrepancy may indicate that if they were to receive higher quality cancer treatment their survival rates would be similar to whites. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5161", "text": "Prostate cancer is also extremely heterogeneous: most prostate cancers are indolent and would never progress to a clinically meaningful stage if left undiagnosed and untreated during a man's lifetime. On the other hand, a subset are potentially lethal, and screening can identify some of these within a window of opportunity for cure. [ 56 ]  Thus, PSA screening is advocated by some as a means of detecting  high-risk , potentially lethal prostate cancer, with the understanding that lower-risk disease, if discovered, often does not need treatment and may be amenable to active surveillance. [ 21 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5162", "text": "Screening for prostate cancer is controversial because of cost and uncertain long-term benefits to patients. [ 58 ]  Horan echos that sentiment in his book. [ 59 ]  Private medical institutes, such as the  Mayo Clinic , likewise acknowledge that \"organizations vary in their recommendations about who should \u2013 and who shouldn't \u2013 get a PSA screening test.\"  They conclude: \"Ultimately, whether you should have a PSA test is something you'll have to decide after discussing it with your doctor, considering your risk factors and weighing your personal preferences.\" [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5163", "text": "A 2009 study in Europe resulted in only a small decline in death rates and concluded that 48 men would need to be treated to save one life. But of the 47 men who were treated, most would be unable to ever again function sexually and would require more frequent trips to the bathroom. [ 59 ] [ page\u00a0needed ]  Aggressive marketing of screening tests by drug companies has also generated controversy as has the advocacy of testing by the  American Urological Association . [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5164", "text": "One commentator observed in 2011: \u201c[I]t is prudent only to use a single PSA determination as a baseline, with biopsy and cancer treatment reserved for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy..... absolute levels of PSA are rarely meaningful; it is the relative change in PSA levels over time that provides insight, but not definitive proof of a cancerous condition necessitating therapy.\u201c [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5165", "text": "Men report low levels of distress surrounding PSA screening. [ 62 ]  Men who present for PSA or have PSA levels at baseline scored low on cancer distress on numerous scales. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5166", "text": "Screening of PSA began in the 1990s. In the European Randomized Study of Screening for Prostate Cancer (ERSPC) initiated in the early 1990s, the researchers concluded that PSA-based screening did reduce the rate of death from prostate cancer but created a high risk of overdiagnosis, i.e., 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent just one death from prostate cancer within 9 years. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5167", "text": "A study published in the European Journal of Cancer (October 2009) documented that prostate cancer screening reduced prostate cancer mortality by 37 percent. By utilizing a control group of men from Northern Ireland, where PSA screening is infrequent, the research showed this substantial reduction in prostate cancer deaths when compared to men who were PSA tested as part of the ERSPC study. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5168", "text": "A study published in the  New England Journal of Medicine  in 2009 found that over a 7 to 10-year period, \"screening did not reduce the death rate in men 55 and over.\" [ 59 ]  Former screening proponents, including some from Stanford University, have come out against routine testing. In February 2010, the  American Cancer Society  urged \"more caution in using the test.\" And the  American College of Preventive Medicine  concluded that \"there was insufficient evidence to recommend routine screening.\" [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5169", "text": "A further study, the  NHS  Comparison Arm for ProtecT (CAP), as part of the Prostate testing for cancer and Treatment (ProtecT) study, randomized  GP  practices with 460,000 men aged 50\u201369 at centers in 9 cities in Britain from 2001\u20132005 to usual care or prostate cancer screening with PSA (biopsy if PSA \u2265 3). [ 65 ]  The \"Comparison Arm\" has yet to report as of early 2018. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5170", "text": "Prostatectomy  (from the  Greek   \u03c0\u03c1\u03bf\u03c3\u03c4\u03ac\u03c4\u03b7\u03c2   prost\u00e1t\u0113s , \"prostate\" and  \u1f10\u03ba\u03c4\u03bf\u03bc\u03ae   ektom\u0113 , \"excision\") is the  surgical  removal of all or part of the  prostate gland . This operation is done for  benign  conditions that cause urinary retention, as well as for  prostate cancer  and for other cancers of the  pelvis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5171", "text": "There are two main types of prostatectomies. A  simple prostatectomy  (also known as a subtotal prostatectomy) involves the removal of only part of the prostate. Surgeons typically carry out simple prostatectomies only for  benign  conditions. [ 1 ]  A  radical prostatectomy , the removal of the entire prostate gland, the  seminal vesicles  and the  vas deferens , is performed for cancer. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5172", "text": "There are multiple ways the operation can be done: with open surgery (via a large incision through the lower abdomen),  laparoscopically  with the help of a  robot  (a type of minimally invasive surgery), through the  urethra  or through the  perineum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5173", "text": "By laser prostatectomy (HoLEP - Holmium laser enucleation of the prostate), a laser is used to cut and remove the excess prostate tissue that is blocking the urethra. Another instrument is then used to cut the prostate tissue into small pieces that are easily removed. HoLEP can be an option for men who have a severely enlarged prostate. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5174", "text": "Other terms that can be used to describe a prostatectomy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5175", "text": "Indications for removal of the prostate in a benign setting include acute urinary retention, recurrent urinary tract infections, uncontrollable  hematuria , bladder stones secondary to bladder outlet obstruction, significant symptoms from bladder outlet obstruction that are refractory to medical or minimally invasive therapy, and  chronic kidney disease  secondary to chronic bladder outlet obstruction. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5176", "text": "A radical prostatectomy is performed due to malignant cancer. For prostate cancer, the best treatment often depends on the risk level presented by the disease. For most prostate cancers classified as \"very low risk\" and \"low risk\", radical prostatectomy is one of several treatment options; others include radiation, watchful waiting, and active surveillance. For intermediate and high risk prostate cancers, radical prostatectomy is often recommended in addition to other treatment options. Radical prostatectomy is not recommended in the setting of known  metastases  when the cancer has spread through the prostate, to the lymph nodes or other parts of the body. [ 6 ]  Prior to deciding the best treatment option for higher risk cancers, imaging studies using CT, MRI or bone scans are done to make sure the cancer has not spread outside of the prostate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5177", "text": "These would be same as the contraindications for any other surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5178", "text": "There are several ways a prostatectomy can be done:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5179", "text": "In an open prostatectomy, the prostate is accessed through a large single incision through either the lower abdomen or the perineum. Further descriptive terms describe how the prostate is accessed anatomically through this incision (retropubic vs. suprapubic vs. perineal). A retropubic prostatectomy describes a procedure that accesses the prostate by going through the lower abdomen and behind the pubic bone. A suprapubic prostatectomy describes a procedure cuts through the lower abdomen and through the bladder to access the prostate. A perineal prostatectomy is done by making an incision between the rectum and scrotum on the underside of the abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5180", "text": "Robotic-assisted instruments are inserted through several small abdominal incisions and controlled by a surgeon. Some use the term 'robotic' for short, in place of the term 'computer-assisted'. However, procedures performed with a computer-assisted device are performed by a surgeon, not a robot. The computer-assisted device gives the surgeon more dexterity and better vision, but no tactile feedback compared to conventional laparoscopy.  When performed by a surgeon who is specifically trained and well experienced in  computer-assisted laparoscopy  (CALP), there can be similar advantages over open prostatectomy, including smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay. [ 7 ] [ 8 ]  The cost of this procedure is higher, while long-term functional and oncological superiority have yet to be established. [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5181", "text": "Complications that occur in the period right after any surgical procedure, including a prostatectomy, include a risk of bleeding, a risk of infection at the site of incision or throughout the whole body, a risk of a blood clot occurring in the leg or lung, a risk of a heart attack or stroke, and a risk of death."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5182", "text": "Severe irritation takes place if a latex  catheter  is inserted in the urinary tract of a person allergic to latex. That is especially severe in case of a radical prostatectomy due to the open wound there and the exposure lasting e.g. two weeks. Intense pain may indicate such situation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5183", "text": "Men can experience changes in their sexual responses after radical prostatectomy, including impairments to sexual desire, penile morphology and orgasmic function. [ 13 ] [ 14 ]  A 2005 article in the medical journal  Reviews in Urology  listed the incidence of several complications following radical prostatectomy: mortality <0.3%, impotence >50%, ejaculatory dysfunction 100%, orgasmic dysfunction 50%, incontinence <5\u201330%, pulmonary embolism <1%, rectal injury <1%, urethral stricture <5%, and transfusion 20%. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5184", "text": "Surgical removal of the prostate contains an increased likelihood that patients will experience  erectile dysfunction . Radical prostatectomy is associated with greater decrease in sexual function than external beam radiotherapy. Nerve-sparing surgery reduces the risk that patients will experience erectile dysfunction. However, the experience and the skill of the nerve-sparing surgeon are critical determinants of the likelihood of positive erectile function of the patient. [ 16 ] [ better\u00a0source\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5185", "text": "Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in the permanent necessity of assisted reproductive techniques in case of desires of future fertility. [ 17 ]  Preservation of normal ejaculation is possible after  transurethral resection of the prostate  (TURP), open or laser enucleation of adenoma and laser vaporisation of prostate. However, retrograde ejaculation is a common problem. Preservation of ejaculation is the aim of some new techniques. [ 18 ]  Once the prostate and vesicles are removed, even if partial erection is achieved, ejaculation is a very different experience, with little of the compulsive release that is common to ejaculation with those organs intact."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5186", "text": "Prostatectomy patients have an increased risk of leaking small amounts of urine immediately after surgery, and for the long-term, often requiring  urinary incontinence  devices such as condom catheters or diaper pads. A large analysis of the incidence of urinary incontinence found that 12 months after surgery, 75% of patients needed no pad, while 9\u201316% did. Factors associated with increased risk of long-term urinary incontinence include older age, higher BMI, more comorbidities, larger prostates surgically excised, as well as experience and technique of the surgeon. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5187", "text": "Surgical management options for urinary incontinence secondary to prostatectomy include implantation of  perineal slings  and  artificial urinary sphincters . [ 20 ]  Although there are limited data on the long-term outcomes in males, perineal slings are offered for mild-to-moderate post-prostatectomy incontinence. [ 21 ] [ 22 ]  In a retrospective study the success rate of perineal  sling  placement in urinary incontinence following prostatectomy achieved 86% at a median follow-up of 22 months. [ 23 ]  Artificial urinary sphincters are offered for moderate-to-severe urinary incontinence in males and have shown good long-term efficacy and safety. [ 22 ] [ 21 ] [ 24 ] [ 25 ]  The use of artificial urinary sphincters for post-prostatectomy incontinence is supported by the recommendations of  European Association of Urology  and International Consultation on Incontinence. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5188", "text": "Transurethral injection of bulking agents  have little role in the management of post-prostatectomy incontinence and there is weak evidence that these agents can offer any improvement. [ 21 ] [ 22 ]   Pelvic floor muscle training  can speed recovery of urinary incontinence following prostatectomy. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5189", "text": "Very few surgeons will claim that patients return to the erectile experience they had prior to surgery.  The rates of erectile recovery that surgeons often cite are qualified by the addition of  sildenafil  to the recovery regimen. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5190", "text": "Remedies to the problem of post-operative sexual dysfunction include: [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5191", "text": "The use of radical prostatectomy as treatment for prostate cancer increased significantly from 1980 to 1990. [ 28 ]  As of 2000, the median age of men undergoing radical prostatectomy for localized prostate cancer was 62. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5192", "text": "Though a very common procedure, the experience level of the surgeon performing the operation is important in determining the outcomes, rate of complications, and side effects. The more prostatectomies performed by a surgeon, the better the outcomes. This is true for prostatectomies done as open procedures [ 29 ]  and those done using minimally invasive techniques. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5193", "text": "William Belfield , MD is generally credited for performing the first intentional prostatectomy via the suprapubic route in 1885, 1886 or 1887 at  Cook County Hospital  in Chicago. [ 31 ] [ 32 ]   Hugh H. Young  MD in collaboration with  William Stewart Halsted  MD developed the open, radical and perineal prostatectomies in 1904 at Johns Hopkins Brady Urological Institute, the first version of the procedure that became generally feasible. [ 33 ]  The Irish surgeon  Terence Millin , MD (1903\u20131980) developed the radical retropubic prostatectomy in 1945. [ 34 ]  American urologist Patrick C. Walsh, MD (1938\u2014present) developed the modern nerve-sparing, retropubic prostatectomy with minimal blood loss. [ 35 ]  The first laparoscopic prostatectomy was performed in 1991 by William Schuessler, MD and colleagues in Texas. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5194", "text": "A 2014 survey of prostatectomy fees for uninsured patients at 70 United States hospitals found an average facility fee of $34,720 and average surgeon and anesthesiologist fees of $8,280. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5195", "text": "Radical perineal prostatectomy  is a  surgical procedure  wherein the entire  prostate  gland is removed through an incision in the area between the  anus  and the  scrotum  ( perineum ). [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5196", "text": "It is used to remove early  prostate cancer , in select people who have a small well defined cancer in the prostate. It is less commonly used than the alternative methods of the  retropubic route , or the robot assisted  laparoscopic  approach. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5197", "text": "When the  cancer  is small and confined to the prostate, radical perineal prostatectomy achieves the same rate of cure as the retropubic approach but less  blood  is lost and recovery is faster. One downside to the perineal approach is an increased risk of  fecal incontinence . [ 2 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5198", "text": "The procedure was first performed in 1904 by  Hugh H. Young  and assisted by  William S. Halstead , as a way of removing the prostate in cancer treatment. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5199", "text": "Radical perineal prostatectomy is used to remove early  prostate cancer , in select people who have a small well defined cancer in the prostate. [ 3 ]  It is less commonly used than the alternative methods of the  retropubic route , or the robot assisted  laparoscopic  approach. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5200", "text": "It is more suited to younger men, age under 70 years, who have at least a ten-year life expectancy, few if any other medical problems, a  Gleason score  of less than 8 (4+4) and PSA of less than 10. [ 3 ]  It may be indicated where the man with prostate cancer is  obese , has had several abdominal operations before, previous pelvic arterial bypass grafts or has a delayed recurrence of prostate cancer after salvage prostatectomy and  radiotherapy . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5201", "text": "Before the operation, an assessment of  life expectancy  is made. Physical examination including a digital rectal examination and routine blood tests are carried out. At least six  transrectal ultrasound  guided  biopsies  taken from different zones of the prostate are usually obtained. Other considerations include bowel preparation the day before surgery and taking antibiotics. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5202", "text": "A radical perineal prostatectomy uses an incision in the area between the  anus  and the  scrotum  ( perineum ). [ 2 ] [ 6 ]  There is more than one way of performing the procedure. [ 7 ]  In men with normal erections, a small cancer which can not be felt and  Gleason scores  of 6 or less, it may be possible to preserve the nerves for erection. [ 7 ]  The procedure usually takes around one hour. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5203", "text": "Over the course of the first day or two after the procedure, many men require a gradual transfer from oral fluids to soft foods. Additionally, men are encouraged to maintain mobility and painkillers may be necessary initially but tapered off over time. The hospital stay is usually short and the  Foley catheter  can be removed usually at three weeks after surgery. Longer term followup with PSA monitoring is required. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5204", "text": "Lymph nodes  can be sampled through the same incision, although this procedure is not common place in the U.S. at this time. When the  cancer  is small and confined to the prostate, radical perineal prostatectomy achieves the same rate of cure as the retropubic approach but less  blood  is lost and recovery is faster. One downside to the perineal approach is an increased risk of  fecal incontinence . [ 2 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5205", "text": "The procedure was first performed on a 70-year old married preacher on 7 April 1904 by American surgeon  Hugh H. Young  and assisted by  William S. Halstead , as a way of removing the prostate in cancer treatment, after prostatic massage and an early type of  transurethral resection of the prostate  had failed to relieve him of pain in his urethra. [ 8 ]  By 1937, Young reported a five-year survival rate of 50%. However, by the time the diagnosis of prostate cancer was made, it was usually too late to perform the procedure. [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5206", "text": "Removing the prostate via the perineal route went out of favour in the 1970s. However, with the introduction the PSA test, better public awareness of options for treating localised disease, the ability to perform nerve-sparing surgery, and the advantage of there being potentially less post-operative complications using the perineal route, rekindled interest in the procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5207", "text": "Radical retropubic prostatectomy  is a  surgical procedure  in which the  prostate  gland is removed through an incision in the  abdomen  (in comparison with  perineal prostatectomy , done through the perineum). It is most often used to treat individuals who have early  prostate cancer . Radical retropubic prostatectomy can be performed under  general ,  spinal , or  epidural anesthesia  and requires  blood transfusion  less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as  urinary incontinence  and  impotence , but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5208", "text": "Radical retropubic prostatectomy was developed in 1945 by Terence Millin at the All Saints Hospital in London. The procedure was brought to the United States by one of Millin's students, Samuel Kenneth Bacon, M.D., adjunct professor of surgery,  University of Southern California , and was refined in 1982 by  Patrick C. Walsh [ 1 ]  at the James Buchanan Brady Urological Institute,  Johns Hopkins Medical School . It can be performed in several different ways with several possible associated procedures. [ 2 ]  The most common approach is to make an incision in the skin between the  umbilicus  and the top of the  pubic bone . Since initial description by Walsh, technical advancements have been made, and incisional length has decreased to 8\u201310\u00a0cm (well below the belt-line). The pelvis is then explored and the important structures such as the  urinary bladder , prostate,  urethra ,  blood vessels , and  nerves  are identified. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5209", "text": "The prostate is removed from the urethra below and the bladder above, and the bladder and urethra are reconnected. The blood vessels leading to and from the prostate are divided and tied off. Recovery typically is rapid; individuals are usually able to walk and eat within 24 hours after surgery. A  catheter  running through the penis into the bladder is typically required for at least a week after surgery. A  surgical drain  is often left in the pelvis for several days to allow drainage of  blood  and other fluid. Additional components of the operation may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5210", "text": "An intraoperative electrical stimulation  penile plethysmograph  may be applied to assist the surgeon in identifying the difficult to see nerves. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5211", "text": "Radical retropubic prostatectomy is typically performed in men who have early stage prostate cancer. Early stage prostate cancer is confined to the prostate gland and has not yet spread beyond the prostate or to other parts of the body. Attempts are made prior to surgery, through  medical tests  such as  bone scans ,  computed tomography  (CT), and  magnetic resonance imaging  (MRI), to identify cancer outside of the prostate. Radical retropubic prostatectomy may also be used if prostate cancer has failed to respond to  radiation therapy , but the risk of urinary incontinence is substantial. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5212", "text": "The most common serious complications of radical retropubic prostatectomy are loss of urinary control and impotence. As many as 40% of men undergoing prostatectomy may be left with some degree of  urinary incontinence , usually in the form of leakage with sneezing, etc. ( stress incontinence ) but this is highly surgeon-dependent. Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Doctors usually allow up to 1 year for recovery between offering medical or surgical treatment. Potency is greatly affected by the psychological attitude of the patient. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5213", "text": "Even though the complications of prostate surgery can be bothersome, treatments are available, and patients should seek guidance from their physician instead of ignoring the problem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5214", "text": "Scrotoplasty , also known as  oscheoplasty , is a type of surgery to create or repair the  scrotum . Scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. [ 1 ]  The development of testicular implants began in 1940 made from materials outside of what is used today. Today, testicular implants are created from saline or gel filled silicone rubber. [ 2 ]  There are a variety of reasons why scrotoplasty is done. Some  transgender men  and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. [ 3 ]  Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. [ 4 ]  For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. [ 4 ]  For older male adults, the scrotum may extend with age. [ 4 ]  Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5215", "text": "Buried penis  is a condition when the penis is attached to the scrotum with an excess of skin. This condition can affect both newborn and adult males. Scrotoplasty can be performed to remove the extra skin in the scrotal area and reshape the scrotum. Penoscrotal webbing is another condition, where the skin connecting the penis to the scrotum extends along the underside of the penis shaft like a web. [ 6 ]  This condition is easily confused with buried penis. Both conditions affect newborn and adult males but they do not always require surgery. Scrotoplasty can be considered to remove excess skin in order to restore normal appearance of the scrotum and penis length, which can improve a man's confidence. In both conditions, the scrotoplasty procedure involves making an incision in the fused part between the penis and scrotum and then reconstructing the scrotum. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5216", "text": "Some trans men and intersex or non-binary people who were assigned female at birth may choose to have gender-affirming surgeries to create male genitals from existing tissue, as part of their female-to-male transition. [ 3 ]  There are two types of gender-affirming surgeries for the creation of a penis,  metoidioplasty  and  phalloplasty . In both of these surgeries, a scrotoplasty can be considered as an additional surgery to add testicular implants. [ 7 ]  Metoidioplasty involves modification of the clitoris into a penis. Generally, the clitoris is hormonally enlarged with  testosterone , making it possible for it to be straightened and lengthened into a penis. Outcomes of this surgery include the ability to urinate while standing and retain sexual stimulation. [ 7 ]  Phalloplasty is the other type of surgery to create a penis, but utilizes skin from other areas of the body besides existing genitals. The most common part of the body used in this surgery is the forearm and has the same outcomes as a metoidioplasty. [ 8 ]  The addition of a scrotoplasty with implants is an optional procedure for individuals to choose based on their goals with their transition. Deciding if a neoscrotum meets their needs in their transition is a consideration for adding a scrotoplasty procedure. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5217", "text": "There are various categories of injuries to the scrotum that result in the loss of scrotal skin tissue. Scrotoplasty in these conditions is needed to remove necrotic skin and reconstruct the scrotum. Scrotal skin loss is not common among adult males who require scrotoplasty. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5218", "text": "The first category of scrotal injury includes  Fournier gangrene , which is a necrotic infection of the soft tissue around the genital. This infection is commonly caused by a poly microbic flora in the individuals who has co-morbidities such as immunocompromised conditions, diabetes mellitus, colorectal infection. To stop the  necrotizing fasciitis  from spreading, the treatment requires an aggressive surgical  debridement  which often results in the loss of the scrotal skin. After the patient is stable and cleared from the infection, scrotal reconstruction is needed to restore its function the scrotum. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5219", "text": "The second category of scrotal injury includes trauma to the scrotum, such as from burns, machinery accidents, traffic accidents, firearm accidents, and surgical accidents. [ 5 ]  People who experience these injuries may require scrotoplasty if they lose more than 50% of their skin. [ 6 ] [ 9 ]  Reconstructing scrotal skin can be accomplished by using skin grafts from other areas of the body. Tissue expansion, a procedure in which the skin is stretched to regenerate new cells, can also be an option in order to restore scrotal skin loss. In addition to surgically reconstructing the scrotum, antimicrobial medication and the tetanus vaccine should be given to prevent infection and reduce the risk of developing an infection. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5220", "text": "The third category of scrotal injury includes  Extramammary Paget  cancer that affects the scrotum. If the tissue is affected by cancer, scrotoplasty can be performed to remove the affected skin. [ 4 ] [ 6 ]  However, if the cancer affects the  testicles , other surgeries such as removal of the testicles and implantation of testicular prosthetics may be required. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5221", "text": "There are many reasons that can cause scrotal sagging such as natural aging,  varicocele , and  hydrocele . Naturally, as a person ages, skin loses elasticity and becomes less taut. The scrotum may start to sag due to the loss of elasticity in the skin as well as weakening of the cremaster muscles in the scrotum that pull the testicles toward the body. [ 10 ]  Many people develop scrotal sagging later in life, but it does not affect everyone. [ 10 ]  Scrotal sagging may also be due to the swelling of the testicles, a condition known as varicocele, which causes increased blood flow and temperature of the testicles. The body's response is to lower the testicles from the body, which causes sagging. [ 10 ]  Another reason for scrotal sagging is when the testicles swell and fill with fluid. This condition is known as a hydrocele which is very common among newborn males but can resolve itself within the first year. In adult males, hydrocele has many causes, including inflammation due to injury or infection. Similar to varicocele, the body lowers the testicles, causing scrotal sagging. [ 10 ]  The specific name for this type of scrotoplasty is commonly known as scrotal lift or scrotal rejuvenation, which is a procedure to remove excess loose scrotal skin, tighten, and reduce the size of the scrotum. [ 11 ]  Scrotal lift is done not just as a cosmetic surgery to improve the appearance of the scrotum, but also as a way to reduce discomfort. [ 4 ]  Scrotal sagging can cause discomfort due to chafing of the scrotum against the body during every day activities and during exercise. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5222", "text": "Candidates must avoid any nicotine products, which can potentially affect wound healings and perioperative complications, for 3 months prior to the surgery. [ 13 ]  People must also be screened for other contraindications, including obesity with specific adipose distribution. Diabetes can also lead to wound complications such as wound separation or wound disruption. [ 14 ]  Other contraindications exist for specific types of phalloplasty. For instance, a body mass index (BMI) of greater than 35\u00a0kg/m2 is contraindicated for radial forearm free flap (RFFF) phalloplasty. A metoidioplasty or anterolateral thigh (ALT) phalloplasty is only recommended for people with an ideal body weight. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5223", "text": "For gender-affirming scrotoplasty, people should have already been receiving hormone therapy for over 1 year with established mental and primary health care. Some transmasculine people have already undergone double mastectomy and hysterectomy. Scrotoplasty for transmasculine individuals is usually done with other gender-related genitourinary surgery (GRGUS), which consists of various procedures with variable personal desires for metoidioplasty, phalloplasty, vaginectomy, and urethroplasty. [ 13 ]   A comprehensive history and physical assessment of the physical sites are taken during consultation to identify the candidates' surgical goals, which then help determine which procedures are needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5224", "text": "Depending on the purpose of scrotoplasty, whether the patients need to remove excess scrotal skin, reconstruct the scrotum due to scrotal skin loss, or create a new scrotum, the scrotoplasty types will vary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5225", "text": "There are various scrotoplasty techniques for the buried penis and penoscrotal web. The surgeon can perform the simplest technique by making a horizontal incision and closing along the longitudinal axis. However, the methods that give patients higher satisfaction are the single or double Z-plasty or V-Y advancement flap because they also can increase the penile length. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5226", "text": "The scrotoplasty procedure requires skin grafting to reconstruct the scrotum for scrotal skin loss. Full-thickness skin grafts (FTSGs) and split-thickness skin grafts STSG  [ 16 ]  are two types of skin graft can be used for reconstruction. [ 17 ]  The  suprapubic  skin and the anterior thigh are the most common donor sites."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5227", "text": "The novo scrotoplasty is one stage of female-to-male transition, performed together with  phalloplasty , which creates the penis. When a trans man or  transmasculine  person has a scrotoplasty, the  labia majora  (the big lips of the  vulva ) are dissected to form hollow cavities and united into an approximation of a scrotal sack. [ 18 ]  If there is not enough skin to make a scrotum, then the surgeon may need to make tissue expansion before the operation by putting expanders under the skin. Over the course of a few months, more salt water ( saline ) will be occasionally added to the expanders through a port on the outside. This helps the skin expand and grow more skin. Each expansion procedure is done in an outpatient hospital visit. The patient does not have to stay overnight in the hospital, but will have to stay near the hospital, and return several times. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5228", "text": "Most cases of gender-affirming scrotoplasty are done with Hoebeke's technique where the majority of people are satisfied with shape, size, and position of their newly constructed scrotum and consider getting prosthetic testicles and erectile inflatable devices . [ 18 ] [ 21 ]  Initially, a secondary surgery was carried out to insert 2 silicone prosthetic testicles into the newly constructed scrotum between 6\u201312 months following the initial scrotoplasty. An erectile inflatable device was then implanted during a tertiary surgery at least 12 months from the initial scrotoplasty. [ 18 ]  Later on, this technique was modified in which 1 silicone prosthetic testicle and an erectile inflatable device were implanted during the same surgery between 6\u201312 months after the initial scrotoplasty. [ 18 ]  These can be inserted through small cuts to fill the new scrotum. At this point, the new scrotum no longer needs expanders. Then the skin is closed up around the artificial testicles. [ 19 ] [ 20 ]  The artificial testicles only give a shape and do not create semen, sperm, or hormones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5229", "text": "In general, post-operative hospital stays for people undergoing scrotoplasty range from days to weeks, corresponding to the complexity of the procedure. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5230", "text": "Usually after the procedure, people may wear a support garment to limit the movement of the surgical sites to limit the risk of complications. In addition, a flexible tube for draining urine from the urinary bladder ( urinary catheter ) is placed and held in place until the genitals heal. Swelling of the scrotal areas is normal and can last up to months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5231", "text": "Individuals with buried penis undergoing a scrotal lift can be discharged on the same day as procedure, and are not allowed to engage in sexual activities for many weeks. [ 23 ]  People can ambulate or must rest in bed during recovery, depending on the surgeon's decision. A blood thinner ( anticoagulant ) is considered for people with risk factors for  deep vein thrombosis . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5232", "text": "People who are candidates for scrotoplasty need to be educated on the associated risks and complications before the procedure. There have been advancements in the surgical techniques. However, the risk of recurrent condition still exists. In addition, the cosmetic results might not be satisfactory to some people after surgery. [ 24 ]  Another factor to consider is the loss of sensation in the scrotal area due to the nature of the procedure which can involve removal of genital tissues. [ 24 ]  These sensation issues occur because the body's  nerve tissue  requires time to be reestablished with the body. In addition to the loss of sensation, individuals may experience other sensory problems including  hypersensitivity  and pain. Because of this, issues regarding sex and orgasms may arise post-operation, making it difficult to be sexually satisfied. Once nerve tissue is reestablished with the body after a few months post-operation, sexual function may return to its full capacity. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5233", "text": "Complications to scrotoplasty among transmasculine individuals primarily deal with testicular implants. If they are too big, there is chance that the implants could feel uncomfortable, or be a cause of  chronic pain . [ 26 ]  Another complication is that the implant could erode the skin of the scrotum. This can cause infection, or an abnormal connection between two body parts (a  fistula ) where the implant may work its way outside the body. [ 26 ]  People with a history of smoking are at increased risk of infections and prosthetic explantation. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5234", "text": "Other complications are those that are typical for any surgery, such as blood loss or problems with  anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5235", "text": "A scrotoplasty for a trans man or  transmasculine  person typically costs around US$3,000 to $5,000. [ 26 ]  These costs can be covered by  health insurance , though the person receiving care must communicate a great deal with their insurance in order to make certain that it will. In the United States, it is considered illegal for  Medicaid ,  Medicare , and private insurance plans to deny individuals transition-related care coverage. [ 27 ]  However, individuals may run into issues with their insurance plan coverage because insurance will only cover surgeries that are considered medically necessary. Insurance plans can deny coverage of a scrotoplasty if deemed to be an esthetic or  cosmetic surgery  instead of a reconstructive one. In this case, all of the costs will be covered by the individual under care. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5236", "text": "A  sperm granuloma  is a lump of leaked  sperm  that appears along the  vasa deferentia  or  epididymides  in  vasectomized  individuals.  While the majority of sperm granulomas are present along the vas deferens, the rest of them form at the epididymis. Sperm granulomas range in size, from one millimeter to one centimeter. They consist of a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. [ 1 ]  Sperm granulomas may also have a yellow, white, or cream colored center when cut open. While some sperm granulomas can be painful, most of them are painless and asymptomatic. [ 2 ]  Sperm granulomas can appear as a result of surgery (such as a vasectomy), trauma, or an infection (such as sexually transmitted diseases). [ 3 ]  They can appear as early as four days after surgery and fully formed ones can appear as late as 208 days later. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5237", "text": "Sperm granulomas are a common complication of different types of vasectomy. In vasectomies, the vas deferens are cut and the two ends are tied to prevent sperm from passing. Sperm granuloma may then form at the point where the vas deferens were cut, due to the possibility of sperm leaking out at this site. History of trauma or inflammation of the epididymis can also lead to a sperm granuloma. [ 2 ]  Sperm granulomas are seen as the body's immune response to sperm being outside of their normal location, and are therefore seen as a protective mechanism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5238", "text": "Sperm granulomas are quite common after surgery, occurring in up to 40% of patients. On the contrary, sperm granulomas comprise only 2.5% of the general population. [ 5 ]  Amongst adolescents and pediatric patients, sperm granulomas are considered a rare phenomenon as this population does not undergo vasectomy often. The most common cause of sperm granuloma in pediatric and adolescent patients is often attributed to tumor obstruction, injury, or infection to the area. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5239", "text": "While sperm granuloma is considered a complication in most cases, it allows decompression of the vas deferens and epididymis at the vasectomy site. This allows for successful future reversal of vasectomy given the good quality sperm in the vas fluid. Any surgery in the genital area can lead to castration anxiety (fear of loss or damage to the genital organ.) [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5240", "text": "Sperm granulomas are diagnosed using a microscope to examine tissues ( histology ) taken from the area, typically done with  fine needle aspiration  and occur within a few weeks of a vasectomy. [ 7 ]  An example of a histology based diagnosis supporting sperm granuloma would be a sperm core surrounded by inflammatory cells,  apoptotic cells , and fibrous tissue. Often, there will be empty tubes with cellular debris near the granuloma. [ 2 ]  Additionally, physicians might use  high frequency ultrasounds  to aid in properly diagnosing epididymal conditions such as sperm granulomas. [ 8 ]  Using these ultrasounds provide a better view of the anatomy of the epididymis, which could prevent misdiagnosis of conditions such as testicular tumors or supernumerary testis (the presence of more than two testes). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5241", "text": "Sperm granulomas appear as hard and firm nodules that do not exceed 1\u00a0cm in size. Sperm granulomas form in 20-50% of vasectomy procedures. [ 6 ]  An injury to the epididymal epithelium is caused by penetration of germ cells into the epididymal supportive tissue. This infiltration of germ cells allows for the pathogenesis of sperm granulomas. Moreover, the penetration of germ cells leads to inflammatory and autoimmune reactions that further increase the risk of sperm granuloma formation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5242", "text": "Sperm granuloma can also mimic the presence of an abnormal number of testis on ultrasound. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5243", "text": "Sperm granulomas are mostly asymptomatic. [ 4 ]  However, they can cause pain and swelling of the epididymis, spermatic cord, and testis. The pain usually radiates to the groin, the junctional area between the abdominal wall and the thigh, and can imitate the feeling of kidney spasms. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5244", "text": "Sperm granuloma is a common complication of vasectomy. [ 2 ]  Vasectomies are a common, effective procedure for the sterilization of males. History of trauma or epididymitis can also lead to sperm granuloma. In vasectomies, the vas deferens are cut and the two ends are tied to prevent sperm from passing. Sperm granuloma may then grow at the point where the vas deferens were cut. [ 2 ]  This could happen two to three weeks post procedure. Sperm granuloma can also form from sperm leaking from the vas deferens into the surrounding interstitium. Leakage of sperm elicits an immune response which can lead to chronic inflammation. A histological examination can confirm a sperm granuloma by checking for inflammatory markers such as macrophages and lymphocytes surrounding the sperm core. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5245", "text": "Most sperm granulomas are asymptomatic and absorbed over time. However, in more severe cases, non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen may be used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5246", "text": "Surgery is very rarely performed. In cases where symptoms do not resolve in a reasonable amount of time and NSAID therapy is ineffective, the provider may choose to surgically resect the area where the pain is localized. Additionally, the stumps of the vas deferens can be burned and closed off in order to reduce the pain the patient is experiencing and prevent it from happening again. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5247", "text": "When sperm granulomas are occasionally mistaken for other conditions, such as testicular tumors, a more complicated treatment approach such as an  orchiectomy  may be accidentally used. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5248", "text": "Cauterization is a vasectomy method used to seal the vas deferens by utilizing heat or electricity to burn the lumen. Using thermal (heat) cautery instead of electrocautery can help prevent granulomas and nodular thickening. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5249", "text": "Refraining from ejaculation for 1 week can potentially reduce the risk of developing a sperm granuloma. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5250", "text": "There is also evidence that sperm granuloma formation may be linked to testosterone deficiency. Testosterone supplementation may reduce the inflammation related to sperm granulomas and potentially even prevent them from occurring. [ 2 ]  However, this evidence is only supported in animal models."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5251", "text": "There have been complications involving sperm granuloma. A pediatric case documented a 13 year old boy who was admitted to the hospital with  edema  and redness on his left  hemiscrotum . [ 13 ]  Upon a physical examination, they found the scrotum to be enlarged, soft, red and painless. Initial sonographs detected possibility of inflammation of the testis and epididymis. The patient received anti-inflammatory and antibiotic treatment, and was examined again one week after treatment. [ 13 ]  The testis were still painless and now hardened. Upon a second reexamination five days later, low perfusion to the testis was detected. This testicular necrosis led the patient into an emergency operation. Histology determined there was a ruptured sperm granuloma that led to the testicular thrombosis and necrosis. [ 13 ]  Specifically, the walls of the vas deferens contained many growths of small ducts and gland-like structures, which came about as a response to the displacement of the sperm and fluid. The exact cause of his ruptured sperm granuloma was not determined, but it was found to be most likely a secondary response to inflammation and/or trauma. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5252", "text": "Another complication with sperm granulomas has been being mistaken for a tumor due to its tumor-like appearance. [ 14 ]  A 45 year old man presented with right testicular chronic pain. He had a vasectomy 7 years ago. Upon physical examination and an ultrasound, a solid nodule in the right epididymis was found, and medical staff suspected a tumor. After findings of sperm that had undergone phagocytosis, a final diagnosis of sperm granuloma was determined.  [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5253", "text": "It is unknown whether sperm granulomas are definitively detrimental to sperm quality and fertility in humans. However, studies in donkeys have shown that sperm quality is only marginally affected. There was a lower percentage of sperm with intact plasma membranes; however, no effects on motility or morphology were observed. [ 15 ]  In some cases, the presence or absence of sperm granulomas may determine the success rate for vasectomy reversal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5254", "text": "It is believed that sperm granulomas may be protective because they can prevent the obstruction of the testicles and epididymis. [ 16 ]  Sperm granulomas are believed to reduce the pressure that is generated after vasectomy and prevent blockages of sperm output into the vas fluid during ejaculation. Therefore, there are no changes in the amount of sperm that are produced into the vas fluid. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5255", "text": "Additionally, sperm granulomas can exist in non-human species such as rats, dogs, horses, fish, etc. Non-human species exhibit the same causes for sperm granulomas, including infection, injury, and trauma to the epididymal region. For example, vasectomized rats were seen to also have a high prevalence of sperm granulomas post-operation while general populations of rats experienced a much lower prevalence of sperm granulomas. [ 17 ]  In the case of sperm granulomas within dogs, their presence is common amongst poorly performed vasectomies. [ 12 ]  This is consistent with the idea that these lesions form at the site where there is trauma or a chance for the sperm to leak outside of the vasa deferentia or epididymis. In multiple species, sperm granulomas have also been linked to the success rate of certain procedures such as vasectomy reversals, or  vasovasostomy . [ 12 ]  There is also an association between sperm granuloma and antibodies produced against sperm antigens. In a case study on sperm granuloma and anti-sperm antibody count in donkeys, it was found that sperm granuloma resulted in an increase in IgA- and IgG-bound sperm in donkeys. They also found donkeys with sperm granuloma had a reduction of sperm motility and a reduction of the percentage of sperm with an intact plasma membrane. However there was no significant damage found in total sperm motility compared to healthy control donkeys. The extent to which sperm granuloma and anti-sperm antibodies affect donkey fertility is still yet to be determined by further research studies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5256", "text": "A  spermatocelectomy  is a  surgical procedure  performed to remove a  spermatocele [ 1 ]  by separating it from the  epididymis . The patient is given an  anesthetic  in the groin and a small incision is made into the  scrotum .  The surgeon pulls the testicle and epididymis to the incision and separates the spermatocele by tying it off with a suture. The surgeon then removes it, and stitches up the area. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5257", "text": "If medical treatment is not effective, surgery may need to be performed for  benign prostatic hyperplasia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5258", "text": "There are two invasive surgical procedures done for BPH:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5259", "text": "There are two types of  transurethral resection of the prostate  (TURP): the standard monopolar and the newer bipolar procedure. A 2019 Cochrane review of 59 studies that included 8924 men with urinary symptoms due to  benign prostatic hyperplasia . [ 4 ]  This review found that bipolar and monopolar TURP probably results in comparable improvements in urinary symptoms, as well as a similar  erectile function , the incidence of urinary incontinence, and the need for retreatment. Bipolar surgery likely reduces the risk of  TUR syndrome  and the need for  blood transfusion . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5260", "text": "Efforts to find newer surgical methods have resulted in newer approaches and different types of energies being used to treat the enlarged gland. However some of the newer methods for reducing the size of an enlarged prostate, have not been around long enough to fully establish their safety or side-effects. These include various methods to destroy or remove part of the excess tissue while trying to avoid damaging what remains. Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), ethanol injection, and others are studied as alternatives. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5261", "text": "Minimally invasive therapies can offer faster recovery compared with traditional prostate surgery. [ 6 ]  They can further be divided into laser surgery (requiring  spinal anesthesia ) and other non-laser procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5262", "text": "Prostate laser surgery is used to relieve moderate to severe urinary symptoms caused by prostate enlargement. The surgeon inserts a scope through the penis tip into the urethra. A laser passed through the scope delivers energy to shrink or remove excess tissue that is preventing urine flow. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5263", "text": "Different types of prostate laser surgery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5264", "text": "Both wavelengths, GreenLight and Holmium, ablate approximately one to two grams of tissue per minute. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5265", "text": "Post-surgical care often involves placement of a  Foley catheter  or a temporary  prostatic stent  to permit healing and allow urine to drain from the bladder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5266", "text": "These procedures are typically performed with local anesthesia, and the patient returns home the same day. Some urologists have studied and published long-term data on the outcomes of these procedures, with data out to five years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5267", "text": "Transurethral microwave thermotherapy  (TUMT) was originally approved by the United States  Food and Drug Administration  (FDA) in 1996, with the first generation system by EDAP Technomed.  Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT.  The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra.  The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis.  It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used.  It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5268", "text": "Transurethral needle ablation  (TUNA) operates with a different type of energy, radio frequency (RF) energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate. The most recent  American Urological Association  (AUA) Guidelines for the Treatment of BPH from 2018 stated that \"TUNA is not recommended for the treatment of LUTS/BPH\". [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5269", "text": "Water vapour thermal therapy  (marketed as Rezum) is a newer office procedure for removing prostate tissue using steam. Several studies including a four-year follow-up provided evidence for improvement of BPH symptoms, preserved sexual function, and low surgical retreatment rates. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5270", "text": "Prostatic urethral lift  (marketed as Urolift) is a procedure for men with urinary symptoms caused by prostate enlargement. It consists of placing small hooks that compress the prostate tissue to open the urinary stream without cutting or removing tissue. This procedure likely improves quality of life without additional negative side effects when compared with a  sham surgery . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5271", "text": "Compared with  transurethral resection of the prostate , the standard surgery for treating benign prostatic hyperplasia, this procedure may be less effective in reducing urinary symptoms but may preserve ejaculation and have fewer unwanted effects on erections. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5272", "text": "Temporary implantable nitinol device (marketed as TIND and iTIND) is a device that is placed in the urethra that, when released, is expanded, reshaping the urethra and the bladder neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5273", "text": "The  American Urological Association  (AUA) guidelines for the treatment of BPH from 2018 list minimally invasive therapies including TUMT - but not TUNA - as acceptable alternatives for certain patients with BPH. [ 11 ]  However, the  European Association of Urology  (EAU) has - as of 2019 - removed both TUMT and TUNA from its guidelines. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5274", "text": "The two most feared complications of prostate surgery are  erectile dysfunction  and  stress urinary incontinence . [ 16 ]  The type of complications depend on the treatment modality used:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5275", "text": "The  National Institute for Health and Care Excellence  (NICE) of the UK in 2018 classified some novel methods as follows. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5276", "text": "Recommended:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5277", "text": "Not recommended:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5278", "text": "The success of  surgery for benign prostatic hyperplasia  (BPH) \u2013 as measured by a significant reduction of  lower urinary tract symptoms  (LUTS) \u2013 strongly depends on a reliable (unequivocal) pre-surgery diagnosis of bladder outlet obstruction (BOO). A pre-surgery diagnosis of other LUTS only, such as  overactive bladder  (OAB) with or without  urinary incontinence  predicts little or no success after surgery. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5279", "text": "If BOO is present or not can be determined by reliable non-invasive tests, such as the Penile cuff test (PCT). In this test, first published in 1997, a software-steered inflatable  cuff  (similar as in a  blood pressure meter ) is placed around the  penis  to measure the pressure of urinary flow. [ 28 ]  By applying this methode, a study of 2013 showed that 94% of the patients with the pre-surgery test result \"Obstruction\" had a successful surgery outcome. In contrast, 70% of the patients with the pre-surgery test result \"No Obstruction\" had a non-successful surgery outcome. [ 29 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5280", "text": "If BPH with obstruction additionally presents with overactive bladder (OAB), which is the case in about 50% of patients, [ 30 ]  this latter symptom (OAB) persists even post-surgery in about 20% of patients. However, this rate only applies to a period of a few years.  10\u201315 years after surgery 48 of 55 patients (87%)  with obstruction and OAB had kept their post-surgery reduction of obstruction, but their OAB symptoms had gone back to the pre-surgery status. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5281", "text": "The UNBLOCS trial compared using transurethral resection of the prostate (TURP) to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better  urinary flow rate . [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5282", "text": "Transrectal biopsy  is a  biopsy  procedure in which a sample of tissue is removed from the  prostate  using a thin needle that is inserted through the  rectum  and into the prostate. [ 1 ]   Transrectal ultrasound  (TRUS) is usually used to guide the needle. [ 2 ] [ 3 ]  The sample is examined under a  microscope  to see if it contains  cancer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5283", "text": "This article incorporates  public domain material  from  Dictionary of Cancer Terms .  U.S. National Cancer Institute ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5284", "text": "This  oncology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5285", "text": "Transurethral biopsy  is a  biopsy  procedure in which a sample of tissue is removed from the  prostate  for examination under a  microscope . A thin, lighted tube is inserted through the  urethra  into the prostate, and a small piece of tissue is removed with a  cutting loop ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5286", "text": "Transurethral incision of the prostate  ( TUIP  or  TIP ) is a surgical procedure for treating  prostate  gland enlargement (benign  prostatic hyperplasia ). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5287", "text": "Transurethral incision of the prostate-\u2014one or two small cuts in the prostate gland\u2014can improve urine flow and correct other problems related to an enlarged prostate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5288", "text": "Compared with other surgical procedures for prostate gland enlargement, TUIP is simpler and generally has fewer complications. However, TUIP can only be used when the prostate is relatively small. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5289", "text": "Transurethral needle ablation  (also called  TUNA  or  transurethral radiofrequency ablation ) is a technique that uses low  energy   radio frequency   delivered through two needles to  ablate  excess  prostate  tissue. A  cystoscope / catheter  deploys the needles toward the obstructing prostate tissue and is inserted into the  urethra  directly through the  penis  under  local anesthetic  before the procedure begins. The energy from the probe heats the abnormal prostate tissue without damaging the urethra. The resulting  scar tissue  later  atrophies , reducing the size of the prostate which in turn reduces the constriction of the urethra. It can be done with a  local anesthetic  on an  outpatient  basis. [ 1 ]  It takes about an hour to perform the procedure. [ 2 ]  It takes about 30 days for the ablated prostate tissue to  resorb . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5290", "text": "Transurethral  needle ablation can be used to treat  benign prostatic hyperplasia  (BPH). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5291", "text": "Some clinical studies have reported that TUNA is safe and effective, improving the  urine  flow with minimal side effects when compared with other procedures, such as  transurethral resection of the prostate  (TURP) and open  prostatectomy . [ 1 ] [ 5 ] [ 6 ]  However, other studies have reported that the procedure has a high failure rate, with the majority of patients requiring  retreatment . [ 7 ]  Some patients have reported long-term  inflammation  of their prostate after undergoing the TUNA process. This is known as chronic  prostatitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5292", "text": "The TUNA system was pioneered by Stuart Denzil Edwards. The device was the main product for a startup company called Vidamed. Vidamed was founded in 1992 by Edwards along with Ron \u00a0 G. Lax, Hugh Sharky and  Ingemar Lundquist , in  Menlo Park, California , before building an international global corporation headed up by Lyle \u00a0 F. Brotherton. Vidamed was floated in an  IPO  on the US  NASDAQ  stock market in 1995 and then acquired by  Medtronic  in 2001. [ 10 ] \nIn 2011, Urologix, Inc. acquired the worldwide exclusive license to Prostiva radiofrequency therapy. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5293", "text": "Transurethral resection of the prostate  (commonly known as a  TURP , plural  TURPs , and rarely as a  transurethral prostatic resection ,  TUPR ) is a  urological  operation. It is used to treat  benign prostatic hyperplasia  (BPH). As the name indicates, it is performed by visualising the  prostate  through the  urethra  and removing tissue by  electrocautery  or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. [ 1 ]  This procedure is done with spinal or general anaesthetic. A triple lumen  catheter  is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The outcome is considered excellent for 80\u201390% of BPH patients. The procedure carries minimal risk for  erectile dysfunction , moderate risk for bleeding, and a large risk for  retrograde ejaculation . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5294", "text": "BPH is normally initially treated medically through  alpha   antagonists  such as  tamsulosin , or  5-alpha-reductase inhibitors  such as  finasteride  and  dutasteride . If medical treatment does not reduce a patient's urinary symptoms, a TURP may be considered following a careful examination of the prostate or bladder through a  cystoscope . If TURP is contraindicated, a urologist may consider a simple  prostatectomy , in and out catheters, or a supra-pubic catheter to help a patient void urine effectively. [ 3 ]   As the medical management of BPH improves, the number of TURPs has been decreasing. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5295", "text": "Traditionally, a  cystoscope  (a \"resectoscope\") has been used to perform TURP. The scope is passed through the  urethra  to the prostate where surrounding prostate tissue can then be excised. There are two types of modalities:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5296", "text": "A 2019 Cochrane review of 59 studies including 8924 men with BPH urinary symptoms found that bipolar and monopolar TURP probably result in comparable improvements in urinary symptoms, as well as in similar  erectile function , incidence of urinary incontinence and need for retreatment. Bipolar surgery likely reduces the risk of  TUR syndrome  and the need for  blood transfusion . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5297", "text": "Another transurethral method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high-powered \"red\" or potassium titanyl phosphate (KTP) \"green\" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a \"Greenlight\" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia (TUR syndrome), the ability to treat larger glands, as well as treating patients who are actively being treated with anticoagulation therapy for unrelated diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5298", "text": "A further transurethal method utilizes a robotically-controlled waterjet to remove prostate tissue. Visualization is provided by a combination of cystoscope and transrectal ultrasound methods.  This procedure claims risk reduction advantages as a result of being heat free."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5299", "text": "Because of bleeding risks associated with the procedure, TURP is not considered safe for many patients with cardiac problems. [ according to whom? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5300", "text": "Postoperative complications include: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5301", "text": "In most cases, urinary incontinence and erectile dysfunction resolve on their own within 6 to 12 months post-TURP. Therefore, many doctors will postpone invasive treatment until a year after the surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5302", "text": "Additionally, transurethral resection of the prostate is associated with a low risk of mortality. [ according to whom? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5303", "text": "The UNBLOCS trial compared using TURP to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better  urinary flow rate . [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5304", "text": "A  urethrectomy  is a  surgical procedure  to remove all or part of the male  urethra , a tube that connects the  urinary bladder  to the genitals for the removal of fluids out of the body. [ 1 ] \n [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5305", "text": "[ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5306", "text": "Vasectomy  is an  elective surgical procedure  that results in male  sterilization , often as a means of permanent  contraception . During the procedure, the male  vasa deferentia  are cut and tied or sealed so as to prevent  sperm  from entering into the  urethra  and thereby prevent  fertilization  of a female through  sexual intercourse . Vasectomies are usually performed in a  physician 's office, medical clinic, or, when performed on a non-human  animal , in a  veterinary clinic .  Hospitalization  is not normally required as the procedure is not complicated, the incisions are small, and the necessary equipment routine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5307", "text": "There are several methods by which a surgeon might complete a vasectomy procedure, all of which occlude (i.e., \"seal\") at least one side of each vas deferens. To help reduce  anxiety and increase patient comfort, those who have an aversion to needles may consider a \" no-needle \" application of anesthesia while the ' no-scalpel ' or 'open-ended' techniques help to accelerate recovery times and increase the chance of healthy recovery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5308", "text": "Due to the simplicity of the surgery, a vasectomy usually takes less than 30 minutes to complete. After a short recovery at the doctor's office (usually less than an hour), the patient is sent home to rest. Because the procedure is minimally invasive, many vasectomy patients find that they can resume their typical sexual behavior within a week, and do so with little or no discomfort."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5309", "text": "Because the procedure is considered a permanent method of contraception and is not easily reversed, patients are frequently counseled and advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically. The procedure is not typically encouraged for young single childless people as their risk of later regret is higher as chances of biological parenthood are thereby permanently reduced, often completely. [ citation needed ] \nA vasectomy without the patient's consent or knowledge is considered  forced sterilization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5310", "text": "A vasectomy is done to prevent fertility in males. It ensures that in most cases the person will be  sterile  after confirmation of success following surgery. The procedure is regarded as permanent because  vasectomy reversal  is costly and often does not restore the male's sperm count or sperm motility to prevasectomy levels. Those with vasectomies have a very small (nearly zero) chance of successfully impregnating someone, but a vasectomy does not protect against  sexually transmitted infections  (STIs). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5311", "text": "After vasectomy, the testes remain in the scrotum where  Leydig cells  continue to produce  testosterone  and other male hormones that continue to be secreted into the bloodstream."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5312", "text": "When the vasectomy is complete, sperm cannot exit the body through the  penis . Sperm is still produced by the testicles but is broken down and absorbed by the body. Much fluid content is absorbed by membranes in the  epididymis , and much solid content is broken down by the responding  macrophages  and reabsorbed via the bloodstream. [ citation needed ]  After vasectomy, the membranes must increase in size to absorb and store more fluid; this triggering of the immune system causes more macrophages to be recruited to break down and reabsorb more solid content. [ citation needed ]  Within one year after vasectomy, sixty to seventy percent of those vasectomized develop  antisperm antibodies . [ 6 ]  In some cases,  vasitis nodosa , a benign proliferation of the ductular epithelium, can also result. [ 7 ] [ 8 ]  The accumulation of sperm increases pressure in the vas deferens and epididymis. The entry of the sperm into the scrotum can cause  sperm granulomas  to be formed by the body to contain and absorb the sperm which the body will treat as a foreign biological substance (much like a virus or bacterium). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5313", "text": "Vasectomy is the most effective permanent form of contraception available to males. (Removing the entire vas deferens would very likely be more effective, but it is not something that is regularly done. [ 13 ] ) In nearly every way that vasectomy can be compared to  tubal ligation  it has a more positive outlook. Vasectomy is more cost effective, less invasive, has techniques that are emerging that may facilitate easier reversal, and has a much lower risk of postoperative complications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5314", "text": "Early failure rates, i.e. pregnancy within a few months after vasectomy, typically result from unprotected  sexual intercourse  too soon after the procedure while some sperm continue to pass through the vasa deferentia. Most physicians and surgeons who perform vasectomies recommend one (sometimes two) postprocedural semen specimens to verify a successful vasectomy; however, many people fail to return for verification tests citing inconvenience, embarrassment, forgetfulness, or certainty of sterility. [ 14 ]  In January 2008, the FDA cleared a home test called SpermCheck Vasectomy that allows patients to perform postvasectomy confirmation tests themselves; [ 15 ]  however, compliance for postvasectomy semen analysis in general remains low."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5315", "text": "Late failure, i.e. pregnancy following spontaneous recanalization of the vasa deferentia, has also been documented. [ 16 ]  This occurs because the  epithelium  of the vas deferens (similar to the epithelium of some other human body parts) is capable of regenerating and creating a new tube if the vas deferens is damaged and/or severed. [ 17 ]  Even when as much as five centimeters (or two inches) of the vas deferens is removed, the vas deferens can still grow back together and become reattached\u2014thus allowing sperm to once again pass and flow through the vas deferens, restoring one's fertility. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5316", "text": "The  Royal College of Obstetricians and Gynaecologists  states there is a generally agreed-upon rate of late failure of about one in 2000 vasectomies\u2014better than  tubal ligations  for which the failure rate is one in every 200 to 300 cases. [ 18 ]  A 2005 review including both early and late failures described a total of 183 recanalizations from 43,642 vasectomies (0.4%), and 60 pregnancies after 92,184 vasectomies (0.07%). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5317", "text": "Short-term possible complications include  infection ,  bruising  and  bleeding  into the scrotum resulting in a collection of blood known as a  hematoma . [ 19 ]  A study in 2012 demonstrated an infection rate of 2.5% postvasectomy. [ 11 ]  The  stitches  on the small incisions required are prone to irritation, though this can be minimized by covering them with gauze or small  adhesive bandages . The primary long-term complications are chronic pain conditions or syndromes that can affect any of the scrotal, pelvic or lower-abdominal regions, collectively known as  post-vasectomy pain syndrome . Though vasectomy results in increases in circulating immune complexes, these increases are transient. Data based on animal and human studies indicate these changes do not result in increased incidence of  atherosclerosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5318", "text": "Complications not withstanding, many men express concerns regarding potential adverse effects of vasectomy, including Cancer.  The risk of testicular cancer is not affected by vasectomy. [ 20 ]  In 2014 the AUA reaffirmed that vasectomy is not a risk factor for prostate cancer and that it is not necessary for physicians to routinely discuss prostate cancer in their preoperative counseling of vasectomy patients. [ 21 ]  There remains ongoing debate regarding whether vasectomy is associated with prostate cancer. A 2017 meta-analysis found no statistically significant increase in risk. [ 22 ]  A 2019 study of 2.1 million Danish males found that vasectomy increased their incidence of prostate cancer by 15%. [ 23 ]  A 2020 meta-analysis found that vasectomy increased the incidence by 9%. [ 24 ]  Other recent studies agree on the 15% increase in risk of developing prostate cancer, but found that people who get a vasectomy are not more likely to die from prostate cancer than those without a vasectomy. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5319", "text": "A vasectomy will not Impact sexual performance: A vasectomy does not affect libido or masculinity aside from its contraceptive effect. Some men have even reported increased sexual satisfaction post-vasectomy.\nIt won't cause permanent damage to sexual organs: The risk of injury to the testicles, penis, or other reproductive organs during surgery is minimal. Although extremely rare, damage to the blood supply could potentially lead to testicular loss, but this occurrence is unlikely with a skilled surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5320", "text": "It won't increase the risk of heart disease: There is no established connection between vasectomy and heart-related issues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5321", "text": "Vasectomy will not result in severe pain: While minor discomfort such as pulling or tugging sensations may occur during the procedure, severe pain is uncommon. Post-surgery, most men experience minor pain that typically resolves within a few days. In rare cases, some men report chronic post surgery pain, Post Vasectomy Pain Syndrome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5322", "text": "Post-vasectomy pain syndrome is a chronic and sometimes debilitating condition that may develop immediately or several years after vasectomy. [ 27 ]  The most robust study of post-vasectomy pain, according to the American Urology Association's Vasectomy Guidelines 2012 (amended 2015) [ 28 ]  surveyed people just before their vasectomy and again seven months later. Of those that responded and who said they did not have any scrotal pain prior to vasectomy, 7% had scrotal pain seven months later which they described as \"Mild, a bit of a nuisance\", 1.6% had pain that was \"Moderate, require painkillers\" and 0.9% had pain that was \"quite severe and noticeably affecting their quality of life\". [ 12 ]  Post-vasectomy pain can be constant  orchialgia  or epididymal pain ( epididymitis ), or it can be pain that occurs only at particular times such as with sexual intercourse, ejaculation, or physical exertion. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5323", "text": "Approximately 90% are generally reported in reviews as being satisfied with having had a vasectomy, [ 29 ]  while 7\u201310% of people regret their decision. [ 30 ]  For those in relationships, regret was less common when both people in the relationship agreed on the procedure. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5324", "text": "Younger people who receive a vasectomy are significantly more likely to regret and seek a reversal of their vasectomy, with one study showing people in their twenties being 12.5 times more likely to undergo a vasectomy reversal later in life (and including some who chose sterilization at a young age). Pre-vasectomy counseling is often emphasised for younger patients. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5325", "text": "An association between vasectomy and  primary progressive aphasia , a rare variety of frontotemporal dementia, was reported. [ 31 ]  However, it is doubtful that there is a causal relationship. [ 34 ]  The putative mechanism is a cross-reactivity between brain and sperm, including the shared presence of neural surface antigens. [ 35 ]   In addition, the cytoskeletal  tau protein  has been found only to exist outside of the CNS in the  manchette  of sperm. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5326", "text": "The traditional incision approach of vasectomy involves numbing of the scrotum with local anesthetic (although some people's physiology may make access to the vas deferens more difficult in which case general anesthesia may be recommended) after which a  scalpel  is used to make two small incisions, one on each side of the scrotum at a location that allows the surgeon to bring each vas deferens to the surface for excision. The vasa deferentia are cut (sometimes a section may be removed altogether), separated, and then at least one side is sealed by ligating ( suturing ),  cauterizing   ( electrocauterization ), or clamping. [ 36 ]  There are several variations to this method that may improve healing, effectiveness, and which help mitigate long-term pain such as post-vasectomy pain syndrome or  epididymitis , however the data supporting one over another are limited. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5327", "text": "The following vasectomy methods have purportedly had a better chance of later reversal but have seen less use by virtue of known higher failure rates (i.e., recanalization). An earlier clip device, the VasClip, is no longer on the market, due to unacceptably high failure rates. [ 46 ] [ 47 ] [ 48 ] [ unreliable medical source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5328", "text": "The VasClip method, though considered reversible, has had a higher cost and resulted in lower success rates. Also, because the vasa deferentia are not cut or tied with this method, it could technically be classified as other than a vasectomy. Vasectomy reversal (and the success thereof) was conjectured to be higher as it only required removing the Vas-Clip device. This method achieved limited use, and scant reversal data are available. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5329", "text": "Both vas occlusion techniques require the same basic patient setup: local anesthesia, puncturing of the scrotal sac for access of the vas, and then plug or injected plug occlusion. The success of the aforementioned vas occlusion techniques is not clear and data are still limited.  Studies have shown, however, that the time to achieve sterility is longer than the more prominent techniques mentioned in the beginning of this article. The satisfaction rate of patients undergoing IVD techniques has a high rate of satisfaction with regard to the surgery experience itself. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5330", "text": "Sexual intercourse can usually be resumed in about a week (depending on recovery); however, pregnancy is still possible as long as the  sperm count  is above zero. Another method of contraception must be relied upon until a sperm count is performed either two months after the vasectomy or after 10\u201320 ejaculations have occurred. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5331", "text": "After a vasectomy, contraceptive precautions must be continued until  azoospermia  is confirmed. Usually two semen analyses at three and four months are necessary to confirm azoospermia. The British Andrological Society has recommended that a single semen analysis confirming azoospermia after sixteen weeks is sufficient. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5332", "text": "Post-vasectomy, testicles will continue to produce sperm cells. As before vasectomy, unused sperm are reabsorbed by the body. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5333", "text": "In order to allow the possibility of reproduction via  artificial insemination  after vasectomy, some opt for  cryopreservation of sperm  before sterilization. Dr Allan Pacey, senior lecturer in andrology at  Sheffield University  and secretary of the British Fertility Society, notes that those he sees for a vasectomy reversal which has not worked express wishing they had known they could have stored sperm. Pacey notes, \"The problem is you're asking a man to foresee a future where he might not necessarily be with his current partner\u2014and that may be quite hard to do when she's sitting next to you.\" [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5334", "text": "The cost of cryo-preservation (sperm banking) may also be substantially less than alternative vaso-vasectomy procedures, compared to the costs of  in-vitro fertilization  (IVF) which usually run from $12,000 to $25,000. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5335", "text": "Sperm can be aspirated from the testicles or the epididymides, and while there is not enough for successful artificial insemination, there is enough to fertilize an ovum by  intracytoplasmic sperm injection . This avoids the problem of  antisperm antibodies  and may result in a faster pregnancy. IVF may be less costly per cycle than reversal in some health-care systems, but a single IVF cycle is often insufficient for conception. Disadvantages include the need for procedures on the woman, and the standard potential side-effects of IVF for both the mother and the child. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5336", "text": "Vasectomies are not always reversible. There is a surgical procedure to reverse vasectomies using  vasovasostomy  (a form of  microsurgery  first performed by Earl Owen in 1971 [ 58 ] [ 59 ] ). Vasovasostomy is effective at achieving pregnancy in a variable percentage of cases, and total out-of-pocket costs in the United States are often upwards of $10,000. [ 60 ]  The typical success rate of pregnancy following a vasectomy reversal is around 55% if performed within 10 years, and drops to around 25% if performed after 10 years. [ 61 ]  After reversal, sperm counts and motility are usually much lower than pre-vasectomy levels. There is evidence that those who had a vasectomy may produce more abnormal sperm, which may explain why even a mechanically successful reversal does not always restore fertility. [ 62 ] [ 63 ]  The higher rates of  aneuploidy  and  diploidy  in the sperm cells of those who have undergone vasectomy reversal may lead to a higher rate of birth defects. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5337", "text": "Approximately 2% of men who have undergone vasectomy will undergo a reversal within 10 years of the procedure. [ 33 ]  A small number of vasectomy reversals are also performed in attempts to relieve post-vasectomy pain syndrome. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5338", "text": "Internationally, vasectomy rates are vastly different. [ 65 ]  While female sterilisation is the most widely used method worldwide, with 223 million women relying on it, only 28 million women rely on their partner's vasectomy. [ 66 ]  In the world's 69 least developed countries less than 0.1% of males use vasectomies on average. Of 54 African countries, only ten report measurable vasectomy use and only Eswatini, Botswana, and South Africa exceed 0.1% prevalence. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5339", "text": "In North America and Europe vasectomy usage is on the order of 10% with some countries reaching 20%. [ 65 ]  Despite its high efficacy, in the United States, vasectomy is utilized less than half the rate of the alternative female  tubal ligation . [ 67 ]  According to the research, vasectomy in the US is least utilized among black and Latino populations, the groups that have the highest rates of female sterilization. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5340", "text": "New Zealand, in contrast, has higher levels of vasectomy than tubal ligation; 18% of all males, and 25% of all married males, have had a vasectomy. The age cohort with the highest level of vasectomy was 40\u201349, where 57% of males had taken it up. [ 68 ]  Canada, the UK, Bhutan and the Netherlands all have similar levels of uptake. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5341", "text": "The first human vasectomies were performed in the late 19th century. The procedure was initially used mainly as a treatment for  prostate enlargement  and as a  eugenic  method for sterilizing \"degenerates\". [ 70 ]  Vasectomy as a method of voluntary birth control began during the Second World War. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5342", "text": "The first recorded vasectomy was performed on a dog in 1823. [ 71 ]  The first human vasectomies were performed to treat  benign prostatic hyperplasia , or enlargement of the prostate.  Castration  had sometimes been used as a treatment for this condition in the 1880s, but, given the serious side effects, doctors sought alternative treatments. The first to suggest vasectomy as an alternative to castration may have been  James Ewing Mears  (in 1890), or  Jean Casimir F\u00e9lix Guyon . [ 70 ] \nThe first human vasectomy is thought to have been performed by  Reginald Harrison . [ 71 ] [ additional citation(s) needed ]  By 1900, Harrison reported that he had performed more than 100 vasectomies with no adverse outcomes. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5343", "text": "In the late 1890s, vasectomy also came to be proposed as a eugenic measure for the sterilization of men considered unfit to reproduce. The first case report of vasectomy in the United States was in 1897, by A.\u00a0J. Ochsner, a surgeon in Chicago, in a paper titled, \"Surgical treatment of habitual criminals\". He believed vasectomy to be a simple, effective means for stemming the tide of  racial degeneration  widely believed to be occurring. [ 72 ] [ 73 ]  In 1902,  Harry C. Sharp , the surgeon at the Indiana Reformatory, reported that he had sterilized 42 inmates in an effort to both reduce criminal behavior in those individuals and prevent the birth of future criminals. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5344", "text": "Eugen Steinach  (1861\u20131944), an Austrian physician, believed that a unilateral vasectomy (severing only one of the two vasa deferentia) in older individuals could restore general vigor and  sexual potency , shrink  enlarged prostates , and cure various ailments by somehow boosting the hormonal output of the vasectomized testicle. [ 75 ]  This surgery, which became very popular in the 1920s, was undertaken by many wealthy individuals, including  Sigmund Freud  and  W. B. Yeats . [ 76 ]   Since these operations lacked rigorous controlled trials, any rejuvenating effect was likely due to the  placebo effect , and with the later development of synthetic injectable hormones, this operation fell out of vogue. [ 75 ] [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5345", "text": "Vasectomy began to be regarded as a method of consensual  birth control  during the  Second World War . [ 71 ]  The first vasectomy program on a national scale was launched in 1954 in  India . [ 78 ]  In the 1970s, India enacted a  coercive sterilization campaign  which resulted in millions of vasectomies. Today, India's  sterilization program  focuses on coercing poor women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5346", "text": "The procedure is seldom performed on dogs, with  castration  remaining the preferred reproductive control option for canines. It is regularly performed on bulls. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5347", "text": "Vasectomy costs are (or may be) covered in different countries, as a method of both contraception or population control, with some offering it as a part of a national health insurance. The procedure was generally considered illegal in  France  until 2001, due to provisions in the  Napoleonic Code  forbidding \"self-mutilation\". No French law specifically mentioned vasectomy until a 2001 law on contraception and infanticide permitted the procedure. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5348", "text": "The U.S.  Affordable Care Act  (signed into law in 2010) does not cover vasectomies, [ 81 ]  although eight states require state- health insurance  plans to cover the cost. These include:  Illinois ,  Maryland ,  New Jersey ,  New Mexico ,  New York ,  Oregon ,  Vermont  and  Washington . [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5349", "text": "In 2014, the Iranian parliament voted for a bill that would ban the procedure. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5350", "text": "An analysis of medical records of 217 million people in the U.S. compared  tubal sterilization  and vasectomy rates in the last six months of 2021 with rates in the last six months of 2022\u2014just after the  Dobbs  ruling (i.e. the overturning of  Roe vs Wade ) in June 2022. Although the effect of Dobbs was different in various social groups, it had a strong impact on those under age 30 with their vasectomy rates increasing by 59%, and tubal sterilization rates increasing by 29%. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5351", "text": "Medical tourism, where a patient travels to a less-developed location where a procedure is cheaper to save money and combine convalescence with a vacation, is infrequently used for vasectomy due to its low cost, but is more likely to be used for vasectomy reversal. Many hospitals list vasectomy as being available. Medical tourism has been scrutinized by some governments for quality of care and postoperative care issues. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5352", "text": "In 1990,  Andrew Rynne , chairperson of the  Irish Family Planning Association , and the  Republic of Ireland 's first vasectomy specialist, [ 86 ]  was shot by a former client, but he survived. The incident is the subject of a short film,  The Vasectomy Doctor , by Paul Webster. [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5353", "text": "Vasectomy reversal  is a term used for surgical procedures that reconnect the  male reproductive tract  after interruption by a  vasectomy . Two procedures are possible at the time of vasectomy reversal:  vasovasostomy  ( vas deferens  to vas deferens connection) and  vasoepididymostomy  ( epididymis  to vas deferens connection). Although vasectomy is considered a permanent form of contraception, advances in microsurgery have improved the success of vasectomy reversal procedures. The procedures remain technically demanding and may not restore the pre-vasectomy condition. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5354", "text": "A general or regional  anesthetic  is most commonly used, as this offers the least interruption by patient movement for microsurgery. Local  anesthesia , with or without  sedation , can also be used. The procedure is generally done on a \u201ccome and go\u201d basis. The actual operating time can range from 1\u20134 hours, depending on the anatomical complexity, skill of the surgeon and the kind of procedure performed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5355", "text": "After anesthesia and scrubbing the  scrotum  with soap and water, the vas deferens is exposed through a small, 1\u20132\u00a0cm incision in the upper scrotum on each side. The vas deferens is cut sharply in half, both above and below the  vasectomy  site. A special bipolar microcautery is used to judiciously control any bleeding. One end of the vas deferens, termed the abdominal end, is inspected and flushed with salt solution to ensure that it is not blocked as it courses from the scrotum to the  prostate  (a \u201csaline vasogram\u201d). In order to assess for the presence of possible obstruction above the vasectomy site the testicular end of the vas deferens can be compressed and inspected for fluid. This fluid is examined with a microscope for color, consistency and for sperm. This information is used by some surgeons to decide whether or not a secondary epididymal obstruction is present [ citation needed ]  (see Table below)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5356", "text": "If sperm are found at the testicular end of the vas deferens, then it is assumed that a secondary epididymal obstruction has not occurred and a vas deferens-to-vas deferens reconnection ( vasovasostomy ) is planned. If sperm are not found, then some surgeon consider this to be prime facie evidence that an epididymal obstruction is present and that an epididymis to vas deferens connection (vasoepididymostomy) should be considered to restore sperm flow. Other, more subtle findings that can be observed in the fluid\u2014including the presence of sperm fragments and clear, good quality fluid without any sperm\u2014require surgical decision-making to successfully treat. There are however, no large randomised prospective controlled trials comparing patency or pregnancy rates following the decision to perform either microsurgical vasovasostomy to microsurgical vasoepididymosty as determined by this paradigm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5357", "text": "For a  vasovasostomy , two microsurgical approaches are most commonly used. Neither has proven superior to the other. [ 2 ]  What has been shown to be important, however, is that the surgeon use optical magnification to perform the vasectomy reversal. One approach is the modified 1-layer vasovasostomy and the other is a formal, 2-layer vasovasostomy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5358", "text": "A  vasoepididymostomy  involves a connection of the  vas deferens  to the  epididymis . This is necessary when there is no sperm present in the vas deferens."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5359", "text": "With vasectomy reversal surgery, there are two typical measures of success: patency rate, or return of some moving sperm to the ejaculate after vasectomy reversal, and  pregnancy  rates. In one study [ 3 ]  95% of men with a vasovasostomy were found to have motile sperm in the ejaculate within 1 year after vasectomy reversal. Almost 80% of these men achieved sperm motility within 3 months of vasectomy reversal. The case for vasoepididymostomy is different. Fewer men will eventually achieve motile sperm counts and the time to achieve motile sperm counts is longer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5360", "text": "Additional information:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5361", "text": "Another issue to consider is the likelihood of vasoepididymostomy at the time of vasectomy reversal, as this technique is generally associated with lower patency and pregnancy rates than vasovasostomy. Web-based, computer models and calculations have been proposed and published that described the chance of needing an vasoepididymostomy at reversal surgery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5362", "text": "The pregnancy rate is often seen as a more reliable way of measuring the success of a vasectomy reversal than the patency rates, as they measure the real-life success of whether the man succeeds in the aim of having a new child."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5363", "text": "It is important to appreciate that female age is the single most powerful factor determining the pregnancy rate following any fertility treatment and vasectomy reversal is no exception. No large studies have stratified the results of vasectomy reversal by female age and hence assessing outcomes is confounded by this issue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5364", "text": "Pregnancy rates range widely in published series, with a large study in 1991 observing the best outcome of 76% pregnancy success rate with vasectomy reversals performed within 3 years or less of the original vasectomy, dropping to 53% for reversals 3\u20138 years out from the vasectomy, 44% for reversals 9\u201314 years out from the vasectomy, and 30% for reversals 15 or more years after the vasectomy. [ 6 ]  BPAS cites the average pregnancy success rate of a vasectomy reversal is around 55% if performed within 10 years, and drops to 25% if performed over 10 years. [ 7 ]  Higher success rates are found with reversal of  vasovasostomy than those with a vasoepididymostomy, and factors such as  antisperm antibodies  and epididymal dysfunction are also implicated in success rates. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5365", "text": "The current measure of success in vasectomy reversal surgery is achievement of a pregnancy. There are several reasons why a vasectomy reversal may fail to achieve this:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5366", "text": "In general, vasectomy reversal is a safe procedure and complication rates are low. There are small chances of infection or bleeding, the latter of which can result in a  hematoma  or blood clot in the scrotum that needs surgical drainage. If there is significant scar tissue encountered during the vasectomy reversal, fluid other than blood ( seroma ) can also accumulate in a small number of cases.  Painful  granulomas , caused by leaking sperm, can develop near the surgical site in some cases. Very rare complications include  compartment syndrome  or deep  venous thrombosis  from prolonged positioning, testis atrophy due to damaged blood supply, and reactions to  anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5367", "text": "Assisted reproduction  uses \u201c test tube baby \u201d technology (also called  in vitro fertilization , IVF) for the female partner along with sperm retrieval techniques for the male partner to help build a family. This technology, including  intracytoplasmic sperm injection  (ICSI), has been available since 1992 and became available as an alternative to vasectomy reversal soon after. This alternative should be discussed with couples during a consultation for vasectomy reversal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5368", "text": "Procedure to extract sperm for IVF include  percutaneous epididymal sperm aspiration  (PESA procedure),  testicular sperm extraction  (TESE procedure) and open testicular biopsy. Needle aspiration in a PESA procedure invariably causes trauma to the epididymal tubule and TESE procedures may damage the intra testicular collecting system (rete testis). Both potentially compromise the prospect of successful vasectomy reversal. Conversely, because in most circumstances vasectomy reversal leads to the restoration of sperm in the semen, it reduces the need for sperm retrieval procedures in association with IVF."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5369", "text": "Published research attempts to identify the issues that matter most as couples decide between IVF-ICSI and vasectomy reversal, two very different approaches to family building. This  research has generally taken the form of cost-effectiveness or cost-benefit analyses [ 14 ]  and decision analyses [ 15 ]  and Markov modeling. [ 16 ]  Since it is difficult to perform randomized, blinded prospective trials on couples in this situation, analytic modeling can help uncover what variables affect outcomes the most. From this body of work, it has been observed that vasectomy reversal can be the most cost-effective way to build a family if: (a) the female partner is reproductively healthy, and (b) the surgeon can achieve good vasectomy reversal outcomes. If the surgeon can achieve high \u201cpatency\u201d rates (moving sperm in the ejaculate) after vasectomy reversal, then vasectomy reversal is competitive with IVF-ICSI. [ 15 ]  In the special instance of couples with  advanced maternal age  (defined as a female partner > 38 years old), case series\u2019 have reported that pregnancy rates with vasectomy reversal are competitive with IVF-ICSI. [ 17 ]  When Markov modeling was applied to probe the issue of pregnancy rates after reversal surgery in more depth, the results revealed that female reproductive health is far more important than: (a) the age of the vasectomy, (b) the age of the man, or (c) the vasectomy reversal patency rate. Ultimately the decision to pursue a vasectomy reversal is a personal one for each couple."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5370", "text": "Every patient who is considering vasectomy reversal should undergo a screening visit before the procedure to learn as much as possible about his current  fertility  potential. At this visit, the patient can decide whether he is a good candidate for vasectomy reversal and assess if it is right for him. Issues to be discussed at this visit include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5371", "text": "Immediately before the procedure, the following information is important for patients:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5372", "text": "After the procedure, patients should perform the following tasks:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5373", "text": "Sperm  are produced in the male sex gland or  testicle . From there they travel through tubes (efferent tubules), exit the  testes  and enter a \u201cstorage site\u201d or  epididymis . The epididymis is a single, 18-foot-long (5.5\u00a0m), tightly coiled, small tube, within which sperm mature to the point where they can move, swim and fertilize eggs. Testicular sperm are not able to fertilize eggs naturally (but can if they are injected directly into the egg in the laboratory), as the ability to fertilize eggs is developed slowly over several months of storage in the epididymis. From the epididymis, a 14-inch, 3\u00a0mm-thick muscular tube called the  vas deferens  carries the sperm to the  urethra  near the base of the penis. The urethra then carries the sperm through the  penis  during  ejaculation . A vasectomy interrupts sperm flow within the vas deferens. After a vasectomy, the testes still make sperm, but because the exit is blocked, the sperm die and eventually are reabsorbed by the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5374", "text": "A problem in the delicate tubes of epididymis can develop over time after vasectomy. [ 6 ]   The longer the time since the vasectomy, the greater the \u201cback-pressure\u201d behind the vasectomy. This \u201cback-pressure\u201d may cause a \u201cblowout\u201d in the delicate epididymal tubule, the weakest point in the system. The blowout may or may not cause symptoms, but will probably scar the epididymal tubule, thus blocking sperm flow at second point. To summarize, with time, a man with a vasectomy can develop a second obstruction deeper in the  reproductive tract  that can make the vasectomy more difficult to reverse. Having the skill to detect and fix this problem during vasectomy reversal is the essence of a skilled surgeon. If the surgeon simply reconnects the two freshened ends of the vas deferens without examining for a second, deeper obstruction, then the procedure can fail, as sperm-containing fluids are still unable to flow to the place of the connection. In this case, the vas deferens must be connected to the epididymis in front of the second blockage, to bypass both blockages and allow the sperm to reenter the urethra in the  ejaculate . Since the epididymal tubule is much smaller (0.3\u00a0mm diameter) than the vas deferens (3\u00a0mm diameter, 10-fold larger), epididymal surgery is far more complicated and precise than the simple vas deferens-to-vas deferens connection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5375", "text": "Vasectomy is a common method of  contraception  worldwide, with an estimated 40-60 million individuals having the procedure and 5-10% of couples choosing it as a  birth control  method. [ 18 ]  In the USA, about 2% of men later go on to have a vasectomy reversal afterwards. [ 19 ]  However the number of men inquiring about vasectomy reversals is significantly higher - from 3% to 8% [ 16 ]  - with many \"put off\" by the high costs of the procedure and pregnancy success rates (as opposed to \"patency rates\") only being around 55%. [ 20 ]  90% of men are satisfied with having had the procedure. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5376", "text": "While there are a number of reasons that men seek a vasectomy reversal, some of these include wanting a family with a new partner following a relationship breakdown / divorce, their original wife/partner dying and subsequently going on re-partner and to want children, the unexpected death of a child (or children - such as by car accident), or a long-standing couple changing their mind some time later often by situations such as improved finances or existing children approaching the age of school or leaving home. [ 22 ]  Patients often comment that they never anticipated such situations as a relationship breakdown or death (of their partner or child) may affect their situation. A small number of vasectomy reversals are also performed in attempts to relieve  post-vasectomy pain syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5377", "text": "In the UK, 16% of all men under 70 have had a vasectomy, and with remarriages accounting for 40% of all marriages, there are a significant proportion of men finding themselves in a new relationship and regretting their decision to have a vasectomy. [ 22 ]  Combined with longer life histories, the rate of divorce and remarriage is thought to be driving the increase in vasectomy reversals and inquiries for vasectomy reversals in recent times. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5378", "text": "Technical advances in vasectomy reversal mirror those in  microsurgery  over the past 100 years.  As a discipline, microsurgery was first performed by Carl Nylen in Sweden for middle ear surgery in 1910, [ 23 ]  but grew most rapidly as a discipline in the 20th century stimulated by its success in microvascular reconstruction of war-injured soldiers. The first microsurgical vasectomy reversal was performed by  Earl Owen  in 1971. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5379", "text": "Vasectomy: A Delicate Matter  is a 1986 film directed by Robert Burge and starring  Paul Sorvino , Cassandra Edwards,  Abe Vigoda ,  Ina Balin , and  Lorne Greene . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5380", "text": "After his wife gives birth to their eighth child, a bank executive reluctantly consents to undergo vasectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5381", "text": "This film article about a 1980s comedy film is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5382", "text": "This article related to an American film of the 1980s is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5383", "text": "Vasoepididymostomy  or  epididymovasostomy  is a surgery by which  vasectomies  are reversed. It involves connection of the severed  vas deferens  to the  epididymis  and is more technically demanding than the  vasovasostomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5384", "text": "For a vasectomy reversal that involves a vasoepididymostomy, there are two microsurgical approaches. The procedure involves a similar surgical incision as  vasovasostomy ; however, unlike with a vasovasostomy, the testis is usually delivered into the field for this more complex microsurgery. After the findings from the vasal fluid are reviewed showing epididymal obstruction, the epididymis is exposed by opening the outer testis covering ( tunica vaginalis ). The epididymis is inspected and an individual tubule is selected to enter and connect to the vas deferens. From this point on, one of two epididymovasostomy techniques is taken. In the  mucosa -to-mucosa, end to side method, [ 1 ]  an opened epididymal tubule is connected to the cut end of the vas deferens with 4 to 6 small (10-0) simple sutures placed around the circumference of each. This \"inner\" layer is supported with an \"outer\" layer of radially placed 9-0 sutures to strengthen the connection. Recently, an \" invagination \" vasoepididymostomy was described as an alternative to the mucosa-to-mucosa method. [ 2 ]  With this technique, one, two or three \"vest\" sutures of 10-0 suture should be placed near the opening of the epididymal tubule to allow the epididymal tubule to \"invaginate\" into the vas deferens, theoretically creating a connection, that, based on studies in animal models, has an improved watertight seal and possibly a higher chance for success. Once the vas-deferens-epididymis connection is completed, the covering around the testis is replaced."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5385", "text": "Vasoepididymostomy  is often considered one of the most technically challenging operations in the field of urology. The procedure requires anastomosis of a single epididymal tubule (luminal diameter 0.15\u20130.25\u00a0mm) to the lumen of the vas deferens (diameter 0.3\u20130.4\u00a0mm), and is reserved for patients with congenital or acquired epididymal obstruction, or patients who have failed previous attempts at surgical reconstruction of the vas deferens. This surgery attaches the vas deferens directly to the epididymis, the coiled tube on the back of each testicle where sperm matures. A vasectomy can cause blockages or a break in the vas deferens or the epididymis. This surgery is used when a vasovasostomy won't work because sperm flow is blocked. The vas deferens is connected to the epididymis above the point of blockage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5386", "text": "Vasovasostomy  (literally connection of the  vas  to the vas) is a surgery by which  vasectomies  are partially reversed. Another surgery for  vasectomy reversal  is  vasoepididymostomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5387", "text": "Vasovasostomy is a form of microsurgery first performed by Australian surgeon Dr. Earl Owen (1934\u20132014) in 1971. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5388", "text": "In most cases the  vas deferens  can be reattached but, in many cases, fertility is not achieved. There are several reasons for this, including blockages in the vas deferens, and the presence of  autoantibodies  which disrupt normal  sperm  activity. If blockage at the level of the  epididymis  is suspected, a  vasoepididymostomy  can be performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5389", "text": "Return of sperm to the ejaculate depends greatly on the length of time from the vasectomy and the skill of the surgeon. Generally, the shorter the interval, the higher the chance of success. The likelihood of pregnancy can depend on female partner factors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5390", "text": "Over half of men who have undergone a vasectomy develop anti-sperm antibodies. The effects of anti-sperm antibodies continue to be debated in the medical literature, but there is agreement that antibodies may reduce sperm  motility ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5391", "text": "Only two conditions must be satisfied for sperm to be returned to a patient's  semen  with vasectomy reversal by vasovasostomy. First, the patient must have sperm available to pass through at least one reconnection. The second condition is that each reconnection must be as watertight as possible. The surgeon's goal is to achieve a very precise circumferential reconnection of the sperm canal edges by using meticulously placed microsurgical sutures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5392", "text": "Vasovasostomy can be performed in the convoluted or straight portion of the vas deferens. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5393", "text": "Vasovasostomy is typically an out-patient procedure (patient goes home the same day)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5394", "text": "The procedure is typically performed by  urologists . Most urologists specializing in the field of male infertility perform vasovasostomies using an operative microscope for magnification, under general or regional  anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5395", "text": "If sperm were seen in one or both vas contents at the time of surgery, or sperm reached the patient's semen only transiently after the reversal, microsurgical vasovasostomy may be successful. Unfortunately, surgeons performing only an occasional vasectomy reversal often neglect examining the vas contents for presence or absence of sperm. A surgeon cannot determine sperm presence or absence by the naked eye. The most common cause for failed vasectomy reversals is the inappropriate non-microsurgical technique using sutures that are too large to achieve watertight reconnections. The failure of a competently performed microsurgical vasovasostomy following the absence of any sperm in the contents of each vas usually is due to \u201cblowouts\u201d in the epididymides. Under these circumstances an operation should be performed only by a micro-surgeon with proven  vasoepididymostomy  expertise, bypassing the blowouts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5396", "text": "The prognosis for each patient should be determined by a  pre-operative examination of the vasectomy sites and consideration of the time interval since vasectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5397", "text": "The rate of pregnancy depends on such factors as the method used for the vasectomy and the length of time that has passed since the vasectomy was performed. The reversal procedures are frequently impermanent, with occlusion of the vas recurring two or more years after the operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5398", "text": "The presence of  sperm granulomas  improves the likelihood of restoring sperm to the semen with a vasovasotomy. A local urologist can easily determine whether a patient has 0, 1, or 2  sperm granuloma  by a painless examination of each vasectomy site. If the interval since the vasectomy is less than fifteen years, the prognosis will be 70% or better and this local examination is probably not needed. [ citation needed ] \nA sperm granuloma develops from post-vasectomy sperm leakage and somehow it behaves like a safety valve preventing internal pressure build up and ruptures of the delicate epididymis tubules with subsequent obstructive scarring."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5399", "text": "Vasovasostomy can be effective regardless of how long it's been since the original vasectomy. However, if more than 15 years have passed since the original vasectomy, one may have a lower chance of having enough healthy sperm in one's own semen to father a child. Also, the longer the obstructive interval, the more likely it is that a  vasoepididymostomy  will be required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5400", "text": "Typical cost of one vasovasostomy is US$5,000\u201315,000 (one side)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5401", "text": "World Vasectomy Day  (WVD) is an annual event to raise global awareness of  vasectomy  as a male-oriented solution to prevent unintended pregnancies. The goal is for doctors all over the world to perform vasectomies, connected to the event via  Skype  and  social media  platforms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5402", "text": "WVD was founded in 2012 by the American film-maker  Jonathan Stack  while he was working on a documentary about the decision of having a vasectomy. [ 1 ]  The underlying goal was to involve men in family planning decisions and educate them about vasectomies as a simple way of taking responsibility for birth control."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5403", "text": "In 2013, prolific vasectomist Dr  Douglas Stein  was scheduled to perform vasectomies in front of an audience at the  Royal Institution of Australia (RiAus)  to launch the inaugural World Vasectomy Day with the world\u2019s first  live-streamed  vasectomy. Stein answered questions from a live audience in  Australia  and an international online audience. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5404", "text": "The event's third edition was hosted by Indonesia in 2015; [ 3 ]  the fourth edition was centered in Kenya and featured a vasectomy broadcast live on Facebook. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5405", "text": "On 17 November 2017, at its fifth anniversary, more than 1,200 vasectomists in more than 50 countries joined the event, making it the largest male-focused family planning event in history. [ 5 ]  The 2017 event's headquarter was located in Mexico. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5406", "text": "Ocular surgery may be performed under  topical ,  local  or  general anesthesia . Local anaesthesia is more preferred because it is economical, easy to perform and the risk involved is less. Local anaesthesia has a rapid onset of action and provides a dilated  pupil  with low  intraocular pressure ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5407", "text": "Susruta Samhita  has evidences of use of anaesthesia for ocular surgeries. Inhalational anaesthesia was used for this purpose. [ citation needed ]  Egyptian surgeons used carotid compression to produce transient  ischemia  during eye surgery to reduce the perception of pain. [ citation needed ]  In 1884,  Karl Koller  used  cocaine  for ocular surgery. [ citation needed ]  The same year,  Herman Knapp  used cocaine for retrobulbar block. [ citation needed ]  In 1914, van Lint achieved  orbicularis  akinesia by local injection. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5408", "text": "Surface anaesthesia is given by instillation of 2.5 ml  xylocaine . One drop of xylocaine instilled four times after every 4 minutes will produce conjunctival and corneal anaesthesia.  Paracaine ,  tetracaine ,  bupivacaine ,  lidocaine  etc. may also be used in place of xylocaine. [ 1 ]  Cataract surgery by  phacoemulsification  is frequently performed under surface anaesthesia.  Facial nerve , which supplies the orbicularis oculi muscle, is blocked in addition for intraocular surgeries. Topical anaesthesia is known to cause endothelial and epithelial toxicity, allergy and surface keratopathy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5409", "text": "There are four types of facial block\u00a0: van Lint's block, Atkinson block, O' Brien block and Nadbath block."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5410", "text": "This technique was first practiced by  Herman Knapp  in 1884. Here, 2% xylocaine is introduced into the muscle cone behind the eyeball. The injection is usually given through the inferior fornix of the skin of the outer part of the lower lid when the eye is in primary gaze. The  ciliary nerves ,  ciliary ganglion ,  oculomotor nerve  and  abducens nerve  are anesthetized in retrobulbar block. [ 2 ]  As a result, global akinesia, anaesthesia and analgesia are produced. The  superior oblique muscle , which is outside the muscle cone, is not usually paralyzed. The complications of retrobulbar block are globe perforation,  optic nerve  injury, retrobulbar  haemorrhage  and extraocular muscle palsy. Retrobulbar anaesthesia is contraindicated in posterior  staphyloma , high axial  myopia  and  enophthalmos . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5411", "text": "This technique was first applied by Davis. In peribulbar block, local anaesthetic is injected to the peripheral spaces of the orbit. The anaesthetic diffuses into the muscle cone and  eyelids , causing global and orbicularis akinesia and anaesthesia. After injection, orbital compression is applied for around 15 minutes. [ clarification needed ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5412", "text": "Nearly all ocular surgeries  viz   keratoplasty ,  cataract extraction ,  glaucoma surgery ,   iridectomy ,  strabismus , [ 5 ]  retinal detachment surgery etc. can be done under regional anaesthesia.  Conjunctiva ,  globe  and orbicularis can be paralysed using a combination of surface anaesthesia, facial anaesthesia and retrobulbar block. [ 1 ]  The advantage is that it produces less post-operative restlessness. It has less post-operative lung complications and less bleeding. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5413", "text": "General anaesthesia is preferred for ocular surgeries in anxious adults, psychiatric patients, infants and children. [ 5 ]  It is also indicated in perforating ocular injuries and major surgeries like exenteration. During the surgery, it has to be ensured that no carbon dioxide retention occurs. If this occurs, the  choroid  swells up and ocular contents may prolapse as soon as the eye is opened. The advantages of general anaesthesia is that it produces complete akinesia, controlled  intraocular pressure  and safe operating environment. It is the safest option for bilateral surgery. The complications of general anaesthesia are  laryngospasm ,  hypotension ,  hypercarbia , respiratory depression and  cardiac arrhythmia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5414", "text": "Anterior chamber paracentesis  ( ACP ) is a surgical procedure done to reduce  intraocular pressure  (IOP) of the eye. The procedure is used in management of  glaucoma  and  uveitis . It is also used for clinical diagnosis of infectious uveitis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5415", "text": "Anterior chamber paracentesis is used in the management of  acute angle closure glaucoma , and uveitis. [ 1 ] [ 2 ]  It can also prevent a raise in IOP after  intravitreal injections . [ 3 ]  Aqueous humor collected using anterior chamber paracentesis may be used for clinical diagnosis of infectious uveitis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5416", "text": "In this procedure  aqueous humor  from the  anterior chamber of eyeball  is drained out by using a tuberculin syringe, with or without a plunger attached to a hypodermic needle or a paracentesis incision. [ 1 ]  Eye is anesthetized using  proparacaine  or  tetracaine   eye drops  prior to ACP. [ 5 ]   Paracentesis  is performed through the clear cornea adjacent to the  limbus . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5417", "text": "Pain, traumatic injuries of the  iris ,  corneal  abscess, inadvertent  lens  touch, occurrence of Anterior chamber  fibrin ,  Intraocular hemorrhage , decompression  retinopathy ,  hyphaema , ocular hypotension due to leakage and exogenous  endophthalmitis  are complication of ACP. [ 1 ] [ 3 ] [ 6 ]   Traumatic cataract  may occur secondary to lens trauma. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5418", "text": "This  ophthalmology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5419", "text": "Hermenegildo Arruga Lir\u00f3, 1st Count of Arruga  (March 15, 1886 \u2013 May 17, 1972) was a Spanish ophthalmologist known for refining several eye surgeries. He devised one of the early procedures to address  retinal detachment , and he received the  Gonin Medal  from the  International Council of Ophthalmology  in 1950."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5420", "text": "Arruga was the second of three generations of eye surgeons. He and his father, ophthalmologist Eduardo Arruga, were both born in Barcelona. He entered medical studies at 16 and graduated in 1908, leaving Spain for a while for further study in France and Germany. His mentors included  Edmund Landolt ,  Julius Hirschberg  and  F\u00e9lix de Lapersonne . He returned to Barcelona, spending the rest of his life seeing patients there, with the exception of a move to South America during the  Spanish Civil War . Arruga lived above his clinic in Barcelona, where patients and physicians from all over the world came to see him. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5421", "text": "One of the first surgeons to promote  intracapsular cataract extraction , Arruga also suggested technical improvements to several other eye surgeries. [ 2 ]  Arruga introduced a procedure for treating  retinal detachment  that became known as Arruga's  suture . In this surgery, a band was made around the  sclera  using Supramid, a synthetic suture material, but the technique caused some problems with  scleral  erosion. Even after the procedure could be performed with  silicone  bands, there were still problems with  ischemia  of the  anterior segment  of the eye, and the procedure was ultimately replaced by newer techniques. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5422", "text": "Arruga was close friends with  Jules Gonin , the Swiss ophthalmologist who devised the first retinal detachment repair surgery. Arruga wrote two influential books:  Retinal Detachment  (1936) and  Ocular Surgery  (1946); for the latter, his son, ophthalmologist Alfredo Arruga-Forgas, wrote a chapter of the third English edition (1962). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5423", "text": "In 1950, Arruga won the  Gonin Medal . [ 4 ]  He was recognized with the  Order of Isabella the Catholic  in 1956. [ 5 ]  He received honorary doctorates from the  University of Barcelona  and  Heidelberg University . [ 6 ] [ 7 ]  Arruga was named an honorary fellow of the  Royal College of Surgeons of Edinburgh . He was created  Count of Arruga  (Spanish:  Conde de Arruga ), in 18 July 1950. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5424", "text": "Arruga enjoyed chess and was a skilled artist. He engaged in mountain climbing, reaching the summit of the  Jungfrau  in the  Bernese Alps  when he was 70 years old. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5425", "text": "He died of  heart disease  in 1972. [ 9 ]  He was preceded in death by his wife, Teresa Forgas, the mother of his four children; she died following an automobile accident. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5426", "text": "Blepharoplasty  ( Greek :  blepharon , \"eyelid\" +  plassein  \"to form\") is the  plastic surgery  operation for correcting defects, deformities, and disfigurations of the  eyelids ; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning (or both) of excess tissues, such as  skin  and  adipocyte fat , and the reinforcement of the corresponding  muscle  and  tendon  tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the  periorbita , which is the area from the eyebrow to the upper portion of the cheek. The procedure is more common among women, who accounted for approximately 85% of blepharoplasty procedures in 2014 in the US and 88% of such procedures in the UK. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5427", "text": "The operative goals of a blepharoplastic procedure are the restoration of the correct functioning to the affected eyelid(s) and the restoration of the aesthetics of the eye-region of the face, which are achieved by eliminating excess skin from the eyelid(s), smoothing the underlying eye muscles, tightening the supporting structures, and resecting and re-draping the excess fat of the retroseptal area of the eye, in order to produce a smooth anatomic transition from the lower eyelid to the cheek."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5428", "text": "In an eye surgery procedure, the usual correction or modification (or both) is of the upper and the lower eyelids, and of the surrounding tissues of the eyebrows, the upper nasal-bridge area, and the upper portions of the cheeks, which are achieved by modifying the  periosteal coverings  of the facial bones that form the  orbit  (eye socket). The periosteum comprises two-layer connective tissues that cover the bones of the human body:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5429", "text": "The  East Asian blepharoplasty  procedure differs from the classic blepharoplasty. In younger patients, the goal of the surgery is to create a supratarsal fold (\"double eyelid surgery\") whereas in older patients the goals are to create or elevate the supratarsal fold and to resect surplus eyelid skin (\"Asian blepharoplasty\"). [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5430", "text": "The thorough pre-operative  medical  and surgical histories, and the physical examination of the patient's  periorbital area  (eyebrow-to-cheek-to-nose), determine if the patient can safely undergo a blepharoplasty procedure to feasibly resolve (correct or modify, or both) the functional and aesthetic indications presented by the patient. Sequentially, lower eyelid blepharoplasty can successfully address the anatomic matters of excess eyelid skin, slackness of the eye-muscles and of the  orbital septum  (palpebral ligament), excess orbital fat, malposition of the lower eyelid, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5431", "text": "Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of  peripheral vision , caused by the slackness of the upper-eyelid skin draping over the eyelashes; the outer and the upper portions of the field of vision of the patient are affected and cause him or her difficulty in performing mundane activities such as driving an automobile and reading a book. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5432", "text": "In many East Asian countries, double eyelid surgery is the most popular surgery, especially in South Korea. Depending on the methods, directing doctors' experience, and the difficulty of the individual case, this surgery can cost between about  US$ 2,000 to $4,000. The procedure is famous for producing double-eyelid for patients for the long-term. [ citation needed ]  This kind of operation normally takes about 30 minutes to an hour, and patients are not required to stay hospitalized afterward. Stitches are removed 5 to 7 days after surgery. Many foreigners go to South Korea each year for blepharoplasty. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5433", "text": "A blepharoplasty procedure usually is performed through external surgical incisions made along the natural skin lines (creases) of the upper and the lower eyelids, which then hide the surgical  scars  from view, especially when affected by the skin creases below the  eyelashes  of the lower eyelid. The incisions can also be made from the  conjunctiva , the interior surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5434", "text": "Transconjunctival lower blepharoplasty technique was pioneered by Clinical Professor of Surgery at the University of Chicago Medicine, [ 10 ]  Dr. Anthony J. Geroulis [ 11 ]  and introduced to medical trial in 1998. Transconjunctival Technique has become the norm in the plastic surgery field with most surgeons preferring it over the external surgical incisions. This technique is particularly useful for patients with darker skin tones where standard external incision often leaves a visible white scar."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5435", "text": "Transconjunctival blepharoplasty technique permits the excision (cutting and removal) of the lower-eyelid  adipose tissue  without leaving a visible scar, but the technique does not allow the removal of excess eyelid-skin. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5436", "text": "A blepharoplasty operation usually requires 1\u20133 hours to complete. Post-operatively, swelling and bruising is expected and will usually resolve without further intervention; application of cold compresses can help to reduce the duration and discomfort. [ 12 ]  There are no standardized outcome measures for upper or lower blepharoplasty. [ 12 ]  Blepharoplasty is generally a relatively safe surgery, but possible complications include hematoma/ecchymosis, lagophthalmos (incomplete or abnormal closure of the eyelids), ptosis (drooping of the upper eyelid), scarring, dry eyes, orbital hematoma/compartment syndrome, lymphedema, and ocular motility disorders. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5437", "text": "After the procedure, a type of stitch known as a canthopexy is placed near the outer corner of the lower eyelid, which is inside the tissue. This allows the eyelid's position to remain fixed during the healing process. The canthopexy is dissolved after four to six weeks of use. For particular patients, a mid-face elevation may be required to rejuvenate the lower eyelid-cheek complex. [ 14 ] [ unreliable source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5438", "text": "The anatomic condition of the eyelids, the \"wear-and-tear\" quality of the patient's skin, age, and the general condition of the adjacent tissues affect the functional and aesthetic results achieved. Additional to the anatomic conditions of the eye region of the patient, the possible occurrence of  medical complications  is determined by factors including: [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5439", "text": "As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures.  Aulus Cornelius Celsus , a first-century Roman, described making an excision in the skin to relax the eyelids in his book  De Medicina . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5440", "text": "Karl Ferdinand von Gr\u00e4fe  coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5441", "text": "Laser blepharoplasty is the performance of eyelid  surgery using a laser  instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation, as the two procedures can be performed in conjunction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5442", "text": "A  CO 2  laser  blepharoplasty offers many benefits over a blepharoplasty performed using a scalpel. Some of these benefits include less bleeding, shortened surgical time, better intraoperative visibility, less bruising and swelling, less pain or discomfort, and smoother healing. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5443", "text": "Historically there has been some contention as to the categorization of laser treatment on upper or lower eyelids as blepharoplasty, which is itself by definition surgical. The statutory definition of surgery and that supported by the American College of Surgeons states that surgery is the \"treatment ... by any instrument causing localized alteration or transportation of live human tissue, which include lasers...\". [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5444", "text": "Boston keratoprosthesis  ( Boston KPro ) is a collar button design  keratoprosthesis  or  artificial cornea . [ 1 ]  It is composed of a front plate with a stem, which houses the optical portion of the device, a back plate and a titanium locking c-ring. [ 2 ]  It is available in type I and type II formats. The type I design is used much more frequently than the type II which is reserved for severe end stage dry eye conditions and is similar to the type I except it has a 2\u00a0mm anterior nub designed to penetrate through a tarsorrhaphy. The type I format will be discussed here as it is more commonly used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5445", "text": "The type I Kpro is available in single standard pseudophakic power or customized  aphakic  optic with an 8.5\u00a0mm diameter adult size or 7.0\u00a0mm diameter pediatric size back plate. The device is currently machined from medical grade  polymethylmethacrylate (PMMA)  in  Wilmington, Massachusetts  in the  United States . [ 3 ]  During implantation of the device, the device is assembled with a donor corneal graft positioned between the front and back plate which is then sutured into place in a similar fashion to  penetrating keratoplasty (corneal transplantation) . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5446", "text": "The Boston KPro is a treatment option for corneal disorders not amenable to standard  penetrating keratoplasty (corneal transplantation)  or corneal transplant. The Boston KPro is a proven primary treatment option for repeat graft failure, [ 5 ]  herpetic keratitis, [ 6 ]   aniridia [ 7 ]  and many pediatric congenital corneal opacities including Peter's anomaly. [ 8 ]  The device is also used to treat  cicatrizing  conditions including  Stevens\u2013Johnson syndrome [ 9 ]  and  ocular cicatricial pemphigoid , and also  ocular burns . [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5447", "text": "Most common postoperative complications in order of decreasing prevalence include retroprosthetic membrane (RPM), elevated intraocular pressure/glaucoma, infectious endophthalmitis, sterile vitritis, retina detachment (rare) and vitreous hemorrhage (rare). [ 12 ] [ 13 ] [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5448", "text": "Four major studies have been completed to date showing outcomes with the type I Boston KPro:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5449", "text": "Boston ophthalmologist Swedish origins  Claes Henrik Dohlman  began developing the Boston keratoprosthesis in 1965, [ 19 ]  and refined it over the next decades. [ 20 ]  It was approved by the U.S.  Food and Drug Administration  in 1992. [ 20 ]  Fewer than 50 of the devices had been implanted before 2002, when popularity began increasing. [ 21 ]  1,161 had been placed by 2009, [ 21 ]  8,000 by 2012, [ 22 ]  9,000 by 2014. [ 21 ]  and 16,000 by 2020. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5450", "text": "The design of the device has evolved over its history. In 1996, eight holes were added in the back plate. [ 21 ]  The holes allow the  aqueous humour  fluids of the eye to provide nutrients to  the donor graft  stroma  and  keratocytes . [ 24 ]  The device is now available with either eight or 16 holes. [ 21 ]  In 2004, a  titanium  locking c-ring was added to prevent intraocular unscrewing of the device. [ 2 ]  In 2007, a threadless design replaced the previous screw-type one, simplifying assembly and reducing damage to the donor graft when the device is assembled during the surgical procedure. [ 24 ]  The back plate was changed to titanium in 2012, due to  titanium's biocompatibility . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5451", "text": "Canthotomy  (also called  lateral canthotomy  and  canthotomy with cantholysis ) is a surgical procedure where the lateral  canthus , or corner, of the  eye  is cut to relieve the  fluid pressure  inside or behind the eye, known as  intraocular pressure  (IOC). [ 1 ]  The procedure is typically done in emergency situations when the intraocular pressure becomes too high, which can damage the  optic nerve  and lead to blindness if left untreated. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5452", "text": "The most common cause of elevated intraocular pressure is orbital  compartment syndrome  (OCS) caused by trauma,  retrobulbar hemorrhage , infections, tumors, or prolonged  hypoxemia . [ 3 ]   Absolute contraindications  to canthotomy include  globe rupture . Complications include bleeding, infections, cosmetic deformities, and functional impairment of eyelids. [ 3 ]  Lateral canthotomy further specifies that the lateral canthus is being cut. Canthotomy with cantholysis includes cutting the  lateral palpebral ligament , also known as the canthal tendon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5453", "text": "The first case of orbital compartment syndrome causing monocular blindness was published in 1950 due to a complication of a  zygomatic fracture  repair. [ 4 ]  In 1953, the first surgical orbital decompression was performed. Two incisions below and above the external canthus were made and  surgical drains  were put in place. [ 5 ]  In 1990, the first lateral canthotomy procedure as presently performed was completed. [ 6 ]  In 1994, lateral canthotomy was first published in a review of procedures that emergency physicians can perform.  [ 7 ]  Today, a canthotomy is almost always performed with cantholysis of the inferior canthal tendon as this provides the best decompression of intraocular pressure. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5454", "text": "A canthotomy is often used as a last resort to decompress orbital compartment syndrome. Orbital compartment syndrome can be caused by trauma, infections, tumors, retrobulbar hemorrhage, or prolonged hypoxemia. [ 9 ]  Orbital compartment syndrome can be recognized by elevated intraocular pressure, globe compressibility,  afferent pupillary defect ,  proptosis , decreased visual acuity, and decreased  extraocular muscle  movements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5455", "text": "Studies in animals have demonstrated irreversible vision loss within 90 to 120 minutes, further indicating the emergent nature of this procedure.  [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5456", "text": "In an unconscious patient who is unable to comply with a physical exam, an intraocular pressure greater than 40 indicates emergent canthotomy. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5457", "text": "The foremost absolute contraindication to canthotomy is  globe rupture , sometimes referred to as an open globe injury. [ 9 ]  Globe rupture can be recognized by these symptoms or physical exam features:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5458", "text": "Due to the emergent nature of this procedure and the possibility of restoring or preventing vision loss, globe rupture is the only absolute contraindication."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5459", "text": "Due to portions of the procedure having poor visualization of anatomical structures, and the overall rarity and difficulty of the procedure,  iatrogenic  globe injury is an immediate complication that can occur. Other complications include infections, bleeding, cosmetic deformities, and functional impairment of eyelids. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5460", "text": "Due to the infrequency and difficulty of canthotomy,  emergency medicine physicians  defer more than 50\u00a0percent of canthotomies to a consulting physician, [ 10 ]  which in turn can increase time to treatment. In an effort to decrease difficulty and improve patient outcomes, vertical lid split or paracanthal \"one-snip\" procedures have been studied. This is performed by making a full-thickness vertical incision a few millimeters medial from the lateral canthus in both the upper and lower eyelids. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5461", "text": "Capsulotomy  (BrE /k\u00e6psju\u02d0'l\u0252t\u0259mi/, AmE /k\u00e6psu\u02d0'l\u0251\u02d0t\u0259mi/) [ 1 ]  is a type of eye surgery in which an incision is made into the  capsule  of the  crystalline lens  of the eye. In modern  cataract  operations, the lens capsule is usually not removed. The most common forms of  cataract surgery  remove nearly all of the crystalline lens but do not remove the crystalline lens capsule (the outer \"bag\" layer of the crystalline lens). The crystalline lens capsule is retained and used to contain and position the  intraocular lens implant  (IOL)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5462", "text": "The removal of the central part of the anterior lens capsule during cataract surgery is known as anterior capsulotomy. It gives the surgeon access to the lens inside so that it can be removed. The remaining part of the capsule is left in place and provides a barrier between the anterior and posterior chambers that prevents leakage of the vitreous into the anterior chamber, and provides a natural support for an implanted intraocular lens in the optimum position. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5463", "text": "Can opener capsulotomy is done by making a circular opening of 5\u20136\u00a0mm diameter in the anterior capsule, by series of small cuts or tears made with a  cystitome . [ 2 ]   Jacques Daviel  invented this technique in 1752. [ 2 ]  This technique was commonly done during extracapsular cataract extraction (ECCE). It often leaves stress raisers at the junction between cuts, which predisposes the edge to further tearing under stress."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5464", "text": "Manual capsulorhexis and particularly the commonly used technique known as  continuous curvilinear capsulorhexis  (CCC), is used to remove the anterior part of the capsule of the lens by  shear  and tensile forces. In effect, by controlled tearing, as opposed to cutting. A well constructed capsulorhexis using the method has good circularity and no stress raisers along the edge of the tear The method can efficiently create different sizes of smooth and circular capsulotomy with a smooth, strong edge that resists tearing during cortical removal and lens implantation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5465", "text": "Envelope capsulotomy is done by making a linear incision in upper one-third of anterior capsule, after which the nucleus is extracted and cortical matter arpirated. After cataract removal cuts are started at the ends of the incision and the opening for implantation is formed by tearing as in CCC. There is a lower risk of radial tearing than with the can-opener method. [ 2 ]  \nSourdilla and Baikuff suggested this technique in 1979. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5466", "text": "This technique uses a  femtosecond laser  to do capsulotomy. The laser produces a precisely spaced row of adjacent perforations through the capsule, and can produce uniformly circular, accurately centred cuts compared with manual CCC, but the edges are relatively rough and this can reduce tear strength due to stress concentrations, though statistically the incidence of tears is low. The equipment is also expensive, and the method is associated with higher incidence of  capsular block syndrome . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5467", "text": "Plasma blade capsulotomy uses plasma technology to make a circular incision through the anterior capsule. The energy destroys the molecular structure, and caused transient microscopic plasma and cavitation bubbles in the tissue. The power output and heating effects are small, it does not cause bleeding, and when used correctly there is no collateral tissue damage. There is no tearing stress applied to the capsule during the cut, and the tip cuts along the line of contact with the capsule, as guided by the surgeon. The cut edge may not be as strong as the edge produced by manual CCC. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5468", "text": "Precision Pulse Capsulotomy is a non laser capsulotomy procedure performed using a device with a soft collapsible tip and circular  Nitinol  cutting element that is connected to a control console. The Nitinol tip can be collapsed sufficiently to pass through an incision of about 2.2 mm, after which it springs back into circular shape inside the anterior chamber. The device is moved into contact with the anterior capsule, held in position by suction, and uses 4 millisecond electrical pulses to make a circular incision of exact size and shape, without overheating the chamber. The edge of the incision is smooth, but care must be taken to ensure a complete cut. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5469", "text": "Months or years after the  cataract operation , the remaining posterior lens capsule can become opaque and vision will be reduced in about 20\u201325% of eyes. [ 4 ]  This is known as posterior capsule opacification (PCO). PCO is best treated by posterior capsulotomy using  YAG laser . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5470", "text": "Retinal detachment ,  ocular hypertension  and  IOL  dislocation are the major complications of posterior capsulotomy. [ clarification needed ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5471", "text": "Clear lens extraction , also known as  refractive lensectomy ,  custom lens replacement  or  refractive lens exchange  is a surgical procedure in which clear  lens  of the human eye is removed. Unlike  cataract surgery , where the cloudy lens is removed to treat a  cataract , clear lens extraction is done to surgically correct  refractive errors  such as high  myopia . It can also be done in  hyperopic  or  presbyopic  patients who wish to have a  multifocal IOL  implanted to avoid wearing glasses. It is also used as a treatment for diseases such as  angle closure glaucoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5472", "text": "As opposed to procedures that use lasers to make corrections to the corneal surface, such as  LASIK , the clear lens extraction procedure uses the same procedures as cataract surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5473", "text": "Clear lens extraction can be done in patients with severe refractive error and/or presbyopia who wish to avoid spectacles. [ 2 ] [ 3 ]  It is often necessary in patients with severe refractive error who cannot undergo other  refractive procedures  such as LASIK or  photorefractive keratectomy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5474", "text": "Clear lens extraction is also used as a treatment of choice in patients with diseases such as  angle closure glaucoma . [ 4 ]  A study also found that CLE is even more effective than laser peripheral  iridotomy  in patients with angle closure glaucoma. [ 5 ] [ 6 ]  A systematic review comparing lens extraction and laser peripheral  iridotomy  for treating acute primary angle closure found that lens extraction potentially provides better  intraocular pressure  control and reduces medication needs over time. However, it remains uncertain if it significantly lowers the risk of  recurrent episodes  or reduces the need for additional  surgeries . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5475", "text": "Procedure is similar to  cataract surgery , most commonly followed by an  intraocular lens  implantation. In patients requiring only distance vision correction, a conventional mono-focal intraocular lens is placed in both eyes after the clear lens is removed. [ 1 ]  While distance vision is fine in this,  reading glasses  are required for near vision. [ 1 ]  Another method is to correct one eye only for distance vision and the other eye for near vision only. [ 1 ]  The best way to achieve both distance vision and near vision is to place  multifocal IOLs  or  accommodating IOLs  in both eyes. [ 1 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5476", "text": "The intraocular lens power calculations for clear lens extraction is similar to calculations used for conventional cataract surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5477", "text": "Under topical anesthesia, through a 2.2 mm  corneal  incision, the lens  nucleus  and cortex are removed by irrigation and aspiration technique using a  phaco  machine. [ 9 ]  After removal of lens material, the viscoelastic solution initially instilled is removed from the  anterior chamber , intraocular lens is inserted and the corneal wound is closed by  stromal  hydration method. [ 9 ]  In some people with very high myopia, the eye may be left  aphakic , without intraocular lens implantation. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5478", "text": "In addition to the common complications of cataract surgery, clear lens extraction may also cause premature posterior  vitreous detachment  and  retinal detachment , [ 2 ]  particularly in patients with high Myopia. However, modern surgical techniques and advanced lens technology have significantly reduced the likelihood of this and other complications. The procedure is generally safe and effective when performed by experienced surgeons, with most patients experiencing improved vision post-surgery without major complications.  [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5479", "text": "As opposed to the more commonly performed cataract treatment, the idea of removing the lens exclusively for refractive purposes first emerged in the 18th century. [ 12 ]  French ophthalmologist Abb\u00e9 Desmonceaux may be the first to suggest such an operation in 1776 for a patient with high myopia. [ 12 ]  He recommended the operation to Baron Michael Johann de Wenzel, although it is not known whether he ever performed the operation. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5480", "text": "The first systematic work on clear lens extraction was carried out by Polish ophthalmologist  Vincenz Fukala  in Vienna. Fucala advised clear lens extraction in young high myopic (\u221213 diopters or more) patients with poor vision and inability to work. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5481", "text": "A  conformer  is a clear  acrylic  shell fitted after an  enucleation of the eye [ 1 ]  if the final artificial eye is not available at the time of surgery, to hold the shape of the  eye socket  and allow the eyelids to blink over the shell without rubbing the  suture  line.\nThe conformer shell holds the shape ready for the artificial eye, and is worn for six to eight weeks after surgery.\nSome  ocularists  will make a temporary artificial eye which can be worn as the conformer shell. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5482", "text": "A  corneal button  is a replacement  cornea  to be transplanted in the place of a damaged, diseased or  opacified  cornea, normally approximately 8.5\u20139.0mm in diameter. [ 1 ]  It is used in a  corneal transplantation  procedure (also corneal grafting) whereby the whole, or part, of a cornea is replaced. [ 2 ]  The donor tissue can now be held for days to even weeks of the donor's death and is normally a small, rounded shape. [ 3 ]  The main use of the corneal button is during procedures where the entirety of the cornea needs to be replaced, also known as penetrating keratoplasty. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5483", "text": "Greek physician  Galen  is said to have first consider the possibility of corneal transplantation [ 4 ]  however, there is no evidence that he actually attempted the procedure. [ 5 ]  It was only until the 18th century that early surgical proposals for keratoplasty would arise and the 19th century for experimentation in the field to begin. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5484", "text": "In 1813, Karl Himley suggested that opaque animal corneas can be replaced by transplanting corneas from other animals; with his student Franz Reisenger commencing experimentation in 1818. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5485", "text": "In 1844, Edward Kissam undertook the first ever recorded attempt of a xenograft on a human; the donor was a pig and was ultimately unsuccessful. [ 6 ]  Henry Power made a suggestion in 1867 that using human tissue rather than animal tissue for transplantation would be more effective however, it would not be until 1905 for the first successful human corneal transplant by MD,  Eduard Zirm . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5486", "text": "Since 1905, various techniques and procedures have been developed to increase the effect of the transplantation and success rate. Traditionally, the most common procedure for corneal transplantation was penetrating keratoplasty whereby an entire corneal button is replaced. [ 6 ]  Recently however, procedures such as anterior and posterior lamellar techniques where only diseased or damaged layers of the cornea are selectively replaced have become increasingly popular. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5487", "text": "After the death of the donor, the cornea must be retrieved within a few hours and will be screened for diseases and assessed for its viability to be used for a corneal transplantation by assessing its health. If passed, the cornea will be stored in a nutrient solution at an  eye bank  until needed for an operation. [ 1 ]  In most cases, the corneal button is removed from the donor cornea prior to storage as this extends its possible storage time. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5488", "text": "For the operation procedure, the patient is anaesthetised and the damaged or diseased corneal button will be removed using a bladed instrument called a  trephine  (approximately 8.0\u20138.5mm in diameter). [ 7 ]  A corneal button of matching size is then put in place of the removed tissue and stitched in place. Usually, twelve clock-hour nylon stitches are used with a continuous band nylon stitch. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5489", "text": "The procedure takes approximately 60\u201390 minutes however, a few months will be required for vision to return to what it was like preceding the operation; and continue to improve from then on.  Approximately 12\u201318 months after the operation, all stitches will be removed. During this time,  anti-rejection  drops will be needed to minimise inflammation; the dosage of which is carefully monitored by a corneal surgeon. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5490", "text": "Due to the swelling, it is impossible to predict the quality of vision without removing the stitches. A few months after the stitches are removed, measurements are made of the shape of the cornea and  refractive error . If the shape of the cornea is fairly regular and refractive error is similar to that of the other eye, it is usually possible to fix any error with  glasses ; if not, a hard lens may be necessary to correct vision. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5491", "text": "One of the largest causes for issue in penetrating keratoplasty is the natural  immune rejection  of a transplanted corneal button which can cause reversible or irreversible damage to the grafted cornea. The types corneal rejection include epithelial rejection, chronic rejection, hyperacute rejection and endothelial rejection and these can occur individually, or in some cases in conjunction. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5492", "text": "There are however, two main preventative methods to reduce the possibility of immune rejection; prevention and management. Prevention involves increasing compatibility of the donor tissue with that of the patient and suppressing host  immune response . These analyses of donor corneas are done during a screening phase soon after receiving the donation. The management aspect mainly involves early detection and therapy with  corticosteroids  along with  Immunosuppressive therapy . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5493", "text": "There are two main storage methods used in the storage of the corneal button. They are stored using a hypothermic storage method or an organ culture method in a  tissue culture  medium. Corneal buttons cannot be reliably frozen as a storage method. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5494", "text": "Usually, the corneal button is removed from the entire globe before storage as this extends the possible storage time. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5495", "text": "The hypothermic storage method was first introduced in 1974 [ 9 ]  and it requires no complex equipment. It is stored in a refrigerator, usually 2\u20136\u00a0\u00b0C, in commercially available storage solutions. Factors such as the temperature, maximal storage time, expiry date, etc. should be maintained according to the storage solution manufacturer's recommendations and can vary depending on the solution. Also, provided donor screening permits are available, the corneal tissue can be used immediately after leaving storage for surgery. Inspection of tissue can however be performed in a closed system under a  slit lamp  or specular microscope. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5496", "text": "The organ culture method, first introduced in 1976, [ 10 ]  is however quite complicated. The corneal button is stored in an incubator approximately 30\u201337\u00a0\u00b0C in a tissue culture medium into which either fetal or new-born calf serum,  antibiotics  and  antimycotics  are added. The corneal cells are also injected with dehydrating  macromolecules  to maintain hydration, this causes the corneal button to swell to approximately twice its original thickness during storage. During storage, the medium must be replaced within every 10\u201314 days. When it is required for surgery, the swollen tissue is placed in a  dextrin  containing storage medium which brings down the swelling and must also be inspected under strict aseptic conditions. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5497", "text": "There are rigorous criteria for donor selection as it is essential to minimise possibility of disease transmission. These criteria focuse on medial medical records and post-mortem  serological tests  which aim not to eliminate risk, but to limit risk to a reasonable level, a balance between safety and availability. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5498", "text": "A health history report is usually used, however, death certificate reports and data from family and acquaintances are also acceptable substitutions. The donation is rejected if no information can be found. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5499", "text": "Donations can be rejected or limited if some specific diseases are found in a donor's medical history. Diseases transmissible via corneal transplantation include  bacterial infection  and  fungal infection , [ 12 ]   rabies , [ 13 ]   Hepatitis B [ 14 ]  and  retinoblastoma . [ 15 ]  Diseases likely to be transmissible via corneal transplantations include  HIV ,  Herpes simplex virus  and  Prion disease . [ 16 ]  There are also many other diseases which may result in rejection of donations. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5500", "text": "Corneal cross-linking  ( CXL ) with  riboflavin  (vitamin B 2 ) and  UV-A  light is a surgical treatment for corneal ectasia such as  keratoconus ,  PMD , and  post-LASIK ectasia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5501", "text": "It is used in an attempt to make the cornea stronger. According to a 2015 Cochrane review, there is insufficient evidence to determine if it is useful in  keratoconus . [ 2 ]  In 2016, the  US Food and Drug Administration  approved riboflavin ophthalmic solution crosslinking based on three 12-month clinical trials. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5502", "text": "A 2015  Cochrane review  found that the evidence on corneal cross-linking was insufficient to determine if it is an effective procedure for the treatment of  keratoconus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5503", "text": "Among those with keratoconus who worsen, CXL may be used. In this group, the most common side effects are haziness of the cornea, punctate keratitis, corneal striae, corneal epithelium defect, and eye pain. [ 4 ]  In those who use it after  post-LASIK ectasia , the most common side effects are haziness of the cornea, corneal epithelium defect, corneal striae, dry eye, eye pain, punctate keratitis, and sensitivity to bright lights. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5504", "text": "There are no long-term studies about crosslinking effect on pregnancy and lactation. According to a manufacturer crosslinking should not be performed on pregnant women. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5505", "text": "People undergoing crosslinking should not rub their eyes for the first five days after the procedure. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5506", "text": "Corneal cross-linking involves application of  riboflavin  solution to the eye that is activated by illumination with  UV-A  light for approximately 30 or fewer minutes. The riboflavin causes new bonds to form across adjacent collagen strands and proteoglycans in the stromal layer of the  cornea , which recovers and preserves some of the cornea's mechanical strength. The corneal epithelial layer is generally removed to increase penetration of the riboflavin into the  stroma , a procedure known as the Dresden protocol. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5507", "text": "People that are considered for treatment must undergo an extensive clinical workup, including corneal tomography, computerized  corneal topography , endothelial  microscopy , ultrasound  pachymetry ,  b-scan   sonography ,  keratometry  and biomicroscopy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5508", "text": "The technique was first developed in Germany in 1997 by  Theo Seiler  and his team at the  Dresden University of Technology . [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5509", "text": "In Germany, CXL has been used in patients with keratoconus since 1998, [ 8 ]  and in Italy, routine interventions have been successfully performed since 2005. [ 10 ]  The standard (Dresden) CXL protocol with  epithelium  removal, is approved for use throughout Europe."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5510", "text": "In the United States, clinical trials commenced only in 2008. Based on three 12-month clinical trials, the  US Food and Drug Administration  approved riboflavin ophthalmic solution and Avedro's KXL system for crosslinking on 18 April 2016, for the treatment of progressive keratoconus, and on 19 July 2016, for corneal ectasia after refractive surgery, making them the first FDA approved treatment for keratoconus and post-LASIK ectasia. [ 3 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5511", "text": "Research studying the safety and efficacy of corneal cross-linking is ongoing. [ 4 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5512", "text": "Transepithelial or epithelium-on (epi-on) cross-linking is a technique which was first performed in 2004 in the U.S., [ 14 ]  the corneal epithelium layer is left intact. [ 15 ]  in this technique, because the epithelium is not removed, riboflavin loading requires more time than with epi-off techniques, and may be less effective, as keratoconus progression may be more likely in epi-on procedures. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5513", "text": "Contact lens-assisted cross-linking (CACXL) may be performed for people with corneal stromal thickness between 350\u00a0\u03bcm to 400\u00a0\u03bcm after epithelial removal. in this method a pre-corneal riboflavin film, a riboflavin-soaked UV barrier-free  soft contact lens  of negligible power and a pre-contact lens riboflavin film are used to decrease UV irradiance to safe levels at the level of the endothelium. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5514", "text": "Topography-guided crosslinking relies on an active eye tracker to allow a patterned delivery of UV light. Both the power and pattern can be programmed into the unit based on the topography of the individual's eyes. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5515", "text": "Accelerated crosslinking allows a shorter treatment time by delivering the same energy more quickly, compared to the standard crosslinking procedure, which involves 3\u00a0mW of UV-A exposure for 30 minutes. [ 19 ]  Some hospitals are using this accelerated CXL technique delivering a similar amount of UV-A energy in eight to ten minutes, following research showing the cornea may better tolerate this shorter burst of UV-A. [ 20 ] [ 21 ]  However, a recent study using the real-world registry data showed that the standard (Dresden) CXL was associated with better visual and corneal curvature outcomes 5-years post-surgery. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5516", "text": "Corneal transplantation , also known as  corneal grafting , is a  surgical procedure  where a damaged or diseased  cornea  is replaced by  donated corneal tissue  (the graft). When the entire cornea is replaced it is  known as  penetrating keratoplasty  and when only part of the cornea is replaced it is known as  lamellar keratoplasty . Keratoplasty simply means surgery to the cornea. The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5517", "text": "The cornea is the  transparent  front part of the  eye  that covers the  iris ,  pupil  and  anterior chamber . The surgical procedure is performed by  ophthalmologists , physicians who specialize in eyes, and is often done on an  outpatient  basis. Donors can be of any age, as is shown in the case of  Janis Babson , who donated her eyes after dying at the age of 10. [ 1 ] [ 2 ]  Corneal transplantation is performed when medicines,  keratoconus  conservative surgery and cross-linking can no longer heal the  cornea ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5518", "text": "This surgical procedure usually treats corneal blindness, [ 3 ] [ 4 ]  with success rates of at least 41% as of 2021. [ 5 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5519", "text": "Indications include the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5520", "text": "The risks are similar to other intraocular procedures, but additionally include graft rejection (lifelong), detachment or displacement of lamellar transplants and primary graft failure. Use of immunosuppressants including cyclosporine A, tacrolimus, mycophenolate mofetil, sirolimus, and leflunomide  to prevent graft rejection is increasing but there is insufficient evidence to ascertain which immunosuppressant is better. [ 8 ]  In a Cochrane review which included low to moderate quality evidence, adverse effects were found to be common with systemic mycophenolate mofetil, but less common with topical cyclosporine A or tacrolimus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5521", "text": "There is also a risk of  infection . Since the cornea has no blood vessels (it takes its nutrients from the  aqueous humor ) it heals much more slowly than a cut on the skin. While the  wound  is healing, it is possible that it might become infected by various  microorganisms . This risk is minimized by antibiotic  prophylaxis  (using antibiotic eyedrops, even when no infection exists)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5522", "text": "There is a risk of cornea rejection, which occurs in about 10% of cases. [ 9 ]  Graft failure can occur at any time after the cornea has been transplanted, even years or decades later. The causes can vary, though it is usually due to new injury or illness. Treatment can be either medical or surgical, depending on the individual case. An early, technical cause of failure may be an excessively tight stitch  cheesewiring  through the  sclera ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5523", "text": "Infectious disease transmission through corneal transplantation is exceedingly rare. [ 10 ]  All corneal grafts are screened for the presence of viruses such as HIV or hepatitis through antibody or nucleic acid testing, and there has never been a reported case of HIV transmission through corneal transplant surgery. [ 11 ]  Prior to the development of reliable HIV testing, many countries instituted  bans on corneal donation by gay men . For example, on 20 May 1994, the United States banned corneal donation by any man who has had sex with another man in the preceding 5 years, even if all HIV testing is negative (a policy which continues to be enforced today). [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5524", "text": "On the day of the  surgery , the patient arrives to either a  hospital  or an outpatient surgery center, where the procedure will be performed. The patient is given a brief physical examination by the surgical team and is taken to the  operating room . In the operating room, the patient lies down on an operating table and is either given  general anesthesia , or  local anesthesia  and a  sedative ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5525", "text": "With anesthesia induced, the surgical team prepares the eye to be operated on and drapes the face around the eye. An eyelid  speculum  is placed to keep the lids open, and some lubrication is placed on the eye to prevent drying. In children, a metal ring is stitched to the sclera which will provide support of the sclera during the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5526", "text": "In most instances, the person will meet with their ophthalmologist for an examination in the weeks or months preceding the surgery. During the exam, the ophthalmologist will examine the eye and diagnose the condition. The doctor will then discuss the condition with the patient, including the different treatment options available. The doctor will also discuss the risks and benefits of the various options. If the patient elects to proceed with the surgery, the doctor will have the patient sign an  informed consent  form. The doctor might also perform a physical examination and order lab tests, such as blood work,  X-rays , or an  EKG ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5527", "text": "The surgery date and time will also be set, and the patient will be told where the surgery will take place. Within the United States, the supply of corneas is sufficient to meet the demand for surgery and research purposes. Therefore, unlike other tissues for transplantation, delays and shortages are not usually an issue. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5528", "text": "A trephine (a circular cutting device), which removes a circular disc of cornea, is used by the surgeon to cut the donor cornea. A second trephine is then used to remove a similar-sized portion of the patient's cornea.  The donor tissue is then sewn in place with sutures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5529", "text": "Antibiotic   eyedrops  are placed, the eye is patched, and the patient is taken to a recovery area while the effects of the anesthesia wear off. The patient typically goes home following this and sees the doctor the following day for the first postoperative appointment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5530", "text": "Lamellar keratoplasty encompasses several techniques which selectively replace diseased layers of the cornea while leaving healthy layers in place.  The chief advantage is improved tectonic integrity of the eye.  Disadvantages include the technically challenging nature of these procedures, which replace portions of a structure only 500\u00a0 \u03bcm  thick, and reduced optical performance of the donor/recipient interface compared to full-thickness keratoplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5531", "text": "In this procedure, the anterior layers of the central cornea are removed and replaced with donor tissue.  Endothelial  cells and the Descemets membrane are left in place.  This technique is used in cases of anterior corneal opacifications, scars, and ectatic diseases such as keratoconus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5532", "text": "Endothelial keratoplasty replaces the patient's endothelium with a transplanted disc of posterior stroma/Descemets/endothelium (DSEK) or Descemets/endothelium (DMEK). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5533", "text": "This relatively new procedure has revolutionized treatment of disorders of the innermost layer of the cornea (endothelium). Unlike a full-thickness corneal transplant, the surgery can be performed with one or no sutures.  Patients may recover functional vision in days to weeks, as opposed to up to a year with full thickness transplants. However, an Australian study has shown that despite its benefits, the loss of endothelial cells that maintain transparency is much higher in DSEK compared to a full-thickness corneal transplant. The reason may be greater tissue manipulation during surgery, the study concluded. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5534", "text": "During surgery the patient's corneal endothelium is removed and replaced with donor tissue.  With DSEK, the donor includes a thin layer of stroma, as well as endothelium, and is commonly 100\u2013150\u00a0\u03bcm thick. With DMEK, only the endothelium is transplanted. In the immediate postoperative period the donor tissue is held in position with an air bubble placed inside the eye (the anterior chamber).  The tissue self-adheres in a short period and the air is adsorbed into the surrounding tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5535", "text": "Complications include displacement of the donor tissue requiring repositioning (\"refloating\").  This is more common with DMEK than DSEK.  Folds in the donor tissue may reduce the quality of vision, requiring repair.  Rejection of the donor tissue may require repeating the procedure.  Gradual reduction in endothelial cell density over time can lead to loss of clarity and require repeating the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5536", "text": "Patients with endothelial transplants frequently achieve best corrected vision in the 20/30 to 20/40 range, although some reach 20/20.  Optical irregularity at the graft/host interface may limit vision below 20/20."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5537", "text": "The  Boston keratoprosthesis  is the most widely used synthetic cornea to date with over 900 procedures performed worldwide in 2008. The Boston KPro was developed at the  Massachusetts Eye and Ear  Infirmary under the leadership of Claes Dohlman. [ 16 ] [ further explanation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5538", "text": "In cases where there have been several graft failures or the risk for keratoplasty is high, synthetic corneas can substitute successfully for donor corneas. Such a device contains a peripheral skirt and a transparent central region. These two parts are connected on a molecular level by an  interpenetrating polymer network , made from  poly-2-hydroxyethyl methacrylate  (pHEMA). AlphaCor is a U.S.  FDA -approved type of synthetic cornea measuring 7.0\u00a0mm in diameter and 0.5\u00a0mm in thickness. The main advantages of synthetic corneas are that they are biocompatible, and the network between the parts and the device prevents complications that could arise at their interface. The probability of retention in one large study was estimated at 62% at 2 years follow-up. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5539", "text": "In a very rare and complex multi-step surgical procedure, employed to help the most disabled patients, a lamina of the person's tooth is grafted into the eye, with an artificial lens installed in the transplanted piece. [ clarification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5540", "text": "The prognosis for visual restoration and maintenance of ocular health with corneal transplants is generally very good.  Risks for failure or guarded prognoses are multifactorial.  The type of transplant, the disease state requiring the procedure, the health of the other parts of the recipient eye and even the health of the donor tissue may all confer a more or less favorable prognosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5541", "text": "The majority of corneal transplants result in significant improvement in visual function for many years or a lifetime.  In cases of rejection or transplant failure, the surgery can generally be repeated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5542", "text": "Different types of  contact lenses  may be used to delay or eliminate the need for corneal transplantation in corneal disorders."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5543", "text": "Diseases that only affect the surface of the cornea can be treated with an operation called  phototherapeutic keratectomy  (PTK). With the precision of an excimer laser and a modulating agent coating the eye, irregularities on the surface can be removed. However, in most of the cases where corneal transplantation is recommended, PTK would not be effective."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5544", "text": "In corneal disorders where vision correction is not possible by using contact lenses,  intrastromal corneal ring segments  may be used to flatten the cornea, which is intended to relieve the  nearsightedness  and  astigmatism . In this procedure, an  ophthalmologist  makes an incision in the cornea of the eye, and inserts two crescent or semi-circular shaped ring segments between the layers of the corneal  stroma , one on each side of the  pupil . [ 18 ]  Intrastromal corneal rings were approved in 2004 by the  Food and Drug Administration  for people with keratoconus who cannot adequately correct their vision with glasses or contact lenses. They were approved under the  Humanitarian Device Exemption , [ 19 ] [ 20 ]  which means the manufacturer did not have to demonstrate effectiveness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5545", "text": "Corneal collagen cross-linking  may delay or eliminate the need for corneal transplantation in  keratoconus  and  post-LASIK ectasia . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5546", "text": "Corneal transplant is one of the most common transplant procedures. [ 22 ]   Although approximately 100,000 procedures are performed worldwide each year, some estimates report that 10,000,000 people are affected by various disorders that would benefit from corneal transplantation. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5547", "text": "In Australia, approximately 2,000 grafts are performed each year. [ 22 ]  According to the  NHS Blood and Transplant , over 2,300 corneal transplant procedures are performed each year in the United Kingdom. [ 24 ]  In the one-year period ending 31 March 2006, 2,503 people received corneal transplants in the UK. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5548", "text": "The first cornea transplant was performed in 1905 by  Eduard Zirm  ( Olomouc Eye Clinic , now  Czech Republic ), making it one of the first types of transplant surgery successfully performed. Another pioneer of the operation was  Ram\u00f3n Castroviejo . Russian eye surgeon  Vladimir Filatov 's attempts at transplanting cornea started with the first try in 1912 and were continued, gradually improving until on 6 May 1931 he successfully grafted a patient using corneal tissue from a deceased person. [ 26 ]  He widely reported another transplant in 1936, disclosing his technique in full detail. [ 27 ]  In 1936, Castroviejo did a first transplantation in an advanced case of  keratoconus , achieving significant improvement in patient's vision. [ 28 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5549", "text": "Tudor Thomas , a clinical teacher for the Welsh National School of Medicine, conceived the idea of a donor system for corneal grafts and an eye bank was established in East Grinstead in 1955. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5550", "text": "Advances in  operating microscopes  enabled surgeons to have a more magnified view of the surgical field, while advances in  materials science  enabled them to use  sutures  finer than a human hair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5551", "text": "Instrumental in the success of cornea transplants were the establishment of  eye banks . These are organizations located throughout the world to coordinate the distribution of donated corneas to surgeons, as well as providing eyes for research. Some eye banks also distribute other  anatomical gifts ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5552", "text": "Blades are being replaced by high speed lasers in order to make surgical incisions more precise. These improved incisions allow the cornea to heal more quickly and the sutures to be removed sooner. The cornea heals more strongly than with standard blade operations. Not only does this dramatically improve visual recovery and healing, it also allows the possibility for improvement in visual outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5553", "text": "Since 2004, Amnitrans Eyebank in Rotterdam, The Netherlands, provides donor corneas pre-cut for advanced keratoplasty procedures, such as DSEK, DSAEK, FS-DSEK and DMEK. In 2007, Seattle-based  SightLife , one of the leading corneal tissue banks in the world, introduced a process for the preparation of donated corneal tissue using a femtosecond laser. This process is known as custom corneal tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5554", "text": "Endothelial keratoplasty (EK) was introduced by Melles et al. in 1998. Today there are two forms of EK: [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5555", "text": "Not all patients with diseased corneas are candidates for endothelial keratoplasty.  These procedures correct corneal endothelial failure, but are not able to correct corneal scarring, thinning, or surface irregularity. There is currently limited data on long-term survival of DMEK grafts however the early indications are very positive. An upcoming systematic review will seek to compare the safety and effectiveness of DMEK versus DSAEK in people with corneal failure from  Fuchs' endothelial dystrophy  and  pseudophakic bullous keratopathy . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5556", "text": "There is a  bioengineering  technique that uses stem cells to create corneas or part of corneas that can be transplanted into the eyes. Corneal stem cells are removed from a healthy cornea. They are collected and, through laboratory procedures,  made into five to ten layers of cells that can be stitched into a patient's eye. The stem cells are placed into the area where the damaged cornea tissue has been removed. This is a good alternative for those that cannot gain vision through regular cornea transplants. A new development, announced by the University of Cincinnati Medical School in May 2007, would use bone marrow stem cells to regrow the cornea and its cells. This technique, which proved successful in mouse trials, would be of use to those with inherited genetic degenerative conditions of the cornea, especially if other means like a transplant are not feasible. It works better than a transplant because these stem cells keep their ability to differentiate and replicate, and so keep the disease from recurring, longer and better."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5557", "text": "On 25 August 2010, investigators from Canada and Sweden reported results from the first 10 people in the world treated with the biosynthetic corneas. Two years after having the corneas implanted, six of the 10 patients had improved vision. Nine of the 10 experienced cell and nerve regeneration, meaning that corneal cells and nerves grew into the implant. To make the material, the researchers placed a human gene that regulates the natural production of collagen into specially programmed yeast cells. They then molded the resulting material into the shape of a cornea. This research shows the potential for these bioengineered corneas but the outcomes in this study were not nearly as good as those achieved with human donor corneas. This may become an excellent technique, but right now it is still in the prototype stage and not ready for clinical use. The results were published in the journal  Science Translational Medicine . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5558", "text": "A 2013 cost-benefit analysis by the  Lewin Group  for Eye Bank Association of America, estimated an average cost of $16,500 for each corneal transplant. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5559", "text": "Couching  is the earliest documented form of  cataract  surgery.  It involves dislodging the lens of the eye, thus removing the cloudiness caused by the cataract.  Couching was a precursor to  modern cataract surgery  and  pars plana vitrectomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5560", "text": "Cataract surgery by \u201ccouching\u201d (lens depression) is one of the oldest surgical procedures. The technique involves using a sharp instrument to push the cloudy lens to the bottom of the eye. Perhaps this procedure is that which is mentioned in the articles of the  Code of Hammurabi  (ca. 1792\u20131750 BC) though it is a mere speculation.   Sushruta , an ancient Indian surgeon, described the procedure in \u201cSushruta Samhita, Uttar Tantra\u201d, an Indian medical treatise (800 BC) (Duke-Elder, 1969; Chan, 2010). From then on the procedure was widespread throughout the world. Evidence shows that couching was widely practiced in China, Europe and Africa. After the 19th century AD, with the development of modern cataract surgery (Intra ocular extraction of lens (1748)), couching fell out of fashion, though it is still used in parts of Asia and Africa. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5561", "text": "Couching was practised in ancient India and subsequently introduced to other countries by the Indian physician  Sushruta  ( c.  6th century BCE), [ 1 ]  who described it in his work  Sushruta Samhita  (\"Compendium of Sushruta\"); the work's Uttaratantra section [ a ]  describes an operation in which a curved needle was used to push the opaque \"phlegmatic matter\" [ b ]  in the eye out of the way of vision. The phlegm was then said to be blown out of the nose. The eye would later be soaked with warm, clarified butter and then bandaged. Here is a translation from the original Sanskrit:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5562", "text": "vv. 55\u201356: Now procedure of surgical operation of  \u015blai\u1e63mika li\u1e45gan\u0101\u015ba  (cataract) will be described. It should be taken up (for treatment) if the diseased portion in the pupillary region is not shaped like half moon, sweat drop or pearl: not fixed, uneven and thin in the centre, streaked or variegated and is not found painful or reddish."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5563", "text": "vv. 57\u201361ab: In moderate season, after unction and sudation, the patient should be positioned and held firmly while gazing at his nose steadily. Now the wise surgeon leaving two parts of white circle from the black one towards the outer  canthus  should open his eyes properly free from vascular network and then with a barley-tipped rod-like instrument held firmly in hand with middle, index and thumb fingers should puncture the natural hole-like point with effort and confidence not below, above or in sides. The left eye should be punctured with right hand and vice-versa. When punctured properly a drop of fluid comes out and also there is some typical sound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5564", "text": "vv. 61bc\u201364ab: Just after puncturing, the expert should irrigate the eye with breast-milk and foment it from outside with  v\u0101ta -[wind-]alleviating tender leaves, irrespective of  do\u1e63a  [defect] being stable or mobile, holding the instrument properly in position. Then the pupillary circle should be scraped with the tip of the instrument while the patient, closing the nostril of the side opposite to the punctured eye, should blow so that  kapha  [phlegm] located in the region be eliminated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5565", "text": "vv. 64cd\u201367: When pupillary region becomes clear like cloudless sun and is painless, it should be considered as scraped properly. (If  do\u1e63a  [defect] cannot be eliminated or it reappears, puncturing is repeated after unction and sudation.) When the sights are seen properly the  \u015bal\u0101k\u0101  [probe] should be removed slowly, eye anointed with ghee and bandaged. Then the patient should lie down in supine position in a peaceful chamber. He should avoid belching, coughing, sneezing, spitting and shaking during the operation and thereafter should observe the restrictions as after intake of  sneha  [oil]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5566", "text": "v. 68: Eye should be washed with  v\u0101ta -[wind-]alleviating decoctions after every three days and to eliminate fear of (aggravation of)  v\u0101yu  [wind], it should also be fomented as mentioned before (from outside and mildly)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5567", "text": "v. 69: After observing restrictions for ten days in this way, post-operative measures to normalise vision should be employed along with light diet in proper quantity. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5568", "text": "Couching continues to be popular in some developing countries where modern surgery may be difficult to access or where the population may prefer to rely on traditional treatments.  It is commonly practiced in  Sub-Saharan Africa . [ 3 ]   In  Mali  it remains more popular than modern cataract surgery, despite the fact that the cost of both methods is similar, but with much poorer outcome with couching. [ 4 ]   In  Burkina Faso , a majority of patients were unaware of the causes of cataracts and believed it to be due to  fate . [ 3 ]   It is not performed by ophthalmologists, but rather by local healers or \" witch doctors \"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5569", "text": "A sharp instrument, such as a thorn or needle, is used to pierce the eye either at the edge of the  cornea  or the  sclera , near the  limbus .  The opaque lens is pushed downwards, allowing light to enter the eye.  Once the patients sees shapes or movement, the procedure is stopped.  The patient is left without a lens ( aphakic ), therefore requiring a powerful positive prescription lens to compensate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5570", "text": "Couching is a largely unsuccessful technique with abysmal outcomes.  A minority of patients may regain low or moderate visual acuity, but over 70% are left clinically blind with worse than 20/400 vision. [ 4 ]   A  Nigerian  study showed other complications include  secondary glaucoma ,  hyphaema , and  optic atrophy . [ 5 ]   Couching does not compare favourably to modern cataract surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5571", "text": "In  ophthalmology ,  cryoextraction  is a form of  intracapsular cataract extraction  in which a  cryoextractor , a special type of  cryoprobe , is used to freeze the  crystalline lens  and pull it intact from the  eye . [ 1 ]  Dr.  Charles Kelman  is credited with pioneering this surgical method in 1962. It can also be used in the treatment of orbital tumors. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5572", "text": "Cyclodestruction  or  cycloablation  is a surgical procedure done in management of  glaucoma . Cyclodestruction reduces  intraocular pressure  (IOP) of the eye by decreasing production of  aqueous humor  by the destruction of  ciliary body . Until the development of safer and less destructive techniques like micropulse diode cyclophotocoagulation and endocyclophotocoagulation, cyclodestructive surgeries were mainly done in refractory glaucoma, or advanced glaucomatous eyes with poor visual prognosis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5573", "text": "Cyclodestruction may be done by using  diathermy , penetrating cyclodiathermy,  cryotherapy ,  ultrasound ,  laser  or by  surgical excision. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5574", "text": "Cyclophotocoagulation  (CPC), the most common cyclodestructive procedure is done using laser beam of different wavelengths.  Ruby laser  (693\u00a0nm wavelength),  Nd:YAG laser  (1064\u00a0nm wavelength) or  diode laser  (810\u00a0nm wavelength) can be used to perform CPC. [ 2 ]  Commomon cyclophotocoagulation techniques include transscleral cyclophotocoagulation (TS-CPC), continuous-wave diode cyclophotocoagulation (CW-TSCPC), MicroPulse diode cyclophotocoagulation (MP-TSCPC), endocyclophotocoagulation (ECP) and high-intensity focused ultrasound cyclodestruction (HIFU). Complications are lesser with Trans-scleral diode laser cyclophotocoagulation and Endoscopic diode laser cyclophotocoagulation. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5575", "text": "Diode laser with a wavelength of 810\u00a0nm is used to perform trans-scleral cyclophotocoagulation. [ 2 ]  In TS-CPC, the laser absorbed by  melanin  of ciliary processes causes  photocoagulation . [ 6 ]  Since it is a painful procedure, TS-CPC is usually performed under  retrobulbar  or  peribulbar   anesthesia . [ 2 ]  Micropulse transscleral diode cyclophotocoagulation (MP-TSCPC), a modified TS-CPC procedure is a more safer procedure. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5576", "text": "Endocyclophotocoagulation (ECP) or endoscopic cyclophotocoagulation using an endoscope allows direct view of the ciliary processes during surgery. [ 8 ]  Compared to TS-CPC,  tissue disruption is lesser with ECP. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5577", "text": "Cyclocryotherapy is done by freezing the  ciliary processes  of the eye. [ 4 ]  In  neovascular glaucoma , cyclocryotherapy is advised when medical control of IOP is not possible. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5578", "text": "Inflammation,  retinal detachment ,  hypotony ,  phthisis bulbi  and sympathetic ophthalmia are some common complications of cyclodestructive procedures. [ 4 ]  Since there is risk of inflammation which lead to hypotony and phthisis bulbi, cyclophotocoagulation must be done with extreme caution in  uveitic  glaucoma. [ 10 ]  Pain,  hyphema  and  iridocyclitis  are possible complications of TS-CPC. [ 2 ]  Fibrin exudates, hyphema, cystoid macular edema and loss of vision are possible complications of ECP."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5579", "text": "The first surgical procedures to reduce intraocular pressure of the eye, by decreasing production of aqueous humor, by damaging the ciliary body by diathermy, penetrating cyclodiathermy or surgical excision was done in the early twentieth century. [ 1 ]  Cyclodestruction by diathermy was first performed by Weve in 1933. [ 11 ]  In 1949, Berens et al. described cyclo-electrolysis. [ 11 ]  Cyclocryotherapy was first described by Bietti in 1950. [ 12 ]  Cyclodestruction by cyclophotocoagulation was first performed by Beckman et al., in 1972, using a ruby laser. [ 13 ]  ECP was developed by Martin Uram in 1992. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5580", "text": "Descemet membrane endothelial keratoplasty  ( DMEK ) is a method of  corneal transplantation  that involves the removal of a thin sheet of tissue from the posterior (innermost) side of a person's cornea to replace it with the two posterior (innermost) layers of corneal tissue from a donor's eyeball."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5581", "text": "The two exchanged corneal layers are the  Descemet's membrane  and the  corneal endothelium . [ 1 ]  The person's corneal tissue is gently excised, peeled off, and replaced with the donor tissue via small 'clear corneal incisions' (small corneal incisions just anterior to the  corneal limbus . The donor tissue is  tamponaded  against the person's exposed posterior corneal  stroma  by injecting a small air bubble into the  anterior chamber . To ensure the air tamponade is effective, people must maintain such a posture that they look up at the ceiling during recovery until the air bubble has fully resorbed. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5582", "text": "Indications for DMEK include: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5583", "text": "A minor variation to DMEK is the Descemet Membrane Automated Endothelial Keratoplasty (DMAEK), which involves automated donor tissue preparation using a microkeratome or  femtosecond laser . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5584", "text": "Enucleation  is the removal of the eye that leaves the  eye muscles  and remaining orbital contents intact. This type of  ocular surgery  is indicated for a number of  ocular tumors , in eyes that have sustained severe trauma, and in eyes that are otherwise blind and painful. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5585", "text": "Self-enucleation  or  auto-enucleation  ( oedipism ) and other forms of serious self-inflicted eye injury are an extremely rare form of severe  self-harm  that usually results from mental illnesses involving acute  psychosis . [ 2 ]  The name comes from  Oedipus  of Greek mythology, who gouged out his own eyes. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5586", "text": "There are three types of eye removal: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5587", "text": "Removal of the eye by enucleation or evisceration can relieve pain and minimize further risk to life and well-being of an individual with the above noted conditions. In addition, procedures to remove the eye should address the resultant appearance of the orbit. Orbital implants and ocular prostheses are used by the surgeon to restore a more natural appearance. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5588", "text": "An orbital implant is placed after removal of the eye to restore volume to the eye socket and enhance movement or motility of an ocular prosthesis and eyelids. [ 5 ]  The eyeball is a slightly elongated sphere with a diameter of approximately 24 millimetres. [ 6 ]   To avoid a sunken appearance to the eye socket, an implant approximating this volume can be placed into the space of the removed eye, secured, and covered with  Tenon's capsule  and  conjunctiva . [ 7 ]  Implants can be made of many materials with the most common being  hydroxylapatite , metal alloy, [ 8 ]  acrylic, or glass. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5589", "text": "Later, once the conjunctiva have healed and post-operative swelling has subsided, an  ocular prosthesis  can be placed to provide the appearance of a natural eye. [ 5 ]  The prosthesis is fabricated by an  ocularist . [ 10 ]   Its form is that of a cupped disc so that it can fit comfortably in the pocket behind the eyelids overlying the conjunctiva that covers the orbital implant. [ 10 ]  The external portion of the ocular prosthesis is painted and finished to mimic a natural eye color, shape and luster. [ 8 ]  It can be removed and cleaned periodically by the individual or a care giver. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5590", "text": "The two part system of orbital implant and ocular prosthesis provides a stable, and well tolerated aesthetic restoration of the eye socket. [ 8 ]  Although vision is not restored by removal of the eye with placement of an orbital implant and ocular prosthesis, a natural appearance can result. [ 5 ]  The implant, along with the attached, visible ocular prosthesis, can be moved by intact extraocular muscles that will track or move simultaneously with the other eye. The eyelids are able to move and blink over the prosthesis as well. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5591", "text": "An  evisceration  is the removal of the  eye 's contents, leaving the  scleral  shell and  extraocular muscles  intact. [ 1 ] [ 2 ]  The procedure is usually performed to reduce pain or improve  cosmesis  in a  blind  eye, as in cases of  endophthalmitis  unresponsive to  antibiotics . [ 1 ] [ 2 ]  An  ocular prosthetic  can be fitted over the eviscerated eye in order to improve cosmesis. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5592", "text": "Either  general  or  local anesthetics  may be used during eviscerations, with antibiotics and  anti-inflammatory  agents injected  intravenously . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5593", "text": "Excimer laser trabeculostomy  (ELT) is a procedure to create holes in the  trabecular meshwork  to reduce  intraocular pressure . It uses a  XeCl  308\u00a0nm  excimer laser . [ 1 ]  It is considered a  minimally invasive glaucoma surgeries , and was first described in 1987 by Michael Berlin. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5594", "text": "Alternative treatments for glaucoma include mechanical drilling, thermal lasers, thermal cauterisation, and tube implants. However, these approaches typically disrupt the eye tissue enough to cause  inflammation  which often outweighs the benefit of the procedure. [ 1 ]  Excimer laser trabeculostomy uses  cold lasers  which reduces tissue  fibrosis  otherwise caused by excimer lasers. A 2020 review of 8 studies found the procedure reduced intraocular pressure by 20-40% and generally had favourable outcomes for reducing glaucoma medication needs. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5595", "text": "Eye transplantation  is the  transplantation  of the  globe  of the human eye from a donor to a recipient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5596", "text": "Research efforts in whole eye transplantation (WET) are focused on its application in living human recipients, still some obstacles need to be addressed. Apart from the surgical and neurological considerations, there are key ethical concerns such as patients' perceptions and desires for both nonvision-restoring WET and vision-restoring WET, risks and benefits compared to  prosthetic  alternatives, psychosocial considerations for potential recipients regarding personal identity related to the donor's eyes, public perceptions of whole-eye donation, implications for  corneal transplantation  eligibility of the donor's eyes, consent for whole-eye donation, and establishment of ethical mechanisms for allocation and distribution of WET. With limited studies available on this topic since the first vascularized composite allotransplantation (VCA) [ 1 ] [ 2 ] [ 3 ]  took place in 1998, the understanding of WET is informed by a few studies with limitations. For example,  amphibian  regeneration cannot directly apply to humans. Ocular transplants may offer a viable option for restoring form in patients undergoing facial transplantation with enucleated orbits. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5597", "text": "In 1885, the  Revue g\u00e9n\u00e9rale d'ophtalmologie  reported that the  staphylomatous  and  buphthalmic  eye of a 17-year-old girl had been replaced by the eye of a  rabbit  by a Dr. Chibret. [ 5 ] [ 6 ]  The operation failed after 15 days due to a lack of effective  immunosuppression . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5598", "text": "In 1969, Conrad Moore of the  Texas Medical Center  claimed that he had carried out the transplantation of a whole eye, but he subsequently  retracted  his claim. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5599", "text": "In November 2023, surgeons at  NYU Langone Health  announced the first successful eye transplantation, [ 8 ]  which was carried out as part of a partial  face transplant  in an operation that took 21 hours. [ 8 ]  The recipient, Aaron James, had lost the left side of his face with his eye, nose and mouth in a  high-voltage power line  accident. [ 8 ]   Reuters  reported that the transplanted eye has \"well-functioning blood vessels and a promising-looking retina\". [ 8 ]  The eye is not using the optic nerve to communicate with the brain, and James has not regained sight through the eye. [ 8 ]   Adult stem cells  have been harvested from his bone marrow and been injected into the optic nerve. [ 8 ]  The lead surgeon, Eduardo D. Rodriguez, said that \"If some form of vision restoration occurred, it would be wonderful, but ... the goal was for us to perform the technical operation\". [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5600", "text": "Eyelid revision   is a procedure that involves correcting or addressing any issues that have arisen from a previous  eyelid surgery . The surgery is more difficult to perform and is more complicated than an initial eyelid revision surgery, since the site of the procedure has been operated on before. The reasons for eyelid revision surgeries include contour abnormalities, asymmetry and unusually high eyelid height. [ 1 ]  The procedure is known to have more complications and issues than initial eyelid surgeries due to the presence of excess scar tissue at the surgery site."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5601", "text": "Contour abnormalities are also a common cause of eyelid revision surgery. Contour abnormalities are often the result of poor wound closure during the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5602", "text": "One of the most frequent complications that arise from an initial  eyelid surgery  is asymmetry, which are often a result of poor markings by the surgeon prior to operation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5603", "text": "Unusually high eyelid heights can make the results of an original eyelid revision procedure appear unnatural.  Thus, an initial  blepharoplasty  may need revision if there is an unusually high eyelid height that is formed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5604", "text": "One of the most troublesome complications of initial  eyelid surgery  is the surgeon discovering the patient has  ptosis  or a \"drooping\" eyelid after the surgery has been performed.  It is also possible for a patient to develop ptosis as a result of an initial eyelid surgery operation. Both require eyelid revision surgeries. Since ptosis patients need correction of delicate anatomical tissues and structures, eyelid revision surgery on ptosis patients is considered one of the more difficult surgical procedures to perform. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5605", "text": "Glaucoma  is a group of diseases affecting the  optic nerve  that results in  vision loss  and is frequently characterized by raised  intraocular pressure  (IOP). There are many glaucoma surgeries, and variations or combinations of those surgeries, that facilitate the escape of excess  aqueous humor  from the eye to lower intraocular pressure, and a few that lower IOP by decreasing the production of aqueous humor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5606", "text": "A  trabeculoplasty  is a modification of the  trabecular meshwork .  Laser trabeculoplasty  (LTP) is the application of a laser beam to burn areas of the trabecular meshwork, located near the base of the iris, to increase fluid outflow. LTP is used in the treatment of various open-angle glaucomas. [ 1 ]  The two types of laser trabeculoplasty are  argon laser trabeculoplasty  (ALT) and  selective laser trabeculoplasty  (SLT). As its name suggests, argon laser trabeculoplasty uses an  argon laser  to create tiny burns on the trabecular meshwork. [ 2 ]  Selective laser trabeculoplasty is newer technology that uses a  Nd:YAG laser  to target specific cells within the trabecular meshwork and create less thermal damage than ALT. [ 3 ] [ 4 ]  SLT shows promise as a long-term treatment. [ 5 ]  In SLT a laser is used to selectively target the melanocytes in the trabecular meshwork. Though the mechanism by which SLT functions is not well understood, it has been shown in trials to be as effective as the older ALT. However, because SLT is performed using a laser with much lower power than ALT, it does not appear to affect the structure of the trabecular meshwork (based on electron microscopy) to the same extent, so retreatment may be possible if the effects from the original treatment should begin to wear off, although this has not been proven in clinical studies. ALT is repeatable to some extent with measurable results possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5607", "text": "An  iridotomy  involves making puncture-like openings through the  iris  without the removal of iris tissue. Performed either with standard surgical instruments or a laser, it is typically used to decrease intraocular pressure in patients with angle-closure glaucoma. A  laser peripheral iridotomy  (LPI) is the application of a laser beam to selectively burn a hole through the iris near its base. LPI may be performed with either an argon laser or Nd:YAG laser. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5608", "text": "There is currently no sufficient evidence to show any benefit on the use of iridotomy versus no iridotomy to slow down visual field loss. This is based on analysing four studies with a sample of 3,086 eyes of 1,543 participants; iridotomy seems to improve gonioscopic findings, but does not show to be clinically significant. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5609", "text": "An  iridectomy , also known as a  corectomy  or  surgical iridectomy , involves the removal of a portion of iris tissue. [ 9 ] [ 10 ]  A basal iridectomy is the removal of iris tissue from the far periphery, near the iris root; a peripheral iridectomy is the removal of iris tissue at the periphery; and a sector iridectomy is the removal of a wedge-shaped section of iris that extends from the pupil margin to the iris root, leaving a keyhole-shaped pupil."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5610", "text": "Clear lens extraction , a surgical procedure in which clear  lens  of the human eye is removed, may be used to reduce intraocular pressure in primary angle closure glaucoma. [ 11 ]  A study found that CLE is even more effective than laser peripheral  iridotomy  in patients with angle closure glaucoma. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5611", "text": "Filtering surgeries are the mainstay of surgical treatment to control intraocular pressure. [ 14 ]  An  anterior sclerotomy  or  sclerostomy  is used to gain access to the inner layers of the eye [ 15 ] [ 16 ]  in order to create a drainage channel from the anterior chamber to the external surface of the eye under the conjunctiva, allowing aqueous to seep into a  bleb  from which it is slowly absorbed. Filtering procedures are typically divided into either penetrating or non-penetrating types depending upon whether an intraoperative entry into the anterior chamber occurs. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5612", "text": "Penetrating filtering surgeries are further subdivided into guarded filtering procedures, also known as protected, subscleral, or partial thickness filtering procedures (in which the surgeon sutures a scleral flap over the sclerostomy site [ 19 ] ), and full thickness procedures. [ 20 ]   Trabeculectomy  is a guarded filtering procedure that removes of part of the trabecular meshwork. [ 21 ] [ 22 ]  Full thickness procedures include sclerectomy, posterior lip sclerectomy (in which the surgeon completely excises the sclera on the area of the sclerostomy [ 19 ] ), trephination, thermal sclerostomy (Scheie procedure), iridenclesis, and sclerostomy (including conventional sclerostomy and enzymatic sclerostomy). [ 18 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5613", "text": "Anterior chamber paracentesis  is a penetrating surgical procedure done to reduce intraocular pressure of the eye. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5614", "text": "Non-penetrating filtering surgeries do not penetrate or enter the eye's  anterior chamber . [ 25 ] [ 26 ]  There are two types of non-penetrating surgeries: Bleb-forming and viscocanalostomy. [ 27 ] [ 28 ]  Bleb forming procedures include ab externo trabeculectomy and deep sclerectomy. [ 28 ]  Ab externo trabeculectomy (AET) involves cutting from outside the eye inward to reach  Schlemm's canal , the trabecular meshwork, and the anterior chamber. Also known as non-penetrating trabeculectomy (NPT), it is an ab externo (from the outside), major ocular procedure in which Schlemm's canal is surgically exposed by making a large and very deep scleral flap. The inner wall of Schlemm's canal is stripped off after surgically exposing the canal. Deep sclerectomy, also known as nonpenetrating deep sclerectomy (PDS) or nonpenetrating trabeculectomy, is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. [ 29 ]  In order to prevent wound adhesion after deep scleral excision and maintain good filtering results, it is sometimes performed with a variety of biocompatible spacers or devices, such as the Aquaflow collagen wick, [ 30 ]  ologen Collagen Matrix, [ 31 ] [ 32 ] [ 33 ]  or Xenoplast glaucoma implant. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5615", "text": "Viscocanalostomy  is also an ab externo, major ocular procedure in which Schlemm's canal is surgically exposed by making a large and very deep scleral flap. In the VC procedure, Schlemm's canal is cannulated and viscoelastic substance injected (which dilates Schlemm's canal and the aqueous collector channels)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5616", "text": "Surgical adjuvants \nWhere wound modulation is needed to prevent closure of surgically created drainage channels, adjuvants such as the ologen collagen matrix implants may be used to facilitate healthy tissue regeneration. Scar formation at the site of excision or operation may block aqueous humor circulation, while healthy tissue regeneration will keep newly created drainage channels functional. [ 35 ] [ 36 ] [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5617", "text": "Goniotomy  and  trabeculotomy  are similar simple and directed techniques of microsurgical dissection with mechanical disruption of the trabecular meshwork. [ 39 ] [ 40 ]  Goniotomy procedures include surgical goniotomy and laser goniotomy. A surgical goniotomy involves cutting the fibers of the trabecular meshwork to allow aqueous fluid to flow more freely from the eye. [ 41 ] [ 42 ] [ 43 ]  Laser goniotomy is also known as goniophotoablation and laser trabecular ablation . In many patients with congenital glaucoma, the cornea is not clear enough to visualize the anterior chamber angle. Although an endoscopic goniotomy, which employs an endoscope to view the anterior chamber angle, may be performed, [ 44 ]  a trabeculotomy which accesses the angle from the exterior surface of the eye, thereby eliminating the need for a clear cornea, is usually preferred in these instances. A specially designed probe is used to tear through the trabecular meshwork to open it and allow fluid flow. [ 41 ] [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5618", "text": "Tube-shunt surgery  or  drainage implant surgery  involves the placement of a tube or  glaucoma valves  to facilitate aqueous outflow from the anterior chamber. [ 41 ] [ 46 ] [ 47 ]  Trabeculopuncture uses a Q switched Nd:YAG laser to punch small holes in the trabecular meshwork. [ 48 ] [ 49 ]   Goniocurretage  is an \"ab interno\" (from the inside) procedure that used an instrument \"to scrape pathologically altered trabecular meshwork off the scleral sulcus\". [ 14 ]  A surgical  cyclodialysis  is a rarely used procedure that aims to separate the ciliary body from the sclera to form a communication between the suprachoroidal space and the anterior chamber. [ 10 ]  A  cyclogoniotomy  is a surgical procedure for producing a cyclodialysis, in which the ciliary body is cut from its attachment at the scleral spur under gonioscopic control. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5619", "text": "A  ciliarotomy  is a surgical division of the ciliary zone in the treatment of glaucoma. [ 10 ] [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5620", "text": "Canaloplasty  is a nonpenetrating procedure utilizing microcatheter technology. To perform a canaloplasty, an incision is made into the eye to gain access to Schlemm's canal in a similar fashion to a viscocanalostomy. A microcatheter will circumnavigate the canal around the iris, enlarging the main drainage channel and its smaller collector channels through the injection of a sterile, gel-like material called viscoelastic. The catheter is then removed and a suture is placed within the canal and tightened. By opening the canal, the pressure inside the eye can then be relieved. Canaloplasty has two main advantages of over more traditional glaucoma surgeries. The first of these advantages is an improved safety profile over trabeculectomy. As canaloplasty does not require the creation of a bleb, significant long-term risks such as infection and hypotony (extremely low eye pressure) are avoided. The second main advantage is that when combined with cataract surgery, the IOP is reduced even further than when done alone. [ 51 ] \nLong term (three year) results have been published both in the US [ 51 ]  and Europe [ 52 ]  demonstrating a significant and sustained reduction in both eye pressure and the number of glaucoma medications required for glaucoma control."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5621", "text": "Certain cells within the eye's  ciliary body  produce aqueous humor. A ciliary destructive or cyclodestructive procedure is one that aims to destroy those cells in order to reduce intraocular pressure. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5622", "text": "Cyclocryotherapy , or cyclocryopexy, uses a freezing probe. [ 54 ]   Cyclophotocoagulation , also known as transscleral cyclophotocoagulation, ciliary body ablation, [ 41 ]  cyclophotoablation, [ 55 ]  and cyclophototherapy, [ 40 ]  uses a laser. [ 56 ] [1]   Cyclodiathermy  uses heat generated from a high frequency  alternating electric current  passed through the tissue, [ 10 ]  while  cycloelectrolysis  uses the chemical action caused by a  direct current . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5623", "text": "A systematic review seeking to assess the safety and effectiveness of diode transscleral cyclophotocoagulation found one study in Ghana comparing patients who received low-energy versus high-energy variations of the procedure to treat glaucoma. [ 57 ]  Overall, the review found that 47% of eyes treated with transscleral cytophotocoagulation saw an IOP decrease of at least 20%. [ 57 ]  There were no differences between the low-energy and high-energy variations of the procedure in all reported outcomes, such as IOP control, and number of medications used after treatment. [ 57 ]  Another  Cochrane Systematic Review  explored whether cyclodestructive procedures are better than other glaucoma treatments for the treatment of refractory glaucoma; however, the evidence was inconclusive. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5624", "text": "In  ophthalmology ,  glued intraocular lens [ 1 ]  or  glued IOL  is a  surgical technique  for implantation, with the use of biological glue, of a  posterior chamber  IOL ( intraocular lens ) in  eyes  with deficient or absent  posterior capsules . A quick-acting surgical  fibrin sealant  derived from human  blood plasma , [ 2 ] [ 3 ]  with both  hemostatic  and adhesive properties, is used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5625", "text": "In 1997, Maggi and Maggi were the first to report the sutureless  scleral  fixation of a special IOL. The sutureless intrascleral fixation of a  posterior chamber  IOL was first described by Gabor Scharioth. [ 4 ] [ 5 ]  This technique was further modified by making scleral flaps and creating scleral pockets for tucking the haptics. The flaps are then reattached to the bed with the help of glue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5626", "text": "On 14 December 2007, the first glued  intraocular lens  (IOL) surgery was performed, at  Dr. Agarwal's Eye Hospital  in  Chennai , India. This new surgical procedure was invented and performed by  Amar Agarwal . Subsequently, the first child on whom a glued IOL surgery was performed was a patient who had a history of injury to her right eye 3 months before, while bursting crackers. She underwent emergency surgery for lens removal due to severe injury to the lens and received a sutured IOL, which was specific for such cases. After 1 month, when the child came for follow up, it was found that there was a decenteration of the IOL. The parents had noted the child's difficulty in performing activities using the right eye. Under  general anaesthesia , Agarwal removed the already existing IOL and placed a new IOL using the Glued IOL technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5627", "text": "Glued IOL surgery can be done both as a primary and as a secondary procedure in cases where the lens capsule is deficient or absent. As a primary procedure it can be done in all cases of  intraoperative  posterior capsule rupture. It can also be done in all cases of  subluxation  or dislocation of the lens, such as in  Marfan syndrome , traumatic dislocation of lens, etc. As a secondary procedure it can be done in all the  aphakic  cases or as a part of an IOL exchange, following an anterior chamber IOL, or  subluxated  or dislocated IOL."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5628", "text": "Fibrin glue has been used previously, in various medical specialties, as a  hemostatic  agent to arrest bleeding, seal tissues, and as an adjunct to wound healing. It is available in a sealed pack that contains freeze-dried human  fibrinogen  (20\u00a0mg/0.5 ml), freeze-dried human  thrombin  (250  IU /0.5 ml),  aprotinin  solution (1,500 KIU in 0.5 ml), one  ampoule  of sterile water, four 21-gauge needles, two 20-gauge blunt application needles, an applicator with two mixing chambers, and one plunger guide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5629", "text": "Preparation of glue: The vials are placed in a water bath which is preheated to 37 degrees for 2 to 3 minutes. 0.5 cc of distilled water is then added to the  thrombin   vial , and the  aprotinin  is mixed with  fibrinogen . Each component is then placed in a separate  syringe  with a  26-gauge  needle attached."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5630", "text": "The glued IOL technique consists of making two partial-thickness, approximately 2.5\u00a0mm by 2.5\u00a0mm, scleral flaps exactly 180\u00b0 apart, followed by a sclerotomy with a 20-gauge needle 1\u00a0mm from the limbus. A 23-gauge vitrectomy cutter is introduced from the sclerotomy site, and a thorough  vitrectomy  is done to remove all the vitreous tractions. A corneal tunnel is fashioned, then a 23-gauge glued-IOL forceps is passed through the sclerotomy site, and the tip of the leading haptic of the IOL is grasped, which is then externalized and brought out onto the ocular surface (Fig 3). Similarly the trailing haptic is then externalized using the \"handshake technique\". Scleral pockets are made at the edge of the flap with a 26-gauge needle just parallel to the sclerotomy site, into which the two haptics are then tucked for additional stability (Fig 4). The scleral flaps are then glued back into place using biological glue. The IOLs that can be used are the three-piece foldable IOLs with slightly firm haptics, or a three-piece non-foldable IOL. The glue is then used to seal the  conjunctival  closure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5631", "text": "The concept of performing a \"vertical glued IOL\" was first suggested by Jeevan Ladi. The vertical corneal diameter is always less than the horizontal diameter. In cases of large eyes, the least corneal diameter (i.e. at 6 o'clock and 9 o'clock) along the vertical axis can be chosen for making the scleral flaps. The IOLs currently available in the market are 13\u00a0mm in length. Choosing the least corneal diameter allows for extra length of the haptic available for tucking, and so gives extra stability."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5632", "text": "Advantages:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5633", "text": "According to some studies by Steven Safran, it is essential to state that the diameter of the ciliary sulcus and the corneal horizontal white-white diameter may not co-relate exactly; and it has been suggested that the surgeon can go ahead with horizontal placement of haptics rather than orienting them vertically. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5634", "text": "No-Assistant technique  \u2013 This technique works on the principle of vector forces and was first performed by Priya Narang. [ 7 ] [ 8 ] [ 9 ]  In this technique, after the externalization of the leading haptic, the trailing haptic is flexed beyond the pupillary plane, towards the 6 o'clock position. This reverses the direction of vector forces and causes the leading haptic to extrude more from the previous sclerotomy site, thereby preventing haptic slippage and its subsequent complications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5635", "text": "Plugging Silicon Tires of Iris Hooks  \u2013 This technique was developed by George Beiko and Roger Steinert, wherein the silicon tires of the iris hooks are plugged to the leading haptic, to prevent its accidental slippage. [ 10 ]  Steven Safran developed the micro-bulldog technique for the same purpose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5636", "text": "Y-Fixation technique  \u2013 This technique was developed by Ohta Toshihiko, et al., wherein a Y-shaped incision is made, in the sclera, that eliminates the need to make a scleral flap. [ 11 ] \nMckee Yuri, Francis Price, et al., modified the scleral flap-making by lifting only two edges of the flap and keeping the flap adherent at the point of haptic enclavation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5637", "text": "This technique is used for easy externalisation of haptics (Fig 5 and 6), especially for externalisation of the trailing haptic and in cases of there being small pupil. [ 13 ]  Two glued IOL forceps are needed for this technique. The haptic is held with one forceps, which is introduced from the corneal tunnel, and the other forceps is introduced from the sclerotomy site. The tip of the haptic is then traced and is caught followed by externalisation from the sclerotomy site. Visualization of the tip of the haptic becomes very difficult in cases of a small pupil. Although iris hooks can be used, the handshake technique simplifies the procedure. The exteriorization of the haptics is a key step in the glued IOL surgery. Since the surgeon is maneuvering with both hands simultaneously, one hand injecting the IOL while the other grasps and exteriorizes the haptics, he/she needs to be familiar with the handshake technique as a means of transferring the haptic from one hand to the other."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5638", "text": "If one of the haptics is not caught or if it is released accidentally after being grasped, the situation can be easily resolved using this technique. It utilizes two glued IOL forceps, one of which holds the haptic. Depending on ease of access, the other forceps is introduced through the opposite sclerotomy or through the side-port. The haptic is transferred from the first to the second forceps, such that the first forceps becomes free. It is essential to hold the haptic at its tip before exteriorizing it so that it doesn't snag on the sclerotomy while being brought out. For this reason, this handshake transfer of the haptic between the two glued IOL forceps is continued until the tip of the haptic is caught by the forceps on the side to which the haptic is to be exteriorized. This technique thus allows easy intra-ocular maneuvering of the entire haptic or IOL within a closed globe system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5639", "text": "Multifocal IOLs allow for good vision at a range of distances. Monofocal intraocular lenses, which are commonly available, give clear far or near point-of-focus, but are limited to only one focal point.  Multifocal intraocular lenses  are designed to avoid the need for glasses by providing two or more points of focus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5640", "text": "Multifocal  glued IOL procedures have been done with the ReZoom (Abbott Medical Optics), and Tecnis ( Advanced Medical Optics  (AMO)) IOLs. This makes it possible to offer the accommodative IOL advantage even to patients with an absent capsule. The modified  Prolene   polyvinylidene fluoride  haptic in these IOLs helps them in being more stiff as well as having superior structural memory. Sutured scleral-fixated IOLs in pediatric eyes have been known to lead to problems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5641", "text": "These intraocular lenses are intended to be placed in the capsular bag. Until recently, it was difficult to provide multifocality for patients who had complicated cataract surgeries and who lacked normal capsules.  Aphakia  with deficient capsule has been a limitation for obtaining multifocality. Now multifocality is possible even in complicated cataract surgeries by the Multifocal Glued IOL procedure, where multifocal IOL implantation can be done even in eyes with large posterior capsular rupture (PCR) and aphakias with deficient posterior capsule."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5642", "text": "Good results are reported for multiple complicated  pediatric  glued IOL situations, such as for  homocystinuria  with  subluxation ,  aniridia  with cataractous  subluxated  lens, and  Weill-Marchesani syndrome  with  microspherophakia  and  glaucoma . In dislocated posterior chamber  PMMA  IOL, the same IOL can be repositioned, thereby reducing the need for further manipulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5643", "text": "This glued IOL technique can be used in cases in which there is  aphakia  with  aniridia  (Fig 7 A and B). In such cases one can use an  aniridia  IOL, which has an artificial iris. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5644", "text": "This procedure combines two techniques: Glued IOL and  IOL Scaffold . [ 15 ] [ 16 ]  In this technique, a glued IOL procedure is initially performed, followed by an IOL Scaffold procedure. [ 17 ]  This technique is specially effective in cases with deficient posterior capsule support and sulcus or iris support. This technique is also applicable for managing a traumatic subluxated lens and Soemmering ring. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5645", "text": "This is a combination of  Pre-Descemet's endothelial keratoplasty  (PDEK) [ 19 ]  and glued IOL (Fig 8). This combined procedure helps to perform two procedures simultaneously, thereby limiting the number of the patient's post-operative hospital visits. PDEK is a kind of endothelial keratoplasty (corneal or eye transplantation), where the Pre-Descemet's layer (PDL), along with Descemet's membrane (DM) and endothelium, is transplanted.\nThe normal cornea has from the front to the back the following layers:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5646", "text": "For the human eye to see, the cornea, the front window of the eye, should be transparent. For that to happen, the inside corneal layer, the endothelium, pumps water from the cornea so that the cornea remains transparent and light can pass into the eye. If the endothelium is bad, the cornea retains a lot of water and becomes damaged, which is called Bullous  Keratoplasty . Thus PDEK helps in replacing the non-functional endothelium."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5647", "text": "On 4 September 2013,  Amar Agarwal , in collaboration with  Harminder Dua , performed the first PDEK surgery technique and demonstrated the significance of the Pre-Descemets layer in corneal transplantation. The initial surgery was performed for pseudophakic bullous keratopathy. Though donor eyes of all age groups were used in the initial PDEK cases, there was a marked difference in eyes with young donor corneas, which resulted in better corneal clarity and visual outcome. This paved the way for the difference of PDEK using young donors and the importance of the endothelial viability.\nGlued IOL can also be performed with various other  corneal transplantation  / keratoplasty procedures, such as Descemet's membrane endothelial keratoplasty (DMEK), Descemet's stripping endothelial keratoplasty (DSEK), and Penetrating keratoplasty (PK)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5648", "text": "This glued IOL technique would be useful in many clinical situations in which scleral-fixated IOLs are indicated, such as luxated IOL, dislocated IOL, zonulopathy, or secondary IOL implantation. In a case with a dislocated posterior chamber, such as  PMMA  IOL, the same IOL can be repositioned, thereby reducing the need for further manipulation. Externalization of the greater part of the haptics along the curvature stabilizes the axial positioning of the IOL and thereby prevents any IOL tilt."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5649", "text": "There is less incidence of uveitis-glaucoma-hyphema syndrome in a fibrin glue\u2013assisted IOL implantation, as compared with a sutured scleral-fixated IOL implantation. In the former, the IOL is well stabilized and stuck onto the scleral bed, and thereby has decreased intraocular mobility; in the latter, there is increased possibility of IOL movement or persistent rub over the ciliary body. Visually significant complications due to late subluxation, which has been known to occur in sutured scleral-fixated IOLs, may also be prevented, as sutures are avoided in this technique. Moreover, the frequent complications of secondary IOL implantation\u2014such as  secondary glaucoma , cystoid macular edema, or bullous keratopathy\u2014were not seen in any patients. Another important advantage of this technique is the prevention of suture-related complications, such as suture erosion, suture knot exposure, or dislocation of IOL after suture disintegration or broken suture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5650", "text": "The other advantages of this technique are the rapidity and ease of surgery. The technique eliminates tying the difficult-to-handle 10-0 Prolene suture to the IOL haptic eyelets, the time required to ensure good centration before tying down the knots, and the time required for suturing scleral flaps and closing the conjunctiva, thus significantly reducing total time in surgery. It is also easier and does not require much surgical expertise to use the 25-gauge forceps to grasp and exteriorize the haptic. Fibrin glue takes only 20 seconds to act in the scleral bed, and it helps in adhesion and  hemostasis . Fibrin glue has been shown to provide airtight closure, and by the time the fibrin starts degrading, surgical adhesions would have already occurred in the scleral bed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5651", "text": "A  Gundersen flap , also known as  Gundersen's flap ,  Gundersen's conjunctival flap , or  conjunctivoplasty , and often misspelled  Gunderson , is a  surgical  procedure for correcting  corneal disease . It involves excising a damaged section of cornea, and replacing it with a section (or \"flap\") of the patient's own  conjunctiva . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5652", "text": "It is named for Trygve Gundersen (1902 \u2013 February 24, 1987), an American  ophthalmologist  of Scandinavian descent, who first described the procedure in 1958 at the  Massachusetts Eye and Ear Infirmary . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5653", "text": "The  Harada\u2013Ito procedure  is an  eye muscle  operation designed to improve the  excyclotorsion  experienced by some patients with  cranial nerve\u00a0IV palsy .   In this procedure, the  superior oblique  tendon is split, and the anterior fibers\u00a0\u2013 the fibers most responsible for  incyclotorsion \u00a0\u2013 are moved anteriorly and laterally.  This selectively stretches and tightens these fibers, enhancing the incyclotorsion power of the superior oblique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5654", "text": "The most common indication for the Harada\u2013Ito procedure is bilateral acquired cranial nerve\u00a0IV palsy following closed  head trauma  (particularly automobile accidents).  In this clinical situation the vertical imbalance is often less symptomatically bothersome to the patient than the induced excyclotorsion.  Affected patients have a particularly annoying type of double vision ( diplopia ), wherein the images are twisted (excyclotorted)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5655", "text": "Patients with cranial nerve\u00a0IV palsy whose complaints are not specifically limited to torsional diplopia, but instead also have significant vertical diplopia, are not good candidates for a Harada\u2013Ito procedure.  Instead, a recession of the  inferior oblique  muscle, or another  strabismus  operation may be indicated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5656", "text": "Cataract surgery  has a long history in Europe, Asia, and Africa. It is one of the most common and successful surgical procedures in worldwide use, thanks to improvements in techniques for cataract removal and developments in  intraocular lens  (IOL) replacement technology, in implantation techniques, and in IOL design, construction, and selection. [ 1 ]  Surgical techniques that have contributed to this success include  microsurgery ,  viscoelastics , and  phacoemulsification . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5657", "text": "Cataract surgery is the removal of the natural  lens  of the  eye  that has developed a  cataract , an opaque or cloudy area. [ 3 ]  \nOver time, metabolic changes of the crystalline lens fibres lead to the development of a cataract, causing impairment or loss of vision. Some infants are born with  congenital cataracts , and environmental factors may lead to cataract formation. Early symptoms may include strong  glare  from lights and small light sources at night and reduced  visual acuity  at low light levels. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5658", "text": "Couching  (lens depression) was the original form of cataract surgery, and was used from antiquity.  Chrysippus of Soli , a  stoic   Greek   philosopher  provided the earliest account of it. [ 6 ]  Couching is still occasionally found in traditional medicine in parts of Africa and Asia. In 1753,  Samuel Sharp  performed the first-recorded surgical removal of the entire lens and lens capsule, equivalent to what became known as intracapsular cataract extraction. The lens was removed from the eye through a limbal incision. [ 1 ]  At the beginning of the 20th century, the standard surgical procedure was intracapsular cataract extraction (ICCE). [ 7 ]  In 1949,  Harold Ridley  introduced the concept of implantation of the  intraocular lens  (IOL), which made visual rehabilitation after cataract surgery a more efficient, effective, and comfortable process. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5659", "text": "In 1967, Charles Kelman introduced  phacoemulsification , which uses ultrasonic energy to emulsify the nucleus of the crystalline lens and remove cataracts by aspiration without a large incision. This method of surgery reduced the need for an extended hospital stay and made out-patient surgery the standard. [ 8 ]  In 1985, Thomas Mazzocco developed and implanted the first foldable IOL. Graham Barrett and associates pioneered the use of silicone, acrylic, and hydrogel foldable lenses, making it possible to reduce the incision width. [ 7 ]  In 1987, Blumenthal and Moisseiev described the use of a reduced incision size for ECCE. [ 9 ]  In 1989,  M. McFarland  introduced a self-sealing incision architecture, [ 9 ]  and in 2009,  Praputsorn Kosakarn  described a method for manual fragmentation of the lens, which consists in splitting the lens into three pieces for extraction, allowing a smaller, sutureless incision, and requires implantation of a foldable IOL. This technique uses less expensive instruments and is suitable for use in developing countries. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5660", "text": "Couching is the earliest-documented form of cataract surgery, and one of the oldest surgical procedures ever performed. In this technique, the lens is dislodged and pushed aside into the vitreous cavity, but not removed from the eye, thus removing the opacity from the visual axis, but also the ability to focus. [ 10 ]  After being used regularly for centuries, couching has been mostly abandoned in favour of more effective techniques, due to its generally poor outcomes, and is currently only routinely practised in remote areas of developing countries. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5661", "text": "Cataract surgery was first mentioned in the  Babylonian   code of Hammurabi  1750\u00a0 BCE . [ 13 ]  The earliest known depiction of cataract surgery is on a statue from the  Fifth Dynasty of Egypt  (2467\u20132457\u00a0 BCE ). [ 13 ]  According to Francisco J Ascaso  et al ,  a \"relief painting from tomb number TT 217 in a worker settlement in  Deir el-Medina \" shows \"the man buried in the tomb,  Ipuy\u00a0... one of the builders of royal tombs in the renowned Valley of the Kings, circa 1279\u20131213 BC\" as he underwent cataract surgery. Although direct evidence for cataract surgery in ancient Egypt is lacking, the indirect evidence, including surgical instruments that could have been used for the procedure, show that it was possible. It is assumed that the couching technique was used. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5662", "text": "Couching was practiced in ancient India and subsequently introduced to other countries by Indian physician  Sushruta  ( c.  6th century BCE), [ 15 ]  who described it in his medical text,  Sushruta Samhita  (\"Compendium of Sushruta\"); the work's Uttaratantra section [ a ]  describes an operation in which a curved needle was used to push the opaque \"phlegmatic matter\" [ b ]  in the eye out of the way of vision. The phlegm was then said to be blown out of the nose. The eye would later be soaked with warm, clarified butter before being bandaged. [ 16 ]  The removal of cataracts by surgery was introduced into China from India, and flourished in the  Sui  (581\u2013618\u00a0 CE ) and  Tang  (618\u2013907\u00a0 CE ) dynasties. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5663", "text": "The first references to cataract and its treatment in Europe are found in 29 CE in  De Medicina , a medical treatise by Latin encyclopedist  Aulus Cornelius Celsus , which describes a couching operation. [ 18 ]  In 2nd century\u00a0 CE ,  Galen  of  Pergamon , a prominent Greek physician, surgeon, and philosopher, reportedly performed an operation to remove a cataract-affected lens using a needle-shaped instrument. [ 19 ] [ 20 ]  Although many 20th-century historians have claimed that Galen believed the lens to be in the exact centre of the eye, there is evidence that he understood the crystalline lens is located in the anterior aspect of the eye. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5664", "text": "The removal of cataracts by couching was a common surgical procedure in  Djenn\u00e9 [ 22 ]  and many other parts of Africa. [ 23 ]  Couching continued to be used throughout the  Middle Ages , and is still used to this day in some parts of Africa and in  Yemen . [ 24 ] [ 12 ]  However, it has been proven to be an ineffective and dangerous method of cataract therapy, which often leads to blindness or only partially restored vision. [ 24 ]  The technique has mostly been replaced by extracapsular cataract surgery, including phacoemulsification. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5665", "text": "The lens can also be removed by suction through a hollow instrument: bronze oral-suction instruments that seem to have been used for this method of cataract extraction during the 2nd century\u00a0 CE  have been unearthed. [ 26 ]  Such a procedure was described by the 10th-century Persian physician  Muhammad ibn Zakariya al-Razi , who attributed it to  Antyllus , a 2nd-century Greek physician. According to al-Razi, the procedure \"required a large incision in the eye, a hollow needle, and an assistant with an extraordinary lung capacity\". [ 27 ]  This suction procedure was also described by Iraqi ophthalmologist  Ammar Al-Mawsili  in his 10th-century medical text,  Choice of Eye Diseases . [ 27 ]  He presented case histories of its usage, while claiming to have successfully performed it on a number of patients. [ 27 ] :\u200ap318\u200a  Extracting the lens has the benefit of removing the possibility of the lens migrating back into the field of vision. [ 28 ]  According to oculist  Al-Sh\u0101dhili , a later variant of the cataract needle in 14th-century Egypt used a screw to grip the lens. It is not clear how often, if ever, this method was used; other writers, including  Abu al-Qasim al-Zahrawi  and Al-Shadhili, appear to have been unfamiliar with this procedure, or claimed it was ineffective. [ 27 ] :\u200ap319"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5666", "text": "On Sep. 18, 1750,  Jacques Daviel  performed the first documented planned primary cataract extraction on a cleric in Cologne. [ 29 ]   In 1753,  Samuel Sharp  performed the first-recorded surgical removal of the entire lens and lens capsule: the lens was removed from the eye through a limbal incision. [ 1 ]  In America, cataract couching may have been performed in 1611, [ 30 ]  while cataract extraction was most likely performed by 1776. [ 31 ]  Cataract extraction by aspiration of lens material through a tube using suction was performed by Philadelphia-based surgeon  Philip Syng Physick  in 1815. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5667", "text": "King Serfoji II , Bhonsle of  Thanjavur , India, reportedly performed cataract surgeries in the early 1800s, according to manuscripts stored in the  Saraswathi Mahal Library . [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5668", "text": "In 1884,  Karl Koller  became the first surgeon to apply a  cocaine  solution to the cornea as a local anaesthetic; the news of his discovery spread rapidly, but was not without controversy. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5669", "text": "At the beginning of the 20th century, the standard surgical procedure was intracapsular cataract extraction (ICCE). The work of  Henry Smith , who first developed a safe, fast way to remove the lens within its capsule by external manipulation, was considered particularly influential; the  capsule forceps , the discovery of enzymatic zonulysis by  Joaquin Barraquer  in 1957, and the introduction of  cryoextraction  of the lens by  Tadeusz Krwawicz  and  Charles Kelman  in 1961 continued the development of ICCE. [ 7 ]  Intracapsular cryoextraction was the favoured form of cataract extraction from the late 1960s to the early 1980s: it consisted in using a  liquid-nitrogen-cooled  probe tip to freeze the encapsulated lens to the probe. This required a large incision and the cornea to be folded back and the anterior chamber to be drained. [ 10 ] [ 36 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5670", "text": "In 1949,  Harold Ridley  introduced the concept of implantation of the  intraocular lens  (IOL) which made visual rehabilitation after cataract surgery a more efficient, effective, and comfortable process. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5671", "text": "Artificial IOLs, which are used to replace the eye's natural lens removed during cataract surgery, increased in popularity since the 1960s, and were first approved by the US  Food and Drug Administration  in 1981. The development of IOLs was considered a notable innovation, as patients previously had to wear very thick glasses, or a special type of  contact lens , in order to cope with the removal of their natural lens. IOLs can be used to correct other vision problems, such as toric lenses for correcting astigmatism. [ 38 ]  IOLs can be classified as monofocal, toric, and multifocal lenses. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5672", "text": "Ocular anaesthesia has improved since  Alfred Einhorn  synthesised  procaine  in 1905, which was used in retrobulbar anaesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5673", "text": "Peribulbar anaesthesia was introduced in 1980 by Mandal and David. Since the turn of the millennium, sub-Tenon's anaesthesia hascome into common use, and by ising a blunt cannula to deliver local anaesthetic, the risk of accidentally puncturing the globe is reduced. The more recent tendency is to administer topical local anesthesia without use of a needle. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5674", "text": "Also in the 1960s, the development of  A-scan ultrasound biometry  contributed to provide more accurate predictions of implant refractive strength. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5675", "text": "In 1967, Charles Kelman introduced  phacoemulsification , which uses ultrasonic energy to emulsify the nucleus of the crystalline lens and remove cataracts by aspiration without a large incision. This method of surgery reduced the need for an extended hospital stay and made out-patient surgery the standard. Patients who undergo cataract surgery rarely complain of pain or discomfort during the procedure, although those who have topical anaesthesia, rather than peribulbar block anaesthesia, may experience some discomfort. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5676", "text": "Ophthalmic viscosurgical devices  (OVDs), which were introduced in 1972, facilitate the procedure and improve overall safety. An OVD is a viscoelastic solution, a gel-like substance used to maintain the shape of the eye at reduced pressure, as well as protect the inside structure and tissues of the eye without interfering with the operation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5677", "text": "In 1980,  D.M. Colvard  made the cataract incision in the sclera, which limited induced astigmatism. [ 9 ]  In the early 1980s,  Dani\u00e8le Aron-Rosa  and colleagues introduced the  neodymium-doped yttrium aluminum garnet laser  (Nd:YAG laser) for posterior capsulotomy. [ 7 ]  In 1985, Thomas Mazzocco developed and implanted the first foldable IOL. Graham Barrett and associates pioneered the use of silicone, acrylic, and hydrogel lenses. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5678", "text": "According to Cionni  et al  (2006), Kimiya Shimizu began removing cataracts using topical anaesthesia in the late 1980s, [ 7 ]  though Davis (2016) attributes the introduction of topical anaesthetics to  R.A. Fischman  in 1993. [ 1 ]  In 1987, Blumenthal and Moissiev described the use of a reduced incision size for ECCE. They used a 6.5 to 7\u00a0mm (0.26 to 0.28\u00a0in) straight scleral tunnel incision 2\u00a0mm (0.079\u00a0in) behind the limbus with two side ports. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5679", "text": "In 1989,  M. McFarland  introduced a self-sealing incision architecture; in 1990,  S.L.Pallin  described a chevron-shaped incision that minimized the risk of induced astigmatism; in 1991,  J.A. Singer  described the frown incision, in which the ends curve away from the limbus, similarly reducing astigmatism. [ 9 ]  Toric IOLs were introduced in 1992 and are used worldwide to correct corneal astigmatism during cataract surgery; [ 38 ] [ 1 ]  they have been approved by the FDA since 1998. [ 41 ]  Also in the late 1990s,  optical biometry  based on partial coherence  infrared   interferometry  was introduced: this technique improves visual resolution, offers much greater precision, and is much quicker and more comfortable than ultrasound. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5680", "text": "According to surveys of members of the  American Society of Cataract and Refractive Surgery , approximately 2.85\u00a0million cataract procedures were performed in the United States throughout 2004, while 2.79\u00a0million operations were executed in 2005. [ 42 ]  In 2009,  Praputsorn Kosakarn  described a method for manual fragmentation of the lens, called \"double-nylon loop\", which consists in splitting the lens into three pieces for extraction, allowing a smaller, sutureless incision of 4.0 to 5.0\u00a0mm (0.16 to 0.20\u00a0in), and requires implantation of a foldable IOL. This technique uses less expensive instruments and is suitable for use in developing countries. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5681", "text": "As of 2013, medical staffs had access to instruments that use infrared  swept-source optical coherence tomography  (SS-OCT), a non-invasive, high-speed method that can penetrate dense cataracts and collects thousands of scans per second, with the ultimate goal of generating high-resolution data in  2D  or  3D . [ 40 ]  As of 2021, approximately four million cataract procedures take place annually in the U.S. and nearly 28 million worldwide, a large proportion of which are performed in India; that is about 75,000 procedures per day globally. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5682", "text": "Hydrodelineation  is a method of separating an outer shell (or multiple shells) of the  lens  of the eye from the central compact mass of inner  nuclear cataract  (also called endonucleus) during a cataract surgery by the forceful irrigation of a fluid into the mass of the nucleus. [ 1 ]  While  hydrodissection  disconnects the lens from the lens capsule, hydrodelineation splits it into endonuclear and epinuclear sections thus reducing the size of the hard nucleus, making its extraction possible through a smaller incision. [ 2 ]  This also facilitates  phacoemulsification ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5683", "text": "An injection of fluid into the body of the lens through the cortex against the nucleus of a cataract separates the hardened nuclear cataract from the softer lens cortex shell by flowing along the interface between them. The smaller hard nucleus can then be expeditiously phacoemulsified, while the posterior cortecx serves as a buffer protecting the posterior capsule membrane. The smaller size of the separated nucleus requires less deep and less peripheral grooving and produces smaller fragments after cracking or chopping. The posterior cortex also maintains the shape of the capsule which reduces risk of posterior capsule rupture. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5684", "text": "Hydrodissection  is the use of a directed jet of water to surgically separate tissues. It is generally used to develop tissue planes or divide soft tissues with less trauma than dissection using a cutting instrument. By using an appropriate pressure it will tend to follow the path of least resistance that is close to the direction of the jet. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5685", "text": "In cataract surgery it is used to release the lens from its capsule by projecting a continuous flow of water from a cannula under the flap of the anterior capsule, which lifts the capsule membrane from the lens. By directing the flow the surgeon lifts the membrane around the sides and back of the capsule until the lens is completely loose as a prelude to  phacoemulsification  or direct extracapslar removal.  [ 2 ] [ 3 ]  Hydrodissection is also used in general surgery to release a trapped nerve or to reduce intraoperative blood losses. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5686", "text": "Ignipuncture  ( Latin :  Ignis  (fire) +  puncture ) is the procedure of closing a retinal separation by transfixation of the break via  cauterization . The procedure was pioneered and named by  Jules Gonin  in the early 1900s. [ 1 ]  Due to the risk of severe complications and the advent of lasers for the controlled delivery of energy, ignipuncture became an obsolete procedure; since the 1980s, ignipuncture has been performed using safer techniques like  endophotocoagulation . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5687", "text": "This article about the  eye  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5688", "text": "Intraocular lens scaffold , [ 1 ]  or  IOL scaffold  technique, is a surgical procedure in  ophthalmology . In cases where the posterior lens capsule is ruptured and the  cataract  is present, an  intraocular lens  (IOL) can be inserted under the cataract. The IOL acts as a scaffold, and prevents the cataract pieces from falling to the back of the eye. The cataract can then be safely removed by emulsifying it with ultrasound and aspiration. This technique is called IOL scaffold, and was initiated by  Amar Agarwal  at  Dr. Agarwal's Eye Hospital  in  Chennai , India."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5689", "text": "The technique can be used to support and protect the posterior capsule membrane during a lens swap procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5690", "text": "The lens capsule may be damaged due to trauma, from birth, or by surgery. [ 2 ] [ 3 ]  During cataract surgery, when half or more of the lens remains and the surgeon notices capsule damage; the IOL scaffold technique can be used to capture the lens and prevent further complications. In this technique, the artificial lens or IOL is placed in the sulcus (remaining part of the lens bag) and  phacoemulsification  surgery using  ultrasound  is performed over it. Once the entire lens is removed, the IOL is well positioned on the sulcus. As soon as the surgeon notices the capsular tear or sinking nucleus, anterior chamber infusion can be used to stabilize the chamber. Anterior  vitrectomy  is performed to remove the  vitreous body  in the  pupil  and anterior part of eye. Then the IOL (already planned to be placed in the lens bag) is inserted under the nucleus on the remaining capsule bag. The nucleus is positioned on the IOL and the surgery is completed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5691", "text": "By this method, the risk of lens fragments falling into the vitreous body or back part of the eye is reduced. The IOL acts as a barrier or scaffold preventing the lens remnants from falling back. Since separation is present in the posterior (vitreous) eye from the anterior (aqueous) part,  retinal  risks are reduced. Moreover, neither special instruments  nor additional training required once this method is learnt. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5692", "text": "The intraocular lens scaffold technique was introduced by Dr.  Amar Agarwal  in 2012. He used this technique in a case which had posterior capsular rupture during a  phacoemulsification  procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5693", "text": "The technique can be used for intraoperative nucleus removal during cataract surgery (phacoemulsification), removal of lens dropped on the retina,  Sommering ring  removal, intraocular foreign body removal, and IOL explantation. [ 4 ] [ 5 ] [ 6 ] [ 1 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5694", "text": "In an eye with total loss of bag where no capsular bag remnant is present, glued IOL scaffold is used. [ 5 ]  In this a glued IOL is placed behind the cataract pieces. The glued IOL then works as a scaffold and the cataract pieces are removed with the phaco handpiece using ultrasound. Two partial thickness  scleral  flaps measuring 2.5 to 2.5\u00a0mm are made 180 degrees diagonally apart. Infusion is placed by anterior chamber maintainer and sclerotomies are made below the flaps with 20 gauge needle. The IOL is injected below the remaining lens particles and the remaining lens is positioned on the artificial lens or IOL (Fig 2). The  haptics  of the IOL are brought out under the flaps as in the glued IOL method and tucked into the scleral tunnel made with 26 gauge needle at the entry site. The  phacoemulsification  procedure is then continued on the IOL and the  anterior chamber  is formed by the end of the procedure. Scleral flaps and conjunctiva are then closed with fibrin glue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5695", "text": "In the IOL scaffold, the IOL is placed above the  iris  or above some remnant of the capsule. Otherwise, a  glued IOL  then acts as a scaffold. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5696", "text": "The  Soemmering ring  is the ring-shaped growth of lens cells after surgical removal of cataractous lens in childhood. This is seen as a peripheral ring after pupil dilatation. Patients who undergo artificial lens implantation in an eye that had earlier cataract surgery use this technique to remove the ring remnant. [ 6 ]  Here the IOL is placed with the glued IOL scaffold method, the Sommering ring is dislodged on the IOL, and is removed (Fig 3)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5697", "text": "Refractive  surprise can happen after IOL implantation; incorrect lens or power is the probable cause for this. In that situation, the IOL is removed and an IOL of correct power is placed. IOL scaffold is used where the new IOL is placed into the lens bag below the old IOL. The new IOL acts as scaffold or barrier and helps as a platform for the removal of the old lens. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5698", "text": "External foreign bodies can enter the eye and become lodged on the retina or vitreous. This is often removed through the open method of opening through the sclera (white coat of the eye). While removing intraocular foreign bodies (IOFB), it may drop or slip onto the back of the eye (Fig 4). This will prevent the accidental slippage of IOFB into the eye. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5699", "text": "No increased risk of postoperative complications such as  endothelial  decompensation or post-operative  uveitis  has been reported. [ 7 ] [ 8 ]  Good visual outcomes are obtained. IOL has been reported to be stable without de-centering in both eyes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5700", "text": "Intravitreal injection  is the method of administration of drugs into the eye by injection with a fine needle. The medication will be directly applied into the  vitreous humor . [ 1 ]  It is used to treat various eye diseases, such as  age-related macular degeneration (AMD) ,  diabetic retinopathy , and infections inside the eye such as  endophthalmitis . [ 1 ]  As compared to  topical administration , this method is beneficial for a more localized delivery of medications to the targeted site, as the needle can directly pass through the anatomical eye barrier (e.g. cornea, conjunctiva and lens) and dynamic barrier (e.g. tears and aqueous humor). [ 2 ] [ 3 ]  It could also minimize adverse drug effects on other body tissues via the systemic circulation, which could be a possible risk for  intravenous injection  of medications. [ 2 ] [ 4 ]  Although there are risks of infections or other complications, with suitable precautions throughout the injection process, chances for these complications could be lowered. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5701", "text": "Intravitreal injection was first mentioned in a study in 1911, in which the injection of air was used to repair a detached retina. [ 6 ] [ 7 ] [ 8 ]  There were also investigations evaluating intravitreal antibiotics injection using  sulfanilamide  and  penicillin  to treat endophthalmitis in the 1940s, yet due to the inconsistency of results and safety concerns, this form of drug delivery was only for experimental use and not applied in patients. [ 8 ]  It was until 1998, that  fomivirsen (Vitravene\u2122) , the first intravitreal administered medication, was approved by the U.S. Food and Drug Administration (FDA). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5702", "text": "In 2004, when Aiello et al. published the first guidelines for intravitreal injection in the journal 'Retina', fomivirsen was still the only medication licensed by the FDA for intravitreal injection. [ 8 ]  At the end of the year, on December 17, the first intravitreal  anti-VEGF drug   pegaptanib (Macugen)  was also licensed by FDA for treatment of wet age-related macular degeneration (wet AMD). [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5703", "text": "Intravitreal injection has then become more common and a surge in the number of injections performed could be seen. [ 10 ]  Six extra medications, namely  triamcinolone acetonide ,  ranibizumab (Lucentis) ,  aflibercept (Eylea/Zaltrap) ,  dexamethasone ,  ocriplasmin  and  fluocinolone acetonide  were approved for this injection by the end of 2014. [ 2 ]  There are also increasing off-label use of  bevacizumab (Avastin)  for the management of various ophthalmologic diseases, like AMD, retinal vein occlusion and diabetic macular edema. [ 2 ] [ 9 ]  On top of that, the number of intravitreal injections has escalated from less than 3000 per year in 1999, to an estimation of near 6 million in 2016. [ 2 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5704", "text": "Intravitreal injection is used to inject a drug into the eye to reduce  inflammation  ( anti-inflammatory ), inhibit the growth and development of new blood vessels ( angiostatic ), or lower the  permeability of blood vessels  (anti-permeability), in turn curing various eye diseases. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5705", "text": "Disorders/diseases that can be treated with intravitreal injection include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5706", "text": "Sometimes, an intravitreal injection of  antibiotics  and  steroids  is given as part of routine  cataract surgery . This avoids having to use drops after surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5707", "text": "Antimicrobials  are intravitreally injected to treat eye infections, such as  endophthalmitis  and  retinitis . [ 10 ]  The medication used depends on the pathogen responsible for the disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5708", "text": "This type of drug targets on bacterial infection. The first use of intravitreal  antibiotics  was dated back to experiments in the 1940s, in which  penicillin  and  sulfonamides  were used to treat the rabbit endophthalmitis models. [ 10 ] [ 14 ]  Later, more studies proved the beneficial effects of intravitreal antibiotics on acute postoperative endophthalmitis. [ 10 ] [ 14 ]  In the 1970s, Peyman's research on the suggested doses for the medications was published. [ 14 ]  Intravitreal antibiotics then has gradually become the major treatment to manage bacterial endophthalmitis. [ 14 ]  Some common antibiotics administered nowadays are  vancomycin  (for  Gram-positive bacteria ) and  ceftazidime  (for  Gram-negative bacteria ). [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5709", "text": "The dosage of antibiotics injected intravitreally is usually low to avoid possible retina toxicity. [ 10 ] [ 14 ]  Some alternative antibiotics have also been tested to replace those that have a higher risk of causing macular toxicity (e.g.  aminoglycosides ). [ 10 ] [ 14 ]  In light of the raised occurrence of  antibiotics resistance , the medications should be chosen and evaluated with the support of  bacterial culture  and  antibiotics sensitivity  test results. [ 14 ]  Sometimes, combinations of different antibiotics may be needed to treat polymicrobial infections (infections that are caused by more than one type of microorganisms), or as an  empirical treatment . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5710", "text": "Antibiotics, such as  moxifloxacin ,  vancomycin , etc., are used perioperatively and postoperatively as a common method of endophthalmitis prevention in cataract surgery. Researches show such injection of antibiotics is more useful to prevent infection as compared to  chemoprophylaxis(chemoprevention)  given topically. [ 16 ]  However, it has recently been controversial whether it has sufficient efficacy for endophthalmitis  prophylaxis , and whether it improves the effectiveness in preventing endophthalmitis by perioperative  povidone-iodine  when used in combination with the antiseptic. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5711", "text": "If the endophthalmitis is suspected to be a fungal infection,  antifungals , such as  amphotericin B  and  voriconazole , could be intravitreally injected to treat the disease. [ 10 ] [ 17 ]  Although amphotericin B has a broad spectrum, voriconazole is more commonly used now as it has a higher efficacy and lower toxicity. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5712", "text": "Since the 1990s, intravitreal  antivirals  have been used to treat  cytomegalovirus retinitis (CMV retinitis)  in immunodeficient patients, such as AIDS patients. [ 10 ] [ 18 ]  Some medications that could be used include  ganciclovir ,  foscarnet , and  cidofovir . [ 10 ] [ 19 ]  The amount and frequency of the intravitreal agent injected varies among the drug chosen: for example, foscarnet has to be given more frequently than ganciclovir as it has a shorter\u00a0intravitreal half-life. [ 10 ]  If the traditional antiviral therapy fails, a combination of these two medications may be injected. [ 10 ]  On the other hand, antiviral drugs could also be administered for patients with  acute retinal necrosis  due to  varicella-zoster virus  retinitis. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5713", "text": "Vascular endothelial growth factor  (VEGF) is a type of protein the body cells produce to stimulate the growth of new blood vessels. [ 20 ]   Anti-VEGF agents  are chemicals that could inhibit these growth factors to reduce or prevent the abnormal growth of blood vessels, which could lead to damage to the eye and vision. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5714", "text": "Anti-VEGF drugs are often injected to reduce the swelling or bleeding of the retina, which can be used to treat wet age-related macular degeneration (AMD), macular oedema (which could be diabetic), diabetic retinopathy, retinal vein occlusion, etc. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5715", "text": "Some common anti-VEGF drugs are  bevacizumab (Avastin) ,  ranibizumab (Lucentis)  and  aflibercept (Eylea/Zaltrap) . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5716", "text": "The primary use of the  corticosteroids  is to reduce the inflammation by inhibiting the inflammatory  cytokines . [ 11 ]  It could be used to treat numerous eye disorders, such as diabetic retinopathy and retinal vein occlusion. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5717", "text": "Below are some examples of this type of medication:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5718", "text": "Triamcinolone acetonide  is one of the most commonly used steroid agents for the treatment of several retinal conditions. The drug is often seen as an ester in commercial drugs and appears as a white- to cream-colored crystalline powder. [ 11 ]  It is much more soluble in alcohol than in water, which could be the reason for its longer duration of action (around 3 months after 4\u00a0mg intravitreal injection of the drug). [ 11 ] [ 24 ]  The drug is also 5 times more potent than  hydrocortisone  while only has a tenth of its sodium-retaining potency. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5719", "text": "It has proven to be effective for the management of abnormal endothelial cell proliferation-associated disorders, and the accumulation of intraretinal and subretinal fluid. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5720", "text": "Dexamethasone  is a potent cytokine inhibitor that is naturally released from human  pericytes . [ 11 ]  It is shown to be able to significantly decrease  intercellular adhesion molecule-1  mRNA and protein levels and therefore reduce  leukostasis  and help maintain the  blood-retinal-barrier . [ 11 ]  Its potency is 5 times greater than triamcinolone acetonide. [ 11 ]  Due to its relatively short half-life, the medication is often given as an  intravitreal implant  for a continuous and stable release to the target site. [ 11 ] [ 25 ]  Some newly developed dexamethasone implants, such as Ozurdex, are made from biodegradable materials that could be intravitreally injected rather than surgically implanted. [ 11 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5721", "text": "This corticosteroid is usually used to treat disorders and diseases including macular edema secondary to  retinal vein occlusion ,  pseudophakic cystoid macular edema ,  macular edema  secondary to  uveitis ,  diabetic macular edema , and  age-related macular degeneration . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5722", "text": "Fluocinolone acetonide  is a synthetic corticosteroid as potent as dexamethasone, but with a much lower water solubility, which could be accounted for the extended period of release from the intravitreal implant injected. [ 11 ]  It was also proven to have a localized effect in the  posterior segment of the eye  and is not absorbed into the systemic circulation, thus less likely to give rise to systemic adverse effect. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5723", "text": "The medication could be used in treatment for  noninfectious posterior uveitis  and diabetic macular edema, while applications in the management of other ophthalmic diseases are still under research. [ 11 ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5724", "text": "Gene therapy drugs [Lenadogene nolparvovec (Lumevoq)] for Leber's hereditary optic neuropathy (LHON) are delivered intravitreally. These are essentially recombinant viral vectors, containing the gene required for the therapy. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5725", "text": "The injection is usually done at the inferotemporal quadrant (i.e. the lower quadrant away from the nose) of the eye undergoing the procedure, as it is usually more accessible. [ 6 ] [ 12 ]  However, depending on the eye's condition, patient's and the ophthalmologist's preference, other regions could also be used. [ 6 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5726", "text": "Patient with  aphakic  (without lens due to cataract surgery), or  pseudophakic  eye (with implanted lens after removal of natural lens) would have the injection 3.0-3.5\u00a0mm posterior to the  limbus , while injection to the phakic eye (with natural lens) is done 3.5-4.0\u00a0mm posterior to the limbus. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5727", "text": "Like many injections, intravitreal injection is commonly performed in the office setting. [ 30 ] [ 31 ]  An operation room may be a better option to provide a more sterile environment for the procedure to lower the chance of infections, yet it will also increase the costs. [ 30 ]  Since the occurrence of serious post-injection infection (e.g.  endophthalmitis ) is low, in-office intravitreal injection is preferred. [ 30 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5728", "text": "The exact procedures and techniques of the intravitreal injection varies among different guidelines, and may depend on the practices of the person performing the injection. Below is an example of the steps for the injection:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5729", "text": "The patient usually leans back on the chair (in  supine position ), in which the headrest is stable and the patient is comfortable. [ 12 ] [ 31 ]  Sterile drape is sometimes used to cover the face of the patient and only show the eye for the injection. [ 12 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5730", "text": "The specialist first applies  anesthetics  to the eye and eyelid to numb the area, so that the patient will not feel the pain during the procedure. [ 12 ] [ 22 ] [ 31 ]  The type of anesthetic used depends on the practitioner practices and the patient's history. Some common forms of anesthetic used are eye drops (e.g.  tetracaine / proparacaine ) or gel (e.g.  lidocaine  2% or 4% jelly), which is applied  topically . [ 12 ] [ 31 ]  Other choices of anesthesia include the use of lidocaine soaked pledget (a small cotton or wool pad) and  subconjunctival injection  (injection under the  conjunctiva ) of anesthetic agents. [ 23 ]  However, the latter may cause a raised chance of  subconjunctival hemorrhage . [ 12 ]  Sometimes, for an eye with inflammation, a  retrobulbar block  may be given, but usually the topical or subconjunctival anesthesia is sufficient. [ 12 ]  The anesthetic takes time to show the numbing effect, ranging from 1\u20135 minutes, depending on the chemical chosen. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5731", "text": "The specialist then  sterilizes  the eye and the surrounding area, often with  povidone-iodine  (PVP-I) solution, to prevent any infection in the injected site. [ 22 ] [ 31 ]  Aqueous  chlorhexidine  is used instead in case of adverse effects to povidone-iodine. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5732", "text": "Next, an  eyelid speculum  is placed to retract the eyelids and thus hold the eye open. [ 22 ] [ 31 ]  It helps to prevent contamination of the needle and the injection site by the eyelid or eyelashes. [ 34 ]  Povidone-iodine solution is applied to the conjunctiva at the site of injection. [ 22 ]  Another dose of local anesthetic may be given to the conjunctival surface again (for example, by placing a cotton swab soaked with the anesthetic drug solution over the targeted region), which is followed by the reapplication of PVP-I solution. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5733", "text": "The injection site is measured and marked with a measuring  caliper  or other devices. [ 6 ] [ 33 ]  The patient is then told to look away from the injection site to show the quadrant to be injected, and the doctor inserts the needle at the target site in a single motion into the mid-vitreous cavity. [ 12 ]  Once the needle is in the vitreous cavity, the doctor pushes the plunger to release the drug into the cavity. [ 12 ]  After that, the needle is removed, and the injection site is immediately covered with a cotton swab to avoid vitreous reflux (reflux of fluid from the vitreous cavity). [ 6 ] [ 12 ]  The excess PVP-I solution is rinsed away. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5734", "text": "Finally, the doctor checks the patient's vision and  intraocular pressure (IOP)  of the eye. [ 12 ]  The injection of certain medications, such as triamcinolone acetonide (Kenalog or Triesence), may cause a sudden increase in the IOP, [ 35 ] [ 36 ]  and the patient should be monitored until the pressure returns to a normal level. If a large volume of drug is injected,  paracentesis  may be required. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5735", "text": "Side effects of intravitreal injection can be classified into two categories: drug-related side effects and injection-related side effects. [ 11 ]  For example, in an intravitreal steroid injection, complications could be divided into steroid-related adverse effects and injection-related adverse effects, in which the former most commonly include cataract formation and increase in intraocular pressure (IOP). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5736", "text": "Other examples of potential adverse effects are listed as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5737", "text": "A surgery may be required to treat certain severe complications. Some of the above complications could also lead to blindness, or even loss of the eye (in the case of a severe infection). [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5738", "text": "Precautions should be taken before, during, and after the injection to lower the chances of complications:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5739", "text": "An  iridectomy , also known as a  surgical iridectomy  or  corectomy , [ 1 ]  is the  surgical  removal of part of the  iris . [ 2 ] [ 1 ]  These procedures are most frequently performed in the treatment of  closed-angle glaucoma  and iris  melanoma . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5740", "text": "In  acute angle-closure glaucoma  cases, surgical iridectomy has been superseded by  Nd:YAG laser   iridotomy , because the laser procedure is much safer. Opening the globe for a surgical iridectomy in a patient with high  intraocular pressure  greatly increases the risk of  suprachoroidal hemorrhage , with potential for associated  expulsive hemorrhage . Nd:YAG laser iridotomy avoids such a catastrophe by using a laser to create a hole in the iris, which facilitates flow of  aqueous humor  from the posterior to the  anterior chamber  of the eye. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5741", "text": "Surgical iridectomy is commonly indicated and performed in the following cases: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5742", "text": "Redirect to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5743", "text": "Micro-invasive glaucoma surgery  ( MIGS ) is the latest advance in surgical treatment for  glaucoma , which aims to reduce  intraocular pressure  by either increasing outflow of  aqueous humor  or reducing its production. MIGS comprises a group of surgical procedures which share common features. [ 1 ]  MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the  cornea  that causes the least amount of trauma to surrounding scleral and conjunctival tissues.  The techniques minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures such as  trabeculectomy  or  glaucoma valve  implantation (also known as glaucoma drainage device) to be performed in the future if needed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5744", "text": "Traditional glaucoma surgery generally involves an external (ab externo) approach through the  conjunctiva  and  sclera ; however, MIGS procedures reach their surgical target from an internal (ab interno) route, typically through a self-sealing corneal incision. By performing the procedure from an internal approach, MIGS procedures often reduce discomfort and lead to more rapid recovery periods. [ 1 ] [ 2 ]  While MIGS procedures offer fewer side effects, the procedures tend to result in less intraocular pressure (IOP) lowering than with trabeculectomy or glaucoma tube shunt implantation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5745", "text": "Glaucoma is a group of  eye disorders  in which there is a chronic and progressive damage of the  optic nerve . [ 4 ]  Increased intraocular pressure (IOP) is the main and only modifiable risk factor, attributed to the progression of the disease. During the last 25 years, glaucoma management has been based in the use of pharmaceutical therapies and incisional surgery. [ 5 ]  MIGS procedures can provide the patient sustained IOP reduction while minimizing the risk and complications associated with glaucoma interventions and decrease the dependence of glaucoma medications. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5746", "text": "MIGS procedures offer an excellent safety profile, with minimal incidence of complications, especially when compared with other forms of glaucoma surgery. [ 1 ] [ 2 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5747", "text": "MIGS objective, like all glaucoma surgeries, is to achieve lowering of IOP by either increasing  aqueous humour  outflow, the fluid that is produced by the eye and fills the space between the  cornea  and the  lens , or decreasing the production of aqueous humour. MIGS encompasses numerous devices and techniques, including  trabecular  outflow and  Schlemm's canal  targeted interventions, suprachoroidal outflow,  gonioscopy -assisted procedures, and subconjunctival shunts. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5748", "text": "The  iStent  Trabecular Micro-Bypass Stent, or simply iStent, is the smallest implantable medical device, designed to lower intraocular pressure by facilitating trabecular outflow of aqueous fluid. [ 8 ]  The trabecular outflow is one of the major outflow pathways for aqueous humor in the eye and has been the target of both pharmaceutical and surgical therapeutic approaches in glaucoma. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5749", "text": "The 1-millimeter long iStent is a  titanium  device inserted via an internal approach through the trabecular meshwork into Schlemm\u2019s Canal, bypassing the trabecular meshwork and facilitating flow of aqueous from the eye. [ 1 ] [ 2 ] [ 3 ]  Studies have shown that the iStent is an effective procedure, typically lowering intraocular pressure to the mid-teens. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5750", "text": "The iStent is the first MIGS device to get  FDA  approval for implantation in combination with cataract surgery. [ 11 ]  The device has also been shown to offer better IOP control than cataract surgery alone up to one year of follow-up in a large randomized controlled FDA study, although the effectiveness was significantly reduced by 2 years. [ 12 ] [ 13 ]  Safety of the iStent was comparable to cataract surgery alone which is much better than conventional trabeculectomy. [ 12 ] [ 13 ] [ 14 ] [ 15 ]   Common complications include failure to implant the device, touching the iris with the device, and touching the undersurface of the cornea (endothelium) with the device. [ 13 ]  Multiple studies have since confirmed the MIGS-type efficacy and safety profile of the iStent. [ 13 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5751", "text": "To address the reduced effectiveness at 2 years, some studies have been performed with multiple iStents. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5752", "text": "A 2019 Cochrane Review found that individuals who receive iStents in combination with cataract surgery may be less likely than those who only receive cataract surgery to need glaucoma eye drops at medium-term follow-up; however, the evidence for this finding was of low quality. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5753", "text": "The trabecular micro-bypass stents have been approved for use in the UK by the  National Institute for Health and Care Excellence (NICE) . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5754", "text": "The CyPass Micro-Stent is the first MIGS device developed for lowering of IOP through the suprachoroidal space (virtual space between the  choroid  and  sclera  created by implantation of the device), a part of the uveoscleral outflow pathway for aqueous humor. The uveoscleral pathway is an important pathway for aqueous outflow and drainage which can account for up to 57% of total outflow. [ 20 ]  Cyclodialysis cleft procedures were initially used to access this pathway with significant IOP lowering, but the cleft was prone to high anatomic variability as well as early postoperative closure due to the lack of a permanent drainage implant with a standardized and uniform conduit. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5755", "text": "It has a microlumen of 300 micrometres (0.012\u00a0in) and is designed to augment outflow to the suprachoroidal space in order to control intraocular pressure; it is indicated for the treatment of primary open-angle glaucoma. [ 22 ]  The stent is implanted through an ab interno approach and inserted into the supraciliary space (between the  ciliary body  and sclera), effectively creating a controlled cyclodialysis cleft, which is kept open by the device. [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5756", "text": "The first clinical data on the device was presented in 2010 showed sustained IOP lowering and MIGS-like safety profile. [ 25 ]  This has been substantiated in subsequent studies in the combined setting with  cataract surgery  and as a stand-alone treatment for patients failing glaucoma topical therapy. [ 6 ] [ 23 ] [ 24 ] [ 26 ]  Data from a large randomized controlled study has reported positive efficacy after 2 years of follow-up and will be submitted to FDA for approval. [ 27 ] [ 28 ]  The CyPass device has been CE-marked since 2009."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5757", "text": "The CyPass micro-stent was voluntarily withdrawn from the market by manufacturers Alcon in August 2018. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5758", "text": "The Hydrus Microstent is an implantable MIGS device for the treatment of primary open angle glaucoma; implantation of this device can be performed in conjunction with cataract surgery. [ 30 ]  The Hydrus Microstent is the longest of the MIGS devices (8-millimeter long implant), and similar to the iStent it is designed to increase trabecular outflow. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5759", "text": "The implant is inserted through the trabecular meshwork, thus bypassing resistance of aqueous flow through the tissue.  However, other glaucoma surgeries, such as canaloplasty, have shown that mechanical dilation of  Schlemm's canal  is also associated with a reduction in intraocular pressure. [ 31 ]  The Hydrus Microstent takes advantage of this property by mechanically dilating and holding open Schlemm\u2019s Canal.  The length of the Hydrus Microstent is thought to open approximately one quarter of Schlemm\u2019s Canal, routing aqueous into open downstream collector channels. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5760", "text": "Clinical data from a randomized controlled study demonstrates efficacy of the device at 1 and 2 years. [ 32 ]  The Hydrus Microstent is currently being investigated in an FDA approved study for mild-to-moderate glaucoma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5761", "text": "The XEN Gel Stent is an implantable transscleral microsurgical device that allows the aqueous fluid to drain from the anterior chamber into the subconjunctival space, a pathway utilized by traditional trabeculectomy and glaucoma drainage device surgeries. [ 33 ]  Unlike the latter two procedures, the XEN Gel Stent is performed through an internal approach and avoids directly incising and disrupting the conjunctiva itself. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5762", "text": "The 6-millimeter stent is placed through the  trabecular meshwork , with one end of the stent sitting directly underneath the conjunctiva, past the outer wall of the sclera.  The inner tip of the stent sits in the anterior chamber, allowing a direct connection for aqueous to flow into the subconjunctival space. The stent is made of a non-bioreactive material, which does not promote scarring of the conjunctiva. [ 34 ]  The XEN Gel Stent was FDA approved on Nov 22, 2016."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5763", "text": "The InnFocus Microshunt is a small tube, 8\u00a0mm in length, that is inserted in to the eye to help lower intraocular pressure and reduce the need for medications. A Cochrane Review published in December 2019 did not find any published clinical trials to assess whether the InnFocus Microshunt is safer and more comfortable for patients than standard glaucoma surgery (trabeculectomy). [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5764", "text": "The InnFocus Microshunt has now been renamed the Preserflo. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5765", "text": "Aqueous humor is produced in the portion of the eye known as the ciliary body.  The ciliary body contains 72 protrusions known as ciliary processes, from which the aqueous is produced. The destruction of these ciliary processes with a  diode laser , known as cyclophotocoagulation, can be used to decrease the amount of aqueous humor produced, thereby reducing the intraocular pressure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5766", "text": "Cyclophotocoagulation traditionally has been performed using an external laser through the sclera, known as transscleral cyclophotocoagulation.  However, side effects of the transscleral approach can include significant inflammation, chronically low intraocular pressure, intraocular bleeding, and permanent shutdown of the eye, known as phthisis. [ 38 ] [ 39 ]  Recent advances have now allowed a diode laser to be combined with a camera (endoscope) allowing for direct visualization of the ciliary processes during the ablation (Endo Optiks, Beaver Visitec, Waltham, MA). [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5767", "text": "Endocyclophotocoagulation is indicated for the treatment of both open and closed angle glaucoma and is performed in eyes which have already undergone cataract surgery or performed concomitantly with cataract removal.   The largest investigation of endocyclophotocoaguation has shown a significant decrease in intraocular pressure of up to 10 mmHg, as well as a significant reduction in number of glaucoma medications needed. Reported adverse reactions include intraocular inflammation, bleeding, and cystoid macular edema (swelling of the retina). [ 41 ]  A Cochrane Review published in 2019 found no relevant published studies on endoscopic cyclophotocoagulation to assess its effectiveness compared to other surgical treatments (including other MIGS), laser treatment or medical treatment. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5768", "text": "The  Trabectome , or trabeculectomy ab interno, is a microsurgical device cleared by the U.S. Food and Drug Administration since 2006, used in patients with open angle glaucoma to excise a strip of trabecular meshwork, the tissue primarily responsible for the increased resistance of aqueous outflow in glaucoma. [ 43 ]   The Trabectome uses electrocautery via an internal approach to vaporize the trabecular meshwork, creating a large pathway for aqueous to flow, with minimal trauma to surrounding tissues. The procedure can be performed alone or in conjunction with cataract surgery. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5769", "text": "Trabectome is unique among the MIGS procedures, as there is no physical device implanted inside the eye; the pressure lowering is a direct result from the destruction and removal of the trabecular meshwork.  Studies have found a decrease in intraocular pressure to the mid-teens following the procedure, which has a favorable safety profile. [ 44 ] [ 45 ]  The most common complication from Trabectome surgery is bleeding, which can blur vision and take extra time to recover.  The surgery site can scar over time and the pressure can go back up. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5770", "text": "In early 2014, the NeoMedix received a warning letter from the FDA regarding marketing practices. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5771", "text": "Excimer laser trabeculostomy is a procedure which creates holes in the  trabecular meshwork  to reduce  intraocular pressure  by using a  excimer laser . First developed in 1987, a 2020 review of 8 studies found the procedure reduced intraocular pressure by 20-40% and had generally positive outcomes. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5772", "text": "Minimally invasive strabismus surgery (MISS)  is a technique in  strabismus surgery  that uses smaller incisions than the classical surgical approach to correct the condition, thus minimizing tissue disruption. The technique was introduced by Swiss ophthalmologist  Daniel Mojon  around 2007, [ 1 ]  after the Belgian ophthalmologist Marc Gobin described the idea in 1994 in a French-language textbook. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5773", "text": "MISS is a technique that can be employed for all major types of strabismus surgery like rectus muscle recessions, resections, plications, reoperations, transpositions, oblique muscle recessions, or plications, and adjustable sutures, even in the presence of restricted motility. The smaller openings and the less traumatic procedure are in general associated with faster postoperative rehabilitation and less swelling and discomfort for the patient immediately after the procedure. It is supposed that the technique can be performed as an outpatient intervention in many patients (mainly adults) who would otherwise be hospitalized.  [ 3 ]  A study published in 2017 documented fewer  conjunctival  and eyelid swelling complications in the immediate postoperative period after MISS than after conventional strabismus surgery with long-term results being similar between both groups. [ 4 ]  Another advantage is that MISS technique may decrease the risk of anterior segment  ischemia  in some patients, particularly those suffering from  Graves' ophthalmopathy .  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5774", "text": "In MISS the operating microscope rather than magnifying glasses should be used by the surgeon. Instead of one large opening of the  conjunctiva  as is done in conventional strabismus surgery, several small cuts are placed where the main surgical steps, usually suturing, have to be performed. Openings are placed as far away from the  corneal limbus  as possible to minimize postoperative discomfort. Between two of these incisions, called keyhole openings, there is a \"tunnel\" used by the surgeon to insert the instrument for the treatment of the eye muscles. [ 6 ]  At the end of the operation, the keyhole openings are closed with resorbable sutures. These mini-incisions are postoperatively covered by the  eyelid . MISS openings markedly reduce the frequency and severity of corneal complications like, for example,  dry eye syndrome  and dellen formation, and will allow wearing  contact lenses  earlier. Long-term benefits are avoidance of an increase in redness of the visible conjunctiva and a decreased scarring of the perimuscular tissue, which will facilitate reoperations - if those should become necessary. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5775", "text": "The results after MISS regarding postoperative ocular alignment are widely described in the so far still limited literature on the technique to be about the same as in classical strabismus surgery. This was documented, for instance, in comparing 40 children; the group that had undergone the minimally invasive procedure, however, did show less swelling of the conjunctiva and the eyelids after surgery. [ 8 ]  Lesser rates of complications and faster reconvalescence have been widely established as the main advantages of MISS. [ 9 ]  The technique's efficacy has been shown for surgery of the rectus muscles [ 10 ] [ 11 ] [ 12 ]  as well as for the surgery of the oblique muscles. [ 13 ]  A group from India reported on the successful performance of MISS in patients with Graves' orbitopathy. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5776", "text": "MISS is more time-consuming than conventional surgery. Operating on the muscles through the tunnel is more demanding on the surgeon. The keyhole cuts may tear in older patients. If the tear involves  Tenon's capsule , a visible scar may result. An excessive bleeding that cannot be stopped makes an enlargement of the cuts necessary to cauterize the vessel. Usually, a conversion to a limbal opening as in classical strabismus surgery can be avoided. There are few reports, though, on complications that are unique to MISS.  [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5777", "text": "Nowatske v. Osterloh , 198 Wis.2d 419, 543 N.W.2d 265 (Wis. 1996),  on remand , 201 Wis.2d 497, 549 N.W.2d 256 (Wis. App. 1996), is a case relating to the law of  medical malpractice  in Wisconsin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5778", "text": "The plaintiff, [ 1 ]  Kim Nowatske underwent  retinal reattachment  surgery in his right eye in 1989. [ 2 ]   After the surgery, Nowatske could not see out of the eye in question.  During routine post-operative testing, defendant surgeon used his finger (instead of a  tonometer ) to measure the pressure inside Nowatske's eye and, noting a normal \"back-off\" response to light, did not specifically ask the patient whether he could see in his right eye or not. [ 3 ] \nThe patient thought the inability to see was a normal consequence of the surgery.  After the patient was discharged, he experienced severe pain; the surgeon, learning that the patient did not receive the pain medication prescribed, called in a prescription to a local pharmacy without inquiring further of the patient regarding the pain.  The next day, Nowatske was examined by the surgeon and learned that the blindness in the right eye was permanent.  In 1991, he and his wife sued the surgeon, and the case went to trial.  A jury determined that the surgeon was not negligent, [ 4 ]  and the plaintiff appealed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5779", "text": "On appeal, the plaintiff argued:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5780", "text": "The  Wisconsin Court of Appeals   certified  the first three legal questions to the  Wisconsin Supreme Court .  The state supreme court agreed to consider only the question of whether the pattern jury instructions were correct or not, and held that the jury instructions contained no  legal error  but \"should be improved.\" [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5781", "text": "The Wisconsin Court of Appeals then determined that the questions asked during impeachment were improper, but that this was  harmless error .  Allowing the defendant to demonstrate the use of an ophthalmoscope in the courtroom was within the trial court's discretion, and although the appeals court did \"not approve of the involvement of jurors in such a demonstration,\" [ 6 ]  this had no effect on the outcome of the case and therefore was not reversible error."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5782", "text": "Finally, the court of appeals held that \"[w]e will sustain a jury verdict if there is any credible evidence to support it.  See   Nieuwendorp v. American Family Ins. Co. , 191 Wis. 2d 462, 472, 529 N.W.2d 594, 598 (1995). Our consideration of the evidence must be done in the light most favorable to the verdict, and when more than one inference may be drawn from the evidence, we are bound to accept the inference drawn by the jury . . . . It is the jury's responsibility to determine the credibility of the witnesses and the weight to be afforded their testimony.\" [ 7 ]   There was conflicting testimony from experts [ 8 ]  regarding the standard of care (as to whether, after this type of surgery, a doctor may measure  intraocular pressure  using his finger or whether the doctor should use a  tonometer ) and, as it is the role of the jury and not the court of appeals to weigh expert testimony, the court of appeals affirmed the judgment of the trial court. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5783", "text": "Ophthalmic viscosurgical devices  (OVDs) are a class of clear gel-like material used in eye surgery to maintain the volume and shape of the  anterior chamber  of the eye, and protect the intraocular tissues during the procedure. They were originally called  viscoelastic  substances , or just  viscoelastics . Their consistency allows the surgical instruments to move through them, but when there is low  shear stress  they do not flow, and retain their shape, preventing collapse of the anterior chamber. OVDs are available in several formulations which may be combined or used individually as best suits the procedure, and are introduced into the anterior chamber at the start of the procedure, and removed at the end. Their tendency to remain coherent helps with removal, [ 1 ]  as the cohesive variants tend to be drawn into the aspiration orifice without breaking up."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5784", "text": "OVDs are used to protect the corneal endothelium from mechanical trauma and to maintain volume and form of the intraocular space during an open incision. The OVD is introduced into the space by syringe through a cannula. [ 2 ]  At the end of the procedure they are removed by aspiration and the space filled with a compatible fluid such as a  buffered saline solution . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5785", "text": "OVDs are commonly used in cataract, cornea, glaucoma, eye trauma, and vitreoretinal surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5786", "text": "Despite the side effects, the advantages of OVDs have made them indispensable in ophthalmic surgery involving the anterior chamber."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5787", "text": "There are no known contraindications to the use of a Sodium Hyaluronate Ophthalmic Viscosurgical Device as a surgical aid in ophthalmic anterior segment procedures. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5788", "text": "OVDs can cause excessive post-operative intraocular pressure, particularly if any is left remaining in the eye after surgery. The pressure rise is dose-related. It develops in the first day and will usually resolve spontaneously within three days. This effect is assumed to be a consequence of the large molecules of the OVD causing reduced outflow in the  trabecular meshwork . Various drugs have been used to limit pressure spikes, and while effective, are not entirely predictable in their effects. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5789", "text": "OVD can be trapped behind the IOL in the capsule during normal surgery, and may cause a forward displacement of the IOL, which in turn shifts the focal plane of the IOL towards near vision. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5790", "text": "The properties of an ideal OVD would include: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5791", "text": "The most relevant physical properties for use in ophthalmic surgery are  viscoelasticity ,  viscosity ,  pseudoplasticity , and  surface tension . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5792", "text": "These physical properties of an OVD are consequences of molecular chain length, and molecular interactions between chains. The  rheologic  properties of an OVD directly affect its clinical characteristics. An OVD can be chosen that best matches the requirements for a specific procedure, or part of a procedure, and combinations may be useful. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5793", "text": "Viscoelasticity is the property of  materials  that exhibit both  viscous  and  elastic  characteristics when undergoing  deformation . Viscous materials, like water, resist  shear flow  and  strain  linearly with time when a  stress  is applied. Elastic materials strain when stretched and immediately return to their original state once the stress is removed. Viscoelasticity allows the OVD to retain its shape under low shear stress, and to spring back into shape after a low deforming stress is removed, but also allow instruments to be moved relatively freely when the critical shear stress is exceeded. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5794", "text": "Viscosity is a measure of its the resistance to shear deformation in a fluid at a given rate, or its resistance to flow. It quantifies the internal frictional force between adjacent layers of fluid that are in relative motion. The viscosity of a  Newtonian fluid  does not vary significantly with the rate of deformation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5795", "text": "Pseudoplasticity is the characteristic of a material to rapidly transform from a gel-like consistency to a liquid and back as the shear stress is varied. A high molecular weight, high viscosity OVD at rest retains its shape well. When under \nsufficient shear stress it will flow, and alignment of the molecules reduces viscosity to allow rapid flow. Under low shear stress the OVD will quickly revert to an elastic gel, which is a good shock absorber. The highest shear rates occur when the OVD is passed through a cannula, in which state viscosity becomes nearly independent of molecular weight. When the molecules are aligned in the direction of flow, viscosity is determined almost entirely by the concentration. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5796", "text": "Surface tension: The coating ability of an OVD is determined partly by the intermolecular cohesive forces within the OVD, and partly adhesive forces between the OVD and the contacted tissue, instrument or IOL. The contact angle between a drop of the OVD and the other material on a flat surface is an indicator of the ability of the OVD to wet and coat that material. Surface tension is a measure of the cohesion between molecules of the OVD, so a lower surface tension and higher adhesion and contact angle indicate a better ability to wet. A solution of sodium hyaluronate has a significantly higher surface tension and contact angle with the relevant tissues than a solution of chondroitin sulfate, HPMC, or a mixture of sodium hyaluronate and chondroitin sulfate, which indicates better coating by the latter materials. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5797", "text": "Cohesive type OVDs adhere to themselves. They have high viscosity and act like a gel. The molecules have long chains, with high molecular weight, and have high surface tension and pseudoplasticity. They are relatively easy to aspirate as they tend to stay in one piece as they are drawn towards the suction orifice. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5798", "text": "Dispersive tyes have lower surface tension and tend to spread and wet contact surfaces. They have lower viscosity, the molecules are not as strongly mutually attracted, they show low pseudoplasticity and have shorter molecular chains and lower molecular weight. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5799", "text": "The OVD occupies the volume of the anterior chamber during surgery, maintains its volume and shape without requiring internal pressure, and does not flow out through open incisions when undisturbed. It allows the free passage of instruments, prevents low viscosity fluids from leaking out, and provides the surgeon with a clear view of the internal volume. The cohesive nature of some types facilitates rapid removal by aspiration at the end of the procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5800", "text": "OVDs are sterile aqueous saline solutions of one or more viscoelatic compounds and buffers to control pH at 7 to 7.5. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5801", "text": "Meyer and Palmer isolated hyaluronic acid from the vitreous cortex in 1934. [ 5 ]  Also in 1934,  Endre A. Balazs  extracted and purified hyaluronic acid from rooster combs and umbilical cord. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5802", "text": "In 1958, Balazs suggested the possibility of using hyaluronic acid as a substitute for the vitreous substitute during surgery for retinal detachment, and in 1972 made the first injection of hyaluronic acid into the vitreous chamber. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5803", "text": "Ophthalmic viscosurgical devices were introduced in 1972. [ 6 ]  Various alternative formulations with varied physical characteristics have been developed since then. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5804", "text": "Balazs developed the procedure of viscosurgery, coined the term, and patented high molecular weight viscoelastic material using purified hyaluronic acid to be used for implantation of IOLs. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5805", "text": "In 1976 an application for the use of the OVD Healon was made with the FDA, and the next year applications were made for its use in surgery for cataracts, IOL implantation, glaucoma, and corneal transplants. In 1979, 510k permission was granted to market Healon, and FDA approval in January 1983. Since then OVDs have become essential tools in ophthalmic surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5806", "text": "Polyacrylamide  is a synthetic compound that was used for a while but withdrawn from the market in 1991, after its use was found to be associated with elevated intraocular pressure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5807", "text": "Osteo-odonto-keratoprosthesis  ( OOKP ), also known as  \"tooth in eye\" surgery , [ 1 ]  is a medical procedure to restore vision in the most severe cases of corneal and ocular surface patients. It includes removal of a tooth from the patient or a donor. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5808", "text": "After removal, a longitudinal  lamina  is cut from the tooth and a hole is drilled perpendicular to the lamina. The hole is then fitted with a cylindrical lens. The lamina is grown in the patients' cheek for a period of months and then is implanted upon the eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5809", "text": "The procedure was pioneered by the Italian ophthalmic surgeon Professor Benedetto Strampelli in the early 1960s. Strampelli was a founder-member of  the International Intra-Ocular Implant Club  (IIIC) in 1966. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5810", "text": "An operation to graft the OOKP is undertaken in severe  pemphigoid ,  chemical burns ,  Stevens\u2013Johnson syndrome ,  trachoma ,  Lyell syndrome  and multiple  corneal graft  failure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5811", "text": "There is a significant risk of anatomical failure of lamina in the long term, estimated at 19% in a small study, [ 5 ]  with the main risks being laminar  resorption , particularly in  allografts , and  glaucoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5812", "text": "Another, bigger study comparing OOKP with the lesser known osteo-keratoprosthesis (OKP) in 145 and 82 patients and follow-up terms up to 10 years yielded the following statistics: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5813", "text": "Another long-term study of 181 patients puts the chances of retaining an intact OOKP after 18 years at 85%. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5814", "text": "In 2022, a retrospective study conducted on 82 eyes with OOKP using original Strampelli technique, showed an anatomical survival of 94% up to 30 years of follow-up. The same study also reported a visual acuity better than 1.00 logMAR (or 20/200 Snellen) at 10 years in 81% of the eyes, and a visual acuity of 1.21 logMAR (or 20/324 Snellen) at 30 years. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5815", "text": "OOKP is a two-stage operation: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5816", "text": "Stage 1  of the surgery involves five separate procedures:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5817", "text": "Stage 2  (about 4 months later) involves two separate procedures:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5818", "text": "At the end of the procedure, light can now enter through the plastic cylinder, and the patient is able to see through this cylinder with good vision. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5819", "text": "The procedure was pioneered by the Italian ophthalmic surgeon Professor Benedetto Strampelli [ citation needed ]  in Rome in the early 1960s."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5820", "text": "The son of the geneticist and agronomist  Nazareno Strampelli , Benedetto Strampelli held the chair of ophthalmic surgery at Rome's Ospedale di San Giovanni in Laterano where he was one of the first surgeons in Italy to transplant cornea. In 1953 he was the first Italian to implant  intraocular lens  which were manufactured to his own design by  Rayners  in UK. Strampelli was a founder-member with  Harold Ridley  and Peter Choyce of  the International Intra-Ocular Implant Club  (IIIC) in 1966. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5821", "text": "A  peritomy  is a procedure carried out during  eye surgery , where an incision is made around the  limbus , usually to expose the  sclera  and/or  extraocular muscles  for a variety of surgical procedures. [ 1 ]   [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5822", "text": "Photodisruption  is a form of  minimally invasive surgery  used in  ophthalmology , utilizing infrared  Nd:YAG lasers  to form plasma (\"lightning bolt\"), which then causes acoustic shock waves (\"thunderclap\") which then in turn affects tissue. [ 1 ] [ 2 ] [ 3 ]  The tissue ruptures as a result of the vapor bubble produced by the laser; the temperature required to produce this effect is between 100 and 305 \u00b0C. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5823", "text": "Because the infrared laser is invisible to the surgeon's eye, typically a companion  HeNe laser  is used in conjunction.  However, the eye lens acts as a prism, so the infrared light bends at a shallower angle than the red light, causing  chromatic aberration .  This means the area highlighted by the HeNe laser is not precisely the area being affected Nd:YAG laser, and therefore some surgical lasers have an added adjustment to compensate. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5824", "text": "The first successful use of photodisruption was in 1972, on a case of trabecular meshwork. [ 1 ]   Photodisruption came to wide use in the early 1980s for the treatment of extracapsular cataract extraction. [ 1 ]   The technique is most commonly used for  lithotripsy  of  urinary calculi  and the treatment of posterior  capsulotomy  of the lens. [ 3 ]   When used in corneal surgery, picosecond and nanosecond disruptors are used on the lamellae of the corneal stroma, and the method may be preferable as it leaves the  epithelium  and  Bowman's layer  unharmed.  This modifies the outer corneal curvature, which affects the refractive property of the eye. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5825", "text": "Phototherapeutic keratectomy  (PTK) is a type of  eye surgery  that uses a  laser  to treat various  ocular disorders  by removing  tissue  from the  cornea . PTK allows the removal of superficial  corneal opacities  and surface irregularities. It is similar to  photorefractive keratectomy , which is used for the treatment of  refractive conditions . The common indications for PTK are  corneal dystrophies , scars, opacities, and  bullous keratopathy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5826", "text": "Pre Descemet's endothelial keratoplasty (PDEK)  is a kind of endothelial  keratoplasty , where the pre descemet's layer (PDL) along with  descemet's membrane  (DM) and  endothelium  is transplanted. [ 1 ]  Conventionally in a  corneal transplantation , doctors use a whole cornea or parts of the five layers of the cornea to perform correction surgeries. In May 2013, Dr  Harminder Dua  discovered a sixth layer between the stroma and the descemet membrane which was named after him as the  Dua's layer . In the PDEK technique, doctors take the innermost two layers of the cornea, along with the  Dua's layer  and graft it in the patient's eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5827", "text": "The normal cornea (Fig 1) has from the front to the back the following layers:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5828", "text": "1. Epithelium"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5829", "text": "2. Bowman's membrane"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5830", "text": "3. Stroma"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5831", "text": "4. Pre Descemets layer"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5832", "text": "5. Descemet's membrane"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5833", "text": "6. Endothelium"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5834", "text": "For the human eye to see, the cornea or the front window of the eye should be clear or transparent. For that to happen the inside corneal layer the endothelium pumps out water from the cornea so that the cornea remains transparent and light can pass into the eye  and one can see. If the endothelium is bad the cornea starts retaining water and gets damaged which is called bullous keratopathy.Thus PDEK helps in replacing the non functioning endothelium in bullous keratopathy.\nPDEK is different from the whole cornea transplantation in which the transplantation of entire donor cornea to the recipient is done. [ 2 ] [ 3 ]  Normal corneal thickness is about 520 to 540 microns in the centre and 600 to 620 microns in the periphery. [ 4 ]  Pre descemet's layer which is dissected in PDEK, measures about 10.15\u00b13.6 microns thick. [ 5 ]  The descemet membrane (DM) measures about 16\u00b12 microns (range 13-20\u03bc) thick and the normal endothelium is about 5 microns thick. Hence, the overall thickness of the PDEK graft will be about 32 to 44 microns. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5835", "text": "Prof  Amar Agarwal  ( India ) in 2013, September 4 performed the first  PDEK surgery technique in collaboration with Prof  Harminder Dua  ( UK ) and showed the significance of the Pre Descemets layer in corneal transplantation. [ 7 ]  The initial surgery was performed for pseudophakic bullous keratopathy. Though donor eyes of all age group were used in the initial PDEK cases; there was marked difference in eyes with young donor corneas which resulted in better corneal clarity and visual outcome. This paved the way for the difference of PDEK using young donors and the importance of the endothelial viability. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5836", "text": "PDEK surgery can be performed in patients with decompensated cornea like pseudophakic bullous keratopathy, aphakic bullous keratopathy, congenital endothelial decompensation like Fuch's dystrophy of cornea and post traumatic endothelial decompensation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5837", "text": "PDEK graft can be harvested from donor of any age. [ 8 ]  Easy dissection of PDL layer in infant (less than 1 year), pediatric (1\u2013 15 years) and young donor (15 \u201340 years) is an added advantage in PDEK procedure, which helps in transfer of viable endothelial cells with maximum regenerating capacity from this group of donors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5838", "text": "PDEK graft is transplanted so far for adult patients who have lost vision due to endothelial decompensation meaning the  Endothelium  is not working. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5839", "text": "Graft can be obtained from a dissected corneoscleral button taken from the deceased. The procedure is performed in sterile operating theatre setup. PDEK graft is prepared initially and kept in the storage medium (Optisol or MK medium) till the recipient bed is prepared. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5840", "text": "The donor corneoscleral rim (donor cornea) is placed on the eye mount with the endothelial side facing the surgeon. A 30 gauge needle attached to a 5 ml syringe filled with sterile air is passed from the limbus (edge of the cornea) into the mid stroma (middle of the corneal layers) with the bevel of the needle facing upwards. Once the needle is stable in the stroma, controlled air injection is performed. Numerous tiny air bubbles are seen cleaving the stroma and finally they coalesce to form one large bubble or Big bubble (BB) (Fig 2A). Once the type 1 BB is formed in the centre, it is gradually enlarged to maximum size which is about 8\u00a0mm. Following this, the bubble is pierced with a trephine or knife (Fig 2B) and the graft is dissected meticulously. It is then stained with a dye (trypan blue) and delineated well (Fig 2C, D). The dissected PDEK graft is then placed in a storage medium till the recipient (patient) is ready for transplantation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5841", "text": "After obtaining the informed consent from the patient, local anesthesia is given. Anterior chamber entry (eye entry) is made by a blade in the superior corneo-limbus area. Descemet's membrane along with endothelium in the patient is removed mechanically by reverse Sinskey hook by controlled stripping on the endothelial side [ citation needed ]  (Fig 3A-C)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5842", "text": "The PDEK graft which is already preserved in the storage medium is then placed in an injector (Fig 3A). The graft takes a shape of scroll immediately after dissection and the surgeons maintains the integrity or orientation of the scroll throughout the procedure. The injector along with the graft is inserted via the corneal wound and the graft is injected in the anterior chamber (Fig 3C). Initially the graft is made sure that it is oriented with endothelium down and PDL against the host stroma. This can be confirmed by using an endoilluminator because in eyes with corneal decompensation, the clarity is usually poor and the visualization of graft is affected under naked eye.8 once the orientation is confirmed, the graft is unfolded under saline (Fig 3D). Then the graft is attached to the overlying host stroma pneumatically (Fig 3E,F). Air fluid pressure is maintained inside the chamber for 60 seconds and then minimal air is released. The wound is closed with 10-0 monofilament suture and subconjunctival antibiotic steroid injection is given. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5843", "text": "Normal human lens is placed inside a capsular bag by nature. During trauma, surgery or sometimes by genetic cause the bag is damaged, weak or absent. Under this condition, one cannot place a normal intraocular lens (IOL) in the bag. To overcome this problem, the technique of glued IOL was introduced by Prof Amar Agarwal in 2007, December for lens implantation in eyes with the absent or deficient capsular bag.9,10 Here 2 scleral flaps about 180 degrees apart are made and the IOL is inserted through the corneal incision (Fig 3). After making the sclerotomy below the flaps, the haptics are externalized and tucked in a scleral tunnel at the point of exit. Maggi and Maggi in 1997 were the first to report sutureless scleral fixation of a special IOL. Gabor Scharioth and Pavilidis in 2006 reported the scleral tuck and intrascleral haptic fixation of a posterior chamber Intra ocular lens (PC IOL). Fibrin glue is applied for apposing the flaps and conjunctiva. PDEK can be combined or performed simultaneously with glued IOL implantation in eyes with existing corneal decompensation with aphakia, IOL decenteration or dislocated lens. Sometimes, one may require removal of the existing lens (as in Anterior Chamber IOL) and replacement with the other by this method. So far we have seen good anatomical and functional outcome in combined PDEK with glued IOL (Fig 4)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5844", "text": "Normal endothelial cell count at birth is about 4000 cells/sq mm. Adult population has a count of about 2500 to 2800 cells/Sq mm and loses around 0.6% cells per year. The cells in infant have potential regenerating capacity unlike the adult cell and this can be utilized for PDEK to obtain excellent functional outcome. Infant donor eyes are eyes of donor less than or equal to 1 year. In our experience we noticed that the infant donors have maximum viable cells which can expand and cover the entire cornea in a decompensated adult cornea. Because type 1 BB is formed easily in young corneas, this is an added advantage in PDEK which can be performed in infant donors. Our preliminary results on Infant donor PDEK have been excellent and we expect to do more research on the functional differences in the young donors.7"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5845", "text": "Post operatively these patients are given topical steroids and antibiotics for 1 month. Low dose steroids are kept in maintenance for one year. Topical lubricants are prescribed according to the ocular surface changes. Preservative free lubricants are initiated in patients with immediate epithelial changes. Intraocular pressure is monitoring on regular basis to assess the steroid induce glaucoma. Follow up visits are preferred as day 1, day 3, day 7, 2 weeks, 1 month, 3 months and then 6 monthly. Post operative anterior segment optical coherence tomography may be performed for assessing the anatomical success of the technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5846", "text": "From the patient's point of view, the chances of rejection are less as compared to whole corneal transplantation as the PDEK graft has minimal PDL layer hence.11,12 Early visual rehabilitation is obtained (Fig 5) and the suture related complications are minimized. From the surgeon's point, PDEK graft is thicker than isolated DM graft and hence there is less intraoperative graft handling challenges like torn graft, tissue loss or ragged edges. Pneumatic dissection induced endothelial cell loss is also noted to be not higher than or in fact better than other endothelial keratoplasty.13 Since it is harvested from all age groups, the limitation of donor age is lessened. Minimal interface opacification, less refractive shift and reduced topographic changes are the extra benefits of PDEK."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5847", "text": "Intraoperatively, bubble related problems can happen in early learning curve. This can be managed by proper positioning of needle and controlled intrabubble pressure. Postoperative graft detachment can happen in eyes with insufficient air or loss of air after surgery.1,6 If the graft is detached in the centre and there is significant cornea edema, immediate graft repositioning by air is performed in operating theatre under sterile precautions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5848", "text": "In the last one and half year, many patients have been benefitted by PDEK surgery.1,6,7 Early visual recovery and less post operative inflammation is the main advantage. Young donor eyes seemed to have made a huge difference in the visual quality and functional outcome. There are additional research studies in progress to elucidate the regenerating capacity of the endothelial cells in vivo."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5849", "text": "A  pterygium  of the eye ( pl. :  pterygia  or  pterygiums , also called  surfer's eye ) is a pinkish, roughly triangular tissue growth of the  conjunctiva  onto the  cornea  of the  eye . [ 2 ]  It typically starts on the cornea near the nose. [ 3 ]  It may slowly grow but rarely grows so large that it covers the  pupil  and impairs vision. [ 2 ]  Often both eyes are involved. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5850", "text": "The cause is unclear. [ 2 ]  It appears to be partly related to long term exposure to  UV light  and dust. [ 2 ] [ 3 ]  Genetic factors also appear to be involved. [ 4 ]  It is a  benign growth . [ 6 ]  Other conditions that can look similar include a  pinguecula , tumor, or  Terrien's marginal corneal degeneration . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5851", "text": "Prevention may include wearing sunglasses and a hat if in an area with strong sunlight. [ 2 ]  Among those with the condition, an  eye lubricant  can help with symptoms. [ 2 ]  Surgical removal is typically only recommended if the ability to see is affected. [ 2 ]  Following surgery a pterygium may recur in around half of cases. [ 2 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5852", "text": "The frequency of the condition varies from 1% to 33% in various regions of the world. [ 7 ]  It occurs more commonly among males than females and in people who live closer to the equator. [ 7 ]  The condition becomes more common with age. [ 7 ]  The condition has been described since at least 1000 BC. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5853", "text": "Symptoms of pterygium include persistent redness, [ 9 ]  inflammation, [ 10 ]  foreign body sensation, tearing, dry and itchy eyes. In advanced cases the pterygium can affect vision [ 10 ]  as it invades the cornea with the potential of obscuring the optical center of the cornea and inducing astigmatism and corneal scarring. [ 11 ]  Many patients do complain of the cosmetic appearance of the eye either with some of the symptoms above or as their major complaint. The use of standard contact lenses can become uncomfortable or even impossible although custom shaping may improve the fit to some extent. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5854", "text": "The exact cause is unknown, but it is associated with excessive exposure to wind, sunlight, or sand. Therefore, it is more likely to occur in populations that inhabit the areas near the equator, as well as windy locations.  In addition, pterygia are twice as likely to occur in men than women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5855", "text": "Pterygium in the conjunctiva is characterized by elastotic degeneration of  collagen  ( actinic elastosis [ 12 ] ) and fibrovascular proliferation.  It has an advancing portion called the head of the pterygium, which is connected to the main body of the pterygium by the neck.  Sometimes a line of iron deposition can be seen adjacent to the head of the pterygium called  Stocker's line .  The location of the line can give an indication of the pattern of growth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5856", "text": "The predominance of pterygia on the nasal side is possibly a result of  peripheral light focusing , where the sun's rays passing laterally through the  cornea , where they undergo refraction and become focused on the  limbic  area.  Sunlight passes unobstructed from the  lateral  side of the eye, focusing on the  medial  limbus after passing through the cornea.  On the  contralateral  (medial) side, however, the shadow of the nose medially reduces the intensity of sunlight focused on the  lateral / temporal   limbus . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5857", "text": "Some research also suggests a genetic predisposition due to an expression of  vimentin , which indicates cellular migration by the keratoblasts embryological development, which are the cells that give rise to the layers of the cornea. Supporting this fact is the congenital pterygium, in which pterygium is seen in infants. [ 13 ]  These cells also exhibit an increased P53 expression likely due to a deficit in the  tumor  suppressor gene. These indications give the impression of a migrating  limbus  because the cellular origin of the pterygium is actually initiated by the limbal epithelium. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5858", "text": "The pterygium is composed of several segments:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5859", "text": "Pterygium (conjunctiva) can be diagnosed without need for a specific exam, however  corneal topography  is a practical test (technique) as the condition worsens. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5860", "text": "Pterygium should be differentiated from  pinguecula , which is histologically and etiologically similar to pterygium. [ 17 ] [ 18 ]  Unlike pterygium, pinguecula is seen only on the conjunctiva, it will not progress to limbus or cornea."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5861", "text": "Another condition which is similar to pterygium is inflammatory adhesion of conjunctiva to cornea known as  pseudopterygium . Unlike pterygium, it may occur anywhere around cornea and the adhesion is usually limited to its apex. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5862", "text": "As it is associated with excessive sun [ 19 ]  or wind exposure, wearing protective  sunglasses  with side shields and/or wide brimmed hats and using artificial tears throughout the day may help prevent their formation or stop further growth. Surfers and other water-sport athletes should wear eye protection that blocks 100% of the UV rays from the water, as is often used by snow-sport athletes. Many of those who are at greatest risk of pterygium from work or play sun exposure do not understand the importance of protection. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5863", "text": "A pterygium typically does not require surgery unless it grows to such an extent that it causes visual problems. [ 2 ]  Some of the symptoms such as irritation can be addressed with artificial tears. [ 2 ]  Surgery may also be considered for unmanageable symptoms. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5864", "text": "A  Cochrane review  found conjunctival autograft surgery was less likely to have reoccurrence of the pterygium at 6 months compared to amniotic membrane transplant. [ 23 ]  More research is needed to determine which type of surgery resulted in better vision or quality of life. [ 23 ]  The additional use of  mitomycin C  is of unclear effect. [ 23 ]   Radiotherapy  has also been used in an attempt to reduce the risk of recurrence. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5865", "text": "Conjunctival auto-grafting is a surgical technique that is an effective and safe procedure for pterygium removal. [ 25 ]  When the pterygium is removed, the tissue that covers the sclera known as the Tenons layer is also removed.  Auto-grafting covers the bare sclera with conjunctival tissue that is surgically removed from an area of healthy conjunctiva. That \"self-tissue\" is then transplanted to the bare sclera and is attached using sutures or tissue adhesive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5866", "text": "Amniotic membrane transplantation is an effective and safe procedure for pterygium removal. Amniotic membrane transplantation offers practical alternative to conjunctival auto graft transplantation for extensive pterygium removal. Amniotic membrane transplantation is tissue that is acquired from the innermost layer of the human placenta and has been used to replace and heal damaged mucosal surfaces including successful reconstruction of the ocular surface. It has been used as a surgical material since the 1940s, and has been shown to have a strong anti-adhesive effect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5867", "text": "Using an amniotic graft facilitates epithelialization, and has anti-inflammatory as well as surface rejuvenation properties. Amniotic membrane transplantation can also be attached to the sclera using sutures, or glue adhesive. [ 26 ] [ 27 ] [ 28 ]  Amniotic membrane by itself does not provide an acceptable recurrence rate. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5868", "text": "A  scleral buckle  is one of several  ophthalmologic  procedures that can be used to repair a  retinal detachment . Retinal detachments are usually caused by retinal tears, and a scleral buckle can be used to close the retinal break, both for acute and chronic retinal detachments. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5869", "text": "Scleral buckles come in many shapes and sizes. A silicone sponge (with air filled cells) is a cylindrical element that comes in various sizes. An encircling band is a thin  silicone  band sewn around the circumference of the  sclera  of the  eye . A solid silicone grooved tyre element is also used. Buckles are often placed under a band to create a dimple on the eye wall. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5870", "text": "The scleral buckle is secured around the eyeball under the  conjunctiva . This moves the wall of the eye closer to the detached retina. This alteration in the relationships of the tissues seems to allow the fluid which has formed under the retina to be pumped out, and the retina to re-attach. The  physics  or  physiology  of this process are not fully understood. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5871", "text": "Retinal detachment surgery usually also involves the use of  cryotherapy  or  laser photocoagulation . The laser or cryotherapy forms a permanent adhesion around the retinal break and prevents further accumulation of fluid and re-detachment. The usage of scleral buckle is a source of debate only for complex retinal detachment surgery amongst surgeons, and research has been conducted to compare safety and effectiveness outcomes of scleral buckling,  pars plana vitrectomy  with scleral buckle versus  pars plana  victrectomy without scleral buckle. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5872", "text": "Scleral buckles are done using local or general  anesthesia  and are often done as  outpatient  procedures. In the majority of treatments the buckle is left in place permanently, although in some instances the buckles can be removed after the retina heals.  The buckle may also be removed in the event of infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5873", "text": "A link between scleral buckles and  Adie syndrome  may exist. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5874", "text": "Results from three randomized controlled trials of 274 patients comparing retinal detachment outcomes from  pneumatic retinopexy  versus scleral buckle found some evidence suggesting that scleral buckle was less likely to result in a recurrence of retinal detachment than pneumatic retinopexy but that overall evidence is of low quality and insufficient. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5875", "text": "Sclerotomy  is a  medical intervention  that involves  surgical cutting  in the white area of the eye, known as the  sclera . [ 1 ]  The goal of this intervention is usually done to correct defects in sclera that resulted as a complication of  glaucoma  of other  ocular diseases . [ 2 ]  Sclerotomy can be divided into anterior sclerotomy and posterior sclerotomy. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5876", "text": "The sclerotomy incisions are made by:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5877", "text": "Strabismus surgery  (also:  extraocular muscle surgery ,  eye muscle surgery , or  eye alignment surgery ) is  surgery  on the  extraocular muscles  to correct  strabismus , the misalignment of the  eyes . [ 1 ]  Strabismus surgery is a one-day procedure that is usually performed under general anesthesia most commonly by either a neuro- or pediatric ophthalmologist. [ 1 ]  The patient spends only a few hours in the hospital with minimal preoperative preparation. After surgery, the patient should expect soreness and redness but is generally free to return home. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5878", "text": "The earliest successful strabismus surgery intervention is known to have been performed on 26 October 1839 by  Johann Friedrich Dieffenbach  on a 7-year-old esotropic child; a few earlier attempts had been performed in 1818 by William Gibson of Baltimore, a general surgeon and professor at the University of Maryland. [ 2 ]  The idea of treating strabismus by cutting some of the extraocular muscle fibers was published in American newspapers by New York oculist John Scudder in 1837. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5879", "text": "Strabismus surgery is one of many options used to treat any misalignment of the eyes, called strabismus. This misalignment or \"crossing\" of the eyes can be caused by a variety of issues. Surgery is indicated when other, less invasive methods have been unable to treat the misalignment or when the procedure will significantly improve quality of life and/or visual function. [ 4 ]  The type of surgery for a given patient depends on the type of strabismus they are experiencing. Exodeviations are when the misalignment of the eyes is divergent (\"crossing out\") and esodeviations are when the misalignment is convergent (\"crossing in\"). [ 4 ]  These conditions are further categorized based on when the misalignment is present. If it is latent the condition is called a \"-phoria\" and if it is present all the time it is a \"-tropia\". [ 4 ]   Esotropias measuring more than 15 prism diopters (PD) and exotropias more than 20 PD that have not responded to refractive correction can be considered candidates for surgery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5880", "text": "The goal of strabismus surgery is to correct misalignment of the eyes. This is achieved by loosening or tightening the extraocular muscles in order to weaken or strengthen them, respectively. [ 1 ]  There are two main types of extraocular muscles - rectus muscles and oblique muscles - which have specific procedures to achieve the desired results. [ 4 ]  The amount of weakening or strengthening required is determined through in-office measurements of the eye misalignment. Measured in PD, the size of the deviation is used along with established formulas and tables to inform the surgeon how the muscle must be manipulated in surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5881", "text": "The main procedure used to weaken a rectus muscle is called a recession. [ 4 ]  This involves detaching the muscle from its original insertion on the eye and moving it towards the back of the eye a specific amount. [ 1 ]  If after a recession the muscle requires more weakening a marginal myotomy can be performed, where a cut is made part way across the muscle. [ 4 ]  The procedures used to strengthen rectus muscles include resections and plications. A resection is when a portion of the muscle is cut away and the new shortened muscle is reattached to the same insertion point. A plication on the other hand is when the muscle is folded and secured to the outer white portion of the eye, known as the sclera. [ 4 ]  Plication has the advantages of being a quicker procedure that involves less trauma than a resection and preserves the anterior ciliary arteries - the latter of which minimizes the risk of blood loss to the front of the eye allowing for operation on multiple muscles at one time. [ 6 ]  Studies on horizontal rectus muscle surgeries have shown that both procedures have similar success rates and no difference in post-operative exodrift or overcorrection rate was discovered. [ 6 ]  However, further investigation is required to determine if there is any difference in long term effects from the two procedures. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5882", "text": "Because of the antagonistic pairings of the rectus muscles and the fact that strabismus can be a binocular problem, in certain cases surgeons have the option of operating on either one eye or both eyes. For example, a recent study compared the outcomes of bilateral lateral rectus recession and unilateral recession/resection of the later/medial recti for intermittent exotropia. [ 7 ]  This study showed that the unilateral procedure had higher success rates and lower recurrence rates for this specific condition. [ 7 ]  This is not necessarily true for all types of strabismus and further investigation is required to reach a consensus on this particular aspect of the surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5883", "text": "There are two oblique muscles attached to the eye - the superior oblique and the inferior oblique - which each have their respective procedures. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5884", "text": "The inferior oblique is weakened through a recession and anteriorization where the muscle is detached from the eye and reinserted at a spot anterior to the original insertion. [ 4 ]  Some surgeons will alternatively perform a myotomy or myectomy, where a muscle is either cut or has a portion of it removed, respectively. [ 4 ]  The inferior oblique muscle is rarely tightened due to the technical difficulty of the procedure and the possibility of damage to the macula, which is responsible for central vision. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5885", "text": "The superior oblique is weakened through either a tenotomy or tenectomy, where part of the muscle tendon is either cut across or removed, respectively. [ 4 ]  The superior oblique is strengthened by folding and securing the tendon to reduce its length, which is called a tuck. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5886", "text": "A technique that is more commonly used for more complicated cases of strabismus is that of adjustable suture surgery. This technique allows for the adjustment of sutures after the initial procedure in order to theoretically achieve a better and more individualized result. This often requires dedicated and specific training in this uncommon procedure that has been reported to be performed in only 7.42% of all strabismus cases. [ 8 ]  Studies have not shown any significant advantage to performing this type of surgery on most forms of simple strabismus. However, its use in some complex cases such as reoperations, strabismus with large or unstable angle, or strabismus in high myopia has been indicated. [ 8 ]  The specific circumstances in which this technique is considered to be superior to non-adjustable suture surgery require further investigation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5887", "text": "A relatively new method, primarily devised by Swiss ophthalmologist  Daniel Mojon , is  minimally invasive strabismus surgery (MISS) [ 9 ]  which has the potential to reduce the risk of complications and lead to faster visual rehabilitation and wound healing. Done under the operating microscope, the incisions into the conjunctiva are much smaller than in conventional strabismus surgery. A study published in 2017 documented fewer conjunctival and eyelid swelling complications in the immediate postoperative period after MISS with long-term results being similar between both groups. [ 10 ]  MISS can be used to perform all types of strabismus surgery, namely rectus muscle recessions, resections, transpositions, and plications even in the presence of limited motility. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5888", "text": "A strabismus surgery is considered a success when the overall deviation has been corrected 60% or more or if the deviation is under 10 PD 6 weeks after the surgery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5889", "text": "Surgical intervention can result in the eyes being entirely aligned ( orthophoria ) or nearly so, or it can result in an alignment that is not the desired result. There are many possible types of misalignment that can occur after the surgery including undercorrection, overcorrection, and torsional misalignment. [ 12 ]  Treating a case of unsatisfactory alignment often involves prisms, botulinum toxin injections, or more surgery. The likelihood that the eyes will stay misaligned over the longer term is higher if the patient is able to achieve some degree of  binocular fusion  after surgery than if not. [ 4 ]  There is tentative evidence that children with infantile esotropia achieve better  binocular vision  post-operatively if the surgical treatment is performed early ( see:   Infantile esotropia ). A recent study reported the reoperation rate in a sample of over 6000 patients being 8.5%. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5890", "text": "Strabismus has been shown to have a variety of negative psychosocial effects on affected patients. Patients are often more fearful, anxious, have lower self-esteem, and increased interpersonal-sensitivity. [ 14 ]  These negative impacts often start in childhood and then progress throughout childhood and adolescence if the misalignment is not corrected quickly. [ 14 ]  There is also data to suggest that society sees this condition as one that negatively affects many qualities important to self-sufficient function such as responsibility, leadership ability, communication, and even intelligence. However, much of this critical mental health burden has been shown to be relieved by corrective surgery. [ 14 ]  Significant increases in self confidence and self-esteem as well as a reduction in general as well as social anxiety was observed. Overall, strabismus surgery has been shown to successfully improve upon many of the negative impacts strabismus can have on one's mental health. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5891", "text": "Complications that occur rarely or very rarely following surgery include: eye infection, hemorrhage in case of scleral perforation, muscle slip or detachment, or even loss of vision. Eye infection occurs at a rate between 1 in 1100 and 1 in 1900 and can lead to permanent loss of vision if not properly treated. [ 15 ]  Surgeons take many measures to prevent infection such as careful surgical draping, using povidone iodine as both drops and a solution to soak the sutures in, as well as a post-op course of steroids and antibiotics. [ 15 ]  There is generally minimal bleeding during strabismus surgery, but medications such as anti-platelet agents and anticoagulants can lead to vision threatening complications retrobulbar hemorrhage. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5892", "text": "Diplopia , or double vision, occurs commonly after strabismus surgery. Although the surgery can be used to treat some types of double vision, it can instead end up making existing symptoms worse or create a new type of double vision. [ 12 ]  The type of double vision can be horizontal, vertical, torsional, or a combination. Treatment of the double vision depends on both the type of double vision and the ability of two eyes to work together, also called binocular function. [ 12 ]  Diplopia with normal binocular function is treated with prism glasses, botulinum injections into the muscles, or repeated surgery. [ 12 ]  If binocular function is not normal, a more individualized approach is necessary to best suit the patient's needs. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5893", "text": "Eye muscle surgery gives rise to scarring ( fibrosis ) as a result of the trauma caused to the ocular tissues. [ 4 ]  The goal of surgery is to produce a thin line of firm scar tissue where the muscle is reattached to the sclera. However, the process of surgery can also result in the formation of scar tissue on other parts of eye. These adhesions can, in rare cases, affect the motion of the eye and the desired alignment. [ 17 ]  If scarring is extensive, it may be seen as raised and red tissue on the white of the eye. [ 4 ]  Fibrosis reducing measures such as cryopreserved amniotic membrane and  mitomycin C  have been shown to have some utility during surgery. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5894", "text": "Very rarely, potentially life-threatening complications may occur during strabismus surgery due to the  oculocardiac reflex . [ 18 ]  This is a physiologic reflex that is described as a reduction in heart rate due to pressure on the globe or traction on the extraocular muscles. It involves activation of the trigeminal nerve leading to activation of the vagus nerve due to the internuclear communication. [ 18 ]  Although the most common arrhythmia is sinus bradycardia, asystole can be seen in its severe form. [ 4 ]  The reflex can also have non cardiac effects such as postoperative nausea and vomiting, which is an extremely common consequence of strabismus surgery in children. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5895", "text": "Toric Markers  are markers made for marking on the outside of the  cornea  or  sclera  part of the eye.\nThey are designed with semi-sharp or pointed line or dot patterns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5896", "text": "There are two kinds of markers - Pre-Op markers and Intra-Op markers. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5897", "text": "Pre-Op markers: these are used before the patient lies down for surgery. The marking is done when the patient is sitting up with eyes looking forward.\nThe patterns are usually two lines that indicate one of the following"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5898", "text": "Intra-Op markers: these are used during surgery, with the patient lying down on the surgery table, and doctor operating with a microscope.\nIn a few cases, the markers are used during the surgery, along with a degree gauge."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5899", "text": "The  Trabectome  is a surgical device that can be used for ab interno trabeculotomy, a minimally invasive glaucoma surgery for the surgical management of adult, juvenile, and  infantile glaucoma . The trabecular meshwork is a major site of resistance to aqueous humor outflow. As angle surgeries such as Trabectome follow the physiologic outflow pathway, the risk of complications is significantly lower than filtering surgeries. Hypotony with damage to the macula ( hypotony maculopathy ),  can occur with pressures below 5 mmHg, for instance, after traditional trabeculectomy, because of the episcleral venous pressure limit. The Trabectome handpiece is inserted into the anterior chamber, its tip positioned into  Schlemm's canal , and advanced to the left and to the right. Different from cautery, the tip generates plasma to molecularize the trabecular meshwork and remove it drag-free and with minimal thermal effect. Active irrigation of the trabectome surgery system helps to keep the anterior chamber formed during the procedure and precludes the need for ophthalmic viscoelastic devices. Viscoelastic devices tend to trap debris or gas bubbles and diminish visualization. The Trabectome decreases the intra-ocular pressure typically to a mid-teen range and reduces the patient's requirement to take glaucoma eye drops and glaucoma medications (see references). The theoretically lowest pressure that can be achieved is equal to 8 mmHg in the episcleral veins. This procedure is performed through a small incision and can be done on an outpatient basis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5900", "text": "When abdomino-interno trabeculectomy is combined with cataract surgery, it is initially performed for optimal angle visualization. Corneal clarity is often damaged during cataract surgery, and this damage may only be noticeable during gonioscopy, when the light path through the cornea is longer. An iris-lanar clear corneal incision of 1.8\u00a0mm width is made approximately 2\u00a0mm in front of the surgical limbus. Cataract surgery uses a larger keratome that requires the incision to be closed, to reduce fluid leakage. No viscoelastic is used, as it can cause bipolar electrodes to carbonize during the incision. The patient's head is then turned away from the surgeon by approximately 40 degrees, and the microscope is turned to the same extent in the opposite direction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5901", "text": "Optimum gonioscopic trabecular meshwork visualization requires an angle of approximately 70 to 80 degrees between the microscope and the patient's eye. An incision is made, which is slightly gaping. This gaping encourages hypotony and enables easy identification of Schlemm's canal from refluxed blood. Trypan blue can also be used to stain the trabecular meshwork [18]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5902", "text": "The trabectome handpiece is inserted, with irrigation turned on. If the anterior chamber is too shallow for it to be fully inserted, the irrigation ports in the metal sleeve can form the anterior chamber by resting against the outer edges of the incision, with the tip already inside the eye. Right-handed surgeons find it easiest to perform counterclockwise removal first. The trabectome is engaged in the trabecular meshwork. This is done with the tip angled 45 degrees upward, just in front of the scleral spur. This angle offers a pointed entry into the meshwork. The trabectome is then moved in a strictly parallel fashion, with no movement toward the wall of the canal. The handpiece is turned 180 degrees, completing the clockwise removal. The superior and inferior angle structures can be seen, and almost 180 degrees of meshwork are removed by tilting the goniolens toward the patient's brow and then toward their cheek. This can be done in reverse, depending on which eye is operated on."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5903", "text": "Once complete, the trabectome is carefully removed from the eye. Viscoelastic is injected into the eye for pressurization, and to tamponade the reflux heme. If cataract surgery is to follow, the microscope and patient's head are returned to their initial positions. The existing access point is used, and a larger keratome is employed to create a larger incision, with a self-sealing biplanar wound [2]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5904", "text": "Microincisional glaucoma surgery [3, 4] is conducted in a space that is approximately 200 times smaller than the space used to implant epibulbar glaucoma drainage devices [5] As such, this type of surgery is particularly challenging to learn. The deep venous plexus distal to the outer wall of Schlemm's canal, the iris root, the ciliary body band and the suprachoroidal space all risk being damaged during surgery. This damage can cause variable sequelae [6, 7]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5905", "text": "To master this surgery, it is important to be able to visualize the angle, identify the correct target, avoid trauma and maximize meshwork removal. Microincisional glaucoma surgery does not yet have dedicated simulators or synthetic models such as those used in cataract surgery wet labs. Therefore, most aspiring surgeons in this field practice on glaucoma patients. This is despite reported complications being almost ten times as common toward the end of training [8]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5906", "text": "A safe and low-cost training environment has recently been created, using pig eyes mounted on a model head. This allows trainee surgeons to track their progress objectively. The pig eyes are infused with diluted fluorescein to trace outflow. Fluorescein can diffuse through the trabecular meshwork, which allows flow speeds to be estimated in non-treated parts of the eye. A disadvantage of this method is that over time, diffusion also takes place through intact vascular endothelium, staining the extravascular space. Fluorescent beads can be used as an alternative, and are suitable in less time-sensitive, more beginner-friendly studies of ablation. However, unlike fluorescein, this method does not account for flow speeds or volume estimates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5907", "text": "There are several surgical steps that can be simulated and practiced for cataract procedures. These include positioning the patient's head, setting up the microscope, gonioscopic visualization of the angle and identification of Schlemm's canal. For the surgery to be performed correctly, the patient's headrest must be close enough to the microscope stand to accommodate the tilted view, and greater distance from it. Trainees can tell their patient that they would like to take a brief look at the angle of the eye. The surgeon should be seated temporally, and the patient's head tilted away by 30 degrees. The microscope should be set up by centering its head, confirming that the tilt knob is covered with a handle. The equipment is then tilted toward the surgeon by 30 degrees. The microscope should be manually lowered, bringing the limbus into focus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5908", "text": "To practice gonioscopic visualization of the angle, the correct handedness of the modified Swan Jacob gonioprism should be confirmed. This is done by placing it on the eye and moving the microscope focus down, toward the nasal angle. The iris root, ciliary body band and trabecular meshwork can be seen through the microscope. They should all be distinguished from Schwalbe's line and the Sampaolesi line. Schlemm's canal should be identified by using a 0.12 forceps to tap lightly on the posterior lip of the primary cataract incision, creating blood reflux. After several seconds, the goniolens should be replaced onto the cornea, to visualize a partially venous, blood-filled Schlemm's canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5909", "text": "By removing the primary resistance (the trabecular meshwork), aqueous humor can pass more freely into collector channels and aqueous veins. The Goldmann equation states that Intraocular Pressure = [Aqueous Humor Formation/Outflow] + Episcleral Venous Pressure. This equation states that free-flowing aqueous humor should cause intraocular pressure to drop to the same level as in the episcleral veins [26]. However, this is rare, and the average postoperative intraocular pressure is around 16 mmHg [27]. Spectral domain optical coherence tomography can be used to view collector channel diameter change, collapse or patency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5910", "text": "Like human eyes, pig eyes have more outflow along the nasal drainage system than the temporal angle. Trabecular meshwork removal from the nasal can enhance outflow beyond physiological levels. It can also cause fluorescein to flow circumferentially, through small connections between Schlemm's canal-like segments, typical of a pig's angular aqueous plexus [3-5]. Reconstruction of outflow tracts via spectral domain optical coherence tomography have confirmed a correlation between aqueous spaces and collectors where flow was seen. However, these studies have also confirmed the existence of non-perfused vascular structures that could be part of the arterial or venous vascular system, or poorly perfused collector channels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5911", "text": "Recent discoveries have shown valve-like structures that appear to guard collector channel orifices and collapsible aqueous veins  9, 10 . These findings contradict the view that collector channel openings are round and unobstructed. Structural data has shown that flaps are suspended by string-like attachments. This research suggests that these attachments should be maintained during surgery, or that the flaps at the opening of collector channels should be removed. Electron microscopic images of the outer wall suggest that most are removed during trabectome procedures, together with their attachments and the trabecular meshwork [30]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5912", "text": "As many patients have both cataract and glaucoma, phacoemulsification is often combined with trabectome surgery, for the cost-effective treatment of both conditions [11]. Combined phaco-trabectome surgery can result in an intraocular pressure reduction of approximately 18% [12]. A recent study of phaco-trabectome surgery patients found the most significant reduction in cases of severe glaucoma, steroid-induced glaucoma [33,34] and pseudoexfoliative glaucoma [13, 14]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5913", "text": "Trabectome surgery alone provides an alternative to more invasive procedures. It is suitable for patients who have previously undergone cataract surgery, as well as those who have no visually significant cataract. Studies have shown that lens status or performance of phacoemulsification in the same session has no significant impact on intraocular pressure reduction [38,39]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5914", "text": "When comparing patients undergoing trabectome-only with those undergoing phaco-trabectome procedures, research has shown greater benefit in phakic or pseudophakic eyes after phaco-trabectome procedures [40]. However, phakic patients undergoing trabectome showed a greater reduction in intraocular pressure, compared to patients undergoing phacoemulsification combined with trabectome. These results suggest that phacoemulsification may not have a significant impact on intraocular pressure reduction [39]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5915", "text": "Historically, angle-based glaucoma surgery in patients with narrow angles was thought more likely to result in synechiae and fibrosis. This was considered a contraindication to trabectome surgery. However, studies of trabectome and phaco-trabectome patients have proven that trabectome surgery can be successful even in these cases. Patients with an angle at Shaffer grade 2 or less (narrow) showed an average intraocular pressure reduction of 42% one year after trabectome surgery, and of 24% one year after phaco-trabectome. Patients with an angle at Shaffer grade 3 or above (open) showed an average intraocular pressure reduction of 37% reduction one year after trabectome surgery, and of 25% reduction one year after phaco-trabectome. These results suggest that trabectome surgery is a viable option for patients with narrow angles [15]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5916", "text": "Reoperation after failed trabeculectomy or tube shunt is very challenging. Trabectome surgery is a minimally invasive alternative to a repeat filter or shunt. Studies of patients undergoing trabectome surgery after a failed tube shunt have shown a statistically significant reduction in intraocular pressure after one year [42]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5917", "text": "When comparing patients undergoing trabectome surgery after failed trabeculectomy with those undergoing phaco-trabectome, research has shown a greater reduction in intraocular pressure after trabectome than after phaco-trabectome [43]. Further research has shown trabectome surgery after failed trabeculectomy to result in an intraocular pressure reduction of 36%, and a 14% decrease in the number of pressure-lowering medications. 25% of patients were seen to require further surgery [44]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5918", "text": "Trabectome surgery has also proven to be a valuable adjuvant at the point of both valved and non-valved tube shunt implantation. When comparing patients undergoing Baerveldt tube implantation alone with those undergoing the same procedure combined with trabectome surgery, both groups showed similar intraocular pressure and visual acuities after the procedures. The combined patients required fewer pressure-lowering drops. These results show that trabectome surgery could improve post-operative quality of life by reducing necessary medication [16]. Results from Ahmed tube implantations showed a similar trend [46]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5919", "text": "When trabectome surgery results are correlated with glaucoma severity, patients with more medication, higher intraocular pressure and worse visual field experience a larger reduction in intraocular pressure than those with less aggressive glaucoma [33,37]. Studies have shown patients with the most advanced glaucoma to have a pressure reduction three times greater than those with mild glaucoma. Individuals with advanced glaucoma have been shown to have a lower success rate than those with mild glaucoma. This risk of failure is important when trabectome surgery is considered as a less risky alternative to traditional procedures. Other factors which have been linked to intraocular pressure reduction are age, Hispanic ethnicity, steroid-induced glaucoma and cup disk ratio [37]. Contradictory results have, however, been presented in the cases of ethnicity and the cup disk ratio [17]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5920", "text": "The trabectome is very safe, particularly when compared to incisional glaucoma surgery. Recent research has shown the most common complications to include hyphema, peripheral anterior synechiae, corneal injury and temporary spikes in intraocular pressure. Less common complications include transient hypotony lasting less than 3 months, iris injury, cystoid macular edema and cataract progression. There are case reports of a few, rare complications, including cyclodialysis cleft, aqueous misdirection, choroidal hemorrhage and endophthalmitis [18]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5921", "text": "1. van der Merwe EL, Kidson SH (2010) Advances in imaging the blood and aqueous vessels of the ocular limbus. Exp Eye Res 91:118\u2013126 \n2. Polat JK, Loewen NA (2016) Combined phacoemulsification and trabectome for treatment of glaucoma. Surv Ophthalmol.  https://doi.org/10.1016/j.survophthal.2016.03.012 \n3. Kaplowitz K, Schuman JS, Loewen NA (2014) Techniques and outcomes of minimally invasive trabecular ablation and bypass surgery. Br J Ophthalmol 98:579\u2013585 \n4. Kaplowitz K, Loewen NA (2013) Minimally Invasive and Nonpenetrating Glaucoma Surgery. In: Yanoff M, S. DJ (eds) Ophthalmology: Expert Consult. Elsevier, pp 1133\u20131146 \n5. Christakis PG, Tsai JC, Kalenak JW, et al. (2013) The Ahmed versus Baerveldt study: three-year treatment outcomes. Ophthalmology 120:2232\u20132240 \n6. Kaplowitz K, Bussel II, Honkanen R, et al. (2016) Review and meta-analysis of ab-interno trabeculectomy outcomes. Br J Ophthalmol.  Review and meta-analysis of ab-interno trabeculectomy outcomes \n7. Kaplowitz K, Abazari A, Honkanen R, Loewen N (2014) iStent surgery as an option for mild to moderate glaucoma. Expert Rev Ophthalmol 9:11\u201316 \n8. Martin KR, Burton RL (2000) The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon. Eye 14 ( Pt 2):190\u2013195 \n9. Xin C, Wang RK, Song S, et al. (2016) Aqueous outflow regulation: Optical coherence tomography implicates pressure-dependent tissue motion. Exp Eye Res.  https://doi.org/10.1016/j.exer.2016.06.007 \n10. Johnstone M (2016) 3. Intraocular pressure control through linked trabecular meshwork and collector channel motion. In: Knepper PA, Samples JR (eds) Glaucoma Research and Clinical Advances 2016 to 2018. Kugler Publications, p 41 \n11. Iordanous Y, Kent JS, Hutnik CM, Malvankar-Mehta MS (2013) Projected Cost Comparison of Trabectome, iStent, and Endoscopic Cyclophotocoagulation Versus Glaucoma Medication in the Ontario Health Insurance Plan. J Glaucoma.  Projected Cost Comparison of Trabectome, iStent, and Endoscopic Cyclophotocoagulation Versus Glaucoma Medication in the Ontario Health Insurance Plan \n12. Minckler D, Mosaed S, Dustin L, et al. (2008) Trabectome (trabeculectomy-internal approach): additional experience and extended follow-up. Trans Am Ophthalmol Soc 106:149\u201359; discussion 159\u201360 \n13. Widder RA, Dinslage S, Rosentreter A, et al. (2014) A new surgical triple procedure in pseudoexfoliation glaucoma using cataract surgery, Trabectome, and trabecular aspiration. Graefes Arch Clin Exp Ophthalmol 252:1971\u20131975 \n14. Ting JLM, Damji KF, Stiles MC, Trabectome Study Group (2012) Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg 38:315\u2013323 \n15. Bussel II, Kaplowitz K, Schuman JS, et al. (2015) Outcomes of ab interno trabeculectomy with the trabectome by degree of angle opening. Br J Ophthalmol 99:914\u2013919 \n16. Knowlton P, Bilonick R, Loewen N (2016) Baerveldt tube shunts with trabectome surgery in a matched comparison to Baerveldt tube shunts \n17. Roy P, Loewen RT, Dang Y, et al. (2016) Stratification of phaco-trabectome surgery results using a glaucoma severity index \n18. Kaplowitz K, Bussel II, Honkanen R, et al. (2016) Review and meta-analysis of ab-interno trabeculectomy outcomes. Br J Ophthalmol 100:594\u2013600"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5922", "text": "Trabeculectomy  is a surgical procedure used in the treatment of  glaucoma  to relieve  intraocular pressure  by removing part of the  eye 's  trabecular meshwork  and adjacent structures. It is the most common  glaucoma surgery  performed and allows drainage of  aqueous humor  from within the eye to underneath the conjunctiva where it is absorbed. This outpatient procedure was most commonly performed under monitored anesthesia care using a  retrobulbar block  or  peribulbar block  or a combination of topical and subtenon ( Tenon's capsule ) anesthesia. Due to the higher risks associated with bulbar blocks, topical analgesia with mild sedation is becoming more common. Rarely general anesthesia will be used, in patients with an inability to cooperate during surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5923", "text": "An initial pocket is created under the conjunctiva and Tenon's capsule and the wound bed is treated for several seconds to minutes with  mitomycin C  (MMC, 0.5\u20130.2\u00a0mg/ml) or  5-fluorouracil  (5-FU, 50\u00a0mg/ml) soaked sponges. These chemotherapeutics help to prevent failure of the filter bleb from scarring by inhibiting fibroblast proliferation. Alternatively, non-chemotherapeutic adjuvants can be implemented to prevent super scarring by wound modulation, such as the ologen collagen matrix implant. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  Some surgeons prefer \"fornix-based\" conjunctival  incisions while others use \"limbus-based\" construction at the corneoscleral junction which may allow easier access in eyes with deep sulci.\nA partial thickness flap with its base at the corneoscleral junction is then made in the sclera after careful cauterization of the flap area, and a window opening is created under the flap with a Kelly-punch to remove a portion of the  sclera ,  Schlemm's canal  and the  trabecular meshwork  to enter the  anterior chamber .\nBecause of the fluid egress the iris will partially prolapse through the sclerostomy and is usually therefore grasped to perform an excision called  iridectomy . This iridectomy will prevent future blockage of the sclerostomy. The scleral flap is then sutured loosely back in place with several sutures. The conjunctiva is closed in a watertight fashion at the end of the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5924", "text": "Intraocular pressure  may be lowered by allowing drainage of aqueous humor from within the eye to the following routes: (1) filtration through the sclerotomy around the margins of the scleral flap into the filtering bleb that forms underneath the conjunctiva, (2) filtration through outlet channels in the scleral flap to underneath the conjunctiva,(3) Filtration through the connective tissue of the scleral flap to underneath the conjunctiva. Into cut ends of Schlemm's canal. (4) aqueous flow into cut ends of Schlemm's canal into collector channels and episcleral veins  (5) into a cyclodialysis cleft between the  ciliary body  and the sclera if tissue is dissected posterior to the scleral spur. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5925", "text": "Glaucoma medications are usually discontinued to improve aqueous humor flow to the bleb. Topical medications consist typically of antibiotic drops four times per day and anti-inflammatory therapy e.g. with prednisolone drops every two hours. A shield is applied to cover the eye until anesthesia has worn off (that also anesthetizes the optic nerve) and vision resumes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5926", "text": "Patients are instructed to call immediately for pain that cannot be controlled with over the counter pain medication or if vision decreases, to not rub the eye and to wear the shield at night for several days after surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5927", "text": "If 5-FU was used during surgery or if no anti-fibrotic agent was applied, 5\u00a0mg 5-FU daily can be injected in the 7\u201314 postoperative days. In the following days to weeks sutures that hold the scleral flap down can be cut by laser suture lysis to titrate the intraocular pressure down by improving outflow. In laser suture lysis a red light laser and a contact lens are used to penetrate noninvasively the overlying conjunctiva and cut the black nylon suture. Some surgeons prefer adjustable flap sutures during the trabeculectomy that can be loosened later on with forceps in a slit lamp office procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5928", "text": "Trabeculectomy is the most common invasive  glaucoma surgery . It is highly effective in the treatment of advanced glaucoma as demonstrated in major  glaucoma  studies. [ citation needed ]  Even if a prior trabeculectomy has failed a second trabeculectomy can be performed at a different site. If scarring is the main reason, anti-fibrotic and anti-inflammatory therapy has to be intensified in the second procedure. Alternatively, insertion of a  glaucoma valve  device can be used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5929", "text": "Trabeculectomy has undergone numerous modifications, e.g. filtering trepanotrabeculectomy (TTE), a modification of the operation after J. Fronimopoulos. A triangular scleral flap is created which is approximately one-half as thick as the sclera. Trepanation is performed with a 2\u00a0mm trephine. The scleral edge of the trepanation opening is heat-cauterized. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5930", "text": "Additional deep scleral dissection can also be performed in the scleral bed with trabeculectomy, first introduced by T. Dada et al.; [ 9 ]  deep scleral excision is performed in non-penetrating filtering surgeries but not traditionally in trabeculectomy. The space created from the deep scleral dissection is proposed to accommodate certain biocompatible spacer or devices in order to prevent subscleral fibrosis and to maintain good filtering results in this modified operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5931", "text": "Various devices have been used with trabeculectomy techniques with the goal of improving safety of the procedure, maintaining drainage of aqueous humor, and to maintain the patency of bleb. [ 10 ]  Examples of Trabeculectomy-modifying devices are Ex-PRESS, Gelfilm, XEN Gel stent,  antifibrotic  materials (e.g Ologen), ePTFE (expanded  polytetrafluoroethylene ) membrane and PreserFlo MicroShunt. Comparing each of these devices for effectiveness and safety is required. [ 10 ]  There is some low-quality evidence that usage of Ex-PRESS implant, a miniature stainless steel shunt, and human amniotic membrane as adjuncts with trabeculectomy have been associated with reduced intraocular pressure in patients after a one-year follow-up, compared to standard trabeculectomy. [ 10 ]  In addition, the PreserFlo MicroShunt may help prevent complications such as postoperative hypotony or bleb leakage; however, this technique may have a lower effectiveness at reducing  intraoculur pressure  compared to a standard trabeculectomy procedures. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5932", "text": "Further research is needed to compare the effectiveness of trabeculectomy techniques. It is not clear if a fornix-based surgical approach has a different safety rating, complication rate, surgical failure rate, or effectiveness compared to a limbal-based conjunctival flaps technique. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5933", "text": "Currently, there are no published trials which compare the efficacy and safety of  ab interno trabeculectomy with Trabectome  with other procedures for treating glaucoma. [ 12 ]  The first trial to do so is the TAGS randomised controlled trial which investigated if eye drops or trabeculectomy is more effective in treating advanced primary open-angle glaucoma. After two years researchers found that vision and quality of life are similar in both treatments. At the same time eye pressure was lower in people who underwent surgery and in the long-run surgery is more cost-effective. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5934", "text": "Peter Gordon Watson  and John Cairns developed the trabeculectomy procedure in the 1970s. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5935", "text": "Trabeculoplasty  is a laser treatment for glaucoma. It is done on an argon laser equipped slit lamp, using a Goldmann gonioscope lens mirror. Specifically, an argon laser is used to improve drainage through the eye's  trabecular meshwork , from which the  aqueous humour  drains. This helps reduce  intraocular pressure  caused by  open-angle glaucoma . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5936", "text": "The LiGHT trial compared the effectiveness of eye drops and selective laser trabeculoplasty for open angle glaucoma. Both contributed to a similar quality of life but most people undergoing laser treatment were able to stop using eye drops. Laser trabeculoplasty was also shown to be more cost-effective. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5937", "text": "Vitrectomy  is a surgery to remove some or all of the  vitreous humor  from the  eye ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5938", "text": "Anterior vitrectomy  entails removing small portions of the vitreous humor from the front structures of the eye\u2014often because these are tangled in an intraocular lens or other structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5939", "text": "Pars plana  vitrectomy  is a general term for a group of operations accomplished in the deeper part of the eye, all of which involve removing some or all of the vitreous humor\u2014the eye's clear internal jelly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5940", "text": "Even before the modern era, some surgeons performed crude vitrectomies. For instance, Dutch surgeon Anton Nuck (1650\u20131692) claimed to have removed vitreous by suction in a young man with an inflamed eye. [ 1 ]  In Boston,  John Collins Warren  (1778\u20131856) performed a crude limited vitrectomy for angle closure  glaucoma . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5941", "text": "Options for  anesthesia  for vitrectomy are  general anaesthesia ,  local anesthesia ,  topical anesthesia  and  intracameral   lidocaine  irrigation. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5942", "text": "Each anesthesia technique has its advantages and disadvantages, and the selection of anesthesia will depend on various factors including the surgeon's and patient's choice, disease and additional surgical steps required. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5943", "text": "Vitrectomy was originated by  Robert Machemer [ 3 ]  with contributions from Thomas M. Aaberg Sr in late 1969 and early 1970. The original purpose of vitrectomy was to remove clouded vitreous humor\u2014usually containing blood. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5944", "text": "The success of these first procedures led to the development of techniques and instruments to remove clouding and also to peel scar tissue off the light sensitive lining of the eye\u2014the  retina \u2014 membranectomy , to provide space for materials injected in the eye to reattach the retina such as gases or liquid silicone, and to increase the efficacy of other surgical steps such as  scleral buckle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5945", "text": "The development of new instruments and surgical strategies through the 1970s and 1980s was spearheaded by surgeon and engineer  Steve Charles . [ 4 ]  More recent advances have included smaller and more refined instruments for use in the eye, the injection of various medications at the time of surgery to manipulate a detached retina into its proper position and mark the location of tissue layers to allow their removal, and for long term protection against scar tissue formation. Several technologies and systems exist to treat vitrectomy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5946", "text": "Additional surgical steps involved as part of modern vitrectomy surgeries may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5947", "text": "Membranectomy  \u2013 removal of layers of unhealthy tissue from the retina with minute instruments such as forceps (tiny grasping tools), picks (miniature hooks), and visco-dissection (separating layers of tissue with jets of fluid.) This layer of unhealthy tissue is called an epiretinal membrane and it can occur in anyone, but is more likely to occur in the elderly or in people who have had prior eye disease or eye surgery. [ 6 ]  If the patient has an epiretinal membrane and is also complaining of symptoms such as decreased visual acuity, then a membranectomy is performed in addition to the vitrectomy. Complications of this additional step are similar to complications of the standard vitrectomy procedure. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5948", "text": "Fluid/air exchange  \u2013 injection of air into the eye to remove the intraocular fluid from the posterior segment of the globe while maintaining intraocular pressure to temporarily hold the retina in place or seal off holes in the retina. The air pressure is temporary as the posterior segment will soon re-fill with fluid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5949", "text": "Air/gas exchange  \u2013 In some cases, gas can be used to help hold the retina in place. Gas, or more typically mixed gas and air, is injected through the sclera and into the posterior segment of the globe. This procedure is often referred to as pneumatic retinopexy. Typical gases used are  perfluoropropane  or  sulfur hexafluoride . The gases are mixed with air to neutralize their expansive properties to provide for a longer acting (than air alone) retinal  tamponade . The retinal tamponade acts to hold the retina in place or temporarily seal off holes in the retina. The mixed gases disappear spontaneously once they have accomplished their purpose and the posterior segment re-fills with fluid. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5950", "text": "Silicone oil injection  \u2013 Similar to an air/gas exchange, or pneumatic retinopexy, the eye can also be filled with  liquid silicone  to hold the retina in place. [ 7 ]  In contrast to the pneumatic retinopexy, however, the silicone oil remains in the eye until it is later removed surgically. Oils have less surface tension and buoyancy than gases so the tension exerted by the oil is about 30 times less than that of the gas. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5951", "text": "Photocoagulation  \u2013 In cases when there is a tear in the retina, or when there are unhealthy damaging blood vessels (which can be seen in patients with diabetic retinopathy), laser treatment can be used. [ 7 ]  In such cases, the laser is used to seal the hole or prevent growth of the unhealthy, damaging blood vessels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5952", "text": "Scleral buckling  \u2013 placement of a support positioned like a belt around the eyeball to maintain the retina in a proper, attached position. This is referred to as an \"exoplant\". Placement of the scleral buckle for patients who have had a retinal detachment has been shown to lead to reattachment approximately 80 to 90 percent of the time after one surgery. In cases of failure, most patients are treated with vitrectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5953", "text": "Lensectomy  \u2013 In some cases, a lensectomy, or \"cataract surgery\", is done in conjunction with the vitrectomy. This extra procedure is performed when the lens of eye is cloudy (cataract), damaged during the vitrectomy, if there is attached to scar tissue, or if the pressure in the eye needs to be lowered (as in the case with some glaucomatous patients). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5954", "text": "Conditions which can benefit from vitrectomy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5955", "text": "Retinal detachment  \u2013 a blinding condition where the lining of the eye peels loose and floats freely within the interior of the eye. Steps to reattach the retina  may include vitrectomy to clear the inner jelly, scleral buckling to create a support for the reattached retina, membranectomy to remove scar tissue, injection of dense liquids to smooth the retina into place, photocoagulation to bond the retina back against the wall of the eye, and injection of a gas or silicone oil to secure the retina in place as it heals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5956", "text": "Macular pucker  \u2013 formation of a patch of unhealthy tissue in the central retina (the  macula ) distorting vision. Also called  epiretinal membrane . After vitrectomy to remove the vitreous gel, membranectomy is undertaken to peel away the tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5957", "text": "Diabetic retinopathy  \u2013 may damage sight by either a non-proliferative or proliferative retinopathy. The proliferative type is characterized by formation of new unhealthy, freely bleeding blood vessels within the eye (called vitreal hemorrhage) and/or causing thick fibrous scar tissue to grow on the retina, detaching it. Often diabetic retinopathy is treated in early stages with a laser in the physician's office to prevent these problems. When bleeding or retinal detachment occur, vitrectomy is employed to clear the blood, membranectomy removes scar tissue, and injection of gas or silicone with scleral buckle may be needed to return sight. Diabetics should have an eye exam yearly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5958", "text": "Macular holes  \u2013 the normal shrinking of the vitreous humor with aging can occasionally tear the central retina causing a macular hole with a blind spot blocking sight."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5959", "text": "Vitreous hemorrhage  \u2013 bleeding in the eye from injuries, retinal tears,  subarachnoid hemorrhages  (as  Terson syndrome ), or blocked blood vessels. Once blood is removed,  photocoagulation  with a laser can shrink unhealthy blood vessels or seal retinal holes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5960", "text": "Vitreous floaters  \u2013 deposits of various size, shape, consistency, refractive index, and motility within the eye's normally transparent vitreous humor which can obstruct vision. Here pars plana vitrectomy has been shown to relieve symptoms. [ 9 ]  Because of possible side effects it is used only in severe cases."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5961", "text": "There are a few complications that can result from vitrectomy surgery.  Cataract  is the most frequent complication. Many patients will develop a cataract within the first few years after surgery. [ 10 ]  Because there have been no published controlled trials evaluating the benefits and risks stemming from post vitrectomy cataract surgery, ophthalmologists have no clear evidence to rely upon when counseling patients about cataract surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5962", "text": "Other common complications include high intraocular pressure, bleeding in the eye, and  retinal edema , swelling in the back of the eye. [ 12 ]  In most cases, the retinal edema can be managed with over-the-counter medication. In severe cases, this swelling can be treated with intra-ocular injections. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5963", "text": "More severe complications after a vitrectomy are  endophthalmitis  (inflammation of the fluids in the eye) or suprachoroidal hemorrhage (bleeding above the choroidal layer of the eye). Rates of these complications have been reported to be less than 0.5%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5964", "text": "Lastly, although vitrectomy surgery is often done to correct retinal detachments, a subsequent retinal detachment is a possible complication as well. Rates of retinal detachment have been reported to be less than 5%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5965", "text": "Patients use eye drops for several weeks, or longer, to allow the surface of the eye to heal. In some cases, heavy lifting is avoided for a few weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5966", "text": "A gas bubble may be placed inside the eye, to keep the retina in place. If a gas bubble is used, sometimes a certain head positioning ( posturing ) has to be maintained, such as face down or sleeping on the right or left side.  The gas bubble will dissolve over time, but this takes several weeks.  Flying should be avoided while the gas bubble is still present."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5967", "text": "Problems such as return of the original condition, bleeding, or infection from the surgery may require additional treatment or can result in blindness.  In the event that the patient would need to remain face down after surgery, a vitrectomy support system can be rented, to help aid during the recovery time.  This particular equipment may be used for as little as five days to as long as three weeks. A  Cochrane review  found that in one study, cataract surgery was needed within two years for about half of the eyes operated on for idiopathic macular hole, and retinal detachment was found in about one in 20 eyes. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5968", "text": "The return of eyesight after vitrectomy depends on the underlying condition which prompted the need for surgery. It also depends on patient age and their visual acuity before surgery. For example, if the eye is healthy, but filled with blood, then vitrectomy can result in return of  20/20  eyesight. With more serious problems, such as a retina which has detached several times, final sight may be only sufficient to safely walk ( ambulatory vision ) or less."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5969", "text": "With a  retinal detachment , some very important considerations are how long the retina has been detached, and what part of the retina was detached. For example, if the  macula  of the retina comes off too, outcomes might not be as good as they would if the macula was still attached. Also, the longer the time between the detachment and the reattachment, the worse the outcomes. Some ophthalmologists believe that if a patient has a retinal detachment that involves the macula and it has been longer than 6 months, then a vitrectomy for that patient is unlikely to help. However, recent studies have shown that visual improvement might still be found in these patients. Given the high variability between outcomes for different patients with retinal detachments, it is very important to be examined by an ophthalmologist as soon as possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5970", "text": "A Cochrane review found vitrectomy for patients with idiopatic macular hole improved visual acuity by about 1.5 lines on an acuity chart. Macular hole closure was 76% in those treated with vitrectomy compared to 11% in those observed. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5971", "text": "In 1996,  Spalding Gray , an American actor, screenwriter and playwright, released  Gray's Anatomy , a film monologue describing his experiences dealing with a  macular pucker  and his decision to undergo surgery. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5972", "text": "Vitreomacular adhesion  ( VMA ) is a  human   medical condition  where the  vitreous gel  (or simply vitreous, AKA vitreous humour) of the  human eye  adheres to the  retina  in an abnormally strong manner. As the eye ages, it is common for the vitreous to separate from the retina. But if this separation is not complete, i.e. there is still an  adhesion , this can create pulling forces on the retina that may result in subsequent loss or distortion of vision. The adhesion in of itself is not dangerous, but the resulting pathological  vitreomacular traction  (VMT) can cause severe ocular damage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5973", "text": "The current  standard of care  for treating these adhesions is  pars plana vitrectomy  (PPV), which involves surgically removing the vitreous from the eye. A biological agent for non-invasive treatment of adhesions called  ocriplasmin  has been approved by the FDA on October 17, 2012."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5974", "text": "Traction caused by VMA is the underlying pathology of an eye disease called symptomatic VMA. There is evidence that symptomatic VMA can contribute to the development of several well-known eye disorders, such as macular hole and macular pucker, that can cause visual impairment, including blindness. It may also be associated with  age-related macular degeneration  (AMD),  diabetic macular edema  (DME),  retinal vein occlusion , and  diabetic retinopathy  (DR). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5975", "text": "Over time, it is common for the vitreous within the human eye to  liquify  and collapse in processes known as  syneresis  and  synchisis  respectively. This creates fluid-filled areas that can combine to form pockets of vitreous gel that are mostly liquid with very small concentrations of  collagen . If these liquid pockets are close enough to the interface between the vitreous gel and the retina, they can cause complete separation of the vitreous from the retina in a normally occurring process in older humans called  posterior vitreous detachment  (PVD). PVD in of itself is not dangerous and a natural process. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5976", "text": "If the separation of the vitreous from the retina is not complete, areas of focal attachment or adhesions can occur, i.e. a VMA. The pulling forces or traction from this adhesion on the retinal surface can sometimes cause  edema  within the retina, damage to retinal blood vessels causing  bleeding , or damage to the  optic nerve  causing disruption in the  nerve signals  sent to the  brain  for  visual processing . It is important to note that while the VMA itself is not dangerous, the resultant pulling on the retina called vitreomacular traction (VMT) causes the above damage. The size and strength of the VMA determine the variety of resulting  pathologies  or symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5977", "text": "VMA can also lead to the development of VMT/traction-related complications such as  macular puckers  and  macular holes  leading to  distorted vision  or  metamorphopsia ;  epiretinal membrane ;  tractional macular oedema ;  myopic macular retinoschisis ; visual impairment; blindness. The incidence of VMA is reported as high as 84% for patients with  macular hole , 100% for patients with  vitreomacular traction syndrome , and 56% in  idiopathic epimacular membrane . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5978", "text": "Careful eye examination by an  ophthalmologist  or  optometrist  is critical for diagnosing symptomatic VMA. Imaging technologies such as  optical coherence tomography  (OCT) have significantly improved the accuracy of diagnosing symptomatic VMA. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5979", "text": "A new FDA approved drug was released on the market late 2013.  Jetrea (Brand name) or Ocriplasmin  (Generic name) is the first drug of its kind used to treat vitreomacular adhesion. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5980", "text": "Mechanism of Action: Ocriplasmin is a truncated human plasmin with proteolytic activity against protein components of the vitreous body and vitreoretinal interface. It dissolves the protein matrix responsible for the vitreomacular adhesion.\nAdverse drug reactions: Decreased vision, potential for lens subluxation, dyschromatopsia (yellow vision), eye pain, floaters, blurred vision.\nNew Drug comparison Rating gave Jetea a 5 indicating an important advance.\nPreviously, no recommended treatment was available for the patient with mild symptomatic VMA. In symptomatic VMA patients with more significant vision loss, the standard of care is pars plana vitrectomy (PPV), which involves surgically removing the vitreous from the eye, thereby surgically releasing the symptomatic VMA. In other words, vitrectomy induces PVD to release the traction/adhesion on the retina. An estimated 850,000 vitrectomy procedures are performed globally on an annual basis with 250,000 in the United States alone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5981", "text": "A standard PPV procedure can lead to serious complications [ 3 ] [ 4 ] [ 5 ] [ 6 ]  including small-gauge PPV. [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ]  Complications can include  retinal detachment ,  retinal tears ,  endophthalmitis , and postoperative  cataract  formation. Additionally, PPV may result in incomplete separation, and it may potentially leave a  nidus  for  vasoactive  and  vasoproliferative  substances, or it may induce development of  fibrovascular membranes . As with any invasive surgical procedure, PPV introduces  trauma  to the vitreous and surrounding tissue. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5982", "text": "There are data showing that nonsurgical induction of PVD using  ocriplasmin  (a  recombinant   protease  with activity against  fibronectin  and  laminin ) [ 14 ]  can offer the benefits of successful PVD while eliminating the risks associated with a surgical procedure, i.e. vitrectomy.  Pharmacologic  vitreolysis is an improvement over invasive surgery as it induces complete separation, creates a more physiologic state of the vitreomacular interface, prevents the development of fibrovascular membranes, is less traumatic to the vitreous, and is potentially  prophylactic . [ 15 ] [ 16 ]  As of 2012,  ThromboGenics  is still developing the ocriplasmin biological agent. Ocriplasmin is approved recently under the name Jetrea for use in the  United States  by the  FDA .view. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5983", "text": "An experimental test of injections of  perfluoropropane  (C 3 F 8 ) on 15 symptomatic eyes of 14 patients showed that vitreomacular traction resolved in 6 eyes within 1 month and resolved in 3 more eyes within 6 months. [ 18 ]  A systematic review found high-certainty evidence that Ocriplasmin compared to no treatment increases the chance of resolution and improves vision in people with symptomatic VMA.  [ 19 ]  Ocriplasmin probably reduces the need for surgery but there were more adverse events in eyes treated with ocriplasmin compared to control."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5984", "text": "The  von Graefe  knife  was a tool used to make corneal incisions in  cataract surgery . [ 1 ]  Use of the knife demanded a high level of skill and mastery, and was eventually supplanted by modifications of cataract surgery through the Kelman  phacoemulsification  technique that emphasized a small incision. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5985", "text": "Until the acceptability of the keratome-and-scissors method after the early 1940s, an essential part of  cataract  surgery was mastery of the von Graefe knife. With increased popularity of  sutures \u2014especially pre-placed scleral groove (McLean) sutures, it became difficult for the occasional surgeon to develop the skill required to make an acceptable von Graefe incision. If the surgeon was not ambidextrous, the use of the von Graefe knife might be even more difficult with the non-dominant hand. With his right hand, he introduced the knife into the anterior chamber of the right eye at 9. He would then perforate the  limbal  area at 3. An upward sweep was then made to complete the incision. Most frequently, there was no conjunctival flap. However, some especially skilled eye surgeons formed a conjunctival flap as they were completing the upward sweep. Normally, the ambidextrous von Graefe surgeon would switch to his left hand so that he could enter the left eye at 3 and exit at 9. If he used his dominant right hand for the left eye, the nose became an impediment when he attempted to enter the eye at 9 and attempted to counter perforate at 3. Often, poor results could have been prevented by the use of post-placed sutures. Unfortunately, in the early years of cataract surgery, suitable sutures and needles were not in the  armamentarium  of many cataract surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5986", "text": "In the 1980s, with the ever-increasing popularity of the Kelman  phacoemulsification  technique that emphasized a small incision and extra-capsular cataract extraction (ECCE), the keratome-and-scissors, large incision surgery technique combined with intracapsular cataract extraction (ICCE) became obsolete, although the use of the von Graefe knife still continued in India. Sutures had limited if any use in routine cataract surgery for the high-volume most experienced and skilled eye surgeons in the world. Their experience and skill resulted in the outstanding rural cataract camps so common in India. Formally trained Indian  ophthalmologists  were and are among the deftest in the use of the von Graefe knife.  Ultraviolet-rich India with its vast rural and underclass population afflicted with nutritional eye diseases combined with a multitude of public health problems was and still is the \u201cLand of Eye Disease and Eye Surgery\u201c. Few Western ophthalmologists have the daily volume of eye pathology and eye surgery that faces their Indian counterparts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5987", "text": "It is possible for an eye to recover from an intracapsular cataract operation that entailed a 170 to 180 degree superior corneal or limbal incision without the closure of the incisional wound by means of sutures. Recovery was significantly dependent on the quality of a well-made von Graefe knife incision with a well-honed and well-maintained knife. Unlike keratome-and-scissors incision, a well-performed von Graefe knife maneuver produced a corneal or limbal incision with well-opposed edges that resulted in rapid healing and a scar that was almost invisible to the naked eye. However, a poorly made von Graefe knife incision could lead to horrendous disasters."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5988", "text": "or"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5989", "text": "Neurosurgery  or  neurological surgery , known in  common parlance  as  brain surgery , is the  medical specialty  that focuses on the surgical treatment or rehabilitation of disorders which affect any portion of the  nervous system  including the  brain ,  spinal cord ,  peripheral nervous system , and cerebrovascular system. [ 1 ]  Neurosurgery as a medical specialty also includes non-surgical management of some neurological conditions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5990", "text": "In different countries, there are different requirements for an individual to legally practice neurosurgery, and there are varying methods through which they must be educated. In most countries, neurosurgeon training requires a minimum period of seven years after graduating from medical school. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5991", "text": "In the  United Kingdom , students must gain entry into medical school. The MBBS qualification ( Bachelor of Medicine, Bachelor of Surgery ) takes four to six years depending on the student's route. The newly qualified  physician  must then complete foundation training lasting two years; this is a paid training program in a hospital or clinical setting covering a range of medical specialties including surgery. Junior doctors then apply to enter the neurosurgical pathway. Unlike most other surgical specialties, it currently has its own independent training pathway which takes around eight years (ST1-8); before being able to sit for  consultant  exams with sufficient amounts of experience and practice behind them. Neurosurgery remains consistently amongst the most competitive medical specialties in which to obtain entry."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5992", "text": "In the  United States , a neurosurgeon must generally complete four years of  undergraduate education , four years of  medical school , and seven years of  residency  (PGY-1-7). [ 4 ]  Most, but not all, residency programs have some component of basic science or clinical research. Neurosurgeons may pursue additional training in the form of a  fellowship  after residency, or, in some cases, as a senior resident in the form of an enfolded fellowship. These fellowships include  pediatric neurosurgery , trauma/neurocritical care, functional and  stereotactic  surgery, surgical neuro- oncology ,  radiosurgery , neurovascular surgery, skull-base surgery, peripheral nerve and complex spinal surgery. [ 5 ]  Fellowships typically span one to two years. In the U.S., neurosurgery is a very small, highly competitive specialty, constituting only 0.5 percent of all physicians. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5993", "text": "Neurosurgery, or the premeditated incision into the head for pain relief, has been around for thousands of years, but notable advancements in neurosurgery have only come within the last hundred years. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5994", "text": "The  Incas  appear to have practiced a procedure known as  trepanation  since before European colonization. [ 8 ]  During the  Middle Ages  in  Al-Andalus  from 936 to 1013 AD,  Al-Zahrawi  performed surgical treatments of head injuries, skull fractures, spinal injuries,  hydrocephalus , subdural effusions and headache. [ 9 ]  During the  Roman Empire , doctors and surgeons performed  neurosurgery  on depressed skull fractures. [ 10 ] [ 11 ]  Simple forms of neurosurgery were performed on  King Henri II  in 1559, after a  jousting  accident with  Gabriel Montgomery  fatally wounded him.  Ambroise Par\u00e9  and  Andreas Vesalius , both experts in their field at the time, \nattempted their own methods, to no avail, in curing Henri. [ 12 ]  In China, Hua Tuo created the first general  anaesthesia  called mafeisan, which he used on surgical procedures on the brain. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5995", "text": "History of tumor removal : In 1879, after locating it via neurological signs alone, Scottish surgeon  William Macewen  (1848\u20131924) performed the first successful brain tumor removal. [ 4 ]   On November 25, 1884, after English physician  Alexander Hughes Bennett  (1848\u20131901) used Macewen's technique to locate it, English surgeon  Rickman Godlee  (1849\u20131925) performed the first primary brain tumor removal, [ 5 ] [ 14 ]  which differs from Macewen's operation in that Bennett operated on the exposed brain, whereas Macewen operated outside of the \"brain proper\" via  trepanation . [ 15 ]  On March 16, 1907, Austrian surgeon  Hermann Schloffer  became the first to successfully remove a  pituitary  tumor. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5996", "text": "Lobotomy : also known as  leucotomy , was a form of  psychosurgery , a neurosurgical treatment of  mental disorders  that involves severing connections in the brain's  prefrontal cortex . [ 17 ]  The originator of the procedure,  Portuguese  neurologist  Ant\u00f3nio Egas Moniz , shared the  Nobel Prize for Physiology or Medicine  of 1949. [ 18 ] [ 19 ]  Some patients improved in some ways after the operation, but complications and impairments\u00a0\u2013 sometimes severe\u00a0\u2013 were frequent. The procedure was controversial from its initial use, in part due to the balance between benefits and risks. It is mostly rejected as a treatment now and non-compliant with  patients' rights ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5997", "text": "History of electrodes in the brain : In 1878,  Richard Caton  discovered that electrical signals transmitted through an animal's brain.  In 1950 Jose Delgado invented the first electrode that was implanted in an animal's brain (bull), using it to make it run and change direction. [ 20 ]  In 1972 the  cochlear implant , a neurological  prosthetic  that allowed deaf people to hear was marketed for commercial use. In 1998 researcher Philip Kennedy implanted the first Brain Computer Interface (BCI) into a human subject. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5998", "text": "A survey done in 2010 on 100 most cited works in neurosurgery shows that the works mainly cover clinical trials evaluating surgical and medical therapies, descriptions of novel techniques in neurosurgery, and descriptions of systems classifying and grading diseases. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_5999", "text": "The main advancements in neurosurgery came about as a result of highly crafted tools. Modern neurosurgical tools, or instruments, include  chisels , curettes, dissectors, distractors, elevators, forceps, hooks, impactors, probes, suction tubes, power tools, and robots. [ 23 ] [ 24 ]  Most of these modern tools have been in medical practice for a relatively long time. The main difference of these tools in neurosurgery, were the precision in which they were crafted. These tools are crafted with edges that are within a millimeter of desired accuracy. [ 25 ]  Other tools, such as hand held power saws and robots have only recently been commonly used inside of a neurological operating room. As an example, the University of Utah developed a device for computer-aided design / computer-aided manufacturing (CAD-CAM) which uses an image-guided system to define a cutting tool path for a robotic  cranial drill . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6000", "text": "The  World Federation of Neurosurgical Societies  ( WFNS ), founded in 1955, in  Switzerland , as a  professional ,  scientific ,  non governmental organization , is composed of 130 member societies: consisting of 5 Continental Associations ( AANS ,  AASNS ,  CAANS ,  EANS  and  FLANC ), 6 Affiliate Societies, and 119 National Neurosurgical Societies, representing some 50,000  neurosurgeons  worldwide. [ 27 ]  It has a consultative status in the  United Nations . The official Journal of the Organization is  World Neurosurgery . [ 28 ] [ 29 ]  The other global organisations being the World Academy of Neurological Surgery (WANS) and the World Federation of Skull Base Societies (WFSBS)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6001", "text": "General neurosurgery involves most neurosurgical conditions including neuro-trauma and other neuro-emergencies such as  intracranial hemorrhage . Most level 1 hospitals have this kind of practice. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6002", "text": "Specialized branches have developed to cater to special and difficult conditions. These specialized branches co-exist with general neurosurgery in more sophisticated hospitals. To practice advanced specialization within neurosurgery, additional higher fellowship training of one to two years is expected from the neurosurgeon.\nSome of these divisions of neurosurgery are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6003", "text": "According to an analysis by the  American College of Surgeons   National Surgical Quality Improvement Program  (NSQIP), the most common surgeries performed by neurosurgeons in between 2006 and 2014 were the following: [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6004", "text": "Neuropathology  is a specialty within the study of  pathology  focused on the disease of the brain, spinal cord, and neural tissue. [ 32 ]  This includes the central nervous system and the peripheral nervous system. Tissue analysis comes from either surgical  biopsies  or post mortem  autopsies . Common tissue samples include muscle fibers and nervous tissue. [ 33 ]  Common applications of neuropathology include studying samples of tissue in patients who have  Parkinson's disease ,  Alzheimer's disease ,  dementia ,  Huntington's disease ,  amyotrophic lateral sclerosis ,  mitochondria disease , and any disorder that has neural deterioration in the brain or spinal cord. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6005", "text": "While pathology has been studied for millennia only within the last few hundred years has medicine focused on a tissue- and organ-based approach to tissue disease. In 1810,  Thomas Hodgkin  started to look at the damaged tissue for the cause. This was conjoined with the emergence of microscopy and started the current understanding of how the tissue of the human body is studied. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6006", "text": "Neuroanesthesia is a field of  anesthesiology  which focuses on neurosurgery. Anesthesia is not used during the middle of an \"awake\" brain surgery. Awake brain surgery is where the patient is conscious for the middle of the procedure and sedated for the beginning and end. This procedure is used when the tumor does not have clear boundaries and the surgeon wants to know if they are invading on critical regions of the brain which involve functions like talking,  cognition , vision, and hearing. It will also be conducted for procedures which the surgeon is trying to combat  epileptic  seizures. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6007", "text": "The physician  Hippocrates  (460\u2013370 BCE) made accounts of using different wines to  sedate  patients while trepanning. In 60 CE,  Dioscorides , a physician, pharmacologist, and botanist, detailed how  mandrake ,  henbane ,  opium , and alcohol were used to put patients to sleep during trepanning. In 972 CE, two brother surgeons in  Paramara , now India, used \"samohine\" to sedate a patient while removing a small tumor, and awoke the patient by pouring onion and vinegar in the patient's mouth. The combination of carbon dioxide, hydrogen, and nitrogen, was a form of neuroanesthesia adopted in the 18th century and introduced by  Humphry Davy . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6008", "text": "Various Imaging methods are used in modern neurosurgery diagnosis and treatment. They include  computer assisted imaging computed tomography (CT) ,  magnetic resonance imaging  (MRI),  positron emission tomography  (PET),  magnetoencephalography  (MEG), and  stereotactic radiosurgery . Some neurosurgery procedures involve the use of intra-operative MRI and functional MRI. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6009", "text": "In  conventional neurosurgery  the neurosurgeon opens the skull, creating a large opening to access the brain. Techniques involving smaller openings with the aid of microscopes and endoscopes are now being used as well. Methods that utilize small  craniotomies  in conjunction with high-clarity microscopic visualization of neural tissue offer excellent results. However, the open methods are still traditionally used in trauma or emergency situations. [ 16 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6010", "text": "Microsurgery  is utilized in many aspects of neurological surgery. Microvascular techniques are used in EC-IC bypass surgery and in restoration  carotid endarterectomy . The clipping of an aneurysm is performed under microscopic vision.  Minimally-invasive  spine surgery utilizes microscopes or endoscopes. Procedures such as microdiscectomy,  laminectomy , and artificial disc replacement rely on microsurgery. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6011", "text": "Using  stereotaxy  neurosurgeons can approach a minute target in the brain through a minimal opening. This is used in functional neurosurgery where electrodes are implanted or  gene therapy  is instituted with high level of accuracy as in the case of Parkinson's disease or Alzheimer's disease. Using the combination method of open and stereotactic surgery, intraventricular hemorrhages can potentially be evacuated successfully. [ 25 ]  Conventional surgery using image guidance technologies is also becoming common and is referred to as surgical navigation, computer-assisted surgery, navigated surgery, stereotactic navigation. Similar to a car or mobile Global Positioning System (GPS), image-guided surgery systems, like Curve Image Guided Surgery and StealthStation, use cameras or electromagnetic fields to capture and relay the patient's anatomy and the surgeon's precise movements in relation to the patient, to computer monitors in the operating room. These sophisticated computerized systems are used before and during surgery to help orient the surgeon with three-dimensional images of the patient's anatomy including the tumor. [ 40 ]  Real-time functional brain mapping has been employed to identify specific functional regions using  electrocorticography  (ECoG) [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6012", "text": "Minimally invasive  endoscopic surgery  is commonly utilized by neurosurgeons when appropriate. Techniques such as  endoscopic endonasal surgery  are used in pituitary tumors,  craniopharyngiomas , chordomas, and the repair of cerebrospinal fluid leaks. Ventricular endoscopy is used in the treatment of intraventricular bleeds, hydrocephalus,  colloid cyst  and  neurocysticercosis . Endonasal endoscopy is at times carried out with neurosurgeons and ENT surgeons working together as a team. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6013", "text": "Repair of craniofacial disorders and disturbance of cerebrospinal fluid circulation is done by neurosurgeons who also occasionally team up with maxillofacial and plastic surgeons. Cranioplasty for  craniosynostosis  is performed by pediatric neurosurgeons with or without plastic surgeons. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6014", "text": "Neurosurgeons are involved in  stereotactic radiosurgery  along with radiation oncologists in  tumor  and  AVM  treatment. Radiosurgical methods such as  Gamma knife ,  Cyberknife  and  Novalis Radiosurgery  are used as well. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6015", "text": "Endovascular neurosurgery  utilize endovascular image guided procedures for the treatment of  aneurysms , AVMs,  carotid stenosis , strokes, and spinal malformations, and vasospasms. Techniques such as  angioplasty , stenting, clot retrieval, embolization, and diagnostic angiography are endovascular procedures. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6016", "text": "A common procedure performed in neurosurgery is the placement of ventriculo-peritoneal shunt (VP shunt). In pediatric practice this is often implemented in cases of congenital  hydrocephalus . The most common indication for this procedure in adults is normal pressure hydrocephalus (NPH). [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6017", "text": "Neurosurgery of the spine  covers the cervical, thoracic and lumbar spine. Some indications for spine surgery include spinal cord compression resulting from trauma, arthritis of the spinal discs, or spondylosis. In cervical cord compression, patients may have difficulty with gait, balance issues, and/or numbness and tingling in the hands or feet.  Spondylosis  is the condition of spinal disc degeneration and arthritis that may compress the spinal canal. This condition can often result in bone-spurring and  disc herniation . Power drills and special instruments are often used to correct any compression problems of the spinal canal. Disc herniations of spinal vertebral discs are removed with special  rongeurs .  This procedure is known as a  discectomy . Generally once a disc is removed it is replaced by an implant which will create a bony fusion between vertebral bodies above and below. Instead, a mobile disc could be implanted into the disc space to maintain mobility. This is commonly used in cervical disc surgery. At times instead of disc removal a Laser discectomy could be used to decompress a nerve root. This method is mainly used for lumbar discs.  Laminectomy  is the removal of the  lamina  of the vertebrae of the spine in order to make room for the compressed nerve tissue. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6018", "text": "Surgery for chronic pain is a sub-branch of functional neurosurgery. Some of the techniques include implantation of deep brain stimulators, spinal cord stimulators, peripheral stimulators and pain pumps. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6019", "text": "Surgery of the peripheral nervous system is also possible, and includes the very common procedures of carpal tunnel decompression and peripheral nerve transposition. Numerous other types of nerve entrapment conditions and other problems with the peripheral nervous system are treated as well. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6020", "text": "Conditions treated by neurosurgeons include, but are not limited to: [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6021", "text": "Pain following brain surgery can be significant and may lengthen recovery, increase the amount of time a person stays in the hospital following surgery, and increase the risk of complications following surgery. [ 50 ]  Severe acute pain following brain surgery may also increase the risk of a person developing a chronic post- craniotomy  headache. [ 50 ]  Approaches to treating pain in adults include treatment with nonsteroidal anti\u2010inflammatory drugs ( NSAIDs ), which have been shown to reduce pain for up to 24 hours following surgery. [ 50 ]  Low-quality evidence supports the use of the medications  dexmedetomidine ,  pregabalin  or  gabapentin  to reduce post-operative pain. [ 50 ]  Low-quality evidence also supports scalp blocks and scalp infiltration to reduce postoperative pain. [ 50 ]   Gabapentin  or  pregabalin  may also decrease  vomiting  and  nausea  following surgery, based on very low-quality medical evidence. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6022", "text": "Neurosurgery is a part of practical  medicine  and the only specialty that involves invasive intervention in the activity of the living brain. The brain ensures the structural and functional integrity of the body and the implementation of all the main life processes of the body. Therefore, neurosurgery faces a wide range of bioethical issues and a significant selection of the latest  treatment  technologies. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6023", "text": "Neurosurgery has the following applied scientific and ethical problems:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6024", "text": "Amygdalotomy , also known as  amygdalectomy , is a form of  psychosurgery  which involves the surgical removal or destruction of the  amygdala , or parts of the amygdala. It is usually a last-resort treatment for severe aggressive behavioral disorders and similar behaviors including hyperexcitability, violent outbursts, and self-mutilation. [ 1 ] [ 2 ] [ 3 ] [ 4 ]  The practice of medical amygdalotomy typically involves the administration of general anesthesia and is achieved through the application of cranial  stereotactic surgery  to target regions of the amygdala for surgical destruction. [ 3 ]  While some studies have found stereotactic amygdalotomy in humans to be an effective treatment for severe cases of intractable aggressive behavior that has not responded to standard treatment methods, [ 5 ] [ 6 ] [ 7 ] [ 8 ]  other studies remain inconclusive. [ 9 ] [ 10 ]  In most cases of amygdalotomy in humans, there is no substantial evidence of impairment in overall cognitive function, including intelligence and working memory, however, deficits in specific areas of memory have been noted pertaining to the recognition and emotional interpretation of facial stimuli.  This is because there are specialized cells in the amygdala which attend to facial stimuli."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6025", "text": "The amygdala is considered to be an important underlying structure in the  fight-or-flight response , playing a mediating role in aggression in both humans and animals. [ 3 ]   Clinical studies have revealed that the stimulation of the amygdala produces or accentuates rageful behavior in animals. [ 4 ]  Research has also revealed that  lesions  of the amygdala in both humans and animals produces a calming effect on aggressive behavior. [ 3 ]  Based on these findings, amygdalotomy was developed as a neurosurgical procedure to ameliorate aggression by reducing arousal levels in the amygdala. [ 3 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6026", "text": "Since the early 1900s there has been an accumulation of experimental evidence to demonstrate the role of the  limbic system , specifically the amygdala complex in mediating emotional expressions of fear and anger. [ 11 ] [ 3 ]  Early primate studies have revealed that chemical and electrical stimulation of the amygdala region accentuates aggressive behavior. Conversely, destruction of the amygdala nucleus results in a taming effect of normal anger and fearing responses in primate behavior. Similarly, clinical studies in humans have revealed the close  etiological  role of temporal lobe structures, particularly the limbic system and the amygdala in mediating fear and rageful behavior. [ 3 ]  These findings have been instrumental in the development of clinical amygdalotomy as a form of neurosurgery to produce placating effects on abnormal aggressive behaviors. [ 11 ] [ 3 ]  Procedural amygdalotomy is used as a last recourse treatment for severe intractable aggression when other options including pharmacological treatments have been exhausted. The  psychopathology  of patients with severe aggressive behavior in clinical cases of amygdalotomy over the past 20th century vary, including  epileptics with violent convulsions, psychotics with violent outbursts, individuals with unmanageable conduct disorder, and patients with self-mutilative tendencies. The clinical practice of amygdalotomy in humans is commonly implemented under the stereotactic frame, with varying techniques used to destroy the amygdala, ranging from  radiofrequency , mechanical destruction and the injection of oil, wax, and alcohol. [ 3 ]  The preferred target zone of the amygdala also varies from basal and lateral nuclei, to the medial region, the cortico-medial group of nuclei and the bed of the  stria terminalis . [ 3 ]  The size of the lesion differs from one-third to one-half, to three-quarters, to the entire amygdalar region. [ 3 ]  In spite of these methodological differences, most published accounts of human amygdalotomy have indicated beneficial outcomes in reducing the intensity and frequency of aggressive behaviors. [ 3 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6027", "text": "Amongst some of the earliest studies conducted on the removal of the amygdala were animal and primate studies. [ 11 ] [ 3 ]  In the early 1890s, Friedrich Goltz conducted experiments on  temporal lobectomy  in dogs including the removal of the amygdala and found that dogs post-surgery experienced a taming effects on aggressive behaviors. [ 11 ]   Deep brain stimulation  studies in animals revealed that the temporal lobe is involved in mediating expressions of rage and aggression. [ 11 ]  A more detailed analysis of specific regions of the temporal lobe in animals revealed that the limbic system, specifically the amygdala complex, is involved in mediating fear and aggression. [ 11 ]  Some of the earliest primate studies on amygdalotomy were carried out on rhesus monkeys by Kluver and Bucy in the late 1930s. [ 11 ]  Data collected from these studies revealed that bilateral destruction of the amygdala resulted in a reduction in the intensity and frequency of fear and aggression behaviors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6028", "text": "The human counterpart of the role of the amygdala was then observed in the 20th century at the height of psychosurgery. [ 11 ]  Professor Hirotaro Narabayashi and his colleagues were the first researchers to carry out stereotactic amygdalotomy for the treatment of abnormal aggression and hyperexcitability in a series of 60 patients with psychological disturbances. [ 3 ] [ 11 ]  The procedure was performed under a stereotactic frame devised by Professor Narabayashi and involved the administration 0.6-0.8ml mixture of oil-wax to destroy the lateral groups of the amygdala nucleus, localized via  pneumoencephalography . [ 11 ]  The clinical results revealed a marked reduction in emotional disturbances amongst 85% of the cases. Following Narabayashi's study, there have been over 1000 cases of amygdalotomy reported in clinical trials as a last-resort treatment for severe intractable aggressive disorders. [ 3 ]  Around the same time, Hatai Chitanondh utilized a slightly different technique of stereotactic amygdalotomy using an injection of an olive oil mixture  to induce lesions to mechanically block signals in the amygdala. The results revealed an improvement in social adaptability of all seven patients. [ 11 ]  In the late 1960s and 1970s, Balasubramaniam and Ramamurthi investigated the largest clinical patient series to undergo stereotactic amygdalotomy for aggression behaviours. The procedure was performed via  high-frequency current generating electrodes inserted stereotactically to induce several small thermal lesions, creating a total lesion volume of 1800mm, a size that is larger than the amygdala. [ 11 ]  The improvement in maladaptive behavior in patients, including hyperexcitability, rebellious behavior, and destructive behavior, ranged from moderate to high. [ 11 ]  The development of  MRI  technology in the recent 20th century has enabled a more accurate and efficient process of amygdalotomy, with easier localization of amygdala regions during neuro-navigation as well as the use of advanced radiofrequency generating electrode to induce surgical lesions. [ 11 ]  Despite these recent advances in technology, there has been a decline in clinical cases of amygdalotomy for treatment of maladaptive behavior, with growing skepticism in the medical community of the cost-benefits of the procedure and partly due to a greater reliance on pharmacological treatments [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6029", "text": "There has been a general consensus amongst many researchers on the general effectiveness of amygdalotomy in reducing aggression amongst patients with psychosis, violent epilepsy, and self-mutilative behavior. [ 8 ] [ 7 ] [ 5 ]  A diverse study [ 8 ]  on stereotactic amygdalotomy used to treat 25 patients primarily for aggressive behavior and violent epilepsy, found that behavioral abnormalities were eliminated in 2 of the 20 patients, with a significant improvement in another 9 of the 20 patients with aggressive behavior manifests. Convulsions were also eliminated in 4 of the 21 patients, whilst 12 of the patients experienced a significant decrease in the number of epileptic convulsions. Patient rehabilitation was also effective with 2 of the 12 patients committed to mental institutions being discharged, whilst 5 of 8 patients awaiting institutionalization were no longer being considered. A multi-disciplinary project carried out on amygdalotomy amongst epileptics with violent outbursts found that amygdalotomy showed promising results, with a decline in violent, aggressive and anti-social behavior as well as a reduction amongst patients and an improvement in the occupational functioning of some of the patients. [ 4 ]  The researchers, however, concluded that the results cannot be generalized to non-epileptics. Other studies [ 5 ] [ 7 ]  conducted on patients with conduct disorder, personality disorder, self-mutilation, and schizophrenics with violent hallucinations found that these maladaptive behaviors also improved across these groups of patients. Using reliable and objective methods of evaluation, Heimburger and colleagues found that in patients who did not respond to non-surgical therapy, amygdalotomy was effective, with both conditions of uncontrolled conduct disorder and seizures seeming improved after surgery. [ 7 ]  Stereotaxic amygdalotomy conducted on 12 patients with schizophrenia and frequent self-mutilations found that, in 11 of the 12 patients, amygdalotomy resulted in elimination and or marked reduction of aggressive episodes. [ 5 ]  In two of patients with frequent self-mutilative episodes and reactive psychotic hallucinations, however, these symptoms disappeared only after an additional basofrontal tractotomy had been performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6030", "text": "There is a scarcity of long-term studies on the follow-up effects of clinical amygdalotomy in humans. [ 3 ]  Amongst the few follow-up studies, includes a research study [ 6 ]  which compared the results of clinical amygdalotomy in 58 patients pre and post-surgery over an average of 6 years using objective analysis such as psychiatric interviews, neuropsychological tests and  EEG analysis  and found no indication of worsening of symptoms. Additionally, the researchers found some evidence for the retention of positive outcomes in one-third of the patients, which were not limited to improvements in rageful behaviour but also included a decrease in the overall frequency of seizures. Another follow-up study [ 13 ]  by Professor Narabayashi and colleagues observed the clinical effects of amygdalotomy in 40 cases from 3 to 5 years and found 27 of the cases had continued a satisfactory improvement in calming and taming effects on what was previously uncontrollable aggression including destructive and violent behaviour."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6031", "text": "In most cases of amygdalotomy in humans, there is no substantial evidence of impairment in overall cognitive function, including intelligence and working memory. [ 10 ] [ 9 ]  However, deficits in specific areas of memory have been noted, particularly areas of memory pertaining to the recognition and emotional interpretation of facial stimuli. [ 10 ]   These findings of face recognition impairment after amygdalotomy are of particular importance due to the neurophysiological data collected on the importance of cells in the amygdala that specifically attend to facial stimuli in both humans and primates. [ 10 ]  A detailed case study of a patient who had undergone a bilateral amygdalotomy found incidences where the patient showed poor learning of new faces and impaired recognition of familiar faces, particularly troubles with naming faces. [ 10 ]  Additionally the patient also revealed further deficits in the emotional processing of facial stimuli, demonstrating difficulty in identifying and matching a range of facial expressions. Another study of 15 patients showed no reduction in general intelligence, but there was a similar pattern of changes in attention and memory involving facial stimuli. This link between the amygdala and social disturbances pertaining to the processing of facial stimuli has been investigated as a possible side-effect of amygdalotomy in some patients [ 10 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6032", "text": "Atypical trigeminal neuralgia  ( ATN ), or  type 2 trigeminal neuralgia , is a form of  trigeminal neuralgia , a disorder of the  fifth cranial nerve .  This form of  nerve pain  is difficult to diagnose, as it is rare and the symptoms overlap with several other disorders. [ 1 ]  The symptoms can occur in addition to having  migraine  headache, or can be mistaken for migraine alone, or dental problems such as  temporomandibular joint disorder  or musculoskeletal issues. ATN can have a wide range of symptoms and the  pain  can fluctuate in intensity from mild aching to a crushing or burning sensation, and also to the extreme pain experienced with the more common trigeminal neuralgia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6033", "text": "ATN pain can be described as heavy, aching, stabbing, and burning. Some patients have a constant migraine-like headache.  Others may experience intense pain in one or in all three trigeminal nerve branches, affecting teeth, ears, sinuses, cheeks, forehead,  upper and lower jaws, behind the eyes, and scalp. In addition, those with ATN may also experience the shocks or stabs found in type 1 TN. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6034", "text": "Many TN and ATN patients have pain that is \"triggered\" by light touch on shifting trigger zones. ATN pain tends to worsen with talking, smiling, chewing, or in response to sensations such as a cool breeze. The pain from ATN is often continuous, and periods of remission are rare. Both TN and ATN can be bilateral, though the character of pain is usually different on the two sides at any one time. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6035", "text": "ATN is usually attributed to inflammation or  demyelination , with increased sensitivity of the  trigeminal nerve . These effects are believed to be caused by infection, demyelinating diseases, or compression of the trigeminal nerve (by an impinging vein or artery, a tumor, dental trauma, accidents, or  arteriovenous malformation ) and are often confused with dental problems. Though TN and ATN most often present in the fifth decade, cases have been documented as early as infancy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6036", "text": "Both forms of facial neuralgia are relatively rare, with an incidence recently estimated between 12 and 24 new cases per hundred thousand population per year. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6037", "text": "ATN often goes undiagnosed or misdiagnosed for extended periods, leading to a great deal of unexplained pain and anxiety. A National Patient Survey conducted by the US Trigeminal Neuralgia Association in the late 1990s indicated that the average facial neuralgia patient may see six different physicians before receiving a first definitive diagnosis.  The first practitioner to see facial neuralgia patients is often a dentist who may lack deep training in facial neurology. Thus ATN may be misdiagnosed as Temporomandibular Joint Disorder. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6038", "text": "This disorder is regarded by many medical professionals to comprise the most severe form of chronic pain known in medical practice. In some patients, pain may be unresponsive even to opioid drugs at any dose level that leaves the patient conscious. The disorder has thus acquired the unfortunate and possibly inflammatory nickname, \"the suicide disease\". [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6039", "text": "Symptoms of ATN may overlap with a pain disorder occurring in teeth called  atypical odontalgia  (literal meaning \"unusual tooth pain\"), with aching, burning, or stabs of pain localized to one or more teeth and adjacent jaw. The pain may seem to shift from one tooth to the next, after root canals or extractions. In desperate efforts to alleviate pain, some patients undergo multiple (but unneeded) root canals or extractions, even in the absence of suggestive X-ray evidence of  dental abscess . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6040", "text": "ATN symptoms may also be similar to those of post-herpetic neuralgia, which causes nerve inflammation when the latent herpes zoster virus of a previous case of chicken pox re-emerges in shingles. Fortunately, post-herpetic neuralgia is generally treated with medications that are also the first medications tried for ATN, which reduces the negative impact of misdiagnosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6041", "text": "The subject of atypical trigeminal neuralgia is considered problematic even among experts.  The term atypical TN is broad and due to the complexity of the condition, there are considerable issues with defining the condition further. Some medical practitioners no longer make a distinction between facial neuralgia (a nominal condition of inflammation) versus facial neuropathy (direct physical damage to a nerve). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6042", "text": "Due to the variability and imprecision of their pain symptoms, ATN or atypical odontalgia patients may be misdiagnosed with  atypical facial pain  (AFP) or \"hypochondriasis\", both of which are considered problematic by many practitioners. [ 7 ]  The term \"atypical facial pain\" is sometimes assigned to pain which crosses the mid-line of the face or otherwise does not conform to expected boundaries of nerve distributions or characteristics of validated medical entities. As such, AFP is seen to comprise a diagnosis by reduction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6043", "text": "As noted in material published by the [US] National Pain Foundation: \"atypical facial pain is a confusing term and should never be used to describe patients with trigeminal neuralgia or trigeminal neuropathic pain. Strictly speaking, AFP is classified as a \"somatiform pain disorder\"; this is a psychological diagnosis that should be confirmed by a skilled pain psychologist. Patients with the diagnosis of AFP have no identifiable underlying physical cause for the pain. The pain is usually constant, described as aching or burning, and often affects both sides of the face (this is almost never the case in patients with trigeminal neuralgia). The pain frequently involves areas of the head, face, and neck that are outside the sensory territories that are supplied by the trigeminal nerve. It is important to correctly identify patients with AFP since the treatment for this is strictly medical. Surgical procedures are not indicated for atypical facial pain.\" [ 8 ]   [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6044", "text": "The term \"hypochondriasis\" is closely related to \"somatoform pain disorder\" and \"conversion disorder\" in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association.  As of July 2011, this axis of the DSM-IV is undergoing major revision for the DSM-V, with introduction of a new designation \"Complex Somatic Symptom Disorder\". However, it remains to be demonstrated that any of these \"disorders\" can reliably be diagnosed as a medical entity with a discrete and reliable course of therapy. [ 9 ] [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6045", "text": "It is possible that there are triggers or aggravating factors that patients need to learn to recognize to help manage their health. Bright lights, sounds, stress, and poor diet are examples of additional stimuli that can contribute to the condition. The pain can cause nausea, so beyond the obvious need to treat the pain, it is important to be sure to try to get adequate rest and nutrition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6046", "text": "Depression is frequently co-morbid with neuralgia and neuropathic pain of all sorts, as a result of the negative effects that pain has on one's life. Depression and chronic pain may interact, with chronic pain often predisposing patients to depression, and depression operating to sap energy, disrupt sleep and heighten sensitivity and the sense of suffering.  Dealing with depression should thus be considered equally important as finding direct relief from the pain. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6047", "text": "Diagnosis for ATN is more difficult and complex than typical TN. However, the diagnosis for ATN can be supported by a positive response to a low dose of tricyclic antidepressant medications (such as amitriptyline or nortriptyline), similar to neuropathic pain diagnoses. [ citation needed ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6048", "text": "Treatment of people believed to have ATN or TN is usually begun with medication.  The long-time first drug of choice for facial neuralgia has been  carbamazepine , an  anti-seizure agent . Due to the significant side-effects and hazards of this drug, others have recently come into common use as alternatives. These include  oxcarbazepine ,  lamotrigine , and  gabapentin .  A positive patient response to one of these medications might be considered as supporting evidence for the diagnosis, which is otherwise made from medical history and pain presentation.  There are no present medical tests to conclusively confirm TN or ATN. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6049", "text": "If the anti-seizure drugs are found ineffective, one of the  tricyclic antidepressant  medications, such as  amitriptyline  or  nortriptyline , may be used. The tricyclic antidepressants are known to have dual action against both depression and neuropathic pain.  Other drugs which may also be tried, either individually or in combination with an anti-seizure agent, include  baclofen ,  pregabalin , and opioid drugs such as  oxycodone  or an oxycodone/paracetamol combination. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6050", "text": "For some people with ATN  opioids  may represent the only viable medical option which preserves quality of life and personal functioning.  Although there is considerable controversy in public policy and practice in this branch of medicine, practice guidelines have long been available and published. [ 15 ] [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6051", "text": "If drug treatment is found to be ineffective or causes disabling side effects, one of several  neurosurgical  procedures may be considered. The available procedures are believed to be less effective with type II (atypical) trigeminal neuralgia than with type I (typical or \"classic\") TN. Among present procedures, the most effective and long lasting has been found to be  microvascular decompression  (MVD), which seeks to relieve direct compression of the trigeminal nerve by separating and padding blood vessels in the vicinity of the emergence of this nerve from the brain stem, below the cranium. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6052", "text": "Choice of a surgical procedure is made by the doctor and patient in consultation, based on the patient's pain presentation and health and the doctor's medical experience.  Some neurosurgeons resist the application of MVD or other surgeries to atypical trigeminal neuralgia, in light of a widespread perception that ATN pain is less responsive to these procedures.  However, recent papers suggest that in cases where pain initially presents as type I TN, surgery may be effective even after the pain has evolved into type II. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6053", "text": "An  auditory brainstem implant  ( ABI ) is a surgically implanted electronic device that provides a sense of sound to a person who is profoundly deaf, due to retrocochlear hearing impairment (due to illness or injury damaging the  cochlea  or  auditory nerve , and so precluding the use of a  cochlear implant ). In Europe, ABIs have been used in children and adults, and in patients with  neurofibromatosis type II . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6054", "text": "The auditory brainstem implant was first developed in 1979 by  William F. House , a  neuro-otologist  associated with the  House Ear Institute , for patients with  neurofibromatosis type 2  (NF2). House's original ABI consisted of two ball electrodes that were implanted near the surface of the  cochlear nucleus  on the  brainstem . In 1997, Robert Behr at the  University of Wurzburg ,  Germany , performed an ABI implantation using a 12- electrode array  implant with an audio processor based on the  MED-EL  C40+ cochlear implant. [ 2 ]  The first pediatric ABI implantation was performed by Vittorio Colletti from  Verona ,  Italy , in 1999. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6055", "text": "In contrast to cochlear implants, ABI implantation is relatively rare. By 2010, there were only 500 patients worldwide who had undergone implantation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6056", "text": "An ABI system consists of an internal part (the implant) and an external part (the audio processor or sound processor). It is similar in design and function to a cochlear implant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6057", "text": "The external audio processor is worn on or behind the  ear . It contains at least one  microphone , which picks up sound signals from the environment. The audio processor converts these signals into digital signals and sends them to the coil. The coil transmits the signals through the  skin  to the implant below. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6058", "text": "The internal implant sends the signals to the electrode array. The design of the electrode array is the key difference between a cochlear implant and an ABI. Whereas the electrode array for a CI is wire-shaped and is inserted into the  cochlea , the electrode array of an ABI is paddle-shaped and is placed on the cochlear nucleus of the brainstem. [ 3 ]  By stimulating the brainstem, the ABI sends the sound signals to the brain, allowing the patient to perceive sound. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6059", "text": "Until 2018, ABI was only indicated for patients with Neurofibromatosis Type 2 (NF2). NF2 is a genetic disorder that is characterised by the development of non-cancerous tumours along the nervous system. These  vestibular schwannomas  (also known as acoustic neuromas) often form on the  auditory nerve , and surgical removal of these NF2 tumours can damage the auditory nerve and limiting the patient's ability to hear. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6060", "text": "NF2 generally presents in adolescence or young adulthood, so candidacy was previously limited to patients aged 15 years or older, with NF2 and bilateral non-functioning auditory nerves. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6061", "text": "In Europe and other countries, ABI is CE-marked and approved for patients 12 months and older who cannot benefit from a cochlear implant due to non-functional auditory nerves. This includes both  congenital  and accrued  etiologies , including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6062", "text": "The US  FDA  approved clinical trials of ABIs for children in 2013. [ 3 ]  A handful of medical centres, including  New York University , are undergoing feasibility studies in the pediatric population. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6063", "text": "ABI implantation requires a  craniotomy  and is therefore much more complex than CI surgery. It is normally performed by both a  neurosurgeon  and an ENT surgeon together, who insert the electrode array through the  fourth ventricle  onto the surface of the cochlear nucleus. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6064", "text": "For patients with NF2, the surgeon will spend a significant amount of time removing the acoustic neuroma tumours before inserting the implant.\u00a0 Depending upon the surgical approach, this may involve sacrificing the auditory nerve, thus rendering the patient deaf. [ 3 ]  Patients with NF2, who undergo both tumour removal and implantation in the same surgery, generally experience a longer post-op stay than patients without NF2. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6065", "text": "Speech perception outcomes with an ABI are generally poorer than those reported in cochlear implant multichannel CI users. Most patients are able to detect the presence of environmental sounds and speech. [ 3 ]  Speech understanding gradually improves during the first three years after activation, and most patients experience better speech understanding using a combination of lip-reading and the ABI, as opposed to lip-reading alone. However, most patients are unable to understand speech using only their ABI. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6066", "text": "There are two reasons that could explain the difference in outcomes between cochlear implants and ABIs. Firstly, non-auditory side-effects, such as  vertigo , limit the overall number of electrodes that can deliver useful frequency information. Electrodes found to cause one of these side-effects are deactivated, resulting in fewer signals reaching the brain. In addition, the brainstem is unable to offer the same tonotopic range as the cochlea. With a cochlear implant, the electrodes positioned in the basal end of the cochlea elicit a higher pitch sensation than those positioned in the apical end. In contrast, the tonotopic map within the cochlear nucleus runs parallel and obliquely through the nucleus and the ABI positioned on the surface does not stimulate neural structures in such a clear, tonotopically ordered way. This makes it harder to achieve optimal results during fitting. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6067", "text": "Patients without NF2 tend to experience better speech outcomes with an ABI than those with NF2. [ 7 ]  A study by Colletti found that a significant number of patients without NF2 were able to understand speech with an ABI, including effortless telephone use. [ 8 ]  It is believed that the tumours caused by the NF2 damage specialised cells in the cochlear nucleus important for speech perception. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6068", "text": "There is some evidence to suggest that ABI can help to reduce the effect of tinnitus and improve quality of life. [ 9 ]  Better language outcomes are also expected with younger children implanted before the age of 2. [ 10 ]  Because of the wide range of possible outcomes, it is crucial that patients and/or their parents are counselled effectively about what they can realistically expect from an ABI. Parents are advised about additional communication modalities available, such as the use of sign language, as the ultimate goal is to facilitate language with the child. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6069", "text": "Brain mapping  is a set of  neuroscience  techniques predicated on the mapping of (biological) quantities or properties onto spatial representations of the (human or non-human)  brain  resulting in  maps ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6070", "text": "According to the definition established in 2013 by  Society for Brain Mapping and Therapeutics  (SBMT), brain mapping is specifically defined, in summary, as the study of the  anatomy  and function of the brain and  spinal cord  through the use of  imaging ,  immunohistochemistry ,  molecular  &  optogenetics ,  stem cell  and  cellular biology ,  engineering ,  neurophysiology  and  nanotechnology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6071", "text": "In 2024, a team of 287 researchers completed a full brain mapping of an adult animal (a  Drosophila melanogaster , or fruit fly) and published their results in  Nature . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6072", "text": "All  neuroimaging  is considered part of brain mapping. Brain mapping can be conceived as a higher form of neuroimaging, producing brain images supplemented by the result of additional (imaging or non-imaging) data processing or analysis, such as maps projecting (measures of) behavior onto brain regions (see  fMRI ). One such map, called a  connectogram , depicts cortical regions around a circle, organized by lobes. Concentric circles within the ring represent various common neurological measurements, such as cortical thickness or curvature. In the center of the circles, lines representing white matter fibers illustrate the connections between cortical regions, weighted by  fractional anisotropy  and strength of connection. [ 3 ]  At higher resolutions brain maps are called  connectomes . These maps incorporate individual neural connections in the brain and are often presented as  wiring diagrams . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6073", "text": "Brain mapping techniques are constantly evolving, and rely on the development and refinement of image acquisition, representation, analysis, visualization and interpretation techniques. [ 5 ]   Functional and structural neuroimaging are at the core of the mapping aspect of brain mapping."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6074", "text": "Some scientists have criticized the brain image-based claims made in  scientific journals  and the popular press, like the discovery of \"the part of the brain responsible\" things like love or musical abilities or a specific memory.  Many mapping techniques have a relatively low resolution, including hundreds of thousands of neurons in a single  voxel .  Many functions also involve multiple parts of the brain, meaning that this type of claim is probably both unverifiable with the equipment used, and generally based on an incorrect assumption about how brain functions are divided.  It may be that most brain functions will only be described correctly after being measured with much more fine-grained measurements that look not at large regions but instead at a very large number of tiny individual  brain circuits .  Many of these studies also have technical problems like small sample size or poor equipment calibration which means they cannot be reproduced - considerations which are sometimes ignored to produce a sensational journal article or news headline.  In some cases the brain mapping techniques are used for commercial purposes,  lie detection , or medical diagnosis in ways which have not been scientifically validated. [ 6 ] [ page\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6075", "text": "In the late 1980s in the United States, the Institute of Medicine of the National Academy of Science was commissioned to establish a panel to investigate the value of integrating neuroscientific information across a variety of techniques. [ 7 ] [ page\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6076", "text": "Of specific interest is using structural and  functional magnetic resonance imaging  (fMRI),  diffusion MRI  (dMRI),  magnetoencephalography  (MEG), electroencephalography ( EEG ),  positron emission tomography  (PET),  Near-infrared spectroscopy  (NIRS)  and other non-invasive scanning techniques to map  anatomy ,  physiology ,  perfusion , function and  phenotypes  of the human brain. Both healthy and  diseased  brains may be mapped to study  memory ,  learning ,  aging , and  drug  effects in various populations such as people with  schizophrenia ,  autism , and  clinical depression . This led to the establishment of the  Human Brain Project . [ 8 ] [ page\u00a0needed ]   It may also be crucial to understanding traumatic brain injuries (as in the case of  Phineas Gage ) [ 9 ]  and improving brain injury treatment. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6077", "text": "Following a series of meetings, the International Consortium for Brain Mapping (ICBM) evolved. [ 12 ] [ page\u00a0needed ]   The ultimate goal is to develop flexible computational  brain atlases ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6078", "text": "The interactive and citizen science website  Eyewire  maps mices' retinal cells and was launched in 2012. In 2021, the most comprehensive 3D map of the human brain was published by researchers at  Google . It shows neurons and their connections along with blood vessels and other components of a millionth of a brain. For the map, the 1 mm\u00b3 sized fragment was sliced into about 5,300 pieces of about 30  nanometer  thickness which were then each scanned with an  electron microscope . The interactive map required 1.4  petabytes  of storage-space. [ 14 ] [ 15 ]  About two months later, scientists reported that they created the first complete neuron-level-resolution 3D map of a monkey brain which they scanned via a new method within 100 hours. They made only a fraction of the 3D map publicly available as the entire map takes more than 1 petabyte of storage space even when compressed. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6079", "text": "In October 2021, the BRAIN Initiative Cell Census Network concluded the first phase of a long-term project to generate an atlas of the entire mouse (mammalian) brain with 17 studies, including an atlas and census of cell types in the  primary motor cortex . [ 18 ] [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6080", "text": "In 2024, FlyWire, a team of 287 researchers spanning 76 institutions completed a brain mapping, or connectome, of an adult animal (a  Drosophila melanogaster , or fruit fly) and published their results in  Nature . [ 1 ]  Prior to this, the only adult animal to have its brain entirely reconstructed was the nematode  Caenorhabditis elegans , but the fruit fly brain map is the first \"complete map of any complex brain\", according to Murthy, one of the researchers involved. [ 2 ]  Primary mapping data was collected through  electron microscopy , assisted by  artificial intelligence  and  citizen scientists , who corrected errors that artificial intelligence made. The resulting model had more than 140,000 neurons with over 50 million synapses. [ 21 ]  From the model, research expect to identify how the brain creates new connections for functions such as vision, creating  digital twin  equivalents to track how segments of the neuron connection map interact to external signals, including the nervous system. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6081", "text": "In 2021, the first connectome that shows how an animal's brain changes throughout its lifetime was reported. Scientists mapped and compared the whole brains of eight isogenic  C. elegans  worms, each at a different stage of development. [ 23 ] [ 24 ]  Later that year, scientists combined electron microscopy and brainbow imaging to show for the first time the development of a mammalian neural circuit. They reported the complete wiring diagrams between the CNS and muscles of ten individual mice. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6082", "text": "In August 2021, scientists of the  MICrONS  program, launched in 2016, [ 26 ]  published a functional connectomics dataset that \"contains calcium imaging of an estimated 75,000 neurons from primary visual cortex (VISp) and three higher visual areas (VISrl, VISal and VISlm), that were recorded while a mouse viewed natural movies and parametric stimuli\". [ 27 ] [ 28 ]  Based on this data they also published \"interactive visualizations of anatomical and functional data that span all 6 layers of mouse primary visual cortex and 3 higher visual areas (LM, AL, RL) within a cubic millimeter volume\" \u2013 the  MICrONS Explorer . [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6083", "text": "In 2022, a first spatiotemporal cellular atlas of the  axolotl  brain development and  regeneration , the interactive  Axolotl Regenerative Telencephalon Interpretation via Spatiotemporal Transcriptomic Atlas  , revealed key insights about axolotl  brain regeneration . [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6084", "text": "A  brain transplant  or  whole-body transplant  is a procedure in which the brain of one organism is transplanted into the body of another organism. It is a procedure distinct from  head transplantation , which involves transferring the entire head to a new body, as opposed to the brain only. Theoretically, a person with complete organ failure could be given a new and functional body while keeping their own personality, memories, and consciousness through such a procedure.  Neurosurgeon   Robert J. White  has grafted the head of a monkey onto the headless body of another monkey. EEG readings showed the brain was later functioning normally. Initially, it was thought to prove that the brain was an  immunologically privileged  organ, as the host's immune system did not attack it at first, [ 1 ]  but immunorejection caused the monkey to die after nine days. [ 2 ]  Brain transplants and similar concepts have also been explored in various forms of science fiction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6085", "text": "One of the most significant barriers to the procedure is the inability of  nerve  tissue to heal properly;  scarred  nerve tissue does not transmit signals well, which is why  spinal cord injuries  devastate muscle function and sensation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6086", "text": "Alternatively, a  brain\u2013computer interface  can be used connecting the subject to their own body. A study [ 3 ]  using a monkey as a subject shows that it is possible to directly use commands from the brain, bypass the spinal cord and enable hand function. An advantage is that this interface can be adjusted after the surgical interventions are done where nerves can not be reconnected without surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6087", "text": "Also, for the procedure to be practical, the age of the donated body must be close to that of the recipient brain: an adult brain cannot fit into a skull that has not reached its full growth, which occurs at age 9\u201312 years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6088", "text": "When organs are transplanted, aggressive  transplant rejection  by the host's  immune system  can occur. Because immune cells of the CNS contribute to the maintenance of neurogenesis and spatial learning abilities in adulthood, the brain has been hypothesized to be an  immunologically privileged  (unrejectable) organ. [ 4 ] [ 5 ] [ 6 ]  However, immunorejection of a functional transplanted brain has been reported in monkeys. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6089", "text": "In 1982, Dr. Dorothy T. Krieger, chief of  endocrinology  at  Mount Sinai Medical Center  in New York City, achieved success with a partial brain transplant in mice. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6090", "text": "In 1998, a team of  surgeons  from the  University of Pittsburgh Medical Center  attempted to transplant a group of  brain cells  to Alma Cerasini, who had suffered a severe  stroke  that caused the loss of mobility in her right  limbs  as well as had limited speech. The team hoped that the cells would correct the listed damage. She died later on. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6091", "text": "The whole-body transplant is just one of several means of putting a consciousness into a new body that have been explored in  science fiction . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6092", "text": "In the film  Get Out  (2017), written and directed by  Jordan Peele , a white woman ( Allison Williams ) lures her black boyfriend ( Daniel Kaluuya ) to her family's estate to be auctioned off for a brain transplant procedure that enables older white people to obtain pseudo-immortality in a black person's body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6093", "text": "In the film  Pichaikkaran 2  (2023), written and directed by  Vijay Antony , a CEO and his accomplice transplanted a beggar's brain to an ultra-rich man to rob him of his wealth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6094", "text": "In  Maxwell Atoms ' Cartoon Network series  Evil Con Carne  (2003\u20132004), Hector Con Carne was reduced to a brain and a stomach and both of them were put in jars attached to the body of a Russian circus bear. Hector's brain is the main character of the cartoon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6095", "text": "Edgar Rice Burroughs'  The Mastermind of Mars  involves a surgeon who performs brain transplants as his main operation, as well as a man from Earth\u2014the narrator and main character\u2014who is also trained to perform brain transplants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6096", "text": "In  Neil R. Jones '  Professeur Jameson  stories (1931), the main character is the last earthman, whose brain is saved by some alien cyborgs called the Zoromes, and is inserted into a robotic body, making him immortal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6097", "text": "Robert Heinlein's 1970 science fiction novel,  I Will Fear No Evil , features a main character named Johann Sebastian Bach Smith whose entire brain is transplanted into his deceased secretary's skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6098", "text": "In the horror film  The Skeleton Key , the protagonist, Caroline, discovers that the old couple she is looking after are poor Voodoo witch doctors who stole the bodies of two young, privileged children in their care using a ritual which allows a soul to swap bodies. Unfortunately the evil old couple also trick Caroline and their lawyer into the same procedure, and both end up stuck in old dying bodies unable to speak while the witch doctors walk off with their young bodies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6099", "text": "In  Anne Rice 's  The Tale of the Body Thief , the vampire Lestat discovers a man, Raglan James, who can will himself into another person's body.  Lestat demands that the procedure be used on him to allow him to be human once again, but soon finds that he has made an error and is forced to recapture James in his vampiric form so he can take his body back."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6100", "text": "In  JoJo's Bizarre Adventure  (part 3:  Stardust Crusaders ), Dio Brando, a vampire who was the main antagonist in the first part of JJBA, comes back from his 100-year sleep with his new body of Jonathan Joestar. He was only left with his head, so he took the body of Jonathan from the neck down."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6101", "text": "In Matthew Broughton's BBC radio drama thriller  Tracks  (series 1 \u2013  Origins ), the protagonist Helen Ash discovers that many of the victims in a plane crash which she witnessed have vital organs missing or deficient, including the brain. She goes on to uncover her estranged father's murky and secretive past and her own connection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6102", "text": "In the horror game  SOMA , the protagonist's brain is scanned in extreme detail for medical purposes; over a century later, the data from the scan are transferred into an artificial body, effectively performing a consciousness transplant. Later in the story, the protagonist comes across many other cases of a similar event, with far worse body choices for the transplanted consciousnesses. The Protagonist's goal is to ensure that an artificial world called the \"ARK\" is as safe as possible. The ARK is a supercomputer, a server hosting a virtual world, which can be explored with one's consciousness alone. Many people, including the protagonist, have had their brains scanned and consciousnesses \"transplanted\" into the computer, so that they may live on, since Earth is no longer habitable in SOMA's story."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6103", "text": "Similar in many ways to this is the idea of  mind uploading , promoted by  Marvin Minsky  and others with a mechanistic view of natural intelligence and an optimistic outlook regarding  artificial intelligence .  It is also a goal of  Ra\u00eblism , a small cult based in Florida, France, and Quebec.  While the ultimate goal of transplanting is transfer of the brain to a new body optimized for it by  genetics ,  proteomics , and/or other medical procedures, in uploading the brain itself moves nowhere and may even be physically destroyed or discarded; the goal is rather to duplicate the information patterns contained within the brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6104", "text": "Another similar literary theme, though different from either procedure described above, is the transplanting of a human brain into an artificial, usually robotic, body.  Examples of this include:  Caprica ;  Ghost in the Shell ;  RoboCop ; the  DC Comics  superhero  Robotman ; the  Cybermen  from the  Doctor Who  television series; the  cymeks  in the  Legends of Dune  series; Dr. Light and Dr. Wily in the  Mega Man  Series, in which their consciousnesses are seen living on a century after through program data in the  Mega Man X  series; as full-body cyborgs in many  manga  or works in the  cyberpunk  genre.  In one episode of  Star Trek ,  Spock's Brain  is stolen and installed in a large computer-like structure; and in \" I, Mudd \" Uhura is offered immortality in an android body. The novel  Harvest of Stars  by  Poul Anderson  features many central characters who undergo such transplants, and deals with the difficult decisions facing a human contemplating such a procedure. In the  Star Wars  expanded universe  the shadow droids were created by taking the brains of grievously wounded  TIE fighter  pilot aces. After surgically transplanting them into a protective cocoon filled with nutrient fluids, they were surgically connected to cybernetic hardware that gave them external sensors, flight control, and tactical computers that augmented their reflexes beyond the biological limit, at the cost of their humanity. Emperor  Palpatine  also imbued them with the dark side giving them a sixth sense, and making them into extensions of his own will."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6105", "text": "An  intracranial aneurysm , also known as a  cerebral aneurysm , is a  cerebrovascular disorder  characterized by a localized dilation or ballooning of a  blood vessel  in the brain due to a weakness in the vessel wall. These  aneurysms  can occur in any part of the brain but are most commonly found in the arteries of the cerebral arterial circle. The risk of rupture varies with the size and location of the aneurysm, with those in the posterior circulation being more prone to rupture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6106", "text": "Cerebral aneurysms are classified by size into small, large, giant, and super-giant, and by shape into saccular (berry),  fusiform , and microaneurysms. Saccular aneurysms are the most common type and can result from various risk factors, including genetic conditions,  hypertension ,  smoking , and  drug abuse ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6107", "text": "Symptoms of an unruptured aneurysm are often minimal, but a ruptured aneurysm can cause severe  headaches ,  nausea ,  vision impairment , and  loss of consciousness , leading to a  subarachnoid hemorrhage . Treatment options include surgical clipping and endovascular coiling, both aimed at preventing further bleeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6108", "text": "Diagnosis typically involves imaging techniques such as  CT  or  MR angiography  and lumbar puncture to detect subarachnoid hemorrhage. Prognosis depends on factors like the size and location of the aneurysm and the patient\u2019s age and health, with larger aneurysms having a higher risk of rupture and poorer outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6109", "text": "Advances in medical imaging have led to increased detection of unruptured aneurysms, prompting ongoing research into their management and the development of predictive tools for rupture risk."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6110", "text": "Cerebral aneurysms are classified both by size and shape. Small aneurysms have a diameter of less than 15\u00a0mm. Larger aneurysms include those classified as large (15 to 25\u00a0mm), giant (25 to 50\u00a0mm) (0.98 inches to 1.97 inches), and super-giant (over 50\u00a0mm). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6111", "text": "Saccular aneurysms, also known as berry aneurysms, appear as a round outpouching and are the most common form of cerebral aneurysm. [ 3 ] [ 4 ]  Causes include connective tissue disorders,  polycystic kidney disease , arteriovenous malformations, untreated  hypertension , tobacco smoking, cocaine and amphetamines, intravenous drug abuse (can cause infectious mycotic aneurysms), alcoholism, heavy caffeine intake, head trauma, and infection in the arterial wall from  bacteremia  (mycotic aneurysms). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6112", "text": "Fusiform  dolichoectatic  aneurysms represent a widening of a segment of an artery around the entire blood vessel, rather than just arising from a side of an artery's wall. They have an estimated annual risk of rupture between 1.6 and 1.9 percent. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6113", "text": "Microaneurysms, also known as  Charcot\u2013Bouchard aneurysms , typically occur in small  blood vessels  (less than 300  micrometre  diameter), most often the  lenticulostriate  vessels of the  basal ganglia , and are associated with  chronic   hypertension . [ 8 ]  Charcot\u2013Bouchard aneurysms are a common cause of  intracranial hemorrhage . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6114", "text": "A small, unchanging aneurysm will produce few, if any, symptoms. Before a larger aneurysm ruptures, the individual may experience such symptoms as a sudden and unusually severe headache,  nausea , vision impairment,  vomiting , and  loss of consciousness , or no symptoms at all. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6115", "text": "If an aneurysm ruptures, blood leaks into the space around the brain. This is called a  subarachnoid hemorrhage . Onset is usually sudden without  prodrome , classically presenting as a \" thunderclap headache \" worse than previous headaches. [ 11 ] [ 12 ]  Symptoms of a subarachnoid hemorrhage differ depending on the site and size of the aneurysm. [ 12 ]  Symptoms of a ruptured aneurysm can include: [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6116", "text": "Almost all aneurysms rupture at their apex. This leads to hemorrhage in the subarachnoid space and sometimes in brain  parenchyma . Minor leakage from aneurysm may precede rupture, causing warning headaches. About 60% of patients die immediately after rupture. [ 14 ]  Larger aneurysms have a greater tendency to rupture, though most ruptured aneurysms are less than 10\u00a0mm in diameter. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6117", "text": "A ruptured microaneurysm may cause an  intracerebral hemorrhage , presenting as a focal neurological deficit. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6118", "text": "Rebleeding,  hydrocephalus  (the excessive accumulation of  cerebrospinal fluid ),  vasospasm  (spasm, or narrowing, of the blood vessels), or multiple aneurysms may also occur. The risk of rupture from a cerebral aneurysm varies according to the size of an aneurysm, with the risk rising as the aneurysm size increases. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6119", "text": "Vasospasm , referring to blood vessel constriction, can occur secondary to subarachnoid hemorrhage following a ruptured aneurysm. This is most likely to occur within 21 days and is seen radiologically within 60% of such patients. The vasospasm is thought to be secondary to the  apoptosis  of  inflammatory  cells such as  macrophages  and  neutrophils  that become trapped in the subarachnoid space. These cells initially invade the subarachnoid space from the circulation in order to  phagocytose  the hemorrhaged red blood cells. Following apoptosis, it is thought there is a massive degranulation of vasoconstrictors, including  endothelins  and  free radicals , that cause the vasospasm. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6120", "text": "Intracranial aneurysms may result from diseases acquired during life, or from genetic conditions.   Hypertension ,  smoking ,  alcoholism , and  obesity  are associated with the development of brain aneurysms. [ 11 ] [ 12 ] [ 17 ]   Cocaine  use has also been associated with the development of intracranial aneurysms. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6121", "text": "Other acquired associations with intracranial aneurysms include head trauma and infections. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6122", "text": "Coarctation of the aorta is also a known risk factor, [ 11 ]  as is  arteriovenous malformation . [ 14 ]  Genetic conditions associated with  connective tissue disease  may also be associated with the development of aneurysms. [ 11 ]  This includes: [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6123", "text": "Specific genes have also had reported association with the development of intracranial aneurysms, including  perlecan ,  elastin ,  collagen  type 1 A2, endothelial  nitric oxide synthase ,  endothelin  receptor A and  cyclin dependent kinase inhibitor . Recently, several  genetic loci  have been identified as relevant to the development of intracranial aneurysms. These include 1p34\u201336, 2p14\u201315, 7q11, 11q25, and 19q13.1\u201313.3. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6124", "text": "Aneurysm  means an outpouching of a  blood vessel  wall that is filled with blood. Aneurysms occur at a point of weakness in the vessel wall. This can be because of acquired disease or hereditary factors. The repeated trauma of blood flow against the vessel wall presses against the point of weakness and causes the aneurysm to enlarge. [ 20 ]  As described by the  law of Young-Laplace , the increasing area increases tension against the aneurysmal walls, leading to enlargement. [ 21 ] [ 22 ] [ 23 ]  In addition, a combination of computational fluid dynamics and morphological indices have been proposed as reliable predictors of cerebral aneurysm rupture. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6125", "text": "Both high and low wall  shear stress  of flowing blood can cause aneurysm and rupture. However, the mechanism of action is still unknown. It is speculated that low shear stress causes growth and rupture of large aneurysms through inflammatory response while high shear stress causes growth and rupture of small aneurysm through mural response (response from the blood vessel wall). Other risk factors that contributes to the formation of aneurysm are: cigarette smoking, hypertension, female gender, family history of cerebral aneurysm, infection, and trauma. Damage to structural integrity of the arterial wall by shear stress causes an inflammatory response with the recruitment of  T cells ,  macrophages , and  mast cells . The inflammatory mediators are:  interleukin 1 beta ,  interleukin 6 ,  tumor necrosis factor alpha  (TNF alpha),  MMP1 ,  MMP2 ,  MMP9 ,  prostaglandin E2 ,  complement system ,  reactive oxygen species  (ROS), and  angiotensin II . However,  smooth muscle cells  from the  tunica media  layer of the artery moved into the  tunica intima , where the function of the smooth muscle cells changed from contractile function into pro-inflammatory function. This causes the fibrosis of the arterial wall, with reduction of number of smooth muscle cells, abnormal collagen synthesis, resulting in a thinning of the arterial wall and the formation of aneurysm and rupture. No specific gene loci has been identified to be associated with cerebral aneurysms. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6126", "text": "Generally, aneurysms larger than 7\u00a0mm in diameter should be treated because they are prone for rupture. Meanwhile, aneurysms less than 7\u00a0mm arise from the  anterior  and  posterior communicating artery  and are more easily ruptured when compared to aneurysms arising from other locations. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6127", "text": "Saccular aneurysms are almost always the result of hereditary weaknesses in blood vessels and typically occur within the arteries of the  circle of Willis , [ 20 ] [ 26 ]  in order of frequency affecting the following arteries: [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6128", "text": "Saccular aneurysms tend to have a lack of  tunica media  and elastic lamina around their dilated locations (congenital), with a wall of sac made up of thickened hyalinized intima and adventitia. [ 14 ]  In addition, some parts of the brain vasculature are inherently weak\u2014particularly areas along the circle of Willis, where small communicating vessels link the main cerebral vessels. These areas are particularly susceptible to saccular aneurysms. [ 11 ]  Approximately 25% of patients have multiple aneurysms, predominantly when there is a familial pattern. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6129", "text": "Once suspected, intracranial aneurysms can be diagnosed radiologically using  magnetic resonance  or  CT  angiography. [ 28 ]  But these methods have limited sensitivity for diagnosis of small aneurysms, and often cannot be used to specifically distinguish them from infundibular dilations without performing a formal  angiogram . [ 28 ] [ 29 ]  The determination of whether an aneurysm is ruptured is critical to diagnosis.  Lumbar puncture  (LP) is the gold standard technique for determining aneurysm rupture ( subarachnoid hemorrhage ). Once an LP is performed, the  CSF  is evaluated for  RBC count , and presence or absence of  xanthochromia . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6130", "text": "Emergency treatment  for individuals with a ruptured cerebral aneurysm generally includes restoring deteriorating  respiration  and reducing  intracranial pressure . Currently there are two treatment options for securing intracranial aneurysms:  surgical clipping  or  endovascular coiling . If possible, either surgical clipping or endovascular coiling is typically performed within the first 24 hours after bleeding to occlude the ruptured aneurysm and reduce the risk of recurrent hemorrhage. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6131", "text": "While a large  meta-analysis  found the outcomes and risks of surgical clipping and endovascular coiling to be statistically similar, no consensus has been reached. [ 32 ]  In particular, the large  randomised control trial   International Subarachnoid Aneurysm Trial  appears to indicate a higher rate of recurrence when intracerebral aneurysms are treated using endovascular coiling. Analysis of data from this trial has indicated a 7% lower eight-year mortality rate with coiling, [ 33 ]  a high rate of aneurysm recurrence in aneurysms treated with coiling\u2014from 28.6 to 33.6% within a year, [ 34 ] [ 35 ]  a 6.9 times greater rate of late retreatment for coiled aneurysms, [ 36 ]  and a rate of rebleeding 8 times higher than surgically clipped aneurysms. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6132", "text": "Aneurysms can be treated by clipping the base of the aneurysm with a specially-designed clip. Whilst this is typically carried out by  craniotomy , a new endoscopic endonasal approach is being trialled. [ 38 ]  Surgical clipping was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. [ 39 ] \nAfter clipping, a catheter angiogram or CTA can be performed to confirm complete clipping. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6133", "text": "Endovascular coiling refers to the insertion of  platinum  coils into the aneurysm. A  catheter  is inserted into a blood vessel, typically the  femoral artery , and passed through blood vessels into the cerebral circulation and the aneurysm. Coils are pushed into the aneurysm, or released into the blood stream ahead of the aneurysm. Upon depositing within the aneurysm, the coils expand and initiate a thrombotic reaction within the aneurysm. If successful, this prevents further bleeding from the aneurysm. [ 41 ]  In the case of broad-based aneurysms, a stent may be passed first into the parent artery to serve as a scaffold for the coils. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6134", "text": "Cerebral bypass surgery was developed in the 1960s in Switzerland by  Gazi Ya\u015fargil . When a patient has an aneurysm involving a blood vessel or a tumor at the base of the skull wrapping around a blood vessel, surgeons eliminate the problem vessel by replacing it with an artery from another part of the body. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6135", "text": "Outcomes depend on the size of the aneurysm. [ 44 ]  Small aneurysms (less than 7\u00a0mm) have a low risk of rupture and increase in size slowly. [ 44 ]  The risk of rupture is less than one percent for aneurysms of this size. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6136", "text": "The  prognosis  for a ruptured cerebral aneurysm depends on the extent and location of the aneurysm, the person's age, general health, and neurological condition. Some individuals with a ruptured cerebral aneurysm die from the initial bleeding. Other individuals with cerebral aneurysm recover with little or no neurological deficit.  The most significant factors in determining outcome are the  Hunt and Hess grade , and age.  Generally patients with Hunt and Hess grade I and II hemorrhage on admission to the emergency room and patients who are younger within the typical age range of vulnerability can anticipate a good outcome, without death or permanent disability.  Older patients and those with poorer Hunt and Hess grades on admission have a poor prognosis.  Generally, about two-thirds of patients have a poor outcome, death, or permanent disability. [ 20 ] [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6137", "text": "Increased availability and greater access to  medical imaging  has caused a rising number of asymptomatic, unruptured cerebral aneurysms to be  discovered incidentally  during medical imaging investigations. [ 47 ]  Unruptured aneurysms may be managed by  endovascular  clipping or stenting. For those subjects that underwent follow-up for the unruptured aneurysm,  computed tomography angiography  (CTA) or  magnetic resonance angiography  (MRA) of the brain can be done yearly. [ 48 ]  Recently, an increasing number of aneurysm features have been evaluated in their ability to predict aneurysm rupture status, including aneurysm height, aspect ratio, height-to-width ratio, inflow angle, deviations from ideal spherical or elliptical forms, and  radiomics  morphological features. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6138", "text": "The  prevalence  of intracranial aneurysm is about 1\u20135% (10 million to 12 million persons in the United States) and the  incidence  is 1 per 10,000 persons per year in the United States (approximately 27,000), with 30- to 60-year-olds being the age group most affected. [ 10 ] [ 20 ]  Intracranial aneurysms occur more in women, by a ratio of 3 to 2, and are rarely seen in pediatric populations. [ 10 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6139", "text": "Cerebral angiography  is a form of  angiography  which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as  arteriovenous malformations  and  aneurysms . [ 1 ] \nIt was pioneered in 1927 by the Portuguese neurologist  Egas Moniz  at the  University of Lisbon , who also helped develop  thorotrast  for use in the procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6140", "text": "Typically a  catheter  is inserted into a large artery (such as the  femoral artery ) and threaded through the circulatory system to the  carotid artery , where a  contrast agent  is injected.  A series of  radiographs  are taken as the contrast agent spreads through the brain's arterial system, then a second series as it reaches the venous system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6141", "text": "For some applications, [ citation needed ]  cerebral angiography may yield better images than less invasive methods such as  computed tomography angiography  and  magnetic resonance angiography .\nIn addition, cerebral angiography allows certain treatments to be performed immediately, based on its findings. In recent decades, cerebral angiography has so assumed a therapeutic connotation thanks to the elaboration of endovascular therapeutic techniques. Embolization (a minimally invasive surgical technique) over time has played an increasingly significant role in the multimodal treatment of cerebral MAVs, facilitating subsequent microsurgical or radiosurgical treatment. [ 3 ] [ 4 ]  Another type of treatment possible by angiography (if the images reveal an aneurysm) is the introduction of metal coils through the catheter already in place and maneuvered to the site of aneurysm; over time these coils encourage formation of  connective tissue  at the site, strengthening the vessel walls. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6142", "text": "In some jurisdictions, cerebral angiography is required to confirm  brain death . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6143", "text": "Prior to the advent of modern neuroimaging techniques such as  MRI  and  CT  in the mid-1970s, cerebral angiographies were frequently employed as a tool to infer the existence and location of certain kinds of lesions and hematomas by looking for secondary vascular displacement caused by the  mass effect  related to these medical conditions. This use of angiography as an  indirect  assessment tool is nowadays obsolete as modern non-invasive diagnostic methods are available to image many kinds of primary intracranial abnormalities directly. [ 7 ]  It is still widely used however for evaluating various types of vascular pathologies within the skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6144", "text": "Cerebral angiography is used for diagnosis but may be followed by treatment procedures in the same setting. [ 8 ]  Cerebral angiography is used to image various intracranial (within the head) or extracranial (outside the head) diseases. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6145", "text": "Intracranial diseases are: non-traumatic  subarachnoid haemorrhage , non-traumatic  intracerebral haemorrhage ,  intracranial aneurysm ,  stroke ,  cerebral vasospasm ,  cerebral arteriovenous malformation  (for Spetzler-Martin grading and plan for intervention),  dural arteriovenous fistula ,  embolisation  of brain tumours such as  meningioma ,  cavernous sinus haemangioma , for  Wada test , and to obtain haemodynamics of cerebral blood flow such as cross flow, circulation time, and collateral flow. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6146", "text": "Extracranial diseases are:  Subclavian steal syndrome , rupture of the carotid artery,  carotid artery stenosis , cervical spine trauma,  epistaxis  (nose bleeding) and plan for embolisation of  juvenile nasopharyngeal angiofibroma  before operation. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6147", "text": "Although  computed tomography angiography  (CTA) and  Magnetic resonance angiography  (MRA) has been used widely in evaluation of intracranial disease, cerebral angiography provides higher resolution on the conditions of blood vessel lumens and vasculature. [ 10 ]  Cerebral angiography is also the standard of detecting intracranial aneurysm and evaluating the feasibility of  endovascular coiling . [ 11 ]  Performing a cerebral angiogram by gaining access through the femoral artery or radial artery is feasible in order to treat cerebral aneurysms with a number of devices [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6148", "text": "Certain conditions such as contrast allergy, renal insufficiency, and coagulation disorders are contraindicated in this procedure. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6149", "text": "Before the procedure, focused history and neurological examination is performed, available imaging, and blood parameters are reviewed. [ 9 ]  When reviewing imaging, arch anatomy and variants are evaluated to select suitable catheters to assess the vessels.  Complete blood count  is reviewed to ensure adequate amount of  haemoglobin  in subject's body, and to rule out the presence of  sepsis . Serum  creatinine  is assessed to rule out renal dysfunction. Meanwhile,  prothrombin time  is assessed to rule out  coagulopathy . [ 8 ]  Informed consent regarding the risks of the procedure is taken. [ 9 ]  Anticoagulants are withheld if possible. [ 9 ]  Fasting is required 6 hours before the procedure and insulin requirement is reduced by half for those diabetics who are fasting. [ 9 ]  Bilateral  groins  (for  femoral artery  access) and left arm/forearm (for  brachial artery / radial artery  access) are prepared. Neurological status of the patient before  sedation  or  anesthesia  is recorded. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6150", "text": "Sedation drug such as  intravenous   midazolam  and  painkiller  such as  fentanyl  can be used if the subject is restless or painful. The subject is then lie down on supine position with arm at the sides. Uncooperative subjects may have their forehead tapped to reduce motion. The subject is advised to stay as still as possible especially when  fluoroscopy  images are taken. The subject is also advised to avoid swallowing when images of neck are taken. These measures are taken to reduce motion artifact in the images. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6151", "text": "Right common  femoral artery  (RFA) is the preferred site of access. If RFA access is not optimal, then brachial artery access is chosen. Either a micropuncture system or an 18G access needle can be used with or without ultrasound guidance. There are four types of catheters that can be used: angled vertebral catheter for usual cases, Judkins right coronary catheter (Terumo) for tourtous vessels, Simmons's catheter and Mani's head hunter catheter (Terumo) for extremely tortous vessels. A 5Fr sheath is also placed within and flushed with heparinised saline to prevent clotting around the sheath. [ 8 ]  In terms of guidewire, Terumo hydrophilic Glidewire 0.035 inches can be used. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6152", "text": "To prevent  embolism  (either due to blood clot or  air embolism , \"double flush\" and \"wet connect\" techniques are used. [ 8 ]  In \"double flush\" technique, a saline syringe is used to  aspirate  blood from the catheter. Then, a second heparinised saline syringe is used to flush the catheter. [ 13 ]  \"Wet connect\" is the technique that connects syringe to a sheath without air bubbles within. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6153", "text": "Digital subtraction angiography  is the main technique of imaging the cerebral blood vessels. Catheter should be advanced over the guidewire. Rotating the catheter during advancement is also helpful. Roadmap (superimposing previous image on live  fluoroscopic  image) is used to advance catheters or guidewires before any vessel bifurcation can help to prevent vessel  dissection . [ 8 ]  After the catheter is in position, guidewire is removed slowly with heparinised saline dripping into the catheter at the same time to prevent air embolism. Prior to contrast injection, backflow of the catheter should be established to ensure there is no wedging, dissection, or intracatheter clotting. During the catheterisation of  vertebral artery , extra care should be taken to prevent vessel dissection or vasospasm. Delayed or incomplete contrast washout may indicate vasospasm or dissection. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6154", "text": "Cervical arch angiogram is taken if there is any suspicion of  aortic arch  narrowing, or any anatomical variants such as bovine arch ( brachiocephalic trunk  shares a common origin with left  common carotid artery ). If such abnormality is present, it results it difficulty in  cannulation  of the main branches of the aortic arch. [ 8 ]  The catheter of choice to cannulate this area is pigtail catheter with multiple side holes. Contrast injection rate of 20 to 25ml/sec is given with total volume of 40 to 50 ml of contrast. The frame rate of fluoroscopy is 4 to 6 frames per second. [ 8 ]  The image is taken in with the x-ray tube in left anterior oblique position. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6155", "text": "To image the vessels of the neck such as common carotid, internal and external carotid arteries, AP, lateral, and 45 degrees bilateral oblique positions are taken. Contrast injection rate is 3 to 4 ml/sec with total volume of 7 to 9 ml. The frame rate of fluoroscopy is 3 to 4 frames/sec. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6156", "text": "To image the anterior cerebral circulation such as internal and external carotid arteries and its branches, AP, Towne's and lateral views are taken. [ 8 ]  The petrous part of the  temporal bone  should be superimposed at the mid or lower orbits when taking the AP/Towne's view. Contrast injection rate is 6 to 7 ml/sec with total volume of contrast at 10 ml. [ 8 ] [ 9 ]  The frame rate of fluoroscopy is 2 to 4 frames/sec. [ 8 ]  Neck extension can help to navigate into tortous cerival part of the  internal carotid artery . [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6157", "text": "At the level of carotid bifurcation, AP and oblique images are taken. At the cavernous (C4) and ophthalmic segments (C6) of the internal carotid artery, Caldwell and lateral views are taken. [ 8 ]  At the supraclinoid segment (C5-clinoid, C6-ophthalmic, and C7-bifurcation to  posterior communicating artery  (PCOM) segments), AP view is used to access the terminal branches such as  anterior cerebral artery  (ACA),  middle cerebral artery  (MCA) while oblique view (25 to 35 degrees) is used to access the ACA,  anterior communicating artery  (ACOM), and MCA bifurcations. [ 8 ]  Lateral view is useful to visualise the PCOM while submentovertical view is useful to project ACOM above the nasal cavity, thus making it easier to access the anatomy of ACOM. Transorbital oblique view is useful to access the MCA anatomy. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6158", "text": "The anatomy of external carotid artery is access via AP and lateral views. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6159", "text": "To image the posterior circulation, such as vertebral and basilar arteries, AP, Towne's view, lateral projections near the back of the head and upper part of the neck is taken. In this case, petrous bone should be projected at the bottom or below the orbits to visualise the  basilar artery  and its branches in AP/Towne's view. The rate of injection is 3 to 5 ml/sec, for a total of 8ml. The fluoroscope will be catching images at a rate of 2 to 4 frames per second. [ 8 ]   Posterior cerebral artery  (PCA) can be seen in AP view. [ 8 ]  The left vertebral artery is easier to cannulate than the right vertebral because of the straightforward anatomy of the left vertebral artery. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6160", "text": "Any activation of primary collateral system (ACOM and PCOM arteries) or secondary collateral system (pial-pial and leptomeningeal-dural) in case of occlusion of internal carotid artery should also be documented. [ 8 ] [ 17 ]  Leptomeningeal collaterals or pial collaterals are the small arterial connections that join the terminal branches of ACAs, MCAs, and PCAs on the surface of the brain. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6161", "text": "Manual compression or percutaneous closure device can be used to stop the bleeding from common femoral artery. Groin  haematoma  should be monitored during  intensive care unit  (ICU) monitoring. The puncture should be immobilised (to prevent movement) for 24 hours post puncture. [ 8 ]  Neurological examination should be performed and new neurological deficit should be documented. Significant neurological changes should be evaluated with MRI scan or a repeat cerebral angiography to rule out acute stroke or vessel dissection. Painkiller should be administered if there is any puncture site pain. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6162", "text": "The most common complication is groin haematoma which occurs in 4% of those affected. Neurologic complications such as  transient ischemic attack  in 2.5% of the cases. There is also the risk of stroke with permanent neurological defect in 0.1% of the cases and may lead to death in 0.06%. [ 8 ]  Rarely, 0.3 to 1% of the cases experience cortical blindness from 3 minutes to 12 hours after the procedure. It is a condition where those affected experienced loss of vision with normal  pupillary light reflex , and normal  extraocular muscles  movement. The condition can sometimes be accompanied by headaches, mental state changes, and memory losses. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6163", "text": "Some risk factors of complications are if the subject is having  subarachnoid haemorrhage , atherosclerotic cerebrovascular disease, frequent transient ischemic attacks, age more than 55 years, and poorly controlled diabetes. Besides, longer procedures, increased in number of catheter exchanges, and the use of larger size of catheters also increases the risk of complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6164", "text": "In 1896, E. Haschek and O.T. Lindenthal in Vienna, Austria, reported angiography of blood vessels by taking a series of X-rays after injecting a mixture of petroleum, quicklime, and mercuric sulfide into the hand of a cadaver. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6165", "text": "Cerebral angiography was first described by  Egas Moniz , a Portuguese physician and politician, in 1927. He performed this procedure on six patients. Two developed  Horner's syndrome  due to leaking of contrast material around the carotid artery, one developed temporary  aphasia , and another died due to thromboembolism to the anterior circulation of the brain. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6166", "text": "Prior to the 1970s the typical technique involved a needle puncture directly into the carotid artery, [ 21 ] [ 22 ]  as depicted in the 1973 horror film  The Exorcist , [ 23 ]  which was replaced by the current method of threading a catheter from a distant artery due to common complications caused by trauma to the artery at the puncture site in the neck (particularly hematomas of the neck, with possible compromission of the airway). [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6167", "text": "Cerebral salt-wasting syndrome  ( CSWS ), also written  cerebral salt wasting syndrome , is a  rare   endocrine condition  featuring a  low blood sodium concentration  and  dehydration  in response to injury (trauma) or the presence of tumors in or surrounding the  brain . In this condition, the kidney is functioning normally but excreting excessive sodium. [ 1 ]  The condition was initially described in 1950. [ 2 ]  Its cause and management remain controversial. [ 3 ] [ 4 ]  In the current literature across several fields, including  neurology ,  neurosurgery ,  nephrology , and  critical care medicine , there is controversy over whether CSWS is a distinct condition, or a special form of  syndrome of inappropriate antidiuretic hormone secretion (SIADH) . [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6168", "text": "Signs and symptoms of CSWS include  large amounts of urination  (polyuria, defined as over three liters of urine output over 24 hours in an adult), high amounts of sodium in the urine, low blood sodium concentration, [ 1 ]   excessive thirst  (polydipsia), extreme  salt  cravings,  dysfunction of the autonomic nervous system  (dysautonomia), and  dehydration .  Patients often self-medicate by consuming high amounts of sodium and by dramatically increasing their water intake. Advanced symptoms include  muscle cramps , lightheadedness, dizziness or  vertigo , feelings of anxiety or panic,  increased heart rate  or  slowed heart rate ,  low blood pressure  and  orthostatic hypotension  which can result in  fainting . [ 12 ]  Other symptoms frequently associated with dysautonomia include  headaches ,  pallor ,  malaise , facial flushing,  constipation  or  diarrhea ,  nausea ,  acid reflux , visual disturbances, numbness,  nerve  pain,  trouble breathing , chest pain, loss of consciousness, and  seizures . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6169", "text": "Although the pathophysiology of CSWS is not fully understood, it is usually caused by neurological injury, most commonly  aneurysmal   subarachnoid hemorrhage . [ 5 ]  It is also reported after surgery for pituitary tumor, acoustic neuroma,  calvarial  remodeling,  glioma  and with infections including  tuberculous meningitis ,  viral meningitis ,  metastatic carcinoma , and  cranial trauma . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6170", "text": "CSWS is a  diagnosis of exclusion  and may be difficult to distinguish from the  syndrome of inappropriate antidiuretic hormone  (SIADH), which develops under similar circumstances and also presents with hyponatremia. [ 1 ]  The main clinical difference is that of total fluid status of the patient: CSWS leads to a relative or overt  low blood volume [ 3 ]  whereas SIADH is consistent with a normal or high blood volume (due to water reabsorption via the V2 receptor). [ 1 ]  If blood-sodium levels increase when fluids are restricted, SIADH is more likely. [ 13 ]  Additionally, urine output is classically low in SIADH and elevated in CSWS. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6171", "text": "While CSWS usually appears within the first week after brain injury and spontaneously resolves in 2\u20134 weeks, it can sometimes last for months or years. In contrast to the use of fluid restriction to treat SIADH, CSWS is treated by replacing the urinary losses of water and sodium with hydration and sodium replacement. [ 1 ]  The  mineralocorticoid  medication  fludrocortisone  can also improve the low sodium level. [ 1 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6172", "text": "In 1858,  Claude Bernard  first raised the possibility of a direct relationship between the central nervous system and renal excretion of osmotically active solutes. He found that a unilateral lesion in the reticular substance at the floor of the fourth ventricle produced a diuresis of chloride, but not glucose. Bernard reproduced this syndrome through renal denervation. [ 15 ]  Through medullary lesioning in animals, Jungmann and Meyer from Germany induced polyuria and increased urinary salt excretion in 1913. Water intake restriction did not stop the polyuria, and salt continued to be excreted in the urine despite. [ 16 ]  In 1936, McCance defined the consequences of salt depletion in normal human. Patients with extra-renal salt losses complicated by hyponatremia were found to be common-place, and consistent with McCance's description, they excreted urine virtually free of sodium. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6173", "text": "Shortly after World War II, the  flame photometer  was developed. The availability of the flame photometer made clinical determinations of the serum sodium concentration possible. Berry, Barnes and Richardson shared the production of this new device to measure sodium and potassium in solution of biological materials by means of the flame photometer in 1945. [ 18 ] [ 19 ] [ 20 ]  Yale was one of the first medical centers to have that new device, the flame photometer, so some of the first published observations about hyponatremia came from Yale. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6174", "text": "Almost a century after the pioneering work of Bernard in animals, Peters et al., in 1950, reported three patients seen at Yale New Haven Hospital with hyponatremia associated with varying cerebral pathologies and severe dehydration. In each patient, urine sodium losses persisted despite hyponatremia and a high-salt diet. All three patients were unable to prevent urinary sodium loss despite low serum sodium levels and no evidence of extrarenal sodium loss. Their hyponatremia responded to salt therapy. They postulated that this provided evidence of an extra-pituitary cerebral structure mediating normal sodium metabolism but were unsure of its location or mechanism of action. A subsequent paper from the group at Yale attributed hyponatremia in neurologic disease to SIADH. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6175", "text": "The normal regulatory mechanism of renal adjustment of salt and water balance was better understood in 1950s. The responsibility for the maintenance of a normal volume and tonicity of the body fluids devolves on the kidneys. This modern concept of renal physiology described the transformation of a large volume of glomerular filtrate to a much smaller volume of bladder urine which has been altered. The proximal portion of renal tubule is largely responsible for the decrease in volume of the filtrate and, to less extent, for alterations in composition. However, it is in the distal tubule that induced fine adjustment of water and sodium balance. [ 23 ]  In 1953, Leaf et al., demonstrated that exogenous administration of the antidiuretic hormone vasopressin resulted in hyponatremia and a natriuresis dependent on water retention and weight gain. This was not \"salt wasting\"; it was a physiologic response to an expanded intravascular volume. Vasopressin-ADH administration to normal humans was shown to result in water retention and urinary loss of electrolytes (primarily sodium) in other studies at the time. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6176", "text": "The term \"cerebral salt wasting\" (CSW) was coined by Cort in 1954. The title of a paper by Cort describing a patient with a thalamic glioma resulting in hydrocephalus and raised intracranial pressure (although it is prudent to note that the earlier-described work by Peters, Welt and colleagues in 1950 was presented in a paper entitled \"A salt-wasting syndrome associated with cerebral disease\"). This patient was hyponatremic and clinically dehydrated with initial salt therapy not reversing this. Salt restriction resulted in ongoing natriuria. Recommencement of salt therapy subsequently increased serum sodium. Treatment with adrenocorticotropic hormone (ACTH) and deoxycortone acetate (having potent mineralocorticoid activity) had no effect. The author postulated an external influence on renal function not adrenal or pituitary in origin. Unfortunately, the patient died three and a half weeks later in \"circulatory failure with terminal shock\". At autopsy, the pituitary and adrenal glands were normal. Given Bernard's ability to create a chloride diuresis without glycosuria though renal denervation, Cort postulated the existence of a neuronal connection between the hypothalamus and proximal tubule of the kidney influencing electrolyte reabsorption. In all above-described cases, there was evidence of hyponatremia and dehydration. In the ensuing years, however, hyponatremia in cerebral pathology was described without clinical or laboratory evidence of dehydration. Renal and adrenal function appeared intact, but, unlike in the earlier case of \"cerebral salt wasting\" described by Cort, an increase in renal absorption and plasma concentration of sodium occurred with administration of ACTH and deoxycortone acetate. [ 25 ] [ 26 ]  A study on a 5-month-old female infant with diffuse cerebral damage and hyponatremia in 1957 suggested that on normal fluid intakes the child was unable to excrete solute-free water in a normal manner. This may represent the result of damage to the cerebral osmoreceptors as part of generalized brain damage. The data do not support the concept that the hyponatremia resulted from true salt-wasting, either cerebral or renal in mediation. If correction of such a state is desirable, the most useful therapeutic measure would appear to be limitation of the intake of fluid to slightly more than the amount needed to cover water expenditure from insensible losses, obligatory urine volume and growth requirements. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6177", "text": "The term \"cerebral hyponatremia\" was suggested in the work of Epstein, et al. 1961. Inappropriate release of endogenous vasopressin is probably responsible for hyponatremia in tuberculous meningitis. Inability to excrete water normally is also a feature of the salt wasting of certain hyponatremic patients with pulmonary tuberculosis. Similarly, it has been suggested that inappropriate release of vasopressin is the cause of hyponatremia and renal salt wasting in certain diseases, including bronchogenic carcinoma, cerebral injuries, and malformations. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6178", "text": "In 1981, Nelson et al. studied hyponatremia in neurosurgical patients, primarily subarachnoid hemorrhage, and found that isotopically measured blood volumes were contracted; he attributed this finding to cerebral salt wasting (CSW). Following these publications, the term \"CSW\" vanished from the literature for over two decades with hyponatremia in patients with cerebral pathology assumed to result from SIADH. Then, in 1981, a study of twelve neurosurgical patients mainly with SAH found ten to have decreased red blood cell mass, plasma volume, and total blood volume despite \"fulfilling laboratory criteria\" for SIADH. [ 29 ]  Other authors associated hyponatremia in subarachnoid hemorrhage with increased levels of natriuretic peptides, negative sodium balance, and low central venous pressure. [ 30 ] [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6179", "text": "A valid diagnosis of \"salt wasting\" requires evidence of inappropriate urinary salt losses and a reduced \"effective arterial blood volume\". Unfortunately, there is no gold standard to define inappropriate urinary sodium excretion. \"Effective arterial blood volume\" is a concept, not a measurable variable; in fact, we often define it clinically by looking at urine sodium excretion. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6180", "text": "William Schwartz  (1922\u20132009) attended Duke University after serving in the US Army in World War II. He observed that sulfanilamide increased excretion of sodium in patients with heart failure. This observation was the basis for the discovery and development of modern diuretic drugs.  Frederic Bartter  (1914\u20131983) worked on hormones affecting the kidney that led to the discovery of  syndrome of inappropriate antidiuretic hormone  (SIADH) in 1957 and Bartter syndrome in 1963. Schwartz-Bartter syndrome is named after these two scientists. The first reports of hyponatremia and renal sodium loss corrected by fluid restriction in patients with bronchogenic carcinoma were published by Bartter. At that time, no direct measurement of vasopressin was done. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6181", "text": "Clipping  is a  surgical procedure  performed to treat an  aneurysm . If the aneurysm is intracranial, a  craniotomy  is performed, and afterwards an  Elgiloy (Phynox)  or  titanium  Sugita clip is affixed around the aneurysm's neck. \nSurgical clipping was introduced by  Walter Dandy  of the  Johns Hopkins Hospital  in 1937. It consists of performing a  craniotomy , exposing the aneurysm, and closing the base of the aneurysm with a clip chosen specifically for the site. The surgical technique has been modified and improved over the years. Surgical clipping has a lower rate of aneurysm recurrence after treatment. Titanium Aneurysm Clips are being used to clip aneurysms and the procedure is known as aneurysm clipping. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6182", "text": "ROSA  is a medical robotic technology, designed to minimize invasiveness of surgeries of the  central nervous system . ROSA robots assist health professionals during surgical procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6183", "text": "The ROSA technology, developed by the French company  Zimmer Biomet Robotics , is used in 120 hospitals across Europe, North America, Asia and the Middle East. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6184", "text": "The device allows frameless  stereotactic procedures  increasing accuracy  [ 2 ]  and reducing operative time. [ 3 ] [ 4 ]  It is especially effective for  SEEG ,  DBS , endoscopic procedures, brain tumor resection and pediatric surgery. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6185", "text": "The ROSA device combines software for neurosurgical planning and navigation, with a robotic arm of high technology. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6186", "text": "The system was designed by  Zimmer Biomet Robotics  (Montpellier, France) and is currently used in Europe, North America, Asia and Australia. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6187", "text": "Cordotomy  (or  chordotomy ) is a surgical procedure that disables selected  pain -conducting tracts in the  spinal cord , in order to achieve loss of  pain  and  temperature   perception . This procedure is commonly performed on patients experiencing severe pain due to  cancer  or other incurable diseases. Anterolateral cordotomy is effective for relieving unilateral, somatic  pain  while bilateral cordotomies may be required for visceral or bilateral pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6188", "text": "Cordotomy is performed as for patients with severe intractable pain, usually but not always due to  cancer .  Being irreversible and relatively invasive, cordotomy is used exclusively for pain where treatment to level 3 of the  World Health Organization   pain ladder  (i.e., use of major opiates such as  morphine ) has proved inadequate. Cordotomy is especially indicated for pain due to  asbestos -related cancers such as  pleural  and  peritoneal mesothelioma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6189", "text": "Most cordotomies are now performed  percutaneously  with  fluoroscopic  or CT guidance while the patient is awake under  local anesthesia .  The  spinothalamic tract  is normally divided at the level C1-C2."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6190", "text": "Open cordotomy, which requires a  laminectomy  (removal of part of one or more vertebrae), takes place under  general anaesthetic  and has a longer recovery time and a higher risk of side-effects including permanent weakness.  However, it is still sometimes used where percutaneous cordotomy is unfeasible, especially in children or other patients who are unable to co-operate.  In open cordotomy, a  thoracic  approach is normally used so that the spinal cord tracts controlling the breathing muscles are not put at risk."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6191", "text": "Cordotomy can be highly effective in relieving pain, but there are significant side effects.  These include  dysesthesia  (abnormal sensation), [ 1 ]  urinary retention and (for bilateral cervical cordotomy) apnea during sleep ( acquired central hypoventilation syndrome ) caused by inadvertent division of the  reticulospinal tracts . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6192", "text": "Cordotomy was first performed in 1912 by the American Neurosurgeons, William Gibson Spiller (1863\u20131940) and Edward Martin (1859\u20131938). [ 3 ]   Due to the surgical risks, it remained a rare procedure until the percutaneous technique was developed in 1965. [ 4 ]   During the 1990s the procedure became less widely used, partly because medical pain-control options had improved, and partly due to concern about side-effects.  Nevertheless, it is still considered an effective treatment for severe pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6193", "text": "A number of alternative surgical procedures have evolved in the 20th century. These include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6194", "text": "Commissural myelotomy , for bilateral pain arising from pelvic or abdominal malignancies  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6195", "text": "Punctate  or  limited midline myelotomy  for pelvic and abdominal visceral pain, [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6196", "text": "Other options for medically intractable pain which do not involve open surgery include implantation of an  intrathecal  pump (a  syringe driver  delivering medication into the space around the spinal cord) administering  local anaesthetics  and/or  opiates [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6197", "text": "A  corpectomy   or  vertebrectomy  is a  surgical procedure  that involves removing all or part of the  vertebral body  ( Latin :  corpus vertebrae , hence the name corpectomy), usually as a way to decompress the  spinal cord  and nerves. Corpectomy is often performed in association with some form of  discectomy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6198", "text": "When the vertebral body has been removed, the surgeon performs a  vertebral fusion . Because a space in the column remains from the surgery, it must be filled using a block of bone taken from the  pelvis  or one of the leg bones or with a manufactured component such as a cage. This  bone graft  holds the remaining vertebrae apart. As it heals, the vertebrae grow together and  fuse . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6199", "text": "Auscultation , a  medical neurological procedure , can be performed upon the skull to check for intracranial  bruits . Such a bruit may be found in such conditions as cerebral angioma, tumour of the  glomus jugulare ,  intracranial aneurysm ,  meningioma , occlusion of the internal carotid artery, or  increased intracranial pressure . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6200", "text": "The following extract details a method of performing cranial auscultation:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6201", "text": "A bruit should be listened for, in quiet surroundings, over the skull and eyeballs, the latter situation being the most favourable for hearing the softest ones. The patient should be asked to close both eyes gently and the stethoscope firmly applied over one eye. During auscultation the other eye should be opened as in this way there is considerable diminution of eyelid flutter, which may cause confusion if rhythmical. Auscultation is then carried out over the other eye in a similar manner. If a murmur is not readily heard the patient should be asked to hold his breath. Finally auscultation should be carried out over the  temporal foss\u00e6  and  mastoid processes . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6202", "text": "The  CyberKnife  system is a  radiation therapy  device manufactured by  Accuray . The system is used to deliver  radiosurgery  for the treatment of  benign tumors ,  malignant tumors  and other medical conditions. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6203", "text": "The device consists of a small  linear accelerator  attached to a  robotic arm , along with an integrated  image guidance  system. During treatment, the image guidance system captures  3D images , tracks the movement of  tumors , and guides the robotic arm to accurately aim the treatment beam at the moving tumor. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6204", "text": "The system is designed for  stereotactic radiosurgery  (SRS) and stereotactic body  radiation therapy  (SBRT). The system is also used for select 3D conformal radiotherapy (3D-CRT) and  intensity modulated radiation therapy  (IMRT)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6205", "text": "The development of the system began in 1989 with contributions from  John R. Adler , a surgeon at  Stanford University , and Peter and Russell Schonberg of Schonberg Radiation Corporation. [ 3 ]  This work expanded upon earlier efforts in the 1980s to adapt standard  linear accelerators  for  radiosurgery . The inaugural CyberKnife system was installed at Stanford University in 1991, receiving clearance for clinical investigation by the  U.S. Food and Drug Administration  (FDA) in 1994. Following extensive  clinical research , the FDA granted approval for the treatment of  intracranial tumors  in 1999 and for  tumors  throughout the body in 2001. Subsequently, Accuray has introduced seven CyberKnife System models, including the CyberKnife G3 System (2005), CyberKnife G4 System (2007), CyberKnife VSI System (2009), CyberKnife M6 System (2012), and CyberKnife S7 System (2020)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6206", "text": "The system is used to treat  tumors  of the  pancreas ,  liver ,  prostate ,  spine , cancer of the  throat  and  brain , and  benign tumors ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6207", "text": "In neurosurgery,  Dandy's point  is a common entry point for  occipital   burr hole . Originally described by  Walter Dandy  in 1918 as a way to perform ventriculography via occipital approach. [ 1 ] [ 2 ]  It is located 2 centimetres (0.79\u00a0in) lateral to the  midline  and 3 centimetres (1.2\u00a0in) above the  inion . The catheter tip is directed toward a point 2\u00a0cm above the glabella and passed to a distance of 4 to 5\u00a0cm or until CSF is encountered. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6208", "text": "Decerebellate  rigidity is caused by a  lesion  in the  cerebellum . The function of the cerebellum is to coordinate  muscular  activity. Animals with decerebellate rigidity show  opisthotonus  with  thoracic limb  extension, flexion of the  pelvic limbs  rigidly extended.  Mentation  of decerebellate animals is generally adequate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6209", "text": "This article about a medical condition affecting the nervous system is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6210", "text": "Decerebration  is the elimination of cerebral brain function in an animal by removing the  cerebrum , cutting across the  brain stem , or severing certain arteries in the brain stem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6211", "text": "As a result, the animal loses certain reflexes that are integrated in different parts of the brain. Furthermore, the reflexes which are functional will be hyperreactive (and therefore very accentuated) due to the removal of inhibiting higher- brain centers (e.g. the facilitatory area of the  reticular formation  will not receive regulating input from  cerebellum ,  basal ganglia  and the  cortex )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6212", "text": "Decerebration describes the ligation along the neural axis in distinct parts of the brain in experimental animals. Generally:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6213", "text": "Lower decerebration results in a \"bulbospinal\" animal: reflexes which are integrated within the spinal cord and medulla oblongata are functional, reflexes integrated in midbrain and cortex are absent."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6214", "text": "With difference to decortication there is pontine transection, thus sparing of the VestibuloSpinal (VS) and ReticuloSpinal (RES). The involved tracts are the corticospinal and rubrospinal tract. Decerebration in humans tends to have a worse prognosis than decortication. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6215", "text": "The most obvious accentuation is seen in the tonic labyrinthine reflexes, the  otolithic organs  mediate input about the gravitational force exerted on the body and the labyrinthine reflex acts on the extensor muscles in order to resist this gravitational force. In an animal where the cortical areas or the midbrain have been \"cut off\" from the neural axis, this reflex is hyperactive and the animal will maximally extend all four limbs. This phenomenon is known as  decerebrate rigidity . In humans, true decerebrate rigidity is rare since the damage to the brain centers it might be caused by usually are lethal. However,  decorticate rigidity  can be caused by bleeding in the  internal capsule  which causes damage to  upper motor neurons . The symptoms of decorticate rigidity are flexion in the upper limbs and extension in the lower limbs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6216", "text": "A  discectomy  (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a  nerve root  or the  spinal cord . The procedure involves removing a portion of an  intervertebral disc , which causes pain, weakness or numbness by stressing the spinal cord or radiating nerves. The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances have produced visualization improvements to traditional discectomy procedures (e.g. microdiscectomy, an open discectomy using an external microscope typically done through a 1-inch or larger skin opening), or endoscopic discectomy (the scope passes internally and typically done through a 2\u00a0mm skin opening or larger, up to 12\u00a0mm). In conjunction with the traditional discectomy or microdiscectomy, a  laminotomy  is often involved to permit access to the intervertebral disc. Laminotomy means a significant amount of typically normal bone (the lamina) is removed from the vertebra, allowing the surgeon to better see and access the area of  disc herniation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6217", "text": "Small or ultra-small endoscopic discectomy (called Nano Endoscopic Discectomy) does not have internal cutting or bone removal and, due to the small size, is not called \"open\". These procedures do not cause post-laminectomy syndrome ( failed back syndrome ). [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6218", "text": "Microdiscectomy is a spine operation with a smaller incision than traditional discectomy, in which a portion of a herniated nucleus pulposus is removed by way of a surgical instrument, while using an external operating microscope for lighting and magnification. They may be \"open\", i.e., with a larger incision, or minimally invasive, i.e., with a 1.5 to 2.0\u00a0cm surgical incision. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6219", "text": "Microdiscectomy may be a surgical option for patients with a single-level  disc herniation  and evidence of nerve root compression with residual unremitting  radicular  symptoms after failed conservative treatment.  Cauda equina syndrome  and progressive or  new motor deficits  are among the urgent surgical indications for microdiscectomy. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6220", "text": "Contraindications  include additional pathologies, including infection, tumor, or segmental instability or vertebral fracture where fusion or instrumentation may be required. However, segmental instability and  spondylolisthesis  may be considered  relative contraindications  by some physicians. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6221", "text": "Degeneration caused by years of repetitive mechanical stress can cause the disc of an athlete to be herniated.  Lumbar disc herniation  (LDH) is a critical injury for elite athletes that could cause extreme pain and significantly hinder performance. To relieve the pain, athletes usually go through microdiscectomy. However, the results of treatments in elite athletes differ due to the demand for optimal treatment, short recovery period, and high performance after the operation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6222", "text": "Most athletes return to their pre-surgery level after a discectomy. A systematic review of 450 athletes shows that 75\u2013100% of athletes return to play after surgery. [ 5 ]  The average recovery period ranged from 2.8 to 8.7 months. Athletes recovered an average of 64.4% to 103.6% of their preoperative performance and had reported career longevity of 2.6 to 4.8 years post-return. [ 5 ] \nThere are unsuccessful cases of discectomy for certain athletes like  Tiger Woods , a world-famous PGA Tour golfer. Woods underwent three microdiscectomy procedures from 2014 to 2015 which failed to alleviate his pain. [ 6 ]  The removal of disc material due to discectomy meant that Woods eventually had to go through  spinal fusion  to recover."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6223", "text": "In the U.S., it has been estimated that the  Medicare  system spends over $300 million annually on lumbar discectomies. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6224", "text": "Howard Dully  (born November 30, 1948) is an American memoirist who is one of the youngest survivors of the  transorbital lobotomy , a procedure performed on him when he was 12 years old."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6225", "text": "Dully received international attention in 2005, following the broadcasting of his story on  National Public Radio . Subsequently, in 2007, he published a  New York Times  Best Seller  memoir ,  My Lobotomy , a story of the hardships of his lobotomy, co-authored by  Charles Fleming ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6226", "text": "Howard Dully was born on November 30, 1948, in  Oakland ,  California , the eldest son of Rodney and June Louise Pierce Dully. Following the death of his mother from  cancer  in 1954, Dully's father married single mother Shirley Lucille Hardin in 1955."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6227", "text": "Neurologist   Walter Freeman  had diagnosed Dully as suffering from childhood  schizophrenia  since age four, although numerous other medical and psychiatric professionals who had seen Dully did not detect a psychiatric disorder and instead blamed poor parenting by his stepmother. Freeman's notes stated that Dully's stepmother feared him, and that \"He doesn't react either to love or to punishment... He objects to going to bed but then sleeps well. He does a good deal of daydreaming and when asked about it he says 'I don't know.' He turns the room's lights on when there is broad sunlight outside.\" [ 1 ]  In 1960, at 12 years of age, Dully was submitted by his father and stepmother for a trans-orbital lobotomy, performed by Freeman for $200 (equivalent to $2,060 in 2023). [ 2 ]  During the procedure, a long, sharp instrument called an  orbitoclast  was inserted through each of Dully's eye sockets 7 centimeters (2.8\u00a0in) into his brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6228", "text": "Dully was institutionalized for years as a juvenile (in Agnews State Hospital as a minor); transferred to Rancho Linda School in San Jose, California, a school for children with behaviour-related problems;  incarcerated ; and was eventually  homeless  and an  alcoholic . After becoming  sober  and getting a college degree in  computer information systems , he became a California state certified behind-the-wheel instructor for a  school bus  company in  San Jose, California . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6229", "text": "In his 50s, with the assistance of  National Public Radio   producer   David Isay , Dully started to research what had happened to him as a child. By this time, both his stepmother and Freeman were dead, and due to the aftereffects of the surgery, he was unable to rely on his own memories. He travelled the country with Isay and Piya Kochhar, speaking with members of his family, relatives of other lobotomy patients, and relatives of Freeman, and also gaining access to Freeman's archives. Dully first relayed his story on a  National Public Radio  broadcast in 2005, prior to co-authoring a memoir published in 2007. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6230", "text": "On November 16, 2005, David Isay broadcast Dully's search as a Sound Portraits  documentary  on NPR. According to  USA Today , the documentary, which  The New York Times  describes as \"celebrated\", [ 5 ]  \"created a firestorm\". [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6231", "text": "The broadcast, aired on  All Things Considered , drew more listener response than any other program that had ever aired, [ citation needed ]  and by May 2006, the  Crown Publishing Group  had negotiated worldwide rights to publish Howard Dully's story in book form. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6232", "text": "In 2007, Dully published  My Lobotomy , a memoir co-authored by Charles Fleming."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6233", "text": "The memoir relates Howard Dully's experiences as a child, the effect of the procedure on his life, his efforts as an adult to discover why the medically unnecessary procedure was performed on him and the effect of the radio broadcast on his life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6234", "text": "The book was critically well received.  The New York Times  described it as \"harrowing\", \"one of the saddest stories you'll ever read\". [ 5 ]   USA Today  called it \"at once horrifying and inspiring\". [ 6 ]  The  San Francisco Chronicle  critiqued it as \"a gruesome but compulsively readable tale, ultimately redemptive\". [ 8 ]  In the United Kingdom,  The Observer  characterized the book as \"a forceful account of his survival\" that \"sheds light on the man who subjected him to one of the most brutal surgical procedures in medical history\". [ 9 ]   The Times  described it as \"uncomfortable reading\", noting that \"[i]t is, given the circumstances, astonishingly free of rancour.\" [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6235", "text": "In the last section of the memoir, entitled \"One Last Word\", Dully compared his  lobotomy  to young children today who are diagnosed with  depression ,  bipolar disorder  or  attention deficit hyperactivity disorder  without a second opinion, and are subsequently  overmedicated . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6236", "text": "The  dura mater , (or just  dura ) is the outermost of the three  meningeal membranes . The dura mater has two layers, an outer  periosteal layer  closely adhered to the  neurocranium , and an inner meningeal layer known as the  dural border cell layer . [ 1 ]  The two dural layers are for the most part fused together forming a  thick fibrous tissue  membrane that covers the brain and the  vertebrae  of the  spinal column . [ 2 ]  But the layers are separated at the  dural venous sinuses  to allow blood to drain from the brain. [ 3 ]  The dura covers the  arachnoid mater  and the  pia mater  the other two meninges in protecting the  central nervous system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6237", "text": "At major boundaries of brain regions such as the  longitudinal fissure  between the  hemispheres , and the  tentorium cerebelli  between the posterior brain and the cerebellum the dura separates, folds and invaginates to make the divisions. These folds are known as dural folds, or reflections. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6238", "text": "The dura mater is primarily derived from  neural crest cells , with postnatal contributions from the  paraxial mesoderm . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6239", "text": "The dura mater has several functions and layers. The dura mater is a membrane that envelops the  arachnoid mater . It surrounds and supports the  dural venous sinuses  that reabsorbs  cerebrospinal fluid  and carries the cerebral  venous return , back toward the heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6240", "text": "Cranial dura mater has two layers which include a superficial  periosteal  layer that is actually the inner  periosteum  of the  neurocranium  (the  calvarium  and  endocranium ); and a deep meningeal layer, which is the true dura mater. The dura mater covering the spinal cord is known as the  dural sac  or  thecal sac , and only has one layer (the meningeal layer) unlike cranial dura mater. The  potential space  between these two layers is known as the  epidural space , [ 5 ]  which can  accumulate blood  in the case of traumatic laceration to the  meningeal arteries ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6241", "text": "The dura separates into two layers at  dural reflections  (also known as  dural folds ), places where the inner dural layer is reflected as sheet-like protrusions into the cranial cavity. There are two main dural reflections:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6242", "text": "Two other dural infoldings are the cerebellar falx and the sellar diaphragm:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6243", "text": "This depends upon the area of the cranial cavity: in the anterior cranial fossa the anterior meningeal artery (branch from the ethmoidal artery) is responsible for blood supply, in the middle cranial fossa the middle meningeal artery and some accessory arteries are responsible for blood supply, the middle meningeal artery is a direct branch from the maxillary artery and enter the cranial cavity through the foramen spinosum and then divides into anterior (which runs usually in vertical direction across the pterion) and posterior (which runs posterosuperiorly) branches, while the accessory meningeal  arteries (which are branches from the maxillary artery) enter the skull through foramen ovale and supply area between the two foramina, and the in posterior cranial fossa the dura mater has numerous blood supply from different possible arteries:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6244", "text": "A. posterior meningeal  artery (from the ascending pharyngeal artery through the jugular foramen) \nB. meningeal arteries (from the ascending pharyngeal artery through hypoglossal canal) \nC. meningeal arteries (from occipital artery through jugular or mastoid foramen) \nD. meningeal arteries (from vertebral artery through foramen magnum)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6245", "text": "The two layers of dura mater run together throughout most of the skull. Where they separate, the gap between them is called a  dural venous sinus . These sinuses drain blood and  cerebrospinal fluid  (CSF) from the brain and empty into the  internal jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6246", "text": "Arachnoid villi , which are outgrowths of the  arachnoid mater  (the middle meningeal layer), extend into the dural venous sinuses to drain CSF. These villi act as one-way valves.\n Meningeal veins , which course through the dura mater, and  bridging veins , which drain the underlying neural tissue and puncture the dura mater, empty into these dural sinuses. A rupture of a bridging vein causes a  subdural hematoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6247", "text": "The supratentorial dura mater membrane is supplied by small meningeal branches of the  trigeminal nerve  (V1, V2 and V3). [ 8 ]  The innervation for the infratentorial dura mater are via upper cervical nerves and the  meningeal branch of the vagus nerve. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6248", "text": "Many medical conditions involve the dura mater. A  subdural hematoma  occurs when there is an abnormal collection of blood between the dura and the arachnoid, usually as a result of torn bridging veins secondary to head trauma. An  epidural hematoma  is a collection of blood between the dura and the inner surface of the skull, and is usually due to  arterial  bleeding.  Intradural procedures, such as removal of a  brain tumour  or treatment of  trigeminal neuralgia  via a  microvascular decompression , require that an incision is made to the dura mater. To achieve a watertight repair and avoid potential post-operative complications, the dura is typically closed with  sutures . If there is a dural deficiency, then a dural substitute may be used to replace this membrane.  Small gaps in the dura can be covered with a  surgical sealant film ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6249", "text": "In 2011, researchers discovered a connective tissue bridge from the  rectus capitis posterior major  to the cervical dura mater. Various clinical manifestations may be linked to this anatomical relationship such as  headaches ,  trigeminal neuralgia  and other symptoms that involved the cervical dura. [ 10 ]  The  rectus capitis posterior minor  has a similar attachment. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6250", "text": "The dura-muscular, dura-ligamentous connections in the upper cervical spine and occipital areas may provide anatomic and physiologic answers to the cause of the  cervicogenic headache . This proposal would further explain manipulation's efficacy in the treatment of cervicogenic headache. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6251", "text": "The American Red Cross and some other agencies accepting blood donations consider  dura mater transplants , along with receipt of pituitary-derived growth hormone, a risk factor due to concerns about  Creutzfeldt\u2013Jakob disease . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6252", "text": "Cerebellar tonsillar ectopia, or  Chiari malformation , is a condition that was previously thought to be congenital but can be induced by trauma, particularly whiplash trauma. [ 14 ]  Dural strain may be pulling the cerebellum inferiorly, or skull distortions may be pushing the brain inferiorly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6253", "text": "Dural ectasia  is the enlargement of the dura and is common in connective tissue disorders, such as  Marfan syndrome  and  Ehlers\u2013Danlos syndrome . These conditions are sometimes found in conjunction with Arnold\u2013Chiari malformation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6254", "text": "Spontaneous cerebrospinal fluid leak  is the fluid and pressure loss of spinal fluid due to holes in the dura mater."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6255", "text": "The name  dura mater  derives from the Latin for  tough mother (or hard mother) , [ 15 ]  a  loan translation  of Arabic  \u0623\u0645 \u0627\u0644\u062f\u0645\u0627\u063a \u0627\u0644\u0635\u0641\u064a\u0642\u0629  ( umm al-dim\u0101gh al-\u1e63af\u012bqah ), literally 'thick mother of the brain', matrix of the brain, [ 16 ] [ 17 ]  and is also referred to by the term \"pachymeninx\" (plural \"pachymeninges\"). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6256", "text": "Dural tear  is a tear occurring in the  dura mater  of the brain. It is usually caused as a result of trauma or as a complication following surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6257", "text": "In case of head injury, a dural tear is likely in case of a  depressed skull fracture . A  burr hole  is made through the normal skull near the fractured portion, and  Adson's elevator  is introduced. Underlying dura is separated carefully from the overlying depressed bone fragments. The dura that is now visible is carefully examined to exclude any dural tear. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6258", "text": "The whole extent of the dural tear is exposed by removing the overlying skull. The ragged edges of the tear are excised. However, care should be taken not to excise too much dura as it may increase the chances for spread of infection into the  subarachnoid space . Removing too much dura will also make it difficult to close the tear. If there is not much dural loss, interrupted sutures are made with non-absorbable material. In case of dural loss, the defect is closed using a transplant from fascia lata or pericranium given that there is not much contamination of the dura. In case of contamination, the defect is left alone and a primary suture is performed at a later date."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6259", "text": "If dural tear is associated with haemorrhage from dural vessels, they are coagulated using  diathermy . This technique is preferred because the vessels are too small to be picked up by an artery forceps. Large vessels, if present, can be under-run with suture. When the dural tear is associated with a dural sinus hemorrhage, a graft of  pericranium  is used for a small tear and a muscle graft from  temporalis  is used for a large tear. The muscle graft is flattened by hammering before using it for grafting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6260", "text": "If dural tear is associated with a brain injury, wide exposure of the wound is done to examine the extent of brain damage. All devitalized brain tissues are removed along with extravasated blood, foreign bodies and pieces of bone. All devitalized tissue and foreign bodies are removed by a combination of irrigation and suction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6261", "text": "Following dural repair, skull deficit is treated by using moulded tantalum plates or acrylic inlays, three to six months after the head injury. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6262", "text": "Eloquent cortex  is a name used by  neurologists  for areas of  cortex  that\u2014if removed\u2014will result in loss of  sensory  processing or linguistic ability, or  paralysis . The most common areas of eloquent cortex are in the left  temporal  and  frontal lobes  for  speech  and  language , bilateral  occipital lobes  for  vision , bilateral  parietal lobes  for  sensation , and bilateral  motor cortex  for movement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6263", "text": "Neuroimaging  techniques such as  magnetic resonance imaging ,  electroencephalography , or  magnetoencephalography  are especially useful non-invasive tools to locate eloquent cortices. [ 1 ]  Much higher spatial and temporal resolution maps of cortical activity can be achieved with a technique called  electrocorticography , however this requires placement of  subdural  electrodes on the surface of the brain and this must be done during surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6264", "text": "Endovascular coiling  is an  endovascular  treatment for  intracranial aneurysms  and  bleeding  throughout the body. The procedure reduces blood circulation to an aneurysm or blood vessel through the implantation of detachable platinum wires, with the clinician inserting one or more into the blood vessel or aneurysm until it is determined that blood flow is no longer occurring within the space. It is one of two main treatments for cerebral  aneurysms, the other being  surgical clipping ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6265", "text": "Endovascular coiling is typically used to treat  cerebral aneurysms . The main goal is prevention of rupture in unruptured aneurysms, and prevention of rebleeding in ruptured aneurysms by limiting blood circulation to the aneurysm space. Clinically, packing density is recommended to be 20-30% or more of the aneurysm's volume, typically requiring deployment of multiple wires. [ 1 ]  Higher volumes may be difficult due to the delicate nature of the aneurysm; intraoperative rupture rates are as high as 7.6% for this procedure. [ 2 ]  In ruptured aneurysms, coiling is performed quickly after rupture because of the high risk of rebleeding within the first few weeks after initial rupture. The patients most suitable for endovascular coiling are those with aneurysms with a small neck size (preferably <4\u00a0mm), luminal diameter <25\u00a0mm and those that are distinct from the parent vessel. [ 3 ]  Larger aneurysms are subject to compaction of coils, due to both looser packing densities (more coils are needed) and increased blood flow. Coil compaction renders them unsuitable as they are incapable of stemming blood flow. [ 4 ]  However, technological advances have made coiling of many other aneurysms possible as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6266", "text": "A number of studies have questioned the efficacy of endovascular coiling over the more traditional surgical clipping. Most concerns involve the chance of later bleeds or other recanalization. [ 5 ] [ 6 ] [ 7 ]  Due to its less invasive nature, endovascular coiling usually presents faster recovery times than surgical clipping, with one study finding a significant decrease in probability of death or dependency compared to a neurosurgical population. [ 8 ]  Complication rates for coiling as well are generally found to be lower than microsurgery (11.7% and 17.6% for coiling and microsurgery, respectively). Despite this, intraoperative rupture rates for coiling have been documented as being as high as 7.6%. [ 2 ]  Clinical results are found to be similar at a two-month and one year follow-up between coiling and neurosurgery. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6267", "text": "Reported recurrence rates are quite varied, with rates between 20 and 50% of aneurysms recurring within one year of coiling, and with the recurrence rate increasing with time. [ 2 ] [ 10 ]  These results are similar to those previously reported by other endovascular groups. [ 11 ]  Other studies have questioned whether new matrix coils work better than bare platinum coils. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6268", "text": "The  International Subarachnoid Aneurysm Trial  tested the efficacy of endovascular coiling against the traditional micro-surgical clipping. The study initially found very favorable results for coiling, however its results and methodology were criticized. Since the study's release in 2002, and again in 2005, some studies have found higher recurrence rates with coiling, while others have concluded that there is no clear consensus between which procedure is preferred. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6269", "text": "Risks of endovascular coiling include  stroke , aneurysm rupture during the procedure and aneurysm recurrence and rupture after the procedure. [ 3 ]  Additionally in some patients coiling may not be successful. In general, coiling is only performed when the risk of aneurysm rupture is higher than the risks of the procedure itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6270", "text": "Similar to patients who experience neurosurgical procedures, coiling results in an increase in resting energy expenditure, albeit at a slightly reduced rate than their neurosurgery counterpart. This can lead to malnutrition if steps are not taken to compensate for the increased metabolic rate. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6271", "text": "The treatment works by promoting blood clotting ( thrombosis ) in the aneurysm, eventually sealing it from the blood flow. This is accomplished by decreasing the amount of blood flow going into the aneurysm, increasing the residence time of the blood (thereby lowering the velocity) in the aneurysm space and reducing the  wall shear stress  of the aneurysm wall. This change in the blood flow, or  hemodynamics , is ultimately dependent on several factors, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6272", "text": "While these factors are crucial to the success of the procedure, thrombosis ultimately is dependent on biological processes, with the coiling only providing the appropriate conditions for the process to occur, and hopefully closing the aneurysm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6273", "text": "Endovascular coiling is usually performed by an  interventional neuroradiologist  or neurosurgeon with the patient under general anaesthesia. The whole procedure is performed under  fluoroscopic imaging  guidance. A guiding catheter is inserted through the femoral artery and advanced to a site close to the aneurysm after which angiography is performed to localize and assess the aneurysm. After this, a microcatheter is navigated into the aneurysm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6274", "text": "The treatment uses detachable coils made of platinum that are inserted into the aneurysm using the microcatheter. A variety of coils are available, including Guglielmi Detachable Coils (GDC) which are platinum, Matrix coils which are coated with a biopolymer, and hydrogel coated coils. Coils are also available in a variety of diameters, lengths, and cross sections. [ 16 ]  A coil is first inserted along the aneurysm wall to create a frame, with the core then being filled with more coils. [ 17 ]  A series of progressively smaller coils may also be used. Success is determined by injecting a contrast dye into parent artery and qualitatively determining if dye is flowing into the aneurysm space during fluoroscopy. If no flow is observed, the procedure is considered completed. [ 2 ]  In the case of wide-necked aneurysms a  stent  may be used. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6275", "text": "Endovascular coiling was a developed through the synthesis of a number of innovations that took place between 1970 and 1990 in the field of electronics, neurosurgery, and  interventional radiology . [ 4 ]  While the procedure itself has been and continues to be compared to surgical clipping, the development of the concept and procedure has resulted in it becoming the gold standard at many centers. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6276", "text": "The first documented technique of using metal coils to induce thrombosis was accomplished by Mullan in 1974. Copper coils were inserted into a giant aneurysm through externally puncturing the aneurysm wall via craniotomy. Five patients died, with ten having satisfactory process. [ 19 ]  It did not gain popularity due to the specialized equipment required, in addition to the technique being unsuitable for many types of aneurysms. [ 4 ]  Later, in 1980, similar techniques were developed by Alksne and Smith using iron suspended in  methyl methacrylate  in a limited set of patients. There were no deaths in 22 consecutive cases with low morbidity. [ 20 ]  This technique also did not gain traction due to advances in clipping. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6277", "text": "As a means of avoiding invasive methods, early endovascular interventions involved the usage of detachable and nondetachable  balloon catheters  to occlude the aneurysm while preserving the  parent artery . [ 21 ]  Despite the innovative approach, the aneurysms were often found to adapt to the shape of the balloon itself resulting in higher incidents of aneurysm rupture. This procedure was deemed \"uncontrollable\" due to its high morbidity and mortality rate, but it demonstrated that the endovascular approach was feasible for many aneurysms. [ 4 ]  Endovascular coils would later be used in 1989 by Hilal et al., but these were short, stiff coils that offered no control, preventing dense packing of the aneurysm. [ 22 ]  Controllable microguidewire systems were later used. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6278", "text": "In 1983 the use of electrically induced thrombosis for intracranial aneurysms was described for the first time. [ 23 ]  A stainless steel electrode  supplied a positive current to the aneurysm to stimulate electrothrombosis. Minimal occlusion was achieved, but the researchers discovered that the erosion of the electrode due to  electrolysis  would be useful as a detachment system. [ 4 ]  Detachable coils were constructed from a platinum coil soldered to a stainless steel delivery wire, first described in 1991 by Guglielmi et al. [ 3 ]  When combined with a controllable microguide wire system, multiple coils could be inserted to fully pack an aneurysm. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6279", "text": "Given the complexity of modeling the vasculature, much research has been devoted towards modeling the hemodynamics of an aneurysm before and after an intervention. Techniques such as  particle image velocimetry  (PIV) and  computational fluid dynamics / finite element analysis  (CFD/FEA) have yielded results that have influenced the direction of research, but no model to date has been able to account for all factors present. [ 2 ] [ 24 ] [ 25 ]  Advantages of the  in-silico  research method include flexibility of selecting variables, but one comparative study has found that simulations tend to over-emphasis results compared to PIV, and are more beneficial for trends than exact values. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6280", "text": "Medical images, particularly  CT angiography , can be used to generate 3D reconstructions of patient specific anatomy. When combined with CFD/FEA, hemodynamics can be estimated in patient specific simulations, giving the clinician greater predictive tools for surgical planning and outcome evaluation to best promote thrombus formation. [ 26 ] [ 27 ]  However, most computer models use many assumptions for simplicity, including rigid walls (non-elastic) for vasculature, substituting a porous medium in place of physical coil representations, and  navier-stokes  for fluid behavior. However, new predictive models are being developed as computational power increases, including algorithms for simulations of coil behavior in-vivo. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6281", "text": "An  external ventricular drain  ( EVD ), also known as a  ventriculostomy  or  extraventricular drain , is a device used in  neurosurgery  to treat  hydrocephalus  and relieve elevated  intracranial pressure  when the normal flow of  cerebrospinal fluid  (CSF) inside the  brain  is obstructed. An EVD is a flexible plastic catheter placed by a  neurosurgeon  or  neurointensivist  and managed by  intensive care unit  (ICU) physicians and nurses. The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of  intracranial pressure . An EVD must be placed in a center with full neurosurgical capabilities, because immediate neurosurgical intervention can be needed if a complication of EVD placement, such as bleeding, is encountered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6282", "text": "EVDs are a short-term solution to hydrocephalus, and if the underlying hydrocephalus does not eventually resolve, it may be necessary to convert the EVD to a  cerebral shunt , which is a fully internalized, long-term treatment for hydrocephalus. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6283", "text": "The EVD catheter is most frequently placed by way of a twist-drill craniostomy placed at  Kocher's point , a location in the  frontal bone  of the skull, with the goal of placing the catheter tip in the frontal horn of the  lateral ventricle  or in the  third ventricle . [ 2 ] [ 3 ]  The catheter is typically inserted on the right side of the brain, but in some cases a left-sided approach is used, and in other situations catheters are needed on both sides. [ 3 ]  EVDs can be used to monitor intracranial pressure in patients with  traumatic brain injury  (TBI), [ 4 ]   subarachnoid hemorrhage  (SAH), [ 5 ]   intracerebral hemorrhage  (ICH), or other brain abnormalities that lead to increased CSF build-up. In draining the ventricle, the EVD can also remove blood products from the ventricular spaces. This is important because blood is an irritant to brain tissue and can cause complications such as  vasospasm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6284", "text": "The EVD is leveled to a common reference point that corresponds to the skull base, usually the  tragus  or  external auditory meatus . The EVD is set to drain into a closed, graduated burette at a height corresponding to a particular pressure level, as prescribed by a healthcare professional, usually a  neurosurgeon  or  neurointensivist . Leveling the EVD to a set pressure level is the basis for  cerebrospinal fluid  (CSF) drainage;  hydrostatic pressure  dictates CSF drainage. The fluid column pressure must be greater than the weight of the CSF in the system before drainage occurs. It is therefore important that family members and visitors understand the patient's head of bed position cannot be changed without assistance. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6285", "text": "An example of a healthcare provider order regarding an EVD is: set EVD to drain CSF for ICP > 15 mm Hg, check and record cerebrospinal fluid drainage and  intracranial pressure  at least hourly. Continuous CSF drainage is associated with a higher risk of complications. [ 7 ]  The  cerebral perfusion pressure  (CPP) can be calculated from data obtained from the EVD and systemic blood pressure. In order to calculate the CPP the  intracranial pressure  and  mean arterial pressure  (MAP) must be available. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6286", "text": "C \n P \n P \n = \n M \n A \n P \n \u2212 \n I \n C \n P \n \n \n {\\displaystyle CPP=MAP-ICP}"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6287", "text": "Other areas that should be monitored are: signs and symptoms of intracranial hypertension, looking for any leaks in the EVD system to prevent infection from entering the brain, and changes in the amount and color of the CSF. A sudden increase in hourly output of CSF may indicate intracranial hypertension, bloody CSF may indicate recurrent aneurysm rupture, and cloudy CSF may indicate brain infection. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6288", "text": "EVD placement is an invasive procedure. It is associated with several potential complications:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6289", "text": "Bleeding can occur along the EVD insertion tract or in the several layers of the meninges that prohibit passage into the brain. If drilling or dural puncture is not successful, the surgeon may dissect away dura and create a secondary bleed known as an epidural or subdural hemorrhage. Bleeding from EVD placement can be life-threatening and can require neurosurgical intervention in some cases. The risk of hemorrhage with EVD placement is increased if the patient suffers from  coagulopathy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6290", "text": "Mechanical complications from EVD placement can be categorized into:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6291", "text": "Malplacement of the EVD tube into the brain tissue instead of ventricles can occur in 10 to 40% of the cases. Therefore, computed tomography (CT), ultrasound, endoscopy, and stereotactic neuronavigation are used to minimize placement errors of EVD tubes. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6292", "text": "Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians or nurses may have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6293", "text": "After EVD placement, the drain is tunneled subcutaneously and secured with  surgical sutures  and/or  surgical staples . However, it is possible for the EVD to dislodge or migrate. This will cause the tip of the drain to migrate away from its intended position and provide inaccurate ICP measurement or lead to occlusion of the drain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6294", "text": "The EVD is a foreign body inserted into the brain, and as such it represents a potential portal for serious infection. Historically, the rate of infections associated with EVDs has been very high, ranging from 5% to > 20%. [ 10 ] [ 11 ]  Infections associated with EVDs can progress to become a severe form of brain infection known as  ventriculitis . Protocols designed to reduce the rate of EVD infections have been successful, applying  infection control  'bundle' approaches to reduce the rate of infection to well less than 1%. [ 12 ] [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6295", "text": "Although neurological deficits from passing the EVD catheter across the brain are uncommon, there can be an association of a patient's poor neurological status with EVD malplacement. [ 15 ]  In one report, the EVD was inserted too deeply into the fourth ventricle; the authors hypothesized that the patient's coma was due to irritation of the  recticular activating system . The patient's level of consciousness improved after the EVD was adjusted. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6296", "text": "Facetectomy  is a  surgical procedure  which involves  decompression  of a  spinal nerve root . For example, it can be performed in severely resistant cases of  cervical rhizalgia , where the cervical nerve roots within the  intervertebral foramina  are decompressed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6297", "text": "Failed Back Syndrome  ( abbreviated  as  FBS )  is a  condition  characterized by  chronic pain  following  back surgeries . [ 1 ] [ 2 ]  The term \"post-laminectomy syndrome\" is sometimes used by doctors to indicate the same condition as failed back syndrome. [ 3 ]  Many factors can contribute to the onset or development of FBS, including residual or recurrent  spinal disc herniation , persistent  post-operative  pressure on a  spinal nerve , altered joint mobility,  joint hypermobility  with instability, scar tissue ( fibrosis ),  depression ,  anxiety ,  sleeplessness ,  spinal  muscular  deconditioning  and  Cutibacterium acnes  infection. [ 4 ]   An individual may be predisposed to the development of FBS due to  systemic disorders  such as  diabetes ,  autoimmune disease  and  peripheral blood vessels (vascular) disease ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6298", "text": "Common symptoms of Failed Back Surgery Syndrome (FBS) include diffuse, dull, and aching pain in the back or legs, often accompanied by abnormal sensations such as sharp, pricking, or stabbing pain in the extremities. [ 5 ]  Patients may also experience pain at a different level from the location originally treated, along with an inability to fully recuperate and restricted mobility. Sharp, stabbing pain in the back, numbness, back spasms, or pain radiating from the lower back into the legs are frequently reported. In addition to physical discomfort, FBS can lead to psychological symptoms such as anxiety, depression, and  insomnia . Some individuals may develop a dependence on pain medication due to  chronic pain . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6299", "text": "The number of  spinal surgeries  varies around the world. The  United States  and the  Netherlands  report the highest number of spinal surgeries, while the  United Kingdom  and  Sweden  report the fewest. Recently, there have been calls for more aggressive surgical treatment in  Europe . Success rates of spinal surgery vary for many reasons. [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6300", "text": "Patients who have undergone one or more operations on the  lumbar spine  and continue to experience pain afterwards can be divided into two groups."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6301", "text": "In 1992, Turner  et al.  published a survey of 74 journal articles which reported the results after decompression for  spinal stenosis .  Good to excellent results were on average reported by 64% of the patients.  There was, however, a wide variation in outcomes reported.  There was a better result in patients who had a degenerative  spondylolisthesis . [ 13 ]  A similarly designed study by Mardjekto et al. found that a concomitant spinal  arthrodesis  (fusion) had a greater success rate. [ 14 ]  Herron and Trippi evaluated 24 patients, all with degenerative  spondylolisthesis  treated with  laminectomy  alone.  At follow-up varying between 18 and 71 months after surgery, 20 out of the 24 patients reported a good result. [ 15 ]   Epstein  reported on 290 patients treated over a 25-year period.  Excellent results were obtained in 69% and good results in 13%. [ 16 ]   These optimistic reports do not correlate with \"return to competitive employment\" rates, which for the most part are dismal in most spinal surgery series. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6302", "text": "In the past two decades there has been a dramatic increase in  fusion surgery  in the U.S.: in 2001 over 122,000 lumbar fusions were performed, a 22% increase from 1990 in fusions per 100,000 population, increasing to an estimate of 250,000 in 2003, and 500,000 in 2006. [ 17 ] [ 18 ] [ 19 ]  In 2003, the national bill for the hardware for fusion alone was estimated to have soared to $2.5 billion a year. [ 18 ] [ 20 ] \nFor patients with continued  pain after surgery  which is not due to the above complications or conditions,  interventional pain physicians  speak of the need to identify the \"pain generator\" i.e. the anatomical structure responsible for the patient's pain. To be effective, the surgeon must operate on the correct  anatomic structure , but is often not possible to determine the source of the pain. [ 21 ] [ 22 ]  The reason for this is that many patients with  chronic pain  often have disc bulges at multiple spinal levels and the physical examination and imaging studies are unable to pinpoint the source of pain. [ 21 ]  In addition,  spinal fusion  itself, particularly if more than one spinal level is operated on, may result in \"adjacent segment degeneration\". [ 23 ]   This is thought to occur because the fused segments may result in increased  torsional  and  stress forces  being transmitted to the  intervertebral discs  located above and below the fused  vertebrae . [ 23 ]  This pathology is one reason behind the development of artificial discs as a possible alternative to fusion surgery.  But fusion surgeons argue that  spinal fusion  is more time-tested, and artificial discs contain metal hardware that is unlikely to last as long as biological material without shattering and leaving metal fragments in the spinal canal. These represent different  schools of thought . (See discussion on disc replacement infra.) [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6303", "text": "Another highly relevant consideration is the increasing recognition of the importance of \" chemical radiculitis \" in the generation of  back pain . [ 24 ]   A primary focus of surgery is to remove \"pressure\" or reduce mechanical compression on a  neural  element: either the  spinal cord , or a  nerve root . But it is increasingly recognized that  back pain , rather than being solely due to compression, may instead entirely be due to chemical  inflammation of the nerve root.   It has been known for several decades that disc herniations result in a massive inflammation of the associated nerve root. [ 24 ] [ 25 ] [ 26 ] [ 27 ]  In the past five years increasing evidence has pointed to a specific inflammatory mediator of this pain. [ 28 ] [ 29 ]   This inflammatory molecule, called  tumor necrosis factor-alpha  (TNF), is released not only by the herniated or protruding disc, but also in cases of disc tear (annular tear), by facet joints, and in  spinal stenosis . [ 24 ] [ 30 ] [ 31 ] [ 32 ]  In addition to causing pain and inflammation, TNF may also contribute to  disc degeneration . [ 33 ]  If the cause of the pain is not compression, but rather is inflammation mediated by TNF, then this may well explain why surgery might not relieve the pain, and might even exacerbate it, resulting in FBS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6304", "text": "A 2005 review by Cohen concluded, 'The SI joint is a real yet underappreciated pain generator in an estimated 15% to 25% of patients with axial LBP'. [ 34 ]  Studies by Ha, et al., show that the incidence of SI joint degeneration in post-lumbar fusion surgery is 75% at 5 years post-surgery, based on imaging. [ 35 ]  Studies by DePalma and Liliang, et al., demonstrate that 40\u201361% of post-lumbar fusion patients were symptomatic for  SI joint dysfunction  based on diagnostic blocks. [ 36 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6305", "text": "Recent studies have shown that  cigarette smokers  will routinely fail all spinal surgery, if the goal of that surgery is the decrease of pain and impairment.  Many surgeons consider smoking to be an absolute  contraindication  to spinal surgery.   Nicotine  appears to interfere with bone metabolism through induced  calcitonin  resistance and decreased  osteoblastic  function.  It may also restrict small blood vessel diameter leading to increased scar formation. [ 38 ] [ 39 ] [ 40 ] [ 41 ] [ 42 ] [ 43 ] [ 44 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6306", "text": "There is an association between  cigarette smoking ,  back pain  and  chronic pain syndromes  of all types. [ 45 ] [ 46 ] [ 39 ] [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6307", "text": "In a report of 426 spinal surgery patients in  Denmark , smoking was shown to have a negative effect on fusion and overall patient satisfaction, but no measurable influence on the functional outcome. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6308", "text": "There is a validation of the hypothetical assumption that postoperative  smoking cessation  helps to reverse the impact of cigarette smoking on outcome after spinal fusion.  If patients cease cigarette smoking in the immediate post operative period, there is a positive impact on success. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6309", "text": "Regular  smoking in adolescence  was associated with low back pain in  young adults . Pack-years of smoking showed an exposure-response relationship among girls. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6310", "text": "A recent study suggested that cigarette smoking adversely affects serum  hydrocodone  levels. Prescribing physicians should be aware that in some cigarette smokers, serum hydrocodone levels might not be detectable. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6311", "text": "In a study from Denmark reviewing many reports in the literature, it was concluded that smoking should be considered a weak risk indicator and not a cause of low back pain. In a multitude of  epidemiologic  studies, an association between smoking and low back pain has been reported, but variations in approach and study results make this literature difficult to reconcile. [ 53 ]  In a massive study of 3482 patients undergoing lumbar spine surgery from the National Spine Network, co-morbidities of (1) smoking, (2) compensation, (3) self reported poor overall health and (4) pre-existing psychological factors were predictive in a high risk of failure. Followup was carried out at 3 months and one year after surgery. Pre-operative depressive disorders tended not to do well. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6312", "text": "Smoking has been shown to increase the incidence of post operative infection as well as decrease fusion rates. One study showed 90% of post operative infections occurred in smokers, as well as  myonecrosis  (muscle destruction) around the  wound . [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6313", "text": "Before the advent of CT scanning, the pathology in failed back syndrome was difficult to understand.  Computerized tomography  in conjunction with  metrizamide   myelography  in the late 1960s and 1970s allowed direct observation of the mechanisms involved in post operative failures. Six distinct pathological conditions were identified: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6314", "text": "Removal of a disc at one level can lead to  disc herniation  at a different level at a later time.  Even the most complete  surgical excision  of the disc still leaves 30\u201340% of the disc, which cannot be safely removed. This retained disc can re-herniate sometime after surgery. Virtually every major structure in the abdomen and the posterior  retroperitoneal space  has been injured, at some point, by removing discs using posterior  laminectomy / discectomy  surgical procedures. The most prominent of these is a laceration of the  left internal iliac vein , which lies in close proximity to the anterior portion of the disc. [ 57 ] [ 58 ]  In some studies, recurrent pain in the same radicular pattern or a different pattern can be as high as 50% after disc surgery. [ 59 ] [ 60 ]    Many observers have noted that the most common cause of a failed back syndrome (FBS) is caused from recurrent disc herniation at the same level originally operated. A rapid removal in a second surgery can be curative. The clinical picture of a recurrent disc herniation usually involves a significant pain-free interval.  However, physical findings may be lacking, and a good history is necessary. [ 61 ] [ 62 ] [ 63 ] [ 64 ]  The time period for the emergence of new symptoms can be short or long.  Diagnostic signs  such as the  straight leg raise  test may be negative even if real  pathology  is present. [ 60 ] [ 65 ]  The presence of a  positive myelogram  may represent a new disc herniation, but can also be indicative of a post operative scarring situation simply mimicking a new disc. Newer  MRI  imaging techniques have clarified this dilemma somewhat. [ 61 ] [ 62 ] [ 66 ] [ 67 ] [ 68 ]  Conversely, a recurrent disc can be difficult to detect in the presence of post op scarring.  Myelography  is inadequate to completely evaluate the patient for recurrent disc disease, and  CT  or MRI scanning is necessary.  Measurement of  tissue density  can be helpful. [ 11 ] [ 66 ] [ 69 ] [ 70 ] [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6315", "text": "Even though the complications of  laminectomy  for disc herniation can be significant, a recent series of studies involving thousands of patients published under auspices of  Dartmouth Medical School  concluded at four-year follow-up that those who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6316", "text": "Spinal stenosis  can be a late complication after  laminectomy  for disc herniation or when surgery was performed for the primary pathological condition of  spinal stenosis . [ 11 ] [ 73 ] [ 74 ]  In the Maine Study, among patients with  lumbar spinal stenosis  completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or non-surgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6317", "text": "A large study of  spinal stenosis  from Finland found the  prognostic factors  for ability to work after surgery were ability to work before surgery, age under 50 years, and no prior back surgery. The very long-term outcome (mean follow-up time of 12.4 years) was excellent-to-good in 68% of patients (59% women and 73% men). Furthermore, in the longitudinal follow-up, the result improved between 1985  and 1991. No special complications were manifested during this very long-term follow-up time. The patients with total or subtotal block in preoperative  myelography  achieved the best result.  Furthermore, patients with block stenosis improved their result significantly in the longitudinal follow-up. The postoperative stenosis seen in  computed tomography  (CT)  scans  was observed in 65% of 90 patients, and it was severe in 23 patients (25%). However, this successful or unsuccessful  surgical decompression  did not correlate with patients' subjective  disability , walking capacity or  severity of pain . Previous back surgery had a strong worsening effect on surgical results. This effect was very clear in patients with total block in the preoperative  myelography . The surgical result of a patient with previous back surgery was similar to that of a patient without previous back surgery when the time interval between the last two operations was more than 18 months. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6318", "text": "Post-operative MRI findings of  stenosis  are probably of limited value compared to symptoms experienced by patients. Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on post-operation  magnetic resonance imaging . Degenerative findings had a greater effect on patients' walking capacity than stenotic findings. [ 77 ] [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6319", "text": "Postoperative radiologic stenosis was very common in patients operated on for  lumbar spinal stenosis , but this did not correlate with  clinical outcome . The clinician must be cautious when reconciling clinical symptoms and signs with postoperative  computed tomography  findings in patients operated on for lumbar spinal stenosis. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6320", "text": "A study from  Georgetown University  reported on one-hundred patients who had undergone  decompressive surgery  for lumbar stenosis between 1980 and 1985.  Four patients with post-fusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The mean age was 67 years, and 80% were over 60 years of age. There was a high incidence of coexisting medical diseases, but the principal disability was lumbar stenosis with neurological involvement.  Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures. By 5 years this number had reached 27% of the available population pool, suggesting that the failure rate could reach 50% within the projected  life expectancies  of most patients. Of the 26 failures, 16 were secondary to renewed neurological involvement, which occurred at new levels of stenosis in eight and recurrence of stenosis at operative levels in eight. Reoperation was successful in 12 of these 16 patients, but two required a third operation. The incidence of  spondylolisthesis  at 5 years was higher in the surgical failures (12 of 26 patients) than in the surgical successes (16 of 64). Spondylolisthetic  stenosis  tended to recur within a few years following decompression.  Because of  age and associated illnesses , fusion may be difficult to achieve in this group. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6321", "text": "A small minority of lumbar surgical patients will develop a post operative infection. In most cases, this is a bad complication and does not bode well for eventual improvement or future employability.  Reports from the surgical literature indicate an infection rate anywhere from 0% to almost 12%. [ 81 ] [ 82 ] [ 83 ] [ 84 ] [ 85 ] [ 86 ] [ 87 ] [ 88 ] [ 89 ] [ 90 ] [ 91 ] [ 92 ] [ 93 ] [ 94 ] [ 95 ] [ 96 ] [ excessive citations ]  The  incidence of infection  tends to increase as the complexity of the procedure and operating time increase.  Usage of  metal implants  (instrumentation) tends to increase the risk of infection.  Factors associated with an increased infection include  diabetes mellitus ,  obesity ,  malnutrition ,  smoking , previous infection,  rheumatoid arthritis , and  immunodeficiency . [ 97 ] [ 98 ] [ 99 ] [ 100 ] [ 101 ] [ 102 ] [ excessive citations ]  Previous wound infection should be considered as a contraindication to any further spinal surgery, since the likelihood of improving such patients with more surgery is small. [ 103 ] [ 104 ] [ 105 ] [ 106 ] [ 107 ] [ 108 ]   Antimicrobial prophylaxis  reduces the rate of surgical site infection in lumbar spine surgery, but a great deal of variation exists regarding its use. In a Japanese study, utilizing the  Centers for Disease Control  recommendations for antibiotic prophylaxis, an overall rate of 0.7% infection was noted, with a single dose antibiotic group having 0.4% infection rate and multiple dosage antibiotic infection rate of 0.8%. The authors had previously used  prophylactic antibiotics  for 5 to 7 postoperative days. Based on the  Centers for Disease Control and Prevention  (CDC) guideline, their antibiotic prophylaxis was changed to the day of surgery only. It was concluded there was no statistical difference in the rate of infection between the two different antibiotic protocols. Based on the  CDC  guideline, a single dose of prophylactic antibiotic was proven to be efficacious for the prevention of infection in  lumbar spine  surgeries. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6322", "text": "Epidural scarring following a  laminectomy  for disc excision is a common feature when re-operating for recurrent  sciatica  or  radiculopathy . [ 61 ]  When the scarring is associated with a  disc herniation  and/or recurrent  spinal stenosis , it is relatively common, occurring in more than 60% of cases. For a time, it was theorized that placing a  fat graft  over the dural could prevent post operative scarring.  However, initial enthusiasm has waned in recent years. [ 110 ] [ 111 ] [ 112 ] [ 113 ] [ 114 ]  In an extensive  laminectomy  involving 2 or more  vertebra , post operative scarring is the norm.  It is most often seen around the  L5  and  S1 nerve roots . [ 115 ] [ 116 ] [ 117 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6323", "text": "Fibrous scarring can also be a complication within the  subarachnoid  space.  It is notoriously difficult to detect and evaluate.  Prior to the development of  magnetic resonance imaging , the only way to ascertain the presence of  arachnoiditis  was by opening the  dura . In the days of  CT  scanning and  Pantopaque  and later,  Metrizamide   myelography , the presence of  arachnoiditis  could be speculated based on  radiographic  findings.  Often,  myelography  prior to the introduction of  Metrizamide  was the cause of  arachnoiditis .   It can also be caused by the long term pressure brought about with either a severe  disc herniation  or  spinal stenosis . [ 62 ] [ 61 ] [ 118 ] [ 119 ] [ 64 ]   The presence of both  epidural scarring  and  arachnoiditis  in the same patient are probably quite common.  Arachnoiditis  is a broad term denoting  inflammation of the meninges  and  subarachnoid  space. A variety of causes exist, including infectious,  inflammatory , and  neoplastic  processes. Infectious causes include  bacterial ,  viral ,  fungal , and  parasitic   agents .  Noninfectious inflammatory processes  include surgery, intrathecal hemorrhage, and the administration of  intrathecal  (inside the  dural canal ) agents such as myelographic contrast media,  anesthetics  (e.g.  chloroprocaine ), and  steroids  (e.g. Depo-Medrol, Kenalog). Lately iatrogenic arachnoiditis has been attributed to misplaced  Epidural Steroid Injection therapy  when accidentally administered intrathecally. The preservatives and suspension agents found in all steroid injectates, which aren't indicated for epidural administration by the  U.S. Food & Drug Administration  (FDA) due to reports of severe adverse events including  arachnoiditis ,  paralysis  and  death , have now been directly linked to the onset of the disease following the initial stage of  chemical meningitis . [ 120 ] [ 121 ] [ 122 ] [ 123 ] \n Neoplasia  includes the  hematogenous spread  of  systemic tumors , such as  breast  and  lung carcinoma ,  melanoma , and  non-Hodgkin lymphoma . Neoplasia also includes direct seeding of the  cerebrospinal fluid  (CSF) from primary central nervous system (CNS) tumors such as  glioblastoma multiforme ,  medulloblastoma ,  ependymoma , and  choroid plexus carcinoma . Strictly speaking, the most common cause of  arachnoiditis  in failed back syndrome is not infectious or from cancer.  It is due to non-specific scarring secondary to the surgery or the underlying pathology. [ 124 ] [ 125 ] [ 126 ] [ 127 ] [ 128 ] [ 129 ] [ 130 ] [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6324", "text": "Laceration  of a  nerve root , or damage from  cautery  or  traction  can lead to  chronic pain , however this can be difficult to determine. Chronic compression of the nerve root by a persistent agent such as  disc , bone ( osteophyte ) or  scarring  can also permanently damage the nerve root.  Epidural scarring  caused by the initial  pathology  or occurring after the surgery can also contribute to  nerve damage .  In one study of failed back patients, the presence of pathology was noted to be at the same site as the level of surgery performed in 57% of cases. The remaining cases developed pathology at a different level, or on the opposite side, but at the same level as the surgery was performed. In theory, all failed back patients have some sort of nerve injury or damage which leads to a  persistence of symptoms  after a reasonable  healing time . [ 59 ] [ 60 ] [ 132 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6325", "text": "Failed back syndrome (FBS) is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as \"spinal cripples\" and are consigned to a life of long-term narcotic treatment with little chance of recovery.  Despite extensive work in recent years, FBS remains a challenging and costly disorder. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6326", "text": "The treatments of post-laminectomy syndrome include  physical therapy ,  microcurrent electrical neuromuscular stimulator , [ 134 ]  minor nerve blocks,  transcutaneous electrical nerve stimulation  (TENS),  behavioral medicine ,  non-steroidal anti-inflammatory  (NSAID) medications,  membrane stabilizers ,  antidepressants ,  spinal cord stimulation , and  intrathecal   morphine   pump . Use of  epidural steroid injections  may be minimally helpful in some cases. The targeted  anatomic  use of a potent anti-inflammatory  anti-TNF   therapeutics  is being investigated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6327", "text": "A study of chronic pain patients from the  University of Wisconsin  found that  methadone  is most widely known for its use in the treatment of  opioid  dependence, but  methadone  also provides effective  analgesia .  Patients who experience inadequate pain relief or intolerable side effects with other opioids or who suffer from neuropathic pain may benefit from a transition to methadone as their  analgesic  agent. Adverse effects, particularly respiratory depression and death, make a fundamental knowledge of  methadone 's pharmacological properties essential to the provider considering  methadone  as  analgesic  therapy for a patient with chronic pain. [ 135 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6328", "text": "Patients who have  sciatic  pain (pain in the back, radiating down the buttock to the leg) and clear clinical findings of an identifiable  radicular  nerve loss caused by a herniated disc will have a better post operative course than those who simply have low back pain. If a specific disc herniation causing pressure on a nerve root cannot be identified, the results of surgery are likely to be disappointing. Patients involved in worker's compensation, tort litigation or other compensation systems tend to fare more poorly after surgery. Surgery for spinal stenosis usually has a good outcome, if the surgery is done in an extensive manner, and done within the first year or so of the appearance of symptoms. [ 11 ] [ 60 ] [ 136 ] [ 137 ] [ 138 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6329", "text": "Oaklander and North define the Failed Back Syndrome as a chronic pain patient after one or more surgical procedure to the spine.  They delineated these characteristics of the relation between the patient and the surgeon:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6330", "text": "In the absence of a financial source for disability or worker's compensation, other psychological features may limit the ability of the patient to recover from surgery.  Some patients are simply unfortunate, and fall into the category of \"chronic pain\" despite their desire to recover and the best efforts of the physicians involved in their care. [ 140 ] [ 141 ] [ 142 ] [ 143 ] [ 144 ] [ 145 ] [ 146 ] [ 147 ] [ 148 ] [ 149 ] [ 150 ]  Even less invasive forms of surgery are not uniformly successful; approximately 30,000-40,000  laminectomy  patients obtain either no relief of symptomatology or a recurrence of symptoms. [ 151 ]  Another less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates as high as 65%. [ 152 ]  It is no surprise, therefore, that FBS is a significant medical concern which merits further research and attention by the medical and surgical communities. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6331", "text": "Lumbar  total disc replacement was originally designed to be an alternative to lumbar  arthrodesis  (fusion). The procedure was met with great excitement and heightened expectations both in the United States and Europe. In late 2004, the first lumbar total disc replacement received approval from the  U.S. Food and Drug Administration  (FDA). More experience existed in Europe.  Since then, the initial excitement has given way to skepticism and concern. [ 153 ] [ 154 ] [ 155 ] [ 156 ] [ 157 ] [ 158 ] [ 159 ]  Various failure rates and strategies for revision of total disc replacement have been reported. [ 160 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6332", "text": "The role of artificial or total disc replacement in the treatment of spinal disorders remains ill-defined and unclear. [ 161 ]  Evaluation of any new technique is difficult or impossible because physician experience may be minimal or lacking.  Patient expectations may be distorted. [ 162 ] [ 163 ]  It has been difficult to establish clear cut indications for artificial disc replacement.  It may not be a replacement procedure or alternative to fusion, since recent studies have shown that 100% of fusion patients had one or more contraindications to disc replacement. [ 164 ] [ 165 ] [ 166 ]    The role of disc replacement must come from new indications not defined in today's literature or a relaxation of current contraindications. [ 161 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6333", "text": "A study by Regan found the result of replacement was the same at L4-5 and L5-S1 with the CHARITE disc.  However, the ProDisc II had more favorable results at L4-5 compared with L5-S1. [ 167 ] [ 168 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6334", "text": "A younger age was predictive of a better outcome in several studies. [ 158 ] [ 169 ] [ 170 ]  In others it has been found to be a negative predictor or of no predictive value. [ 171 ] [ 172 ] [ 173 ] [ 174 ] [ 175 ]  Older patients may have more complications. [ 174 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6335", "text": "Prior spinal surgery has mixed effects on disc replacement.  It has been reported to be negative in several studies. [ 171 ] [ 176 ] [ 177 ] [ 178 ] [ 175 ] [ 179 ]  It has been reported to have  no effect in other studies. [ 180 ] [ 169 ] [ 173 ] [ 178 ] [ 181 ] [ 158 ]  Many studies are simply inconclusive. [ 171 ]  Existing evidence does not allow drawing definite conclusions about the status of disc replacement at present. [ 161 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6336", "text": "Many failed back patients are significantly impaired by chronic pain in the back and legs. Many of these will be treated with some form of electrical stimulation. This can be either a  transcutaneous electrical nerve stimulation  device placed on the skin over the back or a nerve stimulator implanted into the back  with electrical probes which directly touch the spinal cord. Also, some chronic pain patients utilize  fentanyl  or narcotic patches.  These patients are generally severely impaired and it is unrealistic to conclude that application of  neurostimulation  will reduce that impairment. For example, it is doubtful that  neurostimulation  will improve the patient enough to return to competitive employment.  Neurostimulation  is  palliative . TENS units work by blocking  neurotransmission  as described by the pain theory of Melzack and Wall. [ 182 ]  Success rates for implanted  neurostimulation  has been reported to be 25% to 55%. Success is defined as a relative decrease in pain. [ 183 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6337", "text": "Limited case series have shown improvement for patients with failed back surgery who were managed with  chiropractic care . [ 184 ] [ 185 ] [ 186 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6338", "text": "Smaller procedures that do not remove  bone  (such as Endoscopic Transforaminal Lumbar Discectomy and Reconfiguration) do not cause post  laminectomy / laminotomy  syndrome. [ 187 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6339", "text": "Under rules promulgated by Titles II and XVI of the United States  Social Security Act , chronic  radiculopathy ,  arachnoiditis  and spinal stenosis are recognized as disabling conditions under Listing 1.04 A ( radiculopathy ), 1.04 B ( arachnoiditis ) and 1.04 C ( spinal stenosis ). [ 188 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6340", "text": "In a groundbreaking  Canadian  study, Waddell  et al.  reported on the value of repeat surgery and the return to work in worker's compensation cases. They concluded that workers who undergo spinal surgery take longer to return to their jobs. Once two spinal surgeries are performed, few if any ever return to gainful employment of any kind. After two spinal surgeries, most people in the worker's comp system will not be made better by more surgery. Most will be worse after a third surgery. [ 189 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6341", "text": "Episodes of back pain associated with on the job injuries in the worker's compensation setting are usually of short duration. About 10% of such episodes will not be simple, and will degenerate into chronic and disabling back pain conditions, even if surgery is not performed. [ 190 ] [ 191 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6342", "text": "It has been hypothesized that  job dissatisfaction  and individual perception of physical demands are associated with an increased time of recovery or an increased risk of no recovery at all. [ 192 ]  Individual psychological and social work factors, as well as worker-employer relations are also likely to be associated with time and rates of recovery. [ 193 ] [ 194 ] [ 195 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6343", "text": "A Finnish study of return to work in patients with  spinal stenosis  treated by surgery found that:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6344", "text": "In fact, women's and men's working capacity do not differ after  lumbar spinal stenosis  operation. If the aim is to maximize working capacity, then, when a lumbar spinal stenosis operation is indicated, it should be performed without delay. In lumbar spinal stenosis patients who are older than 50 years old and on sick leave, it is unrealistic to expect that they will return to work. Therefore, after such an extensive surgical procedure, re-education of patients for lighter jobs could improve the chances of these patients returning to work. [ 196 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6345", "text": "In a related  Finnish  study, a total of 439 patients operated on for lumbar spinal stenosis during the period 1974\u20131987 was re-examined and evaluated for working and functional capacity approximately 4 years after the  decompressive surgery . The ability to work before or after the operation and a history of no prior back surgery were variables predictive of a good outcome. Before the operation 86 patients were working, 223 patients were on sick leave, and 130 patients were retired. After the operation 52 of the employed patients and 70 of the unemployed patients returned to work. None of the retired patients returned to work. Ability to work preoperatively, age under 50 years at the time of operation and the absence of prior back surgery predicted a postoperative ability to work. [ 197 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6346", "text": "A report from Belgium noted that patients reportedly return to work an average of 12 to 16 weeks after surgery for lumbar disc herniation. However, there are studies that lend credence to the value of an earlier stimulation for return to work and performance of normal activities after a limited  discectomy . At follow-up assessment, it was found that no patient had changed employment because of back or leg pain. The sooner the recommendation is made to return to work and perform normal activities, the more likely the patient is to comply. Patients with ongoing disabling back conditions have a low priority for return to work. The probability of return to work decreases as time off work increases.   This is especially true in Belgium, where 20% of individuals did not resume work activities after surgery for a disc herniation of the lumbar spine. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6347", "text": "In Belgium, the medical advisers of sickness funds have an important role legally in the assessment of working capacity and medical rehabilitation measures for employees whose fitness for work is jeopardized or diminished for health reasons. The measures are laid down in the sickness and invalidity legislation. They are in accordance with the principle of preventing long-term disability. It is apparent from the authors' experience that these measures are not adapted consistently in medical practice. Most of the medical advisers are focusing purely on evaluation of corporal damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is done by social security doctors with a comparable task. [ 198 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6348", "text": "In a comprehensive set of studies carried out by the  University of Washington School of Medicine , it was determined that the outcome of lumbar fusion performed on injured workers was worse than reported in most published case series.  They found 68% of lumbar fusion patients still unable to return to work two years after surgery.  This was in stark contrast to reports of 68% post-op satisfaction in many series. [ 199 ] [ 142 ]  In a follow-up study it was found that the use of intervertebral fusion devices rose rapidly after their introduction in 1996.  This increase in metal usage was associated with a greater risk of complication  without improving disability or re-operation rates. [ 200 ] [ 201 ] [ 202 ] [ 203 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6349", "text": "The identification of  tumor necrosis factor-alpha  (TNF) as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with FBS.  Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating  sciatica  in experimental models beginning in 2001. [ 204 ] [ 205 ] [ 206 ]  Targeted anatomic administration of one of these anti-TNF agents,  etanercept , a patented treatment method, [ 207 ]  has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBS. [ 208 ] [ 209 ]  The scientific basis for pain relief in these patients is supported by the many current review articles. [ 210 ] [ 211 ]  In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the \"pain generators\" responsible for symptom production. These treatments are still experimental. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6350", "text": "If chronic pain in FBS has a chemical component producing inflammatory pain, then prior to additional surgery it may make sense to use an anti-inflammatory approach. Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of  Non-steroidal anti-inflammatory drugs  (NSAIDS) for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in TNF-mediated processes. [ 22 ]  An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as \"epidural steroid injection\". [ 212 ]  Although this technique began more than a decade ago for FBS, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. [ 213 ]  In addition, epidural steroid injections, in certain settings, may result in serious complications. [ 214 ]  Fortunately there are now emerging new methods that directly target TNF. [ 208 ]  These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with FBS. [ 208 ]  Ancillary approaches, such as rehabilitation,  physical therapy ,  anti-depressants , and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. [ 22 ]  In addition, more invasive modalities, such as spinal cord stimulation, may offer relief for certain patients with FBS, but these modalities, although often referred to as \"minimally invasive\", require additional surgery, and have complications of their own. [ 215 ] [ 216 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6351", "text": "A report from  Spain  noted that the investigation and development of new techniques for instrumented  surgery  of the  spine  is not free from  conflicts of interest . The influence of financial forces in the development of new technologies and its immediate application to spine surgery, shows the relationship between the published results and the industry support. Authors who have developed and defended fusion techniques have also published new articles praising new spinal technologies. The author calls spinal surgery the  \"American Stock and Exchange\" and \"the bubble of spine surgery\". The scientific literature doesn't show clear evidence in the cost-benefit  studies  of most instrumented surgical interventions of the spine compared with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than the conservative treatment. It's necessary to point out that at present \" there are relationships between the industry and back pain, and there is also an industry of the back pain \"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6352", "text": "Nonetheless, the \"market of the spine surgery\" is growing because patients are demanding solutions for their back problems. The tide of scientific evidence seems to go against the spinal fusions in the degenerative disc disease,  discogenic pain  and in specific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that \" spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain \". The surgical literature on  spinal fusion  published in the last 20 years establishes that instrumentation seems to slightly increase the fusion rate and that instrumentation doesn't improve the clinical results in general. We still are in need of randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or conservative treatment. The European Guidelines for lumbar chronic pain management show  \"strong evidence\" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper  posterolateral  fusion without instrumentation. Recently, the literature published in this field is sending a message to use \"minimally invasive techniques\"; \u2013 the abandonment of transpedicular fusions. Surgery in general, and usage of metal fixation should be discarded in most cases. [ 217 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6353", "text": "In  Sweden , the national registry of lumbar spine surgery reported in the year 2000 that 15% of patients with spinal stenosis surgery underwent a concomitant fusion. [ 218 ]  Despite the traditionally conservative approach to spinal surgery in Sweden, there have been calls from that country for a more aggressive approach to lumbar procedures in recent years. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6354", "text": "Finally, Cherkin et al. evaluated worldwide surgical attitudes. [ 219 ]  There were twice the number of surgeons per capita in the  United States  compared to the  United Kingdom . Numbers were similar to  Sweden . Despite having very few spinal surgeons, the  Netherlands  proved to be quite aggressive in surgery. Sweden, despite having a large number of surgeons was conservative and produced relatively few surgeries. The most surgeries were done in the United States. In the UK, more than a third of non-urgent patients waited over a year to see a spinal surgeon. In  Wales , more than half waited over three months for consult. Lower rates of referrals in the United Kingdom was found to discourage surgery in general. Fee for service and easy access to care was thought to encourage spinal surgery in the United States, whereas salaried position and a conservative philosophy led to less surgery in the United Kingdom. There were more spinal surgeons in Sweden than in the United States.  However, it was speculated that the Swedish surgeons being limited to compensation of 40\u201348 hours a week might lead to a  conservative  philosophy. There have been calls for a more aggressive approach to lumbar surgery in both the United Kingdom and Sweden in recent years. [ 71 ] [ 220 ] [ 221 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6355", "text": "Foraminotomy  is a medical operation used to relieve pressure on  nerves  that are being compressed by the  intervertebral foramina , the passages through the bones of the  vertebrae  of the  spine  that pass nerve bundles to the body from the  spinal cord ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6356", "text": "A foraminotomy is performed to relieve the symptoms of nerve root compression in cases where the foramen is being compressed by bone, disc, scar tissue, or excessive ligament development and results in a pinched nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6357", "text": "The procedure is often performed as a  minimally invasive procedure  in which an incision is made in the back, the muscle peeled away to reveal the bone underneath, and a small hole cut into the vertebra itself.  Through this hole, using an  arthroscope , the foramen can be visualized, and the impinging bone or disk material removed. Surgery is typically short in duration, taking around 6 hours. Patients stay in hospital for 5-8 nights, can drive after 8 weeks, perform light duties after 8 weeks and make a full recovery within 18 months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6358", "text": "A foraminotomy that removes a large amount of bone or other material may occasionally be described as a  foraminectomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6359", "text": "A  ganglionectomy , also called a  gangliectomy , is the  surgical  removal of a  ganglion . [ 1 ]  The removal of a ganglion  cyst  usually requires a ganglionectomy. Such cysts usually form on the hand, foot or wrist and may cause  pain  or impair body function. Aspiration of the cyst and  steroid  injections are typically performed first. If they fail, the cyst is excised under local, regional or even general  anesthetic . Ganglionectomies are also performed for other reasons, such as the treatment of  chronic pain ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6360", "text": "Global neurosurgery  is a field at the intersection of  public health  and clinical  neurosurgery . It aims to expand provision of improved and equitable neurosurgical care globally. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6361", "text": "Global neurosurgery is \"the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.\" [ 2 ]  The term  global neurosurgery  was first used in 1995 by Canadian neurosurgeon Dwight Parkinson to describe comprehensive clinical neurosurgery care in Manitoba; [ 3 ]  however, the field as defined today was born in the mid-2010s. [ 4 ]  The modern definition of global neurosurgery was born from a combination of  global health  and  neurosurgery . Hence, global neurosurgery is conceived as a subspecialty of  global health  within  global surgery . [ 2 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6362", "text": "Around 22.6 million people are affected by diseases amenable to  neurosurgery  each year, and 13.8 million require surgical intervention. [ 6 ]  The burden of diseases amenable to neurosurgery is disproportionately distributed globally, with  low- and middle-income countries  bearing more than 78.1% of cases. [ 6 ]   Low- and middle-income countries  lack the workforce, infrastructure, funding, and data needed to address the disease burden. [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ]   High-income country  patients, especially in rural areas and from economically-disadvantaged backgrounds, face unique challenges in accessing safe, timely, and affordable neurosurgical care. [ 11 ]  For this reason, most global neurosurgery work has focused on access to care in low- and middle-incomce countries despite the global nature of disparities in accessing neurosurgical care. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6363", "text": "Global neurosurgery practice involves advocacy, education, policy, research, and service delivery. [ 2 ]  The components of global neurosurgery practice are interdependent but global neurosurgeons tend to focus their practice on one or two of them. This trend has allowed for specialization within the field and greater collaboration between individuals and institutions. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6364", "text": "Advocacy  efforts happen at the international, regional, and local levels and in collaboration with health initiatives that share similar goals with global neurosurgery - universal health coverage and sustainable development. Internationally, global neurosurgery advocacy groups participate in high-level health policy events like the  World Health Assembly  and the  United Nations General Assembly . [ 13 ]  Global neurosurgery advocates have contributed to numerous high-level decisions including folate fortification, detection and management of congenital malformations, and injury prevention. [ 13 ] [ 14 ]  Locally, global neurosurgery advocacy groups are constituted of health workers and other patient advocates. These groups affect local decision making but they are equally active internationally. Many local advocacy groups are members of international advocacy groups like the G4 Alliance, [ 15 ] [ 14 ]  People and Organisations United for Spina Bifida and Hydrocephalus (PUSH!) Global Alliance, [ 16 ]  and International Federation Spina Bifida and Hydrocephalus (IFSBH). [ 17 ]  Local global neurosurgery advocacy groups work within these international organizations to coordinate advocacy efforts regionally and globally."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6365", "text": "Global neurosurgery education focuses on two aspects. First, global neurosurgery educators train specialists to serve under-resourced regions. The training focuses primarily on safe and quality service delivery within underserved communities. These global neurosurgery education efforts can be divided into non-specialized and specialized training. Non-specialized training or education for task-sharing/-shifting targets non-specialized healthcare workers such as general surgeons, clinical officers, and general practitioners. [ 18 ] [ 19 ]  Non-specialized training is especially important in increasing access to essential and emergency neurosurgical care rapidly. [ 20 ]  Non-specialized training, unlike specialized training, can be done in shorter periods, with larger cohorts, and with fewer resources. [ 19 ]  Specialized neurosurgery training can last anywhere from a few months to 8 years depending on the training level. [ 21 ]  Postgraduate medical fellowships in one of the neurosurgical subspecialties are open to graduate neurosurgery residents/registrars and can last between three and 24 months. On the other hand, neurosurgery residencies last between 4 and 8 years. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6366", "text": "The other focus of global neurosurgery education is fellowships that introduce trainees to global and  public health  concepts. Global neurosurgery fellowships are relatively new but increasingly popular with institutions like Cambridge, [ 23 ]  Cornell, [ 24 ]  Duke, [ 25 ]  Harvard, [ 26 ]  and the University of Cape Town [ 27 ]  offering specialized training. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6367", "text": "Global neurosurgeons contribute significantly to the design and implementation of health policies that improve access to safe, timely, and affordable neurosurgical care globally. Prime examples of global neurosurgery policy efforts include the comprehensive health policy guidelines for traumatic brain and spine injuries [ 29 ] [ 30 ]  and for spina bifida and hydrocephalus. [ 31 ]  The comprehensive policy guidelines address challenges that affect the patient continuum of care and suggest solutions for every component of the healthcare system. [ 29 ] [ 30 ] [ 31 ]  These documents were designed for policymakers in areas with a large burden of diseases amenable to neurosurgery. Traumatic brain and spine injuries were chosen because they constitute more than 47.1% of the global neurosurgical disease burden while hydrocephalus and spina bifida were chosen for their deleterious impact on children. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6368", "text": "Research is an indispensable aspect of global neurosurgery practice called  academic global neurosurgery . [ 2 ]  Academic global neurosurgery has a broad focus and uses concepts from epidemiology,  health economics , health policy, health services, health systems, implementation & dissemination science, and patient safety & quality improvement research. [ 2 ]  Academic global neurosurgery's exponential growth since 2016 is the result of increased interest and support from the neurosurgical community characterized by the creation of an ad-hoc committee within the World Federation of Neurosurgical Societies, [ 32 ]  publication of special issues in reputable peer-reviewed journals, [ 33 ] [ 34 ]  creation of a specialized journal, [ 35 ]  and the creation of global neurosurgery centers. [ 12 ]  Academic global neurosurgery identifies challenges to accessing neurosurgical care and proposes solutions that increase access to care. [ 12 ]  The evidence generated by academic global neurosurgery informs the other aspects of global neurosurgery practice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6369", "text": "Service delivery is the oldest component of global neurosurgery practice and can be traced back to the colonial era when surgeons would deliver care in colonies. [ 21 ] [ 36 ]  Global neurosurgery aims to reduce barriers to essential and emergency neurosurgery procedures such as those needed for acute stroke, neural tube defects, traumatic brain injuries, and traumatic spine injuries. [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6370", "text": "Low- and middle-income country patients have worse outcomes than their high-income country counterparts because they regularly face barriers to accessing timely and safe neurosurgical care. [ 39 ] [ 40 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6371", "text": "The workforce deficit in low- and middle-income countries constitutes a significant barrier to receiving care. Although former colonies have trained local neurosurgeons since their independence, the neurosurgical workforce density in many low- and middle-income countries remains below the World Federation of Neurosurgical Societies' recommendation of 1 neurosurgeon per 200,000 people. [ 41 ]  In addition, the majority of low- and middle income countries have geographical disparities in the neurosurgical workforce with most neurosurgeons working in urban areas whereas the majority of people in these countries are rural-dwellers. [ 19 ]  In addition, surgical non-governmental organizations from high-income countries help fill the service delivery gap in some low- and middle-income countries. [ 42 ]  Although most neurosurgical non-governmental organizations offer short-term service delivery in low- and middle-income countries, some like CURE International offer long-term care. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6372", "text": "The neurosurgical workforce in low- and middle-income countries has increased gradually in the past decade thanks to targeted efforts from the global neurosurgery community. For example, the  World Federation of Neurosurgical Societies  supports the training of aspiring neurosurgeons from understaffed countries through scholarships at accredited centers in Africa, Asia, and South America. [ 44 ] [ 45 ] [ 46 ] [ 21 ] [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6373", "text": "Young neurosurgeons from under-resourced regions who have been trained in advanced neurosurgical techniques report their patients do not get safe and timely care because of inadequate infrastructure. [ 19 ]  Access to neurosurgical infrastructure can be assessed summarily using the  World Federation of Neurosurgical Societies  facility three-tier classification or using hospital assessment tools. [ 48 ]  The  World Federation of Neurosurgical Societies  facility three-tier classification groups facilities into  level 1  (equipment for emergency neurosurgery procedures),  level 2  (equipment to perform basic microneurosurgical procedures), and  level 3  (equipment for complex and advanced neurosurgery)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6374", "text": "Idiopathic intracranial hypertension  ( IIH ), previously known as  pseudotumor cerebri  and  benign intracranial hypertension , is a condition characterized by increased  intracranial pressure  (pressure around the brain) without a detectable cause. [ 2 ]  The main symptoms are  headache , vision problems,  ringing in the ears , and shoulder pain. [ 1 ] [ 2 ]  Complications may include  vision loss . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6375", "text": "This condition is idiopathic, meaning there is no known cause. Risk factors include being overweight or a recent increase in weight. [ 1 ]   Tetracycline  may also trigger the condition. [ 2 ]  The diagnosis is based on symptoms and a high opening pressure found during a  lumbar puncture  with no specific cause found on a  brain scan . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6376", "text": "Treatment includes a healthy diet, salt restriction, and exercise. [ 2 ]  The medication  acetazolamide  may also be used along with the above measures. [ 2 ]  A small percentage of people may require surgery to relieve the pressure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6377", "text": "About 2 per 100,000 people are newly affected per year. [ 4 ]  The condition most commonly affects women aged 20\u201350. [ 2 ]  Women are affected about 20 times more often than men. [ 2 ]  The condition was first described in 1897. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6378", "text": "The most common symptom of IIH is severe headache, which occurs in almost all (92\u201394%) cases. It is characteristically worse in the morning, generalized in character and throbbing in nature. It may be associated with nausea and vomiting. The headache can be made worse by  any activity that further increases the intracranial pressure , such as  coughing  and  sneezing . The pain may also be experienced in the neck and shoulders. [ 5 ]  Many have  pulsatile tinnitus , a whooshing sensation in one or both ears (64\u201387%); this sound is synchronous with the pulse. [ 5 ] [ 6 ]  Various other symptoms, such as numbness of the extremities, generalized weakness, pain and/or numbness in one or both sides of the face, loss of smell, and  loss of coordination , are reported more rarely; none are specific for IIH. [ 5 ]  In children, numerous nonspecific signs and symptoms may be present. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6379", "text": "The increased pressure leads to compression and traction of the  cranial nerves , a group of nerves that arise from the  brain stem  and supply the face and neck. Most commonly, the  abducens nerve  (sixth nerve) is involved. This nerve supplies the muscle that pulls the eye outward. Those with  sixth nerve palsy  therefore experience horizontal double vision which is worse when looking towards the affected side. More rarely, the  oculomotor nerve  and  trochlear nerve  ( third  and  fourth nerve palsy , respectively) are affected; both play a role in eye movements. [ 7 ] [ 8 ]  The  facial nerve  (seventh cranial nerve) is affected occasionally \u2013 the result is total or partial  weakness of the muscles of facial expression  on one or both sides of the face. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6380", "text": "The increased pressure leads to  papilledema , which is swelling of the  optic disc , the spot where the  optic nerve  enters the  eyeball . This occurs in practically all cases of IIH, but not everyone experiences symptoms from this. Those who do experience symptoms typically report \"transient visual obscurations\", episodes of difficulty seeing that occur in both eyes but not necessarily at the same time. Long-term untreated papilledema leads to visual loss, initially in the periphery but progressively towards the center of vision. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6381", "text": "Physical examination of the nervous system  is typically normal apart from the presence of papilledema, which is seen on examination of the eye with a small device called an  ophthalmoscope  or in more detail with a  fundus camera . If there are cranial nerve abnormalities, these may be noticed on  eye examination  in the form of a  squint  (third, fourth, or sixth nerve palsy) or as facial nerve palsy. If the papilledema has been longstanding,  visual fields  may be constricted and  visual acuity  may be decreased.  Visual field testing  by automated ( Humphrey ) perimetry is recommended as other methods of testing may be less accurate. Longstanding papilledema leads to  optic atrophy , in which the disc looks pale and visual loss tends to be advanced. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6382", "text": "\"Idiopathic\" means of unknown cause. Therefore, IIH can only be diagnosed if there is no alternative explanation for the symptoms.  Intracranial pressure  may be increased due to medications such as high-dose  vitamin A  derivatives (e.g.,  isotretinoin  for  acne ), [ 10 ]  long-term  tetracycline antibiotics  (for a variety of skin conditions). [ 11 ]   Hormonal contraceptives , particularly the oral contraceptive pill (OCP), are not associated with IIH. [ 12 ]  A systematic review published in 2020 suggests the use of the term \" drug-induced intracranial hypertension (DIIH) \" after having applied a 'strict drug-causality algorithm' in determining IIH cases likely caused by the drugs they evaluated. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6383", "text": "There are numerous other diseases, mostly rare conditions, that may lead to intracranial hypertension. If there is an underlying cause, the condition is termed \"secondary intracranial hypertension\". [ 5 ]  Common causes of secondary intracranial hypertension include  obstructive sleep apnea  (a sleep-related breathing disorder),  systemic lupus erythematosus  (SLE),  chronic kidney disease , and  Beh\u00e7et's disease . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6384", "text": "On July 1, 2022, the FDA issued an update that gonadotropin-releasing hormone agonists, drugs that are approved for treating precocious puberty, may be a risk factor for developing pseudotumor cerebri. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6385", "text": "The cause of IIH is not known. The  Monro\u2013Kellie rule  states that the intracranial pressure is determined by the amount of brain tissue,  cerebrospinal fluid  (CSF) and blood inside the bony cranial vault. Three theories therefore exist as to why the pressure might be raised in IIH: an excess of CSF production, increased volume of blood or brain tissue, or obstruction of the  veins that drain blood from the brain . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6386", "text": "The first theory, that of increased production of cerebrospinal fluid, was proposed in early descriptions of the disease. However, there is no experimental data that supports a role for this process in IIH. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6387", "text": "The second theory posits that either increased blood flow to the brain or increase in the brain tissue itself may result in the raised pressure. Little evidence has accumulated to support the suggestion that increased blood flow plays a role, but recently Bateman et al. in phase contrast MRA studies have quantified cerebral blood flow (CBF) in vivo and suggests that CBF is abnormally elevated in many people with IIH. Both  biopsy  samples and various types of brain scans have shown an increased water content of the brain tissue. It remains unclear why this might be the case. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6388", "text": "The third theory suggests that restricted venous drainage from the brain may be impaired resulting in congestion. Many people with IIH have narrowing of the  transverse sinuses . [ 15 ]  It is not clear whether this narrowing is the pathogenesis of the disease or a secondary phenomenon. It has been proposed that a positive biofeedback loop may exist, where raised ICP ( intracranial pressure ) causes venous narrowing in the  transverse sinuses , resulting in venous hypertension (raised venous pressure), decreased CSF resorption via  arachnoid granulation  and further rise in ICP. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6389", "text": "The diagnosis may be suspected on the basis of the history and examination. To confirm the diagnosis, as well as excluding alternative causes, several investigations are required; more investigations may be performed if the history is not typical or the person is more likely to have an alternative problem: children, men, the elderly, or women who are not overweight. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6390", "text": "Neuroimaging , usually with  computed tomography  (CT/CAT) or  magnetic resonance imaging  (MRI), is used to exclude any mass lesions. In IIH these scans typically appear to be normal, although small or slit-like  ventricles , dilatation and buckling [ 18 ]  of the optic nerve sheaths and \" empty sella sign \" (flattening of the  pituitary gland  due to increased pressure) and enlargement of Meckel's caves may be seen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6391", "text": "An MR venogram is also performed in most cases to exclude the possibility of venous sinus stenosis/obstruction or  cerebral venous sinus thrombosis . [ 5 ] [ 7 ] [ 8 ]  A contrast-enhanced MRV (ATECO) scan has a high detection rate for abnormal transverse sinus stenoses. [ 15 ]  These stenoses can be more adequately identified and assessed with catheter cerebral venography and manometry. [ 16 ]  Buckling of the bilateral optic nerves with increased perineural fluid is also often noted on MRI imaging."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6392", "text": "Lumbar puncture  is performed to measure the opening pressure, as well as to obtain  cerebrospinal fluid  (CSF) to exclude alternative diagnoses. If the opening pressure is increased, CSF may be removed for transient relief (see below). [ 8 ]  The CSF is examined for abnormal cells, infections, antibody levels, the  glucose  level, and  protein  levels. By definition, all of these are within their normal limits in IIH. [ 8 ]  Occasionally, the CSF pressure measurement may be normal despite very suggestive symptoms. This may be attributable to the fact that CSF pressure may fluctuate over the course of the normal day. If the suspicion of problems remains high, it may be necessary to perform more long-term monitoring of the ICP by a pressure catheter. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6393", "text": "The original criteria for IIH were described by  Dandy  in 1937. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6394", "text": "They were modified by Smith in 1985 to become the \"modified Dandy criteria\". Smith included the use of more advanced imaging: Dandy had required  ventriculography , but Smith replaced this with  computed tomography . [ 20 ]  In a 2001 paper, Digre and Corbett amended Dandy's criteria further. They added the requirement that the person is awake and alert, as coma precludes adequate neurological assessment, and require exclusion of venous sinus thrombosis as an underlying cause. Furthermore, they added the requirement that no other cause for the raised ICP is found. [ 5 ] [ 9 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6395", "text": "In a 2002 review, Friedman and Jacobson propose an alternative set of criteria, derived from Smith's. These require the absence of symptoms that could not be explained by a diagnosis of IIH, but do not require the actual presence of any symptoms (such as headache) attributable to IIH. These criteria also require that the lumbar puncture is performed with the person lying sideways, as a lumbar puncture performed in the upright sitting position can lead to artificially high pressure measurements. Friedman and Jacobson also do not insist on MR venography for every person; rather, this is only required in atypical cases (see \"diagnosis\" above). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6396", "text": "The primary goal in treatment of IIH is the prevention of visual loss and blindness, as well as symptom control. [ 9 ]  IIH is treated mainly through the reduction of CSF pressure and IIH may resolve after initial treatment, may go into spontaneous remission (although it can still relapse at a later stage), or may continue chronically. [ 5 ] [ 8 ]  There are three main treatment approaches: weight loss, different medications and surgical interventions. Remission is seen for most patients that achieve a weight loss of around 6\u201310%. Bariatric surgery can be an option for those patients that don't achieve weight loss with lifestyle changes and diet. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6397", "text": "The first step in symptom control is drainage of cerebrospinal fluid by lumbar puncture. If necessary, this may be performed at the same time as a diagnostic LP (such as done in search of a CSF infection). In some cases, this is sufficient to control the symptoms, and no further treatment is needed. [ 7 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6398", "text": "The procedure can be repeated if necessary, but this is generally taken as a clue that additional treatments may be required to control the symptoms and preserve vision. Repeated lumbar punctures are regarded as unpleasant by people, and they present a danger of introducing spinal infections if done too often. [ 5 ] [ 7 ]  Repeated lumbar punctures are sometimes needed to control the ICP urgently if the person's vision deteriorates rapidly. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6399", "text": "The best-studied medical treatment for intracranial hypertension is  acetazolamide  (Diamox), which acts by inhibiting the enzyme  carbonic anhydrase , and it reduces CSF production by six to 57 percent. It can cause the symptoms of  hypokalemia  (low blood potassium levels), which include muscle weakness and tingling in the fingers. Acetazolamide cannot be used in pregnancy, since it has been shown to cause embryonic abnormalities in animal studies. Also, in human beings it has been shown to cause  metabolic acidosis  as well as  disruptions in the blood electrolyte levels  of newborn babies. The diuretic  furosemide  is sometimes used for a treatment if acetazolamide is not tolerated, but this drug sometimes has little effect on the ICP. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6400", "text": "Various  analgesics  (painkillers) may be used in controlling the headaches of intracranial hypertension. In addition to conventional agents such as  paracetamol , a low dose of the antidepressant  amitriptyline  or the anticonvulsant  topiramate  have shown some additional benefit for pain relief. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6401", "text": "The use of  steroids  in the attempt to reduce the ICP is controversial. These may be used in severe papilledema, but otherwise their use is discouraged. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6402", "text": "Venous sinus stenoses leading to venous hypertension appear to play a significant part in relation to raised  ICP , and stenting of a  transverse sinus  may resolve venous hypertension, leading to improved  CSF  resorption, decreased ICP, cure of papilledema and other symptoms of IIH. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6403", "text": "A self-expanding metal stent is permanently deployed within the dominant  transverse sinus  across the stenosis under general anaesthesia. In general, people are discharged the next day. People require double antiplatelet therapy for a period of up to 3 months after the procedure and aspirin therapy for up to 1 year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6404", "text": "In a systematic analysis of 19 studies with 207 cases, there was an 87% improvement in overall symptom rate and 90% cure rate for treatment of papilledema. Major complications only occurred in 3/207 people (1.4%). [ 23 ]  In the largest single series of transverse sinus stenting there was an 11% rate of recurrence after one stent, requiring further stenting. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6405", "text": "Due to the permanence of the stent and small but definite risk of complications, most experts will recommend that person with IIH must have papilledema and have failed medical therapy or are intolerant to medication before stenting is undertaken."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6406", "text": "Two main surgical procedures are used for the treatment of IIH:  optic nerve sheath decompression and fenestration  and  cerebral shunting . Surgery would normally only be offered if medical therapy is either unsuccessful or not tolerated. [ 7 ] [ 9 ]  The choice between these two procedures depends on the predominant problem in IIH. Neither procedure is perfect: both may cause significant complications, and both may eventually fail in controlling the symptoms. There are no  randomized controlled trials  to guide the decision as to which procedure is best. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6407", "text": "Optic nerve sheath fenestration  is an operation that involves the making of an incision in the connective tissue lining of the  optic nerve  in its portion behind the eye. It is not entirely clear how it protects the eye from the raised pressure, but it may be the result of either diversion of the CSF into the  orbit  or the creation of an area of scar tissue that lowers the pressure. [ 9 ]  The effects on the intracranial pressure itself are more modest. Moreover, the procedure may lead to significant complications, including blindness in 1\u20132%. [ 5 ]  The procedure is therefore recommended mainly in those who have limited headache symptoms but significant papilledema or threatened vision, and those who have undergone unsuccessful treatment with a shunt or have a contraindication for shunt surgery. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6408", "text": "Shunt surgery, usually performed by  neurosurgeons , involves the creation of a conduit by which CSF can be drained into another body cavity. The initial procedure is usually a  lumboperitoneal (LP) shunt , which connects the subarachnoid space in the  lumbar spine  with the  peritoneal cavity . [ 24 ]  A pressure valve is usually included in the circuit to avoid excessive drainage when the person is erect. LP shunting provides long-term relief in about half the cases; others require revision of the shunt, often on more than one occasion, usually due to shunt obstruction. If the lumboperitoneal shunt needs repeated revisions, a  ventriculoatrial  or  ventriculoperitoneal shunt  may be considered. These shunts are inserted in one of the  lateral ventricles  of the brain, usually by  stereotactic surgery , and then connected either to the  right atrium  of the heart or the peritoneal cavity. [ 5 ] [ 9 ]  Given the reduced need for revisions in ventricular shunts, it is possible that this procedure will become [ when? ]  the first-line type of shunt treatment. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6409", "text": "It has been shown that in obese people,  bariatric surgery  (and especially  gastric bypass surgery ) can lead to resolution of the condition in over 95%. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6410", "text": "It is not known what percentage of people with IIH will remit spontaneously, and what percentage will develop chronic disease. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6411", "text": "IIH does not normally affect life expectancy. The major complications from IIH arise from untreated or treatment-resistant  papilledema . In various case series, the long-term risk of one's vision being significantly affected by IIH is reported to lie anywhere between 10 and 25%. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6412", "text": "On average, IIH occurs in about one per 100,000 people, and can occur in children and adults. The  median  age at diagnosis is 30. IIH occurs predominantly in women, especially in the ages 20 to 45, who are four to eight times more likely than men to be affected.  Overweight  and  obesity  strongly predispose a person to IIH: women who are more than ten percent over their  ideal body weight  are thirteen times more likely to develop IIH, and this figure goes up to nineteen times in women who are more than twenty percent over their ideal body weight. In men this relationship also exists, but the increase is only five-fold in those over 20 percent above their ideal body weight. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6413", "text": "Despite several reports of IIH in families, there is no known genetic cause for IIH. People from all  ethnicities  may develop IIH. [ 5 ]  In children, there is no difference in incidence between males and females. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6414", "text": "From national hospital admission databases it appears that the need for  neurosurgical  intervention for IIH has increased markedly over the period between 1988 and 2002. This has been attributed at least in part to the rising prevalence of obesity, [ 25 ]  although some of this increase may be explained by the increased popularity of  shunting  over optic nerve sheath fenestration. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6415", "text": "The first report of IIH was by the German physician  Heinrich Quincke , who described it in 1893 under the name  serous meningitis . [ 26 ]  The term \"pseudotumor cerebri\" was introduced in 1904 by his compatriot  Max Nonne . [ 27 ]  Numerous other cases appeared in the literature subsequently; in many cases, the raised intracranial pressure may actually have resulted from underlying conditions. [ 28 ]  For instance, the  otitic hydrocephalus  reported by London neurologist Sir  Charles Symonds  may have resulted from venous sinus thrombosis caused by  middle ear infection . [ 28 ] [ 29 ]  Diagnostic criteria for IIH were developed in 1937 by the  Baltimore  neurosurgeon  Walter Dandy ; Dandy also introduced subtemporal decompressive surgery in the treatment of the condition. [ 19 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6416", "text": "The terms \"benign\" and \"pseudotumor\" derive from the fact that increased intracranial pressure may be associated with  brain tumors . Those people in whom no tumour was found were therefore diagnosed with \"pseudotumor cerebri\" (a disease mimicking a brain tumor). The disease was renamed  benign intracranial hypertension  in 1955 to distinguish it from intracranial hypertension due to life-threatening diseases (such as cancer); [ 30 ]  however, this was also felt to be misleading because any disease that can blind someone should not be thought of as benign, and the name was therefore revised in 1989 to \"idiopathic (of no identifiable cause) intracranial hypertension\". [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6417", "text": "Shunt surgery was introduced in 1949; initially, ventriculoperitoneal shunts were used. In 1971, good results were reported with lumboperitoneal shunting. Negative reports on shunting in the 1980s led to a brief period (1988\u20131993) during which optic nerve fenestration (which had initially been described in an unrelated condition in 1871) was more popular. Since then, shunting is recommended predominantly, with occasional exceptions. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6418", "text": "Creutzfeldt\u2013Jakob disease"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6419", "text": "An  infectious intracranial aneurysm  ( IIA , also called  mycotic aneurysm ) is a  cerebral aneurysm  that is caused by  infection  of the cerebral  arterial wall ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6420", "text": "Many patients with unruptured IIA may have no symptoms. In patients who do have symptoms these are often related to rupture of the aneurysm and to its cause. [ 1 ]  Rupture of an IIA results in  subarachnoid hemorrhage , symptoms of which include headache, dizziness, seizures, altered mental status and focal  neurological deficits . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6421", "text": "In contrast to other cerebral aneurysms, large aneurysm size does not increase the chance of rupture. Small IIAs\ntend to have high rupture rates, while larger IIAs more commonly cause symptoms due to pressure on the surrounding brain tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6422", "text": "Most IIAs are caused by bacterial infection, most commonly  Staphylococcus aureus  and  Streptococcus  species. In most cases the infection originates from left-sided  bacterial endocarditis . [ 1 ]  Other common sources include  cavernous sinus thrombosis ,  bacterial meningitis , poor  dental hygiene  and  intravenous drug  use.\nThe use of the term infectious aneurysm by the above authors is incorrect. Refer to Holtzman RNN, Pile-Spellman JMD, Brust JCM, Hughes JEO, Dickinson PCT: Surgical Management of Intracranial Aneurysms Caused by Infection, in: Schmidek HH and Roberts DW(eds): Schmidek & Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results ed.5. Philadelphia: Elsevier Inc. 2006 Vol 1: Chap. 87, pp1223-1259"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6423", "text": "Diagnosis of IIA is based on finding an intracranial aneurysm on  vascular imaging  in the presence of predisposing infectious conditions. [ 1 ]  Positive  bacterial cultures  from blood or the infected aneurysm wall itself may confirm the diagnosis, however blood cultures are often negative. Other supporting findings include  leukocytosis , an elevated  erythrocyte sedimentation rate  and elevated  C-reactive protein  in blood. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6424", "text": "The term  mycotic aneurysm , initially attributed to Osler and used to describe bacterial intracranial aneurysms, is a misnomer. Most investigators currently agree that its use should be strictly limited to descriptions of aneurysms of fungal origin. Yet efforts to establish an accurate nomenclature have been generally unsuccessful. Therefore, we are resigned to the fact that the term mycotic aneurysm will remain in general parlance. At the same time, we prefer the use of a more specific and accurate heading, namely,  infected intracranial aneurysm , to include the categories of intracranial bacterial aneurysm, fungal aneurysm, spirochetal aneurysm, infested or amebic aneurysm, viral aneurysm and phytotic aneurysm, according to the specific infecting organism or agent. The terms  infectious aneurysm  and  infective aneurysm   are flawed because they imply that the aneurysm itself is the infecting agent rather than being the end point of an infecting process. Until such a pathogenesis has been detected, it is the intention of the authors to avoid catachresis and the application of archaic language (Marcus S, The George Delacorte Professor of English and Comparative Literature, Columbia University, New York, personal communication, 1993: \"The correct usage is 'infected'. The term 'infectious' died out as a usage in termed of infected in 1726.\" And Jost, DA, former senior lexicographer of  The American Heritage Dictionary , Boston, personal communication, 1996: \" Infectious aneurysm  will be interpreted by most users of English as an aneurysm that can communicate infection\"). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6425", "text": "The term  infected intracranial aneurysm  lacks the properties of complete definition because it refers to the initial process that affects the arterial wall and to aneurysms found to have bacteria in their walls at the time of excision (Table 87-1, Patient 3; see Case Report 9, Fig. 87-9), but not to the processes of focal dilatation or subsequent aneurysm formation and enlargement. It also accurately describes the congenital or berry aneurysm that has become secondarily infected. The terms  septic aneurysm  and  septic embolism  and  septic arteritis  are also commonly used. However, the word septic refers to infection involving the blood stream and is not really descriptive of the aneurysm themselves. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6426", "text": "Treatment depends on whether the aneurysm is ruptured and may involve a combination of  antimicrobial drugs ,  surgery  and/or  endovascular treatment . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6427", "text": "Mortality  of IIA is high, unruptured IIA are associated with a mortality reaching 30%, while ruptured IIA has a mortality of up to 80%. [ 1 ]  IIAs caused by  fungal infections  have a worse prognosis than those caused by bacterial infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6428", "text": "IIAs are uncommon, accounting for 2.6% to 6% of all  intracranial aneurysms  in autopsy studies. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6429", "text": "The  International Subarachnoid Aneurysm Trial  ( ISAT ) was a large  multicenter  prospective  randomized   clinical medical trial  comparing the safety and efficacy of  endovascular coil  treatment and  surgical clipping  for the treatment of  brain aneurysms . The study began in 1994 with the first results being published in  The Lancet  in 2002, and the 10-year data were published again in  The Lancet  in early September 2005. A total of 2,143 study participants were mostly drawn from  U.K.  hospitals with the rest drawn from North American and European hospitals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6430", "text": "The study found superior results with  endovascular  coil treatment compared to surgical clipping. However, subsequent studies have questioned this conclusion. [ 1 ]  The study was criticized by many clinicians and not well accepted by surgeons. [ 2 ]  Primary criticisms were related to the study's generalizability and the long-term prognosis of coil embolization. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6431", "text": "ISAT sought to measure outcomes of  cerebral aneurysm  patients at 2 and 12 months using a type of a  Rankin scale . [ 4 ] :\u200a114\u200a  The study was prematurely terminated in 2002 after the oversight committee determined there was increased morbidity with surgical clipping compared to  endovascular  coiling. [ 4 ] :\u200a114"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6432", "text": "ISAT was criticized on several factors related to the randomization of the patient population. The randomized patient population in the ISAT was younger on average, the majority had aneurysms under 10mm and in anterior circulation compared to the population of  subarachnoid hemorrhage  patients in the U.S. and Japan. [ 1 ] [ 5 ] :\u200a210\u200a  In response to these criticisms, a facility that participated in ISAT compared the clinical outcomes of their patients who were not selected for the study to those who were. They reported similar outcomes to the ISAT. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6433", "text": "Although the initial ISAT analysis appeared to favor endovascular coiling over microsurgical clipping, subsequent meta-analysis have questioned that conclusion finding higher incidences [ spelling? ]  of recurrence. [ 6 ]  A large meta-analysis from  Johns Hopkins University  published in  Neurosurgery  concluded that \"there is no clear consensus in these two studies or in the 45 observational studies included.\" [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6434", "text": "Updated data from the ISAT group in March 2008 shows that the higher aneurysm rate of recurrence is also associated with a higher re-bleeding rate, given that the re-bleed rate of coiled aneurysms appears to be 8 times higher than that of aneurysms treated with surgical clipping in this study. [ 7 ]  The ISAT authors conclude that \"when treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients younger than 40 years old.\" [ 7 ]  Other studies have directly questioned the ISAT's conclusions. [ 8 ]  This conclusion is based on a number of methodological assumptions itself and other authors have cautioned about extending it to other patient populations. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6435", "text": "It appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher  recurrence  rate after treatment. The long-term data for unruptured  aneurysms  are still being gathered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6436", "text": "Total disc replacement  ( TDR ), or  artificial disc replacement  ( ADR ), is a type of  arthroplasty  in which degenerated  intervertebral discs  in the  vertebral column  are replaced with artificial disc implants in the lumbar (lower) or cervical (upper) spine.  The procedure is used to treat chronic, severe  low back pain  and cervical pain resulting from  degenerative disc disease . Disc replacement is also an alternative intervention for symptomatic disc herniation with associated arm and hand, or leg symptoms ( radicular pain )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6437", "text": "TDR has been developed as an alternative to  spinal fusion , with the goal of pain reduction or elimination, while still allowing motion throughout the spine.  Faster recoveries after surgery have also been widely reported by surgeons. [ 1 ]  Another possible benefit is the prevention of premature breakdown in adjacent levels of the spine, a potential risk in fusion surgeries. [ 2 ]  Recent studies have shown a strong correlation between providing motion in the spine and avoiding adjacent segment degeneration. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6438", "text": "Multiple artificial discs (or disc replacements) have been approved by the FDA for use in the US, although several have been discontinued by their manufacturers. The Charit\u00e9, a mobile core device for use in the lumbar spine, was approved first, in 2004, but is no longer in use. prodisc, the longest continually used disc replacement device in the US, is a fixed core device manufactured by Centinel Spine and was approved in 2006 for the lumbar spine with a cervical device approved in 2007. The first cervical disc replacement available in the US was the Prestige, manufactured by  Medtronic . There have been several Prestige cervical disc replacement designs manufactured by Medtronic, with the current design being the Prestige LP."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6439", "text": "FDA approvals for devices are for one- or two-level use and at specific levels in the cervical or lumbar spine. Clinical studies are currently required to obtain FDA approval for disc replacements. These studies are comparative, noting differences between patients receiving a new device versus patients that receive spinal fusion or another previously-approved disc replacement.\nThe below table illustrates currently-approved disc replacement devices, their approval dates, the number of approved levels for each device, and their current usage status."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6440", "text": "While these discs have received FDA approval, reimbursement by insurance companies is not always automatic. Effective August 14, 2007, the Centers for Medicare & Medicaid Services (CMS) does not cover, on a national basis, Lumbar Artificial Disc Replacement (LADR) for patients over the age of 60. However, individual entities (Medicare Administrative Contractors, or  MACs ) regulate the determination of covered use of devices in patients 60 and under, and several approve the use of LADR for these patients.[1]  \nApproval by insurance companies is generally better for cervical disc replacements, with over 90% of the US population covered by a commercial payer that reimburses for cervical disc replacements, and over 85% for lumbar disc replacements. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6441", "text": "Many countries have their own individualized approval process for medical devices. In Europe,  Regulation (EU) 2017/745  defined the Medical Device Regulation (MDR) used for reviewing, approving, and monitoring the quality of medical devices. There are a large number of total disc replacements available and approved for use in Europe, including all of those available in the US. Some other international regulatory bodies base their approvals upon regulations in third party countries, such as the EU or the US. Nearly all countries have their own approval process.\nThe below table lists cervical disc replacement options available outside of the US."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6442", "text": "The first artificial disc was implanted in 1959, with Swedish surgeon Ulf Fernstr\u00f6m publishing a description of his experience implanting a stainless-steel ball bearing into an intervertebral disc space after  discectomy  in 1966. Fernstr\u00f6m balls, used in approximately 250 patients, created segmental hypermobility and demonstrated a marked tendency to settle into the vertebral endplates.  Reports suggest that function, while initially good, degenerated over time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6443", "text": "During the 1970s, a new concept was introduced: achieving mobility through articulation between the concave and convex surfaces of a multi-component device. Designs patented at that time combined metal, ceramic, or other types of elastic bearings with components made of silicone composites, rubber, polyurethane, plastics, or fluid-filled membranes. Some designs incorporated balloons, cages, pegs, wire screens, hinged plates, or springs. Springs proved to be particularly impractical because they could not withstand biomechanical fatigue tests of stress and strain. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6444", "text": "The first design with wide clinical adoption was the Charit\u00e9 disc replacement, designed by East German scientists: two-time Olympic champion in women's artistic gymnastics Karin B\u00fcttner-Janz and Kurt Schellnack, a doctor, engineer, and professor\u2014both of whom were affiliated with the Charit\u00e9 Center for Musculoskeletal Surgery at the Medical University of Berlin[2]. First implanted in 1984, the disc had a biconvex polyethylene nucleus within a radiopaque metal ring that interfaced with two cobalt-chromium-molybdenum alloy endplates, which were coated with calcium phosphate. Approved for use in the United States in 2004, after a 4-year clinical trial, Charit\u00e9 was removed from the market by 2012."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6445", "text": "The second disc replacement to achieve wide clinical use was the prodisc total disc replacement; it continues to have worldwide use today. Designed by French orthopedic spine surgeon Thiery Marnay, M.D., in the late 1980s, early implantations of the prodisc device began in 1990, with a 7-11 year follow-up published in 2005. After implementing design changes to the bone-facing endplate, and after a clinical study in the United States, the new design was made available worldwide. In October 2001, as part of the FDA trial,  Jack Zigler , M.D., a spine surgeon at Texas Back Institute in Plano, Texas, performed the first prodisc L artificial disc replacement in the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6446", "text": "The US FDA requires manufacturers to conduct clinical studies to assess the safety and efficacy of disc replacements before obtaining approval to market the devices in the United States. Other devices can be approved for use with simpler non-clinical reviews. As a result, disc replacements have the highest level of clinical evidence of any spine devices. However, since this research is funded by industry, some controversy over data bias produced by the clinical studies exists [see Controversy]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6447", "text": "Level 1 and level 1a studies (the highest quality levels: see  Hierarchy of Evidence ) have shown safety and efficacy for both lumbar and cervical discs, and have become the de facto standard of care for appropriate patients outside of the United States. [ 19 ] [ 20 ]   All prospective, randomized clinical studies that have been run in the United States have shown lumbar and cervical disc replacements to provide faster recovery, better long-term patient satisfaction, and fewer incidents of adjacent segment degeneration than comparative spinal fusion options. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6448", "text": "A few non-industry funded studies also exist. In addition to the previously mentioned 7-11 year followup study on prodisc conducted by Thiery Marnay, M.D., [ 21 ]  a Norwegian study published in The Spine Journal in 2017 compared total disc replacement and multidisciplinary rehabilitation with an eight-year follow up. The study was randomized, controlled, multi-center and not funded by industry. 77 patients randomized to surgery and 74 patients randomized to rehabilitation responded at eight-year follow-up. The study found a statistically significant benefit in favor of surgery. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6449", "text": "The  AAOS  states that disc replacement requires a high level of technical skill for accurate placement and has a significant level of risk if revision surgery is needed. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6450", "text": "Members of AAOS and the American Association of Neurological Surgeons joined together as the Association for Ethics in Spine Surgery, formed to raise awareness of the ties between physicians and device manufacturers. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6451", "text": "Aetna rescinded its positive coverage for single level lumbar ADR after merger with Coventry in 2013. [ 25 ]  There is currently (in 2022) a class-action lawsuit against Aetna Life Insurance for denying patients seeking lumbar disc replacement surgery in the United States alleging that patients are being harmed by denials since Aetna has declared them 'experimental or investigational\u2019. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6452", "text": "Despite published meta-analyses (the highest-level clinical evidence) that have illustrated that total disc replacement seems to be superior to fusion in most clinical parameters, new studies have identified concerns regarding long-term durability of some of these devices. One such recent study identifies a large \u201cmidterm failure rate\u201d related to the M6-C. It recommends that \u201cpatients implanted with the M6-C prosthesis should be contacted, informed, and clinically and radiologically assessed\u201d. [ 27 ]  Unfortunately, catastrophic failure of the M6-C prosthesis has also been reported. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6453", "text": "The monitoring of  intracranial pressure  (ICP) is used in the treatment of a number of neurological conditions ranging from severe  traumatic brain injury  to  stroke  and  brain bleeds . [ 1 ]  This process is called  intracranial pressure monitoring . Monitoring is important as persistent increases in ICP is associated with worse prognosis in brain injuries due to decreased oxygen delivery to the injured area and risk of brain herniation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6454", "text": "ICP monitoring is usually used on patients who have decreased score on the  Glasgow Coma Scale , indicating poor neurologic function. It is also used in patients who have non-reassuring imaging on CT, indicating compression of normal structures from swelling."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6455", "text": "Most current clinically available measurement methods are invasive, requiring surgery to place the monitor in the brain itself. Of these,  external ventricular drainage  (EVD) is the current gold standard as it allows physicians to both monitor ICP and treat if necessary. Some  non-invasive intracranial pressure measurement methods  are currently being studied, however none are currently able to deliver the same accuracy and reliability of invasive methods."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6456", "text": "Intracranial pressure monitoring is just one tool to manage ICP. It is used in conjunction with other techniques such as ventilator settings to manage levels of carbon dioxide in the blood, head and neck position, and other therapies such as hyperosmolar therapy, medications, and core temperature. [ 2 ]  However, there is no current consensus on the clinical benefit of ICP monitoring in overall ICP management, with evidence both supporting its use and finding no benefit in reducing mortality. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6457", "text": "Injury to the brain will often result in brain swelling. As the brain is encased in the skull, limited swelling can be accommodated until the brain is no longer able to maintain normal function. There are two potential negative consequences from this swelling: ischemia due to compression of the brain tissue resulting in lack of blood and oxygen, and herniation of the brain. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6458", "text": "The three main components in determining ICP is the blood circulation in the brain,  cerebrospinal fluid (CSF) , and the brain tissue itself. This relationship is dictated by the  Monro-Kellie  doctrine, which states that as the brain swells, intracranial pressure (ICP) rises and cerebral perfusion decreases. As the brain swelling exceeds a certain point called the critical closing pressure (CrCP), the arterioles feeding the brain oxygen-rich blood will collapse, and the brain becomes deprived of blood. [ 1 ]  This secondary injury can cause permanent brain damage from lack of oxygen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6459", "text": "Herniation of the brain can occur when the pressure inside the skull exceeds the pressure of the spinal canal. This is dangerous as it can result in the compression of important areas like the brainstem that regulate breathing leading to significant neurological impairment or death. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6460", "text": "Under normal conditions, regular movements such as leaning forward, normal heartbeat and breathing can cause changes to the ICP. Intracranial monitoring accounts for this by averaging measurements over 30 minutes in non-comatose patients. Readings between 7-15mmHg are considered normal in an adult, 3-7mmHg in children, and 1.4-6mmHg in infants. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6461", "text": "The external ventricular drainage (EVD) method of intracranial pressure monitoring is the current gold standard. The placement of an EVD requires a catheter placed into one of the lateral ventricles from a burr hole made into the skull. Benefits of an EVD include its ability to not only measure changes in pressure but also drain CSF as needed, thus making it both diagnostic and therapeutic. [ 2 ]  Significantly, an EVD can also be re-calibrated after placement which is particularly useful clinically to manage measurement drift. Risks in the operation to place the EVD are minimal but include infection and brain bleeds. Drawbacks to EVDs are the difficulty to place in comparison to other methods -- especially in the setting of brain swelling or anatomical variation in ventricle size \u2013 and once placed, are at increased risk of blockage from blood, air bubbles, or other debris. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6462", "text": "There are three types of intraparenchymal pressure monitors (IPM), also called  bolts : fiber optic, strain gauge, and pneumatic sensors. [ 1 ]  Fiber optic monitors use changes in light reflected back from a mirror at the end of the cable to reflect changes in the ICP. Strain gauge monitors use a diaphragm that is bent by surrounding pressure, which is then converted into electrical signals used to calculate changes in ICP. \u00a0Pneumatic sensors are fitted with a balloon which measures the surrounding pressure, thereby measuring the ICP. [ 4 ]  IPMs are as equally accurate as EVDs, but cannot be recalibrated after placement, which is a major clinical limitation of this method of intracranial pressure monitoring. Risks of IPMs are similar to risks of EVDs as both require a surgical procedure. However, placement of IPMs is still considered less invasive than placement of EVDs. Additionally, placement of IPMs do not require the precision needed for EVD placement, and they are less affected by structural changes to the brain such as brain swelling or midline shift. [ 2 ]  IPMs can be placed not only in the parenchyma but also in the ventricular, subarachnoid, subdural, or epidural spaces. Generally, IPMs are chosen when EVD placement is unsuccessful or if CSF drainage is determined to likely not be necessary. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6463", "text": "This method of intracranial pressure monitoring requires placement of an oxygen probe into the penumbra, the area surrounding the injury that is most at risk of secondary injury from hypoxia. The probe measures levels of oxygen in the area, with levels under 15mmHg treated with increasing oxygen levels in the body. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6464", "text": "There are many noninvasive methods for intracranial pressure monitoring such as transcranial doppler (TCD), and optic nerve sheath diameter (ONSD). While none of these methods have been able to have the accuracy, reliability, and independent validation of invasive methods, they may eventually be used in determining the severity of injury and if there is a need for more invasive measures. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6465", "text": "Intraoperative magnetic resonance imaging  (iMRI) is an operating room configuration that enables surgeons to image the patient via an  MRI  scanner while the patient is undergoing surgery, particularly brain surgery. iMRI reduces the risk of damaging critical parts of the brain and helps confirm that the surgery was successful or if additional resection is needed before the patient's head is closed and the surgery completed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6466", "text": "Compared to other imaging types, high-field iMRI requires the additional cost of specialized operating suites, instrumentation and longer anesthesia and operating room time; however, published studies show use of iMRI increases physicians\u2019 ability to detect residual tumor leading toward an improved rate of procedural success. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6467", "text": "iMRI is available in a range of strengths. Low-field units, less than 1  Tesla  (T), have the advantage of small size, simpler operating theater preparation and portability but are disadvantaged by relatively poor image resolution.  Higher field strengths, currently available in 1.5 and 3T options, provide better spatial and contrast resolution enabling surgeons to more accurately evaluate the findings on an image. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6468", "text": "High-field iMRI operating suites are configured in one of two ways. [ 3 ]   Both require that the MRI magnet be stored in an adjacent room. One configuration requires that the patient be moved to the magnet to obtain an image. [ 2 ] [ 4 ]   The second configuration (only offered by  IMRIS , Inc.) moves the MRI magnet to the patient via ceiling-mounted rails to obtain the image. [ 1 ]   The latter approach has the advantage of not moving the patient from the operating theater during the surgery and enhances workflow and safety in terms of airway control, monitoring and head fixation. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6469", "text": "The most prevalent application for iMRI is  neurosurgery , especially for the removal of  brain tumors . [ 3 ] [ 5 ]  The system is also used for interventional neurovascular  [ 6 ]  procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6470", "text": "By providing iMRI during neurosurgery, clinicians can distinguish between tumor tissue and normal tissue, minimize disturbance of healthy tissue or critical areas of the brain, evaluate and confirm their results and make adjustments during a procedure without moving the patient (in the case of the rail-mounted configuration). Published clinical evidence shows the higher percentage of tumor removed the better the outcome. [ 1 ]   Use of an iMRI suite makes it more likely that surgeons will remove the entire tumor than if surgery is performed in a conventional operating room where iMRI is not used. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6471", "text": "Keen's point  is one of the  ventriculostomy  sites used in  neurosurgery , typically in pediatrics for  ventriculoperitoneal shunt  placement. Keen's point is located 3\u00a0cm superior and 3\u00a0cm posterior to the  helix of the ear . [ 1 ] [ 2 ]  A burr hole or small twist drill hole is made in the skull at the Keen's point, to introduce a catheter into the  lateral ventricle  of brain for the purpose of obtaining or diverting  cerebrospinal fluid . The procedure is done for both diagnostic and therapeutic purposes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6472", "text": "Kocher's point  is a common entry point through the  frontal bone  for an intraventricular  catheter  to drain  cerebrospinal fluid  from the anterior horn of the  lateral ventricle . It is located 2\u20133 centimeters lateral to the midline (at approximately the mid-pupillary line) and approximately 11\u00a0cm posterior to the  nasion , or 10\u00a0cm posterior from the  glabella . [ 1 ]  During cannulation of the  lateral ventricle , Kocher's point is landmarked as a point of entry, and care must be taken to be at least 1\u00a0cm anterior to the coronal suture to avoid damaging the  primary motor cortex . [ 2 ]  It is most often used to remove cerebrospinal fluid for the treatment of  hydrocephalus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6473", "text": "A  laminectomy  is a surgical procedure that removes a portion of a  vertebra  called the  lamina , which is the roof of the  spinal canal . It is a major spine operation with residual scar tissue and may result in  postlaminectomy syndrome . Depending on the problem, more conservative treatments (e.g., small endoscopic procedures, without bone removal) may be viable. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6474", "text": "The lamina is a posterior arch of the vertebral bone lying between the spinous process (which juts out in the middle) and the more lateral pedicles and the transverse processes of each  vertebra . The pair of laminae, along with the  spinous process , make up the posterior wall of the bony spinal canal. Although the literal meaning of laminectomy is 'excision of the lamina', a conventional laminectomy in neurosurgery and orthopedics involves excision of the  supraspinous ligament  and some or all of the spinous process. Removal of these structures with an open technique requires disconnecting the many muscles of the back attached to them. A laminectomy performed as a minimal spinal surgery procedure is a tissue-preserving surgery that leaves more of the muscle intact and spares the spinal process. Another procedure, called the laminotomy, is the removal of a mid-portion of one lamina and may be done either with a conventional open technique or in a minimalistic fashion with the use of tubular retractors and endoscopes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6475", "text": "The reason for lamina removal is rarely, if ever, because the lamina itself is diseased; rather, it is done to break the continuity of the rigid ring of the spinal canal to allow the soft tissues within the canal to:  1) expand (decompress); 2) change the contour of the vertebral column; or 3) permit access to deeper tissue inside the spinal canal. A laminectomy is also the name of a spinal operation that conventionally includes the removal of one or both lamina, as well as other posterior supporting structures of the vertebral column, including ligaments and additional bone. The actual bone removal may be carried out with a variety of surgical tools, including drills, rongeurs and lasers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6476", "text": "The success rate of a laminectomy depends on the specific reason for the operation, as well as proper patient selection and the surgeon's technical ability. The first laminectomy was performed in 1887 by  Victor Alexander Haden Horsley , [ 2 ]  a professor of surgery at  University College London . A laminectomy can treat severe  spinal stenosis  by relieving pressure on the  spinal cord  or nerve roots, provide access to a tumor or other mass lying in or around the spinal cord, or help in tailoring the contour of the vertebral column to correct a spinal deformity such as  kyphosis . A common type of laminectomy is performed to permit the removal or reshaping of a spinal disc as part of a lumbar  discectomy . This is a treatment for a  herniated , bulging, or degenerated disc. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6477", "text": "The recovery period after a laminectomy depends on the specific operative technique, with minimally invasive procedures having significantly shorter recovery periods than open surgery. Removal of substantial amounts of bone and tissue may require additional procedures such as  spinal fusion  to stabilize the spine and generally require a much longer recovery period than a simple laminectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6478", "text": "With spinal fusion, the recovery time may be longer. In some cases after laminectomy and spinal fusion, it may take several months to return to normal activities. [ 1 ]  Potential complications include bleeding, infection, blood clots, nerve injury, and spinal fluid leak. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6479", "text": "Most commonly, a laminectomy is performed to treat spinal stenosis.  Spinal stenosis  is the single most common diagnosis that leads to spinal surgery, of which a laminectomy represents one component. The  lamina  of the  vertebra  is removed or trimmed to widen the  spinal canal  and create more space for the  spinal nerves  and  thecal sac . Surgical treatment that includes a laminectomy is the most effective remedy for severe spinal stenosis; however, most cases of spinal stenosis are not severe enough to require surgery. When the disabling symptoms of spinal stenosis are primarily  neurogenic claudication  and the laminectomy is done without spinal fusion, there is generally a more rapid recovery with less blood loss. [ 3 ]  However, if the spinal column is unstable and fusion is required, the recovery period can last from several months to more than a year, and the likelihood of symptom relief is far less probable. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6480", "text": "In most known cases of lumbar and thoracic laminectomies, [ 5 ]  patients tend to recover slowly, with recurring pain or  spinal stenosis  persisting for up to 18 months after the procedure. According to a  World Health Organization  census in 2001, most patients who had undergone a lumbar laminectomy recovered normal function within one year of their operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6481", "text": "Back surgery can relieve pressure on the spine, but it is not a cure-all for spinal stenosis. There may be considerable pain immediately after the operation, and pain may persist on a longer-term basis. For some people, recovery can take weeks or months and may require long-term occupational and physical therapy. Surgery does not stop the degenerative process and symptoms may reappear within several years. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6482", "text": "A  laminotomy  is an  orthopaedic   neurosurgical  procedure that removes part of the  lamina of a vertebral arch  in order to relieve pressure in the  vertebral canal . [ 1 ]  A laminotomy is less invasive than conventional  vertebral column  surgery techniques, such as  laminectomy  because it leaves more  ligaments  and  muscles  attached to the spinous process intact and it requires removing less bone from the  vertebra . [ 1 ]  As a result, laminotomies typically have a faster recovery time and result in fewer postoperative complications. Nevertheless, possible risks can occur during or after the procedure like  infection ,  hematomas , and  dural tears . [ 2 ]  Laminotomies are commonly performed as treatment for  lumbar spinal stenosis  and  herniated disks . [ 2 ]   MRI  and  CT scans  are often used pre- and post surgery to determine if the procedure was successful. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6483", "text": "The  spinal cord  is housed in a bony hollow tube called the  vertebral column . [ 3 ]  The vertebral column is composed of many ring-like bones called  vertebra  (plural: vertebrae) and it spans from the  skull  to the  sacrum . Each vertebra has a hole in the center called the  vertebral foramen  through which the  spinal cord  traverses. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6484", "text": "Laminae  (singular: lamina) are the anatomical structures of primary importance in a laminotomy. Laminae are part of the  vertebral arch  which is the region of bone on the back side of each vertebra that forms a protective covering for the back side of the spinal cord. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6485", "text": "The  vertebral arch  is composed of several anatomical features in addition to laminae that must be taken into account when performing a laminotomy. In the center of the vertebral arch is a bony projection called the  spinous process . [ 3 ]  The spinous process is located on the posterior or back side of the  vertebra  and serves as the attachment point for  ligaments  and  muscles  which support and stabilize the  vertebral column . [ 3 ]  Each vertebra has two lateral bony projections called the  transverse processes  which are located on either side of the vertebral arch. Transverse processes come into contact with the  ribs  and serve as attachment points for muscles and ligaments that stabilize the vertebral column. [ 3 ]  The lamina is the segment of bone that connects the spinous process to the transverse process. Each vertebra has two  lamina , one on each side of the spinous process. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6486", "text": "Different types of laminotomy are defined by the type of instrument used to visualize the procedure, what  vertebra  the procedure is performed on, and whether or not both  lamina  of a vertebra are operated on or just one.G [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6487", "text": "Common types of laminotomy:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6488", "text": "These classifications of laminotomies can be combined to form the most descriptive name for the procedure possible. For example, an endoscopic unilateral lumbar laminotomy is the removal of bone from only one lamina of a lumbar vertebrae using an endoscope. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6489", "text": "The procedure of a laminotomy remains largely the same regardless of the instrument used, or the level of  vertebrae  operated on. Laminotomies require general or spinal  anesthesia  and frequently require a hospital stay following the procedure\u2014although the duration of the stay depends on the physical condition of the individual and their reason for having a laminotomy. [ 1 ] [ 2 ]  A laminotomy takes about 70\u201385 minutes depending on the type of procedure used. [ 1 ]  Unilateral laminotomies typically require less time because bone is removed from only one lamina, whereas bilateral laminotomies usually take more time because bone is removed from both laminae. The level of the vertebrae that the laminotomy is performed on and what instrument is used produce no significant differences in the length of the procedure. [ 1 ]  Both unilateral and bilateral laminotomies are performed in a shorter time period compared to a conventional  laminectomy  which takes over 100 minutes on average. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6490", "text": "During a laminotomy, the individual lies on his or her stomach with the back facing up towards the physician. [ 1 ]  An initial incision is made down the middle of the back exposing the  vertebrae  on which the laminotomy will be performed. [ 1 ]  In this procedure, the  spinous process  and the ligaments of the  vertebral column  are kept intact, but the muscles adjacent to the vertebral column known as the paraspinous muscles (example:  spinalis muscle ) must be separated from the spinous process and  vertebral arch . [ 1 ]  In a unilateral laminotomy, these muscles are detached only from the side on which the laminotomy is being performed. During a bilateral laminotomy, these muscles must be removed on both sides of the vertebrae. [ 1 ]  The ligaments connecting the lamina of upper and lower vertebrae, known as  Ligamenta flava  are often removed or remodeled in this procedure to adjust for the small amount of bone lost. [ 2 ]  Using either a  microscope  or an  endoscope  to have a visual of the procedure, a small surgical drill is used to remove a part of bone from one or both laminae of the vertebrae. [ 1 ]  Laminotomies can be performed on multiple vertebrae during the same surgery; this is known as a multi-level laminotomy. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6491", "text": "A slightly different, but commonly used procedure of laminotomy is the unilateral laminotomy for bilateral spinal decompression. [ 4 ]  This minimally invasive procedure is often used to treat patients with excessive pressure in the  vertebral column  that must be relieved. [ 4 ]  In this procedure, the same spinal ligaments are kept intact and the paraspinous muscles must still be detached. [ 5 ]  A unilateral laminotomy is performed on one lamina of a vertebra. [ 5 ]  This removal of bone from one lamina provides an opening into the spinal canal. Using a  microscope  or an  endoscope  to visualize the procedure, surgical tools are inserted through this opening into the  spinal canal . The surgical tools are then navigated underneath the  spinous process  and across the spinal canal to reach the other lamina on the opposite side of the  vertebra  to perform a second laminotomy. [ 5 ]  The incision for this procedure is smaller because doctors need only access one lamina yet can perform a bilateral laminotomy\u2014remove bone from both lamina of a single vertebra. [ 5 ]  The unilateral laminotomy with bilateral spinal decompression procedure was developed almost 20 years ago and is a common successful surgical treatment for  lumbar spinal stenosis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6492", "text": "A laminotomy is typically used to relieve pressure from the  spinal canal . Excessive pressure in the spinal canal causes the  spinal canal  and  spinal nerves  to be compressed which can be very painful and can impair motor control and/or sensation. A common disorder that causes increased pressure in the spinal canal is  lumbar spinal stenosis . Lumbar spinal stenosis is formally defined as a decline in diameter length of either the  neural foramina ,  lateral recess , or  spinal canal . [ 1 ]  Stenosis is classified as a decaying disease because it causes the canal to gradually become more and more narrow which can cause pain or loss of function. [ 1 ]  Common symptoms of lumbar stenosis are pain, fatigue, weakness of the muscle and numbness. [ 2 ]  Stenosis can be caused by old age or an injury to the vertebral column and usually requires a  CT scan  or  MRI  to diagnose. [ 2 ]  Performing a laminotomy can relieve pressure in the spinal canal caused by lumbar stenosis and therefore alleviate symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6493", "text": "Laminotomies are also performed to create a window into the  spinal canal . [ 2 ]  Laminotomies are frequently used as a way to surgically repair a  spinal disc herniation  at any level of the vertebral column (cervical, thoracic, lumbar). [ 1 ]  A herniated disc can compress  spinal nerves  and cause intense pain and impaired sensation. [ 4 ]  Removing a portion of the lamina allows physicians to be able to access and repair the herniated disc. Laminotomies may also be used to treat intraspinal lesions such as  spinal tumor  or problems with the blood vessels supplying the spinal cord. [ 4 ]  In any scenario where the inside of the spinal canal must be accessed or there is an increase in pressure in the spinal canal, laminotomy may be used to treat the disorder or alleviate symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6494", "text": "The laminotomy procedure has many benefits as to why it is a preferred spinal surgery since it is less invasive than other spinal procedures such as a laminectomy or a spinal fusion. [ 2 ]  Once a laminotomy procedure is done, patients have a great improvement in their pain and mobility. [ 2 ]  Laminotomies are usually safer than other surgeries that are open or invasive. [ 2 ]  This surgery usually is shorter than other spinal decompression procedures by having an average duration of 70\u201385 minutes, whereas other decompression surgeries can have a duration anywhere from 90 to 109 minutes. Laminotomies are usually more cost efficient than other surgical decompression surgeries. In 2007, it was seen that laminotomies were around $10,000, whereas other surgical procedures were around $24,000. [ 2 ]  Smaller skin incisions and scarring as well as less surgical trauma are also a benefit of laminotomy. [ 4 ]  With this procedure there is usually a faster recovery time, and a shorter hospital stay if one is necessary at all. [ 4 ]  During the surgery there is also a benefit of minimizing the injury to muscles, ligaments, and bones in the spine since more invasive surgeries have a greater risk of damaging them. [ 4 ]  General anesthesia is usually required, but postoperative spinal instability is typically limited. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6495", "text": "Since this procedure is a surgical technique there are many complications that can occur either during or after the surgery. Some major complications that can occur are  cerebrospinal fluid leaks ,  dural tears , infection, or  epidural hematomas . [ 2 ]  Death is also a risk; however, it occurs only once per thousand surgeries. [ 2 ]  Other potential complications are nerve root damage, which can lead to nerve injury or  paraplegia , and a significant amount of blood loss that will lead to blood transfusions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6496", "text": "Historically, laminectomies have been the primary way to treat lumbar spinal stenosis. [ 5 ]  A laminectomy is a more invasive method with the aim to decrease the total amount of pain and numbness associated with lumbar spinal stenosis. [ 2 ]  It is a surgery that eliminates the entire lamina to allow the nerves around this region to function properly. [ 2 ]  Laminectomies also often produce a longer recovery time as well as a greater risk for post-operative complications. There is typically more damage to the surrounding muscle tissue accompanied by a laminectomy. [ 5 ]  Since a laminectomy involves the excision of the entire lamina, a laminectomy will usually cause more spinal instability than a laminotomy. [ 5 ]  When going with the option of laminotomy, the procedure reduces the total amount of muscle severed. Because a laminotomy does not damage the spinous process and critical ligaments, there is not as much muscle weakness, pain, and lumbar instability seen with laminectomies. [ 4 ]  Laminotomies are fairly new compared to laminectomies, and it involves using less invasive methods with precise instruments to minimize the risk of tissue damage. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6497", "text": "For radiographic imaging, an x-ray is the least effective way to collect information when observing a patient with lumbar spinal stenosis. A  CT scan  provides a 360-degree compiled view of the vertebrae that is more precise than an  x-ray . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6498", "text": "Since an  MRI  provides excellent imaging of  blood vessels  and  tissues , it is recognized as the best type of imaging to observe signs associated with lumbar compression. The precise measurement of the diameter of the spinal canal is a particularly important component when determining the severity of the stenosis itself. [ 2 ]  High strength  3-Tesla  MRI machines are being utilized due to the increased vascular imaging capabilities. Better resolution capacity allows for more detailed observations by the healthcare provider. The sharp contrast of the high power MRI outlines details in the vertebra that are critical when examining a patient with lumbar spinal stenosis who may need a laminotomy. [ 1 ]  MRI scanning post invasive surgery is used to see the quality of the surgery itself, yet the appropriate postoperative time elapsed before conducting an MRI is a debated topic. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6499", "text": "A  CT scan  is not the most effective imaging technique when observing lumbar abnormalities, however it can supplement an MRI by detecting certain degenerative processes. When determining whether or not a laminotomy will be beneficial for the patient, a healthcare provider must assess the severity of the possible abnormalities. Out of all the potential reasons to have a laminotomy performed, lumbar  spinal stenosis  is the chief reason. CT scans are used specifically to pinpoint a buckled lumbar  ligamentum flavum  as well as facet  hypertrophy , which are some of the main pathophysiological changes indicative of lumbar spinal stenosis. [ 2 ]  Even though a CT scan can reveal these pertinent signs of lumbar spinal stenosis, it can sometimes give a cloudy image due to the shadowing of the tissue contrast. When this occurs, an  intrathecal myelography  contrast is conducted with the CT scan to fix the abnormal contrast. A CT scan can also reveal an increase in the cross sectional area of the  L3  vertebrae, which ultimately decreases the cross sectional area of the spinal canal. [ 2 ]  As an increase in the size of the L3 vertebrae occurs, pressure builds up on the  cauda equina , commonly causing pain in the lower back and lower extremities. Cauda equina compression can also be due to stenosis of L4-5 region as well. [ 1 ]  Even though the CT scan allows for intensive image studying, the fixed nature of the image collection process alone is not enough to reach a definitive diagnosis of lumbar spinal stenosis. The outcome of the CT scan can help compile physiological evidence that the patient has lumbar spinal stenosis, and that the patient may potentially benefit from a laminotomy to improve his or her quality of life. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6500", "text": "Other than static imaging processes, a CT scan can also be used for observing changes in spinal canal features before and after a laminotomy. One of the main signs of lumbar spinal stenosis is the thickening of the ligamentum flavum, causing it to expand towards the spinal canal. [ 2 ]  When observing the cross sectional area of the spinal canal of a human cadaver, it was found that the area had decreased due to ligamentum flavum thickening. The ligamentum flavum did not appear to alter the dynamic alterations in the dimensions of the spinal cord. Even after the intervertebral  disc  was removed, the ligamentum flavum did not appear to be a factor in the change in the dimensions of the spinal canal. [ 6 ]  By understanding the magnitude of the role that ligamentum flavum hypertrophy plays in lumbar sacral stenosis, the necessity of an invasive lumbar spinal procedure can be accurately measured. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6501", "text": "Minimally invasive procedures  are a more common alternative due to the decreased risk of damaging significant muscle tissue. The difference between invasive and minimally invasive spinal surgeries is that minimally invasive procedures involves a series of small incisions. Minimally invasive procedures can be performed anywhere along the spine, and have been used to treat various abnormalities. [ 2 ]  The percutaneous pedicle screw fixation technique allows for a procedure that presents minimal risk to the patient.  Fluoroscopic  image  guided navigation  through these portals allows for surgeons to perform more efficient procedures. Minimally invasive procedures often yield a much faster recovery time than fully invasive surgeries, making them more appealing to patients.  Laminectomies  have always been the gold standard when treating lumbar spinal stenosis, but recently, less invasive surgeries have emerged as a safer alternative treatment that helps maintain the postoperative structural integrity of the spine. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6502", "text": "Spinal microsurgery is a minimally invasive unilateral laminotomy used to correct bilateral lumbar spinal compression. Spinal microsurgery is the most common and effective microsurgical decompression treatment for patients who present with moderate to severe spinal stenosis. [ 4 ]  Spinal microsurgeries are performed with high magnification 3-D imaging of the fixated area of the spine, reducing the potential risk of harming the architecture of the spine itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6503", "text": "Endoscopic spine surgeries can be used to treat thoracic lesions, and have been proven to be a much safer option than a  thoracotomy . However, an endoscopic spine surgery can be performed to treat other spinal conditions, such as a herniated lumbar disc. [ 4 ]  Recovery time from this type of surgical treatment is often very quick, with patients ambulating within a few hours of the procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6504", "text": "Spinal fusion  involves fusing two vertebrae together using a spacer, and is intended to prohibit movement at that particular segment.  Screws  are typically inserted to assure that the spacer is held in place. The most common lumbar spinal fusion occurs between L4 and L5. [ 4 ]  A lumbar spinal fusion may be recommended when non-surgical treatment options for severe  degenerative disc disease  are ineffective. A laminotomy would not be effective in this case, since this procedure is concerning a degenerated disc that needs to be removed in order to relieve certain symptoms. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6505", "text": "A  leucotome  or  McKenzie leucotome  is a  surgical instrument  used for performing  leucotomies  (also known as  lobotomy ) and other forms of  psychosurgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6506", "text": "Invented by  Canadian  neurosurgeon Dr. Kenneth G. McKenzie in the 1940s, the leucotome has a narrow shaft which is inserted into the brain through a hole in the skull, and then a plunger on the back of the leucotome is depressed to extend a wire loop or metal strip into the brain. The leucotome is then rotated, cutting a core of brain tissue. [ 1 ]  This type was used by the  Nobel Prize -winning Portuguese neurologist  Egas Moniz . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6507", "text": "Another, different, surgical instrument also called a leucotome was introduced by  Walter Freeman  for use in the transorbital lobotomy. Modeled after an  ice-pick , it consisted simply of a pointed shaft. It was passed through the tear duct under the eyelid and against the top of the eyesocket. A mallet was used to drive the instrument through the thin layer of bone and into the brain along the plane of the bridge of the nose, to a depth of 5\u00a0cm. Due to incidents of breakage, a stronger but essentially identical instrument called an  orbitoclast  was later used. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6508", "text": "Lobotomies were commonly performed from the 1930s to the 1960s, with a few as late as the 1980s in France. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6509", "text": "This article related to  medical equipment  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6510", "text": "This  history of medicine  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6511", "text": "Microvascular decompression  ( MVD ), also known as the  Jannetta procedure , [ 1 ]  is a  neurosurgical  procedure used to treat  trigeminal neuralgia  (along with other cranial nerve neuralgias), a pain syndrome characterized by severe episodes of intense facial pain, and  hemifacial spasm . The procedure is also used experimentally to treat  tinnitus  and  vertigo  caused by vascular compression on the  vestibulocochlear nerve . [ 2 ]  As the goal of the Jannetta procedure is to relieve (vascular) pressure on the trigeminal nerve, it is a specific type of a  nerve decompression  surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6512", "text": "Nicholas Andre  first described  trigeminal neuralgia  in 1756.  In 1891 Sir  Victor Horsley  proposed the first open surgical procedure for the disorder involving the sectioning of preganglionic rootlets of the  trigeminal nerve .   Walter Dandy  in 1925 was an advocate of partial sectioning of the nerve in the  posterior cranial fossa .  During this procedure he noted  compression of the nerve  by vascular loops, and in 1932 proposed the theory that trigeminal neuralgia was caused by compression of the nerve by blood vessels, typically the  superior cerebellar artery . [ 4 ]   With the advent of the  operative microscope ,  Peter J. Jannetta  was able to further confirm this theory in 1967 and advocated moving the offending vessel and placing a sponge to prevent the vessel from returning to its native position as a treatment for trigeminal neuralgia. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6513", "text": "Patients most likely to benefit from a microvascular decompression have a classic form of trigeminal neuralgia. [ 6 ]  The diagnosis of this disorder is on the basis of the patients' symptoms and from a neurological examination.  No blood test or genetic marker exists to diagnose the disease. An  MRI scan  can help eliminate other diagnoses. Newer MRI techniques may allow for the visualization of vascular compression of the nerve. Patients who improve with an MVD are likely to have pain which is episodic rather than constant. The pain typically has an electrical quality to it and is intense. The pain can usually be triggered.  Common triggers include light touch, eating, talking or putting on make-up. Most patients whose face pain improved with an MVD also improved at least temporarily with medication."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6514", "text": "In addition to having the proper type of pain, candidates for an MVD must also be healthy enough to undergo surgery.  The risk of surgery may increase with increasing patient age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6515", "text": "Patients are put to sleep using  general anaesthesia  and are positioned on their back with their head turned or on their side with the symptomatic side facing up. Electrical monitoring of facial function and hearing is used.  A straight incision is made two finger-breadths behind the ear about the length of the ear.  A portion of the skull around 30\u00a0mm (1.2 inches) in diameter is removed exposing the underlying brain covering known as the  dura .  The dura is opened to expose the  cerebellum .  The cerebellum is allowed to fall out of the way exposing the side of the  brainstem .  Using a microscope or endoscope and micro-instruments, the  arachnoid membrane  is dissected allowing visualization of the 8th, 7th and finally the trigeminal nerve.  The offending loop of blood vessel is then mobilized.  Frequently a groove or indentation is seen in the nerve where the offending vessel was in contact with the nerve. Less often the nerve is thin and pale.  Once the vessel is mobilized a sponge like material is placed between the nerve and the offending blood vessel to prevent the vessel from returning to its native position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6516", "text": "After the decompression is complete, the wound is flushed clean with saline solution. The dura is closed in a watertight fashion.  The skull is reconstructed and the overlying tissues are closed in multiple layers.  The patient is allowed to wake up and is taken to an intensive care unit or other close observation unit. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6517", "text": "The largest reported series of MVDs was reported by Jannetta and published in  The New England Journal of Medicine  in 1996.  The initial success rate was 82% for complete relief with an additional 16% having partial relief for a combined initial success rate of 98%.  At 10 year follow-up, 68% had excellent or good relief. 32% had recurrent symptoms. [ 8 ]  Other series report similar or better results. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6518", "text": "Serious complications from an MVD include death (0.1%), stroke (1%), hearing loss (3%) and facial weakness (0.5%). Dr. Jannetta has called facial paralysis (as opposed to weakness) a \"major and common complication of the MVD.\" (2 separate depositions under oath: Levy v Jannetta, CCP Allegheny County, GD 81\u20137689."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6519", "text": "Other complications include leakage of spinal fluid and wound infection (1%).  Most patients will have transient neck pain and stiffness from the surgical incision and from seeding of the spinal fluid with small amounts of blood. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6520", "text": "Several other surgical procedures exist for the treatment of trigeminal neuralgia, including percutaneous  rhizotomy , percutaneous  glycerol  injection, percutaneous balloon compression, rhyzotomy and stereotactic  radiosurgery  (SRS).  When compared to the other procedures, MVD carries the highest long-term success rate, but it also carries the highest risk. [ citation needed ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6521", "text": "Migraine surgery  is a  surgical operation  undertaken with the goal of reducing or preventing  migraines .  Migraine surgery most often refers to surgical  nerve decompression  of one or several nerves in the head and neck which have been shown to trigger migraine symptoms in many migraine sufferers. [ 1 ] [ 2 ] [ 3 ] [ 4 ]   Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates. [ 5 ] [ 6 ] [ 7 ]   The nerves that are most often addressed in migraine surgery are found outside of the skull, in the face and neck, and include the  supra-orbital  and  supra-trochlear nerves  in the forehead, the  zygomaticotemporal nerve  and  auriculotemporal nerves  in the temple region, and the  greater occipital ,  lesser occipital , and  third occipital nerves  in the back of the neck. [ 8 ] [ 1 ] [ 9 ] [ 3 ] [ 2 ] [ 4 ] [ 10 ] [ 11 ] [ 12 ]   Nerve impingement  in the nasal cavity has additionally been shown to be a trigger of migraine symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6522", "text": "Migraine surgery is usually reserved for migraine patients who fail more conservative therapy or who cannot tolerate the side effects of drugs used to treat their migraines.  Appropriate patients are screened using injections of  local anesthesia  to provide a temporary  nerve block . In some cases,  Botox  may be used to provide temporary decompression of the nerve. [ 13 ]   Patients who respond to nerve blocks often see an immediate though temporary reduction in their pain by \"shutting off\" the nerve that is triggering the migraine, while pain relief following Botox injections is provided by relaxation of nearby muscle tissue that may be compressing the nerve.  Patients who respond well to these screening procedures are felt to be excellent candidates for migraine surgery. [ 14 ] [ 6 ] [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6523", "text": "Migraine surgery is an outpatient procedure which addresses  peripheral nerves  through limited incisions.  Depending on the symptoms of the patient and the screening results following nerve blocks or Botox, different areas of the head and neck may be addressed to treat the nerves found to be the migraine trigger in a given patient.  Migraine surgery is always individualized to each patient's symptoms and anatomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6524", "text": "Nerves found in the forehead ( supra-orbital  and  supra-trochlear nerves ) are either addressed using  endoscopic surgery  or by using an incision in the crease of the upper eyelid. [ 17 ] [ 18 ]   Structures that are found pressing on the nerves here are released and may include  bone  at the upper orbit,  fascia ,  blood vessels , or muscle tissue.  The  supra-orbital  and  supra-trochlear nerves  travel through the  corrugator supercilii muscle  which enables frowning of the  brow .  These nerves are released from these muscles so they may lie free of pressure from these muscle structures.  Small blood vessels  which travel with these nerves may be divided to prevent pressure as well.  In the  bony notch  where these nerves exit the eye socket, small pieces of bone or connective tissue may be removed so undue pressure is not placed on the nerves in this region. [ 19 ] [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6525", "text": "The  zygomaticotemporal nerve  and  auriculotemporal nerves  are found in areas between the top of the ear and the lateral portion of the eye, in different areas of the temple.  These nerves can also be addressed by endoscopic techniques, or well hidden small incisions.   Blood vessels  next to or crossing these nerves are often found to be the source of compression, and these blood vessels may be divided to prevent irritation of these nerves.  Associated  temporal muscle  release in the region of these nerves may also be indicated. [ 22 ]   Because these nerves are very small and provide feeling to small regions of the scalp, they are often cut or avulsed, allowing the ends to retract into muscle tissue to prevent  neuroma  formation. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6526", "text": "Chronic irritation of the  occipital nerves  is called  occipital neuralgia  and is frequently the cause of migraine symptoms.  The  greater occipital  and  third occipital nerves  are addressed through an incision at the base of the scalp in the upper neck by either a vertical or transverse incision.  Incisions are usually placed within the hairline.  The  greater occipital nerve  travels through several muscle layers (including the  trapezius muscle  and  splenius capitis muscle ) where it is often compressed, and therefore surgery for this nerve involves releasing it from tight muscle and fascia in the upper neck.  Blood vessels found crossing the nerve such as the  occipital artery  may be divided in order to avoid chronic pressure and irritation of the  greater occipital nerve . [ 2 ] [ 24 ]   The  third occipital nerve  is a small nerve that travels near the greater occipital nerve and may treated similarly in order to alleviate chronic irritation. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6527", "text": "The  lesser occipital nerve  is a small nerve that has additionally been found to be associated with migraine pain.  This nerve is found near the  sternocleidomastoid muscle  and may be decompressed or divided here through a small incision.  As this small nerve provides feeling for a small region of the scalp, the minimal numbness resulting from the division of this nerve often goes un-noticed. [ 8 ] [ 11 ] Neurostimulation surgery, in which electrical stimulators are implemented over the occipital and/or superorbital nerves, has also been used to treat migraines, although there is scarce evidence for the effectiveness of this procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6528", "text": "The nerves of the nasal lining may be impinged by structures in the nose such as the  nasal septum  and  turbinates .   Nasal surgery  to decompress these regions may include  septoplasty ,  turbinectomy , or other  rhinoplasty  procedures. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6529", "text": "Though initially thought to be experimental surgery, the benefits of migraine surgery have now been well documented.  Followup data has shown that 88% of migraine surgery patients experienced a positive response to the procedure after 5 years.  29% of patients have been shown to achieve complete elimination of their migraine disease, while an additional 59% of patients reported a significant decrease in their pain and symptoms 5 years following their migraine surgery.  12% of patients undergoing migraine surgery reported no change in their symptoms after 5 years. [ 5 ] [ 6 ] [ 7 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6530", "text": "Migraine surgery has additionally been studied in a  socioeconomic  context and has been shown to reduce both direct and indirect costs associated with migraine disease. Such costs after migraine surgery have been shown to be reduced by a median of $3,949 per patient per year. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6531", "text": "Chronic daily headache is a major worldwide health problem that affects 3\u20135% of the population and results in substantial disability. Advances in the medical management of headache disorders have meant that a substantial proportion of patients can be effectively treated with medical treatments. However, a significant proportion of these patients are intractable to drug treatment. [ 28 ]  The successful use of surgical procedures for the treatment of migraine is becoming more frequently reported in the medical literature, particularly for those patients who do not respond to medication. There is resistance in some quarters the concept of surgery for migraine, on the grounds that it is unnecessarily invasive. On the contrary, others argue that to undergo a relatively minor and minimally invasive once-off surgical procedure is not as invasive as having to permanently take chronic medication, which in many people has unpleasant or intolerable side effects, or is ineffective. The answer to this conundrum lies however in informed consent - the patient must be advised of all the possibilities, and of all the pros and cons of each option, so that an informed choice can be made. In some instances, patients opt for the drug route, and only take the surgical option when the medication has not had the desired effect. For others, the thought of being on chronic medication is anathema."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6532", "text": "In many migraine sufferers, the pain originates in painfully dilated extracranial terminal branches of the external carotid artery. [ 29 ]  That vasodilatation is an important factor in migraine is further confirmed by the fact that the most widely used migraine rescue medications, the ergots, the triptans, and the promising newer drugs, the  gepants , possess one significant common denominator: they all potently constrict abnormally dilated extracranial arteries while simultaneously reducing or eliminating migraine pain. Furthermore, to date all migraine-provoking agents have had vasodilating properties. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6533", "text": "In patients where the pain has been positively diagnosed to originate from the scalp arteries (the terminal branches of the external carotid artery), the preventive treatment of choice is surgical cauterization of the responsible arteries \u2013 known as the Shevel Procedure. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6534", "text": "In order to pinpoint the position of the relevant arteries, a three-dimensional CT scan is done, which allows accurate visualization of the course of each artery. This is necessary, as the course of the arteries varies from person to person, and even from side to side in the same individual. During surgery, the position of the artery is further verified by means of a Doppler Flowmeter, with which one can hear the blood flowing through the vessel. Use of the three-dimensional CT scan and the Doppler Flowmeter allows the surgeon to make use of the smallest possible incision, so the procedure is minimally invasive. The most common vessels involved in the pain of migraine are the terminal branches of the  external carotid artery , and in particular, the  superficial temporal artery  and its frontal branch, and the  occipital artery , but the maxillary, posterior auricular, supra-orbital, and supra-trochlear branches may also be involved. These vessels are subcutaneous (just under the skin) and the small incisions required to access them and the minimally invasive nature of the procedure means that the surgery can be done in a day facility. As these vessels have no connection with the arterial supply to the brain, the Shevel Procedure is exceedingly safe with no unpleasant side effects. The cosmetic effect is excellent as most of the incisions are within the hairline. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6535", "text": "Arterial surgery is only indicated once there is positive confirmation that the arteries are indeed the source of pain. Some migraine sufferers have a visibly distended artery on the temple during an attack, which confirms that the arteries are involved. The distention usually subsides as the pain is controlled by vasoconstrictor drugs ( ergots  or  triptans ). [ 32 ]  In some, this artery is always visible, but it is only when it becomes distended during an attack that it becomes important for diagnosis. Patients who take triptans or ergots for relief of migraine pain are also prime candidates for arterial surgery. The reason for this is that the action of these drugs is to constrict the painfully dilated branches of the external carotid artery - the same arteries that are targeted by the surgery. The purpose of the surgery is to provide a permanent 'triptan or ergot effect'. Most of these arteries are in the scalp and are readily accessible to minimally invasive surgery. This treatment modality is of particular value in: 1) patients who have not responded to preventive drug therapy, 2) patients who are unable to use drug therapy because they experience unacceptable side effects, 3) patients who have to make too frequent use of abortive drugs such as the triptans or ergots, and 4) patients who would prefer not to be on permanent medication. Included in this category are those with Chronic Daily Headache (headache on more than 15 days per month) and patients with what is known as \"refractory headache\" - headache that has not benefited from any other form of treatment. Elliot Shevel, a South African surgeon, showed that patients with chronic migraine experienced a significant reduction in pain levels and significant improvement in their quality of life following the surgery. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6536", "text": "Trigger site release was first described by a plastic surgeon, Dr Bahaman Guyuron. [ 33 ]  The theory is that  trigger sites  (TSs) exist where  sensory nerves  are being compressed by a surrounding  muscle . The nerve becomes inflamed, and a cascade of events is initiated, triggering migraine headaches. Thus far, three muscle trigger areas where the nerve passes through a muscle have been identified as surgical candidates \u2013 where the a)  greater occipital nerve  pierces through the  semispinalis capitis muscle , b) the  zygomaticotemporal nerve  passes through the  temporalis muscle , and c) the  supraorbital / supratrochlear  nerves pass through the  glabellar  muscle group (the  corrugator supercilii ,  depressor supercilii , and  procerus muscles ). [ 34 ] [ 35 ] [ 36 ]  Several large series of studies have been conducted to evaluate the efficacy of surgical obliteration of trigger points. Almost all demonstrated more than 90% response in a carefully selected group of patients who have a positive response to  Botox  therapy, with at least 50% improvement to complete resolution of migraine pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6537", "text": "Patients have to be screened preoperatively with a full  neurological examination , and subsequent  Botox  injection. [ 37 ]  A positive response to Botox has been an accurate predictor of a successful outcome. Single or multiple TSs may be treated. Migraine headaches can start in one area depending on their corresponding trigger site and spread to the rest of the head. It is important to identify the initial trigger sites rather than address all the areas of pain, after the inflammation involves the entire  trigeminal tree .\n Forehead  migraine headaches : In the  glabellar  area the  supra-orbital  and  supra-trochlear  nerves are  skeletonized  by  resecting  the  corrugator  and  depressor supercilii muscle  using an  endoscopic  approach similar that of used for cosmetic  forehead lift .\n Temporal  migraine headaches : The temporal area, where the  zygomaticotemporal  branch of trigeminal nerve passes through the  temporalis  muscle, is addressed using a similar endoscopic approach but involves removing a segment of the nerve rather than transecting the muscle. This results in a slight sensory defect over temporal skin area, but cross- innervation  from other sensory nerves helps to limit the damage.\n Occipital  migraine headaches : The  posterior neck  area where the  greater occipital nerve  passes through the  semispinalis capitis muscle  is addressed with an  open surgical approach  with resection of a small segment of the semispinalis muscle and shielding the nerves with a  subcutaneous adipose  flap. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6538", "text": "A further  trigger point , not involving muscles, has been identified in the  nose  of patients who have significant  nasal septum  deviation with enlargement of the  turbinates . [ 35 ]  The nasal trigger points where enlarged turbinates are in contact with the nasal septum are addressed with a septoplasty and a turbinectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6539", "text": "There is evidence that a link exists between migraine with aura and the presence of a patent foramen ovale (PFO), a hole between the upper chambers (the atria) of the heart. [ 38 ]  It is estimated that 20-25% of the general population in the United States has a PFO. [ 39 ] [ 40 ]  Medical research studies have shown that migraineurs are twice as likely as the general population to have a PFO, [ 38 ] [ 39 ]  that over 50% of sufferers of migraine with aura have a PFO, [ 38 ]  that patients with a PFO are 5.1 times more likely to suffer from migraines and 3.2 times more likely to have migraines with aura than the general population, [ 38 ]  and that patients with migraine with aura are much more likely to have a large opening than the general PFO population. [ 38 ] [ 40 ] [ 41 ]  There is however some controversy, as some have shown a link, [ 42 ]  while others have failed to demonstrate a link. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6540", "text": "A catheter is advanced up to the hole in the heart after it is inserted in a vein in the leg. Through the catheter, a device is then placed which blocks the hole between the left and right atria of the heart. There are a number of different devices being used or tested, the Coherex FlatStent PFO Closure System, [ 44 ]  the CardioSEAL, [ 45 ]  and the AMPLATZER PFO Occluder device. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6541", "text": "Migraine frequency and severity has been shown to be reduced if the hole (PFO) is patched surgically. [ 47 ]  It has been suggested that there is an advantage to non-pharmacological migraine relief - \"in contrast to drugs, PFO closure appears highly effective against migraines and usually has no side effects\". [ 48 ]  Because PFO closure continues to prove successful, new devices are being produced to make the surgery easier to perform and less invasive. Some studies, however, have emphasized caution in relating PFO closure surgeries to migraines, stating that the favorable studies have been poorly designed retrospective studies and that insufficient evidence exists to justify the dangerous procedure. [ 49 ] [ 50 ]  There have however been reports of short-term increases in migraine frequency and intensity following the surgery. [ 46 ] [ 51 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6542", "text": "Published reports from open-label studies have demonstrated possible efficacy of ONS in a variety of primary headache disorders, including chronic migraine. [ 28 ] [ 53 ]  ONS for the treatment of medically intractable headaches was introduced by Weiner and Reed  [ 54 ]  ONS is typically performed with the equipment normally used for spinal cord stimulation (SCS), which includes electrodes and their leads, anchors to fasten the leads to connective tissue, and the implantable pulse generator (IPG)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6543", "text": "Electrodes are placed subcutaneously (under the skin) superficial to the cervical muscle fascia, transverse to the affected occipital nerve trunk at the level of C1, usually using fluoroscopic guidance. The standard procedure is typically performed in two stages. The first stage, carried out under local anesthesia with sedation, is used to test the stimulation and determine optimal placement of electrodes. The second part, which involves insertion of the rest of the ONS system, is carried out under general anesthesia. However, a recent report of a small case series described successful placement of ONS systems entirely under general anesthesia while still achieving the desired occipital region stimulation. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6544", "text": "A stimulation trial can be performed before the permanent implantation, with the view to improving selection of the candidates for a permanent stimulation. The procedure involves inserting percutaneous (through the skin) leads into the epidural space and externally powering them for 5\u20137 days. If the trial is successful in terms of significant pain improvement, the patient is offered a permanent implantation. However, in primary headache syndromes, unlike in neuropathic pain, there can be a considerable delay of several weeks to months before the response emerges and therefore the utility of a stimulation trial in selecting patients for permanent implantation remains questionable for now. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6545", "text": "The involvement of the pericranial muscles in migraine has been well documented, [ 56 ] [ 57 ] [ 58 ] [ 59 ]  and muscle relaxation techniques have been used successfully to prevent migraine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6546", "text": "Intra-oral appliance are designed to relax the pericranial muscles, which have been reported to be tender in 100% of migraine sufferers during an attack. [ 56 ]  There are a number of different designs, which have been reported to be effective in many migraine sufferers. [ 60 ] [ 61 ] [ 62 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6547", "text": "Biofeedback is the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will. [ 64 ] [ 65 ]  Some of the processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception. [ 66 ]  Biofeedback to induce muscle relaxation is widely used in migraine prevention. [ 67 ] [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6548", "text": "OnabotulinumtoxinA (trade name  Botox ) received FDA approval for treatment of chronic migraines (occurring more than 15 days per month) in 2010. The toxin is injected into the muscles of head and neck. Approval followed evidence presented to the agency from two studies funded by Allergan, Inc. showing an improvement in incidence of chronic migraines for migraine sufferers undergoing the Botox treatment. [ 69 ] [ 70 ]  Since then, several randomized control trials have shown Botulinum Toxin Type A to improve headache symptoms and quality of life when used prophylactically for patients with chronic migraine [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6549", "text": "Surgical cauterization of the superficial blood vessels of the scalp (the terminal branches of the external carotid artery) is only carried out if it has been established with certainty that these vessels are indeed the source of pain. It is a safe and relatively atraumatic procedure which can be performed in a day facility. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6550", "text": "Migraine surgery  which involves decompression of certain  nerves  around the head and neck may be an option in certain people who do not improve with medications. [ 73 ]  It is only effective in those who respond well to  Botox  injections in specific areas. [ 74 ] [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6551", "text": "There also appears to be a  causal  link between the presence of a  patent foramen ovale  (PFO) and migraine. [ 76 ] [ 77 ]  There is evidence that the correction of the  congenital heart defect , PFO, reduces migraine frequency and severity. [ 78 ]  Recent studies have advised caution, though, in relation to  PFO  closure for migraine, as insufficient evidence exists to justify this dangerous procedure. [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6552", "text": "Multiple subpial transections  is a surgical treatment modality for  epilepsy  used in scenarios wherein epileptogenic  brain  regions (from where  partial seizures  originate) cannot be removed safely. The surgeon makes a series of shallow cuts (transections) into the brain's  cerebral cortex . These cuts are thought to interrupt some fibers that connect neighboring parts of the brain, but they do not appear to cause long-lasting impairment in the critical functions that these areas perform."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6553", "text": "Multiple subpial transections can help to reduce or eliminate seizures arising from vital functional areas of the cerebral cortex. This procedure has been successful in an unusual type of epilepsy called  Landau-Kleffner syndrome , [ 1 ]  at least for a limited time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6554", "text": "Bleeding at the site of the transection is possible, but the procedure is generally well tolerated. Major complications appear to be rare. Transections in  language  areas of the brain may mildly impair the language function served by that area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6555", "text": "Epilepsy surgery is reserved for people whose seizures are not well controlled by seizure medicines (this situation is sometimes describes as being  medically refractory ). In the past, epilepsy patients were referred for surgery only after they had taken medicine after medicine without success, often for 10 years or more. However, now the definition of medically refractory has changed and surgery is being performed as early as 1 to 2 years after the diagnosis of epilepsy is first made."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6556", "text": "In children, the definition of medically refractory is even more individualized to the specific child's situation. Surgery may be considered for some children after only weeks or months of treatment with seizure medicines."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6557", "text": "In general, a person is considered to be a potential candidate for surgery if adequate trials of two first-line seizure medicines (ones that are commonly effective in controlling the type of seizures the person is experiencing) and one two-drug combination all have failed to control the seizures. A trial of a medication is considered adequate when it has been increased gradually to the maximum dosage that does not cause serious side effects and then is given for a long enough period. If the person has frequent seizures, any improvement will be obvious after a short time. However, if the seizures generally occur far apart it may take months to determine whether the time between seizures is increasing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6558", "text": "At some epilepsy centers, patients are offered additional conventional or experimental medications before surgery is considered. However, research suggests that each time a trial of medication fails to control a person's seizures, it becomes less likely that a different medicine or combination will be successful. Since uncontrolled seizures present serious physical risks and social and  psychological  consequences, the trend these days is to proceed with surgery much sooner than in the past if it seems appropriate for that person."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6559", "text": "Success rates for epilepsy surgery are constantly improving, and advances in preoperative assessments are largely responsible. Proper patient selection and a thorough presurgical workup are the cornerstones of surgical success."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6560", "text": "If a review of the person's experiences with seizure medicines shows that adequate tests of at least a few different medications have not succeeded in controlling the seizures, then the person may be referred to a specialist for a preoperative (or presurgical) assessment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6561", "text": "The preoperative assessment has two general objectives:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6562", "text": "The number and type of tests that make up the preoperative assessment will depend on the type of surgery being considered. General objectives of the tests include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6563", "text": "The  N-localizer [ 3 ]  is a device that enables guidance of  stereotactic surgery  or  radiosurgery  using tomographic images that are obtained via  computed tomography  (CT), [ 4 ]   magnetic resonance imaging  (MRI), [ 5 ]  or  positron emission tomography  (PET). [ 6 ]  The N-localizer comprises a diagonal rod that spans two vertical rods to form an N-shape (Figure 1) and permits calculation of the point where a tomographic image plane intersects the diagonal rod. Attaching three N-localizers to a stereotactic instrument allows calculation of three points where a tomographic image plane intersects three diagonal rods (Figure 2). These points determine the spatial orientation of the tomographic image plane relative to the stereotactic frame. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6564", "text": "The N-localizer is integrated with the Brown-Roberts-Wells (BRW), [ 8 ]  Kelly-Goerss, [ 9 ]  Leksell, [ 10 ]  Cosman-Roberts-Wells (CRW), [ 11 ]  Micromar-ETM03B, FiMe-BlueFrame, Macom, and Adeor-Zeppelin [ 12 ]  stereotactic frames and with the Gamma Knife  radiosurgery  system. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6565", "text": "An alternative to the N-localizer is the  Sturm-Pastyr localizer  that comprises three rods wherein two diagonal rods form a V-shape and a third, vertical rod is positioned midway between the two diagonal rods (Figure 3). [ 14 ]  The Sturm-Pastyr localizer is integrated with the Riechert-Mundinger and Zamorano-Dujovny stereotactic frames. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6566", "text": "Compared to the N-localizer, the Sturm-Pastyr localizer is less accurate and necessitates more elaborate calculations to determine the spatial orientation of the tomographic image plane relative to the stereotactic frame. [ 16 ]  In contrast to the N-localizer that does not require specification of the pixel size in a tomographic image, [ 17 ]  the Sturm-Pastyr localizer requires precise specification of the pixel size. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6567", "text": "Research conducted four decades after the introduction of the N-localizer [ 19 ]  and Sturm-Pastyr localizer [ 20 ]  has revealed computational techniques that improve the accuracy of both localizers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6568", "text": "Nerve allotransplantation  (allo- means \"other\" in Greek) is the transplantation of a nerve to a receiver from a donor of the same species. For example, nerve tissue is transplanted from one person to another. Allotransplantation is a commonly used type of transplantation of which nerve repair is one specific aspect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6569", "text": "The transplant is called an  allograft , allogeneic transplant, or homograft. [ 1 ]  Currently the only FDA approved nerve allograft is the Avance graft of  AxoGen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6570", "text": "A nerve allograft is used for the reconstruction of peripheral nerve discontinuities in order to support the axonal regeneration across a nerve gap caused by any injury. It is human nerve tissue, processed to remove cellular and noncellular factors such as  cells ,  fat ,  blood , axonal debris and chondroitin sulfate proteoglycans while preserving the three-dimensional scaffold and basal lamina tubular structure of the nerve. This means the nerve allograft only consists of  extracellular matrix  (ECM), which is sterile and decullularized. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6571", "text": "There are three types of nerves;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6572", "text": "In a  trauma  or surgical resection, a nerve can be damaged, which is called a nerve defect. This defect needs to be repaired in order to regain full or partial sensory and motor function.\nPeripheral nerve injury is a major clinical problem and can result in  neuropathic pain , which is pain arising as a direct consequence of a lesion or disease affecting the  somatosensory system .\nDamaged nerve fibers continuously excite electric pulses, inducing pain or abnormal sensation  dysesthesia . It has been shown that in allograft surgeries, post-operative neuropathic pain was present in some patients, but only if they had this condition pre-operatively. [ 2 ]  Patients without neuropathic pain before their surgery did not complain about neuropathic pain afterwards. [ 2 ]  Hence, allograft treatment does not seem to be a risk factor for this specific problem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6573", "text": "Golden standard therapy for transected nerves is an end-to-end repair of the nerve, also known as primary nerve repair. With a certain amount of tension on the nerve due to the injury, the blood flow to the nerve decreases, which can eventually lead to ischemia and nerve damage. The gap between the nerve ends could then, for example, be bridged by a nerve that is harvested from a less critical area from the same patient. The piece of nerve used in this case is called an autograft  autotransplantation . [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6574", "text": "A commonly used nerve for autotransplantation is the  sural nerve  in the upper leg. Unfortunately, this treatment does have some disadvantages. First, there is a risk of donor site morbidity and functional loss. Secondly, patients have an increased risk of symptomatic neuroma formation. Thirdly,  a longer  anaesthesia  time is needed because of the additional surgical site for the donor nerve. Lastly, higher costs also due to the extra surgical site. Despite these downsides, reducing the function of the affected area is beyond the risks committed with harvest of the donor nerve. [ 4 ] [ 7 ] [ 8 ] \nIn case of insufficient amount of autologous nerve tissue or the inability to attach both nerve ends securely and tension free, these two options are not possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6575", "text": "Another option to bridge the gap is nerve allotransplantation. Nerve allografts are prepared from donated human nerve tissue. An allograft contains many of the beneficial characteristics of nerve autograft, such as three-dimensional microstructural scaffolding and protein components inherent to nerve tissue. [ 3 ]  One of the adverse effects of nerve allotransplantation is the immunogenic response. Tissue from another human being is used to restore the defect, which can induce an immunogenic response. An immune response against an allograft or xenograft is called  transplant rejection . To prevent this rejection, new immunosuppressive techniques are performed on the graft, before it is transplanted into the receiver. The donated nerve tissue is disinfected, by selectively removing cellular components and debris to cleave growth inhibitors and then terminally sterilized. [ 3 ]  These procedures make the immunogenic response insignificant.  Processed nerve allografts have now been used successfully to restore nerve continuity for over two decades."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6576", "text": "Rhazes , a Persian doctor, was the first who mentioned nerve repair in 900 AD. Nerve regeneration, is described for the first time in 1795 and in 1885 the first nerve allograft transplantation was reported. [ 9 ]  In 1945, after WWII, Sir Sunderland described the anatomy of the peripheral nerves and developed techniques to improve the outcomes of nerve repair.\nA successful regeneration for short allografts (<4\u00a0cm) was achieved. However, there was a period of failure to accomplish successful recovery for all the allografts longer than 4\u00a0cm.  Therefore, 'The Peripheral Nerve Injury committee' did not support nerve allograft until, in the early 1970s the first successful clinical trials on longer grafts were reported by using a new combination of radiation and freeze-drying techniques. [ 4 ] \nNowadays rejection is still an adverse effect of nerve allotransplantation, but modern immunosuppressive regimens are used to prevent this rejection. This is why these days, rejection has become a very rare complication and nerve allograft has become more relevant. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6577", "text": "An  axon  is the part of a  neuron  which conducts electrical impulses. Axons are surrounded by  myelin , which contain  Schwann cells . Schwann cells improve the electrical conduction. The myelin is surrounded by  endoneurium , which is a protective sheath of connective tissue. This is surrounded by  perineurium  and  epineurium , of which the latter is the outmost layer of dense connective tissue. When it comes to nerve repair, it is crucial that those layers make a good connection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6578", "text": "There are several kinds of  organ transplantation  techniques."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6579", "text": "The nervus suralis, a nerve from the lower leg, is most often used. Consequently, the patient will miss the specific nerve used as an autograft; therefore a person's own nerves can not be used for an unlimited number of times."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6580", "text": "The  surgery  of an allograft nerve can be explained in a few steps. First the surgeon has to prepare the broken nerve to do the standard operation procedures. This means the surgeon has to examine the local tissue and resecting scar tissue if needed. The proximal and distal segments of the injured nerves should be debrided to healthy tissue by visual and tactile signs. After that, the surgeon measures the distance between both nerve ends as well as the diameter of the damaged nerve. The processed nerve allografts come in different sizes, so that a gap can be closed without unwanted tension. When he has chosen the right allograft nerve, the procedure is no different from when an autograft is used. The same applies to the  microsurgery , that a surgeon may use to repair the nerve. This means the sutures which connect the allograft with the damaged nerve are placed in the epineurium. So all other important anatomical structures of the nerve are kept intact. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6581", "text": "There are several factors that help a  surgeon  decide whether he should choose a nerve-autograft or an allograft. The differences between autografts and allografts are discussed above.\nThe use of nerve autografts has some disadvantages. One is that the surgeon always creates a defect on the 'donorplace', from where the nerve is taken.\nAnother disadvantage is that when the defect is large, the amount of available autografts may be insufficient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6582", "text": "Nerve allografts bring a possible solution for these problems.\nBecause allografts are human nerves, processed in such a way that the immune response against the transplant is not provoked, the procedure differs little from the autograft-procedure except for the fact that there is no need to create a 'donorplace' defect. Therefore, allografts can be used more often in the same patient than autografts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6583", "text": "After the nerve is repaired, whether it is by using an autograft or an allograft,  wallerian degeneration  will be seen distal to the coaptation. This means that the part of the nerve that lies distal to the breaking point starts dissolving. The other end of the nerve will then grow back in this direction. The surgeon's  transplant  then only functions as the shell through which this growth can take place."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6584", "text": "Studies suggest that nerve allografts work just as good as nerve autografts and are therefore a good alternative to the classic nerve autograft. [ 5 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6585", "text": "Currently nerve reconstruction is limited in length. There is a relationship between the length of the nerve gap and the level of recovery following nerve repair. Two large clinical studies have divided three different gap lengths: 5-14mm, 15-29mm and 30-50mm nerve gaps. After adjustment for technical failures. The nerve grafts of 5-14mm had a 100% meaningful level of functional recovery in both studies. For nerve grafts above 15mm is seen in both studies a meaningful recovery around 80%. It seems likely that a shorter nerve gap has a better recovery, but despite that a significant difference was not found. [ 5 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6586", "text": "Since some studies on nerve allotransplantation determined the outcomes of sensory, motor and mixed nerves separately, the meaningful recovery for each nerve type has been assessed. Comparison of these outcomes has found no difference in successful recovery. [ 5 ] [ 8 ] [ 10 ]  In other words, the sensation and movement of the affected body parts, in most studies the forearm, equally improved. Successful recovery of all three nerve types was achieved in approximately 80 to 85% of cases. [ 5 ] [ 8 ]  Mixed nerves had a slightly lower recovery rate than sensory and motor nerves, but the success rate was still within the range just mentioned. [ 5 ] [ 8 ]  Concluding, allograft surgery can be appropriately used for the functional repair of nerve injury in sensory, motor and mixed nerves. [ 2 ] [ 5 ] [ 8 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6587", "text": "The use of nerve allografts is a relatively new development and therefore autografts are currently still used more frequently.\nEfforts are being made to determine which procedure, i.e. autograft or allograft surgery, is preferred for each nerve type, but more research needs to be done. No comparison of these two procedures has been made in one single clinical study, let alone in a  randomized controlled trial . This specific study type is of crucial value for  evidence-based medicine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6588", "text": "A  neurectomy , or  nerve resection  is a neurosurgical procedure in which a  peripheral nerve  is cut or removed to alleviate  neuropathic pain  or permanently disable some function of a nerve. The nerve is not intended to grow back. For  chronic pain  it may be an alternative to a failed  nerve decompression  when the target nerve has no motor function and  numbness  is acceptable. [ 1 ]  Neurectomies have also been used to permanently block  autonomic function  (e.g.  excessive sweating  in hands [ 2 ]  or involuntary muscle movement causing  cramps [ 3 ] ), and special  sensory function  not related to pain (e.g. vestibular nerve dysfunction causing  vertigo [ 4 ] )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6589", "text": "A temporary  nerve block  with an  anesthetic  is usually performed before surgery to confirm the diagnosis of neuropathic pain. [ 1 ]  Risks include numbness,  neuroma , and complications due to lack of innervation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6590", "text": "A presacral neurectomy is typically conducted to decrease severe pain and  menstrual cramps  in the  lower abdomen . Pain in this region is difficult to treat with noninvasive treatments.  Endometriosis  is the most common cause for this severe pain. One solution that doctors often mistakenly recommend as a cure is a  hysterectomy , or removal of the  uterus .  However, this often does not relieve endometriosis pain because the disease is left behind on other organs such as the bladder, bowels, or pelvic side walls, and  it can thrive on its own hormone supply. Another is to perform a presacral neurectomy. This is a procedure that interrupts the nerves going towards and/or around the uterus. [ 5 ]   Pain located on either side of the lower abdomen (but not mid line) should not be treated with a neurectomy. Only individuals with pain that is not relieved by the use of  NSAIDs  should consider this procedure. Techniques have been developed for this procedure to be performed  laparoscopically . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6591", "text": "The incision is typically directly under the  navel . Normally three small holes are made in the lower abdomen to allow for the instruments and other various surgical tools. Nerve tissue that runs to the uterus is interrupted at the sacral promontory; a point at which  spine  and  sacrum  meet. This is the best area to access and obtain a clear view of the nerves in the uterus. Proper precautions must be taken as to avoid unnecessary complications with the major blood vessels surrounding the uterus. Some of the complications post-operation include  urinary retention , as well as  constipation . Neither has been reported to cause lasting effects. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6592", "text": "Recent technological advances have allowed this same procedure to be done robotically, a minimally invasive technique similar to laparoscopy. The outcome of the procedure is identical to an open approach (laparotomy), but the incisions are much smaller allowing for less post-operation pain. Less pain following this surgery allows for a quicker recovery period too; two weeks as opposed to six weeks, on average. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6593", "text": "A vestibular neurectomy is an operation that severs the vestibular nerve, which contributes to balance, while sparing the cochlear nerve, which contributes to hearing. The procedure has the potential to relieve  vertigo , but may preserve the ability to hear. [ 7 ]   It is important to note that this procedure will not reverse the effects of  deafness .  The risks include:  hearing loss ,  tinnitus , dizziness, facial weakness,  spinal fluid  leak, and various infections. [ 8 ]  There are several different surgical approaches that can be used to complete this procedure: the middle cranial fossa, retrolabrynthine, retrosigmoid, and translabrynthine. [ 9 ]  The  middle cranial fossa  approach is one that most often requires neurosurgical expertise. The advantage of this procedure is that the  vestibular nerve  is clearly visible and can be sectioned without harming the  cochlear nerve  fibers. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6594", "text": "The general procedure begins by positioning the patient supine with the head turned to the side with surgical ear upright. An incision is made at the lower portion of the  zygomatic root  to the area of the  temporal  region for roughly seven centimeters. Precautions are taken by clamping flaps of tissue as to not impede further actions.  To expose the IAC (Inner Auditory Canal) properly, portions of bone from the  metal fundus  and also the  tegmen tympani  must be removed. [ 8 ]  The SVN ( superior vestibular nerve ) is then identified and cut at the point furthest from the vestibular crest. Along with the SVN,  Scarpa's ganglion  is also cut and removed. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6595", "text": "In cases of  M\u00e9ni\u00e8re's disease , a neurectomy may be needed when no other medical treatment is sufficient for over six months. In bilateral M\u00e9ni\u00e8re's disease, the procedure is done on the worse-off ear. Some procedures are done on both ears, but the risk of hearing loss then becomes significantly greater. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6596", "text": "Some ablations that have been previously performed laparoscopically are also now offered via the pulsed  radiofrequency technique . Pulsed radiofrequency ablation relies on delivering an electrical field specifically to neural tissue in order to damage it while minimizing injury to the surrounding area. For example, this technique has been used in patients with chronic shoulder pain as a way to perform a neurectomy of the suprascapular nerve with less risk of damage to nearby muscles within the rotator cuff. [ 10 ]  There is still a lack of evidence directly comparing the efficacy and safety of this technique compared to the traditional laparoscopic method, but there is evidence that it improves range of motion and pain compared to placebo [ 10 ]  or sham surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6597", "text": "Neurectomy can be an alternative to a  nerve decompression  for  nerve entrapment , such as when the nerves have no motor function and numbness along the  dermatome  is acceptable. A neurectomy is not a mutually exclusive option to a decompression as a neurectomy can also be used after a failed decompression. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6598", "text": "There are many nerves in the human body that are purely sensory such as the  cutaneous nerves , which provide innervation to all parts of the skin. The cutaneous nerves are especially susceptible to compression from wearables or injuries due to their superficial location. Some examples of wearable-induced irritation are supraorbital neuralgia from tight goggles, [ 12 ]  superficial radial neuropathy from handcuffs, [ 13 ]  and meralgia paresthetica from tight pants. [ 14 ]  As cutaneous nerves cover all areas of the skin, and any surgery which requires incisions may inadvertently cause injury or scarring, now entrapping a cutaneous nerve. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6599", "text": "A common tradeoff when electing to a neurectomy is that numbness along the nerve distribution is expected. Studies that have measured how bothersome numbness is to patients have found that most patients are not bothered at all by the numbness, and the ones that are find the numbness minimally bothering. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6600", "text": "Intercostal  neuralgia  is a neuropathic condition that involves the  intercostal nerves . The primary symptom is pain and it may be localized to the distribution of one or more of the intercostal nerves, manifesting as chest and abdominal pain. [ 18 ]  No treatment modality prior to neurectomy (e.g. systemic medications,  cryoablation , therapeutic  nerve blocks , and radioablation) has given effective pain relief and none have been curative. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6601", "text": "The success outcome is typically measured as a 50% or more decrease in  visual analog scale  (VAS) scores, which are numerical pain scores from 0 - 10 or 0-100. Success rates are often reported as 70%. [ 20 ] [ 21 ] [ 22 ]  Studies reporting on intercostal neurectomy often report cure rates (100% reduction in symptoms), even though it is not the primary success outcome. For example, patients may say they are cured or report pain scores of zero. There is a wide span of the reported cure rates, ranging from 22 - 67%. [ 20 ] [ 21 ] [ 23 ]  A double-blind, randomized, controlled surgery trial found a 22% cure rate for the surgery group and a 4% cure rate for the sham surgery group, suggesting that these cure rates cannot be purely attributable to the  natural history of the disease  or a  placebo effect . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6602", "text": "Lateral femoral cutaneous neuralgia, often known as  Meralgia Paresthetica , involves neuropathic pain on the outer thigh. The use of a nerve decompression or neurectomy to treat nerve pain along the  lateral femoral cutaneous nerve  is a firmly established surgical treatment.  [ 24 ] [ 25 ]  However, the more effective treatment between a decompression and neurectomy is still being researched."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6603", "text": "Between a nerve decompression and a neurectomy, the neurectomy is associated with a higher success rate which has been validated by two  Cochrane  reviews. The reviews found decompressions beneficial in 88% of cases and neurectomy beneficial in 94% of cases. [ 26 ] [ 27 ]  A German national cohort study found similar results where complete pain relief from decompression was seen in 63% of cases but complete pain relief from neurectomy was seen in 85%. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6604", "text": "Neurectomy is also used in equine medicine, primarily for cases of persistent  lameness  that is non-responsive to other forms of treatment. It is most commonly used for animals with  navicular syndrome  and suspensory ligament desmitis. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6605", "text": "NeuroArm  is an engineering research  surgical robot  specifically designed for  neurosurgery . It is the first  image-guided ,  MR-compatible  surgical robot that has the capability to perform both  microsurgery  and  stereotaxy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6606", "text": "IMRIS , Inc. acquired NeuroArm assets in 2010, and the company is working to develop a next generation of the technology for worldwide commercialization.  It will be integrated with the VISIUS(TM) Surgical Theatre under the name SYMBIS(TM) Surgical System. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6607", "text": "NeuroArm was designed to be image-guided and can perform procedures inside an  MRI . NeuroArm includes two remote detachable manipulators on a mobile base, a workstation and a system control cabinet. For biopsy- stereotaxy , either the left or right arm is transferred to a stereotactic platform that attaches to the MR bore. The procedure is performed with image-guidance, as MR images are acquired in near real-time. The  end-effectors  interface with surgical tools which are based on standard neurosurgical instruments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6608", "text": "End-effectors are equipped with three-dimensional force-sensors, providing the sense of touch. The surgeon seated at the workstation controls the robot using force feedback hand controllers. The workstation recreates the sight and sensation of microsurgery by displaying the surgical site and 3D MRI displays, with superimposed tools. NeuroArm enables remote manipulation of the surgical tools from a control room adjacent to the surgical suite. [ 3 ]  It was designed to function within the environment of 1.5 and 3.0  tesla  intraoperative MRI systems. As neuroArm is MR-compatible, stereotaxy can be performed inside the bore of the magnet with near real-time image guidance. NeuroArm possesses the  dexterity  to perform microsurgery, outside of the MRI system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6609", "text": "Telerobotic operations  both inside and outside the magnet are performed using specialized tool sets based on standard neurosurgical instruments, adapted to the end effectors. Using these, NeuroArm is able to cut and manipulate soft tissue, dissect tissue planes, suture, biopsy, electrocauterize, aspirate and irrigate. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6610", "text": "The project began in 2002 when  Daryl , B.J., and Don Seaman provided $2 million to fund the design efforts.  Dr. Sutherland and his group established a collaboration with the Canadian space engineering company   MacDonald Dettwiler and Associates  (MDA). [ 5 ]   Close collaboration between MDA's robotic engineers and University of Calgary physicians, nurses, and scientists contributed to the design and development of NeuroArm. Official launch of the project was on April 17, 2007. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6611", "text": "NeuroArm was designed to take full advantage of the imaging environment provided by intraoperative MRI. The ability to couple near real-time, high resolution images to robotic technologies provides the surgeon with image guidance, precision, accuracy, and dexterity. [ 7 ]  MDA's engineers were immersed in the operating room to study typical tool and surgeon motions in order to use biomimicry for effective design of the computer-assisted surgical device. The OR environment, personnel, surgical rhythm and instrumentation remain unchanged. The surgeon, sitting at the workstation, is provided a virtual environment that recreates the sight, sound, and touch of surgery. Functions like tremor filtering and motion scaling were applied to increase precision and accuracy while functions like no-go zones and linear lock were applied to enhance safety. Surgical tools near the patient's head are incapable of fully independent movement and are slaved to the surgeon\u2019s movement at all times. Pre-planned automatic motions are used to move the robot arms away from the patient's head for manual tool exchange, and then return them to the original position and orientation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6612", "text": "On May 12, 2008, the first image-guided MR-compatible robotic neurosurgical procedure was performed at  University of Calgary  by Dr. Garnette Sutherland using the NeuroArm. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6613", "text": "Neurofibromatosis type II  (also known as  MISME syndrome  \u2013 multiple inherited schwannomas, meningiomas, and ependymomas) is a genetic condition that may be inherited or may arise spontaneously, and causes benign tumors of the brain, spinal cord, and peripheral nerves. The types of tumors frequently associated with NF2 include vestibular schwannomas, meningiomas, and ependymomas. The main manifestation of the condition is the development of bilateral  benign   brain tumors  in the nerve sheath of the  cranial nerve VIII , which is the \"auditory-vestibular nerve\" that transmits sensory information from the  inner ear  to the  brain . Besides, other benign brain and spinal tumors occur. Symptoms depend on the presence, localisation and growth of the tumor(s). Many people with this condition also experience vision problems. Neurofibromatosis type II (NF2  or  NF II) is caused by  mutations  of the  \"Merlin\"   gene , [ 2 ]  which seems to influence the form and movement of  cells . The principal treatments consist of  neurosurgical  removal of the tumors and surgical treatment of the eye lesions. Historically the underlying disorder has not had any therapy due to the cell function caused by the genetic mutation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6614", "text": "NF2 is an inheritable disorder with an  autosomal dominant  mode of transmission. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6615", "text": "There are two forms of the NF2: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6616", "text": "Symptoms can occur at any age, typically in adolescence and early adulthood, and rarely seen in children, and the severity depends on the location of the tumours. Symptoms include, but are not limited to: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6617", "text": "Because hearing loss in those with NF2 almost always occurs after acquisition of verbal language skills, people with NF2 do not always integrate well into  Deaf culture  and are more likely to resort to auditory  assistive technology . [ citation needed ] \nOne of these devices is the  cochlear implant , which can sometimes restore a high level of auditory function even when natural hearing is totally lost. However, the amount of destruction to the cochlear nerve caused by the typical NF2 schwannoma often precludes the use of such an implant. In these cases, an  auditory brainstem implant  (ABI) can restore some level of hearing, supplemented by  lip reading . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6618", "text": "NF2 is caused by inactivating mutations in the NF2 gene located at 22q12.2 of  chromosome 22 , type of mutations vary and include protein-truncating alterations (frameshift deletions/insertions and nonsense mutations), splice-site mutations, missense mutations and others. Deletions, too, in the  NH 2 -terminal domain  of merlin proteins have been associated with early tumor onset and poor prognosis in people with NF2. [ 5 ]  Protein truncating mutations correlate with more severe phenotype. [ 6 ]   There is a broad clinical spectrum known, but all people with the condition who have been checked have been found to have some mutation of the same gene on  chromosome 22 . Through statistics, it is suspected that one-half of cases are inherited, and one-half are the result of new,   de novo   mutations . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6619", "text": "The hearing loss caused by NF2 is gradual and results from the presences of bilateral cochleovestibular schwannomas, also known as acoustic neuromas, which damage to cochlear nerve causing hearing loss. [ citation needed ]  Hearing loss may also result from benign tumors that grow on the vestibular and auditory nerves, which lead to the inner ear. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6620", "text": "NF2 is caused by a defect in the gene that normally gives rise to a product called  Merlin  or  Schwannomin , located on chromosome 22 band q11-13.1. Merlin was first discovered as a structural protein functioning as an actin cytoskeleton regulator. Later merlin's tumour suppressant role was described. Merlin regulates multiple proliferative signalling cascades such as  receptor tyrosine kinase  signalling,  p21-activated kinase  signalling,  Ras  signalling,  MEK - ERK  cascade,  MST-YAP cascade . [ 7 ]  In a normal cell, the concentrations of active (dephosphorylated) merlin are controlled by processes such as  cell adhesion  (which would indicate the need to restrain cell division). It has been shown that Merlin inhibits  Rac1  which is crucial for cell motility and tumour invasion. [ 8 ]  Also, merlin's interaction with  cyclin D  was described. [ 9 ]  It is known that Merlin's deficiency can result in unmediated progression through the  cell cycle  due to the lack of contact-mediated tumour suppression, mainly because of the cell:cell junction disruption, sufficient to result in the tumors characteristic of Neurofibromatosis type II. Recent studies showed that besides its cytoskeletal and cytoplasmic functions Merlin also translocates to the nucleus and suppresses proliferation by inhibiting E3  ubiquitin ligase  CRL4(DCAF1). [ 10 ]  Finally, most recent studies indicated that Merlin also plays important role in energy metabolism regulation. [ 11 ] [ 12 ]  Mutations of NF2 is presumed to result in either a failure to synthesize Merlin or the production of a defective peptide that lacks the normal tumor-suppressive effect. The Schwannomin-peptide consists of 595  amino acids . Comparison of Schwannomin with other  proteins  shows similarities to proteins that connect the  cytoskeleton  to the  cell membrane . Mutations in the Schwannomin-gene are thought to alter the movement and shape of affected cells with loss of contact inhibition.\nEpendymomas are tumors arising from the  ependyma , an epithelium-like tissue of the  central nervous system . [ 13 ]  In people with NF2 and ependymomas, the tumor suppressant function of Merlin may be compromised. Loss of function mutations occurring in  chromosome 22q , where Merlin proteins are coded, can promote  tumorigenesis , or the creation of new tumorous cells. [ 5 ]  Deletions, too, in the  NH 2 -terminal domain  of merlin proteins have been associated with early tumor onset and poor prognosis in affected people. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6621", "text": "The so-called  acoustic neuroma  of NF2 is in fact a  schwannoma  of the nervus vestibularis, or vestibular schwannoma. The misnomer of acoustic neuroma is still often used. The vestibular schwannomas grow slowly at the inner entrance of the internal auditory meatus (meatus acousticus internus). They derive from the nerve sheaths of the upper part of the nervus vestibularis in the region between the central and peripheral myelin (Obersteiner-Redlich-Zone) within the area of the porus acousticus, 1\u00a0cm from the brainstem. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6622", "text": "Many people with NF2 were included in studies that were designed to compare disease type and progression with exact determination of the associated mutation. The goal of such comparisons of genotype and phenotype is to determine whether specific mutations cause respective combinations of symptoms. This would be extremely valuable for the prediction of disease progression and the planning of therapy starting at a young age. The results of such studies are the following: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6623", "text": "These results suggest that other factors (environment, other mutations) will probably determine the clinical outcome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6624", "text": "NF2 is a genetically transmitted condition. Diagnosis is most common in early adulthood (20\u201330 years); however, it can be diagnosed earlier. NF2 can be diagnosed due to the presence of a bilateral vestibular schwannoma, or an acoustic neuroma, which causes a hearing loss that may begin unilaterally. [ 14 ]  If a patient does not meet this criterion of diagnosis, they must have a family history of NF2, and present with a unilateral vestibular schwannoma and other associated tumors (cranial meningioma, cranial nerve schwannoma, spinal meningioma, spinal ependymomas, peripheral nerve tumor, spinal schwannoma, subcutaneous tumor, skin plaque). This being said, more than half of all patients diagnosed with NF2 do not have a family history of the condition. [ 14 ]  Although it has yet to be included into clinical classification, peripheral neuropathy, or damage to the peripheral nerves, which often causes weakness, numbness and pain in the hands and feet, may also lead to a diagnosis of NF2. In children, NF2 can present with similar symptoms, but generally causes \"visual disturbances (cataracts, hamartomas), skin tumors, mononeuropathhy (facial paresis, drop foot), symptomatic spinal cord tumors, or non-vestibular intracranial tumors\". [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6625", "text": "Bilateral vestibular schwannomas are diagnostic of NF2. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6626", "text": "Ferner et al. [ 16 ]   give three sets of diagnostic criteria for NF2:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6627", "text": "Another set of diagnostic criteria is the following: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6628", "text": "The criteria have varied over time. [ 17 ] \nThe last revision of the NF2 criteria was done by M.J. Smith in 2017. This included the consideration of a LZTR1 mutation (schwannomatosis) instead of NF2 and excluded bilateral vestibular schwannomas that occur after 70 years of age. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6629", "text": "There are several different surgical techniques for the removal of acoustic neuroma. [ 19 ]  The choice of approach is determined by size of the tumour, hearing capability, and general clinical condition of the person."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6630", "text": "Larger tumors can be treated by either the translabyrinthine approach or the retrosigmoid approach, depending upon the experience of the surgical team. With large tumors, the chance of hearing preservation is small with any approach. When hearing is already poor, the translabyrinthine approach may be used for even small tumors. Small, lateralized tumours in people with NF2 with good hearing should have the middle fossa approach. When the location of the tumour is more medial a retrosigmoid approach may be better."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6631", "text": "Auditory canal decompression is another surgical technique that can prolong usable hearing when a vestibular schwannoma has grown too large to remove without damage to the cochlear nerve. In the IAC (internal auditory canal) decompression, a middle fossa approach is employed to expose the bony roof of the IAC without any attempt to remove the tumor. The bone overlying the acoustic nerve is removed, allowing the tumour to expand upward into the middle cranial fossa. In this way, pressure on the cochlear nerve is relieved, reducing the risk of further hearing loss from direct compression or obstruction of vascular supply to the nerve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6632", "text": "Radiosurgery  is a conservative alternative to cranial base or other intracranial surgery. With conformal radiosurgical techniques, therapeutic radiation focused on the tumour, sparing exposure to surrounding normal tissues. Although radiosurgery can seldom completely destroy a tumor, it can often arrest its growth or reduce its size. While radiation is less immediately damaging than conventional surgery, it incurs a higher risk of subsequent malignant change in the irradiated tissues, and this risk is higher in NF2 than in sporadic (non-NF2) lesions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6633", "text": "There are no prescription medicines currently indicated for reduction in tumor burden for NF2 patients, although in patient studies  Bevacizumab  has resulted in reduction in tumor growth rates and hearing improvements in  some  patients. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6634", "text": "As hearing loss in individuals with NF2 is generally gradual, eventually profound and sensorineural, the best options for treatment for hearing loss are cochlear implants and auditory brainstem implants (ABIs), as well as supplementing hearing with lip-reading, cued speech or sign language."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6635", "text": "A cochlear implant is an electronic device that is surgically implants to stimulate the cochlear nerve. [ 22 ]  Cochlear implants will work only when the cochleovestibular nerve (8th nerve) and the cochlea are still functioning. In a study done with open-set speech perception testing and closed-set speech perception testing by Neff et al., they discovered that the use of cochlear implants with NF2 patients allowed significant improvement of hearing abilities. [ 23 ]  In testing of recognition of sentences of everyday speech, five out of six patients scored within the 90\u2013100% range, and in testing of hearing in noise setting, four of six of the patients scored within the 83\u201396%. [ 23 ]  Additionally, all testing was done without lip-reading."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6636", "text": "Auditory Brainstem Implants, or ABIs, are used when the cochlea or any portion of the cochleovestibular nerve are not functioning due to damage to those areas or anatomic abnormalities. [ 24 ]  The procedure is done by implanting a device that send an electrical signal directly to the cochlear nucleus, allowing sound to bypass the peripheral auditory system and straight into the brain stem. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6637", "text": "NF2 is a life limiting condition. It is a rare genetic disorder that involves noncancerous tumors of the nerves that transmit balance and sound impulses from the inner ear to the brain. The prognosis is affected by early age onset, a higher number of meningiomas and schwannomas and having a decrease in mutation. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6638", "text": "An early diagnosis is the best way to ensure improvement in management. Although, even with an early diagnosis, some patients still die very young. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6639", "text": "Meningiomas and schwannomas occur in around half of patients with NF2. Meningiomas are tumors that are both intracranial and intraspinal. Schwannomas are tumors that are often centered on the internal auditory canal. Patients with NF2 who have meningiomas have a higher risk of mortality, and the treatment can be very challenging. Individuals who develop schwannomas frequently develop hearing loss and deafness. [ 25 ]  These individuals may also develop tinnitus after being presented with unilateral hearing loss. The first symptom that individuals may encounter is dizziness or imbalance. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6640", "text": "Truncating mutations lead to smaller and non-functional protein products. Studies have shown that missense mutations and large deletions can both cause predominantly mild phenotypes. Phenotype is more variable in patients with splice-site mutations, and a milder disease in patients with mutations in exons 9\u201315. [ 25 ]  Patients with a missense mutation have a greater survival rate than nonsense and frameshift mutations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6641", "text": "Incidence of the condition is about 1 in 60,000. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6642", "text": "Neurolysis  is the application of physical or chemical agents to a  nerve  in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, it causes an interruption in the transmission of nerve signals. In the medical field, this is most commonly and advantageously used to alleviate pain in  cancer  patients. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6643", "text": "The different types of neurolysis include  celiac plexus  neurolysis,  endoscopic  ultrasound guided neurolysis, and lumbar sympathetic neurolysis. Chemodenervation and  nerve blocks  are also associated with neurolysis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6644", "text": "Additionally, there is  external neurolysis . Peripheral nerves move (glide) across bones and muscles. A peripheral nerve can be trapped by scarring of surrounding tissue which may lead to potential nerve damage or pain. An external neurolysis is when scar tissue is removed from around the nerve without entering the nerve itself. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6645", "text": "Neurolysis is a chemical  ablation  technique that is used to alleviate pain. Neurolysis is only used when the disease has progressed to a point where no other pain treatments are effective. [ 1 ]  A neurolytic agent such as alcohol, phenol, or glycerol is typically injected into the  nervous system . Chemical neurolysis causes deconstructive  fibrosis  which then disrupts the  sympathetic ganglia . This results in a reduction of pain signals being transmitted throughout the nerves. [ 3 ]  The effects generally last for three to six months. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6646", "text": "Certain neurolysis techniques have been reported to be used in the early 1900s for the treatment of pain by the neurologist  Mathieu Jaboulay . Early reported neurolysis helped treat  vasospastic disorders  such as arterial occlusive disease before the introduction of  endovascular  procedures. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6647", "text": "Celiac plexus neurolysis (CPN) is the chemical ablation of the celiac plexus. This type of neurolysis is mainly used to treat pain associated with advanced  pancreatic cancer . Traditional  opioid  medications used to treat pancreatic cancer patients may yield inadequate pain relief in the most advanced stages of pancreatic cancer, so the goal of CPN is to increase the efficiency of the medication. This in turn may lead to a decreased dosage, thereby decreasing the severity of the side effects. [ 3 ]  CPN is also used to decrease the chances of a patient developing an addiction for opioid medications due to the large doses commonly used in treatment. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6648", "text": "CPN can be performed by percutaneous injection either anterior or posterior to the celiac plexus. [ 4 ]  CPN is generally performed complementary to  nerve blocks , due to the severe pain associated with the injection itself. Neurolysis is commonly performed only after a successful celiac plexus block. [ 4 ]  CPN and celiac plexus block (CPB) are different in that CPN is permanent ablation whereas CPB is temporal pain inhibition. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6649", "text": "There are multiple posterior percutaneous approaches, but no clinical evidence suggests that any one technique is more efficient than the rest. The posterior approaches generally utilize two needles, one at each side of the  L1 vertebral body  pointing towards the  T12 vertebral body . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6650", "text": "Increasing the spread of the injection may increase the efficacy of the neurolysis. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6651", "text": "Endoscopic ultrasound (EUS)-guided neurolysis is a technique that performs neurolysis using a linear-array echoendoscope. [ 5 ]  The EUS technique is minimally invasive and is believed to be safer than the traditional percutaneous approaches. EUS-guided neurolysis technique can be used to target the  celiac plexus , the  celiac ganglion , or the broad plexus in the treatment of pancreatic cancer-associated pain. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6652", "text": "EUS-guided celiac plexus neurolysis (EUS-CPN) is performed with either an oblique-viewing or forward-viewing echoendoscope and is passed through the mouth into the  esophagus . From the  gastroesophageal junction , EUS imaging allows the doctor to visualize the  aorta , which can then be traced to the origin of the  celiac artery . The celiac plexus itself cannot be identified, but is located relative to the celiac artery. The neurolysis is then performed with a spray needle that disperses a neurolytic agent, such as alcohol or phenol, into the celiac plexus. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6653", "text": "EUS-CPN can be performed unilaterally (centrally) or bilaterally, however, there is no clinical evidence supporting the superiority of one over the other. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6654", "text": "EUS-guided neurolysis can also be performed on the  celiac ganglion  and the broad plexus in a similar fashion to the EUS-CPN. The celiac ganglion neurolysis (EUS-CGN) is more effective than EUS-CPN and broad plexus neurolysis (EUS-BPN) is more effective than EUS-CGN. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6655", "text": "Lumbar sympathetic neurolysis is typically used on patients with  ischemic  rest pain, generally associated with nonreconstructable  arterial occlusive disease . Although the disease is the basis for this type of neurolysis, other diseases such as peripheral  neuralgia  or vasospastic disorders can receive lumbar sympathetic neurolysis for pain treatment. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6656", "text": "Lumbar sympathetic neurolysis is performed between the  L1-L4 vertebrae  with separate injections at each vertebra junction. The chemicals used for neurolysis of the nerves cause destructive fibrosis and cause a disruption of the  sympathetic ganglia . The vasomotor tone is decreased in the area affected by the neurolysis, which in addition to arteriovenous shunting, create a light pink appearance within the affected area. Lumbar sympathetic neurolysis alters the ischemic rest pain transmission by changing  norepinephrine  and  catecholamine  levels or by disturbing afferent fibers. This procedure is mainly used only when other feasible approaches to pain management are unable to be used. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6657", "text": "Lumbar sympathetic neurolysis is performed by using absolute alcohol, but other chemicals such as phenol, or other techniques such as  radiofrequency  or  laser ablation  have been studied. To aid in the procedure,  fluoroscopy  or  CT  guidance is used. Fluoroscopic guidance is the most frequent, giving better real-time monitoring of the needle. The general technique of administering lumbar sympathetic neurolysis involves using three separate needles rather than one because it allows for better longitudinal spread of the chemicals. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6658", "text": "Complications can arise from this procedure such as  nerve root  injury, bleeding,  paralysis , and more. Complications have been seen to be diminished when using the aforementioned radiofrequency or laser ablation techniques in comparison to the injection of alcohol or phenol. Generally, approximately two-thirds of patients can expect a favorable outcome (pain relief with minimal complications). Overall, the minimally invasive technique of lumbar sympathetic neurolysis is important in the relief of ischemic rest pain. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6659", "text": "Chemodenervation is a process used to manage focal muscle overactivity through the use of either phenol, alcohol, or one of the more recently discovered  botulinum toxins  (BoNTs). [ 1 ]  Chemodenervation is used as a complement to neurolysis. The agent of choice is injected into the muscle fibers as opposed to nerve tissue and the two work together to dull the neuronal signaling within the muscles. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6660", "text": "The effects of alcohol and phenol injections are different from the effects of BoNTs. Neurolysis mediates the effects of alcohol and phenol injections but does not mediate the effects of BoNT injections. Phenol and alcohol are less expensive, faster acting, can treat larger areas, and can be re-administered or boosted in less than three months, however, those injections also require the patient to be sedated, cause muscle scarring, and can lead to muscle fibrosis. [ 1 ]  BoNT injections are easier to inject, better accepted by patients, and have reversible effects on muscles, however, they are more expensive, act very slowly, and the body can develop a resistance to them. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6661", "text": "Neuronavigation  is the set of computer-assisted technologies used by neurosurgeons to guide or \"navigate\" within the confines of the skull or vertebral column during surgery, and used by psychiatrists to accurately target rTMS ( transcranial magnetic stimulation ).  The set of hardware for these purposes is referred to as a  neuronavigator ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6662", "text": "Neuronavigation is recognized as the next evolutionary step of  stereotactic surgery , a set of techniques that dates back to the early 1900s and that gained popularity during the 1940s, particularly in Germany, France and the U.S., with the development of surgery for the treatment of movement disorders such as  Parkinson's disease  and  dystonias . In its infancy the purpose of this technology was to create a mathematical model describing a proposed coordinate system for the space within a closed structure, e.g., the skull. This \"fiducial spatial coordinate system\u201d uses  fiducial markers  as a reference to describe with high accuracy the position of specific structures within this arbitrarily defined space. The surgeon then refers to that data to target particular structures within the brain. This technology was boosted by the collection of data on human anatomy in \u201cstereotactic atlases\u201d, expanding the quantitatively defined \u201ctargets\u201d that could be readily used in surgery. Finally, the advent of modern neuro-imaging technologies such as  computed tomography  (CT) and  magnetic resonance imaging  (MRI)\u2014along with the ever-increasing capabilities of digitalization, computer-graphic modelling and accelerated manipulation of data through complex mathematical algorithms via robust computer technologies\u2014made possible the real-time quantitative spatial fusion of images of the patient's brain with the created \u201cfiducial coordinate system\u201d for the purpose of guiding the surgeon's instrument or probe to a selected target. In this way the observations done via highly sophisticated neuro-imaging technologies (CT, MRI,  angiography ) are related to the actual patient during surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6663", "text": "The ability to relate the position of a real surgical instrument in the surgeon's hand or the microscope's focal point to the location of the imaged pathology, updated in \"real time\" in an \"integrated operating room\", highlights the modern version of this set of technologies.  In its current form, neuronavigation began in the 1990s and has adapted to new neuro-imaging technologies, real-time imaging capabilities, new technologies to transfer the information in the operating room for 3-D localization, real-time neuro-monitoring,  robotics , and new and better algorithms to handle data via more sophisticated computer technology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6664", "text": "In its later conceptualization, the term  neuronavigation  has started to overlap fuse with  surgical-virtualization  in which a neurosurgeon is able to visualize the scenario for surgery in a 3-D model of manipulable computer data. In this way the physician can \"practice and check\" the surgery, try alternative approaches, assess possible difficulties, etc., before the real surgery takes place."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6665", "text": "The standard TMS protocol which was FDA approved in 2008 estimates the location of the  DLPFC  by finding the left motor cortex and marking a spot 5\u00a0cm anterior to it. Later two more methods were introduced using measurements of the head and calculating the location of the  DLPFC  as 1) the F3 (EEG 10/20 system) or 2) the Beam method.  Both were estimations with some limitations. With the introduction of Neuronavigation, direct visualization of structures can be achieved either with an individual's (specially ordered) MRI or an average brain (MNI) stretched to the dimensions of the individual. There is now greater significance of this increased accuracy due to recent evidence that stimulation of the gyral crown is less effective than stimulation of the sulcal bank. The introduction of robotic controlled TMS also may make Neuronavigation more important. Several manufacturers offer complete systems including Ant Neuro or Axilum Robotics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6666", "text": "Assistive technologies are used during spinal fusion surgery to increase accuracy, especially for the placement of  pedicle  screws. [ 1 ]  A review of navigation techniques for spine surgery published in 2019 listed four currently available options: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6667", "text": "Neuroplastic  or  neuroplastic and reconstructive surgery  is the surgical specialty involved in reconstruction or restoration of patients who undergo surgery of the central or peripheral nervous system. The field includes a wide variety of surgical procedures that seek to restore or replace a patient's skull, face, scalp,  dura  (the protective covering of the brain and spinal cord), the spine and/or its overlying tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6668", "text": "Neuroplastic surgery has adapted reconstructive principles from the fields of  craniofacial surgery , and  plastic and reconstructive surgery  and refined them in order to prevent and/or address challenging deformities which result from Neurosurgical Procedures. The evolution of this new specialty and first center for Neuroplastic and Reconstructive Surgery was started at  Johns Hopkins University Hospital  in Baltimore, Maryland by a formal collaboration between the Department of Plastic and Reconstructive Surgery and Department of Neurosurgery, under the vision of Dr. Chad Gordon. [ 1 ]  Upon arrival to Johns Hopkins Hospital, Gordon formed a multi-disciplinary team of physicians, scientists and engineers. [ 2 ]  The team's unified goal was to develop techniques and devices to treat adult neurosurgical patients. These advances led to several \"first-in-human\" publications and skull implant/craniofacial computer-assisted technology patents, and allowed for the establishment of the first formal fellowship training program in Neuroplastic and Reconstructive Surgery. [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ]  In March 2018, Dr. Gordon was appointed the Director of Neuroplastic and Reconstructive Surgery at Johns Hopkins. In 2018, the \"Society of Neuroplastic Surgery\" was officially formed with the mission to \"advance the art, science, and technology related to Neuroplastic and Reconstructive Surgery\", and at that time, Dr. Gordon was elected to be the society's first President. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6669", "text": "The first peer-reviewed journal to recognize neuroplastic and reconstructive surgery as its own field was the  Journal of Craniofacial Surgery  which dedicated its January 2018 issue to introducing the new field of neuroplastic surgery to its readership. In that issue, the editor-in-chief, Mutaz Habal, published an editorial on neuroplastic surgery where he stated:  \"Based on the desire to present the fact that neuroplastic surgery is there, we have a dedicated this issue of the  Journal of Craniofacial Surgery . This presentation mostly involves surgical procedures that will be termed \u2018\u2018neuroplastic\u2019\u2019 in the years to come.\" [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6670", "text": "Training in neuroplastic surgery requires completion of a neuroplastic and reconstructive surgery fellowship which lasts 1\u20132 years. Such fellowships are available to individuals who have completed a residency in P lastic and Reconstructive Surgery ,  ENT Surgery ,  Neurosurgery  or  Oral and Maxillofacial surgery . As of today, the only formal fellowship training program in neuroplastic and reconstructive surgery is located at the  Johns Hopkins School of Medicine  and Johns Hopkins Hospital. [ 16 ]  The fellowship is co-sponsored by both Departments of Plastic Surgery and Neurosurgery. For each of the clinical fellows in the program, there is an expected volume of participating in over 110 neuro-cranial reconstructions per year with Dr. Gordon and his neurosurgery colleagues, as well as a large spectrum of complex scalp reconstruction and craniofacial cases. The first surgeon formally trained in \"Neuroplastic and Reconstructive Surgery\" was Dr. Gabriel Santiago [2016-18], who completed  ENT surgery  residency in the  US Navy  prior to starting the fellowship. [ citation needed ]  The first Neuroplastic Surgery Research Fellow was Dr. Amir Wolff [2017-18], an attending oral-maxillofacial surgeon from Rambam Medical Center in Haifa, Israel. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6671", "text": "The first Annual Neuroplastic and Reconstructive Surgery Symposium was held at  Harvard Medical School / Massachusetts General Hospital  in September 2015, co-chaired by Dr.  Chad Gordon  (Johns Hopkins) and Dr.  Michael Yaremchuk  (Harvard). Its overarching mission was to increase collaboration, awareness and synergy amongst numerous disciplines including  craniofacial plastic surgery , adult-based  cranial neurosurgery ,  biomedical engineering , and  neurology  for improved patient outcomes. Since then, the symposium has grown significantly and rotates annually between Harvard Medical School/Massachusetts General Hospital (Boston, MA) and  Johns Hopkins School of Medicine / Johns Hopkins Hospital  (Baltimore, MD). Its main emphasis relates to  cranioplasty , implants and implantable  neurotechnologies . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6672", "text": "Neurotomy  may refer to the application of heat (as in  radio frequency nerve lesioning ) or freezing to sensory nerve fibers to cause their temporary degeneration, usually to relieve pain. Neurotomy and  neurolysis  (where the degeneration is caused by the application of chemical agents) are forms of  neurolytic block . \"Neurotomy\" is sometimes used as a synonym for  neurectomy , the surgical cutting or removal of nervous tissue. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6673", "text": "Neutron capture therapy  ( NCT ) is a type of  radiotherapy  for treating locally invasive malignant tumors such as primary  brain tumors , recurrent  cancers of the head and neck region , and cutaneous and extracutaneous melanomas. It is a two-step process:  first , the patient is injected with a tumor-localizing drug containing the  stable isotope  boron-10 ( 10 B), which has a high propensity to  capture  low energy \"thermal\"  neutrons . The  neutron cross section  of  10 B (3,837  barns ) is 1,000 times more than that of other elements, such as nitrogen, hydrogen, or oxygen, that occur in tissue. In the  second  step, the patient is radiated with  epithermal neutrons , the sources of which in the past have been nuclear reactors and now are accelerators that produce higher energy epithermal neutrons. After losing energy as they penetrate tissue, the resultant low energy \"thermal\" neutrons are captured by the  10 B atoms. The resulting decay reaction yields high-energy alpha particles that kill the cancer cells that have taken up enough  10 B."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6674", "text": "All clinical experience with NCT to date is with boron-10; hence this method is known as  boron neutron capture therapy  ( BNCT ). [ 1 ]  Use of another non-radioactive isotope, such as  gadolinium , has been limited to experimental animal studies and has not been done clinically. BNCT has been evaluated as an alternative to conventional radiation therapy for malignant brain tumors such as  glioblastomas , which presently are incurable, and more recently, locally advanced recurrent  cancers of the head and neck  region and, much less often, superficial melanomas mainly involving the skin and genital region. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6675", "text": "James Chadwick  discovered the neutron in 1932. Shortly thereafter, H. J. Taylor reported that boron-10 nuclei had a high propensity to capture low energy \"thermal\" neutrons. This reaction causes nuclear decay of the boron-10 nuclei into helium-4 nuclei (alpha particles) and lithium-7 ions. [ 4 ]  In 1936, G.L. Locher, a scientist at the Franklin Institute in Philadelphia, Pennsylvania, recognized the therapeutic potential of this discovery and suggested that this specific type of neutron capture reaction could be used to treat cancer. [ 5 ] [ 1 ]  William Sweet, a neurosurgeon at the Massachusetts General Hospital, first suggested the possibility of using BNCT to treat malignant brain tumors to evaluate BNCT for treatment of the most malignant of all brain tumors, glioblastoma multiforme (GBMs), using borax as the boron delivery agent in 1951. [ 6 ]  A clinical trial subsequently was initiated by Lee Farr using a specially constructed nuclear reactor at the Brookhaven National Laboratory [ 7 ]  in Long Island, New York, U.S.A. Another clinical trial was initiated in 1954 by Sweet at the Massachusetts General Hospital using the Research Reactor at the Massachusetts Institute of Technology (MIT) in Boston. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6676", "text": "A number of research groups worldwide have continued the early ground-breaking clinical studies of Sweet and Farr, and subsequently the pioneering clinical studies of Hiroshi Hatanaka (\u7560\u4e2d\u6d0b) in the 1960s, to treat patients with brain tumors. [ 8 ]  Since then, clinical trials have been done in a number of countries including Japan, the United States, Sweden, Finland, the Czech Republic, Taiwan, and Argentina. After the nuclear accident at Fukushima (2011), the clinical program there transitioned from a reactor neutron source to accelerators that would produce high energy neutrons that become thermalized as they penetrate tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6677", "text": "Neutron capture therapy is a binary system that consists of two separate components to achieve its therapeutic effect. Each component in itself is non-tumoricidal, but when combined they can be highly lethal to cancer cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6678", "text": "BNCT is based on the nuclear capture and decay reactions that occur when non-radioactive  boron-10 , which makes up approximately 20% of natural elemental boron, is irradiated with neutrons of the appropriate energy to yield excited boron-11 ( 11 B*). This undergoes radioactive decay to produce high-energy  alpha particles  ( 4 He nuclei) and high-energy  lithium-7  ( 7 Li) nuclei. The nuclear reaction is: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6679", "text": "Both the alpha particles and the lithium nuclei produce closely spaced ionizations in the immediate vicinity of the reaction, with a range of 5\u20139\u00a0 \u03bcm . This approximately is the diameter of the target cell, and thus the lethality of the capture reaction is limited to boron-containing cells. BNCT, therefore, can be regarded as both a biologically and a physically targeted type of radiation therapy. The success of BNCT is dependent upon the selective delivery of sufficient amounts of  10 B to the tumor with only small amounts localized in the surrounding normal tissues. [ 8 ]  Thus, normal tissues, if they have not taken up sufficient amounts of boron-10, can be spared from the neutron capture and decay reactions. Normal tissue tolerance, however,  is determined by the nuclear capture reactions that occur with normal tissue hydrogen and nitrogen. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6680", "text": "A wide variety of boron delivery agents have been synthesized. [ 9 ]  The first, which has mainly been used in Japan, is a polyhedral borane anion,  sodium borocaptate  or BSH ( Na 2 B 12 H 11 SH ), and the second is a dihydroxyboryl derivative of  phenylalanine , called  boronophenylalanine  or BPA. The latter has been used in many clinical trials. Following administration of either BPA or BSH by intravenous infusion, the tumor site is irradiated with neutrons, the source of which, until recently, has been specially designed nuclear reactors and now is neutron accelerators. Until 1994, low-energy (< 0.5  eV ) thermal neutron beams were used in Japan [ 10 ]  and the United States, [ 6 ] [ 7 ]  but since they have a limited depth of penetration in tissues, higher energy (> .5eV < 10 keV) epithermal neutron beams, which have a greater depth of penetration, were used in clinical trials in the United States, [ 11 ] [ 12 ]  Europe, [ 13 ] [ 14 ]  Japan, [ 15 ] [ 16 ]  Argentina, Taiwan, and China until recently when accelerators replaced the reactors. In theory BNCT is a highly selective type of  radiation therapy  that can target tumor cells without causing radiation damage to the adjacent normal cells and tissues. Doses up to 60\u201370\u00a0 grays (Gy)  can be delivered to the tumor cells in one or two applications compared to 6\u20137 weeks for conventional fractionated external beam photon irradiation. However, the effectiveness of BNCT is dependent upon a relatively homogeneous cellular distribution of  10 B within the tumor, and more specifically within the constituent tumor cells, and this is still one of the main unsolved problems that have limited its success. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6681", "text": "The radiation doses to tumor and normal tissues in BNCT are due to energy deposition from three types of directly ionizing radiation that differ in their  linear energy transfer  (LET), which is the rate of energy loss along the path of an ionizing particle: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6682", "text": "1. Low-LET  gamma rays , resulting primarily from the capture of thermal neutrons by normal tissue hydrogen atoms [ 1 H(n,\u03b3) 2 H];"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6683", "text": "2. High-LET  protons , produced by the scattering of fast neutrons and from the capture of thermal neutrons by nitrogen atoms [ 14 N(n,p) 14 C]; and"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6684", "text": "3. High-LET, heavier charged  alpha particles  (stripped down helium [ 4 He] nuclei) and  lithium -7 ions, released as products of the thermal neutron capture and decay reactions with  10 B [ 10 B(n,\u03b1) 7 Li]."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6685", "text": "Since both the tumor and surrounding normal tissues are present in the radiation field, even with an ideal epithermal neutron beam, there will be an unavoidable, non-specific background dose, consisting of both high- and low-LET radiation. However, a higher concentration of  10 B in the tumor will result in it getting a higher total dose than that of adjacent normal tissues, which is the basis for the therapeutic gain in BNCT. [ 17 ]  The total radiation dose in Gy delivered to any tissue can be expressed in photon-equivalent units as the sum of each of the high-LET dose components multiplied by weighting factors (Gy w ), which depend on the increased radiobiological effectiveness of each of these components. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6686", "text": "Biological weighting factors have been used in all of the more recent clinical trials in patients with high-grade gliomas, using boronophenylalanine (BPA) in combination with an epithermal neutron beam. The  10 B(n,\u03b1) 7 Li part of the radiation dose to the scalp has been based on the measured boron concentration in the blood at the time of BNCT, assuming a blood: scalp boron concentration ratio of 1.5:1 and a compound biological effectiveness (CBE) factor for BPA in skin of 2.5. A  relative biological effectiveness  (RBE) or CBE factor of 3.2 has been used in all tissues for the high-LET components of the beam, such as alpha particles. The RBE factor is used to compare the biologic effectiveness of different types of ionizing radiation. The high-LET components include protons resulting from the capture reaction with normal tissue nitrogen, and recoil protons resulting from the collision of fast neutrons with hydrogen. [ 17 ]  It must be emphasized that the tissue distribution of the boron delivery agent in humans should be similar to that in the experimental animal model in order to use the experimentally derived values for estimation of the  radiation  doses for clinical radiations. [ 17 ] [ 18 ]  For more detailed information relating to computational dosimetry and  treatment planning , interested readers are referred to a comprehensive review on this subject. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6687", "text": "The development of boron delivery agents for BNCT began in the early 1960s and is an ongoing and difficult task. A number of  boron-10  containing delivery agents have been synthesized for potential use in BNCT. [ 9 ] [ 20 ] [ 21 ]  The most important requirements for a successful boron delivery agent are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6688", "text": "However, as of 2021 no single boron delivery agent fulfills all of these criteria. With the development of new chemical synthetic techniques and increased knowledge of the biological and biochemical requirements needed for an effective agent and their modes of delivery, a wide variety of new boron agents has emerged (see examples in Table 1). However, only one of these compounds has ever been tested in large animals, and only boronophenylalanine (BPA) and sodium borocaptate (BSH), have been used clinically. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6689", "text": "a The delivery agents are not listed in any order that indicates their potential usefulness for BNCT. None of these agents have been evaluated in any animals larger than mice and rats, except for boronated porphyrin (BOPP) that also has been evaluated in dogs. However, due to the severe toxicity of BOPP in canines, no further studies were carried out. \n b See Barth, R.F., Mi, P., and Yang, W., Boron delivery agents for neutron capture therapy of cancer, Cancer Communications, 38:35 ( doi : 10.1186/s40880-018-0299-7),  2018 for an updated review. \n c The abbreviations used in this table are defined as follows: BNCT, boron neutron capture therapy; DNA, deoxyribonucleic acid; EGF, epidermal growth factor; EGFR, epidermal growth factor receptor; MoAbs, monoclonal antibodies; VEGF, vascular endothelial growth factor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6690", "text": "The major challenge in the development of boron delivery agents has been the requirement for selective tumor targeting in order to achieve boron concentrations (20-50\u00a0\u03bcg/g tumor) sufficient to produce therapeutic doses of radiation at the site of the tumor with minimal radiation delivered to normal tissues. The selective destruction of infliltrative tumor (glioma) cells in the presence of normal brain cells represents an even greater challenge compared to malignancies at other sites in the body. Malignant gliomas are highly infiltrative of normal brain, histologically diverse, heterogeneous in their genomic profile and therefore it is very difficult to kill all of them. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6691", "text": "There also has been some interest in the possible use of  gadolinium -157 ( 157 Gd) as a capture agent for NCT for the following reasons: [ 22 ]   First , and foremost, has been its very high neutron capture cross section of 254,000  barns .  Second , gadolinium compounds, such as  Gd-DTPA  (gadopentetate dimeglumine Magnevist), have been used routinely as  contrast agents  for  magnetic resonance imaging  (MRI) of brain tumors and have shown high uptake by brain tumor cells in tissue culture ( in vitro ). [ 23 ]   Third , gamma rays and internal conversion and Auger electrons are products of the  157 Gd(n,\u03b3) 158 Gd capture reaction ( 157 Gd + n th  (0.025eV) \u2192 [ 158 Gd] \u2192  158 Gd + \u03b3 + 7.94 MeV). Though the gamma rays have longer pathlengths, orders of magnitude greater depths of penetration compared with alpha particles, the other radiation products (internal conversion and  Auger electrons ) have pathlengths of about one cell diameter and can directly damage  DNA . Therefore, it would be highly advantageous for the production of DNA damage if the  157 Gd were localized within the cell nucleus. However, the possibility of incorporating gadolinium into biologically active molecules is very limited and only a small number of potential delivery agents for Gd NCT have been evaluated. [ 24 ] [ 25 ]  Relatively few studies with Gd have been carried out in experimental animals compared to the large number with boron containing compounds (Table 1), which have been synthesized and evaluated in experimental animals ( in vivo ). Although  in vitro  activity has been demonstrated using the Gd-containing MRI contrast agent Magnevist as the Gd delivery agent, [ 26 ]  there are very few studies demonstrating the efficacy of Gd NCT in experimental animal tumor models, [ 25 ] [ 27 ]  and, as evidenced by a lack of citations in the literature, Gd NCT has not, as of 2019, been used clinically in humans."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6692", "text": "Until 2014, neutron sources for NCT were limited to  nuclear reactors . [ 28 ]  Reactor-derived neutrons are classified according to their energies as thermal (E n  < 0.5 eV), epithermal (0.5 eV < E n  < 10 keV), or fast (E n  >10 keV). Thermal neutrons are the most important for BNCT since they usually initiate the  10 B(n,\u03b1) 7 Li capture reaction. However, because they have a limited depth of penetration, epithermal neutrons, which lose energy and fall into the thermal range as they penetrate tissues, are now preferred for clinical therapy, other than for skin tumors such as melanoma. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6693", "text": "A number of nuclear reactors with very good neutron beam quality have been developed and used clinically. These include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6694", "text": "As of May 2021, only the reactors in Argentina, China, and Taiwan are still being used clinically. It is anticipated that, beginning some time in 2022, clinical studies in Finland will utilize an accelerator neutron source designed and fabricated in the United States by Neutron Therapeutics, Danvers, Massachusetts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6695", "text": "It was not until the 1950s that the first clinical trials were initiated by Farr at the Brookhaven National Laboratory (BNL) in New York [ 7 ]  and by Sweet and Brownell at the Massachusetts General Hospital (MGH) using the Massachusetts Institute of Technology (MIT) nuclear reactor (MITR) [ 32 ]  and several different low molecular weight boron compounds as the boron delivery agent. [ 33 ]  However, the results of these studies were disappointing, and no further clinical trials were carried out in the United States until the 1990s."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6696", "text": "Following a two-year Fulbright fellowship in Sweet's laboratory at the MGH, clinical studies were initiated by Hiroshi Hatanaka in Japan in 1967. He used a low-energy thermal neutron beam, which had low tissue penetrating properties, and sodium borocaptate (BSH) as the boron delivery agent, which had been evaluated as a boron delivery agent by Albert Soloway at the MGH. [ 34 ]  In Hatanaka's procedure, [ 35 ]  as much as possible of the tumor was surgically resected (\"debulking\"), and at some time thereafter, BSH was administered by a slow infusion, usually intra-arterially, but later intravenously. Twelve to 14 hours later, BNCT was carried out at one or another of several different nuclear reactors using low-energy thermal neutron beams. The poor tissue-penetrating properties of the thermal neutron beams necessitated reflecting the skin and raising a bone flap in order to directly irradiate the exposed brain, a procedure first used by Sweet and his collaborators."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6697", "text": "Approximately 200+ patients were treated by Hatanaka, and subsequently by his associate, Nakagawa. [ 10 ]  Due to the heterogeneity of the patient population, in terms of the microscopic diagnosis of the tumor and its  grade , size, and the ability of the patients to carry out normal daily activities (Karnofsky  performance status ), it was not possible to come up with definitive conclusions about therapeutic efficacy. However, the survival data were no worse than those obtained by standard therapy at the time, and there were several patients who were long-term survivors, and most probably they were cured of their brain tumors. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6698", "text": "BNCT of patients with brain tumors was resumed in the United States in the mid-1990s by Chanana, Diaz, and Coderre [ 11 ]  and their co-workers at the Brookhaven National Laboratory using the Brookhaven Medical Research Reactor (BMRR) and at Harvard/Massachusetts Institute of Technology (MIT) using the  MIT Research Reactor (MITR) . [ 12 ]  For the first time, BPA was used as the boron delivery agent, and patients were irradiated with a collimated beam of higher energy epithermal neutrons, which had greater tissue-penetrating properties than thermal neutrons. A research group headed up by Zamenhof at the Beth Israel Deaconess Medical Center/Harvard Medical School and MIT was the first to use an epithermal neutron beam for clinical trials. Initially patients with cutaneous melanomas were treated and this was expanded to include patients with brain tumors, specifically melanoma metastatic to the brain and primary glioblastomas (GBMs). Included in the research team were Otto Harling at MIT and the Radiation Oncologist Paul Busse at the Beth Israel Deaconess Medical Center in Boston. A total of 22 patients were treated by the Harvard-MIT research group. Five patients with cutaneous melanomas were also treated using an epithermal neutron beam at the MIT research reactor (MITR-II) and subsequently patients with brain tumors were treated using a redesigned beam at the MIT reactor that possessed far superior characteristics to the original MITR-II beam and BPA as the capture agent. The clinical outcome of the cases treated at Harvard-MIT has been summarized by Busse. [ 12 ]  Although the treatment was well tolerated, there were no significant differences in the mean survival times (MSTs)of patients that had received BNCT compared to those who received conventional external beam X-irradiation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6699", "text": "Shin-ichi Miyatake and Shinji Kawabata at Osaka Medical College in Japan [ 15 ] [ 16 ]  have carried out extensive clinical studies employing BPA (500\u00a0mg/kg) either alone or in combination with BSH (100\u00a0mg/kg), infused intravenously (i.v.) over 2\u00a0h, followed by neutron irradiation at Kyoto University Research Reactor Institute (KURRI). The Mean Survival Time (MST) of 10 patients with high grade gliomas in the first of their trials was 15.6 months, with one long-term survivor (>5 years). [ 16 ]  Based on experimental animal data, [ 36 ]  which showed that BNCT in combination with X-irradiation produced enhanced survival compared to BNCT alone, Miyatake and Kawabata combined BNCT, as described above, with an X-ray boost. [ 15 ]  A total dose of 20 to 30\u00a0Gy was administered, divided into 2\u00a0Gy daily fractions. The MST of this group of patients was 23.5 months and no significant toxicity was observed, other than hair loss (alopecia). However, a significant subset of these patients, a high proportion of which had small cell variant glioblastomas, developed cerebrospinal fluid dissemination of their tumors. [ 37 ]  Miyatake and his co-workers also have treated a cohort of 44 patients with recurrent high grade meningiomas (HGM) that were refractory to all other therapeutic approaches. [ 38 ]  The clinical regimen consisted of intravenous administration of boronophenylalanine two hours before neutron irradiation at the Kyoto University Research Reactor Institute in Kumatori, Japan. Effectiveness was determined using radiographic evidence of tumor shrinkage, overall survival (OS) after initial diagnosis, OS after BNCT, and radiographic patterns associated with treatment failure. The median OS after BNCT was 29.6 months and 98.4 months after diagnosis. Better responses were seen in patients with lower grade tumors. In 35 of 36 patients, there was tumor shrinkage, and the median progression-free survival (PFS) was  13.7 months. There was good local control of the patients' tumors, as evidenced by the fact that only 22.2% of them experienced local recurrence of their tumors. From these results, it was concluded that BNCT was effective in locally controlling tumor growth, shrinking tumors, and improving survival with acceptable safety in patients with therapeutically refractory HGMs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6700", "text": "In another Japanese trial, carried out by Yamamoto et al., BPA and BSH were infused over 1\u00a0h, followed by BNCT at the Japan Research Reactor (JRR)-4 reactor. [ 39 ]  Patients subsequently received an X-ray boost after completion of BNCT. The overall median survival time (MeST) was 27.1 months, and the 1 year and 2-year survival rates were 87.5 and 62.5%, respectively. Based on the reports of Miyatake, Kawabata, and Yamamoto, combining BNCT with an X-ray boost can produce a significant therapeutic gain. However, further studies are needed to optimize this combined therapy alone or in combination with other approaches including chemo- and immunotherapy, and to evaluate it using a larger patient population. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6701", "text": "The technological and physical aspects of the Finnish BNCT program have been described in considerable detail by Savolainen et al. [ 44 ]  A team of clinicians led by Heikki Joensuu and Leena Kankaanranta and nuclear engineers led by Iro Auterinen and Hanna Koivunoro at the Helsinki University Central Hospital and VTT Technical Research Center of Finland have treated approximately 200+ patients with recurrent malignant gliomas ( glioblastomas ) and head and neck cancer who had undergone standard therapy, recurred, and subsequently received BNCT at the time of their recurrence using BPA as the boron delivery agent. [ 13 ] [ 14 ]  The median time to progression in patients with gliomas was 3 months, and the overall MeST was 7 months. It is difficult to compare these results with other reported results in patients with recurrent malignant gliomas, but they are a starting point for future studies using BNCT as salvage therapy in patients with recurrent tumors. Due to a variety of reasons, including financial, [ 45 ]  no further studies have been carried out at this facility, which has been decommissioned. However, a new facility for BNCT treatment has been installed using an accelerator designed and fabricated by Neutron Therapeutics. [ 46 ]  This accelerator was specifically designed to be used in a hospital, and the BNCT treatment and clinical studies will be carried out there after dosimetric studies have been completed in 2021. Both Finnish and foreign patients are expected to be treated at the facility. [ 47 ] [ 48 ] [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6702", "text": "To conclude this section on treating brain tumors with BNCT using reactor neutron sources, a clinical trial that was carried out by Stenstam, Sk\u00f6ld, Capala and their co-workers in Studsvik, Sweden, using an epithermal neutron beam produced by the Studsvik nuclear reactor, which had greater tissue penetration properties than the thermal beams originally used in the United States and Japan, will be briefly summarized. This study differed significantly from all previous clinical trials in that the total amount of BPA administered was increased (900\u00a0mg/kg), and it was infused i.v. over 6 hours. This was based on experimental animal studies in glioma bearing rats demonstrating enhanced uptake of BPA by infiltrating tumor cells following a 6-hour infusion. [ 34 ] [ 41 ] [ 42 ] [ 50 ]  The longer infusion time of the BPA was well tolerated by the 30 patients who were enrolled in this study. All were treated with 2 fields, and the average whole brain dose was 3.2\u20136.1\u00a0Gy (weighted), and the minimum dose to the tumor ranged from 15.4 to 54.3\u00a0Gy (w). There has been some disagreement among the Swedish investigators regarding the evaluation of the results. Based on incomplete survival data, the MeST was reported as 14.2 months and the time to tumor progression was 5.8 months. [ 41 ]  However, more careful examination [ 42 ]  of the complete survival data revealed that the MeST was 17.7 months compared to 15.5 months that has been reported for patients who received standard therapy of surgery, followed by radiotherapy (RT) and the drug  temozolomide  (TMZ). [ 51 ]  Furthermore, the frequency of adverse events was lower after BNCT (14%) than after radiation therapy (RT) alone (21%) and both of these were lower than those seen following RT in combination with TMZ. If this improved survival data, obtained using the higher dose of BPA and a 6-hour infusion time, can be confirmed by others, preferably in a  randomized clinical trial , it could represent a significant step forward in BNCT of brain tumors, especially if combined with a photon boost."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6703", "text": "The single most important clinical advance over the past 15 years [ 52 ]  has been the application of BNCT to treat patients with recurrent tumors of the head and neck region who had failed all other therapy. These studies were first initiated by Kato et al. in Japan. [ 52 ] [ 53 ]  and subsequently followed by several other Japanese groups and by Kankaanranta, Joensuu, Auterinen, Koivunoro and their co-workers in Finland. [ 14 ]  All of these studies employed BPA as the boron delivery agent, usually alone but occasionally in combination with BSH. A very heterogeneous group of patients with a variety of histopathologic types of tumors have been treated, the largest number of which had recurrent squamous cell carcinomas. Kato et al. have reported on a series of 26 patients with far-advanced cancer for whom there were no further treatment options. [ 52 ]  Either BPA + BSH or BPA alone were administered by a 1 or 2\u00a0h i.v. infusion, and this was followed by BNCT using an epithermal beam. In this series, there were complete regressions in 12 cases, 10 partial regressions, and progression in 3 cases. The MST was 13.6 months, and the 6-year survival was 24%. Significant treatment related complications (\"adverse\" events) included transient mucositis, alopecia and, rarely, brain necrosis and osteomyelitis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6704", "text": "Kankaanranta et al. have reported their results in a prospective Phase I/II study of 30 patients with inoperable, locally recurrent squamous cell carcinomas of the head and neck region. [ 14 ]  Patients received either two or, in a few instances, one BNCT treatment using BPA (400\u00a0mg/kg), administered i.v. over 2 hours, followed by neutron irradiation. Of 29 evaluated patients, there were 13 complete and 9 partial remissions, with an overall response rate of 76%. The most common adverse event was oral mucositis, oral pain, and fatigue. Based on the clinical results, it was concluded that BNCT was effective for the treatment of inoperable, previously irradiated patients with head and neck cancer. Some responses were durable but progression was common, usually at the site of the previously recurrent tumor. As previously indicated in the section on neutron sources, all clinical studies have ended in Finland, for variety of reasons including economic difficulties of the two companies directly involved, VTT and Boneca. However, clinical studies using an accelerator neutron source designed and fabricated by Neutron Therapeutics and installed at the Helsinki University Hospital should be fully functional by 2022. [ 46 ]  Finally, a group in  Taiwan , led by Ling-Wei Wang and his co-workers at the Taipei Veterans General Hospital, have treated 17 patients with locally recurrent head and neck cancers at the Tsing Hua Open-pool Reactor (THOR) of the  National Tsing Hua University . [ 54 ]  Two-year overall survival was 47% and two-year loco-regional control was 28%. Further studies are in progress to further optimize their treatment regimen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6705", "text": "Other extracranial tumors that have been treated with BNCT include malignant  melanomas . The original studies were carried out in Japan by the late Yutaka Mishima and his clinical team in the Department of Dermatology at Kobe University [ 55 ]  using locally injected BPA and a thermal neutron beam. It is important to point out that it was Mishima who first used BPA as a boron delivery agent, and this approach subsequently was extended to other types of tumors based on the experimental animal studies of Coderre et al. at the Brookhaven National Laboratory. [ 56 ]  Local control was achieved in almost all patients, and some were cured of their melanomas. Patients with melanoma of the head and neck region, vulva, and extramammary Paget's disease of the genital region have been treated by Hiratsuka et al. with promising clinical results. [ 57 ]  The first clinical trial of BNCT in Argentina for the treatment of melanomas was performed in October 2003 [ 58 ]  and since then several patients with cutaneous melanomas have been treated as part of a Phase II clinical trial at the RA-6 nuclear reactor in Bariloche. The neutron beam has a mixed thermal-hyperthermal neutron spectrum that can be used to treat superficial tumors. [ 58 ]  The In-Hospital Neutron Irradiator (IHNI) in Beijing has been used to treat a small number of patients with cutaneous melanomas with a complete response of the primary lesion and no evidence of late radiation injury during a 24+-month follow-up period. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6706", "text": "Two patients with colon cancer, which had spread to the liver, have been treated by Zonta and his co-workers at the University of Pavia in Italy. [ 60 ]  The first was treated in 2001 and the second in mid-2003. The patients received an i.v. infusion of BPA, followed by removal of the liver (hepatectomy), which was irradiated outside of the body (extracorporeal BNCT) and then re-transplanted into the patient. The first patient did remarkably well and survived for over 4 years after treatment, but the second died within a month of cardiac complications. [ 61 ]  Clearly, this is a very challenging approach for the treatment of hepatic metastases, and it is unlikely that it will ever be widely used. Nevertheless, the good clinical results in the first patient established  proof of principle . Finally, Yanagie and his colleagues at Meiji Pharmaceutical University in Japan have treated several patients with recurrent rectal cancer using BNCT. Although no long-term results have been reported, there was evidence of short-term clinical responses. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6707", "text": "Accelerators now are the primary source of epithermal neutrons for clinical BNCT. The first papers relating to their possible use were published in the 1980s, and, as summarized by Blue and Yanch, [ 63 ]  this topic became an active area of research in the early 2000s. However, it was the Fukushima nuclear disaster in Japan in 2011 that gave impetus to their development for clinical use. Accelerators also can be used to produce epithermal neutrons. Today several accelerator-based neutron sources (ABNS) are commercially available or under development. Most existing or planned systems use either the lithium-7 reaction,  7 Li(p,n) 7 Be or the beryllium-9 reaction, 9 Be(p,n) 9 B, to generate neutrons, though other nuclear reactions also have been considered. [ 64 ]  The lithium-7 reaction requires a proton accelerator with energies between 1.9 and 3.0 MeV, while the beryllium-9 reaction typically uses accelerators with energies between 5 and 30 MeV. Aside from the lower proton energy that the lithium-7 reaction requires, its main benefit is the lower energy of the neutrons produced. This in turn allows the use of smaller moderators, \"cleaner\" neutron beams, and reduced neutron activation. Benefits of the beryllium-9 reaction include simplified target design and disposal, long target lifetime, and lower required proton beam current."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6708", "text": "Since the proton beams for BNCT are quite powerful (~20-100\u00a0kW), the neutron generating target must incorporate cooling systems capable of removing the heat safely and reliably to protect the target from damage. In the case of the lithium-7, this requirement is especially important due to the low melting point and chemical volatility of the target material. Liquid jets, micro-channels and rotating targets have been employed to solve this problem.Several researchers have proposed the use of liquid lithium-7 targets in which the target material doubles as the coolant. [ 65 ] [ 66 ]  In the case of beryllium-9, \"thin\" targets, in which the protons come to rest and deposit much of their energy in the cooling fluid, can be employed. Target degradation due to beam exposure (\"blistering\") is another problem to be solved, either by using layers of materials resistant to blistering or by spreading the protons over a large target area. Since the nuclear reactions yield neutrons with energies ranging from < 100keV to tens of MeV, a Beam Shaping Assembly (BSA) [ 67 ]  must be used to moderate, filter, reflect and collimate the neutron beam to achieve the desired epithermal energy range, neutron beam size and direction. BSAs are typically composed of a range of materials with desirable nuclear properties for each function. A well-designed BSA should maximize neutron yield per proton while minimizing fast neutron, thermal neutron and gamma contamination. It should also produce a sharply delimited and generally forward directed beam enabling flexible positioning of the patient relative to the aperture. [ 68 ] \nOne key challenge for an ABNS is the duration of treatment time: depending on the neutron beam intensity, treatments can take up to an hour or more. Therefore, it is desirable to reduce the treatment time both for patient comfort during immobilization and to increase the number of patients that could be treated in a 24-hour period. Increasing the neutron beam intensity for the same proton current by adjusting the BSA is often achieved at the cost of reduced beam quality (higher levels of unwanted fast neutrons or gamma rays in the beam or poor beam collimation). Therefore, increasing the proton current delivered by ABNS BNCT systems remains a key goal of technology development programs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6709", "text": "The table below summarizes the existing or planned ABNS installations for clinical use (Updated November, 2024)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6710", "text": "Product"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6711", "text": "Reaction"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6712", "text": "Accelerator Type"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6713", "text": "NeuCure"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6714", "text": "9 Be(p,n) 9 B"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6715", "text": "Cyclotron"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6716", "text": "Fukushima, Japan"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6717", "text": "7 Li(p,n) 7 Be"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6718", "text": "RFQ"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6719", "text": "NeuPex"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6720", "text": "Tandem Electrostatic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6721", "text": "LINAC"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6722", "text": "iBNCT [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6723", "text": "nuBeam"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6724", "text": "Single-ended electrostatic"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6725", "text": "Kanagawa, Japan"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6726", "text": "D-BNCT"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6727", "text": "Alphabeam"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6728", "text": "Treatment of Recurrent Malignant Gliomas"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6729", "text": "The single greatest advance in moving BNCT forward clinically has been the introduction of cyclotron-based neutron sources (c-BNS) in Japan. Shin-ichi Miyatake and Shinji Kawabata have led the way with the treatment of patients with recurrent glioblastomas (GBMs). [ 75 ] [ 76 ]  In their Phase II clinical trial, they used the Sumitomo Heavy Industries accelerator at the Osaka Medical College, Kansai BNCT Medical Center to treat a total of 24 patients. [ 75 ]  These patients ranged in age from 20 to 75 years, and all previously had received standard treatment consisting of surgery followed by chemotherapy with temozolomide (TMZ) and conventional radiation therapy. They were candidates for treatment with BNCT because their tumors had recurred and were progressing in size. They received an intravenous infusion of a proprietary formulation of  10 B-enriched boronophenylalanine (\"Borofalan,\" StellaPharma Corporation, Osaka, Japan) prior to neutron irradiation. The primary endpoint of this study was the 1-year survival rate after BNCT, which was 79.2%, and the median overall survival rate was 18.9 months. Based on these results, it was concluded that c-BNS BNCT was safe and resulted in increased survival of patients with recurrent gliomas. Although there was an increased risk of brain edema due to re-irradiation, this was easily controlled. [ 75 ]  As a result of this trial, the Sumitomo accelerator was approved by the Japanese regulatory authority having jurisdiction over medical devices, and further studies are being carried out with patients who have recurrent, high-grade (malignant) meningiomas. However, further studies for the treatment of patients with GBMs have been put on hold pending additional analysis of the results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6730", "text": "Treatment of Recurrent or Locally Advanced Cancers of the Head and Neck"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6731", "text": "Katsumi Hirose and his co-workers at the Southern Tohoku BNCT Research Center in Koriyama, Japan, recently have reported on their results after treating 21 patients with recurrent tumors of the head and neck region. [ 77 ]  All of these patients had received surgery, chemotherapy, and conventional radiation therapy. Eight of them had recurrent squamous cell carcinomas (R-SCC), and 13 had either recurrent (R) or locally advanced (LA) non-squamous cell carcinomas (nSCC). The overall response rate was 71%, and the complete response and partial response rates were 50% and 25%, respectively, for patients with R-SCC and 80% and 62%, respectively, for those with R or LA SCC. The overall 2-year survival rates for patients with R-SCC or R/LA nSCC were 58% and 100%, respectively. The treatment was well tolerated, and adverse events were those usually associated with conventional radiation treatment of these tumors. These patients had received a proprietary formulation of  10 B-enriched boronophenylalanine (Borofalan), which was administered intravenously. Although the manufacturer of the accelerator was not identified, it presumably was the one manufactured by Sumitomo Heavy Industries, Ltd., which was indicated in the Acknowledgements of their report. [ 77 ]   Based on this Phase II clinical trial, the authors suggested that BNCT using Borofalan and c-BENS was a promising treatment for recurrent head and neck cancers, although further studies would be required to firmly establish this."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6732", "text": "Clinical BNCT first was used to treat highly malignant brain tumors and subsequently for melanomas of the skin that were difficult to treat by surgery. Later, it was used as a type of \"salvage\" therapy for patients with recurrent tumors of the head and neck region. The clinical results were sufficiently promising to lead to the development of accelerator neutron sources, which will be used almost exclusively in the future. [ 46 ]  Challenges for the future clinical success of BNCT that need to be met include the following: [ 78 ] [ 79 ] [ 1 ] [ 2 ] [ 80 ] [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6733", "text": "The  Pakistan Society of Neuro-Oncology  ( PASNO ) [ 1 ]  is Pakistan's first scientific society dedicated to  neuro-oncology . It was created to bring together experts from within and outside Pakistan to improve the care of patients with  tumors  of the brain and spinal cord, and provide a platform for research, teaching and training activities related to neuro-oncology in Pakistan. PASNO is chartered by the  Government of Pakistan  and is a non-profit society."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6734", "text": "The society's inaugural  symposium  was attended by over 50 speakers from 13 countries. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6735", "text": "This article about an organization in Pakistan is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6736", "text": "The  parietal bones  ( / p \u0259 \u02c8 r a\u026a . \u026a t \u0259l /   p\u0259- RY -it-\u0259l ) are two bones in the  skull  which, when joined at a  fibrous joint  known as a  cranial suture , form the sides and roof of the  neurocranium . In  humans , each bone is roughly quadrilateral in form, and has two surfaces, four borders, and four angles. It is named from the Latin  paries  ( -ietis ), wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6737", "text": "The external surface [Fig. 1] is convex, smooth, and marked near the center by an eminence, the  parietal eminence  ( tuber parietale ), which indicates the point where  ossification  commenced."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6738", "text": "Crossing the middle of the bone in an arched direction are two curved lines, the superior and inferior  temporal lines ; the former gives attachment to the  temporal fascia , and the latter indicates the upper limit of the muscular origin of the  temporal muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6739", "text": "Above these lines the bone is covered by a tough layer of fibrous tissue \u2013 the  epicranial aponeurosis ; below them it forms part of the  temporal fossa , and affords attachment to the temporal muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6740", "text": "At the back part and close to the upper or sagittal border is the  parietal foramen  which transmits a vein to the  superior sagittal sinus , and sometimes a small branch of the  occipital artery ; it is not constantly present, and its size varies considerably."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6741", "text": "The internal surface [Fig. 2] is concave; it presents depressions corresponding to the cerebral convolutions, and numerous furrows (grooves) for the ramifications of the  middle meningeal artery ; the latter run upward and backward from the sphenoidal angle, and from the central and posterior part of the squamous border."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6742", "text": "Along the upper margin is a shallow groove, which, together with that on the opposite parietal, forms a channel, the  sagittal sulcus , for the  superior sagittal sinus ; the edges of the sulcus afford attachment to the  falx cerebri ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6743", "text": "Near the groove are several depressions, best marked in the skulls of old persons, for the  arachnoid granulations  (Pacchionian bodies)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6744", "text": "In the groove is the internal opening of the parietal foramen when that aperture exists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6745", "text": "The parietal bone is ossified in membrane from a single center, which appears at the  parietal eminence  about the eighth week of fetal development."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6746", "text": "Ossification gradually extends in a radial manner from the center toward the margins of the bone; the angles are consequently the parts last formed, and it is here that the fontanelles exist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6747", "text": "Occasionally the parietal bone is divided into two parts, upper and lower, by an antero-posterior suture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6748", "text": "In non-human vertebrates, the parietal bones typically form the rear or central part of the  skull roof , lying behind the frontal bones. In many non-mammalian  tetrapods , they are bordered to the rear by a pair of  postparietal bones  that may be solely in the roof of the skull, or slope downwards to contribute to the back of the skull, depending on the species. In the living  tuatara  and some lizards, as well as in many fossil tetrapods, a small opening, the  parietal foramen  (also called the  pineal foramen ), is present between the two parietal bones at the midline of the skull. This opening is the location of the  parietal eye  (also called the pineal or third eye), which is much smaller than the two main eyes. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6749", "text": "The parietal bone is usually present in the posterior end of the skull and is near the midline.  This bone is part of the skull roof, which is a set of bones that cover the brain, eyes and nostrils. The parietal bones make contact with several other bones in the skull.  The anterior part of the bone articulates with the  frontal  bone and the  postorbital bone .  The posterior part of the bone articulates with the  squamosal bone , and less commonly the  supraoccipital  bone.  The bone-supported neck frills of ceratopsians were formed by extensions of the parietal bone.  These frills, which overhang the neck and extend past the rest of the skull is a diagnostic trait of ceratopsians.  The recognizable skull domes present in pachycephalosaurs were formed by the fusion of the frontal and parietal bones and the addition of thick deposits of bone to that unit. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6750", "text": "This article incorporates text in the  public domain  from  page 133  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6751", "text": "Pediatric Neurosurgery  is a subspecialty of  neurosurgery ; which includes  surgical  procedures that are related to the  nervous system ,  brain  and  spinal cord ; that treats  children  with operable  neurological disorders ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6752", "text": "Boston Children's Hospital  was the first hospital in the  United States  with a specialized neurosurgical service for children, established in 1929 by  Harvey Cushing  and  Franc Ingraham . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6753", "text": "As of 2009, there were fewer than 200 pediatric neurosurgeons in the United States. Approximately 80% of them were male. [ 3 ]  In the past 25 years, 391 doctors graduated from a pediatric neurosurgery program. Only 70% of them currently practice primarily pediatric rather than adult neurosurgery. Approximately 70% of them are in  academic medicine . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6754", "text": "This  pediatrics  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6755", "text": "Peripheral nerve tumors , also called tumors of peripheral nerves or tumors of the peripheral nervous system, are a diverse category with a range of morphological characteristics and biological potential. [ 1 ]  They are categorized as either benign or malignant peripheral nerve sheath tumors. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6756", "text": "They vary from benign (soft tissue perineurioma and  schwannoma ) that can be completely removed to benign ( plexiform neurofibroma ) that may be locally aggressive to extremely malignant ( malignant peripheral nerve sheath tumors  [MPNST]). [ 1 ]  New and more precisely defined entities include malignant melanotic nerve sheath tumor (formerly known as melanotic schwannoma) and hybrid nerve sheath tumors. [ 4 ] [ 5 ]  The majority of peripheral nerve tumors are benign tumors of the nerve sheath (usually schwannomas); on rare occasions, they are metastatic tumors or originate from the nerve cells. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6757", "text": "Most peripheral nerve tumors occur for unknown reasons. Some, including  schwannomatosis  and  neurofibromatosis  (types 1 and 2), are associated with recognized  hereditary disorders . Others may be caused by gene mutations. In the case of schwannomatosis and neurofibromatosis, tumors can grow on or close to nerves anywhere in the body. Frequently, there are several tumors. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6758", "text": "The typical symptoms involve a combination of  pain , loss of nerve function, and/or a palpable (or radiographically apparent) mass affecting a peripheral nerve. The etiology and importance of the last two symptoms should be apparent. For example, the presence of a severe nerve palsy is highly suggestive of malignancy as it is most likely the result of the tumor invading and destroying nerves. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6759", "text": "Methods used to identify tumors of the peripheral nervous system include a family history of any predisposition syndrome, including neurofibromatosis types 1 and 2, a targeted and comprehensive  physical examination , and radiological investigations, the primary one being  magnetic resonance imaging . [ 9 ] [ 10 ]  Other radiological investigations may include plain  radiographs ,  ultrasound  examination,  computed tomography , and  positron emission tomography . [ 11 ]  Definitive diagnosis is made by tumor  biopsy . [ 12 ]   Surgery  is the most common method of treating peripheral nerve sheath tumors. [ 11 ]  In malignant tumors, complete resection is the only known curative treatment (with a sufficiently wide margin or even amputation to improve prognosis). [ 12 ]  For larger lesions or those with a more aggressive histology,  adjuvant radiation  is recommended. Novel or combination therapies that are the focus of ongoing clinical trials are highly desirable. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6760", "text": "Formally, the majority of these tumors lack a CNS WHO grade; instead, neoplasms should be graded within each category of tumor. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6761", "text": "(Localized, diffuse, plexiform subtype)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6762", "text": "(Intraneural and soft tissue subtypes)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6763", "text": "(epithelioid and perineural subtypes)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6764", "text": "Phonemic neurological hypochromium therapy (PNHT)  is a technique that uses  insemination  devices to implement  chromium  (Cr3+) into the  hypothalamic  regions of the brain. It has been proposed by Dr. Nicole Kim to offset delayed  phonemic awareness  in children between the ages of 3 and 8. The causes of delayed phonemic awareness have been linked to an inability to break down chromium triastenitephosphate. PNHT has been successfully implemented into  in vivo  mice with some controversial side effects, including;  polydactyly ,  regurgitation ,  fatigue , and  nausea . While  Russia ,  Poland , and  Ukraine  have approved this procedure, the  United States Food and Drug Administration  (USFDA) has not yet granted its approval."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6765", "text": "PNHT functions on the premise that the hypothalamic region of the  human brain  lacks the critical molecule  chromium picolinate , a molecule typically produced by cytochromase B7[1]. The hypothalamus of a developing child may lack cytochromase B7, thereby causing a delay in phonemic awareness. The PNHT process involves passing a chromium mixture (CrAt3PO4) dissolved in a \"mobile phase\" through a stationary phase, which separates the chromium picolinate to be measured from other molecules in the mixture based on differential partitioning between the mobile and stationary phases. Subtle differences in a compound's  partition coefficient  result in differential retention on the stationary phase and thus changing the separation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6766", "text": "In vitro  and animal studies[1 [ unreliable medical source? ] ,2] have shown chromium to have a positive effect on  insulin sensitivity . One of the intracellular proteins influencing the  insulin receptor  is the  oligopeptide   apolipoprotein , low  molecular weight , chromium-binding substance (apo-chromomodulin) [2]. In vitro, this peptide has the ability to increase  tyrosine kinase  activity eightfold, depending on the chromium concentration [3]. This in turn promotes insulin receptor activity, thus eliciting improved insulin sensitivity. Therefore, for some time now, chromium has been thought to play a beneficial role in  glucose metabolism  and, as early as 1957, was referred to as a \u201c glucose tolerance factor \u201d [4]. It has been marketed as such by some companies in the US."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6767", "text": "There are studies that support this proposed effect. Anderson et al. [5] studied the effects of chromium treatment in a group of Chinese patients with  type 2 diabetes . They reported an average decrease in HbA1c (A1C) of almost 2 percentage points after only four months of treatment with 1,000 \u03bcg chromium daily. Since then, the effects of chromium on  glycemic control ,  lipid profile , weight, and  muscular strength  have been investigated, both in nondiabetic healthy subjects and in patients with type 2 diabetes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6768", "text": "2.\tShindea UA, Sharma G, Xu YJ, Dhalla NS, Goyal RK: Insulin sensitising action of chromium picolinate in various experimental models of diabetes mellitus. J Trace Elem Med Biol 18: 23\u201332, 2004"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6769", "text": "3.\tDavis CM, Vincent JB: Chromium oligopeptide activates insulin receptor tyrosine kinase activity. Biochemistry 36: 4382\u20134385, 1997\n4.\tSun Y, Ramirez J, Woski SA, Vincent JB: The binding of trivalent chromium to low-molecular-weight chromium-binding substance (LMWCr) and the transfer of chromium from transferrin and chromium picolinate to LMWCr. J Biol Inorg Chem 5: 129\u2013136, 2000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6770", "text": "5.\t Schwarz K, Mertz W: A glucose tolerance factor and its differentiation from factor 3. Arch Biochem Biophys 72: 515\u2013518, 1957"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6771", "text": "Post-vagotomy diarrhea  is a form of  diarrhea  which occurs in 10% of people after a truncal  vagotomy , which can range from severe to debilitating in approximately 2% to 4% of patients. [ 1 ]  However, the occurrence of post-vagotomy diarrhea is significantly reduced after proximal selective vagotomy, specifically when  celiac  and  hepatic  branches of the  vagus  are retained. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6772", "text": "Surgical treatment for  refractory  post-vagotomy diarrhea is rarely needed and at least one year from the occurrence of  symptoms  should be allotted to ensure all non-surgical treatments have been appropriately explored. Under severe cases, where surgical intervention does become necessary, a 10\u00a0cm reverse  jejunal  interposition is usually the procedure of choice. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6773", "text": "Primary central nervous system lymphoma  ( PCNSL ), also termed  primary diffuse large B-cell lymphoma of the central nervous system (DLBCL-CNS) , [ 2 ]  is a  primary intracranial tumor  appearing mostly in patients with severe  immunodeficiency  (typically patients with  AIDS ). It is a subtype and one of the most aggressive of the  diffuse large B-cell lymphomas . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6774", "text": "PCNSLs represent around 20% of all cases of  lymphomas  in  HIV  infections. (Other types are  Burkitt's lymphomas  and immunoblastic lymphomas). Primary  CNS  lymphoma is highly associated with  Epstein-Barr virus  (EBV) infection (> 90%) in  immunodeficient  patients (such as those with AIDS and those  immunosuppressed ), [ 4 ]  and does not have a predilection for any particular age group. Mean  CD4 + count at time of diagnosis is ~50/\u03bcL. In immunocompromised patients, prognosis is usually poor.  In immunocompetent patients (that is, patients who do not have AIDS or some other acquired or secondary immunodeficiency), there is rarely an association with EBV infection or other  DNA viruses . In the immunocompetent population, PCNSLs typically appear in older patients in their 50s and 60s."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6775", "text": "Importantly, the incidence of PCNSL in the immunocompetent population has been reported to have increased more than 10-fold from 2.5 cases to 30 cases per 10 million population. [ 5 ] [ 6 ]   The cause for the increase in incidence of this disease in the immunocompetent population is unknown."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6776", "text": "A primary CNS lymphoma usually presents with  seizure ,  headache , cranial nerve findings, altered mental status, or other focal neurological deficits typical of a  mass effect . [ 7 ] [ 8 ]   Systemic symptoms may include fever, night sweats, or weight loss. Other symptoms include"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6777", "text": "The current standard for diagnosis typically includes positive  CSF   cytology , vitreous biopsy, or brain/leptomeningeal biopsy. [ 10 ]  Histopathological confirmation is essential for definitive diagnosis. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6778", "text": "MRI  or contrast enhanced  CT  classically shows multiple  ring-enhancing lesions  in the deep  white matter . The major  differential diagnosis  (based on imaging) is cerebral  toxoplasmosis , which is also prevalent in AIDS patients and also presents with a ring-enhanced lesion, although toxoplasmosis generally presents with more lesions and the contrast enhancement is typically more pronounced.   Imaging techniques  cannot distinguish the two conditions with certainty, and cannot exclude other diagnoses.  Thus, patients undergo a  brain biopsy  or  vitreous  biopsy, if there is intraocular involvement. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6779", "text": "Most PCNSLs are diffuse large  B cell   non-Hodgkin lymphomas . [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6780", "text": "Surgical  resection  is usually ineffective because of the depth of the tumour. Treatment with  irradiation  and  corticosteroids  often only produces a partial response and tumour recurs in more than 90% of patients. Median survival is 10 to 18 months in  immunocompetent  patients, and less in those with AIDS. The addition of IV  methotrexate  and  folinic acid  (leucovorin)  may extend survival to a median of 3.5 years. If radiation is added to methotrexate, median survival time may increase beyond 4 years.  However, radiation is not recommended in conjunction with methotrexate because of an increased risk of  leukoencephalopathy  and  dementia  in patients older than 60. [ 14 ]   In AIDS patients, perhaps the most important factor with respect to treatment is the use of  highly active anti-retroviral therapy  (HAART), which affects the CD4+ lymphocyte population and the level of immunosuppression. [ 15 ]  The optimal treatment plan for patients with PCNSL has not been determined. Combination chemotherapy and radiotherapy at least doubles survival time, but causes dementia and leukoencephalopathy in at least 50% of patients who undergo it. The most studied chemotherapeutic agent in PCNSL is  methotrexate  (a folate analogue that interferes with  DNA  repair). Methotrexate therapy in patients with PCNSL typically requires hospitalization for close monitoring and intravenous fluids. Leucovorin is often given for the duration of the therapy. Standard chemotherapeutic regimens for lymphoma such as  CHOP  are ineffective in PCNSL, probably due to poor penetration of the agents through the  blood brain barrier . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6781", "text": "Newer treatments, such as high dose chemotherapy combined with autologous stem cell transplant are proving to increase survival by years. [ 16 ]  New research to increase permeability of the  blood brain barrier  with  NGR-hTNF  followed by  CHOP , produced responses in 75% cases.  [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6782", "text": "A phase 1 clinical trial of  ibrutinib  \u2013 an inhibitor of  Bruton's tyrosine kinase  \u2013 in 13 patients reported responses in 10 (77%). [ 18 ]  Five of the responses were complete."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6783", "text": "The initial response to radiotherapy is often excellent, and may result in a complete remission. However, the duration of response with radiotherapy alone remains short, with median survival after treatment with radiotherapy just 18 months. Methotrexate based chemotherapy markedly improves survival, with some studies showing median survival after methotrexate chemotherapy reaching 48 months. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6784", "text": "Patients with  AIDS  and PCNSL have a median survival of only 4 months with radiotherapy alone. Untreated, median survival is only 2.5 months, sometimes due to concurrent opportunistic infections rather than the lymphoma itself. Extended survival has been seen, however, in a subgroup of AIDS patients with  CD4  counts of more than 200 and no concurrent opportunistic infections, who can tolerate aggressive therapy consisting of either methotrexate monotherapy or  vincristine , procarbazine, or whole brain radiotherapy. These patients have a median survival of 10\u201318 months. Of course,  highly active antiretroviral therapy  (HAART) is critical for prolonged survival in any AIDS patient, so compliance with HAART may play a role in survival in patients with concurrent AIDS and PCNSL. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6785", "text": "aggressive:   S\u00e9zary disease"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6786", "text": "A  pseudomeningocele  is an abnormal collection of  cerebrospinal fluid  (CSF) that communicates with the CSF space around the  brain  or  spinal cord .  In contrast to a  meningocele , in which the fluid is surrounded and confined by  dura mater , in a pseudomeningocele, the fluid has no surrounding membrane, but is contained in a cavity within the  soft tissues ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6787", "text": "Pseudomeningocele may result after  brain surgery ,  spine  surgery, or  brachial plexus   avulsion injury ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6788", "text": "Treatment for pseudomeningocele is conservative or may involve neurosurgical repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6789", "text": "A  pseudosubarachnoid hemorrhage  is an apparent increased  attenuation  on  CT scans  within the  basal cisterns  that mimics a true  subarachnoid hemorrhage . [ 1 ]  This occurs in cases of severe  cerebral edema , such as by  cerebral hypoxia . It may also occur due to  intrathecally administered   contrast material , [ 2 ]  leakage of high-dose  intravenous  contrast material into the  subarachnoid spaces , or in patients with  cerebral venous sinus thrombosis , severe  meningitis ,  leptomeningeal carcinomatosis , [ 3 ]   intracranial hypotension ,  cerebellar infarctions , or  bilateral   subdural hematomas . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6790", "text": "In a true  subarachnoid hemorrhage , there is higher attenuation on CT scans of the  basal cisterns , and blood that has leaked from a  vessel  or formed a  hematoma  is more highly attenuated due to the absorption of  plasma . [ 5 ]  Pseudosubarachnoid hemorrhages have been observed in as much as 20% of patients resuscitated from non-traumatic  cardiopulmonary arrest . Patients with pseudosubarachnoid hemorrhages may have worse  prognoses  than those with true subarachnoid hemorrhages because of underlying disease processes and decreased  cerebral perfusion  with elevated intracranial pressure. [ 6 ]  The identification of a pseudosubarachnoid hemorrhage as opposed to a true subarachnoid hemorrhage may therefore change a patient's treatment plan. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6791", "text": "Psychosurgery , also called   neurosurgery for mental disorder  ( NMD ), is the  neurosurgical treatment  of  mental disorders . [ 1 ]  Psychosurgery has always been a controversial medical field. [ 1 ]  The modern  history of psychosurgery  begins in the 1880s under the Swiss psychiatrist  Gottlieb Burckhardt . [ 2 ] [ 3 ]  The first significant foray into psychosurgery in the 20th century was conducted by the Portuguese neurologist  Egas Moniz  who, during the mid-1930s, developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the  neuropsychiatrist   Walter Freeman  and the  neurosurgeon   James W. Watts  who devised what became the standard prefrontal procedure and named their operative technique  lobotomy , although the operation was called leucotomy in the United Kingdom. [ 4 ]  In spite of the award of the  Nobel prize  to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman-Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with  depression  or  obsessive-compulsive disorder  (OCD). [ 5 ] \nIn some countries it is also used in the treatment of  schizophrenia  and other disorders. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6792", "text": "Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a  general anaesthetic  and using  stereotactic  methods, a small piece of  brain  is destroyed or removed. The most common types of psychosurgery in current or recent use are anterior capsulotomy,  cingulotomy ,  subcaudate tractotomy  and  limbic leucotomy . Lesions are made by radiation, thermo-coagulation, freezing or cutting. [ 1 ]  About a third of patients show significant improvement in their symptoms after operation. [ 1 ]  Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include  seizures , incontinence, decreased drive and initiative, weight gain, and  cognitive  and  affective  problems. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6793", "text": "Currently, interest in the neurosurgical treatment of mental illness is shifting from  ablative  psychosurgery (where the aim is to destroy brain tissue) to  deep brain stimulation  (DBS) where the aim is to stimulate areas of the brain with implanted  electrodes . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6794", "text": "All the forms of psychosurgery in use today (or used in recent years) target the  limbic system , which involves structures such as the  amygdala ,  hippocampus , certain  thalamic  and  hypothalamic  nuclei,  prefrontal  and  orbitofrontal cortex , and  cingulate gyrus \u2014all connected by fibre pathways and thought to play a part in the regulation of emotion. [ 9 ]  There is no international consensus on the best target site. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6795", "text": "Anterior cingulotomy  was first used by  Hugh Cairns  in the UK, and developed in the US by H.T. Ballantine Jr. [ 10 ]  In recent decades it has been the most commonly used psychosurgical procedure in the US. [ 9 ]  The target site is the anterior cingulate cortex; the operation disconnects the thalamic and posterior frontal regions and damages the anterior cingulate region. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6796", "text": "Anterior capsulotomy  was developed in Sweden, where it became the most frequently used procedure. It is also used in Scotland and Canada. The aim of the operation is to disconnect the orbitofrontal cortex and thalamic nuclei by inducing a lesion in the anterior limb of  internal capsule . [ 9 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6797", "text": "Subcaudate tractotomy  was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra-orbital part of the frontal lobe. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6798", "text": "Limbic leucotomy   is a combination of subcaudate tractotomy and anterior cingulotomy. It was used at  Atkinson Morley Hospital  London in the 1990s [ 9 ]  and also at  Massachusetts General Hospital . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6799", "text": "Amygdalotomy , which targets the  amygdala , was developed as a treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the  Medical College of Georgia . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6800", "text": "There is debate about whether  deep brain stimulation  (DBS) should be classed as a form of psychosurgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6801", "text": "Success rates for anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy in treating depression and OCD have been reported as between 25 and 70 percent. [ 1 ]  The quality of outcome data is poor and the Royal College of Psychiatrists in their 2000 report concluded that there were no simple answers to the question of modern psychosurgery's clinical effectiveness; studies suggested improvements in symptoms following surgery but it was impossible to establish the extent to which other factors contributed to this improvement. [ 5 ]  Research into the effects of psychosurgery has not been able to overcome a number of methodological problems, including the problems associated with non-standardised diagnoses and outcome measurements, the small numbers treated at any one centre, and  positive publication bias . Controlled studies are very few in number and there have been no placebo-controlled studies. There are no systematic reviews or meta-analyses. [ 1 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6802", "text": "Modern techniques have greatly reduced the risks of psychosurgery, although risks of adverse effects still remain. Whilst the risk of death or vascular injury has become extremely small, there remains a risk of seizures, fatigue, and personality changes following operation. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6803", "text": "A 2012 follow-up study of eight depressed patients who underwent anterior capsulotomy in Vancouver, Canada, classified five of them as responders at two to three years after surgery. Results on neuropsychological testing were unchanged or improved, although there were isolated deficits and one patient was left with long-term frontal psychobehavioral changes and fatigue. One patient, aged 75, was left mute and  akinetic  for a month following surgery and then developed  dementia . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6804", "text": "In China, psychosurgical operations which make a lesion in the  nucleus accumbens  are used in the treatment of drug and alcohol dependence. [ 17 ] [ 18 ]  Psychosurgery is also used in the treatment of schizophrenia, depression, and other mental disorders. [ 6 ]  Psychosurgery is not regulated in China, and its use has been criticised in the West. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6805", "text": "India had an extensive psychosurgery programme until the 1980s, using it to treat addiction, and aggressive behaviour in adults and children, as well as depression and OCD. [ 19 ] \nCingulotomy and capsulotomy for depression and OCD continue to be used, for example at the BSES MG Hospital in Mumbai. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6806", "text": "In Japan the first lobotomy was performed in 1939 and the operation was used extensively in mental hospitals. [ 21 ]  However, psychosurgery fell into disrepute in the 1970s, partly due to its use on children with behavioural problems. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6807", "text": "In the 1980s there were 10\u201320 operations a year in Australia and New Zealand. [ 8 ]  The number had decreased to one or two a year by the 1990s. [ 8 ]  In Victoria, there were no operations between 2001 and 2006, but between 2007 and 2012 the Victoria Psychosurgery Review Board dealt with 12 applications, all them for DBS. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6808", "text": "In the 20-year period 1971\u20131991 the Committee on Psychosurgery in the Netherlands and Belgium oversaw 79 operations. [ 5 ]  Since 2000 there has been only one centre in Belgium performing psychosurgery, carrying out about 8 or 9 operations a year (some capsulotomies and some DBS), mostly for OCD. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6809", "text": "In France about five people a year were undergoing psychosurgery in the early 1980s. [ 24 ] \nIn 2005 the Health Authority recommended the use of ablative psychosurgery and DBS for OCD. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6810", "text": "In the early 2000s in Spain about 24 psychosurgical operations (capsulotomy, cingulotomy, subcaudate tractotomy, and hypothalamotomy) a year were being performed. OCD was the most common diagnosis, but psychosurgery was also being used in the treatment of anxiety and schizophrenia, and other disorders. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6811", "text": "In the UK between the late 1990s and 2009 there were just two centres using psychosurgery: a few stereotactic anterior capsulotomies are performed every year at the  University Hospital of Wales , Cardiff, while anterior cingulotomies are carried out by the Advanced Interventions Service at  Ninewells Hospital , Dundee. The patients have diagnoses of depression, obsessive-compulsive disorder, and anxiety. Ablative psychosurgery was not performed in England between the late 1990s and 2009, [ 5 ]  although a couple of hospitals have been experimenting with DBS. [ 26 ]  In 2010,  Frenchay Hospital  in Bristol performed an anterior cingulotomy on a woman who had previously undergone DBS. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6812", "text": "In Russia in 1998 the Institute of the Human Brain ( Russian Academy of Sciences ) started a programme of stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on annually. [ 28 ]  In the Soviet Union, leucotomies were used for the treatment of schizophrenia in the 1940s, but the practice was prohibited by the Ministry of Health in 1950. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6813", "text": "In the United States, the  Massachusetts General Hospital  has a psychosurgery program. [ 30 ]  Operations are also performed at a few other centres."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6814", "text": "In Mexico, psychosurgery is used in the treatment of anorexia [ 31 ]  and aggression. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6815", "text": "In Canada, anterior capsulotomies are used in the treatment of depression and OCD. [ 16 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6816", "text": "Venezuela has three centres performing psychosurgery. Capsulotomies, cingulotomies and amygdalotomies are used to treat OCD and aggression. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6817", "text": "Evidence of  trepanning  (or trephining)\u2014the practice of drilling holes in the skull\u2014has been found in a skull from a Neolithic burial site in France, dated to about 5100 BC although it was also used to treat  brain cranial trauma . There have also been archaeological finds in South America, while in Europe trepanation was carried out in classical and medieval times. [ 35 ] \nThe first systematic attempt at psychosurgery is commonly attributed to the Swiss psychiatrist  Gottlieb Burckhardt . [ 36 ]  In December 1888 Burckhardt operated on the brains of six patients (one of whom died a few days after the operation) at the Pr\u00e9fargier Asylum, cutting out a piece of  cerebral cortex . He presented the results at the Berlin Medical Congress and published a report, but the response was hostile and he did no further operations. [ 37 ] \nEarly in the 20th century, Russian neurologist  Vladimir Bekhterev  and Estonian neurosurgeon  Ludvig Puusepp  operated on three patients with mental illness, with discouraging results. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6818", "text": "Although there had been earlier attempts to treat psychiatric disorders with brain surgery, it was Portuguese neurologist  Egas Moniz  who was responsible for introducing the operation into mainstream psychiatric practice. He also coined the term psychosurgery. [ 37 ]  Moniz developed a theory that people with mental illnesses, particularly \"obsessive and melancholic cases\", had a disorder of the  synapses  which allowed unhealthy thoughts to circulate continuously in their brains. Moniz hoped that by surgically interrupting pathways in their brain he could encourage new healthier synaptic connections. [ 38 ]  In November 1935, under Moniz's direction, surgeon Pedro Almeida Lima drilled a series of holes on either side of a woman's skull and injected  ethanol  to destroy small areas of subcortical white matter in the  frontal lobes . After a few operations using ethanol, Moniz and Almeida Lima changed their technique and cut out small cores of brain tissue. They designed an instrument which they called a leucotome and called the operation a  leucotomy  (cutting of the white matter). [ 38 ]  After twenty operations, they published an account of their work. The reception was generally not friendly but a few psychiatrists, notably in Italy and the US, were inspired to experiment for themselves. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6819", "text": "In the US, psychosurgery was taken up and zealously promoted by neurologist  Walter Freeman  and neurosurgeon  James Watts . [ 10 ]  They started a psychosurgery program at  George Washington University  in 1936, first using Moniz's method but then devised a method of their own in which the connections between the prefrontal lobes and deeper structures in the brain were severed by making a sweeping cut through a burr hole on either side of the skull. [ 10 ]  They called their new operation a  lobotomy . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6820", "text": "Freeman went on to develop a new form of lobotomy which could be dispensed without the need for a neurosurgeon. He hammered an ice pick-like instrument, an orbitoclast, through the eye socket and swept through the frontal lobes. The transorbital or \"ice pick\" lobotomy was done under  local anesthesia  or using  electroconvulsive therapy  to render the patient unconscious and could be performed in mental hospitals lacking surgical facilities. [ 39 ]  Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his \"lobotomobile\", demonstrating the procedure in psychiatric hospitals. [ 40 ]  Freeman's patients included 19 children, one of whom was 4 years old. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6821", "text": "The 1940s saw a rapid expansion of psychosurgery, in spite of the fact that it involved a significant risk of death [ 42 ]  and severe personality changes. [ 43 ]  By the end of the decade, up to 5000 psychosurgical operations were being carried out annually in the US. [ 43 ]  In 1949, Moniz was awarded the  Nobel Prize for Physiology or Medicine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6822", "text": "Beginning in the 1940s various new techniques were designed in the hope of reducing the adverse effects of the operation. These techniques included  William Beecher Scoville 's  orbital undercutting , Jean Talairach's  anterior capsulotomy , and Hugh Cairn's  bilateral cingulotomy . [ 10 ]  Stereotactic techniques made it possible to place  lesions  more accurately, and experiments were done with alternatives to cutting instruments such as radiation. [ 10 ]  Psychosurgery nevertheless went into rapid decline in the 1950s, due to the introduction of new drugs and a growing awareness of the long-term damage caused by the operations, [ 10 ]  as well as doubts about its efficacy. [ 1 ]  By the 1970s, the standard or transorbital lobotomy had been replaced with other forms of psychosurgical operations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6823", "text": "During the 1960s and 1970s, psychosurgery became the subject of increasing public concern and debate, culminating in the US with congressional hearings. Particularly controversial in the United States was the work of Harvard neurosurgeon  Vernon Mark  and psychiatrist  Frank Ervin , who carried out amygdalotomies in the hope of reducing violence and \"pathologic aggression\" in patients with temporal lobe seizures and wrote a book entitled  Violence and the Brain  in 1970. [ 1 ]  The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1977 endorsed the continued limited use of psychosurgical procedures. [ 1 ] [ 44 ]  Since then, a few facilities in some countries, such as the US, have continued to use psychosurgery on small numbers of patients. In the US and other Western countries, the number of operations has further declined over the past 30 years, [ timeframe? ]  a period during which there had been no major advances in ablative psychosurgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6824", "text": "Psychosurgery has a controversial history, and despite modifications, still raises serious questions about benefit, risks, and the adequacy with which consent is obtained.  Its continued use is defended by references to the \"therapeutic imperative\" to do something in the case of psychiatric patients who have not responded to other forms of treatment, and the evidence that some patients see improvement in their symptoms following surgery. There remain however problems concerning the rationale, indications and efficacy of psychosurgery, and the results of the operation raise questions of \"identity, spirit, relationships, integrity and human flourishing\". [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6825", "text": "Radiosurgery  is  surgery  using  radiation , [ 1 ]  that is, the destruction of precisely selected areas of  tissue  using  ionizing radiation  rather than excision with a blade. Like other forms of  radiation therapy  (also called radiotherapy), it is usually used to treat  cancer . Radiosurgery was originally defined by the Swedish neurosurgeon  Lars Leksell  as \"a single high dose fraction of radiation, stereotactically directed to an intracranial region of interest\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6826", "text": "In  stereotactic radiosurgery  ( SRS ), the word \" stereotactic \" refers to a three-dimensional  coordinate system  that enables accurate correlation of a virtual target seen in the patient's diagnostic images with the actual target position in the patient. Stereotactic radiosurgery may also be called  stereotactic body radiation therapy  (SBRT) or stereotactic ablative radiotherapy (SABR) when used outside the  central nervous system  (CNS). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6827", "text": "Stereotactic radiosurgery was first developed in 1949 by the Swedish neurosurgeon Lars Leksell to treat small targets in the brain that were not amenable to conventional surgery. The initial stereotactic instrument he conceived used probes and electrodes. [ 4 ]  The first attempt to supplant the electrodes with radiation was made in the early fifties, with  x-rays . [ 5 ]  The principle of this instrument was to hit the intra-cranial target with narrow beams of radiation from multiple directions. The beam paths converge in the target volume, delivering a lethal cumulative dose of radiation there, while limiting the dose to the adjacent healthy tissue. Ten years later significant progress had been made, due in considerable measure to the contribution of the physicists Kurt Liden and B\u00f6rje Larsson. [ 6 ]   At this time, stereotactic  proton  beams had replaced the x-rays. [ 7 ]  The heavy particle beam presented as an excellent replacement for the surgical knife, but the  synchrocyclotron  was too clumsy. Leksell proceeded to develop a practical, compact, precise and simple tool which could be handled by the surgeon himself. In 1968 this resulted in the Gamma Knife, which was installed at the  Karolinska Institute  and consisted of several  cobalt-60   radioactive  sources placed in a kind of helmet with central channels for irradiation with gamma rays. [ 8 ]  This prototype was designed to produce slit-like radiation lesions for functional neurosurgical procedures to treat pain, movement disorders, or behavioral disorders that did not respond to conventional treatment. The success of this first unit led to the construction of a second device, containing 179 cobalt-60 sources. This second Gamma Knife unit was designed to produce spherical lesions to treat brain tumors and intracranial  arteriovenous malformations  (AVMs). [ 9 ]  Additional units were installed in the 1980s all with 201 cobalt-60 sources. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6828", "text": "In parallel to these developments, a similar approach was designed for a  linear particle accelerator  or Linac. Installation of the first 4\u00a0 MeV  clinical linear accelerator began in June 1952 in the Medical Research Council (MRC) Radiotherapeutic Research Unit at the  Hammersmith Hospital , London. [ 11 ]  The system was handed over for physics and other testing in February 1953 and began to treat patients on 7 September that year. Meanwhile, work at the Stanford Microwave Laboratory led to the development of a 6 MeV accelerator, which was installed at Stanford University Hospital, California, in 1956. [ 12 ]  Linac units quickly became favored devices for conventional fractionated  radiotherapy  but it lasted until the 1980s before dedicated Linac radiosurgery became a reality. In 1982, the Spanish neurosurgeon J. Barcia-Salorio began to evaluate the role of cobalt-generated and then Linac-based photon radiosurgery for the treatment of AVMs and  epilepsy . [ 13 ]  In 1984, Betti and Derechinsky described a Linac-based radiosurgical system. [ 14 ]  Winston and Lutz further advanced Linac-based radiosurgical prototype technologies by incorporating an improved stereotactic positioning device and a method to measure the accuracy of various components. [ 15 ]  Using a modified Linac, the first patient in the United States was treated in Boston  Brigham and Women's Hospital  in February 1986. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6829", "text": "Technological improvements in medical imaging and computing have led to increased clinical adoption of stereotactic radiosurgery and have broadened its scope in the 21st century. [ 16 ] [ 17 ]  The localization accuracy and precision that are implicit in the word \"stereotactic\" remain of utmost importance for radiosurgical interventions and are significantly improved via  image-guidance  technologies such as the  N-localizer [ 18 ]  and Sturm-Pastyr localizer [ 19 ]  that were originally developed for  stereotactic surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6830", "text": "In the 21st century the original concept of radiosurgery  expanded to include treatments comprising up to five  fractions , and stereotactic radiosurgery has been redefined as a distinct  neurosurgical  discipline that utilizes externally generated  ionizing radiation  to inactivate or eradicate defined targets, typically in the head or spine, without the need for a surgical incision. [ 20 ]  Irrespective of the similarities between the concepts of stereotactic radiosurgery and fractionated radiotherapy the mechanism to achieve treatment is subtly different, although both treatment modalities are reported to have identical outcomes for certain indications. [ 21 ]  Stereotactic radiosurgery has a greater emphasis on delivering precise, high doses to small areas, to destroy target tissue while preserving adjacent normal tissue. The same principle is followed in conventional radiotherapy although lower dose rates spread over larger areas are more likely to be used (for example as in  VMAT  treatments). Fractionated radiotherapy relies more heavily on the different  radiosensitivity  of the target and the surrounding normal tissue to the  total accumulated radiation dose . [ 20 ]  Historically, the field of fractionated radiotherapy evolved from the original concept of stereotactic radiosurgery following discovery of the principles of  radiobiology : repair, reassortment, repopulation, and reoxygenation. [ 22 ]  Today, both treatment techniques are complementary, as tumors that may be resistant to fractionated radiotherapy may respond well to radiosurgery, and tumors that are too large or too close to critical organs for safe radiosurgery may be suitable candidates for fractionated radiotherapy. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6831", "text": "Today, both Gamma Knife and Linac radiosurgery programs are commercially available worldwide. While the Gamma Knife is dedicated to radiosurgery, many Linacs are built for conventional fractionated radiotherapy and require additional technology and expertise to become dedicated radiosurgery tools. There is not a clear difference in efficacy between these different approaches. [ 23 ] [ 24 ]  The major manufacturers,  Varian  and  Elekta  offer dedicated radiosurgery Linacs as well as machines designed for conventional treatment with radiosurgery capabilities. Systems designed to complement conventional Linacs with beam-shaping technology, treatment planning, and image-guidance tools to provide. [ 25 ]  An example of a dedicated radiosurgery Linac is the  CyberKnife , a compact Linac mounted onto a robotic arm that moves around the patient and irradiates the tumor from a large set of fixed positions, thereby mimicking the Gamma Knife concept."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6832", "text": "The fundamental principle of radiosurgery is that of selective  ionization  of tissue, by means of high-energy beams of radiation. Ionization is the production of  ions  and  free radicals  which are damaging to the  cells . These ions and radicals, which may be formed from the water in the cell or biological materials, can produce irreparable damage to DNA, proteins, and lipids, resulting in the cell's death. Thus, biological inactivation is carried out in a volume of tissue to be treated, with a precise destructive effect. The radiation dose is usually measured in  grays  (one gray (Gy) is the absorption of one  joule  of energy per kilogram of mass). A unit that attempts to take into account both the different organs that are irradiated and the type of radiation is the  sievert , a unit that describes both the amount of energy deposited and the biological effectiveness. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6833", "text": "When used outside the CNS it may be called stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6834", "text": "Radiosurgery is performed by a multidisciplinary team of  neurosurgeons ,  radiation oncologists  and medical  physicists  to operate and maintain highly sophisticated, highly precise and complex instruments, including medical linear accelerators, the Gamma Knife unit and the Cyberknife unit. The highly precise irradiation of targets within the brain and spine is planned using information from medical images that are obtained via  computed tomography ,  magnetic resonance imaging , and  angiography . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6835", "text": "Radiosurgery is indicated primarily for the therapy of tumors, vascular lesions and functional disorders.  Significant clinical judgment must be used with this technique and considerations must include lesion type, pathology if available, size, location and age and general health of the patient.  General contraindications to radiosurgery include excessively large size of the target lesion, or lesions too numerous for practical treatment. Patients can be treated within one to five days as  outpatients . By comparison, the average hospital stay for a  craniotomy  (conventional neurosurgery, requiring the opening of the skull) is about 15 days. The radiosurgery outcome may not be evident until months after the treatment. Since radiosurgery does not remove the tumor but inactivates it biologically, lack of growth of the lesion is normally considered to be treatment success. General indications for radiosurgery include many kinds of brain tumors, such as  acoustic neuromas ,  germinomas ,  meningiomas ,  metastases , trigeminal neuralgia, arteriovenous malformations, and skull base tumors, among others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6836", "text": "Stereotatic radiosurgery of the spinal metastasis is efficient in controlling pain in up to 90% of the cases and ensures stability of the tumours on imaging evaluation in 95% of the cases, and is more efficient for spinal metastasis involving one or two segments. Meanwhile, conventional external beam radiotherapy is more suitable for multiple spinal involvement. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6837", "text": "SRS may be administered alone or in combination with other therapies. For brain metastases, these treatment options include  whole brain radiation therapy  (WBRT), surgery, and systemic therapies. However, a recent systematic review found no difference in the affects on overall survival or deaths due to brain metastases when comparing SRS treatment alone to SRS plus WBRT treatment or WBRT alone. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6838", "text": "Expansion of stereotactic radiotherapy to other lesions is increasing, and includes liver cancer, lung cancer, pancreatic cancer, etc. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6839", "text": "The New York Times  reported in December 2010 that radiation overdoses had occurred with the linear accelerator method of radiosurgery, due in large part to inadequate safeguards in equipment retrofitted for stereotactic radiosurgery. [ 28 ]  In the U.S. the  Food and Drug Administration  (FDA) regulates these devices, whereas the Gamma Knife is regulated by the  Nuclear Regulatory Commission ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6840", "text": "This is evidence that  immunotherapy  may be useful for treatment of radiation necrosis following stereotactic radiotherapy. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6841", "text": "The selection of the proper kind of radiation and device depends on many factors including lesion type, size, and location in relation to critical structures.  Data suggest that similar clinical outcomes are possible with all of the various techniques.  More important than the device used are issues regarding indications for treatment, total dose delivered, fractionation schedule and conformity of the treatment plan. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6842", "text": "A Gamma Knife (also known as the Leksell Gamma Knife) is used to treat  brain tumors  by administering high-intensity gamma radiation therapy in a manner that concentrates the radiation over a small volume. The device was invented in 1967 at the Karolinska Institute in  Stockholm , Sweden, by  Lars Leksell , Romanian-born neurosurgeon Ladislau Steiner, and  radiobiologist  B\u00f6rje Larsson from  Uppsala University , Sweden."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6843", "text": "A Gamma Knife typically contains 201  cobalt-60  sources of approximately 30\u00a0 curies  each (1.1\u00a0 TBq ), placed in a hemispheric array in a heavily  shielded  assembly. The device aims  gamma radiation  through a target point in the patient's brain.  The patient wears a specialized helmet that is surgically fixed to the skull, so that the brain tumor remains stationary at the target point of the gamma rays. An  ablative  dose of radiation is thereby sent through the tumor in one treatment session, while surrounding brain tissues are relatively spared."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6844", "text": "Gamma Knife therapy, like all radiosurgery, uses doses of radiation to kill cancer cells and shrink tumors, delivered precisely to avoid damaging healthy brain tissue. Gamma Knife radiosurgery is able to accurately focus many beams of gamma radiation on one or more tumors. Each individual beam is of relatively low intensity, so the radiation has little effect on intervening brain tissue and is concentrated only at the tumor itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6845", "text": "Gamma Knife radiosurgery has proven effective for patients with benign or malignant brain tumors up to 4\u00a0cm (1.6\u00a0in) in size,  vascular  malformations such as an  arteriovenous malformation  (AVM), pain, and other functional problems. [ 30 ] [ 31 ] [ 32 ] [ 33 ]   For treatment of trigeminal neuralgia the procedure may be used repeatedly on patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6846", "text": "Acute complications following Gamma Knife radiosurgery are rare, [ 34 ]  and complications are related to the condition being treated. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6847", "text": "A linear accelerator (linac) produces x-rays from the impact of accelerated electrons striking a high  z  target, usually tungsten. The process is also referred to as \"x-ray therapy\" or \"photon therapy.\"  The emission head, or \" gantry \", is mechanically rotated around the patient in a full or partial circle. The table where the patient is lying, the \"couch\", can also be moved in small linear or angular steps. The combination of the movements of the gantry and of the couch allow the computerized planning of the volume of tissue that is going to be irradiated. Devices with a high energy of 6\u00a0MeV are commonly used for the treatment of the brain, due to the depth of the target. The diameter of the energy beam leaving the emission head can be adjusted to the size of the lesion by means of  collimators . They may be interchangeable orifices with different diameters, typically varying from 5 to 40\u00a0mm in 5\u00a0mm steps, or multileaf collimators, which consist of a number of metal leaflets that can be moved dynamically during treatment in order to shape the radiation beam to conform to the mass to be ablated. As of 2017 [update]  Linacs were capable of achieving extremely narrow beam geometries, such as 0.15 to 0.3\u00a0mm. Therefore, they can be used for several kinds of surgeries which hitherto had been carried out by open or endoscopic surgery, such as for trigeminal neuralgia. Long-term follow-up data has shown it to be as effective as radiofrequency ablation, but inferior to surgery in preventing the recurrence of pain. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6848", "text": "The first such systems were developed by  John R. Adler , a  Stanford University  professor of neurosurgery and radiation oncology, and Russell and Peter Schonberg at Schonberg Research, and commercialized under the brand name CyberKnife."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6849", "text": "Protons may also be used in radiosurgery in a procedure called  Proton Beam Therapy  (PBT) or  proton therapy . Protons are extracted from proton donor materials by a medical  synchrotron  or  cyclotron , and accelerated in successive transits through a circular, evacuated conduit or cavity, using powerful magnets to shape their path, until they reach the energy required to just traverse a human body, usually about 200\u00a0MeV. They are then released toward the region to be treated in the patient's body, the irradiation target. In some machines, which deliver protons of only a specific energy, a custom mask made of plastic is interposed between the beam source and the patient to adjust the beam energy to provide the appropriate degree of penetration. The phenomenon of the  Bragg peak  of ejected protons gives proton therapy advantages over other forms of radiation, since most of the proton's energy is deposited within a limited distance, so tissue beyond this range (and to some extent also tissue inside this range) is spared from the effects of radiation. This property of protons, which has been called the \" depth charge  effect\" by analogy to the explosive weapons used in anti-submarine warfare, allows for conformal dose distributions to be created around even very irregularly shaped targets, and for higher doses to targets surrounded or backstopped by radiation-sensitive structures such as the  optic chiasm  or brainstem. The development of \"intensity modulated\" techniques allowed similar conformities to be attained using linear accelerator radiosurgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6850", "text": "As of 2013 [update]  there was no evidence that proton beam therapy is better than any other types of treatment in most cases, except for a \"handful of rare pediatric cancers\". Critics, responding to the increasing number of very expensive PBT installations, spoke of a \"medical  arms race \"  and \"crazy medicine and unsustainable public policy\". [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6851", "text": "A  selective dorsal rhizotomy  ( SDR ), also known as a  rhizotomy ,  dorsal rhizotomy , or a  selective posterior rhizotomy , is a  neurosurgical  procedure that selectively cuts problematic  nerve roots  in the  spinal cord . [ 3 ] [ note 1 ]  This procedure has been well-established in the literature as a surgical intervention and is used to relieve negative symptoms of  neuromuscular  conditions such as  spastic diplegia  and other forms of  spastic cerebral palsy . [ 4 ]  The specific sensory nerves inducing spasticity are identified using  electromyographic  (EMG) stimulation and graded on a scale of 1 (mild) to 4 (severe spasticity). Abnormal nerve responses (usually graded a 3 or 4) are isolated and cut, thereby reducing symptoms of spasticity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6852", "text": "Spasticity is defined as a velocity-dependent increase in muscle tone in response to a stretch. [ 5 ]   This  upper motor neuron  condition results from a lack of descending input from the brain that would normally release the inhibitory neurotransmitter  gamma amino butyric acid  (GABA), which serves to dampen neuronal excitability in the nervous system. [ 6 ]   Spasticity is thought to be caused by an excessive increase of excitatory signals from sensory nerves without proper inhibition by GABA. [ 7 ]   Two common conditions associated with this lack of descending input are cerebral palsy and  acquired brain injury . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6853", "text": "Selective dorsal rhizotomy (SDR), less often referred to as selective posterior rhizotomy (SPR), is the most widely used form of rhizotomy, and is today a primary treatment for  spastic diplegia , best done in the youngest years before bone and joint deformities from the pull of spasticity take place. Still, it can be performed safely and effectively on adults as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6854", "text": "SDR is a permanent procedure that addresses the spasticity at its  neuromuscular  root: i.e., in the central nervous system that contains the misfiring nerves that cause the spasticity of those particular muscles in the first place. After SDR, the person's spasticity is usually eliminated, revealing the \"real\" strength (or lack thereof) of the muscles underneath. SDR's result is fundamentally unlike orthopedic surgical procedures, where spasticity is left untreated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6855", "text": "Because there is always temporary weakness after SDR, patients should work hard to strengthen the weak muscles with physical therapy and learn habits of movement and daily tasks in a body without spasticity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6856", "text": "SDR is usually performed on the  pediatric  spastic cerebral palsy population between the ages of 2 and 6. This is the age range where orthopedic deformities from spasticity have not yet occurred or are minimal. It is also variously claimed by clinicians that another advantage of doing the surgery so young is that it is inherently easier for these young children to restrengthen their muscles and to re-learn how to walk, often having the effect that later in life, they do not even remember the period when they lived with the spasticity at all. However, recent cases of successful SDR procedures among those with spastic diplegia across all age ranges (years 3\u201350) have proven its universal effectiveness and safety regardless of the age of the spastic diplegic patient. A counter-argument against the prevailing view concerning the younger years is that it may actually be quicker and easier to restrengthen an older patient's musculature, and regaining walking may happen faster with an older patient because the patient is fully matured and very aware of what is going on, and so may work harder and with more focus than might a young child. These two schools of thought have equally objectively valid bases for their formation and, thus, are each defended quite intensely by their respective proponents. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6857", "text": "In 1913 Otfrid Foerster in Germany reported the results of dorsal root rhizotomy on patients with spastic cerebral palsy. Rhizotomy for spasticity purposes did indeed then proceed to take about a fifty-year hiatus. In 1967 Claude Gros and his colleagues at the neurosurgical hospital (CHU Gui de Chauliac) in  Montpellier  resurrected posterior rhizotomy for spasticity. Fasano of Italy in 1978 introduced 'selective' posterior rootlet rhizotomy for cerebral palsy patients and  Warwick Peacock [ 8 ]  developed the Gros technique in Cape Town, South Africa, by exposing the  cauda equina , rather than at the spinal cord level. Peacock moved to  Los Angeles  in 1986 and began widely campaigning for SDR's viability in cerebral palsy spasticity relief. Peacock and the surgeons he subsequently trained developed the procedure further using their own clinical-intellectual refinements and refinements in medical equipment and technology that occurred from the 1980s through the 2000s (decade)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6858", "text": "Today,  St. Louis Children's Hospital  in  St. Louis, Missouri , has a \"Center for Cerebral Palsy Spasticity\" that is the only internationally known clinic in the world to have conducted concentrated first-hand clinical research on SDR over an extended period. Its chief neurosurgeon in the field, Doctor T.S. Park (who was initially trained by Peacock), has performed over five thousand SDR surgeries since 1987, some of them on adults, and is the originator of the L1- single-level laminectomy  modification to the SDR surgery in 1991, which sections the first  dorsal root  and enables the removal of significantly less spine-bone than in surgeries performed before 1991, as well as the inherent release of the  hip flexor  muscles specifically as a result of that particular sectioning\u2014prior to that, total hip flexor release was not necessarily possible. That L1-laminectomy modification has since become the standard method, and SLCH has become internationally known as a major provider of SDR surgery to those in need. This clinic believes that patients with spastic diplegia, hemiplegia, or quadriplegia should have spasticity reduced first through SDR before undergoing muscle or tendon release procedures, and other surgeons today share this view. A major qualifier in the cases taken on at SLCH, however, is that all of its adults have had relatively mild  cases of spastic diplegia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6859", "text": "In September 2008, SDR was performed that 'closed the gap' on concerns regarding age of the patient in SDR:  Columbia-Presbyterian   Children's Hospital 's Richard C.E. Anderson performed an SDR surgery on a 28-year-old male with  moderate  spastic diplegia, which by the patient's own report has reduced his muscle tone nearly to the level of a \"normal\" person and enabled him to walk and exercise much more efficiently; also, Anderson in the past performed an SDR on a 16-year-old  wheelchair -using female with  severe  spastic diplegia. Reportedly, that particular SDR enabled the young woman to ambulate, whereas before the surgery, she was too tight to do so. In 2011, Anderson reported that another 16-year-old patient of his was considering undergoing the rhizotomy, but that patient subsequently decided to put her decision on hold  [ citation needed ] . And in July 2011, after offering her several months of consultation, the medical team at the Continuing Care department of  Gillette Children's Specialty Healthcare  performed an SDR procedure on a local young-adult Minnesota resident.Meanwhile, many countries such as the United Kingdom, Russia, and China adopted the dorsal rhizotomy to treat spastic cerebral palsy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6860", "text": "Not all people with spastic cerebral palsy benefit from SDR. For those under 18 years of age, rhizotomy requires that they be:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6861", "text": "For adults between 19 and 50 years of age, rhizotomy requires:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6862", "text": "The long-term effects of SDR have been reported. [ 10 ] [ 11 ]  Selective dorsal rhizotomy surgery has been performed routinely over the past several decades on children with spastic cerebral palsy, and the accumulated evidence indicates positive long-term outcomes. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6863", "text": "All candidates for rhizotomy must have good muscle strength in the legs and trunk. There must also be evidence of adequate motor control or the ability to make reciprocal movements for crawling or walking and to move reasonably quickly from one posture to another. Chiefly, pediatric rhizotomy candidates are people with CP who have shown age-appropriate progression in motor development. Still, spasticity hampers the development of skills and/or causes gait patterns like the  scissors gait . In adults, the primary requirements are that the person is able to ambulate independently, but spasticity limits energy, flexibility, walking speed, and balance and sometimes causes pain/muscle spasms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6864", "text": "The criteria for patient eligibility from the St. Louis Children's Hospital are: [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6865", "text": "After the surgery, all patients walking independently before surgery regained independent walking within a few weeks after surgery. Patients maintain independent walking for the long term; when others have more difficulty walking independently they may eventually need an assistive device. In nearly all cases, spasticity can be eliminated and the quality of independent walking improves, however, physical therapy and braces become unnecessary after SDR. Orthopedic surgery is rarely required after SDR."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6866", "text": "In children who are 2\u20137 years old and walk with a walker or crutches before SDR, independent walking after the procedure is possible. Once they have achieved independent walking, they can maintain it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6867", "text": "In children who are older than 7 years and walk with crutches, independent walking (inside or outside house) is possible. If they walk with walker at the age, they will most likely walk with a walker or crutches after the procedure, though it improves the quality of assisted walking and transition movements, and alleviates deformities of the legs. Many of these patients will need orthopedic surgeries after SDR."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6868", "text": "There are a few clinical situations in which, likely, someone may not be a candidate for the surgery. These situations include those who have had  severe   meningitis , a congenital (birth-originating) brain  infection , congenital  hydrocephalus  unrelated to the person's premature birth, a person who has had head trauma, or a person with some sort of  familial disease . Also precluded are people who have a \"mixed\" CP with predominant dystonia; and those who have severe  scoliosis . However, as with any procedure, an individual evaluation is needed to determine eligibility."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6869", "text": "SDR begins with a 1- to 2-inch incision along the center of the lower back just above the waist. An L1  laminectomy  is then performed: a section of the spine's bone, the spinous processes together with a portion of the lamina, are removed, like a drain-cap, to expose the spinal cord and spinal nerves underneath. Ultrasound and an X-ray locate the tip of the spinal cord, where there is a natural separation between sensory and motor nerves. A rubber pad is then placed to separate the motor from the sensory nerves. The sensory nerve roots, each of which will be tested and selectively eliminated, are placed on top of the pad, while the motor nerves are beneath the pad, away from the operative field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6870", "text": "After the sensory nerves are exposed, each sensory nerve root is divided into 3\u20135 rootlets. Each rootlet is tested with electromyography, which records electrical patterns in muscles. Rootlets are ranked from 1 (mild) to 4 (severe) for spasticity. The severely abnormal rootlets are cut. This technique is repeated for rootlets between spinal nerves L2 and S2. Half of the L1 dorsal root fibers are cut without EMG testing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6871", "text": "The neurosurgical team at  Seattle Children's Hospital  has modified the surgical approach described above by tailoring the selection of nerve root sectioning to the individual patient.  This technique selectively analyzes each individual nerve root with  electromyography  to separate dorsal and ventral nerve roots through comparison of stimulus responses. Researchers have utilized objective feedback from the nerve root compared to the above-mentioned approach that relies on subjective visualization to identify motor versus sensory nerve roots, thus improving the likelihood of sectioning only those nerves of interest.  Another important difference between the two approaches is the location of the  laminectomy  to expose the nerve roots.  At Seattle Children's, the laminectomy is performed below the termination of the spinal cord ( conus ), potentially reducing the risk of injury. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6872", "text": "When testing and corresponding elimination are complete, the dura mater is closed, and fentanyl is given to bathe the sensory nerves directly. The other layers of tissue, muscle, fascia, and subcutaneous tissue are sewn. The skin is typically now closed with glue, but there are sometimes stitches to be removed from the back after 3 weeks. The surgery takes approximately 4 hours and typically involves one neurosurgeon, one anesthesiologist, and possibly an assortment of assisting physicians (as in the New York City September 2008 case). The patient then goes to the recovery room for 1\u20132 hours before being transferred to the intensive care unit overnight. Transfer from the ICU to a recovery room in the hospital is then done to enable direct post-surgical observation by the neurosurgeon and surgical team, but this usually lasts only about 3 days, during which the team performs range-of-motion tests that they record and compare to pre-surgery levels. After that short period, the patient, depending on circumstances and appropriateness, is either transferred to inpatient recovery or is linked to an intense outpatient exercise program and discharged from the hospital."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6873", "text": "According to clinicians, it usually takes about one year from the date of surgery to achieve maximum results from SDR. However, videos from St. Louis Children's Hospital website have shown continued marked improvement as much as five years post-surgery, and presumably, if the person keeps exercising intensely, potential for continued improvement and strengthening is, just as in a person born with normal muscle tone and range of motion, unlimited."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6874", "text": "Selective dorsal rhizotomy can alleviate  contractures  caused by spasticity from before the surgery takes place; also it prevents any more contractures or spasticity from occurring in the future. With or without rhizotomy, the only way contractures can ever be relieved is via  orthopaedic surgery . Fixed orthopaedic deformities of the legs caused by the previous years of intense spasticity are also not relieved by the SDR and must also be corrected surgically."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6875", "text": "There is always abnormal sensitivity and tingling of the skin on the feet and legs after SDR because of the nature of the nerves that have been worked on, but this usually resolves within six weeks. There is no way to prevent the abnormal sensitivity in the feet. Transient change in bladder control may occur, but this also resolves within a few weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6876", "text": "If a certain degree of permanent numbness remains in certain leg muscles, such as the quadriceps, ankles, and feet, this is usually not enough to prevent feeling and sensation, sensing of changes in temperature or pressure, etc. The affected muscle areas simply feel less than before, and the trade-off in ease of movement is said to be immensely worth this change, should it occur."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6877", "text": "There is a risk of any of the following more serious risks happening as a result of SDR."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6878", "text": "Outcomes following a SDR can vary based on the number of nerves cut during surgery, joint deformities,  muscle contractures , and level of impairment before the procedure. [ 16 ]  Following the procedure, the child will likely experience muscle weakness, which can be corrected with  physical therapy  (PT). PT is imperative to restore functional status in the shortest amount of time. Physical therapy post SDR aims to promote independent walking, improved gait pattern, transfers, balance, and upper limb motor control. It is important to remember SDR does not cause permanent muscle weakness, rather it is temporary a few weeks following the procedure. A strengthening program is beneficial to combat this expected weakness and improve lower extremity range of motion and facilitate a near normal gait pattern. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6879", "text": "This Leeds Children's Hospital website was used as a sample post-rehabilitation protocol. [ 17 ]   Week 1 post surgery, the child will typically have 30 minute physical therapy sessions for the first four days followed by an increase up to 45 minutes during days 5\u20137. During the second week, sessions range from 45 to 60 minutes with a focus on stretching, strengthening, developmental milestones (if appropriate), and a standing program. If necessary, an orthotic assessment can be performed during the second week. Weeks 3 through 6 focus on the previously mentioned items but adding gait training, assessment for the need of assistive devices, and preparing a home program for the patient. Six weeks to three months following the procedure the patient will attend outpatient physical therapy 3 to 5 times a week for 45\u201360 minutes and focusing primarily on stretching, strengthening, ambulation, and assessing for the need for adaptive equipment such as a tricycle. Three to six months focus on all previous therapies with emphasis on developing proper gait mechanics. At this point, frequency of the sessions will typically decrease to 2-3 times per week. Six to twelve months post surgery focuses on all of the above with increased emphasis on movement patterns the child may be having difficulty with. One year post procedure, frequency of sessions is 1 to 2 times per week to continue working on strengthening and refining motor control and orthotic needs continued to be monitored. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6880", "text": "A  spinal cord stimulator  ( SCS ) or  dorsal column stimulator  ( DCS ) is a type of implantable  neuromodulation  device (sometimes called a \"pain pacemaker\") that is used to send electrical signals to select areas of the  spinal cord  (dorsal columns) for the treatment of certain pain conditions. SCS is a consideration for people who have a pain condition that has not responded to more conservative therapy. [ 1 ]  There are also spinal cord stimulators under research and development that could enable patients with  spinal cord injury  to walk again via epidural electrical stimulation (EES). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6881", "text": "The most common use of SCS is  failed back surgery syndrome  (FBSS) in the United States and peripheral ischemic pain in Europe. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6882", "text": "As of 2014 the FDA had approved SCS as a treatment for FBSS, chronic pain,  complex regional pain syndrome , intractable angina, as well as visceral abdominal and perineal pain [ 1 ]  and pain in the extremities from nerve damage. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6883", "text": "Once a person has had a  psychological evaluation  and deemed an appropriate candidate for SCS, a temporary implant is placed, called a trial, to determine the best stimulation pattern, and the person is sent home for three to ten days with an external pulse generator.  If pain control and increased activity was achieved, a permanent system, with leads and a pulse generator, is placed. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6884", "text": "SCS may be contraindicated in people who have  coagulation  related disorders, or are on  anticoagulant therapy. [ 1 ]  Other contraindications include local and systemic infection,  pacemakers , or those people for whom pre-surgical imaging studies show have anatomy that makes placement difficult, or if concerns arise during psychological evaluation. [ 8 ] [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6885", "text": "Complications with SCS range from simple easily correctable problems to devastating paralysis, nerve injury and death. In a 7-year follow-up, the overall complication rate was 5\u201318%. The most common complications include lead migration, lead breakage, and infection. Other complications include rotation of the pulse generator,  haematomas  (subcutaneous or epidural),  cerebrospinal fluid  (CSF) leak,  post dural puncture headache , discomfort at pulse generator site,  seroma  and transient  paraplegia . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6886", "text": "Some people find the tingling sensation caused by older model SCS to be unpleasant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6887", "text": "The most common hardware related complication is lead migration, in which the implanted electrodes move from their original placement. With this complication, recapturing paraesthesia coverage can be attempted with reprogramming. [ 12 ]  In circumstances involving major lead migration a reoperation may be required to reset the lead placement. [ 13 ]  Studies differ greatly in reporting the percentage of people who have lead migration but the majority of studies report in the range of 10-25% of lead migration for spinal cord stimulation. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6888", "text": "The neurophysiological mechanisms of action of spinal cord stimulation are not completely understood but may involve masking pain sensation with  tingling  by altering the pain processing of the  central nervous system . [ 14 ]  The mechanism of analgesia when SCS is applied in  neuropathic  pain states may be very different from that involved in analgesia due to limb ischemia. [ 15 ] [ 16 ]  In neuropathic pain states, experimental evidence shows that SCS alters the local neurochemistry in dorsal horn, suppressing the hyperexcitability of the neurons. Specifically, there is some evidence for increased levels of  GABA  release,  serotonin , and perhaps suppression of levels of some excitatory amino acids, including  glutamate  and  aspartate . In the case of ischemic pain, analgesia seems to derive from restoration of the oxygen demand supply. This effect could be mediated by inhibition of the  sympathetic system , although  vasodilation  is another possibility. It is also probable that a combination of the two above mentioned mechanisms is involved. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6889", "text": "Spinal cord stimulators are placed in two different stages: a trial stage followed by a final implantation stage. First, the skin is prepped and draped utilizing sterile technique. The  epidural space  is accessed with loss of resistance technique using a 14-gauge  Tuohy needle . The lead is fed through carefully with fluoroscopic guidance to the appropriate spinal level. This process is repeated to place another lead adjacent to the first.  Fluoroscopy  is used often during the procedure to identify proper placement of the SCS leads. The lead placement depends on the patient's pain location. Based on previous studies, the lead placement for patients with low back pain is typically T9 to T10. The device technician will then turn on the stimulation, typically starting at a very low frequency. The patient is prompted to describe the sensation perceived by activation of the leads, and the technician will calibrate the SCS to achieve the maximum paresthesia coverage of the patient's targeted pain area. Finally, the leads are anchored externally to reduce risk of lead migration, the site is cleaned, and a clean dressing is applied. Once the patient has recovered from the procedure, the device is once again tested and programmed. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6890", "text": "Patients who are candidates for stimulator placement should be screened for contraindications and comorbidities. The following should be considered prior to stimulator trial: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6891", "text": "In order to assess the efficacy of the spinal cord stimulator before implantation, a trial must be performed. This trial begins with placement of temporary leads into the epidural space and connected percutaneously to an external generator. The trial typically lasts 3\u20137 days followed by a 2-week reprieve before SCD implantation to ensure that there is no infection from the trial. [ 13 ] [ 20 ]  Successful trial is defined by at least 50% reduction in pain and 80% paresthesia overlap of the original area of pain. If a patient has sudden changes in their pain, then further investigation is needed for possible lead migration or stimulator malfunction. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6892", "text": "Electrotherapy of pain by neurostimulation began shortly after  Melzack  and  Wall  proposed the  gate control theory  in 1965. This theory proposed that nerves carrying painful peripheral stimuli and nerves carrying touch and vibratory sensation both terminate in the  dorsal horn  (the gate) of spinal cord. [ 21 ]  It was hypothesized that input to the latter could be manipulated to \"close the gate\" to the former. As an application of the gate control theory, Shealy et al. [ 22 ]  implanted the first spinal cord stimulator device directly on the dorsal column for the treatment of chronic pain and in 1971, Shimogi and colleagues first reported the analgesic properties of epidural spinal cord stimulation. Since then this technique has undergone numerous technical and clinical developments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6893", "text": "At this time neurostimulation for the treatment of pain is used with  nerve  stimulation, spinal cord stimulation,  deep brain stimulation , and  motor cortex  stimulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6894", "text": "SCS has been studied in people with Parkinson's disease [ 23 ]  and  angina pectoris . [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6895", "text": "Research on improving the devices and software has included efforts to increasing the battery life, efforts to develop  closed loop  control, and combining stimulation with implanted drug delivery systems. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6896", "text": "SCS is being studied to treat spinal cord injury. In August 2018, The European Commission's Horizon 2020  Future and Emerging Technologies  program announced a $3.5 million funding grant for the four-nation project team that is building a prototype of an implant designed to 'rewire' the spinal cord. [ 25 ]  In September 2018,  Mayo Clinic  and  UCLA  reported that spinal cord stimulation supported with physical therapy can help people with paralysis to regain their ability to stand and walk with assistance. [ 26 ]  In December 2019, the first double blinded, randomized controlled pivotal study in the history of spinal cord stimulation was published in  Lancet Neurology . [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6897", "text": "Stereotactic surgery  is a  minimally invasive  form of  surgical  intervention that makes use of a three-dimensional  coordinate  system to locate small targets inside the body and to perform on them some action such as  ablation ,  biopsy ,  lesion , injection,  stimulation , implantation,  radiosurgery  (SRS), etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6898", "text": "In theory, any organ system inside the body can be subjected to stereotactic surgery. However, difficulties in setting up a reliable frame of reference (such as  bone  landmarks, which bear a constant spatial relation to soft tissues) mean that its applications have been, traditionally and until recently, limited to  brain surgery . Besides the  brain , biopsy and surgery of the  breast  are done routinely to locate, sample (biopsy), and remove tissue. Plain X-ray images ( radiographic  mammography),  computed tomography , and  magnetic resonance imaging  can be used to  guide  the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6899", "text": "Another accepted form of \"stereotactic\" is \"stereotaxic\". The  word roots  are  stereo- , a prefix derived from the  Greek  word \u03c3\u03c4\u03b5\u03c1\u03b5\u03cc\u03c2 ( stereos , \"solid\"), and  -taxis  (a suffix of  Neo-Latin  and  ISV , derived from Greek  taxis , \"arrangement\", \"order\", from  tassein , \"to arrange\")."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6900", "text": "The surgery is used to treat various brain cancers, benign, and functional disorders of the brain. [ 1 ]  This is sometimes combined with  whole brain radiotherapy , and a 2021 systematic review found  this combination led to the greatest improvement of survival for those with single brain metastasis. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6901", "text": "Amongst the malignant brain disorders are: brain metastasis and  glioblastoma . [ 1 ]  The benign brain disorders are:  meningioma ,  cerebral arteriovenous malformation ,  vestibular schwannoma , and  pituitary adenoma . [ 1 ]  Functional disorders are:  trigeminal neuralgia ,  Parkinson's disease , and  epilepsy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6902", "text": "Stereotactic surgery works on the basis of three main components: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6903", "text": "Modern stereotactic planning systems are computer based. The stereotactic atlas is a series of cross sections of anatomical structure (for example, a human brain), depicted in reference to a two-coordinate frame. Thus, each brain structure can be easily assigned a range of three coordinate numbers, which will be used for positioning the stereotactic device. In most atlases, the three dimensions are: latero-lateral ( x ), dorso-ventral ( y ) and rostro-caudal ( z )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6904", "text": "The stereotactic apparatus uses a set of three coordinates ( x ,  y  and  z ) in an orthogonal frame of reference ( cartesian coordinates ), or, alternatively, a  cylindrical coordinates  system, also with three coordinates: angle, depth and antero-posterior (or axial) location. The mechanical device has head-holding clamps and bars which puts the head in a fixed position in reference to the coordinate system (the so-called zero or origin). In small laboratory animals, these are usually  bone  landmarks which are known to bear a constant spatial relation to soft tissue. For example, brain atlases often use the  external auditory meatus , the inferior  orbital  ridges, the median point of the  maxilla  between the  incisive teeth . or the  bregma  (confluence of sutures of frontal and parietal bones), as such landmarks. In humans, the reference points, as described above, are intracerebral structures which are clearly discernible in a  radiograph  or  tomograph . In newborn human babies, the \"soft spot\" where the coronal and sagittal sutures meet (known as the  fontanelle ) becomes the bregma when this gap closes. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6905", "text": "Guide bars in the  x ,  y  and  z  directions (or alternatively, in the polar coordinate holder), fitted with high precision  vernier scales  allow the neurosurgeon to position the point of a probe (an  electrode , a  cannula , etc.) inside the brain, at the calculated coordinates for the desired structure, through a small trephined hole in the skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6906", "text": "Currently, a number of manufacturers produce stereotactic devices fitted for  neurosurgery  in humans, for both brain and spine procedures, as well as for animal experimentation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6907", "text": "Stereotactic radiosurgery utilizes externally generated  ionizing radiation  to inactivate or eradicate defined targets in the head or spine without the need to make an incision. [ 5 ]  This concept requires steep dose gradients to reduce injury to adjacent normal tissue while maintaining treatment efficacy in the target. [ 6 ]  As a consequence of this definition, the overall treatment accuracy should match the treatment planning margins of 1\u20132\u00a0 mm  or better. [ 7 ]  To use this paradigm optimally and treat patients with the highest possible  accuracy and precision , all errors, from image acquisition over treatment planning to mechanical aspects of the delivery of treatment and intra-fraction motion concerns, must be systematically optimized. [ 8 ]  To assure quality of patient care the procedure involves a multidisciplinary team consisting of a  radiation oncologist ,  medical physicist , and radiation therapist. [ 9 ] [ 10 ]  Dedicated, commercially available stereotactic radiosurgery programs are provided by the irrespective  Gamma Knife , [ 11 ]   CyberKnife , [ 12 ]  and Novalis Radiosurgery [ 13 ]  devices. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6908", "text": "Stereotactic radiosurgery provides an efficient, safe, and minimal invasive treatment alternative [ 15 ]  for patients diagnosed with  malignant ,  benign  and  functional indications  in the brain and spine, including but not limited to both  primary  and  secondary tumors . [ 16 ]  Stereotactic radiosurgery is a well-described management option for most  metastases ,  meningiomas ,  schwannomas ,  pituitary adenomas ,  arteriovenous malformations , and  trigeminal neuralgia , among others. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6909", "text": "Irrespective of the similarities between the concepts of stereotactic radiosurgery and fractionated  radiotherapy  and although both treatment modalities are reported to have identical outcomes for certain indications, [ 18 ]  the intent of both approaches is fundamentally different. The aim of stereotactic radiosurgery is to destroy target tissue while preserving adjacent normal tissue, where fractionated radiotherapy relies on a different sensitivity of the target and the surrounding normal tissue to the total accumulated radiation  dose . [ 5 ]  Historically, the field of fractionated radiotherapy evolved from the original concept of stereotactic radiosurgery following discovery of the principles of  radiobiology : repair, reassortment, repopulation, and reoxygenation. [ 19 ]  Today, both treatment techniques are complementary as tumors that may be resistant to fractionated radiotherapy may respond well to radiosurgery and tumors that are too large or too close to critical organs for safe radiosurgery may be suitable candidates for fractionated radiotherapy. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6910", "text": "A second, more recent evolution extrapolates the original concept of stereotactic radiosurgery to extra-cranial targets, most notably in the lung, liver, pancreas, and prostate. This treatment approach, entitled stereotactic body radiotherapy or SBRT, is challenged by various types of motion. [ 20 ]  On top of patient immobilization challenges and the associated patient motion, extra-cranial lesions move with respect to the patient's position due to respiration, bladder and rectum filling. [ 21 ]  Like stereotactic radiosurgery, the intent of stereotactic body radiotherapy is to eradicate a defined extra-cranial target. However, target motion requires larger treatment margins around the target to compensate for the positioning uncertainty. This in turn implies more normal tissue exposed to high doses, which could result in negative treatment  side effects . As a consequence, stereotactic body radiotherapy is mostly delivered in a limited number of fractions, thereby blending the concept of stereotactic radiosurgery with the therapeutic benefits of fractionated radiotherapy. [ 22 ]  To monitor and correct target motion for accurate and precise patient positioning prior and during treatment, advanced  image-guided technologies  are commercially available and included in the radiosurgery programs offered by the CyberKnife and Novalis communities. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6911", "text": "Functional neurosurgery comprises treatment of several disorders such as  Parkinson's disease ,  hyperkinesia , disorder of muscle tone, intractable pain, convulsive disorders and psychological phenomena. Treatment for these phenomena was believed to be located in the superficial parts of the CNS and PNS. Most of the interventions made for treatment consisted of cortical extirpation.\nTo alleviate extra pyramidal disorders, pioneer Russell Meyers dissected or transected the head of the  caudate nucleus  in 1939, [ 24 ]  and part of the  putamen  and  globus pallidus .\nAttempts to abolish intractable pain were made with success by transection of the  spinothalamic tract  at spinal medullary level and further proximally, even at mesencephalic levels. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6912", "text": "In 1939-1941 Putnam and Oliver tried to improve Parkinsonism and hyperkinesias by trying a series of modifications of the lateral and antero-lateral  cordotomies . Additionally, other scientists like Schurman, Walker, and Guiot made significant contributions to functional neurosurgery. In 1953, Cooper discovered by chance that ligation of the anterior chorioidal artery resulted in improvement of Parkinson's disease. Similarly, when Grood was performing an operation in a patient with Parkinson's, he accidentally lesioned the  thalamus . This caused the patient's tremors to stop. From then on, thalamic lesions became the target point with more satisfactory results. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6913", "text": "More recent clinical applications can be seen [ 26 ]  in surgeries used to treat Parkinson's disease, such as  Pallidotomy  or  Thalamotomy  (lesioning procedures), or  Deep Brain Stimulation  (DBS). [ 27 ]  During DBS, an electrode is placed into the thalamus, the pallidum of the subthalmamic nucleus, parts of brain that are involved in motor control, and are affected by Parkinson's disease. The electrode is connected to a small battery operated stimulator that is placed under the collarbone, where a wire runs beneath the skin to connect it to the electrode in the brain. The stimulator produces electrical impulses that affect the nerve cells around the electrode and should help alleviate tremors or symptoms that are associated with the affected area. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6914", "text": "In  Thalamotomy , a needle electrode is placed into the thalamus, and the patient must cooperate with tasks assigned to find the affected area- after this area of the thalamus is located, a small high frequency current is applied to the electrode and this destroys a small part of the thalamus. Approximately 90% of patients experience instantaneous tremor relief. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6915", "text": "In  Pallidotomy , an almost identical procedure to thalamotomy, a small part of the pallidum is destroyed and 80% of patients see improvement in rigidity and hypokinesia and a tremor relief or improvement comes weeks after the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6916", "text": "The stereotactic method was first published in 1908 by two British scientists,  Victor Horsley , a physician and neurosurgeon, and Robert H. Clarke, a physiologist and was built by Swift & Son; the two scientists stopped collaborating after the 1908 publication.  The Horsley\u2013Clarke apparatus used a  Cartesian  (three-orthogonal axis) system.  That device is in the  Science Museum, London ; a copy was brought to the US by  Ernest Sachs  and is in the Department of Neurosurgery at  UCLA .  Clarke used the original to do research that led to publications of primate and cat  brain atlases .  There is no evidence it was ever used in a human surgery. [ 28 ] [ 29 ] :\u200a12\u200a [ 30 ]   The first stereotactic device designed for the human brain appears to have been an adaptation of the Horseley\u2013Clarke frame built at Aubrey T. Mussen's behest by a London workshop in 1918, but it received little attention and does not appear to have been used on people.  It was a frame made of brass. [ 29 ] :\u200a12\u200a [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6917", "text": "The first stereotactic device used in humans was used by  Martin Kirschner , for a method to treat  trigeminal neuralgia  by inserting an electrode into the trigeminal nerve and ablating it.  He published this in 1933. [ 29 ] :\u200a13\u200a [ 32 ] :\u200a420\u200a [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6918", "text": "In 1947 and 1949, two neurosurgeons working at Temple University in Philadelphia, Ernest A. Spiegel (who had fled Austria when the Nazis took over [ 28 ] ) and Henry T. Wycis, published their work on a device similar to the Horsley\u2013Clarke apparatus in using a cartesian system; it was attached to the patient's head with a plaster cast instead of screws.  Their device was the first to be used for brain surgery; they used it for  psychosurgery .  They also created the first atlas of the human brain, and used intracranial reference points, generated by using medical images acquired with contrast agents. [ 29 ] :\u200a13\u200a [ 32 ] :\u200a72\u200a [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6919", "text": "The work of Spiegel and Wycis sparked enormous interest and research. [ 29 ] :\u200a13\u200a  In Paris,  Jean Talairach  collaborated with Marcel David, Henri Hacaen, and  Julian de Ajuriaguerra  on a stereotactic device, publishing their first work in 1949 and eventually developing the  Talairach coordinates . [ 28 ] [ 29 ] :\u200a13\u200a [ 32 ] :\u200a93\u200a   In Japan,  Hirotaro Narabayashi  was doing similar work. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6920", "text": "In 1949,  Lars Leksell  published a device that used  polar coordinates  instead of cartesian, and two years later he published work where he used his device to target a beam of radiation into a brain. [ 29 ] :\u200a13\u200a [ 32 ] :\u200a91\u200a [ 35 ] [ 36 ]   Leksell's radiosurgery system is also used by the  Gamma Knife  device, and by other neurosurgeons, using  linear accelerators , proton beam therapy and neutron capture therapy. Lars Leksell went on to commercialize his inventions by founding  Elekta  in 1972. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6921", "text": "In 1979,  Russell A. Brown  proposed a device, [ 38 ]  now known as the  N-localizer , [ 39 ]  that enables guidance of stereotactic surgery using tomographic images that are obtained via medical imaging technologies such as  X-ray computed tomography  (CT), [ 40 ]   magnetic resonance imaging  (MRI), [ 41 ]  or  positron emission tomography  (PET). [ 42 ]  The N-localizer comprises a diagonal rod that spans two vertical rods to form an N-shape that allows tomographic images to be mapped to physical space. [ 43 ]  This device became almost universally adopted by the 1980s [ 44 ]  and is included in the Brown-Roberts-Wells (BRW), [ 45 ]  Kelly-Goerss, [ 46 ]  Leksell, [ 47 ]  Cosman-Roberts-Wells (CRW), [ 48 ]  Micromar-ETM03B, FiMe-BlueFrame, Macom, and Adeor-Zeppelin [ 49 ]  stereotactic frames and in the Gamma Knife  radiosurgery  system. [ 44 ]  An alternative to the N-localizer is the Sturm-Pastyr localizer [ 50 ]  that is included in the Riechert-Mundinger and Zamorano-Dujovny stereotactic frames. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6922", "text": "Other localization methods also exist that do not make use of tomographic images produced by CT, MRI, or PET, but instead conventional radiographs. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6923", "text": "The stereotactic method has continued to evolve, and at present employs an elaborate mixture of  image-guided surgery  that uses  computed tomography ,  magnetic resonance imaging  and stereotactic localization. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6924", "text": "In 1970, in the city of Buenos Aires, Argentina, Aparatos Especiales company, produced the first Stereotactic System in Latin America. Antonio Martos Calvo, together with Jorge Candia and Jorge Olivetti through the request of neurosurgeon Jorge Schvarc (1942-2019), developed an equipment based on the principle of Hitchcock Stereotactic System. The patient was seated in an adapted chair with two telescopic arms attached at it base, which fixed the stereotactic frame preventing the patient\u2019s movement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6925", "text": "A double radiopaque ruler attached to the side of the frame made it possible to obtain the antero-posterior and latero-lateral X-ray images without the need of moving the radiopaque ruler. The thermal coagulation lesion was performed using tungsten monopole electrodes of 1,5mm of diameter (without temperature control) with a 3mm active tip, utilizing an electrical bipolar coagulator. The lesion size was previously determined by testing the electrode in egg albumin. Coagulation size was the result of the electrical coagulator power regulation and the application time of the radiofrequency. The first surgery performed with this system was a Trigeminal Nucleotractothomy. Jorge Schvarcz performed more than 700 functional surgeries until 1994 when, due to health problems he stopped exercising his profession. But the equipment developed kept improving on a neurosurgery history."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6926", "text": "This was the beginning of the developing of technology to produce stereotactic devices in Latin America. This was the beginning of the first stereotactic manufacturer of Latin America \u2013 The Brazilian Micromar."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6927", "text": "Stereotactic surgery is sometimes used to aid in several different types of animal research studies.  Specifically, it is used to target specific sites of the brain and directly introduce pharmacological agents to the brain which otherwise may not be able to cross the  blood\u2013brain barrier . [ 53 ]   In rodents, the main applications of stereotactic surgery are to introduce fluids directly to the brain or to implant  cannulae  and  microdialysis  probes. Site specific central microinjections are used when rodents do not need to be awake and behaving or when the substance to be injected has a long duration of action.  For protocols in which rodents\u2019 behaviors must be assessed soon after injection, stereotactic surgery can be used to implant a cannula through which the animal can be injected after recovery from the surgery.  These protocols take longer than site-specific central injections in anesthetized mice because they require the construction of cannulae, wire plugs, and injection needles, but induce less stress in the animals because they allow for a recovery period for the healing of trauma induced to the brain before injection. [ 54 ]   Surgery can also be used for microdialysis protocols to implant and tether the dialysis probe and guide cannula. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6928", "text": "A  stereotaxic atlas  is a number of records of brain structure of a particular animal accompanied with coordinates used in  stereotactic surgery . Stereotaxic atlases are developed using MRI data from a large number of subjects to visualize the topology of the brain. [ 1 ]  This allows for highly accurate, minimally invasive surgery based on 3D imaging. The development of stereotaxic atlases has been particularly important in making it possible to operate on areas deep in the brain that are not accessible through traditional surgical methods. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6929", "text": "Subarachnoid hemorrhage  ( SAH ) is  bleeding  into the  subarachnoid space \u2014the area between the  arachnoid membrane  and the  pia mater  surrounding the  brain . [ 1 ]  Symptoms may include a  severe headache of rapid onset , vomiting,  decreased level of consciousness ,  fever , weakness, numbness, and sometimes  seizures . [ 1 ]  Neck stiffness or neck pain are also relatively common. [ 2 ]  In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6930", "text": "SAH may occur as a result of a  head injury  or spontaneously, usually from a ruptured  cerebral aneurysm . [ 1 ]  Risk factors for spontaneous cases include  high blood pressure , smoking, family history, alcoholism, and  cocaine  use. [ 1 ]  Generally, the diagnosis can be determined by a  CT scan  of the head if done within six hours of symptom onset. [ 2 ]  Occasionally, a  lumbar puncture  is also required. [ 2 ]  After confirmation further tests are usually performed to determine the underlying cause. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6931", "text": "Treatment is by prompt  neurosurgery  or  endovascular coiling . [ 1 ]  Medications such as  labetalol  may be required to lower the blood pressure until repair can occur. [ 1 ]  Efforts to treat fevers are also recommended. [ 1 ]   Nimodipine , a  calcium channel blocker , is frequently used to prevent  vasospasm . [ 1 ]  The routine use of medications to prevent further seizures is of unclear benefit. [ 1 ]  Nearly half of people with a SAH due to an underlying aneurysm die within 30 days and about a third who survive have ongoing problems. [ 1 ]  Between ten and fifteen percent die before reaching a hospital. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6932", "text": "Spontaneous SAH occurs in about one per 10,000 people per year. [ 1 ]  Females are more commonly affected than males. [ 1 ]  While it becomes more common with age, about 50% of people present under 55 years old. [ 4 ]  It is a form of  stroke  and comprises about 5 percent of all strokes. [ 4 ]  Surgery for aneurysms was introduced in the 1930s. [ 5 ]  Since the 1990s many aneurysms are treated by a less invasive procedure called  endovascular coiling , which is carried out through a large blood vessel. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6933", "text": "A true subarachnoid hemorrhage may be confused with a  pseudosubarachnoid hemorrhage , an apparent increased  attenuation  on  CT scans  within the  basal cisterns  that mimics a true subarachnoid hemorrhage. [ 7 ]  This occurs in cases of severe  cerebral edema , such as by  cerebral hypoxia . It may also occur due to  intrathecally administered   contrast material , [ 8 ]  leakage of high-dose  intravenous  contrast material into the  subarachnoid spaces , or in patients with  cerebral venous sinus thrombosis , severe  meningitis ,  leptomeningeal carcinomatosis , [ 9 ]   intracranial hypotension ,  cerebellar infarctions , or  bilateral   subdural hematomas . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6934", "text": "The classic symptom of subarachnoid hemorrhage is  thunderclap headache  (a headache described as \"like being kicked in the head\", [ 3 ]  or the \"worst ever\", developing over seconds to minutes). This headache often pulsates towards the  occiput  (the back of the head). [ 11 ]  About one-third of people have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid hemorrhage. [ 4 ]  Vomiting may be present, and 1 in 14 have  seizures . [ 4 ]   Confusion , decreased level of consciousness or  coma  may be present, as may neck stiffness and other signs of  meningism . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6935", "text": "Neck stiffness usually presents six hours after initial onset of SAH. [ 12 ]  Isolated  dilation  of a pupil and loss of the  pupillary light reflex  may reflect  brain herniation  as a result of rising  intracranial pressure  (pressure inside the skull). [ 4 ]   Intraocular hemorrhage  (bleeding into the eyeball) may occur in response to the raised pressure: subhyaloid hemorrhage (bleeding under the  hyaloid membrane , which envelops the  vitreous body  of the eye) and vitreous hemorrhage may be visible on  fundoscopy . This is known as  Terson syndrome  (occurring in 3\u201313 percent of cases) and is more common in more severe SAH. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6936", "text": "Oculomotor nerve  abnormalities (affected eye looking downward and outward and  inability to lift the eyelid on the same side ) or  palsy  (loss of movement) may indicate bleeding from the  posterior communicating artery . [ 4 ] [ 11 ]  Seizures are more common if the hemorrhage is from an aneurysm; it is otherwise difficult to predict the site and origin of the hemorrhage from the symptoms. [ 4 ]  SAH in a person known to have seizures is often diagnostic of a  cerebral arteriovenous malformation . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6937", "text": "The combination of intracerebral hemorrhage and raised intracranial pressure (if present) leads to a \"sympathetic surge\", i.e. over-activation of the sympathetic system. This is thought to occur through two mechanisms, a direct effect on the  medulla  that leads to activation of the descending  sympathetic nervous system  and a local release of inflammatory mediators that circulate to the peripheral circulation where they activate the sympathetic system. As a consequence of the sympathetic surge there is a sudden increase in  blood pressure ; mediated by increased  contractility  of the  ventricle  and increased  vasoconstriction  leading to increased  systemic vascular resistance . The consequences of this sympathetic surge can be sudden, severe, and are frequently life-threatening. The high  plasma  concentrations of adrenaline also may cause  cardiac arrhythmias  (irregularities in the heart rate and rhythm),  electrocardiographic changes  (in 27 percent of cases) [ 14 ]  and  cardiac arrest  (in 3 percent of cases) may occur rapidly after the onset of hemorrhage. [ 4 ] [ 15 ]  A further consequence of this process is  neurogenic   pulmonary edema , [ 16 ]  where a process of increased pressure within the pulmonary circulation causes leaking of fluid from the pulmonary  capillaries  into the air spaces, the  alveoli , of the lung. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6938", "text": "Subarachnoid hemorrhage may also occur in people who have had a head injury. Symptoms may include headache, decreased level of consciousness and  hemiparesis  (weakness of one side of the body). SAH is a frequent occurrence in traumatic brain injury and carries a poor prognosis if it is associated with deterioration in the level of consciousness. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6939", "text": "While thunderclap headache is the characteristic symptom of subarachnoid hemorrhage, less than 10% of those with concerning symptoms have SAH on investigations. [ 2 ]  A number of other causes may need to be considered. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6940", "text": "Most cases of SAH are due to  trauma  such as a blow to the head. [ 1 ] [ 21 ]  Traumatic SAH usually occurs near the site of a  skull fracture  or  intracerebral contusion . [ 22 ]  It often happens in the setting of other forms of traumatic brain injury. In these cases prognosis is poorer; however, it is unclear if this is a direct result of the SAH or whether the presence of subarachnoid blood is simply an indicator of a more severe head injury. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6941", "text": "In 85 percent of spontaneous cases the cause is a  cerebral aneurysm \u2014a weakness in the wall of one of the  arteries  in the brain that becomes enlarged. They tend to be located in the  circle of Willis  and its branches. While most cases are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture. [ 4 ]   Aspirin  also appears to increase the risk. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6942", "text": "In 15\u201320 percent of cases of spontaneous SAH, no aneurysm is detected on the first  angiogram . [ 22 ]  About half of these are attributed to non-aneurysmal perimesencephalic hemorrhage, in which the blood is limited to the subarachnoid spaces around the  midbrain  (i.e. mesencephalon). In these, the origin of the blood is uncertain. [ 4 ]  The remainder are due to other disorders affecting the blood vessels (such as  cerebral arteriovenous malformations ), disorders of the blood vessels in the  spinal cord , and bleeding into various  tumors . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6943", "text": "Cocaine  abuse and  sickle cell anemia  (usually in children) and, rarely,  anticoagulant  therapy,  problems with blood clotting  and  pituitary apoplexy  can also result in SAH. [ 12 ] [ 22 ]   Dissection of the vertebral artery , usually caused by trauma, can lead to subarachnoid hemorrhage if the dissection involves the part of the vessel inside the skull. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6944", "text": "Cerebral vasospasm is one of the complications caused by subarachnoid hemorrhage. It usually happens from the third day after the aneurysm event, and reaches its peak on 5th to 7th day. [ 26 ]  There are several mechanisms proposed for this complication. Blood products released from subarachnoid hemorrhage stimulates the  tyrosine kinase  pathway causing the release of calcium ions from intracellular storage, resulting in smooth muscle contraction of cerebral arteries.  Oxyhaemoglobin  in  cerebrospinal fluid  (CSF) causes vasoconstriction by increasing  free radicals ,  endothelin-1 ,  prostaglandin  and reducing the level of  nitric oxide  and  prostacyclin . Besides, the disturbances of  autonomic nervous system  innervating cerebral arteries is also thought to cause vasospasm. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6945", "text": "As only 10 percent of people admitted to the emergency department with a thunderclap headache are having an SAH, other possible causes are usually considered simultaneously, such as  meningitis ,  migraine , and  cerebral venous sinus thrombosis . [ 3 ]   Intracerebral hemorrhage , in which bleeding occurs within the brain itself, is twice as common as SAH and is often misdiagnosed as the latter. [ 28 ]  It is not unusual for SAH to be initially misdiagnosed as a migraine or  tension headache , which can lead to a delay in obtaining a CT scan. In a 2004 study, this occurred in 12 percent of all cases and was more likely in people who had smaller hemorrhages and no impairment in their mental status. The delay in diagnosis led to a worse outcome. [ 29 ]  In some people, the headache resolves by itself, and no other symptoms are present. This type of headache is referred to as \"sentinel headache\", because it is presumed to result from a small leak (a \"warning leak\") from an aneurysm. A sentinel headache still warrants investigations with CT scan and lumbar puncture, as further bleeding may occur in the subsequent three weeks. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6946", "text": "The initial steps for evaluating a person with a suspected subarachnoid hemorrhage are obtaining a  medical history  and performing a  physical examination . The diagnosis cannot be made on clinical grounds alone and in general  medical imaging  and possibly a lumbar puncture is required to confirm or exclude bleeding. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6947", "text": "The modality of choice is  computed tomography  (CT scan), without  contrast , of the brain. This has a high  sensitivity  and will correctly identify 98.7% of cases within six hours of the onset of symptoms. [ 31 ]  A CT scan can rule out the diagnosis in someone with a normal neurological exam if done within six hours. [ 32 ]  Its efficacy declines thereafter, [ 1 ]  and  magnetic resonance imaging  (MRI) is more sensitive than CT after several days. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6948", "text": "After a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm (as determined by the CT scan appearance), the choice is between  cerebral angiography  (injecting radiocontrast through a  catheter  to the brain arteries) and  CT angiography  (visualizing  blood vessels  with  radiocontrast  on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below). [ 4 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6949", "text": "In emergency department patients complaining of acute-onset headache without significant risk factors for SAH, evidence suggests that CT scanning of the head followed by CT angiography can reliably exclude SAH without the need for a lumbar puncture. [ 33 ]  The risk of missing an aneurysmal bleed as the cause of SAH with this approach is less than 1%. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6950", "text": "Lumbar puncture , in which  cerebrospinal fluid  (CSF) is removed from the  subarachnoid space  of the  spinal canal  using a  hypodermic needle , shows evidence of bleeding in three percent of people in whom a non-contrast CT was found normal. [ 4 ]  A lumbar puncture or CT scan with contrast is therefore regarded as mandatory in people with suspected SAH when imaging is delayed to after six hours from the onset of symptoms and is negative. [ 4 ] [ 32 ]  At least three tubes of CSF are collected. [ 12 ]  If an elevated number of  red blood cells  is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a \"traumatic tap\"). [ 30 ]  While there is no official cutoff for red blood cells in the CSF no documented cases have occurred at less than \"a few hundred cells\" per high-powered field. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6951", "text": "The CSF sample is also examined for  xanthochromia \u2014the yellow appearance of  centrifugated  fluid. This can be determined by  spectrophotometry  (measuring the absorption of particular wavelengths of light) or visual examination. It is unclear which method is superior. [ 35 ]  Xanthochromia remains a reliable ways to detect SAH several days after the onset of headache. [ 36 ]  An interval of at least 12\u00a0hours between the onset of the headache and lumbar puncture is required, as it takes several hours for the hemoglobin from the red blood cells to be metabolized into  bilirubin . [ 4 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6952", "text": "Electrocardiographic  changes are relatively common in subarachnoid hemorrhage, occurring in 40\u201370 percent of cases. They may include  QT prolongation ,  Q waves ,  cardiac dysrhythmias , and  ST elevation  that mimics a  heart attack . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6953", "text": "Also one of the characteristic  ECG  changes that could be found in patients with subarachnoid hemorrhage, is the  J waves  or Osborn waves, which are positive deflections that occur at the junction between  QRS complexes  and  ST segments , where the S point, also known as the J point, has a myocardial infarction-like elevation. [ 38 ]  J waves or Osborn waves, which represent an early  repolarization  and delayed  depolarization  of the heart ventricles, are thought to be caused by the high  catecholamines  surge released in patients with subarachnoid hemorrhage or brain damage, the issue that might lead to  ventricular fibrillation  and  cardiac arrest  in unmanaged patients. [ 39 ] [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6954", "text": "There are several grading scales available for SAH. The  Glasgow Coma Scale  (GCS) is ubiquitously used for assessing consciousness. Its three specialized scores are used to evaluate SAH; in each, a higher number is associated with a worse outcome. [ 41 ]  These scales have been derived by retrospectively matching characteristics of people with their outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6955", "text": "The first widely used scale for neurological condition following SAH was published by  Botterell  and Cannell in 1956 and referred to as the Botterell Grading Scale. This was modified by Hunt and Hess [ 42 ] [ 43 ] [ 44 ]  in 1968: [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6956", "text": "The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6957", "text": "This scale has been modified by Claassen and coworkers, reflecting the additive risk from SAH size and accompanying  intraventricular hemorrhage  (0 \u2013 none; 1 \u2013 minimal SAH w/o IVH; 2 \u2013 minimal SAH with IVH; 3 \u2013 thick SAH w/o IVH; 4 \u2013 thick SAH with IVH);. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6958", "text": "The World Federation of Neurosurgeons (WFNS) classification uses Glasgow coma score and  focal neurological deficit  to gauge severity of symptoms. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6959", "text": "A comprehensive  classification scheme  has been suggested by Ogilvy and Carter to predict outcome and gauge therapy. [ 49 ]  The system consists of five grades and it assigns one point for the presence or absence of each of five factors: age greater than 50; Hunt and Hess grade 4 or 5; Fisher scale 3 or 4; aneurysm size greater than 10\u00a0mm; and posterior circulation aneurysm 25\u00a0mm or more. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6960", "text": "Screening  for aneurysms is not performed on a population level; because they are relatively rare, it would not be  cost-effective . However, if someone has two or more first-degree relatives who have had an aneurysmal subarachnoid hemorrhage, screening may be worthwhile. [ 4 ] [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6961", "text": "Autosomal dominant polycystic kidney disease  (ADPKD), a hereditary kidney condition, is known to be associated with cerebral aneurysms in 8 percent of cases, but most such aneurysms are small and therefore unlikely to rupture. As a result, screening is only recommended in families with ADPKD where one family member has had a ruptured aneurysm. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6962", "text": "An aneurysm may be detected incidentally on brain imaging; this presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications. The International Study of Unruptured Intracranial Aneurysms (ISUIA) provided prognostic data both in people having previously had a subarachnoid hemorrhage and people who had aneurysms detected by other means. Those having previously had a SAH were more likely to bleed from other aneurysms. In contrast, those having never bled and had small aneurysms (smaller than 10\u00a0mm) were very unlikely to have a SAH and were likely to sustain harm from attempts to repair these aneurysms. [ 52 ]  On the basis of the ISUIA and other studies, it is now recommended that people are considered for  preventive treatment  only if they have a reasonable  life expectancy  and have aneurysms that are highly likely to rupture. [ 50 ]  Moreover, there is only limited evidence that endovascular treatment of unruptured aneurysms is actually beneficial. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6963", "text": "Management involves general measures to stabilize the person while also using specific investigations and treatments. These include the prevention of rebleeding by obliterating the bleeding source, prevention of a phenomenon known as  vasospasm , and prevention and treatment of complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6964", "text": "Stabilizing the person is the first priority. Those with a depressed level of consciousness may need to be  intubated  and  mechanically ventilated . Blood pressure,  pulse ,  respiratory rate , and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an  intensive care unit  may be preferable, especially since 15 percent may have further bleeding soon after admission. Nutrition is an early priority, mouth or  nasogastric tube  feeding being preferable over  parenteral  routes. In general, pain control is restricted to less-sedating agents such as  codeine , as  sedation  may impact on the mental status and thus interfere with the ability to monitor the level of consciousness.  Deep vein thrombosis  is prevented with  compression stockings , intermittent  pneumatic  compression of the  calves , or both. [ 4 ]  A  bladder catheter  is usually inserted to monitor fluid balance.  Benzodiazepines  may be administered to help relieve distress. [ 12 ]   Antiemetic  drugs should be given to awake persons. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6965", "text": "People with poor clinical grade on admission, acute neurologic deterioration, or progressive enlargement of ventricles on CT scan are, in general, indications for the placement of an  external ventricular drain  by a neurosurgeon. The external ventricular drain may be inserted at the bedside or in the operating room. In either case, strict  aseptic technique  must be maintained during insertion. In people with aneurysmal subarachnoid hemorrhage the EVD is used to remove  cerebrospinal fluid , blood, and blood byproducts that increase  intracranial pressure  and may increase the risk for  cerebral vasospasm . [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6966", "text": "Efforts to keep a person's  systolic blood pressure  somewhere between 140 and 160 mmHg is generally recommended. [ 1 ]  Medications to achieve this may include  labetalol  or  nicardipine . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6967", "text": "People whose CT scan shows a large  hematoma , depressed level of consciousness, or  focal neurologic signs  may benefit from urgent surgical removal of the blood or occlusion of the bleeding site. The remainder are stabilized more extensively and undergo a  transfemoral angiogram  or CT angiogram later. It is hard to predict who will have a rebleed, yet it may happen at any time and carries a dismal prognosis. After the first 24\u00a0hours have passed, rebleeding risk remains around 40 percent over the subsequent four\u00a0weeks, suggesting that interventions should be aimed at reducing this risk as soon as possible. [ 4 ]  Some predictors of early rebleeding are high systolic blood pressure, the presence of a hematoma in the brain or ventricles, poor Hunt-Hess grade (III-IV), aneurysms in the posterior circulation, and an aneurysm >10\u00a0mm in size. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6968", "text": "If a  cerebral aneurysm  is identified on angiography, two measures are available to reduce the risk of further bleeding from the same aneurysm:  clipping [ 56 ]  and  coiling . [ 57 ]  Clipping requires a  craniotomy  (opening of the skull) to locate the aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the large blood vessels (endovascularly): a catheter is inserted into the  femoral artery  in the groin and advanced through the  aorta  to the arteries (both  carotid arteries  and both  vertebral arteries ) that supply the brain. When the aneurysm has been located,  platinum  coils are deployed that cause a  blood clot to form  in the aneurysm, obliterating it. The decision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of a  neurosurgeon ,  neuroradiologist , and often other health professionals. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6969", "text": "In general, the decision between clipping and coiling is made on the basis of the location of the aneurysm, its size and the condition of the person. Aneurysms of the  middle cerebral artery  and its related vessels are hard to reach with angiography and tend to be amenable to clipping. Those of the  basilar artery  and posterior cerebral artery are hard to reach surgically and are more accessible for endovascular management. [ 58 ]  These approaches are based on general experience, and the only  randomized controlled trial  directly comparing the different modalities was performed in relatively well people with small (less than 10\u00a0mm) aneurysms of the  anterior cerebral artery  and  anterior communicating artery  (together the \"anterior circulation\"), who constitute about 20 percent of all people with aneurysmal SAH. [ 58 ] [ 59 ]  This trial, the  International Subarachnoid Aneurysm Trial  (ISAT), showed that in this group the likelihood of death or being dependent on others for  activities of daily living  was reduced (7.4 percent  absolute risk reduction , 23.5 percent  relative risk  reduction) if endovascular coiling was used as opposed to surgery. [ 58 ]  The main drawback of coiling is the possibility that the aneurysm will recur; this risk is extremely small in the surgical approach. In ISAT, 8.3 percent needed further treatment in the longer term. Hence, people who have undergone coiling are typically followed up for many years afterwards with angiography or other measures to ensure recurrence of aneurysms is identified early. [ 60 ]  Other trials have also found a higher rate of recurrence necessitating further treatments. [ 61 ] [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6970", "text": "Vasospasm , in which the blood vessels constrict and thus restrict  blood flow , is a serious complication of SAH. It can cause  ischemic   brain injury  (referred to as \"delayed ischemia\") and permanent  brain damage  due to lack of oxygen in parts of the brain. [ 63 ]  It can be fatal if severe. Delayed ischemia is characterized by new neurological symptoms, and can be confirmed by  transcranial doppler  or cerebral angiography. About one third of people admitted with subarachnoid hemorrhage will have delayed ischemia, and half of those have permanent damage as a result. [ 63 ]  It is possible to screen for the development of vasospasm with transcranial Doppler every 24\u201348\u00a0hours. A blood flow velocity of more than 120\u00a0 centimeters per second  is suggestive of vasospasm. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6971", "text": "The pathogenesis of cerebral vasospasm following subarachnoid hemorrhage is attributed to the higher levels of  endothelin 1 , a potent vasoconstrictor, and the lower levels of  endothelial NOS  (eNOS), a potent vasodilator. Both of which are produced from a series of events that begin from the inflammatory reaction caused by the products released from erythrocytes' degradation. Following subarachnoid hemorrhage, different clotting factors and blood products are released into the surrounding  perivascular spaces  known as ( Virchow-Robin spaces ). The released clotting factors like;  fibrinopeptides ,  thromboxane A2  and others lead to microthrombosis around near vessels that leads to extrinsic vasoconstriction of these vessels. Besides that extrinsic vasoconstriction, the erythrocytes' degradation products like;  bilirubin  and  oxyhemoglobin  lead to neuroinflammation that in turn increases the production of  reactive oxygen species  (ROS) which increases and decreases the production of endothelin 1 and endothelial NOS, respectively, the issue that yields in intrinsic vasoconstriction of the neighboring blood vessels and results in cerebral ischemia if left untreated. [ 64 ] [ 65 ] [ 66 ] [ 67 ] [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6972", "text": "The use of  calcium channel blockers , thought to be able to prevent the spasm of blood vessels by preventing  calcium  from entering smooth muscle cells, has been proposed for prevention. [ 23 ]  The calcium channel blocker  nimodipine  when taken by mouth improves outcome if given between the fourth and twenty-first day after the bleeding, even if it does not reduce the amount of vasospasm detected on angiography. [ 69 ]  It is the only  Food and Drug Administration  (FDA)-approved drug for treating cerebral vasospasm. [ 26 ]  In  traumatic  subarachnoid hemorrhage, nimodipine does not affect long-term outcome, and is not recommended. [ 70 ]  Other calcium channel blockers and  magnesium sulfate  have been studied, but are not presently recommended; neither is there any evidence that shows benefit if nimodipine is given intravenously. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6973", "text": "Nimodipine is readily authorized in the form of tablets and solution for infusion for the prevention and treatment of complications due to vasospasm following subarachnoid hemorrhage. Another sustained formulation of nimodipine administered via an  external ventricular drain  (EVD), called EG-1962, is also available. In contrast to the tablets and solution formulations of Nimodipine which require an administration every 4hrs for a total of 21 days, the sustained formulation, EG-1962, needs to be administered once directly into the ventricles. The CSF concentrations from EG-1962, however, were at least 2 orders of magnitude higher than those with oral nimodipine. These results supported a phase 3 study that demonstrated a favorable safety profile for EG-1962 but yielded inconclusive efficacy results due to notable differences in clinical outcome based on baseline disease severity. [ 71 ] [ 72 ] [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6974", "text": "Some older studies have suggested that  statin  therapy might reduce vasospasm, but a subsequent meta-analysis including further trials did not demonstrate benefit on either vasospasm or outcomes. [ 74 ]  While corticosteroids with mineralocorticoid activity may help prevent vasospasm their use does not appear to change outcomes. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6975", "text": "A protocol referred to as \"triple H\" is often used as a measure to treat vasospasm when it causes symptoms; this is the use of  intravenous fluids  to achieve a state of  hypertension  (high blood pressure),  hypervolemia  (excess fluid in the circulation), and hemodilution (mild dilution of the blood). [ 76 ]  Evidence for this approach is inconclusive; no randomized controlled trials have been undertaken to demonstrate its effect. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6976", "text": "If the symptoms of delayed ischemia do not improve with medical treatment, angiography may be attempted to identify the sites of vasospasms and administer  vasodilator  medication (drugs that relax the blood vessel wall) directly into the artery.  Angioplasty  (opening the constricted area with a balloon) may also be performed. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6977", "text": "Hydrocephalus  (obstruction of the flow of cerebrospinal fluid) may complicate SAH in both the short and long term. It is detected on CT scanning, on which there is enlargement of the  lateral ventricles . If the level of consciousness is decreased, drainage of the excess fluid is performed by therapeutic lumbar puncture,  extraventricular drain  (a temporary device inserted into one of the ventricles), or occasionally a permanent  shunt . [ 4 ] [ 30 ]  Relief of hydrocephalus can lead to an enormous improvement in a person's condition. [ 11 ]  Fluctuations in blood pressure and  electrolyte imbalance , as well as  pneumonia  and  cardiac decompensation  occur in about half the hospitalized persons with SAH and may worsen prognosis. [ 4 ]   Seizures  occur during the hospital stay in about a third of cases. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6978", "text": "People have often been treated with  preventative   antiepileptic medications . [ 30 ] [ 78 ]  This is controversial and not  based on good evidence . [ 79 ] [ 80 ]  In some studies, use of these medications was associated with a worse prognosis; although it is unclear whether this might be because the drugs themselves actually cause harm, or because they are used more often in persons with a poorer prognosis. [ 81 ] [ 82 ]  There is a possibility of a gastric hemorrhage due to stress ulcers. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6979", "text": "SAH is often associated with a poor outcome. [ 84 ]  The death rate ( mortality ) for SAH is between 40 and 50 percent, [ 28 ]  but trends for survival are improving. [ 4 ]  Of those that survive hospitalization, more than a quarter have significant restrictions in their lifestyle, and less than a fifth have no residual symptoms whatsoever. [ 58 ]  Delay in diagnosis of minor SAH (mistaking the sudden headache for migraine) contributes to poor outcome. [ 29 ]  Factors found on admission that are associated with poorer outcome include poorer neurological grade;  systolic hypertension ; a previous diagnosis of  heart attack  or SAH;  liver disease ; more blood and larger aneurysm on the initial CT scan; location of an aneurysm in the  posterior   circulation ; and higher age. [ 81 ]  Factors that carry a worse prognosis during the hospital stay include occurrence of delayed ischemia resulting from  vasospasm , development of  intracerebral hematoma , or intraventricular hemorrhage (bleeding into the  ventricles  of the brain) and presence of  fever  on the eighth\u00a0day of admission. [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6980", "text": "So-called \"angiogram-negative subarachnoid hemorrhage\", SAH that does not show an aneurysm with four-vessel angiography, carries a better prognosis than SAH with aneurysm, but it is still associated with a risk of ischemia, rebleeding, and  hydrocephalus . [ 22 ]  Perimesencephalic SAH (bleeding around the  mesencephalon  in the brain), however, has a very low rate of rebleeding or delayed  ischemia , and the prognosis of this subtype is excellent. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6981", "text": "The prognosis of head trauma is thought to be influenced in part by the location and amount of subarachnoid bleeding. [ 23 ]  It is difficult to isolate the effects of SAH from those of other aspects of traumatic brain injury; it is unknown whether the presence of subarachnoid blood actually worsens the prognosis or whether it is merely a sign that a significant trauma has occurred. [ 23 ]  People with moderate and severe traumatic brain injury who have SAH when admitted to a hospital have as much as twice the risk of dying as those who do not. [ 23 ]  They also have a higher risk of severe disability and  persistent vegetative state , and traumatic SAH has been correlated with other markers of poor outcome such as  post traumatic epilepsy , hydrocephalus, and longer stays in the intensive care unit. [ 23 ]   More than 90 percent of people with traumatic subarachnoid bleeding and a Glasgow Coma Score over 12 have a good outcome. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6982", "text": "There is also modest evidence that genetic factors influence the prognosis in SAH. For example, having two copies of ApoE4 (a variant of the gene encoding  apolipoprotein E  that also plays a role in  Alzheimer's disease ) seems to increase risk for delayed ischemia and a worse outcome. [ 86 ]  The occurrence of  hyperglycemia  (high blood sugars) after an episode of SAH confers a higher risk of poor outcome. [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6983", "text": "Neurocognitive symptoms, such as  fatigue , mood disturbances, and other related symptoms, are common  sequelae . Even in those who have made good neurological recovery, anxiety, depression,  posttraumatic stress disorder , and cognitive impairment are common; 46 percent of people who have had a subarachnoid hemorrhage have cognitive impairment that affects their quality of life. [ 30 ]  Over 60 percent report frequent headaches. [ 88 ]  Aneurysmal subarachnoid hemorrhage may lead to damage of the  hypothalamus  and the  pituitary gland , two areas of the brain that play a central role in hormonal regulation and production. More than a quarter of people with a previous SAH may develop  hypopituitarism  (deficiencies in one or more of the  hypothalamic\u2013pituitary hormones  such as  growth hormone ,  luteinizing hormone , or  follicle-stimulating hormone ). [ 89 ]  SAH is also associated with  SIADH  and  cerebral salt wasting , and is the most common cause of the latter."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6984", "text": "According to a review of 51 studies from 21 countries, the average  incidence  of subarachnoid hemorrhage is 9.1 per 100,000 annually. Studies from Japan and Finland show higher rates in those countries (22.7 and 19.7, respectively), for reasons that are not entirely understood. South and Central America, in contrast, have a rate of 4.2 per 100,000 on average. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6985", "text": "Although the group of people at risk for SAH is younger than the population usually affected by stroke, [ 84 ]  the risk still increases with age. Young people are much less likely than middle-age people (risk ratio 0.1, or 10 percent) to have a subarachnoid hemorrhage. [ 90 ]  The risk continues to rise with age and is 60 percent higher in the very elderly (over 85) than in those between 45 and 55. [ 90 ]  Risk of SAH is about 25 percent higher in women over 55 compared to men the same age, probably reflecting the hormonal changes that result from the  menopause , such as a decrease in  estrogen  levels. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6986", "text": "Genetics may play a role in a person's disposition to SAH; risk is increased three- to fivefold in first-degree relatives of people having had a subarachnoid hemorrhage. [ 3 ]  But lifestyle factors are more important in determining overall risk. [ 84 ]  These risk factors are  smoking , hypertension (high blood pressure), and excessive  alcohol consumption . [ 28 ]  Having smoked in the past confers a doubled risk of SAH compared to those who have never smoked. [ 84 ]  Some protection of uncertain significance is conferred by  caucasian ethnicity ,  hormone replacement therapy , and  diabetes mellitus . [ 84 ]  There is likely an inverse relationship between total serum  cholesterol  and the risk of non-traumatic SAH, though confirmation of this association is hindered by a lack of studies. [ 91 ]  Approximately 4 percent of aneurysmal bleeds occur after  sexual intercourse  and 10 percent of people with SAH are bending over or lifting heavy objects at the onset of their symptoms. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6987", "text": "Overall, about 1 percent of all people have one or more cerebral aneurysms. Most of these are small and unlikely to rupture. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6988", "text": "While the clinical picture of subarachnoid hemorrhage may have been recognized by  Hippocrates , the existence of cerebral aneurysms and the fact that they could rupture was not established until the 18th\u00a0century. [ 92 ]  The associated symptoms were described in more detail in 1886 by  Edinburgh  physician Dr  Byrom Bramwell . [ 93 ]  In 1924, London  neurologist  Sir  Charles P. Symonds  (1890\u20131978) gave a complete account of all major symptoms of subarachnoid hemorrhage, and he coined the term \"spontaneous subarachnoid hemorrhage\". [ 5 ] [ 92 ] [ 94 ]  Symonds also described the use of  lumbar puncture  and  xanthochromia  in diagnosis. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6989", "text": "The first surgical intervention was performed by Norman Dott, who was a pupil of  Harvey Cushing  then working in Edinburgh. He introduced the wrapping of aneurysms in the 1930s, and was an early pioneer in the use of angiograms. [ 5 ]  American  neurosurgeon  Dr  Walter Dandy , working in  Baltimore , was the first to introduce clips in 1938. [ 56 ]   Microsurgery  was applied to aneurysm treatment in 1972 in order to further improve outcomes. [ 96 ]  The 1980s saw the introduction of triple H therapy [ 76 ]  as a treatment for delayed ischemia due to  vasospasm , and trials with nimodipine [ 69 ] [ 97 ]  in an attempt to prevent this complication. In 1983, the Russian neurosurgeon Zubkov and colleagues reported the first use of transluminal balloon angioplasty for vasospasm after aneurysmal SAH. [ 98 ] [ 99 ]  The Italian neurosurgeon Dr Guido Guglielmi introduced his endovascular coil treatment in 1991. [ 6 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6990", "text": "The  SurgiScope  is a microscope and robot designed to hold tools and assist in positioning those tools during neurosurgery. The unit is mounted on the ceiling and can hold instruments such as endoscopy tools, biopsy needles, and electrodes. The associated software allows for target and trajectory determination. The SurgiScope has been used for stereotactic guidance and neuronavigation during surgical procedures. [ 1 ] [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6991", "text": "The  TESSYS method  (transforaminal endoscopic surgical system) is a  minimally-invasive ,  endoscopic spinal procedure  for the treatment of a  herniated disc .\nIt was a further development of the YESS method by the Dutch Dr Thomas Hoogland in the Alpha Klinik in Munich in 1989 and was first called THESSYS (Thomas Hoogland EndoScopic SYStem). The procedure involves  performing a small foramenotomy and removal of soft tissue compressing the nerve root. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6992", "text": "With the Tessys method, the  surgeon  removes the herniated portions of the disc using posterior lateral  endoscopic  access. This surgical method for  spinal disc herniations  is especially gentle for the patient. During the procedure, the patient is positioned either in the lateral or prone position, and local anesthetic is administered, usually in combination with sedation. The patient remains responsive, and typically general anesthesia is not necessary. The surgeon removes the herniated disc tissue through an access tube of mere millimeters via the intervertebral foramen. With special instruments, the surgeon progressively and gently dilates to access the disc without disrupting the surrounding muscles or conjunctive tissue. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6993", "text": "The first blind transforaminal discectomy was done by Parvis Kambin in 1973 with Craig's canula's.\nThe Tessys method was a further development of the existing YESS method (American  Anthony Yeung ) by the Dutch Thomas Hoogland in 1989 in Munich by reaming a few mm's from the SAP (Superior Articular Process). As of January 2018 [update] , more than 400,000 patients worldwide are operated with the TESSYS method. Most of them with the original joimax reamers or the newer safer MaxMoreSpine drills also developed and patented by Dr Thomas Hoogland [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6994", "text": "The system was introduced in the Netherlands in 2004 under the acronym PTED (Percutaneous Transforaminal Endoscopic Discectomy) by orthopaedic surgeon M. Iprenburg, who has since then successfully used the procedure with over 2600 of hernia patients with the joimax reamers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6995", "text": "The Tessys method is suitable for most prolapsed discs, regardless of the anatomical position. Another spinal indication for the Tessys procedure would be cauda equina syndrome, in a case where conservative methods of treatment failed to ameliorate the pain, or if only surrounded nerves are affected. Every intervertebral surgery requires a prior detailed discussion with the patient and imaging diagnostics such as  MRI ,  CT scans  and/or  X-ray . Monitoring of the compressed nerves and associated pathways is indicated due to the proximity of surgical manipulations that are in contact with nerve roots and/or the spinal cord. [ 3 ]  Monitoring modalities indicated are continuous somatosensory evoked potentials and spontaneous electromyography of the muscles supplied by the affected nerve roots. [ 4 ] [ 5 ]  Performing a discogram during the surgery procedure provides additional confirmation of the patient's anatomy and the position of the disc prolapse but might increase the degenerative changes in the disc. . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6996", "text": "To remove a herniated disc, the Tessys method uses a lateral, transforaminal, endoscopic access path via the intervertebral foramen. The surgery takes about 45\u201375 minutes. During the procedure, the patient is either in the lateral or prone position. The operation is preferable done under analgo-sedation in daysurgery. In Germany patients have however to stay for three days in the hospital to get proper payment from insurance companies. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6997", "text": "The access to the prolapse is achieved using a three-step guide wire technique: The surgeon gradually dilates through the soft tissue with the aid of  C-arm  radiographic monitoring and stretches the foramen step-by-step, with little or no disturbance to the surrounding muscles and nerves. Utilizing Tessys via nature's entry point, also known as  Kambin's Triangle , preserves the stability of the spinal column. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6998", "text": "The endoscope features a slim working channel to guide instruments to the anatomy. The surgeon leads the endoscope through the working tube while in surgery. The camera emits pictures and/or video of the operating field to a monitor, while the surgeon uses special surgical instruments to remove the herniated disc material safely, with precision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_6999", "text": "Studies document the advantages and the success of minimally invasive endoscopic spine surgery. The US research clinic the Cleveland Foundation agrees that the recovery period in patients treated with the Tessys method is accelerated by several weeks to months in comparison to conventionally treated patients. Many other studies document a success rate of more than 93%. [ 6 ] [ 7 ] [ 8 ] [ 9 ]  In January 2018 more as 3000 publications about endoscopic spine surgery are found in PubMed. Among them 2 RCT's. In the USA a complete new coding system was started for all endoscopic spine procedures. In the Netherlands the procedure was called experimental in 2006."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7000", "text": "The  translabyrinthine approach  is a surgical approach to treating serious disorders of the  cerebellopontine angle , (CPA), which is the most common location of posterior fossa tumors. especially  acoustic neuroma . [ 1 ]  In this approach, the  semicircular canals  and  vestibule , including the  utricle  and the  saccule  of the  inner ear  are removed, causing complete hearing loss in the operated ear. The procedure is typically performed by a team of surgeons, including a  neurotologist  (an ear, nose, and throat surgeon specializing in skull base surgery) as well as a  neurosurgeon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7001", "text": "The translabyrinthine approach was developed by  William F. House , M.D., [ 2 ]  who began doing dissections in the laboratory with the aid of magnification and subsequently developed the first  middle cranial fossa  and then the translabyrinthine approach for the removal of acoustic neuroma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7002", "text": "This surgical approach is typically performed by a team of surgeons, including a  neurotologist  (an ear, nose, and throat surgeon specializing in skull base surgery) as well as a  neurosurgeon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7003", "text": "In this approach, the  semicircular canals  and  vestibule , including the  utricle  and the  saccule  of the  inner ear  are removed with a surgical drill, causing complete sensorineural hearing loss in the operated ear.  The facial nerve, which innervates the muscles of the face, is preserved in a higher percentage of cases than with other approaches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7004", "text": "Prior to the translabyrinthine approach, in the early 1960s acoustic neuromas were treated utilizing a suboccipital approach without the aid of an operating microscope. With the introduction of the translabyrinthine approach, mortality rates decreased from 40% in the State of California to 1%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7005", "text": "Transsphenoidal surgery  is a type of  surgery  in which an  endoscope  or  surgical instruments  are inserted into part of the brain by going through the nose and the  sphenoid bone  (a butterfly-shaped bone forming the anterior inferior portion of the  brain case ) into the  sphenoidal sinus  cavity. Transsphenoidal surgery is used to remove  tumors  of the  pituitary gland . (Such tumours, although within the skull, are outside the brain itself)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7006", "text": "The transsphenoidal approach was first attempted by  Hermann Schloffer  in 1907. [ 1 ]  Use of the procedure grew in the 1950s and 60s with the introduction of intraoperative  fluoroscopy  and  operating microscope . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7007", "text": "The  transverse sinuses  (left and right lateral sinuses), within the human head, are two areas beneath the brain which allow blood to drain from the back of the head. They run laterally in a  groove  along the interior surface of the  occipital bone . They drain from the  confluence of sinuses  (by the  internal occipital protuberance ) to the  sigmoid sinuses , which ultimately connect to the  internal jugular vein .   See diagram (at right) : labeled under the brain as \" SIN. TRANS. \" (for Latin:  sinus transversus )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7008", "text": "The transverse sinuses are of large size and begin at the  internal occipital protuberance ; one, generally the right, being the direct continuation of the  superior sagittal sinus , the other of the  straight sinus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7009", "text": "Each transverse sinus passes lateral and forward, describing a slight curve with its convexity upward, to the base of the  petrous portion  of the  temporal bone , and lies, in this part of its course, in the attached margin of the  tentorium cerebelli ; it then leaves the tentorium and curves downward and medialward (an area sometimes referred to as the  sigmoid sinus ) to reach the  jugular foramen , where it ends in the  internal jugular vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7010", "text": "In its course it rests upon the  squama  of the  occipital , the  mastoid angle  of the  parietal , the  mastoid part  of the  temporal , and, just before its termination, the  jugular process  of the occipital; the portion which occupies the groove on the mastoid part of the temporal is sometimes termed the  sigmoid sinus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7011", "text": "The transverse sinuses are frequently of unequal size, with the one formed by the  superior sagittal sinus  being the larger; they increase in size as they proceed, from back to center."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7012", "text": "On transverse section, the horizontal portion exhibits a prismatic form, the curved portion has a semicylindrical form."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7013", "text": "They receive the blood from the superior petrosal sinuses at the base of the petrous portion of the temporal bone; they communicate with the veins of the  pericranium  by means of the  mastoid  and  condyloid   emissary veins ; and they receive some of the  inferior cerebral  and  inferior cerebellar veins , and some veins from the  diplo\u00eb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7014", "text": "The  petrosquamous sinus , when present, runs backward along the junction of the squama and petrous portion of the temporal, and opens into the transverse sinus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7015", "text": "Traumatic pneumorrhachis  is a medical condition in which air has entered the  spinal canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7016", "text": "Traumatic pneumorrhachis is very rare phenomenon. Only eight cases with pneumorrhachis extending to more than one spinal region had been reported in the literature. [ 1 ] [ 2 ]  Gordon had initially described the phenomenon of intraspinal air. [ 3 ]  The term  pneumorrhachis  was used for the first time by Newbold et al. [ 4 ]  The two subtypes of pneumorrhachis, which includes  epidural  or  subarachnoid , are difficult to distinguish even with  CT scanning . However, the presence of  pneumocephalus  goes more in favor of subarachnoid subtype. Goh and Yeo in their study have reported that the epidural pneumorrhachis is self-limited, whereas the more common subarachnoid pneumorrhachis type may be complicated by  tension pneumocephalus  and  meningitis . [ 5 ]  Traumatic subarachnoid pneumorrhachis is almost always secondary to major trauma and is a marker of a severe injury. For example, air may migrate via the neural foramina behind the driving pressure of pneumothorax. [ 2 ]  The pathophysiology described for it states that the penetrated air, which had led to the formation of pneumocephalus might have been forced caudally due to the raised intracranial pressure as a consequence of severe brain injury and patient's horizontal position allowing the entrapped air to pass through the  foramen magnum  into the spinal canal. Due to its rareness, asymptomatic presentation and myriad etiologies, no guidelines for its treatment or care has been described. Pneumorrhachis typically resolves spontaneously but occasionally it can have serious complications. Patient with subarachnoid pneumorrhachis should be treated meticulously and a temporary lumbar drainage may be required if they have concomitant  cerebro-spinal fluid  leak. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7017", "text": "A  vagotomy  is a  surgical  procedure that involves  removing part of  the  vagus nerve . It is performed in the  abdomen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7018", "text": "A plain vagotomy eliminates afferent and  parasympathetic  innervation of the stomach and the left side of the  transverse colon .  Other techniques focus on branches leading from the retroperitoneum to the stomach. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7019", "text": "Highly selective vagotomy  refers to denervation of only those branches supplying the lower esophagus and stomach (leaving the  nerve of Latarjet  in place to ensure the emptying function of the stomach remains intact). It is one of the treatments of peptic ulcer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7020", "text": "Vagotomy can be used in the surgical management of peptic (duodenal and gastric) ulcer disease (PUD). Vagotomy was once commonly performed to treat and prevent PUD; however, with the availability of excellent acid secretion control with H2 receptor antagonists, such as cimetidine, ranitidine, and famotidine, and proton pump inhibitors (PPIs), such as pantoprazole, rabeprazole, omeprazole, and lansoprazole, the need for surgical management of peptic ulcer disease has greatly decreased. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7021", "text": "The basic types of vagotomy are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7022", "text": "All types of vagotomy can be performed at open surgery (laparotomy) or using minimally invasive surgery (laparoscopy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7023", "text": "For the management of PUD, vagotomy is sometimes combined with  antrectomy  (removal of the distal half of the stomach) to reduce the rate of recurrence. Reconstruction is performed with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II).  It is left intact in highly selective vagotomy so the function of gastric emptying remains intact. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7024", "text": "Truncal vagotomy is a treatment option for chronic duodenal ulcers. [ 5 ] [ 6 ]  It was once considered the gold standard, but is now usually reserved for patients who have failed the first-line \"triple therapy\" against  Helicobacter pylori  infection: two antibiotics ( clarithromycin  and  amoxicillin  or  metronidazole ) and a  proton pump inhibitor  (e.g.,  omeprazole ). It is also used in the treatment of  gastric outlet obstruction . [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7025", "text": "In 2007, the use of vagotomy to treat  obesity  was being studied. [ 9 ]  The vagus nerve provides  efferent nervous signals  out from the hunger and satiety centers of the  hypothalamus , a region of the brain central to the regulation of food intake and energy expenditure. [ 10 ]  The circuit begins with an area of the hypothalamus, the  arcuate nucleus , which has outputs to the  lateral hypothalamus  (LH) and  ventromedial hypothalamus  (VMH), the brain's feeding and satiety centers, respectively. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7026", "text": "Animals with lesioned VMH will gain weight even in the face of severe restrictions imposed on their food intake, because they no longer provide the signaling needed to turn off energy storage and facilitate energy expenditure and fat burning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7027", "text": "In humans, the VMH is sometimes injured by ongoing treatment for  acute lymphoblastic leukemia  or surgery or radiation to treat  posterior cranial fossa  tumors. [ 10 ]  Disabling the VMH renders it unresponsive to peripheral energy balance signals; this, in turn, suppresses sympathetic activity (which leads to malaise and decreased energy expenditure) and stimulates vagal activity (which augments  insulin  production and  adipogenesis  (fat cell expansion)). [ 13 ]  Research shows that VMH dysfunction affects both energy intake and energy expenditure and is associated with constant weight gain, which results from a chronic positive energy balance caused by excessive energy intake and reduced metabolic rate.  In the past, adrenergic or serotonergic agonists were investigated for the treatment of obesity by suppressing appetite and stimulating thermogenesis, but neither calorie restriction nor treatment with these thermogenic agents has been very successful in achieving and maintaining weight reduction. [ 10 ]  The vagus nerve is thought to be one key mediator of these effects, as lesions lead to chronic elevations in insulin secretion, inhibiting fat oxidation and promoting energy storage in adipocytes.  \nVagotomy may have an impact upon  ghrelin . [ 14 ]  In an open-label, prospective study of 30 obese patients (26 women), response has been variable; the intervention has generally been safe, although  adverse events  have included  gastric dumping syndrome  (n=3), wound infection (n=2), other (n=5), and diarrhea (n=6). [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7028", "text": "Vagotomy was once popular as a way of treating and preventing PUD [ 16 ]  and subsequent  ulcer perforations . [ 17 ] [ 18 ]   PUD  was thought to be due to excess secretion of the acid environment in the  stomach , or at least that PUD was made worse by hyperacidity. Vagotomy was a way to reduce the acidity of the stomach, by denervating the parietal cells that produce acid. This was done with the hope that it would treat or prevent peptic ulcers. It also had the effect of reducing or eliminating symptoms of  gastroesophageal reflux  in those who suffered from it. The incidence of vagotomy decreased following the discovery by  Barry Marshall  and  Robin Warren  that  H. pylori  is responsible for most peptic ulcers, because  H. pylori  can be treated much less invasively. One potential side effect of vagotomy is a  vitamin B 12  deficiency. As vagotomy decreases gastric secretion,  intrinsic factor  production can be impaired. Intrinsic factor is needed to absorb vitamin B 12  efficiently from food, and injections or large oral doses of the vitamin may be required after such a procedure in certain populations. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7029", "text": "Vasospasm  refers to a condition in which an  arterial   spasm  leads to  vasoconstriction . This can lead to tissue  ischemia  (insufficient blood flow) and tissue death ( necrosis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7030", "text": "Along with physical resistance, vasospasm is a main cause of ischemia. Like physical resistance, vasospasms can occur due to  atherosclerosis . Vasospasm is the major cause of  Prinzmetal's angina ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7031", "text": "Cerebral vasospasm may arise in the context of  subarachnoid hemorrhage  as symptomatic vasospasm (or delayed  cerebral ischemia ), where it is a major contributor to post-operative stroke and mortality. Vasospasm typically appears 4 to 10 days after subarachnoid hemorrhage, however the relationship between radiological arterial spasm (seen on angiography) and clinical neurological deterioration is nuanced and uncertain.  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7032", "text": "Normally  endothelial cells  release  prostacyclin  and  nitric oxide  (NO) which induce relaxation of the  smooth muscle  cells, and reduce aggregation of  platelets . [ 2 ]  Aggregating platelets stimulate  ADP  to act on endothelial cells and help them induce relaxation of the smooth muscle cells. However, aggregating platelets also stimulate  thromboxane A2  and  serotonin  which can induce contraction of the smooth muscle cells.  In general, the relaxations outweighs the contractions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7033", "text": "In atherosclerosis, a dysfunctional endothelium is observed on examination. It does not stimulate as much prostacyclin and NO to induce relaxation on smooth muscle cells. Also there is not as much inhibition of aggregation of platelets. In this case, the greater aggregation of platelets produce ADP, serotonin, and thromboxane A2. However the serotonin and the thromboxane A2 cause more contraction of the smooth muscle cells and as a result contractions outweigh the relaxations. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7034", "text": "Vasospasm can occur in a wide variety of peripheral vascular beds under poorly understood mechanisms. Prinzmetal angina, Buerger's disease, contrast mediated selective renal vasospasm, hypercoagulability and cryoglobulinemia likely represent just a few of the known pieces of this puzzling phenomena. Ischemia in the heart due to prolonged  coronary vasospasm  can lead to  angina ,  myocardial infarction  and even death. Vasospasm in the hands and fingers due to prolonged exposure to vibration (30 \u2013 300\u00a0Hz) [ failed verification ] [ dubious  \u2013  discuss ]  and triggered by cold can lead to  Hand-arm vibration syndrome  in which feeling and manual dexterity are lost. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7035", "text": "In angiography, vascular access through femoral and axillary arteries are preferred because they are less prone to vasospasm. Meanwhile, brachial artery is more prone to vasospasm during instrumental access. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7036", "text": "In a case study in 2000, following surgery for head trauma, a patient developed mild  hypothermia , a typical defense mechanism the brain uses to protect itself after injury. After the hypothermia rewarming period, the patient died from increased intracranial pressure and  anisocoria . A sample of the cerebrospinal fluid and autopsy results indicated cerebral vasospasm. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7037", "text": "The occurrence of vasospasm can be reduced by preventing the occurrence of  atherosclerosis . This can be done in several ways, the most important being lifestyle modifications\u2014decreasing  low-density lipoprotein  (LDL),  quitting smoking ,  physical activity , and control for other risk factors including  diabetes ,  obesity , and  hypertension .  Pharmacological therapies  include  hypolipidemic agents ,  thrombolytics  and  anticoagulants . Pharmacological options for reducing the severity and occurrence of  ischemic episodes  include the  organic nitrates , which are rapidly metabolized to release  nitric oxide  in many tissues, [ 9 ]  and are classified as having either long-acting (i.e.  isosorbide dinitrate ) or short-acting (i.e.  nitroglycerin ) durations of action."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7038", "text": "These drugs work by increasing  nitric oxide  levels in the blood and inducing coronary  vasodilation  which will allow for more coronary blood flow due to a decreased coronary resistance, allowing for increased oxygen supply to the vital organs (myocardium). The nitric oxide increase in the blood resulting from these drugs also causes dilation of systemic veins which in turn causes a reduction in venous return, ventricular work load and ventricular radius. All of these reductions contribute to the decrease in ventricular wall stress which is significant because this causes the demand of oxygen to decrease. In general organic nitrates decrease oxygen demand and increase oxygen supply. It is this favourable change to the body that can decrease the severity of ischemic symptoms, particularly angina."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7039", "text": "Other medications used to reduce the occurrence and severity of vasospasm and ultimately ischemia include  L-type   calcium channel blockers  (notably  nimodipine , as well as  verapamil ,  diltiazem ,  nifedipine ) and beta-receptor antagonists (more commonly known as  beta blockers  or \u03b2-blockers) such as  propranolol ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7040", "text": "L-type calcium channel blockers can induce dilation of the coronary arteries while also decreasing the heart's demand for oxygen by reducing  contractility , heart rate, and wall stress. The reduction of these latter three factors decreases the contractile force that the myocardium must exert in order to achieve the same level of  cardiac output ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7041", "text": "Beta-receptor antagonists do not cause vasodilation, but like L-type calcium channel blockers, they do reduce the heart's demand for oxygen. This reduction similarly results from a decrease in heart rate, afterload, and wall stress."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7042", "text": "Like most pharmacological therapeutic options, there are risks that should be considered. For these drugs in particular, vasodilation can be associated with some adverse effects which might include orthostatic hypotension, reflex  tachycardia , headaches and palpitations. Tolerance may also develop over time due compensatory response of the body, as well as depletion of -SH groups of glutathione which are essential for the metabolism of the drugs to their active forms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7043", "text": "Potential side effects:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7044", "text": "Organic nitrates should not be taken with  PDE5  inhibitors (i.e.  sildenafil ) since both NO and PDE5 inhibitors increase  cyclic GMP  levels and the sum of their pharmacodynamic effects will greatly exceed the optimal therapeutic levels. What you could see upon taking both medications at the same time, as caused by the much higher induction of relaxation of smooth muscle cells, include a severe drop in blood pressure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7045", "text": "Beta-receptor antagonists should be avoided in patients with reactive pulmonary disease to avoid asthma attacks. Also Beta-receptor antagonists should be avoided in patients with AV node dysfunction and/or patients on other medications which might cause bradycardia (i.e. calcium channel blockers). The potential for these contraindications and drug-drug interaction could lead to asystole and cardiac arrest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7046", "text": "Certain calcium channel blocker should be avoided with some beta-receptor blockers since they may cause severe bradycardia and other potential side effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7047", "text": "Since vasospasms can be caused by atherosclerosis and contribute to the severity of ischemia there are some surgical options which can restore circulation to these ischemic areas. Regarding coronary vasospasm, one surgical intervention, referred to as percutaneous coronary intervention or angioplasty, involves placing a  stent  at the site of stenosis in an artery and inflating the stent using a balloon catheter. Another surgical intervention is  coronary artery bypass ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7048", "text": "Vertebral fixation  (also known as \"spinal fixation\") is an  orthopedic surgical  procedure in which two or more  vertebrae  are anchored to each other through a synthetic \" vertebral fixation device \", with the aim of reducing vertebral mobility and thus avoiding possible damage to the  spinal cord  and/or  spinal roots ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7049", "text": "A vertebral fixation procedure may be indicated in cases of  vertebral fracture ,  vertebral deformity , or degenerative vertebral disorders (such as  spondylolisthesis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7050", "text": "The device used to achieve vertebral fixation is usually a permanent rigid or semi-rigid  prosthesis  made of  titanium ; examples include rods, plates, screws, and various combinations thereof. A less common alternative is the use of a resorbable fixation device, composed of a bio-resorbable material."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7051", "text": "The medical community uses several different techniques for stabilizing the posterior region of the  spine .  The most radical of these techniques is  spinal fusion .  In recent years/decades spinal  surgeons  have begun to rely more heavily on mechanical implants, which provide increased stability without so severely limiting the recipient's range of motion.  A number of devices have been developed that allow the recipients near natural range of motion while still providing some support.  In many cases the support offered by such devices is insufficient, leaving the  physician  with few other choices than spinal fusion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7052", "text": "A spinal fixation device stabilizes an area of the  posterior spine  while allowing for a significant range of motion and limiting the compression of the affected  vertebrae .  The device consists of two or more arm assemblies (lateral) connected by one or more telescopic assemblies (vertical).  Each arm assembly is composed of a central portion, which connects to the telescopic assembly or assemblies. Left and right arms attach to the corresponding side of the central portion of the arm assembly.  Each arm section is directly connected to its individual pedicle by means of pedicle fasteners."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7053", "text": "More information about this specific spinal fixation device can be found in  The United States Patent Service's  November 13, 2007 publication of new patents.  This patent can currently (September 23, 2008) be found on  The U.S. Patent Website . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7054", "text": "White matter dissection  refers to a special anatomical technique able to reveal the subcortical organization of white matter fibers in the human or animal cadaver brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7055", "text": "The first studies of cerebral  white matter  (WM) were described by  Galen  and by the subsequent efforts of  Vesalius  on human cadaver specimens. [ 2 ] [ 3 ]  The interest for the deep anatomy of the brain  pushed anatomist during centuries to create and develop different techniques  for specimen preparation and dissection in order to better reveal the complex white matter architectural organization. [ 2 ] [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7056", "text": "However, the biggest impact on the dissection of white matter anatomy was made by  Joseph Klingler who developed a new method for specimens preparation and dissection. This technique became more feasible and widely used  due to an increased  quality of dissection and surprising quality of anatomical details. [ 4 ] [ 5 ] [ 6 ] [ 7 ]  Klingler developed a new method of brain fixation, by freezing already formalin-fixed brains before dissection. [ 6 ] [ 7 ]  First, the water crystallization induced by freezing disrupts the structure of the grey matter (which has a high water content). This process made possible to peel off the cortex from the brain surface without damaging the subcortical white matter organization underneath. Second, the freezing process along the WM fibers, induced a clear separation between them facilitating the dissection by progressive peeling of the fibers. [ 4 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7057", "text": "White matter fibre dissection is nowadays considered as a valuable tool to enhance our knowledge about brain connectivity, [ 5 ] [ 9 ] [ 10 ] [ 1 ]  and has been used to validate  tractographic  results and vice versa with good consistency between the two techniques, [ 11 ]  but also for neurosurgical training and neuroanatomical teaching."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7058", "text": "Plastic surgery  is a surgical specialty involving the restoration, reconstruction, or alteration of the human body. It can be divided into two main categories:  reconstructive surgery  and  cosmetic surgery .  Reconstructive surgery  covers a wide range of specialties, including  craniofacial surgery ,  hand surgery ,  microsurgery , and the treatment of  burns . This category of surgery focuses on restoring a body part or improving its function. In contrast,  cosmetic (or aesthetic) surgery  focuses solely on improving the physical appearance of the body. [ 1 ] [ 2 ]  A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7059", "text": "The word  plastic  in  plastic surgery  is in reference to the concept of \"reshaping\" and comes from the Greek \u03c0\u03bb\u03b1\u03c3\u03c4\u03b9\u03ba\u03ae (\u03c4\u03ad\u03c7\u03bd\u03b7),  plastik\u0113  ( tekhn\u0113 ), \"the art of modelling\" of  malleable   flesh . [ 3 ]   This meaning in English is seen as early as 1598. [ 4 ]  In the surgical context, the word \"plastic\" first appeared in 1816 and was established in 1838 by Eduard Zeis, [ 5 ]  preceding the modern technical usage of the word as \"engineering material made from  petroleum \" by 70 years. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7060", "text": "Treatments for the plastic repair of a broken nose are first mentioned in the  c. \u20091600 BC  Egyptian medical text called the  Edwin Smith papyrus . [ 8 ] [ 9 ]  The early trauma  surgery  textbook was named after the American  Egyptologist , Edwin Smith. [ 9 ]  Reconstructive surgery techniques were being carried out in  India  by 800 BC. [ 10 ]   Sushruta  was a  physician  who made contributions to the field of plastic and  cataract  surgery in the 6th century BC. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7061", "text": "The  Romans  also performed plastic cosmetic  surgery , using simple techniques, such as repairing damaged ears, from around the 1st century BC. [ 12 ]  For religious reasons, they did not  dissect  either human beings or animals, thus, their knowledge was based in its entirety on the texts of their  Greek  predecessors. Notwithstanding,  Aulus Cornelius Celsus  left some accurate  anatomical  descriptions, [ 13 ]  some of which\u2014for instance, his studies on the  genitalia  and the  skeleton \u2014are of special interest to plastic surgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7062", "text": "Several ancient Sanskrit medical treatise mentions some types of plastic surgery in India such as the works of  Sushruta  and  Charaka . These works were translated into the  Arabic language  during the  Abbasid  Caliphate in 750 AD. [ 15 ]  The Arabic translations made their way into  Europe  via intermediaries. [ 15 ]  In  Italy , the Branca family [ 16 ]  of  Sicily  and  Gaspare Tagliacozzi  ( Bologna ) became familiar with the techniques of Sushruta. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7063", "text": "All fields of surgery, the  Arab  physician, surgeon, and chemist  Al-Zahrawi  talks of the use of silk thread suture to achieve good  cosmesis . He describes what is thought to be the first attempt at  reduction mammaplasty  for the management of  gynaecomastia . He gives detailed descriptions of other basic surgical techniques such as  cautery  and wound management. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7064", "text": "British  physicians travelled to India to see  rhinoplasties  being performed by Indian methods. [ 18 ] [ 19 ]  Reports on Indian rhinoplasty performed by a  Kumhar  (potter)  vaidya  were published in the  Gentleman's Magazine  by 1794. [ 18 ]   Joseph Constantine Carpue  spent 20 years in India studying local plastic surgery methods. [ 18 ]  Carpue was able to perform the first major surgery in the  Western world  in the year 1815. [ 20 ]  Instruments described in the  Sushruta Samhita  were further modified in the Western world. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7065", "text": "In 1465, Sabuncu's book, description, and classification of  hypospadias  were more informative and up to date. Localization of the  urethral meatus  was described in detail.  Sabuncuoglu  also detailed the description and classification of ambiguous genitalia. In mid-15th-century Europe, Heinrich von Pfolspeundt described a process \"to make a new nose for one who lacks it entirely, and the dogs have devoured it\" by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not  until the 19th and 20th centuries  that such surgery became common."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7066", "text": "In 1814, Joseph Carpue successfully performed an operative procedure on a  British military  officer who had lost his nose to the toxic effects of  mercury  treatments. In 1818, German surgeon  Carl Ferdinand von Graefe  published his major work entitled  Rhinoplastik . Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7067", "text": "The first American plastic surgeon was  John Peter Mettauer , who, in 1827, performed the first  cleft palate  operation with instruments that he designed himself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7068", "text": "Johann Friedrich Dieffenbach  specialized in  skin transplantation  and early plastic surgery. His work in  rhinoplastic  and  maxillofacial  surgery established many modern techniques of  reconstructive surgery . In 1845, Dieffenbach wrote a comprehensive text on rhinoplasty, titled  Operative Chirurgie , and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose. Dieffenbach has been called the \"father of plastic surgery\". [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7069", "text": "Another case of plastic surgery for nose reconstruction from 1884 at  Bellevue Hospital  was described in  Scientific American . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7070", "text": "In 1891, American  otorhinolaryngologist  John Roe presented an example of his work: a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses. In 1896,  James Israel , a  urological  surgeon from Germany, and in 1889 George Monks of the United States each described the successful use of  heterogeneous  free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German  orthopaedic -trained  surgeon , published his first account of reduction rhinoplasty. In 1910,  Alexander Ostroumov , the Russian  pharmacist , and perfume and cosmetics manufacturer, founded a unique plastic surgery department in his Moscow Institute of Medical Cosmetics. [ 24 ]  In 1928, Jacques Joseph published  Nasenplastik und Sonstige Gesichtsplastik . [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7071", "text": "The development of weapons such as  machine guns  and  explosive shells  during  World War I  created trench warfare, which led to a rapid increase in the number of mutilations to the faces and the heads of soldiers because the trenches mainly offered protection to the body. The surgeons, who were not prepared for these injuries, were even less prepared for a large number of injuries and had to react quickly and intelligently to treat the greatest number. Facial injuries were hard to treat on the front line and, because of the sanitary conditions, many infections could occur. Sometimes, some stitches were made on a jagged wound without considering the amount of flesh that had been lost, so the resulting scars were hideous and disfigured soldiers. Some of the wounded had severe injuries and the stitches were not sufficient so some became blind, or were left with gaping holes instead of their nose.  Harold Gillies , scared by the number of new facial injuries and the lack of good surgical techniques, decided to dedicate an entire hospital to the reconstruction of facial injuries as fully as possible. He took into account the psychological dimension. Gillies introduced  skin grafts  to the treatments of soldiers, so they would be less horrified by looking at themselves in the mirror. [ 26 ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7072", "text": "It is the multidisciplinary approach to the treatment of facial lesions, bringing together  plastic surgeons , dental surgeons, technicians, and specialized nurses, which has made it possible to develop techniques leading to the reconstruction of injured faces. Gillies identified the need to advance the specialty of maxillofacial surgery which would be directly dedicated to the management of war wounds at this time. He developed a new technique using rotational and transposition flaps but also bone grafts from the ribs and tibia to reconstruct facial defects caused by the weapons during the war. Gillies experimented with this technique so he knew that he had to start by moving back healthy tissue to its normal position and then he would be able to fill with tissue from another place on the body of the soldier. One of the most successful techniques in skin grafting had the aim of not completely severing the connection to the body. It was possible by releasing and lifting a flap of skin from the wound. The flap of skin, still connected to the donor site, would then be swung over the site of the wound, allowing the maintenance of physical connection and ensuring that blood is supplied to the skin, increasing the chances of the skin graft being accepted by the body. At this time, we [ who? ]  assisted also to improving in treating infections also meant that important injuries had become survivable mostly thanks to the new technique of Gillies. Some soldiers arrived at the hospital of Gillies without noses, chins, cheekbones, or even eyes. But for them, the most important trauma was psychological. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7073", "text": "The father of modern plastic surgery is generally considered to have been Sir  Harold Gillies . A New Zealand  otolaryngologist  working in London, he developed many of the techniques of modern facial surgery in caring for soldiers with disfiguring facial injuries during the  First World War . [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7074", "text": "During  World War I , he worked as a medical minder with the  Royal Army Medical Corps . After working with the French  oral and maxillofacial surgeon   Hippolyte Morestin  on skin grafts, he persuaded the army's chief surgeon,  Arbuthnot-Lane , to establish a facial injury ward at the  Cambridge Military Hospital ,  Aldershot , later upgraded to a new hospital for facial repairs at  Sidcup  in 1917. There Gillies and his colleagues developed many techniques of plastic surgery; more than 11,000 operations were performed on more than 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds). [ 32 ]  After the war, Gillies developed a private practice with  Rainsford Mowlem , including many famous patients, and travelled extensively to promote his advanced techniques worldwide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7075", "text": "In 1930, Gillies' cousin,  Archibald McIndoe , joined the practice and became committed to plastic surgery. When  World War II  broke out, plastic surgery provision was largely divided between the different services of the  armed forces , and Gillies and his team were split up. Gillies himself was sent to  Rooksdown House  near  Basingstoke , which became the principal army plastic surgery unit; Tommy Kilner (who had worked with Gillies during the First World War, and who now has a surgical instrument named after him, the kilner cheek retractor) went to Queen Mary's Hospital, Roehampton; and Mowlem went to St Albans. McIndoe, consultant to the RAF, moved to the recently rebuilt  Queen Victoria Hospital  in  East Grinstead ,  Sussex , and founded a Centre for Plastic and Jaw Surgery. There, he treated very deep burns, and serious facial disfigurement, such as loss of eyelids, typical of those caused to aircrew by burning fuel. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7076", "text": "McIndoe is often recognized for not only developing new techniques for treating badly burned faces and hands but also for recognising the importance of the  rehabilitation  of the casualties and particularly of social reintegration back into normal life. He disposed of the \"convalescent uniforms\" and let the patients use their service uniforms instead. With the help of two friends, Neville and Elaine Blond, he also convinced the locals to support the patients and invite them to their homes. McIndoe kept referring to them as \"his boys\" and the staff called him \"The Boss\" or \"The Maestro\". [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7077", "text": "His other important work included the development of the  walking-stalk skin graft , and the discovery that immersion in  saline  promoted healing as well as improving survival rates for patients with extensive burns\u2014this was a  serendipitous  discovery drawn from observation of differential healing rates in pilots who had come down on land and in the sea. His radical, experimental treatments led to the formation of the  Guinea Pig Club  at  Queen Victoria Hospital , Sussex. Among the better-known members of his \"club\" were  Richard Hillary ,  Bill Foxley  and  Jimmy Edwards . [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7078", "text": "Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by  American Board of Plastic Surgery . [ 36 ]  Subdisciplines of plastic surgery may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7079", "text": "Aesthetic surgery is a central component of plastic surgery and includes facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7080", "text": "Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7081", "text": "Craniofacial surgery  is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, microtia, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with reconstructive surgeries after trauma or cancer and revision surgeries along with orthognathic surgery and facial feminization surgery. Craniofacial surgery is an important part of all plastic surgery training programs. Further training and subspecialisation is obtained via a craniofacial fellowship. Craniofacial surgery is also practiced by  maxillofacial surgeons ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7082", "text": "Ethnic plastic surgery  is plastic surgery performed to change ethnic attributes, often considered used as a way of \"passing\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7083", "text": "Hand surgery  is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. The hand surgery field is also practiced by  orthopedic surgeons  and  general surgeons . Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough. There have been cases of surgery on women's hands in order to correct perceived flaws to create the perfect engagement ring photo. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7084", "text": "Microsurgery  is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7085", "text": "Children often face medical issues very different from the experiences of an adult patient. Many  birth defects  or syndromes present at birth are best treated in childhood, and  pediatric  plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include  craniofacial anomalies , Syndactyly [ 40 ]  (webbing of the fingers and toes), Polydactyly (excess fingers and toes at birth), cleft lip and palate, and congenital hand deformities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7086", "text": "Plastic surgery performed on an incarcerated population in order to affect their  recidivism  rate, a practice instituted in the early 20th century that lasted until the mid-1990s. Separate from surgery performed for medical need."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7087", "text": "In plastic surgery, the transfer of skin tissue ( skin grafting ) is a very common procedure. Skin grafts can be derived from the recipient or donors:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7088", "text": "Usually, good results would be expected from plastic surgery that emphasize careful planning of incisions so that they fall within the line of natural skin folds or lines, appropriate choice of  wound closure , use of best available suture materials, and early removal of exposed sutures so that the wound is held closed by buried sutures. [ original research? ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7089", "text": "Cosmetic surgery is a voluntary or elective surgery that is performed on normal parts of the body with the only purpose of improving a person's appearance or removing signs of aging. Some cosmetic surgeries such as breast reduction are also functional and can help to relieve symptoms of discomfort such as back ache or neck ache. Cosmetic surgeries are also undertaken following breast cancer and mastectomy to recreate the natural breast shape which has been lost during the process of removing the cancer. In 2014, nearly 16 million cosmetic procedures were performed in the United States alone. [ 42 ]  The number of cosmetic procedures performed in the United States has almost doubled since the start of the century. 92% of cosmetic procedures were performed on women in 2014, up from 88% in 2001. [ 43 ]  15.6 million cosmetic procedures were performed in 2020, with the five most common surgeries being  rhinoplasties ,  blepharoplasties ,  rhytidectomies ,  liposuctions , and  breast augmentation . Breast augmentation continues to be one of the top 5 cosmetic surgical procedures and has been since 2006.  Silicone  implants were used in 84% and saline implants in 16% of all breast augmentations in 2020. [ 44 ]  The  American Society for Aesthetic Plastic Surgery  looked at the statistics for 34 different cosmetic procedures. Nineteen of the procedures were surgical, such as rhinoplasties or rhytidectomies. The nonsurgical procedures included  botox  and  laser hair removal . In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p.\u00a05). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p.\u00a012). [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7090", "text": "In 1949, 15,000 Americans underwent cosmetic surgery procedures and by 1969 [ 46 ]  this number rose to almost half a million people. [ 47 ]  The  American Society of Plastic Surgeons  estimates that more than 333,000 cosmetic procedures were performed on patients 18 years of age or younger in the US in 2005 compared to approx. 14,000 in 1996. In 2018, more than 226,994 patients between the ages of 13 and 19 underwent plastic surgery compared to just over 218,900 patients in the same age group in 2010. [ 46 ] [ 48 ]  Concerns about young people undergoing plastic surgery include the financial burden of additional surgical procedures needed to correct problems after the initial cosmetic surgery, long-term health complications from plastic surgery, and unaddressed mental health issues that may have led to surgery. [ 49 ]  The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans, Asian Americans and Hispanic Americans as well as Caucasian Americans. In Asia, cosmetic surgery has become more popular, and countries such as China and India have become Asia's biggest cosmetic surgery markets. [ 50 ]  South Korea is also rising in popularity in Asian and Western countries due to their expertise in facial bone surgeries (see  cosmetic surgery in South Korea ). [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7091", "text": "Plastic surgery is increasing slowly, rising 115% from 2000 to 2015. \"According to the annual plastic surgery procedural statistics, there were 15.9 million surgical and minimally-invasive cosmetic procedures performed in the United States in 2015, a 2 percent increase over 2014.\" [ 52 ]  A study from 2021 found that requests for cosmetic procedures had increased significantly since the beginning of the COVID-19 pandemic, possibly due to the increase in  videoconferencing ; [ 53 ]  cited estimates include a 10% increase in the United States and a 20% increase in France. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7092", "text": "The most popular aesthetic/cosmetic procedures include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7093", "text": "In 2015, the most popular surgeries were botox, liposuction, blepharoplasties, breast implants, rhynoplasties, and rhytidectomies. [ 63 ]  According to the 2020 Plastic Surgery Statistics Report, which is published by the American Society of Plastic Surgeons, the most surgical procedure performed in the U.S. was rhinoplasty (nose reshaping) accounting for 15.2% of all cosmetic surgical procedures that year, followed by blepharoplasty (eyelid surgery), which accounted for 14% of all procedures. The third most populous procedure was rhytidectomy (facelift) (10% of all procedures), then liposuction (9.1% of all procedures). [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7094", "text": "All surgery has risks. Common complications of cosmetic surgery includes  hematoma ,  nerve injury ,  infection ,  scarring ,  implant failure  and  end organ damage . [ 65 ] [ 66 ]   Breast implants  can have many  complications , including rupture. In a study of his 4761 augmentation mammaplasty patients, Eisenberg reported that overfilling saline breast implants 10\u201313% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. [ 67 ]  In 2011 FDA stated that one in five patients who received implants for breast augmentation will need them removed within 10 years of implantation. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7095", "text": "Although media and advertising do play a large role in influencing many people's lives, such as by making people believe plastic surgery to be an acceptable course to change one's identity to their liking, [ 69 ]  researchers believe that plastic surgery obsession is linked to psychological disorders such as  body dysmorphic disorder . [ 70 ]  There exists a correlation between those with BDD and the predilection toward cosmetic plastic surgery in order to correct a perceived defect in their appearance. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7096", "text": "BDD is a disorder resulting in the individual becoming \"preoccupied with what they regard as defects in their bodies or faces\". Alternatively, where there is a slight physical anomaly, then the person's concern is markedly excessive. [ 71 ]  While 2% of people have body dysmorphic disorder in the United States, 15% of patients seeing a dermatologist and cosmetic surgeons have the disorder. Half of the patients with the disorder who have cosmetic surgery performed are not pleased with the aesthetic outcome. BDD can lead to suicide in some people with the condition. While many with BDD seek cosmetic surgery, the procedures do not treat BDD, and can ultimately worsen the problem. The psychological root of the problem is usually unidentified; therefore causing the treatment to be even more difficult. Some say that the fixation or obsession with correction of the area could be a sub-disorder such as anorexia or muscle dysmorphia. [ 72 ]  The increased use of body and facial reshaping applications such as  Snapchat  and  Facetune  have been identified as potential triggers of BDD. Recently, a phenomenon referred to as ' Snapchat dysmorphia ' has appeared to describe people who request surgery to resemble the edited version of themselves as they appear through Snapchat filters. [ 73 ]  In response to the detrimental trend, Instagram banned all augmented reality (AR) filters that depict or promote cosmetic surgery. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7097", "text": "In some cases, people whose physicians refuse to perform any further surgeries, have turned to \" do it yourself \" plastic surgery, injecting themselves and facing extreme safety risks. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7098", "text": "Alarplasty  (or, less commonly,  alaplasty ) is a  plastic surgery  procedure in which a wedge of the  wing of the nose  is removed in order to alter the shape of the  nostrils . [ 1 ] [ 2 ]  Alarplasty may be used to increase or decrease the width of the nostrils, for either cosmetic or functional reasons. [ 3 ] [ 4 ]  In humans it may also make the nose perceptibly narrower. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7099", "text": "Temporary  swelling  is a common consequence of alarplasty. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7100", "text": "Alloplasty  is a  surgical procedure  performed to substitute and repair defects within the body with the use of  synthetic material . [ 1 ]  It can also be performed in order to bridge  wounds . [ 1 ]  The process of undergoing alloplasty involves the construction of an alloplastic  graft  through the use of computed tomography ( CT ), rapid  prototyping  and \"the use of computer-assisted virtual model surgery.\" [ 1 ]  Each alloplastic graft is individually constructed and customised according to the patient's defect to address their personal health issue. [ 2 ]  Alloplasty can be applied in the form of reconstructive surgery. An example where alloplasty is applied in  reconstructive surgery  is in aiding cranial defects. [ 3 ]  The insertion and fixation of alloplastic implants can also be applied in cosmetic enhancement and augmentation. [ 4 ]  Since the inception of alloplasty, it has been proposed that it could be a viable alternative to other forms of transplants. The  biocompatibility  and customisation of alloplastic implants and grafts provides a method that may be suitable for both minor and major medical cases that may have more limitations in surgical approach. Although there has been evidence that alloplasty is a viable method for repairing and substituting defects, there are disadvantages including suitability of patient bone quality and quantity for long term implant stability, possibility of rejection of the alloplastic implant, injuring surrounding nerves, cost of procedure and long recovery times. [ 5 ] [ 6 ] [ 7 ] [ 8 ]  Complications can also occur from inadequate engineering of alloplastic implants and grafts, and poor implant fixation to bone. These include infection, inflammatory reactions, the fracture of alloplastic implants and prostheses, loosening of implants or reduced or complete loss of osseointegration. [ 6 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7101", "text": "Generally, alloplasty requires resource-intensive preparation including a computed tomography (CT) scan of the patient. Following the CT scan, computer-assisted design technology such as interactive virtual surgical planning software, is used to design a surgical simulation. The surgical simulation produced can be utilised to manipulate the 3D CT model to \"preplan the resection, design cutting guides, and choose the appropriate stock prosthesis size\". [ 1 ]  To further improve the safety and outcomes of alloplasty, additive manufacturing technology such as the use of rapid prototyping, fabricates stereolithographic models and cutting guides to be used in the operating room to improve surgical performance. [ 1 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7102", "text": "Prior to the surgical procedure, the alloplastic implant that will be used to repair or substitute the patients defect is designed to be biocompatible with the patient's specific body tissue. [ 2 ] [ 6 ]  The purpose and longevity of the alloplastic implant is also taken into account when considering the materials that are used to create the implant and the structure in order to be able to fixate the implant into the body safely and securely. [ 4 ]  Preventative measures taken to minimise infection include alloplastic implants being thoroughly sterilised through the administration of antibiotics, the implant acting as an antibiotic carrier. The administration of an antibiotic above the minimum biofilm eradication concentration can act as a protective barrier to bacterial adhesion but can also eradicate biofilm remnants. [ 6 ]  Another preventative measure to minimise infection is topical antiseptic cleaning in the area of operation. Patients prior to surgical procedure are to be placed on strict hygiene programs to minimise the production of harmful bacteria that may cause infection. Infection can delay the surgical procedure of the alloplastic implant which would cause the patient to further endure the disadvantages of their defect. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7103", "text": "After completion of surgical preparation and the creation of a final stock prosthesis, the commencement of the surgical procedure, alloplasty, begins. Alloplasty is performed with the use of anaesthesia. The type of anaesthesia is dependent upon the location of the insertion of the alloplastic implant and the severity of the patient's case, but commonly general anaesthetic and local anaesthetic are utilised. General anaesthetic is applied in major cases but for minor cases, the patient is put under local anaesthetic and intravenous sedation. Once the patient is under anaesthetic, surgeons make the appropriate dissections to insert and stabilise the alloplastic implants. [ 2 ]  Post-surgery the patient is monitored over a period of time to identify whether the implant has successfully repaired or substituted the defect of concern, and if infection is present. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7104", "text": "Alloplastic implants are  osteoconductive  and can bridge wounds by osseointegration. [ 6 ] [ 11 ]  After the initial insertion of an alloplastic implant, the implant acts as a guide and pathway for the continuum of bone and tissue reproduction. The alloplastic implant becomes more stabilised and integrated into the surrounding bone as bone production progresses, fixating the implant. [ 8 ]  Initially the method to fixate alloplastic implants is by using miniplates and screws to directly attach the implant to the bone to mechanically stabilise it. [ 1 ] [ 2 ]  In alloplastic surgeries that involve smaller implants, the screw themselves can be used as implants. For example, dental implants can be found in the form of screws. There are two type of screw designs that are suitable as dental implants, screw-root form and plateau-root form designed screws. The two screw designs have different osseointegration outcomes, longevity and healing processes. The screw-root form design is directly threaded into bone and has macroscopic retentive elements for initial bone fixation. A direct connection between bone and the implant provides high initial stability. Over time, screw-root form designs experience bone resorption and \"bone modelling and remodelling at the bone to implant interface\". [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7105", "text": "Plateau-root form designed implants have a different healing process to screw-root form designs. The plateau-root form design has a woven bone formation. In the 0-3 month bone healing phase, osseointegration occurs by intramembranous ossification. Intramembranous ossification provides greater stabilisation and a more significant role in peri-implant bone healing around plateau-root form implants than screw-root form designed implants. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7106", "text": "Miniscrews are another type of implant that can be used to anchor and intrude hard surfaces, such as teeth. This type of implant can stabilise intrusive movement to a certain extent with a varying percentage of relapse of intrusion. Advantages of miniscrews are that they are easily inserted and removed, cheaper compared to other implants, are flexible in regards to insertion sites and cause a lower level of discomfort for the patient. Miniscrews are also able to provide stability without flap surgery and has a \"short healing period and immediate loading\". [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7107", "text": "The approach for the fixation of alloplastic implants will be dependent upon the circumstance of the surgical operation and the required stability of the implant. Some patients will require a combination of approaches. The approach taken to surgically fixate an alloplastic implant can also because of the type of synthetic material that the implant is made of to suit its purposes. [ 2 ]  The alloplastic implant must also be biocompatible with the hosts tissues by being \"non-toxic, non-allergenic, non-carcinogenic and non-inflammatory\". [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7108", "text": "Alloplasty is a method for synthetic implants to be inserted into the body to aid physical and mental function. [ 3 ] [ 14 ]  The procedure can be performed to reconstruct defects such as cranial defects. [ 15 ]  A common synthetic material used in the production of alloplastic grafts for craniotomy is heat-cure polymethyl methacrylate resin due to being nonconductive, radiolucent, light in weight and is easily modified to smoothly mould to the shape of the skull. [ 10 ]  The non-conduciveness and biocompatibility of polymethyl methacrylate resin and alloplastic materials in general, provides the ability for alloplastic implants to be used in aiding brain defects that may have been caused by decompressive craniectomy. [ 3 ] [ 10 ]  Porous titanium implants can also be used to correct calvarial defects such as \"subdural hematoma and meningioma\". [ 16 ]  Implants promote bone formation in osseous defects created by trauma or surgical intervention. [ 6 ]  Custom stock prosthetic implants reconstruct the cranial defects where the skull is too fragmented to be recovered or where bone has become infected and is required to be replaced. [ 3 ] [ 6 ]  Cranial implants are placed and secured through surgical stabilisation using surgical wires, mini plates and screws to fill gaps in the bone of the skull, called the bone flap. [ 10 ]  The conduct of alloplasty on the cranium restores lost or deficient use of the brain through the repair of mechanical defects, but is also able to provide fixations for cosmetic purposes to restore natural anatomy. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7109", "text": "Alloplastic implants can be used in cosmetic facial surgery to restore volume in areas of the face and \"can be serviced or removed without maximally invasive surgery\". [ 4 ]  Implants ideally are \"nonantigenic, durable, non-toxic and resistant to infection\". [ 17 ]  Cosmetic enhancement can be desired for multiple reasons including the physical changes associated with ageing. The continuous change in facial structure and need for volume restoration due to ageing requires implants that can be easily replaced, cost effective, permanent if desired and a reversible procedure. Silicone implants can provide a three-dimensional (3D) augmentation when anchored to the facial skeleton with screws. Implants made from silicone are able to be replaced and reversed in procedure as the silicone is not integrated into skin tissue but is surrounded by a dense and fibrous tissue capsule. Other materials alloplastic implants are made of for cosmetic enhancement include \"expanded polytetrafluorethylene and porous polyethylene\" which are all biocompatible\". [ 4 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7110", "text": "Facial implants that are left immobilised and that create pressure against bone can cause bone resorption. For example, chin implants that are immobilised create pressure on the anterior mandible which can cause an increase in bone resorption. Facial implants that are placed in a supraperiosteal plane centrally and subperiosteal plane laterally minimise bone resorption. The supraperiosteal plane placement of the implant minimises the degree of contact to the bone as the implant is immobilised and the subperiosteal plane has lateral pockets that fixate the implant. Chin implants can also be fixated and equally remove pressure from bone through the use of screw fixation. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7111", "text": "A disadvantage of alloplasty is that there are certain requirements for a patient to have long term stability of an alloplastic implant. [ 9 ]  This can be dependent upon age and health conditions of the patient. The patient must have sufficient maintenance of alveolar bone structure and minimise alveolar bone loss. For example, the removal of teeth results in accelerated loss of facial bone with the alveolar bone receding, resorbing and then disappearing. In the span of 2\u20133 years, patients can experience 40-60% of alveolar bone loss. Severe bone and tissue loss can make it difficult for the proceeding with alloplasty as procedural plans about regenerating bone through alloplastic implants become more complex. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7112", "text": "Another disadvantage with alloplasty is that alloplastic grafts and implants can cause inflammation or be completely rejected by the body and needs to be removed. [ 8 ] [ 19 ]  Alloplasty as a form of reconstructive surgery can be expensive. [ 15 ]  The need to remove and replace a rejected alloplastic graft or implant increases costs for the patient and prolongs the time the patient must endure the defect of concern. For patients that are successful with alloplasty, may experience long recovery times. This is because the patient's body needs to adapt to the foreign material and integrate the alloplastic implant or graft with its surrounding tissue. [ 5 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7113", "text": "The surgical technique of alloplasty if completed incorrectly can cause significant and irreversible damage to surrounding nerves by the improper placement of osteotomy. For example, in osteoplastic genioplasty, the risk of injuring a mental nerve is high. If the mental nerve injured or damaged, the lower lip and front of the chin can perceptually feel numb. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7114", "text": "Although evidence gathered by case-by-case studies have proposed that alloplasty is a viable alternative to other forms of transplants, there can be complications. [ 2 ] [ 3 ] [ 6 ]  Alloplastic implants that are not thoroughly sanitised can be contaminated. Contaminated implants attached to a surface in the body creates an enclosed slimy matrix called biofilm, which protects bacterial organisms from the body's defence mechanisms and antibiotics. The bacteria can infect the bloodstream and cause body tissues to become dysfunctional and suppress the body's immune system. A suppressed immune system exacerbates the growth of invading bacteria. [ 6 ]  Infection is predominant cause of removal of alloplastic implants. A disadvantage of the removal of an infected implant is that bone defects that the implant was responsible for, continue to exist. Another complication is that some synthetic organic materials such as fisiograft, that are used to make alloplastic implants can be hydrolytically decomposed which \"leads to a local acidulation of the tissue and causes an inflammatory reaction during absorption\". [ 5 ]  There can be complications with the long term function of alloplastic implants, if implants are poorly engineered and inadequately fixated. Improper fixation and numerous biomechanical and mechanical factors can contribute to the fracture of alloplastic implants or prostheses, loosening of alloplastic implants and reduced or complete loss of osseointegration. Biomechanical overload from the use of bone as leverage, creating leverage force, can place enormous stress on the implant as well as the bone\u2013implant interface. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7115", "text": "Anaplastology  ( Gk.  ana -again, a new, upon  plastos -something made, formed, molded  logy -the study of ) is a branch of  medicine  dealing with the  prosthetic  rehabilitation of an absent, disfigured or malformed anatomically critical location of the  face  or  body . The term  anaplastology  was coined by  Walter G. Spohn  and is used worldwide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7116", "text": "An anaplastologist (also known as a  maxillofacial prosthetist and technologist  in the  United Kingdom ) is an individual who has the knowledge and skill set to provide the service of customizing a facial ( craniofacial prosthesis ), ocular or  somatic prosthesis . In locations around the world that facial, ocular and somatic prostheses are not readily available, a  dentist  who specializes in  maxillofacial  prosthetics (prosthodontics), or a dental technician or an  ocularist , may also be titled an anaplastologist. In  urban  or more developed locations, an individual referred to as an anaplastologist is one who solely works with facial, ocular or somatic prostheses. In such a setting, the anaplastologist sometimes collaborates with prosthodontists and ocularists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7117", "text": "The studies of an anaplastologist consist of the arts and sciences.  Visual arts  are studied, namely  photography ,  illustration ,  sculpture , and  painting .  Biology ,  behavioral sciences ,  materials science , and  physics  are the studied sciences with emphases in  superficial anatomy  and  physiology  of  humans ,  polymer science ,  optics ,  dermatology ,  oral and maxillofacial surgery ,  otolaryngology , and  oncology  to name a few."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7118", "text": "Certification in the field of anaplastology is provided by the Board for Certification in Clinical Anaplastology (BCCA). Professionals certified by the BCCA are designated as Certified Clinical Anaplastologists and denote their credential with the CCA title."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7119", "text": "In the  Battle of the Somme , an estimated 4,000,000 shots were fired, causing 20,000  facial injuries . [ 1 ]  Individuals whose injuries were unable to be treated with  plastic surgery  or  reconstructive surgery  techniques available to them at the time were given the option of wearing customized pieces to restore the natural appearance of their face. These pieces were crafted by sculptors. A notable sculptor who created prosthetic pieces for victims of war was  Anna Coleman Ladd , a member of the  Red Cross  who made casts of her patients' faces and then, by hand, would create pieces out of  galvanized  copper,  tin foil , and  human hair  for them to wear. [ 2 ] [ 3 ]  Ladd's pieces were secured with bands around the head, which were often concealed by false  eyeglasses ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7120", "text": "In 1980  Walter G. Spohn  and a group of like-minded colleagues found the American Anaplastology Association (AAA) at  Stanford University , in  Palo Alto , California. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7121", "text": "In the 1986 musical,  Andrew Lloyd Weber's The Phantom of the Opera , the character  Erik  wears a facial mask to hide his facial deformities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7122", "text": "In the 2004 film,  The Libertine ,  John Wilmot, 2nd Earl of Rochester , as portrayed by American actor  Johnny Depp  is shown to wear a facial mask to cover the sores on his face caused by  syphilis . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7123", "text": "In the 2010 television show  Boardwalk Empire , the character  Richard Harrow  wears a tin mask with glasses to hide the disfigurement of his face. He endured during his service as a soldier in World War I."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7124", "text": "In the 2017  Wonder Woman  movie, the character Dr. Maru, also known as Dr. Poison, is a chemist working with the Germans in WWI. In the film, Dr. Maru wears a primitive mask colored and shaped like her face, to cover the bottom left side of her face. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7125", "text": "An  angiosome  is a three-dimensional unit of  skin  and  underlying tissues  vascularized by a source  artery , termed an  arteriosome  and drained by a vein termed a  venosome . It is a concept that is used by  plastic surgeons , and other medical disciplines like CMF,  ENT , etc., for the design and harvesting of  free flap  transplants (e.g. fibula free-flap transplant [ 1 ] ), and by  vascular surgeons  and  interventional radiologists  for the  endovascular treatment  of critical  limb ischemia .  It is an alternative model to the traditional \"best vessel\" model. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7126", "text": "An example is the angiosome of the  fibular artery  (also called the  peroneal artery ), that primarily vascularizes the skin of the distal two-thirds of the  lateral-posterior  aspect of the leg. Furthermore, also the underlying  fibula bone  and parts of the local muscles, like the  flexor hallucis longus muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7127", "text": "Small arteries, called  arterial perforators , branch off from the larger arteries below the deep body  fascia . These arterial perforators penetrate the deep body fascia in their course towards the skin and further ramify in the  subcutaneous tissue . A three-dimensional unit of tissue, only encompassing skin and the subcutaneous tissue \u2013 but not the tissue from below the body fascia (like muscle and bone) \u2013 primarily supplied by a dominant arterial perforator, is called a  perforasome . Although multiple other arterial perforators may also supply this unit of tissue with arterial blood, it is the dominant arterial perforator that is essential for the survival of the perforasome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7128", "text": "Arterial perforators can be further defined by their path, in three categories: direct-cutaneous perforator, septo-cutaneous perforator and musculo-cutaneous perforator, depending on what anatomical structure the perforator progresses through, after branching from the deep source artery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7129", "text": "Therefore, generally speaking, one \u201cbig\u201d angiosome can contain multiple \u201csmaller\u201d perforasomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7130", "text": "This article related to  medical imaging  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7131", "text": "An  auricular splint  ( AS ) or  ear splint  is a custom-made medical device that is used to maintain auricular projection and dimensions following second stage auricular reconstruction. The AS is made from  ethylene-vinyl acetate  (EVA), which is typically used to make  custom-made mouthguards  and was developed by a team from  Great Ormond Street Hospital  in the  United Kingdom ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7132", "text": "The  auricle  is typically reconstructed using  autogenous   cartilage , which is the most reliable material for producing the best results with the least complications. [ 1 ]  Cartilage from the  knee  and contralateral auricular cartilage from the  concha  have also been reported but  costal cartilage  is typically used as it is the only donor site that provides sufficient tissue to fabricate the complete auricular framework. The four main elements to consider when assessing the final reconstructed auricle are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7133", "text": "In order to prevent compression during sleep and to prevent the grafted skin from contracting, the use of a  Foley catheter , [ 3 ]   Reston Foam , [ 4 ]   silicone foam , [ 5 ]   polysiloxane [ 6 ] [ 7 ]  and\n dental impression compound [ 8 ]  have been described. The auricular splint was developed with the aim of overcoming the drawbacks associated with these methods."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7134", "text": "The auricular splint (AS) is easy to fit and remove, self-retaining, lightweight and easy to camouflage due to its transparency. The AS is made from  ethylene-vinyl acetate  (EVA), which is inert and non-toxic, non-absorbent, sufficiently elastic to allow it to fitted and removed but sufficiently rigid to avoid breakage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7135", "text": "The concept was first presented at the 2nd Congress of the International Society for Auricular Reconstruction in  Beijing ,  China  in September 2017 [ 9 ]  and published in the  Annals of Plastic Surgery  the following year. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7136", "text": "The first stage involves taking an impression of the reconstructed auricle with Soft Putty Elastomer, which is cast in  dental stone  to make a model of the reconstructed auricle. The splint is made by  thermoforming  a 4mm sheet of transparent  ethylene-vinyl acetate  (EVA) over the stone model. The edges of the splint are trimmed and polished using the outline on the model as a guide. [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7137", "text": "The splint has been found to maintain auricular projection and other key dimensions up to the six-month post-operative follow-up. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7138", "text": "Azficel-T , sold under the brand name  Laviv , is a  cell therapy  product for the improvement of the appearance of moderate to severe  nasolabial fold  wrinkles in adults. [ 1 ] [ 2 ] [ 3 ]  It consists of  fibroblasts  harvested from the patient's own skin. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7139", "text": "It was approved for medical use in the United States in June 2011. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7140", "text": "This  pharmacology -related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7141", "text": "Botulinum toxin , or  botulinum neurotoxin  (commonly called  botox ), is a  neurotoxic   protein  produced by the  bacterium   Clostridium botulinum  and related species. [ 24 ]  It prevents the release of the  neurotransmitter   acetylcholine  from  axon  endings at the  neuromuscular junction , thus causing  flaccid paralysis . [ 25 ]  The toxin causes the disease  botulism . [ 26 ]  The toxin is also used commercially for medical and cosmetic purposes. [ 27 ] [ 28 ]  Botulinum toxin is an acetylcholine release inhibitor and a neuromuscular blocking agent. [ 1 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7142", "text": "The seven main types of botulinum toxin are named types A to G (A, B, C1, C2, D, E, F and G). [ 27 ] [ 29 ]  New types are occasionally found. [ 30 ] [ 31 ]  Types A and B are capable of causing disease in humans, and are also used commercially and medically. [ 32 ] [ 33 ] [ 34 ]  Types C\u2013G are less common; types E and F can cause disease in humans, while the other types cause disease in other animals. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7143", "text": "Botulinum toxins are among the most potent toxins known to science. [ 36 ] [ 37 ]  Intoxication can occur naturally as a result of either wound or intestinal infection or by ingesting formed toxin in food. The estimated human  median lethal dose  of type A toxin is 1.3\u20132.1 \u00a0 ng /kg  intravenously  or  intramuscularly , 10\u201313 \u00a0 ng/kg when inhaled, or 1000 \u00a0 ng/kg when taken by mouth. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7144", "text": "Botulinum toxin is used to treat a number of therapeutic indications, many of which are not part of the approved drug label. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7145", "text": "Botulinum toxin is used to treat a number of disorders characterized by overactive muscle movement, including  cerebral palsy , [ 32 ] [ 33 ]  post-stroke  spasticity , [ 39 ]  post-spinal cord injury spasticity, [ 40 ]   spasms  of the head and neck, [ 41 ]   eyelid , [ 26 ]   vagina , [ 42 ]  limbs, jaw, and  vocal cords . [ 43 ]  Similarly, botulinum toxin is used to relax the clenching of muscles, including those of the  esophagus , [ 44 ]   jaw , [ 45 ]   lower urinary tract  and  bladder , [ 46 ]  or clenching of the anus which can exacerbate  anal fissure . [ 47 ]  Botulinum toxin appears to be effective for  refractory   overactive bladder . [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7146", "text": "Strabismus , otherwise known as improper eye alignment, is caused by imbalances in the actions of muscles that rotate the eyes. This condition can sometimes be relieved by weakening a muscle that pulls too strongly, or pulls against one that has been weakened by disease or trauma. Muscles weakened by toxin injection recover from paralysis after several months, so injection might seem to need to be repeated, but muscles adapt to the lengths at which they are chronically held, [ 49 ]  so that if a paralyzed muscle is stretched by its antagonist, it grows longer, while the antagonist shortens, yielding a permanent effect. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7147", "text": "In January 2014, botulinum toxin was approved by UK's  Medicines and Healthcare products Regulatory Agency  for treatment of restricted ankle motion due to lower-limb spasticity associated with stroke in adults. [ 51 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7148", "text": "In July 2016, the US  Food and Drug Administration  (FDA) approved abobotulinumtoxinA (Dysport) for injection for the treatment of lower-limb spasticity in pediatric patients two years of age and older. [ 53 ] [ 54 ]  AbobotulinumtoxinA is the first and only FDA-approved botulinum toxin for the treatment of pediatric lower limb spasticity. [ 55 ]  In the US, the  FDA approves  the text of the labels of prescription medicines and for which medical conditions the drug manufacturer may sell the drug. However, prescribers may freely prescribe them for any condition they wish, also known as  off-label use . [ 56 ]  Botulinum toxins have been used off-label for several pediatric conditions, including  infantile esotropia . [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7149", "text": "AbobotulinumtoxinA has been approved for the treatment of axillary  hyperhidrosis , which cannot be managed by topical agents. [ 43 ] [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7150", "text": "In 2010, the FDA approved  intramuscular  botulinum toxin injections for  prophylactic   treatment  of  chronic   migraine   headache . [ 59 ]  However, the use of botulinum toxin injections for episodic migraine has not been approved by the FDA. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7151", "text": "In cosmetic applications, botulinum toxin is considered relatively safe and effective [ 61 ]  for reduction of facial  wrinkles , especially in the uppermost third of the face. [ 62 ]  Commercial forms are marketed under the brand names Botox Cosmetic/Vistabel from  Allergan , Dysport/Azzalure from  Galderma  and  Ipsen , Xeomin/Bocouture from Merz, Jeuveau/Nuceiva from Evolus, manufactured by  Daewoong  in South Korea. [ 63 ]  The effects of botulinum toxin injections for  glabellar  lines ('11's lines' between the eyes) typically last two to four months and in some cases, product-dependent, with some patients experiencing a longer duration of effect of up to six months or longer. [ 62 ]  Injection of botulinum toxin into the muscles under facial wrinkles causes relaxation of those muscles, resulting in the smoothing of the overlying skin. [ 62 ]  Smoothing of wrinkles is usually visible three to five days after injection, with maximum effect typically a week following injection. [ 62 ]  Muscles can be treated repeatedly to maintain the smoothed appearance. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7152", "text": "DaxibotulinumtoxinA (Daxxify) was approved for medical use in the United States in September 2022. [ 23 ] [ 64 ]  It is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (wrinkles between the eyebrows). [ 23 ] [ 64 ] [ 65 ]  DaxibotulinumtoxinA is an acetylcholine release inhibitor and neuromuscular blocking agent. [ 23 ]  The FDA approved daxibotulinumtoxinA based on evidence from two clinical trials (Studies GL-1 and GL-2), of 609 adults with moderate to severe glabellar lines. [ 64 ]  The trials were conducted at 30 sites in the United States and Canada. [ 64 ]  Both trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines. [ 64 ]  Participants received a single intramuscular injection of daxibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. [ 64 ]  The most common side effects of daxibotulinumtoxinA are headache, drooping eyelids, and weakness of facial muscles. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7153", "text": "LetibotulinumtoxinA (Letybo) was approved for medical use in the United States in February 2024. [ 1 ] [ 66 ]  It is indicated to temporarily improve the appearance of moderate-to-severe glabellar lines. [ 1 ] [ 67 ]  The FDA approved letibotulinumtoxinA based on evidence from three clinical trials (BLESS I [NCT02677298], BLESS II [NCT02677805], and BLESS III [NCT03985982]) of 1,271 participants with moderate to severe wrinkles between the eyebrows for efficacy and safety assessment. [ 66 ]  These trials were conducted at 31 sites in the United States and the European Union. [ 66 ]  All three trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines (wrinkles between the eyebrows). [ 66 ]  Participants received a single intramuscular injection of letibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. [ 66 ]  The most common side effects of letibotulinumtoxinA are headache, drooping of eyelid and brow, and twitching of eyelid. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7154", "text": "Botulinum toxin is also used to treat disorders of hyperactive nerves including excessive sweating, [ 58 ]   neuropathic pain , [ 68 ]  and some  allergy  symptoms. [ 43 ]  In addition to these uses, botulinum toxin is being evaluated for use in treating  chronic pain . [ 69 ]  Studies show that botulinum toxin may be injected into arthritic shoulder joints to reduce chronic pain and improve range of motion. [ 70 ]  The use of botulinum toxin A in children with  cerebral palsy  is safe in the upper and lower limb muscles. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7155", "text": "While botulinum toxin is generally considered safe in a clinical setting, serious side effects from its use can occur. Most commonly, botulinum toxin can be injected into the wrong muscle group or with time spread from the injection site, causing temporary paralysis of unintended muscles. [ 71 ]  In at least three cases temporary  diplopia  was reported due to subcutenious injections for cosmetic purposes. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7156", "text": "Side effects from cosmetic use generally result from unintended paralysis of facial muscles. These include partial facial paralysis, muscle weakness, and  trouble swallowing . Side effects are not limited to direct paralysis, however, and can also include headaches, flu-like symptoms, and allergic reactions. [ 73 ]  Just as cosmetic treatments only last a number of months, paralysis side effects can have the same durations. [ 74 ]  At least in some cases, these effects are reported to dissipate in the weeks after treatment. [ 75 ]  Bruising at the site of injection is not a side effect of the toxin, but rather of the mode of administration, and is reported as preventable if the clinician applies pressure to the injection site; when it occurs, it is reported in specific cases to last 7\u201311 days. [ 76 ]  When injecting the masseter muscle of the jaw, loss of muscle function can result in a loss or reduction of power to chew solid foods. [ 73 ]  With continued high doses, the muscles can atrophy or lose strength; research has shown that those muscles rebuild after a break from Botox. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7157", "text": "Side effects from therapeutic use can be much more varied depending on the location of injection and the dose of toxin injected. In general, side effects from therapeutic use can be more serious than those that arise during cosmetic use. These can arise from paralysis of critical muscle groups and can include  arrhythmia ,  heart attack , and in some cases, seizures, respiratory arrest, and death. [ 73 ]  Additionally, side effects common in cosmetic use are also common in therapeutic use, including trouble swallowing, muscle weakness, allergic reactions, and flu-like syndromes. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7158", "text": "In response to the occurrence of these side effects, in 2008, the FDA notified the public of the potential dangers of the botulinum toxin as a therapeutic. Namely, the toxin can spread to areas distant from the site of injection and paralyze unintended muscle groups, especially when used for treating muscle spasticity in children treated for cerebral palsy. [ 78 ]  In 2009, the FDA announced that boxed warnings would be added to available botulinum toxin products, warning of their ability to spread from the injection site. [ 79 ] [ 80 ] [ 81 ] [ 82 ]  However, the clinical use of botulinum toxin A in cerebral palsy children has been proven to be safe with minimal side effects. [ 32 ] [ 33 ]  Additionally, the FDA announced name changes to several botulinum toxin products, to emphasize that the products are not interchangeable and require different doses for proper use. Botox and Botox Cosmetic were given the generic name of onabotulinumtoxinA, Myobloc as rimabotulinumtoxinB, and Dysport retained its generic name of abobotulinumtoxinA. [ 83 ] [ 79 ]  In conjunction with this, the FDA issued a communication to health care professionals reiterating the new drug names and the approved uses for each. [ 84 ]  A similar warning was issued by  Health Canada  in 2009, warning that botulinum toxin products can spread to other parts of the body. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7159", "text": "Botulinum toxin produced by  Clostridium botulinum  (an anaerobic, gram-positive bacterium) is the cause of botulism. [ 26 ]  Humans most commonly ingest the toxin from eating improperly canned foods in which  C.\u00a0botulinum  has grown. However, the toxin can also be introduced through an infected wound. In infants, the bacteria can sometimes grow in the intestines and produce botulinum toxin within the intestine and can cause a condition known as  floppy baby syndrome . [ 86 ]  In all cases, the toxin can then spread, blocking nerves and muscle function. In severe cases, the toxin can block nerves controlling the respiratory system or heart, resulting in death. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7160", "text": "Botulism can be difficult to diagnose, as it may appear similar to diseases such as  Guillain\u2013Barr\u00e9 syndrome ,  myasthenia gravis , and  stroke . Other tests, such as brain scan and spinal fluid examination, may help to rule out other causes. If the symptoms of botulism are diagnosed early, various treatments can be administered. In an effort to remove contaminated food that remains in the gut, enemas or induced vomiting may be used. [ 87 ]  For wound infections, infected material may be removed surgically. [ 87 ]  Botulinum antitoxin is available and may be used to prevent the worsening of symptoms, though it will not reverse existing nerve damage. In severe cases, mechanical respiration may be used to support people with respiratory failure. [ 87 ]  The nerve damage heals over time, generally over weeks to months. [ 88 ]  With proper treatment, the case fatality rate for botulinum poisoning can be greatly reduced. [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7161", "text": "Two preparations of botulinum antitoxins are available for treatment of botulism. Trivalent (serotypes A, B, E) botulinum  antitoxin  is derived from equine sources using whole  antibodies . The second antitoxin is  heptavalent botulinum antitoxin  (serotypes A, B, C, D, E, F, G), which is derived from equine antibodies that have been altered to make them less immunogenic. This antitoxin is effective against all main strains of botulism. [ 89 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7162", "text": "Botulinum toxin exerts its effect by cleaving key proteins required for nerve activation. First, the toxin binds specifically to presynaptic surface of  neurons  that use the neurotransmitter  acetylcholine . Once bound to the nerve terminal, the neuron  takes up  the toxin into a  vesicle  by receptor-mediated  endocytosis . [ 91 ]  As the vesicle moves farther into the cell, it acidifies, activating a portion of the toxin that triggers it to push across the vesicle membrane and into the cell  cytoplasm . [ 24 ]  Botulinum neurotoxins recognize distinct classes of receptors simultaneously ( gangliosides ,  synaptotagmin  and  SV2 ). [ 92 ]  Once inside the cytoplasm, the toxin cleaves  SNARE proteins  (proteins that mediate vesicle fusion, with their target membrane bound compartments) meaning that the acetylcholine vesicles cannot bind to the intracellular cell membrane, [ 91 ]  preventing the cell from releasing vesicles of neurotransmitter. This stops nerve signaling, leading to  flaccid paralysis . [ 24 ] [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7163", "text": "The toxin itself is released from the bacterium as a single chain, then becomes activated when cleaved by its own proteases. [ 43 ]  The active form consists of a two-chain  protein  composed of a 100- kDa  heavy chain  polypeptide  joined via  disulfide bond  to a 50-kDa light chain polypeptide. [ 93 ]  The heavy chain contains domains with several functions; it has the domain responsible for binding specifically to  presynaptic  nerve terminals, as well as the domain responsible for mediating translocation of the light chain into the cell cytoplasm as the vacuole acidifies. [ 24 ] [ 93 ]  The light chain is a M27-family zinc  metalloprotease  and is the active part of the toxin. It is translocated into the host cell cytoplasm where it cleaves the host protein  SNAP-25 , a member of the SNARE protein family, which is responsible for  fusion . The cleaved SNAP-25 cannot mediate fusion of vesicles with the host cell membrane, thus preventing the release of the  neurotransmitter  acetylcholine from axon endings. [ 24 ]  This blockage is slowly reversed as the toxin loses activity and the SNARE proteins are slowly regenerated by the affected cell. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7164", "text": "The seven toxin serotypes (A\u2013G) are traditionally separated by their antigenicity. They have different tertiary structures and sequence differences. [ 93 ] [ 94 ]  While the different toxin types all target members of the SNARE family, different toxin types target different SNARE family members. [ 90 ]  The A, B, and E serotypes cause human botulism, with the activities of types A and B enduring longest  in vivo  (from several weeks to months). [ 93 ]  Existing toxin types can recombine to create \"hybrid\" (mosaic, chimeric) types. Examples include BoNT/CD, BoNT/DC, and BoNT/FA, with the first letter indicating the light chain type and the latter indicating the heavy chain type. [ 95 ]  BoNT/FA received considerable attention under the name \"BoNT/H\", as it was mistakenly thought it could not be neutralized by any existing antitoxin. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7165", "text": "Botulinum toxins are closely related to  tetanus toxin . The two are collectively known as  Clostridium  neurotoxins  and the light chain is classified by  MEROPS  as family M27. [ 96 ]   Clostridium  neurotoxins belong in the wider family of  AB toxins , which also includes   Anthrax toxin  and  Diphtheria toxin . Nonclassical types include BoNT/X ( P0DPK1 ), which is toxic in mice and possibly in humans; [ 30 ]  a BoNT/J ( A0A242DI27 ) found in cow  Enterococcus ; [ 97 ]  and a BoNT/Wo ( A0A069CUU9 ) found in the rice-colonizing  Weissella oryzae . [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7166", "text": "One of the earliest recorded outbreaks of foodborne botulism occurred in 1793 in the village of  Wildbad  in what is now  Baden-W\u00fcrttemberg , Germany. Thirteen people became sick and six died after eating pork stomach filled with  blood sausage , a local delicacy. Additional cases of fatal food poisoning in  W\u00fcrttemberg  led the authorities to issue a public warning against consuming smoked blood sausages in 1802 and to collect case reports of \"sausage poisoning\". [ 98 ]  Between 1817 and 1822, the German physician  Justinus Kerner  published the first complete description of the symptoms of botulism, based on extensive clinical observations and animal experiments. He concluded that the toxin develops in bad sausages under anaerobic conditions, is a biological substance, acts on the nervous system, and is lethal even in small amounts. [ 98 ]  Kerner hypothesized that this \"sausage toxin\" could be used to treat a variety of diseases caused by an overactive nervous system, making him the first to suggest that it could be used therapeutically. [ 99 ]  In 1870, the German physician M\u00fcller coined the term  botulism  to describe the disease caused by sausage poisoning, from the Latin word  botulus , meaning 'sausage'. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7167", "text": "In 1895  \u00c9mile van Ermengem , a Belgian microbiologist, discovered what is now called  Clostridium botulinum  and confirmed that a toxin produced by the bacteria causes botulism. [ 100 ]  On 14 December 1895, there was a large outbreak of botulism in the Belgian village of  Ellezelles  that occurred at a funeral where people ate pickled and smoked ham; three of them died. By examining the contaminated ham and performing autopsies on the people who died after eating it, van Ermengem isolated an anaerobic microorganism that he called  Bacillus botulinus . [ 98 ]  He also performed experiments on animals with ham extracts, isolated bacterial cultures, and toxins extracts from the bacteria. From these he concluded that the bacteria themselves do not cause foodborne botulism, but rather produce a toxin that causes the disease after it is ingested. [ 101 ]  As a result of Kerner's and van Ermengem's research, it was thought that only contaminated meat or fish could cause botulism. This idea was refuted in 1904 when a botulism outbreak occurred in  Darmstadt , Germany, because of canned white beans. In 1910, the German microbiologist J. Leuchs published a paper showing that the outbreaks in Ellezelles and Darmstadt were caused by different strains of  Bacillus botulinus  and that the toxins were serologically distinct. [ 98 ]  In 1917,  Bacillus botulinus  was renamed  Clostridium botulinum , as it was decided that term  Bacillus  should only refer to a group of aerobic microorganisms, while  Clostridium  would be only used to describe a group of anaerobic microorganisms. [ 100 ]  In 1919,  Georgina Burke  used toxin-antitoxin reactions to identify two strains of  Clostridium botulinum , which she designated A and B. [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7168", "text": "Over the next three decades, 1895\u20131925, as food canning was approaching a billion-dollar-a-year industry, botulism was becoming a public health hazard.  Karl Friedrich Meyer , a Swiss-American veterinary scientist, created a center at the Hooper Foundation in San Francisco, where he developed techniques for growing the organism and extracting the toxin, and conversely, for preventing organism growth and toxin production, and inactivating the toxin by heating. The California canning industry was thereby preserved. [ 102 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7169", "text": "With the outbreak of World War II, weaponization of botulinum toxin was investigated at  Fort Detrick  in Maryland. Carl Lamanna and James Duff [ 103 ]  developed the concentration and crystallization techniques that Edward J. Schantz used to create the first clinical product. When the Army's  Chemical Corps  was disbanded, Schantz moved to the Food Research Institute in Wisconsin, where he manufactured toxin for experimental use and provided it to the academic community."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7170", "text": "The mechanism of botulinum toxin action \u2013 blocking the release of the neurotransmitter acetylcholine from nerve endings \u2013 was elucidated in the mid-20th century, [ 104 ]  and remains an important research topic. Nearly all toxin treatments are based on this effect in various body tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7171", "text": "Ophthalmologists specializing in eye muscle disorders ( strabismus ) had developed the method of EMG-guided injection (using the  electromyogram , the electrical signal from an activated muscle, to guide injection) of local anesthetics as a diagnostic technique for evaluating an individual muscle's contribution to an eye movement. [ 105 ]  Because  strabismus surgery  frequently needed repeating, a search was undertaken for non-surgical, injection treatments using various anesthetics, alcohols, enzymes, enzyme blockers, and snake neurotoxins. Finally, inspired by  Daniel B. Drachman 's work with chicks at Johns Hopkins, [ 106 ]   Alan B. Scott  and colleagues injected botulinum toxin into monkey extraocular muscles. [ 107 ]  The result was remarkable; a few picograms induced paralysis that was confined to the target muscle, long in duration, and without side effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7172", "text": "After working out techniques for freeze-drying, buffering with  albumin , and assuring sterility, potency, and safety, Scott applied to the FDA for investigational drug use, and began manufacturing botulinum type A neurotoxin in his San Francisco lab. He injected the first strabismus patients in 1977, reported its clinical utility in 1980, [ 108 ]  and had soon trained hundreds of ophthalmologists in EMG-guided injection of the drug he named Oculinum (\"eye aligner\")."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7173", "text": "In 1986, Oculinum Inc, Scott's micromanufacturer and distributor of botulinum toxin, was unable to obtain product liability insurance, and could no longer supply the drug. As supplies became exhausted, people who had come to rely on periodic injections became desperate. For four months, as liability issues were resolved, American blepharospasm patients traveled to Canadian eye centers for their injections. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7174", "text": "Based on data from thousands of people collected by 240 investigators, Oculinum Inc (which was soon acquired by Allergan) received FDA approval in 1989 to market Oculinum for clinical use in the United States to treat adult strabismus and  blepharospasm . Allergan then began using the trademark Botox. [ 110 ]  This original approval was granted under the  1983 US Orphan Drug Act . [ 111 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7175", "text": "The effect of botulinum toxin type-A on reducing and eliminating forehead wrinkles was first described and published by Richard Clark, MD, a plastic surgeon from Sacramento, California. In 1987 Clark was challenged with eliminating the disfigurement caused by only the right side of the forehead muscles functioning after the left side of the forehead was paralyzed during a facelift procedure. This patient had desired to look better from her facelift, but was experiencing bizarre unilateral right forehead eyebrow elevation while the left eyebrow drooped, and she constantly demonstrated deep expressive right forehead wrinkles while the left side was perfectly smooth due to the paralysis. Clark was aware that Botulinum toxin was safely being used to treat babies with strabismus and he requested and was granted FDA approval to experiment with Botulinum toxin to paralyze the moving and wrinkling normal functioning right forehead muscles to make both sides of the forehead appear the same. This study and case report of the cosmetic use of Botulinum toxin to treat a cosmetic complication of a cosmetic surgery was the first report on the specific treatment of wrinkles and was published in the journal  Plastic and Reconstructive Surgery  in 1989. [ 112 ]  Editors of the journal of the American Society of Plastic Surgeons have clearly stated \"the first described use of the toxin in aesthetic circumstances was by Clark and Berris in 1989.\" [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7176", "text": "Also in 1987, Jean and Alastair Carruthers, both doctors in  Vancouver, British Columbia , observed that blepharospasm patients who received injections around the eyes and upper face also enjoyed diminished facial glabellar lines (\"frown lines\" between the eyebrows). Alastair Carruthers reported that others at the time also noticed these effects and discussed the cosmetic potential of botulinum toxin. [ 114 ]  Unlike other investigators, the Carruthers did more than just talk about the possibility of using botulinum toxin cosmetically. They conducted a clinical study on otherwise normal individuals whose only concern was their eyebrow furrow. They performed their study between 1987 and 1989 and presented their results at the 1990 annual meeting of the American Society for Dermatologic Surgery. Their findings were subsequently published in 1992. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7177", "text": "William J. Binder  reported in 2000 that people who had cosmetic injections around the face reported relief from chronic headache. [ 116 ]  This was initially thought to be an indirect effect of reduced muscle tension, but the toxin is now known to inhibit release of peripheral nociceptive neurotransmitters, suppressing the central pain processing systems responsible for  migraine  headache. [ 117 ] [ 118 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7178", "text": "As of 2018 [update] , botulinum toxin injections are the most common cosmetic operation, with 7.4 million procedures in the United States, according to the  American Society of Plastic Surgeons . [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7179", "text": "The global market for botulinum toxin products, driven by their cosmetic applications, was forecast to reach $2.9 billion by 2018. The facial aesthetics market, of which they are a component, was forecast to reach $4.7 billion ($2 billion in the US) in the same timeframe. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7180", "text": "In 2020, 4,401,536 botulinum toxin Type A procedures were administered. [ 121 ]  In 2019 the botulinum toxin market made US$3.19 billion. [ 122 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7181", "text": "Botox cost is generally determined by the number of units administered (avg. $10\u201330 per unit) or by the area ($200\u20131000) and depends on expertise of a physician, clinic location, number of units, and treatment complexity. [ 123 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7182", "text": "In the US, botox for medical purposes is usually covered by insurance if deemed medically necessary by a doctor and covers a plethora of medical problems including overactive bladder (OAB), urinary incontinence due to neurologic conditions, headaches and migraines, TMJ, spasticity in adults, cervical dystonia in adults, severe axillary hyperhidrosis (or other areas of the body), blepharospasm, upper or lower limb spasticity. [ 124 ] [ 125 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7183", "text": "Botox for excessive sweating is FDA approved. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7184", "text": "Standard areas for aesthetics botox injections include facial and other areas that can form fine lines and wrinkles due to every day muscle contractions and/or facial expressions such as smiling, frowning, squinting, and raising eyebrows. These areas include the glabellar region between the eyebrows, horizontal lines on the forehead, crow's feet around the eyes, and even circular bands that form around the neck secondary to platysmal hyperactivity. [ 126 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7185", "text": "Botulinum toxin has been recognized as a potential agent for use in  bioterrorism . [ 127 ]  It can be absorbed through the eyes, mucous membranes, respiratory tract, and non-intact skin. [ 128 ] \nThe effects of botulinum toxin are different from those of nerve agents involved insofar in that botulism symptoms develop relatively slowly (over several days), while nerve agent effects are generally much more rapid. Evidence suggests that nerve exposure (simulated by injection of  atropine  and  pralidoxime ) will increase mortality by enhancing botulinum toxin's mechanism of toxicity. [ 129 ] \nWith regard to detection, protocols using  NBC  detection equipment (such as M-8 paper or the ICAM) will not indicate a \"positive\" when samples containing botulinum toxin are tested. [ 130 ]  To confirm a diagnosis of botulinum toxin poisoning, therapeutically or to provide evidence in death investigations, botulinum toxin may be quantitated by immunoassay of human biological fluids; serum levels of 12\u201324 mouse LD 50  units per milliliter have been detected in poisoned people. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7186", "text": "During the early 1980s, German and French newspapers reported that the police had raided a  Baader-Meinhof  gang safe house in Paris and had found a makeshift laboratory that contained flasks full of  Clostridium botulinum , which makes botulinum toxin. Their reports were later found to be incorrect; no such lab was ever found. [ 132 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7187", "text": "Commercial forms are marketed under the brand names Botox (onabotulinumtoxinA), [ 19 ] [ 83 ] [ 133 ]  Dysport/Azzalure (abobotulinumtoxinA), [ 83 ] [ 134 ]  Letybo (letibotulinumtoxinA), [ 1 ] [ 2 ] [ 135 ]  Myobloc (rimabotulinumtoxinB), [ 21 ] [ 83 ]  Xeomin/Bocouture (incobotulinumtoxinA), [ 136 ]  and Jeuveau (prabotulinumtoxinA). [ 137 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7188", "text": "Botulinum toxin A is sold under the brand names Jeuveau, Botox, and Xeomin. Botulinum toxin B is sold under the brand name Myobloc. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7189", "text": "In the United States, botulinum toxin products are manufactured by a variety of companies, for both therapeutic and cosmetic use. A US supplier reported in its company materials in 2011 that it could \"supply the world's requirements for 25  indications  approved by Government agencies around the world\" with less than one gram of raw botulinum toxin. [ 138 ]  Myobloc or Neurobloc, a botulinum toxin type B product, is produced by Solstice Neurosciences, a subsidiary of US WorldMeds. AbobotulinumtoxinA), a therapeutic formulation of the type A toxin manufactured by  Galderma  in the United Kingdom, is licensed for the treatment of focal dystonias and certain cosmetic uses in the US and other countries. [ 84 ]  LetibotulinumtoxinA (Letybo) was approved for medical use in the United States in February 2024. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7190", "text": "Besides the three primary US manufacturers, numerous other botulinum toxin producers are known. Xeomin, manufactured in Germany by  Merz , is also available for both therapeutic and cosmetic use in the US. [ 139 ]  Lanzhou Institute of Biological Products in China manufactures a botulinum toxin type-A product; as of 2014, it was the only botulinum toxin type-A approved in China. [ 139 ]  Botulinum toxin type-A is also sold as Lantox and Prosigne on the global market. [ 140 ]  Neuronox, a botulinum toxin type-A product, was introduced by Medy-Tox of South Korea in 2009. [ 141 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7191", "text": "Botulism toxins are produced by bacteria of the genus  Clostridium,  namely  C.\u00a0botulinum ,  C.\u00a0butyricum ,  C.\u00a0baratii  and  C.\u00a0argentinense , [ 142 ]  which are widely distributed, including in soil and dust. Also, the bacteria can be found inside homes on floors, carpet, and countertops even after cleaning. [ 143 ]  Complicating the problem is that the taxonomy for  C.\u00a0botulinum  remains chaotic. The toxin has likely been  horizontally transferred  across lineages, contributing to the multi-species pattern seen today. [ 144 ] [ 145 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7192", "text": "Food-borne botulism results, indirectly, from ingestion of food contaminated with  Clostridium  spores, where exposure to an  anaerobic environment  allows the spores to germinate, after which the bacteria can multiply and produce toxin. [ 143 ]  Critically, ingestion of toxin rather than spores or vegetative bacteria causes  botulism . [ 143 ]  Botulism is nevertheless known to be transmitted through canned foods not cooked correctly before canning or after can opening, so is preventable. [ 143 ]  Infant botulism arising from consumption of honey or any other food that can carry these spores can be prevented by eliminating these foods from diets of children less than 12 months old. [ 146 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7193", "text": "Proper refrigeration at temperatures below 4.4\u00a0\u00b0C (39.9\u00a0\u00b0F) slows the growth of  C.\u00a0botulinum . [ 147 ]  The organism is also susceptible to high salt, high oxygen, and low pH levels. [ 35 ] [ failed verification ]  The toxin itself is rapidly destroyed by heat, such as in thorough cooking. [ 148 ]  The spores that produce the toxin are heat-tolerant and will survive boiling water for an extended period of time. [ 149 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7194", "text": "The botulinum toxin is  denatured  and thus deactivated at temperatures greater than 85\u00a0\u00b0C (185\u00a0\u00b0F) for five minutes. [ 35 ]  As a zinc  metalloprotease  (see below), the toxin's activity is also susceptible, post-exposure, to  inhibition  by  protease inhibitors , e.g., zinc-coordinating  hydroxamates . [ 93 ] [ 150 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7195", "text": "University-based ophthalmologists in the US and Canada further refined the use of botulinum toxin as a therapeutic agent. By 1985, a scientific protocol of injection sites and dosage had been empirically determined for treatment of  blepharospasm  and strabismus. [ 151 ]  Side effects in treatment of this condition were deemed to be rare, mild and treatable. [ 152 ]  The beneficial effects of the injection lasted only four to six months. Thus, blepharospasm patients required re-injection two or three times a year. [ 153 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7196", "text": "In 1986, Scott's micromanufacturer and distributor of Botox was no longer able to supply the drug because of an inability to obtain product liability insurance. People became desperate, as supplies of Botox were gradually consumed, forcing him to abandon people who would have been due for their next injection. For a period of four months, American blepharospasm patients had to arrange to have their injections performed by participating doctors at Canadian eye centers until the liability issues could be resolved. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7197", "text": "In December 1989, Botox was approved by the US FDA for the treatment of strabismus, blepharospasm, and  hemifacial spasm  in people over 12 years old. [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7198", "text": "In the case of treatment of  infantile esotropia  in people younger than 12 years of age, several studies have yielded differing results. [ 57 ] [ 154 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7199", "text": "The effect of botulinum toxin type-A on reducing and eliminating forehead wrinkles was first described and published by Richard Clark, MD, a plastic surgeon from Sacramento, California. In 1987 Clark was challenged with eliminating the disfigurement caused by only the right side of the forehead muscles functioning after the left side of the forehead was paralyzed during a facelift procedure. This patient had desired to look better from her facelift, but was experiencing bizarre unilateral right forehead eyebrow elevation while the left eyebrow drooped and she emoted with deep expressive right forehead wrinkles while the left side was perfectly smooth due to the paralysis. Clark was aware that botulinum toxin was safely being used to treat babies with strabismus and he requested and was granted FDA approval to experiment with botulinum toxin to paralyze the moving and wrinkling normal functioning right forehead muscles to make both sides of the forehead appear the same. This study and case report on the cosmetic use of botulinum toxin to treat a cosmetic complication of a cosmetic surgery was the first report on the specific treatment of wrinkles and was published in the journal  Plastic and Reconstructive Surgery  in 1989. [ 112 ]  Editors of the journal of the American Society of Plastic Surgeons have clearly stated \"the first described use of the toxin in aesthetic circumstances was by Clark and Berris in 1989.\" [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7200", "text": "J. D. and J. A. Carruthers also studied and reported in 1992 the use of botulinum toxin type-A as a cosmetic treatment.[78] They conducted a study of participants whose only concern was their glabellar forehead wrinkle or furrow. Study participants were otherwise normal. Sixteen of seventeen participants available for follow-up demonstrated a cosmetic improvement. This study was reported at a meeting in 1991. The study for the treatment of  glabellar  frown lines was published in 1992. [ 115 ]  This result was subsequently confirmed by other groups (Brin, and the Columbia University group under Monte Keen [ 155 ] ). The FDA announced regulatory approval of botulinum toxin type A (Botox Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines) in 2002 after extensive clinical trials. [ 156 ]  Well before this, the cosmetic use of botulinum toxin type A became widespread. [ 157 ]  The results of Botox Cosmetic can last up to four months and may vary with each patient. [ 158 ]  The US  Food and Drug Administration  (FDA) approved an alternative product-safety testing method in response to increasing public concern that  LD50  testing was required for each batch sold in the market. [ 159 ] [ 160 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7201", "text": "Botulinum toxin type-A has also been used in the treatment of  gummy  smiles; [ 161 ]  the material is injected into the hyperactive muscles of upper lip, which causes a reduction in the upward movement of lip thus resulting in a smile with a less exposure of  gingiva . [ 162 ]  Botox is usually injected in the three lip elevator muscles that converge on the lateral side of the ala of the nose; the  levator labii superioris  (LLS), the  levator labii superioris alaeque nasi muscle  (LLSAN), and the  zygomaticus minor  (ZMi). [ 163 ] [ 164 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7202", "text": "Botulinum toxin type-A is now a common treatment for muscles affected by the  upper motor neuron  syndrome (UMNS), such as  cerebral palsy , [ 32 ]  for muscles with an impaired ability to effectively  lengthen . Muscles affected by UMNS frequently are limited by  weakness , loss of  reciprocal inhibition , decreased movement control, and hypertonicity (including  spasticity ). In January 2014, Botulinum toxin was approved by UK's  Medicines and Healthcare products Regulatory Agency  (MHRA) for the treatment of ankle disability due to lower limb spasticity associated with stroke in adults. [ 51 ]  Joint motion may be restricted by severe muscle imbalance related to the syndrome, when some muscles are markedly hypertonic, and lack effective active lengthening. Injecting an overactive muscle to decrease its level of contraction can allow improved reciprocal motion, so improved ability to move and exercise. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7203", "text": "Sialorrhea  is a condition where oral secretions are unable to be eliminated, causing pooling of saliva in the mouth. This condition can be caused by various neurological syndromes such as  Bell's palsy , intellectual disability, and cerebral palsy. Injection of botulinum toxin type-A into salivary glands is useful in reducing the secretions. [ 165 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7204", "text": "Botulinum toxin type-A is used to treat  cervical dystonia , but it can become ineffective after a time. Botulinum toxin type B received FDA approval for treatment of cervical  dystonia  in December 2000. Brand names for botulinum toxin type-B include Myobloc in the United States and Neurobloc in the European Union. [ 139 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7205", "text": "Onabotulinumtoxin A (trade name Botox) received FDA approval for treatment of chronic  migraines  on 15 October 2010. The toxin is injected into the head and neck to treat these chronic headaches. Approval followed evidence presented to the agency from two studies funded by Allergan showing a very slight improvement in incidence of chronic migraines for those with migraines undergoing the Botox treatment. [ 166 ] [ 167 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7206", "text": "Since then, several randomized control trials have shown botulinum toxin type A to improve headache symptoms and quality of life when used prophylactically for participants with chronic  migraine [ 168 ]  who exhibit headache characteristics consistent with: pressure perceived from outside source, shorter total duration of chronic migraines (<30 years), \"detoxification\" of participants with coexisting chronic daily headache due to medication overuse, and no current history of other preventive headache medications. [ 169 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7207", "text": "A few small trials have found benefits in people with  depression . [ 170 ] [ 171 ] [ 172 ]  A 2021 meta-analysis supports the usefulness of botox in unipolar depression, but finds significant heterogenity among the findings. [ 173 ]  The main hypothesis for its action is based on the  facial feedback hypothesis . [ 174 ]  Another hypothesis involves a connection between the facial muscle and specific brain regions in animals, but additional evidence is required to support or disprove this theory. [ 172 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7208", "text": "The drug for the treatment of  premature ejaculation  has been under development since August 2013, and is in  Phase II  trials. [ 171 ] [ 175 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7209", "text": "A  brachioplasty , commonly called an  arm lift , is a  surgical procedure  to reshape and provide improved contour to the upper arms and connecting area of chest wall. [ 1 ]  Although \"brachioplasty\" is commonly used to describe a specific procedure for the upper arms, the term can also be used to describe any surgical arm contouring. Brachioplasty is often used to address issues such as excessive loose skin or excessive fat in the arms when it does not respond well to diet and exercise. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7210", "text": "The least-invasive manner to contour the upper arms is to simply remove extra fat via  liposuction . However, traditional deep liposuction often leaves sagging and wrinkled skin. An alternative to this is Circumferential para-Axillary Superficial Tumescent (CAST) liposuction, which maximizes the skin retraction. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7211", "text": "Under the right conditions such as adequate skin elasticity and minimal excess skin, the surgical incision for the brachioplasty can be placed under the arm. This allows for easy concealment of the scar. Minimal incision brachioplasty includes lipoplasty of the upper arm, wide-axillary and upper-arm skin excision, and dermal suspension of the upper-arm skin to the axillary fascia. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7212", "text": "The typical brachioplasty involves removing excessive loose skin via  surgical excision , leaving a significant scar along the bottom of the upper arms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7213", "text": "If there is also a significant amount of loose skin that goes from the upper arms and continues along the chest wall, an extended brachioplasty may be called for. In an extended brachioplasty, the incision and excision of skin continues along the upper arm onto the area under the arm along the chest wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7214", "text": "This method is used for patients with an enormous amount of soft tissue excess. Fish-incision brachioplasty uses mathematical measurements and anatomic marking that allows the preoperative marking of the incision in the shape of a fish. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7215", "text": "This technique is used to decrease the post- operative seroma formation and nerve injury. In this method liposuction is done for the arm with excessive liposuction under the area of excision to make it paper thin. Only the skin over the marked area is excised followed by invagination of the tissue and closure with dermal to dermal sutures and skin edge closure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7216", "text": "In this procedure anchoring of the arm flap to the  axillary fascia  is secured along with strong superficial fascial system repair of incisions. This method reduces the risk of widening or migration of scars and unnatural contours. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7217", "text": "This technique uses a mold to mark the incision in an italic double S-shape for better incision control, symmetrical and smaller scars. This method has often been used in association with other brachioplasty procedures. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7218", "text": "Some of the possible complications associated with brachioplasty include: [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7219", "text": "Buccal fat pad extraction  or  buccal fat removal  is a  plastic surgery  procedure that removes a piece of   buccal fat-pad  tissue from each side of the face. This reduces the appearance of cheek puffiness, creating a sharper jawline. The amount of fat removed varies based on the desired facial shape. [ 1 ]  It is a strictly cosmetic surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7220", "text": "The  buccal fat pad  was first described by  Lorenz Heister  in 1732 as a glandular tissue. In 1802,  Xavier Bichat  correctly defined the structure as fat tissue and popularized awareness of it. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7221", "text": "In 2021,  Chrissy Teigen  revealed that she had undergone buccal fat removal. The following year,  The New York Times  reported that the procedure was gaining popularity due to discussion on  Twitter  and  TikTok , and quoted a plastic surgeon who called it \"one of the classic celebrity secret plastic surgeries\". [ 2 ]  Speculation about celebrity buccal fat removal became a popular subject online, with people such as  Bella Hadid , [ 5 ]   Lea Michele  and  Khloe Kardashian [ 6 ]  guessed to have undergone it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7222", "text": "The  American Society of Plastic Surgeons  did not collect statistics on buccal fat removal until 2022. That year, they recorded 4,543 such procedures performed by their surgeons, making it the least popular facial technique that they recorded statistics for. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7223", "text": "Buccal fat removal is a cosmetic procedure with no medical benefit, and thus rarely covered by insurance. It is typically performed by plastic surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7224", "text": "According to  RealSelf , the average cost in 2023 was $4,097, but could go as low as $1,000. [ 8 ]  Interviewed by  The New York Times  in 2022, one plastic surgeon stated he charged $40,000 for the procedure, while others said they typically charged between $7,000 and $16,000. The  Times  also described a  medical tourist  who got the procedure for $600 in  Tijuana  2020. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7225", "text": "Buccal fat removal is often performed as a solo procedure but can be done alongside a facelift, chin implant,  neck lift  or any other surgery attempting to add definition to the face. It is also often done in combination with chin liposuction and fat grafting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7226", "text": "The reduction of buccal fat pad is usually performed under local anesthesia with the patient completely awake. The typical approach for removing the buccal fat pad is through an incision in the mouth, towards the back of the oral cavity, near the second upper  molar . The  buccinator muscle  is then encountered and without making an incision, the fibers are separated until the buccal fat is seen. Once the buccal fat is visualized, a thin casing over the fat is opened and the fat is gently teased out while gentle pressure is applied externally. The fat is then cauterized at the base and removed. The remainder of the buccal fat pad then is replaced to its anatomic site and the oral mucosa is sutured close, and the two incisions are  sutured . The procedure typically takes about 30 minutes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7227", "text": "Patients typically have swelling for a few days, but often this swelling is not visible externally. Typically, self absorbing sutures that dissolve on their own are used. The final results can take up to 3 months to manifest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7228", "text": "Injury to the buccal branch of the  facial nerve  is a risk.  The buccal branch nerves that might be affected control facial functions, therefore, such damage might result in partial facial paralysis, regional facial numbness, loss of  taste , et cetera. Likewise, damage to the  parotid duct  also might occur in men and women whose  parotid ducts  run deep to the buccal fat pad, which can lead to a salivary fistula or buildup of saliva. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7229", "text": "Buccal fat removal is permanent; the fat pads do not grow back. However, new techniques for restoring buccal fat such as injecting fat intra-orally back into the buccal space or applying a dermal fat graft are gaining popularity. Other options include mimicry with  injectable fillers . [ 1 ]  There is a lack of research on its long-term health effects. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7230", "text": "In an aesthetic sense, buccal fat removal may cause an excessively gaunt appearance when the cheeks naturally lose more volume with age. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7231", "text": "The surgery and discussion of it became a trend in the early 2020s, gaining the colloquial nickname \"Handsome Squidward surgery\", referencing an exaggeratedly chiseled face from the  SpongeBob SquarePants  episode  \"The Two Faces of Squidward\" . [ 12 ] [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7232", "text": "Capsular contracture  is a response of the  immune system  to foreign materials in the human body. Medically, it occurs mostly in context of the  complications  from  breast implants  and  artificial joint  prosthetics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7233", "text": "The occurrence of capsular contraction follows the formation of capsules of tightly woven  collagen  fibers, created by the  immune response  to the presence of foreign objects surgically installed to the human body, e.g. breast implants,  artificial pacemakers ,  orthopedic prostheses ; biological protection by isolation and toleration. Capsular contracture occurs when the collagen-fiber capsule shrinks, tightens and compresses the breast implant, much like the collapse of a bubble gum bubble. [ 1 ]  It is a medical complication that can be painful and discomforting, and might distort the aesthetics of the breast implant and the breast. Although the cause of capsular contracture is unknown, factors common to its incidence include bacterial contamination, rupture of the breast-implant shell, leakage of the silicone-gel filling, and  hematoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7234", "text": "Moreover, because capsular contracture is a consequence of the immune system defending the patient's bodily integrity and health, it might recur, even after the requisite corrective surgery for the initial incidence. The degree of an incidence of capsular contracture is graded using the four-grade Baker scale:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7235", "text": "The surgical implantation methods that have reduced capsular contracture include submuscular breast implant placement, using either textured or polyurethane-coated implants, [ 2 ] [ 3 ] [ 4 ]  limited handling of the implants, minimal contact with the chest wall skin before their insertions, and irrigating the surgical sites with triple-antibiotic solutions. [ 5 ] [ 6 ]  The use of macrotextured implants and polyurethene-coated implants may increase the risk of  BIA-ALCL , a rare form of lymphoma associated to the presence of breast implants. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7236", "text": "The correction of capsular contracture might require the surgical removal (release) of the capsule, or the removal, and possible replacement, of the breast implant, itself. Closed capsulotomy (disrupting the capsule via external manipulation), a once-common maneuver for treating hard capsules, was discontinued because it might rupture the breast implant. Non-surgical methods of treating capsules include massage, external  ultrasound , [ 9 ]  treatment with  leukotriene  pathway inhibitors (e.g.  Accolate ,  Singulair ), [ 10 ] [ 11 ]  and pulsed electromagnetic field therapy. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7237", "text": "The  Mentor Worldwide LLC  corporation, one of the three, U.S. FDA-approved breast-implant device manufacturers, conducted a study of the  medical complications  suffered by breast implantation surgery patients. In March 2000, at a Food and Drug Administration presentation, the Mentor report indicated that 43 per cent of patients with saline breast implants reported medical complications occurring within three years of the surgery; moreover, 10 per cent of that percentage group complained of capsular contracture. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7238", "text": "Cheiloplasty  or surgical lip restoration (from   Greek :  \u03c7\u03b5\u03af\u03bb\u03bf\u03c2   kheilos  \u2013 \"lip\") is the technical term for surgery of the  lip  usually performed by a  plastic surgeon  or  oral and maxillofacial surgeon . Among other procedures it includes lip reduction, the process of surgically reducing the size of the lip or lips to reduce the appearance of abnormally large or protruding lips, as well as the process of forming an artificial tip or part of the lips by using a piece of healthy  tissue  from some neighboring part. The procedure can also larger."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7239", "text": "Cheiloplasty  can be performed to treat  tight lip syndrome  in  Shar Pei  dogs by repositioning the lower lip and allowing it to heal in a normal position. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7240", "text": "Chin augmentation  using  surgical implants  alter the underlying structure of the  face , intended to balance the facial features. The specific medical terms  mentoplasty  and  genioplasty  are used to refer to the reduction and addition of material to a patient's  chin . This can take the form of chin height reduction or chin rounding by  osteotomy , or chin augmentation using implants. Altering the facial balance is commonly performed by modifying the chin using an implant inserted through the mouth. The intent is to provide a suitable projection of the chin as well as the correct height of the chin which is in balance with the other facial features. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7241", "text": "This operation is often, but not always, performed at the time of  rhinoplasty  to help balance the facial proportions.  Chin augmentation may be achieved by manipulation of the jaw bone (mandible) and augmentation utilizing this technique usually provides a more dramatic correction than with the use of prosthetic implants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7242", "text": "Chin implants are used in the cosmetic industry to alter one's profile [ 2 ]  to resolve confidence and self-esteem issues by the physical augmentation of an individual's jawline and neck. [ 3 ]  Patients' own bone is donated from ribs and from part of the pelvis (the ilium). Use of donated bone implants in chin augmentation, even the patient's own, appears to be associated with a higher rate of  infection , even after the implant has been in place for decades."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7243", "text": "Chin augmentation is still popular because it is a relatively easy operation for the patient while producing noticeable changes in the  silhouette  of the face. This type of surgery is usually performed by an oral and maxillofacial surgeon, otolaryngologist, or plastic surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7244", "text": "T-osteotomy method (or mini V-line) [ 4 ]  is used to narrow and lengthen the chin using an osteotomy technique formulated by Korean surgeons. The surgery is performed under general anesthesia (orotracheal intubation) using an intraoral approach. [ 5 ]  Using a double-bladed reciprocating saw, [ 6 ]  a horizontal osteotomy is performed, leaving a small portion of bone in the middle. Then two vertical osteotomies are performed in an upside-down trapezoidal shape which is excised. The bones remaining from the horizontal osteotomy are then attached and adjusted to lengthen the chin, and advanced forward for an additional frontal chin projection if required. [ 5 ]  Pre-bent titanium plates and screws are used to fixate the bone to its new position. [ 6 ]  The chin can be lengthened 2 to 3\u00a0mm on average. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7245", "text": "The mentalis muscles controls the elevation functions of the lower lip and chin, so extra caution should be taken to carefully attach the mentalis muscle back after the surgery. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7246", "text": "The usual complications are relatively minor and include swelling,  hematoma  (blood pooling), weakness or numbness of the lower lip, which usually does not last long. Other, less common risks include infection, bony changes, displacement of the implant, and nerve damage. [ 10 ]  Surgeon experience can help reduce risks of complications. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7247", "text": "Chewing should be kept at a minimum immediately after this procedure, and patients are recommended to eat only soft food and drink for a time after the surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7248", "text": "Silicone  -  Silicone  chin Implants are one of the most commonly used implants for chin augmentation. They are soft, smooth, flexible and come in different shapes and sizes. They do not incorporate (stick) to the surrounding tissues, so the pocket must be made precisely. They usually stay in place, but may move, buckle and cause bone resorption where they contact the mandible in some cases. Since they are smooth, they can also be removed easily."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7249", "text": "Polyethylene  -  Polyethylene  chin implants, brand name Medpor, are hard, porous, slightly flexible and come in various shapes and sizes. They do incorporate, as the surrounding tissues can grow into the pores of the material. This fixes the polyethylene chin implants in place, and provides a blood supply to help prevent infection. It also makes these implants much more difficult to remove."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7250", "text": "Polytetrafluoroethylene  - Polytetrafluoroethylene, brand name  Gore-Tex , is used in plastic surgery and other operations is known by an abbreviation of its chemical name,  ePTFE  (expanded  polytetrafluoroethylene ) or Gore S.A.M. (subcutaneous augmentation material). [ 12 ]  Because ePTFE is flexible and soft but very strong, it is inserted during operations in trimmed sheets and carved blocks and held to the bone by  titanium  screws. But because the material is  porous , the force that really holds the implant in place is soft tissue and bone growing through and into the implant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7251", "text": "The above artificial materials are used in medicine because they are  biocompatible  and have a low incidence of causing problems inside the human body. They are abundant, FDA cleared and can be used \"off-the-shelf\", without a donor site injury to the recipient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7252", "text": "Acellular dermal matrix  - ADMs are another chin augmentation implant material. Commercially known as AlloDerm and known to physicians as acellular human cadaveric dermis, AlloDerm comes from tissue donors Just after death, technicians remove a layer of skin, remove the epidermis, and treat the remaining dermis with  antibiotics  and other substances to remove the donor's cells and  DNA  that would cause rejection. The  graft  that emerges is often used to cover chin implants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7253", "text": "Other implant materials include Supramid, a braided nonabsorbable synthetic suture material in polymer shell and Mersiline, a mesh-like material that provides a scaffold on the bone. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7254", "text": "Surgical chin augmentation  - The most common type of surgical chin augmentation uses a chin implant. There are many types of chin implants, and many are described in the previous section. Chin augmentation with a chin implant is usually a cosmetic procedure. An incision is made either under the chin or inside the  lower lip, a pocket is made and the implant placed into the pocket. Some chin implants are fixed to the mandible, while others are held in place by the pocket itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7255", "text": "Another surgical chin augmentation uses the lower prominence of the mandible as the \"implant.\" Known as a sliding genioplasty, the procedure involves cutting a horseshoe-shaped piece of bone from the lower border of the mandible known as an osteotomy. For chin augmentation, the piece of bone is advanced forward to increase to projection of the chin. The piece can also be recessed backward for a chin reduction. The new position is held in place with a titanium step plate using titanium screws. The bone segment can also be fixated with 26 or 27 gauge wires and IMF (wiring the jaw shut) for 3-4weeks. This type of surgery is usually performed by an  oral and maxillofacial surgeon  or a  plastic surgeon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7256", "text": "More involved Orthognathic Surgery may be required in cases where the chin is small and a significant overbite co-exist. While the procedures above may improve the cosmetic appearance of the chin, they will not improve dental occlusion.  Mandibular advancement surgery  can be used to correct the alignment of the teeth and improve the projection of the chin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7257", "text": "Non-surgical chin augmentation  - Another method of chin augmentation uses an injectable filler. Most fillers are temporary, with results lasting months to years. Common temporary fillers include  hyaluronic acid  and  calcium hydroxyapatite  preparations. Permanent fillers, like \"free\"   silicone , have fallen out of favor due to the risk of migration, chronic inflammation and infection, which can permanently disfigure the chin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7258", "text": "Clitoral hood reduction , also termed  clitoral hoodectomy , [ 1 ]   clitoral unhooding ,  clitoridotomy , [ 2 ] [ 3 ]  or (partial)  hoodectomy , is a  plastic surgery  procedure (a form of  vulvoplasty ) for reducing the size and the area of the  clitoral hood  in order to further expose the  glans  of the  clitoris ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7259", "text": "It is usually performed as an elective cosmetic surgery meant to improve sexual satisfaction and to change the aesthetic appearance of the  vulva . The reduction of the clitoral hood usually is done together with a  labiaplasty  that reduces the  labia minora , and occasionally within a  vaginoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7260", "text": "Though patient surveys have indicated satisfaction with the outcome of such procedures, the  American College of Obstetricians and Gynecologists  cautioned in 2007 that for this type of vaginal surgeries, which are not medically indicated, women should be informed about the lack of data on their efficacy and potential complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7261", "text": "The procedures for labiaplasty occasionally include a clitoral hood reduction. [ 5 ]  One technique for reducing the clitoral hood is the bilateral excision (cutting) of the prepuce tissues covering the clitoral glans, with especial attention to maintaining the glans in the midline. [ 6 ]  Another technique cuts away (excises) the redundant folds of clitoral prepuce tissue, with incisions parallel to the long axis of the clitoris. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7262", "text": "Clitoral hood reduction can be included in the extended wedge resection labiaplasty technique, wherein the extension of the exterior wedge sections is applied to reducing the prepuce tissues of the clitoral glans. Yet, occasionally excess prepuce-skin, in the center of the clitoral hood, is removed with separate incisions. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7263", "text": "Studies have reported a high rate of patient satisfaction with the aesthetic changes to the  vulvo-vaginal complex  after labioplasty, and a low incidence rate of medical complications. [ 6 ] [ 8 ] [ 9 ] [ 5 ]  The study  Aesthetic Labia Minora and Clitoral Hood Reduction using Extended Central Wedge Resection  (2008) reported that of a 407-woman cohort, 98 per cent were satisfied with the labial reduction outcomes; that the average patient satisfaction score was 9.2 points on a 10-point scale; that 95 per cent of the women experienced reduced pudendal discomfort; that 93 per cent of the women experienced improved  self esteem ; that 71 per cent experienced improved sexual functioning; that 0.6 per cent (one woman) reported lessened sexual functioning; and that 4.4 per cent of the women experienced medical complications. [ 8 ]  The study  Expectations and Experience of Labial Reduction: A Qualitative Study  (2007) reported that the women who underwent labiaplasty had great expectations for the elimination of pubic discomfort and pain, improved cosmetic appearance of the  vulva , and improved sexual functioning. Most of the women experienced improved  self esteem ; yet the study also reported that formal psychological counselling before the surgical operation about what to expect and what not to expect from a labia minora and clitoral prepuce reduction procedure might better serve the prospective patient by assisting her in establishing realistic expectations for her genital beauty and mental health after such a procedure. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7264", "text": "Partial or total hoodectomy is classified by the  World Health Organization  as  female genital mutilation  (FGM) Type 1A. [ 12 ]  However, this classification is criticised as being \"overly-simplified\" and \"culturally insensitive\" by some. They argue that hoodectomy is no different than male  circumcision , which is  legally permitted in most countries , and is often less invasive in practice. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7265", "text": "The  American College of Obstetricians and Gynecologists  (ACOG) published  Committee Opinion No. 378: Vaginal \"Rejuvenation\" and Cosmetic Vaginal Procedures  (2007), the college's formal policy statement of opposition to the  commercial misrepresentations  of labiaplasty, and associated vaginoplastic procedures, as medically \"accepted and routine surgical practices\". The ACOG doubts the medical safety and the therapeutic efficacy of the surgical techniques and procedures for performing vaginoplastic operations such as labiaplasty,  vaginal rejuvenation , the designer vagina, revirgination, and  G-spot amplification , and recommends that women seeking such genitoplastic surgeries must be fully informed, with the available surgical-safety statistics, of the potential health risks of surgical-wound  infection , of  pudendal nerve  damage (resulting in either an insensitive or an over-sensitive vulva), of  dyspareunia  (painful coitus), of tissue adhesions ( epidermoid cysts ), and of painful scars. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7266", "text": "The dorsal nerves of the clitoris travel above the clitoris along the clitoral body. Permanent injury to these nerves can occur with clitoral hood reductions. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7267", "text": "Clitoridectomy  or  clitorectomy  is the  surgical  removal, reduction, or partial removal of the  clitoris . [ 1 ]  It is rarely used as a therapeutic medical procedure, such as when  cancer  has developed in or spread to the clitoris. Commonly, non-medical removal of the clitoris is performed during  female genital mutilation . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7268", "text": "A clitoridectomy is often done to remove  malignancy  or  necrosis  of the clitoris. This is sometimes done along with a radical complete  vulvectomy . Surgery may also become necessary due to therapeutic  radiation treatments  to the pelvic area. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7269", "text": "Removal of the clitoris may be due to malignancy or trauma. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7270", "text": "Female infants born with a  46,XX  genotype but have a clitoris size affected by  congenital adrenal hyperplasia  and are treated surgically with  vaginoplasty  that often reduces the size of the clitoris without its total removal. The atypical size of the clitoris is due to an endocrine imbalance in utero. [ 1 ] [ 5 ]  Other reasons for the surgery include issues involving  microphallism  and those who have  M\u00fcllerian agenesis . Treatments on children raise human rights concerns. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7271", "text": "Clitoridectomy surgical techniques are used to remove an invasive malignancy that extends to the clitoris. Standard surgical procedures are followed in these cases. This includes evaluation and  biopsy . Other factors that will affect the technique selected are age, other existing medical conditions, and obesity. Other considerations are the probability of extended hospital care and the development of infection at the surgical site. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7272", "text": "The surgery proceeds with the use of  general anesthesia , and prior to the vulvectomy/clitoridectomy an inguinal  lymphadenectomy  is first done. The extent of the surgical site extends 1 to 2\u00a0cm (0.39 to 0.79\u00a0in) beyond the boundaries of malignancy. Superficial  lymph nodes  may also need to be removed. If the malignancy is present in any  muscles  in the region, then the affected muscle tissue is also removed. In some cases, the surgeon is able to preserve the clitoris despite extensive malignancy. The cancerous tissue is removed and the incision is closed. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7273", "text": "Post-operative care may employ the use of suction drainage to allow the deeper tissues to heal toward the surface. Follow-up after surgery includes the stripping of the drainage device to prevent blockage. A typical hospital stay can last up to two weeks. The site of the surgery is left unbandaged to allow for frequent examination. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7274", "text": "Complications can include the development of  lymphedema ; not removing the saphenous vein during the surgery can help prevent this. In some instances, the buildup of fluid can be reduced through methods such as foot elevation,  diuretic  medication, and wearing  compression stockings . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7275", "text": "In a clitoridectomy for infants with a  clitoromegaly , the clitoris is often reduced instead of removed. The surgeon cuts the shaft of the elongated phallus and sews the  glans  and preserved nerves back onto the stump. In a less common surgery called clitoral recession, the surgeon hides the clitoral shaft under a fold of skin so only the glans remains visible. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7276", "text": "While much  feminist  scholarship has described clitoridectomy as a practice aimed at controlling women's sexuality, the historic emergence of the practice in ancient European and Middle Eastern cultures may also have derived from ideas about what a normal female genitalia should look like and the policing of boundaries between the sexes. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7277", "text": "In the seventeenth century, anatomists remained divided on whether a clitoris was a normal female organ, with some arguing that it was an abnormality in female development and, if large enough to be visible, it should always be removed at birth. [ 9 ]  In the 19th century, a clitoridectomy was thought by some to curb  female masturbation ; until the late 19th century, masturbation  was thought by many  to be unhealthy or immoral. [ 10 ]   Isaac Baker Brown  (1812\u20131873), an English gynaecologist who was president of the  Medical Society of London   believed that the \"unnatural irritation\" of the clitoris caused  epilepsy ,  hysteria , and  mania , and he worked \"to remove [it] whenever he had the opportunity of doing so\", according to his obituary in the  Medical Times and Gazette .  Peter Lewis Allen  writes that Brown's views caused outrage, and he died penniless after being expelled from the  Obstetrical Society . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7278", "text": "Occasionally, in American and English medicine of the nineteenth century,  circumcision  was done as a cure for insanity. Some believed that  mental and emotional disorders  were related to female reproductive organs and that removing the clitoris would cure the neurosis. This treatment was discontinued in 1867. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7279", "text": "Aesthetics  may determine clitoral norms. A lack of ambiguity of the genitalia is seen as necessary in the  assignment of a sex  to infants and therefore whether a child's genitalia is normal, but what is considered ambiguous or normal can vary from person to person. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7280", "text": "Sexual behavior is another reason for clitoridectomies. Author Sarah Rodriguez stated that the history of medical textbooks has indirectly created accepted ideas about the female body. Medical and gynecological textbooks are also at fault in the way that the clitoris is described in comparison to a male's  penis . The importance and originality of a female's clitoris is underscored because it is seen as \"a less significant organ, since anatomy texts compared the penis and the clitoris in only one direction.\" Rodriguez said that a male's penis created the framework of the sexual organ. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7281", "text": "Not all historical examples of clitoral surgeries should be assumed to be clitoridectomy (removal of the clitoris). In the nineteen thirties, the French psychoanalyst  Marie Bonaparte  studied African clitoral surgical practices and showed that these often involved removal of the clitoral hood, not the clitoris. She also had a surgery done to her own clitoris by the Viennese surgeon Dr Halban, which entailed cutting the  suspensory ligament of the clitoris  to permit it to sit closer to her vaginal opening. These sorts of clitoral surgeries, contrary to reducing women's sexual pleasure, actually appear aimed at making coitus more pleasurable for women, though it is unclear if that is ever their actual outcome. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7282", "text": "Clitoridectomies are the most common form of female genital mutilation. The  World Health Organization  (WHO) estimates that clitoridectomies have been performed on 200 million girls and women that are currently alive. The regions that most clitoridectomies take place are Asia, the Middle East and west, north and east Africa. The practice also exists in migrants originating from these regions. Most of the surgeries are for cultural or religious reasons. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7283", "text": "Clitoridectomy of people with conditions such as  congenital adrenal hyperplasia  that cause a clitoromegaly is controversial when it takes place during childhood or under duress. Many women who were exposed to such treatment have reported loss of physical sensation in the affected area, and loss of  autonomy . [ 17 ] [ 18 ]  In recent years, multiple human rights institutions have criticized early surgical management of such characteristics. [ 19 ] [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7284", "text": "In 2013, it was disclosed in a medical journal that four unnamed elite female athletes from developing countries were subjected to gonadectomies and partial clitoridectomies after  testosterone testing  revealed that they had an  intersex  variation or disorder of sex development. [ 22 ] [ 23 ]  In April 2016, the  United Nations Special Rapporteur  on health, Dainius P\u016bras, condemned this treatment as a form of genital mutilation \"in the absence of symptoms or health issues warranting those procedures.\" [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7285", "text": "Clitoroplasty  is a type of  plastic surgery  involving the  clitoris . It encompasses several procedures, including clitoral reduction, clitoral reconstruction, and the creation of a neoclitoris in male-to-female  gender-affirming surgery . These surgeries aim to retain or restore sensation and function in the clitoris, often employing  nerve-sparing techniques ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7286", "text": "Clitoral reconstruction  is surgery to restore the function and structure of the clitoris. Examples of clitoral reconstruction include its use to mitigate  congenital malformation  or repair damage caused by  female genital mutilation . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7287", "text": "Clitoral reconstruction after female genital mutilation involves surgery to expose the remaining deep structures of the clitoris. As of 2023 [update] , there was little evidence for the therapeutic effectiveness of this procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7288", "text": "Clitoral reduction  is the surgical reduction in size of the clitoris, used to treat  clitoromegaly . Unlike  clitoridectomy , the amputation of part of the clitoris, commonly considered a form of  female genital mutilation , modern clitoral reduction surgery aims to preserve sensation and function through the use of nerve-sparing  microsurgical  techniques. [ 4 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7289", "text": "It should be distinguished from  clitoral hood reduction , an operation on the  clitoral hood  in which the clitoris itself is not damaged."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7290", "text": "During  male-to-female gender-affirming surgery , a neoclitoris is made from the tissue of the  glans penis . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7291", "text": "In  female-to-male gender-affirming surgery ,  metoidioplasty  is an operation in which the clitoris is repositioned to create a  neophallus . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7292", "text": "Contour threads  are used in cosmetic/ plastic surgery  to vertically lift facial tissues that have dropped (\"ptosed\") or become sunken with age. The \" ptosis \" or descent of facial tissues with  aging  is a universal phenomenon to which much cosmetic facial surgery is directed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7293", "text": "Strands of 2/0  Prolene  monofilament thread, with little notches cut into their sides, are placed in the subcutaneous plane under the ptosed facial skin. These are anchored under secure points in  fronto-occipitalis  and  temporalis  tissues. Dropped or \"ptosed\" facial skin is then elevated onto the barbed threads, and stay elevated because of the barbs. Thus the patient gets a \"facelift [ 1 ] \", without any scalpel work and without any removal of skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7294", "text": "In the event that a patient is unhappy with the results, the threads can be readily removed and the patient's face thence returns to its position prior to treatment. [ 2 ]  Thus, Contour threads have negligible permanent \"biological cost\", as the effect is reversible. Effects last for a number of years, quoted as 2\u20135 years, after which time the positive effect is gradually lost and the patient's face returns to its state prior to treatment. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7295", "text": "Cosmetic camouflage  is the application of  make-up   creams  and/or powders to conceal colour or contour irregularities or abnormalities of the face or body. It offers an answer to solve all related skin problems  such as Congenital origin, Traumatic origin and Dermatological origin ( angiomas, couperose, redness, teleangectasy, vitiligo, skin dyschromia, sunspots, senile spots, acne, results of burns, stretch-mark, scars, bruises, blue stains, eye sockets, tattoos). Furthermore, cosmetic camouflage solves  the psychological problems that a skin imperfection is sometimes able to provoke, it allows to rediscover its own beauty and to return with serenity to its own social life.\nCosmetic camouflage creams were first developed by  plastic surgeons  during  World War II  to cover the massive burns received by  fighter pilots . Nowadays, men, women and children can use cosmetic camouflage. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7296", "text": "Cosmetic camouflage is also called camouflage makeup, cover makeup, or corrective makeup."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7297", "text": "In the United States, a  craniofacial surgery fellowship  is a one-year program that prepares plastic surgeons to perform cosmetic, dental, and  craniofacial surgery  as well as the clinical application used in relevant medical procedures. The fellowship allows plastic surgeons to learn how to reconstruct and reshape the faces and heads of infants and children with facial anomalies, as well as those with traumatic injuries or cancer. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7298", "text": "To be eligible for craniofacial surgery fellowship, the candidate must have graduated from an accredited craniofacial surgery residency program (as defined in the American Society of Craniofacial Surgeons standards) and be in possession of a letter of recommendation from a person who has experienced a craniofacial surgery procedure with the surgeon. [ 2 ]  If the applicant is from another country, they should have completed the  ECFMG  examination or the  USMLE  and should be qualified for clinical activities. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7299", "text": "This article relating to education in the United States is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7300", "text": "Culture of cosmetic surgery  is a set of attitudes and behavior regarding making changes to one's appearance via  plastic surgery .  World War I  left thousands of soldiers with unprecedented levels of facial damage, creating a massive need for reconstructive surgery.  Harold Gillies  of  New Zealand  developed methods to restore function and structure to the faces of soldiers and these processes rapidly gained popularity. During the 1940s and 50s, personal appearance became more emphasized in the  United States . As  beauty standards  changed, new products and techniques were developed to meet those demands."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7301", "text": "World War I left thousands of soldiers with unprecedented levels of facial damage; trench warfare and progressive weapons lead to massive amounts of death and destruction. Explosions and rapid gunfire left those who survived with horribly disfigured faces, creating a dire demand for medical intervention. Dr. Harold Gillies of New Zealand developed and tested methods to restore function and structure to the faces of soldiers, such as taking cartilage or skin from an easily concealed part of the patient's body and using it to reform the injured area. Due to the thousands of soldiers in need of immediate medical attention, there were no shortage of willing trial subjects. Gillies based his work on methods that had been developed previously, but were never intended for such drastic application. He improved upon these efforts and, when combined with anaesthesia and sedating medication, found his techniques rapidly gaining in popularity. [ 1 ]  The call for doctors able to perform facial reconstruction grew rapidly and received national attention. Dr. Varaztad Kazanjian became the first recognized post-war plastic surgery specialist at Harvard Medical School. [ 2 ]  Years after the war ended, the supply of patients in need of life-saving facial reconstruction was steadily reducing. As such, surgeons were able to take on less dire cases, such as industrial accidents or other injuries. Techniques and procedures became more advanced and public knowledge of them grew."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7302", "text": "Throughout the 1940s and 50s fashion and personal appearance was emphasized more strongly in the United States; both world wars were over and years in the past, and normalcy was returning to the average American household. As ideas about what was considered beautiful changed, services, products, and techniques were developed to help consumers meet those standards if they so chose. Women felt pressure to be symmetrical, have smooth skin, and be slim yet curvy in all the right places. Being too thin was equated with being fragile and sickly, but being too large suggested poor self-care. [ 3 ]  The emphasize on  bust-waist-hip measurements  grew, with Miss America's proclaimed ideal in the 1950s being 36\u201324\u201336. [ 3 ]  Despite the physical risks they carry, corsets and waist-trainers returned to popularity during this time to help women achieve the \"hourglass figure\" that was so sought after. While fitted dresses and push-up bras were readily available, some women chose to undergo surgery to enhance their bodies. The rate of breast augmentation operations soared in the 1960s, and a decade later rates of anorexia-nervosa hit record highs. In the 1970s breast reduction surgery became more prevalent, as well as reduction of the thighs and buttocks. These surgeries were newly developed and experimental; some common unintended outcomes were numbness, loss of range of motion, and infection. At the same time, women were anxious to look youthful as they age in order to \"keep their men\". Suffering from poor self-image also became reason to improve one's appearance via surgery. Working women believed that good looks help secure or advance their livelihoods. Studies have shown that attractive individuals receive higher earnings and faster promotions than unattractive people across professions. In addition, people from different ethnic groups, such as Black, Asian and Jewish women, struggled to look more like other Americans and sought  WASP  noses and breasts as seen in  Playboy  magazines. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7303", "text": "Many people who have plastic surgery in today's era choose to do so because of their mental state and lack of confidence in their own bodies. [ citation needed ]  Instead of working to accept and love what they look like as they are, millions of people turn to getting something changed about themselves instead because it requires less mental/ emotional work and is readily available. One example of this is people with eating disorders; a person who has body dysmorphia may try and get surgery in order to feel that they are skinnier than they already are. The major problem with this is that many eating disorder patients are not overweight, so this surgery will not be helpful to their physical health or appearance. These patients expect to come out of the operation room looking like a new person, and they believe that they will be able to feel confident in this new body. [ 6 ]  This can happen to certain people, but for the majority of people with these diagnoses, the surgery will not be able to change their mindset. These patients need therapy and mental treatments, so a physical surgery will be a waste of time and money. Besides eating disorder patients, a large number of people who choose to undergo plastic surgery are victims of anxiety, depression, or other mental illnesses. These people, just like an eating disorder patient, falsely believe the surgery will fix their mental state. These patients deserve to get mental health treatments because the surgery will most likely not be able to change their mindsets. However, cosmetic surgery can have profoundly wonderful affects for the transgender community and those who have significant facial damage. Trans folk who choose to have surgery so their physical form aligns more closely with their gender identity often feel more comfortable in their own skin and are able to see their external figure the way they want to see it, giving a marginalized and under-recognized group a significant amount of power back over their own lives. Burn victims and other patients who have experienced significant facial deformation also benefit psychologically from plastic surgery; victims of an accident or attack commonly feel much of their power has been taken away, and having a plethora of surgical procedures available to them may make the healing process easier. These procedures are intended to restore normalcy to people who have had traumatic experiences, and help them lead as normal of a life as possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7304", "text": "Plastic surgery started to become commonly used during the world wars in order to help soldiers and veterans who were injured. Surgeons used skin grafts to reshape faces that had been impacted by bombs and bullets. [ 7 ]  After, plastic surgery became mainstream in the 1950s for American women to change themselves as beauty standards were changing. Most popular were, and is the third most popular today, rhinoplasties, which is a reconstruction of the nose.  Over the course of the 1900s American beauty standards became more narrow and created a rigid definition of beauty, which made these procedures more common in order to be seen as fitting into the definition of beauty. [ 3 ]   Today, many procedure can be done to meet society's definition of beauty and media and research has found the most common procedures sought out each year. The most popular procedure performed in 2018 were breast augmentations, followed by liposuction, nose reshaping, eyelid surgery, and tummy tucks. [ 8 ]  These procedures have become less invasive and more available as plastic surgeons expand their services and accessibility. These procedures are still expensive, but there are recently more ways to gets parts covered by health insurances. The criteria for medical intervention in contemporary society can be as simple as disliking the appearance of that part of the body; cosmetic surgery is the only medical specialty where the patient decides what is wrong with her and what the course of treatment will be. The prevalence of cosmetic surgery in the United States can make it feel less like a choice and more like a medical need; advertisements in everyday media, worship of celebrities who transform their bodies, and constant critique of the natural female form can suggest that there is something innately wrong or flawed about the way one looks, and surgical intervention is required to \"fix\" these issues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7305", "text": "A  custom-made medical device , commonly referred to as a  custom-made device  ( CMD ) (Canada, the European Union, the United Kingdom) or a  custom device  (United States), is a  medical device  designed and manufactured for the sole use of a particular patient. Examples of custom-made medical devices include  auricular splints ,  dentures ,  orthodontic appliances ,  orthotics  and  prostheses ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7306", "text": "There is no globally agreed definition, but a custom-made medical device can be broadly defined as a medical device that has been designed and manufactured in accordance with a prescription from an appropriately qualified person for the sole use of a particular patient to meet their specific needs. Mass-produced medical devices that have been adapted for specific patient requirements such as customised wheelchairs, hearing aids, and spectacle frames do not typically fall within the definition of a custom-made medical device."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7307", "text": "The requirements of sections 360d and 360e of this title shall not apply to a device that\u2014"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7308", "text": "(A) is created or modified to comply with the order of an individual physician or dentist (or any other specially qualified person designated under regulations promulgated by the Secretary after an opportunity for an oral hearing);"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7309", "text": "(B) to comply with an order described in subparagraph (A), necessarily deviates from an otherwise applicable performance standard under section 360d of this title or requirement under section 360e of this title;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7310", "text": "(C) is not generally available in the United States in finished form through labeling or advertising by the manufacturer, importer, or distributor for commercial distribution;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7311", "text": "(D) is designed to treat a unique pathology or physiological condition that no other device is domestically available to treat;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7312", "text": "(E)(i) is intended to meet the special needs of such physician or dentist (or other specially qualified person so designated) in the course of the professional practice of such physician or dentist (or other specially qualified person so designated); or"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7313", "text": "(ii) is intended for use by an individual patient named in such order of such physician or dentist (or other specially qualified person so designated);"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7314", "text": "(F) is assembled from components or manufactured and finished on a case-by-case basis to accommodate the unique needs of individuals described in clause (i) or (ii) of subparagraph (E); and"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7315", "text": "(G) may have common, standardized design characteristics, chemical and material compositions, and manufacturing processes as commercially distributed devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7316", "text": "(2) Limitations"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7317", "text": "Paragraph (1) shall apply to a device only if\u2014"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7318", "text": "(A) such device is for the purpose of treating a sufficiently rare condition, such that conducting clinical investigations on such device would be impractical;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7319", "text": "(B) production of such device under paragraph (1) is limited to no more than 5 units per year of a particular device type, provided that such replication otherwise complies with this section; and"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7320", "text": "(C) the manufacturer of such device notifies the Secretary on an annual basis, in a manner prescribed by the Secretary, of the manufacture of such device."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7321", "text": "Depending on the jurisdiction, custom-made medical devices can be  prescribed  by various  healthcare professionals  working within numerous  medical specialties  such as dentists,  hearing aid dispensers ,  ocularists/orbital prosthetists ,  orthotists ,  medical practitioners/physicians  and  prosthetists . Manufacturers of custom-made medical devices include  anaplastologists ,  audiologists ,\n clinical dental technicians/dental prosthetists/denturists ,  dental assistants / dental nurses ,  dental technicians , dentists,  ocularists/orbital prosthetists ,  ophthalmologists ,  optometrists ,  orthopaedic shoe fitters ,  orthopedic technicians ,  orthotists  and  prosthetists . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7322", "text": "In Australia manufacturers of custom-made medical devices are exempt from registering with the Australian Register of Therapeutic Goods (ARTG). Manufacturers of custom-made medical devices cannot advertise such devices directly to patients and are required to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7323", "text": "In Canada, custom-made medical devices are subject to Part 2 of the Medical Devices Regulations ( SOR /98-282) [ 2 ]  under the  Food and Drugs Act . Serious adverse incidents with medical devices must be  reported  to  Health Canada  within 72 hours. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7324", "text": "Custom-made devices manufactured in the European Union are subject to  Regulation (EU) 2017/745 (Medical Device Regulation [EU MDR]) , [ 4 ]  which replaced and  repealed   Directive 93/42/EEC (Medical Devices Directive [MDD]) . [ 9 ]  Under the MDD, manufacturers of custom-made devices were required to follow the relevant Essential Requirements set out in Annex I and the procedure set out in Annex VIII. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7325", "text": "The EU MDR was published on 5 April 2017, came into force on 25 May 2017 and, following a three-year transition period, was expected to replace and repeal the MDD on 26 May 2020. But on 23 April 2020, Regulation (EU) 2020/561 was adopted which deferred the full implementation of the EU MDR for one year until 26 May 2021 so that efforts could be concentrated on the response to the  coronavirus disease 2019 (COVID-19) pandemic . Under the EU MDR, manufacturers of custom-made devices are required to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7326", "text": "Custom-made devices are not required to carry the  CE marking ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7327", "text": "In the UK manufacturers of custom-made devices are required to register with the  Medicines and Healthcare products Regulatory Agency . Until the UK  left the European Union  on 31 January 2020, custom-made devices were governed by the MDD, which was given effect in UK law by The Medical Devices Regulations 2002 (Statutory Instrument 2002/618 [UK MDR 2002] [ 5 ] ). Immediately after the UK's departure, the UK entered an 11-month  implementation period (IP) , during which EU law continued to apply."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7328", "text": "In preparation for the UK's departure from the EU, the EU MDR was essentially transposed into The Medical Devices (Amendment etc.) (EU Exit) Regulations 2019, (Statutory Instrument 2019/791 [UK MDR 2019]), an amendment of the UK MDR 2002 [ 11 ] ) and was expected to be fully implemented on exit day. The UK MDR 2002 was further amended by The Medical Devices (Amendment etc.) (EU Exit) Regulations 2020 (Statutory Instrument 2020/1478 [UK MDR 2020] [ 12 ] ), which removed the provisions of the EU MDR and substituted 'exit day' for 'IP completion day'."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7329", "text": "In Great Britain medical devices can conform to either the UK MDR 2002 (as amended) or the EU MDR until 30 June 2023.  Northern Ireland  remains in line with EU law under the terms of the  Protocol on Ireland/Northern Ireland . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7330", "text": "Custom-made devices are not required to carry the  CE marking  or the  UK Conformity Assessed (UKCA) marking . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7331", "text": "Custom devices are subject to requirements including labelling ( 21 CFR  Part 801),  reporting  (21 CFR Part 803), corrections and removals (21 CFR Part 806), registration and listing (21 CFR Part 807) and  quality systems regulation  (21 CFR 820). Manufacturers of custom devices are obligated to submit an annual report of custom devices to the  Food and Drug Administration  but are exempt from Premarket Approval (PMA) requirements and conformance to mandatory performance standards. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7332", "text": "Dermabrasion  is a type of surgical skin planing, generally with the goal of removing  acne , scarring and other skin or tissue irregularities, typically performed in a professional medical setting by a  dermatologist  or  plastic surgeon  trained specifically in this procedure. Dermabrasion has been practiced for many years (before the advent of lasers) and involves the controlled deeper  abrasion  (wearing away) of the upper to mid layers of the  skin  with any variety of strong abrasive devices including a wire brush, diamond wheel or fraise, sterilized sandpaper, salt crystals or other mechanical means."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7333", "text": "Dermabrasion procedures are surgical, invasive procedures that typically require a  local anaesthetic . Often, they are performed in surgical suites or in professional medical centers. Since the procedure can typically remove the top to deeper layers of the epidermis and extend into the  reticular dermis , there is always minor skin bleeding. The procedure carries risks of scarring, skin discoloration, infections and facial herpes virus ( cold sore ) reactivation. In aggressive dermabrasion cases, there is often tremendous skin bleeding and spray during the procedure that has to be controlled with pressure. Afterward, the skin is normally very red and raw-looking. Depending on the level of skin removal with dermabrasion, it takes an average of 7\u201330 days for the skin to fully heal ( re-epithelialize ). Often, the procedure is performed for deeper acne scarring and deep surgical scars. Dermabrasion is currently rarely practiced and there are very few doctors who are trained and still perform this surgery. Dermabrasion has largely been replaced by technologies including lasers,  CO 2  or  Erbium:YAG   laser . Laser technologies carry the advantage of little to no bleeding and are often less operator dependent than dermabrasion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7334", "text": "The purpose of surgical dermabrasion is to help diminish the appearance of deeper scars and skin imperfections. Often, the goal is to smooth the skin and, in the process, remove small scars (as from acne), uneven skin tone from scars or  birthmarks , sun damage,  tattoos , age spots,  Stretch marks   [ citation needed ]  or fine  wrinkles . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7335", "text": "Dermabrasion is a mechanical surgical skin planing method which has remained popular partially because it may afford an overall lower cost and may provide similar or superior results as newer laser methods for certain skin conditions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7336", "text": "Microdermabrasion is a light cosmetic procedure that uses a mechanical medium for  exfoliation  to remove the outermost layer of dead  skin cells  from the  epidermis . Most commonly, microdermabrasion uses two parts: an exfoliating material such as crystals or diamond flakes, and a machine-based suction to gently lift up the skin during exfoliation. It is a non-invasive procedure and may be performed in-office by a trained  skin care  professional. [ 3 ]  It may also be performed at home using a variety of products which are designed to mechanically exfoliate the skin. Many salon machines and home-use machines use adjustable  suction  to improve the efficacy of the abrasion tool."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7337", "text": "Microdermabrasion is considered a relatively simple, easy, painless and non-invasive skin rejuvenation procedure. Typically there are no needles or anesthetics required for microdermabrasion. The vacuum pressure and speed are adjusted depending on the sensitivity and tolerance of the skin. [ citation needed ]  Microdermabrasion is often compared to the feeling of a cat licking the skin - a rough but gentle texture.  Typical microdermabrasion sessions can last anywhere from 5 to 60 minutes. Minimal to no recovery time is required after microdermabrasion and most people immediately return to daily activity after a session. Makeup and non-irritating creams can usually be applied within a few hours or right after microdermabrasion. Since there is an often immediate increased minor skin sensitivity after microdermabrasion, irritating products such as  glycolic acids ,  Alpha Hydroxy Acids ,  Retinoid  products or fragranced creams and lotions are typically avoided right after the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7338", "text": "Traditionally, a \"crystal\" microdermabrasion system includes a pump, a connecting tube, a hand piece, and a vacuum. While the pump creates a high-pressure stream of inert crystals (aluminum oxide, magnesium oxide, sodium chloride, or sodium bicarbonate) to abrade the skin, the vacuum removes the crystals and exfoliated skin cells. Alternatively, the inert crystals can be replaced by a roughened surface of the tip in the diamond microdermabrasion system. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7339", "text": "Unlike the older crystal microdermabrasion system, the diamond microdermabrasion does not produce particles from crystals that may be inhaled into patients' nose or blown into the eyes. Hence, diamond microdermabrasion is regarded as having higher safety for use on areas around the eyes and lips. Generally, the slower the movement of the microdermabrasion handpiece against the skin and the greater the numbers of passes over the skin, the deeper the skin treatment. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7340", "text": "One of the safest methods of microdermabrasion involves the use of corundum or aluminum oxide crystals suspended in an antioxidant cream.   This version of microdermabrasion is generally the most cost efficient as it involves the use of a small handheld skincare tool instead of expensive equipment used by a salon.  This method of microdermabrasion rose to popularity in the early 2000s and is widely available today."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7341", "text": "Often called \"microderm\" for short, microdermabrasion is a procedure to help exfoliate or temporarily remove a few of the top layers of the skin called the stratum corneum. Much like brushing one's teeth, microdermabrasion helps to gently remove skin \"plaque\" and skin debris. [ citation needed ]  Since human skin typically regenerates at approximately 30-day intervals, skin improvement with microdermabrasion is temporary and needs to be repeated at average intervals of two - four weeks for continued improvement.  Multiple treatments in combination with sunscreen, sun avoidance and skin care creams yield best results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7342", "text": "Dermabrasion is generally used to refer to a true surgical procedure that aggressively abrades away the top to mid layers of the skin. The term microdermabrasion generally refers to a non-surgical procedure that abrades less deeply than dermabrasion. Although the mechanism of the two procedures is similar, the difference in the depth of the abrasion results in different recovery times. Dermabrasion recovery time may take as much as several weeks to several months whereas microdermabrasion recovery time may be as little as one to two days. [ 5 ]  After microdermabrasion, skin will be much more sensitive to sun exposure. It is best to keep out of the sun and wear sunscreen at all times after the procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7343", "text": "Microdermabrasion may be performed to help diminish the appearance of superficial  hyperpigmentation  or  photo-damage  (sunburn), as well as diminish fine lines, wrinkles, acne and shallow acne scars. A further benefit of microdermabrasion is enhanced skin penetration by skin creams and serums. Removing dead skin (stratum corneum of the epidermis) will aid in the penetration of skin care products and medications by up to 10-50%. The controlled skin exfoliation afforded by microdermabrasion will allow make-up and self-tanning products to go on much more smoothly. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7344", "text": "Microdermabrasion treatment carries minimal to very few possible side effects or complications. However, some patients may experience temporary mild dryness, sun sensitivity and rarely temporary bruising or scratches in the area of skin treated. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7345", "text": "The first microdermabrasion unit was developed in  Italy  in 1985, using small inert  aluminium oxide  crystals to abrade the skin. In 1986, other European markets had introduced the technology which was immediately adopted by physicians for mechanical exfoliation. There were 10 microdermabrasion units on the market in Europe by the end of 1992. In 1996,  Mattioli Engineering  partnered with one of the Italian designed machines and started working towards meeting FDA requirements for the USA. By the end of 1996, the  Food and Drug Administration | (FDA) issued the first approval letter for microdermabrasion machines. In January 1997, the first microderm machine was being sold and marketed in the US. The diamond tip was introduced in 1999 and the bristle tip brush was introduced in 2005. [ 7 ]  The first standard vacuum based microdermabrasion system called Vacubrasion was introduced in 2012 in the US and world markets, and provides diamond tip exfoliation and suction. Vacubrasion's patented air regulator delivery system was designed and underwent extensive testing by US dermatologists and physicians. Its straightforward design revolutionized microdermabrasion to permit use of almost any type of suction source (primarily retail brand vacuums with a 1.25\u00a0in (31.8\u00a0mm) standard round hose such as Eureka, Stanley vacuums) with a non-disposable, attached electroplated fine diamond abrasive tip. While traditional, older crystal based microdermabrasion and home microdermabrasion systems are sometimes fraught with clogging issues and potential loss of suction, the crystal-free Vacubrasion systems utilize a universal, larger and more powerful suction source that avoids many of these issues. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7346", "text": "Microdermabrasion has evolved from  rocks , stones and  shells  to  crystals , particle-free diamond tips and particle-free bristle tips. Once the desired amount of exfoliation has been reached, some microdermabrasion units will then spray or infuse a skin enhancing solution into the skin. Since microderm essentially manually removes limited layers of the stratum corneum (dead layers of the outer layer of the skin), any serum or topical product applied in any fashion to the skin following microdermabrasion will potentially have a greater opportunity for penetration into the skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7347", "text": "Microdermabrasion crystals are typically made of a very fine, abrasive material like  aluminum oxide . Other inert microderm crystals include magnesium oxide, sodium chloride, and sodium bicarbonate. All ultra-fine white crystals are disposable and should be discarded after each use. The microdermabrasion vacuum removes the crystals and exfoliated skin cells. Inhalation of crystals should be avoided and masks are sometimes worn by the operator doing the treatment. Ocular injury may occur if crystals are inadvertently sprayed in the eye or if crystals remain around the eye and cause a corneal abrasion. There are some possible concerns of inhalation exposure and basic safety precautions should be taken. Patient goggles or eye shields, as well as operator face masks are recommended when treating with crystal based systems. Alternatively, microderm crystals can be safely replaced by the roughened surface of a diamond tip microdermabrasion system. The newer diamond based systems like Vacubrasion utilize a fine  diamond dust  that is essentially electroplated onto a stainless steel round tip that comes in contact with the skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7348", "text": "A  dermatome  is a  surgical instrument  for producing thin slices of  skin  from a donor area, for use in  skin grafts . One of its main applications is for reconstituting skin areas damaged by third degree  burns  or  trauma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7349", "text": "Dermatomes can be operated either manually or electrically. The first drum dermatomes, developed in the 1930s, were manually operated. Afterwards, dermatomes which were operated by air pressure, such as the Brown dermatome, achieved higher speed and precision. Electrical dermatomes are better for cutting out thinner and longer strips of skin with a more homogeneous thickness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7350", "text": "Those are manual dermatomes and the term  knife  or  scalpel  is used to describe them. Their disadvantages are harvesting of grafts with irregular edges and grafts of variable thickness. Their operator has to be experienced in their use for optimal results. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7351", "text": "There are several types of dermatomes, usually named after their inventor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7352", "text": "An  escharotomy  is a surgical procedure used to treat full-thickness (third-degree) circumferential  burns . In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed  eschar . Following a full-thickness burn, as the underlying tissues are rehydrated, they become constricted due to the eschar's loss of elasticity, leading to impaired circulation distal to the wound. An escharotomy can be performed as a prophylactic measure as well as to release pressure, facilitate circulation and combat burn-induced  compartment syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7353", "text": "An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below.  Due to the residual pressure, the incision will often widen substantially."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7354", "text": "Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30\u00a0mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death. If ischemia (poor blood flow) persists for over six hours, then the irreversible process of muscle necrosis will begin. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7355", "text": "The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. Due to the primarily diaphragmatic breathing done by children, anterior burns may be enough to warrant an escharotomy. [ 2 ]  Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7356", "text": "Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7357", "text": "Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7358", "text": "Neurovascular integrity should similarly be monitored frequently and in a scheduled manner. Capillary refilling time,  Doppler signals , pulse oximetry, and sensation distal to the burned area should be checked every hour. [ 4 ]  Limb deep compartment pressures should be checked initially to establish a baseline. Subsequently, any increase in capillary refill time, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures. Compartment pressures greater than 30\u00a0mm Hg should be treated by immediate decompression via escharotomy and  fasciotomy , if needed. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7359", "text": "During an escharotomy the patient is often sedated despite the insensible eschar. The burnt skin is incised down to the subcutaneous fat and into the healthy skin (up to 1\u00a0cm). The incisions should be deep enough to release all restrictive effects from the eschar. The operation can be performed on the trunk, limbs, or neck, all while avoiding critical nerves, veins, and vessels. [ 2 ]  Following the operation the wounds are dressed primarily with an absorbent, antimicrobial material, then wrapped lightly in a bandage. Elevation (if possible) and observation are encouraged. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7360", "text": "Ethnic plastic surgery , or  ethnic modification , refers to the types of  plastic surgery  performed frequently due to certain racial or ethnic traits, or with the intention of making one's appearance more similar or less similar to people of a particular  race  or  ethnicity . [ 1 ]  Popular procedures which may have an ethnically motivated component are  rhinoplasties  (nose jobs) and  blepharoplasties  (double eyelid surgeries). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7361", "text": "Michael Jackson 's  plastic surgery  has been discussed in the context of ethnic plastic surgery. [ 3 ]  In her book,  Venus Envy: A History of Cosmetic Surgery , Elizabeth Haiken devotes a chapter to \"The Michael Jackson Factor\" presenting \" Black ,  Asian , and  Jewish  women who seek  WASP  noses and  Playboy  breasts. They are caught in the vexed immigrants' dilemma of struggling not only to  keep up with the Joneses  but to look like them, too.\" [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7362", "text": "Plastic surgeons Chuma J. Chike-Obi, M.D., Kofi Boahene, M.D., and Anthony E. Brissett, M.D., F.A.C.S. distinguish between motivations of aesthetics and racial transformation for patients of African descent seeking plastic surgery. In their opinion, \"Patients whose desired surgical outcomes result in racial transformation should be educated about the potential risks of this objective, and these requests should generally be discouraged.\" [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7363", "text": "Feminist scholars have split views on the subject.  Christine Overall , professor of philosophy at  Queen's University at Kingston , has written that personal racial transformation, or as she puts it \"transracialism\", belongs to a larger class of personal surgical interventions. This larger class includes  transsexual  identity change,  body art ,  cosmetic surgery ,  Munchhausen syndrome , and  labiaplasty . Her basic thesis is that the arguments against the ethical nature of racial transformation (e.g. \"it's not possible\", \"betrayal of group identity\", \"reinforces oppression\", etc.) stand or fall with the ethical arguments related to transsexual change. [ 6 ]   Cressida Heyes , professor of Philosophy of Gender and Sexuality at the  University of Alberta , disagrees with Overall's schema. Heyes feels that racial transformation is fundamentally different from gender transformation since race is also determined by ancestry, personal cultural history and societal definitions. Hence ethical considerations of transracial surgery are different from ethical considerations in transsexual surgery. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7364", "text": "In the  South Park  episode \" Mr. Garrison's Fancy New Vagina \" Kyle undergoes an ethnic plastic surgery called \"negroplasty\" to qualify for the basketball team."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7365", "text": "In the 2008 movie  Tropic Thunder , Kirk Lazarus goes through a controversial surgery to make his skin darker to play an African-American soldier."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7366", "text": "Eyebrow restoration  is a  surgical procedure  to reposition the  eyebrow .  With advancing age, a common occurrence is descent of the eyebrow, or  brow ptosis . A similar condition is  eyelid ptosis . Eyebrow repositioning is a commonly performed procedure in  cosmetic surgery .  The brow is repositioned, optimally, for the wishes of the patient as well as to correct the descent."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7367", "text": "The procedure may be performed either  open  (through a standard or modified coronal incision) which allows for partial or complete  ablation  of  corrugator supercilii musclesto  avoid any need for them in the future but still allow for facial expression, or closed when an  endoscopic  approach is employed albeit with shorter long-term results.  In the very young, eyebrow position may be modified with injection of paralytics but only to a limited extent.  Lateral injection into a portion of the  orbicularis  muscle can elevate the lateral brow to some extent.  Generally, injection of paralytics into the forehead will cause a descent of the brow and thus brow position can be tailored by selective injection of paralytic agents, again, to a limited extent.  Significant change in position or posture of the brow generally requires a surgical procedure to accomplish the desired goals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7368", "text": "Another purpose of this procedure is to customize the appearance of the eyebrows."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7369", "text": "It was originally intended for  burn victims  and patients of illnesses that prevent hair from growing in the eyebrow region. Eyebrow restoration surgeries - or transplants - have since evolved into a cosmetic procedure favored by people wishing to have perfect eyebrows."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7370", "text": "Some traditional  hair restoration  surgeons offer eyebrow restorations as well. Both procedures should be only performed by certified surgeons who specialize in hair and eyebrow transplantation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7371", "text": "The most popular hair and eyebrow restoration surgery technique is  follicular unit transplantation , which involves the removal of donor follicles from the back of the patient's head where hair tends to be more permanent. The most advanced form of follicular unit surgery is with the robotic system. Once removed, the \"donor area\" is then stitched back up with no visible scarring. The donor follicles are then transplanted into the \"problem areas\" of the patient's scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7372", "text": "Eyebrow transplants are designed to restore growing hair to eyebrows that are overly thin, scarred, or completely missing. The absence of hair can be due to genetics, prior  electrolysis  or  laser hair removal , over-plucking,  thyroid  or other hormonal abnormalities, or trauma due to surgery, burns or other types of accidents."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7373", "text": "The donor hairs come from the scalp which, when transplanted into the eyebrows, continue to grow for a lifetime and therefore need to be trimmed typically once a month. To provide a natural appearance, the hairs are transplanted primarily one and occasionally two at a time, the natural way eyebrow hairs grow. This is a very delicate procedure, requiring perfect placement of these hairs into tiny half-millimeter incisions that are angled at just the right direction and positioned to mimic natural growth. The use of all-microscopically dissected  grafts  allows their placement into the smallest possible incisions so as to minimize scarring and damage to already existing hairs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7374", "text": "A procedure typically involves the placement of 50 to as many as 325 hairs into each eyebrow, depending upon the existing amount of hair and the desired size and density. Performed usually under a mild oral  sedative , the two-hour procedure is essentially painless, as is the recovery period."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7375", "text": "For the first two to four days after the procedure, tiny crusts form around each transplanted hair. By three to five days, other than some occasional mild pinkness which fades out by the first week, patients are able to return to normal activities without any sign of having had a procedure.  Sutures  that are placed in the donor area are removed at one week. The transplanted hairs fall out at around two weeks, then start to regrow at three months, and continue to grow for a lifetime. [ 1 ] [ unreliable medical source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7376", "text": "Facial Autologous Muscular Injection  is also known as  Fat Autograft Muscular Injection , as  Autologous Fat Injection , as  Micro-lipoinjection , as  Fat Transfer   and as  Facial Autologous Mesenchymal Integration , abbreviated as  FAMI . The technique is a non-incisional pan-facial rejuvenation procedure using the patient's own stem cells from fat deposits. [ 1 ]  FAMI is an Adult stem cell procedure used to address the loss of volume in the face due to aging or surgery repair in restoring facial muscles, bone surfaces and very deep fat pads. [ 2 ] \nThe procedure involves removing adult stem cells of fatty tissue from lower body, and refining it to be able to re-inject living adipose stem cells into specific areas of the face without incision. FAMI is an outpatient procedure and an alternative to artificial fillers, blepharoplasty or various face lifts. [ 3 ] [ 4 ]  The procedure does not require general anesthesia and risks of an allergic reaction are minimal due to the use of the patient's own tissue used as the facial injection. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7377", "text": "Fat transplantation procedures have been in use for decades to restore volume to the face, and as a result, various techniques have been developed over the years. [ 6 ]  Facial autologous muscular injection (FAMI) was developed from 1996 by Roger E. Amar M.D., a French plastic surgeon. [ 6 ] [ 7 ]  Roger  Amar is the founder and director of the AMARCLINIC which hosts the FAMI international Academy in  Marbella ,  Spain . [ 8 ]  FAMI was introduced to the  United States  in 2001, [ 6 ]  and in 2010 in London UK. The FAMI procedure differs from other fat transplantation procedures in that it takes the patient's facial vascular paths into account while using their own fatty tissue to address the loss of volume in the face without having to make incisions. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7378", "text": "Facial autologous muscular injections are performed to  rejuvenate  the face of the patient and reduce the appearance of the natural effects of aging. The procedure can also be used to improve unsatisfactory results from other procedures such as a face-lift surgery. Indications include depressions or hollows across the face from aging, trauma or previous surgery as well as sagging jowls due to loss of volume in the upper face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7379", "text": "FAMI can be used in combination with surgery below the jawline to address the look of sagging necks and skeletonized faces, or faces that exhibit extreme skinny structures characterized by  infraorbital  hollowness usually due to weight loss. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7380", "text": "Facial autologous muscular injections are procedures that target deep multiplane  autologous  fat. FAMI consists of an autograft of adult stem cells in order to rebuild muscles and bones. [ 9 ]  The adult stem cells are taken from an area of fatty tissue in a separate area of the body, typically from the patient's hip, knee or abdomen. The collected fat and stem cells are concentrated and refined. [ 10 ]  The stem cells are then re-injected into the muscles of the face. Specifically, the injections are made in close proximity or within the muscles responsible for facial expression. [ 2 ] [ 6 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7381", "text": "By reconstructing the structures of the face with one's own adult stemcells, FAMI rejuvenates the patient's face with restored volume to the facial muscles and bones. [ 9 ]   FAMI procedures are not surgical, they are  outpatient procedures  that do not require the use of a scalpel or incisions, rather specially designed disposable  cannulas  that follow skull curvatures are used to transfer and place the fatty tissue around the face. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7382", "text": "The results of the procedure are long-lasting, or relatively permanent due to the use of natural tissue rather than fillers and also because the injections are made to facial expression muscles and improve graft retention. Because it is a non-incisional procedure, facial autologous muscular injections are scar-less and results appear natural. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7383", "text": "FAMI procedures are non-surgical and done as outpatient procedure outside of a hospital. The procedure is  minimally invasive and does not require the use of general  anesthesia , however, local anesthesia is used to block the patient from feeling pain or discomfort. Complications from facial autologous muscular injections are very rare. From the 2011 Advanced Techniques in Liposuction and Fat Transfer report, it was noted that in 726 cases over 14 years there were no reports of complications such as cytosteatonecrosis,  pseudocyst  formation, infections or other issues. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7384", "text": "Facial implants  are used to enhance certain features of the face. The  surgery  may be  elective , or needed as the result of prior surgery on the face. Each involves placing  synthetic  materials deep under the  subcutaneous tissue  and onto the underlying  bone . A  maxillofacial  or  plastic surgeon  uses them to aesthetically improve facial contours,  proportion  and correct imbalances caused by  injury  or  hereditary traits . However, in cases that require  orthognathic osteotomies , those should be done before any implants are considered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7385", "text": "In most cases, facial implant surgery is completed on an  outpatient  basis in a hospital, a surgeon's office or a surgical center. A  local anesthesia  or  oral sedative  may be used, or the patient may be put to sleep during the procedure using  general anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7386", "text": "The most commonly used implants are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7387", "text": "Less commonly used implants are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7388", "text": "Fat removal procedures  are used mostly in  cosmetic surgery  with the intention of removing unwanted  adipose tissue . The procedure may be invasive, as with  liposuction , [ 1 ]  or noninvasive using  laser therapy ,  radiofrequency ,  ultrasound  or cold ( cryoablation  or cryolipolysis) to reduce fat, sometimes in combination with injections. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7389", "text": "Fat is sometimes removed from one location to another on a person in an  autograft , such as in some  breast reconstruction  and  breast augmentation  procedures. [ 4 ]  These techniques are distinct from  bariatric surgery , which aims to treat  obesity  by minimizing food consumption or by interfering with the absorption of food during  digestion , and from  injection lipolysis , which relies solely on injections marketed as causing  lipolysis . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7390", "text": "Liposuction  is a type of  cosmetic surgery  that removes  fat  from the human body in an attempt to change its shape. [ 5 ]  Evidence does not support an effect on weight beyond a couple of months and it does not appear to affect  obesity  related problems. [ 6 ] [ 7 ]  In the United States it is the most commonly done cosmetic surgery. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7391", "text": "Serious complications include  deep vein thrombosis ,  organ perforation , bleeding, and  infection . [ 10 ]  Death occurs in about one per ten thousand cases. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7392", "text": "The procedure may be performed under general, regional, or local  anesthesia  and involves using a cannula and negative pressure (suction) to suck out fat. [ 8 ]  It is believed to work best on individuals of normal or near normal weight and good skin elasticity. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7393", "text": "Post operational downtime can last anywhere from 2 \u2013 4 weeks to 3 full months for patients to fully heal and be able to resume normal activities. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7394", "text": "Focused thermal ultrasound techniques work by raising the tissue temperature up to 48\u00a0\u00b0C, [ 13 ]  resulting in coagulative necrosis of adipocytes, with sparing of vessels and nerves. Passive heating of the skin may also induce collagen remodeling. [ 14 ] [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7395", "text": "Hydrolipoclasy  is a technique that is being studied as an alternative to  liposuction . [ 17 ]  It involves injecting a  hypotonic solution  into an area of fat and then subjecting it to  ultrasound  waves. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7396", "text": "Low level laser light reduces the stability of  adipocyte  cell membranes, allowing cells to release their stores of fat without damaging the cell. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7397", "text": "Cryolipolysis is the removal of fat by freezing. [ 19 ] [ 20 ] [ 21 ]  It involves controlled application of  cooling  within the temperature range of \u221211 to +5\u00a0\u00b0C (+12.2 to +41\u00a0\u00b0F) for the localized reduction of  fat  deposits, intended to reshape the contours of the body. [ 19 ] [ 20 ]  The degree of exposure to cooling causes  cell death  of  subcutaneous fat  tissue, without apparent damage to the overlying  skin . [ 20 ] [ 22 ]  It appears primarily applicable to limited discrete fat bulges. [ 19 ] [ 20 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7398", "text": "Adverse effects  include transient local redness, bruising and  numbness  of the skin, and these are expected to subside. [ 20 ] [ 23 ]  Typically, sensory deficits (numbness) will subside within a month. The effect on peripheral nerves was investigated and failed to show permanent detrimental results. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7399", "text": "Another adverse effect is paradoxical adipose hypertrophy (PAH) which causes fat tissue to grow larger rather than become reduced in size as a consequence of the procedure. [ 24 ] [ 25 ]  Supermodel  Linda Evangelista  has initiated legal action for damage caused by PAH. [ 26 ] [ 27 ]  Some studies indicate that PAH side effects are common on a per-patient basis, since a typical patient receives multiple treatments. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7400", "text": "Based on the premise that fat cells are more easily damaged by cooling than skin cells (such as  popsicle panniculitis ), cryolipolysis was developed to apply low temperatures to tissue via thermal conduction. [ 29 ]  In order to avoid  frostbite , a specific temperature level and exposure are determined, such as 45 minutes at \u221210\u00a0\u00b0C (14\u00a0\u00b0F). [ 20 ] [ 30 ]  While the process is not fully understood, it appears that fatty tissue that is cooled below body temperature, but above freezing, undergoes localized cell death (\" apoptosis \") followed by a local inflammatory response that gradually over the course of several months results in a reduction of the fatty tissue layer. [ 20 ] [ 22 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7401", "text": "Typical cost per treatment area varies depending on location. Price in the US ranges from $750 to $1,500, [ 31 ]  with UK prices about \u00a3750 per area to be treated and in India, the Coolsculpting cost typically ranges from \u20b960,000 to \u20b9115,000. [ 32 ]  In the U.S., the CoolSculpting procedure is FDA-cleared for the treatment of visible fat bulges in the  submental area , thigh, abdomen and flank, along with bra fat, back fat, underneath the  buttocks , and upper arm. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7402", "text": "Injection lipolysis is a procedure that reduces localized subcutaneous fat deposits, most commonly submental fat ( double chin ). This technique involves the injection of lipolytic substances, such as  deoxycholic acid  (branded as Kybella in the United States), directly into the targeted fat tissue. Deoxycholic acid is a naturally occurring  bile acid  that aids in the breakdown and absorption of dietary fat. When injected into subcutaneous fat, it causes the dissolution of the fat cell membranes, causing them to die. The destroyed fat cells are then gradually eliminated by the body's natural metabolic processes over the following weeks. [ 33 ] [ 34 ]  While the procedure is generally considered safe when performed by a qualified healthcare professional, potential side effects may include swelling, bruising, numbness, and rarely, nerve injury in the treated area. [ 33 ] [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7403", "text": "In 2010, Zerona, another low-level laser treatment, was cleared for marketing by the FDA as an infrared lamp. [ 36 ]  Zeltiq obtained FDA marketing clearance for  cryolipolysis  of the flanks, and in 2012 received marketing clearance for cryolipolysis of the abdomen. [ 20 ]  This treatment has also been cleared for the treatment of the upper arm, back fat, bra fat, banana roll, submental area, and thighs. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7404", "text": "Various lipolysis techniques including injection lipolysis, RF, laser, ultrasound, and cryolipolysis were forbidden in France by a decree of the French Public Health Authority in 2011. The decree was revised in 2012, distinguishing invasive techniques, which remain forbidden, from permitted non-invasive techniques; laser, RF, ultrasound and cryolipolysis that did not penetrate the skin became legal, and injection lipolysis and  mesotherapy  remained illegal.  Laser devices that involve inserting the probe through the skin transcutaneously but do not suck out the liquefied material are also prohibited. Surgeons are permitted to perform surgical liposuction techniques using laser-assisted lipolysis so long as suction is performed. [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7405", "text": "Flap surgery  is a technique in  plastic  and  reconstructive surgery  where  tissue  with an intact  blood supply  is lifted from a donor site and moved to a recipient site. Flaps are distinct from  grafts , which do not have an intact blood supply and relies on the growth of new blood vessels. Flaps are done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, wound contraction is to be avoided or to rebuild more complex anatomic structures like breasts or jaws. [ 1 ] [ 2 ]  Flaps may also carry with them tissues such as muscle and bone that may be useful in the ultimate reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7406", "text": "Flap surgery is a technique essential to  plastic  and  reconstructive surgery . A flap is defined as tissue that can be moved to another site and has its own  blood supply . This is in comparison to a  skin graft  which does not have its own blood supply and relies on  vascularization  from the recipient site. [ 2 ]  Flaps have many uses in  wound healing  and are used when wounds are large, complex, or need tissue of various types and bulk for successful closure and function. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7407", "text": "Flaps can contain many different combination of layers of tissue, from skin to bone (see  \u00a7\u00a0Classification ). The main goal of a flap is to maintain blood flow to tissue to maintain survival, and understanding the anatomy in flap design is key to a successful flap surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7408", "text": "Flaps may include skin in their construction. Skin is important for many reasons, but namely its role in  thermoregulation ,  immune function , and blood supply aid in flap survival. [ 2 ]  The skin can be divided into three main layers: the  epidermis ,  dermis , and  subcutaneous tissue . Blood is mainly supplied to the skin by two networks of blood vessels. The deep network lies between the dermis and the subcutaneous tissue, while the shallow network lies within the papillary layer of the dermis. [ 3 ]  The epidermis is supplied by diffusion from this shallow network and both networks are supplied by  collaterals , and by perforating arteries that bring blood from deeper layers either between muscles (septocutaneous perforators) or through muscles (musculocutaneous perforators). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7409", "text": "This robust and redundant blood supply is important in flap surgery, [ 2 ]  because flaps are cut off from other blood vessels when it is raised and removed from its surrounding native tissue. [ 2 ]  The remaining blood supply must then keep the tissue alive until additional blood supply can be formed through  angiogenesis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7410", "text": "The  angiosome  is a concept first coined by Ian Taylor in 1987. [ 5 ]  It is a three-dimensional region of tissue that is supplied by a single artery and can include skin, soft tissue, and bone. [ 5 ] [ 6 ]  Adjacent angiosomes are connected by narrower choke vessels, and multiple angiosomes can be supplied by a single artery. Knowledge of these supply arteries and their associated angiosomes is useful in planning the location, size, and shape of a flap. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7411", "text": "Flaps can be fundamentally classified by their mechanism of movement, the types of tissues present, or by their blood supply. [ 2 ]  The surgeon generally chooses the least complex type that will achieve the desired effect via a concept known as the  reconstructive ladder . [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7412", "text": "Flaps can be classified by the content of the tissue within them."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7413", "text": "Classification based on blood supply to the flap:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7414", "text": "Anyone who is unstable for surgery should not undergo flap surgery. As with most surgeries, people who are sicker may have more difficulties with  wound healing , which include individuals with  comorbidities  such as  diabetes ,  smoking ,  immunosuppression , and  vascular disease . [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7415", "text": "The risks of flap surgery include infection,  wound breakdown ,  fluid accumulation ,  bleeding , damage to nearby structures, and  scarring . [ 10 ]  The most notable risk in this procedure is flap death, where the flap loses blood supply. The loss of blood can be due to many reasons, but is commonly due to tension on the vascular supply and insufficient blood flow to the end segments of the flap. [ 10 ]  This can sometimes be fixed with another surgery or using additional methods of healing in the reconstructive ladder. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7416", "text": "As with healing of any wound, healing of a flap maintains the same process of wound healing. There are four stages to wound healing:  hemostasis ,  inflammation ,  proliferation , and  remodeling , all of which can take up to a year to complete. [ 18 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7417", "text": "Following flap surgery, the biggest risk in recovery is flap death. Flap failure is an uncommon occurrence but does happen. The reported flap failure rate in free flaps is less than 5%. [ 19 ]  The most commonly cause is by  venous insufficiency  consisting of 54% of all causes. [ 19 ]  Venous insufficiency is commonly caused by a  venous thrombus  within the first 2 days following surgery. [ 19 ] [ 18 ]  After the immediate postoperative risk, the flap will continue to heal adhering to the stages of normal wound healing and will take over 3 months for an incision to be at 80% tensile strength compared to normal tissue. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7418", "text": "Skin flaps are an essential part of a surgeon's toolbox in plastic surgery. It is part of the reconstructive ladder. [ 17 ]  The first known reports of surgical flaps originated in 600 BC in India by  Sushruta  where the tilemakers' caste would reconstruct noses using regional flaps due to the practice of nose amputations as a form of legal punishment. [ 20 ] [ 17 ]  The next description of flap surgery comes from Celsus, an ancient Roman who described the advancement of skin flaps from 25 BC to 50 AD. [ 20 ] [ 17 ]  In the 15th century,  Gaspare Tagliacozzi , an Italian surgeon, helped develop the \"Italian method\" for nasal reconstruction, a delayed pedicle skin graft, where the skin from the arm would be attached to the nose for many months to create the reconstruction, first printed in the 1597 book  De Curtorum Chirurgia per Insitionem . [ 21 ]  The Italian method was rediscovered in 1800 by German surgeon  Carl Ferdinand von Graefe . [ 22 ]  Major advancements in modern plastic surgery are mostly attributed to  Harold Gillies , who pioneered facial reconstruction during World War I using pedicled tube flaps on patients like  Walter Yeo , and the development of the  walking-stalk skin flap  by Gilles' cousin  Archibald McIndoe  in 1930. [ 20 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7419", "text": "Advancements continued in flap surgery. With the introduction of the  operating microscope , microvascular surgery advancements allowed for the anastomosis of blood vessels. [ 12 ]  This led to the ability of free tissue transfers, and in 1958 Bernard Seidenberg transferred a part of the  jejunum  to the  esophagus  to remove a  cancer . [ 12 ] [ 24 ]  Modern advancements in flap surgeries have continued since this time and are now commonly used in many procedures. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7420", "text": "Foreskin restoration  or  foreskin reconstruction  refers to the process of recreating the  foreskin  of the  penis , which has been removed by  circumcision  or injury.  Foreskin restoration is primarily accomplished by stretching the residual skin of the penis, but  surgical  methods also exist. Restoration creates a facsimile of the foreskin, but specialized tissues removed during circumcision cannot be reclaimed.  Some forms of restoration involve only partial regeneration in instances of a  high-cut  wherein the circumcisee feels that the circumciser removed too much skin and that there is not enough skin for erections to be comfortable. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7421", "text": "In the  Greco-Roman world , uncircumcised  genitals , including the  foreskin , were considered a sign of beauty,  civility , and masculinity. [ 2 ]   In  Classical Greek and Roman societies  (8th century BC to 6th century AD), exposure of the glans was considered disgusting and improper, and did not conform to the  Hellenistic  ideal of gymnastic nudity. [ 2 ]  Men with short foreskins would wear the  kynodesme  to prevent exposure. [ 3 ]  As a consequence of this  social stigma , an early form of foreskin restoration known as  epispasm  was practiced among some  Jews  in  Ancient Rome  (8th century BC to 5th century AD). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7422", "text": "Foreskin restoration is of ancient origin and dates back to the  Alexandrian Empire  (333 BC). Males participated in the gymnasium nude and because the  Greeks  did not practice circumcision anyone who was circumcised was socially shunned. Hellenized Jews stopped circumcising their sons to avoid persecution and so they could participate in the gymnasium. Some Jews at this time attempted to restore their foreskins. This caused conflict within Second Temple Judaism, some Jews viewed circumcision as an essential part of the Jewish identity (1 Maccabees 1:15). [ 5 ]  Following the death of Alexander, Judea and the Levant was part of the  Seleucid Empire  under  Antiochus Epiphanes  (175-164 BC). Antiochus outlawed the Jewish practice of circumcision, both 1st and 2nd Maccabees records Jewish mothers being put to death for circumcising their sons (1:60-61 and 6:10 respectively). [ 6 ]  Some Jews during Antiochus' persecution sought to undo their circumcision. [ 7 ]  Within the 1st century A.D., there was still some forms of foreskin restoration being sought after (1 Corinthians 7:18). During the third  Jewish-Roman Wars  (AD 132\u2013135), the Romans had renamed Jerusalem as Aelia Capitolian and may have banned circumcision; however, Roman sources from the period only mention  castration  and say nothing about banning circumcision. During the  Bar Kokhba  revolt, there is Rabbinic evidence that records, Jews who had removed their circumcision (meaning that foreskin restoration was still being practiced) they were recircumcised, voluntarily or by force. [ 8 ]  Again, during  World War II , some  European Jews  sought foreskin restoration to avoid  Nazi persecution . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7423", "text": "Non-surgical foreskin restoration, accomplished through  tissue expansion , is the more commonly used method. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7424", "text": "Tissue expansion has long been known to stimulate  mitosis , and research shows that regenerated human tissues have the attributes of the original tissue. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7425", "text": "During restoration via tissue expansion, the remaining penile skin is pulled forward over the glans, and  tension  is maintained either manually or through the aid of a  foreskin restoration device . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7426", "text": "Surgical methods of foreskin restoration, known as foreskin reconstruction, usually involve a method of  grafting  skin onto the  distal  portion of the penile shaft. The grafted skin is typically taken from the  scrotum , which contains the same  smooth muscle  (known as  dartos fascia ) as does the skin of the penis. One method involves a four-stage procedure in which the penile shaft is buried in the scrotum for a period of time. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7427", "text": "Restoration creates a facsimile of the  prepuce , but specialized tissues removed during circumcision cannot be reclaimed. [ medical citation needed ]  Surgical procedures exist to reduce the size of the opening once restoration is complete (as depicted in the image above), [ 14 ]  or it can be alleviated through a longer commitment to the skin expansion regime to allow more skin to collect at the tip. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7428", "text": "The natural foreskin is composed of smooth dartos muscle tissue (called the  peripenic muscle [ 16 ] ), large blood vessels, extensive innervation, outer skin, and inner mucosa. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7429", "text": "The process of foreskin restoration seeks to regenerate some of the tissue removed by circumcision, as well as provide coverage of the glans.  According to research, the foreskin comprises over half of the skin and mucosa of the human penis. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7430", "text": "In a survey restorers reported restoration; increased their sexual pleasure for 69% and improved their relationship for 25%  [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7431", "text": "Various groups have been founded since the late 20th century, especially in  North America  where circumcision has been routinely performed on infants. In 1989, the  National Organization of Restoring Men  (NORM) was founded as a non-profit support group for men undertaking foreskin restoration. In 1991, the group UNCircumcising Information and Resource Centers (UNCIRC) was formed, [ 20 ]  which was incorporated into NORM in 1994. [ 21 ]  NORM chapters have been founded throughout the United States, as well as in Canada, the United Kingdom, Australia, New Zealand, and Germany. In France, there are two associations about this. The \" Association contre la Mutilation des Enfants \" AME (association against child mutilation), and more recently \" Droit au Corps \" (right to the body). [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7432", "text": "Circumcised  barbarians , along with any others who revealed the  glans penis , were the butt of ribald  humor . For  Greek art  portrays the foreskin, often drawn in meticulous detail, as an emblem of male beauty; and children with congenitally short foreskins were sometimes subjected to a treatment, known as  epispasm , that was aimed at elongation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7433", "text": "The terms  free flap ,  free autologous tissue transfer  and  microvascular free tissue transfer  are synonymous terms used to describe the \"transplantation\" of tissue from one site of the body to another, in order to reconstruct an existing defect.  \"Free\" implies that the tissue is completely detached from its blood supply at the original location (\"donor site\") and then transferred to another location (\"recipient site\") and the circulation in the tissue re-established by  anastomosis of artery(s) and vein(s) .  This is in contrast to a \"pedicled\" flap in which the tissue is left partly attached to the donor site (\"pedicle\") and simply transposed to a new location; keeping the \"pedicle\" intact as a conduit to supply the  tissue  with blood."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7434", "text": "Various types of tissue may be transferred as a \"free flap\" including skin and fat, muscle, nerve, bone, cartilage (or any combination of these),  lymph nodes  and intestinal segments.  An example of \"free flap\" could be a \"free toe transfer\" in which the great toe or the second toe is transferred to the hand to reconstruct a thumb. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7435", "text": "For all \"free flaps\", the blood supply is reconstituted using  microsurgical techniques  to reconnect the artery (brings blood into the flap) and vein (allows blood to flow out of the flap)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7436", "text": "Free  autologous  tissue transfer is performed by many surgical specialties."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7437", "text": "Free flaps are used to reconstruct tissue defects. Particularly when postoperative radiotherapy is indicated, vascularized free tissue is preferred over non-vascularized free tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7438", "text": "Breast reconstruction:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7439", "text": "Hand reconstruction:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7440", "text": "Head and Neck reconstruction:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7441", "text": "When reconstructing complex head and neck defects, the reconstruction often requires bone and soft tissue from a distant donor site to be harvested. Functional reconstruction in the head and neck area often requires reconstruction of the oral cavity, the jawbone and the dental occlusion. Type of defects include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7442", "text": "The most common serious complication of a free flap is loss of the venous outflow (e.g. a clot forms in the vein that drains the blood from the flap). Loss of arterial supply is serious too and both will cause  necrosis  (death) of the flap. Close monitoring of the flap both by nurses and by the surgeon is mandatory following the completion of the operation. [ 2 ] [ 3 ]  If detected early, loss of either the venous or arterial blood supply may be corrected by operative intervention. Many times an implantable Doppler probe or other devices can be installed during surgery to provide better monitoring in the post-operative period. The Doppler probe can be removed before discharge from the hospital."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7443", "text": "Usually the harvest of a \"free flap\" is performed in such a fashion to cause the least amount of disability. Despite this some disability may occur following removal of this tissue from the \"donor site\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7444", "text": "Other complications/sequalae which may occur with any surgery are also possible, including infection and pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7445", "text": "Genitoplasty  is  plastic surgery  to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from  cancer treatment , or congenital disorders, endocrine conditions, or they may be cosmetic. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7446", "text": "Genitoplasty surgery includes the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7447", "text": "The grafts used in genitalplasty can be an  allogenic , an  autograft , a  xenograft , or an  autologous  material. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7448", "text": "Genital reconstruction surgery can correct  prolapse  of the  urinary bladder  into the vagina and protrusion of the rectum into the vagina. [ 2 ]  Female infants born with a  46,XX  genotype but have genitalia affected by  congenital adrenal hyperplasia  may undergo the surgical creation of a vagina. [ citation needed ]  Vaginoplasty is commonly used to treat women with the congenital absence of the vagina. [ 3 ]  Other reasons for the surgery are to treat adrenal hyperplasia, microphallus, Mayer-Rokitansky-Kustner disorder and for women who have had a vaginectomy after malignancy or trauma. Reconstructive and corrective vaginal surgery restores or creates the vagina. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7449", "text": "Surgeries to modify the cosmetic appearance of infants' and children's genitals  are controversial due to their  human rights implications . There is no clinical consensus about necessity, timing, indications or evaluation. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7450", "text": "A  ghost surgery  is a surgery in which the person who performs the operation, the \"ghost surgeon\" or \"ghost doctor\", is not the surgeon that was hired for and is credited with the operation. The ghost doctor substitutes the hired surgeon while the patient is unconscious from  anesthesia . [ 1 ] [ 2 ]  Ghost doctors are often unlicensed and unqualified to perform the operations they are hired for. [ 1 ] [ 3 ]  Ghost surgery is widely considered to be unethical. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7451", "text": "Today, ghost surgery is particularly common in the  South Korean cosmetic surgery industry , in which it is \"rampant.\" [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7452", "text": "The term \"ghost surgery\" was originally used to refer to qualified surgeons performing operations in the place of the unqualified physicians credited with the operation. [ 5 ] [ 6 ]  By the late 1970s, following multiple highly publicized cases of medical equipment  salesmen  participating in surgery, it came to refer to multiple kinds of scenarios in which one individual substitutes the officially credited surgeon in an operation. [ 5 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7453", "text": "The Lifflander Report, a 1978 investigation commissioned by Speaker of the State Assembly of New York  Stanley Steingut , found that 50-95% of surgeries in teaching hospitals were performed by  residents  under supervision, rather than by the lead surgeon. The report concluded that this generally does not decrease the quality of care, and is necessary for medical students to gain experience. However, patients typically do not understand and are not properly notified of the extent to which persons besides the lead surgeon will participate in the surgery. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7454", "text": "Ghost surgery has continued as a practice into the present day; most reports of ghost surgery in the United States involve associates or residents performing operations to a greater extent than the patient consented to. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7455", "text": "In  South Korea , ghost surgery boomed in the 2010s with the increase in demand for  plastic surgery , following the government's promotion of  medical tourism . Ghost surgeries allow surgeons to double-book operations and otherwise maximize the number of patients they accept. [ 2 ]  Reports of ghost surgery in South Korea often involve dentists, nurses, or salespeople. One former ghost doctor reported that most substitutes were dentists. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7456", "text": "As ghost surgeries are untracked, it is unclear how common they are. Patients typically discover a ghost surgery took place after undergoing an unsuccessful operation. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7457", "text": "Hospital records from  Parkland Hospital  in 2007-2008 showed that there were 161 surgeries in which residents operated for some time without supervision. Of these surgeries, 18% of the time the surgeon was not present for any part of the operation. Overall, across these surgeries, the surgeon was absent from 83% of the total operating time. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7458", "text": "Ghost surgeries are \"rampant\" in the South Korean cosmetic surgery industry today, and are increasingly common nationwide in other areas such as spinal surgeries. [ 1 ] [ 2 ] [ 3 ]  The Korean Society of Plastic Surgeons estimated that there were about 100,000 victims of ghost surgery in South Korea between 2008 and 2014. About five patients died during ghost surgeries in South Korea between 2014 and 2022. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7459", "text": "In 1975, William MacKay, the general sales manager of a prosthetics company, participated in the bone surgery of Franklin Mirando at the request of the lead surgeons, David Lipton and Harold Massoff. [ 7 ] [ 11 ]  MacKay had never gone to high school and had no medical training, but was interested in surgery; by the time of Mirando's operation, he had been frequently involved in surgical procedures, especially in those where prosthetics his company sold were involved. [ 7 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7460", "text": "MacKay was present for Mirando's operation while his hip was replaced, using equipment from his company. [ 12 ]  Feeling that his advice was being ignored by Lipton and Massoff, he left to go golfing, but was called back to the operating room by Lipton and Massoff when it was discovered the implant had come loose. [ 12 ] [ 13 ]  MacKay spent three and a half hours operating. [ 7 ]  It was later found that medical records had been manipulated to remove evidence of MacKay's participation in the operation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7461", "text": "Mirando, who had been permanently crippled by the 10-hour operation, filed a $2 million malpractice suit against Lipton, Massoff, and Smithtown General Hospital; the case was settled out of court for $1 million in 1980. [ 11 ] [ 13 ]  He stated that he was unaware of MacKay's involvement when suing and that he filed the suit because the surgery had only worsened his condition. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7462", "text": "Lipton and Massoff were indicted for allowing a non-licensed person to practice medicine and for manipulation of medical records, but charges were dropped in 1978, after the District Attorney spearheading the investigation was defeated for re-election. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7463", "text": "In October 2016, university student Kwon Dae-hee died from excessive bleeding after undergoing a jawline surgery partially conducted by a ghost doctor. [ 1 ] [ 2 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7464", "text": "Kwon had been bullied in high school for his chin shape and was insecure about his appearance; he booked his cosmetic surgery after seeing an ad for Center A, a well-known cosmetic surgery clinic in Seoul at the time. His family was not aware of the surgery until Kwon's subsequent hospitalization. [ 1 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7465", "text": "After reviewing  CCTV  footage of the surgery, Kwon's mother found that much of the operation took place with a general doctor, rather than the hired surgeon, in charge, and portions of the operation were performed by nursing assistants with neither doctor nor surgeon present. [ 1 ] [ 2 ]  The hired surgeon, who had been explicitly advertised as performing surgeries from start to finish, was carrying out operations on multiple patients at the same time. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7466", "text": "After the surgery, both doctors went home. Kwon lost over 3.5 liters of blood, over three times the amount later reported by the medical staff; the unsupervised assistants had to mop the bloodied floor over a dozen times. [ 1 ] [ 14 ]  Kwon was transferred to the hospital that night, and died seven weeks later. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7467", "text": "Kwon's family won 430 million  won  in damages against the clinic in 2019. [ 1 ]  The surgeon in the case was sentenced in 2021 to three years of prison for involuntary manslaughter. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7468", "text": "Following Kwon's death, his mother protested regularly in front of the  Korea National Assembly Proceeding Hall  to call for a bill, sometimes known as the \"Kwon Dae-hee bill\", that mandates the installation of security cameras in operating rooms. [ 1 ] [ 16 ]  The bill was passed in August 2021, in part due to the public response to Kwon's death. [ 14 ] [ 16 ]  The bill received objections from doctors, hospitals and medical groups, including the  Korean Medical Association , claiming that the cameras in the operating rooms would undermine trust in doctors, violate patient privacy and discourage doctors from taking risks to save lives. A poll by the Anti\u2011Corruption and Civil Rights Commission found that 97.9% of respondents supported the bill. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7469", "text": "Ghost surgery was included in the plot of  Squid Game . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7470", "text": "Glanuloplasty  is  plastic surgery  carried out on a  glans .  Typical examples include correcting a  hypospadias  on the  penis , [ 1 ]  or attempting to restore a  clitoris  mutilated by  female genital cutting ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7471", "text": "Hair removal  is the deliberate removal of  body hair  or head  hair . This process is also known as  epilation  or  depilation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7472", "text": "Hair is a common feature of the human body, exhibiting considerable variation in thickness and length across different populations. Hair becomes more visible during and after  puberty . Additionally, men typically exhibit thicker and more conspicuous body hair than women. [ 1 ] \nBoth males and females have visible body hair on the  head ,  eyebrows ,  eyelashes ,  armpits ,  genital area ,  arms , and  legs . Males and some females may also have thicker hair growth on their  face ,  abdomen ,  back ,  buttocks ,  anus ,  areola ,  chest ,  nostrils , and  ears . Hair does not generally grow on the  lips , back of the ear, the underside of the  hands  or  feet , or on certain areas of the  genitalia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7473", "text": "Hair removal may be practiced for cultural,  aesthetic ,  hygienic , sexual, medical, or religious reasons. Forms of hair removal have been practiced in almost all human cultures since at least the  Neolithic  era. The methods used to remove hair have varied in different times and regions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7474", "text": "The term \"depilation\" is derived from the  Medieval Latin  \"depilatio,\" which in turn is derived from the  Latin  \"depilare,\" a word formed from the prefix \"de-\" and the root \"pilus,\" meaning \"hair.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7475", "text": "For centuries, hair removal has long shaped  gender roles , served to signify  social status  and defined notions of femininity and the ideal \" body image \". [ 2 ] [ 3 ]  In early periods, the condition of being hairless was mostly done as a way to keep the body clean, using flint, seashells, beeswax and various other depilatory utensils and exfoliator substances, some highly questionable and highly caustic. [ 3 ] [ 4 ]   Ancient Rome  also associated hair removal with status: a person with smooth skin was associated with purity and superiority. Removing body hair was done by both men and women [ 2 ] [ 3 ] [ 5 ] [ 6 ] \nPsilothrum or psilotrum ( Ancient Greek :  \u03c8\u03af\u03bb\u03c9\u03b8\u03c1\u03bf\u03bd ) and dropax (Ancient Greek:  \u03b4\u03c1\u1ff6\u03c0\u03b1\u03be ) were depilatories in ancient Greece and Rome. [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7476", "text": "In  Ancient Egypt , besides being a fashion statement for affluent Egyptians of all genders, [ 3 ] [ 10 ]  hair removal served as a treatment for  louse infestation , which was a prevalent issue in the region. [ 11 ]  Very often, they would replace the removed head hair with a  Nubian wig , which was seen as easier to maintain and also fashionable. [ 11 ]  Ancient Egyptian priests also shaved or depilated all over daily, so as to present a \"pure\" body before the images of the gods. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7477", "text": "In ancient times, one highly abrasive depilatory paste consisted of an admixture of  slaked lime , water, wood-ash and yellow  orpiment  ( arsenic trisulfide ); In rural India and Iran, where this mixture is called  vajibt , it is still commonly used to remove  pubic hair . [ 3 ] [ 4 ] [ 12 ]  In other cultures, oil extracted from unripe olives (which had not reached one-third of their natural stage of ripeness) was used to remove body hair. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7478", "text": "During the  medieval period ,  Catholic  women were expected to let their hair grow long as a display of femininity, whilst keeping the hair concealed by wearing a  wimple  headdress in public places. [ 2 ]  The face was the only area where hair growth was considered unsightly; 14th-century ladies would also pick off hair from their foreheads to recede the hairline and give their face a more oval form. From the mid-16th century, it is said when Queen  Elizabeth I  came to power, she made  eyebrow  removal fashionable. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7479", "text": "By the 18th century, body hair removal was still considered a non-necessity by European and American women. But in 1760, when the first safety  straight razor  appeared for men to safely shave their beard and not inadvertently cut themselves, some women allegedly used this safety razor too. [ 2 ]  It was invented in Paris by the French master cutler  Jean-Jacques Perret \u00a0[ fr ] , author of  La pogonotomie, ou L'art d'apprendre \u00e0 se raser soi-m\u00eame  ( Pogonotomy , or The Art of Learning to Shave). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7480", "text": "It was not until the late 19th century that women in Europe and America started to make hair removal a component of their  personal care  regime. According to  Rebecca Herzig , the modern-day notion of body hair being unwomanly can be traced back to  Charles Darwin 's book first published in 1871 \"The Descent of Man and Selection in Relation to Sex\". Darwin's theory of natural selection associated body hair with \"primitive ancestry and an atavistic return to earlier less developed forms\", writes Herzig, a professor of gender and sexuality studies at Bates College in Maine. [ 2 ]  Darwin also suggests having less body hair was an indication of being more evolved and sexually attractive. [ 2 ]  As Darwin's ideas polarized, other 19th century medical and scientific experts started to link hairiness to \"sexual inversion, disease pathology, lunacy, and criminal violence\". Those connotations were mostly applied to women's and not men's body hair. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7481", "text": "By the early 20th century, the upper- and middle-class  white America  increasingly saw smooth skin as a marker of femininity, and female body hair as repulsive, with hair removal giving \"a way to separate oneself from cruder people, lower class and immigrant\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7482", "text": "Harper's Bazaar , in 1915, was the first women's fashion magazine to run a campaign devoted to the removal of  underarm hair  as \"a necessity\". Shortly after,  Gillette  launched the first safety razor marketed specifically for women\u2014the \"Milady D\u00e9collet\u00e9 Gillette\", one that solves \"...an embarrassing personal problem\" and keeps the underarm \"...white and smooth\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7483", "text": "Body hair characteristics such as thickness and length vary across human populations, some people have less pronounced  body hair  and others have more conspicuous body hair characteristics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7484", "text": "Each  culture  of human  society  developed  social norms  relating to the presence or absence of body hair, which has changed from one time to another. Different standards of  human physical appearance  and  physical attractiveness  can apply to females and males. People whose hair falls outside a culture's aesthetic  body image  standards may experience real or perceived  social acceptance  problems, psychological distress and  social pressure . For example, for women in several societies, exposure in public of body hair other than head hair, eyelashes and eyebrows is generally considered to be  unaesthetic , unattractive and  embarrassing . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7485", "text": "With the increased popularity in many countries of women wearing  fashion  clothing,  sportswear  and  swimsuits  during the 20th century and the consequential exposure of parts of the body on which hair is commonly found, there has emerged a popularization for women to remove visible  body hair , such as on legs, underarms and elsewhere, or the consequences of  hirsutism  and  hypertrichosis . [ 2 ] [ 15 ]  In most of the  Western world , for example, the vast majority of women regularly shave their legs and armpits, while roughly half also shave hair that may become exposed around their  bikini  pelvic area (often termed the \"bikini line\"). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7486", "text": "In Western and Asian cultures, in contrast to most Middle Eastern cultures, a majority of men are accustomed to shaving their facial hair, so only a minority of men reveal a  beard , even though fast-growing facial hair must be shaved daily to achieve a  clean-shaven  or beardless appearance. Some men shave because they cannot genetically grow a \"full\" beard (generally defined as an even density from cheeks to neck), their beard color is genetically different from their scalp hair color, or because their facial hair grows in many directions, making a  groomed  or contoured appearance difficult to achieve. Some men shave because their beard growth is excessive, unpleasant, or coarse, causing skin irritation. Some men grow a beard or  moustache  from time to time to change their appearance or visual style."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7487", "text": "Some men  tonsure  or  head shave , either as a religious practice, a fashion statement, or because they find a shaved head preferable to the appearance of  male pattern baldness , or in order to attain enhanced cooling of the skull \u2013 particularly for people suffering from  hyperhidrosis . A much smaller number of Western women also shave their heads, often as a fashion or political statement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7488", "text": "Some women also shave their heads for cultural or social reasons. In India, tradition required widows in some sections of the society to shave their heads as part of being  ostracized  (see  Women in Hinduism \u00a7\u00a0Widowhood and remarriage ). The outlawed custom is still infrequently encountered mostly in rural areas. Society at large and the government are working to end the practice of ostracizing widows. [ 16 ]  In addition, it continues to be common practice for men to shave their heads prior to embarking on a pilgrimage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7489", "text": "The  unibrow  is considered a sign of beauty and attractiveness for women in  Oman  and for both genders in  Tajikistan , often emphasized with  kohl . [ 2 ]  In Middle Eastern societies, regular trimming or removal of female and male  underarm hair  and pubic hair has been considered proper personal  hygiene , necessitated by local customs, for many centuries. [ 3 ] [ 17 ] [ 18 ]  Young girls and unmarried women, however, are expected to retain their body hair until shortly before marriage, when the whole body is depilated from the neck down. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7490", "text": "In China, body hair has long been regarded as normal, and even today women are confronted with far less  social pressure  to remove body hair. [ 2 ]  The same attitude exists in other countries in Asia. While hair removal has become routine for many of the continent's younger women, trimming or removing pubic hair, for instance, is not as common or popular as in the  Western world , [ 2 ]  where both women and men may trim or remove all their pubic hair for  aesthetic  or  sexual reasons . This custom can be motivated by reasons of potentially increased personal cleanliness or hygiene, heightened sensitivity during  sexual activity , or the desire to take on a more exposed appearance or visual appeal, or to boost  self-esteem  when affected by excessive hair. In Korea, pubic hair has long been considered a sign of fertility and sexual health, and it has been reported in the mid-2010s that some Korean women were undergoing pubic hair transplants, to add extra hair, [ 2 ]  especially when affected by the condition of pubic atrichosis (or  hypotrichosis ), which is thought to affect a small percentage of Korean women. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7491", "text": "Unwanted or excessive hair is often removed in preparatory situations by both sexes, in order to avoid any perceived  social stigma  or prejudice. For example, unwanted or excessive hair may be removed in preparation for an intimate encounter, or before visiting a public beach or swimming pool."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7492", "text": "Though traditionally in Western culture women remove body hair and men do not, some women choose not to remove hair from their bodies, either as a non-necessity or as an act of rejection against  social stigma , while some men remove or trim their body hair, a practice that is referred to in modern society as being a part of \"manscaping\" (a  portmanteau expression  for  male-specific grooming )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7493", "text": "The term \" glabrousness \" also has been applied to human fashions, wherein some participate in culturally motivated hair removal by depilation (surface removal by  shaving ,  dissolving ), or  epilation  (removal of the entire hair, such as  waxing  or  plucking )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7494", "text": "Although the appearance of secondary hair on parts of the human body commonly occurs during  puberty , and therefore, is often seen as a symbol of adulthood, removal of this and other hair may become fashionable in some cultures and subcultures. In many modern  Western cultures , men are encouraged to shave their beards, and women are encouraged to remove hair growth in various areas. Commonly depilated areas for women are the underarms, legs, and pubic hair. Some individuals depilate the forearms. In recent years, bodily depilation in men has increased in popularity among some subcultures of Western males. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7495", "text": "For men, the practice of depilating the pubic area is common, especially for aesthetic reasons. Most men will use a razor to shave this area, however, as best practice, it is recommended to use a body trimmer to shorten the length of the hair before shaving it off completely."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7496", "text": "In ancient Egypt, depilation was commonly practiced, with  pumice  and  razors  used to shave. [ 20 ] [ 21 ]  In both  Ancient Greece  and  Ancient Rome , the removal of body and pubic hair may have been practiced among both men and women. It is represented in some artistic depictions of male and female nudity,  [ citation needed ]  examples of which may be seen in  red figure pottery  and sculptures like the  Kouros  of Ancient Greece in which both men and women were depicted without body or pubic hair. Emperor  Augustus  was said, by Suetonius, to have applied \"hot nutshells\" on his legs as a form of depilation. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7497", "text": "In the  clothes free movement , the term \"smoothie\" refers to an individual who has removed their body hair. In the past, such practices were frowned upon and in some cases,  forbidden: violators could face exclusion from the club. Enthusiasts grouped together and formed societies of their own that catered to that fashion, and smoothies became a major percentage at some nudist venues. [ 23 ]  The first Smoothie club (TSC) was founded by a British couple in 1991. [ 24 ]  A Dutch branch was founded in 1993 [ 25 ]  in order to give the idea of a hairless body greater publicity in the  Netherlands . Being a Smoothie is described by its supporters as exceptionally comfortable and liberating. The Smoothy-Club is also a branch of the World of the Nudest Nudist (WNN) and organizes nudist ship cruises and regular nudist events."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7498", "text": "Head-shaving ( tonsure ) is a part of some  Buddhist ,  Christian ,  Muslim ,  Jain  and  Hindu  traditions. [ 26 ]  Buddhist and Christian  monks  generally undergo some form of tonsure during their induction into monastic life. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7499", "text": "Within  Amish  society, tradition ordains men to stop shaving a part of their facial hair upon marriage and grow a  Shenandoah  style beard which serves the significance of wearing a  wedding ring ,  moustaches  are rejected as they are regarded as martial (traditionally associated with the  military ). [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7500", "text": "In  Judaism  (see  Shaving in Judaism ), there is no obligation for women to remove body hair or facial hair, unless they wish to do so. However, in preparation for a woman's immersion in a  ritual bath  after concluding her days of purification (following her menstrual cycle), the custom of Jewish women is to shave off their pubic hair. [ 28 ]  During a  mourning  ritual, Jewish men are restricted in the  Torah  and  Halakha  to using scissors and prohibited from using a razor blade to shave their beards or sideburns, [ 29 ]  and, by custom, neither men nor women may cut or shave their hair during the  shiva  period. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7501", "text": "The  Bah\u00e1\u02bc\u00ed Faith  recommends against complete and long-term head-shaving outside of medical purposes. It is not currently practiced as a law, contingent upon a future decision by the  Universal House of Justice , its highest governing body.  Sikhs  take an even stronger stance, opposing all forms of hair removal. One of the \" Five Ks \" of Sikhism is  Kesh , meaning \"hair\". [ 32 ]  Baptized Sikhs are specifically instructed to have unshorn Kesh (the hair on their head and beards for men) as a major tenet of the Sikh faith. To Sikhs, the maintenance and management of long hair is a manifestation of one's piety. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7502", "text": "The majority of Muslims believe that adult removal of pubic and axillary hair, as a hygienic measure, is religiously beneficial. Under Muslim law ( Sharia ), it is recommended to keep the beard. [ citation needed ]  A Muslim may trim or cut hair on the head. In the 9th century, the use of  chemical depilatories  for women was introduced by  Ziryab  in  Al-Andalus . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7503", "text": "The body hair of surgical patients is often removed beforehand on the skin surrounding  surgical sites . Shaving was the primary form of hair removal until reports in 1983 showed that it may lead to an increased risk of infection.  [ 33 ]   Clippers  are now the recommended pre-surgical hair removal method. [ 34 ] [ 35 ]  A 2021  systematic review  brought together evidence on different techniques for hair removal before surgery. This involved 25 studies with a total of 8919 participants. Using a razor probably increases the chance of developing a surgical site infection compared to using clippers or hair removal cream or not removing hair before surgery. [ 36 ]  Removing hair on the day of surgery rather than the day before may also slightly reduce the number of infections. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7504", "text": "Some people with  trichiasis  find it medically necessary to remove ingrown eyelashes. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7505", "text": "The shaving of hair has sometimes been used in attempts to eradicate  lice  or to minimize  body odor  due to the accumulation of odor-causing  micro-organisms  in hair. In extreme situations, people may need to remove all body hair to prevent or combat infestation by  lice ,  fleas  and other parasites. Such a practice was used, for example, in  Ancient Egypt . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7506", "text": "It has been suggested that an increasing percentage of humans  removing  their pubic hair has led to reduced  crab louse  populations in some parts of the world. [ 39 ] [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7507", "text": "A  buzz cut  or completely shaven haircut is common in military organizations where, among other reasons, it is considered to promote uniformity and neatness. [ 41 ] [ 42 ]  Most militaries have  occupational safety and health  policies that govern the hair length and hairstyles permitted; [ 41 ]  in the field and living in close-quarter environments where bathing and sanitation can be difficult, soldiers can be susceptible to parasite infestation such as  head lice , that are more easily propagated with long and unkempt hair. [ 43 ]  It also requires less maintenance in the field and in adverse weather it dries more quickly. Short hair is also less likely to cause severe burns from flash flame exposure (as a result of  flash fires  from  explosions ) which can easily set hair alight. [ 41 ]  Short hair can also minimize interference with safety equipment and fittings attached to the head, such as  combat helmets  and  NBC suits . [ 41 ]  Militaries may also require men to maintain clean-shaven faces as facial hair can prevent an air-tight seal between the face and  military gas masks  or other  respiratory  equipment, such as a  pilot's oxygen mask , or  full-face diving mask . [ 41 ]  The process of testing whether a mask adequately fits the face is known as a \" respirator fit test \"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7508", "text": "In many militaries, head-shaving (known as the  induction cut ) is mandatory for men when beginning their  recruit training . However, even after the initial recruitment phase, when head-shaving is no longer required, many soldiers maintain a completely or partially shaven hairstyle (such as a \" high and tight \", \" flattop \" or \" buzz cut \") for personal convenience or neatness. Head-shaving is not required and is often not permitted for women in military service, although they must have their hair cut or tied to regulation length. [ 42 ]  For example, the shortest hair a female soldier can have in the U.S. Army is 1/4 inch from the scalp. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7509", "text": "It is a common practice for professional  footballers (soccer players)  and  road cyclists  to remove leg hair for a number of reasons. In the case of a crash or tackle, the absence of the leg hair means the injuries (usually  road rash  or scarring) can be cleaned up more efficiently, and treatment is not impeded. Professional cyclists, as well as professional footballers, also receive regular leg  massages , and the absence of hair reduces the friction and increases their comfort and effectiveness. [ citation needed ]  Football players are also required to wear shin guards, and in case of a skin rash, the affected area can be treated more efficiently."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7510", "text": "It is also common for  competitive swimmers  to shave the hair off their legs, arms, and torsos (and even their whole bodies from the neckline down), to reduce drag and provide a heightened \"feel\" for the water by removing the exterior layer of skin along with the body hair. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7511", "text": "In some situations, people's hair is shaved as a punishment or a form of humiliation. After World War II, head-shaving was a common punishment in France, the Netherlands, and Norway for women who had collaborated with the Nazis during the occupation, and, in particular, for women who had sexual relations with an occupying soldier. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7512", "text": "In the United States, during the  Vietnam War , conservative students would sometimes attack student radicals or \"hippies\" by shaving beards or cutting long hair. One notorious incident occurred at  Stanford University , when unruly fraternity members grabbed  Resistance  founder (and student-body president)  David Harris , cut off his long hair, and shaved his beard."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7513", "text": "During European  witch-hunts  of the  Medieval  and  Early Modern periods , alleged  witches  were stripped naked and their entire body shaved to discover the so-called  witches' marks . The discovery of witches' marks was then used as evidence in trials. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7514", "text": "Inmates have their heads shaved upon entry at certain prisons. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7515", "text": "\"Depilation\", or temporary removal of hair to the level of the skin, lasts several hours to several days and can be achieved by"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7516", "text": "\"Epilation\", or removal of the entire hair from the root, lasts several days to several weeks and may be achieved by"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7517", "text": "Electrology  has been practiced in the United States since 1875. [ 56 ]  It is approved by the  FDA . This technique permanently destroys germ cells [ citation needed ]  responsible for hair growth by way of the insertion of a fine probe into the hair follicle and the application of a current adjusted to each hair type and treatment area. [ citation needed ]  Electrology is the only permanent hair removal method recognized by the FDA. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7518", "text": "A 2006 review article in the journal \"Lasers in Medical Science\" compared intense pulsed light (IPL) and both alexandrite and diode lasers. The review found no statistical difference in effectiveness, but a higher incidence of side effects with diode laser-based treatment. Hair reduction after 6 months was reported as 68.75% for alexandrite lasers, 71.71% for diode lasers, and 66.96% for IPL. Side effects were reported as 9.5% for alexandrite lasers, 28.9% for diode lasers, and 15.3% for IPL. All side effects were found to be temporary and even  pigmentation  changes returned to normal within 6 months. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7519", "text": "A 2006 meta-analysis of randomized controlled trials found that alexandrite and diode lasers caused 50% hair reduction for up to 6 months, while there was no evidence of hair reduction from intense pulsed light, neodymium-YAG or ruby lasers. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7520", "text": "Many methods have been proposed or sold over the years without published clinical proof they can work as claimed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7521", "text": "There are several disadvantages to many of these hair removal methods."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7522", "text": "Hair removal can cause issues: skin inflammation, minor burns, lesions, scarring, ingrown hairs, bumps, and infected hair follicles ( folliculitis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7523", "text": "Some removal methods are not permanent, can cause medical problems and permanent damage, or have very high costs. Some of these methods are still in the testing phase and have not been clinically proven."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7524", "text": "One issue that can be considered an advantage or a disadvantage depending upon an individual's viewpoint, is that removing hair has the effect of removing information about the individual's hair growth patterns due to  genetic  predisposition, illness,  androgen  levels (such as from pubertal hormonal imbalances or drug side effects), and/or  gender  status."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7525", "text": "In the hair follicle, stem cells reside in a discrete microenvironment called the bulge, located at the base of the part of the follicle that is established during morphogenesis but does not degenerate during the hair cycle. The bulge contains multipotent stem cells that can be recruited during wound healing to help repair the epidermis. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7526", "text": "Hairline lowering  (alternately, a  scalp advancement  or  forehead reduction ) is a  surgical  technique that allows an individual to have their frontal hairline advanced certain distances depending on variables such as pre-operative hairline height,  scalp  laxity, and patient preference. [ 1 ]  It can be used to address a congenitally high hairline or  sometimes a hairline that has recessed from  hair loss . It is performed mostly on women. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7527", "text": "Hairline lowering surgery is also recommended to many patients undergoing  facial feminization surgery  (FFS). The shape of the hairline is altered, creating a low, feminine hairline. For MTF (male to female) patients who have very prominent brow bones, brow bone shaving may be performed additionally."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7528", "text": "Satisfactory hairline lowering is a balance between patient expectations and anatomical limitations. Scalp laxity is a primary determinant of extent of hairline advancement. When scalp laxity is insufficient for the desired amount of advancement, use of  tissue expanders  can greatly increase the possible advancement. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7529", "text": "Hairline lowering is typically performed on an outpatient basis with local anesthesia and intravenous sedation. The surgeon marks the anticipated postoperative hairline prior to surgery. The new hairline can be tailored to the patient's preferences and is often wavy to mimic a natural hairline. During the surgery, the excess forehead and/or scalp is excised and the scalp is advanced to the new hairline. The incisions are made in such a manner (trichophytic) so that hair regrows through and in front of the eventual hairline scar making it undetectable. [ 4 ]   The scalp has to be separated from the skull going far back almost to the neck. [ 3 ]    Additional scalp advancement can be achieved by incising the galea (the deep fibrous inelastic scalp layer)  which allows the scalp to stretch. [ 3 ]  Sometimes the surgeon will use implantable devices or sutures to secure the scalp to the bone at its new forward location. The surgeon will usually close the wound with two layers of  sutures or surgical clips. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7530", "text": "The resultant scar from hairline advancement is typically hidden by regrowth of hair, in some cases with  cowlicks , the scar can be seen. In such cases  hair transplants  can totally disguise the scar. In males with progressive baldness, the surgical scar may become more visible as balding advances. Hair thinning from \"shock loss\" can occur and is usually temporary. [ 5 ]  Infections are rare. Follicular unit hair transplants can be done as an alternative treatment although the results take up to two years to get enough hair length and density to compare with the near instantaneous results of the hairline lowering operation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7531", "text": "Hand surgery  deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or  upper extremity  (commonly from the tip of the hand to the shoulder) [ 1 ]  including injury and infection. [ 2 ]  Hand surgery may be practiced by post graduates of  orthopedic surgery  and  plastic surgery  and  MCh Hand surgery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7532", "text": "Plastic surgeons  and orthopedic surgeons receive significant training in hand surgery during their residency training. Also, some graduates do an additional one-year hand fellowship. Board certified general, plastic, or orthopedics surgeons who have completed approved fellowship training in hand surgery and have met a number of other practice requirements are qualified to take the \"Certificate of Added Qualifications in Surgery of the Hand\" examination, formerly known as the CAQSH, it is now known as the SOTH.\" [ 3 ] [ 4 ] [ 5 ]  Now super speciatity training called MCh Hand Surgery required to be a qualified hand surgeon. Regardless of their original field of training, once candidates have completed an approved fellowship in hand surgery, all hand surgeons have received training in treating all injuries both to the bones and soft tissues of the hand and upper extremity. Among those without additional hand training, plastic surgeons have usually received training to handle traumatic hand and digit amputations that require a \"replant\" operation. Orthopedic surgeons are trained to reconstruct all aspects to salvage the appendage:  tendons ,  muscle ,  bone . As well, orthopedic surgeons are trained to handle complex fractures of the hand and injuries to the  carpal bones  that alter the mechanics of the wrist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7533", "text": "The historical context for the three qualifying fields is that both plastic surgery and orthopedic surgery are more recent branches off the general surgery main trunk. Modern hand surgery began in  World War II  as a military planning decision.  US Army Surgeon General , Major General Norman T. Kirk, knew that hand injuries in  World War I  had poor outcomes in part because there was no formal system to deal with them. [ 6 ]  Kirk also knew that his civilian general surgical colleague Dr. Sterling Bunnell had a special interest and experience in hand reconstruction. Kirk tapped Bunnell to train military surgeons in the management of hand injuries to treat the war casualties, and at that time hand surgery became a formal specialty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7534", "text": "Orthopedic surgeons continued to develop special techniques to manage small bones, as found in the wrist and hand. [ 7 ]  Pioneering plastic surgeons developed microsurgical techniques for repairing the small nerves and arteries of the hand. Surgeons from all three specialties have contributed to the development of techniques for repairing tendons and managing a broad range of acute and chronic hand injuries. Hand surgery incorporates techniques from orthopaedics, plastic surgery, general surgery,  neurosurgery ,  vascular  and  microvascular surgery  and  psychiatry . A recent advance is the progression to 'wide awake hand surgery.' [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7535", "text": "In a few countries such as  Sweden ,  Finland  and  Singapore , hand surgery is recognized as a clinical specialty in its own right, [ 9 ]  with a formal four to six years hand surgery resident training program. Hand surgeons going through these programs are trained in all aspects of hand surgery, combining and mastering all the skills traditionally associated with \"Orthopedic hand surgeons\" and \"Plastic hand surgeons\" to become equally adept at handling tendon, ligament and bone injuries as well as microsurgical reconstruction such as reattachment of severed parts or free tissue transfers and transplants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7536", "text": "Hand surgeons perform a wide variety of operations such as fracture repairs, releases, transfer and repairs of tendons and reconstruction of injuries, rheumatoid deformities and congenital defects. [ 10 ]  They also perform microsurgical reattachment of amputated digits and limbs, microsurgical reconstruction of soft tissues and bone, nerve reconstruction, and surgery to improve function in paralysed upper limbs. There are two medical societies that exist in the United States to provide continuing medical education to hand surgeons: the  American Society for Surgery of the Hand  and the American Association for Hand Surgery. In Britain, the medical society for hand surgeons is the:  British Society for Surgery of the Hand  (BSSH). In Europe, several societies are brought together by the Federation of European Societies for Surgery of the Hand (FESSH). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7537", "text": "The following conditions can be indications for hand surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7538", "text": "Some complications of hand surgery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7539", "text": "Hand transplantation,  or simply a  hand transplant,  is a surgical procedure to  transplant  a  hand  from one human to another. The donor hand, usually from a  brain-dead  donor, is transplanted to a recipient amputee. Most hand transplants to date have been performed on below-elbow amputees, although above-elbow transplants are gaining popularity. Hand transplants were the first of a new category of transplants where multiple organs are transplanted as a single functional unit, now termed vascularized composite  allotransplantation  (VCA)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7540", "text": "The operation is quite extensive and typically lasts from 8 to 12 hours. In comparison, a typical  heart transplant  operation lasts 6 to 8 hours. Surgeons usually connect the bones first, followed by tendons, arteries, nerves, veins, and skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7541", "text": "For a hand transplant to succeed the recipient is required to take  immunosuppressive drugs , [ 1 ]  as in other organ transplants such as kidney or liver, to minimize rejection, or risk destruction of the hand by the recipient's natural  immune system . These drugs risk weakening the recipient's immune system, which may increase the risk of infections and some cancers. Many recent advances in solid organ transplantation have made these medications more tolerable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7542", "text": "A period of extensive hand therapy/rehabilitation after transplantation helps the recipient gain function of the transplanted hand. [ 2 ]  Compliance with immunosuppressive medications and intensive physical therapy after hand transplants is associated with significant success in regaining the function of the new hands/arms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7543", "text": "A hand transplant was performed in Ecuador in 1964, but the patient experienced transplant rejection after only two weeks due to the primitive nature of the immune-suppressing medications at that time. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7544", "text": "The first short-term success in human hand transplant surgery occurred with Clint Hallam, [ 4 ]  from New Zealand. Hallam lost his hand in an accident while in prison. [ 5 ] [ 6 ] [ 7 ]  The operation was performed on September 23, 1998, [ 8 ]  in  Lyon ,  France , by a team assembled from different countries around the world led by French Professor  Jean-Michel Dubernard , including Professor  Nadey Hakim , from the UK. [ 7 ] [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7545", "text": "A microsurgeon on the team,  Earl Owen  from Australia, was privy to the detailed basic research, much of it unpublished, that had been carefully gathered by the team in Louisville. [ 8 ]  After the operation, Hallam wasn't comfortable with the idea of his transplanted hand and failed to follow the prescribed post-operative drug and physiotherapy regime. [ 6 ] [ 8 ]  His inaccurate expectations became a vivid example of the necessity of a fully committed team of caregivers, including psychologists, who can correctly select and prepare the potential transplant recipients for the lengthy and difficult recovery and for the modest functional restoration of a transplanted hand to be expected. [ 6 ] [ 5 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7546", "text": "Hallam's transplanted hand was removed [ 10 ]  at his request by the transplant surgeon  Nadey Hakim  on February 2, 2001, following another episode of rejection that was, at least in part, caused by his stopping the anti-rejection medication. [ 11 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7547", "text": "The first hand transplant to achieve prolonged success was directed by a team of Kleinert Kutz Hand Care surgeons including  Warren C. Breidenbach , Tsu-Min Tsai, Luis Scheker, Steven McCabe, Amitava Gupta, Russell Shatford, William O'Neill, Martin Favetto and Michael Moskal in cooperation with the Christine M. Kleinert Institute,  Jewish Hospital  and the  University of Louisville  in  Louisville, Kentucky . The procedure was performed on  New Jersey  native Matthew Scott on January 14, 1999. Scott had lost his hand in a fireworks accident at age 24. Later in 1999, the Philadelphia Phillies baseball team asked him to do the honors of throwing out the ceremonial first pitch. The Louisville group went on to perform the first five hand transplants in the United States and have performed 12 hand transplants in ten recipients as of 2016. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7548", "text": "In contrast to the earlier attempts at hand transplantation, the Louisville group had performed extensive basic science research and feasibility studies for many years before their first clinical procedure (for example, Shirbacheh  et al. , 1998). [ 12 ]  There was also considerable transparency and institutional review board oversight involved in the screening and selection of prospective patients. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7549", "text": "In March 2000, a team of surgeons at the  University of Innsbruck  in  Austria  began a series of three bilateral hand transplants over six years. The first was an Austrian police officer who had lost both hands attempting to defuse a bomb. He has completed an around-the-world solo motorcycle trip using his transplanted hands. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7550", "text": "University of Louisville doctors also performed a successful hand transplant on Michigan native Jerry Fisher in February 2001, and Michigan resident David Savage in 2006. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7551", "text": "On 14 January 2004, the team of Professor  Jean-Michel Dubernard  (Edouard-Herriot Hospital, France) declared a five-year-old double hand transplant a success. The lessons learned in this case, and in the 26 other hand transplants (6 double) which occurred between 2000 and 2005, encouraged other transplant operations of such organs as the  face , abdominal wall, and  larynx . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7552", "text": "On 4 May 2009  Jeff Kepner , a 57-year-old Augusta, Georgia resident underwent the first double hand transplant in the United States at the  University of Pittsburgh Medical Center  by a team led by  W.P. Andrew Lee , who also had been performing careful basic research on such transplants for many years. A CNN story on his follow up demonstrated the limited functional restoration to be expected, particularly following bilateral transplantation. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7553", "text": "On 18 February 2010, the first female in the United States underwent hand transplantation at Wilford Hall Medical Center in San Antonio, Texas. The procedure was performed by surgeons from The Hand Center of San Antonio and US Air Force. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7554", "text": "On 22 June 2010, a  Polish  soldier received two new hands from a female donor, after losing them three years earlier while saving a young recruit from a bomb. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7555", "text": "On 8 March 2011, 26-year-old Emily Fennell underwent an 18-hour surgery to attach a right hand. This was performed in the  Ronald Reagan UCLA Medical Center . [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7556", "text": "On 12 March 2011 Linda Lu became the recipient of a hand transplant, performed at Emory University Hospital, [ 18 ]  from a donor Leslie Sullivent. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7557", "text": "In the fall of 2011, 28-year-old Lindsay Ess received a double hand transplant at the  Hospital of the University of Pennsylvania  in an 11 1/2 hour surgery. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7558", "text": "On 27 December 2012, 51-year-old Mark Cahill received a right hand transplant at  Leeds General Infirmary  in the UK. The recipient's hand was removed during the same 8 hour operation, reportedly allowing very accurate restoration of nerve structures, believed to be an international first. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7559", "text": "On 27 February 2013, 38-year-old Eskandar Moghaddami received hand transplant surgery by the 15th of Khordad Hospital plastic surgery team in Tehran, Iran. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7560", "text": "On 13 January 2015, doctors at the  Kochi -based  Amrita Institute of Medical Sciences and Research Centre  (AIMS) successfully conducted India's first hand transplant. A 30-year-old man, who had lost both his hands in a train accident, received the hands of a 24-year-old accident victim. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7561", "text": "On 28 July 2015, doctors at the  Children's Hospital of Philadelphia  performed the first successful bilateral hand transplant on a child. [ 24 ]  At the age of 2, Zion Harvey lost his hands and feet to a life-threatening infection. Six years later, at age 8, he had both of his hands replaced in a double hand transplant. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7562", "text": "On 2 August 2016, the reconstructive transplantation team at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, performed the first intergender hand transplantation in India on a 16-year-old boy who had lost both his hands in an electrocution injury. The donor was a 54-year-old lady who was brain dead following a road traffic accident. [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7563", "text": "On 26 October 2016, the Director of hand transplantation at  UCLA , Dr.  Kodi Azari , and his team, [ 28 ]  performed a hand transplant on 51-year-old entertainment executive from Los Angeles,  Jonathan Koch  at  Ronald Reagan UCLA Medical Center . Koch underwent a 17-hour procedure to replace his left hand, which he lost to a mysterious, life-threatening illness that struck him in January 2015. [ 29 ]  On June 23, 2015, Koch had the amputation surgery, also performed by Dr. Kodi Azari, which was designed to prep him to receive a transplanted limb. This included severing the left hand closer to the wrist than the elbow. Azari kept all the nerves and tendons long and extended, which would give him plenty to work with later. Then he sutured them together and attached them to the stump of bone to keep them from retracting. [ 30 ]  This is the first known hand transplant case in which the hand was amputated in preparation for a hand transplant, as opposed to previous hand transplant patients who have undergone typical amputation surgeries. Azari's theory about prepping the hand for a transplant during the initial amputation surgery would later be supported by Koch when he was able to move his thumb only two hours after he woke up from the 17-hour transplant surgery [ 31 ]  and move his entire hand only two days after surgery. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7564", "text": "On 15 January 2021, Icelander  Gu\u00f0mundur Felix Gr\u00e9tarsson  underwent the first double-arm and double-shoulder transplant from doctors in France. [ 33 ]  The transplant was deemed successful. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7565", "text": "The long-term functionality varies patient to patient and is affected by several factors including level of amputation and transplant and participation in occupational therapy post hand transplant surgery. Hand transplant recipient Jonathan Koch was able to pick up a napkin and a tennis ball with his newly transplanted hand 7 days after his 17-hour surgery and by day 9, he was able to pick up a bottle of water and take a drink. 3 months after surgery, Koch was able to use his transplanted hand to tie his shoe. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7566", "text": "Although the one-year survival rate of transplanted hands has been excellent at institutions that are fully committed to the procedure, the number of hand transplants performed after 2008 has been small due to drug-related side effects, uncertain long-term outcome, and the high costs of surgery, rehabilitation and immunosuppression. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7567", "text": "The Johns Hopkins University School of Medicine Hand and Arm Transplant Program was approved by the Johns Hopkins Medicine Institutional Review Board in July 2011. This is one of only two programs in the United States approved to perform hand/arm transplants using an immunomodulatory protocol, which enables patients to take one drug (instead of three) after the transplant to maintain the hand or arm. The program is funded by the US Army Medical Research and Materiel Command (MRMC) Armed Forces Institute of Regenerative Medicine (AFIRM) to transplant up to six Wounded Warriors or civilians who have a hand or arm amputation on one or both sides. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7568", "text": "The Southern Illinois University School of Medicine Hand Transplant Program is located in  Springfield, Illinois . The program was officially launched in January 2014 after receiving IRB approval and grant funding to transplant five patients, unilateral or bilateral, at minimal cost to the patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7569", "text": "The UCLA Hand Transplant Program, located in  Los Angeles, California , was launched July 28, 2010. At the time, it was the only one on the West Coast and one of only four in the country. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7570", "text": "In 2016, it was announced that  NHS  patients in  England  were to become some of the first in the world to benefit from publicly funded pioneering hand and upper arm transplants delivered by a specialist team at Leeds General Infirmary. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7571", "text": "Hao Lulu  ( Chinese :  \u90dd\u7490\u7490 , born 9 January 1979) is a  Manchu  Chinese woman who has become well known for having undergone extensive  cosmetic surgery  in 2003 to alter her appearance, tagged \"The Artificial Beauty\" ( \u4eba\u9020\u7f8e\u5973 )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7572", "text": "Born in  Beijing , Hao entered the  China University of Geosciences  in 1999. After graduation in 2001, she studied for a  master's degree  in  gemology  in the  United Kingdom  until 2003."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7573", "text": "She became a freelance fashion writer briefly until July 19, 2003, to August 14, 2003, when she started a series of operations to modify her eyes, nose, chin, breasts, abdomen, buttocks, legs, and skin, at just 24 years old."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7574", "text": "In before-and-after photographs widely circulated in the media, her appearance was indeed radically altered, in particular her eyes, which were given double eyelids to give her a more  occidental  appearance (see  Asian blepharoplasty ). The color of her skin was also lightened."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7575", "text": "The transformation of Lulu, the \"Beauty Dreamwork Project\" ( \u6cbb\u9020\u7f8e\u4eba ), was organized by EverCare ( \u4f0a\u7f8e\u5c14 ), a Beijing cosmetic surgery clinic, to promote its business, which had been languishing in the aftermath of the  SARS  epidemic. Evercare organized a press conference around Lulu to promote the company's cosmetic surgery services. The clinic came out with numerous ads, that claimed they have the confidence and capacity to help Chinese women create new physiques through the use of advanced technologies and surgical skills. After her surgeries, H\u00e0o then worked as a spokesperson for the cosmetic surgery clinic that transformed her body. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7576", "text": "The company's actions have been criticized in China by doctors, who deplored it as a publicity stunt. However, it led to a great upsurge in interest in cosmetic surgery among China's  nouveau riche . After her transformation, news stories on body alternations increased tremendously in China's mainstream media, marginalized tabloids, and cyberspace, from a number of different beauty companies. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7577", "text": "Hao's diary, published on the clinic's website, stated the pain and numbness she felt after certain procedures. She also constantly expressed her wish to go home tomorrow, where \"freedom\" is. In the second last entry, she concluded, however, that all pain is gone and that it was such a relief: \"How wonderful all these things are; I have no regret for my very first choice!\" ( \u8fd9\u4e00\u5207\u662f\u591a\u4e48\u7684\u7f8e\u597d\uff0c\u6211\u65e0\u6094\u6211\u6700\u521d\u7684\u9009\u62e9\uff01 )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7578", "text": "Hirudo medicinalis , or the  European medicinal leech , is one of several  species  of  leeches  used as  medicinal leeches ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7579", "text": "Other species of  Hirudo  sometimes also used as medicinal leeches include  H. orientalis ,  H. troctina , and  H. verbana . The Asian medicinal leech includes  Hirudinaria  manillensis , and the North American medicinal leech is  Macrobdella  decora ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7580", "text": "Medicinal leech populations were reduced significantly in many countries during the 19th century due to the high demand in medical contexts, and remain endangered in many countries today. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7581", "text": "The general  morphology  of medicinal leeches follows that of most other leeches. Fully mature adults can be up to 20 centimeters in length, and are green, brown, or greenish-brown with a darker tone on the  dorsal  side and a lighter  ventral  side. The dorsal side also has a thin red stripe. These organisms have two suckers, one at each end, called the  anterior  and  posterior  suckers. The posterior is used mainly for leverage, whereas the anterior sucker, consisting of the  jaw  and  teeth , is where the feeding takes place. Medicinal leeches have three jaws (tripartite) that resemble saws, on which are approximately 100 sharp edges used to incise the host. The incision leaves a mark that is an inverted Y inside of a circle. After piercing the skin, they suck out  blood  while injecting blood thinners similar to  Anophelins ;  anticoagulants  ( hirudin ). [ 4 ]  Large adults can consume up to ten times their body weight in a single meal, with 5\u201315 mL being the average volume taken. [ 5 ]  These leeches can live for up to a year between feedings. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7582", "text": "Medicinal leeches are  hermaphrodites  that reproduce by  sexual  mating, laying eggs in clutches of up to 50 near (but not under) water, and in shaded, humid places. A study done in Poland found that medicinal leeches sometimes breed inside the nests of large aquatic birds, noting that conservation efforts directed at bird habitats may also indirectly help preserve dwindling leech populations. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7583", "text": "Their range extends over almost the whole of  Europe  and into  Asia  as far as  Kazakhstan  and  Uzbekistan . The preferred  habitat  for this species is muddy freshwater pools and ditches with plentiful weed growth in temperate climates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7584", "text": "Over-exploitation  by  leech collectors  in the 19th century has left only scattered populations, [ 3 ]  and reduction in natural habitat through drainage has also contributed to their decline. Another factor includes the replacement of  horses  - medicinal leeches' preferred host species - by motor vehicles and mechanical farming equipment, and the provision of artificial water supplies for cattle. As a result, this species is now considered  near threatened  by the  IUCN , and European medicinal leeches are legally protected through nearly all of their natural range. They are particularly sparsely distributed in  France  and  Belgium , and in the UK there may be as few as 20 remaining isolated populations (all widely scattered). The largest, located at  Lydd, England , is estimated to contain several thousand individuals; 12 of these areas have been designated  Sites of Special Scientific Interest . There are small, transplanted populations in several countries outside their natural range, including the USA. The species is protected under Appendix II of  CITES  meaning international trade (including in parts and derivatives) is regulated by the CITES permitting system. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7585", "text": "Medicinal leeches have been found to secrete  saliva  containing about 60 different  proteins . [ 8 ]  These achieve a wide variety of goals useful to the leech as it feeds, helping to keep the blood in liquid form and increasing blood flow in the affected area. Several of these secreted proteins serve as  anticoagulants  (such as  hirudin ),  platelet aggregation  inhibitors (most notably  apyrase ,  collagenase , and calin),  vasodilators , and  proteinase  inhibitors. [ 9 ]   It is also thought that the saliva contains an  anesthetic , [ 10 ]  as leech bites are generally not painful."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7586", "text": "The first recorded use of leech therapy was 3,500 years ago in Ancient Egypt. [ 11 ]  The next recorded uses of leeches in medicine come in the last few centuries BCE, by the Greek physician  Nicander  in  Colophon [ 5 ]  and in the ancient Sanskrit text  Sushruta Samhita . [ 12 ]  Leech therapy is mentioned a few hundred years later in  Shennong Bencaojing , a 3rd-century CE book of traditional Chinese medicine. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7587", "text": "Medical use of leeches was discussed by  Avicenna  in  The Canon of Medicine  (1020s), and by  Abd al-Latif al-Baghdadi  in the 12th century. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7588", "text": "These sources indicated leech therapy for a wide variety of ailments, including  edema , [ 12 ]  \"blood stasis\", [ 13 ]  and skin diseases. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7589", "text": "In medieval and early modern European medicine, the medicinal leech ( Hirudo medicinalis  and its congeners  H. verbana ,  H. troctina , and  H. orientalis ) was used to remove blood from a patient as part of a process to balance the  humors  that, according to  Galen , must be kept in balance for the human body to function properly. (The four humors of ancient medical philosophy were blood,  phlegm ,  black bile , and  yellow bile .) Any sickness that caused the subject's skin to become red (e.g.  fever  and inflammation), so the theory went, must have arisen from too much blood in the body. Similarly, any person whose behavior was strident and sanguine was thought to be suffering from an excess of blood. Leeches, by removing blood, were thought to help with these kinds of conditions \u2014 a wide range which included illnesses like  polio  and  laryngitis . [ 5 ]  Leeches were often gathered by leech collectors and were eventually farmed in large numbers. A unique 19th-century \" Leech House \" survives in  Bedale ,  North Yorkshire  on the bank of the Bedale Beck, used to store medicinal leeches until the early 20th century."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7590", "text": "Manchester Royal Infirmary  used 50,000 leeches a year in 1831. The price of leeches varied between one penny and threepence halfpenny each. In 1832 leeches accounted for 4.4% of the total hospital expenditure. The hospital maintained an aquarium for leeches until the 1930s. [ 15 ]  The use of leeches began to become less widespread towards the end of the 19th century. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7591", "text": "Medicinal leech therapy (also referred to as  Hirudotherapy  or  Hirudin therapy ) made an international comeback in the 1970s in  microsurgery , [ 16 ] [ 17 ] [ 18 ]  used to stimulate circulation in tissues threatened by postoperative venous congestion, [ 16 ] [ 19 ]  particularly in finger reattachment and  reconstructive surgery  of the ear, nose, lip, and eyelid. [ 17 ] [ 20 ]  Other clinical applications of medicinal leech therapy include  varicose veins , muscle cramps,  thrombophlebitis , and  osteoarthritis , among many varied conditions. [ 21 ]  The therapeutic effect is not from the small amount of blood taken in the meal, but from the continued and steady bleeding from the wound left after the leech has detached, as well as the anesthetizing, anti-inflammatory, and vasodilating properties of the secreted leech saliva. [ 5 ]  The most common complication from leech treatment is prolonged bleeding, which can easily be treated, but more serious allergic reactions and bacterial infections may also occur. [ 5 ]  Leech therapy was classified by the US  Food and Drug Administration  as a medical device in 2004. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7592", "text": "Because of the minuscule amounts of  hirudin  present in leeches, it is impractical to harvest the substance for widespread medical use. Hirudin (and related substances) are synthesized using  recombinant  techniques. Devices called \"mechanical leeches\" that dispense  heparin  and perform the same function as medicinal leeches have been developed, but they are not yet commercially available. [ 23 ] [ 24 ] [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7593", "text": "Hydradermabrasion  is a  dermatological  procedure which combines simultaneous dermal infusion of medicinal products and crystal-free  exfoliation . Hydradermabrasion's mechanism of actions includes: (a) mechanical stimulation activates the basal layer, and (b) thickening and smoothing the  epidermis .  Fibroblast  activity results in  extracellular matrix  deposition and dermal thickening.  Antioxidants  introduced through the procedure hydrate and decrease  inflammation  in the skin, reversing photo damage, while protecting lipid membranes, collagen fibers, and enzyme systems. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7594", "text": "It is considered to be a relatively new procedure which combines microdermabrasion with the pneumatic application of antioxidant-based serums. [ 2 ]  The addition of  polyphenolic  antioxidants through hydradermabrasion to a  phototherapy  regimen enhanced the clinical, biochemical, and histological changes seen following phototherapy alone. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7595", "text": "\"Hydradermabrasion has the same indications for use as  microdermabrasion , making it an excellent choice for persons with darker skin tones, aging skin, sensitive skin areas, oily, and dry skin complexions\". [ 4 ]  A study on the efficacy of hydradermabrasion for facial rejuvenation was conducted comparing volunteers who received hydradermabrasion facial treatments using an antioxidant serum or who just received the same antioxidant serum manually applied to the skin. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7596", "text": "Skin treated with Hydradermabrasion demonstrated \"significantly increased epidermal and papillary dermal thickness, and increased fibroblast density (p<0.01)\u201d. [ 5 ]  A study on the efficacy of hydradermabrasion for facial rejuvenation was conducted comparing volunteers who received hydradermabrasion facial treatments using an antioxidant serum or who just received the same antioxidant serum manually applied to the skin. Six treatments were conducted on a 7- to 10-day interval to determine whether antioxidant levels could be increased in the skin and skin quality improved with this technique. Results of this study demonstrated that hydradermabraded skin possessed increased epidermal and papillary dermal thickness as well as greater antioxidant levels. Further histological examination saw a replacement of elastic dermal tissue, collagen hyalinization, and fibroblast density correlating with a decrease in the appearance of fine lines, pore size, and hyperpigmentation in hydradermabrasion treated areas 6 weeks post-treatment with no patient complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7597", "text": "Hymenorrhaphy  or \" hymen reconstruction surgery \" is the  surgical  alteration of the  hymen , with the goal of producing bleeding on intercourse and a tight  vaginal introitus , falsely believed to indicate virginity. The term comes from the Greek words  hymen  meaning \"membrane\", and  raph\u1e17  meaning \" suture \". It is also known as  hymenoplasty , although strictly this term would also include  hymenotomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7598", "text": "The normal aim is to cause  bleeding  during post-nuptial  intercourse , which in some cultures is wrongly considered  proof of virginity . Roughly half of women having vaginal intercourse for the first time do not bleed; a small study found that of 19 women who underwent hymenorrhaphy and attended follow-up, 17 did not have bleeding at the next intercourse. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7599", "text": "It is also based on the false belief that there are \"intact\" and \"broken\" hymens, distinct in appearance or feel. It is not possible to determine whether someone is a virgin by the appearance of their hymen or the tightness of the vagina. [ 2 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7600", "text": "Hymenorrhaphies are not generally regarded as part of mainstream  gynecology , but are available from some  plastic surgery  centers, particularly in the United States, Middle East,  South Korea  and  Western Europe , generally as  outpatient surgery . [ citation needed ]  Hymenorraphy is considered a form of cosmetic surgery, and is not generally accepted, taught, or regulated by the medical profession. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7601", "text": "Hymenorraphy is based on the false belief that all women bleed when first having vaginal intercourse; in fact, only about half bleed; [ 1 ]  as few as a third in one informal survey. [ 3 ]  Hymens have few blood vessels and may not bleed significantly even when torn, and vaginal walls may bleed significantly when torn. Blood on the sheets on first intercourse is more likely to be due to lacerations to the vaginal wall caused by inadequate  vaginal lubrication  or forced penetration. [ 2 ]  This false belief is ancient; it is found in  Deuteronomy . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7602", "text": "Despite common cultural beliefs, there are not distinct \"intact\" and \"broken\" states for the hymen, and the state of a hymen cannot be used to  prove or disprove virginity . [ 2 ] [ 1 ]  Medical professionals therefore recommend against describing hymens as \"intact\" or \"broken\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7603", "text": "Hymens vary greatly in appearance.  Imperforate hymens , completely covering the vagina, can cause medical problems and are fortunately rare. Septate, cribriform, and microperforate hymens may also cause medical difficulties. Labiate, carunculate, redundant, fimbriate, crescentic, and annular hymens are naturally-occurring variations. [ 1 ] [ 5 ] [ 2 ]  The most common form of hymen is a crescent-shaped band along the back edge of the vaginal opening. [ 2 ]  Bumps, mounds, clefts, and notches in the edge of the hymen are normal, even in newborns. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7604", "text": "Inserting objects (including penises) into the vagina may or may not affect the  hymen . [ 2 ]  Penile penetration does not lead to predictable changes to female genital organs; after puberty, hymens are highly elastic and can stretch during penetration without trace of injury. Females with a confirmed history of sexual abuse involving genital penetration may have normal hymens. Young females who say they have had consensual sex mostly show no identifiable changes in the hymen. Hymens naturally have irregularities in width, and hymens can heal spontaneously without scarring. Visible breaks in the hymen, including complete hymenal clefts, are also common in girls and women who have never been sexually active. [ 2 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7605", "text": "It is not possible to tell by feel or tightness whether someone has previously had vaginal intercourse. Tightness of the vagina during first intercourse is mostly caused by an involuntary clenching the muscles of the  pelvic floor  due to nervousness. [ 1 ]  Such involuntary clenching can be strong enough to make intercourse difficult, painful, or impossible; when this occurs in a woman who has previously been able to have vaginal intercourse, it is called secondary  vaginismus . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7606", "text": "In a purely cosmetic procedure, a membrane without blood supply is created, sometimes including a  gelatine  capsule of an artificial bloodlike substance. This operation is intended to be performed within a few days before an intended  marriage . [ 3 ]  Operations have grown more sophisticated over time. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7607", "text": "Because there is no standard \"intact\" appearance of a hymen, the surgeon must creatively shape a hymen that conforms to social expectations. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7608", "text": "Some hymen reconstruction operations are legal in some countries, while other countries ban all hymenorrhaphy. [ 9 ]  For example, in 2020 in the  Netherlands  the professional surgeon associations adjusted their codes to prohibit hymenorrhaphy, and the government stated it would consider a legal ban if practice continues. The number of women undergoing the operation in the country at the time was estimated as several hundreds per year. [ 10 ]  The  United Kingdom  criminalised the procedure (referred to as \"hymenoplasty\") even with consent, along with  aiding and abetting  it or offering to carry it out, with the  Health and Care Act 2022 . The same Act also banned  virginity testing . [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7609", "text": "The operation is popular in Middle Eastern countries, in particular in Iran, where women are expected to keep virginity until their wedding night. Grand Ayatollah  Sayyid Sadeq Rohani  has issued a  fatwa  which says that a woman who has undergone hymenorrhaphy is a virgin, and a man marrying her cannot divorce her on the grounds that she is not a virgin. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7610", "text": "Injectable filler  is a special type of substance made for injections into connective tissues, such as  skin ,  cartilage  or even  bone , for cosmetic or medical purposes. The most common application of injectable fillers is to change one's facial appearance, but they also are used to reduce symptoms of osteoarthritis, treat tendon or ligament injuries, support bone and gum regeneration, and for other medical applications. Injectable fillers can be in the form of  hydrogel  or gels made from pulverized  grafts ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7611", "text": "Injectable fillers have risen in popularity mostly due to the wide application of dermal fillers in 80's. Their premise is to help fill in facial  wrinkles , provide facial volume, and augment facial features. Side effects include bruising or infections from improper sterilisation. This may include  HIV infection , also allergic reactions, which may cause scarring and lumps. Blindness due to retrograde (opposite the direction of normal blood flow)  embolization  into the  ophthalmic  and  retinal arteries  can occur."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7612", "text": "Injection of dermal fillers is the second most common nonsurgical cosmetic procedure in the USA, used for addressing volume deficiency,  scars ,  wrinkles , and enhancing facial features and specific anatomical sites like the  lips . The variety of available dermal fillers increases annually, requiring dermatologists and cosmetic surgeons to stay informed about the latest options to ensure safe and effective treatments.  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7613", "text": "Fillers are made of  polysaccharides  such as  hyaluronic acids , a naturally occurring in skin and cartilage, [ 2 ]   collagens  which may come from pigs, cows, cadavers, or may be generated in a laboratory, [ 3 ]  the person's own transplanted fat tissue, and/or biosynthetic polymers. Examples of the latter include  calcium hydroxylapatite ,  polycaprolactone ,  polymethylmethacrylate , and  polylactic acid . [ 4 ]  In 2012, \"Artiste Assisted Injection System\" was launched in the US market to assist in the delivery of dermal fillers. A study in 2013 concluded that the injecting device can achieve reductions in patient discomfort and adverse events by controlling the rate of flow of injection of the filler the practitioner is using to fill in the lips and frown lines. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7614", "text": "Soft-tissue augmentation has grown in popularity recently, particularly with the use of  hyaluronic acid  (HA) based dermal fillers. These non-permanent injectables can restore lost volume, smooth fine lines and wrinkles, and enhance facial contours. Despite their widespread use since the late 1990s, there is limited comparative data and literature on the diverse range of HA fillers and their tissue performance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7615", "text": "The studies explore various methods and parameters for characterizing dermal fillers, providing key insights for clinicians to select the most suitable products for their patients. The aging face undergoes complex changes due to  bone resorption ,  gravity , fat redistribution, and skin damage, which dermal fillers aim to counteract. HA fillers are considered medical devices rather than medicines, thus lacking stringent regulatory requirements for safety and efficacy data."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7616", "text": "The scientific community emphasizes the importance of understanding the physico-chemical properties of fillers, such as their behavior under stress and deformation, and their performance over time. These properties are influenced by different crosslinking technologies used in manufacturing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7617", "text": "A literature search identified key studies on the rheological properties of HA fillers, focusing on FDA-approved products and others like Revolax. The review analyzes methodologies and critiques the existing literature to provide a comprehensive understanding of HA fillers' properties.\n [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7618", "text": "Dermal fillers, also known as \"injectables\" or \"soft-tissue fillers,\" fill in the area under the skin, and have some non-cosmetic uses, such as non-surgical  facial cleft  repair or cleft modification, treating fat loss secondary to  HIV : [ 7 ]  Fillers were found to give a temporary acceptable therapeutic effect in  HIV \u2010infected patients with severe facial  lipodystrophy  caused by highly active  antiretroviral  therapy. [ 8 ] [ 9 ]  A 2009 review concluded that injectable fillers resulted in high satisfaction, but further research was needed to determine safety of its use. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7619", "text": "Most wrinkle fillers are temporary because they are eventually metabolized by the body. Some people may need more than one injection to achieve the wrinkle-smoothing effect. The effect lasts for about six months. Results depend on health of the skin, skill of the health care provider, and the type of filler used. Regardless of material (whether synthetic or organic) filler duration is highly dependent on amount of activity in the body area where it is injected. Exercise and high intensity activities such as manual labor can stimulate blood flow and shorten the lifespan of fillers. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7620", "text": "Risks of an improperly performed dermal filler procedure commonly include bruising, redness, pain, or itching. Less commonly, there may be infections or allergic reactions, which may cause scarring and lumps that may require surgical correction. [ 13 ]  In 2024, a cluster of  HIV infections  was described amongst clients receiving microneedling facials at a Spa. [ 14 ]  More rarely, serious adverse effects such as blindness due to retrograde (opposite the direction of normal blood flow)  embolization  into the  ophthalmic  and  retinal arteries  can occur. [ 15 ]  Delayed skin necrosis can also occur as a complication of embolization. [ 16 ]  Embolic complications are more frequently seen when  autologous  fat is used as a filler, followed by  hyaluronic acid . Though rare, when vision loss does occur, it is usually permanent. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7621", "text": "In the US, fillers are approved as medical devices by the  Food and Drug Administration  (FDA) and the injection is prescribed and performed by a provider. What defines a qualified dermal injection provider varies by country and is a point of debate between  board-certified doctors  and injectors who operate under cosmetic or aesthetician licenses. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7622", "text": "Fillers are not to be confused with  neurotoxins  such as  Botox . Fillers are not approved for certain parts of the body where they can be unsafe, including the penis. [ 18 ]  In Europe and the UK, fillers are non-prescription medical devices that can be injected by anyone licensed to do so by the respective medical authorities. They require a CE mark, which regulates adherence to production standards, but does not require any demonstration of medical efficacy.  As a result, there are over 140 injectable fillers in the UK/European market and only six approved for use in the US. [ 19 ]  In China, the market of cosmetic surgery increase in recent 10 years, NMPA (formerly CFDA) also has issued several guidance to regulate injectable filler. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7623", "text": "Injection lipolysis  is a controversial cosmetic procedure in which drug mixtures are injected into patients with the goal of destroying fat cells. This practice, using drugs generally based on  phosphatidylcholine  and  deoxycholate  (PCDC), evolved from the initial intravenous use of those drug formulations to treat blood disorders. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7624", "text": "While no placebo-controlled studies have demonstrated the safety or efficacy of this therapy, numerous retrospective studies of Lipostabil injections have reported the efficacy of this practice. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ]   The mixture is injected directly into the subcutaneous fat through multiple microinjections administered over multiple treatment sessions.  The desired result is the removal of localized fat deposits. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7625", "text": "In 1966, investigators noted that the intravenous infusion of PC-containing solutions could remove fat emboli. [ 11 ]   Later, a drug formulation called Lipostabil containing 5% PC and 2.5% deoxycholate (DC) was approved in Germany and used in the treatment of fat embolism, [ 12 ] [ 13 ]  dyslipidemia, [ 14 ]  and alcohol-induced liver cirrhosis. [ 15 ]   The first report of Lipostabil injection for fat removal demonstrated that infra-orbital (\"under the eyelid\") fat could be removed by Lipostabil injection. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7626", "text": "In 2015, the US  Food and Drug Administration  approved deoxycholic acid (branded as Kybella) for use as an injection lipolysis product when used\u00a0to reduce moderate to severe submental fullness ( double chin ). [ 17 ] [ 18 ] [ 19 ]   While the procedure is generally considered safe when performed by a qualified healthcare professional, potential side effects may include swelling, bruising, numbness, and rarely, nerve injury in the treated area. [ 17 ] [ 18 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7627", "text": "Three medical associations have issued health warnings cautioning against the use of injection lypolysis, including the  American Society of Plastic Surgeons  (ASPS), the  American Society for Aesthetic Plastic Surgery  (ASAPS), and the  American Society of Dermatologic Surgery  (ASDS).The Aesthetic Surgery Education and\nResearch Foundation has funded on behalf of the American Society for Aesthetic Plastic Surgery a half side comparison study with interesting results [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7628", "text": "On April 7, 2010, the US Food and Drug Administration issued  Warning Letters  to six U.S. based  medspas  and a company in Brazil for making false or misleading statements on their Web sites about drugs they claimed will eliminate fat in a procedure called \"lipodissolve\", or for otherwise misbranding lipodissolve products. \"We are concerned that these companies are misleading consumers\", said Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research. \"It is important for anyone who is considering this voluntary procedure to understand that the products used to perform lipodissolve procedures are not approved by the FDA for fat removal\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7629", "text": "For the complete FDA statement, see here  [1] . To see the warning letter, see  [2] ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7630", "text": "The FDA received reports of adverse effects in persons who had the procedure using these drugs, including permanent scarring, skin deformation, and deep painful knots under the skin in areas where the lipodissolve products have been injected.  The warning letters were issued to the following U.S. companies: Monarch Medspa, King of Prussia, Pa; Spa 35, Boise, Idaho; Medical Cosmetic Enhancements, Chevy Chase, Md.; Innovative Directions in Health, Edina, Minn PURE Med Spa, Boca Raton, Fl.; and All About You Med Spa, Madison, Ind. The Brazilian company receiving a warning letter markets lipodissolve products on two Web sites: zipmed.net and mesoone.com."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7631", "text": "The FDA is requesting a written response from the U.S. companies within 15 business days of receipt of the warning letters stating how they will correct these violations and prevent similar violations in the future. Each U.S. company has been informed in its warning letter that failure to promptly correct the violations may result in legal action.\nEach of the companies involved has been cited for a variety of regulatory violations, including making unsupported claims that the products have an outstanding safety record and are superior to other fat loss procedures, including liposuction. Additionally some of the letters indicate that the companies have made claim that lipodissolve products can be used to treat certain medical conditions, such as male breast enlargement, benign fatty growths known as lipomas, excess fat deposits and surgical deformities. The FDA is not aware of clinical evidence to support any of these claims. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7632", "text": "The  Medicines and Healthcare products Regulatory Agency , the governmental body regulating the manufacture and commercialization of drugs in the United Kingdom, issued a similar warning to physicians considering the use of these substances for cosmetic purposes, stating these drugs \"are being unlawfully advertised in the UK as a cosmetic product for the reduction of fat.\"  The MHRA also pointed out that considerable safety concerns remain because these agents have not been tested in controlled clinical trials. While British physicians can still inject Lipodissolve for fat removal, the drug cannot be promoted as a drug for that purpose.  As of July, 2005, The  Medical Protection Society , the organization that provides British doctors with legal advice and coverage against litigation costs and damages, ceased offering malpractice insurance for use of Lipodissolve because of safety concerns. [ 22 ] \nOn the other hand, the therapy is very often administered especially in German speaking countries because the drug Lipostabil N has been approved in Germany for more than 40 years. A physicians' network, the NETWORK-Lipolysis with 3,000 members worldwide amongst them 1,000 alone in German speaking countries has collected safety data. The latest published so-called Lipolysis Report 2015 has been published in 2016. [ 23 ]  4% of the members have answered the survey. 29,889 patient results have been collected with in total ca. 76,000 treatment sessions. Nowadays the composition is compounded by pharmacies in Germany and  Switzerland. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7633", "text": "Jaw reduction  or mandible angle reduction is a type of surgery to narrow the lower one-third of the face\u2014particularly the contribution from the  mandible  and its muscular attachments. There are several techniques for treatment\u2014including surgical and non-surgical methods. A square lower jaw can be considered a masculine trait, especially in Asian countries. [ 1 ]  As a result, whereas square lower jaws are often considered a positive trait in men, a wide mandible can be perceived as discordant or masculine on women, or sometimes in certain men, particularly when there is asymmetry. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7634", "text": "A wide lower face can primarily be caused by a wide  mandibular bone  or large  masseter muscle . A large masseter muscle can be reduced in apparent size with the use of botox injections whereas having a wide mandibular bone requires surgical intervention to reduce the size of the bones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7635", "text": "A facial structure with a larger mandible arch and wide zygoma is common, particularly among Asians, although it is also present in other populations. It can also be the result of certain developmental disorders such as  acromegaly ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7636", "text": "Prior to selection of a treatment, the patient is examined to determine whether the wide jaw is due to the  bone  size, the masseter muscle or both. Three-dimensional analysis of the clinical photos,  X-rays  and  3D CT scans  from the front, lateral, oblique, basal and overhead views are required for a detailed evaluation. [ 3 ]  The level of protrusion of the mandible angle, the size of the masseter muscle and the overall structure of the jaw are evaluated. Based on the analysis and face-to-face consultation, the surgery plan can be created to produce the desired aesthetic results. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7637", "text": "Surgical techniques are used to directly reduce the size of a large mandible. Depending on the candidate's individual facial structure, either mandibular resection can be performed alone or in conjunction with a sagittal mandibular reduction. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7638", "text": "The surgery is performed under  general anesthesia  through  tracheal intubation . The standard surgical procedure uses an intraoral approach, as it leaves no visible scars. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7639", "text": "A guarded oscillating saw is first used to mark the proposed osteotomy line to avoid excessive resection of the mandibular bone. Following this process, the bone resection is then performed with the appropriate size of oscillating saws. [ 1 ]  Additional sagittal split ramus resection can be performed using a burr. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7640", "text": "Inferior alveolar nerve is the most important anatomic structure during mandible reduction surgery and great care should be taken to avoid injury to this nerve. [ 6 ]  Potential complications include injury to the  inferior alveolar nerve  which provides permanent numbness and damage to the lower lip and even death."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7641", "text": "Another factor to consider is the  mentalis muscle  which elevates the lower lip and chin. During the surgery, the mentalis muscles should be carefully reattached after the mandible bone has been excised. Failure to reattach the mentalis muscles will lead to the chin and lower lip to sag, causing permanent damage. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7642", "text": "Common symptoms include  haematoma , infection, asymmetry, over- or under-correction of the mandibular bone, sensory deficit. Excluding asymmetry and over- or under-correction, the other symptoms dissipate within three to six months post-surgery. [ 7 ]  Individuals with abundant soft tissue or thick skin may consider an additional lifting procedure done simultaneously with the jaw reduction surgery, as there is a high possibility of sagging soft tissue. Age and skin elasticity level also determines whether a lifting procedure is required. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7643", "text": "Non-surgical techniques are essentially limited to cases in which the masseter is enlarged. While a masseter muscle can be large due to genetic reasons, it can commonly be an acquired trait. Like any muscle it increases in size with exercise. Behaviors such as repeated gum chewing, teeth clenching, or  bruxism  can contribute to enlargement of the muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7644", "text": "A convenient method to treat an enlarged muscle is through the use of  botox  injections. Botox is injected into the muscle, weakening it so it slowly becomes smaller through  atrophy  over several months. There is no down-time and improvement is gradual\u2014individuals who interact with the patient may never know that a plastic surgical procedure was performed"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7645", "text": "The use of Botox for jaw reduction has been studied scientifically.  Improvement is generally not seen for at least 2\u20133 weeks. Peak improvement occurs at months 3 to 9 with good results still observable at one year in many patients. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7646", "text": "The procedure can result in temporary  paralysis  of the muscles that move the lips, a rare, but danger acknowledged complication."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7647", "text": "Labiaplasty  (also known as  labioplasty ,  labia minora reduction , and  labial reduction ) is a  plastic surgery  procedure for creating or altering the  labia minora  (inner labia) and the  labia majora  (outer labia), the folds of skin of the human  vulva . It is a type of  vulvoplasty . There are two main categories of women seeking cosmetic genital surgery: those with conditions such as  intersex , and those with no underlying condition who experience physical discomfort or wish to alter the appearance of their vulvas because they believe they do not fall within a normal range. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7648", "text": "The size, colour, and shape of labia vary significantly, and may change as a result of childbirth, aging, and other events. [ 1 ]  Conditions addressed by labiaplasty include  congenital defects  and  abnormalities  such as  vaginal atresia  (absent vaginal passage),  M\u00fcllerian agenesis  (malformed uterus and fallopian tubes), intersex conditions (male and female sexual characteristics in a person); and tearing and stretching of the labia minora caused by childbirth, accident, and age. In a male-to-female  sexual reassignment   vaginoplasty  for the creation of a  neovagina , labiaplasty creates labia where once there were none."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7649", "text": "A 2008 study reported that 32 percent of women who underwent the procedure did so to correct a functional impairment; 31 percent to correct a functional impairment and for aesthetic reasons; and 37 percent for aesthetic reasons alone. [ 2 ]  According to a 2011 review, overall patient satisfaction is in the 90\u201395 percent range. [ 3 ]  Risks include permanent scarring, infections, bleeding, irritation, and nerve damage leading to increased or decreased sensitivity. A change in requirements of publicly funded Australian plastic surgery requiring women to be told about natural variation in labias led to a 28% reduction in the number of surgeries performed. [ 4 ]  Unlike public hospitals, cosmetic surgeons in private practice are not required to follow these rules, and critics say that \"unscrupulous\" providers are charging to perform the procedure on women who would not want it if they had more information. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7650", "text": "Images of vulvae are absent from the popular media [ 5 ] [ 6 ]  and advertising [ 7 ] [ 8 ] :\u200a19\u200a  and do not appear in some anatomy textbooks, [ 9 ]  while community opposition to  sex education [ 10 ] [ 11 ]  limits the access that young women have to information about natural variation in labias. [ 12 ]  Many women have limited knowledge of vulval anatomy, and are unable to say what a \"normal\" vulva looks like. [ 13 ] :\u200a6\u200a   [ 14 ] [ 15 ] [ 16 ]  At the same time, many  pornographic  images of women's genitals are  digitally manipulated , changing the size and shape of the labia to fit with the censorship standards in different countries. [ 12 ] [ 17 ] [ 18 ] [ 19 ]  Medical researchers have raised concerns about the procedure and its increasing prevalence rates, with some speculating that exposure to pornography images on the Internet may lead to  body image  dissatisfaction in some women. [ 20 ]  Although it is also suggested that evidence for this is lacking, [ 20 ]  the  National Health Service  stated that some women bring along advert or pornographic images to illustrate their desired genital appearance. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7651", "text": "The external  genitalia  of a woman are collectively known as the vulva. This comprises the labia majora (outer labia), the labia minora (inner labia), the  clitoris , the  urinary meatus , and the  vaginal opening . The labia majora extend from the  mons pubis  to the  perineum ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7652", "text": "The size, shape, and color of women's inner labia vary greatly. [ 23 ]  One is usually larger than the other. They may be hidden by the outer labia, or may be visible, and may become larger with sexual arousal, sometimes two to three times their usual diameter. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7653", "text": "The size of the labia can change because of childbirth.  Genital piercings  can increase labial size and asymmetry, because of the weight of the ornaments. In the course of treating identical twin sisters, S.P. Davison  et al  reported that the labia were the same size in each woman, which indicated  genetic determination . [ 25 ]  In or around 2004, researchers from the Department of Gynaeology, Elizabeth Garret Anderson Hospital, London, measured the labia of 50 women between the ages of 18 and 50, with a mean age of 35.6: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7654", "text": "compared to the surrounding skin ( n )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7655", "text": "Labia reduction surgery is relatively contraindicated for the woman who have active gynecological disease, such as an infection or a  malignancy ; the woman who is a  tobacco smoker  and is unwilling to quit, either temporarily or permanently, in order to optimize her wound-healing capability; and the woman who is unrealistic in her aesthetic goals. The latter should either be counselled or excluded from labioplastic surgery. Davison  et al  write that it should not be performed when the patient is menstruating to reduce potential hormonal effects and the increased risk of infection. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7656", "text": "In  sexual reassignment  surgery, in the case of the male-to-female  transgender  patient, labiaplasty is usually the second stage of a two-stage vaginoplasty/ vulvoplasty  operation, where labiaplastic techniques are applied to create labia minora and a clitoral hood. In this procedure, the labiaplasty is usually performed some months after the first stage of vaginoplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7657", "text": "Labial reduction can be performed under  local anaesthesia ,  conscious sedation , or  general anaesthesia , either as a discrete, single surgery, or in conjunction with another,  gynecologic  or cosmetic, surgery procedure. [ 26 ]  The resection proper is facilitated with the administration of an anaesthetic solution (lidocaine + epinephrine in saline solution) that is infiltrated to the labia minora to achieve the tumescence (swelling) of the tissues and the constriction of the pertinent labial circulatory system, the hemostasis that limits bleeding. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7658", "text": "The original labiaplasty technique was simple resection of tissues at the free edge of the labia minora. One resection-technique variation features a clamp placed across the area of labial tissue to be resected, in order to establish hemostatis (stopped blood-flow), and the surgeon resects the tissues, and then sutures the cut labium minus or labia minora. This procedure is used by most surgeons because it is easiest to perform. The technical disadvantages of the labial-edge resection technique are the loss of the natural rugosity (wrinkles) of the labia minora free edges, thus, aesthetically, it produces an unnatural appearance to the vulva, and also presents a greater risk of damaging the pertinent nerve endings. Moreover, there also exists the possibility of everting (turning outwards) the inner lining of the labia, which then makes visible the normally hidden internal, pink labial tissues. The advantages of edge-resection include removal of the hyper-pigmented (darkened) irregular labial edges with a linear scar. Another disadvantage of the trim or \"amputation\" method, is that it is unable to excise redundant tissues of the clitoral hood, when present. [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ]  Complete amputation of the labia minora is more common with this technique, which often requires additional surgery to correct. In addition, the trim method does not address the clitoral hood. Clitoral hood deformities are common with this approach, again requiring additional corrective surgery. Some women complain of a \"small penis\" when the trim procedure is performed, owing to the un-addressed clitoral hood tissue and completely removed (amputated) labia minor. [ 33 ]  Most plastic surgeons do not perform this procedure, and instead favor the extended wedge approach, which is technically more demanding, but produces a more natural result and is able to create a natural and proportioned appearance to the vulva. [ 34 ]  Reconstructive procedures are often required after the trim (amputation) labiaplasty. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7659", "text": "Labial reduction by means of a central wedge-resection involves cutting and removing a partial-thickness wedge of tissue from the thickest portion of the labium minus. [ 28 ]  Unlike the edge-resection technique, the resection pattern of the central wedge technique preserves the natural rugosity (\"wrinkled\" edge) of the labia minora. If performed as a full-thickness resection, there exists the potential risk of damaging the pertinent labial nerves, which can result in painful  neuromas , and numbness. A partial thickness removal of mucosa and skin, leaving the submucosa intact, decreases the risk of this complication. F. Giraldo  et al.  procedurally refined the central wedge resection technique with an additional 90-degree  Z-plasty  technique, which produces a refined surgical scar that is less tethered, and diminishes the physical tensions exerted upon the surgical-incision wound, and, therefore, reduces the likelihood of a notched (scalloped-edge) scar. [ 28 ] [ 36 ]  The central wedge-resection technique is a demanding surgical procedure, and difficulty can arise with judging the correct amount of labial skin to resect, which might result in either undercorrection (persistent tissue-redundancy), or the overcorrection (excessive tension to the surgical wound), and an increased probability of  surgical-wound separation . The benefit of this technique is that an extended wedge can be brought upwards towards the prepuce to treat a prominent clitoral hood without a separate incision. [ 35 ]  This leads to a natural contour for the finished result, and avoids direct incisions near the highly-sensitive clitoris."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7660", "text": "Labial reduction by means of the de-epithelialization of the tissues involves cutting the  epithelium  of a central area on the medial and lateral aspects of each labium minus (small lip), either with a scalpel or with a  medical laser . This labiaplasty technique reduces the vertical excess tissue, whilst preserving the natural rugosity (corrugated free-edge) of the labia minora, and thus preserves the sensory and erectile characteristics of the labia. Yet, the technical disadvantage of de-epithelialization is that the width of the individual labium might increase if a large area of labial tissue must be de-epithelialized to achieve the labial reduction. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7661", "text": "Labial reduction occasionally includes the resection of the  clitoral hood  when the thickness of its skin interferes with the woman's  sexual response  or is aesthetically displeasing. [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7662", "text": "The surgical unhooding of the clitoris involves a V\u2013to\u2013Y advancement of the soft tissues, which is achieved by  suturing  the clitoral hood to the pubic bone in the midline (to avoid the  pudendal nerves ); thus, uncovering the clitoris further tightens the labia minora. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7663", "text": "Labial reduction by means of  laser  resection of the labia minora involves the de-epithelialization of the labia. The technical disadvantage of laser labiaplasty is that the removal of excess labial  epidermis  risks causing the occurrence of  epidermal inclusion cysts . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7664", "text": "Labial reduction by de-epithelialization cuts and removes the unwanted tissue and preserves the natural rugosity (wrinkled free-edge) of the  labia minora , and preserves the capabilities for  tumescence  and  sensation . Yet, when the patient presents with much labial tissue, a combination procedure of de-epithelialization and clamp-resection is usually more effective for achieving the aesthetic outcome established by the patient and her surgeon. In the case of a woman with labial webbing (redundant folding) between the labia minora and the labia majora, the de-epithelialization labiaplasty includes an additional resection technique \u2013 such as the five-flap Z-plasty (\"jumping man plasty\") \u2013 to establish a regular and symmetric shape for the reduced labia minora. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7665", "text": "Post-operative pain is minimal, and the woman is usually able to leave hospital the same day. No vaginal packing is required, although she might choose to wear a sanitary pad for comfort. The physician informs the woman that the reduced labia are often very swollen during the early post-operative period, because of the  edema  caused by the anaesthetic solution injected to swell the tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7666", "text": "She is also instructed on the proper cleansing of the surgical wound site, and the application of a topical antibiotic ointment to the reduced labia, a regimen observed two to three times daily for several days after surgery. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7667", "text": "The woman's initial, post-labiaplasty follow up appointment with the surgeon is recommended within the week after surgery. She is advised to return to the surgeon's consultation room should she develop  hematoma , an accumulation of blood outside the pertinent ( venous  and  arterial ) vascular system. Depending on her progress, the woman can resume physically unstrenuous work three to four days after surgery. To allow the wounds to heal, she is instructed not to use tampons, not to wear tight clothes (e.g. thong underwear), and to abstain from sexual intercourse for four weeks after surgery. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7668", "text": "Medical complications to a labiaplasty procedure are uncommon, yet occasional complications \u2013 bleeding,  infection ,  labial asymmetry , poor wound-healing, undercorrection, overcorrection \u2013 do occur, and might require a revision surgery. An over-aggressive resection might damage the nerves, causing painful  neuromas . Performing a flap-technique labiaplasty occasionally presents a greater risk for  necrosis  of the labia minora tissues. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7669", "text": "Labiaplasty is a controversial subject. Critics argue that a woman's decision to undergo the procedure stems from an unhealthy self-image induced by their comparison of themselves to the prepubescent-like images of women they see in commercials or pornography. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7670", "text": "In Australia, the  Royal Australian College of General Practitioners  has issued guidelines on referring patients with dissatisfaction with their genitals to specialists. [ 13 ]  A change in requirements of publicly funded Australian  plastic surgery  requiring women to be told about natural variation in labias led to a 28% reduction in the numbers of surgeries performed. [ 4 ]  Unlike public hospitals, cosmetic surgeons in private practise are not required to follow these rules, and critics say that \"unscrupulous\" providers are charging to perform the procedure on women who would not undergo it if they had more information. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7671", "text": "Increasing numbers of women in Western countries are also using  Brazilian waxing  to remove pubic hair, and choosing to wear tight-fitting swimwear and clothing. [ 13 ] [ 40 ]  This has led to increased numbers of women complaining of pain and discomfort from chafing of the  labia minora , as well as cosmetic concerns around how the appearance of genitals. [ 13 ] [ 41 ] [ 42 ]  In many countries, media regulation classifies \"hardcore\" and \"softcore\" pornography \u2013 demanding that magazines with \"hardcore\" pornography be wrapped in black plastic and sold only to people over 18 who show photo ID. [ 17 ] [ 43 ]  Sales of magazines in black plastic tend to be low, and thus many magazine publishers choose to comply with the \"softcore\" standards. [ 17 ]  In Australian magazines, images of vulvas that do not look like \"a single crease\" are digitally modified to comply with the censorship standard. [ 17 ]  An Australian pornographic actress says that images of her own genitals sold to pornographic magazines in different countries are  digitally manipulated  to change the size and shape of the labia according to censorship standards in different countries. [ 12 ] [ 18 ] [ 19 ]  Community opposition to  sex education [ 10 ] [ 11 ]  limits the access that young women have to information about natural variation in labias. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7672", "text": "Linda Cardozo , a gynaecologist at  King's College Hospital , London, told the newspaper that women were placing themselves at risk in an industry that is largely unregulated.  Nina Hartley  says that \"she\u2019s seen every type of vulva in her three decades working in the industry. When young women start out in porn, producers don\u2019t send them off for a routine labiaplasty.\" [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7673", "text": "Although  female genital mutilation  \u2013 the practice of cutting off a woman's labia and sometimes clitoris, and in some cases creating a seal across her entire vulva \u2013 is illegal across the Western world, Simone Davis, a professor and gender theorist at Mount Holyoke College in Massachusetts, argues that \"when you really look carefully at the language used in some of those laws, they would also make illegal the labiaplasties that are being done by plastic surgeons in the U.S.\" [ 45 ]  The  World Health Organization  (WHO) defines female genital mutilation as \"all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.\" [ 46 ]  The WHO writes that the term is not generally applied to elective procedures such as labiaplasty. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7674", "text": "The  American College of Obstetricians and Gynecologists  (ACOG) published an opinion in the September 2007 issue of  Obstetrics & Gynecology  that several \"vaginal rejuvenation\" procedures were not medically indicated, and that there was no documentation of their safety and effectiveness. ACOG argued that it was deceptive to give the impression that the procedures were accepted and routine surgical practices. It recommended that women seeking such surgeries must be given the available surgical-safety statistics, and warned of the potential risks of infection, altered sensation caused by damaged nerves,  dyspareunia  (painful sexual intercourse),  tissue adhesions , and painful scarring. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7675", "text": "In the UK, Lih Mei Liao and Sarah M. Creighton of the University College London Institute for Women's Health wrote in the  British Medical Journal  in 2007 that \"the few reports that exist on patients' satisfaction with labial reductions are generally positive, but assessments are short-term and lack methodological rigour.\" They wrote that the increased demand for cosmetic genitoplasty (labiaplasty) may reflect a \"narrow social definition of normal.\" The  National Health Service  performed double the number of genitoplasty procedures in the year 2006 than in the 2001\u20132005 period. The authors noted that \"the patients consistently wanted their vulvas to be flat, with no protrusion beyond the labia majora ... some women brought along images to illustrate the desired appearance, usually from adverts or pornography that may have been digitally altered.\" [ 21 ] [ 22 ]  The Royal Australian and New Zealand College of Obstetricians and Gyn\u00e6cologists published the same concern about the exploitation of psychologically insecure women. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7676", "text": "The International Society for the Study of Women's Sexual Medicine produced a report in 2007 concluding that \"vulvar plastic surgery may be warranted only after counseling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery\". [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7677", "text": "Notes"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7678", "text": "Further reading"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7679", "text": "Media related to  Labiaplasty  at Wikimedia Commons"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7680", "text": "Laser hair removal  is the process of  hair removal  by means of exposure to pulses of  laser  light that destroy the  hair follicle . It had been performed experimentally for about twenty years before becoming commercially available in 1995\u20131996. [ 1 ]  One of the first published articles describing laser hair removal was authored by the group at  Massachusetts General Hospital  in 1998. [ 2 ] [ 3 ]  Laser hair removal is widely practiced in clinics, and even in homes using devices designed and priced for consumer self-treatment. Many reviews of laser hair removal methods, safety, and efficacy have been published in the dermatology literature. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7681", "text": "R. Rox Anderson  and Melanie Grossman [ 5 ]  discovered that it was possible to selectively target a specific  chromophore  with a laser to partially damage basal stem cells inside the hair follicles. This method proved to be successful, and was first applied in 1996. In 1997, the  United States Food and Drug Administration  approved this tactic of hair removal. As this technology continued to be researched, laser hair removal became more effective and efficient; thus, it is now a common method in removing hair for long periods of time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7682", "text": "The primary principle behind laser hair removal is  selective photothermolysis  (SPTL), the matching of a specific  wavelength  of  light  and pulse duration to obtain optimal effect on a targeted tissue with minimal effect on surrounding tissue. Lasers can cause localized damage by selectively heating dark target matter,  melanin , thereby heating up the basal stem cells in the follicle which causes hair growth, the  hair follicle , while not directly heating the rest of the  skin . Light is absorbed by dark objects but reflected by light objects and water, so laser energy can be absorbed by dark material in the hair or skin, with much more speed and intensity than just the skin without any dark adult hair or melanin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7683", "text": "Melanin is considered the primary  chromophore  for all hair removal lasers currently on the market. Melanin occurs naturally in the skin and gives skin and hair their color. There are two types of melanin in hair.  Eumelanin  gives hair brown or black color, while  pheomelanin  gives hair blonde or red color. Because of the selective absorption of  photons  of laser light, only hair with color such as black, brown, or reddish-brown hair or dirty blonde can be removed. White hair, light blonde and strawberry blonde hair does not respond well.  Laser works best with dark coarse hair. Light skin and dark hair are an ideal combination, being most effective and producing the best results, but lasers such as the  Nd:YAG laser  are able to target black hair in patients with dark skin with some success. [ 6 ] [ self-published source? ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7684", "text": "Hair removal lasers have been in use since 1997 and have been approved for \"permanent hair reduction\" in the United States by the  Food and Drug Administration  (FDA). [ 7 ] [ 10 ]  Under the FDA's definition, \"permanent\" hair reduction is the long-term, stable reduction in the number of hairs regrowing after a treatment regime. Many patients experience complete regrowth of hair on their treated areas in the years following their last treatment. This means that although laser treatments with these devices will permanently reduce the total number of body hairs, they will not result in a permanent removal of all hair. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7685", "text": "Laser hair removal has become popular because of its speed and efficacy, although some of the efficacy is dependent upon the skill and experience of the laser operator, and the choice and availability of different laser technologies used for the procedure. Some will need touch-up treatments, especially on large areas, after the initial set of 3\u20138 treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7686", "text": "IPL, though technically not containing a  laser , is sometimes incorrectly referred to as \"laser hair removal\". IPL-based methods, sometimes called \"phototricholysis\" or \"photoepilation\", use  xenon flash lamps  that emit full  spectrum   light . IPL systems typically output wavelengths between 400\u00a0nm and 1200\u00a0nm. Filters are applied to block shorter wavelengths, thereby only using the longer, \"redder\" wavelengths. IPLs offer certain advantages over laser, principally in the pulse duration. While lasers may output trains of short pulses to simulate a longer pulse, IPL systems can generate pulse widths up to 250 ms, which is useful for larger diameter targets. Some current IPL systems have proven to be more successful in the removal of hair and blood vessels than many lasers. [ 11 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7687", "text": "A 2006 review article in the journal  Lasers in Medical Science  compared  intense pulsed light  (IPL), and both alexandrite and diode lasers. The review found no statistical difference in short-term effectiveness, but a higher incidence of side effects with diode laser-based treatment. Hair reduction after six months was reported as 68.75% for alexandrite lasers, 71.71% for diode lasers, and 66.96% for IPL. Side effects were reported as 9.5% for alexandrite lasers, 28.9% for diode lasers, and 15.3% for IPL. All side effects were found to be temporary and even pigmentation changes returned to normal within six months. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7688", "text": "Electrolysis  is another hair removal method that has been used for over 135 years. [ 15 ]  Like newer laser technology used properly and with several treatments, electrolysis can be used to remove 100% of the hair from an area and is effective on hair of all colors, if used at an adequate power level with proper technique. But the treatment is slow and tedious compared with typical newer laser hair removal.  More hair may grow in certain areas that are prone to hormone-induced growth (e.g. a woman's chin and neck) based on individual hormone levels or changes therein, and one's genetic predisposition to grow new hair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7689", "text": "A study conducted in 2000 at the ASVAK Laser Center in  Ankara , Turkey, comparing  alexandrite  laser and electrolysis for hair removal on 12 patients concluded that laser hair removal was 60 times faster, less painful and more reliable than electrolysis. The type of electrolysis performed in the study was  galvanic electrolysis , rather than  thermolysis  or a blend of the two. Galvanic current requires 30 seconds to more than a minute to release each hair whereas thermolysis or a blend can require much less. This study thus did not test the capability of all forms of modern electrolysis. [ 16 ] [ improper synthesis? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7690", "text": "Shaving  is a technique in which one removes hair from the skin with a razor. Shaving, however, is only temporary and can lead to irritation of the shaved area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7691", "text": "Waxing  is another option for hair removal. This method is an efficient way of removing hair; it is longer-lasting than shaving but not permanent. The ancient Egyptians developed a similar mechanism, sugaring, in which one would mix oil and honey then apply it to the skin. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7692", "text": "In some countries, including the U.S., hair removal is an unregulated procedure that anyone can do. In some places, only doctors and doctor-supervised personnel can do it, while in other cases permission extends to licensed professionals, such as regular nurses, physician assistants, estheticians, and/or cosmetologists. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7693", "text": "In Florida, the use of lasers, laser-like devices and intense pulsed light devices is considered medicine, and requires they be used only by a  physician  ( M.D.  or  D.O. ), a  physician assistant  under the supervision of a physician, or an advanced registered nurse practitioner under a protocol signed by a physician.  An electrologist working under the direct supervision and responsibility of a physician is also allowed to perform laser hair removal in the state of Florida. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7694", "text": "Several wavelengths of laser energy have been used for hair removal, from  visible light  to near- infrared   radiation . These lasers are characterized by their wavelength, measured in  nanometers  (nm): [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7695", "text": "Pulse width (or duration) is one of the most important considerations. The length of the heating pulse relates directly to the damage achieved in the follicle. When attempting to destroy hair follicles the main target is the germ cells which live on the surface of the hair shaft. Light energy is absorbed by the melanin within the hair and heat is generated. The heat then conducts out towards the germ cells. As long as a sufficient temperature is maintained for the required time then these cells will be successfully destroyed. This is absolutely critical \u2013 attaining the required temperature is not sufficient unless it is kept at that temperature for the corresponding time. This is determined by the Arrhenius Rate Equation. [ 22 ]  To achieve these conditions the laser/IPL system must be able to generate the required power output. The main reason why hair removal fails is simply because the equipment cannot generate the desired temperature for the correct time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7696", "text": "Spot size, or the width of the laser beam, directly affects the depth of penetration of the light energy due to scattering effects in the dermal layer. Larger beam diameters or those devices that has a linear scanning [ 23 ] [ 24 ]  results in deeper deposition of energy and hence can induce higher temperatures in deeper follicles. Hair removal lasers have a spot size about the size of a fingertip (3\u201318\u00a0mm)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7697", "text": "Fluence  or energy density is another important consideration. Fluence is measured in  joules  per square centimeter (J/cm 2 ). It's important to get treated at high enough settings to heat up the follicles enough to disable them from producing hair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7698", "text": "Epidermal  cooling has been determined to allow higher fluences and reduce pain and side effects, especially in darker skin. Three types of cooling have been developed:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7699", "text": "In essence, the important output parameter when treating hair (and other skin conditions) is power density \u2013 this is a combination of energy, spot diameter and pulse duration. These three parameters determine what actually happens when the light energy is absorbed by the tissue chromophore be it melanin, hemoglobin or water, with the amount of tissue damaged being determined by the temperature/time combination."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7700", "text": "Hair grows in several phases ( anagen ,  telogen ,  catagen ) and a laser can only affect the currently active growing  hair follicles  (early anagen). Hence, several sessions are needed to damage the hair in all phases of growth and force it to revert to a vellus non-colored small hair. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7701", "text": "Multiple treatments depending on the type of hair and skin color have been shown to provide long-term reduction of hair. Most people need a minimum of eight treatments. Current parameters differ from device to device but manufacturers and clinicians generally recommend waiting from three to eight weeks between sessions, depending on the area being treated. The number of sessions depends on various parameters, including the area of the body being treated, skin color, coarseness of hair, reason for  hirsutism , and sex.  Certain areas (notably men's facial hair) may require considerably more treatments to achieve desired results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7702", "text": "Laser does not work well on light-colored hair, red hair, grey hair, white hair, as well as fine hair of any color, such as  vellus . For darker skinned patients with black hair, the long-pulsed  Nd:YAG laser  with a cooling tip can be safe and effective when used by an experienced practitioner."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7703", "text": "Typically the shedding of the treated hairs takes about two to three weeks. These hairs should be allowed to fall out on their own and should not be manipulated by the patient for certain reasons, chiefly to avoid infections. Pulling hairs after a session can be more painful as well as counteract the effects of the treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7704", "text": "Some normal side effects may occur after laser hair removal treatments, including itching, pink skin, redness, and swelling around the treatment area or swelling of the follicles (follicular edema). These side effects rarely last more than two or three days. The two most common serious side effects are acne and skin discoloration."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7705", "text": "Some level of pain should also be expected during treatments. Numbing creams are available at most clinics, sometimes for an additional cost. Some numbing creams are available over the counter. Use of strong numbing creams over large skin areas being treated at one time must be avoided, since it can cause serious harm, and even death. [ 26 ]  Typically, the cream is applied about 30 minutes before the procedure. Icing the area after the treatment helps relieve the side effects faster. Ibrahimi and Kilmer reported a study of a novel device of diode handpiece with a large spot size which used vacuum-assisted suction to reduce the level of pain associated with laser treatment. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7706", "text": "Unwanted side effects such as hypo- or hyper-pigmentation or, in extreme cases, burning of the skin call for an adjustment in laser selection or settings. Risks include the chance of burning the skin or discoloration of the skin,  hypopigmentation  (white spots), flare of  acne , swelling around the hair follicle (considered a normal reaction),  scab  formation,  purpura , and  infection . These risks can be reduced by treatment with an appropriate laser type used at appropriate settings for the individual's skin type and treatment area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7707", "text": "Some patients may show side effects from an  allergy  to either the hair removal gel used with certain laser types or to a numbing cream, or to simply shaving the area too soon after the treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7708", "text": "Lip augmentation  is a cosmetic procedure that modifies the shape of the  lips  using fillers, such as  collagen  or implants. The procedure may be performed to increase lip size, correct asymmetry, create protrusion, or adjust the ratio of the top and bottom lips. The procedure typically involves surgical injection, though temporary non-surgical alternatives exist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7709", "text": "Swelling and bruising are common after lip augmentation, and irritation or allergic reaction may also occur. Lip augmentations can have undesired cosmetic effects, including scarring and lumping, and implants pose the risk of shifting underneath the lip or breaking through the skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7710", "text": "Around 1900,  surgeons  tried injecting  paraffin  into the lips without success. [ 1 ]  Liquid  silicone  was used for lip augmentation, starting in the early 1960s but was abandoned thirty years later due to fears about the effects of silicone on general health and long term aesthetic outcome. [ 2 ]  About 1980, injectable  bovine   collagen  was introduced to the  cosmetic surgery  market and became the standard against which other  injectable  fillers were measured. [ 3 ]  However, that collagen does not last very long and requires an  allergy  test, causing the patient to wait at least three weeks before another appointment, after which more waiting is required to see cosmetic results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7711", "text": "The aim of lip augmentation is to provide an aesthetic, symmetric, and healthy appearance for the patient. Naturally, the face is not perfectly symmetric, and if the asymmetry is too big - with lip augmentation, the asymmetry can be corrected. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7712", "text": "The ideal upper / lower lip ratio is around 1:1.6, [ 4 ]  and this ratio is also achievable by lip augmentation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7713", "text": "In the late 1990s, with the huge popularity of surgical rejuvenation and concomitant increase of  cosmetic surgery  procedures worldwide, more substances, along with  biocompatible  materials commonly used in other medical applications for years, became available to  surgeons  for use in augmenting thinning or misshapen lips into more plump and attractive features."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7714", "text": "Some of the first widely used lip augmentation substances were:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7715", "text": "Since 2000, more products and techniques have been developed to make lip augmentation more effective and patient friendly. The relative ease of many injections is due to surgeons using tiny 30 and 31 gauge (about as thick as a dozen human hairs)  needles  that are used to inject the very sensitive lips. [ citation needed ]  Nonetheless,  topical  anesthesias are often used for lip augmentation procedures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7716", "text": "Some of these new techniques and substances include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7717", "text": "Several studies have found fat grafting of the lip to be one of the best methods of maintaining a semi-permanent fuller and softer lip. [ 11 ]  When the lips are overfilled, the results can be comic, often supplying fodder to  tabloid  newspapers and offbeat websites. This look is sometimes mockingly called a 'trout pout.' Overaggressive injections can lead to lumpiness while too little can result in ridges."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7718", "text": "Common reactions can range from redness, swelling or  itching  at the injection site(s). Other possible complications include  bleeding , uneven lips,  movement  of the implants or extrusion, when an  implant  breaks through the outermost surface of the skin. The usual, expected  swelling  and  bruising  can last from several days to a week. [ citation needed ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7719", "text": "Some patients are allergic to the common local anesthetics like  lidocaine  and probably should not consider lip injections. Some react badly to the skin test that patients must take before receiving collagen. Other patients who should forego procedures to the lip include those who have active skin conditions like  cold sores , blood  clotting  problems,  infections , scarring of the lips or certain diseases like  diabetes  or  lupus  that cause slower healing. Patients with facial  nerve  disorders, severe  hypertension  or recurrent  herpes simplex   lesions  should also eschew lip augmentation. As in all surgeries,  smokers  complicate completion of their procedure as well as the speed of  healing ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7720", "text": "Fat transfer can last longer than other injected materials but can have lumping or scarring effects. The length of time a fat transfer may last in the lips is often determined by how much the area moves and how close it is to a major blood supply. In addition, the donor fat must be harvested from another area of the patient's body which leaves another\u2014albeit tiny\u2014surgical  wound . However, donor fat harvesting techniques have become extremely well refined. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7721", "text": "Cosmetic surgery providers often advise their patients that many options now exist for improving the appearance of the lips. Most practitioners also admit that successful lip augmentation is highly dependent on the skill of the provider, with that skill stemming from many years of experience injecting the lips of many types of patients. Moreover, the surgeon must master various injection techniques. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7722", "text": "With many injectables, the benefit to the patient is an immediate return to normal, usual activities. [ citation needed ]  A few surgeons offer a procedure known as surgical flap augmentations in which small sections of skin near the lips or inside the mouth are excised and added to the lips. But the technique does not add volume and achieves only a slight outward protrusion of the lips. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7723", "text": "A  lip lift  is the most common  plastic surgery  procedure that modifies the cosmetic appearance of the  lips , by reshaping them to increase the prominence of the  vermilion border  and to enhance the facial area above the lips into a more aesthetically pleasing shape. In corrective praxis, a lip lift procedure is distinguished from  lip enhancement , the augmentation of the lips, which can be affected with a non-surgical procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7724", "text": "There are surgical and non-surgical techniques for effecting lip lift and lip augmentation to the lips. The surgical techniques include incisions below the  nose  and in the periphery of the lips area of the face, the perioral area; other techniques effect the surgical incisions from inside the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7725", "text": "The  aesthetic ideal  of a mouth with youthful lips\u2014shaped like a lozenge\u2014features an upper lip with a pronounced  Cupid's bow , and much fullness to each lip; however, such an ideal physiognomy declines with age, and the lips shrink and lose anatomic definition, as the lips sag, which affects the aesthetics of the smile, by revealing less of the teeth during a relaxed smile. [ 1 ] [ 2 ]  The  American Society of Plastic Surgeons  reported 3.2 million cosmetic surgery procedures performed to mature patients, aged 55 years and older, in 2008. The patient demand for facial rejuvenation indicates that most requests do not include the mouth, which results in a surgical outcome that is aesthetically deficient. [ 1 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] \nIn the 1980s, when  collagen , originally the principal filler for the lips, proved limited in effecting permanent correction, plastic surgeons then developed surgical techniques for lifting and augmenting the lips, and correcting aesthetic defects and deformities. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7726", "text": "A systematic review regarding \"non-filling\" procedures for lip augmentation classified lip lift techniques in four surgical categories: the direct lip lift (DLL), indirect lip lift (ILL), corner of the mouth lift (CML), and the V\u2013Y lip advancement (VYLA). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7727", "text": "The \"gull-wing lift\" is an effective surgical technique for increasing the prominence (display) of the vermilion coloring of the lips, by removing  skin  (and other tissues) as required, either directly from or from above the white line of skin that borders onto, and sets off, the vermilion of the lips (the white roll). The incisions remove tissue and significantly alter the shape of the lips by moving up the vermilion from both peaks of the Cupid's bow outwards to the commissures, the corners of the mouth. Incisions are also made below the lower lip to increase the projection of the vermilion of the lower lip. This gull-wing lip lift usually requires an OR time of approximately 20 minutes; post-operatively, the swelling of the lips subsides at 1\u20132 weeks and the tightness subsides at 2\u20134 months. Asymmetry, under-correction, and  hypertrophic scarring  are possible complications. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7728", "text": "A technical variant of the gull-wing lip lift is the sub-nasal lip lift (bull-horn lip lift), which involves the removal of either an ellipse or a curved-edge ellipse of tissue from under the nose. The skin then is raised, and sutured to lift the lip and expose more of the upper-lip vermilion. [ 2 ] [ 9 ]  Depending upon the indications of the patient, this technique can increase the drooping the corners of the mouth (commissures); thus, the sub-nasal lip lift often includes a corner-lift surgical step. [ 6 ]  In the corner lift procedure (external angle oral  commissuroplasty ), triangles of tissue are resected from above the commissures, thereby elevating the corners of the mouth. [ 3 ]  A descending wedge of tissue can also be removed to add contour to the Cupid's bow or to reduce bulky lips. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7729", "text": "Another variation is the thread lift, in which a square stitch is placed from one nostril to the other and down to the peaks of the Cupid's bow. This variation has fallen out of favor because the results are short-lived. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7730", "text": "Another variation is the double duck lip lift, in which the columella of the nose is not incised. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7731", "text": "Another variation of the procedure consists of a lenticular excision of the white skin surrounding the upper oral commissure in order to lift this part of the lips. This technique has also been dubbed the \"Smile Lift\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7732", "text": "Another variation of the procedure is for a surgeon to make an incision inside the mouth to loosen the mucosa and vermilion, which are then advanced and secured, leaving a portion of scar tissue inside the mouth which may take 2\u20134 months to heal. [ 3 ]  Yet another technique uses a \"W\" incision inside the mouth to create several \"V\" flaps, which are then used in a V-to-Y plasty technique to advance the vermilion of either or both lips. [ 3 ]  This procedure leaves no exposed areas inside the mouth, but can be painful and has a lengthy recovery period. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7733", "text": "Although surgeons report patient satisfaction with these techniques to be \"high,\" no one variation has been sufficiently applauded to become the standard procedure. [ 7 ]  Most of these methods result in an increase in the amount of vermilion visible. Quantitative data exists for the V-Y lip augmentation, for which statistically significant increases in upper vermilion height and surface area have been measured. [ 7 ]  A systematic review regarding \"non-filling\" procedures for lip augmentation published in 2014 showed that philtrum length decreases with Indirect Lip Lift techniques, but not with V-Y lip augmentation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7734", "text": "Complications which may arise from lip lift surgery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7735", "text": "Because of this, patients must be on bed rest for at least a week. In particular, the technique of removing skin at or directly above the white roll has been singled out as resulting in unfavorable scarring and stiffness in the lips. [ 2 ] [ 4 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7736", "text": "Advancements and improvements in non-surgical fillers available for lip enhancement has reduced demand for the lip lift procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7737", "text": "Liposuction , or simply  lipo , is a type of  fat-removal procedure  used in  plastic surgery . [ 1 ]  Evidence does not support an effect on weight beyond a couple of months and does not appear to affect  obesity -related problems. [ 2 ] [ 3 ]  In the United States, liposuction is the most common  cosmetic surgery . [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7738", "text": "The procedure may be performed under general, regional, or local  anesthesia . It involves using a  cannula  and negative pressure to suck out fat. [ 4 ]  As a  cosmetic procedure  it is believed to work best on people with a normal weight and good skin elasticity. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7739", "text": "While the suctioned fat cells are permanently gone, after a few months overall body fat generally returns to the same level as before treatment. [ 2 ]  This is despite maintaining the previous diet and exercise regimen. While the fat returns somewhat to the treated area, most of the increased fat occurs in the abdominal area.  Visceral fat \u2014\u2060the fat surrounding the internal organs\u2014increases, and this condition has been linked to life-shortening diseases such as  diabetes ,  stroke , and  heart attack . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7740", "text": "There are two different uses for liposuction:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7741", "text": "Cosmetic liposuction is used to change the body's contour or shape, to aesthetically improve the appearance of body parts and contour. It should not be used for  weight loss . [ 6 ]  Benefits from cosmetic liposuction appear to be of a short-term nature with little long-term effect. [ 2 ]  After a few months fat typically returns and redistributes. [ 2 ]  Liposuction does not help  obesity -related metabolic disorders like  insulin resistance . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7742", "text": "Reconstructive, medically necessary liposuction is used to treat  lipedema , [ 7 ]  to remove excess fat in the chronic medical condition  lymphedema , [ 8 ]  and to remove  lipomas  from areas of the body. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7743", "text": "Many articles refer to liposuction as \"cosmetic\" and not reimbursable by medical insurance companies. Most of this information is outdated. If the documentation supports the liposuction for a medical reason ( lipedema ,  lymphedema ,  lipomas ) as reconstructive, and not investigational, experimental, or unproven, the claim is medically necessary and should be reimbursed. [ 11 ]  While most insurance companies may initially deny the claim, many can be won upon appeal if the documentation and patient's need supports the criteria for  reconstructive surgery . [ 12 ] [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7744", "text": "The techniques and terms listed below: tumescent, lymph-sparing, Tumescent Local Anesthesia (TLA), Water-Assisted Liposuction (WAL), Power-Assisted Liposuction (PAL), Laser-Assisted Liposuction (LAL) all apply to reconstructive, medically necessary liposuction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7745", "text": "In general, fat is removed via a  cannula  (a hollow tube) and  aspirator  (a suction device). Liposuction techniques can be categorized by the amount of fluid injected, and by the mechanism by which the cannula works. If the removed fat is used as filler for the face, lips, or breasts, knowledge of the precise technique used to remove the fat is indicated. [ 15 ]  There are numerous types of liposuction. Some can be described as techniques or modalities. These techniques of liposuction are categorized depending upon the type of energy used for the liquifaction of fat. Often surgeons will use two or more of the different techniques below in the same session. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7746", "text": "This is the most generic term for liposuction. In the CPT manual it is referred to as \"suction-assisted lipectomy\" and includes codes: 15876\u201315879. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7747", "text": "This does not address a particular technique but the diameter of the cannula, a stainless steel tube which is inserted into subcutaneous fat through a small opening or incision in the skin. The outside diameter of micro-cannulas range from 1\u00a0mm to 3\u00a0mm. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7748", "text": "This technique does not require a particular wand and is most often performed with either tumescent liposuction or WAL (below). It refers to the specific surgical technique, the skill of the surgeon, and the extensive training that is unique to removing lipedema fat. [ 18 ]  Because the scope is different for removal of lipedema fat versus cosmetic contouring, if lymph-sparing is not addressed in the surgical operative notes, a medical necessity review committee could determine that the procedure poses \u201ca risk to the lymph system.\u201d [ 19 ] [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7749", "text": "This may be referenced either way above, but the technique is the same. [ 22 ]  This is an anesthesia technique recommended for lymph-sparing liposuction surgery. Tumescent Liposuction refers to the use of anesthesia during liposuction. The word \u201ctumescent\u201d means swollen and firm. By injecting a large volume of very dilute lidocaine (local anesthetic) and epinephrine (capillary constrictor) into subcutaneous fat, the targeted tissue becomes swollen and firm, or tumescent. This technique does not require a special or specific type of wand. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7750", "text": "Referred to as \"a vibrating cannula\" in research studies, PAL uses a specific type of wand that creates an up and down, vibrating-like motion of the cannula to acquire greater fat removal. When compared to simple suction-assisted liposuction, PAL requires less energy for the surgeon to operate while also resulting in greater fat removal. It is commonly used for difficult, secondary, scarred areas, and when harvesting large volumes of fat for transfers to other areas. [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7751", "text": "Note that techniques can be combined; for instance one could refer to the procedure as \"lymph-sparing, tumescent liposuction using a vibrating (PAL) microcannula to treat lipedema.\" [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7752", "text": "A specific technique and wand commonly used for patients who require lymph-sparing liposuction for lipedema. The lipedema fat is removed using a fan-shaped jet of water, which includes the anesthetic. In contrast to tumescent liposuction above, where the anesthetic solution is injected separately and beforehand, the WAL wand both injects the solution and suctions the fat. BodyJet is a Water-Assisted Liposuction system. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7753", "text": "This rare and unique term for liposuction for lipedema is used in a specific paper by Campisi,  Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol . This term emphasizes the uniqueness of the reconstructive procedure versus the cosmetic procedure. Everything about the surgical suction application via cannula is different from standard suction lipectomy. The goal of FLLA is to relieve symptoms such as pain, ameliorate disability, improve function and quality of life, and halt disease progression. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7754", "text": "Only small blunt cannulas are used, great care is used to not injure lymphatic which are already abnormal and increased risk of injury. Only the longitudinal orientation of cannulas is used at critical junctures. Preoperatively critical lymphatic structures are scanned and marked. FLLA surgery is significantly more time-consuming than cosmetic surgery often requiring 4\u20135 hours per body part; much larger aspirate volume is removed versus cosmetic suction lipectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7755", "text": "The benefit to lymphatics function comes not only from the removal of subcutaneous adipose tissue, but also the all components of the loose connective tissue including removing fibrosis in the interstitial space. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7756", "text": "Ultrasound-assisted liposuction techniques used in the 1980s and 1990s were associated with cases of tissue damage, usually from excessive exposure to ultrasound energy. [ 28 ]  Third-generation UAL devices address this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat. [ 29 ]  UAL is beneficial in people with a particular skin tone, in liposuction of areas that are more difficult to remove fat, that include treatment of gynecomastia, or areas where secondary liposuction is being performed. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7757", "text": "Referred to as Smart Lipo, this technique uses laser technology to coagulate and tighten the skin and boost collagen performance. [ 31 ]  Uses include \"cankles\", debulking surgery for elephantiasis nostras [ 32 ]  and lipedema. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7758", "text": "Sold under the brand name of CoolSculpting, cryolipolyis is not a type of liposuction but rather a non-surgical fat reduction procedure that freezes fat cells; it is an FDA-approved, non-invasive procedure that uses cooling to disrupt fat cells underneath the dermis. [ 34 ]  This freezing energy crystallizes and eventually kills targeted fat cells without harming the surrounding healthy tissue. The body's metabolic processes work to remove the dead fat cells. [ 35 ] [ 36 ]  Coolsculpting is not recommended for those with lipedema, lymphedema or other conditions that affect the lymphatic system. Comparing fat freezing to liposuction, [ 37 ]  which requires immediate removal of larger quantities of fat, needs anesthesia with a higher potential for scarring and subsequent significant recovery period."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7759", "text": "The model  Linda Evangelista  reportedly was left unrecognisable after a cryolipolysis procedure. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7760", "text": "Radiofrequency-assisted Liposuction, also known as RFAL, is a new procedure that is being done by thermal energy to promote skin tightening and remove unwanted fat. In this technique, radio waves of specific frequency are used to melt fat. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7761", "text": "Doctors disagree on the issues of scarring with not suturing versus resolution of the swelling allowed by leaving the wounds open to drain fluid. Suturing is more common with a large cannula. [ 24 ]  Since the  incisions  are small, and the amount of fluid that must drain out is large, some surgeons opt to leave the incisions open, while others  suture  them only partially, leaving space for the fluid to drain out. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7762", "text": "Liposuction is considered very safe, though not all liposuction surgery is equal. Small volume liposuction (<1,000\u00a0cc) done awake is different from large volume liposuction (>5,000\u00a0cc, in some cases 10,000\u00a0cc) done with anesthesia and a hospital stay. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7763", "text": "Suction-assisted lipectomy (aka liposuction) were identified [ when? ]  from the Tracking Operations and Outcomes for Plastic Surgeons database maintained by the  American Society of Plastic Surgeons  (ASPS). [ 42 ]  The ASPS maintains a registry of plastic surgery cases called TOPS (Tracking Operations & Outcomes for Plastic Surgeons) which is the largest database of plastic surgery cases. The TOPS database is only voluntary, not available to the public, and does not follow cases long-term or get testimony and experience of patients, only from doctors who profit from doing liposuction. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7764", "text": "Based on this database, no deaths were found in about 4,500 cases done by plastic surgeons 2009\u201310. However, non-plastic surgeons are not included in this. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7765", "text": "In a 2015 study, 69 of 4,534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Their conclusion was that: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors' risk assessment model showed that volumes above 100 ml per unit of body mass index confer an increased risk of complications. [ 45 ]  An example is the case of  Aarthi Agarwal , a Bollywood actress who died six weeks after liposuction surgery after going into cardiac arrest. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7766", "text": "A spectrum of complications may occur due to any liposuction. Risk is increased when treated areas cover a greater percentage of the body, incisions are numerous, a large amount of tissue is removed, and concurrent surgeries are done at the same time. To address safety issues, in 2009 the American Society of Plastic Surgeons (ASPS) published  Evidence-Based Patient Safety Advisory: Liposuction . This 17-page document addresses key safety issues and offers recommendations. [ 42 ] \nIn addition, the increase in tumescent and lymph-sparing techniques have had a positive impact on diminishing complications. [ 47 ]  In a 2009 paper, the author found from a series of 3,240 procedures, no deaths occurred, and no complications requiring hospitalization were experienced. In nine cases, complications developed that needed further action. The conclusion was that liposuction using exclusively Tumescent Local Anesthesia (TLA) is a proven safe procedure provided that the existing guidelines are meticulously followed. [ 48 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7767", "text": "Serious complications include  deep vein thrombosis ,  organ perforation , bleeding, and  infection . [ 49 ]  As of 2011, death was reported to occurs in about one per ten thousand cases. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7768", "text": "To obtain liposuction at lower cost or at a shorter wait may encourage  medical tourism . The  Dominican Republic  has been a popular destination for US medical tourists, because it is fairly close. Since 2003, the  CDC  has reported adverse events after  cosmetic surgery , particularly due to liposuction in combination with gluteal fat transfer,  abdominoplasty , and  breast augmentation . During 2009\u20132022, 93 U.S. citizens died after cosmetic surgery in the Dominican Republic, and 90% of autopsy-confirmed deaths were due to  embolism ; in 55% due to  fat embolism  and in 35% due to  pulmonary venous thromboembolism . [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7769", "text": "Relatively modern techniques for body contouring and removal of fat were first performed by a French surgeon, Charles Dujarier, but a 1926 case that resulted in the amputation of the leg of a French dancer due to excessive tissue removal and too-tight suturing set back interest in body contouring for decades. [ 54 ] [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7770", "text": "Liposuction evolved from work in the late 1960s from surgeons in Europe using techniques to cut away fat, which were limited to regions without many blood vessels due to the amount of bleeding the technique caused. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7771", "text": "In the mid-1970s in Rome, Arpad Fischer and his son Giorgio Fischer created the technique of using a blunt  cannula  linked to suction; they used it only to remove fat on the outer thighs. [ 56 ]  In 1977, Arpad Fischer and Giorgio Fischer reviewed 245 cases with the planotome [ clarification needed ]  instrument for treating  cellulite  in the lateral  trochanteric  (hip-thigh) areas. There was a 4.9 per cent incidence of  seromas , despite incision-wound suction  catheters  and compression dressings; 2 per cent of the cases developed  pseudocysts  that required removal of the capsule ( cyst ) through a wider incision (>5\u00a0mm (0.20\u00a0in)) and the use of the panotome. [ 57 ] [ 58 ]  The Fischers called their procedure liposculpture. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7772", "text": "Yves-G\u00e9rard Illouz  and Fournier extended the Fischers' work to the whole body, which they were able to use by using different sized cannulae. [ 54 ]  Illouz later developed the \"wet\" technique in which the fat tissue was injected with saline and  hyaluronidase , which helped dissolve tissue holding the fat, prior to suctioning. [ 54 ]   Lidocaine  was also added as a local anesthetic. [ 54 ]  Fournier also advocated using compression after the operation, and travelled and lectured to spread the technique. [ 54 ]  The Europeans had performed the procedures under general anesthesia; in the 1980s, American dermatologists pioneered techniques allowing only local anesthetics to be used;  Jeffrey A. Klein  published a method that became known as \"tumescent\" in which a large volume of very dilute lidocaine, along with  epinephrine  to help control bleeding via  vasoconstriction , and  sodium bicarbonate  as a  buffering agent . [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7773", "text": "In 2015, liposuction surpassed  breast augmentation surgery  as the most commonly performed cosmetic procedure in the US. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7774", "text": "Lipotuck  is a procedure trademarked in 2006, by Dr.  A. H. Ahmadi . The procedure is a single cosmetic surgery combining  abdominoplasty  (a.k.a. a \" tummy tuck \") and  liposuction ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7775", "text": "Some abdominoplastic procedures, while removing flesh from the abdomen, do nothing to correct for shaping around hips, thighs, and \" love handles .\" Alternatively, the desired look can be achieved through multiple procedures: tummy tuck first, liposuction after. [ 1 ]  Lipotuck adds to a more traditional \"tummy tuck\" procedure with significant liposuction to the abdomen, hips, and thighs. This procedure is engineered to create flattering curves according to traditional notions of female beauty. [ 2 ]  Lipotuck also includes a repositioning of the patient's belly button, as the excess skin removed generally includes the original one. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7776", "text": "One plastic surgeon in Australia describes Lipotuck as a procedure that \"tends to be safer\" because it uses  tumescent liposuction , a procedures that \"numbs and softens the fat,\" which \"avoid[s] bleeding.\" [ 3 ]  Lipotuck is also more routine, and can be done as an  outpatient procedure . [ 3 ]  Lipotucks can have the risk of  seroma , which happens when some fluid collects in the surgical area that requires a small incision to drain afterwards. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7777", "text": "The  American Society of Plastic Surgeons  does not currently recognize the term \"Lipotuck\" as an FDA-approved brand name for specific plastic surgery treatments. [ 4 ]  However, the term was successfully trademarked in 2006 by A. H. Ahmadi, a cosmetic surgeon in  Sugar Land, Texas . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7778", "text": "The Lipotuck procedure is commonly used by plastic surgeons around the world; many procedures now use a combination of abdominoplasty, liposuction, and buttock contouring. [ 6 ] [ 7 ]  Practitioners have also begun to offer \"mommy makeovers,\" which generally include a combination of liposuction and abdominoplasty among other enhancements, most commonly  breast augmentation . [ 8 ]  These have been called the \"mommy makeover trifecta.\" [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7779", "text": "Marionette lines  (melomental folds) are long vertical lines that laterally circumscribe the  chin . [ 1 ]  They are important landmarks for the general impression of the face. Marionette lines appear with advancing age, but some people never get them, depending on facial structure and anatomy. They tend to appear as the  ligaments  around the mouth and chin relax and begin to loosen and sag, and fatty tissues of the cheek deflate and descend during the aging process. It can be difficult to get rid of them, but they can be minimized with facelifts that lift  cheek  tissue away from the area of the mouth combined with synthetic facial fillers, or with facial fillers alone. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7780", "text": "MyFreeImplants  is the largest website used by women to find donations, particularly from men, via  crowdfunding  for  breast augmentation . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7781", "text": "The women frequently converse with their donors. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7782", "text": "The site has been criticized by professional organizations including the  British Association of Aesthetic Plastic Surgeons  (BAAPS) for tasteless marketing and trivializing a significant surgical procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7783", "text": "It has also been criticized for providing a platform for men to ask for sexual favors. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7784", "text": "Nasal reconstruction using a paramedian forehead flap  within  oral and maxillofacial surgery , is a  surgical  technique to reconstruct different kinds of nasal defects. [ 1 ]  In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7785", "text": "The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7786", "text": "Probably the first  nasal reconstructions  using a forehead flap were performed by  Sushruta  in India during 600 to 700 BC. [ 3 ]  The method was introduced in Europe in the 15th century. The first English description of the Indian midline forehead  rhinoplasty  was published in the Madras Gazette in 1793  [ 3 ]  and later Carpue, an English surgeon, published his experience with two successful median forehead flaps in 1816. The classic median forehead flap supplied by paired supratrochlear vessels was popularized in the United States by Kazanjian in 1947, however, this flap was not optimal because it was not long enough. To solve the problem of the short median forehead flap, its design was modified so that central forehead tissue could be transferred on a unilateral paramedian blood supply. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7787", "text": "A forehead flap is usually required if the nasal defect is larger than 1.5\u00a0cm, requires replacement of support or lining, or if it is located within the infratip or columella. [ 4 ]  If the defect is small and superficial it can be resurfaced with a skin graft or it can heal by  secondary intention . [ 4 ]  Limited alar defects can be resurfaced using a nasolabial flap, however, the amount of tissue available from the nasolabial area is limited and the flap is thicker, less vascular, and hair bearing in males. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7788", "text": "Nasal defects mostly result from excision of (malignant) skin tumours as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, keratoacanthoma, lentigo maligna, lymphoma, and sweat gland carcinoma. [ 5 ]  Other acquired nasal defects are usually caused by trauma, burns or sepsis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7789", "text": "The forehead flap is known as the best donor site for repairing nasal defects because of its size, superior vascularity, skin color, texture and thickness. [ 1 ] [ 3 ] [ 4 ]  Especially the color and texture of the forehead skin matches exactly with the skin of the nose. This is why the forehead flap is used so much for nasal reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7790", "text": "Vascularisation of the scalp and forehead is supplied by the supraorbital,  supratrochlear , superficial temporal, postauricular and occipital vessels. [ 1 ] [ 4 ] [ 6 ]  All these vessels are lined vertically and permit safe and effective transfer of the forehead flap on multiple individual vascular pedicles. [ 1 ] [ 6 ]  The pedicle is the anatomic part that resembles the stem of the flap. The perfusion of the paramedian forehead flap comes from three sources: randomly, through the frontalis muscle and through the supratrochlear artery. [ 1 ]  Because the forehead flap is an axial flap with a pedicle containing its dominant vessel, the pedicle can safely be narrowed to 1 to 1.2\u00a0cm. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7791", "text": "Four types of flap design are historically described in literature: the median forehead flap, oblique forehead flap, sickle flap and vertical paramedian forehead flap. [ 4 ]  However, the vertical paramedian forehead flap based on the ipsilateral or contralateral supratrochlear vessels has become standard, because it has a low turning point, making it easy to reach the defect without using hair-bearing scalp. [ 1 ] [ 4 ]  Also,  primary closing  of the proximal forehead is possible as a result of the narrow pedicle. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7792", "text": "Lateral nasal defects are usually closed with an ipsilateral paramedian forehead flap. Central nasal defects can be reconstructed using either a right- or left-sided forehead flap. The ipsilateral pedicle is closer to the defect than the contralateral pedicle, therefore the flap can be made shorter when using the ipsilateral side. [ 1 ] [ 4 ]  Some experts suggest that a contralateral flap is easier to rotate, but this difference is minimal. [ 1 ]  The only problem with the contralateral flap is the extra length needed, not the difficulty of the technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7793", "text": "Most foreheads are at least 5\u00a0cm long, when measured from eyebrow to hairline. [ 1 ]  This is usually enough to resurface the entire nose using a vertical paramedian forehead flap design. [ 1 ] [ 3 ]  Still, there are some short foreheads. A forehead is called short when it is shorter than 4.5\u00a0cm. When using the forehead flap on a short forehead, there are multiple ways to get the length that is needed. [ 1 ] [ 3 ]  First, the turning point of the flap can be moved down, so that the base of the flap is closer to the nasal defect and a shorter flap can be used to reach the nasal defect. [ 1 ]  Second, the distal end of the flap can be placed within the hairline. [ 1 ]  The reconstructed nose will then have some hair on it, but it can be plucked, depilated or lasered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7794", "text": "Aesthetic regions are used to describe the normal features of the face. These regions (forehead, cheeks, eyelids, lips, nose and chin) are defined by skin quality, border outline, and three-dimensional contour. [ 4 ]  The nose has nine aesthetic subunits, which are most important for reconstruction of the nose. These subunits are: the tip, dorsum, alae, sidewalls, columella, and soft triangles. For an optimal aesthetic result, scars should be positioned between nasal subunits. If enlarging the defect will make the aesthetic result better, normal tissue within the subunit can be safely removed. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7795", "text": "For reconstructing any nasal defect, the contralateral side should be used as a guide. Templates of the defect should be made based on the healthy contralateral side. This is important for defining dimension, outline, and landmark position. [ 4 ]  If more than 50% of a convex nasal subunit (tip, ala nasi) is missing, resurfacing the entire nasal subunit is better than only resurfacing the defect. [ 3 ]  Ideally, nasal reconstruction is performed on a stable platform. Support and shaping by soft tissue sculpting should be accomplished before pedicle division. [ 4 ]  Concha, septum or rib  cartilage  grafts should be used for creating enough support and a good shape."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7796", "text": "A second repair can sometimes be required; causes are recurrence of cancer, new cancer or new trauma. A second flap can be harvested from the contralateral forehead after a prior vertical flap. [ 1 ]  If an oblique or angled flap was used during the first surgery, the second repair becomes more difficult. On one side the pedicle is destroyed and on the other side the forehead is scarred. [ 1 ]  This is another reason to use the unilateral paramedian forehead flap design."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7797", "text": "The donor defect after using a paramedian forehead flap is limited to the central-lateral forehead. The defect is closed as much as possible using a T-shaped scar. [ 1 ]  The adjoining tissues are pulled together vertically and horizontally. Often there is a persisting defect depending on the size of the flap. Any possible resultant defect is high in the forehead and left to heal by secondary intention. [ 1 ]  Eyebrow malformation can occur, but is usually avoided if this method is used correctly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7798", "text": "The two most used forehead flap techniques are the two stage and three stage forehead flap. [ 1 ] [ 3 ] [ 4 ]  The forehead consists of multiple layers; skin, subcutaneous tissue, frontalis muscle with fascia and a thin areolar layer. [ 1 ] [ 4 ]  Traditionally, the forehead flap is transferred in two stages, where the flap is thinned during the first stage to improve the aesthetic result, possibly jeopardizing its vascularity and increasing chance for flap necrosis. To overcome this problem, Menick [ 1 ] [ 3 ] [ 4 ]  described a three-stage forehead flap technique, [ 1 ]  where initially the flap is transferred containing all tissue layers, making it an extremely safe technique. Only during the second stage, the flap - which now acts as a delayed flap - can safely be thinned aggressively according to aesthetic needs. [ 1 ] [ 3 ] [ 4 ]  During the final stage the pedicle is severed, the flap is thinned further and pedicle and flap are trimmed and inset. This three stage flap is especially useful for reconstructing large defects, complex contour deformations, or lining defects, while the two stage flap is used for smaller and superficial defects. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7799", "text": "Before surgery all important landmarks and reference points must be identified and marked. Important landmarks are the hairline, frown lines, location of the supratrochlear vessels, outline of the defect, nasal and lip subunits. [ 1 ]  Then templates are made using the intact side of the nose to make a precise symmetric reconstruction of the nose. The template resembling the defect is placed just under the hairline and the vascular pedicle is drawn downwards into the medial eyebrow. The pedicle is based on the supratrochlear vessels and can be 1.2\u00a0cm wide. [ 1 ]  This way the flap design has been made."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7800", "text": "The flap is incised and elevated from distal to proximal. [ 1 ] [ 3 ]  Distally, the frontalis muscle and subcutaneous tissue are excised, this is done for 1.5 to 2\u00a0cm. [ 1 ] [ 3 ]  Then more downwards the disscection goes through the muscle and over the  periosteum . [ 1 ]  When reaching the brow, all of the skin borders are incised and the flap is carefully released. [ 1 ]  As soon as the flap reaches the defect without tension further incision of the flap is stopped and the flap is inset into the area of the defect. [ 1 ] [ 3 ] [ 4 ]  This is done using a single layer of fine suture. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7801", "text": "The second stage is three to four weeks later, when the flap is well healed at the recipient site. [ 1 ]  At this stage the pedicle is divided, the inferior forehead is reopened and the proximal pedicle replaces the medial brow by an inverted V. The nose side of the pedicle is elevated superiorly with 2\u00a0mm of subcutaneous fat. [ 1 ]  If needed the recipient site can be altered to reach a better aesthetic result. The scar is eventually sculpted between the nasal subregions to create a satisfying aesthetic result. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7802", "text": "The flap is incised and elevated over the periosteum from distal to proximal. [ 1 ]  The flap consists of skin, subcutaneous tissue, fat and frontalis muscle and is not thinned. When reaching the brow, all of the skin borders are incised and the flap is carefully released. [ 1 ]  The full-thickness flap is then sutured into the defect without tension."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7803", "text": "Three to four weeks later, when the full thickness forehead flap is well healed at the recipient site, the second stage begins. The skin of the flap and 3\u20134\u00a0mm of subcutaneous fat is elevated. [ 1 ] [ 3 ]  The underlying excess of soft tissue is then excised and the remaining healed tissue is sculpted in an ideal nasal subunit. The flap is then resutured to the recipient site."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7804", "text": "This stage is completely identical to the second stage of the two stage forehead flap."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7805", "text": "For an optimal aesthetic result a difficult nose reconstruction is often followed by revision surgery. [ 4 ]  There are different types of revisions: minor revisions, major revisions and reoperations. [ 4 ]  Revisions are done not sooner than eight months after completion of the primary forehead flap technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7806", "text": "The goal of nasal reconstruction is to look as normal as possible after reconstruction. [ 7 ]  The results of nasal reconstruction using the paramedian forehead flap are quite good, although some patients report functional difficulties. Airway passage difficulties, mucosal crusts, dry mucosa, and difficulties with smelling are uncommon. [ 5 ]  A minority of the patients reported snoring more often or having a spontaneous nose bleed more often. [ 5 ]  Difficulties with phonation are not likely to occur. The majority of patients are satisfied with function of the nose after reconstruction. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7807", "text": "Ideally, standardized semistructered interviews are used to assess aesthetic outcome after nasal reconstruction. Studies using these interviews showed that generally patients are very satisfied with the result although they reported aggravating of their nasal appearance compared to before surgery. [ 5 ]  Patients were especially satisfied with flap color match and shape of the nasal tip. [ 5 ]  Remarkably, patients scored subjective aesthetic outcome significantly higher compared to a professional panel. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7808", "text": "In comparison to the two stage flap, the three stage flap technique has shown better results, lower revision rates and more possibilities for use of skin grafts for lining. [ 4 ]  Most likely this is because of the reliable vascularisation of the three stage flap."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7809", "text": "Because of the flap's rich perfusion, flap necrosis is unlikely to occur. If it happens the result of severe  ischemia  is normally caused by excessive tension on the flap, a misidentification of past injury, nearby scar formation, fanatic inset to the recipient site or exaggerated flap thinning. [ 4 ]  To solve the problem, to keep the underlying cartilage from infecting and to stop the situation from getting worse, it is better to excise dead tissue at an early stage than to wait watchfully allowing the injury to heal secondarily  [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7810", "text": "It is unlikely for the operation area to get infected. In this situation failure in aseptic techniques or necrosis of the lining are the main causes. Early discovery of infection is very important so complete  debridement  can take place before underlying cartilage is exposed. Chronically infected cartilage is cured by reelevating the flap and excising the infected parts. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7811", "text": "In some patients a new tumor develops in the skin injured by the sun or an old cancer can redevelop. In a few cases the result of the first reconstruction was not good enough. When this takes place the next step is to take away the old flap and redo the reconstruction. A second flap can be taken from the contra lateral side in most instances  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7812", "text": "The defect created at the donor site is usually positioned at the central/lateral forehead. The defect can be closed by pulling the different sides of the wound together in vertical and horizontal direction. [ 1 ]  If there is a resulting defect after closure it is situated high in the forehead and it closes by secondary healing. In spite of the fact that, as a result, the eyebrow could be distorted, this is usually avoided. [ 1 ]  As a result of a large initial defect, the flap has to be larger and the bigger the forehead defect will be. When there is a large resultant forehead defect it logically lies closer to the eyebrow. That is why there is a significant risk of superior eyebrow malposition, especially if a horizontal or oblique oriented forehead flap is used. [ 1 ]  Then the solution is to close the remaining defect with a skin graft. However a skin graft is esthetically inferior and will always look like a shiny, irregularly pigmented, mismatched piece of skin. Alternatively, secondary placement of a  tissue expander  in the forehead can be used to correct the eyebrow malposition and to excise the skin graft and primarily close the forehead defect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7813", "text": "Negative-pressure wound therapy  ( NPWT ), also known as a  vacuum assisted closure  ( VAC ), is a  therapeutic  technique using a  suction  pump, tubing, and a  dressing  to remove excess  exudate  and promote healing in acute or  chronic wounds  and  second- and third-degree burns . The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment using a sealed wound dressing connected to a vacuum pump. [ 1 ] [ 2 ] [ 3 ]  The use of this technique in wound management started in the 1990s and this technique is often recommended for treatment of a range of wounds including  dehisced  surgical wounds, closed surgical wounds, open abdominal wounds,  open fractures , pressure injuries or  pressure ulcers ,  diabetic foot ulcers ,  venous insufficiency ulcers , some types of  skin grafts , burns, sternal wounds. It may also be considered after a clean surgery in a person who is obese. [ 1 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7814", "text": "NPWT is performed by applying a  vacuum  through a special sealed dressing. The continued vacuum draws out  fluid  from the wound and increases blood flow to the area. [ 1 ]  The vacuum may be applied continuously or intermittently, depending on the type of wound being treated and the clinical objectives. Typically, the dressing is changed two to three times per week. [ 3 ]  The dressings used for the technique include foam dressings and gauze, sealed with an  occlusive dressing  intended to contain the vacuum at the wound site. [ 1 ]  Where NPWT devices allow delivery of fluids, such as saline or  antibiotics  to irrigate the wound, intermittent removal of used fluid supports the cleaning and drainage of the wound bed. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7815", "text": "In 1995,  Kinetic Concepts  was the first company to have a NPWT product cleared by the US  Food and Drug Administration . [ 7 ]  Following increased use of the technique by hospitals in the US, the procedure was approved for reimbursement by the  Centers for Medicare and Medicaid Services  in 2001. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7816", "text": "General technique for NPWT is as follows: A  dressing  or filler material is fitted to the contours of a wound to protect the  periwound  and the overlying foam or gauze is then sealed with a transparent film. [ 9 ]  A drainage tube is then connected to the dressing through an opening of the transparent film. Tubing is connected through an opening in the film drape to a canister on the side of a  vacuum pump . [ 10 ]  This turns an open wound into a controlled, closed wound with an airtight seal while removing excess fluid from the wound bed to enhance circulation and remove wound fluids. [ 11 ]  This creates a moist healing environment and reduces  edema . [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7817", "text": "There are four types of dressings used over the wound surface:  foam  or  gauze , a transparent film, and a non-adherent (woven or non-woven) contact layer if necessary. Foam dressings or woven gauze are used to fill open cavity wounds. Foam can be cut to size to fit wounds. Once the wound is filled, then a transparent film is applied over the top to create a seal around the dressing. The tubing is then attached and connected to the pump."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7818", "text": "Once the dressing is sealed, the vacuum pump can be set to deliver continuous or intermittent pressures, with levels of pressure depending on the device used, [ 10 ] [ 12 ] [ 13 ]  varying between \u2212200 and \u221240  mmHg  depending on the material used and patient tolerance. [ 14 ]  Pressure can be applied constantly or intermittently. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7819", "text": "The dressing type used depends on the type of wound, clinical objectives and patient. For pain sensitive patients with shallow or irregular wounds, wounds with undermining or explored tracts or tunnels, gauze may be used, while foam may be cut easily to fit a patient's wound that has a regular contour and perform better when aggressive granulation formation and wound contraction is the desired goal. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7820", "text": "Contraindications  for NPWT use include: [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7821", "text": "Negative pressure wound therapy is usually used with  chronic wounds  or wounds that are expected to present difficulties while healing (such as those associated with  diabetes ). [ 3 ]  Negative pressure wound therapy is approved by the  FDA  and numerous randomized controlled trials have been conducted on this technique, however, the evidence supporting how effective NPWT is compared to standard wound care dressings is not clear. [ 1 ]  Low-level evidence indicates that there may be a lower risk of death and less surgical site infections associated with NPWT compared to standard dressing care, however there may not be a difference in the risk of wound reopening when comparing the two approaches. [ 1 ]  NPWT may increase the risk of skin blistering compared to standard wound care. [ 1 ]  NPWT may be a more cost effective approach for closing wounds following a caesarean section in women who are obese, however, NPWT is not likely as cost effective for closing wounds associated with fracture surgeries. It is not clear if NPWT is cost effective for closing wounds associated with other types of surgery. [ 1 ]  NPWT has been used to treat non-trauma patients after abdominal surgery. [ 18 ]  Non-trauma patients are people who might need surgery for conditions such as abdominal infections or cancer. However, it is still not clear how safe and effective NPWT is for treating non-trauma patients with open abdomens. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7822", "text": "For treating diabetic ulcers of the feet, \"consistent evidence of the benefit of NPWT\" in the treatment of  diabetic ulcers  of the feet has been reported. [ 19 ]  Results for  bedsores  were conflicting and research on mixed wounds was of poor quality, but promising. [ 19 ]  There is no evidence of increased  significant complications . [ 19 ]  The review concluded \"There is now sufficient evidence to show that NPWT is safe, and will accelerate healing, to justify its use in the treatment of diabetes-associated chronic leg wounds. There is also evidence, though of poor quality, to suggest that healing of other wounds may also be accelerated.\" [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7823", "text": "The use of NPWT to enhance wound healing is thought to be by removing excess extracellular fluid and decreasing tissue edema, which leads to increased blood flow and stabilization of the wound environment. [ citation needed ]  A reduction in systemic (e.g. interleukins, monocytes) and local mediators of inflammation has been demonstrated in experimental models, while decreased matrix metalloproteinase activity and bacterial burden have been documented clinically. [ citation needed ]   In vivo , NPWT has been shown to increase fibroblast proliferation and migration, collagen organization, and to increase the expression of vascular endothelial growth factor and fibroblast growth factor-2, thereby enhancing wound healing. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7824", "text": "Otoplasty  ( Greek :  \u03bf\u1f56\u03c2 ,  o\u00fbs , \"ear\" +  \u03c0\u03bb\u03ac\u03c3\u03c3\u03b5\u03b9\u03bd ,  pl\u00e1ssein , \"to shape\") is a procedure for correcting the deformities and defects of the  auricle  ( external ear ), whether these defects are  congenital  conditions (e.g.  microtia ,  anotia , etc.) or caused by  trauma . [ 1 ]  Otoplastic surgeons may reshape, move, or augment the  cartilaginous  support framework of the auricle to correct these defects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7825", "text": "Congenital ear deformities occasionally overlap with other medical conditions (e.g.  Treacher Collins syndrome  and  hemifacial microsomia )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7826", "text": "Otoplasty  (surgery of the ear) was developed in  ancient India  and is described in the medical compendium, the  Sushruta Samhita  (Sushruta's Compendium,  c. \u2009500 AD ). The book discussed otoplastic and other  plastic surgery  techniques and procedures for correcting, repairing and reconstructing ears,  noses , lips, and genitalia that were amputated as criminal, religious, and military punishments. The ancient Indian  medical  knowledge and plastic surgery techniques of the  Sushruta Samhita  were practiced throughout Asia until the late 18th century; the October 1794 issue of the contemporary British  Gentleman's Magazine  reported the practice of  rhinoplasty , as described in the  Sushruta Samhita . Moreover, two centuries later, contemporary practices of otoplastic praxis were derived from the techniques and procedures developed and established in antiquity by Sushruta. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7827", "text": "In  Die operative Chirurgie  ( Operational Surgery , 1845),  Johann Friedrich Dieffenbach  (1794\u20131847) reported the first surgical approach for the correction of prominent ears \u2014 a combination otoplasty procedure that featured the simple excision (cutting) of the problematic excess  cartilage  from the posterior sulcus (back groove) of the ear, and the subsequent affixing, with sutures, of the corrected auricle to the  mastoid   periosteum , the membrane covering the mastoid process at the underside of the mastoid portion of the  temporal bone , at the back of the head. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7828", "text": "In 1920,  Harold D. Gillies  (1882\u20131960) first reproduced the auricle by burying an external-ear support framework, made of autologous rib cartilage, under the skin of the mastoid region of the head, which reconstructed the auricle; he then separated this from the skin of the mastoid area by means of a cervical flap. In 1937, Dr. Gillies also attempted a similar pediatric ear reconstruction with an auricle support framework fabricated from maternal cartilage. This otoplasty correction technique proved inadequate, due to the problems inherent to the biochemical breakdown and elimination (resorption) of the cartilage tissue by the patient's body. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7829", "text": "In 1964, Radford C. Tanzer (1921\u20132004) re-emphasized the use of autologous cartilage as the most advantageously reliable organic material for resolving  microtia  (abnormally small ears), because of its great  histologic  viability, resistance to shrinkage, and resistance to softening, and lower incidence of resorption."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7830", "text": "The development of plastic surgery procedures, such as the refinement of J.F. Dieffenbach's ear surgery techniques, has established more than 170 otoplasty procedures for correcting prominent ears, and for correcting  defects  and  deformities  of the auricle; as such, otoplasty corrections are in three surgical-technique groups:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7831", "text": "The external ear (auricle) is a surgically challenging area in terms of anatomy, composed of a delicate and complex framework of shaped cartilage that is covered, on its visible surface, with thin, tightly adherent, hairless  skin . Although of small area, the surface anatomy of the external ear is complex, consisting of the auricle and the external auditory meatus (auditory canal). The outer framework of the auricle is composed of the rim of the helix, which arises from the front and from below (anteriorly and inferiorly), from a crus (shank) that extends horizontally above the auditory canal. The helix merges downwards (inferiorly) into the cauda helices (tail of the helix), and connects to the lobule (earlobe). The region located between the crura (shanks) of the antihelix is the triangular fossa (depression), while the scapha (elongated depression) lies between the helix and antihelix. The antihelix borders in the middle (medially) to the rim of the concha (shell) and the concha proper, which is composed of the conchal cymba above (superiorly) and the conchal cavum below (inferiorly), which are separated by the helical crus, and meet the antihelix at the antihelical rim. The tragus (auditory canal lobule) and the antitragus (counterpart lobule) are separated by the intertragal notch; the auditory canal lobule does not contain cartilage, and displays varied morphologic shapes and attachments to the adjacent cheek and scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7832", "text": "The superficial temporal and  posterior auricular arteries  preserve the  arterial blood  supply of the external ear. The sensory innervation involves the front and back (anterior and posterior) branches of the  greater auricular nerve , and is reinforced by the auricular temporal and lesser occipital nerves. The auricular branch of the  vagus nerves  supplies a portion of the posterior wall of the external auditory canal. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7833", "text": "The support framework of the reconstructed auricle must be more rigid than the natural cartilage framework of a normal ear, in order for it to remain of natural size, proportion, and contour. If the reconstructed auricle framework were as structurally delicate as the cartilage framework of a natural auricle, its anatomic verisimilitude as an ear would gradually be eroded by a combination of the pressure of the tight skin-envelope in the temporal region of the head, and of the pressure of the progressive contracture of the surgical scar(s). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7834", "text": "In the practice of otoplasty, the term \"prominent ears\" describes external ears (auricles) that, regardless of their size, protrude from the sides of the head. The abnormal appearance exceeds the normal head-to-ear measures, wherein the external ear is less than 2\u00a0cm (0.79\u00a0in), and at an angle of less than 25 degrees, from the side of the head. Ear configurations, of distance and angle, that exceed the normal measures, appear prominent when the man or the woman is viewed from either the front or the back perspective. In the occurrence of prominent ears, the common causes of anatomic defect,  deformity , and abnormality can occur individually or in combination; they are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7835", "text": "Although most prominent ears are anatomically normal,  morphologic  defects, deformities, and abnormalities do occur, such as the:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7836", "text": "The degrees of angle between the head and the ear, and the degrees of angle between the scapha and the concha, determine the concept of prominent ears. The study,  Comparing Cephaloauricular and Scaphaconchal Angles in Prominent Ear Patients and Control Subjects  (2008) reported that the comparisons of the head-to-ear angles and the scapaha-to-concha angles of a 15-patient cohort with prominent ears, with the analogous ear angles of a 15-person control group, established that the average head-to-ear angle was 47.7 degrees for the study group, and 31.1 degrees for the control group; and that the average scapha-to-concha angle was 132.6 degrees for the study cohort, and 106.7 degrees for the control group. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7837", "text": "The antihelix normally forms a symmetric Y-shaped structure in which the gently rolled (folded) crest of the root of the antihelix continues upwards as the superior crus, and the inferior crus branches forwards, from the root, as a folded ridge. The root of the inferior crus of the antihelix sharply defines the rim of the concha. Moreover, the inferior crus also forms the wall that separates the concha from the triangular fossa. The root and superior crus of the antihelix form the anterior wall of the scaphoid fossa, and the helix forms the posterior wall. The triangular fossa dips within the Y-arms of the superior and inferior crura. The corrugated contours of these auricular crests and valleys provide a pillar effect (support) that stabilizes the auricle. The vertical walls of the conchal cup translate to a semi-horizontal plane as the concha merges with the folded crest of the antihelix. The scapha\u2013helix is nearly parallel to the plane of the temporal surface of the head. If the roll of the antihelix and its crest are effaced and flat, rather than rolled or folded, the steep pitch of the conchal wall continues into the un-formed antihelix and scapha and ends at the helix, with little interruption. Said planar orientation places the scapha\u2013helix complex nearly perpendicular to the temporal plane of the head \u2014 because of which the ear appears prominent, thus, such an ear also lacks the stability provided by the pillar effect, and so allows the superior auricular pole to protrude. In the literature, effacement (deficiency) of the antihelical fold is the foremost subject of most discussions of the prominent ear, because it is an aurical deformity manifested as a spectrum of defects and deformities \u2014 ranging from an indistinguishable antihelix (with a confluent concavity, from antihelix to scapha and the helical rim projected outwards and forwards) to loss of definition solely of the superior antihelix (with prominence of the upper pole of the ear)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7838", "text": "The concha of the ear is an irregular hemispheric bowl with a defined rim. The normal scapha\u2013helix surrounds the posterior part of the bowl (much as the brim of an inverted hat surrounds the crown). The pitch at which the scapha\u2013helix projects from the conchal cup is determined:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7839", "text": "If the posterior wall of the concha is excessively high, and the concha is excessively spherical, then there is an excessive angle and distance between the plane of the scapha\u2013helix and the plane of the temporal surface of the head. Such protrusion usually is evenly distributed around the posterior conchal wall, however, the cephalad part of the concha can protrude disproportionately, another cause for a protruding upper pole. Similarly, the caudal part of the concha can project disproportionately, and cause a protruding lower auricular pole, therefore, these deformational features require special attention in the operating room."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7840", "text": "Moreover, regarding the shape and projection of the ear, the importance of the concha must be considered in relation to the three-tiered configuration of the auricular cartilage framework, because the more delicate antihelix and helical complex are mounted upon the sturdier concha; therefore, changes in conchal size and shape greatly influence the overlying tiers, hence it is rare to see prominence of the ear that does not have a conchal element. The concha affects the prominence of the ear three-fold ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7841", "text": "Understanding the first deformational element is well recognized, and, despite limited attention to the second element, once seen, it is easily understood. Therefore, understanding the third element leads to understanding the surgical-technical approach to correcting the isolated lower-pole and lobule prominence. The latter feature of conchal shape, while not the sole cause of lobular prominence, appears to play a key role. As the cartilage angle, between the concha cavum and the antitragus, becomes more acute (i.e. as the antitragus tips closer towards the concha), this supporting structure outwardly projects the lobule and the lower-third of the ear. This feature has a greater influence upon the lobule position than does the commonly described helical tail."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7842", "text": "The combined effects of an effaced antihelix and a deep concha also contribute to severe auricular protrusion (a very prominent ear)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7843", "text": "The occurrence of a prominent  mastoid process  tends to push the concha forward, which extends the auricle (external ear) away from the side of the head. The external ear is mounted upon the bony base of the underlying temporal bone, therefore, anomalies and asymmetries of the skeletal shape can cause either auricle, or both auricles, to become prominent. In relation to the protruding mastoid process, the most recognizable skeletal anomaly is the change in the position and in the projection of the auricle, as associated with non-synostotic  plagiocephaly  (the positional flattening of the side of the head, not caused by the inappropriate union of two bones). Hence, in the occurrence of a flattening of the skull (parallelogram deformation of the cranial vault), the side of the head afflicted with occipital plagiocephaly presents a prominent ear. In subtle cases, the prominent ear might be more readily evident in an elder patient, whose ears are asymmetrically positioned, reason for which the residual occipital flattening (occipital plagiocephaly), and mild facial asymmetry, are unapparent at first view. This effect, of the shape of the patient's head, upon the outward and extended position of the ear is notably indicated in the 1881 illustrations that describe the Ely otoplasty technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7844", "text": "The undersized development of one side of a person's face, demonstrates the influence of skeletal development upon the position of the external ear on the head, as caused by the deficient morphologic development of the  temporal bone , and by the medial positioning of the  temporomandibular joint , the synovial joint between the  temporal bone  and the  mandible  (upper jaw). Moreover, in severe cases of hemifacial microsomia, without the occurrence of microtia (small ears), the normal external ear might appear to have been sheared off the head, because the upper half of the auricle is projecting outwards, and, at the middle point, the lower half of the auricle is canted inwards, towards the  hypoplastic , underdeveloped side of the face of the patient. A similar type of asymmetric development of the head and face features a relatively broad head, a narrow face, and a narrow  mandible ; when observed from the front perspective, the head and face of the person present a triangular configuration. Such wide-to-narrow skeletal sloping, from the head to the face, might create the bone promontory upon which rests and from which projects the upper anatomy of the auricle, which otherwise is an external ear of normal proportions, size, and contour."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7845", "text": "The  cauda helicis  (tail of the helix) is bound to the fibrofatty tissues of the earlobe by a network of  connective tissue . The tail of the helix (cauda helicis), which projects outwards from the concha, carries the earlobe with it, causing it to protrude, which physical condition contributes to prominence of the lower pole of the auricle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7846", "text": "Given the  morphological  diversity of the earlobes found among men, women, and children, some earlobes are large, some earlobes are pendulous, and some earlobes are large and pendulous, but some are prominent because of the structure and form of the dense, interlacing connective tissue fibers that shape the earlobe anatomy independent of the tail of the helix (cauda helicis)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7847", "text": "Functionally, the external ear is served by three ear muscles, the auricularis posterior muscle (rear ear-muscle), the auricularis superior muscle (upper ear-muscle), and the auricularis anterior muscle (front ear-muscle), the most notable of which is the  auricularis posterior muscle , which functions to pull the ear backwards, because it is superficially attached to the  ponticulus  (bridge) of the conchal cartilage, and to the posterior auricular ligament (rear ligament of the ear). The posterior muscle of the ear is composed of two to three  fascicles  (skeletal-muscle fibers contained in perimysium connective tissue), originates from the  mastoid process  of the  temporal bone  and is inserted to the lower part of the cranial surface of the concha, where it is surrounded by fibroareolar tissue deep within the temporal fascia. The  posterior auricular artery  irrigates the ear tissues with small, branch-artery blood vessels (rami). Likewise, the rear muscle of the ear is innervated with fine rami of the  posterior auricular nerve , which is a branch of the  facial nerve . Deep within these muscle and ligament structures lie the mastoid fascia and the tendinous origin of the  sternomastoid muscle . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7848", "text": "The corrective goal of otoplasty is to set back the ears so that they appear naturally proportionate and contoured without evidence or indication of surgical correction. Therefore, when the corrected ears are viewed, they should appear normal, from the:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7849", "text": "The severity of the ear deformity that is to be corrected determines the advantageous timing of an otoplasty; for example, in children with extremely prominent ears, 4 years old is a reasonable age. In cases of  macrotia  associated with prominent ears, the child's age might be 2 years. Nonetheless, it is advantageous to restrict the further growth of the deformed ear. Regardless of the patient's age, the otoplasty procedure requires that the patient be under  general anaesthesia . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7850", "text": "Generally, for reconstructing an entire ear, or a portion of the rim cartilage, the surgeon first harvests a  costal cartilage  graft from the patient's rib cage, which then is sculpted into an auricular framework that is emplaced under the temporal skin of the patient's head, so that the skin envelope encompass the cartilage framework, the ear prosthesis. Once placed and anchored with sutures, the surgeon then creates an auricle (outer ear) of natural proportions, contour, and appearance. In the next months, in follow-up surgeries, the surgeon then creates an earlobe, and also separates the reconstructed auricle from the side of the head (15\u201318 millimetres (0.59\u20130.71\u00a0in)), in order to create a  tragus , the small, rounded projection located before the external entrance to the ear canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7851", "text": "In the case of the patient encumbered with several congenital defects of the ear or who has insufficient autologous cartilage to harvest, it might be unfeasible to effect the corrections with grafts of rib cartilage. In such a case, the reconstructive Antia\u2013Buch helical advancement technique may instead be used, wherein tissue is moved from behind the ear rim and then around and forward to repair the defective front of the ear rim. [ 20 ]  To perform the Antia\u2013Buch helical advancement, the surgeon first designs the incision inside the helical rim and around the crus (shank) of the helix with ink. The surgeon then cuts the skin and the cartilage, but does not pierce the posterior skin of the ear. The helical rim then is advanced to allow the suturing (closure), and a dog-ear-shaped graft of skin is removed from the back of the ear. The closure of the sutures advances the crus of the helix into the helical rim. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7852", "text": "The ear defect or deformity to be corrected determines the otoplasty techniques and procedures to be applied: for example, a torn  earlobe  can be repaired solely with  sutures ; a slight damage to the rim of the auricle might be repaired with an  autologous  skin graft harvested from the scalp; and conversely, a proper ear reconstruction might require several surgeries. In the correction of infantile ear defects and deformities, the otoplasty usually is performed when the child is about six years old, as the healthy ear is almost adult-sized, and thus can act as a corrective template for the auricular reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7853", "text": "The otoplastic technique(s) applied to correct, reconstruct, or replace a deformed, defective, or a missing ear, is determined by the indications that the patient presents; some are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7854", "text": "Otoplastic surgery can be performed upon a patient under  anesthesia  \u2014  local anesthesia , local anesthesia with  sedation , or  general anesthesia  (usual for children). In order to correct a lop ear with a small helix (the cartilage-supported outer rim of the auricle), an incision to one side of a flat cartilage piece leaves unopposed elastic forces on the opposite side, which permits the evolution of the ear contour; thus, a small incision on one side of the lop-ear cartilage, along the new anti-helical fold, can be a technical element of the corrective ear surgery. Yet, when done without an incision, the procedure is deemed an 'incisionless otoplasty', wherein the surgeon places a needle through the skin, to model the cartilage and to emplace the retention  sutures  that will affix the  antihelix  and  conchal bowl  areas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7855", "text": "Depending upon the auricular defect, deformity, or reconstruction required, the surgeon applies these three otoplastic techniques, either individually or in combination to achieve an outcome that produces an ear of natural proportions, contour, and appearance:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7856", "text": "Repositioning the earlobe is the most difficult part of the otoplasty, because when an auricle that has been repositioned in its upper two-thirds, and that yet retains a prominent lobule (earlobe) will appear disproportionate to and malpositioned upon the head \u2014 as it did in the original, uncorrected deformity. The otoplastic technique most effective for lobular repositioning is the Gosain technique (or a variant), wherein the surgeon cuts the skin on the medial surface of the earlobe, and, in suturing it closed, takes a bite of the conchal undersurface to pull the earlobe towards the head."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7857", "text": "Another prominent-earlobe correction technique is suturing the helical-cartilage tail to the concha, yet, because the tail of the helix does not extend much into the lobule, setting it back does not reliably correct the set back of the earlobe proper; other techniques involve skin excision and sutures, between the fibrofatty tissue of the lobule and the tissues of the neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7858", "text": "Depending upon the pre-surgical degree of prominence of the upper-third of the auricle, the surgical creation of the antihelical fold might be inadequate to fully correct the position of the helical rim, near the root of the helix. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7859", "text": "The internal  sutures  usually are permanent (non-absorbable), but the surgical wound or wounds can be sutured with either absorbable sutures or with non-absorbable sutures that the plastic surgeon removes when the surgical wound has healed. Depending upon the deformity to be corrected, the otoplasty can be performed either as an  outpatient surgery  or at hospital; while the operating room time varies between 1.5 and 5 hours."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7860", "text": "For several days after the surgery, the otoplasty patient wears a voluminous, non-compressive dressing upon the corrected ear(s), and must avoid excessive bandage pressure upon the ear during the convalescent period, lest it cause pain and increased swelling, which might lead to the abrasion, or even to the  necrosis  of the ear's skin. After removing the dressing, the patient then wears a loose headband whilst sleeping for a 3\u20136-week period; it should be snug, not tight, because its purpose is preventing the corrected ear(s) from being pulled forward, when the sleeping patient moves whilst asleep. An overly-tight headband can abrade and erode the side surface of the ear, possibly creating an open wound. [ 21 ]  A dressing does not have to be worn if the patient was operated upon with the stitch method. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7861", "text": "Approximately 20\u201330 per cent of newborn children are born with deformities of the external ear (auricle) that can occur either  in utero  (congenitally) or in the birth canal (acquired). The possible defects and deformities include protuberant ears (\"bat ears\"); pointed ears (\"elfin ears\"); helical rim deformity, wherein the superior portion of the ear lacks curvature; cauliflower ear, which appears as if crushed; lop ear, wherein the upper portion of the auricle is folded onto itself; and others. Such deformities usually are self-correcting, but, if at 1 week of age, the child's external ear deformity has not self-corrected, then either surgical correction (otoplasty 5\u20136 years of age) or non-surgical correction (tissue molding) is required to achieve an ear of normal proportions, contour, and appearance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7862", "text": "In the early weeks of infancy, the cartilage of the infantile auricle is unusually malleable, because of the remaining maternal  estrogens  circulating in the organism of the child. During that biochemically privileged period, prominent ears, and related deformities, can be permanently corrected by molding the auricles (ears) to the correct shape, either by the traditional method of taping, with tape and soft dental compound (e.g.  gutta-percha latex ), or solely with tape; or with non-surgical tissue-molding appliances, such as custom-made, defect-specific splints designed by the physician. Therapeutically, the splint-and-adhesive-tape treatment regimen is months-long, and continues until achieving the desired outcome, or until there is no further improvement in the contour of the auricle, likewise, with the custom and commercial tissue-molding devices. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7863", "text": "The traditional, non-surgical correction of protuberant ears is taping them to the head of the child, in order to \"flatten\" them into the normal configuration. The physician effects this immediate correction to take advantage of the maternal estrogen-induced malleability of the infantile ear cartilages during the first 6 weeks of their life. The taping approach can involve either adhesive tape and a splinting material, or only adhesive tape; the specific deformity determines the correction method. This non-surgical correction period is limited, because the extant maternal estrogens in the child's organism diminish within 6\u20138 weeks; afterwards, the ear cartilages stiffen, thus, taping the ears is effective only for correcting \"bat ears\" (prominent ears), and not the serious deformities that require surgical re-molding of the auricle to produce an ear of normal size, contour, and proportions. Furthermore, ear correction by splints and tape requires the regular replacement of the splints and the tape, and especial attention to the child's head for any type of skin erosion, because of the cumulative effects of the mechanical pressures of the splints proper and the adhesive of the fastener tape."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7864", "text": "Congenital ear deformities are defined as either malformations (microtia, cryptotia) or deformations, wherein the term \"ear deformation\" implies a normal chondrocutaneous component with an abnormal auricular architecture. The conditions are categorized as constricted ears, Stahl's ear deformity, and prominent ears, which derive from varied causes, such as the abnormal development and functioning of the intrinsic and extrinsic ear muscles, which might generate forces that deform the auricle; and external forces consequent to malpositioning of the head during the prenatal and neonatal periods of the child's life. A study,  Postpartum Splinting of Ear Deformities  (2005), reported the efficacy of splinting the ears of a child during the early neonatal period as a safe and effective non-surgical treatment for correcting congenital ear deformities. [ 28 ]  The study used a variety of physician-designed, physician-fabricated and commercially fabricated splints, such as a wire core segment in 6-French silastic tubing, self-adhering foam, temporary stopping with dental material, dental waxes, thermoplastic materials and other commercial ear-splint devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7865", "text": "28. Merck, W.H. (2017)  \"Ohrmuschelkorrektur ohne Hautschnitt - die Fadenmethode von Merck\". In: K.Bumm (Herausgeber): Korrektur und Rekonstruktion der Ohrmuschel. Springer, 153\u2013169."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7866", "text": "Pediatric plastic surgery  is  plastic surgery  performed on children. Its procedures are predominantly conducted for reconstructive purposes, although some cosmetic procedures are performed on children as well. In children, the line between cosmetic and reconstructive surgery is often blurred, as many  congenital deformities  impair physical function as well as aesthetics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7867", "text": "Children make up roughly 3% of all plastic surgery procedures, and the majority of these procedures correct a congenital deformity. [ 1 ]  Cleft lip, syndactyly, and polydactyly are among the most common conditions treated with pediatric reconstructive surgery. Common pediatric cosmetic procedures include breast augmentation or reduction, auricular reconstruction, and rhinoplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7868", "text": "Reconstructive plastic surgery is performed on abnormal structures of the body that are the result of congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While reconstructive surgery is most often undertaken to regain normal motor function or prevent current or future health problems, aesthetics is also considered by the surgical team. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7869", "text": "Several of the most common congenital birth defects can be treated by a plastic surgeon operating as an individual, or as a part of a multi-disciplinary team. The most common pediatric birth defects requiring plastic surgeon involvement include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7870", "text": "Cosmetic plastic surgery is defined as a surgical procedure undertaken to improve the physical appearance and self-esteem of a patient. These procedures are usually  elective ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7871", "text": "While the majority of pediatric plastic surgery procedures done are reconstructive; there are those performed for cosmetic purposes. The most common procedures done for cosmetic benefit in children include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7872", "text": "Out of all procedures, nose reshaping generally has the most cases on an annual basis (4,313 procedures in 1996). However, children make up only 9% of the total caseload for all nose reshaping. On the opposite end of the spectrum, children requiring ear surgery accounted for 2,470 procedures in 1996, a total of 34% of all total ear surgeries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7873", "text": "While many of these procedures are done for purely cosmetic benefit, many plastic surgeons work on these features (giving them a more normal appearance), while performing a surgery to improve function as the result of a congenital deformity. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7874", "text": "With the unique challenges created in the field of plastic surgery, an increasingly popular trend has been to utilize the multi-disciplinary team approach in treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7875", "text": "Common conditions involving team treatment include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7876", "text": "Perforator flap surgery  is a technique used in  reconstructive surgery  where skin and/or  subcutaneous fat  are removed from a distant or adjacent part of the body to reconstruct the excised part. [ 1 ]  The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some  perforators  can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle. [ 1 ]  If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example, a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator. [ 1 ]  According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the  deep fascia , they don't traverse any other structural tissue. Indirect perforators first run through other structures before piercing the  deep fascia . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7877", "text": "Soft tissue defects due to trauma or after tumor extirpation are important medical and cosmetic topics. Therefore, reconstructive surgeons have developed a variety of surgical techniques to conceal the soft tissue defects by using tissue transfers, better known as flaps. In the course of time these flaps have rapidly evolved from \"random-pattern flaps with an unknown blood supply, through axial-pattern flaps with a known blood supply to muscle and musculocutaneous perforator flaps\" for the sole purpose of optimal reconstruction with minimum donor-site  morbidity . [ 2 ] \nKoshima and Soeda were the first to use the name \u201cperforator flaps\u201d in 1989  [ 3 ]  and since then perforator flaps have become more popular in reconstructive microsurgery. [ 1 ]  Thus perforator flaps, using autologous tissue with preservation of  fascia , muscle and  nerve   represent the future of flaps. [ 4 ]  The most frequently used perforator flaps nowadays are the deep inferior epigastric perforator flap ( DIEP flap ), [ 5 ] [ 6 ]  and both the superior and inferior gluteal (SGAP/ IGAP) flap, [ 7 ]  all three mainly used for  breast reconstruction ; the lateral circumflex femoral artery perforator (LCFAP) flap (previously named anterolateral thigh or ALT flap) [ 8 ]  and the thoracodorsal artery perforator (TAP) flap, [ 9 ]  mainly for the extremities and the head and neck region as a free flap and for breast and thoracic wall reconstruction as a pedicled perforator flap."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7878", "text": "Perforator flaps can be classified in many different ways. Regarding the distinct origin of their blood supply and the structures they cross before they pierce the  deep fascia , perforators can either be direct perforators or indirect perforators. [ 10 ]  We will discuss this classification based on the perforators' anatomy below."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7879", "text": "[ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7880", "text": "Direct cutaneous perforators only perforate the  deep fascia , they do not traverse any other structural tissue. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7881", "text": "It is questionable whether these perforators are true perforators, because it might be more logical to not include these perforators. The surgical approach needed for direct perforators is slightly different from the one needed for indirect perforators. When direct perforators are not included, surgeons can focus on the anatomy of the perforator and the source vessel. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7882", "text": "Indirect cutaneous perforators traverse other structures before going through the  deep fascia . These other structures are deeper tissues, and consist of mainly muscle, septum or  epimysium . [ 10 ]  According to the clinical relevance, two types of indirect cutaneous perforators need to be distinguished. [ 1 ]  We will clarify these two types below. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7883", "text": "Musculocutaneous perforators supply the overlying skin by traversing through muscle before they pierce the  deep fascia . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7884", "text": "A perforator which traverses muscle before piercing the  deep fascia  can do that either transmuscular or transepimysial. This latter subdivision is however not taken into account during the  dissection  of the perforator. Only the size, position, and course of the perforator vessel are considered then. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7885", "text": "When a flaps\u2019 blood supply depends on a muscle perforator, this flap is called a muscle perforator flap. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7886", "text": "Septocutaneous perforators supply the overlying skin by traversing through an intermuscular septum before they pierce the deep fascia. These perforators are cutaneous side branches of muscular vessels and perforators. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7887", "text": "When a flap's blood supply depends on a septal perforator, this flap is called a septal perforator flap. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7888", "text": "Due to confusion about the definition and nomenclature of perforator flaps, a consensus meeting was held in Gent, Belgium, on September 29, 2001. Regarding the nomenclature of these flaps, the authors stated the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7889", "text": "\" A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle. \"  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7890", "text": "This so-called 'gent consensus' was needed because the lack of definitions and standard rules on terminology created confusion in communication between surgeons. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7891", "text": "Flaps can be transferred either free or pedicled. Regarding the nomenclature, one is free to add the type of transfer to the name of a flap. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7892", "text": "A free flap is defined as a tissue mass that has been taken away from the original site to be used in tissue transplantation. [ 11 ]  When a surgeon uses a free flap, the blood supply is cut and the pedicle reattached to recipient vessels, performing a microsurgical anastomosis. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7893", "text": "For more information on free flaps, see also  free flap ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7894", "text": "Pedicled perforator flaps can be transferred either by translation or rotation. These two types will be discussed separately below. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7895", "text": "This type of transfer is also called \"advancement\".The surgeon disconnects the flap from the body, except for the perforators. After this procedure, the flap is advanced into the defect. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7896", "text": "The subgroup of pedicled perforator flaps, transferred in the defect by rotation is the so-called \"propeller flap\".\nConfusion concerning definition, nomenclature and classification of propeller flaps led to a consensus meeting similar to the \"gent consensus meeting\u201d. The consensus that was reached is named \"the tokyo consensus\". This article stipulates the definitions of propeller flaps and especially perforator propeller flaps. [ 14 ]  The definition that was set up is cited below:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7897", "text": "\"A propeller flap can be defined as an \u201cisland flap that reaches the recipient site through an axial rotation.\u201d Every skin island flap can become a propeller flap. However, island flaps that reach the recipient site through an advancement movement and flaps that move through a rotation but are not completely islanded are excluded from this definition. \"   [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7898", "text": "Regarding the classification of propeller flaps, the surgeon should specify several aspects of these flaps. It is important that the type of nourishing pedicle, the degree of skin island rotation and, when possible, the artery of origin of the perforator vessel are mentioned. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7899", "text": "The perforator propeller flap is the propeller flap which is used most commonly. It is a perforator flap with a skin island, which is separated in a larger and smaller paddle by the nourishing perforator. These paddles can rotate around the perforator (pedicle), for as many degrees as the anatomical situation requires (90-180 degrees). This flap looks like a propeller when the two paddles are not too different in size. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7900", "text": "Trauma, oncological treatments or pressure ulcers can result in severe tissue defects. Those defects can be covered and closed by using autologe tissue transposition. The fact that each tissue defect is different makes it necessary for each tissue defect to be assessed individually. The choice of the type of tissue transposition depends on the location, nature, extent and status of the deformity. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7901", "text": "However, the health of the patient and possible contra-indications play an important role as well. Due to the development and improvement of cutaneous, myocutanous and fasciocutaneous tissue transpositions plastic surgeons are able to successfully restore the defect to its original shape. [ 15 ]  Nevertheless, functional recovery is not guaranteed in all patients. For the optimal renewal of shape and function, a suitable flap can be chosen to reconstruct the defect. In the case of using a so-called perforator flap, a reliable vascularization and the possibility of sensory (re) innervation can be combined with less donor-site morbidity and limited loss of function in the donor area. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7902", "text": "The surgical removal of both benign and  malignant tumors  often result in serious tissue defects involving not only soft tissue but also parts of the bone. [ 16 ]  Depending on the location aneligible flap can be selected. In breast reconstruction for example, perforator flaps have raised the standard by replacing like with like. [ 17 ]  When taking  breast reconstruction  into consideration, several surgical options are available to achieve lasting natural results with decreased donor-site deformities. The broad option of donor-sites makes practically all patients candidates for autogenous perforator flap reconstruction. [ 17 ]  Some examples include, Deep inferior epigastric perforator flap ( DIEP flap ), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7903", "text": "Treatment of tissue defects caused after a trauma present major surgical challenges especially those of the upper and lower limb, due to the fact that they often not only cause damage to the skin but also to bones, muscles/ tendons , vessels and/or  nerves . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7904", "text": "If there is extensive destruction a  fasciotomy  is needed, therefore it is generally accepted that the best way to cover these types of tissue defects is a  free flap transplantation. [ 18 ] \n [ 19 ] [ 20 ]  Nevertheless, over the years surgeons have tried to increase the application of perforator flaps, due to their proven advantages. In the case of upper limb surgery, perforator flaps are successfully used in minor and major soft tissue defects provided that in major defects the flap is precisely planed. [ 18 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7905", "text": "In lower limb surgery there have also been reports of successful use of perforator flaps. [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7906", "text": "Twenty three years after the first perforator flap was described by Koshima and Soeda, [ 3 ]  there has been a significant step towards covering tissue defects by using only cutaneous tissue. [ 24 ]  Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps have shown a reduction of donor-site morbidity to a minimum  [ 24 ] [ 25 ]  due to refined perforator flap techniques that allow collection of tissue without scarifying the underlying muscles. [ 24 ] [ 26 ]  As a matter of fact, preventing damage to the underlying muscle including its innervation, has led to less cases of abdominal  hernia , [ 26 ]  the absence of postoperative muscle atrophy  [ 27 ]  and a better vascularised and functioning donor muscle. [ 17 ]  Furthermore, patients have shown decreased postoperative pain and accelerated rehabilitation  [ 17 ] [ 25 ]  Nevertheless, there will always be a chance that the displaced tissue partially or completely dies considering the fact that the perfusion of  the flap is difficult to assess intraoperatively. [ 28 ]  Furthermore, when using this technique additional scars are made. Thus considering the complexity and length of this procedure microsurgical expertise is required and patients need to undergo a longer period of anesthetics that of course could result in increased risk factors. [ citation needed ]  Microsurgical expertise in perforator flap dissection can be acquired using perforator flap training models in living tissue. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7907", "text": "Indications :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7908", "text": "Contraindications : [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7909", "text": "Associated with the patient:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7910", "text": "Any condition that probably increases the risk of intraoperative or postoperative complications: [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7911", "text": "By inducing  thrombogenic  state through  vasoconstriction  of the microvasculature, tobacco influences  blood flow , wound healing and the survival of pedicled flaps. On the contrary there is no published data on damaging effects of cigarette smoke on free tissue transfer. [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7912", "text": "Permanent makeup , also known as  permanent cosmetics ,  derma-pigmentation ,  micro-pigmentation ,  semi-permanent makeup  and  cosmetic tattooing , [ 1 ]  is a  cosmetic  technique which employs  tattooing  techniques to replicate the appearance of traditional  makeup . By implanting pigments into the  dermis , long-lasting designs are created such as  eye liner , eyebrows, and lip color. This procedure appeals to a diverse range of people; from those who want to make their daily routines more simple to individuals with  medical conditions . By eliminating the need to apply traditional makeup regularly, permanent makeup has become a very convenient and effective solution. More than an aesthetic technique, permanent makeup plays a crucial role in procedures of  reconstructive  type."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7913", "text": "Permanent makeup has evolved from a tattooing practice to a more widely accepted, sophisticated procedure. It has become very popular, not only because of its cosmetic advantages but also for its convenience and enhancing quality of life. However, it does come with risks. Complications include  allergic reactions , migration of pigment, or even  infections , which underscore the importance of high-quality materials and skilled technicians"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7914", "text": "As permanent makeup gradually gained popularity, its safety concerns, regulatory challenges, and options for removal also attracted attention. Whether selected for restoration, convenience, or other reasons, this technique represents a blend of science, personal care, and aesthetics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7915", "text": "The most widely documented first use of permanent makeup treatment was done by the famous U.K. tattoo artist  Sutherland MacDonald . [ 2 ]  In 1902, at his parlor, #76 Jermyn Str., London, he \"perfected his method of giving a lasting complexion of the utmost delicacy to pale cheeks.\" [ 3 ]  The tattooist  George Burchett , a major developer of the technique in the 1930s, described in his memoirs how beauty salons tattooed many women without their knowledge, offering it as a \"complexion treatment... of injecting vegetable dyes under the top layer of the skin.\" [ 4 ] [ 5 ]  Permanent makeup became much more commonplace beginning in the 1970s and 1980s, when it was used to address hair and pigment loss due to disease, [ 6 ]  and now it is considered very normal. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7916", "text": "One may opt for permanent makeup for a plethora of reasons. For some, it can replace the daily application of traditional  makeup  products in favor of a more lasting solution. [ 8 ]  This is especially useful for older women whose eyesight might not be good enough to apply the makeup [ 9 ]  or who have degenerative diseases such as  Parkinson's  which severely limits motor ability. [ 6 ]  Others may have the procedure to restore color areas that have lost it due to disease. This includes micro pigmentation for people with  alopecia  and  vitiligo , and areola recoloring for  breast cancer  patients. Permanent makeup is also a common practice in some African cultures, who use certain tattoos to signify status. [ 7 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7917", "text": "Some of the most common permanent makeup procedures for Americans are eyebrows and eyeliner. However, other types of permanent makeup include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7918", "text": "As with any  tattoo , there are cases of undesired results, whether that be from the initial application or degradation over time. [ 11 ]  Since this is the case, patients should come in with realistic expectations of what the  makeup  will look like. [ 9 ]  One factor that heavily influences how the cosmetic tattoo looks is  skin tone . This is because the same color may look different on different skin tones. Another factor that affects the appearance of these tattoos is sun exposure and lifestyle, which can fade the tattoos. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7919", "text": "As with any occupation, permanent makeup technicians need to complete required training in order to practice, although these requirements vary from state to state. The average technician completes an  apprenticeship  around nine months in length; however, certification programs vary from a single day to four years. [ 1 ] [ 9 ]  Once they complete their certification, the technician must submit various documents, including proof of certification, apprenticeship, and insurance, before practicing. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7920", "text": "Permanent cosmetics technicians are urged to comply with \u201cstandard precautions\u201d and a uniform code of safe practice while performing cosmetic tattooing procedures. [ 13 ] [ 14 ]  This includes assessing whether the patient should receive permanent makeup at all and informing adequately informing them about the risks associated with the practice. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7921", "text": "In a study done regarding the possible complications of permanent makeup, the most common side effects were  itching , redness, and the occasional swelling, all of which tended to heal after a few days. [ 15 ]  While uncommon, permanent makeup can potentially come with more serious  complications , including  allergic reactions  to the pigments,  infection ,  granulomas ,  keloids , bleeding, crusting, loss of eyelashes, or general damage to the tattooed area. [ 11 ] [ 16 ]  Although properly trained technicians will maintain sterile conditions during application, [ 17 ]  the use of unsterilized tattooing instruments may also infect the patient with serious diseases such as  HIV  and  hepatitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7922", "text": "On very rare occasions, people with permanent makeup have reported swelling or burning in the affected areas when they underwent  magnetic resonance imaging  (MRI). [ 18 ]  Nevertheless, most such cases indicated that poor quality pigments, pigments adulterated with heavy metals, and pigments with  diamagnetic  properties may have been the causative factors. [ 19 ] [ 20 ]  Permanent makeup can also reportedly affect the quality of an MRI image, however, complications can be avoided as long as medical professionals are previously informed. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7923", "text": "In the  United States , the inks used in permanent makeup are subject to approval as cosmetics by the  Food and Drug Administration . While certain pigments in tattoos lack  FDA  approval for use in permanent cosmetics, competing public health priorities and lack of safety problems have consequently caused loose regulations around what color pigments tattoo inks can contain. Thus, there is little regulation on the type of inks used, with some pigments not approved for skin contact or refined only to an industrial-grade level, i.e. printers\u2019 ink, automobile paint, etc. . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7924", "text": "If a tattooist lacks proper training, patients run the risk of the artist injecting the ink too deep into their skin, causing the pigment to migrate into the surrounding tissue. As a result, the makeup may appear blurry and lack definition for thin line work. [ 11 ]  Due to their lymphatic distribution, older patients may have an increased risk for pigment migration following permanent eyelash makeup, [ 22 ]  Although migration is generally avoidable by not over-working swollen tissue. Removing migrated pigment is a difficult and complicated process, so it must be avoided if possible. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7925", "text": "As with tattoos, permanent makeup can be difficult, or even impossible, to remove. [ 12 ]  Common techniques used for this are laser  tattoo removal ,  dermabrasion  (physical or chemical  exfoliation ), and surgical removal. [ 23 ]  Different types of chemical removals have also become a popular option for permanent makeup removal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7926", "text": "Follicular unit transplantation  ( FUT ) is a  hair restoration  technique, also known as the strip procedure, where a patient's hair is transplanted in naturally occurring groups of 1 to 4 hairs, called  follicular units . Follicular units also contain  sebaceous (oil) glands , nerves, a small muscle, and occasional fine  vellus hairs . In follicular unit transplantation, these small units allow the surgeon to safely transplant thousands of grafts in a single session, which maximizes the cosmetic impact of the procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7927", "text": "FUT is considered an advance over older  hair transplantation  procedures that used larger grafts and often produced a pluggy, unnatural look. In a properly-performed follicular unit transplant, the results will mimic the way hair grows in nature and will be undetectable as a hair transplant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7928", "text": "In recent history, FUT had been the most common procedure for hair restoration.  As of 2017, the newer  follicular unit extraction  (FUE) procedure has become the most common procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7929", "text": "Follicular unit transplantation uses follicular units to accomplish a number of objectives critical to the hair restoration process:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7930", "text": "Since the follicular unit is a distinct anatomic and physiologic entity, preserving it intact during the graft dissection is felt to maximize growth. In FUT, after hair is removed from the back of the scalp in a single strip, stereo-microscopic dissection allows the individual follicular units to be removed from this strip without being damaged. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7931", "text": "In the older mini-micrografting techniques, hair was harvested in multiple strips with the follicular units in each strip edge showing damage from the harvesting blades. The strips were then cut into smaller pieces, a process that would break up follicular units and risk additional damage to the follicles.\n [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7932", "text": "Follicular Unit Transplantation enables the hair transplant to look natural both at the individual follicular unit level and in regards to the overall graft distribution. Since scalp hair normally grows in follicular units of 1 to 4 hairs, the exclusive use of these naturally-occurring units in FUT ensures that each graft will be identical to the surrounding follicular units. Thus, when the transplanted follicular units grow hair after a transplant, the overall results of the transplant will appear natural."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7933", "text": "Additionally, by using individual follicular units, rather than larger grafts, the surgeon has a greater total number of grafts with which to work. This allows the surgeon to distribute the grafts more evenly over the scalp for a more natural overall distribution of hair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7934", "text": "The density of naturally-occurring follicular units in a normal scalp is relatively constant, measured at approximately 1 unit per mm 2 . [ 5 ]  This helps in the planning of a hair transplant in two ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7935", "text": "In patients with high hair density, there are usually a sufficient number of follicular units in the donor area to accomplish the patient's goals. However, in the patient with low hair density, a compromise must be made, and this is guided by the follicular unit constant.  By transplanting a patient with low hair density using the same number and spacing of follicular units as in a patient with high density, the transplant surgeon will produce a thinner look, but will allow proper conservation of donor hair for future procedures. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7936", "text": "The key to a natural appearing hair transplant is to have the hair emerge from perfectly normal skin, so minimizing trauma to the scalp is an important aspect of follicular unit transplantation.  This can be accomplished by trimming away the excess tissue around the follicular units and then inserting them into small recipient sites on the patient's scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7937", "text": "Follicular units are relatively compact structures, but are surrounded by substantial amounts of non-hair bearing skin.  This extra tissue can be removed without injuring the follicles, using stereo-microscopic dissection.  These small, trimmed, follicular unit grafts can then be placed into tiny incisions in the patient's scalp; thereby minimizing damage to the scalp's connective tissue and blood supply. In contrast; the larger wounds produced by mini-micrografting and plug transplants caused cosmetic problems that included dimpling and pigment changes in the skin; depression or elevation of the grafts; and a thinned, shiny look to the scalp. These problems can be avoided using very small grafts and very small recipient wounds."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7938", "text": "Another advantage of making small recipient wounds is the ability to create a \"snug fit\" for the follicular unit grafts. Unlike the punch grafts and some mini-grafting techniques; each of which removes a small bit of tissue in the recipient area; the trimmed follicular unit grafts used in FUT fit into small, needle-made incisions without any need for removing tissue. This preserves the elasticity of the scalp and holds the tiny grafts snugly in place. After surgery, the snug fit facilitates wound healing and helps to ensure that the grafts will get enough oxygen from the surrounding tissue in order to maximize their survival. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7939", "text": "There are four reasons why the follicular unit transplantation procedure allows a hair transplant surgeon to transplant large numbers of grafts in each session:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7940", "text": "The \" platelet-rich fibrin matrix \" ( PRFM ) method is a  cosmetic surgery  procedure involving  plasma needling . It is a way of extracting  platelets  from the patient's own blood and using them as a  dermal filler  \u2013 that is, as a substance injected under the skin of the face to try to fill out  wrinkles . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7941", "text": "PRFM is an  outpatient  procedures that, as of March 2011 [update] , costs about $900 to $1,500 in the U.S. and takes less than half an hour. Blood is drawn from the patient's arm and spun in a  centrifuge  to separate out the platelets, which are then injected back under the patient's facial skin. It can also be combined in a specific way with other fillers. A procedure using this combination has been marketed as the \"Vampire facelift\".\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7942", "text": "PRFM has been available on the U.S. market since 2009. It was developed and is marketed by the  Aesthetic Factors  corporation. [ 1 ]  While a platelet extraction centrifuge was cleared by the U.S.  Food and Drug Administration  (FDA) in 2002 As of March 2011 [update]  platelets extracted in this centrifuge have not been cleared or approved by the FDA for facial rejuvenation. [ 1 ]  Nonetheless, Selphyl has been described as a \"FDA approved dermal filler\" in YouTube videos and trade publications. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7943", "text": "The  efficacy  of PRFM is contested. As of March 2011 [update] , according to a  New York Times  report, it is attested by several plastic surgeons who use it but remains unproven by research. [ 1 ]   Phil Haeck , the president of the  American Society of Plastic Surgeons , dismissed the procedure as \"creepy\", \"a gimmick\" and as \"antiquated as  bloodletting \". [ 1 ]  It is marketed as Selphyl, TruPRP, Emcyte, Regen, and Pure Spin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7944", "text": "Platysmaplasty , commonly referred to as a neck lift, is a form of cosmetic  plastic surgery  involving tightening and removing  skin  from the human  neck . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7945", "text": "Because it doesn't often follow a predictable pattern of aging, neck lift surgery must be tailored to each patient's specific needs. Loss of collagen is a major contributor to facial aging, and the neck is certainly no exception. [ 3 ]  As the aging process progresses, collagen production declines and the skin becomes lax, sags, and looks wrinkled. With time, neck muscles also weaken causing a \"turkey wattle\" appearance. The thin skin of the neck is also especially vulnerable to creases and lines. Neck lifts tend to last 7-10 years and can be repeated in the future if necessary. [ 4 ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7946", "text": "Pollicization  (or  pollicisation ) is a  hand surgery  technique in which a  thumb  is created from an existing finger. Typically this consists of surgically migrating the index finger to the position of the thumb in patients who are either born without a functional thumb (most common) or in patients who have lost their thumb traumatically and are not amenable to other preferred methods of thumb reconstruction such as toe-to-hand transfers. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7947", "text": "During pollicization the index finger  metacarpal  bone is cut and the finger is rotated approximately 120 to 160 degrees and replaced at the base of the hand at the usual position of the thumb. The arteries and veins are left attached. If nerves and tendons are available from the previous thumb these are attached to provide sensation and movement to the new thumb (\"neopollex\"). If the thumb is congenitally absent other tendons from the migrated index finger may be shortened and rerouted to provide good movement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7948", "text": "The presence of an  opposable thumb  is considered important for manipulation of most objects in the physical world. Children born without thumbs often adapt to the condition very well with few limitations, so the decision to proceed with pollicization lies with the child's parents with the recommendation of their surgeon. Persons who have grown to adulthood with functional thumbs and then lost a thumb find it highly beneficial to have a thumb reconstruction, not only from a functional but from a mental and emotional standpoint."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7949", "text": "Other cases for pollicization are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7950", "text": "Prison plastic surgery  is  plastic surgery  or cosmetic surgery (often the terms are used interchangeably) offered and performed to people who are incarcerated, as a means of social rehabilitation. These services were normally provided as part of a larger package of care that may include work  training ,  psychological services , and more. Popular surgeries included  rhinoplasties ,  blepharoplasty ,  facelifts ,  scar removal  and  tattoo removal . These programs began in the early 20th century and were commonplace up till the early 1990s. They took place across the US (in 42+ states), the UK, Canada, and Mexico. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7951", "text": "\"Incarceration itself is famously  hard on the body ,\" reports journalist and author  Zara Stone  in her book,  Killer Looks: The Forgotten History of Plastic Surgery In Prisons ; [ 2 ]  in 2017, facial injuries accounted for 33% of all inmate hospitalizations in New York City, compared to  0.7 percent of the general population. \"The existence of prison plastic surgery programs is America\u2019s dirty little secret.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7952", "text": "In  San Quentin prison , California, the prison's chief medical doctor Dr.  Leo L. Stanley  was one of the first people to develop a prison plastic surgery practice, focused on reforming the faces of convicts. [ 3 ]  \"Considerable plastic surgery has been done, particularly that done for deformed noses,\u201d Dr. Leo Stanley wrote in his 1918 report to the warden. [ 4 ]  \u201cThis work has been of benefit in that it has improved the appearance of many of the men and removed a deforming feature. Some work has been done on ears which were very prominent.\" Stanley reported long waiting lists, noted researcher Ethan Blue. [ 5 ]  Dr. Stanley's \"typical prison malingerer,\" [ 6 ]  had a fractured nose or scarred face, and was treated with crude methods: for nose surgery, a six-inch length of broomstick was placed against the nose and hit with a mallet. \"The physician of the future will be an increasing powerful antagonist in the war against crime,\" Stanley wrote. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7953", "text": "New York was an early adopter, with attention to prisoner beautification baked in from the early 1900s. In 1915, NYC police commissioner Arthur Woods referred to a 15-year-old inmate's appearance in relation to his crime. \u201cHe was an inferior looking lad, small and flabby...mild  acne  on the face...forehead broad, nose small, eyes rather sly\u2026chin pointed and  receding ,\u201d wrote Woods. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7954", "text": "Prison plastic surgery became more prevalent throughout the 20th century. In 1954  the American Correctional Association added prisoner plastic surgery to its manual, stating: \u201celective surgery\u2026[for] especially repulsive facial disfigurements has a definite place in the rehabilitation of prisoners. [ 9 ] \u201d Many states followed suit, including Texas, North Carolina, and Hawaii."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7955", "text": "Some of these early surgeries fell in the  eugenics  bracket, the idea that criminality could be  seen and displayed on the face , reports social Psychologist  Ray Bull  and Nichola Rumsey. [ 10 ]  An examination of some of the mid-20th century prison programs suggested that by and large, plastic surgeries did reduce recidivism\u2014in some cases, dropping it from 76% to 33%. Some findings: Plastic surgery is effective in enhancing the outcome for non-addict prisoners. In 1970, the former director of the Federal Bureau of Prisons from 1937 to 1964, James Van Benschoten Bennett, analyzed these programs. [ 11 ]  \"One of the more fruitful areas of research now under way in the federal prisons concerns plastic surgery: the way to rehabilitate a misshapen prisoner.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7956", "text": "\" Discriminatory practices based on physical appearance  perpetuate social inequalities and hinder individuals' opportunities for reintegration into society,\" noted author Zara Stone, in a Rockefeller research paper. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7957", "text": "The scholar and feminist critic  Jessica Mitford  was one of the first to question the ethics of performing plastic surgery on prisoners, and if in such a circumstance the prisoners could really consent to such treatment. In her book,  Kind and Usual Punishment , she wrote that one doctor told her that inmates had become \u201cour companions in medical science.. . . . This has been a rewarding experience both for the physician and for the subjects.\u201d This was in regards to a  scurvy  experiment where inmates suffered hemorrhages in the skin and whites of the eyes, excessive loss of hair, mental depressions, and abnormal emotional responses... at a time when scurvy was already curable and treatable.\" [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7958", "text": "The writer  Allen M. Hornblum  explored the issue of consent  [ 14 ]  in his book,  Acres Of Skin , where he reported of strips of skin being flayed off the back of inmates that participated in dermatological trials in the Eastern Penitentiary, Pennsylvania. [ 15 ]  Ostensibly, they were volunteers, but a payment incentive was the reason for their volunteerism and abuse. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7959", "text": "In the movie  Dark Passage , Humphrey Bogart plays the role of Vincent Parry, a man sentenced for murder. [ 17 ]  Parry escapes San Quentin and undergoes plastic surgery to change his appearance and hide from the law while he tries to clear his name. In the 1996 movie  A Face to Die For ,  Yasmine Bleeth plays the part of a scarred young woman that is conned into participating in a crime. [ 18 ]  In prison she gets plastic surgery as part of a reform program, and when released sets out to seek her revenge."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7960", "text": "The  reconstructive ladder  is the set of levels of increasingly complex management of wounds in reconstructive  plastic surgery . [ 1 ]  The surgeon should start on the lowest rung and move up until a suitable technique is reached."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7961", "text": "There are several small variations in the reconstructive ladder [ 2 ] [ 3 ]  in the scientific literature, but the principles remains the same:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7962", "text": "Rhinoplasty  ( Ancient Greek :  \u1fe5\u03af\u03c2 ,  romanized :\u00a0 rh\u012b\u0301s ,  nose  +  Ancient Greek :  \u03c0\u03bb\u03ac\u03c3\u03c3\u03b5\u03b9\u03bd ,  romanized :\u00a0 pl\u00e1ssein ,  to shape ), commonly called  nose job , medically called  nasal reconstruction , is a  plastic surgery  procedure for altering and reconstructing the  nose . [ 1 ]  There are two types of plastic surgery used \u2013  reconstructive surgery  that restores the form and functions of the nose and  cosmetic surgery  that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal  injuries  caused by various  traumas  including  blunt , and  penetrating trauma  and trauma caused by  blast injury . Reconstructive surgery can also treat  birth defects , [ 2 ]   breathing problems , and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a  deviated nasal septum  or a sinus condition. [ citation needed ]  Surgery only on the septum is called a  septoplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7963", "text": "In  closed rhinoplasty  and  open rhinoplasty  surgeries \u2013 a plastic surgeon, an  otolaryngologist  (ear, nose, and throat specialist), or an  oral and maxillofacial surgeon  (jaw, face, and neck specialist), creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the  soft tissues  from the  nasal framework , altering them as required for form and function,  suturing  the incisions, using  tissue glue  and applying either a package or a  stent , or both, to immobilize the altered nose to ensure the proper healing of the surgical incision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7964", "text": "Treatments for the plastic repair of a broken nose are first mentioned in the  Edwin Smith Papyrus , [ 4 ]  a transcription of text dated to the  Old Kingdom  from 3000 to 2500  BCE . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7965", "text": "The  Ebers Papyrus  ( c.  1550 BC), an  Ancient Egyptian   medical papyrus , describes rhinoplasty as the  plastic surgical  operation for reconstructing a nose destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7966", "text": "Rhinoplasty techniques are described in the  ancient Indian  text  Sushruta samhita  by  Sushruta , where a nose is reconstructed by using a flap of skin from the cheek. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7967", "text": "During the  Roman Empire  (27 BC \u2013 476 AD) the encyclopaedist  Aulus Cornelius Celsus  ( c.  25 BC\u00a0\u2013 50 AD) published the 8-tome  De Medicina  (On Medicine,  c.  14 AD), which described plastic surgery techniques and procedures for the correction and the reconstruction of the nose and other body parts. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7968", "text": "At the  Byzantine  Roman court of the Emperor  Julian the Apostate  (331\u2013363 AD), the royal physician  Oribasius  ( c.  320\u2013400 AD) published the 70-volume  Synagogue Medicae  (Medical Compilations, 4th century AD), which described facial-defect reconstructions that featured loose  sutures  that permitted a  surgical  wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound;  debridement , how to remove damaged tissue to forestall  infection  and so accelerate healing of the  wound ; and how to use  autologous skin flaps  to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient's normal  visage . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7969", "text": "In Italy,  Gasparo Tagliacozzi  (1546\u20131599), professor of  surgery  and  anatomy  at the  University of Bologna , published  Curtorum Chirurgia Per Insitionem  (The Surgery of Defects by Implantations, 1597), a technico\u2013procedural manual for the  surgical  repair and reconstruction of facial wounds in soldiers. The illustrations featured a  re-attachment  rhinoplasty using a  biceps muscle  pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7970", "text": "In Great Britain,  Joseph Constantine Carpue  (1764\u20131846) published the descriptions of two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an  arsenic -damaged nose. (cf.  Carpue's operation ). [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7971", "text": "In Germany, rhinoplastic technique was refined by surgeons such as the  Berlin University  professor of surgery  Karl Ferdinand von Gr\u00e4fe  (1787\u20131840), who published  Rhinoplastik  (Rebuilding the Nose, 1818) wherein he described 55 historical plastic surgery procedures, and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient's arm), and surgical approaches to eyelid,  cleft lip , and  cleft palate  corrections. Dr. von Gr\u00e4fe's  prot\u00e9g\u00e9 , the  medical  and  surgical   polymath   Johann Friedrich Dieffenbach  (1794\u20131847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published  Die Operative Chirurgie  (Operative Surgery, 1845), which became a foundational medical and plastic surgical text (see  strabismus ,  torticollis ). Moreover, the  Prussian   Jacques Joseph  (1865\u20131934) published  Nasenplastik und sonstige Gesichtsplastik  (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7972", "text": "In the United States, in 1887, the otolaryngologist John Orlando Roe (1848\u20131915) performed the first modern endonasal rhinoplasty (closed rhinoplasty) in order to treat  saddle nose  deformities. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7973", "text": "In the early 20th century, Freer, in 1902, and Killian, in 1904, pioneered the  submucous resection  septoplasty (SMR) procedure for correcting a deviated  septum ; they raised mucoperichondrial tissue flaps, and resected the  cartilaginous  and  bony   septum  (including the  vomer bone  and the  perpendicular plate  of the  ethmoid bone ), maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard  septoplastic  procedure. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1934, Aurel Rethi introduced the open rhinoplasty approach featuring an incision to the nasal septum to facilitate modifying the tip of the nose. [ 15 ]  In 1947, Maurice H. Cottle (1898\u20131981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach. [ 6 ]  In 1957, A. Sercer advocated the \"decortication of the nose\" ( Dekortication des Nase ) technique which featured a columellar-incision open rhinoplasty that allowed greater access to the  nasal cavity  and to the nasal septum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7974", "text": "The endonasal rhinoplasty was the usual approach to nose surgery until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. [ 16 ] [ 17 ]  Goodman impelled technical and procedural progress and popularized the open rhinoplasty approach. [ 18 ] [ secondary source needed ]  In 1987, Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery. [ 19 ] [ secondary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7975", "text": "In early 2021, it was reported that a trend that involved getting a rhinoplasty had emerged on the social media platform  TikTok . The trend became known as the #NoseJobCheck trend and involved users of the platform posting videos that showed how their noses looked before and after their rhinoplasty surgeries, with a specific audio soundtracking the video. From October 2020 to January 2021, the #NoseJobCheck audio had been used in over 120,000 videos and videos with the #NoseJobCheck hashtag had accumulated over one billion views. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7976", "text": "For plastic surgical correction, the structural anatomy of the nose comprises:  A.  the nasal soft tissues;  B.  the aesthetic subunits and segments;  C.  the blood supply arteries and veins;  D.  the nasal lymphatic system;  E.  the facial and nasal nerves;  F.  the nasal bone; and  G.  the nasal cartilages."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7977", "text": "To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine  aesthetic nasal subunits , and six  aesthetic nasal segments , which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7978", "text": "In turn, the nine aesthetic nasal subunits are configured as six aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7979", "text": "Using the co-ordinates of the subunits and segments to determine the topographic location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 percent of an  aesthetic subunit  is lost (damaged, defective, destroyed) the surgeon replaces the entire  aesthetic segment , usually with a regional  tissue graft , harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient's body. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7980", "text": "Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant  blood . The principal arterial blood-vessel supply to the nose is two-fold:  (i)  branches from the  internal carotid artery , the branch of the  anterior ethmoidal artery , the branch of the  posterior ethmoidal artery , which derive from the  ophthalmic artery ;  (ii)  branches from the  external carotid artery , the  sphenopalatine artery , the  greater palatine artery , the  superior labial artery , and the  angular artery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7981", "text": "The  external nose  is supplied with blood by the  facial artery , which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region ( sella turcica , \"Turkish chair\") and the dorsal region of the nose are supplied with blood by branches of the internal  maxillary artery  ( infraorbital artery ) and the  ophthalmic arteries  that derive from the internal  common carotid artery  system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7982", "text": "Internally, the  lateral nasal wall  is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The  nasal septum  also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three vascular supplies to the internal nose converge in the  Kiesselbach plexus  ( the Little area ), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the  cavernous sinus , which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply,  tobacco smoking  does therapeutically compromise post-operative healing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7983", "text": "The pertinent nasal  lymphatic system  arises from the superficial mucosa, and drains posteriorly to the  retropharyngeal nodes  (in back), and anteriorly (in front), either to the upper  deep cervical nodes  (in the neck), or to the  submandibular glands  (in the lower jaw), or into both the nodes and the glands of the neck and the jaw."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7984", "text": "The sensations registered by the human nose derive from the first two branches of  cranial nerve V , the  trigeminal nerve . The  nerve  listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7985", "text": "The supply of  parasympathetic  nerves to the face and the upper jaw (maxilla) derives from the  greater superficial petrosal  (GSP) branch of  cranial nerve VII , the  facial nerve . The GSP nerve joins the  deep petrosal nerve  (of the sympathetic nervous system), derived from the carotid plexus, to form the  vidian nerve  (in the vidian canal) that traverses the  pterygopalatine ganglion  (an autonomic ganglion of the maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the  lacrimal gland  and the glands of the nose and of the palate, via the (upper jaw) maxillary division of  cranial nerve V , the  trigeminal nerve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7986", "text": "In the upper portion of the nose, the paired  nasal bones  attach to the  frontal bone . Above and to the side (superolaterally), the paired nasal bones connect to the  lacrimal bones , and below and to the side (inferolaterally), they attach to the ascending processes of the  maxilla  (upper jaw). Above and to the back (posterosuperiorly), the bony nasal septum is composed of the  perpendicular plate of the ethmoid bone . The  vomer  bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the  pharynx  that is continuous with the nasal passages). The floor of the nose comprises the  premaxilla bone  and the  palatine bone , the roof of the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7987", "text": "The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of  turbinates  (nasal conchae), which are small, thin, shell-form bones: (i) the  superior concha , (ii) the  middle concha , and (iii) the  inferior concha , which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the  maxillary sinus . Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated  cribriform plate  (of the ethmoid bone) through which pass sensory filaments of the  olfactory nerve  ( cranial nerve I ); finally, below and behind (posteroinferior) the cribriform plate, sloping down at an angle, is the bony face of the  sphenoid sinus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7988", "text": "The cartilaginous  septum  ( septum nasi ) extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper half is flanked by two triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the  pyriform (pear-shaped) aperture , while the inferior ends of the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the  sesamoid cartilages  are adjacent to the upper  lateral-cartilages  in the fibroareolar connective tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7989", "text": "Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling\u2014i.e., an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7990", "text": "The form of the nasal subunits\u2014the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella\u2014are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine (narrow-sided nose). The respective  external nasal valve  of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7991", "text": "In the midline of the nose, the  septum  is a composite (osseo-cartilaginous) structure that divides the nose into two similar halves. The lateral nasal wall and the  paranasal sinuses , the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The  superior meatus  is the drainage area for the posterior  ethmoid bone  cells and the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the  nasolacrimal duct ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7992", "text": "The  internal nasal valve  comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader grafts and flaring sutures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7993", "text": "The surgical management of nasal defects and deformities divides the nose into six  anatomic subunits : (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 percent of the subunit. Aesthetically, the nose\u2014from the nasion (the midpoint of the nasofrontal junction) to the columella-labial junction\u2014ideally occupies one-third of the vertical dimension of the person's face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person's face. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7994", "text": "The  nasofrontal angle , intersection of the line from the  nasion  to the nasal tip with the line from the  nasion  to the  glabella , usually is 115-130 degrees; the nasofrontal angle is more acute in the male face than in the female face. The  nasofacial angle , intersection of the line from the  nasion  to the nasal tip with the line from the  nasion  to the pogonion, is approximately 30\u201340 degrees. The  nasolabial angle , the slope between the columella and the  philtrum , is approximately 90\u201395 degrees in the male face, and approximately 100\u2013105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2\u00a0mm; and the dorsum should be rectilinear (straight). When observed from below (worm's-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose's tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be 55\u201360 percent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7995", "text": "The  Goode Method  determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture) to the alar\u2013facial\u2013groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7996", "text": "Systematic approaches to nasal analysis have been described. For example, the 10-7-5 method allows for methodical analysis of the nose. It describes 10 features from the frontal view, 7 features from the lateral view, and 5 features from the basal view. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7997", "text": "3D simulations and planning  can be used to communicate the patients existing deformities, and plan or propose the desired approach. [ 26 ] [ 27 ] [ 28 ]   3-dimensional cameras allow photographic capture, inspection, analysis, and modification to understand the existing nasal anatomy, and communicate a potential result to the patient. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7998", "text": "To determine the patient's suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates them with a complete  medical history  ( anamnesis ) to determine their physical and  psychological health . The prospective patient must explain to the physician\u2013surgeon the functional and aesthetic nasal problems that they have. The surgeon asks about the ailments' symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability\u2014the patient's psychological motive for undergoing nose surgery is critical to the surgeon's pre-operative evaluation of the patient. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_7999", "text": "The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient's medical data. Specific facial and nasal evaluations record the patient's skin-type, existing surgical scars, and the symmetry and asymmetry of the  aesthetic nasal subunits . The external and internal nasal examination concentrates upon the  anatomic thirds  of the nose\u2014upper section, middle section, lower section\u2014specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the  turbinates , and the nasal lining, paying special attention to the structure and the form of the nasal dorsum and the tip of the nose. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8000", "text": "Furthermore, when warranted, specific tests\u2014the mirror test, vasoconstriction examinations, and the Cottle maneuver\u2014are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898\u20131981), the  Cottle maneuver  is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient's cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient's inspiration, that result is a positive  Cottle sign \u2014which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a  false-positive Cottle sign , usually observed in the patient affected by alar collapse, and in the patient with a scarred nasal-valve region. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8001", "text": "There is limited evidence that a single dose of corticosteriods decreases oedema and bleeding first two days post operation but the difference is not maintained after this. [ 31 ]   Swelling and edema can take at least 1-year to diminish. [ 32 ]   Certain adjuncts, including fat grafting may help quicken the time to edema and bruising resolution. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8002", "text": "The plastic surgical correction of  congenital  and acquired abnormalities of the  nose  restores functional and aesthetic properties by the surgeon's manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework, and the  mucous membrane  lining. Technically, the plastic surgeon's incisional approach classifies the  nasal surgery  either as an  open rhinoplasty  or as a  closed rhinoplasty  procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the  columella , the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8003", "text": "Except for the columellar incision, the technical and procedural approaches of open rhinoplasty and of closed rhinoplasty are similar; yet closed rhinoplasty procedure features:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8004", "text": "The open rhinoplasty approach affords the plastic surgeon advantages of ease in securing grafts ( skin ,  cartilage ,  bone ) and, most importantly, in securing the nasal cartilage properly, and so better to make the appropriate assessment and remedy. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic alteration of the thick-skinned \"ethnic nose\" of the person of color. The study,  Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip  (2009), reports that a nasal-tip classification system, based upon skin thickness, has been proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty can best correct the defect or deformity affecting the patient's nose. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8005", "text": "Cause, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8006", "text": "Recently, ultrasonic rhinoplasty [ 36 ]  which was introduced by Massimo Robiony in 2004 has become an alternative to traditional rhinoplasty. [ 37 ]  Ultrasonic rhinoplasty uses  piezoelectric  instruments [ 38 ]  to reshape atraumatically nasal bones, also known as rhinosculpture. Ultrasonic rhinoplasty uses piezoelectric instruments (scrapers rasps, saws) that affect only the bones and the stiff cartilages through ultrasonic vibrations, as the instruments used in  dental surgery . [ 39 ]  The use of piezoelectric instruments requires a more extended approach than the isial one, allowing to visualize the whole bony vault, to reshape it with rhinosculpture or to mobilize and stabilize bones after controlled osteotomies. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8007", "text": "A rhinoplastic correction can be performed on a person who is under  sedation , under  general anaesthesia , or under  local anaesthesia ; initially, a  local anaesthetic  mixture of  lidocaine  and  epinephrine  is injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the  plastic surgeon  first separates the nasal skin and the  soft tissues  from the  osseo - cartilagenous  nasal framework, and then reshapes them, sutures the incisions, and applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either an  autologous  cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal contour(s). The autologous grafts usually are harvested from the  nasal septum , but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the  rib cage ) or an auricular cartilage graft ( concha  from the  ear ) is harvested from the patient's body.\u00a0Homologous (donor) rib cartilage is also sometimes used if the patient's own cartilage is unsuitable. [ 41 ] [ 42 ]  When the rhinoplasty requires a bone graft, it is harvested from either the  cranium , the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft ( nasal implant ) is used to augment the nasal bridge. [ 43 ]   The main types of grafts to support and reposition the nasal tip (or the central/medial limb of the tripod) are either columellar strut, or the septal extension graft.  Both are useful and effective, but the septal extension graft (SEG) is shown to impart greater control, and less changes over time. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8008", "text": "For the benefit of the patient and the physician\u2013surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the \"before-and-after\" physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worm's-eye view (from below), the bird's-eye view (overhead), and three-quarter-profile views. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8009", "text": "In  plastic surgical  praxis, the term  primary rhinoplasty  denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term  secondary rhinoplasty  denotes the revision of a failed rhinoplasty, an occurrence in 5\u201320 per cent of rhinoplasty operations, hence a  revision rhinoplasty . The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of a functional breathing deficit from an over aggressive rhinoplasty, asymmetry, deviated or crooked nose, areas of collapses, hanging columella, pinched tip, scooped nose and more. Although most revision rhinoplasty procedures are \"open approach\", such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the  ear  (auricular cartilage graft) or from the  rib cage  (costal cartilage graft)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8010", "text": "A  functional rhinoplasty  refers to a rhinoplasty performed to alleviate nasal obstruction, whereas a  cosmetic rhinoplasty  refers to a rhinoplasty performed for aesthetic reasons. Procedures performed as part of a functional rhinoplasty typically include septoplasty, inferior turbinate reduction, and spreader graft placement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8011", "text": "Results"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8012", "text": "Can be good if performed by an experienced practitioner.  As in all plastic surgery procedures, there can be some unpredictability, and biologic systems can heal in different ways."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8013", "text": "In reconstructive rhinoplasty, the defects and deformities that the  plastic surgeon  encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose;  congenital defect ,  trauma  ( blunt ,  penetrating ,  blast ),  autoimmune disorder ,  cancer , intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When  cartilage  is disrupted,  suturing  for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial)  nose prostheses , because of the reduced incidence of  histologic  rejection and medical complications. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8014", "text": "The  human nose  is a sensory organ that is structurally composed of three types of tissue: (i) an  osseo - cartilaginous  support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic  topography  of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into  nasal subunits : (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures. [ 46 ] [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8015", "text": "Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three anatomic layers:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8016", "text": "The technical principles for the  surgical  reconstruction of a  nose  derive from the essential operative principles of  plastic surgery : that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the  mucosa ;  cartilage  battens to brace against  tissue  contraction and depression (topographic collapse); axial  skin flaps  designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of  bone , cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a  collagen -glued collage\u2014of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of  ear  cartilage\u2014which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8017", "text": "In nasal reconstruction, the plastic surgeon's ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient's \"normal nose\", as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient's required rhinoplasty, with the patient's  aesthetic ideal  (body image). In the context of surgically reconstructing the patient's physiognomy, the \"normal nose\" is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials\u2014such as  bone ,  cartilage , and  flaps of skin and of tissue . In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the \"normal nose\" and from photographs of the patient before they sustained the nasal damage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8018", "text": "The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with  mucosa , cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable  scarring  propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8019", "text": "The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the  topographic  transition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with  skin flaps . Nonetheless, in the final stage of nasal reconstruction\u2014replicating the \"normal nose\" anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8020", "text": "Reconstruction rhinoplasty is indicated for the correction of defects and deformities caused by:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8021", "text": "The effectiveness of a rhinoplastic reconstruction of the  external nose  derives from the contents of the surgeon's  armamentarium  of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the  bilobed flap , the  nasolabial flap , the  paramedian forehead flap , and the  septal mucosal flap ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8022", "text": "The design of the bilobed flap derives from the creation of two adjacent random transposition flaps (lobes). In its original design, the leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with  sutures . The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome \"dog ears\" of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh \"dog ears\", and thus required a smaller area of donor skin; resultantly, the  broad-based, bilobed flap  is less prone to the \"trap door\" and the \"pin cushion\" deformities common to skin-flap transposition procedure. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8023", "text": "The design of the bilobed flap co-ordinates its lobes with the long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8024", "text": "In the 19th century, the surgical techniques of  J.F. Dieffenbach  (1792\u20131847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral  angular artery  (the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the  supraorbital artery  in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8025", "text": "The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the \"bridge effect\" of a flap emplaced across the nasofacial angle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8026", "text": "The paramedian forehead flap is the premier  autologous  skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the  supraorbital artery  (an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of  necrosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8027", "text": "The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8028", "text": "The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an  ultrasonic scanner , the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the subdermal plexus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8029", "text": "The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested. [ 52 ] [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8030", "text": "The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only as required to allow the rotation of the tissue-flap into the nasal wound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8031", "text": "A technical variant of the septal mucosal flap technique is the  trap-door flap , which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral  nasal cavity , as a superiorly based septal mucosal flap of rectangular shape, like that of a \"trap-door\". This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8032", "text": "The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8033", "text": "A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10\u00a0mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8034", "text": "In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8035", "text": "Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient's  ear  is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient's neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8036", "text": "The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue  morbidity . The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural  histologic  tendency for such skin grafts to contract, which might distort the shape of the corrected nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8037", "text": "Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8038", "text": "The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of  wound contracture ; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8039", "text": "Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient's wound-healing capacity, nasal wounds measuring up to 10\u00a0mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two opposing  Z-plasties , technique which relieves the disfiguring tensions exerted by the scar tissue's contracture, its shape, and location on the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8040", "text": "The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8041", "text": "The width of the human nasal-tip ranges 20\u201330\u00a0mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25\u00a0mm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8042", "text": "The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the  anterior nares ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8043", "text": "The reconstruction rhinoplasty of an extensive heminasal defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the  Washio retroauricular-temporal flap  and the  Tagliacozzi flap . The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules. [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8044", "text": "The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from  iatrogenic  septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8045", "text": "Illustration 1:  The surgeon cuts the excessively wide bones of the upper nasal  dorsum  (violet) with an  osteotome  (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8046", "text": "Illustration 2:  The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8047", "text": "The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications\u2014 antibiotics ,  analgesics ,  steroids \u2014to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can go outdoors. Post-operatively, external sutures are removed at 4\u20135 days; the external cast is removed at 1-week; the stents are removed within 4\u201314 days; and the \"panda eyes\"  periorbital bruising  heal at 2-weeks. If an alar base reduction is performed conjunctively within the Rhinoplasty, these sutures need to be removed within 7\u201310 days post operatively. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose.  Furthermore, as rhinoplasty climbs the ladder of surgical procedures performed to achieve an aspired appearance, especially amongst women, the relationship between body image and mental state must be examined in order to destigmatize motives behind the surgical intervention. [ 61 ] [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8048", "text": "Rhinoplasty is safe, yet  complications  can arise; post-operative bleeding is uncommon, but usually resolves without treatment.  Infection  is rare, but, when it does occur, it might progress to become an  abscess  requiring the surgical drainage of the  pus , whilst the patient is under  general anaesthesia . Adhesions,  scars  that obstruct the airways, can form a bridge across the nasal cavity, from the  septum  to the  turbinates , and lead to difficulty breathing and may require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a \"polly beak\" deformity, resembling the beak of a  parrot . Likewise, if the septum is unsupported, the bridge of the nose can sink, resulting in a \"saddle nose\" deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a  porcine  nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Other deformities that may result from a rhinoplasty include Rocker deformity, inverted V deformity, and open room deformity. [ 63 ]  Furthermore, in the course of the rhinoplasty, the surgeon might  accidentally  perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing. A  turbinectomy  may result in  empty nose syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8049", "text": "Non-surgical rhinoplasty  is a medical procedure in which injectable fillers, such as  collagen  or  hyaluronic acid , are used to alter and shape a person's nose without  invasive surgery . The procedure fills in depressed areas on the nose, lifting the angle of the tip or smoothing the appearance of bumps on the bridge. [ 64 ]  The procedure does not alter nose size, though it can be used to correct some functional  birth defects ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8050", "text": "Originally developed at the turn of the twenty-first century, early attempts used biologically harmful soft-tissue fillers such as  paraffin wax  and  silicone . After 2000, physicians use  minimally invasive  techniques using modern fillers. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8051", "text": "A  rotation flap  is a semicircular  skin flap  that is rotated into the defect on a  fulcrum point . Rotation flaps provide the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. The flap must be adequately large, and a large base is necessary if a back-cut will be needed to lengthen the flap. If the flap is too small, the residual defect can be covered by mobilizing the surrounding tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8052", "text": "A drawback of rotation flaps is the extended cutting and undermining needed to create the flap, thus increasing the risk of  hemorrhage  and  nerve damage ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8053", "text": "This term is often used in contrast with the term \" free flap \" where the transferred tissue is completely detached."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8054", "text": "Skin grafting , a type of  graft surgery , involves the  transplantation  of  skin  without a defined circulation. The transplanted  tissue  is called a  skin graft . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8055", "text": "Surgeons may use skin grafting to treat:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8056", "text": "Skin grafting often takes place after serious injuries when some of the body's skin is damaged. Surgical removal (excision or  debridement ) of the damaged skin is followed by skin grafting.  The grafting serves two purposes: reducing the course of treatment needed (and time in the hospital), and improving the function and appearance of the area of the body which receives the skin graft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8057", "text": "There are two types of skin grafts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8058", "text": "A full-thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean-section scar. In the case of full-thickness skin grafts, the donor section will often heal much more quickly than the injury and causes less pain than a partial-thickness skin graft. A partial thickness donor site must heal by re-epithelialization which can be painful and take an extensive length of time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8059", "text": "Two layers of skin created from animal sources has been found to be useful in  venous leg ulcers . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8060", "text": "Grafts can be classified by their thickness, the source, and the purpose. By source:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8061", "text": "Allografts, xenografts, and prosthetic grafts are usually used as temporary skin substitutes, that is a wound dressing for preventing infection and fluid loss. They will eventually need to be removed as the body starts to reject the foreign material. Autologous grafts and some forms of treated allografts can be left on permanently without rejection. [ 5 ]  Genetically modified pigs can produce allograft-equivalent skin material, [ 6 ]  and  tilapia  skin is used as an experimental cheap xenograft in places where porcine skin is unavailable and in veterinary medicine. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8062", "text": "By thickness:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8063", "text": "When grafts are taken from other animals, they are known as heterografts or xenografts. By definition, they are temporary biologic dressings which the body will reject within days to a few weeks. They are useful in reducing the bacterial concentration of an open wound, as well as reducing fluid loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8064", "text": "For more extensive tissue loss, a full-thickness skin graft, which includes the entire thickness of the skin, may be necessary. This is often performed for defects of the face and hand where contraction of the graft should be minimized. The general rule is that the thicker the graft, the less the contraction and deformity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8065", "text": "Cell cultured  epithelial   autograft  (CEA) procedures take skin cells from the person needing the graft to grow new skin cells in sheets in a laboratory; because the cells are taken from the person, that person's immune system will not reject them. However, because these sheets are very thin (only a few cell layers thick) they do not stand up to trauma, and the \"take\" is often less than 100%.  Newer grafting procedures combine CEA with a dermal matrix for more support. [ clarify ] Research is investigating the possibilities of combining CEA and a dermal matrix in one product."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8066", "text": "Experimental procedures are being tested for burn victims using stem cells in solution which are applied to the burned area using a  skin cell gun . Recent [ when? ]  advances have been successful in applying the cells without damage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8067", "text": "In order to remove the thin and well preserved skin slices and strips from the donor, surgeons use a special surgical instrument called a  dermatome . This usually produces a split-thickness skin graft, which contains the  epidermis   with only a portion of the  dermis . The dermis left behind at the donor site contains  hair follicles  and  sebaceous glands , both of which contain epidermal cells which gradually proliferate out to form a new layer of epidermis. The donor site may be extremely painful and vulnerable to infection. There are several ways to treat donor site pain. These include subcutaneous anesthetic agents, topical anesthetic agents, and certain types of wound dressings. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8068", "text": "The graft is carefully spread on the bare area to be covered. It is held in place by a few small  stitches  or  surgical staples .  The healing process for skin grafts typically occurs in three stages: plasmatic imbibition, capillary  inosculation , and  neovascularization ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8069", "text": "During the first 24 hours, the graft is initially nourished by a process called  plasmatic imbibition  in which the graft \"drinks  plasma \" (i.e., absorbs nutrients from the underlying recipient bed)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8070", "text": "Between 2\u20133 days, new blood vessels begin growing from the recipient area into the transplanted skin in a process called  capillary inosculation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8071", "text": "Between 4\u20137 days,  neovascularization  occurs in which new blood vessels form between the graft and the recipient tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8072", "text": "To prevent the accumulation of fluid under the graft which can prevent its attachment and revascularization, the graft is frequently  meshed  by making lengthwise rows of short, interrupted cuts, each a few millimeters long, with each row offset by half a cut length like bricks in a wall. In addition to allowing for drainage, this allows the graft to both stretch and cover a larger area as well as to more closely approximate the contours of the recipient area. However, it results in a rather pebbled appearance upon healing that may ultimately look less aesthetically pleasing. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8073", "text": "An increasingly common aid to both pre-operative wound maintenance and post-operative graft healing is the use of  negative pressure wound therapy  (NPWT). This system works by placing a section of foam cut to size over the wound, then laying a perforated tube onto the foam. The arrangement is then secured with bandages. A vacuum unit then creates negative pressure, sealing the edges of the wound to the foam, and drawing out excess blood and fluids. This process typically helps to maintain cleanliness in the graft site, promotes the development of new blood vessels, and increases the chances of the graft successfully taking. NPWT can also be used between debridement and graft operations to assist an infected wound in remaining clean for a period of time before new skin is applied. Skin grafting can also be seen as a skin transplant. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8074", "text": "This is based upon the principle of mobilizing a full segment of skin from an area to the site needing tissue replacement. The flaps are triangularly shaped opposite each other. It can be used in direct excision and closure of a contracted scar to produce a better looking and healing scar. It helps to elongate and break up a linear scar. It also gives a good result in the release of linear contractures. [ 12 ] [ 13 ] [ 14 ] [ 15 ]  Z-plasty is of paramount importance to the plastic surgeon and a frequently used method in both single multiple forms. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8075", "text": "Risks for the skin graft surgery are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8076", "text": "Rejection may occur in  xenografts . To prevent this, the person receiving the graft usually must be treated with long-term  immunosuppressant  drugs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8077", "text": "Most skin grafts are successful, but in some cases grafts do not heal well and may require repeat grafting. The graft should also be monitored for good circulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8078", "text": "Recovery time from skin grafting can be long.  Graft recipients wear compression garments for several months and are at risk for depression and anxiety consequent to long-term pain and loss of function. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8079", "text": "Skin grafting, in more rudimentary forms, has been practiced since ancient times. The  Ebers Papyrus  of  ancient Egypt  contains a brief treatise on xenografting. [ 18 ]  Around 500 years later, members of the  Hindu   Kamma  caste are described as performing skin grafts which included the usage of subcutaneous fat. [ 19 ]  The 2nd century AD Greek philosopher  Celsus  is also known to have developed a method to reconstruct the foreskins of  Jewish  men using skin grafts, as  circumcision  was considered barbaric in Greek and Roman society. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8080", "text": "More modern uses of skin grafting were described in the mid-to-late 19th century, including Reverdin's use of the pinch graft in 1869; Ollier's and Thiersch's uses of the split-thickness graft in 1872 and 1886, respectively; and Wolfe's and Krause's use of the full-thickness graft in 1875 and 1893, respectively.  John Harvey Girdner  demonstrated skin graft transplant from a deceased donor in 1880. [ 21 ]  Today, skin grafting is commonly used in dermatologic surgery. [ 22 ]  Recently Reverdin's technique is used but with very small (less than 3\u00a0mm diameter). Such small wounds heal in a short time without scars. This technique is called  SkinDot . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8081", "text": "There are alternatives to skin grafting including skin substitutes using cells from patients, [ 24 ]  skin from other animals, such as pigs, known as Xenograft and medical devices that help to close large wounds. Xenograft was originally known as \"zoografting.\" Other animals that can be used include dogs, rabbits, frogs, and cats, with the greatest success achieved with porcine skin. [ 12 ] [ 13 ]  Other skin substitutes include Allograft, Biobrane, TransCyte, Integra, AlloDerm, Cultured epithelial autografts (CEA)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8082", "text": "There are medical devices that help close large wounds. The device uses skin anchors that are attached to healthy skin. An adjustable tension controller then exerts a constant pulling tension on sutures looped around the skin anchors. The device gradually closes the wound over time. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8083", "text": "\u201cMicrocolumn grafting\u201d is a new grafting method being researched that uses needles to take autologous skin biopsies from the patient & implant them in the wound site. [ 26 ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8084", "text": "Snapchat dysmorphia , also known as \" selfie  dysmorphia\", is a trending phenomenon used to describe patients who seek out  plastic surgery  in order to replicate and appear like their filtered selfies or altered images of themselves. [ 1 ]  The increasing availability and variety of  filters  used on social media apps, such as  Snapchat  or  Instagram , allow users to edit and apply filters to their photos in an instant \u2013 blemish the skin, narrow the nose, enlarge the eyes, and numerous other edits to one's facial features. These heavily edited images create unrealistic and unnatural expectations of one's appearance, showing users a \"perfected\" view of themselves. [ 2 ]  The disconnection between one's real-life appearance and the highly filtered versions of oneself manifest into body insecurity and dysmorphia. [ 3 ]  The distorted perception of oneself can potentially evolve into an obsessive preoccupation with perceived flaws in one's appearance, a mental disorder known as  body dysmorphic disorder  (or BDD). [ 4 ]  BDD has been classified as part of the obsessive-compulsive spectrum and it is currently affecting one in 50 Americans. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8085", "text": "In 2018, many newspaper outlets questioned the rising impact of social media applications on the choice of plastic surgeries for users. [ 5 ]  Researchers from the  Boston Medical Center  (BMC) wrote in a  JAMA Facial Plastic Surgery  essay that with the rise of Snapchat in 2011, there has been increasing cases of patients going into the cosmetic doctors\u2019 offices to request for surgeries to look like filtered versions of themselves, similar to how they appear through Snapchat filters. [ 3 ]  These filters create a dysmorphic illusion in which the unattainable filters establish a disconnection from the realities of how individuals look like and what they desire to look like. Hence, the filtered photos from social media apps encourages users to drive for constant improvements to their appearance based on the filters. The pressure to achieve this impossible aesthetic look may be a casual factor in triggering BDD, [ 2 ]  and individuals with BDD tend to engage in heavy plastic surgery use. Based on a 2022 survey results from the  American Academy of Facial Plastic and Reconstructive Surgery  (AAFPRS), 79% of plastic surgeons reported a trend of patients seeking improvement in their physical appearances with the desire to look better in selfies. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8086", "text": "The British cosmetic surgeon  Tijion Esho  coined the term \u201cSnapchat Dysmorphia\u201d to explain the increasing trend of patients seeking cosmetic surgeries to achieve the filtered versions of themselves. [ 7 ]  Esho noticed that with the rising popularity of social media platforms and filters, more patients were coming into consultations with filtered images of themselves. [ 8 ]  In the past, patients would show up to clinics with photos of celebrities or models they wanted to look like, but in this new filtered age, patients were now making use of their heavily edited selfies as references for their cosmetic procedures. [ 9 ]  We are now living in a generation where both women and men are more visually aware than ever before [ 7 ]  and due to the accessibility of these filtered images through social media, our feelings of self-worth may be highly determined by the number of likes and followers we receive through these social media applications. Researchers have found that users that engage in image-heavy social media platforms, such as Instagram, are more likely to consider undergoing plastic surgery. [ 9 ]  As we receive and share highly curated images, these images are publicly displayed and readily judged by peers, family, and even strangers \u2013 making us more critical of our appearances and how we present ourselves online. Therefore, filtered images creates and maintains unrealistic expectations of beauty ideals which drives a greater demand for cosmetic surgeries and procedures. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8087", "text": "Because of the prevalence of digital imaging and sharing, members of the \" selfie generation \" can hyper-fixate and obsess over minor or even nonexistent flaws in their appearance, and that can lead to lower self-esteem and higher self-dissatisfaction as well as dysmorphia. [ 11 ]  Social media platforms provide users with an online space to not only control the ways in which they present themselves, but they can go far as to curate idealized versions of themselves. These filters reinforce a new standard of unattainable beauty, including \u201c Instagram Face \u201d, in which users can adjust their facial features and conform to an unrealistic version of themselves through social media: high cheekbones, poreless skin, cat-like eyes, plump lips, and small nose. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8088", "text": "Today, more young people, especially adolescent girls, are using these filters through social media that \u201cbeautify\u201d their looks which promise to deliver an enhanced version of their appearances. Specifically, with the rise of selfie culture, Snapchat claimed that there are \u201c200 million daily active users that play with or view Lenses every day to transform the way they look\u201d, [ 12 ]  with more than 90% of young people in the U.S., France, and the U.K. currently using Snapchat filters. Body image expert Jasmine Fardouly, argues that there is a strong relationship between negative body image and the use of photo editing. Social media provides users with the tools to control how they appear online, and the constant investigation into one's self-presentation and alteration of one's images can be harmful to users\u2019 self-esteem and body satisfaction. [ 13 ]  McLean et al. (2015) showed that adolescent girls who had higher engagement in manipulation of and investment in self-images tend to be more preoccupied with their appearance and body image, as well as association with greater eating and body-related concerns. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8089", "text": "According to research with the  Dove Self-Esteem Project , 60% of young girls felt upset that their actual appearance did not match the online, retouched version of themselves. [ 9 ]  These girls who dedicated much time to photo editing felt more anxious, less confident, and less physically attractive after comparing themselves to their idealized versions of themselves. This conflicting gap between idealized expectations and harsh realities of appearance can lead to BDD, and BDD can often lead to mental health issues, including depression, anxiety disorders, substance abuse, and suicidal behavior. [ 15 ]  By the age of 13, 80% of young girls manipulate and distort the way they look online through face-altering and editing filters. [ 16 ]  Adolescents are at high risk of depression, body image concerns, and eating disorders through social media usage \u2013 with 52% of girls using social media filters every day. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8090", "text": "With the rising debate about the potential negative impacts of social media filters and the increasing awareness of body dysmorphia, social media filters were heavily criticized for simulating explicit distortion effects to promote cosmetic surgeries. Third-party filters on Instagram such as  FixMe  allowed users to annotate their faces similar to how cosmetic surgeons may mark up areas for surgical improvement. After a public controversy around these distorted filters, in August 2020, a new policy banned filters that directly promoted cosmetic surgery. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8091", "text": "Meta , which operates  Facebook ,  Instagram ,  Threads , and  WhatsApp , has made some attempts to restrict the use of distortion effects and filters through social media. Facial distortion filters no longer appear in Instagram's \u201cEffects Gallery,\u201d which displays the most popular filters at that time. [ 13 ]  Any effects or  augmented reality  (AR) filters that explicitly encourage cosmetic surgery are not allowed on Instagram, as research has shown that face-altering filters can make users feel worse about their appearances. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8092", "text": "Dove's #NoDigitalDistortion campaign project supports young adolescents in building self-confidence and positive body image on social media. [ 16 ]  For example, the Dove Self-Esteem Project created a Confidence Kit: an online resource guide for discussions surrounding social media usage and body image with young people."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8093", "text": "A study in  JAMA Facial Plastic Surgery  has also emphasized the need for plastic surgeons to screen their patients for BDD before undergoing surgery procedures to check for underlying problems of body dysmorphia. [ 18 ]  Cosmetic surgery is not a solution or treatment for BDD [ 19 ]  and it is important for cosmetic surgeons to provide interventions and discussions around achievable aesthetic goals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8094", "text": "Spray-on skin  is a  skin culturing  treatment for  burn , or other skin damage victims. It involves taking small samples of the patient's skin and spraying them on the wound. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8095", "text": "The treatment was developed by Marie Stoner and plastic surgeon Fiona Wood. Their technique worked quicker than previous skin culturing techniques. [ 2 ]  Wood established the company  Avita Medical  in 1993 to commercialise the procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8096", "text": "After the  2002 Bali bombings , Wood used the experimental technology on victims before it had been subjected to proper clinical trials, garnering criticism from other burn specialists since at the time there was little evidence of its efficacy, and Wood had an apparent conflict of interest since she founded the company that sold the technology. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8097", "text": "A 2006  clinical trial  in US attracted only small numbers of participants and was suspended by Avita. [ 5 ]  Clinical trials commenced again in 2010 with the assistance of a grant from the US Army. [ 5 ] [ 1 ]  Participant rates for the new trial were again lower than expected. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8098", "text": "The technology is currently approved for use in Australia, Europe, Britain and North America. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8099", "text": "Thumb hypoplasia  is a spectrum of congenital abnormalities of the  thumb  varying from small defects to complete absence of the thumb. [ 1 ]  It can be isolated, when only the thumb is affected, and in 60% of the cases [ 2 ]  it is associated with radial dysplasia [ 1 ]  (or radial club, radius dysplasia, longitudinal radial deficiency). Radial dysplasia is the condition in which the forearm bone and the soft tissues on the thumb side are underdeveloped or absent. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8100", "text": "In an embryo the upper extremities develop from week four of the gestation. [ 1 ]  During the fifth to eighth week the thumb will further develop. [ 4 ]  In this period something goes wrong with the growth of the thumb but the exact cause of thumb hypoplasia is unknown. [ 1 ] \nOne out of every 100,000 live births shows thumb hypoplasia. [ 2 ]  In more than 50% of the cases both hands are affected, otherwise mainly the right hand is affected. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8101", "text": "About 86% of the children with hypoplastic thumb have associated abnormalities. [ 1 ] [ 2 ]  Embryological hand development occurs simultaneously with growth and development of the cardiovascular, neurologic and hematopoietic systems. [ 2 ]  Thumb hypoplasia has been described in 30 syndromes wherein those abnormalities have been seen. A syndrome is a combination of three or more abnormalities. Examples of syndromes with an hypoplastic thumb are  Holt\u2013Oram syndrome ,  VACTERL association [ 1 ]  and thrombocytopenia absent radius ( TAR syndrome ). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8102", "text": "In general there are five types of thumb hypoplasia, originally described by Muller in 1937 and improved by Blauth, Buck-Gramcko and Manske. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8103", "text": "-  Type I : the thumb is small, normal components are present but undersized. [ 3 ]  Two muscles of the thumb, the  abductor pollicis brevis  and  opponens pollicis , are not fully developed. [ 2 ] [ 3 ]  This type requires no surgical treatment in most cases. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8104", "text": "-  Type II  is characterized by a tight web space between the thumb and index finger which restricts movement, [ 5 ]  poor  thenar  muscles and an unstable middle joint of the thumb  metacarpophalangeal joint . [ 3 ]  This unstable thumb is best treated with reconstruction of the mentioned structures. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8105", "text": "-  Type III  thumbs are subclassified into two subtypes by Manske. Both involve a less developed first metacarpal and a nearly absent thenar musculature. [ 2 ]  Type III-A has a fairly stable  carpometacarpal joint  and type III-B does not. [ 1 ] [ 2 ] [ 3 ]  The function of the thumb is poor. [ 2 ]  Children with type III are the most difficult patients to treat because there is not one specific treatment for the hypoplastic thumb. The limit between  pollicization  and reconstruction varies. Some surgeons have said that type IIIA is amenable to reconstruction and not type IIIB. Others say type IIIA is not suitable for reconstruction too. [ 4 ]  Based on the diagnosis the doctor has to decide what is needed to be done to obtain a more functional thumb, i.e. reconstruction or pollicization. In this group careful attention should be paid to anomalous tendons coming from the forearm (extrinsic muscles, like an aberrant long thumb flexor \u2013  flexor pollicis longus ). [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8106", "text": "-  Type IV  is called a pouce flottant, floating thumb. [ 1 ] [ 2 ] [ 3 ] [ 5 ]  This thumb has a  neurovascular bundle  which connects it to the skin of the hand. [ 1 ] [ 3 ] [ 5 ]  There's no evidence of thenar muscles and rarely functioning tendons. [ 4 ] [ 5 ]  It has a few rudimentary bones. [ 4 ] [ 5 ]  Children with type IV are difficult to reconstruct. [ 1 ] [ 4 ]  This type is nearly always treated with an index finger pollicization to improve hand function. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8107", "text": "-  Type V  is no thumb at all [ 2 ] [ 3 ]  and requires pollicization. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8108", "text": "The cause is unknown, and likely related to genetic abnormalities. Children with Fanconi anemia can sometimes display hypoplasia of the thumb. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8109", "text": "Three main points in diagnosing thumb hypoplasia are: width of the first web space, instability of the involved joints and function of the thumb. [ 5 ]  Thorough  physical examination  together with anatomic verification at operation reveals all the anomalies. [ 1 ] [ 5 ]  An X-ray of the hand and thumb in two directions is always mandatory. [ 5 ]  When the pediatrician thinks the condition is associated with some kind of syndrome other tests will be done. [ 1 ]  More subtle manifestations of types I and II may not be recognized, especially when more obvious manifestations of longitudinal radial deficiency in the opposite extremity are present. Therefore, a careful examination of both hands is important. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8110", "text": "When it comes to treatment it is important to differentiate a thumb that needs stability, more web width and function, or a thumb that needs to be replaced by the index finger. [ 4 ]  Severe thumb hypoplasia is best treated by pollicization of the index finger. [ 3 ] [ 5 ]  Less severe thumb hypoplasia can be reconstructed by first web space release, ligament reconstruction and muscle or tendon transfer. [ 3 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8111", "text": "It has been recommended that pollicization is performed before 12 months, but a long-term study of pollicizations performed between the age of 9 months and 16 years showed no differences in function related to age at operation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8112", "text": "It is important to know that every reconstruction of the thumb never gives a normal thumb, because there is always a decline of function. [ 4 ]  When a child has a good index finger, wrist and fore-arm the maximum strength of the thumb will be 50% after surgery in comparison with a normal thumb. [ 3 ] [ 4 ]  The less developed the index finger, wrist and fore-arm is, the less strength the reconstructed thumb will have after surgery. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8113", "text": "Tissue expansion  is a technique used by  plastic ,  maxillofacial  and reconstructive  surgeons  to cause the body to grow additional  skin ,  bone , or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion (see tissue inflammation below). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8114", "text": "Skin expansion is a common surgical procedure to grow extra skin through controlled mechanical overstretch. It creates skin that matches the color, texture, and thickness of the surrounding tissue, while minimizing scars and risk of rejection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8115", "text": "When skin is stretched beyond its physiological limit,  mechanotransduction  pathways are activated. This leads to  cell  growth as well as to the formation of new cells. In some cases, this may be accomplished by the implantation of inflatable balloons under the skin. By far the most common method, the surgeon inserts the inflatable expander beneath the skin and periodically, over weeks or months, injects a  saline  solution to slowly stretch the overlaying skin. The growth of tissue is permanent, but will retract to some degree when the expander is removed. [ 2 ]  Topically applied tissue expansion devices also exist. These have the benefit of being inexpensive and do not require a surgical procedure to implant them under the skin. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8116", "text": "Breast reconstruction  surgery, for example, can use this technique when the  mammary gland  is removed by surgery ( mastectomy ). Later, a more permanent breast implant filled with saline or silicone gel is inserted under the expanded skin pocket. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8117", "text": "In other applications, excess skin is grown purposely by expansion on the back or the buttocks, so that it can be harvested later for  transplantation  to another site where skin was lost due to  trauma , extensive  wounds ,  surgery ,  burns , etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8118", "text": "Stretching the skin beyond normal expansion invokes several mechanotransduction pathways which increase mitotic activity and promote collagen synthesis. As a result, the skin surface area increases.  Continuum mechanics  approaches can be used to model skin growth during tissue expansion and non-linear  finite element methods  can be used to computationally simulate different tissue growth scenarios. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8119", "text": "Tissue growth due to skin expansion can be modeled as anisotropic surface area growth as described by the following equations: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8120", "text": "where  \n \n \n \n \n F \n \n e \n \n \n \n \n {\\displaystyle F^{e}} \n \n  is elastic area stretch that is reversible and  \n \n \n \n \n F \n \n g \n \n \n \n \n {\\displaystyle F^{g}} \n \n  is irreversible area growth described by: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8121", "text": "where  \n \n \n \n \n n \n \n 0 \n \n \n \n \n {\\displaystyle n_{0}} \n \n  is a vector in the direction of skin thickness. We assume that the skin does not grow in the thickness direction for area growth is equal to volume growth or  \n \n \n \n \n \u03b8 \n \n g \n \n \n = \n d \n e \n t \n ( \n \n F \n \n g \n \n \n ) \n = \n \n J \n \n g \n \n \n \n \n {\\displaystyle \\theta ^{g}=det(F^{g})=J^{g}} \n \n . [ 4 ] \nWe also assume that the newly created skin will have the same density, stiffness, and microstructure as the original, non-expanded skin. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8122", "text": "Recent studies have demonstrated that using topical tissue expansion can reduce the need for a split thickness skin graft after harvesting a forearm free flap. [ 6 ]  The authors noted that this results in less pain as well as reduced healing time. This method has also been shown to be cost effective [ 3 ]  as well as improve cosmetics. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8123", "text": "Tissue expansion has been used on the scalp for treating scalp scarring and baldness, in lieu of hair transplantation when there is insufficient donor hair to transplant on the scar or the scar tissue is not vascularized to support hair growth. [ 7 ] [ 8 ]  For instance, in a patient who had  melanomas  removed from the scalp resulting in  alopecia  defects (hair loss), tissue expansion can be used to allow for the removal of scars and complete hair coverage. The two main indications for choosing tissue expansion over hair grafting are the size and shape of the defect relative to potential supply of donor hair, and the quality and thickness of the scar tissue. Areas of significant scarring and/or tissue atrophy, which is likely to make hair grafting unsuccessful, are best excised and replaced by normal expanded scalp skin. According to research from Dr Jeffrey Stuart Epstein while he was a professor at  University of Miami , theoretically there is no limit to the amount of tissue that can be created with tissue expansion, provided the process is conducted gradually. [ 9 ] [ unreliable medical source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8124", "text": "Tissue expansion has also been used for the technique of  foreskin restoration , which is usually non-surgical and applies tension externally using specialized devices to replace circumcised tissues with new cells. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8125", "text": "Non-surgical tissue expansion techniques can expand one's surviving penile skin, making it a longer tube so it can function like a  foreskin . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8126", "text": "Men who have been circumcised stretch and apply tension to their shaft and foreskin remnants to expand and elongate tissue in efforts to produce a functional foreskin. This form of tissue expansion can take years, as the amount of skin growth required is typically around 15 in 2 . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8127", "text": "Bone  is another tissue that can be expanded relatively easily, by using external devices which are slowly separated using mechanical contraptions, so that bone grows in response to elongation ( bone distractor ). Other techniques and external devices have been studied and have shown some success, such as in the  fitbone surgery . [ 13 ]  This technique was pioneered in 1951 by the  Russian   physician   Ilizarov , and is called the  Ilizarov apparatus . It is capable of lengthening limbs in cases of pathological loss of bone, asymmetry of limbs,  dwarfism , short stature, etc. In reconstructive and cosmetic surgery, bone expanders have been used to elongate the  mandibula  in cases of  congenital disorders ,  trauma ,  tumors , etc. Other newer devices such as the  orthofix  and  intramedullary skeletal kinetic distractor  (ISKD) are also used for limb lengthening. It can add over 6\u00a0inches per bone, but is expensive, painful, and time-consuming (each procedure lasts around 8\u201312 months). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8128", "text": "Muscle tissue may also expand and grow, in a process known as  stretch-induced  myofibrillogenesis. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8129", "text": "Inflammation, in the biological sense, refers to the cellular response of the body to disturbances, be they internal or external. In the case of  asthma  or  chronic bronchitis  the human body responds to allergens or pollutants by flooding the bronchial tree and airway walls with mononuclear cells. The layers of the airway wall, including the inner epithelial tissue lining thickens and expands anywhere from 10% to 300% of healthy individuals, and obstructs air flow. [ 16 ]  Enduring the disease long term coupled with airway hyperresponsiveness (smooth muscle contraction or  Bronchial hyperresponsiveness ) leads to chronic continuous inflammation and thickening, and noticeable airway remodeling consisting of stiffer airways and lost elasticity. [ 17 ]  Inflammation in a constricted cylinder, as with an airway, eventually folds over on itself, leading to mechanically studied buckling patterns and growth relationships within tissue linings. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8130", "text": "Tissue expansion is a common technique used for  breast reconstruction . [ 20 ]  This essentially involves expansion of the breast skin and muscle using a temporary  tissue expander . [ 21 ]  Three to four weeks after the  mastectomy , a saline solution will be injected into the expander to gradually fill it. This process is supported by a tiny valve mechanism located inside the expander and it will continue until its size is slightly larger than the other breast. Typically it can take several weeks to months to complete the process. This tissue expander is removed after a few months and microvascular flap reconstruction or the insertion of a permanent breast implant is done at the time. Chemotherapy or radiation is sometimes recommended by the medical/radiation oncologist following mastectomy. These treatments delay the tissue expansion process by approximately four to eight weeks. Tissue expanders have silicone outer shells and either an internal valve or external port to allow for saline fluid injections. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8131", "text": "Research dedicated to alternative skin grafts is currently within the purview of tissue engineering. Multiple engineered tissue-derived and tissue-like substances have made it through the FDA and into the market, though financial success has been moderate. [ 22 ]  Limitations of this strategy include long incubation times, as well as difficulty in mimicking that exact mechanical and biological properties of functional skin. [ 23 ]  However, benefits range from decreased donor site morbidity (as a result of no longer needing to harvest from skin expansion) as well as a ready-available source of materials for emergency medicine in the case of traumatic burn or injury. There remains much clinical interest today in developing inexpensive engineered skin grafts that possess the mechanical and biological properties of skin. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8132", "text": "Triphalangeal thumb  ( TPT ) is a  congenital  malformation where the  thumb  has three  phalanges  instead of two. The extra phalangeal bone can vary in size from that of a small pebble to a size comparable to the phalanges in non-thumb digits. The true  incidence  of the condition is unknown, but is estimated at 1:25,000 live births. [ 1 ]  In about two-thirds of the patients with triphalangeal thumbs, there is a hereditary component. [ 2 ]  Besides the three phalanges, there can also be other malformations. It was first described by Columbi in 1559. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8133", "text": "The triphalangeal thumb has a different appearance than normal thumbs. The appearance can differ widely; the thumb can be a longer thumb, it can be deviated in the radio-ulnar plane ( clinodactyly ), or thumb strength can be diminished. In the case of a five-fingered hand it has a finger-like appearance, with the position in the plane of the four fingers,  thenar muscle  deficiency, and additional length. There is often a combination with radial  polydactyly ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8134", "text": "Generally, triphalangeal thumbs are non-opposable. In contrast to most people with  opposable thumbs , a person suffering from TPT cannot easily place his or her thumb opposite the other four digits of the same hand. The opposable thumb's ability to effortlessly utilize fingers in a \"pinch\" formation is critical in precision gripping. For the thumb to adequately grip, certain thumb criteria must be met (e.g. suitable position and length, stable  joints  and good  thenar muscle  strength). [ 4 ]  Because triphalangeal thumbs cannot easily oppose and do not possess many of the optimal qualities found in most opposable thumbs, they tend to cause the hand to be less effective in use and, therefore, prove to be more problematic in daily life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8135", "text": "Malformations of the upper extremities can occur in the third to seventh embryonic week. [ 5 ]  In some cases the TPT is hereditary. In these cases, there is a mutation on  chromosome 7q 36. [ 6 ]  If the TPT is hereditary, it is mostly inherited as an autosomal dominant trait, [ 7 ]  non-opposable and bilateral. [ 2 ]  The sporadic cases are mostly opposable and unilateral. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8136", "text": "Triphalangeal thumb can occur in syndromes but it can also be isolated. The triphalangeal thumb can appear in combination with other malformations or syndromes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8137", "text": "Syndromes include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8138", "text": "Malformations include: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8139", "text": "There are multiple classifications for the triphalangeal thumb. The reason for these different classifications is the heterogeneity in appearance of the TPT.\nThe classification according to Wood  [ 9 ]  describes the shape of the extra phalanx: delta (Fig. 4), rectangular or full phalanx (Table 1). With the classification made by Buck-Gramcko a surgical treatment can be chosen (Table 1). Buck-Gramcko differentiates between six different shapes of the extra phalanx and associated malformations. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8140", "text": "Table 1 : Classifications of Wood  [ 9 ]  and Buck-Gramcko  [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8141", "text": "The goals of surgical treatment are: reducing length of the thumb, creating a good functioning, a stable and non-deviated joint and improving the position of the thumb if necessary. Hereby improving function of the hand and thumb."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8142", "text": "In general the surgical treatment is done for improvement of the thumb function. However, an extra advantage of the surgery is the improvement in appearance of the thumb. In the past, surgical treatment of the triphalangeal thumb was not indicated, [ 11 ]  but now it is generally agreed that operative treatment improves function and appearance. Because an operation was not indicated in the past, there's still a population with an untreated triphalangeal thumb. The majority of this population doesn't want surgery, because the daily functioning of the hand is good. [ 11 ]  The main obstacle for the untreated patients might not be the diminished function, but the appearance of the triphalangeal thumb. [ 11 ] \nThe timing of surgery differs between Wood and Buck-Gramcko. Wood advises operation between the age of six months and two years, [ 12 ]  while Buck-Gramcko advises to operate for all indications before the age of six years. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8143", "text": "Upper-limb surgery in tetraplegia  includes a number of surgical interventions that can help improve the quality of life of a patient with  tetraplegia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8144", "text": "Loss of upper-limb function in patients with following a  spinal cord injury  is a major barrier to regain autonomy. The functional abilities of a tetraplegic patient increase substantially for instance if the patient can extend the elbow. This can increase the workspace and give a better use of a manual wheelchair. To be able to hold objects a patient needs to have a functional pinch grip, this can be useful for performing daily living activities. [ 1 ] \nA large survey in patients with tetraplegia demonstrated that these patients give preference to improving upper extremity function above other lost functions like being able to walk or sexual function. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8145", "text": "Surgical procedures do exist to improve the function of the tetraplegic patient's arms, but these procedures are performed in fewer than 10% of the tetraplegic patients. [ 2 ]  Each tetraplegic patient is unique, and therefore surgical indication should be based on the remaining physical abilities, wishes and expectations of the patient. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8146", "text": "In 2007 a resolution was presented and accepted at the world congress in reconstructive hand surgery and rehabilitation in tetraplegia, that stated that every patient with tetraplegia should be examined and informed about the options for reconstructive surgery of the tetraplegic arms and hands. This resolution demonstrates mostly the necessity to increase the awareness on this subject amongst physicians. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8147", "text": "Reconstructive surgery of the upper limb in tetraplegic patients began during the mid-20th century. The first attempts at regaining gripping function of the hand probably took place in Europe at the end of the 1920s [ 5 ]  with the construction of flexor-hinge splints. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8148", "text": "In the early 1940s, a surgeon called Sterling Bunnell (1882\u20131957) was probably one of the first to refer to the reconstruction of gripping function for the tetraplegic hand. He described surgeries of combining tenodeses and tendon transfers to restore hand function. He also advocated transferring the m. brachioradialis to the wrist extensors when these muscles are paralyzed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8149", "text": "In the 1950s, understanding of the tenodesis effect (See  Tenodesis grasp ) influenced the development of surgical techniques such as the static flexor tenodesis. These procedures provided the basic functions of grasp and pinch. [ 7 ] [ 8 ] [ 9 ]  Tendon transfers were developed to accomplish both digital release and gripping functions in two surgical stages. The originators of these procedures were Lipscomb  et al.  [20], Zancolli, [ 10 ] [ 11 ] [ 12 ]  House  et al. [ 13 ] [ 14 ]  House  et al.  contributed important clinical investigations while showing the value of different surgical procedures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8150", "text": "According to Zancolli, [ 11 ]  transfer of the m. brachioradialis to the m. extensor carpi radialis tendons was proposed by Vulpius and Stoffel in 1920. In tetraplegia, this was first proposed by Wilson. [ 11 ]   and first described fully by Freehafer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8151", "text": "In 1967, Alvin Freehafer of Cleveland, Ohio, contributed valuable ideas towards achieving independence in the arms of tetraplegic patients. He and his team published the results of six patients who underwent transfer of the m. brachioradialis to restore active wrist extension. [ 15 ]  In 1974, Freehafer et al. [ 16 ]  recommended opposition transfers and finger-flexion transfers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8152", "text": "In 1971, surgery of the tetraplegic upper limb experienced a revival after Moberg's clinical investigations. His main contributions were (1) to restore elbow extension through transfer of the posterior deltoid to triceps (the initial procedure); and (2) to reconstruct a key pinch. [ 17 ]  Moberg's idea of posterior deltoid transfer to restore elbow extension has been used extensively by many surgeons, such as Bryan [ 18 ]  and DeBenedetti. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8153", "text": "In 1983, Douglas Lamb of Edinburgh, Scotland, gave great headway to surgery of the tetraplegic upper extremity when Lamb and Chan recommended reconstruction of elbow extension by transferring the posterior deltoid to the triceps according to Moberg's technique, which was published in 1975. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8154", "text": "A publication by Friedenberg [ 21 ]  was the starting point for future indications of biceps-to-triceps transfers, including those of Zancolli, [ 22 ]  Hentz  et al. , Kuts  et al. , Allieu  et al.  and Revol et al."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8155", "text": "Another major change was the change to one-step procedures, reconstructiong opening and closing phases at the same time. Especially Jan Friden, from Gothenburg, with major experience in this area championed this thought, partially driven by the transport problems in Sweden during winter, it saved the patients an operation and minimized hospital stay."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8156", "text": "The development of hand surgery for tetraplegia has received important contributions through published reports and by the international conferences initiated with the influence of Erik Moberg from Goteborg, Sweden. Conferences have been of great interest because of the convergences of hand surgeons interested in the field, promoting discussion and comparison of different surgical methods and experiences. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8157", "text": "A common goal of surgical reconstruction of the arms in patients with tetraplegia is to restore elbow extension, key pinch and palmar grip. Restoration of these functions, results in increasing a patient's independence. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8158", "text": "Elbow extension is an important part of upper limb surgical reconstruction in patients with tetraplegia.  Although gravity can extend the arm, active elbow extension is needed to maintain a stable arm while extended in space. This is needed to reach for something or replace an object. [ 25 ]  Other functional gains include: increasing available workspace, performing pressure relief maneuvers, propelling a manual wheelchair, enhancing self-care and leisure activities, and promoting independent transfer. Elbow extension against gravity further enhances these activities above the shoulder level and reachable workspace. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8159", "text": "The key pinch is a simple grasp in which the thumb applies force to an object to hold it against the lateral side of the index finger. [ 24 ]  Restoring this function allows a patient to hold objects such as a fork or pen that are necessary for activities of daily living such as eating, self-grooming and self-catheterization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8160", "text": "Palmar grip allows the patient to grasp objects in the palm of the hand and secure the object by flexing the fingers at the metacarpal joint. This gives the patient the possibility to hold objects such as a cup and also permits use of the hand for wheelchair propulsion. [ 1 ]  A social aspect of regaining the palmar grip is that the patient is able to give a handshake."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8161", "text": "Spinal cord injuries are classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification.  The ASIA scale grades patients based on their functional impairment as a result of the injury, grading a patient from A to D. This has considerable consequences for surgical planning and therapy. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8162", "text": "More information on  classification of tetraplegia  can be found on the tetraplegia page."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8163", "text": "A group of hand surgeons realized in the 1970s that the level of injury did not predict the number of available muscles in the upper limb very well. Therefore, the international classification was established in 1979, at the Edinburgh meeting. It was called \"The international classification (IC) of hand surgery in tetraplegic patients\" (table 2) and it describes the number of possible transferable muscles. To measure and evaluate hand strength each muscle is tested and all muscles with a  BMRC grade  of M4 or more are recorded. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8164", "text": "Table 2:  International Classification of Hand surgery in Tetraplegic Patients [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8165", "text": "A muscle not included in the International Classification, but of great importance, is the triceps muscle. When assessing a patient pre-operatively the triceps strength must also be recorded. An active triceps means a patient can reach in space, and the elbow can be stabilized against gravity and against other muscles to be transferred. (see further) [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8166", "text": "Furthermore, to classify patients it is essential to record sensation in at least the thumb and index pulpa. Patients with a  two point discrimination  of less than 10mm are classified as cutaneous sensation (OCu) and patients with a two-point discrimination of more than 10mm are classified as ocular sensation (O) (meaning that control of the to be operated limb cannot be performed by normal sensation, but is controlled visually). [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8167", "text": "Therefore, patients are classified as: O or OCu, IC gr(0-X), Triceps + or \u2013"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8168", "text": "For example: a patient has sensation of 8\u00a0mm in thumb and index pulpa, and has a good brachioradialis, extensor carpi radialis longus and brevis and a pronator teres (all of M4) but no Triceps. This patient is classified as OCu 4, Tr -."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8169", "text": "The pre-operative assessment of patients has turned more patient-goal oriented. This means that the patients are asked to define their goals before surgery. In order to evaluate this the  Canadian Occupational Performance Measure  (COPM) was developed. This test is based on the World Health Organisation's framework of measuring health and disability:  The International Classification of Function  (ICF): This framework measures health and disability by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. [ 29 ]  Functional deficits can be measured according to the level of loss of structure and function, the level of activity limitations, and the level of restriction in social participation. Reaching or gripping represents the integration of strength, sensation and range of motion, and therefore occur at the individual level rather than at the organ system level. For this reason, reaching and gripping are on the ICF level of activities. However, this level includes a broad range of activities, from basic activities (for example grasping and moving objects) to complex activities (such as dressing, grooming). It is useful to make a distinction between basic activities and complex activities. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8170", "text": "As mentioned above, The Canadian Occupational Performance Measure (COPM) is used to measure a tetraplegic patient's performance and satisfaction before and after upper limb surgery. [ 26 ]  This is done by identifying important goals of hand surgery and evaluating patient-perceived performance and satisfaction of hand surgery for these goals. Goals are identified through an interview between the therapist and the patient based on past experience. Published reports [ 26 ]  are provided about the expected outcomes of elbow extension transfers on strength and function of patients with a spinal cord injury. For each goal, the subject rated performance and satisfaction using a 10-point Likert scale, in which 1 was negative (\"cannot perform\", \"not satisfied\") and 10 was positive (\"performs very well\", \"very satisfied\"). After surgery, performance and satisfaction are rated again for each goal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8171", "text": "A positive change is seen in patient-perceived performance and satisfaction with self-identified goals after tendon transfers. A good example of the use of the COPM can be found in a report published by Scott Kozin, [ 26 ]  thirty-three goals for surgery were established. Following the biceps-to-triceps transfer, improvement in at least one goal was seen in all patients. Performance and satisfaction were greatly improved (an improvement of at least 4 points) in certain activities of daily living, including reaching for objects, recreational activities, wheelchair propulsion, and transfers. Although improvement was seen in most goals, a reduction was reported in 2 goals (one pertaining to dressing and the other to transfer). After tendon transfers, the total mean score statistically increased from 2.6 to 5.6 for performance (p .001) and from 1.8 to 5.7 for satisfaction (p .001). [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8172", "text": "General indications for functional surgery of the hand and arm in tetraplegic patients:\n \nThere are different views on optimal timing of surgery after a spinal cord injury. The general consensus is to operate the patient when he or she is neurologically stable. Some surgeons try to operate a patient as early as possible. The advantages of this are that the patient can take advantage of the new functional possibilities before new adjustments and adaptations develop. Other surgeons operate when it becomes feasible. This is usually 12\u201318 months after injury (can be shortened to 6\u20137 months) and only after stabilization of motor function. Important spasticity (see further) and neurovegetative complications (i.e. bladder function, bowel function, pulmonary function and pressure sores) must have been treated already. The patient must be able to sit in a wheelchair so that he/she can move the arm against gravity. Usually a compromise is found between the patient's wishes and the surgeon when timing the surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8173", "text": "An indication for biceps-to-triceps surgery is when the patient plateaud for more than 3 months in their motor recovery. It is usually the choice of procedure for patients who have a flexion contractures greater than 45 degrees. The procedure will release the contracture and allows for active flexion by transferring the biceps. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8174", "text": "It is important that the psychological condition of the patient is evaluated before surgery. The dramatic change in the patient's life requires a psychological adjustment. This should be evaluated and addressed before surgery. Follow-up by a psychologist is necessary.  Patient must be psychologically ready to understand the surgical planning, aims and possible outcomes. The patient must be motivated, well-informed, in sound psychological condition and must have a precise and realistic need for rehabilitation. Individual factors must be taken into account. (age, profession, hobbies, education, family support and social background). This is especially important in associated brain injury. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8175", "text": "Contraindications for surgery are severe pressure sores, severe spasticity, inability to stabilize the trunk."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8176", "text": "Spasticity, if present, can be very important. It is not a contraindication per se, but severe spasticity must be treated first depending in which muscle groups it is present. Spascticity can be treated with botox or myotomies. In some cases spastic tone can be useful to facilitate hand grasp and grip. Harmful spasticity that does not respond to medication or surgical treatment is a contraindication. The shoulder muscles, pectoralis major and latissimus dorsi, must be evaluated. The shoulder must not only have good motor condition but also good proprioceptive control. The trophicity and articular condition of the upper limb must also be considered. A poor condition requires a preoperative rehabilitation program. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8177", "text": "Before any hand surgery is performed, the patient should be able to actively extend the elbow. Therefore, if there is no active elbow extension, elbow extension reconstruction surgery should precede any hand surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8178", "text": "A contraindication specifically for posterior deltoid to triceps transfer is a flexion contracture of the elbow, biceps to triceps transfer might then be a possible transfer for elbow extension reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8179", "text": "The contraindications for biceps-to-triceps transfer relate to the muscle balance surrounding the elbow. The m. supinator and m. brachialis function is a prerequisite for this surgery. If one of these muscles is nonfunctional the patient will lose forearm supination and elbow flexion if the tendon is transferred."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8180", "text": "In general, reconstruction of the upper limb can only be performed if active elbow extension is present. This stabilizes the elbow and gives the patient a reach. It will also allow the transfer of the other muscles crossing the elbow joint (like the m. brachioradialis and m. extensor carpi radialis longus). It is also an operation whose results allow the patient to gain confidence in the rest of the treatment. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8181", "text": "Wrist-related tenodesis effect ( Tenodesis grasp ) means that wrist flexion passively opens the hand and wrist extension passively closes the hand. (see pictures below) Wrist-related tenodesis effect is the key point of any functional surgery in a paralyzed hand, therefore active wrist extension is required and reconstruction of this active wrist extension is of utmost importance for the tetraplegic hand. [ 30 ]  If no active wrist extension is available (IC group 0 and 1), the brachioradialis (only IC group 1) can be transferred to achieve wrist extension. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8182", "text": "Active tendon transfers are possible if m. extensor carpi radialis longus and m. extensor carpi radialis brevis are present. The use of the m. extensor carpi radialis longus and the m. brachioradialis are possible to restore hand function. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8183", "text": "There are two major techniques used to gain elbow extension."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8184", "text": "Deltoid-to-triceps transfer:\nFor this transfer, the posterior part of the deltoid muscle is released from its origin and attached to the triceps muscle (usually by means of a tendon graft or a synthetic graft) leaving the rest of the deltoid muscle intact. This transfer is usually very successful because the line of pull of the posterior deltoid muscle is in the same direction as the triceps muscle. Also, there is hardly any loss of function. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8185", "text": "The deltoid muscle is usually innervated by the fifth and sixth cervical nerve roots and is therefore often functional in patients with tetraplegia, though the triceps muscle, which is innervated by the seventh cervical root, is paralysed. Because of the location at the back of the arm, the posterior part of the deltoid muscle can give strength in the same direction as the triceps muscle and is therefore theoretically a good donor to regain elbow extension."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8186", "text": "Not only the direction of the strength provided by the donormuscle is important, Smith  et al.  showed that the matching between the original functional properties of the donor and recipient muscles affects the outcome of the transfer. [ 31 ] [ 32 ]  Therefore, Frid\u00e9n studied the architectural properties of the deltoid and triceps muscle in cadavers and concluded that the posterior deltoid would be a very suitable transfer to provide elbow extension. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8187", "text": "Since the tendon of the triceps is not long enough to reach the posterior deltoid muscle, an interposition graft is needed. Different procedures have been described to achieve the transfer. Moberg  [ 5 ]  used free tendon grafts from the long toe extensors to connect the posterior deltoid to the triceps, other interposition grafts have been described, including fascia lata and a triceps tendon turnup. [ 33 ] [ 34 ]  One should keep in mind that many patients hold out a hope for a cure and are therefore concerned about incurring a significant donor defect that could cause impairment if they recovered a lowerextremity function. [ 35 ] \nThe first part of the surgery should be to make an incision along the posterior border of the deltoid. The muscle is exposed to its insertion on the humerus. Next the part of the muscles that originates from the spina scapulae, the posterior one third to one half, is isolated from the anterior portion of the muscle. The insertion of the posterior deltoid is then elevated of the muscle and the distance between the mobilized deltoid tendon to the olecranon is measured to determine the length of the interposition graft needed. The interposition graft must now be harvested from its donor site. It should be 5 to 10\u00a0cm longer than the gap.\nAfter this a longitudinal incision should be made over the triceps tendon in which two transverse slits are made. One end of the graft should be wrapped around the posterior deltoid and sutured securely to it, after which the grafted is passed through an intercutaneous tunnel towards the triceps tendon, woven through the transverse slits and sutured securely to the triceps tendon and itself.\nOnce the graft is securely in place, the wound is closed and a long armcast is applied with the elbow at 10 degrees of flexion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8188", "text": "This tendon transfer has a high risk of being stretched, during the postsurgical period. It is extremely important that a challenging and precise post-surgical rehabilitation program is implemented, in order to maximize the results and prevent the tendon from becoming stretched. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8189", "text": "Biceps-to-triceps transfer:\nThe biceps muscle can only be used for this transfer if the other elbow flexors are intact (m. brachialis and m. brachioradialis). [ 30 ]  This procedure is typically performed under general anesthesia but can be performed under supraclavicular brachial plexus blockade. The incision depends on whether there is a contracture that needs to be released. If this is the case a wide exposure of the anterior side of the elbow joint is needed. The distal side of the incision should allow complete dissection of the tendon of the biceps. The primary tendon of the biceps is released from its insertion on the radius and then rerouted medial or lateral. If the ulnar nerve is functional a lateral route is favored to prevent compression, however, the lateral route can cause compression of the radial nerve. A second incision is made to expose the triceps insertion and the triceps is dissected from its insertion on the olecranon. A hole is then drilled in the olecranon and a gauge wire is then looped in the hole. The biceps is routed through a skin tunnel to the posterior side and woven into the triceps tendon to create more length. Then the tendon is inserted to the olecranon. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8190", "text": "Restoration of key pinch:\nIn general for key pinch the thumb has to be activated. In the lower groups according to the International Classification (IC groups 0\u20131) this can be done onyby means of tenodesis. In IC groups 2 and higher the m. brachioradialis is used to strengthen the thumb flexor. [ 30 ]  Usually the thumb extensor is fixed to the extensor retinaculum and the carpometacarpal joint is fused in the right position. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8191", "text": "Restoration of palmar grip:\nWhen active wrist extension is present, it must not be weakened. Therefore, the extensor carpi radialis longus can only be used on patients in IC 3 and higher where active extension is supplied by both the extensor carpi radialis longus and the extensor carpi radialis brevis. In IC 2 patients active extension of the wrist depends only on the m. extensor carpi radialis longus, therefore this muscle must not be used for a transfer in this group of patients. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8192", "text": "The brachioradialis muscle is a versatile motor muscle and is used for different transfers in tetraplegic patients. In IC 1 it is used to restore wrist extension, while in IC 2\u20138 it is used to restore finger extension (m.extensor digitorum communis) and finger (m.flexor digitorum profundus) or thumb flexion (m.flexor pollicis longus). [ 30 ]  Surgical techniques in this type of  hand surgery  are mainly the same for the different transfers. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8193", "text": "Technique for transferring the m. extensor carpi radialis longus: the m. extensor carpi radialis longus tendon is divided at its insertion on the second metacarpal. The muscle is separated, and freed entirely from the surrounding tissues. The m. extensor carpi radialis longus tendon is strongly attached to the planned tendon under maximum tension. The m. extensor carpi radialis longus can be transferred to the flexor digitorum profundus or flexor pollicis longus. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8194", "text": "Technique for transferring the m. brachioradialis: The brachioradialis is freed entirely from the surrounding tissues up to the elbow to get extra excursion. The brachioradialis tendon is strongly attached to the planned tendon. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8195", "text": "The post-operative regimens depend on the surgical procedures used. However, they tend to constrain the tetraplegic patient considerably. During most regimens they are not allowed to drive hand-driven wheelchairs, or to make transfers alone, because of the risk of rupturing a tendon suture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8196", "text": "In general the elbow extension reconstructions are immobilised for a few weeks and then slowly allowed to flex the elbow in the following weeks, at a rate of 10 degrees per week.\nAfter 10 weeks the patient is allowed to move freely again. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8197", "text": "After the posterior deltoid-triceps transfer, a cast is applied with the elbow at 10 degrees of flexion. The cast should be worn for 4 to 6 weeks and then exchanged for an elbow brace with an adjustable range of motion. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8198", "text": "After the biceps-to-triceps surgery the patient's arm is immobilized for 3\u20135 weeks in slight flexion, this only counts for patient who could fully extend their arm before the operation. Otherwise the patient is immobilized in maximum extension and casted. This stays on for 10\u201314 days and a second cast is applied in further extension. After the immobilization the patient is given a protective polyaxial brace, which allows the patient to begin active limited flexion and still keep the full extension. This brace is worn by day and at night the patient wears a semi-firm splint that keeps the arm in maximal extension. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8199", "text": "With the emergence of the one step procedures for the hand, the post-operative rehabilitation programmes became even more important, since early movement is essential. Patients are mobilised 24 hrs post-operatively, with protective splints. The regimen takes approximately 12 weeks, before the hand is allowed to be fully loaded. Patients are not required to stay as an in-patient for the entire regimen, but can be treated as an outpatient after 1\u20134 weeks, depending on the centre where the procedures are performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8200", "text": "Vaginoplasty  is any surgical procedure that results in the construction or reconstruction of the  vagina . It is a type of  genitoplasty .  Pelvic organ prolapse  is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of  malignant growths  or  abscesses  to restore a normal vaginal structure and function. Surgery to the vagina is done to correct  congenital defects  to the vagina,  urethra   and  rectum . It may correct protrusion of the  urinary bladder  into the vagina ( cystocele ) and protrusion of the rectum ( rectocele ) into the vagina. [ 1 ]  Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8201", "text": "Congenital disorders  such as  adrenal hyperplasia  can affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty. [ 2 ]  Other candidates for the surgery include babies born with a microphallus, people with  M\u00fcllerian agenesis  resulting in  vaginal hypoplasia ,  trans women , and women who have had a vaginectomy after malignancy or trauma. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8202", "text": "Vaginoplasty is the description of the following surgical interventions:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8203", "text": "In some instances, extra tissue is needed to reconstruct or construct the vagina. These grafts used in vaginoplasty can be an  allotransplantation , a  heterograft , or an  autologous  material. [ 9 ] [ 10 ]  A woman can use an autologous in vitro cultured tissue taken from her vaginal vestibule as transplanted tissue to form the lining of the reconstructed vagina. [ 9 ]  A reconstructed or newly constructed vagina is called a  neovagina . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8204", "text": "Conditions such as  congenital adrenal hyperplasia  virilize genetic females due to a  21-hydroxylase  deficiency. Specific procedures include: clitoral reduction,  labiaplasty , normalizing appearance, vagina creation, initiating vaginal dilation. [ 12 ]   Vaginal atresia , or congenital absence of the vagina, can be another reason for surgery to construct a normal and functional vagina. [ 13 ]  Vaginoplasty is used as part of the series of surgeries needed to treat those girls and women born with the  bladder located outside of their abdomen . After the repairs, women have been able to give birth but are at risk of prolapse. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8205", "text": "There are human rights concerns about vaginoplasties and other genital surgeries in children who are not old enough to consent, [ 14 ] [ 15 ]  including concern with post-surgical sexual function, [ 16 ]  and assumptions of  cisnormativity . [ 17 ]  There is no consensus attitude among clinicians about their necessity, timing, method or evaluation. [ 12 ]  Vaginoplasties may be performed in children or adolescents with  intersex  conditions or  disorders of sex development . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8206", "text": "Non-surgical vagina creation was used in the past to treat the  congenital  absence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameter  dilators . The procedure took several months and was sometimes painful. It was not effective in every instance. [ 2 ]  Uncommon growths, cysts, septums in the vagina can also require vaginoplasty. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8207", "text": "Radiological cancer treatment  can result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8208", "text": "A canal is surgically constructed between the  urinary bladder  and  urethra  in the anterior portion of the pelvic region and the  rectum . A skin graft is used from another area of the person's body. The graft is removed from the  thigh ,  buttocks , or  inguinal  region. Other materials have been used to create the lining of the new vagina. These have been cutaneous  skin flaps ,  amniotic membranes , and  buccal mucosa . [ 3 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8209", "text": "Several techniques may be used in  gender-affirming surgery   to create a neovagina."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8210", "text": "Inversion of the penile skin is the method most often selected to create a neovagina by surgeons performing gender-affirming surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the neovagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8211", "text": "The penile inversion technique was pioneered by  Georges Burou  in his Morocco clinic in the 1950s. [ 20 ]   By the 1970s he had performed hundreds of them, and gave his first public presentation of his technique to a conference at Stanford University in 1973, [ 21 ]  after which it gradually became the predominant technique worldwide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8212", "text": "Bowel vaginoplasty is another common vaginoplasty technique. It is also used for vaginoplasty in cisgender women. [ 22 ]  As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal, penile and urethral tissue. However, in bowel vaginoplasty a segment of  rectosigmoid colon  is grafted into a surgically created canal to form the neovagina. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8213", "text": "Transgender peritoneal vaginoplasty,  a.k.a.  peritoneal pull-down or pull-through (PPT), is based on neovaginal techniques documented in the 1970s and 80s [ 25 ] [ 26 ] [ 27 ]  for cisgender women born without a vaginal canal due to  agenesis / atresia , [ 28 ] [ 29 ]  which were referred to as the \"Davydov\" procedure [ 29 ] [ 30 ]  or \"Rothman's\" method. [ 31 ]  A 2022 review states, \"In the last 5 years, peritoneal flap vaginoplasty has emerged as a promising technique\". [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8214", "text": "This form of vaginoplasty utilizes tissue of the  peritoneum  to form the canal lining of the neovagina. [ 33 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8215", "text": "For trans women who had their  puberty blocked , insufficient penile and scrotal skin may be available for traditional penile inversion. In such cases, peritoneal vaginoplasty remedies the issue of insufficient tissue. [ 33 ] [ 28 ] [ 29 ] [ 34 ]  Peritoneal vaginoplasty can be used as a surgical revision to increase or restore vaginal depth in persons who have had a previous vaginoplasty. [ 33 ] [ 29 ] [ 34 ] [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8216", "text": "Penile- scrotal  skin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8217", "text": "Critics have labeled such surgery as the \"designer vagina\". The  American College of Obstetricians and Gynecologists  issued a warning against these procedures in 2007 [ 38 ]  as did the  Royal Australian and New Zealand College of Obstetricians and Gynaecologists , [ 39 ]  and a commentary in the  British Medical Journal  strongly criticized the \"designer vagina\" in 2009. [ 39 ] [ 40 ]   The  Society of Obstetricians and Gynaecologists of Canada  published a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8218", "text": "The World Health Organization describes any medically unnecessary surgery to the vaginal tissue and organs as  female genital mutilation . [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8219", "text": "Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8220", "text": "An  imperforate hymen  is the presence of tissue that completely covers the vaginal opening. It is cut to allow menstrual flow to exit during a short surgical procedure. [ 1 ]  A  hymenorrhaphy  is the surgical procedure that reconstructs the hymen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8221", "text": "In this procedure, a  Foley catheter  is  laparoscopically  inserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8222", "text": "In treating  M\u00fcllerian agenesis , the Vecchietti procedure is a  laparoscopic  surgical technique that produces a  vagina  of dimensions (depth and width) comparable to those of a normal vagina (ca. 8\u00a0cm deep). [ 43 ] [ 44 ]  A small, plastic sphere called an olive is threaded ( sutured ) against the vaginal area; the threads are drawn though the vaginal skin, up through the  abdomen , and through the  navel . There, the threads are attached to a traction device, and then daily are drawn tight so that the olive is pulled inwards and stretches the vagina, by approximately 1\u00a0cm per day, thereby creating a vagina, approximately 7\u00a0cm deep by 7\u00a0cm wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time. [ 45 ]  The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy. [ 46 ]  In  vaginal hypoplasia , traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments. [ 47 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8223", "text": "Other surgical techniques that have been developed include ileal neovagina (Monti's technique), Creatsas vaginoplasty, Wharton\u2013Sheares\u2013George neovaginoplasty, or the Davydov procedure. The most widely used is the Vecchietti laparoscopic procedure. Sometimes sexual intercourse can result in the dilation of a newly constructed vagina. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8224", "text": "The most techniques of vaginoplasty are using inflatable vaginal expanders or vaginal stents to design the vaginal diameter and length. [ 48 ] [ 49 ]  At the end of the procedure the device stays in place to maintain the neovagina against the pelvic wall which also favors the process of microscopic neovascularization and reduces the risks of hematoma. In post-operative setting the expander can be used regularly to prevent post-operative vaginal retraction. [ 50 ]  Solid vaginal dilators can also be used immediately after surgery to keep the passage from attachments, and regularly thereafter to maintain the viability of the neovagina. The frequency required to use decreases over time, however remains obligatory lifelong. [ 51 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8225", "text": "Reconstructive vaginoplasty in children and adolescents carries the risk of  superinfection . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8226", "text": "In adults, rates and types of  complications  varied with gender-affirming surgery.  Necrosis  of the clitoral region was 1\u20133%. Necrosis of the surgically created vagina was 3.7\u20134.2%. Vaginal shrinkage occurred was documented in 2\u201310% of those treated.  Stricture , or narrowing of the vaginal orifice was reported in 12\u201315% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two  scrotal  flaps has been described. Posterior vaginal wall is a rare complication.  Genital pain  was reported in 4\u20139%. Rectovaginal  fistula  is also rare with 1% documented. Vaginal prolapse was seen in 1\u20132% of people  assigned male at birth  undergoing this procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8227", "text": "The ability of emptying the  bladder  was affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported that  voiding  got worse. Those reporting a negative outcome who experienced loss of bladder control and  urinary incontinence  were 19%.  Urinary tract infections  occurred in 32% of those treated. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8228", "text": "Reports of people seeking vaginoplasty go back to the 2nd century. [ 53 ] [ 54 ]   The first modern vaginoplasty was performed in 1931 on  Dora Richter . [ 53 ] [ 55 ] [ 56 ]   Lili Elbe  also underwent a vaginoplasty the same year. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8229", "text": "Vulvoplasty , also known as  zero-depth vaginoplasty , [ 1 ]  is a  plastic surgery  procedure for altering the appearance of one's  vulva  or constructing a vulva from  penile  and  scrotal  tissue (a neovulva)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8230", "text": "Women with congenital disorders or women post- vulvectomy  or with  genital trauma  may receive vulvoplasty for medical reasons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8231", "text": "Women who experience vulvar discomfort may also receive vulvoplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8232", "text": "In  gender-affirming surgery , some male-to-female  transgender  patients receive vulvoplasty without  vaginoplasty  to reconstruct the exterior of female genitalia. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8233", "text": "During  clitoroplasty , a  clitoris  is made from the tissue of the  glans penis . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8234", "text": "Labiaplasty  can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty. [ 4 ] [ 5 ]  The  labia minora  are typically constructed from genital skin and the  labia majora  using skin from the  scrotum . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8235", "text": "The  urinary meatus  in trans women is created by shortening the urethra and positioning it above the neovagina in such a way that the urine will descend downward while urinating in a seated position. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8236", "text": "A  walking-stalk skin flap  or  waltzing tube pedicle  is a reconstructive technique in which the skin and soft tissue to be used for the  flap  is formed into a tubular pedicle and moved from the source to the target site by anchoring at both ends, periodically severing one end and anchoring it closer to the flap target site.  As antibiotics had not yet been invented when this procedure was developed, wrapping the flap in a tube was important because the risk of infection was reduced. [ 1 ]   The technique was invented by  Harold Gillies  and developed by  Archibald McIndoe  for the treatment of battle injuries. Archibald Mcindoe was widely recognised for many of these techniques. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8237", "text": "The technique is now largely redundant due to advances in  vascular surgery  and  microsurgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8238", "text": "Walter Ernest O'Neil Yeo  (20 October 1890 \u2013 December 1960) was an English sailor in the First World War, who is thought to have been one of the first people to benefit from advanced  plastic surgery , namely a skin  flap . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8239", "text": "Yeo was born in  Plymouth ,  Devon , to Petty Officer Francis Yeo and his wife Rhoda Sarah Yeo ( n\u00e9e  Jarman). He had two elder sisters, Adelaide and Elsie. Three weeks after his birth, his father was killed aboard  HMS\u00a0 Serpent  while on route to  Sierra Leone , after hitting rocks off  Cape Vilan , Spain. Three of the 176 people on board survived the shipwreck. His mother was later an alemaker at the  Royal William Victualling Yard ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8240", "text": "Yeo entered into the  Royal Navy  aged 15. As he was under 18, he was rated as a boy, second class. His sub-rating was that of  bugler  until 1911. His date of formally joining was 1 October 1906. He signed up for 12 years' service, and this period would only start when he turned 18. Thus the date of his adult service, and hence the start of his 12 years' service, started on his 18th birthday in 1908. He had his initial training aboard  HMS  Ganges  (shore establishment) , and first went to sea aboard  HMS\u00a0 Dido \u00a0(1896)  in 1907, by this time a boy, first class. He was rated  ordinary seaman  on his 18th birthday and conducted his adult training at  HMS Vivid (shore establishment 1890) . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8241", "text": "He was assigned to  HMS\u00a0 Bellerophon \u00a0(1907)  in 1911, and was promoted to  leading seaman  in 1912. After further training back at HMS  Vivid I , he joined  HMS\u00a0 Warspite \u00a0(03)  on 1 April 1915, becoming a  petty officer  whilst aboard on 20 May 1915. [ 2 ]  He would be promoted to acting  warrant officer  in June 1917 as a gunner. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8242", "text": "Yeo was wounded on 31 May 1916, during the  Battle of Jutland , while manning the guns aboard the battleship  HMS\u00a0 Warspite . [ 1 ]  He sustained terrible facial injuries, including the loss of upper and lower eyelids. [ 1 ]  There is some uncertainty as to where he was first admitted to hospital, due to the poor documentation. However, he is known to have been admitted to Plymouth Hospital while waiting for a place at  Queen Mary's Hospital  in  Sidcup , Kent, which was granted on 8 August 1917.  He was treated by  Harold Gillies , the first man to transfer skin from undamaged areas on the body. [ 1 ]  Gillies's notes on this case indicate that the main disfigurement was severe  ectropion  as well as waxy scar tissue of the forehead and nose. Gillies opened a specialist ward at Queen Mary's Hospital for the treatment of the facially wounded. [ 1 ]  Yeo is thought to have been one of the first patients to be treated with this newly developed technique, a form of skin transplantation called a 'tubed pedicle' flap. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8243", "text": "During the long process of surgery, a 'mask' of skin was transplanted across Yeo's face and eyes, including new eyelids. The operation to replace the skin of the midface and forehead took place in multiple stages. The first stage was the outlining of the graft as well as placement of a  stent  to contour for the  nasal dorsum  on 12 November 1917. On post-operative day five, a serious infection was noted as well as complications with the stent requiring surgical intervention. On 30 November, the second stage of the surgery was performed which consisted of excision of the scar tissue of the face and transfer of the graft. Again, post-operative infection was a major complication. Gillies described the flap as \"floating in  pus  at one point\" which required extensive care to salvage most of the tissue. In January 1918, the  pedicles  were returned to the chest with the surgery deemed a success. Minor revisions were performed in the following months to improve the aesthetics of the graft. [ 3 ]  By July 1919, he was found to be fit for active service again and was recorded as having completed courses in September 1919. He underwent a further operation in August 1921, after which his disfigurement was recorded as 'improved, but still severe', and he was recommended for medical discharge, which took place on 15 December 1921. Yeo later received further treatment for a  corneal ulcer  at the Royal Naval Hospital in Plymouth in 1938."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8244", "text": "Yeo married Ada Edwards in 1914, and had two daughters with her: Lilian Evelyn Yeo, born 21 October 1914, and Doreen Y. Yeo, born in 1919. He died in his hometown, Plymouth, where he had spent the majority of his life, in 1960 at the age of seventy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8245", "text": "Z-plasty  is a versatile  plastic surgery  technique that is used to improve the functional and cosmetic appearance of  scars . It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central element) is made along the line of the greatest tension or contraction, and triangular flaps are raised on opposite sides of the two ends and then transposed. The length and angle of each flap are usually the same to avoid mismatched flaps that may be difficult to close. Some possible complications of Z-plasty include flap  necrosis ,  haematoma  (blood clot) formation under the flaps, wound infection, trapdoor effect and sloughing (necrosis) of the flap caused by wound tension and inadequate blood supply."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8246", "text": "Z-plasties can be functional (elongate and relax scars) or cosmetic (realign scars to make them less noticeable). They can be single or multiple.  Variations include skew and planimetric Z-plasties."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8247", "text": "The transposition of two triangular flaps"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8248", "text": "The incisions are designed to create a Z shape with the central limb aligned with the part of the scar that needs lengthening or re-aligning. The traditional 60\u00b0 angle Z-plasty will give a theoretical lengthening of the central limb of 75%. [ 1 ]  Single or multiple z-plasties can be used. Specific modifications include the double-opposing z-plasty (sometimes called a \"jumping man\" flap) which can be useful for release of webbing of the medial canthus or release of 1st web space contractures. It is one of the techniques used in scar revision, especially in  burn scar contracture ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8249", "text": "The lengthening of a scar. Used to help relax or release linear burn scar contractures. The technique is dependent on the availability of mobile adjacent skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8250", "text": "The irregularisation of a scar to make it less noticeable. Re-alignment of the central element can place the scar in natural skin tension lines and thereby disguise it. One of a family of similar techniques (such a W plasty)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8251", "text": "The first Z-plasty was performed by  Horner  in 1837, followed by  Denonvilliers  in 1854, both for correction of  ectropion . [ 2 ]   The first standard double transposition Z-plasty was reported by Berger in 1904, and McCurdy introduced the term in 1913."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8252", "text": "Zygoma reduction , also known as cheekbone reduction surgery, is a surgery used to reduce the facial width by excising part of the  zygomatic bone  and arch. Wide cheekbones are a characteristic facial trait of Asians, whose skull shapes tend to be more brachycephalic (broad, short skull) in comparison with Caucasian counterparts, whose skull shapes tend to be more dolichocephalic (narrow and long).This surgery is popular among Asians due to their inherent wide cheekbones. Due to the advanced surgical skills of Korean surgeons who perform facial contouring surgeries, the number of Asian people undergoing this surgery is increasing. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8253", "text": "The goal of a zygoma reduction surgery is not to flatten out the cheekbone but rather it is used to reduce the facial width while simultaneously creating a more three-dimensional projection to suit the overall facial contour of an individual. [ 2 ]  The  infraorbital nerve  supplies skin and mucous membranes to the middle portion of the face and also supplies sensation to the skin of the cheek, upper lip, nose and upper teeth. Therefore, special care should be taken to avoid contact with the infraorbital nerve, as damage to this nerve can result in possible loss of sensation or dysesthesia. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8254", "text": "Before surgery, the zygoma type should be identified in order to create a surgical plan suited to the individual. Vital points that factor in the evaluation are the zygomatic width, volume, and position which determine the surgical technique best suited to the individual. [ 2 ]  The surgeon evaluates the surgery candidate in person whilst simultaneously examining clinical photos,  X-ray  and  CT scans  in frontal, lateral, three-quarter oblique and basal views. The assessment of the three-quarter oblique view is the most important as it determines the level of projection of the zygomatic bone. [ 2 ]  Further attention should be paid in evaluation of the skin, subcutaneous fat, muscles and the underlying structure to accurately formulate the surgical plan. Depending on the skin thickness and soft tissues, additional liposuction or lifting procedures may be recommended in conjunction with the zygoma reduction surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8255", "text": "During consultation process, it is essential that the surgeon discusses the surgery outcome, and ensure that the candidate's surgery expectations are realistic. [ 4 ]  MMP (maximal malar projection) is the most protruded portion of the outer contour of zygomatic complex in the basal three-quarters view. MMP is measured using either the Hinderer Analysis or Wilkinson Analysis methods. Using these methods, the MMP is calculated to find the ideal placement of the zygomatic body and arch. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8256", "text": "Once the MMP is calculated and the new position of the zygoma bone is planned then the surgery method is planned. The surgery is performed under  general anesthesia  through  orotracheal intubation . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8257", "text": "The osteotomy method is based on an individual's bone structure. There is the standard L-shaped Osteotomy method, the High L-shaped osteotomy method (link), High L-shaped osteotomy with orbital rim shaving and High L-shaped osteotomy with tripod osteotomy. High L-shaped osteotomy zygoma reduction provides the most precise level of osteotomy, with the least amount of scarring. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8258", "text": "Zygoma reduction surgical approach can be divided into two types, external or intraoral approach. External approach requires incision made externally, which will cause visible scarring. Intraoral approach is the most favored approach as the incision site will be hidden inside the mouth. For some cases, both an intraoral and external approach is required to achieve maximum shaving of the zygomatic body and arch. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8259", "text": "Onizuka et al. [ 6 ]  introduced zygoma reduction surgery using the intraoral approach in 1983. The High L-shaped osteotomy technique also uses an intraoral approach. The incision is made on the lateral edge of the infraorbital rim to access the zygomatic bone. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8260", "text": "Preauricular approach requires an incision to be made on the sideburns to access the zygomatic arch. Based on the zygoma shape and classification, the surgeon can ascertain whether intraoral and preauricular approach are both required to sufficiently decrease the zygoma protrusion. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8261", "text": "\"Double bladed\" reciprocating saw is used for this procedure to produce symmetric osteotomy. The saws come in different sizes ranging from two to 7 millimeters. Pre-bent titanium plates and screws are used to fixate the zygoma bone and arch in its new position. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8262", "text": "Post-surgery symptoms include haematoma, swelling, numbness, reduced sensation and usually clear within three to six months after surgery. Complications like asymmetry, infection, motor nerve injury, excessive scarring, and malunion can also occur, albeit it is a rare possibility. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8263", "text": "Certain candidates are prone to requiring additional surgery in conjunction with the zygoma reduction surgery. Soft tissue sagging is one of the main issues and the can be aggravated depending on the candidate's age, skin thickness and elasticity level, and excess cheek fat. Depending on the severity of the aforementioned factors, the surgeon may recommend additional procedures like lifting, buccal fat removal, fat graft etc. to combat any issues that may arise from having surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8264", "text": "S. Park (ed.), Facial Bone Contouring Surgery, \u00a9 Springer Nature Singapore Pte Ltd. 2018  ISBN \u00a0 978-981-10-2725-3"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8265", "text": "Caesarean delivery on maternal request   (CDMR) is a  caesarean section birth  requested by the  pregnant  woman without a  medical reason . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8266", "text": "The concept of \"Caesarean delivery on maternal request\" (CDMR) is not well-recognized in health care, and consequently, when it occurs there are no mechanisms in place for reporting it for research or distinguishing it in  medical billing . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8267", "text": "Over the last century, delivery by Caesarean section (CS) has become increasingly safer; the medical reasons, therefore, for selecting a CS delivery over a vaginal birth are less likely to be those of necessity, and more likely to be motivated by other factors, such as considerations of pain in vaginal delivery and the effects of childbirth on vaginal muscle tone. Until recently, [ when? ]  an  elective caesarean section  was done on the basis of medical grounds; however, the existence of CDMR makes the mother's preference the determining factor for the delivery mode."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8268", "text": "An elective Caesarean will be agreed in advance. An elective Caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any Caesarean section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8269", "text": "The popular media suggest that many women are opting for Caesareans in the belief that it is a practical solution. [ 3 ]  The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8270", "text": "The movement for CDMR may have started in  Brazil . [ 3 ]  It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by. [ 1 ]  The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8271", "text": "Increasingly, caesarean sections are performed in the absence of obstetrical or medical necessity at the patient's request, and the term  Caesarean delivery on maternal request  has been used. [ 1 ]  Another term that has been used is \"planned elective cesarean section\". [ 6 ]  As of 2006 [update] , there is no ICD code, thus the extent of the use of this indication is difficult to determine. The mother is the only party who may request such an intervention without indication. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8272", "text": "Caesarean sections are in some cases performed for reasons other than  medical necessity . These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined. [ 7 ]  It is through these lenses that CDMR can sometimes be viewed as an example of  unnecessary health care ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8273", "text": "Non-medically indicated scheduling of childbirth before 39 weeks gestation brings \"significant risks for the baby with no known benefit to the mother.\" Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%. [ 8 ]  The researchers found many benefits but \"no adverse effects\" in the health of the mothers and babies at those hospitals. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8274", "text": "In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic). [ 10 ]  For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8275", "text": "Another contributing factor for doctor-ordered procedures may be fear of  medical malpractice  lawsuits. Italian gynaecologist Enrico Zupi, whose clinic in Rome, Mater Dei, was under  media attention  for carrying a record of Caesarian sections (90% over total birth), explained: \"We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to  defensive medicine . We will keep acting this way as long as medical mistakes are not depenalized. We are not  martyrs . So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section\". [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8276", "text": "Studies of  United States  women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. [ 12 ]  In contrast, a 2004 study in the  British Medical Journal  retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes. [ 13 ]  Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, women should be discouraged or forbidden from choosing it. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8277", "text": "Some 42% of obstetricians [ clarification needed ]  believe the media and women are responsible for the rising Caesarean section rates. [ 15 ]  A study conducted in  Sweden , however, concludes that relatively few women wish to deliver by Caesarean section. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8278", "text": "Requirements for a  second opinion  from an additional doctor before giving a caesarean section has a small effect on reducing the rate of unnecessary caesarean sections. [ 17 ]  Communities of health care providers who peer review each other and come to agreement about the necessity of caesarean sections tend to use them less frequently. [ 17 ]  When medical guidelines are shared by local community leaders which mothers trust, then those mothers are more likely to have vaginal delivery after having had a previous caesarean delivery. [ 17 ]  When mothers have access to childbirth classes and relaxation classes mothers are more likely to use vaginal delivery when the pregnancy is otherwise low risk. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8279", "text": "A meeting of experts sponsored by the  NIH  in March, 2006 attempted to address the medical issues and  found \"insuffient evidence to evaluate fully the benefits and risks\" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand. [ 1 ]  The available evidence suggests certain differences as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8280", "text": "Proponents for CDMR point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby. [ 1 ]  Furthermore, there is some evidence that urinary  stress incontinence  as a long-term result of damage to the  pelvic floor  is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher,  infection  rates are higher, hospitalization longer, and rates for  breastfeeding  decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk. Further, babies born after a vaginal delivery tend to be at a lower risk for the  infant respiratory distress syndrome . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8281", "text": "Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section. [ 18 ]  This study was harshly criticized for excluding cases where unforeseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with \"no indicated risk\", and thereby inappropriately including emergent cesarean sections in their \"elective cesarean\" cohort. [ 19 ] [ 20 ] [ 21 ]  In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate. [ 22 ]   A study published in the February 13, 2007 issue of the  Canadian Medical Association Journal  found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8282", "text": "Caesarean section , also known as  C-section , cesarean, or  caesarean delivery , is the  surgical procedure  by which one or more babies are  delivered  through an incision in the mother's abdomen. It is often performed because  vaginal delivery  would put the mother or child at risk. [ 2 ]  Reasons for the operation include  obstructed labor ,  twin pregnancy ,  high blood pressure  in the mother,  breech birth ,  shoulder presentation , and problems with the  placenta  or  umbilical cord . [ 2 ] [ 3 ]  A caesarean delivery may be performed based upon the shape of the mother's  pelvis  or history of a previous C-section. [ 2 ] [ 3 ]  A trial of  vaginal birth after C-section  may be possible. [ 2 ]  The  World Health Organization  recommends that caesarean section be performed only when medically necessary. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8283", "text": "A C-section typically takes 45 minutes to an hour. [ 2 ]  It may be done with a  spinal block , where the woman is awake, or under  general anesthesia . [ 2 ]  A  urinary catheter  is used to drain the  bladder , and the skin of the  abdomen  is then cleaned with an  antiseptic . [ 2 ]  An  incision  of about 15\u00a0cm (6 inches) is then typically made through the mother's lower abdomen. [ 2 ]  The  uterus  is then opened with a second incision and the baby delivered. [ 2 ]  The incisions are then  stitched  closed. [ 2 ]  A woman can typically begin  breastfeeding  as soon as she is out of the  operating room  and awake. [ 5 ]  Often, several days are required in the hospital to recover sufficiently to return home. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8284", "text": "C-sections result in a small overall increase in poor outcomes in low-risk pregnancies. [ 3 ]  They also typically take about six weeks to heal from, longer than vaginal birth. [ 2 ]  The increased risks include breathing problems in the baby and  amniotic fluid embolism  and  postpartum bleeding  in the mother. [ 3 ]  Established guidelines recommend that caesarean sections not be used before 39  weeks of pregnancy  without a medical reason. [ 6 ]  The method of delivery does not appear to have an effect on subsequent  sexual function . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8285", "text": "In 2012, about 23 million C-sections were done globally. [ 8 ]  The international healthcare community has previously considered the rate of 10% and 15% to be ideal for caesarean sections. [ 4 ]  Some evidence finds a higher rate of 19% may result in better outcomes. [ 8 ]  More than 45 countries globally have C-section rates less than 7.5%, while more than 50 have rates greater than 27%. [ 8 ]  Efforts are being made to both improve access to and reduce the use of C-section. [ 8 ]  In the United States as of 2017, about 32% of deliveries are by C-section. [ 9 ]  The surgery has been performed at least as far back as 715 BC following the death of the mother, with the baby occasionally surviving. [ 10 ]  A popular idea is that the Roman statesman  Julius Caesar  was born via caesarean section and is the namesake of the procedure, but if this is the true etymology, it is based on a misconception: until the modern era, C-sections seem to have been invariably fatal to the mother, and Caesar's mother  Aurelia  not only survived her son's birth but lived for nearly 50 years afterward. [ 11 ] [ 12 ]  There are many ancient and medieval legends, oral histories, and historical records of laws about C-sections around the world, especially in Europe, the Middle East and Asia. [ 13 ] [ 14 ]  The first recorded successful C-section (where both the mother and the infant survived) was performed on a woman in Switzerland in 1500 by her husband,  Jakob Nufer , though this was not recorded until 8 decades later. [ 13 ]  With the introduction of antiseptics and  anesthetics  in the 19th century, survival of both the mother and baby, and thus the procedure, became significantly more common. [ 10 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8286", "text": "Caesarean section (C-section) is recommended when  vaginal delivery  might pose a risk to the mother or baby. C-sections are also carried out for personal and social reasons on  maternal request  in some countries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8287", "text": "Complications of labor and factors increasing the risk associated with vaginal delivery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8288", "text": "Other complications of pregnancy, pre-existing conditions, and concomitant disease, include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8289", "text": "The prevalence of caesarean section is generally agreed to be higher than needed in many countries, and physicians are encouraged to actively lower the rate, as a caesarean rate higher than 10\u201315% is not associated with reductions in maternal or infant mortality rates, [ 4 ]  although some evidence support that a higher rate of 19% may result in better outcomes. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8290", "text": "Some of these efforts are: emphasizing a long  latent phase  of labor is not abnormal and not a justification for C-section; a new definition of the start of active labor from a cervical dilatation of 4\u00a0cm to a dilatation of 6\u00a0cm; and allowing women who have previously given birth to push for at least 2 hours, with 3 hours of pushing for women who have not previously given birth, before  labor arrest  is considered. [ 3 ]   Physical exercise  during pregnancy decreases the risk. [ 19 ]  Additionally, results from a 2021 systematic review of the evidence on outpatient  cervical ripening  found that in women with low-risk pregnancies, the risk of cesarean delivery with harms to the mother or child were not significantly different from when done in an inpatient setting. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8291", "text": "Adverse outcomes in low-risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of caesarean section deliveries. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8292", "text": "In those who are low risk, the  risk of death  for caesarean sections is 13 per 100,000 vs. for vaginal birth 3.5 per 100,000 in the developed world. [ 3 ]  The United Kingdom  National Health Service  gives the risk of death for the mother as three times that of a vaginal birth. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8293", "text": "In Canada, the difference in serious morbidity or mortality for the mother (e.g. cardiac arrest, wound hematoma, or hysterectomy) was 1.8 additional cases per 100. [ 22 ]  The difference in in-hospital maternal death was not significant. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8294", "text": "A caesarean section is associated with risks of postoperative  adhesions , incisional hernias (which may require surgical correction), and wound infections. [ 23 ]  If a caesarean is performed in an emergency, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the risk of anaesthesia. [ 24 ]  Other risks include severe blood loss (which may require a blood transfusion) and  post-dural-puncture spinal- headaches . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8295", "text": "Wound infections occur after caesarean sections at a rate of 3\u201315%. [ 25 ]  The presence of  chorioamnionitis  and  obesity  predisposes the woman to develop a surgical site infection. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8296", "text": "Women who had caesarean sections are more likely to have problems with later pregnancies, and women who want larger families should not seek an elective caesarean unless medical indications to do so exist. The risk of  placenta accreta , a potentially life-threatening condition which is more likely to develop where a woman has had a previous caesarean section, is 0.13% after two caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more.  Along with this is a similar rise in the risk of emergency hysterectomies at delivery. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8297", "text": "Mothers can experience an increased incidence of  postnatal depression , and can experience significant psychological trauma and ongoing  birth-related post-traumatic stress disorder  after obstetric intervention during the birthing process. [ 27 ]  Factors like pain in the first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the subsequent development of psychological issues related to labor and delivery. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8298", "text": "Women who have had a caesarean for any reason are somewhat less likely to become pregnant again as compared to women who have previously delivered only vaginally. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8299", "text": "Women who had just one previous caesarean section are more likely to have problems with their second birth. [ 3 ]   Delivery after previous caesarean section  is by either of two main options: [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8300", "text": "Both have higher risks than a vaginal birth with no previous caesarean section. A vaginal birth after caesarean section (VBAC) confers a higher risk of  uterine rupture  (5 per 1,000), blood transfusion or  endometritis  (10 per 1,000), and  perinatal death  of the child (0.25 per 1,000). [ 30 ]  Furthermore, 20% to 40% of planned VBAC attempts end in caesarean section being needed, with greater risks of complications in an emergency repeat caesarean section than in an elective repeat caesarean section. [ 31 ] [ 32 ]  On the other hand, VBAC confers less  maternal morbidity  and a decreased risk of complications in future pregnancies than elective repeat caesarean section. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8301", "text": "There are several steps that can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as the formation of  adhesions . Such techniques and principles may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8302", "text": "Despite these proactive measures, adhesion formation is a recognized complication of any abdominal or pelvic surgery. To prevent adhesions from forming after caesarean section,  adhesion barrier  can be placed during surgery to minimize the risk of adhesions between the uterus and ovaries, the small bowel, and almost any tissue in the abdomen or pelvis. This is not current UK practice, as there is no compelling evidence to support the benefit of this intervention."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8303", "text": "Adhesions can cause long-term problems, such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8304", "text": "The risk of adhesion formation is one reason why vaginal delivery is usually considered safer than elective caesarean section where there is no medical indication for section for either maternal or fetal reasons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8305", "text": "Non-medically indicated (elective) childbirth before 39 weeks gestation \"carry significant risks for the baby with no known benefit to the mother.\" Newborn mortality at 37 weeks may be up to 3 times the number at 40 weeks, and is elevated compared to 38 weeks gestation. These early term births were associated with more death during infancy, compared to those occurring at 39 to 41 weeks (full term). [ 34 ]  Researchers in one study and another review found many benefits to going full term, but no adverse effects in the health of the mothers or babies. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8306", "text": "The  American Congress of Obstetricians and Gynecologists  and medical policy makers review research studies and find more incidence of suspected or proven  sepsis , RDS, hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4\u20135 days. In the case of caesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor caesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery before 39 weeks. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8307", "text": "For otherwise healthy  twin  pregnancies where both twins are head down a trial of  vaginal delivery  is recommended at between 37 and 38 weeks. [ 36 ] [ 37 ]  Vaginal delivery, in this case, does not worsen the outcome for either infant as compared with caesarean section. [ 37 ]  There is some controversy on the best method of delivery where the first twin is head first and the second is not, but most obstetricians will recommend normal delivery unless there are other reasons to avoid vaginal birth. [ 37 ]  When the first twin is not head down, a caesarean section is often recommended. [ 37 ]  Regardless of whether the twins are delivered by section or vaginally, the medical literature recommends delivery of dichorionic twins at 38 weeks, and monochorionic twins (identical twins sharing a placenta) by 37 weeks due to the increased risk of stillbirth in monochorionic twins who remain in utero after 37 weeks. [ 38 ] [ 39 ]  The consensus is that  late preterm delivery  of monochorionic twins is justified because the risk of stillbirth for post-37-week delivery is significantly higher than the risks posed by delivering monochorionic twins near term (i.e., 36\u201337 weeks). [ 40 ] \nThe consensus concerning monoamniotic twins (identical twins sharing an amniotic sac), the highest risk type of twins, is that they should be delivered by caesarean section at or shortly after 32 weeks, since the risks of intrauterine death of one or both twins is higher after this gestation than the risk of complications of prematurity. [ 41 ] [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8308", "text": "In a research study widely publicized, singleton children born earlier than 39 weeks may have developmental problems, including slower learning in reading and math. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8309", "text": "Other risks include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8310", "text": "Birth by caesarean section also seems to be associated with worse health outcomes later in life, including overweight or obesity, problems in the immune system, and poor digestive system. [ 48 ] [ 49 ]  However, caesarean deliveries are found to not affect a newborn's risk of developing food allergy. [ 50 ]  This finding contradicts a previous study that claims babies born via caesarean section have lower levels of  Bacteroides  that is linked to peanut allergy in infants. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8311", "text": "Caesarean sections have been classified in various ways by different perspectives. [ 52 ]  One way to discuss all classification systems is to group them by their focus either on the urgency of the procedure (most common), characteristics of the mother, or as a group based on other, less commonly discussed factors. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8312", "text": "Conventionally, caesarean sections are classified as being either an  elective surgery  or an  emergency  operation. [ 53 ]  Classification is used to help communication between the obstetric, midwifery and anaesthetic team for discussion of the most appropriate method of anaesthesia. The decision whether to perform  general anesthesia  or  regional anesthesia  (spinal or epidural anaesthetic) is important and is based on many indications, including how urgent the delivery needs to be as well as the medical and obstetric history of the woman. [ 53 ]  Regional anaesthetic is almost always safer for the woman and the baby but sometimes general anaesthetic is safer for one or both, and the classification of urgency of the delivery is an important issue affecting this decision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8313", "text": "A planned caesarean (or elective/scheduled caesarean), arranged ahead of time, is most commonly arranged for medical indications which have developed before or during the pregnancy, and ideally after 39 weeks of gestation. In the UK, this is classified as a 'grade 4' section (delivery timed to suit the mother or hospital staff) or as a 'grade 3' section (no maternal or fetal compromise but early delivery needed).\nEmergency caesarean sections are performed in pregnancies in which a vaginal delivery was planned initially, but an indication for caesarean delivery has since developed. In the UK they are further classified as grade 2 (delivery required within 90 minutes of the decision but no immediate threat to the life of the woman or the fetus) or grade 1 (delivery required within 30 minutes of the decision: immediate threat to the life of the mother or the baby or both.) [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8314", "text": "Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or because of a medically non-indicated  maternal request . [ 36 ]  Among women in the United Kingdom, Sweden and Australia, about 7% preferred caesarean section as a method of delivery. [ 36 ]  In cases without medical indications the  American Congress of Obstetricians and Gynecologists  and the UK Royal College of Obstetricians and Gynaecologists recommend a planned vaginal delivery. [ 55 ]  The  National Institute for Health and Care Excellence  recommends that if after a woman has been provided information on the risk of a planned caesarean section and she still insists on the procedure it should be provided. [ 36 ]  If provided this should be done at 39 weeks of gestation or later. [ 55 ]  There is no evidence that ECS can reduce mother-to-child  hepatitis B  and  hepatitis C virus  transmission. [ 56 ] [ 57 ] [ 58 ] [ 59 ] [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8315", "text": "Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section, where the conduct of a  childbirth  via a caesarean section is requested by the  pregnant  patient even though there is not a medical  indication  to have the surgery. [ 61 ]  Systematic reviews have found no strong evidence about the impact of caesareans for nonmedical reasons. [ 36 ] [ 62 ]  Recommendations encourage counseling to identify the reasons for the request, addressing anxieties and information, and encouraging vaginal birth. [ 36 ] [ 63 ]  Elective caesareans at 38 weeks in some studies showed increased health complications in the newborn. For this reason  ACOG  and  NICE  recommend that elective caesarean sections should not be scheduled before 39 weeks gestation unless there is a medical reason. [ 64 ] [ 65 ] [ 55 ]   Planned caesarean sections  may be scheduled earlier if there is a medical reason. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8316", "text": "Mothers who have previously had a caesarean section are more likely to have a caesarean section for future pregnancies than mothers who have never had a caesarean section. There is discussion about the circumstances under which women should have a vaginal birth after a previous caesarean."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8317", "text": "Vaginal birth after caesarean (VBAC) is the practice of  birthing a baby  vaginally after a previous baby has been delivered by caesarean section (surgically). [ 66 ]  According to  the American College of Obstetricians and Gynecologists  (ACOG), successful VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. [ 33 ]  According to the American Pregnancy Association, 90% of women who have undergone caesarean deliveries are candidates for VBAC. [ 31 ]  Approximately 60\u201380% of women opting for VBAC will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010. [ 31 ] [ 32 ] [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8318", "text": "For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks. [ 36 ] [ 37 ]  Vaginal delivery in this case does not worsen the outcome for either infant as compared with caesarean section. [ 37 ]  There is controversy on the best method of delivery where the first twin is head first and the second is not. [ 37 ]  When the first twin is not head down at the point of labor starting, a caesarean section should be recommended. [ 37 ]  Although the second twin typically has a higher frequency of problems, it is not known if a planned caesarean section affects this. [ 36 ]  It is estimated that 75% of twin pregnancies in the United States were delivered by caesarean section in 2008. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8319", "text": "A breech birth is the birth of a baby from a breech  presentation , in which the baby exits the pelvis with the  buttocks  or  feet  first as opposed to the normal  head-first presentation . In breech presentation, fetal heart sounds are heard just above the umbilicus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8320", "text": "Babies are usually born head first. If the baby is in another position the birth may be complicated. In a 'breech presentation', the unborn baby is bottom-down instead of head-down. Babies born bottom-first are more likely to be harmed during a normal (vaginal) birth than those born head-first. For instance, the baby might not get enough oxygen during the birth. Having a planned caesarean may reduce these problems. A review looking at planned caesarean section for singleton breech presentation with planned vaginal birth, concludes that in the short term, births with a planned caesarean were safer for babies than vaginal births. Fewer babies died or were seriously hurt when they were born by caesarean. There was tentative evidence that children who were born by caesarean had more health problems at age two. Caesareans caused some short-term problems for mothers such as more abdominal pain. They also had some benefits, such as less urinary incontinence and less perineal pain. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8321", "text": "The bottom-down position presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus caesarean) is controversial in the fields of  obstetrics  and  midwifery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8322", "text": "Though vaginal  birth  is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States and the UK are delivered by caesarean section as studies have shown increased risks of morbidity and mortality for vaginal breech delivery, and most obstetricians counsel against planned vaginal breech birth for this reason.  As a result of reduced numbers of actual vaginal breech deliveries, obstetricians and midwives are at risk of de-skilling in this important skill. All those involved in delivery of obstetric and midwifery care in the UK undergo mandatory training in conducting breech deliveries in the simulation environment (using dummy pelvises and mannequins to allow practice of this important skill) and this training is carried out regularly to keep skills up to date."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8323", "text": "A resuscitative  hysterotomy , also known as a peri-mortem caesarean delivery, is an emergency caesarean delivery carried out where maternal  cardiac arrest  has occurred, to assist in  resuscitation  of the mother by removing the  aortocaval compression  generated by the gravid uterus. Unlike other forms of caesarean section, the welfare of the fetus is a secondary priority only, and the procedure may be performed even prior to the limit of  fetal viability  if it is judged to be of benefit to the mother."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8324", "text": "There are several types of caesarean section (CS). An important distinction lies in the type of incision (longitudinal or transverse) made on the  uterus , apart from the incision on the skin: the vast majority of skin incisions are a transverse suprapubic approach known as a  Pfannenstiel incision  but there is no way of knowing from the skin scar which way the uterine incision was conducted."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8325", "text": "The  EXIT procedure  is a specialized surgical delivery procedure used to deliver babies who have airway compression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8326", "text": "The Misgav Ladach method is a modified caesarean section which has been used nearly all over the world since the 1990s. It was described by Michael Stark, the president of the New European Surgical Academy, at the time he was the director of  Misgav Ladach , a general hospital in Jerusalem. The method was presented during a FIGO conference in Montr\u00e9al in 1994 [ 70 ]  and then distributed by the University of Uppsala, Sweden, in more than 100 countries. This method is based on minimalistic principles. He examined all steps in caesarean sections in use, analyzed them for their necessity and, if found necessary, for their optimal way of performance. For the abdominal incision he used the modified Joel Cohen incision and compared the longitudinal abdominal structures to strings on musical instruments. As blood vessels and muscles have lateral sway, it is possible to stretch rather than cut them. The peritoneum is opened by repeat stretching, no abdominal swabs are used, the uterus is closed in one layer with a big needle to reduce the amount of foreign body as much as possible, the peritoneal layers remain unsutured and the abdomen is closed with two layers only. Women undergoing this operation recover quickly and can look after the newborns soon after surgery. There are many publications showing the advantages over traditional caesarean section methods. There is also an increased risk of abruptio placentae and uterine rupture in subsequent pregnancies for women who underwent this method in prior deliveries. [ 71 ] [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8327", "text": "Since 2015, the  World Health Organization  has endorsed the  Robson classification  as a holistic means of comparing childbirth rates between different settings, with a view to allowing more accurate comparison of caesarean section rates. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8328", "text": "Antibiotic prophylaxis  is used before an incision. [ 74 ]  The  uterus  is incised, and this incision is extended with blunt pressure along a cephalad-caudad axis. [ 74 ]  The infant is delivered, and the  placenta  is then removed. [ 74 ]  The surgeon then makes a decision about uterine exteriorization. [ 74 ]  Single-layer uterine closure is used when the mother does not want a future pregnancy. [ 74 ]  When subcutaneous tissue is 2\u00a0cm thick or more,  surgical suture  is used. [ 74 ]  Discouraged practices include manual  cervical dilation , any subcutaneous  drain , [ 75 ]  or supplemental  oxygen therapy  with intent to prevent infection. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8329", "text": "Caesarean section can be performed with  single  or  double layer suturing  of the uterine incision. [ 76 ]  Single layer closure compared with double layer closure has been observed to result in reduced blood loss during the surgery. It is uncertain whether this is the direct effect of the suturing technique or if other factors such as the type and site of abdominal incision contribute to reduced blood loss. [ 77 ]  Standard procedure includes the closure of the  peritoneum . Research questions whether this is needed, with some studies indicating peritoneal closure is associated with longer operative time and hospital stay. [ 78 ]  The Misgav Ladach method is a surgery technical that may have fewer secondary complications and faster healing, due to the insertion into the muscle. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8330", "text": "Both  general  and  regional anaesthesia  ( spinal ,  epidural  or  combined spinal and epidural anaesthesia ) are acceptable for use during caesarean section. Evidence does not show a difference between regional anaesthesia and general anaesthesia with respect to major outcomes in the mother or baby. [ 80 ]  Regional anaesthesia may be preferred as it allows the mother to be awake and interact immediately with her baby. [ 81 ]  Compared to general anaesthesia, regional anaesthesia is better at preventing  persistent postoperative pain  3 to 8 months after caesarean section. [ 82 ]  Other advantages of regional anesthesia may include the absence of typical risks of general anesthesia:  pulmonary aspiration  (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and  esophageal   intubation . [ 80 ]  One trial found no difference in satisfaction when general anaesthesia was compared with either spinal anaesthesia. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8331", "text": "Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled caesarean section. [ 83 ]  Regional anaesthesia during caesarean section is different from the  analgesia  (pain relief) used in labor and vaginal delivery. [ 84 ] [ 85 ] [ 86 ]  The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense  nerve block ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8332", "text": "General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8333", "text": "Postpartum infection is one of the main causes of maternal death and may account for 10% of maternal deaths globally. [ 87 ] [ 36 ] [ 88 ]  A caesarean section greatly increases the risk of infection and associated morbidity, estimated to be between 5 and 20 times as high, and routine use of antibiotic prophylaxis to prevent infections was found by a  meta-analysis  to substantially reduce the incidence of febrile morbidity. [ 88 ]  Infection can occur in around 8% of women who have caesareans, [ 36 ]  largely  endometritis ,  urinary tract infections  and wound infections. The use of preventative antibiotics in women undergoing caesarean section decreased wound infection, endometritis, and serious infectious complications by about 65%. [ 88 ]  Side effects and effect on the baby is unclear. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8334", "text": "Women who have caesareans can recognize the signs of fever that indicate the possibility of wound infection. [ 36 ]  Taking antibiotics before skin incision rather than after  cord clamping  reduces the risk for the mother, without increasing adverse effects for the baby. [ 36 ] [ 89 ]  Moderate certainty evidence suggest that  chlorhexidine gluconate  as a skin preparation is slightly more effective in prevention surgical site infections than  povidone-iodine  but further research is needed. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8335", "text": "Some doctors believe that during a caesarean section, mechanical  cervical dilation  with a finger or forceps will prevent the obstruction of blood and  lochia  drainage, and thereby benefit the mother by reducing the risk of death. The evidence as of 2018 [update]  neither supported nor refuted this practice for reducing postoperative morbidity, pending further large studies. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8336", "text": "Hypotension  (low blood pressure) is common in women who have spinal anaesthesia; intravenous fluids such as  crystalloids , or compressing the legs with bandages, stockings, or inflatable devices may help to reduce the risk of hypotension but the evidence is still uncertain about their effectiveness. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8337", "text": "The  WHO  and  UNICEF  recommend that infants born by Caesarean section should have skin-to-skin contact (SSC) as soon as the mother is alert and responsive.  Immediate SSC following a spinal or epidural anesthetic is possible because the mother remains alert; however, after a general anesthetic the father or other family member may provide SSC until the mother is able. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8338", "text": "It is known that during the hours of labor before a vaginal birth a woman's body begins to produce  oxytocin  which aids in the bonding process, and it is thought that SSC can trigger its production as well.  Indeed, women have reported that they felt that SSC had helped them to feel close to and bond with their infant.  A review of literature also found that immediate or early SSC increased the likelihood of successful breastfeeding and that newborns were found to cry less and relax quicker when they had SSC with their father as well. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8339", "text": "It is common for women who undergo caesarean section to have reduced or absent bowel movements for hours to days.  During this time, women may experience abdominal cramps, nausea and vomiting. This usually resolves without treatment. [ 94 ]  Poorly controlled pain following non-emergent caesarean section occurs in between 13% and 78% of women. [ 95 ]  Following caesarean delivery, complementary and alternative therapies (e.g.,  acupuncture ) may help to relieve pain, though evidence supporting the efficacy of such treatments is extremely limited. [ 96 ]  Abdominal, wound and back pain can continue for months after a caesarean section.  Non-steroidal anti-inflammatory drugs  can be helpful. [ 36 ]  For the first couple of weeks after a caesarean, women should avoid lifting anything heavier than their baby. To minimize pain during breastfeeding, women should experiment with different breastfeeding holds including the football hold and side-lying hold. [ 97 ]  Women who have had a caesarean are more likely to experience pain that interferes with their usual activities than women who have vaginal births, although by six months there is generally no longer a difference. [ 98 ]  Pain during sexual intercourse is less likely than after vaginal birth; by six months there is no difference. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8340", "text": "There may be a somewhat higher incidence of postnatal depression in the first weeks after childbirth for women who have caesarean sections, but this difference does not persist. [ 36 ]  Some women who have had caesarean sections, especially emergency caesareans, experience  post-traumatic stress disorder . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8341", "text": "A woman who undergoes caesarean section has 18.3% chance of chronic surgical pain at three months and 6.8% chance of surgical pain at 12 months. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8342", "text": "In recent meta-analyses, caesarean section has been associated to a lower risk of urinary incontinence and pelvic organ prolapse compared to vaginal delivery. [ 100 ] [ 101 ]  Women who have vaginal births, after a previous caesarean, are more than twice as likely to subsequently have pelvic floor surgery as those who have another caesarean. [ 102 ] [ 103 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8343", "text": "Global rates of caesarean section are increasing. [ 25 ]  It doubled from 2003 to 2018 to reach 21%, and is increasing annually by 4%. The trend towards increasing rates is particularly strong in middle and high income countries. [ 104 ] :\u200a101\u200a  In southern Africa, the cesarean rate is less than 5%; while the rate is almost 60% in some parts of Latin America. [ 105 ]  The Canadian rate was 26% in 2005\u20132006. [ 106 ]  Australia has a high caesarean section rate, at 31% in 2007. [ 107 ]  At one time a rate of 10% to 15% was thought to be ideal; [ 4 ]  a rate of 19% may result in better outcomes. [ 8 ]  The World Health Organization officially withdrew its previous recommendation of a 15% C-section rate in June 2010. Their official statement read, \"There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them.\" [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8344", "text": "More than 50 nations have rates greater than 27%. Another 45 countries have rates less than 7.5%. [ 8 ]  There are efforts to both improve access to and reduce the use of C-section. [ 8 ]  Globally, 1% of all caesarean deliveries are carried out without medical need. Overall, the caesarean section rate was 25.7% for 2004\u20132008. [ 109 ] [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8345", "text": "There is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care. [ 111 ]  More emergency caesareans\u2014about 66%\u2014are performed during the day rather than the night. [ 112 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8346", "text": "The rate has risen to 46% in  China  and to levels of 25% and above in many Asian, European and Latin American countries. [ 113 ]  In Brazil and Iran the caesarean section rate is greater than 40%. [ 114 ]  Brazil has one of the highest caesarean section rates in the world, with rates in the public sector of 35\u201345%, and 80\u201390% in the private sector. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8347", "text": "Across Europe, there are differences between countries: in Italy the caesarean section rate is 40%, while in the  Nordic countries  it is 14%. [ 116 ]  In the United Kingdom, in 2008, the rate was 24%. [ 117 ]  In Ireland the rate was 26.1% in 2009. [ 118 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8348", "text": "In Italy, the incidence of caesarean sections is particularly high, although it varies from region to region. [ 119 ]  In  Campania , 60% of 2008 births reportedly occurred via caesarean sections. [ 120 ]  In the  Rome  region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics. [ 121 ] [ 122 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8349", "text": "In the United States, cesarean deliveries began rising in the 1960s and started becoming routine in the 1960s and 1970s. [ 104 ] :\u200a101"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8350", "text": "In the United States the rate of C-section is around 33%, varying from 23% to 40% depending on the state. [ 3 ]  One of three women who gave birth in the US delivered by caesarean in 2011. In 2012, close to 23 million C-sections were carried out globally. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8351", "text": "With nearly 1.3 million stays, caesarean section was one of the most common procedures performed in U.S. hospitals in 2011. It was the second-most common procedure performed for people ages 18 to 44 years old. [ 123 ]  Caesarean rates in the U.S. have risen considerably since 1996. [ 124 ]  The rate has increased in the United States, to 33% of all births in 2012, up from 21% in 1996. [ 3 ]  In 2010, the caesarean delivery rate was 32.8% of all births (a slight decrease from 2009's high of 32.9% of all births). [ 125 ]  A study found that in 2011, women covered by private insurance were 11% more likely to have a caesarean section delivery than those covered by Medicaid. [ 126 ]  The increase in use has not resulted in improved outcomes, resulting in the position that C-sections may be done too frequently. [ 3 ]   It is believed that the high rate of induced deliveries has also led to the high rate of c-sections because they are twice as likely to lead to one. [ 127 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8352", "text": "Hospitals and doctors make more money from C-section births than vaginal deliveries. Economists have calculated that hospitals may make a few thousand dollars more and doctors a few hundred. It has been found that for-profit hospitals do more c-sections than non-profit hospitals. [ 127 ]  One study looked at the rate of c-sections done for women who were themselves doctors.  It found that there was a 10 percent decrease to the rate of c-sections vs the general population.  But if the hospital paid their doctors a flat salary removing the incentive to do the surgical procedures, which take more time, the rate of c-sections done on women who were themselves physicians exceeded that of the procedure done on non-medically knowledgeable mothers, suggesting that some women who actually needed c-sections were not getting them. [ 128 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8353", "text": "Concerned over the rising number of cesarean deliveries and hospital costs, in 2009  Minnesota  introduced a blended payment rate for either vaginal or cesarean uncomplicated births (i.e., a similar payment regardless of delivery mode).  As a result, the prepolicy cesarean rate of 22.8% dropped 3.24 percentage points. The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time the policy was initiated and continued to drop by $95.04 per quarter with no significant effects on maternal morbidity. [ 129 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8354", "text": "The rise of cesarean births in the United States has coincided with counter-movements emphasizing  natural childbirth  with a lesser degree of medical intervention. [ 104 ] :\u200a101\u2013102"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8355", "text": "The rate of cesarean sections began to sharply increase in China in the 1990s. [ 104 ] :\u200a101\u200a  This increase was driven by the  expansion of China's modern hospital infrastructure , and occurred first in urban areas. [ 104 ] :\u200a101\u200a  The rise in cesarean deliveries has also resulted in social critique of the medical establishment over the medical necessity of performing cesarean sections. [ 104 ] :\u200a101\u2013102"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8356", "text": "Historically, caesarean sections performed upon a live woman usually resulted in the death of the mother. [ 130 ]  It was considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. By way of comparison, see the  resuscitative hysterotomy  or perimortem caesarean section."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8357", "text": "According to the ancient Chinese  Records of the Grand Historian , Luzhong ( \u9678\u7d42 ), a sixth-generation descendant of the mythical  Yellow Emperor , had six sons, all born by \"cutting open the body\".  The sixth son  Jilian  founded the House of Mi that ruled the  State of Chu  ( c. \u20091030 \u2013223 BC). [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8358", "text": "The  Sanskrit  medical treatise  Sushruta Samhita , composed in the early 1st millennium CE, mentions post-mortem caesarean sections. [ 132 ]  The first available non-mythical record of a C-section is the mother of  Bindusara  (born  c. \u2009320 BC , ruled 298\u00a0\u2013  c. \u2009272 BC ), the second  Mauryan   Samrat  ( emperor ) of India, accidentally consumed poison and died when she was close to delivering him.  Chanakya , Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8359", "text": "An early account of caesarean section in Iran (Persia) is mentioned in the book of  Shahnameh , written around 1000 AD, and relates to the birth of  Rostam , the legendary hero of that country. [ 134 ] [ 135 ]  According to the  Shahnameh , the  Simurgh  instructed  Zal  upon how to perform a caesarean section, thus saving  Rudaba  and the child Rostam. In Persian literature caesarean section is known as  Rostamina  ( \u0631\u0633\u062a\u0645\u06cc\u0646\u0647 ). [ 136 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8360", "text": "In the  Irish mythological  text the  Ulster Cycle , the character  Furbaide Ferbend  is said to have been born by posthumous caesarean section, after his mother was murdered by his evil aunt  Medb ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8361", "text": "The  Babylonian Talmud , an ancient  Jewish  religious text, mentions a procedure similar to the caesarean section. The procedure is termed  yotzei dofen . It also discusses at length the permissibility of performing a C-section on a dying or dead mother. [ 133 ]  There is also some basis for supposing that Jewish women regularly survived the operation in Roman times (as early as the 2nd century AD). [ 137 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8362", "text": "Pliny the Elder  theorized that Julius Caesar's (born 100 BC) name came from an ancestor who was born by caesarean section, but the truth of this is debated (see the discussion of  the etymology of  Caesar ). Some popular misconceptions involve Caesar himself being born from the procedure; which is considered false because the procedure was lethal to mothers in ancient Rome and Caesar's mother  Aurelia Cotta  lived until he was an adult. [ 138 ] [ 11 ]  The Ancient Roman caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth, a practice sometimes called the  Caesarean law . [ 139 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8363", "text": "The  Spanish  saint  Raymond Nonnatus  (1204\u20131240) received his surname\u2014from the  Latin   non-natus  ('not born')\u2014because he was born by caesarean section. His mother died while giving birth to him. [ 140 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8364", "text": "There is some indirect evidence that the first caesarean section that was survived by both the mother and child was performed in  Prague  in 1337. [ 141 ] [ 142 ]  The mother was  Beatrice of Bourbon , the second wife of the  King of Bohemia John of Luxembourg .  Beatrice  gave birth to the king's son  Wenceslaus I , later the duke of Luxembourg, Brabant, and Limburg, and who became the half brother of the later  King of Bohemia and Holy Roman Emperor, Charles IV ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8365", "text": "In an account from the 1580s,  Jakob Nufer , a  veterinarian  in  Siegershausen , Switzerland, is supposed to have performed the operation on his wife after a prolonged labour, with her surviving. His wife allegedly bore five more children, including twins, and the baby delivered by caesarean section purportedly lived to the age of 77. [ 143 ] [ 144 ] [ 145 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8366", "text": "For most of the time since the 16th century, the procedure had a high mortality rate by modern standards. Key steps in reducing mortality were:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8367", "text": "Indigenous people in the  Great Lakes region  of Africa, including  Rwanda  and  Uganda , performed caesarean sections which in one account by  Robert William Felkin  from 1879 resulted in the survival of both mother and child. Banana wine was used, although the site of the incision was then also washed with water and, post operation, covered with a paste made by chewing two different roots. From the well-developed nature of the medical procedures employed he concluded that these procedures had been employed for some time. [ 146 ] [ 147 ] [ 148 ]   James Barry  was the first European doctor to carry out a successful caesarean in Africa, while posted to Cape Town between 1817 and 1828. [ 149 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8368", "text": "The first successful caesarean section to be performed in the United States took place in Rockingham County, Virginia in 1794. The procedure was performed by Dr.  Jesse Bennett  on his wife Elizabeth. [ 150 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8369", "text": "The  patron saint  of caesarean section is  Caesarius , a young deacon martyred at  Terracina , who has replaced and Christianized the pagan figure of  Caesar . [ 151 ]  The martyr (Saint Cesareo in Italian) is invoked for the success of this surgical procedure, because it was considered the new \"Christian Caesar\" \u2013 as opposed to the \"pagan Caesar\" \u2013 in the Middle Ages it began to be invoked by pregnant women to wish a physiological birth, for the success of the expulsion of the baby from the uterus and, therefore, for their salvation and that of the unborn. The practice continues, in fact the martyr Caesarius is invoked by the future mothers who, due to health problems or that of the baby, must give birth to their child by caesarean section. [ 152 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8370", "text": "The origin of the term is not definitively known. Roman  Lex Regia  (royal law), later the  Lex Caesarea  (imperial law), of  Numa Pompilius  (715\u2013673 BC), [ 153 ]  required the child of a mother who had died during childbirth to be cut from her womb. [ 154 ] \nThere was a cultural  taboo  that mothers should not be buried pregnant, [ 155 ]  that may have reflected a way of saving some fetuses. Roman practice required a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery. [ 156 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8371", "text": "Speculations that the Roman dictator  Julius Caesar  was born by the method now known as C-section are false. [ 157 ]  Although caesarean sections were performed in  Roman  times, no classical source records a mother surviving such a delivery, while Caesar's mother lived for years after his birth. [ 154 ] [ 158 ]  As late as the 12th century, scholar and physician  Maimonides  expresses doubt over the possibility of a woman's surviving this procedure and again becoming pregnant. [ 159 ]  The term has also been explained as deriving from the verb  caedere , 'to cut', with children delivered this way referred to as  caesones .  Pliny the Elder  refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as  ab utero caeso , 'cut from the womb' giving this as an explanation for the  cognomen   Caesar  which was then carried by his descendants. [ 154 ]  Nonetheless,  the  false etymology  has been widely repeated until recently. For example, the first (1888) and second (1989) editions of the  Oxford English Dictionary  say that caesarean birth \"was done in the case of Julius C\u00e6sar\". [ 160 ]  More recent dictionaries are more diffident: the online edition of the OED (2021) mentions \"the traditional belief that Julius C\u00e6sar was delivered this way\", [ 161 ]  and  Merriam-Webster's Collegiate Dictionary  (2003) says \"from the legendary association of such a delivery with the Roman cognomen  Caesar \". [ 162 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8372", "text": "The word  Caesar , meaning either Julius Caesar or an emperor in general, is also borrowed or  calqued  in the name of the procedure in many other languages in Europe and beyond. [ 163 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8373", "text": "Finally, the Roman  praenomen  (given name)  Caeso  was said to be given to children who were born via C-section. While this was probably just  folk etymology  made popular by Pliny the Elder, it was well known by the time the term came into common use. [ 164 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8374", "text": "The term  caesarean  is spelled in various accepted ways,  as discussed at Wiktionary . The  Medical Subject Headings  (MeSH) of the  United States National Library of Medicine  (NLM) uses  cesarean section , [ 165 ]  while some other American medical works, e.g.  Saunders Comprehensive Veterinary Dictionary , use  caesarean , [ 166 ]  as do most British works. The online versions of the US-published  Merriam-Webster Dictionary [ 167 ]  and  American Heritage Dictionary [ 166 ]  list  cesarean  first and other spellings as \"variants\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8375", "text": "In re A.C. , 573  A.2d  1235 (1990), was a  District of Columbia Court of Appeals  case. It was the first American appellate court case decided against a forced Caesarean section, although the decision was issued after the fatal procedure was performed. [ 168 ]  Physicians performed a Caesarean section upon patient Angela Carder (n\u00e9e Stoner) without informed consent in an unsuccessful attempt to save the life of her baby. [ 169 ]   The case stands as a landmark in United States  case law  establishing the  rights  of informed consent and bodily integrity for pregnant women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8376", "text": "In Illinois,  In re Baby Boy Doe , 632 N.E.2d 326 (Ill. App. Ct. 1994) was a court case holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a Cesarean section must be honored even if the choice may be harmful to the fetus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8377", "text": "Pemberton v. Tallahassee Memorial Regional Center , 66 F. Supp. 2d 1247 (N.D. Fla. 1999), is a case in the  United States  regarding  reproductive rights . Pemberton had a previous Caesarean section (vertical incision), and with her second child attempted to have a  VBAC  (vaginal birth after c-section). [ 170 ]  When a doctor she had approached about a related issue at the  Tallahassee Memorial Regional Center  found out, he and the hospital sued to force her to get a c-section. The court held that the rights of the fetus at or near birth outweighed the rights of Pemberton to determine her own medical care. [ 171 ] [ 172 ]  She was physically forced to stop laboring, and taken to the hospital, where a c-section was performed. [ 170 ]  Her suit against the hospital was dismissed. [ 170 ]   The court held that a cesarean section at the end of a full-term pregnancy was here deemed to be medically necessary by doctors to avoid a substantial risk that the fetus would die during delivery due to uterine rupture, a risk of 4\u20136% according to the hospital's doctors and 2% according to Pemberton's doctors. Furthermore, the court held that a state's interest in preserving the life of an unborn child outweighed the mother's constitutional interest of bodily integrity. [ 173 ]  The court held that  Roe v. Wade  was not applicable, because bearing an unwanted child is a greater intrusion on the mother's constitutional interests than undergoing a cesarean section to deliver a child that the mother affirmatively desires to deliver. The court further distinguished  In re A.C.  by stating that it left open the possibility that a non-consenting patient's interest would yield to a more compelling countervailing interest in an \"extremely rare and truly exceptional case.\" The court then held this case to be such. [ 170 ] [ 174 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8378", "text": "In many hospitals, the mother's partner is encouraged to attend the surgery to support her and share the experience. [ 175 ]  While traditionally there has been an opaque surgical drape obstructing the parents' view, some patients and doctors are opting for a \"gentle C-section\" using a clear drape, allowing the parents to watch the delivery and see their infant immediately. [ 176 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8379", "text": "In  Judaism , there is a dispute among the  poskim  (Rabbinic authorities) as to whether the first-born son from a caesarean section has the laws of a  bechor . [ 177 ]  Traditionally, a male child delivered by caesarean is not eligible for the  Pidyon HaBen  dedication ritual. [ 178 ] [ 179 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8380", "text": "In rare cases, caesarean sections can be used to remove a dead  fetus ; otherwise, the woman has to labour and deliver a baby known to be a  stillbirth . A  late-term abortion  using caesarean section procedures is termed a  hysterotomy abortion  and is very rarely performed. [ 180 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8381", "text": "The mother may perform  a caesarean section on herself ; there have been successful cases, such as In\u00e9s Ram\u00edrez P\u00e9rez of Mexico who, on 5 March 2000, took this action. She survived, as did her son, Orlando Ruiz Ram\u00edrez. [ 181 ] [ 182 ] [ 183 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8382", "text": "In 2024, a female  western lowland gorilla  had a successful cesarean section after zoo veterinarians diagnosed her with  pre-eclampsia . The premature gorilla infant survived, as a result of similar methods used with human infants. [ 184 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8383", "text": "The  EXIT procedure , or  ex utero intrapartum treatment procedure , is a specialized surgical delivery procedure used to deliver babies who have airway compression. [ 1 ]   Causes of airway compression in newborn babies result from a number of  rare   congenital disorders , including  bronchopulmonary sequestration ,  congenital cystic adenomatoid malformation , mouth or neck tumor such as  teratoma , and lung or pleural tumor such as  pleuropulmonary blastoma . [ 2 ]   Airway compression discovered at birth is a medical emergency.  In many cases, however, the airway compression is discovered during prenatal ultrasound exams, permitting time to plan a safe delivery using the EXIT procedure or other means."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8384", "text": "The EXIT is an extension of a standard classical  Caesarean section , where an opening is made on the midline of the anesthetized mother's abdomen and uterus.  Then comes the EXIT:  the baby is partially delivered through the opening but remains attached by its  umbilical cord  to the  placenta , while a pediatric otolaryngologist-head & neck surgeon establishes an airway so the fetus can breathe.   Once the EXIT is complete, the umbilical cord is clamped then cut  and the infant is fully delivered.  Then the remainder of the C-section proceeds. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8385", "text": "The ex utero intrapartum treatment (EXIT) procedure was originally developed to reverse temporary tracheal occlusion in patients who had undergone fetal surgery for severe  congenital diaphragmatic hernia  (CDH). In a select group of fetuses with CDH, tracheal occlusion is used to obstruct the normal flow of fetal lung fluid and to stimulate lung expansion and growth. With the airway obstructed, airway management at birth is critical. The solution was to arrange delivery in such a way that the occlusion could be removed and the airway secured while the baby remained on placental support. If the uterus was kept relaxed and the utero-placental blood flow kept intact, the fetus could remain on a maternal 'heart-lung machine' while the airway was secured. While the technique of tracheal occlusion remains under study in clinical trials, EXIT procedures have been shown to be useful for management of other causes of fetal airway obstruction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8386", "text": "The EXIT is much more complex than a standard C-section, as it requires careful coordination between the mother's physicians and the specialists operating on the newborn baby. The difficulty lies in preserving enough blood flow through the umbilical cord, protecting the placenta, and avoiding contractions of the uterus so that there is sufficient time to establish the airway. Also, the umbilical cord should not be manipulated, but should be kept in warmed fluids to avoid physiological occlusion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8387", "text": "Fetendo  or  Fetal Endoscopic surgery [ 1 ]  is a form of  fetal intervention  in the treatment of  birth defects  and other fetal problems. The procedure uses real-time video imagery from  fetoscopy  and  ultrasonography  to guide very small surgical instruments into the uterus in order to surgically help the fetus. The name Fetendo was adopted for the procedure because of how the video-based manipulation recalls a video game."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8388", "text": "Fetendo intervention is less invasive than  open fetal surgery . [ 2 ]  It can be often be achieved with just a small guided wire sent through a needle-puncture of the skin (percutaneous), though in some cases it may require that a small opening be made in the mother's abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8389", "text": "The fact that it is less invasive reduces the mother's postoperative recovery and lessens the troubles with preterm labor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8390", "text": "Fetendo has proven to be very useful for some, but not all, fetal conditions. Some examples include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8391", "text": "Fetoscopy  is an endoscopic procedure during  pregnancy  to allow surgical access to the  fetus , the  amniotic cavity , the  umbilical cord , and the fetal side of the  placenta . A small (3\u20134\u00a0mm) incision is made in the  abdomen , and an  endoscope  is inserted through the  abdominal wall  and  uterus  into the amniotic cavity. Fetoscopy allows for medical interventions such as a  biopsy  (tissue sample) or a  laser  occlusion of abnormal blood vessels (such as  chorioangioma ) or the treatment of  spina bifida . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8392", "text": "Fetoscopy is usually performed in the second or third trimester of pregnancy. The procedure can place the fetus at increased risk of adverse outcomes, including fetal loss or preterm delivery, so the risks and benefits must be carefully weighed in order to protect the health of the mother and fetus(es). The procedure is typically performed in an  operating room  by an  obstetrician-gynecologist . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8393", "text": "In 1945,  Bj\u00f6rn Westin  published a study which documented his use of a  panendoscope  to directly observe embryos. [ 2 ]  In 1966, Ag\u00fcero et al. published a study which used  hysteroscopy  to observe various features of the fetus, cervix, and uterus. [ 2 ]  In 1972, Carlo Valenti of the  SUNY Downstate Medical Center  recorded a technique which he called \"endoamnioscopy\", which allowed for direct visualization of the developing fetus. [ 3 ]  Gallinat made the first attempt to standardize these techniques in 1978. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8394", "text": "Because of the invasiveness of these procedures and the high risk they posed to the fetus, they were largely discarded in favor of  transvaginal sonography  until the 1990s. [ 2 ]  By that time, smaller instruments had been developed which reduced the risk to the fetus and provided a better visual for the physician. This in turn allowed for the development of techniques for surgical interventions such as biopsy. [ 2 ]  By 1993, authors such as Cullen, Ghirardini, and Reece had referred to this technique as \"fetoscopy\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8395", "text": "The field of minimally-invasive surgical fetoscopy has continued to develop since the 2000s. Physicians such as  Michael Belfort  and  Ruben Quintero  have used the technique to remove tumors and correct  spina bifida  on fetuses within the uterus. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8396", "text": "Fetoscopy is a surgical procedure which may involve the use of a fibreoptic device called a  fetoscope . Some confusion may arise from the use of specialized forms of  stethoscopes , including  Pinard horns  and  Doppler wands , to audibly monitor fetal heart rate (FHR). These audio diagnostic tools are also called \"fetoscopes\" but are not related to visual fetoscopy. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8397", "text": "Joel-Cohen incision  is a skin incision used for  Caesarean section . It is a straight incision that is 3\u00a0cm below the line joining both anterior superior  iliac spines . It is similar to the Pfannenstiel incision, another commonly used incision in obstetric surgery. The Joel-Cohen cesarean section technique relies more heavily on blunt dissection than the traditional  Pfannenstiel technique . [ 1 ]  Joel-Cohen technique has lower rates of fever, hospital stay, post-operative pain and blood loss compared to Pfannenstiel. The operating time and use of analgesia are also reduced. Additionally, the time needed to get out of bed, walk without support and time for re-appearance of audible intestinal sounds were shorter in Joel-Cohen group than the Pfannenstiel group in a study conducted with 153 women. [ 2 ]  In the two studies  (with 411 participants) that compared the Joel-Cohen incision with the Pfannenstiel incision, the Joel-Cohen incision was associated with a 65% reduction in postoperative febrile morbidity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8398", "text": "The skin incision is made 3\u00a0cm above the location of Pfannenstiel incision. The subcutaneous tissue is incised in three medial centimetres. The lateral tissue separation is done manually and the fascia is divided by blunt dissection using both index fingers. This incision is extended laterally by the fingers. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8399", "text": "A  lower  ( uterine )  segment caesarean section  ( LSCS ) is the most commonly used type of  caesarean section . [ 1 ]  Most commonly, a baby is delivered by making a  transverse incision  in the lower uterine segment, above the attachment of the  urinary bladder  to the uterus. This type of incision results in less  blood loss  and is easier to repair than other types of caesarean sections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8400", "text": "A vertical incision in the lower uterine segment may be performed in the following circumstances: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8401", "text": "The location of an LSCS is beneficial for the following reasons: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8402", "text": "Most bleeding takes place from the angles of the incision, and  forceps  can be applied to control it. Green Armytage forceps are specifically designed for this purpose. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8403", "text": "Although the incision is made using a sharp scalpel, care must be taken not to injure the foetus, especially if the membranes are ruptured, or in emergencies like  abruption . The incision can be extended to either sides using scissors or by blunt dissection using hands. While using the scissors, the surgeon should ensure that a finger is placed underneath the uterus so that the foetus in protected from unintentional injury. If blunt dissection is done, intraoperative blood loss can be minimized. In cases where Pfannenstiel incision cannot be done (such as large baby),  Kronig incision  (low vertical incision), [ 4 ]  classical (midline), J [ 5 ]  or T-shaped incisions [ 6 ]  may be used to incise the uterus. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8404", "text": "The German gynecologist  Hermann Johannes Pfannenstiel  (1862\u20131909) invented the technique. [ 8 ]  In the  United Kingdom , the surgery was first popularised by Dr.  Monroe Kerr , who first used it in 1911, so in English speaking countries it is sometimes called the Kerr incision or the Pfannenstiel-Kerr incision. Kerr published the results in 1920, proposing that this method would cause less damage to the vascularized areas of uterus than the classical operation. He claimed that it was better than the longitudinal uterine incision in terms of chances for scar rupture and injury to vessels. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8405", "text": "Obstetric anesthesia  or  obstetric anesthesiology , also known as  ob-gyn anesthesia  or  ob-gyn anesthesiology , is a sub-specialty of  anesthesiology  that provides peripartum (time directly preceding, during or following childbirth) [ 1 ]  pain relief ( analgesia ) for labor and  anesthesia  (suppress consciousness) for  cesarean deliveries  ('C-sections'). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8406", "text": "Other subspecialty options for anesthesiology include cardiac anesthesiology, pediatric anesthesiology, pain medicine, critical care, neuroanesthesia, regional anesthesia, transplant anesthesia and trauma anesthesia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8407", "text": "Obstetric anesthesiologists typically serve as consultants to ob-gyn physicians and provide pain management for both complicated and uncomplicated pregnancies. [ 3 ]  An obstetric anesthesiologist's practice may consist largely of managing pain during vaginal deliveries and administering anesthesia for cesarean sections; however, the scope is expanding to involve anesthesia for both maternal as well as fetal procedures. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8408", "text": "Maternal-specific procedures include  cerclage , external  cephalic version  (ECV), postpartum bilateral  tubal ligation  (BTL), and  dilation and evacuation  (D and E). [ 4 ]   Fetus-specific procedures include fetoscopic laser photocoagulation and  ex-utero intrapartum treatment (EXIT) . [ 4 ]   However, the majority of care given by anesthesiologists on most labor and delivery units is management of labor analgesia and anesthesia for cesarean section. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8409", "text": "The administration of general anesthesia in operative procedures was publicly demonstrated by  William Thomas Green Morton  (1819\u20131868) in Boston, October 1846 as the first successful practice of its kind. [ 5 ]  This practice revealed the pain-annulling properties of ether inhalation during surgery. Pioneers of obstetric anesthesia extended these findings to cases of parturition or childbirth, notably including   James Young Simpson  of Scotland (1811\u20131870),  John Snow  of London (1813\u20131858) and  Walter Channing  of the United States (1786\u20131876). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8410", "text": "Prior to the anesthetizing of  Queen Victoria  in 1853, the use of diethyl ether and chloroform as obstetric anesthetics faced social, religious, and medical opposition. [ 6 ]  With the shift in social attitudes, women became less reserved towards this novel practice and began coercing physicians to administer powerful anesthetics during labor. Medical objections were similarly disintegrated with casebook publications that reflected the safety of obstetric anesthesia for both mother and child. Thus the advent of obstetric anesthesia facilitated the use of instruments during delivery as obstetricians were afforded greater scope in terms of these materials. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8411", "text": "Following Morton's use of ether as an anesthetic, James Simpson conducted his own obstetric anesthetic trial on January 19, 1847 using an open-drop approach to administer ether. [ 7 ] [ 8 ] [ 9 ]  However, due to its post-analgesic effect of nausea and vomiting, he later switched to using chloroform instead. [ 8 ]  Simpson's later personal discovery of chloroform's anesthetic properties inspired subsequent trials with chloroform that he went on to make public in November 1847. The Medico Surgical Society publication of Simpson's findings was not well received and required significant defense thereafter. Three months later, on April 7, 1847, ether was used for the first time in American obstetrics. [ 7 ] [ 8 ]  Following that initial administration documented in the Boston Medical and Surgical Journal by N.C Keep, Walter Channing described several obstetric cases in which he successfully employed sulfuric ether in the United States. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8412", "text": "John Snow was responsible for anesthetizing the Queen and is also attributed for influencing public and medical opinions on obstetric anesthesia through his various recorded experiences  Though the birth of the Queen's 8th child  Prince Leopold  on April 7, 1853, was not generally publicized, the London social elite were aware of the use of chloroform in this delivery and found it appealing. [ 7 ] [ 8 ] [ 10 ]  Until this time, there had been considerable public and religious opposition to obstetric anesthesia. [ 10 ]  A woman, Eufame MacAlayne, was buried alive in Scotland in 1591 just for  seeking  pain relief for the birth of her two sons. [ 10 ]  This societal aspect of childbirth was recognized by Dr. Churchill of Dublin and later published on the statistics of obstetric anesthesia. [ 11 ]  Churchill suggested wealthier individuals were recorded to have easier births from the use of such drugs. In the practice of obstetric anesthesia,  John Snow greatly differed from Simpson in that Snow emphasized proper quantity measurements and the delay of administration until the second stage of labor commenced. [ 12 ]  Snow additionally disagreed with Simpson's argument that the laboring patient should be anesthetized to the level of unconsciousness. These differences among others are why the title \"Father of Obstetric Anesthesia\" has become so controversial. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8413", "text": "Labor analgesia was debated on the grounds of religion and morality, which John Simpson used as his own weapon against opposition. Biblical literalism led many to interpret labor pains as punishment for sin and deemed obstetric anesthesia impious with respect to the primeval curse. [ 14 ]  Simpson advocated that \u201cwhosoever shall keep the whole law and yet offend in one point, is guilty of all\u201d. In this sentiment he is referring to many of the medical practitioners who mitigate minor pains but avoid obstetric anesthetics for fear of opposition or religious persecution. [ 15 ]  Critic Charles Meigs exemplified this belief of the physiological value in parturition pain, which the greater public supported throughout the mid 19th century."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8414", "text": "The natural benefits of such labor pains which initially inhibited the practice of obstetrical analgesia, originated from another religious consideration of perfection. Religious opponents argued that individuals of God\u2019s creation and His standard of perfection should not be in need of such obstetrical interference. Natural processes employed by the Almighty Himself should be left untouched. In support of this claim, M. Roussel advocated that the refinement of society through technical operations (i.e. anesthesia) causes more harm then good to the natural process of childbirth. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8415", "text": "Medical historian Richard Shyrock suggested that humanitarian sentiments motivated 19th century physicians, while science shaped their practice. [ 17 ]  Victorian practitioners believed that if suffering was preventable it was their duty to abolish it in any way possible. Though physicians responsible for administering anesthesia were known to evade interfering in delivery if the mother was an uncivilized member of society. These individuals were left to their own resources, perhaps benefiting from midwife assistance. [ 18 ]   The pathological process of childbirth was seen to be of necessity for successful delivery and dulling the pain of contractions would hinder this process, until Simpson was able to overturn this theory in 1854. The inhalation of anesthetic agents do not affect the act of labor or the mechanism by which uterine contractions occur, but rather renders the woman insensible to the high degree of pain. [ 19 ]  With this finding, along with the statistical records of safely executed anesthetic administrations, the medical opposition to obstetric analgesia for pain annulment was suppressed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8416", "text": "The conflicting clinical interpretation of obstetric labor as natural pain, as opposed to discomfort induced by an abnormal or diseased condition, led obstetric practitioners and midwives alike to endorse laissez-faire treatment. Natural, animalistic functions of child rearing were determined thereafter not to require the assistance of obstetricians or subsequent labor analgesia. Following an era of natural philosophy, physicians evoked the ability of wild animals and \u2018savaged individuals\u2019 to deliver offspring in regions where the practice of child rearing had never been reduced to an art form. The likening of any obstetrical practice to mere pretend science, including the delivery of anesthetic agents, further prolonged the advancement of this field considerably throughout the 19th century. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8417", "text": "The social distinction of labor analgesia practice strengthened the divide between savaged and civilized society, while highlighting gender roles in medical practice. The results of unassisted labor in uncivilized communities, specifically the vitality of both mom and fetus, were not documented well. The news of this \u2018anti-obstetric\u2019 practice failed to spread to the civilized community, allowing the means of obstetric interference through general and anesthetic intervention to persist. [ 21 ]  Documentation and statistical evidence was favored throughout the development of obstetric anesthesia to determine the viability of physician strategies. The obstetric diary of midwife   Martha Ballard  (1735\u20131812) is historically valued for she documented the details of all midwife calls, as well as physician assistance, instrument usage, and symptoms. Being one of the first women to provide a history of obstetrical practice, Martha Ballard\u2019s notes regarding the marginalization of women in medical practice and the arrogance of male physicians were taken into careful consideration. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8418", "text": "The isolation of morphine in the early 1800s was yet another milestone in obstetric anesthesia. [ 7 ] [ 8 ]  However, the drug would not be widely used until the invention of the hypodermic needle in the 1850s. [ 7 ] [ 8 ]  The first to use a hypodermic syringe in the United States was  Fordyce Barker , who actually received the syringe from H.J Simpson as a gift during a visit to Edinburgh. [ 8 ]  Eventually, the use of morphine for pain control during labor lost favor due to its effects of respiratory depression in the newborn and was replaced largely by meperidine, a synthetic narcotic, first made in Germany in 1939, that had less of an effect on respiratory depression. [ 7 ] [ 8 ]  Meperidine is still popular in obstetrics today. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8419", "text": "Probably the most important discovery in obstetric anesthesia was the introduction of  regional anesthesia , [ 8 ]  in which local anesthetics are used to block pain from a large area (or nerve distribution). Cocaine, the first local anesthetic [ 9 ]  was used topically in ophthalmology in 1884 by Carl Koller. [ 8 ] [ 9 ]  William Halstead completed the first  nerve block ; [ 8 ]  August Bier, the first clinical  spinal anesthesia ; [ 8 ]  Sicard and Cathlein, the caudal approach to epidural anesthesia in 1901; [ 8 ]  and Fidel Pages, the  lumbar epidural  approach in 1921. [ 7 ] [ 8 ]  In 1921, the first vaginal delivery under spinal analgesia was reported by Kreiss in Germany. [ 8 ]  George Pitkin is credited with popularizing obstetric spinal anesthesia in the United States. [ 8 ]  Charles B. Odom introduced lumbar epidural analgesia to obstetrics in 1935. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8420", "text": "The anesthesiologist relies on several patient monitors intraoperatively to safely care for the patient. These include, but are not limited to,  pulse oximetry ,  capnography ,  electrocardiogram , non-invasive blood pressure cuff monitoring and temperature. [ 22 ]  In some cases, arterial blood gas monitoring may be used. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8421", "text": "Anesthesia for labor and vaginal delivery includes various modalities including pharmacological and non-pharmacological techniques. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8422", "text": "Non-pharmacological techniques include  Lamaze  breathing,  acupuncture ,  acupressure , LeBoyer technique, transcutaneous nerve stimulation, massage, hydrotherapy, vertical positioning, presence of a support person, intradermal water injections, and biofeedback amongst many more. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8423", "text": "Water immersion in the first stage of labor may reduce women's use of epidural. [ 25 ]  A meta analysis showed there may be benefits to the presence of a support individual (doula, family member) including lower use of pharmacologic analgesia, decreased length of labor, and lower incidence of cesarian section. [ 24 ] [ 26 ]  Hypnosis warrants further investigation. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8424", "text": "Obstetric anesthesiologists employ the following pharmacological agents and techniques:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8425", "text": "Anesthesia for cesarean sections (C-sections) most commonly uses neuraxial (regional) anesthesia due to its better safety profile for both mother and baby. [ 24 ] [ 27 ]  However, for emergencies or cases where neuraxial anasthesia cannot be used, general anesthesia is used instead. [ 24 ]  Drugs used to induce general anesthesia include  thiopental ,  propofol ,  etomidate , and  ketamine . [ 24 ]  Unconsciousness is maintained using inhalation agents, and muscle relaxing agents are used as needed. [ 24 ]   Opioids are less commonly used prior to delivery due to fear of adverse effects on the neonate.  However under certain circumstances it is important to attenuate the hypertensive responses to induction and incision and ultra-short acting opioids (remifentanil and alfentanil) appear to be efficacious and safe. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8426", "text": "In the United States, obstetric anesthesiology is a sub-specialty of anesthesiology (i.e., an anesthesiologist trains for an additional year as a fellow to qualify as an obstetric anesthesiologist).  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8427", "text": "After earning a four-year undergraduate bachelor's degree, students enroll in a four-year graduate education leading to a degree in medicine (the  Doctor of Medicine  degree (M.D.)) or in osteopathic medicine (the  Doctor of Osteopathic Medicine  degree (D.O.)). [ 29 ]  After receiving a medical degree, students must complete a four-year residency training at an approved anesthesiology program [ 30 ]  and pass certification exams to become a  board-certified, general anesthesiologist. [ 29 ]  Obstetric anesthesiologists then complete an additional year of study (fellowship) to gain specialized experience. [ 29 ]  Currently, obstetric anesthesia is not associated with an additional certification period over being board-certified in anesthesiology. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8428", "text": "Anesthesiologists use safe blood transfusions in certain situations as a therapy for patients with low oxygen carrying capacity or to correct coagulation problems. [ 31 ]  Certain religions (e.g.,  Jehovah's Witnesses ) prohibit the use of blood transfusions based on their religious beliefs. [ 32 ]  Medical ethics stand on the four pillars of autonomy, beneficence, non-maleficence and justice. [ 33 ]  Based on the basis of patient autonomy, a person who is deemed to have capacity and refuses a blood transfusion for religious reason has the right to do so. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8429", "text": "Symphysiotomy  is a surgical procedure in which the  cartilage  of the  pubic symphysis  is divided to widen the  pelvis  allowing  childbirth  when there is a mechanical problem ( obstructed labour ).  It is also known as  pelviotomy [ 1 ]  and  synchondrotomy. [ 1 ]  It has largely been supplanted by  C-sections , with the exception of certain rare obstetric emergencies or in resource poor settings. It is different than  pubiotomy , where the pelvic bone itself is cut in two places, rather than cutting though the symphysis pubis joint. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8430", "text": "Symphysiotomy was advocated in 1597 by  Severin Pineau  after his description of a  diastasis of the pubis  on a hanged pregnant woman. [ 3 ]   Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour. [ citation needed ]  They became less frequent in the late 20th century after the risk of maternal death from  caesarean section  decreased (due to improvement in techniques, hygiene, and clinical practice). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8431", "text": "The most common indications are a trapped head of a  breech baby , [ 5 ] [ 6 ]   shoulder dystocia  which does not resolve with routine manoeuvres, and obstructed labor at full  cervical dilation , especially with failed  vacuum extraction . [ 5 ]  Use for shoulder dystocia is controversial. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8432", "text": "Currently the procedure is rarely performed in developed countries, but is still performed in \"rural areas and resource-poor settings of developing countries\" [ 7 ]  where caesarean sections are not available, or where obstetricians may not be available to deliver subsequent pregnancies. [ 8 ]  Current practice guidelines in Canada recommend symphysiotomy for trapped head during vaginal delivery of a breech birth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8433", "text": "A 2016 meta-analysis found that in low and middle income countries, there was no difference between maternal and perinatal mortality following either symphysiotomy or C-section. [ 9 ]  There was a lower risk of infection following symphysiotomy, but a higher risk of fistula, compared to C-section. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8434", "text": "Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 centimetres (0.79\u00a0in)) by surgically dividing the  ligaments  of the  symphysis  under local anaesthesia. This procedure should be carried out only in combination with  vacuum extraction . [ 10 ]  Symphysiotomy can be a life-saving procedure in areas of the world where caesarean section is not feasible or immediately available as it does not require an operating theatre or \"advanced\" surgical skills. [ 5 ]  Since this procedure does not scar the  uterus , the concern of future uterine rupture that exists with cesarean section is not a factor. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8435", "text": "The procedure carries the risks of urethral and bladder injury,  fistulas , [ 9 ]  infection, pain, and long-term walking difficulty. [ 10 ]  Symphysiotomy should, therefore, be carried out only when there is no safe alternative. [ 10 ]   It is advised that this procedure should not be repeated due to the risk of  gait  problems and continual pain. [ 10 ]  Abduction of the thighs more than 45 degrees from the midline may cause tearing of the urethra and bladder. If long-term walking difficulties and pain are reported, the patient's condition generally improves with physical therapy. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8436", "text": "In 2002 an advocacy group called Survivors of Symphysiotomy (SoS) was set up alleging religiously motivated symphysiotomies were performed without consent and against best medical practice in  Republic of Ireland  between 1944 and 1987. [ 12 ] [ 13 ]  In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8437", "text": "From approximately 2000, there was a controversy over the use of  symphysiotomies  during childbirth in the  Republic of Ireland  between 1944 and 1987. In 2002 an advocacy group called Survivors of Symphysiotomy (SoS) was set up in Ireland alleging religiously motivated symphysiotomies were performed without consent and against best medical practice in  Republic of Ireland  between 1944 and 1987. [ 1 ] [ 2 ]  In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability. [ 3 ]  Some media reported that  pubiotomy  was also practised, [ 4 ]  but only one payout was given in 2014 for an \"accidental\" pubiotomy that occurred in the 1950s. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8438", "text": "It is estimated that 1,500 women unknowingly and without consent underwent symphysiotomies during childbirth in the  Republic of Ireland  between 1944 and 1987. [ 6 ]  A 2012 report found that many of the victims say the  Catholic Church  \"encouraged, if not insisted upon, symphysiotomies.\" [ 7 ]  It has been suggested that during that period, non-Catholic doctors recommended  sterilisation of women  after three  caesarean section  operations, while Catholic doctors usually recommended \"compassionate hysterectomies\" as a solution to the prohibition on sterilisations. [ 8 ]  Despite  legal restrictions  being placed on the use of artificial contraceptives, the average size of families in Ireland declined from the 1930s. [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8439", "text": "Dr. Alex Spain was master of the  National Maternity Hospital  during the mid-20th century, and performed 43 symphysiotomies during his tenure. Spain's successor, Arthur Barry, was also a strong supporter of Catholicism and the practice of symphysiotomy. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8440", "text": "In 2002, survivor Matilda Behan and her daughter, Bernadette, set up an advocacy group for the victims called Survivors of Symphysiotomy (SoS). [ 13 ]  Matilda was operated upon at NMH 17 days before her baby was born. She thought she was being brought to theatre for a caesarean section. No one told her the plan was to do the 'new procedure,' a pubiotomy. [ 14 ]  In 2008, the  Irish Human Rights Commission  recommended that the Government should reconsider its decision not to set up an independent inquiry into symphysiotomy. The Minister for Health refused. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8441", "text": "On 18 February 2010, an  RT\u00c9   Prime Time  documentary revealed that, over half a century, some 1,500 women had symphysiotomies performed on them during childbirth by doctors in order to train medical personnel and perfect the surgery for Africa. Following the programme, victims of the procedure called on the Minister for Health,  Mary Harney , to initiate an independent inquiry. Instead, she commissioned the IOG, a training body, to inquire into itself by reviewing operations carried out by some of its own members for teaching purposes. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8442", "text": "A  D\u00e1il  debate on the issue was heard on 15 March 2012, which was organised by Deputy  Caoimhgh\u00edn \u00d3 Caol\u00e1in . Leading the debate in the D\u00e1il, \u00d3 Caol\u00e1in compared symphysiotomy to  clerical abuse : \"The infliction of symphysiotomy on women in Ireland is one of the greatest medical scandals not only here but on an international scale. Symphysiotomy is a clinical scandal on a par with the clerical scandals we have seen exposed in the past two decades.\" [ 18 ]   Gerry Adams  described the procedure as \"institutional abuse involving acts of butchery against women.\" [ 19 ]  While  Clare Daly  declared that \"it is an important acknowledgment by the State of the crimes committed against many of the women present today, crimes which led to the suffering endured by them and their families for decades\". [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8443", "text": "Eight days later, on 23 March 2012, a  County Louth  woman, Olivia Kearney, who was subjected to a post caesarean-section symphysiotomy, which was performed by Dr. Gerard Connolly, was awarded \u20ac450,000 by the  High Court . [ 20 ]  The Kearney case was appealed to the  Irish Supreme Court , which found in favour of Ms. Kearney and declared that symphysiotomy was not a generally approved obstetric practice in 1969. While the Supreme Court reduced the award of damages from \u20ac450,000 to \u20ac325,000, the decision represented the first court condemnation of the practice of symphysiotomy by an institution of the Irish state. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8444", "text": "In June 2012 details of Professor Oonagh Walsh's draft report on the use of this procedure in Ireland were released. The report by Prof. Walsh (UCC) found that although symphysiostomies were phased out in most medical institutions across the country, Our Lady of Lourdes Hospital was practising the procedure until the 1980s, a fact linked to the \"unswervingly Catholic ethos\" of the hospital. [ 22 ]  The draft Walsh report nevertheless found that symphysiotomy was justifiable and sought to consult with survivors on its findings. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8445", "text": "The draft Walsh report was criticised by victims' advocate group Survivors of Symphysiotomy, as well as by a number of opposition TDs and journalists, for failing to adequately address issues such as patient consent and for perceivably justifying the performance of the operation. Survivors of Symphysiotomy members subsequently decided to boycott the second stage of the Walsh report. [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8446", "text": "Also in June 2012, Survivors of Symphysiotomy testified publicly before the Joint Oireachtas (Select) Committee on Justice. Catherine McKeever, a private patient at the Lourdes Hospital, Drogheda in 1969, told the Committee that she did not realise what had happened: 'I saw him [the doctor] with an instrument which I thought was a  bit brace  because my father was a wood turner. I felt a crack ... Nobody answered me or said anything'. Margaret Conlan, who was operated upon in 1962 in St Finbarr's Hospital, Cork, testified that she had never been told anything about it: 'My baby's head was perforated and the baby died... I did not find out [about the symphysiotomy] until I read it in the newspaper'. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8447", "text": "\u00d3 Caol\u00e1in introduced the Statute of Limitations (Amendment) Bill, which was unanimously supported by D\u00e1il on 17 April 2013. [ 27 ]  The proposed legislation sought to lift the statute of limitations for a period of one year, to enable all survivors of symphysiotomy to bring their cases through the Irish courts. By July 2013, the Bill had stalled before the Joint Oireachtas (Select) Committee on Justice, leading SoS to protest outside the Parliament on 26 June. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8448", "text": "In November 2013, Minister for Health  James Reilly  announced that Judge Yvonne Murphy had been appointed to review the findings of the Walsh report, to meet with survivors of symphysiotomy, hospital authorities, and insurers with a view to deciding on whether an ex gratia redress scheme would be preferred to allowing legal actions to proceed. The terms of reference for the Murphy inquiry were criticised by  Caoimhgh\u00edn \u00d3 Caol\u00e1in , who stated that the \"type of scheme outlined in the terms of reference offers the women no prospect of adequate compensation for what was so barbarically done to them nor the choice to pursue their rights in the courts\". [ 29 ]  It also emerged that the Government would no longer support the statute of limitations bill, which had been unanimously adopted by the D\u00e1il in April 2013. [ 30 ]  SoS  rejected the Government's statement and described their plans as 'paternalistic'. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8449", "text": "In March 2014, Survivors of Symphysiotomy made a complaint to the  United Nations Committee Against Torture  about the Irish State's failure to properly, thoroughly or impartially investigate the practice of symphysiotomy in Ireland. [ 32 ] [ 33 ] [ 34 ]  In July, the United Nations committee on human rights called for the Irish government to hold an investigation into the issue. [ 4 ] [ 35 ]  In 2014 an investigation was established under Judge Harding Clark to allow the Ex-gratia Payment. In October 2016, this body published their report establishing that this procedure was used only rarely, and in very difficult labours. She found no evidence to support the claim that a symphysiotomy caused lifelong disability or suffering. Nevertheless, women who had the procedure were awarded compensation. The report found that at least one third of women claiming to have suffered from having the procedure never had symphysiotomies. Although these claimants were denied compensation, others with weak evidence received pay-outs. Judge Harding Clark stated 'I believe that early uncritical reliance on medical reports led me to make awards where it is highly probable that no symphysiotomy was performed.'  [ 36 ] \nCommenting on the Harding Clark report, Nil Mui\u017enieks on behalf of the Council for Europe stated that he was \u2018particularly struck by the patronising tone\u2019 of the report and that it did not \u2018give acknowledgement to women\u2019s suffering and seems to perpetuate some gender stereotypes against (elderly) women.\u2019 [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8450", "text": "Bariatrics  is a discipline that deals with the causes, prevention, and treatment of  obesity , [ 1 ]  encompassing both  obesity medicine  and  bariatric surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8451", "text": "The term  bariatrics  was coined around 1965, [ 2 ]  from the  Greek  root  bar - (\"weight\" as in  barometer ),  suffix  - iatr  (\"treatment,\" as in  pediatrics ), and  suffix  - ic  (\"pertaining to\"). The field encompasses  dieting ,  exercise  and  behavioral therapy  approaches to  weight loss , as well as  pharmacotherapy  and  surgery . The term is also used in the medical field as somewhat of a euphemism to refer to people of larger sizes without regard to their participation in any treatment specific to weight loss, such as medical supply catalogs featuring larger hospital gowns and hospital beds referred to as \"bariatric\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8452", "text": "Being  overweight  or  obese  are both rising medical problems. [ 3 ] [ 4 ]  There are many detrimental health effects of obesity: [ 5 ] [ 6 ]  Individuals with a  BMI  (Body Mass Index) exceeding a healthy range have a much greater risk of medical issues. [ 7 ]  These include  heart disease ,  diabetes mellitus , many types of  cancer ,  asthma ,  obstructive sleep apnea , and chronic  musculoskeletal  problems. There is also a focus on the correlation between obesity and  mortality . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8453", "text": "Overweight and obese people, including children, may find it difficult to lose weight on their own. [ 9 ]  It is common for dieters to have tried fad diets only to find that they gain weight, or return to their original weight, after ceasing the diet. [ 10 ]  Some improvement in patient psychological health is noted after bariatric surgery. [ 11 ]  51% of bariatric surgery candidates report a history of  mental illness , specifically  depression , as well as being prescribed at least one psychotropic medication at the time of their surgery candidacy. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8454", "text": "Although  diet ,  exercise ,  behavior therapy  and  anti-obesity drugs  are first-line treatment, [ 14 ]  medical therapy for severe obesity has limited short-term success and very poor long-term success. [ 15 ]   Weight loss surgery  generally results in greater weight loss than conventional treatment, and leads to improvements in  quality of life  and obesity related diseases such as  hypertension  and  diabetes mellitus . [ 16 ]  A meta-analysis of 174772 participants published in  The Lancet  in 2021 found that bariatric surgery was associated with 59% and 30% reduction in all-cause mortality among obese adults with or without  type 2 diabetes  respectively. [ 17 ]  This meta-analysis also found that median life-expectancy was 9.3 years longer for obese adults with diabetes who received bariatric surgery as compared to routine (non-surgical) care, whereas the life expectancy gain was 5.1 years longer for obese adults without diabetes. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8455", "text": "The combination of approaches used may be tailored to each patient. [ 18 ]   Bariatric treatments in youth  must be considered with great caution and with other conditions that may not have to be considered in adults."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8456", "text": "Techniques used in bariatrics include  bioelectrical impedance analysis , a method to measure  body fat percentage ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8457", "text": "A  bariatric ambulance  is an  ambulance  vehicle modified to carry the severely  obese . They have extra-wide interiors and carry \"bariatric stretchers\" and specialized  lifting gear  that is capable of carrying very large patients. [ 1 ]  They are required as a result of the increasing prevalence of obesity in the general population. [ 2 ] [ 3 ]  Currently, there is no  standardized  weight capacity for bariatric ambulances, and requirements may vary in populations according to epidemiological demand. However, they are typically designed to carry weights between 350\u00a0kg (770\u00a0lb) and up to at least 450\u00a0kg (990\u00a0lb). [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8458", "text": "This vehicle-related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8459", "text": "The  American Society for Metabolic & Bariatric Surgery (ASMBS)  is a non-profit medical organization dedicated to metabolic and  bariatric surgery , and  obesity -related diseases and conditions. [ 1 ] [ 2 ]  It was established in 1983. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8460", "text": "The ASMBS, as part of its mission statement, says it is \u201ccommitted to educating  health professionals  and the  lay public  about metabolic and bariatric surgery as an option for the treatment of obesity and  morbid obesity  and improving the care and treatment of people with obesity and obesity-related diseases and conditions.\u201d This surgical specialty organization says it \u201cencourages its members to investigate and discover new advances in metabolic and bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved patient outcomes.\u201d [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8461", "text": "In 2012, the ASMBS had approximately 4,000 members, [ 5 ]  which includes  surgeons ,  nurses , bariatricians,  psychologists ,  dietitians , and other medical specialists focused on the disease of obesity. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8462", "text": "The ASMBS is also an advocate for  healthcare policy  to promote patient access to high quality  prevention  and treatment of obesity. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8463", "text": "The ASMBS was established in 1983. Its founding president was  Edward Eaton Mason , MD, a surgeon who is considered the \"father\" of bariatric or obesity surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8464", "text": "On August 15, 2007, the ASBS changed its name to the American Society for Metabolic & Bariatric Surgery (ASMBS) to reflect mounting clinical evidence demonstrating the effectiveness of surgery on  metabolic diseases , particularly  type 2 diabetes , [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ]  in addition to its effectiveness on obesity and morbid obesity. [ 14 ] [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8465", "text": "The ASMBS has held 29 annual scientific meetings. In 2013, the ASMBS and  The Obesity Society (TOS)  combined their respective annual meetings for \"ObesityWeek,\" which was held from November 11 to November 16, 2013 in Atlanta, Georgia.  The scientific and educational conference drew  clinicians  and  scientists  from all over the world to review and discuss new data on the full spectrum of the disease of obesity. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8466", "text": "In 2006,  Centers for Medicare and Medicaid Services  (CMS) established a national coverage policy for bariatric/metabolic surgery to help reduce health risks associated with obesity, including death and disability, as long as the procedures were performed at facilities certified by the AMBS or the American College of Surgeons. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8467", "text": "In 2012, the ACS and ASMBS announced plans to combine their respective national bariatric surgery  accreditation  programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers. [ 19 ]  More than 750 facilities are now enrolled in the program called Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program MBSAQIP) in the United States. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8468", "text": "The ASMBS Certified Bariatric Nurse (CBN) program was established in June 2007. [ 21 ]  Certification indicates nurses have met all testing requirements and have proven to be competent in the care of obese and bariatric surgery patients. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8469", "text": "Aspiration therapy  is a  bariatric approach  to siphon ingested food from the  stomach  via an implanted tube and port to the outside of the body to be discarded. [ 1 ]  The device for this approach was developed by researchers at  Washington University in St. Louis  to treat  obesity  and  has been named  AspireAssist . [ 1 ]  The device has also been termed a  reverse feeding tube . [ 2 ]   It was approved by the  Food and Drug Administration  (FDA) on June 14, 2016. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8470", "text": "AspireAssist is made by Aspire Bariatrics. It is inserted in an outpatient setting using an  endoscope  during an about 15 minutes procedure. [ 4 ]  People with the device can discharge yet undigested food via the port into the toilet, typically 20 to 30 minutes after a meal. Critics have called the approach \u201cassisted bulimia\u201d. [ 2 ]  In an initial study 18 people those with the device lost more weight than controls. [ 5 ]  The therapy is supported by a lifestyle counseling program, and requires regular medical supervision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8471", "text": "Candidates for the device cannot have an eating disorder, should be 22 years old or more, and should have a body mass index of 35 to 55. Short-term use is not encouraged. [ 3 ]  Contraindications for the device are certain eating disorders (i.e.  bulimia ), certain types of previous abdominal surgery, pregnancy, stomach ulcers and inflammatory bowel disease. [ 3 ]  Side effects reported are local skin irritation at the port site and abdominal discomfort, nausea, vomiting, constipation, and diarrhea. [ 3 ]  Local infection may require removal of the tube. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8472", "text": "The device is removable. [ 4 ]  Removal is performed on an outpatient basis and requires about ten minutes. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8473", "text": "Stanley K. Bernstein  is a  Canadian   physician  who founded and is the current owner of 60  weight-loss   clinics  in  Canada  known collectively as the Dr. Bernstein Diet & Health Clinics. Bernstein has owned and operated weight-loss clinics since 1974 [ 1 ]  and employs a weight-loss regimen involving a low  calorie  intake, frequent physician visits and injections of a  Vitamin B  solution. Bernstein is a member of the American Society of  Bariatric  Physicians."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8474", "text": "Bernstein was raised near the  Moss Park  area of  Toronto  by Polish immigrant parents who owned a used clothing outlet called Bernstein's Second Hand Store on  Queen East . [ 2 ]  Bernstein graduated from the  University of Toronto  in 1966 and followed this by interning at  Mount Sinai Hospital  in Toronto. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8475", "text": "After completing his  internship , Bernstein set up a general family practice in 1967 near Gerrard and Greenwood in  Toronto , [ 2 ]  and was also involved in  geriatric  work at  Baycrest Centre."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8476", "text": "In 1972, Bernstein traveled to  Las Vegas  to attend a conference hosted by the American Society of Bariatric Physicians. [ 2 ]  It was at this conference where Bernstein learned about a group of physicians who were using what was called the Simeons Approach as a way to help patients achieve weight loss. In order to achieve weight loss, the Simeons Approach prescribed a very low-calorie intake and injections of a hormone called  Human Chorionic Gonadotropin , or hCG, a hormone produced by pregnant women to break down fat stores thought to feed the baby. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8477", "text": "Bernstein returned to Toronto and began using this knowledge to treat patients at his practice by helping them achieve a state of Ketosis. [ 2 ]  Subsequently, Bernstein opened his first dedicated weight-loss clinic at the  Richmond-Adelaide Centre  of Toronto in 1977 and in 1978, his second clinic in Toronto's Yorkville neighbourhood and his third in 1978 at  Yonge and Eglinton , also in Toronto. [ 2 ]  By the early 2000s, Bernstein had 14 diet clinics in  Ontario . Over the next few years, his practice expanded to Ottawa, Vancouver, Edmonton and Calgary. Around 2005, Bernstein opened his first American clinics in  Virginia  and  Florida . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8478", "text": "As of 2010, Bernstein owned and operated 62 clinics across Canada, treating nearly 10,000 active patients. [ 4 ]  It is estimated that Bernstein's clinics have treated approximately 450,000 patients over the years, including Canadian Archbishop Marcel Gervais and comedian  Mike Bullard , who appeared in company advertisements for a period of time. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8479", "text": "Starting in 1979, the  Ontario College of Physicians and Surgeons  warned against the use of hCG in the treatment of  obesity  due to the lack of scientific evidence concerning the effects of its use. [ 3 ]  The Ontario College also warned against a 500-calorie diet used in conjunction with hCG treatment, citing the treatment's risk to a patient's health. [ 3 ]  Several doctors, including Bernstein, continued to administer and use hCG in their weight-loss treatments. In 1987, the Ontario College formally banned hCG as a weight-loss treatment. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8480", "text": "Following the ban on hCG, Bernstein discontinued using hCG injections as part of his diet program and replaced it with injections of a Vitamin B complex, the exact composition of which is a closely guarded secret. While on Bernstein's diet program, patients are administered Vitamin B injections multiple times a week and are instructed to maintain an intake of 800 to 1,500 calories per day on a strict diet regimen. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8481", "text": "In February 2009, Bernstein publicly complained that an editorial in the  Canadian Medical Association Journal  (CMAJ) concerning commercial diets unfairly targeted his clinics. [ 6 ]  CMAJ's editorial commented on commercial diet clinics and specifically their pattern of manipulating patients with false hopes and using medically unproven weight-loss techniques. As evidence of the latter, CMAJ's editorial specifically pointed out the use of Vitamin B injections. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8482", "text": "Bernstein's use of Vitamin B injections as part of his weight-loss program has met with skepticism and a lack of agreement by multiple members of the medical community. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8483", "text": "In 1988, Glenn Duffin, a thirty-one-year-old Canadian died of  cardiac arrhythmia  eight days after beginning Bernstein's diet program. [ 5 ]  Following Duffin's death, a  jury  concluded that his death was caused by stress brought about by family and financial issues and Bernstein's diet program. The jury also advised that patients using commercial weight-loss programs should be encouraged to lose no more than two pounds a week when considering a diet of 1,200 calories per day. [ 7 ]  Duffin's family filed a malpractice suit against Bernstein and was awarded $700,000 in damages in an out-of-court settlement. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8484", "text": "Bernstein has been a part of a number of litigation suits involving the proprietary secrets of his weight-loss clinics and his Vitamin B-based weight-loss program. In 2007, Bernstein brought to court Daniela Stoytcheva-Todorova and Vesselin Todorov under allegations that their weight-loss clinic, Veda Healthy Weight Loss Centre Inc., used trade secrets and confidential information belonging to Bernstein. Bernstein ended up discontinuing all claims against Todorov and Todorova. [ 8 ]  In 2009, Bernstein sought litigation against Dr. Nadia Brown under similar claims, [ 9 ]  and, following this, in 2011, Bernstein filed suit against Dr. Scott Seagrist, a former partner at two of  Bernstein's clinics, and his spouse, seeking $10.5 million in damages under allegations that Seagrist had improperly used trade secrets to begin his own weight-loss clinic. Bernstein's lawsuit against Seagrist was settled in an out-of-court agreement. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8485", "text": "In September 2009, Bernstein launched a lawsuit against Pat Poon, a  Canadian  weight-loss doctor who operates four weight-loss clinics in the Greater Toronto Area. [ 11 ]  In the lawsuit, Bernstein argued that Poon had defamed Bernstein in Poon's book  Dr. Poon's Metabolic Diet , as well as in a subsequent television show that Poon was a guest on. Dr. Poon's Metabolic Diet book has numerous breathing techniques for assisting with passing large bowel movements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8486", "text": "After a six-year lawsuit, the judge ruled in Bernstein\u2019s favor, awarding $10,000 to Bernstein in damages.[12] In making the final decision, the judge admitted that the trial was more than a reputational dispute, saying, \u201cIt is more about turf warfare in the competitive world of diet medicine than about reputation\u201d.[11]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8487", "text": "In April 2014, the  College of Physicians and Surgeons of Ontario  ruled that Bernstein had repeatedly breached rules established by the College by advertising his weight-loss clinics through customer testimonials, before and after photos and medically unproven, superlative language. [ 4 ]  The College also ruled that Bernstein had acted against medical standards by connecting himself with the sale of his product, in this case, his diet clinics. As a result, Bernstein was instructed to appear before the College for a verbal warning. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8488", "text": "In May 2014, it was reported that Bernstein was set to contest the formal caution imposed on him by the College of Physicians and Surgeons. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8489", "text": "In February 2015, the  Health Professions Appeal and Review Board  dismissed a protest from Bernstein and his request that a formal caution on his use of advertising be thrown out. [ 13 ]  The appeal board found that previous investigations into the complaint that Bernstein had violated advertising rules were \u201cadequate and reasonable\u201d. The appeal board requested that further investigation be done into whether Bernstein was guilty of \u201csteering\u201d members of the public to visit doctors in his own clinics, which is a violation of rules. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8490", "text": "In October 2013 Bernstein applied for an order for inspectorship over 31 jointly owned properties with The Rose & Thistle Group owners and Toronto attorneys, Norma and Ronauld Walton.  In November 2013 he petitioned their entire real estate portfolio into receivership without notice to the lenders. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8491", "text": "Bernstein and the Waltons were legal partners in a property investment agreement, in which Bernstein financed the ventures and the Waltons were responsible for the finances, bookkeeping, accounting and filing of tax returns. < [ 15 ]  By 2013, Bernstein had invested $110 million into 31 different projects through the Rose & Thistle Group."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8492", "text": "Bernstein's receivership caused the portfolio to go into automatic default across all 31 joint entities and receivership and power of sale of the portfolio followed by Schonfeld & Associates, receivers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8493", "text": "In 2016, Bernstein was awarded $66.9 million in damages also by Justice Newbould via application.  The Waltons asked for a trial but that request was denied by the Court."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8494", "text": "The Waltons have communicated publicly that they \"strongly disagree\" with the accusations and have appealed the findings of  Ontario Superior Court 's ordered investigation. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8495", "text": "In 2015 Trez Capital sued Bernstein for over $14 million, alleging fraud and deceit. Trez Capital, a mortgage lender, financed four of the projects owned by Rose & Thistle and Bernstein. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8496", "text": "Bernstein brought a motion to dismiss Trez's claim on the basis of his and his CFO James Reitan\u2019s evidence that Trez knew about their claim in September 2013 and thus were outside of the limitation period for filing. During a mini trial, the judge did not accept the testimony of Bernstein and Reitan as credible in comparison to the evidence of Coscia. Bernstein later appealed to the Court of Appeal and lost. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8497", "text": "Bernstein has now paid Trez money to settle the Trez litigation that alleged fraud and deceit. [ 18 ]  He paid this money pursuant to a Pierringer Agreement that mandates confidentiality of the amount paid by him.  An amended Statement of Claim is being filed with the Court accordingly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8498", "text": "Bernstein has been married to his second wife, Judy Bernstein, since 1992. [ 2 ]  Bernstein also has three adult sons, one who is a  radiologist  in  New York City , one a lawyer, and the third son, a business graduate who works at Bernstein's clinics. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8499", "text": "In 1977, Bernstein was instructed to testify before the Discipline Committee of the College of Physicians and Surgeons of Ontario in allegations that he had inappropriate sexual relations with Jo-Anne Johnston, who was mentally fragile and a patient of his from 1970 to 1973. The Committee concluded that Bernstein was guilty of the charge and disciplined Bernstein with a suspension from practice for 12 months, as well as a fine of $4,500. Bernstein successfully appealed this ruling and the guilty charge, fine and suspension were removed from his record. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8500", "text": "In 1992, Bernstein was arrested alongside Peter Gassyt and Arnold Markowitz, who were arrested and charged in a conspiracy to murder a business colleague and a friend. [ 20 ]  In the trial that followed, both Gassyt and Markowitz were charged with a conspiracy to murder, and in 1993, the two were convicted on a sole count of conspiracy to commit murder. [ 21 ]  At the time of Bernstein's arrest, undercover officers undertook an unannounced search of Bernstein's residence, where they found $2 million in stolen goods, including 24  Rolex  watches. [ 10 ]  As a result, along with conspiracy to murder, Bernstein was also charged with possession of stolen property. Both charges  were later dropped. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8501", "text": "In 1998, Bernstein, along with his wife, were robbed at gunpoint in their Toronto residence and bound and forced into the trunk of Bernstein's Mercedes. [ 22 ]  The assailants emptied Bernstein's safe of valuables and fled. Both Bernstein and his wife were unharmed in the robbery and the assailants were never captured. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8502", "text": "Pradeep Kumar Chowbey  is an Indian surgeon, known for  laparoscopic  and  bariatric  surgeries. [ 3 ]  He is the incumbent Executive vice chairman of the  Max Healthcare , Chairman of the  Minimal Access, Metabolic & Bariatric Surgery  and  Allied Surgical Specialities  of the Max Healthcare Institute, New Delhi. [ 4 ]  He is the founder of the  Minimal Access, Metabolic & Bariatric Surgery Centre  at the  Sir Ganga Ram Hospital , New Delhi [ 2 ]  and has served as the Honorary Surgeon to the  President of India ,  Dalai Lama  and the  Indian Armed Forces  (AFMS). [ 3 ]   The Government of India awarded him the fourth highest civilian honour of the  Padma Shri  in 2002. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8503", "text": "Chowbey graduated in medicine (MBBS) and secured his master's degree in surgery (MS) from  Netaji Subhash Chandra Bose Medical College  (then known as Government Medical College),  Jabalpur , after which he earned a diplomate from the  National Board of Examinations , New Delhi, in 1979. [ 6 ]  After starting his medical practice at a public hospital in Delhi, he moved to  Sir Ganga Ram Hospital  in 1984 to take up the post of a consultant surgeon, handling  hepatobiliary , pancreatic and breast surgeries. When  minimally invasive surgical method  was first developed in France in 1989, Chowbey underwent training in the procedure at  Singapore General Hospital  from the pioneers of the technology such as  Mohan Chellappa  which helped him to perform the first  Laparoscopic   Cholecystectomy  in North India. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8504", "text": "At Sir Ganga Ram Hospital, Chowbey established  Minimal Access, Metabolic and Bariatric Surgery Centre  where the team led by him is reported to have performed over 55,000  minimally invasive procedures . [ 7 ]  His list of patients included  K. R. Narayanan , former President of India,  Dalai Lama  and  Arun Jaitley [ 8 ]  who were operated on by him in 2001, 2008 and 2014 respectively. He has been involved in the designing of the  International Centre of Excellence for Bariatric Surgery Program  of the Surgical Review Corporation, USA [ 9 ]  and was one of the key members among the founders of the Asia Pacific Hernia Society where he served as the founder president. [ 10 ]  He is the president of the Asia Pacific Metabolic and Bariatric Surgery Society, Asia Pacific Chapter of International Federation for the Surgery of Obesity and Metabolic Disorders, and International Federation for the Surgery of Obesity and Metabolic Disorders and has served Obesity and Metabolic Surgery Society of India and the Indian Association of Gastrointestinal Endo-Surgeons as their president. He sits in the Board of Governors of the Gasless Laparoscopic and Endoscopic Surgeons Society International and is the Advisor to the Asia Pacific Endosurgery Task Force (AETF). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8505", "text": "Chowbey is a founding designee in the International Centre of Excellence for Bariatric Surgery Program by Surgical Review Corporation, USA. [ 11 ]  He is an Honorary Fellow of the American Society of Metabolic and Bariatric Surgery, [ 12 ]  International Medical Science Academy (IMSA), International Congress of Surgeons (ICS) and Association of Surgeons of India (ASI). [ 6 ]  He is also an Honorary Member of the Japanese Society of Endoscopic Surgeons, [ 13 ]  German Hernia Society, Indonesian Hernia Society and Gulf Cooperation Council Hernia Society (National Chapter of Asia Pacific Hernia Society, Dubai). [ 7 ]  He was included in the  Guinness Book of World Records  in 1997 and the  Limca Book of Records  for more than 80,000 major minimal access surgeries (1992-2018) performed by a surgeon. [ 14 ]  Dr Chowbey also has a Limca Book of Record for establishing the first dedicated Department of Minimal Access Surgery (MAS ) in the Asian subcontinent in 1995 [ 15 ] [ 9 ]  The Government of India awarded him the civilian honour of the  Padma Shri  in 2002. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8506", "text": "Chowbey was the first to introduce the technique called MAFT (Minimally Invasive Fistula Treatment) in entire Asia-Pacific region. The technique is performed for surgical treatment of anal fistulas through a fistulascope. This concept was a breakthrough surgical treatment for anal fistulas as it has a very short recovery period, requires no dressings and there are no chances of loss of control (fecal incontinence). [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8507", "text": "He operated on 14 years old Mihir Jain, believed to be World's heaviest teenager weighing 237 Kilograms in July 2018. [ 18 ]  By December 2018, Mihir's weight reduced by 100 Kg and now stands at 137\u00a0kg. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8508", "text": "In 2021, Dr Chowbey embarked on unleashing the excellence of next generation robot, Versius to extend the benefits of robotic surgery even in common surgical conditions like Gallbladder surgery, hernia etc.This next-generation robotic surgery is designed to provide all benefits of laparoscopic surgery with added precision, accuracy and safety. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8509", "text": "A  gastric balloon , also known as an  intragastric balloon  ( IGB ) or a  stomach balloon , is an inflatable  medical device  that is temporarily placed into the  stomach  to help  reduce weight . It is designed to help provide weight loss when diet and exercise have failed and surgery is not wanted by or recommended for the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8510", "text": "Intragastric balloons are an alternative to  bariatric surgery  (or weight loss surgery), which is not generally offered to patients with a  body mass index  of less than 35. Gastric balloons are also designed for patients who require weight-loss support but who do not want to commit to surgical interventions. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8511", "text": "Intragastric balloons help induce weight loss by increasing satiety, delaying gastric emptying, and reducing the amount of food eaten at each meal. [ 1 ]  Gastric balloons take up space in the stomach, which limits the amount of food that can be held. This creates an early feeling of fullness and satiety. A reduced intake of food then results in weight loss."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8512", "text": "Most balloons require  endoscopy  for removal or placement. They are usually placed for up to six months, though some devices are placed for twelve months. The device is then removed, again using endoscopy. Longer placement is not advised because of the danger of damage to the tissue wall and degradation of the balloon. The use of the balloon is complemented with counseling and nutritional support or advice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8513", "text": "Endoscopic placement of the balloon is temporary and reversible without surgical incisions. The gastric balloon for weight loss differs from the  Sengstaken-Blakemore  balloon used to stop esophageal and gastric bleeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8514", "text": "Gastric balloon uptake has until recently been limited due to the need for endoscopy for placement or removal. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8515", "text": "Procedureless, or non-endoscopic, intragastric balloons offer a promising alternative to historic endoscopic balloons. Non-endoscopic balloons are also a less invasive alternative to weight-loss surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8516", "text": "In 2015, Allurion's Elipse gastric balloon became the world's first non-endoscopic swallowable gastric balloon when it gained approval in Europe. [ 3 ] [ 4 ]  Except under exceptional circumstances, it does not require endoscopy or surgery for placement or removal. [ 2 ]  The non-endoscopic gastric balloon capsule is swallowed for placement and once in the stomach is filled with saline liquid. After 16 weeks, the non-endoscopic gastric balloon then automatically deflates and passes naturally at the end of placement. A recent meta analysis of 6 studies found the balloon was a safe device offering effective weight loss. Total pooled weight loss at the completion of treatment (4\u20136 months) was 12.8% and at 12 months was 10.9%. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8517", "text": "Adjustable gastric balloons are able to increase or decrease their volume. While non-adjustable gastric balloons have been successfully used for weight loss for the last 30 years, the adjustability function was developed to address the following issues: (1) variability of response and reduced efficacy after 3 months  [ 5 ] [ 6 ] [ 7 ]  and (2) intolerance necessitating early balloon extraction. [ 8 ] [ 9 ]  Alleviating intolerance with a downward adjustment and renewing weight loss after balloon upward adjustment, are responsible for higher success rates compared with non-adjustable balloons. [ 10 ] [ 11 ]  The Spatz3 adjustable gastric balloon is the first intragastric balloon approved for 1-year implantation (outside of the US), while featuring an adjustability function that provides balloon volume changes as needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8518", "text": "The device is intended to be used by people with a  body mass index  of more than 27\u00a0kg/m 2 . [ 12 ]  or between 30 and 40\u00a0kg/m 2 [ 13 ]  and have weight-related co-morbidity. It should not be applied to patients with certain intestinal problems such as inflammatory bowel disease or delayed gastric emptying, who are pregnant, or who are taking blood thinner medications such as Coumadin. Low dose aspirin (100\u00a0mg) is permitted. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8519", "text": "A 2016 meta analysis of studies showed short term weight loss without any mortality. [ 14 ]  It was calculated that the weight loss was 1.59 and 1.34\u00a0kg/m 2  for overall and 3-month  body mass index  (BMI) loss, respectively, and 4.6 and 4.77\u00a0kg for overall and 3-month weight loss, respectively. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8520", "text": "Results are influenced by the adherence to nutritional and dietary programs. Long-term studies show promise for patients who combine balloon treatment with exercise and a healthy diet. In a study on the 'Long-Term Efficacy of the Elipse Gastric Balloon System: An International Multicenter Study, Dr. Roberta Ienca and colleagues' report on 509 patients who received the non-endoscopic Elipse balloon and were followed for one year. After 4 months of treatment, patients achieved weight loss of 14.4\u00a0kg or 13.9% of total body weight. At one-year follow-up, 95% of this weight loss was maintained by patients included in the study. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8521", "text": "Gastric balloons are generally considered to be safe and effective in the short term. [ 15 ]  Existing clinical data shows an acceptable safety profile. One of the largest intragastric balloon studies ever performed, which included 1770 patients, demonstrated an excellent safety profile. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8522", "text": "There can be procedure-related side effects due to endoscopy and anesthesia on balloons that require medical intervention for placement or removal. [ 13 ]  On very rare occasions, the endoscopic placement of a balloon has led to death. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8523", "text": "Several studies have demonstrated that the data on both the efficacy and safety for the non-endoscopic Allurion Elipse gastric balloon compares favorably with balloons that require endoscopy. [ 2 ]  It showed an acceptable safety profile with 0.2% of serious adverse events, which is comparable to the Orbera balloon, which requires endoscopy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8524", "text": "Post-placement side effects of gastric balloons are common and may include nausea, vomiting, reflux and stomach cramps. [ 18 ]  Other side effects include indigestion, bloating, flatulence and diarrhea. [ 14 ]  Rare side effects include esophagitis, gastric ulcer formation or gastric perforation. [ 19 ]  The device can become deflated and slip into the lower intestines. Migration of a balloon can lead to  bowel obstruction . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8525", "text": "Currently, there are three types of  FDA -approved gastric balloons in the USA. These approved devices are placed via the esophagus using endoscopy. This can be done in an  outpatient setting  under sedation. One further balloon, Allurion's Ellipse, has European  CE  approval and does not require endoscopy for placement or removal. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8526", "text": "Once in place the balloon is filled with saline and remains as a free-floating object in the stomach cavity, too big to pass through the  pylorus . In addition to saline, the balloon that is made from silicone may contain some radio-opaque material as a radiographic marker and a dye such as  methylene blue  to alert the patient if the balloon leaks. [ 15 ]  Studies have suggested that fluid is superior to air for distending gastric balloons. [ 14 ]  Inflated balloons reduce the operative volume capacity of the stomach. While the typical gastric volume is about 900 ml, an inflated balloon may take up most of the space, about 700 (+/-100) ml."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8527", "text": "Gastric balloon-type devices have been approved in many countries, among them Australia, Canada, Mexico, India, Guatemala and several European and South American countries. [ 20 ]  They became available in the United States in 2015 when two different balloon devices were approved by the FDA. [ 21 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8528", "text": "Costs for the gastric balloon are surgeon-specific and vary by region. Average cost in the US is US$8,150, and generally less in other countries. Average cost in Europe is around \u20ac3,000. Insurance coverage is usually not provided in the US. [ 24 ]  There are three cost categories for the intragastric balloon: pre-operative (e.g. professional fees, lab work and testing), the procedure itself (e.g. surgeon, surgical assistant, anesthesia and hospital fees) and post-operative (e.g. follow-up physician office visits, vitamins and supplements)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8529", "text": "The first person to use a gastric balloon for the treatment of obesity was A. Henning 1979. (Inn. Med.6(1979),149) He and his wife used it in a self-experiment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8530", "text": "The use of gastric filling devices to induce weight loss is not new.  DeBakey's  review in 1938 showed that  bezoars  led to weight loss. [ 25 ]  Free floating intragastric balloons were used by Nieben and Harboe in 1982. [ 26 ]  Percival presented a \u201cballoon diet\u201d in 1984 when he placed inflated mammary implants as gastric balloons. [ 27 ]   Elipse mide Balonu   In 1985 the Garren-Edwards Bubble was introduced as the first FDA-approved device, but the approval was withdrawn seven years later because of complications. [ 28 ]  Analysis of its problems led to recommendations for safer designs. [ 12 ]  While a number of further developed devices were used outside of the US, mostly in Europe and South America, the FDA did not approve any new devices until 2015. [ 28 ]  In October 2017, ReShape Medical, which makes gastric balloons, was acquired by EnteroMedics in $38m cash-and-stock deal. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8531", "text": "Gelesis100 , sold under the brand name  Plenity , is an oral  hydrogel  used to treat  overweight  and  obesity . [ 1 ]  It absorbs water and expands in the  stomach  and  small bowel  thereby increasing feelings of fullness. Possible side effects include primarily gastrointestinal symptoms, [ 2 ]  such as  diarrhea ,  abdominal distention , infrequent bowel movements,  constipation ,  abdominal pain , and  flatulence . [ 3 ]  It is contraindicated in  pregnancy ,  chronic malabsorption syndromes , and  cholestasis . [ 1 ]  The  US Food and Drug Administration  approved it in 2019 as a medical device. Gelesis100 was developed by the company  Gelesis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8532", "text": "The US Food and Drug Administration approved the use of Gelesis100 in April 2019 as a  medical device . [ 4 ]  Gelesis100 is the first treatment of its kind for overweight and obesity. [ 2 ]  In 2022, the American Gastroenterology Association published a guideline for the management of obesity, which recommended the use of Gelesis100 be limited to clinical trials due to limited evidence. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8533", "text": "Gelesis100 is used to treat obesity and overweight as an  anti-obesity medication . [ 1 ]  Gelesis100 is taken as a pill before meals with water. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8534", "text": "Gelesis100 has been criticized for its small impact on weight loss relative to side effects. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8535", "text": "Gelesis100 is an oral superabsorbent hydrogel, which is produced from  carboxymethylcellulose  and  citric acid . [ 1 ] [ 9 ]  The cross-linked product forms a hydrophilic matrix, which absorbs water. [ 1 ]  Taken in capsule form by mouth, [ 10 ]  as Gelesis100 absorbs water, it expands in the stomach and small intestine. [ 3 ] [ 6 ]  After absorbing water, a semisolid gel structure forms, which may promote satiety and result in weight loss [ 1 ]  via reduced caloric intake. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8536", "text": "Gelesis100 is contraindicated in pregnancy, chronic malabsorption syndromes, and cholestasis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8537", "text": "Side effects consist of minor gastrointestinal symptoms, [ 2 ]  including diarrhea, abdominal distention, infrequent bowel movements, constipation, abdominal pain, and flatulence. [ 3 ]  Gelesis100 is not associated with any severe adverse events. [ 11 ]  However, long-term safety data beyond 24 weeks is not available. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8538", "text": "Younan Nowzaradan  ( Persian :  \u06cc\u0648\u0646\u0627\u0646 \u0646\u0648\u0632\u0631\u0627\u062f\u0627\u0646 ; born October 11, 1944), [ 1 ]  also known as  Dr. Now , is an Iranian-born American doctor of  Assyrian  heritage, TV personality, and author. He specializes in  vascular surgery  and  bariatric surgery . He is known for helping  morbidly obese  people lose weight on  My 600-lb Life  (2012\u2013present). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8539", "text": "Nowzaradan was born and raised in  Tehran , Iran, and is of Assyrian heritage. In 1970, he graduated from the  University of Tehran  with a  Doctor of Medicine  degree. [ 4 ]  He then moved to the  United States . He participated in the Medical Orientation Program at  Saint Louis University  in 1971 and completed a Rotating Surgical Internship at St. John Hospital (operated by  St. John Providence Health System ) in  Detroit ,  Michigan . [ 4 ]  Nowzaradan is a fellow of the  American College of Surgeons ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8540", "text": "Nowzaradan is currently affiliated with Houston Obesity Surgery in  Houston, TX , and practices at several local hospitals. [ 4 ]   He is  the author of several scholarly publications on  obesity  and  laparoscopy . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8541", "text": "He has been on  My 600-lb Life  since 2012. [ 6 ]  He has also appeared on installments of  Body Shock , including the episodes \"Half Ton Dad\", \"Half Ton Teen\", and \"Half Ton Mum\". [ 6 ]  He also published two books titled  Last Chance to Live  (2017) and  The Scale Does Not Lie, People Do  (2019). [ 7 ]  Dr. Now made several appearances at Texas theme parks such as Six Flags  AstroWorld  to promote health awareness in the early 2000s, reaching out to youth and encouraging them to make good dietary choices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8542", "text": "He was married to Delores McRedmond for 31 years; they divorced in 2004. The couple had three children together. [ 8 ]  His son, Jonathan Nowzaradan (b. 1978), works as a director and producer for  My 600-lb Life . [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8543", "text": "Obesity  is a medical condition, sometimes considered a  disease , [ 8 ] [ 9 ] [ 10 ]  in which excess  body fat  has accumulated to such an extent that it can potentially have negative effects on  health . People are classified as obese when their  body mass index  (BMI)\u2014a person's weight divided by the square of the person's height\u2014is over  30\u00a0 kg / m 2 ; the range  25\u201330\u00a0 kg / m 2  is defined as  overweight . [ 1 ]  Some  East Asian  countries use lower values to calculate obesity. [ 11 ]  Obesity is a major cause of disability and is  correlated with various diseases and conditions , particularly  cardiovascular diseases ,  type 2 diabetes ,  obstructive sleep apnea , certain types of  cancer , and  osteoarthritis . [ 2 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8544", "text": "Obesity has individual, socioeconomic, and environmental causes. Some known causes are  diet , physical activity,  automation ,  urbanization ,  genetic susceptibility ,  medications ,  mental disorders ,  economic policies ,  endocrine disorders , and exposure to  endocrine-disrupting chemicals . [ 1 ] [ 4 ] [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8545", "text": "While a many people living with obesity attempt to lose weight and are often successful, maintaining weight loss long-term is rare. [ 16 ]  Obesity prevention requires a complex approach, including interventions at medical, societal, community, family, and individual levels. [ 1 ] [ 13 ]  Changes to  diet  as well as  exercising  are the main treatments recommended by health professionals. [ 2 ]  Diet quality can be improved by reducing the consumption of energy-dense foods, such as those high in fat or sugars, and by increasing the intake of  dietary fiber , although the  World Health Organization  stresses that these improvements are a societal responsibility and that these dietary choices should be made the most available, affordable, and accessible options. [ 1 ]   Medications  can be used, along with a suitable diet, to reduce appetite or decrease fat absorption. [ 5 ]  If diet, exercise, and medication are not effective, a  gastric balloon  or  surgery  may be performed to reduce stomach volume or length of the intestines, leading to feeling full earlier, or a reduced ability to absorb nutrients from food. Many do not realize that metabolic surgery is not only about reducing intake, it has also been shown to alter gut hormones for a period of time.  [ 6 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8546", "text": "Obesity is a leading  preventable cause of death  worldwide, with increasing rates in adults and  children . [ 18 ]  In 2022, over 1 billion people lived with obesity worldwide (879 million adults and 159 million children), representing more than a double of adult cases (and four times higher than cases among children) registered in 1990. [ 7 ] [ 19 ]  Obesity is more common in women than in men. [ 1 ]  Today, obesity is  stigmatized  in most of the world. Conversely, some cultures, past and present, have a favorable view of obesity, seeing it as a symbol of wealth and fertility. [ 2 ] [ 20 ]  The  World Health Organization , the US, Canada, Japan, Portugal, Germany, the  European Parliament  and medical societies, e.g. the  American Medical Association , classify obesity as a disease. Others, such as the  UK , do not. [ 21 ] [ 22 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8547", "text": "Obesity is typically defined as a substantial accumulation of  body fat  that could impact health. [ 26 ]  Medical organizations tend to classify people living with obesity as based on  body mass index  (BMI) \u2013 a ratio of a person's weight in  kilograms  to the  square  of their height in  meters . For adults, the  World Health Organization  (WHO) defines \" overweight \" as a BMI 25 or higher, and \"obesity\" as a BMI 30 or higher. [ 26 ]  The U.S.  Centers for Disease Control and Prevention  (CDC) further subdivides obesity based on BMI, with a BMI 30 to 35 called class 1 obesity; 35 to 40, class 2 obesity; and 40+, class 3 obesity. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8548", "text": "For children, obesity measures take age into consideration along with height and weight. For children aged 5\u201319, the WHO defines obesity as a BMI two  standard deviations  above the  median  for their age (a BMI around 18 for a five-year old; around 30 for a 19-year old). [ 26 ] [ 28 ]  For children under five, the WHO defines obesity as a weight three standard deviations above the median for their height. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8549", "text": "Some modifications to the WHO definitions have been made by particular organizations. [ 29 ]  The surgical literature breaks down class II and III or only class III obesity into further categories whose exact values are still disputed. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8550", "text": "As Asian populations develop negative health consequences at a lower BMI than  Caucasians , some nations have redefined obesity; Japan has defined obesity as any BMI greater than 25\u00a0kg/m 2 [ 11 ]  while China uses a BMI of greater than 28\u00a0kg/m 2 . [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8551", "text": "The preferred obesity metric in scholarly circles is the  body fat percentage  (BF%) \u2013 the ratio of the total weight of person's fat to his or her body weight, and BMI is viewed merely as a way to approximate BF%. [ 31 ]  According to  American Society of Bariatric Physicians , levels in excess of 32% for women and 25% for men are generally considered to indicate obesity. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8552", "text": "BMI is now viewed as outdated in numerous countries. It ignores variations between individuals in amounts of lean body mass, particularly  muscle  mass. Individuals involved in heavy physical labor or sports may have high BMI values despite having little fat. For example, more than half of all  NFL  players are classified as \"obese\" (BMI \u2265 30), and 1 in 4 are classified as \"extremely obese\" (BMI \u2265 35), according to the BMI metric. [ 33 ]  However, their mean  body fat percentage , 14%, is well within what is considered a healthy range. [ 34 ]  Similarly,  Sumo  wrestlers may be categorized by BMI as \"severely obese\" or \"very severely obese\" but many Sumo wrestlers are not categorized as obese when body fat percentage is used instead (having <25% body fat). [ 35 ]  Some Sumo wrestlers were found to have no more body fat than a non-Sumo comparison group, with high BMI values resulting from their high amounts of lean body mass. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8553", "text": "Canada utilises BMI sparingly within their method of defining levels of obesity through use of the Edmonton Scale (for adult obesity). This scale also introduces factors such as Quality of Life, Mental Health & Mobility amongst others. In recent years, Canada chose to allow both Chilli & Ireland to adapt their obesity guidelines to suit both countries' health systems. In Ireland, obesity is now defined as \"a Complex, Chronic & Relapsing Disease\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8554", "text": "Obesity increases a person's risk of developing various metabolic diseases,  cardiovascular disease ,  osteoarthritis ,  Alzheimer disease ,  depression , and certain types of cancer. [ 36 ]  Depending on the degree of obesity and the presence of comorbid disorders, obesity is associated with an estimated 2\u201320 year shorter life expectancy. [ 37 ] [ 36 ]  High BMI is a marker of risk for, but not a direct cause of, diseases caused by diet and physical activity. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8555", "text": "Obesity is one of the leading  preventable causes of death  worldwide. [ 38 ] [ 39 ] [ 40 ]  The mortality risk is lowest at a BMI of 20\u201325\u00a0kg/m 2 [ 41 ] [ 37 ] [ 42 ]  in non-smokers and at 24\u201327\u00a0kg/m 2  in current smokers, with risk increasing along with changes in either direction. [ 43 ] [ 44 ]  This appears to apply in at least four continents. [ 42 ]  Other research suggests that the association of BMI and waist circumference with mortality is U- or J-shaped, while the association between  waist-to-hip ratio  and  waist-to-height ratio  with mortality is more positive. [ 45 ]  In Asians the risk of negative health effects begins to increase between 22 and 25\u00a0kg/m 2 . [ 46 ]  In 2021, the  World Health Organization  estimated that obesity caused at least 2.8 million deaths annually. [ 47 ]  On average, obesity reduces life expectancy by six to seven\u00a0years, [ 2 ] [ 48 ]  a BMI of 30\u201335\u00a0kg/m 2  reduces life expectancy by two to four years, [ 37 ]  while severe obesity (BMI\u00a0\u2265\u00a040\u00a0kg/m 2 ) reduces life expectancy by ten years. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8556", "text": "Obesity increases the risk of many physical and mental conditions. These comorbidities are most commonly shown in  metabolic syndrome , [ 2 ]  a combination of medical disorders which includes:  diabetes mellitus type 2 ,  high blood pressure ,  high blood cholesterol , and  high triglyceride levels . [ 49 ]  A study from the  RAK Hospital  found that obese people are at a greater risk of developing  long COVID . [ 50 ]  The CDC has found that obesity is the single strongest risk factor for severe COVID-19 illness. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8557", "text": "Complications are either directly caused by obesity or indirectly related through mechanisms sharing a common cause such as a poor diet or a  sedentary lifestyle . The strength of the link between obesity and specific conditions varies. One of the strongest is the link with  type 2 diabetes . Excess body fat underlies 64% of cases of diabetes in men and 77% of cases in women. [ 52 ] :\u200a9"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8558", "text": "Health consequences fall into two broad categories: those attributable to the effects of increased fat mass (such as  osteoarthritis ,  obstructive sleep apnea , social stigmatization) and those due to the increased number of  fat cells  ( diabetes ,  cancer ,  cardiovascular disease ,  non-alcoholic fatty liver disease ). [ 2 ] [ 53 ]  Increases in body fat alter the body's response to insulin, potentially leading to  insulin resistance . Increased fat also creates a  proinflammatory state , [ 54 ] [ 55 ]  and a  prothrombotic  state. [ 53 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8559", "text": "Newer research has focused on methods of identifying healthier obese people by clinicians, and not treating obese people as a monolithic group. [ 81 ]  Obese people who do not experience medical complications from their obesity are sometimes called  (metabolically) healthy obese , but the extent to which this group exists (especially among older people) is in dispute. [ 82 ]  The number of people considered  metabolically healthy  depends on the definition used, and there is no universally accepted definition. [ 83 ]  There are numerous obese people who have relatively few metabolic abnormalities, and a minority of obese people have no medical complications. [ 83 ]  The guidelines of the  American Association of Clinical Endocrinologists  call for physicians to use  risk stratification  with obese patients when considering how to assess their risk of developing type 2 diabetes. [ 84 ] :\u200a59\u201360"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8560", "text": "In 2014, the BioSHaRE\u2013 EU  Healthy Obese Project (sponsored by Maelstrom Research, a team under the  Research Institute of the McGill University Health Centre ) came up with two definitions for  healthy obesity , one more strict and one less so: [ 82 ] [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8561", "text": "To come up with these criteria, BioSHaRE controlled for age and tobacco use, researching how both may effect the metabolic syndrome associated with obesity, but not found to exist in the metabolically healthy obese. [ 86 ]  Other definitions of metabolically healthy obesity exist, including ones based on waist circumference rather than BMI, which is unreliable in certain individuals. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8562", "text": "Another identification metric for health in obese people is  calf   strength , which is positively correlated with  physical fitness  in obese people. [ 87 ]   Body composition  in general is hypothesized to help explain the existence of metabolically healthy obesity\u2014the metabolically healthy obese are often found to have low amounts of  ectopic  fat (fat stored in tissues other than adipose tissue) despite having overall fat mass equivalent in weight to obese people with  metabolic syndrome . [ 88 ] :\u200a1282"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8563", "text": "Although the negative health consequences of obesity in the general population are well supported by the available research evidence, health outcomes in certain subgroups seem to be improved at an increased BMI, a phenomenon known as the obesity survival paradox. [ 89 ]  The paradox was first described in 1999 in overweight and obese people undergoing  hemodialysis [ 89 ]  and has subsequently been found in those with  heart failure  and  peripheral artery disease  (PAD). [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8564", "text": "In people with heart failure, those with a BMI between 30.0 and 34.9 had lower mortality than those with a normal weight. This has been attributed to the fact that people often lose weight as they become progressively more ill. [ 91 ]  Similar findings have been made in other types of heart disease. People with class I obesity and heart disease do not have greater rates of further heart problems than people of normal weight who also have heart disease. In people with greater degrees of obesity, however, the risk of further cardiovascular events is increased. [ 92 ] [ 93 ]  Even after  cardiac bypass surgery , no increase in mortality is seen in the overweight and obese. [ 94 ]  One study found that the improved survival could be explained by the more aggressive treatment obese people receive after a cardiac event. [ 95 ]  Another study found that if one takes into account  chronic obstructive pulmonary disease  (COPD) in those with PAD, the benefit of obesity no longer exists. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8565", "text": "The \" a calorie is a calorie \" model of obesity posits a combination of excessive  food energy  intake and a lack of  physical activity  as the cause of most cases of obesity. [ 96 ]  A limited number of cases are due primarily to genetics, medical reasons, or psychiatric illness. [ 15 ]  The  satiety value  shows that the feeling of  satiety  per  calorie  varies between food types. [ 97 ]  Increasing rates of obesity at a societal level are felt to be due to an easily accessible and palatable  diet , [ 98 ]  increased  reliance on cars , and mechanized manufacturing. [ 99 ] [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8566", "text": "Some other factors have been proposed as causes towards rising rates of obesity worldwide, including  insufficient sleep ,  endocrine disruptors , increased usage of certain medications (such as  atypical antipsychotics ), [ 101 ]  increases in ambient temperature, decreased rates of  smoking , [ 102 ]  demographic changes, increasing maternal age of first-time mothers, changes to  epigenetic  dysregulation from the environment, increased phenotypic variance via  assortative mating , social pressure to  diet , [ 103 ]  among others. According to one study, factors like these may play as big of a role as excessive food energy intake and a lack of physical activity; [ 104 ]  however, the relative magnitudes of the effects of any proposed cause of obesity is varied and uncertain, as there is a general need for randomized controlled trials on humans before definitive statement can be made. [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8567", "text": "According to the  Endocrine Society , there is \"growing evidence suggesting that obesity is a disorder of the  energy homeostasis  system, rather than simply arising from the passive accumulation of excess weight\". [ 106 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8568", "text": "Excess appetite for palatable, high-calorie food (especially fat, sugar, and certain animal proteins) is seen as the primary factor driving obesity worldwide, likely because of imbalances in  neurotransmitters  affecting the drive to eat. [ 108 ]   Dietary energy supply  per capita varies markedly between different regions and countries. It has also changed significantly over time. [ 107 ]  From the early 1970s to the late 1990s the average  food energy  available per person per day (the amount of food bought) increased in all parts of the world except Eastern Europe. The United States had the highest availability with 3,654 calories (15,290\u00a0kJ) per person in 1996. [ 107 ]  This increased further in 2003 to 3,754 calories (15,710\u00a0kJ). [ 107 ]  During the late 1990s, Europeans had 3,394 calories (14,200\u00a0kJ) per person, in the developing areas of Asia there were 2,648 calories (11,080\u00a0kJ) per person, and in sub-Saharan Africa people had 2,176 calories (9,100\u00a0kJ) per person. [ 107 ] [ 109 ]  Total food energy consumption has been found to be related to obesity. [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8569", "text": "The widespread availability of  dietary guidelines [ 111 ]  has done little to address the problems of overeating and poor dietary choice. [ 112 ]  From 1971 to 2000, obesity rates in the United States increased from 14.5% to 30.9%. [ 113 ]  During the same period, an increase occurred in the average amount of food energy consumed. For women, the average increase was 335 calories (1,400\u00a0kJ) per day (1,542 calories (6,450\u00a0kJ) in 1971 and 1,877 calories (7,850\u00a0kJ) in 2004), while for men the average increase was 168 calories (700\u00a0kJ) per day (2,450 calories (10,300\u00a0kJ) in 1971 and 2,618 calories (10,950\u00a0kJ) in 2004). Most of this extra food energy came from an increase in carbohydrate consumption rather than fat consumption. [ 114 ]  The primary sources of these extra carbohydrates are sweetened beverages, which now account for almost 25 percent of daily food energy in young adults in America, [ 115 ]  and potato chips. [ 116 ]  Consumption of  sweetened beverages  such as soft drinks, fruit drinks, and iced tea is believed to be contributing to the rising rates of obesity [ 117 ] [ 118 ]  and to an increased risk of  metabolic syndrome  and  type 2 diabetes . [ 119 ]   Vitamin D deficiency  is related to diseases associated with obesity. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8570", "text": "As societies become increasingly reliant on  energy-dense , big-portions, and  fast-food  meals, the association between fast-food consumption and obesity becomes more concerning. [ 121 ]  In the United States, consumption of fast-food meals tripled and food energy intake from these meals quadrupled between 1977 and 1995. [ 122 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8571", "text": "Agricultural policy  and  techniques  in the United States and Europe have led to lower  food prices . In the United States, subsidization of corn, soy, wheat, and rice through the  U.S. farm bill  has made the main sources of processed food cheap compared to fruits and vegetables. [ 123 ]   Calorie count laws  and  nutrition facts labels  attempt to steer people toward making healthier food choices, including awareness of how much food energy is being consumed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8572", "text": "Obese people consistently under-report their food consumption as compared to people of normal weight. [ 124 ]  This is supported both by tests of people carried out in a  calorimeter  room [ 125 ]  and by direct observation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8573", "text": "A sedentary lifestyle may play a significant role in obesity. [ 52 ] :\u200a10\u200a  Worldwide there has been a large shift towards less physically demanding work, [ 126 ] [ 127 ] [ 128 ]  and currently at least 30% of the world's population gets insufficient exercise. [ 127 ]  This is primarily due to increasing use of mechanized transportation and a greater prevalence of labor-saving technology in the home. [ 126 ] [ 127 ] [ 128 ]  In children, there appear to be declines in levels of physical activity (with particularly strong declines in the amount of walking and physical education), likely due to safety concerns, changes in social interaction (such as fewer relationships with neighborhood children), and inadequate urban design (such as too few public spaces for safe physical activity). [ 129 ]  World trends in active leisure time  physical activity  are less clear. The World Health Organization indicates people worldwide are taking up less active recreational pursuits, while research from Finland [ 130 ]  found an increase and research from the United States found leisure-time physical activity has not changed significantly. [ 131 ]  Physical activity in children may not be a significant contributor. [ 132 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8574", "text": "In both children and adults, there is an association between television viewing time and the risk of obesity. [ 133 ] [ 134 ] [ 135 ]  Increased media exposure increases the rate of childhood obesity, with rates increasing proportionally to time spent watching television. [ 136 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8575", "text": "Like many other medical conditions, obesity is the result of an interplay between genetic and environmental factors. [ 138 ]   Polymorphisms  in various  genes  controlling  appetite  and  metabolism  predispose to obesity when sufficient food energy is present. As of 2006, more than 41 of these sites on the human genome have been linked to the development of obesity when a favorable environment is present. [ 139 ]  People with two copies of the  FTO gene  (fat mass and obesity associated gene) have been found on average to weigh 3\u20134\u00a0kg more and have a 1.67-fold greater risk of obesity compared with those without the risk  allele . [ 140 ]  The differences in BMI between people that are  due to genetics  varies depending on the population examined from 6% to 85%. [ 141 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8576", "text": "Obesity is a major feature in several syndromes, such as  Prader\u2013Willi syndrome ,  Bardet\u2013Biedl syndrome ,  Cohen syndrome , and  MOMO syndrome . (The term \"non-syndromic obesity\" is sometimes used to exclude these conditions.) [ 142 ]  In people with early-onset severe obesity (defined by an onset before 10\u00a0years of age and body mass index over three  standard deviations  above normal), 7% harbor a single point DNA mutation. [ 143 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8577", "text": "Studies that have focused on inheritance patterns rather than on specific genes have found that 80% of the offspring of two  obese parents  were also obese, in contrast to less than 10% of the offspring of two parents who were of normal weight. [ 144 ]  Different people exposed to the same environment have different risks of obesity due to their underlying genetics. [ 145 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8578", "text": "The  thrifty gene hypothesis  postulates that, due to dietary scarcity during human evolution, people are prone to obesity. Their ability to take advantage of rare periods of abundance by storing energy as fat would be advantageous during times of varying food availability, and individuals with greater adipose reserves would be more likely to survive  famine . This tendency to store fat, however, would be maladaptive in societies with stable food supplies. [ medical citation needed ]  This theory has received various criticisms, and other evolutionarily-based theories such as the  drifty gene hypothesis  and the  thrifty phenotype hypothesis  have also been proposed. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8579", "text": "Certain physical and mental illnesses and the pharmaceutical substances used to treat them can increase risk of obesity. Medical illnesses that increase obesity risk include several rare genetic syndromes (listed above) as well as some congenital or acquired conditions:  hypothyroidism ,  Cushing's syndrome ,  growth hormone deficiency , [ 146 ]  and some  eating disorders  such as  binge eating disorder  and  night eating syndrome . [ 2 ]  However, obesity is not regarded as a psychiatric disorder, and therefore is not listed in the  DSM-IVR  as a psychiatric illness. [ 147 ]  The risk of overweight and obesity is higher in patients with psychiatric disorders than in persons without psychiatric disorders. [ 148 ]  Obesity and  depression  influence each other mutually, with obesity increasing the risk of clinical depression, and also depression leading to a higher chance of developing obesity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8580", "text": "Certain medications may cause weight gain or changes in  body composition ; these include  insulin ,  sulfonylureas ,  thiazolidinediones ,  atypical antipsychotics ,  antidepressants ,  steroids , certain  anticonvulsants  ( phenytoin  and  valproate ),  pizotifen , and some forms of  hormonal contraception . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8581", "text": "While genetic influences are important to understanding obesity, they cannot completely explain the dramatic increase seen within specific countries or globally. [ 149 ] [ better\u00a0source\u00a0needed ]  Though it is accepted that energy consumption in excess of energy expenditure leads to increases in body weight on an individual basis, the cause of the shifts in these two factors on the societal scale is much debated. There are a number of theories as to the cause but most believe it is a combination of various factors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8582", "text": "The correlation between  social class  and BMI varies globally. Research in 1989 found that in developed countries women of a high social class were less likely to be obese. No significant differences were seen among men of different social classes. In the developing world, women, men, and children from high social classes had greater rates of obesity. [ better\u00a0source\u00a0needed ] [ 150 ]  In 2007 repeating the same research found the same relationships, but they were weaker. The decrease in strength of correlation was felt to be due to the effects of  globalization . [ 151 ]  Among developed countries, levels of adult obesity, and percentage of teenage children who are overweight, are correlated with  income inequality . A similar relationship is seen among US states: more adults, even in higher social classes, are obese in more unequal states. [ 152 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8583", "text": "Many explanations have been put forth for associations between BMI and social class. It is thought that in developed countries, the wealthy are able to afford more nutritious food, they are under greater social pressure to remain slim, and have more opportunities along with greater expectations for  physical fitness . In  undeveloped countries  the ability to afford food, high energy expenditure with physical labor, and cultural values favoring a larger body size are believed to contribute to the observed patterns. [ 151 ]  Attitudes toward body weight held by people in one's life may also play a role in obesity. A correlation in BMI changes over time has been found among friends, siblings, and spouses. [ 153 ]  Stress and perceived low social status appear to increase risk of obesity. [ 152 ] [ 154 ] [ 155 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8584", "text": "Smoking has a significant effect on an individual's weight. Those who quit smoking gain an average of 4.4\u00a0kilograms (9.7\u00a0lb) for men and 5.0\u00a0kilograms (11.0\u00a0lb) for women over ten years. [ 156 ]  However, changing rates of smoking have had little effect on the overall rates of obesity. [ 157 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8585", "text": "In the United States, the number of children a person has is related to their risk of obesity. A woman's risk increases by 7% per child, while a man's risk increases by 4% per child. [ 158 ]  This could be partly explained by the fact that having dependent children decreases physical activity in Western parents. [ 159 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8586", "text": "In the developing world urbanization is playing a role in increasing rate of obesity. In China overall rates of obesity are below 5%; however, in some cities rates of obesity are greater than 20%. [ 160 ]  In part, this may be because of urban design issues (such as inadequate public spaces for physical activity). [ 129 ]  Time spent in motor vehicles, as opposed to  active transportation  options such as cycling or walking, is correlated with increased risk of obesity. [ 161 ] [ 162 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8587", "text": "Malnutrition  in early life is believed to play a role in the rising rates of obesity in the  developing world . [ 163 ]  Endocrine changes that occur during periods of malnutrition may promote the storage of fat once more food energy becomes available. [ 163 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8588", "text": "The study of the effect of infectious agents on metabolism is still in its early stages.  Gut flora  has been shown to differ between lean and obese people. There is an indication that gut flora can affect the metabolic potential. This apparent alteration is believed to confer a greater capacity to harvest energy contributing to obesity. Whether these differences are the direct cause or the result of obesity has yet to be determined unequivocally. [ 164 ]  The use of  antibiotics  among children has also been associated with obesity later in life. [ 165 ] [ 166 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8589", "text": "An association between  viruses  and obesity has been found in humans and several different animal species. The amount that these associations may have contributed to the rising rate of obesity is yet to be determined. [ 167 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8590", "text": "Not getting enough sleep  is also associated with obesity . [ 168 ] [ 169 ]  Whether one causes the other is unclear. [ 168 ]  Even if short sleep does increase weight gain, it is unclear if this is to a meaningful degree or if increasing sleep would be of benefit. [ 170 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8591", "text": "Some have proposed that chemical compounds called \" obesogens \" may play a role in obesity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8592", "text": "Certain aspects of  personality  are associated with being obese. [ 171 ]   Loneliness , [ 172 ]   neuroticism ,  impulsivity , and sensitivity to reward are more common in people who are obese while  conscientiousness  and  self-control  are less common in people who are obese. [ 171 ] [ 173 ]  Because most of the studies on this topic are questionnaire-based, it is possible that these findings overestimate the relationships between personality and obesity: people who are obese might be aware of the  social stigma of obesity  and their questionnaire responses might be biased accordingly. [ 171 ]  Similarly, the personalities of people who are obese as children might be influenced by obesity stigma, rather than these personality factors acting as risk factors for obesity. [ 171 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8593", "text": "In relation to globalization, it is known that trade liberalization is linked to obesity; research, based on data from 175 countries during 1975\u20132016, showed that obesity prevalence was positively correlated with trade openness, and the correlation was stronger in developing countries. [ 174 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8594", "text": "Two distinct but related processes are considered to be involved in the development of obesity: sustained positive energy balance (energy intake exceeding energy expenditure) and the resetting of the body weight \"set point\" at an increased value. [ 106 ]  The second process explains why finding effective obesity treatments has been difficult. While the underlying biology of this process still remains uncertain, research is beginning to clarify the mechanisms. [ 106 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8595", "text": "At a biological level, there are many possible  pathophysiological  mechanisms involved in the development and maintenance of obesity. [ 175 ]  This field of research had been almost unapproached until the  leptin  gene was discovered in 1994 by J. M. Friedman's laboratory. [ 176 ]  While leptin and  ghrelin  are produced peripherally, they control appetite through their actions on the  central nervous system . In particular, they and other appetite-related hormones act on the  hypothalamus , a region of the brain central to the regulation of food intake and energy expenditure. There are several circuits within the hypothalamus that contribute to its role in integrating appetite, the  melanocortin  pathway being the most well understood. [ 175 ]  The circuit begins with an area of the hypothalamus, the  arcuate nucleus , that has outputs to the  lateral hypothalamus  (LH) and  ventromedial hypothalamus  (VMH), the brain's feeding and satiety centers, respectively. [ 177 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8596", "text": "The arcuate nucleus contains two distinct groups of  neurons . [ 175 ]  The first group coexpresses  neuropeptide Y  (NPY) and  agouti-related peptide  (AgRP) and has stimulatory inputs to the LH and inhibitory inputs to the VMH. The second group coexpresses  pro-opiomelanocortin  (POMC) and  cocaine- and amphetamine-regulated transcript  (CART) and has stimulatory inputs to the VMH and inhibitory inputs to the LH. Consequently, NPY/AgRP neurons stimulate feeding and inhibit satiety, while POMC/CART neurons stimulate satiety and inhibit feeding. Both groups of arcuate nucleus neurons are regulated in part by leptin. Leptin inhibits the NPY/AgRP group while stimulating the POMC/CART group. Thus a deficiency in leptin signaling, either via leptin deficiency or leptin resistance, leads to overfeeding and may account for some genetic and acquired forms of obesity. [ 175 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8597", "text": "The main treatment for obesity consists of  weight loss  via lifestyle interventions, including prescribed  diets  and  physical exercise . [ 22 ] [ 96 ] [ 178 ] [ 179 ]  Although it is unclear what diets might support long-term weight loss, and although the effectiveness of  low-calorie diets  is debated, [ 180 ]  lifestyle changes that reduce calorie consumption or increase physical exercise over the long term also tend to produce some sustained weight loss, despite slow weight regain over time. [ 22 ] [ 180 ] [ 181 ] [ 182 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8598", "text": "Although 87% of participants in the  National Weight Control Registry  were able to maintain 10% body weight loss for 10 years, [ 183 ] [ clarification needed ]  the most appropriate dietary approach for long term weight loss maintenance is still unknown. [ 184 ]  In the US, intensive behavioral interventions combining both dietary changes and exercise are recommended. [ 22 ] [ 178 ] [ 185 ]   Intermittent fasting  has no additional benefit of weight loss compared to continuous energy restriction. [ 184 ]  Adherence is a more important factor in weight loss success than whatever kind of diet an individual undertakes. [ 184 ] [ 186 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8599", "text": "Several hypo-caloric diets are effective. [ 22 ]  In the short-term  low carbohydrate diets  appear better than  low fat diets  for weight loss. [ 187 ]  In the long term, however, all types of low-carbohydrate and low-fat diets appear equally beneficial. [ 187 ] [ 188 ]  Heart disease and diabetes risks associated with different diets appear to be similar. [ 189 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8600", "text": "Promotion of the Mediterranean diets among the obese may lower the risk of heart disease. [ 187 ]  Decreased intake of  sweet drinks  is also related to weight-loss. [ 187 ]  Success rates of long-term weight loss maintenance with lifestyle changes are low, ranging from 2\u201320%. [ 190 ]  Dietary and lifestyle changes are effective in limiting excessive weight gain in  pregnancy  and improve outcomes for both the mother and the child. [ 191 ]  Intensive behavioral counseling is recommended in those who are both obese and have other risk factors for heart disease. [ 192 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8601", "text": "Obesity is a complex public health and policy problem because of its prevalence, costs, and health effects. [ 193 ]  As such, managing it requires changes in the wider societal context and effort by communities, local authorities, and governments. [ 185 ]  Public health efforts seek to understand and correct the  environmental factors  responsible for the increasing prevalence of obesity in the population. Solutions look at changing the factors that cause excess food energy consumption and inhibit physical activity. Efforts include federally reimbursed meal programs in schools, limiting direct  junk   food marketing  to children, [ 194 ]  and decreasing access to sugar-sweetened beverages in schools. [ 195 ]  The World Health Organization recommends the taxing of sugary drinks. [ 196 ]  When constructing urban environments, efforts have been made to increase access to parks and to develop pedestrian routes. [ 197 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8602", "text": "Mass media  campaigns seem to have limited effectiveness in changing behaviors that influence obesity, but may increase knowledge and awareness regarding physical activity and diet, which might lead to changes in the long term. Campaigns might also be able to reduce the amount of time spent  sitting or lying down  and positively affect the intention to be active physically. [ 198 ] [ 199 ]   Nutritional labelling  with energy information on menus might be able to help reducing energy intake while dining in restaurants. [ 200 ]  Some call for policy against  ultra-processed foods . [ 201 ] [ 202 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8603", "text": "Since the introduction of medicines for the management of obesity in the 1930s, many compounds have been tried. Most of them reduce body weight by small amounts, and several of them are no longer marketed for obesity because of their side effects. Out of 25 anti-obesity medications withdrawn from the market between 1964 and 2009, 23 acted by altering the functions of chemical  neurotransmitters  in the brain. The most common side effects of these drugs that led to withdrawals were mental disturbances, cardiac side effects, and  drug abuse  or  drug dependence . Deaths were reportedly associated with seven products. [ 203 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8604", "text": "Five medications beneficial for long-term use are:  orlistat ,  lorcaserin ,  liraglutide ,  phentermine\u2013topiramate , and  naltrexone\u2013bupropion . [ 204 ]  They result in weight loss after one year ranged from 3.0 to 6.7\u00a0kg (6.6-14.8\u00a0lbs) over placebo. [ 204 ]  Orlistat, liraglutide, and naltrexone\u2013bupropion are available in both the United States and Europe, phentermine\u2013topiramate is available only in the United States. [ 205 ]  European regulatory authorities rejected lorcaserin and phentermine-topiramate, in part because of associations of heart valve problems with lorcaserin and more general heart and blood vessel problems with phentermine\u2013topiramate. [ 205 ]  Lorcaserin was available in the United States and then removed from the market in 2020 due to its association with cancer. [ 206 ]  Orlistat use is associated with high rates of gastrointestinal side effects [ 207 ]  and concerns have been raised about negative effects on the kidneys. [ 208 ]  There is no information on how these drugs affect longer-term complications of obesity such as cardiovascular disease or death; [ 5 ]  however, liraglutide, when used for type 2 diabetes, does reduce cardiovascular events. [ 209 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8605", "text": "In 2019 a  systematic review  compared the effects on weight of various doses of  fluoxetine  (60\u00a0mg/d, 40\u00a0mg/d, 20\u00a0mg/d, 10\u00a0mg/d) in obese adults. [ 210 ]  When compared to placebo, all dosages of fluoxetine appeared to contribute to weight loss but lead to increased risk of experiencing side effects such as dizziness, drowsiness, fatigue, insomnia and nausea during period of treatment. However, these conclusions were from low certainty evidence. [ 210 ]  When comparing, in the same review, the effects of fluoxetine on weight of obese adults, to other  anti-obesity agents ,  omega-3  gel and not receiving a treatment, the authors could not reach conclusive results due to poor quality of evidence. [ 210 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8606", "text": "Among antipsychotic drugs for treating schizophrenia  clozapine  is the most effective, but it also has the highest risk of causing the  metabolic syndrome , of which obesity is the main feature. For people who gain weight because of clozapine, taking  metformin  may reportedly improve three of the five components of the metabolic syndrome: waist circumference, fasting glucose, and fasting triglycerides. [ 211 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8607", "text": "The most effective treatment for obesity is  bariatric surgery . [ 6 ] [ 22 ]  The types of procedures include  laparoscopic adjustable gastric banding ,  Roux-en-Y gastric bypass ,  vertical-sleeve gastrectomy , and  biliopancreatic diversion . [ 204 ]  Surgery for severe obesity is associated with long-term weight loss, improvement in obesity-related conditions, [ 212 ]  and decreased overall mortality; however, improved metabolic health results from the weight loss, not the surgery. [ 213 ]  One study found a weight loss of between 14% and 25% (depending on the type of procedure performed) at 10\u00a0years, and a 29% reduction in all cause mortality when compared to standard weight loss measures. [ 214 ]  Complications occur in about 17% of cases and reoperation is needed in 7% of cases. [ 212 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8608", "text": "In earlier historical periods obesity was rare and achievable only by a small elite, although already recognised as a problem for health. But as prosperity increased in the  Early Modern period , it affected increasingly larger groups of the population. [ 215 ]  Prior to the 1970s, obesity was a relatively rare condition even in the wealthiest of nations, and when it did exist it tended to occur among the wealthy. Then, a confluence of events started to change the human condition. The average BMI of populations in first-world countries started to increase, and consequently there was a rapid increase in the proportion of people overweight and obese. [ 216 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8609", "text": "In 1997, the WHO formally recognized obesity as a global epidemic. [ 115 ]  As of 2008, the WHO estimates that at least 500\u00a0million adults (greater than 10%) are obese, with higher rates among women than men. [ 217 ]  The global prevalence of obesity more than doubled between 1980 and 2014. In 2014, more than 600 million adults were obese, equal to about 13 percent of the world's adult population, [ 218 ]  with that figure growing to 16% by 2022, according to the World Health Organisation  [ 219 ]  The percentage of adults affected in the United States as of 2015\u20132016 is about 39.6% overall (37.9% of males and 41.1% of females). [ 220 ]  In 2000, the  World Health Organization  (WHO) stated that  overweight  and obesity were replacing more traditional  public health  concerns such as  undernutrition  and  infectious diseases  as one of the most significant cause of poor health. [ 221 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8610", "text": "The rate of obesity also increases with age at least up to 50 or 60\u00a0years old [ 52 ] :\u200a5\u200a  and severe obesity in the United States, Australia, and Canada is increasing faster than the overall rate of obesity. [ 30 ] [ 222 ] [ 223 ]  The  OECD  has projected an increase in obesity rates until at least 2030, especially in the United States, Mexico and England with rates reaching 47%, 39% and 35%, respectively. [ 224 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8611", "text": "Once considered a problem only of high-income countries, obesity rates are rising worldwide and affecting both the developed and developing world. [ 225 ]  These increases have been felt most dramatically in urban settings. [ 217 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8612", "text": "Sex- and gender-based differences also influence the prevalence of obesity. Globally there are more obese women than men, but the numbers differ depending on how obesity is measured. [ 226 ] [ 227 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8613", "text": "Obesity  is from the  Latin   obesitas , which means \"stout, fat, or plump\".  \u0112sus  is the past participle of  edere  (to eat), with  ob  (over) added to it. [ 228 ]   The Oxford English Dictionary  documents its first usage in 1611 by  Randle Cotgrave . [ 229 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8614", "text": "Ancient Greek medicine  recognizes obesity as a medical disorder and records that the Ancient Egyptians saw it in the same way. [ 215 ]   Hippocrates  wrote that \"Corpulence is not only a disease itself, but the harbinger of others\". [ 2 ]  The Indian surgeon  Sushruta  (6th century BCE) related obesity to diabetes and heart disorders. [ 231 ]  He recommended physical work to help cure it and its side effects. [ 231 ]  For most of human history, mankind struggled with food scarcity. [ 232 ]  Obesity has thus historically been viewed as a sign of wealth and prosperity. It was common among high officials in Ancient East Asian civilizations. [ 233 ]  In the 17th century, English medical author  Tobias Venner  is credited with being one of the first to refer to the term as a societal disease in a published English language book. [ 215 ] [ 234 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8615", "text": "With the onset of the  Industrial Revolution , it was realized that the military and economic might of nations were dependent on both the body size and strength of their soldiers and workers. [ 115 ]  Increasing the average body mass index from what is now considered underweight to what is now the normal range played a significant role in the development of industrialized societies. [ 115 ]  Height and weight thus both increased through the 19th\u00a0century in the developed world. During the 20th century, as populations reached their genetic potential for height, weight began increasing much more than height, resulting in obesity. [ 115 ]  In the 1950s, increasing wealth in the developed world decreased child mortality, but as body weight increased, heart and kidney disease became more common. [ 115 ] [ 235 ] \nDuring this time period, insurance companies realized the connection between weight and life expectancy and increased premiums for the obese. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8616", "text": "Many cultures throughout history have viewed obesity as the result of a character flaw. The  obesus  or fat character in  Ancient Greek comedy  was a glutton and figure of mockery. During Christian times, food was viewed as a gateway to the sins of  sloth  and  lust . [ 20 ]  In modern Western culture, excess weight is often regarded as unattractive, and obesity is commonly associated with various negative stereotypes. People of all ages can face social stigmatization and may be targeted by bullies or shunned by their peers. [ 236 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8617", "text": "Public perceptions in Western society regarding healthy body weight differ from those regarding the weight that is considered ideal \u2013 and both have changed since the beginning of the 20th century. The weight that is viewed as an ideal has become lower since the 1920s. This is illustrated by the fact that the average height of Miss America pageant winners increased by 2% from 1922 to 1999, while their average weight decreased by 12%. [ 237 ]  On the other hand, people's views concerning healthy weight have changed in the opposite direction. In Britain, the weight at which people considered themselves to be overweight was significantly higher in 2007 than in 1999. [ 238 ]  These changes are believed to be due to increasing rates of adiposity leading to increased acceptance of extra body fat as being normal. [ 238 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8618", "text": "Obesity is still seen as a sign of wealth and well-being in many parts of Africa. This has become particularly common since the  HIV  epidemic began. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8619", "text": "The first sculptural representations of the human body 20,000\u201335,000\u00a0years ago depict obese females. Some attribute the  Venus figurines  to the tendency to emphasize fertility while others feel they represent \"fatness\" in the people of the time. [ 20 ]  Corpulence is, however, absent in both Greek and Roman art, probably in keeping with their ideals regarding moderation. This continued through much of Christian European history, with only those of low socioeconomic status being depicted as obese. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8620", "text": "During the  Renaissance  some of the upper class began flaunting their large size, as can be seen in portraits of  Henry VIII of England  and  Alessandro dal Borro . [ 20 ]   Rubens  (1577\u20131640) regularly depicted heavyset women in his pictures, from which derives the term  Rubenesque . These women, however, still maintained the \"hourglass\" shape with its relationship to fertility. [ 239 ]  During the 19th\u00a0century, views on obesity changed in the Western world. After centuries of obesity being synonymous with wealth and social status, slimness began to be seen as the desirable standard. [ 20 ]  In his 1819 print,  The Belle Alliance, or the Female Reformers of Blackburn!!!,  artist  George Cruikshank  criticised the work of female reformers in  Blackburn  and used fatness as a means to portray them as unfeminine. [ 240 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8621", "text": "In addition to its health impacts, obesity leads to many problems, including disadvantages in employment [ 241 ] :\u200a29\u200a [ 242 ]  and increased business costs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8622", "text": "In 2005, the medical costs attributable to obesity in the US were an estimated $190.2\u00a0billion or 20.6% of all medical expenditures, [ 243 ] [ 244 ] [ 245 ]  while the cost of obesity in Canada was estimated at CA$2\u00a0billion in 1997 (2.4% of total health costs). [ 96 ]  The total annual direct cost of overweight and obesity in Australia in 2005 was A$21\u00a0billion. Overweight and obese Australians also received A$35.6\u00a0billion in government subsidies. [ 246 ]  The estimated range for annual expenditures on diet products is $40\u00a0billion to $100\u00a0billion in the US alone. [ 247 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8623", "text": "The Lancet  Commission on Obesity in 2019 called for a global treaty\u2014modelled on the  WHO Framework Convention on Tobacco Control \u2014committing countries to address obesity and undernutrition, explicitly excluding the food industry from policy development. They estimate the global cost of obesity $2\u00a0trillion a year, about or 2.8% of world GDP. [ 248 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8624", "text": "Obesity prevention programs have been found to reduce the cost of treating obesity-related disease. However, the longer people live, the more medical costs they incur. Researchers, therefore, conclude that reducing obesity may improve the public's health, but it is unlikely to reduce overall health spending. [ 249 ]  Sin taxes such as a  sugary drink tax  have been implemented in certain countries globally to curb dietary and consumer habits, and as an effort to offset the economic tolls."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8625", "text": "Obesity can lead to social stigmatization and disadvantages in employment. [ 241 ] :\u200a29\u200a  When compared to their ideal weight counterparts, workers with obesity, on average have higher rates of absenteeism from work and take more disability leave, thus increasing costs for employers and decreasing productivity. [ 251 ]  A study examining Duke University employees found that people with a BMI over 40\u00a0kg/m 2  filed twice as many  workers' compensation  claims as those whose BMI was 18.5\u201324.9\u00a0kg/m 2 . They also had more than 12\u00a0times as many lost work days. The most common injuries in this group were due to falls and lifting, thus affecting the lower extremities, wrists or hands, and backs. [ 252 ]  The Alabama State Employees' Insurance Board approved a controversial plan to charge obese workers $25 a month for health insurance that would otherwise be free unless they take steps to lose weight and improve their health. These measures started in January 2010 and apply to those state workers whose BMI exceeds 35\u00a0kg/m 2  and who fail to make improvements in their health after one year. This becomes a Catch 22 position as many insurance companies will refuse to pay for treatment methods for workers living with obesity. [ 253 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8626", "text": "Some research shows that people with obesity are less likely to be hired for a job and are less likely to be promoted. [ 236 ]  People with obesity are also paid less than their counterparts who do not live with obesity for an equivalent job; women with obesity on average make 6% less and men with obesity make 3% less. [ 241 ] :\u200a30"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8627", "text": "Specific industries, such as the airline, healthcare and food industries, have special concerns. Due to rising rates of obesity, airlines face higher fuel costs and pressures to increase seating width. [ 254 ]  In 2000, the extra weight of passengers with obesity cost airlines US$275\u00a0million. [ 255 ]  The healthcare industry has had to invest in special facilities for handling  patients with class III obesity, including special lifting equipment and  bariatric ambulances . [ 256 ]  Costs for restaurants are increased by litigation accusing them of causing obesity. [ 257 ]  In 2005, the US Congress discussed legislation to prevent civil lawsuits against the food industry in relation to obesity; however, it did not become law. [ 257 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8628", "text": "With the  American Medical Association 's 2013 classification of obesity as a chronic disease, [ 23 ]  it is thought that health insurance companies will more likely pay for obesity treatment, counseling and surgery, and the cost of research and development of adipose treatment pills or gene therapy treatments should be more affordable if insurers help to subsidize their cost. [ 258 ]  The AMA classification is not legally binding, however, so health insurers still have the right to reject coverage for a treatment or procedure. [ 258 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8629", "text": "In 2014, The European Court of Justice ruled that morbid obesity is a disability. The Court said that if an employee's obesity prevents them from \"full and effective participation of that person in professional life on an equal basis with other workers\", then it shall be considered a disability and that firing someone on such grounds is discriminatory. [ 259 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8630", "text": "In low-income countries, obesity can be a signal of wealth. A 2023 experimental study found that obese individuals in Uganda were more likely to access credit. [ 260 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8631", "text": "The principal goal of the fat acceptance movement is to decrease discrimination against people who are overweight and obese. [ 262 ] [ 263 ]  However, some in the movement are also attempting to challenge the established relationship between obesity and negative health outcomes. [ 264 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8632", "text": "A number of organizations exist that promote the acceptance of obesity. They have increased in prominence in the latter half of the 20th\u00a0century. [ 265 ]  The US-based  National Association to Advance Fat Acceptance  (NAAFA) was formed in 1969 and describes itself as a civil rights organization dedicated to ending size discrimination. [ 266 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8633", "text": "The  International Size Acceptance Association  (ISAA) is a  non-governmental organization  (NGO) which was founded in 1997. It has more of a global orientation and describes its mission as promoting size acceptance and helping to end weight-based discrimination. [ 267 ]  These groups often argue for the recognition of obesity as a disability under the US  Americans With Disabilities Act  (ADA). The American legal system, however, has decided that the potential public health costs exceed the benefits of extending this anti-discrimination law to cover obesity. [ 264 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8634", "text": "In 2015, the  New York Times  published an article on the  Global Energy Balance Network , a nonprofit founded in 2014 that advocated for people to focus on increasing exercise rather than reducing calorie intake to avoid obesity and to be healthy. The organization was founded with at least $1.5M in funding from the  Coca-Cola Company , and the company has provided $4M in research funding to the two founding scientists Gregory A. Hand and  Steven N. Blair  since 2008. [ 268 ] [ 269 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8635", "text": "Many organizations have published reports pertaining to obesity. In 1998, the first US Federal guidelines were published, titled \"Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report\". [ 270 ]  In 2006, the  Canadian Obesity Network , now known as  Obesity Canada  published the \"Canadian Clinical Practice Guidelines (CPG) on the Management and Prevention of Obesity in Adults and Children\". This is a comprehensive evidence-based guideline to address the management and prevention of overweight and obesity in adults and children. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8636", "text": "In 2004, the United Kingdom  Royal College of Physicians , the  Faculty of Public Health  and the  Royal College of Paediatrics and Child Health  released the report \"Storing up Problems\", which highlighted the growing problem of obesity in the UK. [ 271 ]  The same year, the  House of Commons   Health Select Committee  published its \"most comprehensive inquiry [...] ever undertaken\" into the impact of obesity on health and society in the UK and possible approaches to the problem. [ 272 ]  In 2006, the  National Institute for Health and Clinical Excellence  (NICE) issued a guideline on the diagnosis and management of obesity, as well as policy implications for non-healthcare organizations such as local councils. [ 273 ]  A 2007 report produced by  Derek Wanless  for the  King's Fund  warned that unless further action was taken, obesity had the capacity to debilitate the  National Health Service  financially. [ 274 ]  In 2022 the  National Institute for Health and Care Research  (NIHR) published a comprehensive review of research on what  local authorities  can do to reduce obesity. [ 199 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8637", "text": "The Obesity Policy Action (OPA) framework divides measure into  upstream  policies,  midstream  policies, and  downstream  policies. Upstream policies have to do with changing society, while midstream policies try to alter behaviors believed to contribute to obesity at the individual level, while downstream policies treat currently obese people. [ 275 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8638", "text": "The healthy BMI range varies with the age and sex of the child. Obesity in children and adolescents is defined as a BMI greater than the 95th\u00a0 percentile . [ 276 ]  The reference data that these percentiles are based on is from 1963 to 1994 and thus has not been affected by the recent increases in rates of obesity. [ 277 ]  Childhood obesity has reached epidemic proportions in the 21st\u00a0century, with rising rates in both the developed and the developing world. Rates of obesity in Canadian boys have increased from 11% in the 1980s to over 30% in the 1990s, while during this same time period rates increased from 4 to 14% in Brazilian children. [ 278 ]  In the UK, there were 60% more obese children in 2005 compared to 1989. [ 279 ]  In the US, the percentage of overweight and obese children increased to 16% in 2008, a 300% increase over the prior 30 years. [ 280 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8639", "text": "As with obesity in adults, many factors contribute to the rising rates of childhood obesity. Changing diet and decreasing physical activity are believed to be the two most important causes for the recent increase in the incidence of child obesity. [ 281 ]   Advertising of unhealthy foods to children  also contributes, as it increases their consumption of the product. [ 282 ]  Antibiotics in the first 6 months of life have been associated with excess weight at age seven to twelve years of age. [ 166 ]  Because childhood obesity often persists into adulthood and is associated with numerous chronic illnesses, children who are obese are often tested for  hypertension ,  diabetes ,  hyperlipidemia , and  fatty liver disease . [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8640", "text": "Treatments used in children are primarily lifestyle interventions and behavioral techniques, although efforts to increase activity in children have had little success. [ 283 ]  In the United States, medications are not FDA approved for use in this age group. [ 278 ]  Brief weight management interventions in  primary care  (e.g. delivered by a physician or nurse practitioner) have only a marginal positive effect in reducing childhood overweight or obesity. [ 284 ]  Multi-component behaviour change interventions that include changes to dietary and physical activity may reduce BMI in the short term in children aged 6 to 11 years, although the benefits are small and quality of evidence is low. [ 285 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8641", "text": "Obesity in pets is common in many countries. In the United States, 23\u201341% of dogs are overweight, and about 5.1% are obese. [ 286 ]  The rate of obesity in cats was slightly higher at 6.4%. [ 286 ]  In Australia, the rate of obesity among dogs in a veterinary setting has been found to be 7.6%. [ 287 ]  The risk of obesity in dogs is related to whether or not their owners are obese; however, there is no similar correlation between cats and their owners. [ 288 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8642", "text": "Obesity and the environment  aims to look at the different  environmental factors  that researchers worldwide have determined cause and perpetuate  obesity . Obesity is a condition in which a person's weight is higher than what is considered healthy for their height, and is the leading cause of preventable death worldwide. Obesity can result from several factors such as poor nutritional choices, overeating, genetics, culture, and metabolism. [ 1 ]  Many diseases and health complications [ 2 ]  are associated with obesity (e.g., Type-II diabetes, heart disease, cancer, stroke). Worldwide, the rates of obesity have nearly tripled since 1975, leading health professionals to label the condition as a modern epidemic in most parts of the world. Current (as of 2022) worldwide population estimates of obese adults are near 13%; overweight adults total approximately 39%. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8643", "text": "Studies have shown that  obesity  has become increasingly prevalent in both people and animals (pets and laboratory animals). [ 3 ]  Proper diet and exercise is not linked to lower obesity rates or the trending toward obesity despite these being the assumed cure and preventative for obesity. According to Professor  Robert H. Lustig  from the  University of California, San Francisco , \"[E]ven those at the lower end of the  body mass index  (BMI) curve are gaining weight. Whatever is happening is happening to everyone, suggesting an environmental trigger.\" [ 4 ]  The theory of environmental  obesogens  proposes a different causal facet to obesity \u2013 that lifetime exposure to  xenobiotic  chemical obesogens, molecules that do not properly regulate  lipid metabolism  in the body and may cause obesity, changes the body's metabolic system. Data is scarce, but some in-vitro studies have found this model could be an accurate predictor of future obesity. A study suggested that smoking before and during pregnancy, for example, increases the risk of obesity twofold in children of school age. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8644", "text": "Many chemicals in common-use products are known or suspected to be obesogens and act as  endocrine disruptors  in the body. In a  University at Albany, State University of New York  study,  organotin compounds , toxic chemicals derived from tin and hydrocarbon substituents, were found in a designer handbag, vinyl blinds, wallpaper, tile, and vacuum cleaner dust collected from 20 houses. [ 6 ]  The study linked obesity to  phthalates , present in many PVC items, in addition to scented items like fresheners, laundry products, and personal care products. [ 7 ]  Also linked is  Bisphenol A  (BPA), a known environmental obesogen that reduces the body's overall number of fat cells but which makes remaining fat cells larger. Additionally, glucose intolerance and more abdominal fat were found to be the results of obesogens in animals and the long-term effects of low-birth weight babies. [ 6 ]   The study strongly indicates that obesogens change an individual's metabolic set points for gaining weight. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8645", "text": "Research on obesogens indicate some  endocrine disrupting chemicals  (EDCs) belong to this class of compounds. Bruce Blumberg, a professor of developmental and cell biology at  UC Irvine , has found compelling evidence that exposure to the chemical  Tributyltin  (TBT), a compound used in  pesticides , can trigger fat cell creation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8646", "text": "As several cases have confirmed, farm workers in America have unwillingly or unknowingly worked in fields that had been recently sprayed with TBT and other dangerous chemicals. Among a wide variety of health risks, farm workers may bear a disproportionate risk of exposure to such obesogens. While legislation has been enacted to require a minimum amount of time to pass before workers enter sprayed fields, the lack of legal and political power of many farm workers combined with the fact that enforcing such laws can be difficult, makes exposure to obesogens a possible threat to the livelihood of many farm workers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8647", "text": "The country to country rates of obese adults in a total population vary due to different environments, lifestyles, and diets. While there is no direct correlation between obesity rates and economic status, wealthier countries have more resources to utilize for health and fitness awareness. [ 9 ]  According to World Population Review, in 2022 all of the top ten countries with the highest percentage of obese adults are found in the South Pacific. Several theories attempt to explain this fact, including the popularity of unhealthy fast food, the use of frying as a means to prepare food, and possible genetic predispositions. In contrast, the country with the lowest percentage of total obese adults is Vietnam, with only 2.1%, attributed to chronic food insecurity and child malnutrition. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8648", "text": "In the United States, the prevalence of obese adults in the mid-1990's was substantially lower than current figures. In 1994, the prevalence of obesity in every state was less than 22%, but by 2000, 11 states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, South Carolina, Tennessee, Texas, and West Virginia) had surpassed that figure. Six states had a population percentage of obese adults of more than 30%; the remaining states ranged between 20% and 30%. By 2015, no state had a prevalence of obesity under 18%; almost all states exceeded 22%, and six states exceeded 26%. [ 10 ]   According to the  Centers for Disease Control and Prevention  (CDC), in 2016 the number of obese people in the United States reached an all-time high of about 93 million, up 33% from 2008. [ 11 ]  By 2020, the U.S, obesity prevalence was 41.9%, an increase from 30.5% in 2017 to 41.9% in 2020. During the same time, the prevalence of severe obesity increased from 4.7% to 9.2%. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8649", "text": "Race and genetics are two other dimensions of obesity that have been extensively studied. Some researchers have found that genetics increase the likelihood of occurrence of obesity through higher levels of fat deposition and  adipokine  secretion. [ 13 ]  Other critics suggest that race itself may affect the way obesity presents itself in individuals. In a recent study of 70,000 men and women of African ancestry, researchers found three new common genetic variants. [ 14 ]  These  single-nucleotide polymorphisms  (SNPs) are connected to body mass index (BMI) and obesity. Therefore, individuals who carry these variants are more at risk of becoming obese. Researchers noted that these genetic variants are very small determinants in most cases of obesity. Most medical professionals agree that  environmental factors , poor health, and eating habits are still considered to be the strongest contributors of obesity. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8650", "text": "One study found that Black men and women have a lower percentage of body fat than White men and women with the same  body mass index  (BMI). [ 16 ]   A similar study concluded that obese Black adolescents had significantly less dangerous visceral fat than obese White adolescents. This finding is significant because visceral fat has been more strongly linked to the risk of disease compared to fat stored in other parts of the body. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8651", "text": "Between 1980 and 2000, obesity rates in the United States doubled among young children and tripled among teens. Numerous studies aimed to provide insight into genetic, economic, and/or environmental causes of obesity. According to the \" thrifty gene hypothesis , [ 18 ]  a genetic theory explaining rising obesity rates, certain individuals are genetically predisposed to metabolize food more efficiently than others as a result of human evolution. In times of scarcity, these genes were essential in ensuring survival; in times of abundance, these same genes cause obesity. In first-world countries like the United States, the UK, Australia, and most Western European countries, evolution has led to an increased sedentary lifestyle and high rates of sugar and fat consumption, directly leading to obesity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8652", "text": "According to the CDC, studies show that members of racial and ethnic minority communities are disproportionately obese. Hispanics (47%) and non-Hispanic Blacks (46.8%) had the highest age-adjusted prevalence of obesity compared to non-Hispanic Whites (37.9%) and non-Hispanic Asians (12.7%). [ 19 ]  A similar study in the  American Journal of Public Health  found a strong correlation between community demographics and the likelihood of obesity: Hispanics (28.7%) and non-Hispanic Blacks (36.1%) evidenced higher percentages of obesity than non-Hispanic Whites (24.5%) and non-Hispanic Asians (7.1%). [ 20 ]  Many theories exist to explain these disparities, including differing dietary behaviors among ethnic groups, differing cultural norms in regards to body weight and size, and unequal access to healthy foods. [ 21 ]  Due to economic factors, many Hispanics and non-Hispanic Blacks rely on cheap calories with little nutritional value. According to television broadcast statistics, Hispanic and Black teens and children are specifically targeted by fast food restaurants. Spanish-language TV advertisement has increased by 8%, and restaurants such as KFC and Burger King have increased their spending on Spanish advertisements from 35% to 41% while decreasing English-language advertising. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8653", "text": "The Department of Agriculture defines  food deserts  as neighborhoods without ready access to fresh, healthy, and affordable food. Communities suffering in food deserts are more likely to be Hispanic and Black neighborhoods, limiting available healthy food options. In 2015, Chicago's Mayor Emmanuel partnered with Growing Power, which transported affordable fresh fruits and vegetables to food desert areas. [ 23 ]  \u00a0In 2004, Pennsylvania enacted a $100 million economic stimulus package that subsidized grocery stores by offering a low-cost business loan from the Fresh Food Financing Initiative (FFFI) if they were located in a food desert. [ 23 ]  In 2008, former New York City Mayor Bloomberg introduced the Green Cart amendment, which allowed pushcart vendors to receive a low-cost permit if they were willing to operate in under-served neighborhoods. The Green Cart program projected an improvement in the health of 75,000 New Yorkers, and save at least 50 lives a year over the long term. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8654", "text": "Hispanic and Black communities frequently have less access to exercise and fitness opportunities (i.e., public parks) as well as healthy green spaces which creates a obesogenic environment. [ 24 ] [ 25 ]  Low income neighborhoods are burdened with an abundance of fast food outlets. A 2005 study conducted in Chicago found that Black neighborhoods had 14 fast food restaurants per 100,000 neighborhood residents, while White neighborhoods had 9.4 fast food restaurants per 100,000 residents. Fast food restaurants offer inexpensive, calorie-dense food that is nutrient-poor and unhealthy with high levels of sugar, fat, and sodium. According to the USDA recommendation for daily caloric intake, a McDonald's meal has more than half a day's worth of calories. [ 26 ]  In the short term, the residents of these communities are making an economically rational decision when purchasing fast food as it is easily accessible and inexpensive. The alternative would be purchasing low quality groceries at a high cost. [ 27 ]  In the long-term, however, studies show that the consumption of fast food hurts overall health, raising the probability of becoming obese. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8655", "text": "Economic status of individuals in ethnic groups does not fully explain the disparity between communities. A 2009 study in the  Journal of Epidemiology and Community Health  found that racial/ethnic minorities have a higher risk of being obese within each observed socioeconomic group, [ 29 ]  suggesting that race is a key indicator in determining disparities of obesity risk. The study also implies that  structural racism  may cause certain racial/ethnic groups to experience a disproportionate risk of obesity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8656", "text": "Weight bias  is an ongoing field of study focusing on obesity-related stigmatization. Multiple academics cite evidence of differential, negative treatment of the overweight and obese due to commonly attributed  stereotypes  such as laziness, incompetence, weakness of will, sloppiness, and untrustworthiness. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8657", "text": "In one study of 2,249 obese and overweight women, 54% reported experiencing weight stigma by their colleagues; 43% reported experiencing weight stigma by their superiors. Weight stigma can be defined as derogatory comments, preferential treatment towards average-weight colleagues, and denial of employment. In another study of 2,838 nationally representative adults aged 25\u201374, overweight, obese, and severely obese respondents were, respectively, 12, 37, and 100 times more likely to report  employment discrimination  than average-weight respondents, including loss or reduction of wages. Data suggests that after controlling for other socioeconomic factors, limitations of health, and other household variables, obese men were expected to see a 0.7 to 3.4% wage depression, and obese women were expected to see a wage depression between 2.3 and 6.1%. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8658", "text": "Studies show that physicians are most likely to attribute lack of motivation as the primary cause of obesity, coupled with non-compliance and general laziness. In one United Kingdom study, physicians tended to follow a  victim-blaming  approach regarding the causes of obesity, while the obese patients themselves attributed their weight to specific medical causes or other socioeconomic factors, such as low income. Disparities in perceived causation are a major hindrance towards physicians' and patients' abilities to create and maintain a balanced obesity management plan. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8659", "text": "Educational weight bias also presents in the correlation between obesity and educational attainment. A study of over 700,000 Swedish men found that, after controlling for intelligence and parental socioeconomic levels, those who were obese at the age of 18 had a lower chance of going to college than their average-weight peers. Similarly, a study based on data gathered by the  National Longitudinal Study of Adolescent Health  concluded that obese women were 50% less likely to attend college than their average-sized peers. Female students who attended school where most of the females were obese, however, had a relatively similar chance of attending college as non-obese women. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8660", "text": "Weight bias, fat stigma, and discrimination are factors that many academics say can contribute to hopelessness and depression, encouraging the same unhealthy habits that initially caused obesity. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8661", "text": "Scientific and healthcare communities agree that obesity and mental illness are directly related. Awareness of the complicated relationship between these health concerns will develop solutions that are as of yet inaccessible. Patients assessed for obesity need to be examined with respect to their mental health status. Public health policies should recognize frequently paired mental illness and weight-related disorders and their influence on and from cultural, gender, socioeconomic, and other health elements. Policy and training should also highlight the likelihood of the obese developing mental health co-morbid disorders, and vice versa. Training health professionals with a focus on interventions, support, prevention, and collaboration with related specialties is crucial."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8662", "text": "Obesity is a chronic health condition associated with extreme conditions in mental health. A variety of psychological disorders or mental illnesses such as eating disorders (anorexia, bulimia, binge-eating disorder), schizophrenia, bipolar disorder, and depression/anxiety, are associated with an increased risk of obesity and other obesity-related illnesses like diabetes and coronary heart disease. A 2014 study of over 10,000 people suffering from schizophrenia, bipolar disorder, or depression showed that 80% of the participants were overweight or obese. [ 34 ]  Psychological issues obesity can trigger include low self-esteem, distorted body image, and body shaming. Obese individuals tend to have higher rates of depression than those who are not obese. Research at the  University of Wisconsin-Madison  by Dr. David A. Kats and his colleagues indicated that of the 2,931 patients tested exhibiting chronic health conditions, clinical depression was highest in extremely obese patients (patients with a BMI over 35). A Swedish Obese Subjects (SOS) research study indicated that clinically significant depression is about three- to four-times higher in severely obese individuals than in those who are not obese. Professor Marianne Sullivan and her team from  Sahlgrenska University Hospital  noted that obese subjects exhibited depression scores similar to patients living with chronic pain. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8663", "text": "Children tend to be less active when their communities lack safe play areas and after-school programs regardless of their community's socioeconomic status. Rates of after-school program participation are low across all socioeconomic groups; current research shows that this may be due to external factors other than willingness or a need to participate. Research indicates children that come from high socioeconomic households typically do not participate in after-school programs because they are already involved in a wide range of extra-curricular activities. Children that come from low-socioeconomic households, however, typically do not utilize play spaces and after-school programs due to lack of ability and frequently a lack of transportation. [ 37 ] [ 38 ] [ 39 ]  The CCLC, an after-school program serving low-income youth, conducted a survey in which 20% of youth responders cite transportation, rather than a lack of interest or willingness, as the primary reason they do not attend after-school programs. [ 40 ]  Additionally, parents of low-income and minority youth are less likely to have easy access to after-school programs as compared to high-income and White parents."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8664", "text": "Disadvantaged youth and young adults face similar problems with transportation to safe and engaging spaces. Poor youth are less likely to have access to a car, and more likely to live in high crime neighborhoods, making it difficult to take public transportation or walk. Additionally, children from disadvantaged families often have more worries and less free time to exercise, as they struggle alongside family members to find ways to meet their basic needs. By contrast, privileged families have the financial means and time to take their children to playgrounds, after-school activities, competitive sports, and more."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8665", "text": "Children of higher-class families have more access to technology and tend to make less use of the \" environmental space \" of their everyday life; such technology removes opportunities for youth outdoor interaction. Children with frequent access to technology tend to spend more time indoors engaged with a computer/television screen rather than playing outdoors. [ 41 ]  In this sense, technology is a detriment to children as it frequently hampers physical activity, thus negatively impacting a child's health. This issue contradicts the belief held by many in the United States that children who come from high-income homes are less likely to become obese as they can be active in safe environmental spaces."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8666", "text": "Technology also plays a detrimental role for adults who spend most of their time working on a computer. Economists from the  Milken Institute , working with statistics from the United States, correlated a 10% increase in the sale of technology with a 1.4% increase in obesity rates \u2013 approximately 4.2 million people in a country with the same population as the United States. [ 42 ]  This increase in time spent using technology not only absorbs time potentially spent being active, it also changes the way people eat. Employees may feel pressured while at work and may eat hurriedly or absentmindedly; once home, workers frequently turn on the TV or engage in their mobile phones instead of focusing on their food consumption and diet. Ross DeVol, a chief research officer at the Milken Institute, quipped: \"Common sense says if you sit around in front of the screen, don't exercise while you are working, change your diet...you are going to gain weight.\" [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8667", "text": "In 2009, the  U.S. Department of Agriculture  conducted a food desert study to examine the public's access to supermarkets. Evidence showed that 23.5 million people within the United States did not have access to a supermarket within a one-mile radius of their residence. More than 113 studies have been conducted to determine if healthy food and supermarkets are equally distributed and accessible to every socioeconomic class. Of these, 85% (97) of the studies found that supermarkets and healthy food stores are unequally distributed between different socioeconomic groups. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8668", "text": "Other research teams have studied the comparison between supermarkets and smaller food outlets such as small grocery stores and convenience stores. They found that supermarkets were used as a proxy for food access as they provide the most reliable access to a wide variety of nutritious and affordable food. The study showed that low-income and minority communities had less supermarkets and more convenience and small grocery stores as compared to predominantly wealthy and White communities. 89 out of the 98 (90%) studies of national data indicated that urban areas have uneven geographic access to supermarkets."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8669", "text": "National studies have concluded that ZIP codes composed primarily of low-income households are 25% less likely to have a chain supermarket store but contain 1.3 times as many convenient stores when compared to ZIP codes composed of middle-income households. ZIP codes composed of predominantly African-American households have about half the amount of chain supermarkets, as do ZIP codes composed of predominantly White households. [ 45 ]  An assessment of 685 urban and rural census tracts spanning three states show that low-income neighborhoods have approximately half as many supermarkets and four times as many small grocery stores when compared to high-income neighborhoods. The same study also found that predominantly White neighborhoods have four times as many supermarkets as predominantly African-American neighborhoods. [ 46 ]  Also, a study of 10,763 residences in four states reported the existence of supermarkets in the surveyed residential area was directly related with a 24% lower prevalence of obesity and a 9% lower prevalence of overweight residents. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8670", "text": "Studies done at the local level demonstrate similar trends to those done at the national level. There are 2.3 times as many supermarkets per household in low-poverty areas in  Los Angeles  compared to high-poverty areas. Predominantly white regions have 1.7 times as many supermarkets as Hispanic regions, and 3.2 times as many as African-American regions. [ 48 ]   West Louisville, Kentucky , a low-income African-American community that suffers from high rates of diabetes, has one supermarket for every 25,000 residents; in comparison, the U.S. in total has an average of one supermarket for every 12,500 residents. [ 49 ]  In Washington, DC, the city's lowest income wards (Wards 7 and 8) have one supermarket for every 70,000 people, while two of the three highest-income wards (Wards 2 and 3) have one for every 11,881 people. One in five of the city's  food stamp  recipients lives in a neighborhood without a grocery store. [ 50 ]  Twenty-one studies have found that food stores in low-income communities are less likely to stock healthy or fresh food or snacks, and are instead more likely to offer lower quality items at higher prices, compared to food stores in predominantly white communities. [ 51 ] [ 52 ] [ 53 ] [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8671", "text": "The  Child Nutrition and WIC Reauthorization Act of 2004  created the team nutrition network to promote healthy eating and physical activity in school-aged children, awarding grants to states that created healthy eating and physical activity programs for the children they serve. [ 55 ]  The CDC released its own guidelines for schools to promote physical and health education for schoolchildren, specifically suggesting that public and private schools:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8672", "text": "The  2010 Healthy Kids Act  was part of Michelle Obama \"Let's Move\" program.\u00a0This program authorized the USDA to regulate competitive food (i.e., any food that is not included in a school's lunch program, such as fast food and vending machines) and required more stringent nutritional standards for meals served in cafeterias. These nutritional standards were required to be scientifically founded and in compliance with the published  Dietary Guidelines for Americans . Soon schools began to replace food which were high in fat and sodium, and any food that was lacking nutritional value, As replacements, schools implement more fruits, whole grain, vegetables, and low or nonfat milk\u00a0into provided lunches.  By 2014, assessments of the Healthy Kids Act indicated that school-aged kids were beginning to eat more fruits and vegetables while at school. One of these assessments included a Harvard study proving that after the Act was implemented, kids ate 16% more vegetables and 23% more fruit at lunch. [ 57 ]  The Act remains in place, but has not gone unchallenged: on May 1, 2017,  Secretary of Agriculture   Sonny Perdue  signed a proclamation to make nutrition requirements for school meals more flexible. This includes restoring local control of guidelines on whole grains, sodium, and milk. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8673", "text": "Approximately once every five years, Congress drafts legislation known as the  United States Farm Bill , an umbrella term containing different Bills affecting America's agriculture and food. The Farm Bill focuses on two major thrusts: food stamps and nutritional programs, and income and price supports for commodity crops. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8674", "text": "The Farm Bill has been touted as one of the biggest contributors to the ongoing obesity epidemic. [ 60 ]  Over the past decade, the U.S. government's farm policy focused on the overproduction of and the reduction in prices of  commodity crops  such as corn and soybeans. Low commodity prices incentivize farms to create new ways to use these commodity crops. These subsidies caused a decrease in the prices of corn and soybeans, and led to the creation of  high fructose corn syrup  and hydrogenated vegetable oils \u2013 ingredients directly linked to obesity that are frequent components of many modern food products. In 1998, over 11,000 food products were introduced to Americans; of these, approximately 75% were candies, condiments, cereals, and beverages \u2013 all foods high in added high fructose corn syrup. [ 61 ]  Between 1974 and 2004, U.S. consumption of high fructose corn syrup increased over 1,000%. [ 62 ]  Agricultural subsidies in other countries also tend to favor energy-dense crops. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8675", "text": "Unhealthy foods tend to be inexpensive when compared to their healthy counterparts. As fruits and vegetables are not subsidized, the real cost of such crops has risen nearly 40%. In contrast, the prices of soda, sweets, fats, and oils declined due to the Farm Bill's subsidy to farmers growing commodity crops. [ 64 ]  Currently, the least expensive food available is also the most caloric and the least nutritious: for example, a dollar's worth of cookies or potato chips yields 1200 calories, while a dollar's worth of carrots yields only 250 calories. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8676", "text": "U.S. farmers feed commodity crops to livestock that provide the country with meat, milk, and other products. Essential nutrients are taken away when cows are fed corn and/or soybeans instead of a natural grass diet. A 2014 University of Utah study claimed that \"grass-fed beef has been shown to be higher in health-promoting nutrients,  omega-3 fatty acids , and cancer-fighting conjugated  linoleic acid  (CLA) than beef that is fed grain.\" [ 66 ]  Ultimately, the U.S. government provides the subsidy for grain-fed livestock that causes farmers who raise grass-fed livestock financial stress and competition problems; hence, the U.S. government is partially responsible for causing increased rates of obesity and its associated serious co-morbid health conditions/diseases in its citizens. The government works to lower these rates but does not ratify or eliminate the subsidies partially responsible for their increase. An example of attempts the U.S. government has made to combat obesity is the 2008 Farm Bill's funding of community gardens located primarily in low income neighborhoods. A Michigan study of 766 adults in low-income neighborhoods showed that community garden participants were 3.5 times more likely to consume fruits and vegetables at least 5 times each day, and to consume more than 1.4 times the amount of fruits and vegetables than those who did not participate in  community gardening . [ 67 ]  In addition, children who participate in a community garden tend to eat healthier and become interested in farming and eating locally grown food. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8677", "text": "The 2008 Farm Bill also attempted to lower the cost of purchasing vegetables; researchers found that lowering vegetable costs by just 10% increased produce purchases by low-income families by 7%. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8678", "text": "The  food justice  movement works to address the obesity epidemic by promoting access to affordable and healthy food to communities. The New York-based non-profit organization Just Food defines food justice as \"communities exercising their right to grow, sell, and eat healthy food.\" [ 68 ]  Underlying this discourse is the belief that healthy food is a right of every person, regardless of race, ethnicity, socioeconomic status, or community. As a potential remedy for obesity, food justice advocates support providing affordable, quality food through  community supported agriculture  and the  slow food  movement. [ 69 ]  Proponents seek to empower historically disadvantaged communities by advocating equal access to healthy food for all people. While commending the movement for making healthy food more accessible, critics of this discourse claim the movement does not call into question the structural dynamics that make obesity a likely risk for many people. [ 70 ]  In addition, critics claim the movement offers alternative food as a solution to obesity but does not consider how food itself is produced and who is involved in production and consumption decisions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8679", "text": "The  food sovereignty  movement seeks to increase empowerment fostered by the food justice movement by addressing structural issues of the  food system . Leading food sovereignty organization  Via Campesina  defines food sovereignty as \"[the] peoples', country's, or State Union's right to define their agricultural and food policy\". [ 71 ]  Advocates believe that healthy food is a right of all people in every country, and that people should participate in food production and consumption decisions. To that end, the movement seeks to empower those most affected by the obesity epidemic by including them in the process of brainstorming and creating alternatives to the current food system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8680", "text": "Transport:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8681", "text": "Obesity and walking  describes how the locomotion of  walking  differs between an obese individual ( BMI\u00a0 \u2265 30\u00a0kg/m 2 ) and a non-obese individual. The prevalence of  obesity  is a worldwide problem. In 2007\u20132008, prevalence rates for obesity among adult American men were approximately 32% and over 35% amongst adult American women. [ 1 ]   According to the  Johns Hopkins Bloomberg School of Public Health , 66% of the American population is either overweight or obese and this number is predicted to increase to 75% by 2015. [ 2 ]  Obesity is  linked to health problems  such as decreased insulin sensitivity and  diabetes , [ 3 ]   cardiovascular disease , [ 4 ]   cancer , [ 5 ]   sleep apnea , [ 6 ]  and  joint  pain such as  osteoarthritis . [ 7 ]   It is thought that a major factor of obesity is that obese individuals are in a positive  energy balance , meaning that they are consuming more calories than they are expending. Humans expend energy through their  basal metabolic rate , the  thermic effect of food ,  non-exercise activity thermogenesis  (NEAT), and  exercise . [ 8 ]  While many treatments for obesity are presented to the public, exercise in the form of  walking  is an easy, relatively safe activity. Walking may initially result in reduced weight, but adopting the habit over the long term may not result in additional weight loss. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8682", "text": "Knee osteoarthritis  and other joint pain are common complaints amongst obese individuals and are often a reason as to why  exercise prescriptions  such as walking are not continued after prescribed. [ citation needed ]  To determine why an obese person might have more joint problems than a non-obese individual, the  biomechanical  parameters must be observed to see differences between obese and non-obese walking. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8683", "text": "Numerous studies have examined the differences in  stride  between obese and non-obese individuals. Spyropoulos et al. in 1991 examined stride length, width, and joint angle differences between the two groups. They found that obese individuals take shorter (1.25\u00a0m vs. 1.67\u00a0m) and wider (0.16\u00a0m vs. 0.08\u00a0m) strides than their non-obese counterparts. [ 10 ]  Browning and Kram also observed obese people taking wider strides (~30% greater) across differing walking speeds (0.50, 0.75, 1.00, 1.50, and 1.75\u00a0m/s), but the stride width did not change with differing speed. [ 11 ]  They did not find stride lengths to be different across speeds. [ 11 ]  Along with taking wider strides, several articles have found obese individuals to walk at slower velocities than their non-obese counterparts, claiming that this might be due to  balance  and  body control  while walking. [ 10 ] [ 12 ] [ 13 ]  Ledin and Odkivst support this theory in a study when they added mass by way of a weighted shirt (20% body weight) to lean individuals and saw sway increase. [ 14 ]  Increased  sway  has also been observed in pre- pubertal  boys. [ 15 ]  Though obese individuals may be able to accommodate for the extra mass in terms of balance because they walk with it every day, several studies have found that obese people spend more time in the stance rather than swing phase during the walking cycle and increase double support time. [ 10 ] [ 11 ] [ 13 ] [ 15 ]  Slower cadences, or number of steps within a certain period of time, have also been associated with obese individuals when compared to lean individuals and would be expected with slower walking speeds.   Others have found no difference in obese people walking  velocities  and find that they share a similar preferred walking speed with lean individuals. [ 11 ] [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8684", "text": "In a study by DeVita and Hortob\u00e1gyi, obese people were found to be more erect throughout the stance phase with greater hip  extension , less knee  flexion , and more  plantarflexion  during the course of stance than non-obese people. [ 12 ]  They also found that obese individuals had less knee flexion in early stance and greater plantarflexion at toe off. [ 12 ]  In a study looking at knee extension, Messier et al. found a significant positive  correlation  with maximum knee extension and BMI. [ 18 ]  That same study looked at mean  angular velocities  at the hip and ankle and found no difference between obese and lean individuals. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8685", "text": "A  ground reaction force  is the force that is exerted by the ground onto whatever body is in contact with the ground and is equal to the force that is placed on the ground. An example is the force that the ground exerts onto the foot and then up the leg of a person when walking and making contact with the ground. These can be measured by having a subject walk across a  force platform  and collect the forces exerted on the ground. These forces have long been thought to increase  loads  on the knee and would increase with greater mass from an obese person. This may be a predictor of osteoarthritis for an obese subject as the vertical force has been documented to potentially be the most significant force that is transmitted up the leg to the knee. [ 18 ]  In 1996, Messier and colleagues observed the differences in ground reaction forces between obese and lean older adults with osteoarthritis.  They found that when they accounted for age and walking velocity, the vertical force was significantly positively correlated with BMI. [ 18 ]  Therefore, as BMI increased, the forces increased. They found this in not only the vertical force, but also in the  anteroposterior  and mediolateral forces. [ 18 ]  Because of the study population, this study did not compare obese adults with lean counterparts. Browning and Kram in 2006 observed two groups (one obese and one non-obese group) of young adult\u2019s ground reaction forces across different speeds. They found that absolute ground reaction forces were significantly greater for the obese people than the non-obese group at slower walking speeds and at each walking speed the peak vertical force was approximately 60% greater. [ 11 ]  Absolute peak in the anteroposterior and mediolateral directions were also greater for the obese group but the difference was erased when scaled to body weight. [ 11 ]  Forces were also greatly reduced at slower walking speeds. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8686", "text": "Lower extremity  joint loading is estimated through net muscle  moments , joint reaction forces, and joint loading rates. Net muscle moments can increase up to 40% as walking speeds rise from 1.2 to 1.5\u00a0m/s. [ 19 ]  One could then predict that as speed increases, loads felt by the lower-extremity joints would increase as the net muscle moments and ground reaction forces increase. Browning and Kram have also found that stance-phase sagittal-plane net muscle moments are greater in obese adults when compared to lean individuals. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8687", "text": "It is well established that obese individuals expend a greater amount of  metabolic  energy at rest and when performing some physical activity such as walking than lean individuals,. [ 20 ] [ 21 ]   [ 22 ]  Added mass demands more energy to move. This is observed in a study by Foster et al. in 1995 when they took 11 obese women and calculated their energy expenditure before and after weight loss. They found that after significant weight loss, the subjects expended less energy on the same task as they did when they were heavier. [ 23 ]   To determine if walking was more expensive per kilogram of body mass and if obese individuals preferred walking speeds would be slower, Browning and Kram sought to characterize the metabolic energy obese females would expend while walking across differing speeds. They found that walking for obese women was 11% more expensive per kilogram of body mass than lean individuals and that the obese women preferred to walk at a similar speed as the lean individuals that minimized their  gross energy  cost per distance. [ 17 ]   Wanting to look at metabolic rates of obese men compared to obese women and determine if the adipose distribution ( gynoid  vs.  android ) differing between the sexes play a role in energy expenditure, Browning et al. observed class II obese males and females walking across differing speeds. They found that standing metabolic rate when normalized for body weight was ~20% less for obese people (more adipose tissue and less metabolically active tissue), but that metabolic rates during walking were ~10% greater per kilogram body mass for obese individuals when compared to lean. [ 16 ]  These researchers also found that increased thigh mass and  adipose  distribution did not matter, overall body composition of percent body fat was related to net metabolic rate. [ 16 ]  Therefore, obese individuals are using more metabolic energy than their lean counterparts when walking at the same speed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8688", "text": "Many measurements are  normalized  to body weight in order to account for differing body weights when doing comparisons (see  VO 2  max  testing). Normalizing body weight when comparing obese and lean individuals' metabolic rates reduces the difference, indicating that body weight rather than body fat composition is the primary indicator for the metabolic cost of walking. [ 24 ]  Caution must be taken when analyzing the  scientific literature  to understand if findings are normalized or not because they may be interpreted differently."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8689", "text": "One possible suggested strategy to maximize energy expenditure while reducing lower joint extremity is to have obese people walk at a slow speed with an incline. Researchers found that by walking at either 0.5 or 0.75\u00a0m/s and a 9\u00b0 or 6\u00b0  incline  respectively would equate to the same net metabolic rate as an obese individual walking at 1.50\u00a0m/s with no incline. [ 25 ]  These slower speeds with an incline also had significantly reduced loading rates and reduced lower-extremity net muscle moments. [ 25 ]   Other strategies to consider are slow walking for extended periods of time and training underwater to reduce loads on joints and increase lean body mass. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8690", "text": "It is often very difficult to recruit obese people that do not have other  comorbidities  such as osteoarthritis or cardiovascular disease. It is also difficult to deduce if a healthy population is representative of the entire obese population because the people that volunteer may already be somewhat active and have a greater fitness than their sedentary counterparts. Another difficulty lies in the ability to characterize  biomechanical  variables due to the large variability between research groups placement of biomechanical markers. Marker placement often used for lean individuals can be difficult to find on obese individuals due to the excess of adipose between the bone landmark and the marker. The uses of  DEXA  and  X-rays  have improved the placement of these biomechanical markers, but variability still remains and should be taken into account when analyzing scientific findings."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8691", "text": "Arghavan Salles  ( Persian :  \u0627\u0631\u063a\u0648\u0627\u0646 \u062b\u0627\u0644\u062b ; born February 23, 1980) is an  Iranian American [ 1 ]   bariatric surgeon . Salles is a Director of the American Medical Women's Association, a Special Advisor for DEI Programs in the Department of Medicine at  Stanford University School of Medicine  and a Senior Research Scholar at the  Clayman Institute for Gender Research . Salles' research focuses on  gender equity , well-being, and the challenges women face in the workplace. [ 2 ]  Salles works as an advocate for equity and inclusion and as an activist against sexual harassment. Salles is an international speaker who worked on the front lines and supported health professionals during the  COVID-19 pandemic  through social media."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8692", "text": "Salles was born in  Iran  and emigrated to the United States with her mother when she was five years old. [ 1 ]  While in high school Salles loved math. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8693", "text": "In 2002, Salles received a B.S. in Biomedical Engineering and a B.A. in French from the  University of Southern California . [ 3 ] [ 5 ]  In 2006, Salles received an M.D. from  Stanford University School of Medicine . [ 5 ]  Salles did a residency in general surgery from Stanford University School of Medicine from 2006 to 2015. [ 6 ]  In 2014,\u00a0Salles completed a PhD  social psychology  from  Stanford University , after which she finished her last two years of surgical residency, going on to become a Board Certified Surgeon in 2016. [ 5 ]  After finishing her residency and PhD in 2016, Salles then completed a year-long fellowship training in minimally invasive surgery at  Washington University School of Medicine  in St. Louis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8694", "text": "While Salles was Chief Resident of General Surgery at Stanford, [ 6 ]  a graduate of the surgery program took his life just six months after graduating. [ 7 ]  Salles has said that this event dramatically impacted the program to enact changes and educate the community about burnout, depression, and wellbeing in medicine. [ 7 ]  In 2011, she and a professor of surgery at Stanford at the time,  Ralph Greco , created a \"Balance in Life\" program for surgery\u00a0residents. This program included weekly psychotherapy session, mentor-mentee pairing between senior and junior residents, and support for residents in their search to find their own doctors and dentists for medical needs. The  Accreditation Council for Graduate Medical Education  (ACGME) has since tried to model a nationwide wellness program after the Stanford program. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8695", "text": "In addition to issues of mental health burden due to burnout, Salles also began to see evidence of inequities, bias, and gender harassment in medicine, specifically in surgery, [ 3 ]  so she took a break from her residency to pursue a PhD in education. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8696", "text": "From September 2016 to June 2019, Salles was an assistant professor in the Department of Surgery at Washington University, where her lab conducted research on gender bias and inequities in medicine. [ 9 ]  In 2017, she developed an online wellness resource for Washington University residents that offered counselling and crisis lines. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8697", "text": "In 2018, Salles became a founding member of  Time's Up  Healthcare, part of the organization's initiative which supports \"safe, fair, and dignified\" work for women around the world and helps to prevent sexual assault and gender-based discrimination in the workplace. [ 11 ] [ 12 ]  This same year, she and five other female medical trainees at  Washington University , helped start 500 Women in Medicine, a satellite of  500 Women Scientists [ 13 ] [ 14 ]  established to make medicine more inclusive and reflect the true diversity of society. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8698", "text": "In 2019, Salles became a Board Certified Physician of Obesity Medicine, and returned to Stanford to develop Educational Programs and Services at the medical school. [ 16 ] [ 5 ]  Her research focused on the representation of women at surgical conferences, implicit and explicit gender bias in healthcare and in performance evaluations, and how to maintain the health and wellbeing of physicians and medical trainees. [ 17 ]  She has also advocated against  weight bias , [ 18 ]  and spoken publicly about the challenges faced by female doctors who want to have children. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8699", "text": "During the  COVID-19 pandemic , [ 20 ]  Salles created fitness challenges, free weekly yoga classes, and daily videos on Twitter and Instagram to engage her followers and bring together a supportive community. [ 20 ]  She also shared challenges women in medical fields face in getting  personal protective equipment  in sizes appropriate for a wide range of body sizes, [ 21 ]  and issues associated with the requirements for in-persons admissions testing during the pandemic. [ 22 ]  In 2022 Salles expressed her concern that the United States has moved on from COVID too rapidly, and people are still at risk if they contract COVID. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8700", "text": "In 2022, Salles was selected as a Director on the Board of Directors for the  American Medical Women's Association , [ 24 ]  a nationally recognized organization, founded in 1915 that is committed to the advancement of women in medicine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8701", "text": "During her PhD, Salles learned about  stereotype threat . [ 3 ]  Salles began to realize the ways in which stereotype threat might be affecting her and her female peers in their evaluations during her surgery residency. [ 4 ]  Salles' dissertation research focused on the negative stereotypes about women in surgery and how those affect women training to become surgeons. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8702", "text": "Due to strongly ingrained gender biases in society, both patients and medical peers hold strong misconceptions that women are not as competent surgeons as men. [ 3 ] [ 25 ]  This is exemplified by the old \"surgeon riddle\" which unveils strong gender stereotypes in medicine such that the majority of the population much more easily associate surgeons with being male than being female. [ 26 ]  These stereotypes that society holds, about women being less competent surgeons than men, leads to a phenomenon called stereotype threat which Salles explored in her work. [ 27 ]  Salles hypothesized that stereotype threat, the fear of affirming a negative stereotype about one's group, causes women increased stress and leads to decreased performance in surgical residency. [ 27 ]  Salles tested this hypothesis by implementing methods to combat stress and stereotype threat through value affirmations. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8703", "text": "Salles saw increases in the performance of female surgeons who had done value affirmation exercises compared to those who had not, suggesting that low-cost interventions targeted towards social-psychological well-being can improve female residents' performance. [ 27 ]  Salles later also showed that women surgeons who have higher stereotype perception have worse psychological health. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8704", "text": "At  Washington University , Salles explored gender bias in clinical evaluations of surgical residents. [ 29 ]  Their results, published in  The American Journal of Surgery  in 2018, showed that evaluations display gendered differences and the overall tones of men's evaluations were more positive and included more standout words than women's. [ 29 ]   Salles and her colleagues then used the  Implicit Association Test  (IAT) to assess implicit biases in the medical field. [ 30 ]  They found that respondents associated men with career and surgery while they associated women with family and family medicine. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8705", "text": "Salles also explores different facets of how well-being impacts the retention of residents in the progression towards careers in surgery. In 2018, Salles found that feelings of social belonging were positively correlated with well-being and negatively correlated with thoughts of leaving surgery. [ 32 ]  She then explored how general self-efficacy impacted retention in surgical specialties and found that self-efficacy was a strong predictor of well-being, which prevents physician burnout and improves retention in the medical field. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8706", "text": "Trauma surgery  is a  surgical   specialty  that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. Trauma surgeons generally complete  residency  training in  general surgery [ 1 ] [ 2 ]  and often fellowship training in trauma or surgical  critical care . The trauma surgeon is responsible for initially resuscitating and stabilizing and later evaluating and managing the patient. The  attending  trauma surgeon also leads the trauma team, which typically includes nurses and support staff, as well as resident physicians in  teaching hospitals . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8707", "text": "Most United States trauma surgeons practice in larger centers and complete a 1- to 2-year trauma-surgery fellowship, which often includes a surgical critical-care fellowship. They may therefore sit for the  American Board of Surgery  (ABS) certifying examination in surgical critical care.\nNational surgical boards usually supervise European training programs; they also certify for subspecialization in trauma surgery. An official European trauma surgical examination exists. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8708", "text": "Training for trauma surgeons is sometimes difficult to obtain. In the US, the Advanced Trauma Operative Management (ATOM) course and the Advanced Surgical Skills for Exposure in Trauma (ASSET) provide operative trauma training to surgeons and surgeons in training. The Advanced Trauma Life Support course (ATLS) is what most US practitioners who take care of trauma patients are required to take (emergency medicine, surgery, and trauma attending physicians, physician extenders, as well as trainees)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8709", "text": "The broad scope of their surgical critical care training enables trauma surgeons to address most injuries to the neck, chest, abdomen, and extremities. In large parts of Europe, trauma surgeons treat most of the musculoskeletal trauma, whereas injuries to the central nervous system are generally treated by  neurosurgeons . In the US and Britain, skeletal injuries are treated by trauma  orthopedic  surgeons. Facial injuries are often treated by  maxillofacial  surgeons.  Significant variation occurs across hospitals in the degree to which other specialists, such as  cardiothoracic surgeons ,  plastic surgeons ,  vascular surgeons , and  interventional radiologists  are involved in treating trauma patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8710", "text": "Trauma surgeons must be familiar with a large variety of general surgical,  thoracic , and  vascular  procedures and must be able to make complex decisions, often with little time and incomplete information. Proficiency in all aspects of  intensive care medicine /critical care is required. Hours are irregular with a considerable amount of night, weekend, and holiday work."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8711", "text": "Most patients presenting to trauma centers have multiple injuries involving different organ systems, so the care of such patients often requires a significant number of diagnostic studies and operative procedures. The trauma surgeon is responsible for prioritizing such procedures and for designing the overall treatment plan. This process starts as soon as the patient arrives in the emergency department and continues to the operating room,  intensive care unit , and hospital floor. In most settings, patients are evaluated according to a set of predetermined protocols ( triage ) designed to detect and treat life-threatening conditions as soon as possible. After such conditions have been addressed (or ruled out), nonlife-threatening injuries are addressed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8712", "text": "Over the last few decades, a large number of advances in trauma and critical care have led to an increasing frequency of non-operative care for injuries to the neck, chest, and abdomen. Most injuries requiring operative treatment are musculoskeletal. For this reason, part of US trauma surgeons devote at least some of their practice to  general surgery . In most American university hospitals and medical centers, a significant portion of the emergency general surgery calls are taken by trauma surgeons. The field combining trauma surgery and emergency general surgery is often called acute care surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8713", "text": "Dr.  George E. Goodfellow  is credited as the United States' first civilian trauma surgeon. [ 4 ]  He opened a medical practice in the silver boom town of  Tombstone ,  Arizona Territory , in November\u00a01880,  where he practiced for the next 11 years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8714", "text": "On July 2, 1881, U.S. President  Garfield  was shot in the abdomen by  Charles J. Guiteau . Two days later, a miner was shot outside Tombstone. On July 13, 1881, Goodfellow performed the first recorded  laparotomy  to treat the miner's gunshot wound. The man had a perforated small intestine, large intestine, and bowel. Goodfellow sutured six holes in the man's organs. Similarly, President Garfield was thought later to have a bullet possibly lodged near his liver, but it could not be found. [ 5 ] [ 6 ] :\u200aM-9\u200a  Sixteen doctors attended to Garfield and most probed the wound with their fingers or dirty instruments. [ 7 ]  Unlike the President, the miner survived. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8715", "text": "Goodfellow treated a number of notorious  outlaw   cowboys  in  Tombstone, Arizona , during the 1880s, [ 10 ]  including  Curly Bill Brocius . [ 11 ]  During the  gunfight at the O.K. Corral  on October 26,\u00a01881, Deputy U.S. Marshal  Virgil Earp  and his brother Assistant Deputy U.S. Marshal  Morgan Earp  were both seriously wounded. Goodfellow treated both men's injuries. [ 12 ] :\u200a27\u200a  Goodfellow treated Virgil Earp again two months later on December\u00a028,\u00a01881,  after he was ambushed, removing 3 inches (76\u00a0mm) of bone from his  humerus [ 13 ]  and attended to Morgan Earp on March\u00a018,\u00a01882, when he was shot while playing a round of  billiards  at the Campbell and Hatch Billiard Parlor. Morgan died of his wounds. [ 12 ] :\u200a38"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8716", "text": "Goodfellow once traveled to  Bisbee , 30 miles (48\u00a0km) from Tombstone, to treat an abdominal gunshot wound. He operated on the patient stretched out on a billiard table. Goodfellow removed a .45-caliber bullet, washed out the cavity with hot water, folded the intestines back into position, stitched the wound closed with silk thread, and ordered the patient to take it to a hard bed for recovery. He wrote about the operation: \"I was entirely alone having no skilled assistant of any sort, therefore was compelled to depend for aid upon willing friends who were present\u2014these consisting mostly of hard-handed miners just from their work on account of the fight. The anesthetic was administered by a barber, lamps held, hot water brought, and other assistance rendered by others.\" [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8717", "text": "Goodfellow pioneered the use of sterile techniques in treating gunshot wounds, [ 14 ]  washing the patient's wound and his hands with lye soap or whisky. [ 8 ]  He became America's leading authority on gunshot wounds [ 15 ]  and was widely recognized for his skill as a surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8718", "text": "By the late 1950s, mandatory laparotomy had become the standard of care for managing patients with abdominal  penetrating trauma . [ 16 ]   A laparotomy is still the standard procedure for treating abdominal gunshot wounds today. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8719", "text": "In the United Kingdom, trauma surgery is now generally considered a subspeciality of  general surgery . [ 17 ]  However, at the  Royal London Hospital , which is Britain's busiest  major trauma centre  and the busiest trauma unit in Europe, [ 18 ]  their trauma surgeons come from backgrounds in  vascular surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8720", "text": "Courses in the UK for aspiring trauma surgeons include the  advanced trauma life support  and  Definitive Surgical Trauma Skills  courses, both provided by the  Royal College of Surgeons ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8721", "text": "Damage control surgery  is surgical intervention to keep the patient alive rather than correct the  anatomy . [ 1 ] [ 2 ] \nIt addresses the  \"lethal triad\"  for critically ill patients with severe  hemorrhage  affecting  homeostasis  leading to  metabolic acidosis ,  hypothermia , and increased  coagulopathy . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8722", "text": "This lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, though complications can result.\nIt stabilizes patients for clinicians to subsequently reverse the physiologic insult prior to completing a definitive repair. While the temptation to perform a definitive operation exists, surgeons should avoid this practice because the deleterious effects on patients can result in them succumbing to the physiologic effects of the injury, despite the anatomical correction.\nThe leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30\u201340% of trauma-related deaths. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8723", "text": "While typically  trauma surgeons  are heavily involved in treating such patients, the concept has evolved to other sub-specialty services.\nA multi-disciplinary group of individuals is required: nurses, respiratory therapist, surgical-medicine intensivists, blood bank personnel and others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8724", "text": "Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Each of these phases has defined timing and objectives to ensure best outcomes. The following goes through the different phases to illustrate, step by step, how one might approach this. There are clearly different approaches throughout the country, and no one way is necessarily correct. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8725", "text": "This is the first part of the damage control process whereby there are some clear-cut goals surgeons should achieve. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. [ 5 ]  Minimizing the length of time spent in this phase is essential."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8726", "text": "For groups (i.e., trauma centers) to be effective in damage control surgery, a multi-disciplinary team is critical. The approach to caring for such critically ill patients is dependent on nurses, surgeons, critical care physicians, operating room staff, blood bank personnel, and administrative support. In addition to having the right team in place is having a prepared team. The more facile the team is enhances the ability for centers to effectively implement damage control surgery. This is referred to by some as damage control ground zero (DC0). [ 6 ]  The ability to mobilize personnel, equipment, and other resources is bolstered by preparation; however, standardized protocols ensure that team members from various entities within the health care system are all speaking the same language. This has been seen during implementation of complex processes such as the  massive transfusion protocol  (MTP)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8727", "text": "Controlling of hemorrhage as discussed above is the most important step in this phase. Eviscerating the intra-abdominal small bowel and packing all four  abdominal quadrants  usually helps surgeons establish initial hemorrhagic control. Depending up on the source of hemorrhage a number of different maneuvers might need to be performed allowing for control of aortic inflow. Solid organ injury (i.e., spleen, kidney) should be dealt with by resection. When dealing with hepatic hemorrhage a number of different options exist such as performing a  Pringle maneuver  that would allow for control of hepatic inflow. [ 7 ]  Surgeons can also apply manual pressure, perform  hepatic packing , or even plugging penetrating wounds. Certain situations might require leaving the liver packed and taking the patient for angio-embolization or if operating in a hybrid operating room having perform an on table  angio-embolization . Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. This has been described by Reilly and colleagues when they shunted the superior mesenteric artery to decrease the length of time in the operating room. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8728", "text": "Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. The perception might be that one could quickly perform an  anastomosis . This should not be attempted in the damage control setting. The key is to simply prevent continued intra-abdominal contamination, and to leave patients in discontinuity. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. Once this is complete the abdomen should be packed. Many of these patients become coagulopathic and can develop diffuse oozing. It is important to not only pack areas of injury but also pack areas of surgical dissection. There are various methods that can be used to pack the abdomen. Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. As a rule abdomens should not be definitively closed until there has been radiologic confirmation that no retained objects are present in the abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8729", "text": "The final step of this phase is applying a temporary closure device. Numerous methods of temporary closure exist, with the most common technique being a negative-vacuum type device. Regardless of which method one decides to use it is important that the abdominal fascia is not reapproximated. The ability to develop  abdominal compartment syndrome  is a real concern and described by Schwab. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8730", "text": "On completion of the initial phase of damage control, the key is to reverse the physiologic insult that took place. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia ( lethal triad ) that many of these critically ill patients develop. When developing a strategy to best care for these patients, the same principles of having a multi-disciplinary team that work together in parallel for the same result apply. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8731", "text": "In using a number of different resuscitation parameters, the critical care team can have a better idea as to which direction is progressing. The first 24 hours often require a significant amount of resources (i.e., blood products) and investment of time from personnel within the critical care team. In many circumstances, especially trauma patients, require that other specialties address a variety of injuries. Moving the patient early on, unless absolutely necessary,  can be detrimental. Certain circumstances might require this, and the patients should continue to receive care from the critical care team during the entire transport period. As the literature begins to grow within the field of damage control surgery, the medical community is continuously learning how to improve the process. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8732", "text": "In some cases, temporary abdominal closure itself or underlying conditions may contribute to abdominal compartment syndrome, causing increased intraabdominal pressure and compromising organ perfusion. [ 10 ]  Temporary abdominal dressings with high negative pressures can be a cause of recurrent abdominal compartment syndrome and one should not hesitate to turn off the dressing's suction when evaluating a patient with signs of recurrent abdominal compartment syndrome. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8733", "text": "While it might sound counterintuitive since the fascia is left open during the placement of these temporary closure devices, they can create a similar type process that leads to abdominal compartment syndrome. If this occurs the temporary closure device should be taken down immediately. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8734", "text": "The third step in damage control surgery is addressing closure of the abdomen. Definitive reconstruction occurs only when the patient is improving. At this point in process the critical care team has been able to correct the physiologic derangements. The optimization typically takes 24 to 48 hours, depending on how severe the initial insult is. Prior to being taken back to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8735", "text": "The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Typically the number of packs has been documented in the initial laparotomy; however, an abdominal radiograph should be taken prior to definitive closure of the fascia to ensure that no retained sponges are left in the abdomen. Once the abdominal packs are removed the next step is to re-explore the abdomen allowing for the identification of potentially missed injuries during the initial laparotomy and re-evaluating the prior injuries. Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8736", "text": "An attempt should be made to close the abdominal fascia at the first take back, to prevent complications that can result from having an open abdomen. The concern for early closure of the abdomen with development of compartment syndrome is a real one. A method to pre-emptively evaluate whether fascial closure is appropriate would be to determine the difference in peak airway pressure (PAP) prior to closure and the right after closure. An increase of over 10 would suggest that the abdomen be left open. [ 9 ]  As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8737", "text": "Considering that not all patients can undergo definitive reconstruction at first return, there are other options that surgeons can consider. Data would suggest that the longer the abdomen is left open from initial laparotomy the higher the rate of complications. [ 12 ]  After about one week, if surgeons can't close the abdomen, they should consider placing a Vicryl mesh to cover the abdominal contents. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. These patients clearly have a hernia that must be fixed 9 to 12 months later."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8738", "text": "Damage control resuscitation has had a dramatic impact on how care for critically ill patients is administered. [ citation needed ] . The core principles of resuscitation involve permissive hypotension, transfusion ratios, and massive transfusion protocol. The resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8739", "text": "Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. The term permissive hypotension refers to maintaining a low blood pressure to mitigate hemorrhage; however, continue providing adequate end-organ perfusion [Duchesene, 2010]. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. Permissive hypotension is not a new concept, and had been described in penetrating thoracic trauma patients during World War I by Bickell and colleagues demonstrating an improvement in both survival and complications. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8740", "text": "Subsequent animal studies have shown equivalent outcomes with no real benefit in mortality  [ 4 ]  Recently there has been further data in trauma patients that has demonstrated increased survival rates [Morrison, 2011]. Cotton and colleagues found that the use of a permissive hypotension resuscitation strategy resulted in better outcomes (increased 30-day survival) in those undergoing damage control laparotomy. This would not be used in situations where patients might have injuries such as a traumatic brain injury considering that such patients are excluded from the studies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8741", "text": "For over a century the casualties of war have provided valuable lessons that can be applied within the civilian sector. Specifically the past decade has seen a paradigm shift in early resuscitation of critically injured patients. Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, we have now learned that maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes [Borgman 2007] [ 4 ]  While this was initially demonstrated in the military setting, Holcomb and colleagues extrapolated this to the civilian trauma center showing improved results as well  [ 14 ] [ 15 ]  Broad implementation across both the military and civilian sector has demonstrated a decreased mortality in critically injured patients. [ 4 ]  Debate has gone back and forth as to the correct ratio that should be used; however, recently Holcomb and colleagues published the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study. [ 15 ] [ 16 ]  They compared administration a higher ratio of plasma and platelets (1:1:1) compared to a lower ratio (1:1:2). The patients that received a higher ratio had an associated three to four-fold decrease in mortality. To help mitigate confounding variables a randomized control trial called the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) has been performed to evaluate the transfusion requirement. There was no difference in 24 hour or 30 day mortality between the 1:1:1 group and the 1:1:2 group -  https://jamanetwork.com/journals/jama/fullarticle/2107789 . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8742", "text": "Initial resuscitation of trauma patients continues to evolve. Massive transfusion (defined as receiving greater than or equal to 10 units of packed red blood cells with a 24-hour period) is required in up to 5% of civilian trauma patients that arrive severely injured. [ 17 ]  Patients who are arriving severely injured to trauma centers can be coagulopathic. Data suggests that around 25% of patients arrive with coagulopathy. [ 18 ]  New ways of measuring coagulopathy such at thromboelastography and rotational thromboelastometry have allowed for a more robust assessment of the coagulation cascade compared to traditional methods of measuring international normalized ratio allowing clinicians to better target areas of deficiency. [ 4 ]  For trauma teams to systematically and efficiently deliver blood products institutions have created protocols that allow for this. The protocols allow for clear communication between the trauma center, blood bank, nurses, and other ancillary staff. They also allow for the quick delivery of certain set of blood products depending upon the institution. One example might be that a \u201ccooler\u201d would contain 10 units of packed red blood cells, 10 units of plasma, and 2 packs of platelets. The idea is that the coolers would continue to be delivered to the location where the patient is being treated until the trauma team leader (typically the trauma surgeon) would discontinue the order. [ 17 ]  Systolic blood pressure <90\u00a0mmHg, hemoglobin <11\u00a0g/dL, temperature <35.5 o C, international normalized ratio >\u00a01.5, base deficit \u22656\u00a0mEq/L, heart rate \u2265120\u00a0bpm, presence of penetrating trauma, and Focused Abdominal Sonography Trauma exam have been evaluated to determine their predictive ability in patients arriving at trauma centers. All were be predictive of the need of massive transfusion protocol except for temperature. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8743", "text": "Surgeons have used the concept of damage control surgery for years, and controlling hemorrhage with packing is over a century old. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. [ 7 ]  The U.S. military did not encourage this technique during World War II and the Vietnam War. Lucas and Ledgerwood described the principle in a series of patients. [ 19 ]  Subsequent studies were repeated by Feliciano and colleagues, [ 20 ]  and they found that hepatic packing increased survival by 90%. This technique was then specifically linked to patients who were hemorrhaging, hypothermic, and coagulopathic. [ 21 ]  This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term \u201cdamage control\u201d. [ 22 ]  This term was taken from the United States Navy who initially used the term as \u201cthe capacity of a ship to absorb damage and maintain mission integrity\u201d (DOD 1996). This was the first article that brought together the concept of limiting operative time in these critically ill patients to allow for reversal of physiologic insults to improve survival. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Since this description the development of this concept has grown both within the trauma community and beyond."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8744", "text": "The data that have been published regarding definitive laparotomy versus damage control surgery demonstrate a decrease in mortality when performed in the critically ill patient. [ 21 ] [ 6 ]  Subsequent studies by Rotondo and colleagues in a group of 961 patients that had undergone damage control surgery demonstrate an overall mortality of 50% and a 40% morbidity rate. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8745", "text": "There are four main complications. The first is development of an intra-abdominal abscess. This has been reported as high as 83%. [ 20 ] [ 21 ]  Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. [ 5 ] [ 24 ]  The third is abdominal compartment syndrome that has been reported anywhere from 10 to 40% of the time. [ 25 ] [ 26 ]  Finally fascial dehiscence has been shown to result in 9\u201325% of patients that have undergone damage control surgery. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8746", "text": "Diagnostic peritoneal lavage  ( DPL ) or  diagnostic peritoneal aspiration  ( DPA ) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the  abdominal cavity . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8747", "text": "This procedure is performed when intra-abdominal bleeding ( hemoperitoneum ), usually secondary to trauma, is suspected. [ 2 ]  In a hemodynamically  unstable patient with high-risk mechanism of injury, peritoneal lavage is a means of rapidly diagnosing intra-abdominal injury requiring laparotomy, but has largely been replaced in trauma care by the use of a  focused assessment with sonography for trauma  (FAST scan) due to its repeatability, non-invasiveness and non-interference with subsequent  computed tomography  (CT scan). Abdominal CT and  contrast duodenography  may complement lavage in stable patients, but in an unstable or uncooperative persons, these studies are too time-consuming or require ill-advised sedation.  Magnetic resonance imaging  is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma. [ 3 ] [ 4 ] \nThe procedure was first described in 1965 by Hauser Root. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8748", "text": "After the application of  local anesthesia , a vertical skin incision is made one third of the distance from the  umbilicus  to the  pubic symphysis .  The  linea alba  is divided and the  peritoneum  entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material attempted using a syringe. If no blood is aspirated, 1 litre of warm 0.9% saline is infused and after a few (usually 5) minutes this is drained and sent for analysis. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8749", "text": "If any of the following are found then the DPL is positive and operative exploration is warranted: [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8750", "text": "Early appropriate care  (EAC) is a system in  orthopaedic   trauma surgery  aiming to identify serious  major trauma  patients and treat the most  time-critical  injuries without adding to their physiological burden."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8751", "text": "EAC prescribes that definitive management of unstable  axial skeleton  and  long bone   fractures  should only be undertaken within 36 hours if an adequate response to  resuscitation  has been demonstrated by: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8752", "text": "Other factors such as  coagulopathy  and  hypothermia  (parts of the  Trauma triad of death ) would also be indications for DCO with  external fixation . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8753", "text": "Early total care  (ETC) became widespread in the 1980s, when studies showed early definitive  fixation  of  long bone   fractures  lead to better outcomes, with a reduction in incidence of secondary  ARDS ,  fat embolism  and  sepsis . [ 1 ]   Subsequent studies showed that in the unstable patient, long operations lead to a 'second hit' which actually worsened  mortality  outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8754", "text": "A philosophy of  damage control orthopaedics  (DCO) was proposed in 2000, [ 2 ]  aiming to prevent early death in a critically wounded patient via stabilization and not definitive  fixation , often with the use of  external fixation  systems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8755", "text": "EAC was developed by  Heather Vallier  while at MetroHealth in Cleveland. [ 3 ]  The term early appropriate care was first proposed in her  Journal of Orthopaedic Trauma  article in 2013 [ 3 ]  as an evolution of DCO, with a focus on  resuscitation  rather than  injury severity score ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8756", "text": "Paula Andrea Ferrada Tolra  (born April 28, 1977 in  Cali, Colombia ) is a Colombian-born surgeon and physician. She is a leader in trauma and acute care surgery. She is an internationally recognized advocate for equity, diversity and inclusion. [ 1 ]  Dr Ferrada currently serves as the system and division chief for Trauma and Acute Care Surgery Services at Inova Healthcare system. [ 2 ]  She also serves as an educator with an appointment as a Professor of Medical Education at the  University of Virginia . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8757", "text": "In 1994, Paula was awarded the title of  Miss Belleza Juvenil  a beauty pageant in Colombia, and became the hostess of a local TV show called  Super Bien . After acting in numerous episodes in the Colombian comedy  O todos en la cama , [ 4 ]  Paula began a modeling career, appearing in more than 50 television commercials."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8758", "text": "Ferrada finished medical school in  Cali, Colombia , and arrived in the United States to pursue further training. After a year of research at the  University of Miami , [ 5 ]  Ferrada joined  Beth Israel Deaconess Medical Center , one of the major  Harvard  teaching hospitals for surgical residency. She was the first Colombian woman to graduate from a surgical specialty from Harvard. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8759", "text": "Ferrada trained for one more year in Trauma and Critical care at the  University of Pittsburgh , [ 7 ]  and then joined the  R Adams Cowley Shock Trauma Center  at the  University of Maryland Medical Center [ 8 ]  as their first Acute Care Surgery  Fellow . She joined  Virginia Commonwealth University  as faculty in the Division of Acute Care Surgical Services. [ 9 ]  She advanced to the rank of Professor of Surgery at this institution."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8760", "text": "Ferrada is now a well-established surgeon-scientist, educator and leader  [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8761", "text": "While still a resident, Ferrada became an  American College of Surgeons   Ultrasound Instructor  and in 2007 she directed her first ultrasound course for residents."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8762", "text": "As a result of her hard work in educating medical students and residents, she was recognized with multiple teaching awards from  Harvard Medical School . As a surgeon she continued to work arduously in medical education. She was the recipient of the Irby-James Award for Excellence in Clinical Teaching and the  Leonard Tow  Humanism in Medicine Award during her tenure at the Virginia Commonwealth University  VCU School of Medicine . [ 11 ]  She was also the recipient of the Leadership in Graduate Medical Education at this institution. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8763", "text": "Ferrada directed multiple  ultrasound courses  for residents and trained multiple surgeons in the use of bedside ultrasound. She is well-versed in  echocardiography  and its use in fluid status management as a result of her training at the Trauma Echocardiography Service at  Shock Trauma . She is the creator of a course designed to train first responders in the use of ultrasound to guide therapy in hypotensive patients. In collaboration with the Panamerican Trauma Society, Dr Ferrada taught this course in over 10 countries throughout Latin America. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8764", "text": "Ferrada is a member of the  Eastern Association for the Surgery of Trauma . Through this organization, Dr. Ferrada began dedicating her career toward mentoring young surgeons. During her tenure as the Chair of the mentoring committee she created a mid-career mentoring program. [ 14 ]  While serving as the Division Chair of Member Services for this organization, she developed a Twitter chat, a speaker's bureau, and several recruitment initiatives. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8765", "text": "As a statement of Dr Ferrada\u2019s commitment to education and mentoring she was inducted as a Member of The Academy of Master Surgeon Educators\u2122 (MAMSE). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8766", "text": "In 2022, she earned the recognition of The Olga Jonasson Distinguished Member Award from the Association of Women surgeons as a statement of her service as mentor to countless women surgeons. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8767", "text": "After joining the American College of Surgeons she dedicated her service to help other surgeons, using her leadership skills to open opportunities for others. She held multiple leadership roles in this organization, including President of the Virginia Chapter, [ 18 ]  Chair or the Young Fellows Association, [ 19 ]  served as a member of the program committee for the American College of Surgeons Clinical Congress, [ 20 ]  and she is currently the Vice Chair for verification and certification for the National Ultrasound Faculty. [ 21 ]  She has also served as part of the Women In Surgery Committee for this organization. These leadership positions have allowed Dr Ferrada to empower women and unrepresented minorities and increase their involvement and participation in the activities of this organization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8768", "text": "She served as past president for the Virginia Chapter of the Association for Women Surgeons. During her tenure she worked to support and mentor medical students in all the medical school programs in the state. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8769", "text": "She is very active in global surgery education through her membership in the Panamerican Trauma Society and with empowering women and young surgeons in  Latin American  countries. During her tenure as the Chair of the Education and Research committee she created a path for multi-institutional trials, founded a travel scholarship for young surgeons, founded an award for surgeon scientists and created a program to support Latin American surgeons in publishing their research. She served as the Executive Secretary for this organization, and in 2023 she became President of this organization, making her the second woman representing North America, and the youngest surgeon to serve in this role."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8770", "text": "She has collaborated with social media effectively to create awareness about equality and diversity issues in surgery. [ 1 ]  Through Twitter, Facebook, blogs and other channels, Dr Ferrada has empowered a diverse group of people to shatter stereotypes and show that surgeons do not need to conform to a specific image."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8771", "text": "Dr Ferrada is an alumna of The Hedwig van Ameringen Executive Leadership in Academic Medicine\u00ae program (ELAM\u00ae). This is a competitive program is dedicated to developing the professional and personal skills required to lead and manage in today's complex health care environment, with special attention to the unique challenges facing women in leadership positions. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8772", "text": "In addition to her academic and clinical work, Dr. Ferrada has been awarded multiple grants providing support for her research in trauma resuscitation, including but not limited to, surgeon-performed ultrasound. In addition, Dr. Ferrada has over 120 publications in peer-reviewed journals. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8773", "text": "She currently serves as an Associate Editor for the American Journal of Surgery. [ 25 ]  She serves on the editorial boards for the Journal of the American College of Surgeons, [ 26 ]  the Journal Surgery, [ 27 ]  and the Journal of Trauma and Acute Care Surgery. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8774", "text": "In the  United States Army , Medical Detachments (Forward Surgical), popularly known as  Forward Surgical Teams  (FST), are small, mobile surgical units. A functional operating room can be established within one and a half hours of being on scene and break down to move to a new location within two hours of ceasing operations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8775", "text": "The FST typically includes 20 staff members: 4  surgeons , 3  RNs , 2 certified registered nurse anesthetists (CRNAs), 1 administrative officer, 1 detachment sergeant, 3  licensed practical nurses (LPN)'s , 3  surgical techs  and 3  medics .\nSurgeons perform damage control surgery on combat casualties within the \"golden hour\" of injury whenever possible.  Casualties can then be packaged for medical evacuation to a higher level of care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8776", "text": "First fielded during Operation Just Cause in December 1989. [ 1 ]  FSTs are utilized in a variety of ways, and can be fielded with support elements, including a  Forward Support Medical Company  (FSMC), Area Support Medical Company (ASMC), Brigade Medical Company also known as C-Med or in some cases stand alone (although The FST is not designed, staffed, or equipped for standalone\noperations or for conducting sick-call operations.\nAugmentation requirements are discussed in FM 4-02.25) to provide a surgical capability at Role 2 for those patients unable to survive MEDEVAC to Role 3 (hospital) care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8777", "text": "By doctrine, given in ATP 4-02.5 (May 2013) Chapter 3 section 10, [ 2 ]  and ARTEP 8-518-10, the team is capable of continuous operations with a divisional or non-divisional medical company for up to 72 hours with a planned caseload of 30 critical patients. The FST can sustain surgery for 24 total operating table hours and has the ability to separate into two teams while jumping from one site to another.  Sustained split operations are common in Iraq and Afghanistan, although not supported by current doctrine in FM 8-10-25."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8778", "text": "FSTs are currently deployed in both Afghanistan and Iraq. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8779", "text": "The forward surgical team is organized into four functional areas:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8780", "text": "The Forward Surgical Team equipment and supplies are packed into four  HMMWVs  each with an M1101 trailer and two LMTV 2.5 ton cargo trucks each with a M1082 cargo trailer.  Units are normally augmented with two trailers mounting a power generator and an air conditioning system.  These trailers are referred to as ECU [Environmental Control Units] or GET [Generator/ECU Trailers].  When so equipped, two of the M1101 trailers are removed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8781", "text": "The airborne Forward Surgical Team can be slingloaded onto cargo helicopters and moved by the headquarters unit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8782", "text": "The Journal of Trauma and Acute Care Surgery  is a monthly  peer-reviewed   medical journal  covering the study of  traumatic injuries . It was established in 1961 as the  Journal of Trauma  by Williams & Wilkins, obtaining its current name in 2012. [ 1 ]  The journal is currently published by  Lippincott Williams & Wilkins  and is the official journal of the  American Association for the Surgery of Trauma , the  Eastern Association for the Surgery of Trauma , the  Trauma Association of Canada , and the  Western Trauma Association . [ 2 ]  The  editor-in-chief  is Ernest E. Moore ( Denver Health Medical Center )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8783", "text": "According to the  Journal Citation Reports , the journal has a 2016  impact factor  of 3.403, ranking it 11th out of 33 journals in the category \"Critical Care Medicine\". [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8784", "text": "This article about a  surgery   journal  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8785", "text": "See tips for writing articles about academic journals . Further suggestions might be found on the article's  talk page ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8786", "text": "Hans-Christoph Pape  is a German surgeon and trauma surgeon and was appointed full professor of traumatology at the Medical Faculty of the  University of Zurich  on 31 October 2016, effective 1 February 2017. He heads the Department of Traumatology at the  University Hospital Zurich . [ 1 ]  In particular, his research on  polytrauma ,  pelvic fractures  and severe joint injuries (articular) helped him to achieve a high international profile. From 2005 to 2009, he was head of the trauma surgery department at the  University of Pittsburgh Medical Center  (UPMC),  Pittsburgh , USA. From 2009 to 2016, he was head of the Department of Trauma and Reconstructive Surgery at the  University Hospital RWTH Aachen . Since March 2018, he has also once again been an adjunct professor at the University of Pittsburgh Medical Center (UPMC), Pittsburgh."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8787", "text": "Pape studied human medicine at  Hannover Medical School   from 1981 to 1988 [ 2 ]  and subsequently trained there as a specialist surgeon from 1989 to 1995. In 1989, he received his doctorate in Hanover with the dissertation titled:  Wirkungen von Iloprost auf die lysosomale Membran des Katzenhirns promoviert  (Effects of Iloprost on the Lysosomal Membrane of the Cat Brain). [ 3 ]  This was followed by the overlapping specialist qualification in orthopaedics and trauma surgery (2010). This was followed by the overarching specialist qualification in orthopaedics and trauma surgery (2010). He received his additional training in trauma surgery from  Harald Tscherne  (1996). [ 4 ]  During this time he devoted himself to polytrauma (injuries to several regions of the body), pelvic fractures and severe joint injuries and habilitated in this field (1996)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8788", "text": "In 2000, he was appointed Professor of Trauma Surgery at the  Hannover Medical School . From 2003 to 2005 he was a visiting professor at  Massachusetts General Hospital , Boston, the  University of Leeds ,  McGill University Health Centre  in Montreal, the  University of Colorado Denver , the  University of Alabama  in Birmingham, the University of Texas in El Paso, Ganga Medical Center & Hospitals,  Coimbatore  (India), the University of New York at Buffalo, the  University of Mississippi Medical Center  in Jackson,  Vanderbilt University , Nashville, Tennessee, Horten General Hospital, Banbury, Oxford, among others. From 2005 to 2009, Pape was head of the Department of Trauma Surgery at the University of Pittsburgh Medical Center UPMC, Pittsburgh, USA. Since 2009, he has been Clinic Director of the Department of Trauma and Reconstructive Surgery at  RWTH Aachen University  Hospital. In November 2016, he was elected to succeed  Hans-Peter Simmen  as Director of the Clinic for Trauma Surgery at the  University Hospital Zurich  and as Full Professor of Traumatology at the Medical Faculty of the University of Zurich. [ 5 ]  He took up the post on 1 February 2017. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8789", "text": "Hans-Christoph Pape is a fellow of several societies as follows:  Fellow of the American College of Surgeons (FACS) , Fellow of the  European Board of Surgery  (FEBS) and  Fellow of the American Association of Orthopaedic Surgeons (FAAOS).  He also has a qualification in  emergency medicine  and  physical therapy  (July 2014)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8790", "text": "Hans-Christoph Pape is the lead author of more than 90 and co-author of more than 400 scientific articles. [ 7 ]  His  h-index  stands at 83, his current ResearchGate score at 50.43. He is the editor and co-editor of several textbooks. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8791", "text": "In 2002, he established a then new course concept for the treatment of multiply injured patients, named  Polytrauma Course  in cooperation  with  Peter Giannoudis of the University of Leeds, which achieved recognition at international specialists\u2019 conventions. [ 10 ]  He also directed the  trauma group  of the Soci\u00e9t\u00e9 Internationale de Chirurgie Orthop\u00e9dique et de Traumatologie (SICOT)] between 2015 and 2020. [ 11 ]  He is likewise a member of the  founding committee of the Orthopaedic Trauma Association (OTA)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8792", "text": "Pape has chaired the International Committee of the Orthopaedic Trauma Association since 2019. [ 12 ]  He chaired the  Polytrauma Section of  the  European Society for Trauma and Emergency Surgery (ESTES) until May, 2023, \n [ 13 ]  He was President of the European Society for Trauma and Emergency Surgery (ESTES) from 2015 to 2016. [ 14 ]   He has been the General Secretary of the European Society for Trauma and Emergency Surgery (ESTES) since May 2023."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8793", "text": "A  trauma center , or  trauma centre , is a  hospital  equipped and staffed to provide care for patients suffering from  major traumatic injuries  such as  falls ,  motor vehicle collisions , or  gunshot wounds . The term \"trauma center\" may be used incorrectly to refer to an  emergency department  (also known as a \"casualty department\" or \"accident and emergency\") that lacks the presence of specialized services or certification to care for victims of  major trauma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8794", "text": "In the United States, a hospital can receive trauma center status by meeting specific criteria established by the  American College of Surgeons  (ACS) and passing a site review by the Verification Review Committee. [ 1 ]  Official designation as a trauma center is determined by individual state law provisions. Trauma centers vary in their specific capabilities and are identified by \"Level\" designation, Level I (Level-1) being the highest and Level III (Level-3) being the lowest (some states have four or five designated levels)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8795", "text": "The highest levels of trauma centers have access to specialist medical and  nursing  care, including  emergency medicine ,  trauma surgery ,  critical care ,  neurosurgery ,  orthopedic surgery ,  anesthesiology , and  radiology , as well as a wide variety of highly specialized and sophisticated surgical and diagnostic equipment. [ 2 ] [ 3 ] [ 4 ]  Lower levels of trauma centers may be able to provide only initial care and stabilization of a traumatic injury and arrange for transfer of the patient to a higher level of trauma care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8796", "text": "The operation of a trauma center is often expensive and some areas may be underserved by trauma centers because of that expense. [ citation needed ]  As there is no way to schedule the need for emergency services, patient traffic at trauma centers can vary widely. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8797", "text": "A trauma center may have a  helipad  for receiving patients that have been  airlifted  to the hospital. In some cases, persons injured in remote areas and transported to a distant trauma center by  helicopter  can receive faster and better medical care than if they had been transported by ground  ambulance  to a closer hospital that does not have a designated trauma center."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8798", "text": "Trauma centres grew into existence out of the realisation that  traumatic injury  is a disease process unto itself requiring specialised and experienced multidisciplinary treatment and specialised resources. The world's first trauma centre, the first hospital to be established specifically to treat injured rather than ill patients, was the  Birmingham Accident Hospital , which opened in  Birmingham , England in 1941 after a series of studies found that the treatment of injured persons within England was inadequate. By 1947, the hospital had three  trauma teams , each including two surgeons and an anaesthetist, and a burns team with three surgeons. The hospital became part of the  National Health Service  in its formation in July 1948 and closed in 1993. [ 5 ]  The NHS now has 27  major trauma centres  established across  England , four in  Scotland , and one planned in  Wales ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8799", "text": "According to the  CDC , injuries are the leading cause of death for American children and young adults ages 1\u201319. [ 6 ]  The leading causes of trauma are motor vehicle collisions, falls, and assaults with a deadly weapon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8800", "text": "In the United States, Robert J. Baker and Robert J. Freeark established the first civilian Shock Trauma Unit at Cook County Hospital (opened 1834) in Chicago, Illinois on March 16, 1966. [ 7 ]  The concept of a shock trauma center was also developed at the  University of Maryland, Baltimore , in the 1950s and 1960s by thoracic surgeon and  shock  researcher  R Adams Cowley , who founded what became the  Shock Trauma Center  in  Baltimore ,  Maryland , on July 1, 1966. The R Adams Cowley Shock Trauma Center is one of the first shock trauma centers in the world. [ 8 ]   Cook County Hospital  in Chicago trauma center (opened in 1966). [ 9 ]  David R. Boyd interned at  Cook County Hospital  from 1963 to 1964 before being drafted into the  Army of the United States of America . Upon his release from the Army, Boyd became the first shock-trauma fellow at the R Adams Cowley Shock Trauma Center, and then went on to develop the National System for  Emergency Medical Services , under  President Ford . [ 10 ]  In 1968 the American Trauma Society was created by various co-founders, including  R Adams Cowley  and  Rene Joyeuse  as they saw the importance of increased education and training of emergency providers and for nationwide quality trauma care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8801", "text": "According to the founder of the Trauma Unit at  Sunnybrook Health Sciences Centre  in  Toronto , Ontario,  Marvin Tile , \"the nature of injuries at Sunnybrook has changed over the years. When the trauma centre first opened in 1976, about 98 per cent of patients suffered from blunt-force trauma caused by accidents and falls. Now, as many as 20 per cent of patients arrive with gunshot and  knife  wounds\". [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8802", "text": "Fraser Health Authority  in  British Columbia , located at  Royal Columbian Hospital  and Abbotsford Regional Hospital, services the BC area, \"Each year, Fraser Health treats almost 130,000 trauma patients as part of the integrated B.C. trauma system\". [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8803", "text": "In the United States, trauma centers are certified by the  American College of Surgeons  (ACS) or local state governments, from Level I (comprehensive service) to Level III (limited-care). The different levels refer to the types of resources available in a trauma center and the number of patients admitted yearly. These are categories that define national standards for trauma care in  hospitals . Level I through Level II designations are also given adult or  pediatric  designations. [ 13 ]  Additionally, some states have their own trauma-center rankings separate from that of the ACS. These levels may range from Level I to Level IV. Some hospitals are less-formally designated Level V."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8804", "text": "The ACS does not  officially  designate hospitals as trauma centers. Numerous U.S. hospitals that are not verified by ACS claim trauma center designation. Most states have legislation that determines the process for designation of trauma centers within that state. The ACS describes this responsibility as \"a geopolitical process by which empowered entities, government or otherwise, are authorized to designate.\" The ACS's self-appointed mission is limited to confirming and reporting on any given hospital's ability to comply with the ACS standard of care known as  Resources for Optimal Care of the Injured Patient . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8805", "text": "The Trauma Information Exchange Program (TIEP) [ 15 ]  is a program of the American Trauma Society in collaboration with the Johns Hopkins Center for Injury Research and Policy and is funded by the  Centers for Disease Control and Prevention . TIEP maintains an inventory of trauma centers in the US, collects data and develops information related to the causes, treatment and outcomes of injury, and facilitates the exchange of information among trauma care institutions, care providers, researchers, payers and policymakers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8806", "text": "A trauma center is a hospital that is designated by a state or local authority or is verified by the American College of Surgeons. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8807", "text": "A Level I trauma center provides the highest level of surgical care to  trauma  patients. Being treated at a Level I trauma center can reduce mortality by 25% compared to a non-trauma center. [ 17 ]  It has a full range of specialists and equipment available 24 hours a day [ 18 ]  and admits a minimum required annual volume of severely injured patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8808", "text": "A Level I trauma center is required to have a certain number of the following people on duty 24 hours a day at the hospital:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8809", "text": "Key elements include 24\u2011hour in\u2011house coverage by general surgeons and prompt availability of care in varying specialties\u2014such as  orthopedic surgery ,  cardiothoracic surgery ,  neurosurgery ,  plastic surgery ,  anesthesiology ,  emergency medicine ,  radiology ,  internal medicine ,  otolaryngology ,  oral and maxillofacial surgery , and  critical care , which are needed to adequately respond and care for various forms of trauma that a patient may suffer, as well as provide rehabilitation services. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8810", "text": "Most Level I trauma centers are teaching hospitals/campuses. Additionally, a Level I center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8811", "text": "A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Oftentimes, level II centers possess critical care services capable of caring for almost all injury types indefinitely. Minimum volume requirements may depend on local conditions. Such institutions are not required to have an ongoing program of research or a surgical residency program. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8812", "text": "A Level III trauma center does not have the full availability of specialists but has resources for emergency resuscitation, surgery, and intensive care of most trauma patients. A Level III center has transfer agreements with Level I or Level II trauma centers that provide back-up resources for the care of patients with exceptionally severe injuries, such as multiple trauma. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8813", "text": "A Level IV trauma center exists in some states in which the resources do not exist for a Level III trauma center. It provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may also provide surgery and critical-care services, as defined in the scope of services for trauma care. A trauma-trained nurse is immediately available, and physicians are available upon the patient's arrival in the Emergency Department. Transfer agreements exist with other trauma centers of higher levels, for use when conditions warrant a transfer. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8814", "text": "A Level V trauma center provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. They may provide surgical and critical-care services, as defined in the service's scope of trauma care services. A trauma-trained nurse is immediately available, and physicians are available upon patient arrival in the emergency department. If not open 24 hours daily, the facility must have an after-hours trauma response protocol. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8815", "text": "A facility can be designated an adult trauma center, a pediatric trauma center, or an adult and pediatric trauma center. If a hospital provides trauma care to both adult and pediatric patients, the level designation may not be the same for each group. For example, a Level I adult trauma center may also be a Level II pediatric trauma center because pediatric trauma surgery is a specialty unto itself. Adult trauma surgeons are not generally specialized in providing surgical trauma care to children and vice versa, and the difference in practice is significant. In contrast to adult trauma centers, pediatric trauma centers only have two ratings, either level I or level II. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8816", "text": "A  trauma team  is a multidisciplinary group of healthcare workers under the direction of a team leader that works together to assess and treat the severely injured. [ 1 ]  This team typically meets before the patient reaches the trauma center. Upon arrival, the team does an initial assessment and necessary resuscitation, adhering to a defined protocol. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8817", "text": "Trauma teams can consist of the following: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8818", "text": "Other specialties can be added depending on the nature of the injury. For example a  neurosurgeon  will attend if there is a serious head injury; However, added members should not draw away from the functioning and responsibilities of the core team. [ 2 ]  Many hospitals will have neurosurgeons,  orthopedic surgeons ,  plastic surgeons ,  cardiothoracic surgeons , and physicians from other specialties on standby. [ 4 ] [ 7 ]  All staff should be trained in  Advanced Trauma Life Support  techniques. Each  hospital  will have a list of criteria that require the activation of the trauma team, such as a fall of over 6 meters or a  fracture  of 2 or more  bones ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8819", "text": "There is no single universal list that dictates trauma team activation across different facilities. Each individual trauma center should generate its own criteria that are specifically designed for the location, available resources, and the patients. These criteria should also be easy to understand and readily available to the necessary individuals. Trauma team activation should be closely monitored and evaluated constantly to adapt to the changing healthcare field and regulations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8820", "text": "Hospitals should clearly define when the team must be assembled, who is to respond, and how they will be notified. Most trauma centers have multiple tiers, meaning not every member of a trauma team needs to respond to every emergency.  [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8821", "text": "Trauma teams are important to reduce mortality of patients. Its multi-faceted approach incorporates a variety of medical fields both in the hospital and out of the hospital in the form of  Emergency Medical Services . Trauma teams reduce the time between the emergency department arrival and other necessary steps to treat patents such as CT scans and  operating rooms . Patients who have traumatic injuries but are not treated by the trauma team have increased mortality. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8822", "text": "Trauma teams are assessed in multiple ways: by video, simulators, and third party observers. All three are used to identify errors and improve care. Video is one of the most efficient methods of review because trauma team members can see the errors being done in real time. Some common errors noted from video review are failure of team coordination, poor communication, and failure to do certain tasks. One downfall of video review is its inability to review vital signs without a specific vital sign monitor recording. Confidentiality can also be an issue with video review because patient consent is difficult to obtain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8823", "text": "Simulators can be an effective learning tool as well. A benefit of using simulators is the ability to stop mid procedure. Doing so offers the team an opportunity to pause while no lives are at stake, providing a learning environment that feels safer and more open. The simulator itself can be a downfall as it may be difficult to use."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8824", "text": "Observation by third party is effective when assessing one team member, but can be less effective if one observer is expected to monitor all members. It may also yield biased data.  [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8825", "text": "The  trauma triad of death  is a medical term describing the combination of  hypothermia ,  acidosis , and  coagulopathy . [ 1 ]  This combination is commonly seen in patients who have sustained severe  traumatic injuries  and results in a significant rise in the  mortality rate . [ 2 ]  Commonly, when someone presents with these signs,  damage control surgery  is employed to reverse the effects. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8826", "text": "The three conditions share a complex relationship; each factor can compound the others, resulting in high mortality if this  positive feedback  loop continues uninterrupted. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8827", "text": "Severe  bleeding  in trauma diminishes  oxygen delivery , and may lead to  hypothermia . This in turn can halt the  coagulation cascade , preventing  blood from clotting . In the absence of blood-bound oxygen and nutrients ( hypoperfusion ), the body's cells burn glucose  anaerobically  for energy, causing the release of  lactic acid ,  ketone bodies , and other  acidic  compounds into the blood stream, which lower the blood's  pH , leading to  metabolic acidosis . Such an increase in acidity damages the tissues and organs of the body and can reduce  myocardial performance , further reducing the oxygen delivery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8828", "text": "TraumaMan  is a surgical simulation  manikin  used for teaching surgical skills, including the American College of Surgeons'  Advanced Trauma Life Support  (ATLS) program, to medical professionals. [ 1 ]  TraumaMan is also used to advance surgical skills in combat situations. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8829", "text": "The TraumaMan surgical trainer has become a preferred alternative to the use of animals by both medical students and instructors alike for teaching emergency trauma surgical skills. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8830", "text": "TraumaMan is used to train on the following surgical procedures  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8831", "text": "Wound healing  refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8832", "text": "In undamaged skin, the  epidermis  (surface,  epithelial  layer) and  dermis  (deeper,  connective  layer) form a protective barrier against the external environment. When the barrier is broken, a regulated sequence of biochemical events is set into motion to repair the damage. [ 1 ] [ 2 ]  This process is divided into predictable phases: blood clotting ( hemostasis ),  inflammation , tissue growth ( cell proliferation ), and tissue remodeling (maturation and  cell differentiation ). Blood clotting may be considered to be part of the inflammation stage instead of a separate stage. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8833", "text": "The wound-healing process is not only complex but fragile, and it is susceptible to interruption or failure leading to the formation of non-healing  chronic wounds . Factors that contribute to non-healing chronic wounds are diabetes, venous or arterial disease, infection, and metabolic deficiencies of old age. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8834", "text": "Wound care encourages and speeds wound healing via cleaning and protection from reinjury or infection. Depending on each patient's needs, it can range from the simplest  first aid  to entire nursing specialties such as  wound, ostomy, and continence nursing  and  burn center  care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8835", "text": "Timing is important to wound healing. Critically, the timing of wound re-epithelialization can decide the outcome of the healing. [ 11 ]  If the epithelization of tissue over a denuded area is slow, a  scar  will form over many weeks, or months; [ 12 ] [ 13 ]  If the epithelization of a wounded area is fast, the healing will result in regeneration. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8836", "text": "Wound healing is classically divided into  hemostasis , inflammation, proliferation, and remodeling. Although a useful construct, this model employs considerable overlapping among individual phases. A complementary model has recently been described [ 1 ]  where the many elements of wound healing are more clearly delineated. The importance of this new model becomes more apparent through its utility in the fields of  regenerative medicine  and  tissue engineering  (see Research and development section below). In this construct, the process of wound healing is divided into two major phases: the  early phase  and the  cellular phase : [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8837", "text": "The early phase, which begins immediately following skin injury, involves cascading molecular and cellular events leading to hemostasis and formation of an early, makeshift extracellular matrix that provides structural  staging  for cellular attachment and subsequent cellular proliferation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8838", "text": "The cellular phase involves several types of cells working together to mount an inflammatory response, synthesize granulation tissue, and restore the epithelial layer. [ 1 ]  Subdivisions of the cellular phase are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8839", "text": "Just before the inflammatory phase is initiated, the  clotting cascade  occurs in order to achieve  hemostasis , or the stopping of blood loss by way of a fibrin clot. Thereafter, various soluble factors (including chemokines and cytokines) are released to attract cells that  phagocytise  debris, bacteria, and damaged tissue, in addition to releasing signaling molecules that initiate the proliferative phase of wound healing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8840", "text": "When  tissue  is first wounded, blood comes in contact with  collagen , triggering blood  platelets  to begin secreting inflammatory factors. [ 15 ]  Platelets also express sticky  glycoproteins  on their  cell membranes  that allow them to  aggregate , forming a mass. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8841", "text": "Fibrin  and  fibronectin  cross-link together and form a plug that traps  proteins  and particles and prevents further blood loss. [ 16 ]   This fibrin-fibronectin plug is also the main structural support for the wound until collagen is deposited. [ 7 ]  Migratory cells use this plug as a matrix to crawl across, and platelets adhere to it and secrete factors. [ 7 ]  The clot is eventually lysed and replaced with  granulation tissue  and then later with collagen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8842", "text": "Platelets, the cells present in the highest numbers shortly after a wound occurs, release mediators into the blood, including  cytokines  and  growth factors . [ 15 ]  Growth factors stimulate cells to speed their rate of division. Platelets release other proinflammatory factors like  serotonin ,  bradykinin ,  prostaglandins ,  prostacyclins ,  thromboxane , and  histamine , [ 3 ]  which serve several purposes, including increasing cell proliferation and migration to the area and causing  blood vessels  to become dilated and  porous . In many ways, extravasated platelets in trauma perform a similar function to tissue  macrophages  and  mast cells  exposed to  microbial molecular signatures  in infection: they become activated, and secrete molecular mediators \u2013 vasoactive amines,  eicosanoids , and  cytokines   \u2013 that initiate the  inflammatory  process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8843", "text": "Immediately after a  blood vessel  is breached, ruptured  cell membranes  release inflammatory factors like  thromboxanes  and  prostaglandins  that cause the vessel to spasm to prevent blood loss and to collect inflammatory cells and factors in the area. [ 3 ]  This  vasoconstriction  lasts five to ten minutes and is followed by  vasodilation , a widening of blood vessels, which peaks at about 20 minutes post-wounding. [ 3 ]  Vasodilation is the result of factors released by platelets and other cells. The main factor involved in causing vasodilation is  histamine . [ 3 ] [ 15 ]  Histamine also causes blood vessels to become porous, allowing the tissue to become  edematous  because proteins from the bloodstream leak into the extravascular space, which increases its osmolar load and draws water into the area. [ 3 ]  Increased  porosity  of blood vessels also facilitates the entry of inflammatory cells like  leukocytes  into the wound site from the  bloodstream . [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8844", "text": "Within an hour of wounding,  polymorphonuclear neutrophils  (PMNs) arrive at the wound site and become the predominant cells in the wound for the first two days after the injury occurs, with especially high numbers on the second day. [ 19 ]  They are attracted to the site by fibronectin, growth factors, and substances such as  kinins . Neutrophils phagocytise debris and kill bacteria by releasing  free radicals  in what is called a  respiratory burst . [ 20 ] [ 21 ]  They also cleanse the wound by secreting  proteases  that break down damaged tissue. Functional neutrophils at the wound site only have life-spans of around two days, so they usually undergo apoptosis once they have completed their tasks and are engulfed and degraded by  macrophages . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8845", "text": "Other leukocytes to enter the area include  helper T cells , which secrete  cytokines  to cause more T cells to divide and to increase inflammation and enhance vasodilation and vessel permeability. [ 17 ] [ 23 ]  T cells also increase the activity of macrophages. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8846", "text": "One of the roles of  macrophages  is to phagocytize other expended  phagocytes , [ 24 ]  bacteria and damaged tissue, [ 19 ]  and they also debride damaged tissue by releasing proteases. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8847", "text": "Macrophages function in regeneration [ 26 ] [ 27 ]  and are essential for wound healing. [ 19 ]  They are stimulated by the low  oxygen  content of their surroundings to produce factors that induce and speed  angiogenesis [ 20 ]  and they also stimulate cells that reepithelialize the wound, create granulation tissue, and lay down a new  extracellular matrix . [ 28 ]  By secreting these factors, macrophages contribute to pushing the wound healing process into the next phase. They replace PMNs as the predominant cells in the wound by two days after injury. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8848", "text": "The  spleen  contains half the body's monocytes in reserve ready to be deployed to injured tissue. [ 29 ] [ 30 ]  Attracted to the wound site by growth factors released by platelets and other cells,  monocytes  from the bloodstream enter the area through blood vessel walls. [ 31 ]  Numbers of monocytes in the wound peak one to one and a half days after the injury occurs. [ 23 ]  Once they are in the wound site, monocytes mature into macrophages. Macrophages also secrete a number of factors such as growth factors and other cytokines, especially during the third and fourth post-wounding days. These factors attract cells involved in the proliferation stage of healing to the area. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8849", "text": "In wound healing that result in incomplete repair, scar contraction occurs, bringing varying gradations of structural imperfections, deformities and problems with flexibility. [ 32 ]  Macrophages may restrain the contraction phase. [ 27 ]  Scientists have reported that removing the macrophages from a  salamander  resulted in failure of a typical regeneration response (limb regeneration), instead bringing on a repair (scarring) response. [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8850", "text": "As inflammation dies down, fewer inflammatory factors are secreted, existing ones are broken down, and numbers of neutrophils and macrophages are reduced at the wound site. [ 19 ]  These changes indicate that the inflammatory phase is ending and the proliferative phase is underway. [ 19 ]  In vitro evidence, obtained using the  dermal equivalent  model, suggests that the presence of macrophages actually delays wound contraction and thus the disappearance of macrophages from the wound may be essential for subsequent phases to occur. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8851", "text": "Because inflammation plays roles in fighting infection, clearing debris and inducing the proliferation phase, it is a necessary part of healing. However, inflammation can lead to  tissue  damage if it lasts too long. [ 7 ]  Thus the reduction of inflammation is frequently a goal in therapeutic settings. Inflammation lasts as long as there is debris in the wound. Thus, if the individual's immune system is compromised and is unable to clear the debris from the wound and/or if excessive detritus, devitalized tissue, or microbial  biofilm  is present in the wound, these factors may cause a prolonged inflammatory phase and prevent the wound from properly commencing the proliferation phase of healing. This can lead to a  chronic wound ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8852", "text": "About two or three days after the wound occurs,  fibroblasts  begin to enter the wound site, marking the onset of the proliferative phase even before the inflammatory phase has ended. [ 35 ]  As in the other phases of wound healing, steps in the proliferative phase do not occur in a series but rather partially overlap in time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8853", "text": "Also called neovascularization, the process of angiogenesis occurs concurrently with fibroblast proliferation when endothelial cells migrate to the area of the wound. [ 36 ]  Because the activity of fibroblasts and epithelial cells requires oxygen and nutrients, angiogenesis is imperative for other stages in wound healing, like epidermal and fibroblast migration. The tissue in which angiogenesis has occurred typically looks red (is  erythematous ) due to the presence of  capillaries . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8854", "text": "Angiogenesis occurs in overlapping phases in response to inflammation:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8855", "text": "Stem cells  of  endothelial cells , originating from parts of uninjured blood vessels, develop  pseudopodia  and push through the  ECM  into the wound site to establish new blood vessels. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8856", "text": "Endothelial cells  are attracted to the wound area by fibronectin found on the fibrin  scab  and  chemotactically  by angiogenic factors released by other cells, [ 37 ]  e.g. from macrophages and platelets when in a low-oxygen environment. Endothelial growth and proliferation is also directly stimulated by  hypoxia , and presence of  lactic acid  in the wound. [ 35 ]  For example, hypoxia stimulates the endothelial  transcription factor ,  hypoxia-inducible factor  (HIF) to  transactivate  a set of proliferative genes including  vascular endothelial growth factor  (VEGF) and  glucose transporter 1  (GLUT1)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8857", "text": "To migrate, endothelial cells need  collagenases  and  plasminogen activator  to degrade the clot and part of the ECM. [ 3 ] [ 19 ]   Zinc -dependent  metalloproteinases  digest  basement membrane  and ECM to allow cell migration, proliferation and angiogenesis. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8858", "text": "When macrophages and other growth factor-producing cells are no longer in a hypoxic, lactic acid-filled environment, they stop producing angiogenic factors. [ 20 ]  Thus, when tissue is adequately  perfused , migration and proliferation of endothelial cells is reduced. Eventually blood vessels that are no longer needed die by  apoptosis . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8859", "text": "Simultaneously with angiogenesis,  fibroblasts  begin accumulating in the wound site. Fibroblasts begin entering the wound site two to five days after wounding as the inflammatory phase is ending, and their numbers peak at one to two weeks post-wounding. [ 19 ]  By the end of the first week, fibroblasts are the main cells in the wound. [ 3 ]  Fibroplasia ends two to four weeks after wounding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8860", "text": "As a model the mechanism of fibroplasia may be conceptualised as an analogous process to angiogenesis (see above) - only the cell type involved is fibroblasts rather than endothelial cells. Initially there is a latent phase where the wound undergoes plasma exudation, inflammatory decontamination and debridement. Oedema increases the wound histologic accessibility for later fibroplastic migration. Second, as inflammation nears completion, macrophage and mast cells release fibroblast growth and chemotactic factors to activate fibroblasts from adjacent tissue. Fibroblasts at this stage loosen themselves from surrounding cells and ECM. Phagocytes further release proteases that break down the ECM of neighbouring tissue, freeing the activated fibroblasts to proliferate and migrate towards the wound. The difference between vascular sprouting and fibroblast proliferation is that the former is enhanced by hypoxia, whilst the latter is inhibited by hypoxia. The deposited fibroblastic connective tissue matures by secreting ECM into the extracellular space, forming granulation tissue (see below). Lastly collagen is deposited into the ECM."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8861", "text": "In the first two or three days after injury, fibroblasts mainly migrate and proliferate, while later, they are the main cells that lay down the collagen matrix in the wound site. [ 3 ]  Origins of these fibroblasts are thought to be from the adjacent uninjured cutaneous tissue (although new evidence suggests that some are derived from blood-borne, circulating adult stem cells/precursors). [ 39 ]  Initially fibroblasts utilize the fibrin cross-linking fibers (well-formed by the end of the inflammatory phase) to migrate across the wound, subsequently adhering to fibronectin. [ 37 ]    Fibroblasts then deposit  ground substance  into the wound bed, and later collagen, which they can adhere to for migration. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8862", "text": "Granulation tissue  functions as rudimentary tissue, and begins to appear in the wound already during the inflammatory phase, two to five days post wounding, and continues growing until the wound bed is covered.  Granulation tissue consists of new blood vessels, fibroblasts, inflammatory cells, endothelial cells, myofibroblasts, and the components of a new, provisional  extracellular matrix  (ECM). The provisional ECM is different in composition from the ECM in normal tissue and its components originate from fibroblasts. [ 28 ]  Such components include fibronectin, collagen,  glycosaminoglycans ,  elastin ,  glycoproteins  and  proteoglycans . [ 37 ]  Its main components are fibronectin and  hyaluronan , which create a very hydrated matrix and facilitate cell migration. [ 31 ]  Later this provisional matrix is replaced with an ECM that more closely resembles that found in non-injured tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8863", "text": "Growth factors ( PDGF ,  TGF-\u03b2 ) and fibronectin encourage proliferation, migration to the wound bed, and production of ECM molecules by fibroblasts. Fibroblasts also secrete growth factors that attract epithelial cells to the wound site.  Hypoxia also contributes to fibroblast proliferation and excretion of growth factors, though too little oxygen will inhibit their growth and deposition of ECM components, and can lead to excessive, fibrotic  scarring ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8864", "text": "One of fibroblasts' most important duties is the production of  collagen . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8865", "text": "Collagen deposition is important because it increases the strength of the wound; before it is laid down, the only thing holding the wound closed is the fibrin-fibronectin clot, which does not provide much resistance to  traumatic injury . [ 20 ]  Also, cells involved in inflammation, angiogenesis, and connective tissue construction attach to, grow and differentiate on the collagen matrix laid down by fibroblasts. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8866", "text": "Type III collagen  and  fibronectin  generally begin to be produced in appreciable amounts at somewhere between approximately 10 hours [ 41 ]  and 3 days, [ 37 ]  depending mainly on wound size. Their deposition peaks at one to three weeks. [ 28 ]  They are the predominating tensile substances until the later phase of maturation, in which they are replaced by the stronger  type I collagen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8867", "text": "Even as fibroblasts are producing new collagen, collagenases and other factors degrade it. Shortly after wounding, synthesis exceeds degradation so collagen levels in the wound rise, but later production and degradation become equal so there is no net collagen gain. [ 20 ]  This homeostasis signals the onset of the later maturation phase. Granulation gradually ceases and fibroblasts decrease in number in the wound once their work is done. [ 42 ]  At the end of the granulation phase, fibroblasts begin to commit apoptosis, converting granulation tissue from an environment rich in cells to one that consists mainly of collagen. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8868", "text": "The formation of granulation tissue into an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment. [ 37 ]   Basal   keratinocytes  from the wound edges and  dermal appendages  such as  hair follicles ,  sweat glands  and  sebaceous (oil) glands  are the main cells responsible for the epithelialization phase of wound healing. [ 42 ]  They advance in a sheet across the wound site and proliferate at its edges, ceasing movement when they meet in the middle. In healing that results in a scar, sweat glands, hair follicles [ 43 ] [ 44 ]  and nerves do not form. With the lack of hair follicles, nerves and sweat glands, the wound, and the resulting healing scar, provide a challenge to the body with regards to temperature control. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8869", "text": "Keratinocytes  migrate without first proliferating. [ 45 ]  Migration can begin as early as a few hours after wounding. However, epithelial cells require viable tissue to migrate across, so if the wound is deep it must first be filled with granulation tissue. [ 46 ]  Thus the time of onset of migration is variable and may occur about one day after wounding. [ 47 ]  Cells on the wound margins proliferate on the second and third day post-wounding in order to provide more cells for migration. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8870", "text": "If the  basement membrane  is not breached, epithelial cells are replaced within three days by division and upward migration of cells in the  stratum basale  in the same fashion that occurs in uninjured skin. [ 37 ]  However, if the basement membrane is ruined at the wound site, reepithelization must occur from the wound margins and from skin appendages such as hair follicles and sweat and oil glands that enter the  dermis  that are lined with viable keratinocytes. [ 28 ]  If the wound is very deep, skin appendages may also be ruined and migration can only occur from wound edges. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8871", "text": "Migration of keratinocytes over the wound site is stimulated by lack of  contact inhibition  and by chemicals such as  nitric oxide . [ 48 ]  Before they begin to migrate, cells must dissolve their  desmosomes  and  hemidesmosomes , which normally anchor the cells by  intermediate filaments  in their  cytoskeleton  to other cells and to the ECM. [ 23 ]   Transmembrane   receptor   proteins  called  integrins , which are made of  glycoproteins  and normally anchor the cell to the basement membrane by its  cytoskeleton , are released from the cell's intermediate filaments and relocate to  actin  filaments to serve as attachments to the ECM for  pseudopodia  during migration. [ 23 ]  Thus keratinocytes detach from the basement membrane and are able to enter the wound bed. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8872", "text": "Before they begin migrating, keratinocytes change shape, becoming longer and flatter and extending cellular processes like  lamellipodia  and wide processes that look like ruffles. [ 31 ]   Actin  filaments and  pseudopodia  form. [ 35 ]  During migration,  integrins  on the pseudopod attach to the ECM, and the actin filaments in the projection pull the cell along. [ 23 ]  The interaction with molecules in the ECM through integrins further promotes the formation of actin filaments, lamellipodia, and  filopodia . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8873", "text": "Epithelial cells climb over one another in order to migrate. [ 42 ]  This growing sheet of epithelial cells is often called the epithelial tongue. [ 45 ]  The first cells to attach to the  basement membrane  form the  stratum basale . These basal cells continue to migrate across the wound bed, and epithelial cells above them slide along as well. [ 45 ]  The more quickly this migration occurs, the less of a scar there will be. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8874", "text": "Fibrin , collagen, and fibronectin in the ECM may further signal cells to divide and migrate.  Like fibroblasts, migrating keratinocytes use the fibronectin cross-linked with fibrin that was deposited in inflammation as an attachment site to crawl across. [ 25 ] [ 31 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8875", "text": "As keratinocytes migrate, they move over granulation tissue but stay underneath the scab, thereby separating the scab from the underlying tissue. [ 42 ] [ 47 ]  Epithelial cells have the ability to phagocytize debris such as dead tissue and bacterial matter that would otherwise obstruct their path.  Because they must dissolve any scab that forms, keratinocyte migration is best enhanced by a moist environment, since a dry one leads to formation of a bigger, tougher scab. [ 25 ] [ 37 ] [ 42 ] [ 50 ]  To make their way along the tissue, keratinocytes must dissolve the clot, debris, and parts of the ECM in order to get through. [ 47 ] [ 51 ]  They secrete  plasminogen activator , which activates  plasminogen , turning it into  plasmin  to dissolve the scab.  Cells can only migrate over living tissue, [ 42 ]  so they must excrete collagenases and proteases like  matrix metalloproteinases  (MMPs) to dissolve damaged parts of the ECM in their way, particularly at the front of the migrating sheet. [ 47 ]  Keratinocytes also dissolve the basement membrane, using instead the new ECM laid down by fibroblasts to crawl across. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8876", "text": "As keratinocytes continue migrating, new epithelial cells must be formed at the wound edges to replace them and to provide more cells for the advancing sheet. [ 25 ]  Proliferation behind migrating keratinocytes normally begins a few days after wounding [ 46 ]  and occurs at a rate that is 17 times higher in this stage of epithelialization than in normal tissues. [ 25 ]  Until the entire wound area is resurfaced, the only epithelial cells to proliferate are at the wound edges. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8877", "text": "Growth factors, stimulated by integrins and MMPs, cause cells to proliferate at the wound edges.  Keratinocytes themselves also produce and secrete factors, including growth factors and basement membrane proteins, which aid both in epithelialization and in other phases of healing. [ 52 ]  Growth factors are also important for the innate immune defense of skin wounds by stimulation of the production of antimicrobial peptides and neutrophil chemotactic cytokines in keratinocytes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8878", "text": "Keratinocytes continue migrating across the wound bed until cells from either side meet in the middle, at which point  contact inhibition  causes them to stop migrating. [ 31 ]   When they have finished migrating, the keratinocytes secrete the proteins that form the new basement membrane. [ 31 ]   Cells reverse the morphological changes they underwent in order to begin migrating; they reestablish  desmosomes  and  hemidesmosomes  and become anchored once again to the basement membrane. [ 23 ]   Basal cells  begin to divide and differentiate in the same manner as they do in normal skin to reestablish the strata found in reepithelialized skin. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8879", "text": "Contraction is a key phase of wound healing with repair. If contraction continues for too long, it can lead to disfigurement and loss of function. [ 32 ]  Thus there is a great interest in understanding the biology of wound contraction, which can be modelled in vitro using the  collagen gel contraction assay  or the  dermal equivalent  model. [ 27 ] [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8880", "text": "Contraction commences approximately a week after wounding, when fibroblasts have differentiated into  myofibroblasts . [ 54 ]   In  full thickness  wounds, contraction peaks at 5 to 15 days post wounding. [ 37 ]  Contraction can last for several weeks [ 46 ]  and continues even after the wound is completely reepithelialized. [ 3 ]  A large wound can become 40 to 80% smaller after contraction. [ 31 ] [ 42 ]   Wounds can contract at a speed of up to 0.75\u00a0mm per day, depending on how loose the tissue in the wounded area is. [ 37 ]   Contraction usually does not occur symmetrically; rather most wounds have an 'axis of contraction' which allows for greater organization and alignment of cells with collagen. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8881", "text": "At first, contraction occurs without myofibroblast involvement. [ 55 ]   Later, fibroblasts, stimulated by growth factors, differentiate into myofibroblasts.  Myofibroblasts, which are similar to smooth muscle cells, are responsible for contraction. [ 55 ]   Myofibroblasts contain the same kind of actin as that found in  smooth muscle  cells. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8882", "text": "Myofibroblasts are attracted by fibronectin and growth factors and they move along fibronectin linked to fibrin in the provisional ECM in order to reach the wound edges. [ 25 ]   They form connections to the ECM at the wound edges, and they attach to each other and to the wound edges by  desmosomes .  Also, at an adhesion called the  fibronexus , actin in the myofibroblast is linked across the cell membrane to molecules in the extracellular matrix like fibronectin and collagen. [ 55 ]   Myofibroblasts have many such adhesions, which allow them to pull the ECM when they contract, reducing the wound size. [ 32 ]   In this part of contraction, closure occurs more quickly than in the first, myofibroblast-independent part. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8883", "text": "As the actin in myofibroblasts contracts, the wound edges are pulled together.  Fibroblasts lay down collagen to reinforce the wound as myofibroblasts contract. [ 3 ]  The contraction stage in proliferation ends as myofibroblasts stop contracting and commit apoptosis. [ 32 ]   The breakdown of the provisional matrix leads to a decrease in hyaluronic acid and an increase in chondroitin sulfate, which gradually triggers fibroblasts to stop migrating and proliferating. [ 19 ]   These events signal the onset of the maturation stage of wound healing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8884", "text": "When the levels of collagen production and degradation equalize, the maturation phase of tissue repair is said to have begun. [ 20 ]  During maturation,  type III collagen , which is prevalent during proliferation, is replaced by type I collagen. [ 17 ]  Originally disorganized collagen fibers are rearranged, cross-linked, and aligned along  tension lines . [ 31 ]  The onset of the maturation phase may vary extensively, depending on the size of the wound and whether it was initially closed or left open, [ 28 ]  ranging from approximately three days [ 41 ]  to three weeks. [ 56 ]  The maturation phase can last for a year or longer, similarly depending on wound type. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8885", "text": "As the phase progresses, the  tensile strength  of the wound increases. [ 28 ]  Collagen will reach approximately 20% of its tensile strength after three weeks, increasing to 80% after 12 months. The maximum scar strength is 80% of that of unwounded skin. [ 57 ]  Since activity at the wound site is reduced, the scar loses its red appearance as  blood vessels  that are no longer needed are removed by  apoptosis . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8886", "text": "The phases of wound healing normally progress in a predictable, timely manner; if they do not, healing may progress inappropriately to either a  chronic wound [ 7 ]  such as a  venous ulcer  or pathological scarring such as a  keloid scar . [ 58 ] [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8887", "text": "Many factors controlling the efficacy, speed, and manner of wound healing fall under two types: local and systemic factors. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8888", "text": "In the 2000s there arose the first Mathematical models of the healing process, based on simplified assumptions and on a  system of differential equations  solved through  MATLAB . The models show that the \"rate of the healing process\" appears to be \"highly influenced by the activity and size of the injury itself as well as the activity of the healing agent.\" [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8889", "text": "Up until about 2000, the classic paradigm of wound healing, involving  stem cells  restricted to organ-specific lineages, had never been seriously challenged. Since then, the notion of  adult stem cells  having cellular  plasticity  or the ability to  differentiate  into non-lineage cells has emerged as an alternative explanation. [ 1 ]  To be more specific,  hematopoietic   progenitor cells  (that give rise to mature cells in the blood) may have the ability  de-differentiate   back into hematopoietic stem cells and/or  transdifferentiate  into non-lineage cells, such as fibroblasts. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8890", "text": "Multipotent adult stem cells have the capacity to be self-renewing and give rise to different cell types. Stem cells give rise to progenitor cells, which are cells that are not self-renewing, but can generate several types of cells. The extent of stem cell involvement in cutaneous (skin) wound healing is complex and not fully understood. [ citation needed ]  Stem cell injection leads to wound healing primarily through stimulation of angiogenesis. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8891", "text": "It is thought that the epidermis and dermis are reconstituted by mitotically active stem cells that reside at the apex of  rete ridges  (basal stem cells or BSC), the bulge of  hair follicles  (hair follicular stem cell or HFSC), and the papillary dermis (dermal stem cells). [ 1 ]  Moreover, bone marrow may also contain stem cells that play a major role in cutaneous wound healing. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8892", "text": "In rare circumstances, such as extensive cutaneous injury, self-renewal subpopulations in the bone marrow are induced to participate in the healing process, whereby they give rise to collagen-secreting cells that seem to play a role during wound repair. [ 1 ]  These two self-renewal subpopulations are (1) bone marrow-derived  mesenchymal stem cells  (MSC) and (2)  hematopoietic stem cells  (HSC). Bone marrow also harbors a progenitor subpopulation ( endothelial  progenitor cells or EPC) that, in the same type of setting, are mobilized to aid in the reconstruction of blood vessels. [ 39 ]  Moreover, it is thought that extensive injury to skin also promotes the early trafficking of a unique subclass of  leukocytes  (circulating  fibrocytes ) to the injured region, where they perform various functions related to wound healing. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8893", "text": "An injury is an interruption of morphology and/or functionality of a given tissue. After injury, structural tissue heals with incomplete or complete regeneration. [ 71 ] [ 72 ]  Tissue without an interruption to the morphology almost always completely regenerates. An example of complete regeneration without an interruption of the morphology is non-injured tissue, such as skin. [ 73 ]  Non-injured skin has a continued replacement and regeneration of cells which always results in complete regeneration. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8894", "text": "There is a subtle distinction between 'repair' and 'regeneration'. [ 1 ] [ 71 ] [ 72 ]   Repair  means  incomplete regeneration . [ 71 ]  Repair or incomplete regeneration, refers to the physiologic adaptation of an organ after injury in an effort to re-establish continuity without regards to exact replacement of lost/damaged tissue. [ 71 ] \n True tissue regeneration  or  complete regeneration , [ 72 ]  refers to the replacement of lost/damaged tissue with an 'exact' copy, such that both morphology and functionality are completely restored. [ 72 ]   Though after injury mammals can completely regenerate spontaneously, they usually do not completely regenerate. An example of a tissue regenerating completely after an interruption of morphology is the  endometrium ; the endometrium after the process of breakdown via the menstruation cycle heals with complete regeneration. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8895", "text": "In some instances, after a tissue breakdown, such as in skin, a regeneration closer to complete regeneration may be induced by the use of biodegradable ( collagen - glycoaminoglycan ) scaffolds. These scaffolds are structurally analogous to  extracellular matrix  (ECM) found in normal/un-injured dermis. [ 74 ]  Fundamental conditions required for tissue regeneration often oppose conditions that favor efficient wound repair, including inhibition of (1) platelet activation, (2) inflammatory response, and (3) wound contraction. [ 1 ]  In addition to providing support for fibroblast and endothelial cell attachment, biodegradable scaffolds inhibit wound contraction, thereby allowing the healing process to proceed towards a more-regenerative/less-scarring pathway. Pharmaceutical agents have been investigated which may be able to turn off  myofibroblast  differentiation. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8896", "text": "A new way of thinking derived from the notion that  heparan sulfates  are key player in tissue homeostasis:  the process that makes the tissue replace dead cells by identical cells. In wound areas, tissue homeostasis is lost as the heparan sulfates are degraded preventing the replacement of dead cells by identical cells.  Heparan sulfate analogues  cannot be degraded by all known heparanases and glycanases and bind to the free heparin sulfate binding spots on the ECM, therefore preserving the normal tissue homeostasis and preventing scarring. [ 76 ] [ 77 ] [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8897", "text": "Repair or regeneration with regards to hypoxia-inducible factor 1-alpha (HIF-1a). In normal circumstances after injury  HIF-1a  is degraded by prolyl hydroxylases (PHDs). Scientists found that the simple up-regulation of HIF-1a via PHD inhibitors regenerates lost or damaged tissue in mammals that have a repair response; and the continued down-regulation of Hif-1a results in healing with a scarring response in mammals with a previous regenerative response to the loss of tissue. The act of regulating HIF-1a can either turn off, or turn on the key process of mammalian regeneration. [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8898", "text": "Scarless wound healing  is a concept based on the healing or repair of the skin (or other tissue/organs) after injury with the aim of healing with subjectively and relatively  less   scar  tissue than normally expected. Scarless healing is sometimes mixed up with the concept of  scar free healing ,  which is wound healing which results in absolutely no scar ( free  of scarring). However they are different concepts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8899", "text": "A reverse to scarless wound healing is  scarification  (wound healing to scar more). Historically, certain cultures consider scarification attractive; [ 81 ]  however, this is generally not the case in the modern western society, in which many patients are turning to  plastic surgery  clinics with unrealistic expectations. Depending on  scar  type, treatment may be  invasive  (intralesional steroid injections, surgery) and/or conservative ( compression therapy , topical  silicone gel ,  brachytherapy ,  photodynamic therapy ). [ 82 ]  Clinical judgment is necessary to successfully balance the potential benefits of the various treatments available against the likelihood of a poor response and possible complications resulting from these treatments. Many of these treatments may only have a  placebo effect , and the evidence base for the use of many current treatments is poor. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8900", "text": "Since the 1960s, comprehension of the basic biologic processes involved in wound repair and  tissue regeneration  have expanded due to advances in cellular and  molecular biology . [ 84 ]  Currently, the principal goals in wound management are to achieve rapid wound closure with a functional tissue that has minimal aesthetic scarring. [ 85 ]  However, the ultimate goal of wound healing biology is to induce a more perfect reconstruction of the wound area. Scarless wound healing only occurs in mammalian foetal tissues [ 86 ]  and complete  regeneration  is limited to lower vertebrates, such as  salamanders , and  invertebrates . [ 87 ]  In adult humans, injured tissue are repaired by  collagen  deposition, collagen remodelling and eventual scar formation, where fetal wound healing is believed to be more of a regenerative process with minimal or no scar formation. [ 86 ]  Therefore, foetal wound healing can be used to provide an accessible mammalian model of an optimal healing response in adult human tissues. Clues as to how this might be achieved come from studies of wound healing in embryos, where repair is fast and efficient and results in essentially perfect regeneration of any lost tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8901", "text": "The etymology of the term scarless wound healing has a long history. [ 88 ] [ 89 ] [ 90 ]  In print the antiquated concept of scarless healing was brought up in the early 20th century and appeared in a paper published in the London Lancet. This process involved cutting at a surgical slant to the skin surface, rather than at a right angle it; the process was described in various Newspapers. [ 88 ] [ 89 ] [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8902", "text": "After inflammation, restoration of normal tissue integrity and function is preserved by feedback interactions between diverse cell types mediated by adhesion molecules and secreted cytokines. Disruption of normal feedback mechanisms in cancer threatens tissue integrity and enables a malignant tumor to escape the immune system. [ 91 ] [ 92 ]  An example of the importance of the wound healing response within tumors is illustrated in work by  Howard Chang  and colleagues at  Stanford University  studying breast cancers. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8903", "text": "Preliminary results are promising for the  short and long-term use of oral collagen supplements for wound healing  and skin aging. Oral collagen supplements also increase skin elasticity, hydration, and dermal collagen density. Collagen supplementation is generally safe with no reported adverse events. Further studies are needed to elucidate medical use in skin barrier diseases such as atopic dermatitis and to determine optimal dosing regimens. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8904", "text": "Modern wound dressing to aid in wound repair has undergone considerable research and development in recent years. Scientists aim to develop wound dressings which have the following characteristics: [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8905", "text": "Cotton gauze dressings have been the standard of care, despite their dry properties that can adhere to wound surfaces and cause discomfort upon removal. Recent research has set out to improve cotton gauze dressings to bring them closer in line to achieve modern wound dressing properties, by coating cotton gauze wound dressing with a  chitosan / Ag / ZnO   nanocomposite . These updated dressing provide increase water absorbency and improved antibacterial  efficacy . [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8906", "text": "Dirt or dust on the surface of the wound, bacteria, tissue that has died, and fluid from the wound may be cleaned. The evidence supporting the most effective technique is not clear and there is insufficient evidence to conclude whether cleaning wounds is beneficial for promoting healing or whether wound cleaning solutions ( polyhexamethylene biguanide ,  aqueous   hydrogen peroxide , etc.) are better than  sterile water  or  saline solutions  to help venous leg ulcers heal. [ 95 ]  It is uncertain whether the choice of cleaning solution or method of application makes any difference to  venous leg ulcer  healing. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8907", "text": "Considerable effort has been devoted to understanding the physical relationships governing wound healing and subsequent scarring, with mathematical models and simulations developed to elucidate these relationships. [ 96 ]   The growth of tissue around the wound site is a result of the migration of cells and collagen deposition by these cells.  The alignment of collagen describes the degree of scarring; basket-weave orientation of collagen is characteristic of normal skin, whereas aligned collagen fibers lead to significant scarring. [ 97 ]   It has been shown that the growth of tissue and extent of scar formation can be controlled by modulating the stress at a wound site. [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8908", "text": "The growth of tissue can be simulated using the aforementioned relationships from a biochemical and biomechanical point of view.  The biologically active chemicals that play an important role in wound healing are modeled with Fickian diffusion to generate concentration profiles.  The balance equation for open systems when modeling wound healing incorporates mass growth due to cell migration and proliferation.  Here the following equation is used:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8909", "text": "D t \u03c1 0  = Div (R) + R 0 ,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8910", "text": "where  \u03c1  represents mass density,  R  represents a mass flux (from cell migration), and  R 0  represents a mass source (from cell proliferation, division, or enlargement). [ 99 ]  Relationships like these can be incorporated into an  agent-based models , where the sensitivity to single parameters such as initial collagen alignment, cytokine properties, and cell proliferation rates can be tested. [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8911", "text": "Successful wound healing is dependent on various cell types, molecular mediators and structural elements. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8912", "text": "Primary intention is the healing of a clean wound without tissue loss. [ 101 ]  In this process, wound edges are brought together, so that they are adjacent to each other (re-approximated). Wound closure is performed with sutures (stitches), staples, or adhesive tape or glue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8913", "text": "Primary intention can only be implemented when the wound is precise and there is minimal disruption to the local tissue and the epithelial basement membrane, e.g. surgical incisions. [ 102 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8914", "text": "This process is faster than healing by secondary intention. [ 101 ]  There is also less scarring associated with primary intention, as there are no large tissue losses to be filled with granulation tissue, though some granulation tissue will form. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8915", "text": "(Delayed primary closure):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8916", "text": "If the wound edges are not reapproximated immediately, delayed primary wound healing transpires. This type of healing may be desired in the case of contaminated wounds. By the fourth day, phagocytosis of contaminated tissues is well underway, and the processes of epithelization, collagen deposition, and maturation are occurring. Foreign materials are walled off by macrophages that may metamorphose into epithelioid cells, which are encircled by mononuclear leukocytes, forming granulomas. Usually the wound is closed surgically at this juncture, or the scab is eaten, and if the \"cleansing\" of the wound is incomplete, chronic inflammation can ensue, resulting in prominent scarring."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8917", "text": "Following are the main  growth factors  involved in wound healing:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8918", "text": "The major complications are many:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8919", "text": "Other complications can include infection and  Marjolin's ulcer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8920", "text": "Advancements in the clinical understanding of wounds and their  pathophysiology  have commanded significant biomedical innovations in the treatment of acute, chronic, and other types of wounds. Many biologics,  skin substitutes ,  biomembranes  and scaffolds have been developed to facilitate wound healing through various mechanisms. [ 108 ]  This includes a number of products under the trade names such as  Epicel ,  Laserskin ,  Transcyte, Dermagraft, AlloDerm/Strattice, Biobrane, Integra, Apligraf, OrCel, GraftJacket and PermaDerm. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8921", "text": "Railway surgery  was a branch of medical practice that flourished in the 19th and early 20th centuries.  It concerned itself with the medical requirements of railway companies.  Depending on country, it included some or all of:  general practice  for railway staff,  trauma surgery  as a result of accidents on the railways,  occupational health and safety ,  medico-legal  activities regarding compensation claims against the company, and occupational testing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8922", "text": "Railway surgery was especially well-developed in the US with formal professional organisations and scholarly journals.  One of the reasons for this was that US railways were particularly dangerous with a high number of casualties from crashes and an even higher number of workers hurt in  industrial accidents .  Another reason was that many US routes passed through areas with little or no existing medical infrastructure.  In Europe the railways were safer and infrastructure was generally already in place.  The duties of railway surgeons in Europe mostly involved investigations into accidents and the resulting claims arising from passengers.  In India the railways also faced a lack of existing medical infrastructure and, like the US, had to build it from scratch.  Indian Railways  still maintains a network of hospitals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8923", "text": "By the middle of the 20th century railway surgery had lost its separate identity.  The growth of other industries and improving rail safety meant that the railways no longer stood out as a leading cause of injuries.  Likewise, industrial medicine and health and safety became a concern for all industries.  There was no longer a need for an industry-specific branch of medicine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8924", "text": "The primary purpose of railway surgeons was to attend to the many injuries of staff and passengers on the railways.  Railway surgeons were also responsible for assessing medical claims against their companies and providing routine medical examinations of employees and applicants. [ 1 ]   Railway surgeons were keen to establish their profession as a separate discipline with unique problems.  For instance, the textbook  Railway Surgery , published in 1899, spends a whole chapter on the claim that crushing injuries from the heavy moving equipment on railways are of a kind not found in other industries. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8925", "text": "Railway surgeons were generally not well paid.  While a chief surgeon or consultant surgeon might attract a good salary, the ordinary doctors working out on the lines were not well rewarded. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8926", "text": "Rail crashes were common in the 19th century with many deaths and broken bones. [ 5 ]   In Europe, the majority of injuries were due to collisions, hence passengers rather than employees formed the bulk of the injured.  For instance, in Britain, accidents on the line such as crushing between  wagons  and being struck by trains (accidents suffered mostly by railway staff) were far fewer than passenger injuries through collisions in 1887. [ 6 ]   In the US, the railways were significantly more dangerous. [ 7 ]   Counterintuitively, this led to staff injuries being by far the greatest proportion. In 1892, US railroads reported 28,000 injuries to workers compared to 3,200 for passengers.  The most dangerous role was  brakeman , whose job included coupling and uncoupling wagons.  The most frequent injury was the brakeman being crushed between wagons while carrying out this task. [ 8 ]   One third of all railway injuries to staff were crushed hands or fingers. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8927", "text": "The number of deaths and injuries grew rapidly as the century progressed.  In the US, the first death occurred in 1831. There were 234 deaths in 1853, the year in which there were eleven major crashes. [ 10 ]   In 1890, there were 6,335 deaths and 35,362 injuries, [ 11 ]  and by 1907 it had reached its peak at nearly 12,000 deaths. [ 12 ]   In England, an early railway death was  William Huskisson ,  Member of Parliament  for  Liverpool , killed during the  opening of the Liverpool and Manchester Railway  in 1830. [ 13 ]   In the UK as a whole, deaths and injuries grew much less dramatically than the US.  There were 338 passenger deaths and injuries in 1855 and 435 in 1863, but at the same time passenger numbers were increasing.  From about the middle of this period the  rate  of injury started to go down with improving safety\u20142.85 per million passengers in 1855 to 2.12 in 1863. [ 14 ]   A similar picture of low rates pertained in other European countries such as France, Prussia, Belgium and Germany. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8928", "text": "Many injuries required amputation.  For instance, in 1880 the  Baltimore and Ohio Railroad  reported 184 crushed limbs, including 85 fractures and fifteen amputations. [ 16 ]   The need to perform amputations and other surgery may be why railway surgeons were named  surgeon  rather than  doctor  or  physician .  While traumatic injuries were not the most frequent ailment they had to deal with (that was infectious diseases) it did distinguish them from typical  general practitioners .  Other influences may have been the comparison to  ship's surgeons  in the age of sail, and the greater status and pay of surgeons. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8929", "text": "First aid kits  and training were introduced at the instigation of Charles Dickson of the  Canadian St. John Ambulance Association  and backed by many railway surgeons.  One railway surgeon reported that his fatality rate following amputation more than halved after first aid was introduced.  There was some opposition to first aid through fear that it eroded the professional status of doctors and that local contract railway surgeons would lose the fees they would otherwise have accrued for the work. [ 18 ]   However, by  World War I  first aid kits on trains had become widespread. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8930", "text": "As the twentieth century progressed, rail safety improved dramatically.  So much so that by 1956 the president of the Association of Surgeons of the  Chesapeake and Ohio Railway , when asked if he saw a lot of accident cases at the company hospital, could reply \"yes, I see a lot of accidents from the highway\" and \"[t]he primary purpose of our group has all but passed out of the picture.\" [ 20 ]   The discipline of railway surgery had been folded into the more general discipline of  trauma surgery . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8931", "text": "An important function of railway surgeons was to control the costs of claims against their companies, leading to conflicts of interest regarding treatment of their patients.  For instance, the chief surgeon of the  Missouri Pacific Railroad  proudly boasted that he kept claims in the region of 14\u201335 dollars whereas claims against another railroad were nearly 600 dollars on average.  Company medical staff were also expected to help achieve political aims with expert evidence. In some cases chief surgeons were appointed purely on the basis of their relationship to important politicians. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8932", "text": "Fraudulent claims were a big concern for railway companies.  Sometimes, these were entirely contrived \"accidents\" by confidence tricksters; more commonly, however, they were exaggerations of the results of a genuine accident.  In 1906, railway surgeon Willis King claimed that 96% of claimants were actually  malingering . [ 23 ]   One common claim that was hotly debated [ 24 ]  by railway surgeons was the condition known as  railway spine .  Over a hundred papers were published on the subject in the medical literature for the period 1866\u20131890. [ 25 ]   In this condition, the patient reports cerebral symptoms such as headache or loss of memory, but there is no visible damage to the spine.  It was first described by Danish-British surgeon  John Eric Erichsen .  Erichsen believed the condition was  physiological , due to inflammation of the spinal cord.  He compared it to  meningitis  which had similar symptoms and a similar cause.  Others, such as  Herbert W. Page  (surgeon to the  London and North Western Railway ), argued that it was  psychological , or else, like  Arthur Dean Bevan  (1918 president of the  American Medical Association ), outright faked.  Railway surgeons were generally skeptical of the condition and disliked the implication that there was an injury peculiar to railways.  British surgeon Edwin Morris described the term as \"most reprehensible\". [ 26 ]   Bevan claimed to have cured one patient in ten minutes by standing him up and speaking to him forcefully. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8933", "text": "In Britain, a number of major train crashes led to parliament passing an  act  which compelled rail companies to pay compensation to victims of accidents.  A large proportion of the thousands of resulting claims were for railway spine.  In a five-year period in the 1870s English railway companies paid  \u00a32.2 million ($11 million) in claims for railway spine. [ 28 ]   Following a similar law in Germany, 78% of claims in the period 1871\u20131879 were for back injury.  Claims for railway spine had subsided by 1900.  From 1890 there were more claims for  psychosomatic  conditions such as  hysteria  and the  neurasthenia  of  George Miller Beard  rather than physiological conditions such as railway spine.  Even Erichsen himself agreed that his original cases were actually traumatic neurasthenia.  However, medical concern remained over these emotional damage claims regarding malingering and false claims. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8934", "text": "Railway companies pioneered the disciplines of  industrial medicine  and  occupational safety and health .  They were the first organisations to give physical examinations to prospective employees.  The motivation was partly to prevent fraudulent claims for pre-existing conditions, but also to improve rail safety.  The  Baltimore and Ohio Railroad  in 1884 was the first to do this and had a particularly thorough examination.  They rejected 7% of applicants.  Colour blindness  tests were introduced for all employees in most US railway companies in the 1880s because of the need for correct signal recognition.  Hearing tests  were also implemented. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8935", "text": "Colour blindness tests were a result of the 1875  Lagerlunda rail accident  in Sweden.  The accident was investigated by  Frithiof Holmgren  who concluded that the crash was a result of colour blindness of the driver. [ 31 ]   Holmgren created a test for use in the transportation industry based on matching coloured  skeins of yarn .  However, Holmgren's test was disliked by employees and there were many complaints of unfairness.  Many companies preferred to test with lamps and flags, but this led to conflict with the railway surgeons who were concerned that non-professionals were administering medical tests. [ 32 ]   Holmgren's identification of colour blindness as the cause of the Swedish crash has also been disputed. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8936", "text": "Railway companies increasingly improved the health of their employees with preventative measures against disease.  Vaccination schemes were introduced.  Sanitation aboard trains became an issue, as did the quality of water supplies.  In the 1920s the  Cotton Belt Railroad  succeeded in cutting hospitalization due to  malaria  of its workers from 21.5% to 0.2%.  They did this with a program that included suppressing mosquito populations, preventative  quinine  treatment, education, and blood tests. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8937", "text": "Railway surgery was particularly well-developed in the US in the nineteenth and early-twentieth centuries.  Early American railroads passed through vast, thinly populated regions with little possibility of finding local medical care.  At the same time American railways were uniquely dangerous.  Accident rates were far higher than European railways.  That, together with difficulty in retaining skilled staff and the risk of legal action by injured passengers resulted in American railway companies developing medical infrastructure and organisations to a degree that was not seen elsewhere. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8938", "text": "The difference in risk between the US and Europe was largely driven by economics.  With their higher population densities and shorter routes, European countries carried more freight per mile of track than in the US.  To be profitable, American railways needed to be built and run more cheaply.  This led to a host of safety issues.  American railways were poorly signalled compared to British railways; in the US there were no  signal boxes , instead signalling was largely the responsibility of staff on board trains.  Rails were laid on thin beds and badly secured leading to many derailments.  Most tracks in Europe were double tracks whereas in the US they were usually single track.  Poor control of single-track rails led to many collisions.  There was no fencing on American tracks, leading to many collisions with people and animals. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8939", "text": "Certainly, railway companies in other countries had railway surgeons.  In Australia and Canada railway surgeons were appointed during the construction of major lines in remote regions. [ 37 ]   British companies employed railway surgeons as consultants. [ 38 ]   However, only in the US were railway surgeons employed in such large numbers and as such an organised discipline. [ 39 ]   India is perhaps the closest to the US in widespread use of railway surgeons which continues to this day, but there they never seem to have organised themselves as a discipline with professional associations until the 2000s. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8940", "text": "Construction of railways in the US began in 1828, becoming significant by 1840. By 1900 the railways were the largest US industry employing over a million, far more than any other dangerous occupation. [ 41 ]   Many thousands of injuries occurred on these railroads throughout the 19th century.  From 1850 until World War I, American railroad companies developed their own medical arrangements in order to retain workers, care for their passengers and injured third parties, and avoid legal action.  The earliest example of a company railroad surgeon was James P. Quinn [ 42 ]  on the Baltimore and Ohio Railroad in 1834, but the practice did not become widespread until the 1850s.  By the end of the 1850s most companies had some kind of medical service. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8941", "text": "Legal claims for compensation in the nineteenth century under  tort  laws were weaker than under twentieth century compensation laws.  Railroad workers (the majority of injuries) were not usually able to claim.  Nor were trespassers on railway property.  Passengers, however, were able to claim, but payments were low and few victims got anything compared to modern standards.  Nevertheless, the large number of crashes still led to a substantial number of legal actions. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8942", "text": "These organisations pioneered industrial medical care and predated the provision of medical care in manufacturing industries (although some mining companies did so).  Railway surgery was an important sector of the medical profession; by World War I railway organisations employed 14,000 doctors, some 10% of the US total.  Railway surgery operated outside of the  American Medical Association  (AMA) which railway surgeons were not permitted to join.  Many in the medical profession opposed company doctors altogether on the grounds of ethical conflict between the needs of the patient and the needs of the company.  The AMA also disliked the practice of doctors bidding for local contracts with the railway companies as this also introduced commercial pressures. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8943", "text": "Early medical arrangements on the railroads were informal.  The  Philadelphia & Reading Railroad  in particular had no formal contracts as late as the 1870s.  This led to many disputes over payment.  By the 1880s, however, all railroads had more formal arrangements.  They appointed a salaried chief surgeon and the larger ones had salaried regional surgeons as well.  Local doctors were paid according to fixed fees under contract.  In the West, the lack of existing medical facilities led to employee-funded hospitals.  The first of these was set up by the  Central Pacific Railroad  around 1867 and modelled on the US  Marine Hospital Service .  It was funded by a fixed deduction from all employees, except Chinese employees, who were excluded from the service.  A different kind of arrangement was the  mutual benefit society .  The first of these was set up by the Baltimore & Ohio Railroad in 1880 following the  Great Railroad Strike of 1877 .  Other railroads started to follow this model, partly because of its effect of dampening industrial strife.  By World War I about 30% (around two million) of railroad workers were members. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8944", "text": "By 1896 there were twenty-five railway hospitals run by thirteen different railway companies.  Between them they treated 165,000 patients annually.  Some of these hospitals became important  teaching hospitals  and generally they were all well financed and well equipped. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8945", "text": "After World War I railway surgery began to decline as a separate discipline.  It lost its political influence in the 1930s during the  Great Depression  as industry, including the railroads, reduced their involvement in health care for their workers. [ 48 ]   At the same time accident risks were steadily falling.  Between 1890 and 1940 risks for passengers and workers fell by 90% and 80% respectively. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8946", "text": "The first inter-city railway passenger service in the world was the  Liverpool and Manchester Railway , opened in 1830. [ 50 ]   By 1860, the UK had 10,000 miles of track and employed 180,000 people. [ 51 ]   Despite being the pioneer, British railways (and European railways in general) were much safer than American lines and consequently had fewer injuries, although early injury rates were still high by modern standards. [ 52 ]   Furthermore, British lines did not pass through vast, thinly populated regions.  Medical infrastructure was already well developed in the country.  Railway companies still employed surgeons.  Page at the London and North Western has already been mentioned.  Another example is  Thomas Bond  who was retained as surgeon by both the  Great Eastern  and  Great Western Railways .  However, Bond's function for the railways was primarily as medico-legal consultant regarding injury claims rather than practical surgery. [ 53 ]   He did, however, treat the injured of an overturned train on which he was himself a passenger.  Bond's last major work for the railways was investigations in connection with the  Slough rail accident  of 1900. [ 54 ]   Bond also wrote a lengthy article on railway injuries for Heath's  Dictionary of Practical Surgery . [ 55 ]   There is a similar picture with James O. Fletcher, surgeon to the  Manchester, Sheffield and Lincolnshire  and  Great Northern Railways , who wrote the book  Railways in Their Medical Aspects .  Fletcher's book discusses numerous cases where he examined or treated patients post-surgery and discusses medico-legal issues at length.  However, he does not cite a single example of his own, or railway colleagues', emergency surgery. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8947", "text": "The first dedicated  accident and emergency  (A&E) service in Britain was associated with the building of the  Manchester Ship Canal , 1887\u20131894, rather than railways.  However, the  civil engineer  in charge,  Thomas A. Walker , had a background in railway construction around the world, particularly in Canada where he had experience of employing British  navvies .  He was also responsible for construction of the  District Railway  in London.  Walker predicted, correctly, that there would be a high incidence of accidents during the canal construction.  He had a chain of A&E hospitals and first aid stations built and staffed along the route to service the 17,000 workers.  These were linked to the construction sites by purpose built railways.  The service was financed by compulsory worker contributions.  In total, there were 3,000 injuries and 130 deaths during construction. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8948", "text": "Railways in India began to be built during the  British India  period.  The first passenger service opened between  Mumbai  and  Thane  in 1853. [ 58 ]   As in many parts of the US, there was no pre-existing medical infrastructure.  Medical facilities had to be entirely provided by the railways themselves.  This, along with other social needs, led to the establishment of railway \"colonies\" to house the railway workers and their families.  For instance, the railway colony of  Jamalpur  was established in 1862. [ 59 ]   By 1869, one railway surgeon and four assistants were employed at Jamalpur by the  East Indian Railway Company  to cover the 800 inhabitants of the colony and over 200 miles of railway line.  This section had around 200 accidents per year to deal with but that was not their only duty.  They also acted as  general practitioners  for the colony, including attending at childbirth. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8949", "text": "By 1956, the railways had established 80 hospitals and 426 dispensaries.  Additionally, mobile railway surgeons served railway staff posted along the line. [ 61 ]   This infrastructure of railway colonies, medical staff, and hospitals is still maintained by the railways.  A major example of a railway colony is the colony at  Kharagpur , West Bengal, established 1898\u20131900. [ 62 ]   It serves one of the largest railway workshops in India. [ 63 ]   A major example of a railway hospital is the  Southern Railway Headquarters Hospital  at  Chennai .  Southern Railway  also maintain divisional hospitals such as the  Divisional Railway Hospital, Golden Rock  as do the other zones of  Indian Railways . [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8950", "text": "Hospital trains  were in use early in the railway age, but usually in wartime, starting in the  Crimean War  in 1855. [ 65 ]   For normal civilian use, they were a fairly late development in the railway surgery period.  In the US, a hospital car came into use on several railways that could be coupled to a train to transport the surgeon and staff to the scene of an incident along with all the required equipment.  It contained an  operating theatre  and a number of beds for patients in a  recovery room .  Hospital cars significantly improved the outcomes for victims. [ 66 ]   These mobile hospitals were the forerunner of the US Army's  mobile army surgical hospitals . [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8951", "text": "Indian Railways introduced the  Lifeline Express  hospital train in 1991.  Its purpose was to serve the needs of rural poor in India.  In 2007 a modernised hospital train, the New Lifeline Express replaced it. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8952", "text": "From the 1880s onwards specific societies were formed for railway surgery.  The first of these was the Surgical Society of the Wabash, formed in 1881 and organised by the chief surgeon of the  Wabash Railroad .  The inaugural meeting had only twenty-two attendees with two papers presented.  This was soon followed by many other company centred organisations.  The  Pennsylvania Railroad  organisation was the prime mover in forming the  National Association of Railway Surgeons  (NARS) in 1888.  The inaugural meeting had two hundred attendees and by 1891 the membership had grown to nearly a thousand. [ 69 ]   However, NARS was short-lived, dying out in the 1920s as industrial expansion caused the railways to no longer be unique in their medical needs.  Nevertheless, there were still practising railway surgeons for some time after this. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8953", "text": "In 1891, the journal  Railway Age  began a column on railway surgery, including the proceedings of NARS.  The editor, R. Harvey Reed, was a  charter member  of NARS but left to form the more exclusive  American Academy of Railway Surgeons .  The two organisations remained rivals until 1904 when they merged to form the  American Association of Railway Surgeons  (AARS).  The  Railway Surgeon  was launched in 1894 and took over from  Railway Age  as the official journal of NARS, but it also carried articles from the American Academy. [ 71 ]   It was the official journal of NARS, 1894\u20131897; of the  International Association of Railway Surgeons , 1897\u20131904; and of the AARS, 1904\u20131929. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8954", "text": "The changing names and affiliations of the  Railway Surgeon  across the years reflects the absorption of railway surgery into the more general occupational health and the spread of industrial medicine.   Railway Surgeon  (1894\u20131904), became  Railway Surgical Journal  (1904\u20131921), [ 73 ]  became  Surgical Journal Devoted to Traumatic and Industrial Surgery  (1921\u20131929), [ 74 ]  absorbed by  International Journal of Medicine and Surgery  (1923\u20131935), [ 75 ]  with  Industrial Medicine  (1932\u20131935), [ 76 ]  became  International Journal of Industrial Medicine and Surgery  (1935\u20131949), became  Industrial Medicine and Surgery  (1949\u20131967), [ 77 ]  became  IMS, Industrial Medicine and Surgery  (1968\u20131973), [ 78 ]  became  The International Journal of Occupational Health and Safety  (1974\u20131975), [ 79 ]  became  Occupational Health and Safety  (1976\u2013present). [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8955", "text": "Criticism of Erichsen and \"railway spine\" was particularly strident in the US with NARS and its journal, the  Railway Surgeon  leading the attack.  So much effort was devoted to discrediting the condition as medically valid that one writer claimed the issue was the reason for existence of the association.  Prominent in NARS for speaking out against Erichsen was  Warren Bell Outten , chief surgeon for the Missouri Pacific Railway. [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8956", "text": "In India, the  Association of Railway Surgeons of India  held its first annual meeting in 2001. [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8957", "text": "Surgical oncology  is the branch of  surgery  applied to  oncology ; it focuses on the surgical management of  tumors , especially  cancerous  tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8958", "text": "As one of several modalities in the  management of cancer , the specialty of surgical oncology has evolved in steps similar to medical oncology ( pharmacotherapy  for cancer), which grew out of  hematology , and  radiation oncology , which grew out of  radiology . The Ewing Society\u2014known today as the Society of Surgical Oncology\u2014was started by surgeons interested in promoting the field of oncology. In 2011, the  American Board of Surgery  ratified Complex General Surgical Oncology via a specialty Board certification. [ 1 ]  The field was expected to continue expanding via the proliferation of cancer centers, as well as advanced minimally invasive techniques,  palliative surgery , and neo-adjuvant treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8959", "text": "Whether surgical oncology constitutes a medical specialty  per se  is the topic of a heated debate. Today, some would agree that it is simply impossible for any one surgeon to be competent in the surgical management of  all  malignant disease [ 2 ]   There are currently 19 surgical oncology fellowship training programs in the United States that have been approved by the Society of Surgical Oncology and this number is expect to grow. [ 3 ]  While many general surgeons are actively involved in treating patients with malignant neoplasms, the designation of \"surgical oncologist\" is generally reserved for those surgeons who have completed one of the approved fellowship programs.  However, this is a matter of semantics, as many surgeons who are thoroughly involved in treating cancer patients may consider themselves to be surgical oncologists. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8960", "text": "Most often,  surgical oncologist  refers to a general surgical oncologist (a subspecialty of  general surgery ), but thoracic surgical oncologists, gynecologic oncologists and so forth can all be considered surgeons who specialize in treating cancer patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8961", "text": "The importance of training surgeons who sub-specialize in cancer surgery lies in evidence, supported by a number of  clinical trials , [ 5 ]  that outcomes in surgical cancer care are positively associated to surgeon volume\u2014i.e., the more  cancer  cases a surgeon treats, the more proficient he or she becomes, and his or her patients experience improved survival rates as a result. This is another controversial point, but it is generally accepted\u2014even as common sense\u2014that a surgeon who performs a given operation more often, will achieve superior results when compared with a surgeon who rarely performs the same procedure. This is particularly true of complex cancer resections such as,  Breast Cancer Surgery ,  pancreaticoduodenectomy  (Whipple procedure) for pancreatic cancer, and  gastrectomy  with extended (D2)  lymphadenectomy  for gastric cancer.  In the United States and Canada, fellowship trained surgical oncologists have among the longest training periods of any physicians/surgeons. In some areas like  Breast Diseases  and  Breast Cancer  there we know as Breast Surgeon the specialist that only works with patients with  breast diseases  and  breast cancer . A training period (clinical and research) of 6 to 8 years is typical and 8\u201310 years is not uncommon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8962", "text": "These are the most common types and forms of oncological surgery: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8963", "text": "Newer surgical techniques are less invasive, use different types of surgical instruments, and lead to less pain and shorter recovery times. The most effective surgical oncology techniques are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8964", "text": "One of the first text books dedicated to surgical oncology was written by the American-Irish surgeon, Theodore O'Connell in 1981. [ 9 ]  Many publications in surgical oncology are also appearing. The majority are large reference textbooks that seemingly combine specialties that are not generally practiced by a single practitioner but cover the academic subject. A number of practical handbooks such as \"surgical oncology\" in the well read Oxford Handbooks series, have recently been published, perhaps alluding to the evolving practicality of this emerging discipline. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8965", "text": "Adrenalectomy  (Latin root  Ad  \"near/at\" +  renal  \"related to the kidneys\" + Greek  \u2011ectomy  \u201cout-cutting\u201d; sometimes written as  ADX  for the procedure or resulting state) [ 1 ] [ 2 ]  is the surgical removal of one ( unilateral ) or both ( bilateral )  adrenal glands . It is usually done to remove  tumors of the adrenal glands  that are producing excess hormones or is large in size (more than 2 inches or 4 to 5 centimeters). Adrenalectomy can also be done to remove a cancerous tumor of the adrenal glands, or cancer that has spread from another location, such as the kidney or lung. Adrenalectomy is not performed on those who have severe  coagulopathy  or whose heart and lungs are too weak to undergo surgery. The procedure can be performed using an open incision ( laparotomy ) or minimally invasive  laparoscopic  or  robot-assisted  techniques. [ 3 ]  Minimally invasive techniques are increasingly the gold standard of care due to shorter length of stay in the hospital, lower blood loss, and similar complication rates. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8966", "text": "One  adrenal gland  sits above each  kidney . The two adrenal glands produce  hormones  ( steroid hormones  and  catecholamines ) that help regulate  blood pressure ,  blood sugar level ,  metabolism ,  immune system ,  stress  and other essential functions. If one adrenal gland is removed, the other adrenal gland will take over the hormone-producing role. If both adrenal glands are removed, the patient will require lifelong  steroid  supplementation. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8967", "text": "Most adrenal tumors are noncancerous ( benign ), often found incidentally as a mass via imaging such as  CT scans ,  MRI , or  ultrasound  that were taken for other health workups (see  incidentaloma ). Although these adrenal masses do require evaluation, the majority of them (approximately 80% [ 7 ] ) do not require adrenalectomy. However, due to the hormone-producing function of the adrenal glands, some noncancerous adrenal tumors may produce too much hormones, such as  aldosterone  (called  primary aldosteronism ),  cortisol  (called  Cushing's disease  or  Cushing's syndrome ), or  catecholamines  (called  pheochromocytoma ). These hormone-producing tumors may need adrenalectomy. Additionally, adrenal tumors that are larger than 4 centimeters in size, regardless of whether they produce hormones, also require adrenalectomy due to increased risk of adrenal cancer. Rarely (5\u201312%), the adrenal tumor may be cancerous ( adrenocortical carcinoma ), requiring adrenalectomy. Rarer still, the mass may be a  metastatic cancer that spread from another location , such as the kidney or lung. If the metastasis is isolated to the adrenal gland, it may be a candidate for adrenalectomy. [ 5 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8968", "text": "An absolute  contraindication  (a reason not to do the surgery under any situation) for adrenalectomy are patients who are generally unsuited to surgery: having severe coagulopathy and poor cardiopulmonary performance due to the stress to the body that surgery will produce. In addition,  American Association of Clinical Endocrinologists  and  American Association of Endocrine Surgeons  guidelines state minimally-invasive techniques should be avoided when there is a large tumor size (larger than 6\u00a0cm) due to difficulties in maneuvering around a large mass, and in adrenocortical carcinoma where there is a risk of not fully removing the cancerous tissue. [ 3 ] [ 7 ]  However, at least one meta-analysis of 898 patients has found shorter length of stay, less blood loss, and no higher rates of complications even in large (>5\u00a0cm) tumors using minimally-invasive techniques. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8969", "text": "Techniques for adrenalectomy is largely divided into two types: open surgical  laparotomy  versus  minimally invasive  techniques."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8970", "text": "Surgeons usually reserve open surgery for large (larger than 6\u00a0cm) or cancerous tumors where there is a risk of not fully removing the cancerous tissue. They perform open surgery using traditional instruments and cuts (incisions). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8971", "text": "Minimally invasive techniques may be  laparoscopic , where several small cuts (incisions) are made to allow for the surgeon to directly control surgical instruments with their hands while visualizing the surgery via a tiny camera that provides a magnified, 3D view of the surgical site. Laparoscopic surgery has many benefits. For example, this surgery has smaller scars, less pain, less blood loss, similar complication rates, and a shorter recovery period than traditional open surgery. [ 8 ] [ 3 ]  Traditionally, this has been through the laparoscopic transperitoneal approach (LTA) where the small cuts are made in the abdomen to reach the adrenal glands through the  peritoneum  from the front-side."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8972", "text": "However, an alternative approach is possible called retroperitoneoscopic adrenalectomy (PRA), where the adrenal glands are reached through small cuts made in the back. Studies have shown that both LTA and PRA are equally safe and effective, though some suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery, and lower early morbidity. A 2018  systematic review  suggests that laparoscopic retroperotenial adrenalectomy appears to reduce late morbidity, time to oral fluid or food intake and time to ambulation when compared to laparoscopic transperitoneal adrenalectomy; however, there is uncertainty about these effects due to very low-quality evidence. [ 9 ]  For outcomes such as all-cause mortality, early morbidity, socioeconomic effects, and operative and postoperative parameter, the evidence is uncertain about the effects of either interventions over the other. [ 9 ]  PRA involves high pressure CO\u2082 within a limited  retroperitoneal space , and therefore may cause kidney injury in those at high risk. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8973", "text": "Sometimes surgeons perform  robot-assisted  adrenalectomies. They perform the surgery through small cuts (incisions) using robotic arms with a camera and instruments attached. The camera gives doctors a high-definition, magnified, 3D view of the surgical site. No significant differences were found between laparoscopic and robot-assisted adrenalectomy in two meta-analyses for complications, blood loss, or mortality, however robotic adrenalectomy had shorter hospital stays at the cost of longer operating time and higher cost of surgery. [ 4 ] [ 10 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8974", "text": "Postoperative care is highly dependent on what the adrenalectomy was performed for. After adrenalectomy for a  cortisol -producing adenoma, patients should be treated with exogenous  glucocorticoids  such as  cortisone  or  hydrocortisone  until the  hypothalamic-pituitary-adrenal (HPA) axis  has recovered. This process may take 6 to 18 months after unilateral adrenalectomy. Similarly, for patients who have undergone adrenalectomy for (subclinical)  Cushing syndrome , perioperative glucocorticoid therapy and postoperative assessment of HPA axis recovery are necessary. For patients who have undergone adrenalectomy for a pheochromocytoma, long-term followup is necessary because 10-15% of patients may have recurrence. [ 7 ]  For those with high blood pressure ( secondary hypertension ) from primary aldosteronism, adrenalectomy provides a clinical cure rate of approximately 27.1%. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8975", "text": "If both adrenal glands are removed, the patient can no longer create the adrenal hormones necessary for life ( primary adrenal insufficiency ). Signs and symptoms include volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. This requires lifetime treatment with the hormones produced by the removed adrenal glands, including glucocorticoids and  mineralocorticoids  ( fludrocortisone ). The glucocorticoid dose needs to be increased when in  stress  or during  infections  or else  adrenal crisis  may occur. [ 5 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8976", "text": "For women with deficiency in androgens as a result of the loss of androgen production from the adrenal glands following adrenalectomy,  dehydroepiandrosterone (DHEA)  replacement can be considered. The signs and symptoms include low libido, depressive symptoms, and/or low energy levels despite optimized glucocorticoid and mineralocorticoid replacement. [ 7 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8977", "text": "Complications from an adrenalectomy can include insufficient  cortisol  production,  acute kidney injury , post-operative bleeding, damage to nearby organs, and post-operative infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8978", "text": "Annals of Surgical Oncology  is a  peer-reviewed   medical journal  published by  Springer International Publishing  on behalf of the  Society of Surgical Oncology . It is an official journal of the Society of Surgical Oncology, and the  American Society of Breast Surgeons . [ 1 ]  The  editor-in-chief  is  Kelly M. McMasters  ( University of Louisville School of Medicine )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8979", "text": "The journal is abstracted and indexed in  Index Medicus / MEDLINE / PubMed , [ 2 ]   Current Contents /Clinical Medicine, [ 3 ]   Excerpta Medica , and the  Science Citation Index . [ 3 ]  According to the  Journal Citation Reports , the journal has a 2020  impact factor  of 5.344. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8980", "text": "This article about an  oncology   journal  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8981", "text": "A  bowel resection  or  enterectomy  ( enter-  +  -ectomy ) is a  surgical procedure  in which a part of an intestine (bowel) is removed, from either the  small intestine  or  large intestine . Often the word  enterectomy  is reserved for the  sense  of small bowel resection, in distinction from  colectomy , which covers the sense of large bowel resection. Bowel resection may be performed to treat  gastrointestinal cancer , bowel  ischemia ,  necrosis , or  obstruction  due to  scar  tissue, volvulus, and hernias. Some patients require  ileostomy  or  colostomy  after this procedure as alternative means of  excretion . [ 1 ]  Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be  digestive  and  metabolic  challenges afterward, such as  short bowel syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8982", "text": "Types of enterectomy are named according to the relevant bowel segment:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8983", "text": "The anatomy and surgical technique for bowel resection varies based on the location of the removed segment and whether or not the surgery is due to malignancy. The below sections describe resection for non-malignant causes. Malignancy may require more extensive tissue resection beyond what is described here."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8984", "text": "Bowel resection may be done as an open surgery, with a long incision in the abdomen. It may also be done laparoscopically or robotically by creating several small incisions in the abdomen through which surgical instruments are inserted. [ 2 ] [ 3 ] [ 4 ]  Once the abdomen is accessed by one of these methods the surgery may proceed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8985", "text": "Once the abdomen is accessed, the surgeon \"runs\" the small bowel, viewing the entire small bowel from the  ligament of treitz  to the  ileocecal valve . This allows for total evaluate of the small bowel to identify any and all pathologic sections. Once the area of concern is located, two small holes are created in the  mesentery  on either end of the segment. These holes are used to place a  surgical stapler  across the bowel and separate the segment of injured bowel from the healthy bowel on each end. Then bowel is then dissected away from the mesentery. Following this the remaining bowel is observed to verify continued blood flow. After resection the surgeon will create an  anastomosis  between the two ends of the bowel. Following this the hole in the mesentery created by removing the section of bowel is closed with sutures to prevent internal herniation. The resected section of bowel will then be removed from the abdomen and the abdomen closed. This concludes the procedure. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8986", "text": "The right and left colon sit in the  retroperitoneum . To access this space an incision is made along the  line of Toldt . The colon is then mobilized from the retroperitoneum. Care is taken to avoid injury to the  ureters  and  duodenum . The surgery then follows the same steps as small bowel resection. However, due to the colon's placement in the retroperitoneum, more dissection is often required to allow for tension free anastomosis. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8987", "text": "Small bowel  or  colon cancer  may require surgical resection. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8988", "text": "Small bowel cancer often presents late in the course due to non-specific symptoms and has poor survival rates. Risk factors for small bowel cancer include genetically inherited polyposis syndromes, age over sixty years, and history of Crohn's or Celiac disease. Cases that present before stage IV show survival benefit from surgical resection with clear margins. It is recommended that surgical resection also include lymph node sampling of a minimum of 12 nodes with some groups extolling more extensive resection. When evaluation determines cancer to be stage IV, surgical intervention is no longer curative, and is only used for symptom relief. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8989", "text": "Colon cancer is the third most common cancer and the second most common cause of cancer death in the USA. [ 8 ]  Due to its prevalence, screening protocols have been created for prevention of disease. Screening colonoscopies with or without polypectomy have been shown to decrease cancer morbidity and mortality. [ 9 ]  When cancer is more advanced and polypectomy is not possible surgical resection is necessary. Using imaging and pathologic evaluation of resected tissue the tumor may be staged using AJCC stages. [ 9 ]  Surgical resection of tumors for staging and for curative purposes requires removal of local blood vessel and lymph nodes. Standard lymph node resection includes three consecutive levels of lymph nodes and is known as a D3 lymphadenectomy. [ 10 ]  In addition to surgery adjuvant chemotherapy may be used to decrease risk of recurrence. Chemotherapy is standard with stage III cancer, case dependant in stage II and palliative in stage IV. [ 11 ]  Diet high in processed food and sugary drinks has also been shown to increase recurrence of stage III colon cancer. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8990", "text": "Bowel obstructions are commonly secondary to  adhesions ,  hernias , or cancer. Bowel obstruction can be an emergency requiring immediate surgery. Original testing and imaging include blood tests for electrolyte levels, and abdominal X-rays or CT scans. Treatment often begins with IV fluids to correct electrolyte imbalances. Obstructions may be complicated by ischemia or perforation of the bowel. These cases are surgical emergencies and often require bowel resection to remove the cause of obstruction. [ 13 ]  Adhesions are a common causes of obstruction, and frequently resolve without surgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8991", "text": "Other causes of bowel obstruction include  volvulus ,  strictures , inflammation and  intussusception . This is not an exhaustive list."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8992", "text": "Bowel perforation presents with abdominal pain, free air in the abdomen on standing X-ray, and sepsis. [ 15 ] [ 16 ] [ 17 ]  Depending on the cause and size, perforations may be medically or surgically managed. Some common causes of perforation are cancer,  diverticulitis , and  peptic ulcer disease ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8993", "text": "When caused by cancer, bowel perforation typically requires surgery, including resection of blood and lymph supply to the cancerous area when possible. When perforation is at the site of the tumor, the perforation may be contained in the tumor and self resolve without surgery. However, surgery may be required later for the malignancy itself. Perforation before the tumor usually requires immediate surgery due to release of fecal material into the abdomen and infection. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8994", "text": "Perforated diverticulitis often requires surgery due to risks of infection or recurrence. Recurrent diverticulitis may required resection even in the absence of perforation. Bowel resection or repair is typically initiated earlier in patients with signs of infection, the elderly, immunocompromised, and those with severe comorbidities. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8995", "text": "Peptic ulcer disease may cause perforation of the bowel but rarely requires bowel resection. Peptic ulcer disease is caused by stomach acid overwhelming the protection of mucus production. Risk factors include  H. pylori  infection, smoking, and NSAID use. The standard treatment is medical management, endoscopy followed by surgical omental patch repair. In rare cases where omental patch fails bowel resection may become necessary. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8996", "text": "Traumatic injuries , whether blunt force such as car accidents or penetrating wounds such as gunshot wounds, or stabbings, may also cause bowel perforation or ischemia requiring emergency surgery. Initial evaluation in trauma includes a  FAST  ultrasound exam followed by contrast CT abdomen in stable patients. The most common bowel injury in trauma is perforation and is repaired rather than resected if the injury involves less than half the bowel circumference and does not involve loss of blood supply. Resection is indicated with more extensive or ischemic injuries. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8997", "text": "Bowel ischemia is caused by decreased or absent blood flow through the Celiac, Superior Mesenteric, and Inferior Mesenteric arteries or any combination thereof. Untreated  acute mesenteric ischemia  can cause bowel  necrosis  in the affected area. This requires emergent surgery as survival without endovascular or operative intervention is around 50%. Ischemic bowel injury often requires multiple surgeries days apart to allow bowel recovery and increase odds of successful  anastomosis . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8998", "text": "An anastomotic leak is a fault in the surgical connection between the two remaining sections of bowel after a resection is performed. This allows the bowel contents to leak into the abdomen. Anastomotic leaks may cause infection, abscess development, and organ failure if untreated. Surgical steps are taken to prevent leaks when possible. These include creating anastomoses with minimal tension on the connection and aligning the bowel to prevent twisting of the bowel at the anastomosis. However, it is believed that most leaks are caused by poor healing, not surgical technique. Risk factors for poor healing of anastomosis include obesity, diabetes mellitus, and smoking. [ 20 ]  Treatment of the leak includes antibiotics, placement of a drain near the leak or developing abscess, stenting of the anastomosis, surgical repair, or creating of an  ileostomy  or  colostomy . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_8999", "text": "Any abdominal surgery may result in an incisional hernia where the abdomen was accessed. Hernias develop when the fascia of the abdominal cavity separates after the surgical closure. This may be due to suture failure, poor wound healing. Other risk factors include obesity and smoking. [ 22 ]  Smaller closure stitches and the use of mesh when closing open surgeries may decrease the risk of hernia occurrence. However, the use of mesh is limited by the surgery performed and contamination or risk infection. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9000", "text": "When colon is resected hernias may form through the mesenteric defect. This is more common with  gastric bypass surgery . Internal hernias may cause ischemia and require emergency surgery to resolve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9001", "text": "A common complication of all abdominal surgeries is adhesions. Adhesions are bands of scar tissue that form after surgery or injury to the abdomen. They can displace or obstruct areas of the bowel. Approximately 1 in 5 emergency surgeries are due to adhesive bowel obstruction. When possible this is managed without surgery with IV fluids, and NG tube to drain the stomach and intestines, and bowel rest (not eating) until the obstruction resolves. If signs of bowel ischemia or perforation are present then emergency surgery is required. Laparoscopic adhesiolysis is the most common surgery used when bowel rest and medical management fail to resolve the obstruction. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9002", "text": "When large amounts of small bowel are resected it can cause short bowel syndrome. Short bowel syndrome is a failure of absorption of nutrients due to resection of portions of the small bowel. It can be limited to a single nutrient or it can be total malabsorption. If the distal ileum is resected it commonly causes a mild form of short bowel syndrome with deficiency of only vitamin B12. When the entire small bowel is resected it can cause chronic complications. [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9003", "text": "The acute form lasts up to one month following bowel resection. Symptoms include diarrhea, malabsorption, and metabolic derangements. This is treated primarily by IV fluids and electrolyte replacement. Acute short bowel syndrome is followed by the adaptation phase which can last up to two years. During this time the small bowel slows movement of bowel contents to allow for more absorption. About half of all patients with short bowel syndrome progress to chronic disease.  Chronic short bowel syndrome may require  total parenteral nutrition  and chronic  central line  use. These may cause complications such as bacteremia and sepsis. Other complications of short bowel syndrome are chronic diarrhea or high output from the ostomy site, intestinal failure associated liver disease, and electrolyte level abnormalities. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9004", "text": "Short bowel syndrome is rare and usually follows extensive ischemic bowel caused by internal hernias, volvulus, or mesenteric ischemia where the remaining small bowel is under 200\u00a0cm long. [ 24 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9005", "text": "Cervical conization  refers to an excision of a cone-shaped portion of tissue from the  mucous membrane  of the  cervix . Conization is used for diagnostic purposes as part of a  biopsy  and for therapeutic purposes to remove pre-cancerous cells ( cervical intraepithelial neoplasia ) or early stage  cervical cancer . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9006", "text": "Types include: [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9007", "text": "Cervical conization effectively reduces the risk of cancer developing or spreading but it causes an increased risk of  premature birth  in future pregnancies. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9008", "text": "The chances of cancer recurrence and premature birth depends on the type of conization. Cold knife conization is associated with 7% chance of the cancer recurring and 16% chance of premature birth, laser conisation comes with 6% cancer recurrence and 13% premature birth, and loop excision comes with 10% recurrence and 11% premature birth. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9009", "text": "Coccygectomy  is a surgical procedure in which the  coccyx  or tailbone is removed. It is considered a required treatment for  sacrococcygeal teratoma  and other  germ cell tumors  arising from the coccyx. Coccygectomy is the treatment of last resort for  coccydynia  (coccyx pain) which has failed to respond to nonsurgical treatment.  Non surgical treatments include use of seat cushions, external or internal manipulation and massage of the coccyx and the attached muscles, medications given by local injections under fluoroscopic guidance, and medications by mouth. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9010", "text": "To remove the coccyx, an incision is made from the tip of the coccyx to its joint with the sacrum. The coccyx is cut away from the surrounding tissues, cut off at the joint with the sacrum, and removed. If the tip of the sacrum is rough, it is filed down. The wound is closed in layers. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9011", "text": "As with any operation under anaesthetic, there are risks associated with  general anaesthesia  itself. An additional possible complication of coccygectomy is infection at the surgical site, due to the site's proximity to the anus, leading to contamination by bacteria from the patient's feces. An analysis of 24 studies of coccygectomy (covering 702 patients) [ 4 ]  reported that 19 studies (covering 493 patients) reported the post-surgery infection rate, while the other five studies gave incomplete information. Among the patients in the 19 studies with full information, the infection rate was 12%. In most cases the infection was superficial, but 4% of operations caused an infection that required repeat surgery to treat the infection. However, the use of prophylactic antibiotics, preoperative rectal enema, closure of the wound in two layers and use of a topical skin adhesive have been shown to reduce the rate of infection to 0%. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9012", "text": "In adults who undergo coccygectomy, one rare complication is a subsequent  perineal hernia  or coccygeal hernia. In these hernias, bowel or other pelvic contents bulge downward and out of the pelvis through a weakened pelvic floor. This complication has not been reported in persons who underwent coccygectomy while a baby or child. A milder version of hernia is when someone just has prolapse (sagging) of the pelvic floor. To repair these hernias, a variety of surgical techniques have been described. [ 5 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9013", "text": "The coccygectomy operation had a poor reputation in the past, and some doctors still advise that the surgery should be avoided. However current data from clinical trials reports success rates of 50 up to 90%, a percentage that rises to 80-90% in patients that are considered to be 'good candidates' for this kind of surgery. A study that was published in 2001 covering a total of 702 patients found good or excellent results in 83% of cases. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9014", "text": "Colectomy  ( col-  +  -ectomy ) is the  surgical  removal of any extent of the  colon , the longest portion of the  large bowel . Colectomy may be performed for prophylactic, curative, or palliative reasons. Indications include cancer, infection, infarction, perforation, and impaired function of the colon. Colectomy may be performed  open ,  laparoscopically , or  robotically . Following removal of the bowel segment, the surgeon may restore continuity of the bowel or create a  colostomy .  Partial or subtotal colectomy refers to removing a portion of the colon, while total colectomy involves the removal of the entire colon. Complications of colectomy include anastomotic leak, bleeding, infection, and damage to surrounding structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9015", "text": "Common indications for colectomy include: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9016", "text": "Before surgery, patients typically undergo preoperative bloodwork, including a complete blood count and type and screen of blood type. Diagnostic imaging may include colonoscopy or  CT  scans of the abdomen and pelvis. In cancer patients, lesions are commonly tattooed via colonoscopy before colectomy to give the surgeon an intraoperative visual guide. [ 1 ]  For non-emergent procedures, patients are typically instructed to follow a clear liquid diet or fast and take a  mechanical bowel preparation  (oral osmotic agents or laxative) to clear the bowels before surgery. [ 4 ] [ 1 ]  Antibiotics may also be prescribed ahead of surgery to reduce risk of post-operative infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9017", "text": "Traditionally, colectomy is performed via an abdominal incision, a technique known as  laparotomy . Minimally invasive colectomy using  laparoscopy  is a well-established procedure in many medical centers. [ 5 ] [ 6 ]  Robot-assisted colectomy is growing in scope of indications and popularity. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9018", "text": "As of 2012, more than 40% of colon resections in the United States are performed via a laparoscopic approach. [ 5 ]  For laparoscopic colectomy, the typical operative technique involves 4-5 separate incisions made in the abdomen.  Trochars  are introduced to gain access to the  peritoneal cavity  and serve as ports for the laparoscopic camera and other instruments. [ 8 ]   Studies have proven the feasibility of single port access colectomy, which would require only one small incision, but no clear benefit in terms of outcome or complication rate has been demonstrated. [ 6 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9019", "text": "Before removal, the portion of the bowel to be resected must be freed or mobilized. This is done by dissection and removal of the  mesentery  and other peritoneal attachments. Resection of any part of the colon entails mobilization and the cutting and sealing, or  ligation , of the blood vessels supplying the portion of the colon to be removed. [ 8 ]  A stapler is typically used to cut across the colon to prevent spillage of intestinal contents into the peritoneal cavity. [ 10 ]  Colectomy as treatment for colorectal cancer also includes  lymphadenectomy , or removal of surrounding lymph nodes, which may be done for staging of the cancer or removal of cancerous nodes. [ 11 ]  More extensive lymphadenectomy is sometimes accomplished by the removal of the  mesocolon , the fatty tissue adjacent to the colon, which contains blood supply, lymphatics, and nerves to the colon. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9020", "text": "When the resection is complete, the surgeon has the option of reconnecting the bowel by stitching or stapling together the cut ends of the bowel (primary  anastomosis ) or performing a  colostomy  to create a  stoma , an opening of the bowel to the  abdominal wall  that provides an alternate exit for the contents of the  gastrointestinal tract . [ 1 ]  When colectomy is performed as part of damage control surgery in life-threatening trauma resulting in destructive colon injury, the surgeon may opt to leave the cut ends of the bowel sealed and disconnected for a short time to allow for further resuscitation of the patient before returning to the operating room for definitive repair (anastomosis or colostomy). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9021", "text": "In modern times,  surgical staplers  are typically used to create colorectal anastomoses, although hand sewn, or  sutured , anastomoses are still done today. Studies have shown that differences in rates of anastomotic leak and surgical site contamination for stapled vs. sutured anastomoses are not statistically significant. The increased speed and decreased human variability afforded by stapling make it an attractive option for most surgeons. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9022", "text": "Several factors are taken into account when deciding between anastomosis or colostomy, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9023", "text": "Giving a patient a  colostomy  avoids the risk of a failed anastomosis. Still, it places a societal, psychological, and physical burden on the patient, as a stoma requires special care and consideration. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9024", "text": "All surgery involves a risk of serious complications, including bleeding, infection, damage to surrounding structures, and death. Additional complications associated with colectomy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9025", "text": "An anastomosis carries the risk of  dehiscence  or breakdown of the surgical connection. Contamination of the  peritoneal cavity  with fecal matter as a result of the anastomotic leak can lead to  peritonitis ,  sepsis  or  death . In patients who underwent colectomy as a treatment for colorectal cancer, an anastomotic leak increases the risk of recurrence of cancer in the same area and reduces survival in the long term. Several factors influence the risk of anastomotic dehiscence, including preservation of blood supply to the cut ends of the bowel, tension on the anastomosis, and the patient's intestinal microbiome, which affects wound healing and potential for surgical site infection. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9026", "text": "The use of  NSAIDS  for analgesia following gastrointestinal surgery remains controversial, given mixed evidence of an increased risk of leakage from any bowel  anastomosis  created. This risk may vary according to the class of NSAID prescribed. [ 17 ] [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9027", "text": "Right hemicolectomy  and  left hemicolectomy  refer to the resection of the  ascending colon  (right) and the  descending colon  (left), respectively. When  middle colic vessels  and  transverse colon  are also resected, it may be referred to as an  extended hemicolectomy. [ 20 ]  Left hemicolectomy is most commonly indicated for cancer in the splenic flexure or descending colon, diverticular disease of the descending colon, and colovesicular or colovaginal  fistulas  that develop as a consequence of diverticular disease. [ 11 ]  The main limitation to performing a left extended colectomy is the difficulty of achieving a colorectal anastomosis afterward. Different techniques, such as Deloyer's or Rosi-Cahil's techniques, have been proposed to solve this issue. [ 21 ]  Right hemicolectomy is most commonly indicated for masses in the right, or ascending, colon but may also be performed for neoplasms of the cecum or appendix. Right-sided diverticulitis, cecal volvulus, inflammatory bowel disease, and  adenomatous polyps  are benign conditions that may require right hemicolectomy. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9028", "text": "Transverse colectomy  involves resection of the transverse colon, the segment of the colon between the hepatic flexure and the splenic flexure. Transverse colectomy is uncommon, as malignant pathologies of the transverse colon typically call for removal of the left colon or right colon as well as the transverse colon due to the variable contributions of the  ileocolic ,  right colic , and  left colic  blood vessels to  lymphatic  drainage of the transverse colon. Transverse colectomy is sometimes appropriate for focal benign pathologies such as local inflammation and local trauma or injury such as  perforation .  [ 11 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9029", "text": "Sigmoidectomy  is a resection of the last part of the colon, known as the sigmoid colon, and can include part or all of the rectum ( proctosigmoidectomy ). Precancerous polyps and sigmoid colon cancer are common indications for sigmoidectomy. Benign indications for sigmoidectomy include diverticular disease, especially when complicated by perforation or  fistulae ,  sigmoid volvulus , trauma, and ischemic or  infectious colitis . [ 11 ]  When a sigmoidectomy is followed by terminal colostomy and closure of the rectal stump; it is called a  Hartmann operation . This is usually done out of the impossibility of performing a \"double-barrel\" or Mikulicz colostomy, which is preferred because it makes \"takedown\" (reoperation to restore intestinal continuity using an anastomosis) considerably easier. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9030", "text": "When the entire colon is removed, this is called a  total colectomy , also known as Lane's Operation. [ 24 ]  Total colectomy may be indicated as a prophylactic measure in certain hereditary polyposis syndromes such as familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer. Total colectomy is also performed for certain forms of inflammatory bowel disease, severe acute colitis, slow-transit constipation, and cancer. [ 1 ] [ 11 ]  If the rectum is also removed, it is a  total proctocolectomy .  Sir William Arbuthnot-Lane  was one of the early proponents of the usefulness of total colectomies and was considered a pioneer of colon surgery for routinely performing this procedure. However, his overuse of the procedure called the wisdom of the surgery into question. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9031", "text": "Subtotal colectomy  is resection of part of the colon or a resection of all of the colon without complete resection. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9032", "text": "The first concepts of colon surgery were thought to have originated in the 15th century as a means to relieve obstructed bowel. The first reported ostomy, performed in 1776 by Pillore of Rouen as an attempt to circumvent blockage caused by a rectal tumor, was done at the insistence of the patient despite opposition from other doctors. While this initial attempt resulted in the death of the patient after only 20 days, subsequent attempts in the following years were more successful. [ 25 ]  By the mid 1880's, hundreds of colectomies had been performed, with a fatality rate between 50 and 60% (lower for those performed in cases of cancer). Dr. Robert Weir suggested in his 1886 case report on the resection of a rectal tumor that shock from the operation and leakage of intestinal contents both during and after surgery contributed to these numbers. [ 28 ]  The introduction of exteriorization, where the intestinal segment of interest was brought out of the abdomen and resected after the abdomen was closed around it, decreased the morbidity of the procedure. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9033", "text": "Jean Francois Reybard performed the first successful end-to-end colonic anastomosis following sigmoid colon resection in 1823. Primarily criticized as dangerous, Reybard's procedure went against the standard protocol of the day: resection of the colon with stoma creation and distal closure. However, colonic anastomosis became more acceptable by the end of the 19th century. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9034", "text": "Many different methods and materials were used to join ends of the bowel in the early days of intestinal anastomosis, including animal  tracheas , artificial pipes made of reed, wood or other materials, cardboard, and rings of silver or wax. Absorbable vegetable plates or sutures became the preference of most by the 1990s. [ 25 ]  With the advent of the surgical stapler, most surgeons have moved on from hand sewing colorectal anastomoses. However, the dexterity and precision afforded by current robotic surgical technology have spurred new interest in the role of sutured anastomosis. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9035", "text": "A report of the first laparoscopically assisted colectomies was published by Jacobs et al. in 1991. [ 29 ] [ 30 ]  While initial concerns were raised about the incidence of port site reoccurrence of tumors after laparoscopic colectomy for cancer, it was later found to be similar to that of wound implant of tumor cells as a result of open colectomy for cancer. [ 29 ]  By the mid-2000s, several studies had been published demonstrating that laparoscopic colectomy was at least as safe as open colectomy and could lead to shorter post-operative recovery times when performed by a skilled surgeon. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9036", "text": "Luis Jose De Souza  is an Indian  surgical oncologist  and the founder of  Shanti Avedna Ashram , a charitable trust which runs a network of hospices in Mumbai and Goa. [ 1 ] [ 2 ]  He has also contributed to the establishment of  Indian Cancer Cell , an educational program co-sponsored by  Tata Memorial Centre , Union for International Cancer Control (UICC) and Indian Cancer Society, for creating cancer awareness in schools. [ 1 ]  The Government of India awarded him the fourth-highest civilian honour of the  Padma Shri  in 1992. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9037", "text": "De Souza was born to Luis Jose and Juliet Mary on 11 December 1943 in  Mumbai , in the western Indian state of  Maharashtra  and graduated in medicine (MBBS) from the  Grant Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals   in 1967. [ citation needed ]  His master's degree was also obtained from the same institution in 1970 after which he joined  Tata Memorial Hospital , Mumbai and reached the position of the professor and head of the gastroenterology department. [ 4 ] [ 5 ]  Later, he moved to  P.D. Hinduja National Hospital and Medical Research Centre  as their consultant oncosurgeon. [ 6 ] [ 7 ]  He has also served as a consultant Oncologist to  Air India  and  Indian Airlines . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9038", "text": "In 1986, De Souza founded  Shanti Avedna Ashram , a charitable trust, and under the aegis of the trust, set up a network of hospices in Mumbai and Goa, reported to be the first such venture for the care of advanced and terminally ill cancer patients in India. [ 8 ]  Representing Tata Memorial Centre, he associated with  Union for International Cancer Control  (UICC) and the Indian Cancer Society in 1993 and founded the  Indian Cancer Cell , a national program for promoting cancer education in Indian schools. [ 8 ]  He has served as the associate editor of the  Indian Journal of Cancer , editorial consultant of  The Practitioner  and as a consultant editor of  Palliative Medicine . [ citation needed ]  He has written over 70 articles in peer reviewed journals, has delivered keynote addresses in conferences and has organised many medical conferences. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9039", "text": "De Souza is married to Carmen Mary Julia Saldanha and the couple has three children. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9040", "text": "De Souza is a fellow of the  American College of Surgeons ,  Royal College of Surgeons of England  and the  Royal College of Surgeons of Edinburgh  and a life member of the  Indian Medical Association , Association of Surgeons of India, Indian Association for the Study of Liver Diseases, Indian Society of Gastroenterology, Indian Society of Oncology and the Indian Association of Palliative Care. [ 10 ]  He is the vice president of the Ostomy Association of India since 1990 and is the director of the International Psycho-Oncology Society since 1992. [ 6 ]  He is also a member of several medical associations such as Indian Cancer Society and International Hepato-Pancreato-Biliary Association. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9041", "text": "The Government of India included De Souza in the 1992  Republic Day honours  list for the civilian award of the Padma Shri. [ 3 ]  The same year, he received three more awards, Fr. Maschio Platinum Jubilee Humanitarian Award, Vasantrao Naik Pratishtan Award, and the Rotary Club of Mumbai Public Award and was felicitated by the Mumbai chapter of the Indian Medical Association. [ 1 ]  He received the Suvidha Trust Award in 1993 and Goa Hindu Association made him their honorary member the next year. [ 1 ]  Ramniklal Kinariwal Cancer Research Award of the Gujarat Cancer Society and the Dr. Manoel Agostinho de Heredia Award reached him in 1996. He received three awards in 1998, Diwaliben Mohanlal Mehta Award, Old Campionites Association Award and Rotary Club of Bombay South Vocational Excellence Award. [ 1 ] [ 6 ]  Mumbai Medical Aid Association awarded him the  Karmayogi Puraskar  in 2010. [ 11 ]  The next year, he was selected as the  QIMPRO Platinum Standard 2011 . [ 8 ]  He is also a recipient of the Scroll of Honour from the Breast Cancer Conference of 2000, NATCON-ISO Award and Appreciation Award for Services to Humanity from St. Elizabeth Hospital. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9042", "text": "Debulking  is the reduction of as much of the bulk ( volume ) of a  tumour  without the intention of a complete eradication. It is usually achieved by  surgical  removal. [ 1 ] [ 2 ]  When performed for curative intent, it is a different procedure, which is called surgical debulking of tumors is known as  cytoreduction  or  cytoreductive surgery [ 3 ]  ( CRS ); \"cytoreduction\" refers to reducing the number of tumor cells. Debulking is used with  curative intent  in only some types of  cancer , as generally partial removal of a  malignant  tumor is not a worthwhile intervention for curative purposes (because malignant cells left behind soon multiply and renew the threat).  Ovarian cancer [ 4 ]  and some types of  brain tumor [ 5 ]  are debulked before  radiotherapy  or  chemotherapy  begin, making those therapies more effective. It may also be used in the case of slow-growing tumors  to shift tumor cells from phase of cell cycle to replicative pool [ clarification needed ] ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9043", "text": "In other types of cancer where debulking is not curative, it is sometimes done with  palliative intent  to relieve  mass effect . For example, tumors whose bulk presses on the lungs or esophagus can impair breathing or swallowing, in which case debulking can improve  quality of life [ 1 ]  and extend  survival [ 1 ]  regardless of not curing the cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9044", "text": "Debulking procedures are usually long and often complicated, taking several hours or more to perform, depending on internal involvement and location."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9045", "text": "An  esophageal stent  is a  stent  (tube) placed in the  esophagus  to keep a blocked area open so the patient can  swallow  soft food and liquids.  They are effective in the treatment of conditions causing intrinsic esophageal obstruction or external esophageal compression.  For the  palliative  treatment of esophageal cancer most esophageal stents are  self-expandable metallic stents .  For benign esophageal disease such as refractory esophageal strictures, plastic stents are available.  Common complications include chest pain, overgrowth of tissue around the stent and stent migration. [ citation needed ]  Esophageal stents may also be used to staunch the bleeding of  esophageal varices . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9046", "text": "Esophageal stents are placed using  endoscopy  when after the tip of the endoscope is positioned above the area to be stented, then guidewire is passed through the obstruction into the stomach. The endoscope is withdrawn and using the guidewire with either  fluoroscopic  or endoscopic guidance the stent is passed down the guidewire to the affected area of the esophagus and deployed. [ 2 ]   Finally, the guidewire is removed and the stent is left to fully expand over the next 2\u20133 days."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9047", "text": "In one study of 997 patients who had self-expanding metal stents for  malignant  esophageal obstruction it was found that esophageal stents were 95% effective. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9048", "text": "Pros of Esophageal Stent"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9049", "text": "There are several potential benefits of an esophageal stent procedure:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9050", "text": "Cons of Esophageal Stent"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9051", "text": "There are also several potential drawbacks to an esophageal stent procedure:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9052", "text": "Esophagectomy  or  oesophagectomy  is the surgical removal of all or parts of the  esophagus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9053", "text": "The principal objective is to remove the esophagus, a part of the  gastrointestinal tract . This procedure is usually done for patients with  esophageal cancer . It is normally done when esophageal cancer is detected early, before it has  spread to other parts of the body .  Esophagectomy of early-stage cancer represents the best chance of a cure.  Despite significant improvements in technique and postoperative care, the long-term survival for esophageal cancer is still poor. Multimodality treatment ( chemotherapy  and  radiation therapy ) is needed for advanced tumors. Esophagectomy is also occasionally performed for benign disease such as  esophageal atresia  in children,  achalasia , or  caustic  injury. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9054", "text": "In those who have had an esophagectomy for cancer, omentoplasty (a procedure in which part of the greater omentum is used to cover or fill a defect, augment arterial or portal venous circulation, absorb effusions, or increase lymphatic drainage) appears to improve outcomes. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9055", "text": "There are two main types of esophagectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9056", "text": "In most cases, the  stomach  is transplanted into the neck and the stomach takes the place originally occupied by the esophagus.  In some cases, the removed esophagus is replaced by another hollow structure, such as the patient's  colon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9057", "text": "Another option that is slowly becoming available is minimally invasive surgery (MIS) which is performed  laparoscopically  and thoracoscopically."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9058", "text": "After surgery, patients may have trouble with a regular diet and may have to consume softer foods, avoid liquids at meals, and stay upright for 1\u20133 hours after eating.  Dysphagia  is common and patients are encouraged to chew foods very well or grind their food.  Patients may complain of substernal pain that resolves by sipping fluids or regurgitating food.   Reflux -type symptoms can be severe, including intolerance to acidic foods and large, fatty meals.   Jejunal   feeding tubes  may be placed during surgery to provide a temporary route of nutrition until oral eating resumes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9059", "text": "Esophagectomy is a very complex operation that can take between 4 and 8 hours to perform. It is best done exclusively by doctors who specialise in  thoracic surgery  or  upper gastrointestinal surgery .  Anesthesia  for an esophagectomy is also complex, owing to the problems with managing the patient's  airway  and  lung  function during the operation. [ 3 ]  Lung collapse is highly probable, as well as loss of diaphragmatic function, and possible injury to the spleen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9060", "text": "Average mortality rates (deaths either in hospital or within 30 days of surgery) for the operation are around 10% in US hospitals. Recognized major cancer hospitals typically report mortality rates under 5%. Major complications occur in 10\u201320% of patients, and some sort of complication (major and minor) occurs in 40%. Time in hospital is usually 1\u20132 weeks and recovery time 3\u20136 months. It is possible for the recovery time to take up to a year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9061", "text": "Forequarter amputation  is  amputation  of the  arm ,  scapula  and  clavicle . It is usually performed as a last resort to remove a cancer, but decreasingly so as  limb-sparing operations  improve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9062", "text": "The rhomboid muscles, trapezius, levator scapulae and latissimus dorsi are transected. The  neurovascular bundle  consisting of the  axillary artery ,  axillary vein  and  brachial plexus  is ligated and cut. The area of the chest left exposed is then normally covered with a split-thickness  skin graft . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9063", "text": "In 2008, David Nott, a British vascular surgeon in the  Democratic Republic of the Congo  with  M\u00e9decins Sans Fronti\u00e8res , performed a forequarter amputation to save the life of a 16-year-old boy, whose arm had been severed by an injury. He was left with a  gangrenous  stump and had a few days to live."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9064", "text": "\"The first thing I realised when I saw J was that he was dying. All that remained of this 16-year-old's arm was six inches of skin; the rest had been shot off when he became caught in gunfire between the Congolese army and rebel forces. A further amputation had left him open to infection, and now he was facing the prospect of an awful, agonising death over a period of several days \u2013 hallucinations, dehydration, his kidneys packing up, his breathing going and then, finally, his heart.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9065", "text": "It made the news because his colleague, Joseph Meirion Thomas, sent pointers via  SMS text message . [ 3 ]  The text message included 10 steps to be followed and finished by saying, \"Easy! Good luck.\" [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9066", "text": "The text David Nott received:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9067", "text": "\"Start on clavicle. Remove middle third. Control and divide subsc art and vein. Divide large nerve trunks around these as prox as poses. Then come onto chest wall immed anterior and divide Pec maj origin from remaining clav. Divide pec minor insertion and (very imp) divide origin and get deep to serrates anterior. Your hand sweeps behind scapula. Divide all muscles attached to scapula. Stop muscle bleeding with count suture. Easy! Good luck. Meirion\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9068", "text": "The  frozen section procedure  is a  pathological   laboratory  procedure to perform rapid  microscopic  analysis of a specimen. It is used most often in  oncological surgery . [ 1 ]  The technical name for this procedure is  cryosection . The  microtome  device that cold cuts thin blocks of frozen  tissue  is called a  cryotome . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9069", "text": "The quality of the slides produced by frozen section is of lower quality than formalin fixed paraffin embedded tissue processing. While diagnosis can be rendered in many cases, fixed tissue processing is preferred in many conditions for more accurate diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9070", "text": "The  intraoperative consultation  is the name given to the whole intervention by the  pathologist , which includes not only frozen section but also  gross  evaluation of the specimen, examination of  cytology  preparations taken on the specimen (e.g. touch imprints), and aliquoting of the specimen for special studies (e.g. molecular pathology techniques, flow cytometry). The report given by the pathologist is often limited to a \"benign\" or \"malignant\" diagnosis, and communicated to the surgeon operating via intercom. When operating on a previously confirmed malignancy, the main purpose of the pathologist is to inform the surgeon if the  resection margin  is clear of residual cancer, or if residual cancer is present at the resection margin. The method of processing is usually done with the  bread loafing  technique. But margin controlled surgery ( CCPDMA ) can be performed using a variety of tissue cutting and mounting methods, including  Mohs surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9071", "text": "The frozen section procedure as practiced today in medical laboratories is based on the description by Dr  Louis B. Wilson  in 1905. Wilson developed the technique from earlier reports at the request of Dr  William Mayo , surgeon and one of the founders of the  Mayo Clinic   [ 3 ]  Earlier reports by Dr  Thomas S. Cullen  at  Johns Hopkins Hospital  in  Baltimore  also involved frozen section, but only after formalin fixation, and pathologist Dr William Welch, also at Hopkins, experimented with Cullen's procedure but without clinical consequences. Hence, Wilson is generally credited with truly pioneering the procedure (Gal & Cagle, 2005). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9072", "text": "The key instrument for cryosection is the  cryostat , which is essentially a  microtome  inside a freezer. The microtome can be compared to a very accurate \"deli\" slicer, capable of slicing sections as thin as 1 micrometre. The usual histology slice is cut at 5 to 10 micrometres. The surgical specimen is placed on a metal tissue disc which is then secured in a chuck and frozen rapidly to about \u201320 to \u201330\u00a0\u00b0C. The specimen is placed in a gel-like embedding medium, usually  OCT  which consists of  polyethylene glycol  and  polyvinyl alcohol ; this compound is known by many names and when frozen has the same density as frozen tissue. At this temperature, most tissues become rock-hard. Usually a lower temperature is required for fat or lipid rich tissue. Each tissue has a preferred temperature for processing. Subsequently, it is cut frozen with the microtome portion of the cryostat, the section is picked up on a glass slide and stained (usually with  hematoxylin  and  eosin , the  H&E stain ). The preparation of the sample is much more rapid than with traditional  histology  technique (around 10 minutes vs 16 hours). However, the technical quality of the sections is much lower. The entire laboratory can occupy a space less than 9-square-foot (0.84\u00a0m 2 ), and minimal ventilation is required compared to a standard wax embedded specimen laboratory. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9073", "text": "Steps of cryotomy:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9074", "text": "The principal use of the frozen section procedure is the examination of tissue while surgery is taking place. This may be for various reasons. In the performance of  Mohs surgery , it is a simple method for real-time margin control of a surgical specimen. If a tumor appears to have  metastasized , a sample of the suspected metastasis is sent for cryosection to confirm its identity. This will help the surgeon decide whether there is any point in continuing the operation. Usually, aggressive surgery is performed only if there is a chance to cure the patient. If the tumor has metastasized, surgery is usually not curative, and the surgeon will choose a more conservative surgery, or no resection at all. If a tumor has been resected but it is unclear whether the resection margin is free of tumor, an intraoperative consultation is requested to assess the need to make a further resection for clear margins. In a  sentinel node procedure , a sentinel node containing tumor tissue prompts a further lymph node dissection, while a benign node will avoid such a procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9075", "text": "If surgery is explorative, rapid examination of a lesion might help identify the possible cause of a patient's symptoms. It is important to note, however, that the pathologist is very limited by the poor technical quality of the frozen sections. A final diagnosis is rarely offered intraoperatively. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9076", "text": "Rarely, cryosections are used to detect the presence of substances lost in the traditional histology technique, for example lipids. They can also be used to detect some  antigens  masked by formalin. The cryostat is available in a small portable device weighing less than 80\u00a0lb (36\u00a0kg), to a large stationary device 500\u00a0lb (230\u00a0kg) or more. The entire histologic laboratory can be carried in one portable box, making frozen section histology a possible tool in primitive medicine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9077", "text": "A Cochrane systematic review published in 2016 analysed all studies that reported diagnostic accuracy of frozen sections in women undergoing surgery for suspicious tumor in ovary. The review concluded that for tumors that were clearly either benign or malignant on frozen section, the accuracy of the diagnosis was good, as confirmed later by regular biopsy. On the contrary, where the frozen section diagnosis was a borderline tumor, neither confirming not ruling out cancer, the diagnosis was less accurate. The review suggests that in such situations of uncertainty, surgeons may choose to perform additional surgery in this group of women at the time of their initial surgery in order to reduce the need for a second operation, as on an average one out of five of these women were subsequently found to have cancer. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9078", "text": "An  ultracryotome , which is a very similar device to crytome, can cut ultrathin blocks of tissue, and that tissue can be observed by  transmission electron microscopy . The cutting thickness of ultracryotome is about dozens of nanometers. The  ultrastructural  properties can be studied without embedding of the tissue, and so the molecular conservation is better. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9079", "text": "A  proctosigmoidectomy ,  Hartmann's operation  or  Hartmann's procedure  is the surgical  resection  of the  rectosigmoid colon  with closure of the anorectal stump and formation of an end  colostomy . It was used to treat  colon cancer  or  inflammation  (proctosigmoiditis, proctitis,  diverticulitis ,  volvulus , etc.). Currently, its use is limited to emergency surgery when immediate  anastomosis  is not possible, or more rarely it is used  palliatively  in patients with colorectal tumours. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9080", "text": "The Hartmann's procedure with a proximal end  colostomy  or  ileostomy  is the most common operation carried out by general surgeons for management of malignant obstruction of the distal colon. During this procedure, the lesion is removed, the distal bowel closed intraperitoneally, and the proximal bowel diverted with a  stoma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9081", "text": "The indications for this procedure include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9082", "text": "Use of the Hartmann's procedure initially had a mortality rate of 8.8%. [ 3 ]  Currently, the overall mortality rate is lower but varies greatly depending on indication for surgery. One study showed no statistically significant difference in morbidity or mortality between laparoscopic versus open Hartmann procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9083", "text": "The procedure was first described in 1921 by French surgeon  Henri Albert Hartmann . [ 5 ]  The original two-paragraph article in French together with an English translation by Thomas P\u00e9zier [ 6 ]  and a modern commentary is available. [ 7 ]  The procedure is described in detail in his book,  Chirurgie du Rectum , which was published in 1931 and constituted volume 8 of his  Travaux de Chirurgie . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9084", "text": "Hematopoietic stem-cell transplantation  ( HSCT ) is the  transplantation  of  multipotent hematopoietic stem cells , usually derived from  bone marrow ,  peripheral blood , or  umbilical cord blood , in order to replicate inside a patient and produce additional normal blood cells. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]  HSCT may be  autologous  (the patient's own stem cells are used),   syngeneic  (stem cells from an  identical twin ), or  allogeneic  (stem cells from a donor). [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9085", "text": "It is most often performed for patients with certain  cancers  of the  blood  or bone marrow, such as  multiple myeloma ,  leukemia , some types of  lymphoma  and  immune deficiencies . [ 5 ]  In these cases, the recipient's immune system is usually suppressed with  radiation  or  chemotherapy  before the transplantation. Infection and  graft-versus-host disease  are major complications of allogeneic HSCT. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9086", "text": "HSCT remains a dangerous procedure with many possible complications; it is reserved for patients with life-threatening diseases. As survival following the procedure has increased, its use has expanded beyond cancer to  autoimmune diseases [ 7 ] [ 8 ]  and hereditary  skeletal dysplasias , notably  malignant infantile osteopetrosis [ 9 ] [ 10 ]  and  mucopolysaccharidosis . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9087", "text": "Indications for stem-cell transplantation are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9088", "text": "Many recipients of HSCTs are  multiple myeloma [ 15 ]  or  leukemia  patients [ 16 ]  who would not benefit from prolonged treatment with, or are already resistant to,  chemotherapy . Candidates for HSCTs include  pediatric  cases where the patient has an inborn defect such as  severe combined immunodeficiency  or  congenital neutropenia  with defective stem cells, and also children or adults with  aplastic anemia [ 17 ]  who have lost their stem cells after birth. Other conditions [ 18 ]  treated with stem cell transplants include  sickle cell disease ,  myelodysplastic syndrome ,  neuroblastoma ,  lymphoma ,  Ewing's sarcoma ,  desmoplastic small round cell tumor ,  chronic granulomatous disease ,  Hodgkin's disease  and  Wiskott\u2013Aldrich syndrome . Non-myeloablative, so-called  mini transplant (microtransplantation)  procedures, have been developed requiring smaller doses of preparative chemotherapy and  radiation therapy , allowing HSCT to be conducted in the elderly and other patients who would otherwise be considered too weak to withstand a conventional treatment regimen. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9089", "text": "In 2006, 50,417 first HSCTs were recorded worldwide, according to a global survey of 1,327 centers in 71 countries conducted by the Worldwide Network for Blood and Marrow Transplantation.  Of these, 28,901 (57%) were autologous and 21,516 (43%) were allogeneic (11,928 from family donors and 9,588 from unrelated donors).  The main indications for transplant were lymphoproliferative disorders (55%) and leukemias (34%), and many took place in either Europe (48%) or the Americas (36%). [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9090", "text": "The Worldwide Network for Blood and Marrow Transplantation reported the millionth transplant to have been undertaken in December 2012. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9091", "text": "In 2014, according to the  World Marrow Donor Association , stem-cell products provided for unrelated transplantation worldwide had increased to 20,604 (4,149 bone-marrow donations, 12,506 peripheral blood stem-cell donations, and 3,949 cord-blood units). [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9092", "text": "Autologous HSCT requires the extraction ( apheresis ) of hematopoietic stem cells (HSCs) from the patient and storage of the harvested cells in a freezer. The patient is then treated with high-dose  chemotherapy  with or without  radiotherapy  with the intention of eradicating the patient's malignant cell population at the cost of partial or complete  bone marrow  ablation (destruction of patient's bone marrow's ability to grow new blood cells).  The patient's own stored stem cells are then transfused into his/her bloodstream, where they replace destroyed tissue and resume the patient's normal blood-cell production. [ 2 ]  Autologous transplants have the advantage of lower risk of infection during the immune-compromised portion of the treatment, since the recovery of immune function is rapid. Also, the incidence of patients experiencing rejection is very rare (and graft-versus-host disease impossible) due to the donor and recipient being the same individual. These advantages have established autologous HSCT as one of the standard second-line treatments for such diseases as  lymphoma . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9093", "text": "For other cancers such as  acute myeloid leukemia , though, the reduced mortality of the autogenous relative to allogeneic HSCT may be outweighed by an increased likelihood of cancer relapse and related mortality, so the allogeneic treatment may be preferred for those conditions. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9094", "text": "Researchers have conducted small studies using nonmyeloablative HSCT as a possible treatment for  type I (insulin dependent) diabetes  in children and adults. Results have been promising, but as of 2019 [update] , speculating whether these experiments will lead to effective treatments for diabetes is premature. [ 25 ] [ 26 ] [ 27 ]  Autologous HSCT is an effective treatment against aggressive Multiple Sclerosis. [ 28 ]  The type of autologous HSCT used as a Multiple Sclerosis treatment is considered safe and the serious adverse events rare. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9095", "text": "Allogeneic HSCT involves two people \u2013 the (healthy) donor and the (patient) recipient. Allogeneic HSC donors must have a tissue ( human leukocyte antigen , HLA) type that matches the recipient. Matching is performed on the basis of variability at three or more  loci  of the HLA gene, and a perfect match at these loci is preferred. Even if a good match exists at these critical  alleles , the recipient will require  immunosuppressive  medications to mitigate graft-versus-host disease. Allogeneic transplant donors may be related (usually a closely HLA-matched sibling), syngeneic (a  monozygotic  or identical twin of the patient \u2013 necessarily extremely rare since few patients have an identical twin, but offering a source of perfectly HLA-matched stem cells), unrelated (donor who is not related and found to have very close degree of HLA matching), or, as in the case of Haploidentical Transplantation, a half-matched relative such as a parent, child, or sibling. Unrelated donors may be found through a registry of bone-marrow donors, such as the  National Marrow Donor Program  (NMDP) in the U.S.  A \" savior sibling \" may be intentionally selected by  preimplantation genetic diagnosis  to match a child both regarding HLA type and being free of any obvious inheritable disorder. Allogeneic transplants are also performed using umbilical  cord blood  as the source of stem cells. In general, by transfusing healthy stem cells to the recipient's bloodstream to reform a healthy immune system, allogeneic HSCTs appear to improve chances for cure or long-term remission once the immediate transplant-related complications are resolved. [ 30 ] [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9096", "text": "A compatible donor is found by doing additional HLA testing from the blood of potential donors. The HLA genes fall in two categories (types I and II). In general, mismatches of the type-I genes (i.e.  HLA-A ,  HLA-B , or  HLA-C ) increase the risk of graft rejection.  A mismatch of an HLA type II gene (i.e.  HLA-DR  or   HLA-DQB1 ) increases the risk of graft-versus-host disease.  In addition, a genetic mismatch as small as a single  DNA   base pair  is significant, so perfect matches require knowledge of the exact DNA sequence of these genes for both donor and recipient.  Leading transplant centers currently perform testing for all five of these HLA genes before declaring that a donor and recipient are HLA-identical. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9097", "text": "Race  and  ethnicity  are known to play a major role in donor recruitment drives, as members of the same ethnic group are more likely to have matching genes, including the genes for HLA. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9098", "text": "As of 2013 [update] , at least two commercialized allogeneic cell therapies have been developed,  Prochymal  and  Cartistem . [ 34 ]   Omidubicel  was approved for medical use in the United States in April 2023. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9099", "text": "To limit the risks of transplanted stem-cell  rejection  or of severe graft-versus-host disease in allogeneic HSCT, the donor should preferably have the same HLA-typing as the recipient. About 25 to 30% of allogeneic HSCT recipients have an HLA-identical sibling. Even so-called \"perfect matches\" may have mismatched minor alleles that contribute to graft-versus-host disease. With recent advances in  T-cell -depleting therapies such as post-transplant  cyclophosphamide ,  haploidentical  (half-matched) transplants have permitted successful transplantation of many patients who would otherwise have lacked a donor. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9100", "text": "In the case of a bone-marrow transplant, the HSCs are removed from a large bone of the donor, typically the  pelvis , through a large  needle  that reaches the center of the bone. The technique is referred to as a bone-marrow harvest and is performed under  local  or  general anesthesia . [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9101", "text": "Peripheral blood stem cells [ 38 ]  are now the most common source of stem cells for HSCT. They are collected from the blood through a process known as  apheresis . The donor's blood is withdrawn through a sterile needle in one arm and passed through a machine that removes  white blood cells . The  red blood cells  are returned to the donor. The peripheral stem cell yield is boosted with daily  subcutaneous injections  of  granulocyte-colony stimulating factor , serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9102", "text": "Extracting stem cells from  amniotic fluid  is possible and may have applications for  autologous  and  heterologous  use. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9103", "text": "Unlike other organs, bone-marrow cells can be frozen ( cryopreserved ) for prolonged periods without damaging too many cells. This is a necessity with autologous HSCs because the cells must be harvested from the recipient months in advance of the transplant treatment. In the case of  allogeneic transplants , fresh HSCs are preferred to avoid cell loss that might occur during the freezing and thawing process. Allogeneic cord blood is stored frozen at a  cord blood bank  because it is only obtainable at the time of  childbirth . To cryopreserve HSCs, a preservative,  dimethyl sulfoxide , must be added, and the cells must be cooled very slowly in a controlled-rate freezer to prevent  osmotic  cellular injury during ice-crystal formation. HSCs may be stored for years in a cryofreezer, which typically uses  liquid nitrogen . [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9104", "text": "The chemotherapy or irradiation given immediately prior to a transplant is called the conditioning regimen, the purpose of which is to help eradicate the patient's disease prior to the infusion of HSCs and to suppress immune reactions. The bone marrow can be ablated (destroyed) with dose-levels that cause minimal injury to other tissues. In allogeneic transplants, a combination of  cyclophosphamide  with  total body irradiation  is conventionally employed. This treatment also has an  immunosuppressive  effect that prevents rejection of the HSCs by the recipient's  immune system . The post-transplant prognosis often includes acute and chronic graft-versus-host disease that may be life-threatening. In certain leukemias, though, this can coincide with protection against cancer relapse owing to the  graft-versus-tumor effect . [ 42 ]  Autologous transplants may also use similar conditioning regimens, but many other chemotherapy combinations can be used depending on the type of disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9105", "text": "A newer treatment approach, nonmyeloablative allogeneic transplantation, also termed reduced-intensity conditioning (RIC), uses doses of chemotherapy and radiation too low to eradicate all the bone-marrow cells of the recipient. [ 43 ] :\u200a320\u2013321\u200a  Instead, nonmyeloablative transplants run lower risks of serious infections and transplant-related mortality while relying upon the graft versus tumor effect to resist the inherent increased risk of cancer relapse. [ 44 ] [ 45 ]  Also significantly, while requiring high doses of  immunosuppressive agents  in the early stages of treatment, these doses are less than for conventional transplants. [ 46 ]  This leads to a state of mixed  chimerism  early after transplant where both recipient and donor HSC coexist in the bone marrow space. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9106", "text": "Decreasing doses of immunosuppressive therapy then allow donor  T-cells  to eradicate the remaining recipient HSCs and to induce the graft-versus-tumor effect. This effect is often accompanied by mild graft-versus-host disease, the appearance of which is often a surrogate marker for the emergence of the desirable graft versus tumor effect, and also serves as a signal to establish an appropriate dosage level for sustained treatment with low levels of immunosuppressive agents. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9107", "text": "Because of their gentler conditioning regimens, these transplants are associated with a lower risk of transplant-related mortality, so allow patients who are considered too high-risk for conventional allogeneic HSCT to undergo potentially curative therapy for their disease. The optimal conditioning strategy for each disease and recipient has not been fully established, but RIC can be used in elderly patients unfit for myeloablative regimens, for whom a higher risk of cancer relapse may be acceptable. [ 43 ] [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9108", "text": "After several weeks of growth in the bone marrow, expansion of HSCs and their progeny is sufficient to normalize the blood cell counts and reinitiate the immune system. The offspring of donor-derived HSCs have been documented to populate many different organs of the recipient, including the  heart ,  liver , and  muscle , and these cells had been suggested to have the abilities of regenerating injured tissue in these organs.  However, recent research has shown that such lineage infidelity does not occur as a normal phenomenon. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9109", "text": "Chimerism  monitoring is a method to monitor the balance between the patient's own stem cells and the new stem cells from a donor. In cases where the patient's own stem cells are increasing in number after treatment, the treatment may potentially not have worked as intended. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9110", "text": "HSCT is associated with a high treatment-related  mortality  in the recipient, which limits its use to conditions that are themselves life-threatening. (The one-year survival rate has been estimated to be roughly 60%, although this figure includes deaths from the underlying disease, as well as from the transplant procedure.) [ 51 ]  Major complications include  veno-occlusive disease ,  mucositis , infections ( sepsis ), graft-versus-host disease, and the development of new  malignancies . [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9111", "text": "Bone-marrow transplantation usually requires that the recipient's own bone marrow be destroyed (myeloablation). Prior to the administration of new cells (engraftment), patients may go for several weeks without appreciable numbers of white blood cells to help fight  infection . This puts a patient at high risk of infections, sepsis, and  septic shock , despite  prophylactic   antibiotics . However,  antiviral   medications , such as  acyclovir  and  valacyclovir , are quite effective in prevention of HSCT-related outbreak of  herpetic  infection in  seropositive  patients. [ 53 ]  The immunosuppressive agents employed in allogeneic transplants for the prevention or treatment of graft-versus-host disease further increase the risk of  opportunistic infection . Immunosuppressive drugs are given for a minimum of six months after a transplantation, or much longer if required for the treatment of graft-versus-host disease. Transplant patients lose their acquired immunity, for example immunity to childhood diseases such as  measles  or  polio . So, transplant patients must be retreated with childhood  vaccines  once they are off immunosuppressive medications. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9112", "text": "Severe liver injury can result from hepatic veno-occlusive disease (VOD), newly termed sinusoidal obstruction syndrome (SOS). [ 55 ]  Elevated levels of  bilirubin ,  hepatomegaly , and fluid retention are clinical hallmarks of this condition. The appreciation of the generalized cellular injury and obstruction in  hepatic vein  sinuses is now greater. Severe cases of SOS are associated with a high mortality rate.  Anticoagulants  or  defibrotide  may be effective in reducing the severity of VOD but may also increase bleeding complications.  Ursodiol  has been shown to help prevent VOD, presumably by facilitating the flow of  bile ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9113", "text": "The injury of the mucosal lining of the mouth and throat is a common regimen-related toxicity following ablative HSCT regimens. It is usually not life-threatening, but is very painful, and prevents eating and drinking. Mucositis is treated with pain medications plus intravenous infusions to prevent dehydration and malnutrition. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9114", "text": "The mucosal lining of the bladder is affected in about 5% of children undergoing HSCT. This causes  hematuria  (blood in urine), frequent urination, abdominal pain and  thrombocytopenia . [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9115", "text": "Graft-versus-host disease (GvHD) is an inflammatory disease that is unique to allogeneic transplantation. It is an attack by the \"new\" bone marrow's immune cells against the recipient's tissues. This can occur even if the donor and recipient are HLA-identical because the immune system can still recognize other differences between their tissues. It is named graft-versus-host disease because the transplanted cells must accept the body rather than the body accepting the new cells. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9116", "text": "Acute GvHD typically occurs in the first three months after transplantation and may involve the  skin ,  intestine , or  liver . High-dose  corticosteroids , such as  prednisone , are a standard treatment, but this immunosuppressive treatment often leads to deadly infections. Chronic GvHD may also develop after allogeneic transplant. It is the major source of late treatment-related complications, although it less often results in death. In addition to inflammation, chronic GvHD may lead to the development of  fibrosis , or scar tissue, similar to  scleroderma ; it may cause functional disability and require prolonged immunosuppressive therapy. GvHD is usually mediated by T cells, which react to foreign peptides presented on the  major histocompatibility complex  of the host. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9117", "text": "Further research is needed to determine whether mesenchymal stromal cells can be use for prophylaxis and treatment of GvHD. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9118", "text": "Graft-versus-tumor effect (GVT), or \"graft versus leukemia\" effect, is the beneficial aspect of the GvHD phenomenon. For example, HSCT patients with either acute, or in particular chronic, GvHD after an allogeneic transplant tend to have a lower risk of cancer relapse. [ 61 ] [ 42 ]  This is due to a therapeutic immune reaction of the grafted donor T lymphocytes against the diseased bone marrow of the recipient. This lower rate of relapse accounts for the increased success rate of allogeneic transplants, compared to transplants from identical twins, and indicates that allogeneic HSCT is a form of immunotherapy. GVT is the major benefit of transplants that do not employ the highest immunosuppressive regimens."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9119", "text": "Graft versus tumor is mainly beneficial in diseases with slow progress, e.g. chronic leukemia, low-grade lymphoma, and in some cases multiple myeloma, but is less effective in rapidly growing acute leukemias. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9120", "text": "If cancer relapses after HSCT, another transplant can be performed, infusing the patient with a greater quantity of donor white blood cells ( donor lymphocyte infusion ). [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9121", "text": "Patients after HSCT are at a higher risk for  oral   carcinoma . Post-HSCT  oral cancer  may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9122", "text": "A meta-analysis showed that the risk of secondary cancers such as  bone cancer ,  head and neck cancers , and  melanoma , with standardized incidence ratios of 10.04 (3.48\u201316.61), 6.35 (4.76\u20137.93), and 3.52 (2.65\u20134.39), respectively, was significantly increased after HSCT. So, diagnostic tests for these cancers should be included in the screening program of these patients for the prevention and early detection of these cancers. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9123", "text": "Prognosis  in HSCT varies widely dependent upon disease type, stage, stem-cell source, HLA-matched status (for allogeneic HSCT), and conditioning regimen. A transplant offers a chance for cure or long-term remission if the inherent complications of graft versus host disease, immunosuppressive treatments and the spectrum of opportunistic infections can be survived. [ 30 ] [ 31 ]  In recent years, survival rates have been gradually improving across almost all populations and subpopulations receiving transplants. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9124", "text": "Mortality for allogeneic stem cell transplantation can be estimated using the prediction model created by Sorror  et al ., [ 66 ]  using the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI). The HCT-CI was derived and validated by investigators at the  Fred Hutchinson Cancer Research Center  in the U.S. The HCT-CI modifies and adds to a well-validated comorbidity index, the  Charlson Comorbidity Index  (CCI) (Charlson,  et al .) [ 67 ]  The CCI was previously applied to patients undergoing allogeneic HCT, but appears to provide less survival prediction and discrimination than the HCT-CI scoring system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9125", "text": "Patients who were successfully treated with HSCT and total body irradiation in childhood were found to have increased fat mass percentage, leading to significantly decreased exercise capacity in adulthood. This suggests patients who underwent successful treatment with HSCT have an increased predisposition to cardiovascular disease later in life. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9126", "text": "The risks of a complication depend on patient characteristics, health care providers, and the apheresis procedure, and the colony-stimulating factor used ( G-CSF ). G-CSF drugs include  filgrastim  (Neupogen, Neulasta), and  lenograstim  (Graslopin)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9127", "text": "Filgrastim is typically dosed in the 10 microgram/kg level for 4\u20135 days during the harvesting of stem cells. The documented adverse effects of filgrastim include  splenic rupture ,  acute respiratory distress syndrome , alveolar hemorrhage, and allergic reactions (usually experienced in first 30 minutes). [ 69 ] [ 70 ] [ 71 ]  In addition, platelet and hemoglobin levels dip postprocedurally, not returning to normal until after a month. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9128", "text": "The question of whether geriatrics (patients over 65) react the same as patients under 65 has not been sufficiently examined.  Coagulation issues and inflammation of atherosclerotic plaques are known to occur as a result of G-CSF injection. G-CSF has also been described to induce genetic changes in  agranulocytes  of normal donors. [ 70 ]  There is no statistically significant evidence either for or against the hypothesis that myelodysplasia (MDS) or acute myeloid leukaemia (AML) can be induced by G-CSF in susceptible individuals. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9129", "text": "Blood is drawn from a peripheral vein in a majority of patients, but a central line to the jugular, subclavian, and femoral veins may be used. Adverse reactions during apheresis were experienced in 20% of women and 8% of men, these adverse events primarily consisted of numbness/tingling, multiple line attempts, and nausea. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9130", "text": "A study involving 2,408 donors (aged 18\u201360 years) indicated that  bone pain  (primarily back and hips) as a result of filgrastim treatment is observed in 80% of donors. [ 71 ]  Donation is not recommended for those with a history of back pain. [ 71 ]  Other symptoms observed in more than 40 percent of donors include muscle pain, headache, fatigue, and difficulty sleeping. [ 71 ]  These symptoms all returned to baseline 1 month after donation in the majority of patients. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9131", "text": "In one meta-study that incorporated data from 377 donors, 44% of patients reported having adverse side effects after peripheral blood HSCT. [ 72 ]  Side effects included pain prior to the collection procedure as a result of G-CSF injections, and postprocedural generalized skeletal pain, fatigue, and reduced energy. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9132", "text": "A study that surveyed 2,408 donors found that serious adverse events (requiring prolonged hospitalization) occurred in 15 donors (at a rate of 0.6%), although none of these events was fatal. [ 71 ]  Donors were not observed to have higher than normal rates of cancer with up to 4\u20138 years of follow-up. [ 71 ] \nOne study based on a survey of medical teams covered about 24,000 peripheral blood HSCT cases between 1993 and 2005, and found a serious cardiovascular adverse reaction rate of about one in 1,500. [ 70 ]  This study reported a cardiovascular-related fatality risk within the first 30 days of HSCT of about two in 10,000. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9133", "text": "In 1939, a woman with aplastic anaemia received the first human bone marrow transfusion. This patient received regular blood transfusions, and an attempt was made to increase her leukocyte and platelet counts by intravenous bone marrow injection without unexpected reaction. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9134", "text": "Stem-cell transplantation was pioneered using bone marrow-derived stem cells by a team at the  Fred Hutchinson Cancer Research Center  from the 1950s through the 1970s led by  E. Donnall Thomas , whose work was later recognized with a  Nobel Prize in Physiology or Medicine . Thomas' work showed that bone-marrow cells infused intravenously could repopulate the bone marrow and produce new blood cells. His work also reduced the likelihood of developing a life-threatening graft-versus-host disease. [ 74 ]  Collaborating with  Eloise Giblett , a professor at the  University of Washington , he discovered genetic markers that could confirm donor matches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9135", "text": "The first physician to perform a successful human bone-marrow transplant on a disease other than cancer was  Robert A. Good  at the  University of Minnesota  in 1968. [ 75 ] \nIn 1975, John Kersey, also of the University of Minnesota, performed the first successful bone-marrow transplant to cure lymphoma. His patient, a 16-year-old-boy, is today the longest-living lymphoma transplant survivor. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9136", "text": "At the end of 2012, 20.2 million people had registered their willingness to be a bone-marrow donor with one of the 67 registries from 49 countries participating in  Bone Marrow Donors Worldwide . Around 17.9 million of these registered donors had been ABDR typed, allowing easy matching.  A further 561,000 cord blood units had been received by one of 46 cord blood banks from 30 countries participating.  The highest total number of bone-marrow donors registered were those from the U.S. (8.0 million), and the highest number per capita were those from Cyprus (15.4% of the population). [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9137", "text": "Within the U.S., racial minority groups are the least likely to be registered, so are the least likely to find a potentially life-saving match.  In 1990, only six African Americans were able to find a bone-marrow match, and all six had common European genetic signatures. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9138", "text": "Africans are more genetically diverse than people of European descent, which means that more registrations are needed to find a match. Bone marrow and cord blood banks exist in  South Africa , and a new program is beginning in  Nigeria . [ 78 ]  Many people belonging to different races are requested to donate as a shortage of donors exists in African, mixed race, Latino, aboriginal, and many other communities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9139", "text": "Two registries in the U.S. recruit unrelated allogeneic donors: NMDP or Be the Match, and the  Gift of Life Marrow Registry ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9140", "text": "In 2007, a team of doctors in Berlin, Germany, including  Gero H\u00fctter , performed a stem-cell transplant for  leukemia  patient  Timothy Ray Brown , who was also  HIV -positive. [ 79 ]  From 60 matching donors, they selected a  [CCR5]-\u039432 homozygous  individual with two  genetic copies  of a rare variant of a  cell surface receptor . This genetic trait confers resistance to HIV infection by blocking attachment of HIV to the cell. Roughly one in 1,000 people of European ancestry have this inherited  mutation , but it is rarer in other populations. [ 80 ] [ 81 ]  The transplant was repeated a year later after a leukemia relapse. Over three years after the initial transplant, and despite discontinuing  antiretroviral therapy , researchers cannot detect HIV in the transplant recipient's blood or in various biopsies of his tissues. [ 82 ]  Levels of HIV-specific antibodies have also declined, leading to speculation that the patient may have been functionally cured of HIV, but scientists emphasise that this is an unusual case. [ 83 ]  Potentially fatal transplant complications (the \"Berlin patient\" developed graft-versus-host disease and  leukoencephalopathy ) mean that the procedure could not be performed in others with HIV, even if sufficient numbers of suitable donors were found. [ 84 ] [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9141", "text": "In 2012,  Daniel Kuritzkes  reported results of two stem-cell transplants in patients with HIV.  They did not, however, use donors with the \u039432 deletion. After their transplant procedures, both were put on antiretroviral therapies, during which neither showed traces of HIV in their blood plasma and purified  CD4 +  T cells  using a sensitive culture method (less than 3 copies/ml). The virus was once again detected in both patients some time after the discontinuation of therapy. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9142", "text": "In 2019, a British man became the second to be cleared of HIV after receiving a bone-marrow transplant from a virus-resistant (\u039432) donor. This patient is being called \"the London patient\" (a reference to the famous Berlin patient). [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9143", "text": "Since McAllister's 1997 report on a patient with  multiple sclerosis  (MS) who received a bone-marrow transplant for chronic myelogenous leukemia (CML), [ 88 ]  over 600 reports have been published describing HSCTs performed primarily for MS. [ 89 ]  These have been shown to \"reduce or eliminate ongoing clinical relapses, halt further progression, and reduce the burden of disability in some patients\" who have aggressive, highly active MS, \"in the absence of chronic treatment with disease-modifying agents\". [ 89 ]  A randomized clinical trial including 110 patients showed that HSCT significantly prolonged time to disease progression compared to disease-modifying therapy. [ 90 ]  Long-term outcome in patients with severe disease has showed that complete disease remission after HSCT is possible. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9144", "text": "HSCT can also be used for treating selected, severe cases of other autoimmune neurological diseases such as  neuromyelitis optica ,  chronic inflammatory demyelinating polyneuropathy , and  myasthenia gravis . [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9145", "text": "Peripheral blood stem cell transplantation  ( PBSCT ), also called \"Peripheral stem cell support\", [ 1 ]  is a method of replacing  blood-forming   stem cells . Stem cells can be destroyed through cancer treatments such as chemotherapy or radiation, as well as any blood-related diseases, such as  leukemia ,  lymphoma ,  neuroblastoma  and  multiple myeloma . [ 2 ]  PBSCT is now a much more common procedure than its  bone marrow harvest  equivalent due to the ease and less invasive nature of the procedure. [ 3 ] [ 4 ]  Studies suggest that PBSCT has a better outcome in terms of the number of  hematopoietic stem cell  ( CD34+ cells ) yield. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9146", "text": "Immature  hematopoietic stem cells  in the circulating  blood  that are similar to those in the  bone marrow  are collected by  apheresis  from a donor (PBSC collection). The product is then administered  intravenously  to the patient after treatment. The administered  hematopoietic stem cells  then migrate to the recipient's bone marrow, through a process known as  stem cell homing , where the transplanted cells override the previous  bone marrow . This allows the  bone marrow  to recover, proliferate and continue producing healthy  blood cells . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9147", "text": "The transplantation may be  autologous  (an individual's own blood cells),  allogeneic  (blood cells donated by someone else with matching  HLA ), or  syngeneic  (blood cells donated by an  identical twin ). The apheresis procedure typically lasts for 4\u20136 hours, depending on the  blood volume  of the donor. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9148", "text": "Granulocyte colony stimulating factor  (GCSF) are naturally occurring  glycoproteins  that stimulate white blood cell proliferation.  Filgrastim  is a synthetic form of GCSF produced in  E.coli . [ 7 ]  PBSC donors are given a course of GCSF prior to PBSC collection. The increase in white blood cell proliferation as a result of the Filgrastim ensures a better results from the donation. The course is usually given over a 4-day period prior to PBSC collection. [ 8 ]  The most common side effects of Filgrastim are bone, joint, back, arm, leg, mouth, throat, and muscle pain. [ 9 ]  Additionally, headache, nausea, vomiting, dizziness, fatigue, rash, loss of appetite, and difficulty falling or staying asleep are common. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9149", "text": "Since  allogeneic  PBSCT involves transformation of blood between different individuals, this naturally carries more complications than  autologous  PBSCT. [ 10 ] \nFor example, calculations must be made to ensure consistency in the amount of total blood volume between the donor and recipient. If the total blood volume of the donor is less than that of the recipient (such as when a child is donating to an adult), multiple PBSCT sessions may be required for adequate collection. Performing such a collection in a single setting could result in risks such as  hypovolemia , which could lead to  cardiac arrest  and death. Health care providers must exercise careful precaution when considering donor-recipient matching in  allogeneic  PBSCT. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9150", "text": "An early example of a successful peripheral stem cell transplant was carried out in the wake of the  1999 Tokaimura nuclear accident . Hisashi Ouchi, who received the highest dose of  radiation  was treated with PBSCT in an attempt to restore his destroyed immune system. Cells from the patient's sister's bone marrow were administered, and in the following weeks successfully began dividing and differentiating into  white blood cells . However, several weeks later, the cells were found to have been mutated by the radiation still present within the patient's body, and were observed carrying out  autoimmune responses . [ 12 ]  Later studies on the incident and subsequent use of PBSCT found that the transplant had also induced  neoendothelialization  of the aortic  endothelium . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9151", "text": "Hemicorporectomy  is a  radical surgery  in which the body below the  waist  is amputated, transecting the  lumbar spine . This removes the  legs , the  genitalia  (internal and external),  urinary system ,  pelvic  bones,  anus , and  rectum . [ 1 ] [ 2 ]  It is a major procedure recommended only as a last resort for people with severe and potentially fatal illnesses such as  osteomyelitis ,  tumors , severe  traumas  and intractable  decubiti  in, or around, the  pelvis . [ 3 ]  By 2009, 66 cases had been reported in medical literature. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9152", "text": "The operation is performed to treat spreading cancers of the spinal cord and pelvic bones. Other reasons may include  trauma  affecting the pelvic girdle (\" open-book fracture \"), uncontrollable  abscess  or  ulcers  of the pelvic region (causing  sepsis ) or other locally uncontainable conditions. [ 2 ]   It is used in cases wherein even  pelvic exenteration  would not remove sufficient tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9153", "text": "The surgical procedure is typically done in two stages, but it is possible to conduct the surgery in one stage. The first stage is the discontinuation of the waste functions by performing a  colostomy  and  ileal conduit  in the upper abdominal quadrants. The second stage is the amputation at the  lumbar spine . [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9154", "text": "With the removal of almost half of the circulatory system,  cardiac  function needs to be closely monitored while a new  blood pressure  set-point develops. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9155", "text": "Removal of large parts of the  colon  can lead to loss of  electrolytes . Similarly, calculated measurements of  renal function  (such as the  Cockcroft-Gault formula ) are unlikely to reflect actual activity of the  kidney , as these calculations were developed for patients in whom the circulatory system correlates with the body weight; this relation is lost in a post-hemicorporectomy patient. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9156", "text": "Extensive  physiotherapy  and  occupational therapy  are necessary after the procedure. A return to mobility generally involves the use of a  wheelchair  and potentially a prosthetic. Designing a  prosthesis  for the removed body parts is difficult, as there is generally no remaining  pelvic girdle  musculature (unless this has been spared expressly)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9157", "text": "Individuals sustaining a severe bisection injury that is essentially a  de facto  hemicorporectomy rarely reach a hospital before dying. Apart from the very low likelihood of surviving such an injury, even an operative hemicorporectomy is unlikely to be successful unless the patient has \"sufficient emotional and psychological maturity to cope\" and \"sufficient determination and physical strength to undergo the intensive rehabilitation\". [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9158", "text": "Emergency rooms  and ambulance service policies advise against the resuscitation of such patients. The UK's  National Health Service , for example, in its \"Policy and Procedures for the Recognition of Life Extinct\" describes traumatic hemicorporectomy (along with  decapitation ) as \"unequivocally associated with death\" and that such injuries should be considered \" incompatible with life \" in patients under 18. [ 8 ]  The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (COT) have also released similar position statements and policy allowing on-scene personnel to determine if patients are to be considered unresuscitatable. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9159", "text": "In one case documented by the  Archives of Emergency Medicine  in 1989, a woman who sustained a complete corporal transection (hemicorporectomy) after being struck by a train arrived at a hospital in a \"fully conscious\" state and \"was aware of the nature of her injury and wished for further treatment.\" Although the patient was initially stabilized and underwent three hours of emergency surgery, she died approximately two hours later due to \" hypovolemia ,  cardiac arrhythmia  and biochemical imbalance.\" [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9160", "text": "Following a hemicorporectomy, patients are fitted with a socket-type prosthesis often referred to as a bucket. Early bucket designs often presented significant pressure problems for patients, but new devices have incorporated an inflatable rubber lining composed of air pockets that evenly distributes pressure based on the patient's motions. Two openings at the front of the bucket create space for the  colostomy bag  and the  ileal conduit . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9161", "text": "The development of  surgical medicine  was vastly accelerated during, and following, the  Second World War . Rarely-experienced traumas were made more common by new weaponry. This required decisive surgical action as well as the development of new techniques. As B. E. Ferrara stated in his summative article on hemicorporectomy,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9162", "text": "Lessons learned from battle field injuries quickened innovative treatment of congenital and acquired conditions\u00a0... [the general surgeon] devised extensive cancer operations including extended radical  mastectomy , radical  gastrectomy  and  pancreatectomy ,  pelvic exenteration , the ' Commando Operation ' (tongue, jaw and neck dissection), bilateral back dissection,  hemipelvectomy , and then hemicorporectomy or translumbar amputation, referred to as the most revolutionary of all operative procedures. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9163", "text": "It was into this environment that Frederick E. Kredel first proposed the operation in February 1951 while discussing a paper on pelvic exenteration. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9164", "text": "Hemipelvectomy , also known as a  pelvic resection , is a surgical procedure that involves the removal of part of the  pelvic girdle . This procedure is most commonly performed to treat  oncologic  conditions of the pelvis. [ 1 ] [ 2 ]  Hemipelvectomy can be further classified as  internal  and  external  hemipelvectomy. [ 1 ] [ 2 ]  An  internal  hemipelvectomy is a  limb-sparing procedure  where the  innominate bone  is  resected  while preserving the  ipsilateral  limb. [ 1 ] [ 2 ]  An  external  hemipelvectomy involves the resection of the innominate bone plus  amputation  of the ipsilateral limb. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9165", "text": "Hemipelvectomy is generally reserved for the treatment of pelvic  neoplasms . [ 1 ] [ 2 ]  Examples of malignancies that are treated with hemipelvectomy include  osteosarcoma ,  chondrosarcoma , and  Ewing's sarcoma . [ 1 ]  Rarely, hemipelvectomy is performed in settings of  traumatic injury  and  osteomyelitis . [ 1 ]  Indications for  external  hemipelvectomy include neoplastic extension into the  sciatic nerve , where loss of function of the lower extremity is anticipated. [ 1 ]   Internal  hemipelvectomy is preferred when complete resection of the tumor is possible without sacrificing the lower extremity. [ 1 ]  If  external  hemipelvectomy cannot provide a greater degree of tumor resection compared to  internal  hemipelvectomy,  internal  hemipelvectomy is recommended. [ 1 ]   Internal  hemipelvectomy must only be considered when the surgical approach can ensure the preservation of critical  neurovascular structures  in the region. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9166", "text": "As with any surgical procedure, risks include infection, blood loss, damage to surrounding structures, cardiac/pulmonary complications, and adverse reactions to anesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9167", "text": "Complications of  external  hemipelvectomy include: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9168", "text": "Complications of  internal  hemipelvectomy include: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9169", "text": "Prior to performing a hemipelvectomy, surgeons must possess detailed knowledge of the pelvic anatomy and its relation to the pelvic tumor. [ 1 ]  Imaging studies such as  conventional radiography ,  computed tomography , and  magnetic resonance imaging  help the surgeon visualize the anatomy and its relationship to the local pathology. [ 1 ]   Surgical oncology  techniques are utilized when resecting tumors of the pelvis. [ 1 ]  Such techniques ensure that adequate  resection margins  are obtained at the time of surgery to minimize tumor recurrence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9170", "text": "The Enneking and Dunham classification system was developed in 1978 to aid surgeons in characterizing pelvic resections. [ 1 ] [ 3 ] [ 4 ]  This classification scheme breaks down pelvic resections into 3 subtypes: Type I, Type II, and Type III. [ 1 ] [ 3 ] [ 4 ]  Type I resections involve removal of the  ilium . [ 1 ] [ 3 ] [ 4 ]  Type II resections involve removal of the  peri-acetabular  region. [ 1 ] [ 3 ] [ 4 ]  Type III resections involve removal of the  ischial  and/or  pubic  region. [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9171", "text": "Resection of pelvic bone typically requires subsequent reconstruction to ensure stability of the hip joint, particularly in  internal  hemipelvectomy. [ 1 ]  Examples of pelvic reconstruction include the use of an  allograft ,  autograft , or  prosthesis  to bridge the remaining ends of pelvic bone following resection. [ 1 ] [ 4 ]   Arthrodesis  is a technique that can be used in  internal  hemipelvectomy to fix the proximal  femur  to a segment of pelvic bone for the purposes of stabilizing the lower extremity. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9172", "text": "Hepatectomy  is the surgical resection (removal of all or part) of the  liver . While the term is often employed for the removal of the liver from a  liver transplant  donor, this article will focus on  partial resections  of hepatic tissue and  hepatoportoenterostomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9173", "text": "The first hepatectomies were reported by Dr. Ichio Honjo (1913\u20131987) of ( Kyoto University ) in 1949, [ 1 ]  and Dr. Jean-Louis Lortat-Jacob (1908\u20131992) of France in 1952. [ 2 ]  In the latter case, the patient was a 58-year-old woman diagnosed with  colorectal cancer  which had  metastasized  to the liver. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9174", "text": "Most hepatectomies are performed for the treatment of hepatic  neoplasms , both benign or malign. Benign neoplasms include  hepatocellular adenoma , hepatic  hemangioma  and  focal nodular hyperplasia . The most common malignant neoplasms (cancers) of the liver are  metastases ; those arising from colorectal cancer are among the most common, and the most amenable to surgical resection. The most common primary malignant tumour of the liver is the  hepatocellular carcinoma . Another primary malignant liver tumor is the  cholangiocarcinoma . Hepatectomy may also be the procedure of choice to treat intrahepatic  gallstones  or  parasitic  cysts of the liver. [ citation needed ]  Partial hepatectomies are also performed to remove a portion of a liver from a living donor for transplantation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9175", "text": "A hepatectomy is considered a major surgical procedure performed under  general anesthesia . Access is accomplished by  laparotomy , historically by a bilateral subcostal (\"chevron\") incision, possibly with midline extension (Calne or \"Mercedes-Benz\" incision). Nowadays a broadly used approach for open liver resections is the J incision, consisting in a right subcostal incision with midline extension. [ 4 ]  The anterior approach, one of the most innovative, is made simpler by the liver hanging maneuver. [ 5 ] \nIn most recent years the minimal invasive approach, consisting in laparoscopic and then robotic surgery, has become increasingly common in liver resective surgery.\nHepatectomies may be anatomic, i.e. the lines of resection match the limits of one or more functional segments of the liver as defined by the  Couinaud  classification (cf.  liver#Functional anatomy ); [ 6 ]  or they may be non-anatomic, irregular or \"wedge\" hepatectomies. Anatomic resections are generally preferred because of the smaller risk of bleeding and biliary fistula; however, non-anatomic resections can be performed safely as well in selected cases. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9176", "text": "The  Pringle manoeuvre  is usually performed during a hepatectomy to minimize blood loss - however this can lead to  reperfusion injury  in the liver due to  Ischemia . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9177", "text": "Bleeding  is a feared technical complication and may be grounds for urgent reoperation. It has been demonstrated that the intraoperative blood loss during liver resections affects the outcome in terms of postoperative morbidity and mortality. [ 8 ]   Biliary   fistula  is also a possible complication, albeit one more amenable to nonsurgical management. Pulmonary complications such as  atelectasis  and  pleural effusion  are commonplace, and dangerous in patients with underlying lung disease.  Infection  is relatively rare. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9178", "text": "Liver failure  is the most serious complication of liver resection; this is a major deterrent in the surgical resection of hepatocellular carcinoma in patients with  cirrhosis . It is also a problem, to a lesser degree, in patients with previous hepatectomies (e.g. repeat resections for reincident  colorectal cancer  metastases). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9179", "text": "Liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a marked tendency towards optimal results at the hands of surgeons with high caseloads in selected centres (typically cancer centres and transplantation centres). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9180", "text": "For optimal results, combination treatment with systemic or regionally infused chemo or biological therapy should be considered.  Prior to surgery, cytotoxic agents such as oxaliplatin given systemically for colorectal metastasis, or chemoembolization for hepatocellular carcinoma can significantly decrease the size of the tumor bulk, allowing then for resections which would remove a segment or wedge portion of the liver only.  These procedures can also be aided by application of liver clamp (Lin or Chu liver clamp; Pilling no.604113-61995) in order to minimize blood loss. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9181", "text": "The word \"hepatectomy\" is derived from Greek. In Greek liver is  hepar  and -ectomy comes from the Greek  ektom\u0113 , \"to remove.\" [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9182", "text": "Hypophysectomy  is the surgical removal of the  hypophysis  (pituitary gland). It is most commonly performed to treat tumors, especially  craniopharyngioma  tumors. [ 1 ]  Sometimes it is used to treat  Cushing's syndrome  due to  pituitary adenoma [ 2 ]  or  Simmond's disease [ 3 ]  It is also applied in  neurosciences  (in experiments with lab animals) to understand the functioning of hypophysis.  There are various ways a hypophysectomy can be carried out.  These methods include transsphenoidal hypophysectomy, open craniotomy, and stereotactic radiosurgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9183", "text": "Medications that are given as  hormone replacement therapy  following a complete hypophysectomy (removal of the pituitary gland) are often  glucocorticoids . [ 4 ]  Secondary Addison's and hyperlipidemia can occur. Thyroid hormone is useful in controlling cholesterol metabolism that has been affected by pituitary deletion. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9184", "text": "Hypophysectomies can be performed in three ways. These include transsphenoidal hypophysectomy, open craniotomy, and stereotactic radiosurgery.  Each of these methods differ in the method in which the pituitary gland is removed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9185", "text": "In a transsphenoidal hypophysectomy, the pituitary gland or section of the pituitary gland is removed through the  sphenoid sinus  and out through the nose. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9186", "text": "In an open  craniotomy , a cavity is opened within the skull to reach the pituitary gland. [ 4 ]   Once the cavity is open, the pituitary gland is removed through the cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9187", "text": "in stereotactic radiosurgery, a headframe is applied to a patient. [ 7 ]   MRI  or  CT scans  are then administered on the patient to allow a map of the head/brain to be formed.  This map will then be used as a guide to allow correct orientation of the lasers administering radiation to specifically destroy the pituitary gland or part of the pituitary gland."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9188", "text": "Hypophysectomy performed at any age causes atrophy of the  thyroid  and  adrenal glands  as well as  asthenia  and  cachexia . When the procedure is performed before sexual maturity, the reproductive tract remains undeveloped and non-functional. There is also a general lack of growth.  If performed after sexual maturity, there will be a loss of reproductive function along with atrophy of gonads and accessory reproductive structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9189", "text": "There is a risk of cerebral spinal fluid leak due to penetration of the basal skull and risk of increased cerebral spinal fluid pressure that may lead to central nervous system changes. Post surgery, patients may have a severely altered  self-image  that may lead to an increased risk of suicide. There is also an increased risk of hemorrhage and infection secondary to the surgical procedure. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9190", "text": "Hysterectomy  is the surgical removal of the  uterus  and  cervix . Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the  ovaries  ( oophorectomy ),  fallopian tubes  ( salpingectomy ), and other surrounding structures. The term \u201cpartial\u201d or \u201ctotal\u201d hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a  gynecologist . Removal of the uterus renders the patient unable to bear children (as does removal of  ovaries  and  fallopian tubes ) and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed  gynecological surgical procedure , after  cesarean section , in the United States. [ 1 ]  Nearly 68 percent were performed for conditions such as  endometriosis ,  irregular bleeding , and  uterine fibroids . [ 1 ]  It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9191", "text": "Hysterectomy is a major surgical procedure that has risks and benefits.  It affects the hormonal balance and overall health of patients. Because of this, hysterectomy is normally recommended as a last resort after pharmaceutical or other surgical options have been exhausted to remedy certain intractable and severe uterine/reproductive system conditions. There may be other reasons for a hysterectomy to be requested. Such conditions and/or indications include, but are not limited to: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9192", "text": "In 1995, the short-term mortality (within 40 days of surgery) was reported at 0.38 cases per 1000 when performed for benign causes. Risks for surgical complications were presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9193", "text": "The mortality rate is several times higher when performed in patients who are pregnant, have cancer or other complications. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9194", "text": "Long-term effect on all case mortality is relatively small. Women under the age of 45 years have a significantly increased long-term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy. [ 14 ] [ 15 ]  This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9195", "text": "Approximately 35% of women after hysterectomy undergo another related surgery within 2 years. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9196", "text": "Ureteral injury is not uncommon and occurs in 0.2 per 1,000 cases of vaginal hysterectomy and 1.3 per 1,000 cases of abdominal hysterectomy. [ 18 ]  The injury usually occurs in the distal ureter close to the  infundibulopelvic ligament  or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9197", "text": "Hospital stay is 3 to 5 days or more for the abdominal procedure and between 1 and 2 days (but possibly longer) for vaginal or laparoscopically assisted vaginal procedures. [ 20 ]  After the procedure, the American College of Obstetricians and Gynecologists recommends not inserting anything into the vagina for the first 6 weeks (including inserting tampons or having sex). [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9198", "text": "Removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovary sparing. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9199", "text": "The average onset age of  menopause  after hysterectomy with ovarian conservation is 3.7 years earlier than average. [ 23 ]  This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% of people, some of them even require  hormone replacement therapy . Surprisingly, a similar and only slightly weaker effect has been observed for  endometrial ablation  which is often considered as an alternative to hysterectomy. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9200", "text": "A substantial number of women develop benign ovarian cysts after a hysterectomy. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9201", "text": "After hysterectomy for benign indications the majority of patients report improvement in sexual life and pelvic pain. A smaller share of patients report worsening of sexual life and other problems. The picture is significantly different for hysterectomy performed for malignant reasons; the procedure is often more radical with substantial side effects. [ 26 ] [ 27 ]  A proportion of patients who undergo a hysterectomy for chronic pelvic pain continue to have pelvic pain after a hysterectomy and develop  dyspareunia  (painful sexual intercourse). [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9202", "text": "Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as \"surgical menopause\", although it is substantially different from a naturally occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce hormones even after the cessation of menstrual periods. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9203", "text": "One study showed that risk of subsequent cardiovascular disease is substantially increased for women who had hysterectomy at age 50 or younger. No association was found for women undergoing the procedure after age 50. The risk is higher when ovaries are removed but still noticeable even when ovaries are preserved. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9204", "text": "Several other studies have found that  osteoporosis  (decrease in bone density) and increased risk of  bone fractures  are associated with hysterectomies. [ 31 ] [ 32 ]  This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9205", "text": "Hysterectomies have also been linked with higher rates of heart disease and weakened bones. Those who have undergone a hysterectomy with both ovaries removed typically have reduced  testosterone  levels as compared to those left intact. [ 22 ]  Reduced levels of testosterone in women are predictive of height loss, which may occur as a result of reduced bone density, [ 33 ]  while increased  testosterone  levels in women are associated with a greater sense of sexual desire. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9206", "text": "Oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9207", "text": "Urinary incontinence and  vaginal prolapse  are well known adverse effects that develop with high frequency a very long time after the surgery. Typically, those complications develop 10\u201320 years after the surgery. [ 36 ]  For this reason exact numbers are not known, and risk factors are poorly understood. It is also unknown if the choice of surgical technique has any effect. It has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. One long-term study found a 2.4 fold increased risk for surgery to correct urinary stress incontinence following hysterectomy. [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9208", "text": "The risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor. [ 39 ]  Overall incidence is approximately doubled after hysterectomy. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9209", "text": "The formation of postoperative  adhesions  is a particular risk after hysterectomy because of the extent of dissection involved as well as the fact the hysterectomy wound is in the most gravity-dependent part of the pelvis into which a loop of bowel may easily fall. [ 41 ]  In one review,  incidence  of  small bowel obstruction  due to intestinal adhesion was found to be 15.6% in non-laparoscopic total abdominal hysterectomies vs. 0.0% in laparoscopic hysterectomies. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9210", "text": "Wound infection  occurs in approximately 3% of cases of abdominal hysterectomy. The risk is increased by obesity, diabetes, immunodeficiency disorder, use of systemic corticosteroids, smoking, wound hematoma, and preexisting infection such as chorioamnionitis and  pelvic inflammatory disease . [ 43 ]  Such wound infections mainly take the form of either  incisional abscess  or wound  cellulitis . Typically, both confer  erythema , but only an incisional abscess confers purulent drainage. The recommended treatment of an incisional abscess after hysterectomy is by  incision and drainage , and then coverage by a thin layer of  gauze  followed by sterile  dressing . The dressing should be changed and the wound irrigated with normal saline at least twice each day. In addition, it is recommended to administer an antibiotic active against staphylococci and streptococci, preferably  vancomycin  when there is a risk of  MRSA . [ 43 ]  The wound can be allowed to close by  secondary intention . Alternatively, if the infection is cleared and healthy granulation tissue is evident at the base of the wound, the edges of the incision may be reapproximated, such as by using  butterfly stitches ,  staples  or  sutures . [ 43 ]  Sexual intercourse remains possible after hysterectomy. Reconstructive surgery remains an option for women who have experienced benign and malignant conditions. [ 44 ]   :\u200a1020\u20131348"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9211", "text": "Hysterectomy may cause an increased risk of the relatively rare  renal cell carcinoma . The increased risk is particularly pronounced for young women; the risk was lower after vaginally performed hysterectomies. [ 45 ]  Hormonal effects or injury of the ureter were considered as possible explanations. [ 46 ] [ 47 ]  In some cases the renal cell carcinoma may be a manifestation of an undiagnosed  hereditary leiomyomatosis and renal cell cancer  syndrome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9212", "text": "Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in  ectopic pregnancy  due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the  Blackwell Journal of Obstetrics and Gynecology ; over 20 other cases have been discussed in additional medical literature. [ 48 ]  On very rare occasions, sexual intercourse after hysterectomy may cause a transvaginal evisceration of the small bowel. [ 49 ]  The  vaginal cuff  is the uppermost region of the vagina that has been sutured closed. A rare complication, it can dehisce and allow the evisceration of the small bowel into the vagina. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9213", "text": "Depending on the indication there are alternatives to hysterectomy:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9214", "text": "Levonorgestrel intrauterine devices  are highly effective at controlling  dysfunctional uterine bleeding  (DUB) or  menorrhagia  and should be considered before any surgery. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9215", "text": "Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive  endometrial ablation  which is an outpatient procedure in which the lining of the uterus is destroyed with heat, mechanically or by radio frequency ablation. [ 52 ]  Endometrial ablation greatly reduces or eliminates monthly bleeding in ninety percent of patients with DUB. It is not effective for patients with very thick uterine lining or uterine fibroids. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9216", "text": "Levonorgestrel intrauterine devices  are highly effective in limiting menstrual blood flow and improving other symptoms. Side effects are typically very moderate because the  levonorgestrel  (a  progestin ) is released in low concentration locally. There is now substantial evidence that Levongestrel-IUDs provide good symptomatic relief for women with fibroids. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9217", "text": "Uterine fibroids may be removed and the uterus reconstructed in a procedure called \" myomectomy \". A myomectomy may be performed through an open incision, laparoscopically, or through the vagina (hysteroscopy). [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9218", "text": "Uterine artery embolization  (UAE) is a minimally invasive procedure for treatment of  uterine fibroids . Under local anesthesia a catheter is introduced into the femoral artery at the groin and advanced under radiographic control into the uterine artery. A mass of microspheres or  polyvinyl alcohol  (PVA) material (an  embolus ) is injected into the uterine arteries in order to block the flow of blood through those vessels. [ 56 ]  The restriction in blood supply usually results in significant reduction of fibroids and improvement of heavy bleeding tendency. The 2012 Cochrane review comparing hysterectomy and UAE did not find any major advantage for either procedure. While UAE is associated with shorter hospital stay and a more rapid return to normal daily activities, it was also associated with a higher risk for minor complications later on. There were no differences between UAE and hysterectomy with regards to major complications. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9219", "text": "Uterine fibroids can be removed with a non-invasive procedure called  Magnetic Resonance guided Focused Ultrasound  (MRgFUS)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9220", "text": "Prolapse may also be corrected surgically without removal of the uterus. [ 58 ]  There are several strategies that can be utilized to help strengthen pelvic floor muscles and prevent the worsening of prolapse. These include, but are not limited to, use of \" kegel exercises \", vaginal pessary, constipation relief, weight management, and care when lifting heavy objects. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9221", "text": "Hysterectomy, in the literal sense of the word, means merely removal of the uterus. However other organs such as ovaries, fallopian tubes, and the cervix are very frequently removed as part of the surgery. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9222", "text": "Subtotal (supracervical) hysterectomy was originally proposed with the expectation that it may improve sexual functioning after hysterectomy, it has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening,  vaginal vault prolapse , and vaginal cuff granulations. [ 62 ]  These theoretical advantages were not confirmed in practice, but other advantages over total hysterectomy emerged. The principal disadvantage is that risk of cervical cancer is not eliminated and women may continue cyclical bleeding (although substantially less than before the surgery).\nThese issues were addressed in a systematic review of total versus supracervical hysterectomy for  benign gynecological conditions , which reported the following findings: [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9223", "text": "In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9224", "text": "Supracervical hysterectomy does not eliminate the possibility of having  cervical cancer  since the cervix itself is left intact and may be contraindicated in women with increased risk of this cancer; regular  pap smears  to check for  cervical dysplasia  or  cancer  are still needed. [ 66 ] [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9225", "text": "Hysterectomy can be performed in different ways. The oldest known technique is vaginal hysterectomy. The first planned hysterectomy was performed by  Konrad Johann Martin Langenbeck  - Surgeon General of the Hannovarian army, although there are records of vaginal hysterectomy for prolapse going back as far as 50BC. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9226", "text": "The first abdominal hysterectomy recorded was by Ephraim McDowell. He performed the procedure in 1809 for a mother of five for a large ovarian mass on her kitchen table. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9227", "text": "In modern medicine today, laparoscopic vaginal (with additional instruments passing through ports in small abdominal incisions, close or in the navel) and total laparoscopic techniques have been developed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9228", "text": "Most hysterectomies in the United States are done via  laparotomy  (abdominal incision, not to be confused with  laparoscopy ). A  transverse (Pfannenstiel) incision  is made through the abdominal wall, usually above the  pubic bone , as close to the upper hair line of the individual's lower  pelvis  as possible, similar to the incision made for a  caesarean section . This technique allows  physicians  the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. [ 70 ]  The recovery time for an open hysterectomy is 4\u20136 weeks and sometimes longer due to the need to cut through the  abdominal wall . Historically, the biggest problem with this technique was infections, but infection rates are well-controlled and not a major concern in modern medical practice. An open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. Before the refinement of the vaginal and laparoscopic vaginal techniques, it was also the only possibility to achieve subtotal hysterectomy; meanwhile, the vaginal route is the preferable technique in most circumstances. [ 71 ] [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9229", "text": "Vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. [ 73 ] [ 74 ]  Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected, or surgical exploration is required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9230", "text": "With the development of laparoscopic techniques in the 1970s and 1980s, the \"laparoscopic-assisted vaginal hysterectomy\" (LAVH) has gained great popularity among  gynecologists  because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries than the vaginal procedure. LAVH begins with  laparoscopy  and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy; the cervix is removed with the uterus. [ 75 ]  If the cervix is removed along with the uterus, the upper portion of the vagina is sutured together and called the  vaginal cuff . [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9231", "text": "The \"laparoscopic-assisted supracervical hysterectomy\" (LASH) was later developed to remove the uterus without removing the cervix using a  morcellator  which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9232", "text": "Total laparoscopic hysterectomy (TLH) was developed in the early 90s by Prabhat K. Ahluwalia in Upstate New York. [ 78 ]  TLH is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus, typically with a uterine manipulator. The entire uterus is disconnected from its attachments using long thin instruments through the \"ports\". Then all tissue to be removed is passed through the small abdominal incisions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9233", "text": "Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similar to the total laparoscopic surgery but the uterus is amputated between the cervix and fundus. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9234", "text": "Dual-port laparoscopy is a form of laparoscopic surgery using two 5\u00a0mm midline incisions: the uterus is detached through the two ports and removed through the vagina. [ 80 ] [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9235", "text": "\"Robotic hysterectomy\" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision. [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9236", "text": "Patient characteristics such as the reason for needing a hysterectomy, uterine size, descent of the uterus, presence of diseased tissues surrounding the uterus, previous surgery in the pelvic region, obesity, history of pregnancy, the possibility of  endometriosis , or the need for an  oophorectomy , will influence a surgeon's surgical approach when performing a hysterectomy. [ 83 ] [ needs update ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9237", "text": "Vaginal hysterectomy is recommended over other variants where possible for women with benign diseases. [ 71 ] [ 72 ] [ 83 ]  Vaginal hysterectomy was shown to be superior to LAVH and some types of laparoscopic surgery causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. [ 84 ] [ 85 ] [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9238", "text": "Laparoscopic surgery offers certain advantages when vaginal surgery is not possible but also has the disadvantage of significantly longer time required for the surgery. [ 83 ] [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9239", "text": "In one 2004 study conducted in the UK comparing abdominal (laparotomic) and laparoscopic techniques, laparoscopic surgery was found to cause longer operation time and a higher rate of major complications while offering much quicker healing. [ 87 ]  In another study conducted in 2014, laparoscopy was found to be \"a safe alternative to laparotomy\" in patients receiving total hysterectomy for endometrial cancer. Researchers concluded the procedure \"offers markedly improved perioperative outcomes with a lower reoperation rate and fewer postoperative complications when the standard of care shifts from open surgery to laparoscopy in a university hospital\". [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9240", "text": "The abdominal technique is very often applied in difficult circumstances or when complications are expected. Given these circumstances the complication rate and time required for surgery compares very favorably with other techniques, however time required for healing is much longer. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9241", "text": "Hysterectomy by abdominal laparotomy is correlated with much higher incidence of intestinal adhesions than other techniques. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9242", "text": "Time required for completion of surgery in the eVAL trial is reported as follows: [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9243", "text": "Morcellation  has been widely used especially in laparoscopic techniques and sometimes for the vaginal technique, but now appears to be associated with a considerable risk of spreading benign or malignant tumors. [ 89 ] [ 90 ]  In April 2014, the FDA issued a memo alerting medical practitioners to the risks of power morcellation. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9244", "text": "Robotic assisted surgery is presently used in several countries for hysterectomies. Additional research is required to determine the benefits and risks involved, compared to conventional laparoscopic surgery. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9245", "text": "A 2014 Cochrane review found that robotic assisted surgery may have a similar complication rate when compared to conventional laparoscopic surgery. In addition, there is evidence to suggest that although the surgery make take longer, robotic assisted surgery may result in shorter hospital stays. [ 92 ]  More research is necessary to determine if robotic assisted hysterectomies are beneficial for people with cancer. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9246", "text": "Previously reported marginal advantages of robotic assisted surgery could not be confirmed; only differences in hospital stay and cost remain statistically significant. [ 93 ] [ 94 ] [ 95 ]  In addition, concerns over widespread misleading marketing claims have been raised. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9247", "text": "In  Canada , the number of hysterectomies between 2008 and 2009 was almost 47,000. The national rate for the same timeline was 338 per 100,000 population, down from 484 per 100,000 in 1997. The reasons for hysterectomies differed depending on whether the woman was living in an urban or rural location. Urban women opted for hysterectomies due to  uterine fibroids  and rural women had hysterectomies mostly for  menstrual disorders . [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9248", "text": "Hysterectomy is the second most common major surgery among women in the United States (the first is cesarean section). In the 1980s and 1990s, this statistic was the source of concern among some consumer rights groups and puzzlement among the medical community, [ 102 ]  and brought about informed choice advocacy groups like Hysterectomy Educational Resources and Services (HERS) Foundation, founded by  Nora W. Coffey  in 1982."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9249", "text": "According to the  National Center for Health Statistics , of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. There are currently an estimated 22 million women in the United States who have undergone this procedure. Nearly 68 percent were performed for benign conditions such as endometriosis, irregular bleeding and uterine fibroids. [ 1 ]  Such rates being highest in the industrialized world has led to the controversy that hysterectomies are being largely performed for unwarranted reasons. [ 103 ]  More recent data suggests that the number of hysterectomies performed has declined in every state in the United States. From 2010 to 2013, there were 12 percent fewer hysterectomies performed, and the types of hysterectomies were more minimally invasive in nature, reflected by a 17 percent increase in laparoscopic procedures. [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9250", "text": "In the UK, 1 in 5 women is likely to have a hysterectomy by the age of 60, and ovaries are removed in about 20% of hysterectomies. [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9251", "text": "The number of hysterectomies in  Germany  has been constant for many years. In 2006, 149,456 hysterectomies were performed. Additionally, of these, 126,743 (84.8%) successfully benefitted the patient without incident. Women between the ages of 40 and 49 accounted for 50 percent of hysterectomies, and those between the ages of 50 and 59 accounted for 20 percent. [ 106 ]  In 2007, the number of hysterectomies decreased to 138,164. [ 64 ]  In recent years, the technique of laparoscopic or laparoscopically assisted hysterectomies has been raised into the foreground. [ 107 ] [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9252", "text": "In  Denmark , the number of hysterectomies from the 1980s to the 1990s decreased by 38 percent. In 1988, there were 173 such surgeries per 100,000 women, and by 1998 this number had been reduced to 107. The proportion of abdominal supracervical hysterectomies in the same time period grew from 7.5 to 41 percent. A total of 67,096 women underwent hysterectomy during these years. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9253", "text": "Irreversible electroporation  or  IRE  is a soft tissue  ablation  technique using short but strong  electrical fields  to create permanent and hence lethal nanopores in the  cell membrane , to disrupt cellular  homeostasis . The resulting cell death results from induced  apoptosis  or  necrosis  induced by either membrane disruption or secondary breakdown of the membrane due to transmembrane transfer of electrolytes and  adenosine triphosphate . [ 1 ] [ 2 ] [ 3 ] [ 4 ]  The main use of IRE lies in tumor ablation in regions where precision and conservation of the  extracellular matrix , blood flow and nerves are of importance. The first generation of IRE for clinical use, in the form of the NanoKnife System, became commercially available for research purposes in 2009, solely for the surgical ablation of soft tissue tumors. [ 5 ]  Cancerous tissue ablation via IRE appears to show significant cancer specific immunological responses which are currently being evaluated alone and in combination with  cancer immunotherapy . [ 6 ] [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9254", "text": "First observations of IRE effects go back to 1754. Nollet reported the first systematic observations of the appearance of red spots on animal and human skin that was exposed to electric sparks. [ 10 ]  However, its use for modern medicine began in 1982 with the seminal work of Neumann and colleagues. [ 11 ]  Pulsed electric fields were used to temporarily permeabilize cell membranes to deliver foreign DNA into cells. In the following decade, the combination of high-voltage pulsed electric fields with the chemotherapeutic drug bleomycin and with DNA yielded novel clinical applications:  electrochemotherapy  and  gene electrotransfer , respectively. [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ]  The use of irreversible electroporation for therapeutic applications was first suggested by Davalos, Mir, and Rubinsky. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9255", "text": "Utilizing ultra short pulsed but very strong electrical fields, micropores and nanopores are induced in the  phospholipid bilayers  which form the outer cell membranes. [ citation needed ]  Two kinds of damage can occur:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9256", "text": "It should be stated that even though the ablation method is generally accepted to be apoptosis, some findings seem to contradict a pure apoptotic cell death, making the exact process by which IRE causes cell death unclear. [ 18 ] [ 4 ]  In any case, all studies agree that the cell death is an induced one with the cells dying over a varying time period of hours to days and does not rely on local extreme heating and melting of tissue via high energy deposition like most ablation technologies  (see  radiofrequency ablation ,  microwave ablation ,  High-intensity focused ultrasound ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9257", "text": "When an electrical field of more than 0.5 V/nm [ 19 ]  is applied to the resting trans-membrane potential, it is proposed that water enters the cell during this dielectric breakdown. Hydrophilic pores are formed. [ 20 ] [ 21 ]  A molecular dynamics simulation by Tarek [ 22 ]  illustrates this proposed pore formation in two steps: [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9258", "text": "It is proposed that as the applied electrical field increases, the greater is the perturbation of the phospholipid head groups, which in turn increases the number of water filled pores. [ 24 ]  This entire process can occur within a few nanoseconds. [ 22 ]  Average sizes of nanopores are likely cell-type specific. In swine livers, they average around 340-360\u00a0nm, as found using  SEM . [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9259", "text": "A secondary described mode of cell death was described to be from a breakdown of the membrane due to transmembrane transfer of electrolytes and adenosine triphosphate. [ 3 ]  Other effects like heat [ 25 ]  or electrolysis [ 26 ] [ 27 ]  were also shown to play a role in the currently clinically applied IRE pulse protocols."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9260", "text": "A number of electrodes, in the form of long needles, are placed around the target volume. The point of penetration for the electrodes is chosen according to anatomical conditions. Imaging is essential to the placement and can be achieved by ultrasound, magnetic resonance imaging or tomography. The needles are then connected to the IRE-generator, which then proceeds to sequentially build up a potential difference between two electrodes. The geometry of the IRE-treatment field is calculated in real time and can be influenced by the user. Depending on the treatment-field and number of electrodes used, the ablation takes between 1 and 10 minutes. In general muscle relaxants are administered, since even under general anesthetics, strong muscle contractions are induced by excitation of the motor end-plate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9261", "text": "Typical parameters (1st generation IRE system): [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9262", "text": "The shortly pulsed, strong electrical fields are induced through thin, sterile, disposable electrodes. The potential differences are calculated and applied by a computer system between these electrodes in accordance to a previously planned treatment field. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9263", "text": "One specific device for the IRE procedure is the  NanoKnife  system manufactured by AngioDynamics, which received FDA 510k clearance on October 24, 2011. [ 40 ]  The NanoKnife system has also received an Investigational Device Exemption (IDE) from the FDA that allows AngioDynamics to conduct clinical trials using this device. [ 40 ]  The Nanoknife system transmits a low-energy direct current from a generator to electrode probes placed in the target tissues for the surgical ablation of soft tissue. In 2011, AngioDynamics received an FDA warning letter for promoting the device for indications for which it had not received approval. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9264", "text": "In 2013, the UK National Institute for Health and Clinical Excellence issued a guidance that the safety and efficacy of the use of irreversible electroporation of the treatment of various types of cancer has not yet been established. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9265", "text": "Newer generations of Electroporation-based ablation systems are being developed specifically to address the shortcomings of the first generation of IRE but, as of June 2020, none of the technologies are available as a medical device. [ 27 ] [ 43 ] [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9266", "text": "Potential organ systems, where IRE might have a significant impact due to its properties include the pancreas, liver, prostate and the kidneys, which were the main focus of the studies listed in Table 1-3 (state: June 2020)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9267", "text": "None of the potential organ systems, which may be treated for various conditions and tumors, are covered by randomized multicenter trials or long-term follow-ups (state. June 2020)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9268", "text": "2016 [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9269", "text": "3.0\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9270", "text": "laparoscopic\n(n = 20)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9271", "text": "2013 [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9272", "text": "CRLM (n = 20),\nOther (n = 10);\n2.5\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9273", "text": "(n = 28), open\n(n = 14), laparoscopic\n(n = 2)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9274", "text": "2017 [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9275", "text": "CRLM (n = 23),\nother (n = 7); 2.4\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9276", "text": "(n = 30)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9277", "text": "(at 6 months)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9278", "text": "2014 [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9279", "text": "2.7\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9280", "text": "(n = 28)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9281", "text": "2012 [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9282", "text": "CRLM (n = 21),\nother (n = 5);\n1.0\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9283", "text": "(n = 6), open\n(n = 22)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9284", "text": "2014 [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9285", "text": "CRLM (n = 20),\nCCC (n = 5);\n2.7\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9286", "text": "(n = 67)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9287", "text": "2015 [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9288", "text": "CRLM (n = 16),\nCCC (n = 6),\nother (n = 4); 1.7\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9289", "text": "(n = 25)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9290", "text": "2016 [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9291", "text": "CRLM (n = 22),\nCCC (n = 5),\nother (n = 5); 2.4\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9292", "text": "(n = 34)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9293", "text": "2017 [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9294", "text": "CRLM (n = 16),\nCCC (n = 6), other\n(n = 4); 2.3\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9295", "text": "(n = 71)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9296", "text": "2013 [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9297", "text": "CRLM (n = 23),\nCCC (n = 2),\nother (n = 22);\n3.8\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9298", "text": "(NS) open\n(NS)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9299", "text": "2014 [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9300", "text": "2.4\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9301", "text": "2011 [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9302", "text": "CRLM (n = 15), other\n(n = 31); 2.5\u00a0cm"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9303", "text": "Hepatic IRE appears to be safe, even when performed near vessels and bile ducts [ 59 ] [ 60 ]  with an overall complication rate of 16%, with most complications being needle related (pneumothorax and hemorrhage).The COLDFIRE-2 trial with 50 patients showed 76% local tumor progression-free survival after 1 year. [ 61 ]  Whilst there are no studies comparing IRE to other ablative therapies yet, thermal ablations have shown a higher efficacy in that matter with around 96% progression free survival. Therefor Bart et al. [ 36 ]  concluded that IRE should currently only be performed for only truly unresectable and non-ablatable tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9304", "text": "Patients"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9305", "text": "and Median\nLargest Tumor Diameter"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9306", "text": "Follow-up"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9307", "text": "(mo)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9308", "text": "Overall\nSurvival (mo)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9309", "text": "Recurrence\n(%)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9310", "text": "Downstaging\nCaused by IRE"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9311", "text": "2017 [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9312", "text": "2019 [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9313", "text": "(88% after chemotherapy or radiation\ntherapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9314", "text": "(n = 32), open (n = 1)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9315", "text": "10.7 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9316", "text": "2016 [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9317", "text": "2016 [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9318", "text": "percutaneous (n = 2)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9319", "text": "2018 [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9320", "text": "chemotherapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9321", "text": "2016 [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9322", "text": "7.0 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9323", "text": "2019 [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9324", "text": "2015 [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9325", "text": "chemo- or radiation\ntherapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9326", "text": "18 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9327", "text": "et al., 2016 [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9328", "text": "(after chemo- or radiation therapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9329", "text": "14.2 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9330", "text": "2015 [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9331", "text": "6.4 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9332", "text": "2019 [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9333", "text": "and local recurrence (n = 10), 4.0\u00a0cm (68% after chemotherapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9334", "text": "9.6 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9335", "text": "2017 [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9336", "text": "(52% after chemotherapy)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9337", "text": "11.0 (IRE)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9338", "text": "2018 [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9339", "text": "percutaneous, NS"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9340", "text": "2017 [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9341", "text": "2016 [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9342", "text": "2017 [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9343", "text": "Animal studies have shown the safety and efficacy of IRE on pancreatic tissue. [ 78 ]  The overall survival rates in studies on the use of IRE for pancreatic cancer provide an encouraging nonvariable endpoint and show an additive beneficial effect of IRE compared with standard-of care chemotherapeutic treatment with FOLFIRINOX (a combination of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) (median OS, 12\u201314months). [ 79 ] [ 80 ]  However, IRE appears to be more effective in conjunction with systemic therapy and is not suggested as first-line treatment. [ 68 ]  Despite that IRE makes adjuvant tumor mass reduction therapy for  LAPC  possible, IRE remains, in its current state, a high risk procedure requiring additional safety data before it can be used widely. [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9344", "text": "Concurrent Treatment"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9345", "text": "(% of patients)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9346", "text": "(no. of patients)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9347", "text": "(2010) [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9348", "text": "3+4: n = 6"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9349", "text": "4+4: n = 3"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9350", "text": "urinary incontinence 0% erectile dysfunction 0%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9351", "text": "out-of-field occurrence, n = 1"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9352", "text": "(2016) [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9353", "text": "4+3: n = 3"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9354", "text": "4+4: n = 2"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9355", "text": "4 weeks after IRE"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9356", "text": "complete fibrosis or necrosis of ablation zone"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9357", "text": "(2018) [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9358", "text": "3+4: n = 38"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9359", "text": "4+3: n = 16"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9360", "text": "Grade 2: 11%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9361", "text": "Grade 3\u20135: 0%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9362", "text": "urinary incontinence 0%;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9363", "text": "erectile dysfunction 23%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9364", "text": "out-of-field recurrence, n = 4"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9365", "text": "(2019) [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9366", "text": "3+4/4+3:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9367", "text": "n = 225"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9368", "text": "4+4: n = 68"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9369", "text": "5+3/3+5: n = 3"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9370", "text": ">4+4 = 42"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9371", "text": "prostatectomy (n = 21),"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9372", "text": "radiation therapy (n = 28),"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9373", "text": "TURP (n = 17),"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9374", "text": "HIFU (n = 8)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9375", "text": "ADT (n = 29)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9376", "text": "erectile dysfunction 3%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9377", "text": "local recurrence, n = 20;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9378", "text": "out-of-field recurrence, n = 27"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9379", "text": "(2014) [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9380", "text": "3+4: n = 19"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9381", "text": "4+3: n = 5"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9382", "text": "4+4: n = 1"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9383", "text": "incontinence 0%;"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9384", "text": "erectile dysfunction 5%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9385", "text": "only one histologic verification. Out-of-field\nrecurrence, NS"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9386", "text": "(2016) [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9387", "text": "3+4: n = 15"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9388", "text": "4+3: n = 8"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9389", "text": "4+4: n = 0"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9390", "text": "Grade 2: 29%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9391", "text": "erectile dysfunction, unknown"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9392", "text": "out-of-fieldrecurrence, n = 5 (with histologic verification)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9393", "text": "3+4: n = 37"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9394", "text": "4+3: n = 6"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9395", "text": "Grade 2: 9"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9396", "text": "erectile dysfunction 6%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9397", "text": "out-of-field recurrence, NS"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9398", "text": "Focal ablation using IRE for PCa in the distal apex appears safe and feasible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9399", "text": "The concept of treating prostate cancer with IRE was first proposed by Gary Onik and Boris Rubinsky in 2007. [ 89 ]  Prostate carcinomas are frequently located near sensitive structures which might be permanently damaged by thermal treatments or radiation therapy. The applicability of surgical methods is often limited by accessibility and precision. Surgery is also associated with a long healing time and high rate of side effects. [ 90 ]  Using IRE, the urethra, bladder, rectum and neurovascular bundle and lower urinary sphincter  can potentially be included in the treatment field without creating (permanent) damage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9400", "text": "IRE has been in use against prostate cancer since 2011, partly in form of clinical trials, compassionate care or individualized treatment approach. As for all other ablation technologies and also most conventional methods, no studies employed a randomized multi-center approach or targeted  cancer-specific mortality  as endpoint.  Cancer-specific mortality  or  overall survival  are notoriously hard to assess for prostate cancer, as the trials require more than a decade and usually several treatment types are performed during the years making treatment-specific survival advantages difficult to quantify. Therefore, the results of ablation-based treatments and focal treatments in general usually use local recurrences and functional outcome (quality of life) as endpoint. In that regard, the clinical results collected so far and listed in Table 3 shown encouraging results and uniformly state IRE as a safe and effective treatment (at least for focal ablation) but all warrant further studies. The largest cohort presented by Guenther et al. [ 85 ]  with up to 6-year follow-up is limited as a heterogeneous retrospective analysis and no prospective clinical trial. Therefore, despite that several hospitals in Europe have been employing the method for many years with one private clinic even listing more than one thousand treatments as of June 2020, [ 91 ]  IRE for prostate cancer is currently not recommended in treatment guidelines."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9401", "text": "While nephron-sparing surgery is the gold standard treatment for small, malignant renal masses, ablative therapies are considered a viable option in patients who are poor surgical candidates. Radiofrequency ablation (RFA) and cryoablation have been used since the 1990s; however, in lesions larger than 3\u00a0cm, their efficacy is limited. The newer ablation modalities, such as IRE, microwave ablation (MWA), and high-intensity focused ultrasound, may help overcome the challenges in tumor size. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9402", "text": "The first human studies have proven the safety of IRE for the ablation of renal masses; however, the effectiveness of IRE through histopathological examination of an ablated renal tumor in humans is yet to be known. Wagstaff et al. have set out to investigate the safety and effectiveness of IRE ablation of renal masses and to evaluate the efficacy of ablation using MRI and contrast-enhanced ultrasound imaging. In accordance with the prospective protocol designed by the authors, the treated patients will subsequently undergo radical nephrectomy to assess IRE ablation success. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9403", "text": "Later phase 2 prospective trials showed good results in terms of safety and feasibility   [ 94 ] [ 95 ]  for small renal masses but the cohort was limited in numbers (7 and 10 patients respectively), hence efficacy is not yet sufficiently determined. IRE appears safe for small renal masses up to 4\u00a0cm. However, the consensus is that current evidence is still inadequate in quality and quantity. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9404", "text": "In a prospective, single-arm, multi-center, phase II clinical trial, the safety and efficacy of IRE on lung cancers were evaluated. The trial included patients with primary and secondary lung malignancies and preserved lung function. The expected effectiveness was not met at interim analysis and the trial was stopped prematurely. Complications included pneumothoraces (11 of 23 patients), alveolar hemorrhage not resulting in significant hemoptysis, and needle tract seeding was found in 3 cases (13%). Disease progression was seen in 14 of 23 patients (61%). Stable disease was found in 1 (4%), partial remission in 1 (4%) and complete remission in 7 (30%) patients. The authors concluded that IRE is not effective for the treatment of lung malignancies. [ 96 ]  Similarly poor treatment outcomes have been observed in other studies. [ 97 ] [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9405", "text": "A major obstacle of IRE in the lung is the difficulty in positioning the electrodes; placing the probes in parallel alignment is made challenging by the interposition of ribs. Additionally, the planned and actual ablation zones in the lung are dramatically different due to the differences in conductivity between tumor, lung parenchyma, and air. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9406", "text": "Maor et el have demonstrated the safety and efficiency of IRE as an ablation modality for smooth muscle cells in the walls of large vessels in rat model. [ 100 ]  Therefore, IRE has been suggested as preventive treatment for coronary artery re-stenosis after  percutaneous coronary intervention . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9407", "text": "Numerous studies in animals have demonstrated the safety and efficiency of IRE as a non-thermal ablation modality for pulmonary veins in the context of  atrial fibrillation  treatment. [ 101 ]  In 2023, irreversible electroporation is being widely used and evaluated in humans, as  cardiac ablation therapy  to kill very small areas of heart muscle. This is done to treat  irregularities of heart rhythm . A  cardiac catheter  delivers trains of high-voltage ultra-rapid electrical pulses that form irreversible pores in cell membranes, resulting in cell death. It is thought to allow better selectivity than the previous techniques, which used heat or cold to kill larger volumes of muscle. [ 102 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9408", "text": "IRE has also been investigated in ex-vivo human eye models for treatment of uveal melanoma [ 103 ]  and in thyroid cancer. [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9409", "text": "Successful ablations in animal tumor models have been conducted for lung, [ 105 ] [ 106 ]  brain, [ 107 ] [ 108 ]  heart, [ 109 ]  skin, [ 110 ] [ 111 ]  bone, [ 112 ] [ 113 ]  head and neck cancer, [ 114 ]  and blood vessels. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9410", "text": "The  Journal of Surgical Oncology  is a monthly  peer-reviewed   medical journal  covering  surgical oncology . It was established in 1969 and is published by  Wiley-Liss . The  editor-in-chief  is Stephen F. Sener ( Keck School of Medicine of USC ). According to the  Journal Citation Reports , the journal has a 2020  impact factor  of 3.454, ranking it 157th out of 243 journals in the category \"Oncology\" [ 1 ]  and 60th out of 212 journals in the category \"Surgery\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9411", "text": "Laryngectomy  is the removal of the  larynx . In a total laryngectomy, the entire larynx is removed (including the  vocal folds ,  hyoid bone ,  epiglottis ,  thyroid  and  cricoid cartilage  and a few  tracheal cartilage  rings) with the separation of the airway from the  mouth ,  nose  and  esophagus . [ 1 ]  In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a  stoma . [ 2 ]  This procedure is usually performed by an  ENT surgeon  in cases of  laryngeal cancer . Many cases of  laryngeal cancer  are treated with more conservative methods (surgeries through the mouth,  radiation  and/or  chemotherapy ). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of  head and neck cancer . [ 3 ]  Less invasive partial laryngectomies, including  tracheal shaves  and  feminization laryngoplasty  may also be performed on  transgender women  and other  female  or  non-binary  identified individuals to feminize the larynx and/or voice.  Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be  affected post-surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9412", "text": "The first total laryngectomy was performed in 1873 by  Theodor Billroth . [ 4 ] [ 5 ]  The patient was a thirty-six-year-old man with a  subglottic squamous cell carcinoma . On November 27, 1873, Billroth performed a partial laryngectomy. Subsequent  laryngoscopic examination  in mid-December 1873 found tumor recurrence. On December 31, 1873, Billroth performed the first total laryngectomy. The patient was discharged four months later after he learned to use the artificial larynx, which enabled him to speak despite the removal of his vocal cords. Unfortunately, the patient developed a recurrence of the lesion, accompanied by metastatic nodes, and passed away a year following the surgery. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9413", "text": "Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866, [ 7 ] [ 8 ] \nbut this patient's larynx was only excised after death."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9414", "text": "The first artificial larynx was constructed by  Johann Nepomuk Czermak  in 1869.  Vincenz Czerny  developed an artificial larynx which he tested in dogs in 1870. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9415", "text": "Following the pioneering efforts of Billroth, the practice of total laryngectomy gained momentum among surgeons. The early attempts at this procedure, including the second ever performed by Bernhard Heine in 1874 and subsequent operations by Hermann Maas and others, often resulted in the patient's death due to complications or recurrence of disease within months. It wasn't until Enrico Bottini in Italy achieved the first long-term survival of a laryngectomy patient that the potential for lasting success was realized. The period also saw notable failures and challenges, including the tragic case of Crown Prince Frederick of Germany (the future  Frederick III ). Misdiagnosed initially in 1887 by  Morell Mackenzie  as benign, Frederick's condition was later identified as cancerous, leading to his death after a tracheostomy. This case highlighted the controversies and difficulties in diagnosing and treating laryngeal cancer, which persisted into the early 20th century. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9416", "text": "Advancements in direct laryngoscopy and suspension laryngoscopy, credited to Killian and Lynch respectively, improved the evaluation and surgical management of the larynx. Despite significant challenges such as wound infection, anesthesia, and shock, pioneers like  George Washington Crile \u2014which performed the first laryngectomy in U.S. in 1892\u2014made significant contributions to reducing operative mortality and advancing techniques in neck surgery and the management of metastatic disease. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9417", "text": "According to the GLOBOCAN, 2,018 estimates of cancer incidence and mortality produced by the  International Agency for Research on Cancer , there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer.\n [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9418", "text": "In 2019, it is estimated that there will be 12,410 new laryngeal cancer cases in the  United States , (3.0 per 100,000). [ 11 ]  The number of new cases decreases every year at a rate of 2.4%, [ 11 ]  and this is believed to be related to decreased cigarette smoking in the general population. [ 12 ]  The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate [ 13 ]  due to the development of less invasive techniques. [ 14 ]  A study using the  National Inpatient Sample  found that there were 8,288 total laryngectomy cases performed in the US between 1998 and 2008, and that hospitals performing total laryngectomy decreased by 12.3 per year. [ 15 ]  As of 2013, one reference estimates that there are 50,000 to 60,000 laryngectomees in the US. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9419", "text": "To determine the severity/spread of the laryngeal cancer and the level of vocal fold function,  indirect laryngoscopies  using mirrors,  endoscopies  (rigid or flexible) and/or  stroboscopies  may be performed. [ 1 ]  Other methods of visualization using  CT scans , MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the  glottis ) can cause an individual's voice to sound hoarse. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9420", "text": "Examinations are used to determine the tumor classification ( TNM classification ) and the stage (1\u20134) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. [ 1 ]  Radiation and/or  chemotherapy  may also be used. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9421", "text": "The anatomy and physiology of the airways change after laryngectomy. After a total laryngectomy, the individual breathes through a stoma where the  tracheostomy  has created an opening in the neck. There is no longer a connection between the trachea and the mouth and nose. After a partial laryngectomy, the individual breathes mainly through the stoma, but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose. The extent of breathing through the upper airways in these individuals varies and a  tracheostomy  tube is present in many of them. Ventilation and resuscitation of total and partial neck breathers is performed through the stoma. However, for these individuals, the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9422", "text": "Different types of complications can follow total laryngectomy. The most frequent postoperative complication is pharyngocutaneous  fistula  (PCF), characterized by an abnormal opening between the  pharynx  and the  trachea  or the skin resulting in the leaking of saliva outside of the throat. [ 17 ] [ 18 ]  This complication, which requires feeding to be completed via  nasogastric tube , increases morbidity, length of hospitalization, and level of discomfort, and may delay rehabilitation. [ 19 ]  Up to 29% of persons who undergo total laryngectomy will be affected by PCF. [ 17 ]  Various factors have been associated with an increased risk of experiencing this type of complication. These factors include  anaemia ,  hypoalbuminaemia , poor nutrition,  hepatic  and  renal  dysfunction, preoperative  tracheostomy , smoking, alcohol use, older age,  chronic obstructive pulmonary disease  and localization and stage of cancer. [ 17 ] [ 18 ]  However, the installation of a  free-flap  has been shown to significantly reduce the risks of PCF. [ 17 ]  Other complications such as wound infection,  dehiscence  and  necrosis , bleeding, pharyngeal and stomal  stenosis , and  dysphagia  have also been reported in fewer cases. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9423", "text": "Total laryngectomy results in the removal of the  larynx , an organ essential for natural sound production. [ 20 ]  The loss of voice and of normal and efficient verbal communication is a negative consequence associated with this type of surgery and can have significant impacts on the quality of life of these individuals. [ 20 ] [ 21 ]  Voice rehabilitation is an important component of the recovery process following the surgery. Technological and scientific advances over the years have led to the development of different techniques and devices specialized in voice restoration. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9424", "text": "The desired method of voice restoration should be selected based on each individual's abilities, needs, and lifestyle. [ 22 ]  Factors that affect success and candidacy for any chosen voice restoration method could include: cognitive ability, individual physiology, motivation, physical ability, and pre-existing medical conditions. [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9425", "text": "Pre and post-operative sessions with a  speech-language pathologist  (SLP) are often part of the treatment plan for people undergoing a total laryngectomy. [ 25 ]  Pre-operative sessions would likely involve counselling on the function of the  larynx ,  the options for post-op voice restoration, and managing expectations for outcomes and rehabilitation. [ 23 ]  Post-operative therapy sessions with an SLP would aim to help individuals learn to vocalize and care for their new  voice prosthesis  as well as refine their use of speech depending on the chosen method of voice restoration. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9426", "text": "Available methods for voice restoration:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9427", "text": "For individuals using tracheoesophageal or esophageal speech,  botulinum toxin  may be injected to improve voice quality when spasms or increased tone (hypertonicity) is present at the level of the pharyngoesophageal segment muscles. [ 29 ]  The amount of botulinum toxin administered unilaterally into two or three sites along the pharyngoesophageal segment varies from 15 to 100 units per injection. Positive voice improvements are possible after a single injection, however outcomes are variable. Dosages may need to be re-administered (individual-dependent) after a number of months, where effective results are expected to last for about 6 to 9 months. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9428", "text": "The laryngectomy surgery results in anatomical and physiological changes in the larynx and surrounding structures. Consequently,  swallowing  function can undergo changes as well, compromising the patient's oral feeding ability and nutrition. [ 30 ]  Patients may experience distress, frustration, and reluctance to eat out due to swallowing difficulties. [ 31 ]  Despite the high prevalence of post-operative swallowing difficulties in the first days following the laryngectomy, most patients recover swallowing function within 3 months. [ 32 ]  Laryngectomy patients do not  aspirate  due to the structural changes in the larynx, but they may experience difficulty swallowing solid food. They may also experience changes in appetite due to a significant loss in their senses of taste and smell. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9429", "text": "In order to prevent the development of pharyngocutaneous fistula, it is common practice to reintroduce oral feeding as of the seventh to tenth day post-surgery, although the ideal timeline remains controversial. [ 34 ]  Pharyngocutaneous fistula typically develops before the reintroduction of oral feeding, as the  pH  level and presence of  amylase  in saliva is more harmful to tissues than other liquids or food. Whether the reintroduction of oral feeding at an earlier post-operative date decreases the risk of fistula remains unclear. However, early oral feeding (within 7 days of the operation) can be conducive to reduced length of hospital stay and earlier discharge from the hospital, entailing a decrease in costs and psychological distress. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9430", "text": "A total laryngectomy causes the separation of the upper air respiratory tract ( pharyn ), nose, mouth) and lower air respiratory tract (lungs, lower  trachea ). [ 36 ]  Breathing is no longer done through the nose (nasal airflow), which causes a loss/decrease of the sense of smell, leading to a decrease in the sense of taste. [ 36 ]  The Nasal Airflow Inducing Manoeuvre (NAIM), also known as the \"Polite Yawning\" manoeuvre, was created in 2000 and is widely accepted and used by speech-language pathologists in the  Netherlands , while also becoming more widely used in  Europe . [ 37 ]  This technique consists of increasing the space in the  oral cavity  while keeping the lips closed, simulating a yawn with a closed mouth by lowering the jaw, tongue and floor of the mouth. [ 37 ]  This causes a negative pressure in the oral cavity, leading to nasal airflow. [ 38 ]  The NAIM has been recognized as an effective rehabilitation technique to improve the sense of smell. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9431", "text": "People with a partial laryngectomy are more likely to have a higher  quality of life  than individuals with a total laryngectomy. [ 36 ]  People having undergone total laryngectomy have been found to be more prone to depression and anxiety, and often experience a decrease in the quality of their social life and physical health. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9432", "text": "Voice quality, swallowing and reflux are affected in both types, with the sense of smell and taste ( hyposmia / anosmia  and  dysgeusia ) also being affected in total laryngectomies (a complaint which is given very little attention by medical professionals). [ 36 ] [ 40 ]   Partial or total laryngectomy can lead to swallowing difficulties (known as  dysphagia ). [ 1 ]  Dysphagia can have a significant effect on some patients' quality of life following surgery. [ 1 ]  Dysphagia poses challenges in eating and social involvement, often causing patients to experience increased levels of  distress . [ 1 ]  This effect holds true even after the acute phase of recovery. [ 1 ]  More than half of patients who received total laryngectomy were found to experience restrictions in their food intake, specifically in what they can eat and how they can eat it. [ 1 ]  The diet limitations imposed by dysphagia can negatively impact a patient's quality of life, as it can be perceived as a form of participation restriction. [ 1 ]  Accordingly, these perceived restrictions are more commonly experienced by dysphasic laryngectomy patients compared to non-dysphasic laryngectomy patients. [ 1 ]  Therefore, it is important to consider dysphagia in short and long-term outcomes post-laryngectomy in order for patients to uphold a higher quality of life. [ 41 ]  Often,  speech-language pathologists  are involved in the process of prioritizing swallowing outcomes. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9433", "text": "People receiving  voice rehabilitation  report best voice quality and overall quality of life when using a  voice prosthesis  as compared to  esophageal speech  or  electrolarynx . [ 39 ]  Furthermore, individuals going through non-surgical therapy report a higher quality of life than those having undergone a total laryngectomy. [ 39 ]  Lastly, it is much more difficult for those using  alaryngeal speech  to vary their pitch, [ 42 ]  which particularly affects the social functioning of those speaking a  tonal language . [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9434", "text": "The  loop electrosurgical excision procedure  ( LEEP ) is one of the most commonly used approaches to treat high grade  cervical dysplasia  ( CIN  II/III,  HGSIL ) and early stage  cervical cancer  discovered on  colposcopic  examination. In the UK, it is known as  large loop excision of the transformation zone  ( LLETZ ). It is considered a type of  conization. [ 1 ]  It has been in use since the 1970s, after its invention by Dr. Sheldon Weinstein.  [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9435", "text": "LEEP has many advantages including low cost and a high success rate. [ 3 ]  The procedure can be done in an office setting and usually only requires a  local anesthetic , though sometimes IV sedation or a  general anesthetic  is used. [ 4 ]  Disadvantages include reports of decreased sexual satisfaction  [ 5 ]  and potential for  preterm labor , though a meta-analysis published in 2014 suggested that in patients with existing CIN lesions as opposed to controls, the risk is not more than their baseline risk. [ 6 ]  Approximately 500,000 LEEP procedures are performed in the U.S. annually.  [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9436", "text": "When performing a LEEP, the  physician  uses a wire loop through which an  electric current  is passed at variable  power  settings. Various shapes and sizes of loop can be used depending on the size and orientation of the lesion.  The  cervical  transformation zone and  lesion  are excised to an adequate depth, which in most cases is at least 8\u00a0mm, and extending 4 to 5\u00a0mm beyond the lesion. A second pass with a more narrow loop can also be done to obtain an  endocervical  specimen for further  histologic  evaluation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9437", "text": "The LEEP technique results in some thermal artifact in all specimens obtained due to the use of electricity which simultaneously cuts and cauterizes the lesion, but this does not generally interfere with  pathological  interpretation provided depth is not exceeded. [ 9 ]  The thermal artifact can be a function of depth and time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9438", "text": "Complications are less frequent in comparison to a  cold-knife conization  but can include  infection  and  hemorrhage . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9439", "text": "LEEP effectively reduces the risk of cancer developing or spreading but it causes an increased risk of  premature birth  in future pregnancies. [ 11 ] [ 12 ] [ 13 ]  Following LEEP there is a 10% chance of cancer recurrence and 11% chance of preterm birth. [ 11 ] [ 12 ]  This perspective carries significant implications when it comes to pregnancy timing and decision making in women of child bearing age who have cervical dysplasia and would like to decide whether they should have the lesions removed before or after pregnancy. As pregnancy is generally understood to be an immune suppressed state, the viral mediated character of cervical lesions might also inform revisions to treatment recommendations in such instances. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9440", "text": "Some women report a small decrease in sexual arousal and satisfaction following LEEP but there is a lack of high quality research showing how LEEP affects sexual function. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9441", "text": "Lumpectomy  (sometimes known as a  tylectomy, partial mastectomy, breast segmental resection or breast wide local excision ) is a  surgical  removal of a discrete portion or \"lump\" of  breast  tissue, usually in the treatment of a malignant  tumor  or  breast cancer . [ 1 ]   It is considered a viable  breast conservation therapy , as the amount of tissue removed is limited compared to a full-breast  mastectomy , and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumors. Although a lumpectomy is used to allow for most of the breast to remain intact, the procedure may result in adverse affects that can include sensitivity and result in scar tissue, pain, and possible disfiguration of the breast if the lump taken out is significant. [ 2 ]  According to National Comprehensive Cancer Network guidelines, lumpectomy may be performed for  ductal carcinoma in situ  (DCIS),  invasive ductal carcinoma , or other conditions. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9442", "text": "DCIS, or intraductal carcinoma, is by definition a breast cancer that is limited to the lining of the milk ducts, [ 4 ]  and accounts for about 20% of breast cancer in the US. [ 5 ]  Although early treatment of DCIS was similar to invasive breast cancer, involving full mastectomy and sometimes lymph node dissection, an evolution in understanding about the different kinds of breast cancer prompted investigations into the adequacy of less extreme surgical treatments. The results of an eight-year randomized clinical trial in the late 1980s showed that, although lumpectomy alone was associated with significant recurrence, lumpectomy with local radiation therapy achieved similar outcomes to total mastectomy in treatment of DCIS. [ 6 ]  This was the first substantial data that showed that so-called \"breast conserving therapy\" was a real possibility."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9443", "text": "After a lumpectomy is performed for DCIS, local  radiation therapy  is typically performed to help eliminate microscopic-level disease.  Axillary sentinel  lymph node biopsy , as a method of screening for metastatic disease in otherwise non-invasive DCIS, is falling out of favor because the risks of procedure outweigh any effect on outcomes. [ 7 ]  For DCIS,  chemotherapy  is not recommended, but  tamoxifen  may be recommended for tumors which contain an abundance of  estrogen receptors . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9444", "text": "For patients with invasive ductal carcinoma who have lumpectomies, lymph node biopsy and radiation therapy are usually recommended.   Adjuvant  chemotherapy is often recommended, but it may not be recommended if the tumor is small and there are no lymph node  metastases . For larger tumors,  neoadjuvant  chemotherapy may be recommended."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9445", "text": "A lumpectomy is a surgery to remove a breast tumor along with a  resection margin  of normal breast tissue. The margin is the healthy, noncancerous tissue that is next to the tumor. A pathologist analyzes the margin excised by the lumpectomy to detect any possible cancer cells. A cancerous margin is \"positive\", while a healthy margin is \"clean\" or \"negative\". A re-excision lumpectomy is performed if the margin is detected to be positive or cancerous cells are very close to the margin. [ 9 ]  Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) may be used to determine if the cancer has progressed away from the breast and into other parts of the body. [ 10 ]  Sentinel lymph node biopsy is the analysis of a few removed sentinel nodes for the presence of cancerous cells. A radioactive substance is used to dye the sentinel nodes for easy identification and removal. [ 2 ]   If cancer is detected in the sentinel node then further treatment is needed. Axillary node dissection involves the excision of lymph nodes connected to the tumor by the armpit (axilla). Radiation is usually used in conjunction with the lumpectomy to prevent recurrence. [ 11 ]  The radiation treatment can last five to seven weeks following the lumpectomy. Although the lumpectomy with radiation helps to decrease the risk of the cancer returning (local recurrence); it does not prolong survival; it is not a cure, and cancer may still come back. However, local recurrences (confined to the breast area) after lumpectomy can be treated effectively with mastectomy, and these women were still disease-free 20 years after their original lumpectomies and recurrence treatments.  [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9446", "text": "Lobectomy of the lung  is a  surgical  operation where a  lobe  of the  lung  is removed. [ 1 ]  It is done to remove a portion of diseased lung, such as early  stage   lung cancer . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9447", "text": "The most common type of lobectomy is known as a  thoracotomy .  When this type of surgery is done the chest is opened up.  An incision will be made on the side of the chest where the affected area of the lung is located. The incision will be in between the two ribs located in that area.  The surgeon will then be able to have access to the chest cavity once the two involved ribs have been pried open. The surgeon will then be able to remove the lobe where the problem is contained. [ 3 ] \nAnother less invasive lobectomy procedure can be performed through a  video assisted surgery , where the surgeon does not need to pry the two ribs open in order to get access.  A few small incisions are made and surgical tools are inserted into the chest cavity aided by a small video camera. The video images will be projected onto a screen that the surgeon can see. Once the problem area is located the small tools that were previously inserted will be utilized to perform the surgery. [ 3 ]  Once the surgery is complete, the patient will remain in the intensive care unit of the hospital for a day. They will then remain in a regular hospital room for about 4 to 7 days. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9448", "text": "As with any surgery, complications may occur. Post lobectomy air leak is a significant clinical problem, [ 5 ]  and patients undergoing pulmonary resections often present with postoperative air leaks. [ 6 ]  Other risk factors include infections, reactions to anesthesia, bleeding,  pneumothorax  and  bronchopleural fistula . [ 7 ]  New methods for sealing tissue are evaluated in research studies, aimed to determine their efficacies in preventing air leakages. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9449", "text": "The main infection that a patient runs the risk of is  pneumonia . Pneumothorax occurs when there is air trapped between the lung and the chest wall; this can leave the patient's lung unable to fully inflate (\"collapsed lung\"). A bronchopleural fistula is when there is a tube-like opening that allows air to escape. [ 9 ]  Minimally invasive surgery is beneficial for patient outcome, with reduced risk of complications. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9450", "text": "Once the surgery is complete, the patient will remain in the intensive care unit of the hospital for a day. They will then remain in a regular hospital room for about 4 to 7 days. [ 4 ]   After the patient returns home they typically remain in recovery for about four to six weeks, although some patients may be able to return to work and normal activities sooner. [ medical citation needed ]   Pain is very common amongst patients for quite some time after a lobectomy and doctors will usually prescribe pain medication to help with this. [ 11 ]   Chest tubes are left inside the patient in order to help excess fluid drain and are removed after a few days. Before removal, doctors must ensure that there is no air or  fluid leaking from them. [ 11 ]   In addition to this, follow-up appointments will be scheduled with the patient's doctor. X-rays will be taken of the patient's lung to make sure everything is healing properly. Patients that have had a lobectomy with no major risks shall recover in no longer than three months. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9451", "text": "Lymphadenectomy,   or  lymph node dissection,  is the surgical removal of one or more groups of  lymph nodes . [ 1 ]  It is almost always performed as part of the  surgical management of cancer . In a  regional lymph node dissection , some of the lymph nodes in the  tumor  area are removed; in a  radical lymph node dissection , most or all of the lymph nodes in the tumor area are removed. [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9452", "text": "Lymphadenectomies are usually done because many types of  cancer  have a marked tendency to produce lymph node  metastasis  early in their natural histories. This is particularly true of  melanoma ,  head and neck cancer , differentiated  thyroid cancer ,  breast cancer ,  lung cancer ,  gastric cancer ,  and  colorectal cancer . Famed British surgeon  Berkeley Moynihan  once remarked that \"the surgery of cancer is not the surgery of organs; it is the surgery of the lymphatic system.\" [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9453", "text": "The better-known examples of lymphadenectomy are  axillary lymph node  dissection  for breast cancer;  radical  neck dissection  for head and neck cancer and thyroid cancer;  D2 lymphadenectomy  for gastric cancer; and  total mesorectal excision  for rectal cancer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9454", "text": "For clinical stages I and II breast cancer, axillary lymph node dissection should only be performed  after first attempting a sentinel node biopsy. [ 5 ]  A sentinel node biopsy can establish  cancer staging  of the  axilla  if there are positive lymph nodes present. [ 5 ]  It is also less risky than performing a lymphadenectomy, having fewer side effects and a much lower chance of causing  lymphedema . [ 5 ]  If cancer is not present in the sentinel lymph nodes, then the axillary lymph node dissection should not be performed. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9455", "text": "If one or two sentinel nodes have cancer that is not extensive, then no axillary dissection should be performed, but the person with cancer should have  breast-conserving surgery  and  chemotherapy  appropriate for their stage of cancer. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9456", "text": "Lymphedema  may result from lymphadenectomy. Extensive resection of lymphatic tissue can lead to the formation of a  lymphocele . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9457", "text": "It is uncertain whether inserting wound drainage after groin lymph nodes dissection can reduce complications such as seroma, haematoma, wound dehiscence, and wound infection. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9458", "text": "Mastectomy  is the medical term for the surgical removal of one or both  breasts , partially or completely. A mastectomy is usually carried out to treat  breast cancer . [ 1 ] [ 2 ]  In some cases, women believed to be at high risk of breast cancer choose to have the operation as a  preventive measure . [ 1 ]  Alternatively, some women can choose to have a  wide local excision , also known as a  lumpectomy , an operation in which a small volume of breast tissue containing the  tumor  and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as \"local therapies\" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as  chemotherapy ,  hormonal therapy , or  immunotherapy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9459", "text": "The decision to perform a mastectomy to treat cancer is based on various factors, including breast size, the number of  lesions , biologic aggressiveness of a breast cancer, the availability of  adjuvant  radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and/or radiation. [ 3 ]  Outcome studies comparing mastectomy to lumpectomy with radiation have suggested that routine radical mastectomy surgeries will not always prevent later distant secondary tumors arising from  micro-metastases  prior to discovery, diagnosis, and operation. In most circumstances, there is no difference in both overall survival and breast cancer recurrence rate. [ 4 ] [ 5 ]  While there are both medical and non-medical indications for mastectomy, the clinical guidelines and patient expectations for before and after surgery remain the same."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9460", "text": "Mastectomies may also be carried out to  transgender  and  non-binary  people who were  assigned female at birth  to help lessen symptoms of  gender dysphoria . [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9461", "text": "Despite the increased ability to offer breast conservation techniques to those with breast cancer, certain groups may be better served by traditional mastectomy procedures including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9462", "text": "Mastectomy has non-cancer medical uses as well, including  cosmetic or reconstructive surgery . [ 12 ]  Men with  gynecomastia  may be eligible for mastectomy, but minimally invasive surgical techniques also exist. [ 13 ] [ 14 ]   Transgender  men and  non-binary  people  assigned female at birth  may undergo a mastectomy as a  gender-affirming surgery . [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9463", "text": "Aside from the post-surgical pain and the obvious change in the shape of the chest and/or breast(s), possible side effects of a mastectomy include soreness, scar tissue at the site of the incision, short-term swelling, phantom breast pain (pain in the breast or tissue that has been removed), wound infection or bleeding, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed, additional side effects such as lymphedema (swelling of the lymph nodes) may occur. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9464", "text": "Upper limb problems such as shoulder and arm pain, weakness, and restricted movement are a common side effect after breast cancer surgery. [ 16 ]  According to research in the UK, an exercise programme started 7\u201310 days after surgery can reduce upper limb problems. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9465", "text": "Currently, there are several surgical approaches to mastectomy, and the type that a person decides to undergo (or whether they will decide instead to have a lumpectomy) depends on factors such as the size, location, and behavior of the tumor (if one is present), whether or not the surgery is prophylactic or preventative, and whether the person intends to undergo reconstructive surgery after the mastectomy. [ 19 ]  For trans people undergoing a  gender-affirming mastectomy , the type of procedure chosen can also vary depending on the desired results, the scarring (or lack thereof), the recovery process, the person's desire for nipple sensation, and other different factors based both on personal preference and input from medical experts. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9466", "text": "Prior to undergoing the mastectomy, it is important to meet with the surgeon to discuss the relevant risks and benefits of receiving the surgery. Depending on the indication for mastectomy, there may be other options to address the clinical condition. One important consideration to discuss with the surgeon is whether breast reconstruction will occur and when this procedure will take place. One option is to have the reconstruction immediately after the mastectomy in the same surgery, whereas other patients opt for a subsequent surgery for reconstruction. This breast reconstruction surgery will be conducted by a plastic surgeon. In addition to the surgeon, a meeting with an anesthesiologist is pertinent in order to review the patient's medical history and determine the plan of anesthesia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9467", "text": "Leading up to the day of the surgery, there are various considerations that patients can be cognizant of to facilitate their recovery following surgery. As with other surgeries that may lead to appreciable blood loss, it is advised not to take aspirin or aspirin-containing products for 10 days before the surgery. [ 33 ]  The reason for this is to prevent the anti-coagulative function of aspirin and other blood thinners that would make it difficult to achieve coagulation during the surgery. In addition, it is important for patients to tell the doctor about any medications, vitamins, or supplements that they are taking because some substances could interfere with the surgery. [ 34 ]  It is also pertinent for patients to not eat or drink 8 to 12 hours before surgery, however, there may be specific pre-operative instructions given by each patient's care team. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9468", "text": "Maintaining fitness and proper nutrition is also an important measure to consider prior to receiving a surgery because it has been shown that postoperative outcomes are improved in patients that exercise and maintain a healthy diet prior to surgery. In addition to nutrition and exercise, it is advised to reduce alcohol consumption and smoking. This concept of pre-rehabilitation is beneficial in mitigating post-operative complications and decreasing length of stay in the hospital. [ 36 ]  The rationale is that increasing a patient's functional status prior to surgery will allow for a smoother and faster recovery in the postoperative setting. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9469", "text": "Recent research has indicated that mammograms should not be done with any increased frequency than the normal procedure in women undergoing breast surgery, including breast augmentation,  mastopexy , and breast reduction. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9470", "text": "Prior to leaving the hospital, people who have had a mastectomy will typically be given a prescription for pain medication to ameliorate any pain or discomfort at the surgery site. [ 33 ] [ 39 ] [ 40 ]  Recognizing signs of a surgical site infection including fever, redness, swelling, or pus is important. Any signs of infection should be reported to and assessed by a medical professional. In addition, signs of  lymphedema  due if lymph node removal is performed during mastectomy may be detected by the presence of heaviness, tightness, or fullness in the hand, arm, or axillary area region. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9471", "text": "Regarding return to activity, it is advised not to engage in strenuous activity or lift objects above 5 pounds for up to six weeks after a mastectomy at the discretion of the physician. [ 39 ]  However, it is common for a member of the medical team to provide home exercises designed to maintain arm and shoulder movement and flexibility. Walking is also highly encouraged and allowed immediately after surgery. Most people who undergo a mastectomy can return to work and other regular physical activities in approximately 4 weeks after surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9472", "text": "People who have had a mastectomy will usually have a post-operative follow-up visit with their provider 1\u20132 weeks after surgery. [ 33 ] [ 40 ]  The time at which a person can start to wear a bra or reconstructive breast varies and is often at the discretion of the physician. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9473", "text": "Some people with breast cancer may require additional  radiotherapy  after their mastectomy procedure with the goal of reducing the risk of the cancer returning to the lymph nodes and the tissue remaining in the wall of the person's chest. [ 41 ]  The decision by the medical team for suggesting radiotherapy may differ between individual professionals. [ 41 ]  Most teams recommend radiotherapy after a masectomy for people who are at a higher risk of cancer recurrence including those with large breast tumours (5\u00a0cm and larger) and people with cancer that has spread to multiple  axillary lymph nodes  (4 or more). [ 41 ]  The necessity and usefulness of radiotherapy on people at slightly lower risk, for example, the cancer has spread to 1-3 axillary lymph nodes, is not as clear. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9474", "text": "Between 2005 and 2013, the overall rate of mastectomy increased 36 percent, from 66 to 90 per 100,000 adult women. The rate of hospital-based bilateral mastectomies (inpatient and outpatient combined) more than tripled, from 9.1 to 29.7 per 100,000 adult women, whereas the rate of unilateral mastectomies remained relatively stable at around 60 per 100,000 women. From 2005 to 2013, the rate of bilateral outpatient mastectomies increased more than fivefold and the inpatient rate nearly tripled. The rate of unilateral mastectomies nearly doubled in the outpatient setting but decreased 28 percent in the inpatient setting. By 2013, nearly half of all mastectomies were performed outpatient. [ 42 ]  However, there are concerns that these rising rates of mastectomies are most greatly seen in women with node-negative and noninvasive lesions, which are subsets of patients that do not require mastectomy. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9475", "text": "Mastectomy rates vary tremendously worldwide, as was documented by the 2004 'Intergroup  Exemestane  Study', [ 44 ]  an analysis of surgical techniques used in an international trial of adjuvant treatment among 4,700 females with early breast cancer in 37 countries. The mastectomy rate was highest in central and eastern Europe at 77%. The USA had the second highest rate of mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and Australia and New Zealand 34%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9476", "text": "Breast surgery was first described 3000 years ago. [ 45 ]  In the earliest stages, breast tumors were treated with simple cauterization. Later, alternating incision and cauterization with complete removal of tumors was suggested by  Leonides , one of the first breast oncologic surgeons recorded in history. [ 9 ]  Other surgeons recommended excision and cauterization only if the tumor could be removed completely; otherwise, avoiding surgery was recommended. Ambrose Pare (b. 1510), a well-known surgeon from Paris who was well known for his experience treating soldiers who were injured, proposed a multi-tiered approach to breast surgery. While superficial cancers could be excised, more advanced cancers were managed through compression by lead plates to reduce blood supply to the tumor. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9477", "text": "In the 1500s, William Fabry (b.1560), a German surgeon known as the father of German surgery, created a device that compressed and fixed the base of the breast during mastectomy, which subsequently allowed for faster excision of the breast. Another technique developed during this time to improve efficiency of breast dissection was using ligatures to achieve anterior traction. Despite the development of these techniques, there were few mastectomies actually performed at the time due to lack of qualified surgeons and the high morbidity, mortality and disfigurement associated with the surgery. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9478", "text": "During the 1700s, large contributions in mapping lymph nodes for surgery were made by Pieter Camper (b. 1722) and Paolo Mascagni (b. 1752). Lymph node removal was advocated for in managing breast cancer. [ 10 ]  At this time, surgeries were still performed without proper aseptics and without anesthesia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9479", "text": "In the 19th century, Seishu Hanaoka, a Japanese surgeon, performed the first surgery in the world under general anesthesia. Many more advancements in anesthesia and aseptic technique were made during this century. William Roentgen discovered x-rays in 1895, which radically shifted breast cancer treatment from a solely surgical approach to the multi-pronged approach employed today, including imaging, hormonal therapy, radiation, chemotherapy and immunotherapy. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9480", "text": "During the 20th century, progress was made towards skin-sparing mastectomies for treatment of breast cancer. Recent literature suggests that these procedures allow for improved aesthetic outcomes while also not increasing risk for local recurrence compared to conventional mastectomies. [ 47 ] [ 48 ] [ 49 ] [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9481", "text": "For example, in 1937, the  Tauton State Hospital  in Massachusetts reported 1 mastectomy in its operating rooms that year, listed alongside other operations including  colostomy  (1),  enterostomy  (1),  herniorrhaphy  (4),  laparotomy  (1), and  circumcision  (2). [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9482", "text": "Mesenteric pseudocyst , or  pseudomesenteric cyst [ 1 ] ) is a mass in the abdomen that is devoid of any epithelial lining. [ 2 ]  They are caused either due to trauma or infection. [ 2 ] [ 3 ]  The term mesenteric pseudocyst was first used by Ros  et al  in 1987. [ 2 ] [ 4 ]  Mesenteric pseudocysts are very rare, making up only about less than one in 250,000 hospital admissions. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9483", "text": "This Epidermal nevi, neoplasms, cysts article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9484", "text": "In  oncology ,  metastasectomy  is the  surgical  removal of  metastases , which are secondary  cancerous   growths  that have spread from cancer originating in another organ in the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9485", "text": "In many cases, metastases are not treated surgically.  There are two common reasons for this.  Often, even with a successful surgery, the patient would have a poor  prognosis . If the cancer is widely disseminated, it is likely that after the surgical removal of all known metastases, new ones will occur elsewhere. Sometimes, surgery itself has a low likelihood of success due to the location and/or extensiveness of the cancer. If complete surgical excision is feasible, however, removing both the primary cancer and its metastases may substantially improve the patient's prognosis.  Some patients may even be cured. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9486", "text": "The use of metastasectomy evolved in the field of  liver resection  for metastasised  colorectal cancer , but has evolved to include resection of metastases from different primary cancers (such as  breast cancer ,  melanoma ,  renal cell carcinoma , etc.) to the  lungs ,  brain , and other organs. Not all of these applications are equally  evidence-based , although with respect to some other primary cancers, metastasectomy may be underutilized. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9487", "text": "Among colorectal cancer patients, 15 to 25% will have liver metastases already when the colorectal cancer is discovered, and another 25 to 50% will develop them in the three years after resection of their primary cancer. [ 2 ]   Of patients who die from metastasised colorectal cancer, 20% have metastasis in the liver alone. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9488", "text": "Surgical resection of liver metastases from colorectal cancer has been found to be safe and cost-effective. [ 3 ] \nReports from several large  retrospective  patient series suggest that it has a 5-year  overall survival rate  (5y OSR) averaging 30 to 40% and a 10y OSR around 16%, [ 1 ] [ 2 ] [ 4 ] [ 5 ]  whereas the highest 5y OSR for modern  chemotherapy regimens  is only 9% (with  FOLFOX ). [ 6 ]  However, no  randomized clinical trial  has directly compared surgical management to chemotherapy or treatment with  bevacizumab . Some have argued that the excellent results of liver metastasectomy for colorectal cancer are partially confounded by  selection bias  or  reporting bias . [ 7 ] [ 8 ]  Nevertheless, surgery for resectable metastases has become the standard of care, [ 9 ]  probably making such a trial ( ethically ) infeasible. [ 2 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9489", "text": "Previously, liver metastasectomy was limited to patients with less than four sites of metastasis in the liver, with a tumour-free margin of at least 1 centimetre, and no cancer elsewhere. [ 10 ] [ 11 ] \nThese criteria have been challenged, however, and today the main criteria are a tumour-free margin and enough functional liver tissue (70%) preserved after surgery. [ 12 ] [ 13 ] [ 14 ]  Patients with initially unresectable liver metastases can be pre-treated with chemotherapy (this is called  neoadjuvant chemotherapy ). [ 9 ]   This pre-treatment causes the tumors to shrink, resulting in a larger proportion of liver tissue that is functional, with broader margins. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9490", "text": "Preoperative evaluation involves imaging of the liver and its metastases, for example with  ultrasound ,  computed tomography  or  magnetic resonance imaging .  Positron emission tomography can be useful to check the entire body for metastases, although the test can be falsely normal with small lesions or preoperative chemotherapy. [ 15 ]  Baseline  blood tests  typically include  liver function tests  and  tumour markers . [ 12 ]  During surgery, intraoperative ultrasound can aid the surgeon to find additional metastases. [ 2 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9491", "text": "A clinical risk score first proposed by Fong et al. [ 17 ]  is often used to assess the risk of recurrence after hepatic resection. The score assigns one point to each of the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9492", "text": "The median survival for each score is:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9493", "text": "Despite the score being highly predictive of long-term outcome, the clinical usefulness is often called into question because the chance of long-term survival is often enough to warrant surgery even in cases with high Fong Score. Some researchers have suggested that the Fong Score has become less useful with the advent of more effective neoadjuvant therapy. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9494", "text": "Surgery is the mainstay of treatment for patients with isolated lung metastasis from colorectal cancer. [ 19 ]  Again, no randomized clinical trials exist, and the scientific evidence is weak, limited only to case series. [ 20 ]  The surgery can be performed with a low operative mortality. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9495", "text": "For patients in whom the primary tumour is controlled and metastases are limited to the lung, criteria for eligibility include the technical resectability of the metastases and the general fitness and lung function reserve of the patient. If there are both liver and lung metastases, a resection of both can be attempted. In general, only 10% of patients with pulmonary metastases from colorectal cancer are resectable. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9496", "text": "Blalock  reported the first lung resection for metastasis from colorectal cancer in 1944. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9497", "text": "Microtransplantation  ( MST ) is an advanced technology to treat malignant hematological diseases and tumors by infusing patients with  granulocyte colony-stimulating factor  (G-CSF) mobilized  human leukocyte antigen  (HLA)-mismatched allogeneic  peripheral blood stem cells  following a reduced-intensity chemotherapy or targeted therapy. The term \"microtransplantation\" comes from its mechanism of reaching donor cell microchimerism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9498", "text": "Chemotherapy is used by lower doses only to destroy cancer and partially suppress patient\u2019s immune system, which will be reinitiated by donor\u2019s stem cells soon after transplantation, and will play a role as recipient-versus-tumor (RVT) effect combining donor cells\u2019 graft-versus-tumor (GVT) effect. Donor\u2019s stem cells, which have been processed, will also accelerate functional recovery of recipient\u2019s hematopoietic stem cells, greatly reducing infections and transplant-related mortality. Practices of microtransplantation has shown none  graft-versus-host disease  (GVHD) till present, thus  immunosuppressive drugs  for relieving GVHD wouldn't be necessary. Possible mechanisms of the successful avoidance of GVHD include donor cell microchimerism, less-toxic cells processed prior to transplantation, and the preservation of host immune system that is capable of resisting the GVH alloresponse. Moreover, as HLA-mismatched stem cells are employed, donor availability is extremely extended. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9499", "text": "Indications for microtransplantation are as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9500", "text": "Hematologic Malignancies Tumors"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9501", "text": "The cells employed are allogeneic peripheral blood stem cells. Matched HLA between donor and recipient is not necessary. The stem cells are collected from donor\u2019s blood through a process known as apheresis after a certain period of daily subcutaneous injections of Granulocyte-colony stimulating factor, serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation. Fresh cells are infused to recipient for the first time, and then stored in a controlled-rate freezer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9502", "text": "Donor\u2019s Requirements:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9503", "text": "In a randomized controlled trial from 2004 to 2009, 58 AML patients aged 60\u201388 years were randomly assigned to receive chemotherapy (control group; n=28) or it plus HLA-mismatched G-CSF\u2013mobilized donor peripheral blood stem cell (G-PBSC) (G-PBSC group/ Microtransplantation; n = 30). The complete remission rate was significantly higher in the G-PBSC group than in the control group (80.0% vs 42.8%); The median recovery times of neutrophils and platelets were 11 days and 14.5 days, respectively, in the G-PBSC group and 16 days and 20 days, respectively, in the control group after chemotherapy; The 2-year probability of disease-free survival (DFS) was significantly higher in the G-PBSC group than in the control group (38.9% vs 10.0%). [ 1 ]  No graft-versus-host disease was observed in any patient. [ 2 ]  Persistent donor microchimerism was successfully detected in all of the 4 female patients. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9504", "text": "In another long-term research from 2004\u20132011, 101 patients with AML-CR1 (9 to 65 years old) received Microtransplantation regimen. The 6-year leukemia-free survival (LFS) and overall survival (OS) rates were 84.4% and 89.5%, respectively, in the low-risk group, which were similar to the rates in the intermediate-risk group (59.2% and 65.2%, respectively); The 6-year LFS and OS were 76.4% and 82.1%, respectively, in patients who received a high dose of donor CD3+ T cells, which were significantly higher than the LFS and OS in patients who received a lower dose of donor CD3+ T cells (49.5% and 55.3%, respectively). [ 4 ]  No GVHD was observed in any of the patients. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9505", "text": "The positive results have also been verified by healthcare centers in Italy, [ 6 ]  America, [ 7 ]  Spain, [ 8 ]  etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9506", "text": "Led by Dr. Huisheng Ai and his medical team at MST International Clinic for Leukemia in the 307th Hospital of Chinese People\u2019s Liberation Army located in Beijing, multicenter collaborative study on Microtransplantation has started since 2013 in nine authoritative blood institutes from China, Duke University and Keck School of Medicine-University of Southern California in United States, University of Sydney in Australia and University of Montreal in Canada. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9507", "text": "To overcome the intolerable severe reactions of high-dose chemotherapy and GVHD, as well as the challenge to find HLA-matched donors for conventional hematopoietic stem cell transplantation, Dr  Huisheng Ai ,  Guo Mei , etc. developed a new regimen of reduced-intensity chemotherapy plus G-CSF mobilized HLA-mismatched allogeneic peripheral blood stem cell infusion, which was firstly employed for a 75-year-old patient in 2002 and later named as microtransplantation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9508", "text": "A  nephrectomy  is the surgical removal of a  kidney , performed to treat a number of kidney diseases including  kidney cancer . It is also done to remove a normal healthy kidney from a living or deceased donor, which is part of a  kidney transplant  procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9509", "text": "The first recorded nephrectomy was performed in 1861 by  Erastus B. Wolcott  in  Wisconsin . [ 2 ]  The patient had had a large tumor and the operation was initially successful, but the patient died fifteen days later. [ 3 ] [ 4 ]  The first planned nephrectomy was performed by the German surgeon  Gustav Simon  on August 2, 1869, in  Heidelberg . [ 5 ] [ 6 ]  Simon practiced the operation beforehand in animal experiments. He proved that one healthy kidney can be sufficient for urine excretion in  humans . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9510", "text": "There are various indications for this procedure, including  renal cell carcinoma , a non-functioning kidney (which may cause  high blood pressure ) and a congenitally small kidney (in which the kidney is swelling, causing it to press on nerves, which can cause pain in unrelated areas such as the back). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9511", "text": "Nephrectomy for renal cell carcinoma is rapidly being modified to allow partial removal of the kidney. Nephrectomy is also performed for the purpose of living  donor   kidney transplantation . [ 1 ]   A  nephroureterectomy  is the removal of a kidney and the entire ureter and a small cuff of the bladder for  urothelial cancer  of the kidney or ureter. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9512", "text": "The surgery is performed with the patient under  general anesthesia . A kidney can be removed through an open incision or by  laparoscopic surgery . For the open procedure, the surgeon makes an incision in the side of the  abdomen  to reach the kidney. Depending on circumstances, the incision can also be made  midline . The  ureter  and blood vessels are disconnected, and the kidney is then removed. The laparoscopic approach utilizes three or four small (5\u201310\u00a0mm) cuts in the abdominal and flank area. The kidney is completely detached inside the body and then placed in a bag. One of the incisions is then expanded to remove the kidney for cancer operations. If the kidney is being removed for other causes, it can be  morcellated  and removed through the small incisions. Recently, this procedure is performed through a single incision in the patient's navel. This advanced technique is called  single port laparoscopy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9513", "text": "A total nephrectomy is the removal of at least the entire kidney, whereas a 'radical nephrectomy' also includes at least some perinephric fat, possibly including  Gerota's fascia , and usually also the ipsilateral  adrenal gland . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9514", "text": "For some illnesses, there are alternatives today that do not require the extraction of a kidney. Such alternatives include  renal embolization [ 11 ]  for those who are poor candidates for surgery, or partial nephrectomy if possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9515", "text": "Occasionally renal cell cancers can involve adjacent organs, including the  inferior vena cava  (IVC), the  colon , the pancreas or the liver. If the cancer has not spread to distant sites, it may be safely and completely removed surgically via open or laparoscopic techniques. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9516", "text": "In January 2009, a woman who had previously had a  hysterectomy  was able to donate a kidney and have it removed through her vagina. The operation took place at  Johns Hopkins Medical Center . This is the first time a healthy kidney has been removed via this method, though it has been done in the past for nephrectomies carried out due to  pathology . Removing organs through orifices prevents some of the pain of an incision and the need for a cosmetically unappealing larger scar. Any advance which leads to a decrease in pain and scarring has the potential to boost donor numbers. [ 13 ]  This operation has also taken place at the Cleveland Clinic, which first performed transvaginal Nephrectomy. [ 14 ]   Living donation has a mortality risk of 0.03% during the procedure and seems to result in similar health outcomes to controls. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9517", "text": "Pain medication  is often given to the patient after the surgery because of pain at the site of the incision. An  IV  with fluids is administered.  Electrolyte  balance and fluids are carefully monitored, because these are the functions of the kidneys. It is possible that the remaining kidney does not take over all functionality. A patient has to stay in the hospital between 2 and 7 days depending on the procedure and complications. Patients who have had open surgery will have to stay in hospital longer than those who have had laparoscopic surgery. [ 17 ]  In long-term, a person with only one kidney (\"solitary kidney\") may be more prone to developing  chronic kidney disease  (CKD). [ 18 ]  A 2014 study suggested that lifelong risk of CKD is several-fold higher in kidney donors, although the absolute risk is still very small. [ 19 ]  A 2017 article in the  New England Journal of Medicine  suggests that persons with only one kidney including those who have donated a kidney for transplantation or those whose kidney was removed for cancer, should avoid high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of CKD. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9518", "text": "Partial nephrectomy is the surgical removal of a kidney tumor along with a thin rim of normal  kidney , with the two aims of curing the cancer and preserving as much normal kidney as possible. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9519", "text": "Czerny first described a partial nephrectomy in 1890. [ 21 ]   However, due to limited x-ray and imaging capabilities to find small kidney tumors and significant complications associated with early operations it was largely abandoned.  More recently, with improved imaging, improved surgical techniques and increased kidney tumor detection, partial nephrectomy is performed more often. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9520", "text": "A partial nephrectomy should be attempted when there is a kidney tumor in a solitary kidney, when there are kidney tumors in both kidneys, or when removing the entire kidney could result in kidney failure and the need for dialysis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9521", "text": "Partial nephrectomy is also the standard of care for nearly all patients with small renal masses (<4\u00a0cm in size). [ 22 ]   Most renal masses between 4-7 centimeters can also be treated by partial nephrectomy if they are located in the proper position. [ 23 ]   Renal masses larger than 7 centimeters are generally treated with radical nephrectomy unless the tumor occurs in a solitary kidney, there are tumors on both sides or kidney function is bad.  Patients who are told their tumors are too big or too hard for a partial nephrectomy may want to seek another opinion because surgeons who take care of many patients with kidney cancer are more often able to spare the kidney than those who only see a few cases. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9522", "text": "A partial nephrectomy is performed with a patient under general anesthesia as well.  A partial nephrectomy can be performed through an  open ,  laparoscopic [ 25 ]  or  robotic  approach.   The patient is typically placed on the operating room bed lying on the side opposite the kidney tumor.  The goal of the procedure is to remove the kidney tumor along with a thin rim of normal kidney tissue.  Because the kidneys clean the blood, all blood eventually flows through the kidneys and 25% of it will go into the kidneys with each heart beat.  In order to safely remove the kidney tumor, the blood flow to the kidney is often temporarily blocked off.  The tumor is then cut out and the surgeon must sew the remaining kidney back together.  Partial nephrectomy is often an alternative to complete, or radical, nephrectomy for  renal cell cancer . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9523", "text": "Patients who undergo partial nephrectomy experience complications around 15-25% of the time. [ 25 ] [ 26 ]   The most common complications are bleeding, infection, and urinary leak. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9524", "text": "Partial nephrectomy offers the same chance of cure from the renal cell cancer as radical nephrectomy. [ 22 ] [ 23 ]   This was confirmed in a recent  meta-analysis . [ 27 ] \nPartial nephrectomy has been shown to maintain kidney function better than total removal. [ 23 ]    There is some debate whether this preservation of kidney function leads to long-term benefits to the patient. [ 28 ]  Some studies have found that patients treated by partial nephrectomy live longer than patients who had their whole kidney removed. [ 23 ]   Other studies have found the opposite. [ 29 ] \nPartial nephrectomy has been associated with better  quality of life  compared to radical nephrectomy. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9525", "text": "In  medicine , a  pancreatectomy  is the  surgical removal  of all or part of the  pancreas . Several types of pancreatectomy exist, including  pancreaticoduodenectomy  (Whipple procedure), distal pancreatectomy, segmental pancreatectomy, and total pancreatectomy.  In total pancreatectomy, the  gallbladder , distal  stomach , a portion of the  small intestine , associated  lymph nodes  and in certain cases the  spleen  are removed in addition to the entire pancreas. [ 1 ]   In recent years, the  TP-IAT  (Total Pancreatectomy with Islet Autotransplantation [ 2 ] [ 3 ] ) has also gained respectable traction within the medical community.  These procedures are used in the management of several conditions involving the pancreas, such as benign  pancreatic tumors ,  pancreatic cancer , and  pancreatitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9526", "text": "It is performed for a variety of reasons, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9527", "text": "The most common surgical procedure involving removal of a portion of the pancreas is called a  pancreaticoduodenectomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9528", "text": "Among common consequences of complete or nearly complete pancreatectomy are deficiencies of pancreatic endocrine or exocrine function requiring replacement of  insulin  or  digestive enzymes . The patient immediately develops type 1 diabetes, with little hope for future type 1 diabetes treatments involving the restoration of endocrine function to a damaged pancreas, since the pancreas is either partially or completely absent. Type 1 diabetes can be treated with careful blood glucose monitoring and insulin therapy. Because the pancreas is responsible for the production of many digestive enzymes, a pancreatectomy should only be given as an option for pancreatic disease which is life-threatening, such as pancreatic cancers. Even after a pancreatectomy, pain still exists in most patients. [ citation needed ] [ original research? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9529", "text": "A  distal pancreatectomy  is removal of the body and tail of the pancreas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9530", "text": "After a total pancreatectomy, the body no longer produces its own insulin or pancreatic enzymes, so patients have to take insulin and enzyme supplements. Those who were not already diabetic become so.  Glycemic control  is challenging even for relatively young and healthy apancreatic people, owing to the  digestive  challenges of not having endogenous insulin and pancreatic enzymes under  autonomic  control. It can be insurmountably challenging depending on age and comorbidities. But overall, quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9531", "text": "An experimental procedure called  islet cell transplantation , most frequently the autotransplantation of islets isolated from the explanted pancreas into the portal vein, exists to help mitigate the loss of endocrine function following total pancreatectomy. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9532", "text": "A  pancreaticoduodenectomy , also known as a  Whipple procedure , is a major surgical operation most often performed to remove  cancerous  tumours from the head of the  pancreas . [ 2 ]  It is also used for the treatment of pancreatic or  duodenal  trauma, or chronic  pancreatitis . [ 2 ]  Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the  duodenum , proximal  jejunum ,  gallbladder , and, occasionally, part of the  stomach . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9533", "text": "The most common technique of a pancreaticoduodenectomy consists of the  en bloc  removal of the distal segment (antrum) of the stomach, the first and second portions of the duodenum, the head of the  pancreas , the  common bile duct , and the  gallbladder .  Lymph nodes  in the area are often removed during the operation as well (lymphadenectomy). However, not all lymph nodes are removed in the most common type of pancreaticoduodenectomy because studies showed that patients did not benefit from the more extensive surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9534", "text": "At the very beginning of the procedure, after the surgeons have gained access to the abdomen, the surfaces of the  peritoneum  and the liver are inspected for disease that has metastasized. This is an important first step as the presence of active metastatic disease is a contraindication to performing the operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9535", "text": "The vascular supply of the pancreas is from the  celiac artery  via the  superior pancreaticoduodenal artery  and the  superior mesenteric artery  from the  inferior pancreaticoduodenal artery . There are additional smaller branches given off by the  right gastric artery  which is also derived from the  celiac artery . The reason for the removal of the duodenum along with the head of the pancreas is that they share the same arterial blood supply (the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery). These arteries run through the head of the pancreas so that both organs must be removed if the single blood supply is severed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum, resulting in tissue  necrosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9536", "text": "While the blood supply to the liver is left intact, the  common bile duct  is removed. This means that while the liver remains with a good blood supply the surgeon must make a new connection to drain bile produced in the liver. This is done at the end of the surgery. The surgeon will make a new attachment between the pancreatic duct and the jejunum or stomach. During the surgery, a  cholecystectomy  is performed to remove the  gallbladder . This portion is not done en bloc, as the gallbladder is removed separately."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9537", "text": "Relevant nearby anatomy not removed during the procedure include the major vascular structures in the area: the  portal vein , the  superior mesenteric vein , and the  superior mesenteric artery , the  inferior vena cava . These structures are important to consider in this operation especially if done for resection of a tumor located in the head of the pancreas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9538", "text": "Pancreaticoduodenectomy is most often performed as a curative treatment for  periampullary cancer , which includes cancer of the bile duct, duodenum, ampulla or head of the pancreas. [ 4 ]  The shared blood supply of the pancreas, duodenum and common bile duct necessitates en bloc resection of these multiple structures. Other indications for pancreaticoduodenectomy include  chronic pancreatitis ,  benign tumors of the pancreas , cancer  metastatic  to the pancreas, multiple endocrine neoplasia type 1 [ 5 ]  and  gastrointestinal stromal tumors . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9539", "text": "Pancreaticoduodenectomy is the only potentially curative intervention for  malignant tumors of the pancreas . [ 6 ]  However, the majority of patients with pancreatic cancer present with  metastatic  or locally advanced un-resectable disease; [ 7 ]  thus only 15\u201320% of patients are candidates for the Whipple procedure. Surgery may follow  neoadjuvant chemotherapy , which aims to shrink the tumor and increase the likelihood of complete resection. [ 8 ]  Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 30 to 10% in the 1980s to less than 5% in the 2000s. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9540", "text": "Ampullary cancer arises from the lining of the ampulla of Vater. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9541", "text": "Duodenal cancer arises from the lining of the duodenal mucosa. Majority of duodenal cancers originate in the second part of the duodenum, where ampulla is located. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9542", "text": "Cholangiocarcinoma , or cancer of the  bile duct , is an indication for the Whipple procedure when the cancer is present in the distal biliary system, usually the common bile duct that drains into the duodenum. Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require  hepatectomy , or removal of part of the liver, with or without pancreaticoduodenectomy. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9543", "text": "Treatment of  chronic pancreatitis  typically includes pain control and management of  exocrine insufficiency . Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis. [ 12 ]  Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9544", "text": "Damage to the pancreas and duodenum from  blunt abdominal trauma  is uncommon. In rare cases when this pattern of trauma has been reported, it has been seen as a result of a lap belt in motor vehicle accidents. [ 14 ]  Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum. [ 15 ]  Due to the rarity of this procedure in the setting of trauma, there is not robust evidence regarding post-operative outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9545", "text": "In order to be considered for surgical removal, the tumor cannot encase more than 50% of any of the following vessels: the celiac artery, superior mesenteric artery, or inferior vena cava. In cases where less than 50% of the vessel is involved,  vascular surgeons  remove the involved portion of the vessel, and repair the residual artery or vein. [ 16 ]  Tumors are still borderline resectable even if they involve the superior mesenteric or portal veins, gastroduodenal artery, superior mesenteric vein or colon.  [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9546", "text": "Metastatic disease is another contradiction to surgery. It most often occurs in the peritoneum, in the liver, and in the omentum. In order to determine if there are metastases, surgeons will inspect the abdomen at the beginning of the procedure after gaining access. Alternatively, they may perform a separate procedure called a diagnostic  laparoscopy  which involves insertion of a small camera through a small incision to look inside the abdomen. This may spare the patient the large abdominal incision that would occur if they were to undergo the initial part of a pancreaticoduodenectomy that was cancelled due to metastatic disease. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9547", "text": "Further contraindications include encasement of major vessels (such as celiac artery, inferior vena cava, or superior mesenteric artery) as mentioned above."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9548", "text": "Clinical trials have failed to demonstrate significant survival benefits of  total pancreatectomy , mostly because patients who submit to this operation tend to develop a particularly severe form of  diabetes mellitus  called  brittle diabetes . Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the  spleen ) is removed to prevent further spread of infection and possible  morbidity . In recent years the pylorus-preserving pancreaticoduodenectomy (also known as Traverso\u2013Longmire procedure/PPPD) has been gaining popularity, especially among European surgeons. The main advantage of this technique is that the  pylorus , and thus normal gastric emptying, should in theory be preserved. [ 19 ]  There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying. [ 20 ] [ 21 ]  In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9549", "text": "Compared to the standard Whipple procedure, the pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. Post-operative complications, hospital mortality and survival do not differ between the two methods. [ 22 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9550", "text": "Pancreaticoduodenectomy is considered, by any standard, to be a major surgical procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9551", "text": "Many studies have shown that hospitals where a given operation is performed more frequently have better overall results (especially in the case of more complex procedures, such as pancreaticoduodenectomy). A frequently cited study published in  The New England Journal of Medicine  found operative  mortality rates  to be four times higher (16.3 v. 3.8%) at low-volume (averaging less than one pancreaticoduodenectomy per year) hospitals than at high-volume (16 or more per year) hospitals. Even at high-volume hospitals, morbidity has been found to vary by a factor of almost four depending on the number of times the surgeon has previously performed the procedure. [ 25 ] \nde Wilde et al. have reported statistically significant mortality reductions concurrent with centralization of the procedure in the Netherlands. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9552", "text": "One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9553", "text": "Three of the most common post-operative complications are delayed gastric emptying, bile leak, and pancreatic leak. Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations. [ 28 ] [ 29 ]  During the surgery, a new biliary connection (normally a choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. This new connection may leak in 1\u20132% of operations. As this complication is fairly common, it is normal in this procedure for the surgeon to leave a drain in place at the end. [ 30 ]  This allows for detection of a bile leak via elevated bilirubin in the fluid drained. Pancreatic leak or pancreatic fistula, defined as fluid drained after postoperative day 3 that has an  amylase  content greater than or equal to 3 times the upper limit of normal, occurs in 5\u201310% of operations, [ 31 ] [ 32 ]  although changes in the definition of fistula may now include a much larger proportion of patients (upwards of 40%). [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9554", "text": "Immediately after surgery, patients are monitored for return of bowel function and appropriate closed-suction drainage of the abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9555", "text": "Ileus , which refers to functional obstruction or  aperistalsis  of the intestine, is a physiologic response to abdominal surgery, including the Whipple procedure. [ 34 ]  While post-operative ileus is typically self-limited, prolonged post-operative ileus occurs when patients develop nausea, abdominal distention, pain or intolerance of food by mouth. [ 35 ]  Various measures are taken in the immediate post-operative period to minimize prolonged post-operative ileus. A  nasogastric tube  is typically maintained to suction, to drain gastric and intestinal contents. Ambulation is encouraged to stimulate return of bowel function. Use of  opioid medications , which interfere with intestinal motility, is limited. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9556", "text": "This procedure was originally described by  Alessandro Codivilla , an Italian surgeon, in 1898. [ 37 ]  The first resection for a  periampullary  cancer was performed by the German surgeon  Walther Kausch  in 1909 and described by him in 1912. It is often called  Whipple's procedure  or the  Whipple procedure , after the American surgeon  Allen Whipple  who devised an improved version of the surgery in 1935 while at  Columbia-Presbyterian Medical Center  in New York [ 38 ]  and subsequently came up with multiple refinements to his technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9557", "text": "Fingerhut et al. argue that while the terms  pancreatoduodenectomy  and  pancreaticoduodenectomy  are often used interchangeably in the medical literature, scrutinizing their etymology yields different definitions for the two terms. [ 1 ]  As a result, the authors prefer  pancreatoduodenectomy  over  pancreaticoduodenectomy  for the name of this procedure, as strictly speaking  pancreaticoduodenectomy  should refer to the resection of the duodenum and pancreatic duct rather than the pancreas itself. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9558", "text": "Pelvic exenteration  (or  pelvic evisceration ) is a radical  surgical  treatment that removes all organs from a person's  pelvic cavity . It is used to treat certain advanced or recurrent  cancers . The  urinary bladder ,  urethra ,  rectum , and  anus  are removed. In women, the  vagina ,  cervix ,  uterus ,  Fallopian tubes ,  ovaries  and, in some cases, the  vulva  are removed. In men, the  prostate  is removed. The procedure leaves the person with a permanent  colostomy  and  urinary diversion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9559", "text": "Pelvic exenteration often leads to complications, such as  infection ,  kidney damage ,  embolism ,  perineal hernia , and problems with the  stomas  created. However, it increases 5-year survival rate from certain cancers. The procedure was first described by  Alexander Brunschwig  in 1948."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9560", "text": "Pelvic exenteration is an option in cases of very advanced or recurrent  cancer , for which less radical surgical options are not technically possible or would not be sufficient to remove all the tumor. This procedure is performed for several types of cancer including genitourinary cancer, [ 1 ]  and  colorectal cancers . [ 2 ]  It is rarely performed due to common complications. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9561", "text": "Pelvic exenteration may not cure certain  cancers . [ 3 ]  This can happen if there are  metastases  in the  liver , the sidewall of the  pelvic cavity , the aortic  lymph nodes , or through  carcinosis . [ 3 ]  In these cases, it may not be used. It may also not be used when both  ureters are obstructed . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9562", "text": "Between 60% and 90% of all people who have a pelvic exenteration have a complication. [ 1 ]  The large  surgical incision  may become  infected . [ 1 ]   Fever  and  sepsis  may occur. [ 1 ]  The  kidneys  may be damaged, usually due to reduced blood flow and  ischaemia . [ 1 ]   Embolisms  may occur. [ 1 ]  After pelvic exenteration, many patients will have  perineal hernia , often without symptoms, but only 3\u201310% will have perineal hernia requiring surgical repair. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9563", "text": "Many problems can occur with the  stoma . [ 1 ]   Bowel obstruction  may occur, or the  anastomosis  created by the surgery may leak. [ 1 ]  The stoma may retract, or may prolapse. [ 1 ]  Rarely, it may  necrose . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9564", "text": "Pelvic exenteration involves removal of all of the pelvic organs. [ 3 ]  These include the  urinary bladder ,  urethra ,  rectum , and  anus . In women, the  vagina ,  cervix ,  uterus ,  fallopian tubes ,  ovaries  and, in some cases, the  vulva  are removed. In men, the  prostate  is removed. Patients receive significant counselling before the procedure so that they fully understand the benefits and risks. [ 5 ]   Radiology  is used before surgery. [ 5 ]  The surgery itself is complex. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9565", "text": "Pelvic exenteration leaves a person with a permanent  colostomy  and  urinary diversion . A 2015 article reports that pelvic exenteration can provide long-term survival for patients with locally advanced primary  rectal carcinoma . The 5-year survival rate of patients undergoing pelvic exenteration following complete resection of disease was 59.3%. Factors shown to influence the survival rate following a pelvic exenteration procedure include age, the  presence of metastatic disease, lymph node status, circumferential  resection margin , local recurrence of disease, and the need for  neoadjuvant therapy . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9566", "text": "The procedure was first described by  Alexander Brunschwig  in 1948. [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9567", "text": "A  pneumonectomy  (or pneumectomy) is a  surgical  procedure to remove a  lung . It was first successfully performed in 1933 by Dr. Evarts Graham. This is not to be confused with a lobectomy or segmentectomy, which only removes one part of the lung."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9568", "text": "There are two types of pneumonectomy: simple and extrapleural. A simple pneumonectomy removes just the lung. An extrapleural pneumonectomy also takes away part of the diaphragm, the parietal pleura, and the pericardium on that side. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9569", "text": "The most common reason for a pneumonectomy is to remove  tumorous  tissue arising from  lung cancer . Other reasons can arise are a traumatic lung injury, bronchiectasis, tuberculosis, a congenital defect, and fungal infections. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9570", "text": "The operation will reduce the respiratory capacity of the patient, and before conducting a pneumonectomy, survivability after the removal has to be assessed. If at all possible, a  pulmonary function test  (PFT) should be done. It has been found that forced expiratory volume in one second (FEV1) and diffusion capacity of the lungs (DLCO) provides the best indicator of survival. [ 3 ]  Other tools can be used to assess effectiveness as well, such as cardiopulmonary exercise testing to measure maximal oxygen consumption (VO 2  max), stair climbing, shuttle walk test, and a 6-minute walk test. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9571", "text": "If someone has severe valvular disease, severe pulmonary hypertension, or poor ventricular function or if cancer has spread from the lungs into the other intra-abdominal structures, ribs, or contralateral hemithorax, it is contraindicated. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9572", "text": "Posterolateral thoracotomy using the fourth or fifth intercostal space is the most common approach used for pneumonectomy. In case of inflammatory and infectious indications, excision of the fifth rib may be necessary to achieve adequate surgical exposure if there is rib crowding. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9573", "text": "Video-assisted thoracoscopic surgery (VATS) approach: VATS pneumonectomy is a safe and feasible treatment for advanced malignant and benign diseases and has lower morbidity. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9574", "text": "Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With a sound technique most procedures can be completed robotically without any major complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9575", "text": "After a pneumonectomy is performed, changes in the thoracic cavity occur to compensate for the altered anatomy. The remaining lung hyperinflates as well as shifting over along with the  heart  towards the now empty space. This space is full of air initially after surgery, but then it is absorbed, and fluid eventually takes its place. [ 9 ]  The fluid which fills the residual space in the chest cavity slowly gelatinizes into a proteinaceous material, and the chest scaffold collapses slightly. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9576", "text": "As with the  kidneys , it is often possible for a person to live with just one lung. Although it is not possible for the lung to re-grow like the  liver , the body is able to compensate for the reduced lung capacity by slow and gradual expansion of the other remaining lung. Post-pneumonectomy patients in due time reach about 70\u201380 percent of their pre-surgery lung function. [ 10 ]  People have been able to return to near-normal lives, including running marathons after a pneumonectomy, provided there has been adequate cardio-pulmonary conditioning. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9577", "text": "Most common complications after a pneumonectomy are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9578", "text": "A  preventive mastectomy  or  prophylactic mastectomy  or risk-reducing mastectomy (RRM) is an  elective operation  to  remove the breasts  so that the risk of  breast cancer  is reduced. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9579", "text": "The procedure is a surgical option for individuals who are at high risk for the development of breast cancer. High risk women without a prior history of personal breast cancer might consider bilateral risk-reducing mastectomy (BRRM) as an option for minimising the risk of primary breast carcinoma development. [ 3 ]  The procedure includes the surgical removal of both breasts before any pathologic diagnosis has been made. Women that were previously diagnosed with a breast cancer in one breast (ipsilateral breast cancer) might elect to undergo risk-reducing mastectomy of the other unaffected (contralateral) breast, that is to say contralateral risk-reducing mastectomy (CRRM), to minimize the risk of a second breast cancer development. CRRM has been shown to reduce the incidence of contralateral breast cancer, but there is not sufficient evidence that it improves survival. [ 4 ]  Women who had a bilateral mastectomy in 2013 were about 10 years younger than those who had a unilateral mastectomy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9580", "text": "This  preventive operation  pertains to women with these characteristics: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9581", "text": "Discussions and decision should be made with the help of specialists who can use relevant information and statistical models to predict the individual lifetime risk of development of breast cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9582", "text": "Undergoing a preventive mastectomy does not guarantee that breast cancer will not develop later, however, it reduces the risk by 90% in high risk women. [ 2 ] [ 8 ]  Also, a preventive mastectomy may not be able to remove all breast tissue as some of it may be in the arm pit, near the collar bone, or in the abdominal wall. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9583", "text": "Male carriers of BRCA1 and BRCA2 mutations have a higher risk of breast cancer than other males, approximately 1.2% and 6.8%, [ 9 ]  but their risk is much lower than in female mutation carriers (about 60%) and lower than in the general female population (12%). [ 10 ]  Thus, preventive mastectomy has not been advocated for affected men."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9584", "text": "In most situations the operation involves both breasts and thus represents a bilateral procedure. When cancer has affected already one breast, the other breast, still healthy, may be removed in a unilateral preventive mastectomy. Typically either a simple, a subcutaneous or a nipple-sparing mastectomy is performed. With the former the areola and  nipple  are removed, while the other two approaches preserve the nipple area for cosmetic reasons. To increase the  viability  of the nipple area for preservation during mastectomy, a so-called \" nipple delay \" procedure can be done several weeks before the mastectomy. [ 11 ]   Reconstructive breast surgery  can be  performed in the same surgical setting, added after the mastectomy. [ 12 ]  Saline or silicone  implants  may be used in the reshaping process and may be placed in a later setting. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9585", "text": "A preventive mastectomy carries certain risks including those of anesthesia, bleeding, infection, pain, disfiguration, anxiety and disappointment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9586", "text": "After surgery, routine screening for breast cancer is recommended. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9587", "text": "There are other options to reduce the risk of future breast cancer. [ 2 ] \nIntensified breast cancer screening for high risk women may detect cancer at an early, treatable stage. Certain medications that block the effect of  estrogen  (i.e.  tamoxifen ,  raloxifen ,  exemestane ) can reduce the risk by about 50% but also have side effects. Prophylactic salpingo- oophorectomy  reduces estrogen levels and the risk of both ovarian and breast cancer, however, the reduction in breast cancer risk is about 50% in high risk women [ 8 ]  as compared to 90% when preventive mastectomy is done.   Lifestyle  changes (in weight, diet, exercise, avoidance of smoking, limiting alcohol) may reduce the risk to some degree. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9588", "text": "A factor that facilitates the decision to undergo a preventive mastectomy is that results of breast reconstructive surgery have improved. [ 15 ]  A 2004 Canadian study found that 70% of women were satisfied or extremely satisfied with the reconstruction after bilateral prophylactic mastectomy. [ 12 ]  In the United States preventive mastectomy is gaining increased acceptance. [ 15 ] [ 16 ]  The decision of famous actresses such as  Christina Applegate  and  Angelina Jolie [ 13 ]  to undergo preventive mastectomy has given the procedure wider media attention. [ 15 ]   The trend towards prophylactic mastectomy appears to be less pronounced in Europe [ 15 ]  and India. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9589", "text": "Radiation lobectomy  is a form of  radiation therapy  used in  interventional radiology  to treat  liver cancer . It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with  yttrium-90  into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from  portal vein embolization  (PVE)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9590", "text": "RL is performed in people with liver cancer, both primary such as  hepatocellular carcinoma  and metastatic such as from  colon adenocarcinoma . Surgical resection is considered the only curative treatment for liver cancer (other than liver transplantation for hepatocellular carcinoma) but it can only be performed in patients with sufficient remnant liver after resection (amongst other criteria). Both PVE and RL are performed in patients who are not surgical candidates due to insufficient future liver remnant (FLR), which is advised to be between 20-30% and 30-40% of the native liver volume in healthy and cirrhotic livers, respectively. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9591", "text": "Radiation lobectomy is a relatively new application of  radioembolization  and results are mainly reported in the form of retrospective chart review studies and case reports, without any prospective validation. Most authors report a comparable future liver remnant hypertrophy between portal vein embolization and RL, ranging between 10 and 47% [ 2 ] [ 3 ] [ 4 ] [ 5 ]  with cases reaching up to 119% with RL. [ 6 ]  The main difference between the two is the time interval necessary for appropriate hypertrophy, greater for RL. PVE requires a shorter time frame to achieve comparable results, ranging between 2\u20136 weeks, [ 7 ] [ 8 ]  while the hypertrophy kinetics of RL are slower but more constant, without significant plateau (some studies report continued hypertrophy up to 9 months). [ 2 ]  Some authors have even raised concerns regarding PVE and the potential interval disease progression in the embolized and treatment naive lobes while allowing hypertrophy, which is of less concern with RL due to its added tumoricidal effect. [ 9 ]  Additionally, RL has been demonstrated to aid surgical resection in some cases by inducing a \u201cvascular shift\u201d of tumor masses via necrosis and contraction away from major vascular pedicles, converting patients to resectable status. [ 4 ]  One study has shown preliminary 600-day survival in 12 out of 13 patients who received RL and subsequent resection. [ 4 ]  Ultimately, further studies are needed to prospectively compare survival and recurrence outcomes in patients receiving RL versus PVE. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9592", "text": "Common side effects include fatigue, abdominal pain, nausea and anorexia, usually self-limiting. Post-radioembolization syndrome occurs in 20-70% of patients that undergo traditional radioembolization, presenting with shakes, chills, fatigue, nausea/vomiting, abdominal pain/discomfort, and/or cachexia and possibly hemodynamic changes, rarely requiring admission. Unfortunately, most data, if not all, is derived from traditional radioembolization outcomes studies and more will be needed to assess the actual incidence and risk of post-radioembolization syndrome in RL. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9593", "text": "Complications are abscess formation, biliary complications (biloma, radiation induced cholecystitis and cholangitis, biliary necrosis), gastrointestinal complications (diarrhea, radiation induced gastritis and gastrointestinal ulceration), radiation induced pancreatitis, dermatitis, pneumonitis and lymphopenia. [ 10 ] [ 11 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9594", "text": "RL is performed by an interventional radiologist in the  angiography  suite, in a fashion similar to radioembolization. The procedure is composed of two different portions, a planning phase and the actual radiation lobectomy, usually performed in two different sessions: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9595", "text": "Patients undergo cross-sectional imaging at approximately 30\u201360 days from the procedure for evaluation of the degree of  hypertrophy  undergone by the contralateral side (as assessed by future liver remnant) and to assess tumor burden. At this time, the surgeons and/or a multi-specialty tumor board will convene to determine if the patient can/should undergo safe surgical resection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9596", "text": "Radical mastectomy  is a surgical procedure that treats  breast cancer  by removing the breast and its underlying chest muscle (including  pectoralis major  and  pectoralis minor ), and  lymph nodes  of the  axilla  (armpit). Breast cancer is the most common cancer among women. During the early twentieth century it was primarily treated by surgery, when the mastectomy was developed. [ 1 ]  However, with the advancement of technology and surgical skills in recent years, mastectomies have become less invasive. [ 2 ]  As of 2016 [update] , a combination of  radiotherapy  and breast conserving mastectomy are considered optimal treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9597", "text": "Halsted  and Meyer were the first to achieve successful results with the radical mastectomy, thus ushering in the modern era of surgical treatment for breast cancer. In 1894,  William Halsted  published his work with radical mastectomy from the 50 cases operated at Johns Hopkins between 1889 and 1894. [ 3 ]  Willy Meyer also published research on radical mastectomy from his interactions with New York patients in December 1894. [ 4 ]  The  en bloc  removal of the breast tissue became known as the Halsted mastectomy before adopting the title \"the complete operation\" and eventually, \"the radical mastectomy\" as it is known today. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9598", "text": "Radical mastectomy was based on the medical belief at the time that breast cancer spread locally at first, invading nearby tissue and then spreading to surrounding lymph ducts where the cells were \"trapped\". It was thought that hematic spread of tumor cells occurred at a much later stage. [ 1 ]  Halsted himself believed that cancer spread in a \"centrifugal spiral\", solidifying this opinion in the medical community at the time. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9599", "text": "Radical mastectomy involves removing all the breast tissue, overlying skin, the pectoralis muscles, and all the axillary lymph nodes. Skin was removed because the disease involved the skin, which was often ulcerated. [ 3 ] [ 7 ]  The pectoralis muscles were removed not only because the chest wall was involved, but also because it was thought that removal of the transpectoral lymphatic pathways were necessary. It was also thought, at that time, that it was anatomically impossible to do a complete axillary dissection without removing the pectoralis muscle. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9600", "text": "William Halsted  accomplished a three-year recurrence rate of 3% and a locoregional recurrence rate of 20% with no  perioperative mortality . The five-year survival rate was 40%, which was twice that of untreated patients. [ 3 ]  However, post-operation morbidity rates were high as the large wounds were left to heal by  granulation ,  lymphedema  was  ubiquitous, and arm movement was highly restricted. Thus, chronic pain became a prevalent  sequela . Because surgeons were faced with such large breast cancers that seemed to need drastic treatment methods, the quality of patient life was not taken into consideration. [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9601", "text": "Nonetheless, due to  Halsted  and Meyer's work, it was possible to cure some cases of breast cancer and knowledge of the disease began to increase. Standardized treatments were created, and controlled long-term studies were conducted. Soon, it became apparent that some women with advanced stages of the disease did not benefit from surgery. In 1943, Haagensen and Stout reviewed over 500 patients who had radical mastectomy for breast cancer and identified a group of patients who could not be cured by radical mastectomy thus developing the concepts of operability and inoperability. [ 14 ]  The signs of inoperability included ulceration of the skin, fixation to the chest wall, satellite nodules, edema of the skin (peau d'orange), supraclavicular lymph node enlargement, axillary lymph nodes greater than 2.5\u00a0cm, or matted, fixed lymph nodes. [ 14 ]  This contribution of Haagensen and his colleagues would eventually lead to the development of a clinical staging system for breast cancer, the Columbia Clinical Classification, which is a landmark in the study of biology and treatment of breast cancer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9602", "text": "Today, surgeons rarely perform radical mastectomies, as a 1977 study by the National Surgical Adjuvant Breast and Bowel Project (NSABP), led by  Bernard Fisher , showed that there was no statistical difference in survival or recurrence between radical mastectomies and less invasive surgeries. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9603", "text": "According to the Halsted-Meyer theory, the major pathway for breast cancer dissemination was through the  lymphatic ducts . Therefore, it was thought that performing wider and more mutilating surgeries that removed a greater number of lymph nodes would result in greater chances of cure. [ 17 ]  From 1920 onwards, many surgeons performed surgeries more invasive than the original procedure by  Halsted .  Sampson Handley  noted  Halsted 's observation of the existence of malignant metastasis to the chest wall and breast bone via the chain of internal mammary nodes under the sternum and employed an \"extended\" radical mastectomy that included the removal of the lymph nodes located there and the implantation of radium needles into the anterior intercostal spaces. [ 18 ]  This line of study was extended by his son, Richard S. Handley, who studied internal mammary chain nodal involvement in breast cancer and demonstrated that 33% of 150 breast cancer patients had internal mammary chain involvement at the time of surgery. [ 19 ]  The radical mastectomy was subsequently extended by a number of surgeons such as Sugarbaker and Urban to include removal of internal mammary lymph nodes. [ 20 ] [ 21 ]  Eventually, this \"extended\" radical mastectomy was extended even further to include removal of the supraclavicular lymph nodes at the time of mastectomy by Dahl-Iversen and Tobiassen. [ 22 ]  Some surgeons like Prudente even went as far as amputating the upper arm  en bloc  with the mastectomy specimen in an attempt to cure relatively advanced local disease. [ 23 ]  This increasingly radical progression culminated in the \u2018super-radical\u2019 mastectomy which consisted of complete excision of all breast tissue, axillary content, removal of the latissimus dorsi, pectoralis major and minor muscles and dissection of the internal mammary lymph nodes. [ 24 ]  After retrospective analysis, the extended radical mastectomies were abandoned as these massive and disabling operations proved to be not superior to those of the standard radical mastectomies. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9604", "text": "Radiofrequency ablation  ( RFA ), also called  fulguration , [ 1 ]  is a medical procedure in which part of the  electrical conduction system of the heart ,  tumor ,  sensory nerves  or a dysfunctional  tissue  is  ablated  using the heat generated from  medium frequency   alternating current  (in the range of 350\u2013500\u00a0kHz). [ 2 ] [ 3 ]  RFA is generally conducted in the  outpatient  setting, using either a  local anesthetic [ 3 ]  or  twilight anesthesia . When it is delivered via  catheter , it is called radiofrequency  catheter ablation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9605", "text": "Two advantages of  radio frequency  current (over previously used low frequency AC or pulses of DC) are that it does not directly stimulate nerves or heart muscle, and therefore can often be used without the need for  general anesthesia , and that it is specific for treating the desired tissue without significant collateral damage. [ 3 ] [ 4 ]  Due to this, RFA is an alternative for eligible patients who have  comorbities  or do not want to undergo surgery. [ 3 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9606", "text": "Documented benefits have led to RFA becoming widely used during the 21st century. [ 3 ] [ 5 ] [ 7 ] [ 8 ] [ 9 ]  RFA procedures are performed under image guidance (such as X-ray screening,  CT scan  or  ultrasound ) by an interventional pain specialist (such as an anesthesiologist),  interventional radiologist ,  otolaryngologists , a gastrointestinal or surgical endoscopist, or a  cardiac electrophysiologist , a subspecialty of  cardiologists ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9607", "text": "RFA may be performed to treat tumors in the lung, [ 10 ] [ 11 ] [ 12 ]  liver, [ 13 ]  kidney, and bone, as well as other body organs less commonly. Once the diagnosis of tumor is confirmed, a needle-like RFA probe is placed inside the tumor. The radiofrequency waves passing through the probe increase the temperature within tumor tissue, which results in destruction of the tumor. RFA can be used with small tumors, whether these arose within the organ (primary tumors) or spread to the organ ( metastases ). The suitability of RFA for a particular tumor depends on multiple factors. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9608", "text": "RFA can usually be administered as an outpatient procedure, though may at times require a brief hospital stay. RFA may be combined with locally delivered chemotherapy to treat hepatocellular carcinoma (primary liver cancer). A method currently in phase III trials uses the low-level heat (hyperthermia) created by the RFA probe to trigger release of concentrated chemotherapeutic drugs from heat-sensitive liposomes in the margins around the ablated tissue as a treatment for  hepatocellular carcinoma  (HCC). [ 14 ] \nRadiofrequency ablation is also used in pancreatic cancer and bile duct cancer. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9609", "text": "RFA has become increasingly important in the care of benign bone tumors, most notably  osteoid osteomas . Since the procedure was first introduced for the treatment of osteoid osteomas in the 1990s, [ 16 ]  it has been shown in numerous studies to be less invasive and expensive, to result in less bone destruction and to have equivalent safety and efficacy to surgical techniques, with 66 to 95% of people reporting freedom from symptoms. [ 17 ] [ 18 ] [ 19 ]  While initial success rates with RFA are high, symptom recurrence after RFA treatment has been reported, with some studies demonstrating a recurrence rate similar to that of surgical treatment. [ 20 ]  RFA is also increasingly used in the palliative treatment of painful  metastatic bone disease  in people who are not eligible or do not respond to traditional therapies ( i.e.  radiation therapy ,  chemotherapy , palliative surgery,  bisphosphonates  or analgesic medications). [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9610", "text": "Radiofrequency energy is used in heart tissue or normal parts to destroy abnormal electrical pathways that are contributing to a  cardiac arrhythmia . It is used in recurrent  atrial flutter  (Afl),  atrial fibrillation  (AF),  supraventricular tachycardia  (SVT),  atrial tachycardia ,  Multifocal Atrial Tachycardia  (MAT) and some types of  ventricular arrhythmia . The energy-emitting probe (electrode) is at the tip of a catheter which is placed into the heart, usually through a vein. This catheter is called the  ablator . The practitioner first \"maps\" an area of the heart to locate the abnormal electrical activity ( electrophysiology study ) before the responsible tissue is eliminated. Radiofrequency ablation technique can be used in AF, either to block the  atrioventricular node  after implantation of a pacemaker or to block conduction within the  left atrium , especially around the  pulmonary veins . Radiofrequency ablation for AF can be unipolar (one electrode) or bipolar (two electrodes). [ 22 ]  Although bipolar can be more successful, it is technically more difficult, resulting in unipolar being used more often. [ 22 ]  But bipolar is more effective in preventing recurrent atrial arrhythmias. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9611", "text": "Ablation is now the standard treatment for SVT and typical atrial flutter, In some conditions, especially forms of intra-nodal re-entry (the most common type of SVT), also called atrioventricular nodal reentrant tachycardia or AVNRT, ablation can also be accomplished by cryoablation (tissue freezing using a coolant which flows through the catheter) which avoids the risk of complete heart block \u2013 a potential complication of radiofrequency ablation in this condition. Recurrence rates with cryoablation are higher, though. [ 24 ]  Microwave ablation, where tissue is ablated by the microwave energy \"cooking\" the adjacent tissue, and ultrasonic ablation, creating a heating effect by mechanical vibration, or laser ablation have also been developed but are not in widespread use. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9612", "text": "A new indication for the use of radiofrequency technology has made news in the last few years.  Hypertension  is a very common condition, with about 1\u00a0billion people over the world, nearly 75 million in the US alone. Complications of inadequately controlled hypertension are many and have both individual and global impact. Treatment options include medications, diet, exercise, weight reduction and meditation. Inhibition of the neural impulses that are believed to cause or worsen hypertension has been tried for a few decades. Surgical sympathectomy has helped but not without significant side effects. Therefore, the introduction of non-surgical means of renal denervation using a radiofrequency ablation catheter was enthusiastically welcomed. Although the initial use of radiofrequency-generated heat to ablate nerve endings in the renal arteries to aid in management of 'resistant hypertension' were encouraging, the most recent phase 3 studying looking at catheter-based renal denervation for the treatment of resistant hypertension failed to show any significant reduction in systolic blood pressure. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9613", "text": "Radiofrequency  ablation [ 26 ]  is a dermatosurgical procedure by using various forms of alternating current. Types of radiofrequency are electrosection, electrocoagulation, electrodessication and fulguration. The use of radiofrequency ablation has obtained importance as it can be used to treat most of the skin lesions with minimal side effects and complications. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9614", "text": "Radiofrequency ablation is a minimally invasive procedure used in the treatment of  varicose veins . It is an alternative to the traditional stripping operation. Under ultrasound guidance, a radiofrequency catheter is inserted into the abnormal vein and the vessel treated with radio-energy, resulting in closure of the involved vein. Radiofrequency ablation is used to treat the  great saphenous vein , the  small saphenous vein , and the  perforator veins . The latter are connecting veins that transport blood from the superficial veins to the deep veins. Branch varicose veins are then usually treated with other minimally invasive procedures, such as  ambulatory phlebectomy ,  sclerotherapy , or  foam sclerotherapy . Currently, the VNUS ClosureRFS stylet is the only device specifically cleared by FDA for endovenous ablation of perforator veins. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9615", "text": "The possibility of skin burn during the procedure is very small, because the large volumes (500 cc) of dilute Lidocaine (0.1%) tumescent anesthesia injected along the entire vein prior to the application of radiofrequency provide a heat sink that absorbs the heat created by the device. Early studies have shown a high success rate with low rates of complications. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9616", "text": "RFA was first studied in  obstructive sleep apnea  (OSA) in a pig model. [ 29 ]  RFA has been recognized as a  somnoplasty  treatment option in selected situations by the  American Academy of Otolaryngology [ 29 ]  but was not endorsed for general use in the  American College of Physicians  guidelines. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9617", "text": "The clinical application of  RFA in obstructive sleep apnea  is reviewed in that main article, including controversies and potential advantages in selected  medical situations .\nUnlike other electrosurgical devices, [ 31 ]  RFA allows very specific treatment targeting of the desired tissue with a precise  line of demarcation  that avoids collateral damage, which is crucial in the head and neck region due to its high density of major nerves and blood vessels. RFA also does not require high temperatures. However, overheating from misapplication of RFA can cause harmful effects such as coagulation on the surface of the electrode, boiling within tissue that can leave \"a gaping hole\", tears, or even charring. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9618", "text": "RFA, or  rhizotomy , was developed by  Nikolai Bogduk  to treat chronic pain arising from the  facet joints  in the lower ( lumbar ) back.  Radiofrequency waves  are used to produce heat on specifically identified nerves surrounding the  facet joints  called the lumbar medial branches of the  dorsal ramus of the spinal nerves . [ 33 ]   By generating heat around the nerve, the nerve is ablated, thus destroying its ability to transmit signals to the brain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9619", "text": "The nerves to be ablated are identified through injections of local anesthesia (such as  lidocaine ) around the medial branches prior to the RFA procedure to first confirm the diagnosis. If the  local anesthesia  injections provide temporary pain relief, the injection is repeated a second time to confirm the diagnosis. Then RFA is performed on the nerve(s) that responded well to the injections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9620", "text": "RFA is a minimally invasive procedure which can usually be done in day-surgery clinics, going home shortly after completion of the procedure. The person is awake during the procedure, so risks associated with general anesthesia are avoided. Whether for back or knee pain, a drawback for this procedure is that nerves recover function over time, so the pain relief achieved lasts only temporarily (3\u201315 months) in most people. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9621", "text": "Radiofrequency ablation of sensory nerves in the knee, also called  genicular neurotomy  or  genicular RFA , is clinically preceded by confirming pain reduction upon anesthetizing the main knee sensory nerves in a test procedure called  genicular nerve block . [ 3 ] [ 34 ] [ 35 ]  Genicular nerve block is a short (10-30 minutes), outpatient procedure usually performed weeks before genicular RFA. [ 3 ] [ 36 ] [ 37 ]  The extent of pain reduction by injecting a local anesthetic, such as  bupivacaine , at specific locations of the target genicular nerves, is self-assessed by the person for hours after the procedure, leading to confirmation with the physician of the need for RFA. [ 3 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9622", "text": "In the procedure for genicular RFA, a guide cannula is first directed under local anesthesia and imaging ( ultrasound  or  fluoroscopy ) to each target genicular nerve, then the radiofrequency electrode is passed through the cannula, and the electrode tip is heated to about 80\u00a0\u00b0C (176\u00a0\u00b0F) for one minute to  cauterize  a small segment of the nerve. [ 3 ] [ 34 ]  The heat destroys that segment of the nerve, which is prevented from sending pain signals to the brain. [ 3 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9623", "text": "As of 2019, several hundred publications showed promise for substantial, long-term (6 months or longer) reduction of knee pain following genicular RFA. [ 3 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9624", "text": "The US  Food and Drug Administration  had approved in 2017 a commercial device using cooled RFA, with effects lasting for up to a year of pain relief from  knee arthritis . [ 9 ] [ 39 ]  As of 2023, reviews of clinical outcomes indicated that efficacy for reducing knee pain was achieved by ablating three or more branches of the genicular nerve (one of the  articular  branches of the  tibial nerve ). [ 36 ] [ 38 ] [ 40 ] [ 41 ]  Other sources indicate 4-5 genicular nerve targets may be justified for ablation to optimize pain relief, [ 35 ] [ 36 ]  while a 2022 analysis indicated that as many as 10 genicular nerve targets for RFA would produce better long-term relief of knee pain. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9625", "text": "Knee pain relief of 50% or more following genicular RFA may last from several months to two years, [ 3 ] [ 40 ] [ 41 ]  and can be repeated by the same outpatient procedure when pain recurs. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9626", "text": "An anatomical study of  cadaver  knees indicated that ultrasound-guided bony landmarks could be used to effectively target the superior medial geniculate nerve, superior lateral geniculate nerve, and inferior medial geniculate nerve \u2013 the three nerves commonly targeted for knee RFA [ 3 ]  \u2013 with average nerve-to-needle distances of 1.7, 3.2, and 1.8 mm, respectively. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9627", "text": "Radiofrequency ablation has been shown to be a safe and effective treatment for  Barrett's esophagus . The balloon-based radiofrequency procedure was invented by Robert A. Ganz, Roger Stern and Brian Zelickson in 1999 (System and Method for Treating Abnormal Tissue in the Human Esophagus). While the person is sedated, a catheter is inserted into the esophagus and radiofrequency energy is delivered to the diseased tissue. This outpatient procedure typically lasts from fifteen to thirty minutes. Two months after the procedure, the physician performs an upper endoscopic examination to assess the esophagus for residual Barrett's esophagus. If any Barrett's esophagus is found, the disease can be treated with a focal RFA device. Between 80 and 90% or greater of people in numerous clinical trials have shown complete eradication of Barrett's esophagus in approximately two to three treatments with a favorable safety profile. The treatment of Barrett's esophagus by RFA is durable for up to 5 years. [ 44 ] [ 45 ] [ 46 ] [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9628", "text": "Radiofrequency ablation has been used successfully on benign thyroid nodules for decades, most notably in Europe, South America and Korea. [ citation needed ]  In the United States, the FDA approved the use of RFA techniques for thyroid nodules in 2018. Since then, professional guidelines reflect its use as a viable treatment modality for thyroid nodules, and the procedure is increasingly applied. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9629", "text": "- 2023: the  American Thyroid Association  issued the position statement \"Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9630", "text": "- 2022: the  American Association of Clinical Endocrinologists  published an update in Endocrine Practice, stating that the \"new image-guided minimally invasive approaches appear safe and effective alternatives when used appropriately and by trained professionals to treat symptomatic or enlarging thyroid masses\". [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9631", "text": "- 2018: FDA approved the RFA procedure for treatment of benign thyroid nodules. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9632", "text": "The procedure is similar to a thyroid biopsy, although instead of using a needle to remove cells from the nodule, a probe delivers heat to the interior of the nodule that effectively  cauterizess  the tissue. [ medical citation needed ]  Over the course of 3-6 months, the nodule will continue to shrink, typically achieving a 50-80% reduction total size. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9633", "text": "In order to qualify for an RFA procedure, a person must have a clearly benign thyroid nodule, usually proven by two fine needle aspiration biopsies. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9634", "text": "As of 2020, RFA is not recommended for the treatment of  malignant  thyroid nodules, although research into this topic is ongoing. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9635", "text": "RFA is also used in radiofrequency lesioning for vein closure in areas where intrusive surgery is contraindicated by trauma, and in liver resection to control bleeding (hemostasis) and facilitate the transection process. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9636", "text": "This process has also been used to treat  TRAP sequence  in multiple gestation pregnancies. This has an acceptable success rate for saving the 'pump' twin in recent studies compared to previous methods including laser photocoagulation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9637", "text": "RFA is used to treat  uterine fibroids  using the heat energy of radio frequency waves to ablate the fibroid tissue. The Acessa device [ 52 ]  obtained FDA approval in 2012. [ 53 ]  The device is inserted via a laparoscopic probe and guided inside the fibroid tissue using an ultrasound probe. The heat shrinks the fibroids. Clinical data on the procedure show an average of 45% shrinkage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9638", "text": "RFA is also used in the treatment of  Morton's neuroma [ 54 ]  where the outcome appears to be more reliable than alcohol injections. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9639", "text": "A  resection margin  or  surgical margin  is the margin of apparently non-tumorous tissue around a tumor that has been surgically removed, called \" resected \", in  surgical oncology .  The resection is an attempt to remove a  cancer   tumor  so that no portion of the malignant growth extends past the edges or margin of the removed tumor and surrounding tissue.  These are retained after the surgery and examined microscopically by a  pathologist  to see if the margin is indeed free from tumor cells (called \"negative\"). If cancerous cells are found at the edges (called \"positive\") the operation is much less likely to achieve the desired results. [ 1 ] :\u200asections 1-2"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9640", "text": "The size of the margin is an important issue in areas that are functionally important (i.e., large vessels like the  aorta  or vital organs) or in areas for which the extent of surgery is minimized due to aesthetic concerns (i.e.,  melanoma  of the face or  squamous cell carcinoma  of the  penis ). [ 2 ]  The desired size of margin around the tumour can vary. In resections for  breast cancer , there appears to be a difference between European and American radiation oncologists, with the former preferring larger margins of over 5\u00a0mm. [ 1 ] :\u200asection 2"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9641", "text": "Residual tumour at the primary site after treatment (it does not address the surgical margin as commonly believed) is classified by the pathologist as (AJCC 8th Edition):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9642", "text": "The Margin Status following tumour resection (AJCC 8th Edition):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9643", "text": "Apart from traditional methods looking at stained \"shaves\" (thin slices of tissue removed from the edge of the margin) or smeared and stained imprints, more recent techniques used to assess margins include x-rays with compression, frozen specimens, and new techniques such as intraoperative fluorescence imaging,  Raman spectroscopy ,  optical coherence tomography  and quantitative diffuse reflectance  spectroscopy . [ 3 ] [ 1 ] :\u200asections 5-6"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9644", "text": "Surgical margin in a surgery report defines the visible margin or free edge of \"normal\" tissue seen by the  surgeon  with the naked eye.  Surgical margin as read in a  pathology  report defines the histological measurement of normal or unaffected tissue surrounding the visible  tumor  under a  microscope  on a glass mounted histology section. [ 4 ] [ 5 ]   A \"narrow\" surgical margin implies that the tumor exists very close to the surgical margin, and a \"wide\" surgical margin implies the tumor exists far from the cut edge or the surgical margin.  Narrow surgical margin using the  bread loafing  technique suggests that residual cancer might be left due to  false negative  error.  A surgeon often will perform a second surgery if a narrow surgical margin is noted on a pathology report."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9645", "text": "This determination is made with the full understanding of \" false negative  error\" intrinsic in the  bread loafing  technique of histology (also known as POMA - a term used by the NCCN). [ 6 ]   The higher the false negative error is, the higher the recurrence rate of a cancer or tumor at the surgical margin. This is due to the misreading of a pathology specimen as being clear of residual tumor when there is actually residual tumor left where the specimen was not cut and mounted on the histology slide. The \" false negative  error\" is very low in the  CCPDMA  method of histology processing, and can be very high in the  bread loafing  (POMA) method of histology processing. [ 6 ]   In the bread loafing method of processing, one will note a high  false negative  error rate with narrow surgical margin; and one will note a low  false negative  error with a wide surgical margin [ 7 ]   Surgical margin has a much less significant effect on the  false negative  error rate of  CCPDMA  methods, allowing the surgeon to routinely use very narrow surgical margins (1 to 2\u00a0mm for non-melanoma skin cancer). [ 7 ]  The worldwide extent of  inadequate resection of the tumor is illustrated in following Table showing the percentage of positive surgical margins for the most common cancer types."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9646", "text": "Retroperitoneal lymph node dissection  (RPLND) is a  surgical procedure  to remove abdominal  lymph nodes . It is used to treat  testicular cancer , as well as to help establish the exact  stage  and type of the cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9647", "text": "Testicular cancer  metastasizes  in a predictable pattern, and lymph nodes in the  retroperitoneum  are typically the first place it lands. [ 1 ] [ 2 ]  By examining the removed lymphatic tissue, a  pathologist  can determine whether the disease has spread. If no malignant tissue is found, the cancer can be labeled Stage I, limited to the  testicle . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9648", "text": "The procedure is common in the treatment of Stage I and II  non-seminomatous germ cell tumors . [ 2 ]  In  seminomas , another form of testicular cancer,  radiation therapy  is generally preferred to the invasive RPLND procedure. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9649", "text": "Whether RPLND is needed after  orchiectomy  depends on the type of tumor and its stage. RPLND may be performed to remove tumor remnants that persist after chemotherapy, because these remnants might otherwise spread and become resistant to the chemotherapy agents previously used. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9650", "text": "Chemotherapy may be administered before RPLND and, if successful, may render surgery unnecessary. However, if the cancer does recur, surgery is much more difficult in a patient previously treated with chemotherapy. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9651", "text": "RPLND is usually performed using an incision that extends from the  sternum  to several inches below the  navel . A less invasive procedure (L-RPLND) can be performed  laparoscopically , but this is more costly and time-consuming, and requires specialized equipment that not every hospital has. Additionally, it is unclear whether L-RPLND is as effective as the standard, open procedure. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9652", "text": "Potential complications of RPLND include damage to the  sympathetic nerves  running parallel to the  spinal cord , which can result in  retrograde ejaculation  and  infertility . [ 6 ]  In most cases nerve sparing is feasible leading to reduced rates of retrograde ejaculation. However, prior chemotherapy or very large residual masses may make nerve sparing challenging. [ 7 ]  Contrary to popular belief,  erectile function  is not compromised by RPLND because the nerves responsible for erection are located elsewhere. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9653", "text": "As with any major surgery,  infection  is a possibility, as are  bowel obstructions  and  adhesions . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9654", "text": "Stereotactic injection  is a procedure in which a  computer  and a  3-dimensional   scanning device  are used to  inject   anticancer drugs  directly into a  tumor ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9655", "text": "Stereotactic injection may also refer to the use of injections during  stereotactic surgery  to precisely target specific sites, such as brain regions, during experimental research. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9656", "text": "Vulvectomy  refers to a  gynecological  procedure in which the  vulva  is partly or completely removed.  The procedure is usually performed as a last resort in certain cases of  cancer , [ 1 ]   vulvar dysplasia ,  vulvar intraepithelial neoplasia , [ 2 ]  or as part of  female genital mutilation . Although there may be severe pain in the groin area after the procedure, for a number of weeks, sexual function is generally still possible but limited. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9657", "text": "A  simple vulvectomy  can be either complete (more than 80% of the vulvar area) or partial (less than 80% of vulvar area).  It removes the skin and superficial subcutaneous tissues.  A  radical vulvectomy  is the same with regard to complete or partial, however, includes removal of skin and deep subcutaneous tissue.  An  inguinofemoral lymphadenectomy  may be performed along with a radical vulvectomy (whether partial or complete) on one or both sides if spread of a cancer is suspected. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9658", "text": "A  simple partial vulvectomy  is the least severe, only removing the affected portion of the vulva."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9659", "text": "A \"skinning vulvectomy\" is the removal of the top layer of vulvar skin (the external female genital organs, including the clitoris, vaginal lips and the opening of the vagina). In this case  skin grafts  from other parts of the body may be needed to cover the area. There are two types of skinning vulvectomy, the \"partial\" and the \"total\". The objective of the first is the preservation of the cosmetic and functional integrity of the vulva in younger and sexually active patients, in whom a steady increase in the incidence of  vulvar intraepithelial neoplasia  has been observed in the last decade. [ when? ]  The objective of the latter is the removal of the entire vulva with total skin graft replacement in patients with an entire  vulvar cancer  involvement. \"Modified radical vulvectomy\" involves the removal of vulva containing cancer and some of the normal tissue around it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9660", "text": "Wedge resection  is a  surgical procedure  to remove a triangle-shaped slice of tissue. It may be used to remove a  tumor  or some other type of tissue that requires removal and typically includes a small amount of normal tissue around it.\nIt is easy to repair, does not greatly distort the shape of the underlying organ and leaves just a single stitch line as a residual."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9661", "text": "Wedge resection of the lung  is a  surgical  operation where a part of a  lung  is removed. It is done to remove a localized portion of diseased lung, such as early  stage   lung cancer . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9662", "text": "The  Wertheim\u2013Meigs operation  (named after  Ernst Wertheim  and  Joe Vincent Meigs ) is a surgical procedure for the treatment of  cervical cancer  performed by way of an abdominal incision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9663", "text": "The German surgeon  Wilhelm Alexander Freund  undertook the first ever abdominal  extirpation  of a cancerous uterus on January 30, 1878. [ 1 ]  The first radical hysterectomy operation was described by John G. Clark, resident  gynecologist  under  Howard Kelly  at the  Johns Hopkins Hospital  in 1895. [ 2 ] [ 3 ]  In 1898, Ernst Wertheim, a Viennese physician, developed the radical total hysterectomy with removal of the pelvic lymph nodes and the parametrium. In 1905, he reported the outcomes of his first 270 patients. The operative  mortality rate  was 18%, and the major morbidity rate was 31%. [ 4 ]  In 1912, Wertheim reported on his first 500 operations and had his name assigned to the operation. In 1944, Meigs repopularized the surgical approach when he developed a modified Wertheim operation with removal of all pelvic nodes. [ 2 ] [ 4 ]  Meigs reported a survival rate of 75% for patients with stage I disease and demonstrated an operative mortality rate of 1% when these procedures were performed by a specially trained gynecologist. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9664", "text": "The Wertheim\u2013Meigs operation is used to treat  stage IA2, IB1, IB2 and IIA cervical cancers , stage II  adenocarcinomas  of the  endometrium , upper vaginal carcinomas, uterine or cervical sarcomas, and other rare malignancies confined to the area of the cervix, uterus, and/or upper vagina. [ 5 ]  It is one of the most comprehensive gynecological interventions. It consists of the following measures: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9665", "text": "The  ovaries  and  fallopian tubes  are typically left intact, although this decision is made on an individual basis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9666", "text": "The morbidity associated with the Wertheim\u2013Meigs operation is substantial. The most important complications are  ureteral , ureterovaginal, and  vesicovaginal fistulae , appearing during the immediate postoperative  convalescence  period or later mainly in patients who received subsequent  radiotherapy . Other complications are described: intraoperative  hemorrhage  due to pelvic large vessel lesion, ureter or  bladder  accidental section,  abdominal wall dehiscence , ureteral obstruction causing  hydronephrosis  and  renal exclusion , disorders such as  urinary incontinence ,  pollakiuria ,  vesical atony , often accompanied by  urinary tract infection  and  hematuria . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9667", "text": "Aesthetic medicine  is a branch of modern medicine that focuses on altering natural or acquired unwanted appearance through the treatment of conditions including  scars , skin laxity, wrinkles, moles,  liver spots , excess fat,  cellulite , unwanted hair, skin discoloration,  spider veins [ 1 ]  and or any unwanted externally visible appearance. Traditionally, it includes  dermatology ,  oral and maxillofacial surgery ,  reconstructive surgery  and  plastic surgery , [ 2 ]  surgical procedures ( liposuction ,  facelifts ,  breast implants ,  Radio frequency ablation ), non-surgical procedures ( radio frequency skin tightening ,  non- surgical liposuction ,  chemical peel ,  high-intensity focused electromagnetic field , radio frequency fat removal), and a combination of both. [ 3 ]  Aesthetic medicine procedures are usually elective. [ 4 ]  There is a long history of aesthetic medicine procedures, dating back to many notable cases in the 19th century, [ 5 ]  though techniques have developed much since then."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9668", "text": "Physical beauty  has been a consistently coveted notion. [ 6 ]   Efforts to improve and enhance beauty through aesthetic medical practices can be seen as early as 2000 years ago, in India, where the 'forehead flap' was used to reconstruct the noses and faces of soldiers injured in war and criminal punishments. [ 7 ]  This technique, though thoroughly developed and modified, is still used today as a common method to repair nasal defects. [ 8 ]  Although Greek and Roman medical practices have been considered the foundation for European and modern-day medicine for a long time, ancient Egyptian texts have revealed that Egyptian medicine produced many key medical discoveries and the basis for many modern practices. [ 9 ]  The Egyptians recorded their use of oils, waxes,  Cyperus , [ 9 ]  and other plant materials to reduce the signs of aging, like wrinkles and spots, and to restore youthful skin. [ 10 ]  They studied bodily functions, like inflammatory processes, and were able to make discoveries that allowed them to treat cosmetic wounds and burns using therapies and medicines. This included the initial application of fresh meat to the wound, followed by the use of oil/lipids, honey, and fibers, generally woven linen, until the wound had healed. [ 11 ]  As physicians have discovered more about medicine throughout history, these practices have been developed to be more efficient and sanitary and can be seen today in common skin reparation remedies. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9669", "text": "In more recent history, within the past 30 years, the industry of aesthetic medicine has been developing rapidly with the addition of and growing demand for \"injectables,\" [ 12 ]  a form of transcutaneous treatment used to rejuvenate and restore the skin of a patient. [ 13 ]  These medical injectables have become well established due to their associated low risk, especially compared to other aesthetic surgical practices, as well as the practically non-existent recovery time needed after the procedures are performed. [ 14 ]  Within the past ten years, the  U.S. Food and Drug Administration  has reviewed and approved [ 15 ]  over 20 injectable products used for medical aesthetics, in response to the growing demand. [ 12 ]  The most commonly used injectables in the industry today are  botulinum neurotoxin , commonly referred to as botox, and hyaluronic acid fillers. [ 16 ]  According to statistics from an annual survey conducted by the  American Society for Aesthetic Plastic Surgery , from 1997 to 2011 the number of nonsurgical procedures performed by aesthetic physicians increased by 356%. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9670", "text": "Aesthetic medicine specializes in altering the cosmetic appearance.  It has diverse applications for dermatological and surgical conditions.  It includes indications related to minimizing signs of aging, such as skin laxity, wrinkles, and  liver spots .  Aesthetic medicine also plays a role in the treatment of excess fat,  cellulite , and obesity.  Laser based therapies can be indicated for the treatment of  scars , unwanted hair, skin discoloration, and  spider veins . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9671", "text": "Overall health is assessed by a physician to ensure that the symptom being treated (for example, weight gain and  excessive hair ) is not a sign of an underlying medical condition (like hypothyroidism) that should be stabilized with medical therapies.\nIt is also very important for the medical aesthetician to be inclusive in providing a team approach for minimally invasive facial aesthetic procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9672", "text": "A career in aesthetic medicine can be approached from a number of professions.  A multidisciplinary or team based approach is often necessary to adequately address an aesthetic need.  To perform certain procedures, one must be a  surgeon ,  medical doctor  (Dermatologist/plastic surgeon/ENT surgeon/Oculoplastic surgeon) or  maxillofacial surgeon /Cosmetic Dentist . [ 27 ]  Medical Aesthetics requires specialized training and certification beyond a nurse license / aesthetic license.  Counselors ,  psychologists  or  psychiatrists  can help people determine if their reasons for pursuing aesthetic procedures are healthy and help to identify psychiatric disorders such as  compulsive eating ,  anorexia , and  body dysmorphic disorder .  Reconstructive surgeons  can help correct appearance after accidents, burns, surgery for  cancer  (such as  breast reconstruction  after  mastectomy  for cancer), or for  congenital deformities  like correction of  cleft lip .  Orthodontists  work to improve alignment of teeth, often partially for aesthetic reasons, and  oral and maxillofacial surgeons  can perform cosmetic facial surgery & correct deformities of the mouth and jaw.  Both orthodontists and maxillofacial surgeons can be assisted by  dental technicians ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9673", "text": "Anthropometric cosmetology  ( Anthropometry  from Greek \u0391\u03bd\u03b8\u03c1\u03c9\u03c0\u03bf\u03c2, \"man\") is the medical practice to correct or modify deformities in the upper and lower extremities of the body. This is done in order to attain an aesthetically pleasing appearance or to eliminate physical and psychological discomforts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9674", "text": "Anthropometric (orthopedic) cosmetology appeared in the 1990s based on  traumatology ,  orthopedic , and  aesthetic surgery [ citation needed ] . In 1965,  Gavriil Ilizarov  determined that  bone  fragments could be carefully pulled apart without disrupting their alignment. These bone fragments could then grow back to a complete form. This discovery was groundbreaking for the fields of traumatology orthopedics. In complex cases of comminuted fractures, the  Ilizarov apparatus  method makes it possible to avoid squeezing the remnant fragments together, which otherwise might result in shortened  limbs . Traumatic injuries, as well as congenital and acquired deformities, may be treated with this technique."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9675", "text": "Chondrodysplasia  is a disease where a child's growth stops abruptly, resulting in an adult dwarf, with shortened and often deformed arms and legs and is regarded as a congenital deformity. Ilizarov began to solve the problems associated with such diseases using his own apparatus. The apparatus he initially used was modified to support the lengthening of finger ( phalanx ) bones. The first experiments involved stretching the bones in the arms and legs of people with chondrodysplasia. New techniques, involving artificial fractures, have been developed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9676", "text": "Ilizarov's followers, Kaplunov and Yegorov, first used anthropometric cosmetology in  Volgograd , Russia in 1992, on a healthy patient for strictly cosmetic purposes. [ 1 ]  The surgical operation was a success: the tibia was lengthened 6\u00a0cm over 11 months. Later, this technique was used elsewhere. Yegorov, Chernov, and Nekrasov subsequently wrote a book  Orthopedic Cosmetology , the first scientific publication in this field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9677", "text": "Surgical intervention:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9678", "text": "Anthropometric cosmetology can be used when the patient has: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9679", "text": "Types of anthropometric cosmetology:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9680", "text": "Breast augmentation  and  augmentation mammoplasty  is a cosmetic surgery procedure, which uses  breast-implants  and/ or fat-graft  mammoplasty  technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct  congenital defects  of the breasts and the chest wall [ 1 ]  in other cases it is performed purely for cosmetic reasons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9681", "text": "The surgical implantation approach creates a  spherical  augmentation of the breast hemisphere, using a breast implant filled with either  saline  solution or  silicone gel ; the fat-graft transfer approach augments the size and corrects contour defects of the breast hemisphere with grafts of the  adipocyte fat tissue , drawn from the person's body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9682", "text": "In a breast reconstruction procedure, a  tissue expander  (a temporary breast implant device) is sometimes put in place and inflated with saline to prepare (shape and enlarge) the recipient site (implant pocket) to receive and accommodate the breast implant prosthesis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9683", "text": "In most instances of fat-graft breast augmentation, the increase is of modest volume, usually only one  bra  cup size or less, [ 2 ]  which is thought to be the physiological limit allowed by the metabolism of the human body. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9684", "text": "There are four types of implant:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9685", "text": "The saline breast implant, filled with  saline solution , was first manufactured by the Laboratoires Arion company, in France, and introduced for use as a prosthetic  medical device  in 1964. Modern-day versions of saline breast implants are manufactured with thicker, room-temperature  vulcanized  (RTV) shells made of a  silicone   elastomer . The study  In vitro Deflation of Pre-filled Saline Breast Implants  (2006) reported that the rates of deflation (filler leakage) of the pre-filled saline breast implant made it a second-choice prosthesis for \"corrective breast surgery\". [ clarification needed ] [ 5 ]  Nonetheless, in the 1990s, the saline breast implant was mandated to be the prosthesis usual for breast augmentation surgery, the result of the U.S.   Food and Drug Administration 's (FDA) temporary restriction against the importation of silicone-filled breast implants. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9686", "text": "The technical goal of saline-implant technique was a less-invasive surgical technique, by inserting an empty, rolled-up breast implant through a smaller surgical incision. [ 6 ]  In surgical practice, after having installed the empty breast implants in the implant pockets, the plastic surgeon would then fill each device with saline solution through a  one-way valve  and, because the required insertion incisions were short and small, the resultant incision scars would be smaller and shorter than the surgical scars typical of the pre-filled, silicone-gel implant surgical technique. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9687", "text": "When compared with the results achieved with a silicone-gel breast implant, the saline implant can yield \"good-to-excellent\" results of increased breast size, a smoother hemisphere-contour, and realistic consistency; yet it is likelier to cause cosmetic problems, such as the rippling and the wrinkling of the breast-envelope skin, and technical problems, such as the implant's presence being noticeable to the eye and to the touch. The occurrence of such cosmetic problems is likelier in the case of a person with very little breast tissue; in the case of a person who requires  post-mastectomy  breast reconstruction, the silicone-gel implant is the technically superior  prosthetic  device for  breast reconstruction . In the case of the person with much breast tissue, for whom sub-muscular placement is the recommended surgical approach, saline breast implants can give an aesthetic result much like that produced by silicone breast implants: an appearance of proportionate breast size, smooth contour, and realistic consistency. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9688", "text": "The modern  prosthetic breast  was invented in 1961, by the American  plastic surgeons  Thomas Cronin and Frank Gerow, and manufactured by the  Dow Corning Corporation ; in due course, the first augmentation mammoplasty was performed in 1962. [ 9 ]  There are five generations of  medical device   technology  for the breast-implant models filled with silicone gel; each generation of breast prosthesis is defined by common model-manufacturing techniques."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9689", "text": "The Cronin\u2013Gerow implant, prosthesis model 1963, was a silicone rubber envelope-sack, shaped like a teardrop, which was filled with viscous silicone-gel. [ 10 ]  To reduce the rotation of the emplaced breast-implant upon the chest wall, the model 1963 prosthesis was affixed to the implant pocket with a fastener-patch, made of Dacron material ( polyethylene terephthalate ), which was attached to the rear of the breast implant shell. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9690", "text": "In the 1970s, manufacturers offered the second generation of breast implant prostheses"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9691", "text": "In the 1980s, the third- and fourth-generation implants were stepwise advances in manufacturing technology, such as  elastomer -coated shells that decreased gel bleed (filler leakage), and a thicker, increased-cohesion filler gel. The manufacturers of implantable breast prostheses then designed and made anatomic models (like the natural breast) and \"shaped\" models, which realistically corresponded with the breast and body types of actual women. The tapered models of breast implant have a uniformly textured surface, to reduce rotation of the prosthesis within the implant pocket; round models of breast implant are available in both smooth-surface and textured-surface models, as rotation is not an issue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9692", "text": "Since the mid-1990s, the fifth generation of silicone gel breast implant is made of a semi-solid gel, which mostly eliminates the occurrences of filler leakage (\"silicone-gel bleed\") and of the migration of the silicone filler from the implant-pocket to other areas of the person's body. The studies  Experience with Anatomical Soft Cohesive Silicone gel Prosthesis in Cosmetic and Reconstructive Breast Implant Surgery  (2004) and  Cohesive Silicone gel Breast Implants in Aesthetic and Reconstructive Breast Surgery  (2005) reported relatively lower rates of  capsular contracture  and of device-shell rupture, and relatively  greater rates of \"medical safety\" and \"technical efficacy\" than those of early-generation breast implants. [ 15 ] [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9693", "text": "Saline and silicone gel are the most common types of breast implant used in the world today. [ 18 ]  Alternative-composition implants have largely been discontinued. These implants featured fillers such as soy oil and polypropylene string. Other discontinued materials include ox  cartilage ,  Terylene  \"wool\", ground  rubber ,  silastic  rubber, and  Teflon -silicone prostheses. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9694", "text": "Structured implants were approved by the FDA and Health Canada in 2014 as a fourth category of breast implant. [ 4 ]  These implants incorporate both saline and silicone gel implant technology. The filler is saline solution, in case of rupture, and has a natural feel, like silicone gel implants. [ 19 ]  This implant type uses an internal structure consisting of three nested silicone rubber \"shells\" that support the upper half of the breast, with the two spaces between the three shells filled with saline. The implant is inserted, empty, then filled once in place, which requires a smaller incision than a pre-filled implant. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9695", "text": "The breasts are  apocrine glands  which produce  milk  for the feeding of infant children, [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9696", "text": "Digestive tract contamination and systemic toxicity due to the leakage of breast implant filler to the breast milk are the principal infant-health concerns with breast implants. Breast implant fillers are biologically inert:  silicone  filler is  indigestible  and saline filler is mostly salt and water. Each of these substances should be chemically inert and present in the environment. [ citation needed ]  Moreover, \"proponent\" physicians have stated that there \"should be no absolute contraindication to breast-feeding by women with silicone breast implants.\" [ 21 ]  In the early 1990s, at the beginning of the silicone gel breast implant illness panic, small-scale, non-randomized studies indicated possible breast-feeding complications from silicone implants; no one study was able to demonstrate disease causality due to implants. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9697", "text": "A person with breast implants is usually able to  breastfeed  an infant; yet implants can cause functional breastfeeding difficulties, especially with  mammoplasty  procedures that involve cutting around the areola, and implant placement directly beneath the breast, which tend to cause greater breast-feeding difficulties. Patients are advised to select a procedure which causes the least damage to the  lactiferous ducts  and the nerves of the nipple-areola complex (NAC). [ 23 ] [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9698", "text": "Functional breastfeeding difficulties arise if the surgeon cuts the milk ducts or the major nerves innervating the breast, or if the milk glands are otherwise damaged. Some surgical approaches, including IMF (inframammary fold), TABA (trans-axillary breast augmentation), and TUBA ( trans-umbilical breast augmentation ), avoid the tissue of the nipple-areola complex; if the person is concerned about possible breast-feeding difficulties, the periareolar incisions can sometimes be made so as to reduce damage to the milk ducts and to the nerves of the NAC. The milk glands are affected most by subglandular implants (under the gland), and by large-sized breast implants, which pinch the lactiferous ducts and impede milk flow. Small-sized breast implants, and submuscular implantation, cause fewer breast function problems; however, some women have managed to successfully breastfeed after undergoing periareolar incisions and subglandular emplacement. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9699", "text": "The studies  Body Image Concerns of Breast Augmentation Patients  (2003) and  Body Dysmorphic Disorder and Cosmetic Surgery  (2006) reported that the woman who underwent breast augmentation surgery also had undergone  psychotherapy , had low  self-esteem , presented frequent occurrences of  psychological depression , had attempted  suicide , and had  body dysmorphia \u00a0\u2013 a type of mental illness wherein she perceives non-existent physical defects. Post-operative patient surveys about the mental health and the quality of life of the women, reported improved physical health, physical appearance, social life, self-confidence, self-esteem, and satisfactory  sexual functioning . Furthermore, most of the women reported long-term satisfaction with their breast implants; some despite having had medical complications that required surgical revision, either corrective or aesthetic. Likewise, in Denmark, 8.0 percent of breast augmentation patients had a pre-operative history of psychiatric hospitalization. [ 26 ] [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ 34 ] [ 35 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9700", "text": "The Cosmeticsurgery.com article  They Need Bosoms, too\u00a0\u2013 Women Weight Lifters  (2013) reported that women weight-lifters have resorted to breast augmentation surgery to maintain a feminine physique, and so compensate for the loss of breast mass consequent to the increased lean-body mass and decreased body-fat consequent to  lifting weights . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9701", "text": "The  longitudinal study   Excess Mortality from Suicide and other External Causes of Death Among Women with Cosmetic Breast Implants  (2007), reported that women who sought breast implants are almost 3.0 times as likely to commit suicide as are women who have not sought breast implants. Compared to the standard suicide-rate for women of the general populace, the suicide-rate for women with augmented breasts remained alike until 10-years post-implantation, yet it increased to 4.5 times greater at the 11-year mark, and so remained until the 19-year mark, when it increased to 6.0 times greater at 20-years post-implantation. Moreover, additional to the suicide risk, women with  breast implants  also faced a trebled death risk from  alcoholism  and drugs abuse (prescription and recreational). [ 37 ] [ 38 ]  Although seven studies have statistically connected a woman's undergoing a breast augmentation procedure to a greater suicide rate, the research indicates that augmentation [ 39 ] [ 40 ]  surgery does not increase the suicide rate; and that, in the first instance, it is the  psychopathologically  inclined woman who is likelier to undergo breast augmentation. [ 41 ] [ 42 ] [ 43 ] [ 44 ] [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9702", "text": "Moreover, the study  Effect of Breast Augmentation Mammoplasty on Self-Esteem and Sexuality: A Quantitative Analysis  (2007), reported that the women attributed their improved self-esteem, self-image, and increased, satisfactory sexual functioning to having undergone breast augmentation; the cohort, aged 21\u201357 years, averaged post-operative self-esteem increases ranging from 20.7 to 24.9 points on the 30-point  Rosenberg self-esteem scale , which data supported the 78.6 percent increase in the woman's  libido , relative to her pre-operative level of libido. Therefore, before agreeing to any surgical procedure, the plastic surgeon evaluates and considers the woman's  mental health  to determine if breast implants can positively affect her self-esteem and  sexual functioning . [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9703", "text": "An augmentation mammoplasty for emplacing  breast implants  has three therapeutic purposes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9704", "text": "The  operating room  time of post\u2013 mastectomy   breast reconstruction , and of breast augmentation surgery is determined by the emplacement procedure employed, the type of incisional technique, the breast implant (type and materials), and the pectoral locale of the implant pocket. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9705", "text": "The emplacement of a breast implant device is performed with five types of  surgical  incisions: [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9706", "text": "The four surgical approaches to emplacing a breast implant to the implant pocket are described in  anatomical  relation to the  pectoralis major muscle ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9707", "text": "The  surgical   scars  of a breast augmentation  mammoplasty  heal at 6-weeks post-operative, and fade within several months, according to the skin type of the woman. Depending upon the daily physical activity the woman might require, the augmentation mammoplasty patient usually resumes her normal life activities at about 1-week post-operative. The woman who underwent submuscular implantation (beneath the  pectoralis major  muscles) usually has a longer post\u2013operative convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the chest muscles for the breast augmentation. The patient usually does not exercise or engage in strenuous physical activities for about six weeks. Moreover, during the initial convalescence, the patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and discomfort; and, as required,  analgesic  medication catheters for alleviating pain. [ 57 ] [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9708", "text": "The plastic surgical emplacement of breast-implant devices, either for  breast reconstruction  or for  aesthetic purpose , presents the same health risks common to  surgery , such as adverse reaction to  anesthesia ,  hematoma  (post-operative bleeding),  seroma  (fluid accumulation), incision-site breakdown (wound infection). [ 59 ]  Complications specific to breast augmentation include breast pain, altered sensation, impeded breast-feeding function, visible wrinkling, asymmetry, thinning of the breast tissue, and  symmastia , the \"bread loafing\" of the bust that interrupts the natural plane between the breasts. Specific treatments for the complications of indwelling breast implants\u00a0\u2013  capsular contracture  and capsular rupture\u00a0\u2013 are periodic  MRI  monitoring and physical examinations. Furthermore,  complications  and re-operations related to the implantation surgery, and to  tissue expanders  (implant placeholders during surgery) can cause unfavorable  scarring  in approximately 6\u20137% of the patients.\n [ 34 ] [ 60 ] [ 61 ]  Statistically, 20% of women who underwent cosmetic implantation, and 50% of women who underwent breast reconstruction implantation, required their explantation at the 10-year mark. [ 62 ]  In 2019, a direct link was identified between Allergan BIOCELL textured breast implants of Allergan and the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a cancer of the immune system. FDA recalled all Allergan BIOCELL implants. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9709", "text": "Because a breast implant is a  Class III medical device  of limited product-life, the principal rupture-rate factors are its age and design; Nonetheless, a breast implant device can retain its mechanical integrity for decades in a woman's body. [ 64 ]  When a saline breast implant ruptures, leaks, and empties, it quickly deflates, and thus can be readily explanted (surgically removed). The follow-up report,  Natrelle Saline-filled Breast Implants: a Prospective 10-year Study  (2009) indicated rupture-deflation rates of 3\u20135 percent at 3-years post-implantation, and 7\u201310 percent rupture-deflation rates at 10-years post-implantation. [ 65 ]  In a study of his 4761 augmentation mammaplasty patients, Eisenberg reported that overfilling saline breast implants 10-13% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9710", "text": "When a silicone breast implant ruptures it usually does not deflate, yet the filler gel does leak from it, which can migrate to the implant pocket; therefore, an intracapsular rupture (in-capsule leak) can become an extracapsular rupture (out-of-capsule leak), and each occurrence is resolved by explantation. Although the leaked silicone filler-gel can migrate from the chest tissues to elsewhere in the woman's body, most clinical  complications  are limited to the breast and  armpit  areas, usually manifested as  granulomas  (inflammatory nodules) and axillary  lymphadenopathy  (enlarged  lymph glands  in the armpit area). [ 67 ] [ 68 ] [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9711", "text": "Silicone implant rupture can be evaluated using magnetic resonance imaging; from the long-term  MRI  data for single-lumen  breast implants, the European literature about second generation silicone-gel breast implants (1970s design), reported silent device-rupture rates of 8\u201315 percent at 10-years post-implantation (15\u201330% of the patients). [ 71 ] [ 72 ] [ 73 ] [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9712", "text": "The study  Safety and Effectiveness of Mentor's MemoryGel Implants at 6 Years  (2009), which was a branch study of the U.S. FDA's core  clinical trials  for primary breast augmentation surgery patients, reported low device-rupture rates of 1.1 percent at 6-years post-implantation. [ 75 ]  The first series of MRI evaluations of the silicone breast implants with thick filler-gel reported a device-rupture rate of 1.0 percent, or less, at the median 6-year device-age. [ 76 ]  Statistically, the manual examination (palpation) of the woman is inadequate for accurately evaluating if a breast implant has ruptured. The study,  The Diagnosis of Silicone Breast-implant Rupture: Clinical Findings Compared with Findings at Magnetic Resonance Imaging  (2005), reported that, in asymptomatic patients, only 30 percent of the ruptured breast implants is accurately palpated and detected by an experienced plastic surgeon, whereas MRI examinations accurately detected 86 percent of breast-implant ruptures. [ 77 ]  Therefore, the U.S. FDA recommended scheduled MRI examinations, as silent-rupture screenings, beginning at the 3-year-mark post-implantation, and then every two years, thereafter. [ 34 ]  Nonetheless, beyond the U.S., the medical establishments of other nations have not endorsed routine MRI screening, and, in its stead, proposed that such a  radiologic  examination be reserved for two purposes: (i) for the woman with a suspected breast-implant rupture; and (ii) for the confirmation of  mammographic  and  ultrasonic  studies that indicate the presence of a ruptured breast implant. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9713", "text": "Furthermore,  The Effect of Study design Biases on the Diagnostic Accuracy of Magnetic Resonance Imaging for Detecting Silicone Breast Implant Ruptures: a Meta-analysis  (2011) reported that the breast-screening MRIs of asymptomatic women might overestimate the incidence of breast-implant rupture. [ 79 ]  In the event, the U.S. Food and Drug Administration emphasised that \"breast implants are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely she is to experience complications.\" [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9714", "text": "When one lumen of a structured implant ruptures, it leaks and empties. The other lumen remain intact and the implant only partially deflates, allowing for ease of explant and replacement. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9715", "text": "The human body's  immune response  to a surgically installed foreign object\u00a0\u2013 breast implant, cardiac  pacemaker ,  orthopedic   prosthesis \u00a0\u2013 is to encapsulate it with  scar tissue  capsules of tightly woven  collagen  fibers, in order to maintain the integrity of the body by isolating the foreign object, and so tolerate its presence.  Capsular contracture \u00a0\u2013 which should be distinguished from normal capsular tissue\u00a0\u2013 occurs when the collagen-fiber capsule thickens and compresses the breast implant; it is a painful  complication  that might distort either the breast implant, or the breast, or both. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9716", "text": "The cause of capsular contracture is unknown, but the common incidence factors include bacterial contamination, device-shell rupture, filler leakage, and  hematoma . The surgical implantation procedures that have reduced the incidence of capsular contracture include submuscular emplacement, the use of breast implants with a textured surface (polyurethane-coated); [ 81 ] [ 82 ] [ 83 ]  limited pre-operative handling of the implants, limited contact with the chest skin of the implant pocket before the emplacement of the breast implant, and irrigation of the recipient site with triple-antibiotic solutions. [ 84 ] [ 85 ]  The use of a funnel device for implant insertion has also been shown to reduce the rate of capsular contracture. [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9717", "text": "The correction of capsular contracture might require an open capsulotomy (surgical release) of the collagen-fiber capsule, or the removal, and possible replacement, of the breast implant. Furthermore, in treating capsular contracture, the closed capsulotomy (disruption via external manipulation) once was a common maneuver for treating hard capsules, but now is a discouraged technique, because it can rupture the breast implant. Non-surgical treatments for collagen-fiber capsules include massage, external  ultrasonic  therapy,  leukotriene pathway inhibitors  such as  zafirlukast  (Accolate) or  montelukast  (Singulair), and  pulsed electromagnetic field therapy  (PEMFT). [ 87 ] [ 88 ] [ 89 ] [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9718", "text": "When the woman is unsatisfied with the outcome of the augmentation mammoplasty; or when technical or medical complications occur; or because of the breast implants' limited product life ( Class III medical device , in the U.S.), it is likely she might require replacing the breast implants. The common revision surgery indications include major and minor medical complications, capsular contracture, shell rupture, and device deflation. [ 70 ]  Revision incidence rates were greater for breast reconstruction patients, because of the post-mastectomy changes to the soft-tissues and to the skin envelope of the breast, and to the  anatomical  borders of the breast, especially in women who received adjuvant external  radiation therapy . [ 70 ]  Moreover, besides breast reconstruction,  breast cancer  patients usually undergo revision surgery of the nipple-areola complex (NAC), and symmetry procedures upon the opposite breast, to create a bust of natural appearance, size, form, and feel. Carefully matching the type and size of the breast implants to the patient's pectoral soft-tissue characteristics reduces the incidence of revision surgery. Appropriate tissue matching, implant selection, and proper implantation technique, the re-operation rate was 3.0% at the 7-year-mark, compared with the re-operation rate of 20% at the 3-year-mark, as reported by the U.S. Food and Drug Administration. [ 91 ] [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9719", "text": "Since the 1990s, reviews of the studies that sought causal links between silicone-gel breast implants and  systemic disease  reported no link between the implants and subsequent systemic and autoimmune diseases. [ 78 ] [ 93 ] [ 94 ] [ 95 ]  Nonetheless, during the 1990s, thousands of women claimed sicknesses they believed were caused by their breast implants, including  neurological  and  rheumatological  health problems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9720", "text": "In the study  Long-term Health Status of Danish Women with Silicone Breast Implants  (2004), the national healthcare system of Denmark reported that women with implants did not risk a greater incidence and diagnosis of  autoimmune disease , when compared to same-age women in the general population; that the incidence of musculoskeletal disease was lower among women with breast implants than among women who had undergone other types of cosmetic surgery; and that they had a lower incidence rate than like women in the general population. [ 96 ] [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9721", "text": "Follow-up  longitudinal studies  of these breast implant patients confirmed the previous findings on the matter. [ 98 ]  European and North American studies reported that women who underwent augmentation mammoplasty, and any plastic surgery procedure, tended to be healthier and wealthier than the general population, before and after implantation; that plastic surgery patients had a lower  standardized mortality ratio  than did patients for other surgeries; yet faced an increased risk of death by  lung cancer  than other plastic surgery patients. Moreover, because only one study, the Swedish  Long-term Cancer Risk Among Swedish Women with Cosmetic Breast Implants: an Update of a Nationwide Study  (2006), controlled for  tobacco smoking  information, the data were insufficient to establish verifiable statistical differences between smokers and non-smokers that might contribute to the higher  lung cancer  mortality rate of women with breast implants. [ 99 ] [ 100 ]  The long-term study of 25,000 women,  Mortality among Canadian Women with Cosmetic Breast Implants  (2006), reported that the \"findings suggest that breast implants do not directly increase mortality in women.\" [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9722", "text": "The study  Silicone gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a Population of Women  (2001), reported increased incidences of  fibromyalgia  among women who had  extracapsular silicone-gel leakage  than among women whose breast implants neither ruptured nor leaked. [ 101 ]  The study later was criticized as significantly methodologically flawed, and a number of large subsequent follow-up studies have not shown any evidence of a causal device\u2013disease association. After investigating, the U.S. FDA has concluded \"the weight of the  epidemiological  evidence published in the literature does not support an association between fibromyalgia and breast implants.\" [ 102 ] [ 103 ]  The systemic review study,  Silicone Breast implants and Connective tissue Disease: No Association  (2011) reported the investigational conclusion that \"any claims that remain regarding an association between cosmetic breast implants and CTDs are not supported by the scientific literature\". [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9723", "text": "The manufacture of silicone breast implants requires the  metallic element   platinum  (Pt, 78) as a  catalyst  to accelerate the transformation of  silicone oil  into silicone gel for making the  elastomer  silicone shells, and for making other medical-silicone devices. [ 105 ]  The literature indicates that trace quantities of platinum leak from such types of silicone breast implant; therefore, platinum is present in the surrounding pectoral tissue(s). The rare pathogenic consequence is an accumulation of platinum in the  bone marrow , from where blood cells might deliver it to  nerve endings , thus causing  nervous system  disorders such as blindness, deafness, and  nervous tics  (involuntary muscle contractions). [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9724", "text": "In 2002, the U.S. Food and Drug Administration (U.S. FDA) reviewed the studies on the human biological effects of breast-implant platinum, and reported little causal evidence of platinum toxicity to women with breast implants. [ 106 ]  Furthermore, in the journal  Analytical Chemistry , the study \"Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS\" (2006) proved controversial for claiming to have identified previously undocumented toxic platinum oxidative states  in vivo . [ 107 ]  Later, in a letter to the readers, the editors of  Analytical Chemistry  published their concerns about the faulty  experimental design  of the study, and warned readers to \"use caution in evaluating the conclusions drawn in the paper\". [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9725", "text": "Furthermore, after reviewing the research data of the study \"Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS\", and other pertinent literature, the U.S. FDA reported that the data do not support the findings presented; that the platinum used in new-model breast implant devices likely is not  ionized , and therefore is not a significant risk to the health of the women. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9726", "text": "Non-implant breast augmentation with injections of autologous fat grafts (adipocyte tissue) is indicated for women requiring  breast reconstruction ,  defect correction , and the \u00e6sthetic enhancement of the bust."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9727", "text": "The  operating room  time of breast reconstruction, congenital defect correction, and primary breast augmentation procedures is determined by the indications to be treated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9728", "text": "The advent of  liposuction  technology facilitated medical applications of the liposuction-harvested fat tissue as autologous filler for injection to correct bodily defects, and for breast augmentation. Melvin Bircoll introduced the practice of contouring the breast and for correcting bodily defects with autologous fat grafts harvested by liposuction; and he presented the fat-injection method used for emplacing the fat grafts. [ 110 ] [ 111 ]  In 1987, the Venezuelan plastic surgeon Eduardo Krulig emplaced fat grafts with a syringe and blunt needle (lipo-injection), and later used a disposable fat trap to facilitate the collection and to ensure the sterility of the harvested adipocyte tissue. [ 112 ] [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9729", "text": "To emplace the grafts of autologous fat-tissue, doctors J. Newman and J. Levin designed a lipo-injector gun with a gear-driven plunger, which allowed the even injection of autologous fat-tissue to the desired recipient sites. The control afforded by the lipo-injector gun assisted the plastic surgeon in controlling excessive pressure to the fat in the barrel of the syringe, thus avoiding over-filling the recipient site. [ 114 ]  The later-design lipo-injector gun featured a ratchet-gear operation that afforded the surgeon greater control in accurately emplacing grafts of autologous fat to the recipient site; a trigger action injected 0.1\u00a0cm 3  of filler. [ 115 ]  Since 1989, most non-surgical, fat-graft augmentations of the breast employ adipocyte fat from sites other than the breast, up to 300\u00a0ml of fat in three equal injections, is placed into the subpectoral space and the intrapectoral space of the  pectoralis major muscle , as well as the submammary space, to achieve a breast outcome of natural appearance and contour. [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9730", "text": "The technique of autologous fat-graft injection to the  breast  is applied for the correction of breast asymmetry or deformities, for  post-mastectomy   breast reconstruction  (as a primary and as an adjunct technique), for the improvement of soft-tissue coverage of breast implants, and for the aesthetic enhancement of the bust. The careful harvesting and  centrifugal  refinement of the mature adipocyte tissue (injected in small aliquots) allows the transplanted fat tissue to remain viable in the breast, where it provides the anatomical structure and the hemispheric contour that cannot be achieved solely with breast implants or with corrective plastic surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9731", "text": "In fat-graft breast augmentation procedures, there is the risk that the  adipocyte tissue  grafted to the breast(s) can undergo  necrosis ,  metastatic calcification , develop cysts, and agglomerate into palpable lumps. Although the cause of metastatic calcification is unknown, the post-procedure biological changes occurred to the fat-graft tissue resemble the tissue changes usual to breast surgery procedures such as  reduction mammoplasty . The French study  Radiological Evaluation of Breasts Reconstructed with Lipo-modeling  (2005) indicates the therapeutic efficacy of fat-graft breast reconstruction in the treatment of  radiation therapy  damage to the chest, the incidental reduction of  capsular contracture , and the improved soft-tissue coverage of breast implants. [ 117 ] [ 118 ] [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9732", "text": "The study  Fat Grafting to the Breast Revisited: Safety and Efficacy  (2007) reported successful transfers of body fat to the  breast , and proposed the fat-graft injection technique as an alternative (i.e., non-implant) augmentation mammoplasty procedure instead of the surgical procedures usual for effecting breast augmentation, breast defect correction, and breast reconstruction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9733", "text": "Structural fat-grafting was performed either to one breast or to both breasts of the 17 women; the age range of the women was 25\u201355 years; the mean age was 38.2 years; the average volume of a tissue-graft was 278.6\u00a0cm 3  of fat per operation, per breast. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9734", "text": "The pre-procedure mammograms were negative for  malignant neoplasms . In the 17-patient cohort, it was noted that two women developed  breast cancer  (diagnosed by  mammogram ) post-procedure: one at 12 months, and the other at 92 months. [ 120 ]  Further, the study  Cell-assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells  (2007), an approximately 40-woman cohort indicated that the inclusion of adipose  stem cells  in the grafts of adipocyte fat increased the rate of corrective success of the autologous fat-grafting procedure. [ 121 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9735", "text": "The centrifugal refinement of the liposuction-harvested adipocyte tissues removes blood products and free  lipids  to produce autologous breast filler. The injectable filler-fat is obtained by centrifuging (spinning) the fat-filled syringes for sufficient time to allow the serum, blood, and oil (liquid fat) components to collect, by density, apart from the refined, injection-quality fat. [ 122 ]  To refine the fat for facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 RPM, which separates the unnecessary solution, leaving refined filler-fat. [ 123 ]  Moreover, centrifugation at 10,000 RPM for 10 minutes produces a \"collagen graft\"; the  histologic  composition of which is  cell  residues,  collagen  fibres, and 5.0 percent intact fat cells. Furthermore, because the patient's body naturally absorbs some of the fat grafts, the breasts maintain their contours and volumes for 18\u201324 months. [ 124 ] [ 125 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9736", "text": "In the study  Fat Grafting to the Breast Revisited: Safety and Efficacy  (2007), the investigators reported that the autologous fat was harvested by liposuction, using a 10-ml syringe attached to a two-hole Coleman harvesting  cannula ; after centrifugation, the refined breast filler fat was transferred to 3-ml syringes. Blunt infiltration cannulas were used to emplace the fat through 2-mm incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal measures) of fat, and reduced the possibility of intravascular fat injection; no sharp needles are used for fat-graft injection to the breasts. The 2-mm incisions were positioned to allow the infiltration (emplacement) of fat grafts from at least two directions; a 0.2\u00a0ml fat volume was emplaced with each withdrawal of the cannula. [ 126 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9737", "text": "The breasts were contoured by layering the fat grafts into different levels within the breast, until achieving the desired breast form. The fat-graft injection technique allows the plastic surgeon precise control in accurately contouring the breast\u00a0\u2013 from the chest wall to the breast skin envelope\u00a0\u2013 with subcutaneous fat grafts to the superficial planes of the breast. This greater degree of breast sculpting is unlike the global augmentation realised with a breast implant emplaced below the breast or below the pectoralis major muscle, respectively expanding the  retromammary space  and the retropectoral space. The greatest proportion of the grafted fat usually is infiltrated to the pectoralis major muscle, then to the retropectoral space, and to the prepectoral space, (before and behind the pectoralis major muscle). Moreover, although fat grafting to the breast  parenchyma  usually is minimal, it is performed to increase the degree of projection of the  bust . [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9738", "text": "The biologic survival of autologous fat  tissue  depends upon the correct handling of the fat graft, of its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-cannula injection (emplacement) of the refined fat-tissue grafts to an adequately  vascularized  recipient site. Because the body resorbs some of the injected fat grafts (volume loss), compensative over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of large-volume fat grafts greater than required, because only 25\u201350 percent of the fat graft survives at 1-year post-transplantation. [ 127 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9739", "text": "The correct technique maximizes fat graft survival by minimizing  cellular  trauma during the liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots (equal measures), not clumps (too-large measures). Injecting minimal-volume aliquots with each pass of the  cannula  maximizes the surface area contact, between the grafted fat-tissue and the recipient breast-tissue, because proximity to a vascular system ( blood supply ) encourages  histologic  survival and minimizes the potential for fat necrosis. [ 120 ]  Transplanted autologous fat tissue undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by  fibrous tissue . New fat tissue is generated by the activity of a large, wandering  histocyte -type  cell , which ingests fat and then becomes a fat cell. [ 128 ]  When the breast-filler fat is injected to the breasts in clumps (too-large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9740", "text": "The operating room time required to harvest, refine, and emplace fat to the breasts is greater than the usual 2-hour OR time; the usual infiltration time was approximately 2 hours for the first 100\u00a0cm 3  volume, and approximately 45 minutes for injecting each additional 100\u00a0cm 3  volume of breast-filler fat. The technique for injecting fat grafts for breast augmentation allows the plastic surgeon great control in sculpting the breasts to the required contour, especially in the correction of  tuberous breast deformity . In which case, no fat-graft is emplaced beneath the nipple-areola complex (NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater verisimilitude than is achieved solely with breast implants. The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and  capsular contracture , achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. Furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule. [ 129 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9741", "text": "The successful outcome of fat-graft breast augmentation is enhanced by achieving a pre-expanded recipient site to create the breast-tissue  matrix  that will receive grafts of autologous adipocyte fat. The recipient site is expanded with an external vacuum tissue-expander applied upon each breast. The biological effect of negative pressure ( vacuum ) expansion upon  soft tissues  derives from the ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. (see  distraction osteogenesis ) The study reported the technical effectiveness of recipient-site pre-expansion. In a single-group study, 17 healthy women (aged 18\u201340 years) wore a brassiere-like vacuum system that applied a 20-mmHg vacuum (controlled, mechanical, distraction force) to each breast for 10\u201312 hours daily for 10 weeks. Pre- and post-procedure, the breast volume (size) was periodically measured; likewise, a magnetic resonance image ( MRI ) of the breast-tissue architecture and water density was taken during the same phase of the patient's  menstrual cycle ; of the 17-woman study group, 12 completed the study, and 5 withdrew, because of non-compliance with the  clinical trial protocol . [ 130 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9742", "text": "The breast volume (size) of all 17 women increased throughout the 10-week treatment period, the greatest increment was at week 10 (final treatment)\u00a0\u2013 the average volume increase was 98+/\u201367 percent over the initial breast-size measures. Incidences of partial recoil occurred at 1-week post-procedure, with no further, significant, breast volume decrease afterwards, nor at the follow-up treatment at 30-weeks post-procedure. The stable, long-term increase in breast size was 55 percent (range 15\u2013115%). The MRI visualizations of the breasts showed no  edema , and confirmed the proportionate enlargement of the adipose and glandular components of the breast-tissue  matrices . Furthermore, a statistically significant decrease in body weight occurred during the study, and  self-esteem  questionnaire scores improved from the initial-measure scores. [ 130 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9743", "text": "Because external vacuum expansion of the recipient-site tissues permits injecting large-volume fat grafts (+300\u00a0cc) to correct defects and enhance the bust, the  histologic  viability of the breast filler (adipocyte fat) and its volume must be monitored and maintained. The long-term, volume maintenance data reported in  Breast Augmentation using Pre-expansion and Autologous Fat Transplantation: a Clinical Radiological Study  (2010) indicate the technical effectiveness of external tissue expansion of the recipient site for a 25-patient study group, who had 46 breasts augmented with fat grafts. The indications included  micromastia  (underdevelopment), explantation deformity (empty implant pocket), and congenital defects ( tuberous breast deformity ,  Poland's syndrome ). [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9744", "text": "Pre-procedure, every patient used external vacuum expansion of the recipient-site tissues to create a breast tissue matrix to be injected with autologous fat grafts of adipocyte tissue, refined via low G-force centrifugation. Pre- and post-procedure, the breast volumes were measured; the patients underwent pre-procedure and 6-month post-procedure MRI and  3D volumetric imaging  examinations. At six months post-procedure, each woman had a significant increase in breast volume, ranging 60\u2013200 percent, per the MRI (n=12) examinations. The size, form, and feel of the breasts was natural; post-procedure MRI examinations revealed no oil  cysts  or  abnormality  ( neoplasm ) in the fat-augmented breasts. Moreover, given the sensitive, biologic nature of breast tissue, periodic MRI and 3-D volumetric imaging examinations are required to monitor the breast-tissue viability and the maintenance of the large volume (+300\u00a0cc) fat grafts. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9745", "text": "Surgical post-mastectomy  breast reconstruction  requires general anaesthesia, cuts the chest muscles, produces new scars, and requires a long post-surgical recovery for the patient. The surgical emplacement of breast implant devices (saline or silicone) introduces a foreign object to the patient's body (see  capsular contracture ). The  TRAM flap  (Transverse Rectus Abdominis Myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal, cutaneous, and muscle tissues. The latissimus myocutaneous flap employs skin fat and muscle harvested from the back, and a breast implant. The  DIEP flap  (Deep Inferior Epigastric Perforators) procedure uses an autologous flap of abdominal skin and fat tissue. [ 132 ] [ full citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9746", "text": "The reconstruction of the breast(s) with grafts of autologous fat is a non-implant alternative to further surgery after a breast cancer surgery, be it a  lumpectomy  or a breast removal\u00a0\u2013 simple (total) mastectomy, radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, and  subcutaneous (nipple sparing) mastectomy . The breast is reconstructed by first applying external tissue expansion to the recipient-site tissues ( adipose ,  glandular ) to create a breast-tissue matrix that can be injected with autologous fat grafts (adipocyte tissue); the reconstructed breast has a natural form, look, and feel, and is generally sensate throughout and in the nipple-areola complex (NAC). [ 132 ]  The reconstruction of breasts with fat grafts requires a three-month treatment period\u00a0\u2013 begun after 3\u20135 weeks of external vacuum expansion of the recipient-site tissues. The autologous breast-filler fat is harvested by liposuction from the patient's body (buttocks, thighs, abdomen), is refined and then is injected (grafted) to the breast-tissue matrices (recipient sites), where the fat will thrive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9747", "text": "One method of non-implant breast reconstruction is initiated at the concluding steps of the breast cancer surgery, wherein the  oncological  surgeon is joined by the reconstructive plastic surgeon, who immediately begins harvesting, refining, and seeding (injecting) fat grafts to the post-mastectomy recipient site. After that initial post-mastectomy fat-graft seeding in the operating room, the patient leaves hospital with a slight breast mound that has been seeded to become the foundation tissue matrix for the breast reconstruction. Then, after 3\u20135 weeks of continual external vacuum expansion of the breast mound (seeded recipient-site)\u00a0\u2013 to promote the  histologic  regeneration of the extant tissues ( fat ,  glandular ) via increased blood circulation to the mastectomy scar (suture site)\u00a0\u2013 the patient formally undergoes the first fat-grafting session for the reconstruction of her breasts. The external vacuum expansion of the breast mound created an adequate,  vascularised , breast-tissue matrix to which the autologous fat is injected; and, per the patient, such reconstruction affords almost-normal sensation throughout the breast and the nipple-areola complex. Patient recovery from non-surgical fat graft breast reconstruction permits her to resume normal life activities at 3-days post-procedure. [ 132 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9748", "text": "The breast-tissue matrix consists of engineered tissues of complex, implanted, biocompatible scaffolds seeded with the appropriate cells. The  in-situ  creation of a tissue matrix in the breast mound is begun with the external vacuum expansion of the mastectomy defect tissues (recipient site), for subsequent seeding (injecting) with autologous fat grafts of adipocyte tissue. A 2010 study, reported that serial fat-grafting to a pre-expanded recipient site achieved (with a few 2-mm incisions and minimally invasive blunt-cannula injection procedures), a non-implant outcome equivalent to a surgical breast reconstruction by  autologous-flap  procedure. Technically, the external vacuum expansion of the recipient-site tissues created a skin envelope as it stretched the mastectomy scar, and so generated a fertile breast-tissue matrix to which were injected large-volume fat grafts (150\u2013600\u00a0ml) to create a breast of natural form, look, and feel. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9749", "text": "The fat graft breast reconstructions for 33 women (47 breasts, 14 irradiated), whose clinical statuses ranged from zero days to 30 years post-mastectomy, began with the pre-expansion of the breast mound (recipient site) with an external vacuum tissue-expander for 10 hours daily, for 10\u201330 days before the first grafting of autologous fat. The breast mound expansion was adequate when the mastectomy scar tissues stretched to create a 200\u2013300\u00a0ml recipient matrix (skin envelope), that received a fat-suspension volume of 150\u2013600\u00a0ml in each grafting session. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9750", "text": "At one week post-procedure, the patients resumed using the external vacuum tissue-expander for 10 hours daily, until the next fat grafting session; 2\u20135 outpatient procedures, 6\u201316 weeks apart, were required until the plastic surgeon and the patient were satisfied with the volume, form, and feel of the reconstructed breasts. The follow-up mammogram and  MRI  examinations found neither defects (necrosis) nor abnormalities ( neoplasms ). At six months post-procedure, the reconstructed breasts had a natural form, look, and feel, and the stable breast-volumes ranged 300\u2013600\u00a0ml per breast. The post-procedure mammographies indicated normal, fatty breasts with well-vascularized fat, and few, scattered, benign oil cysts. The occurred complications included  pneumothorax  and transient cysts. [ 133 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9751", "text": "The autologous fat graft replacement of breast implants (saline and silicone) resolves  medical complications  such as:  capsular contracture , implant shell rupture, filler leakage (silent rupture), device deflation, and silicone-induced  granulomas , which are medical conditions usually requiring re-operation and explantation (breast implant removal). The patient then has the option of surgical or non-implant breast corrections, either replacement of the explanted breast implants or fat-graft breast augmentation. Moreover, because fat-grafts are biologically sensitive, they cannot survive in the empty implantation pocket, instead, they are injected to and diffused within the breast-tissue matrix (recipient site), replacing approximately 50% of the volume of the removed implant\u00a0\u2013 as permanent breast augmentation. The outcome of the explantation correction is a bust of natural appearance; breasts of volume, form, and feel, that\u00a0\u2013 although approximately 50% smaller than the explanted breast size\u00a0\u2013 are larger than the original breast size, pre-procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9752", "text": "The outcome of a breast augmentation with fat-graft injections depends upon proper patient selection, preparation, and correct technique for recipient site expansion, and the harvesting, refining, and injecting of the autologous breast filler fat. Technical success follows the adequate external vacuum expansion of the recipient-site tissues (matrix) before the injection of large-volume grafts (220\u2013650\u00a0cc) of autologous fat to the breasts. [ 134 ]  After harvesting by liposuction, the breast-filler fat was obtained by low G-force syringe centrifugation of the harvested fat to separate it, by density, from the crystalloid component. The refined breast filler then was injected to the pre-expanded recipient site; post-procedure, the patient resumed continual vacuum expansion therapy upon the injected breast, until the next fat grafting session. The mean operating room (OR) time was 2-hours, and there occurred no incidences of  infection , cysts,  seroma ,  hematoma , or tissue necrosis. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9753", "text": "The breast-volume data reported in  Breast Augmentation with Autologous Fat Grafting: A Clinical Radiological Study  (2010) indicated a mean increase of 1.2 times the initial breast volume, at six months post-procedure. In a two-year period, 25 patients underwent breast augmentation by fat graft injection; at three weeks pre-procedure, before the fat grafting to the breast-tissue matrix (recipient site), the patients were photographed, and examined via intravenous contrast  MRI  or  3-D volumetric imaging , or both. The breast-filler fat was harvested by liposuction (abdomen, buttocks, thighs), and yielded fat-graft volumes of 220\u2013650\u00a0cm 3  per breast. At six months post-procedure, the follow-up treatment included photographs, intravenous contrast MRI or 3-D volumetric imaging, or both. Each woman had an increased breast volume of 250\u00a0cm 3  per breast, a mean volume increase confirmed by quantitative MRI analysis. The mean increase in breast volume was 1.2 times the initial breast volume measurements; the statistical difference between the pre-procedure and the six-month post-procedure breast volumes was (P< 00.0000007); the percentage increase basis of the breast volume was 60\u201380% of the initial, pre-procedure breast volume. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9754", "text": "In 2003, the  Thai  government endorsed a regimen of self-massage exercises as an alternative to surgical breast augmentation with  breast implants . The Thai government enrolled more than 20 women in publicly funded courses for the teaching of the technique; nonetheless, beyond Thailand, the technique is not endorsed by the mainstream medical community. Despite the promising results of a six-month study of the therapeutic effectiveness of the technique, the research physician recommended to the participant women that they also contribute to augmenting their busts by gaining weight. [ 135 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9755", "text": "In every surgical and nonsurgical procedure, the risk of  medical complications  exists before, during, and after a procedure, and, given the sensitive biological nature of breast tissues (adipocyte, glandular), this is especially true in the case of fat graft breast augmentation. Despite its relative technical simplicity, the injection (grafting) technique for breast augmentation is accompanied by post-procedure complications\u00a0\u2013 fat necrosis, calcification, and  sclerotic nodules \u00a0\u2013 which directly influence the technical efficacy of the procedure, and of achieving a successful outcome. The Chinese study  Breast Augmentation by Autologous Fat-injection Grafting: Management and Clinical analysis of Complications  (2009), reported that the incidence of medical complications is reduced with strict control of the injection-rate (cm 3 /min) of the breast-filler volume being administered, and by diffusing the fat-grafts in layers to allow their even distribution within the breast tissue matrix. The complications occurred to the 17-patient group were identified and located with  3-D volumetric  and  MRI  visualizations of the breast tissues and of any sclerotic lesions and  abnormal tissue  masses (malignant neoplasm). According to the characteristics of the defect or abnormality, the sclerotic lesion was excised and liquefied fat was aspirated; the excised samples indicated biological changes in the intramammary fat grafts\u00a0\u2013 fat necrosis, calcification,  hyalinization , and  fibroplasia . [ 136 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9756", "text": "The complications associated with injecting fat grafts to augment the breasts are like, but less severe, than the medical complications associated with other types of breast procedure. [ dubious  \u2013  discuss ]  Technically, the use of minuscule (2-mm) incisions and blunt- cannula  injection much reduce the incidence of damaging the underlying breast structures (milk ducts, blood vessels, nerves). Injected fat-tissue grafts that are not perfused among the tissues can die, and result in necrotic cysts and eventual calcifications\u00a0\u2013 medical complications common to breast procedures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9757", "text": "When the patient's body has insufficient adipocyte tissue to harvest as injectable breast filler, a combination of fat grafting and breast implants might provide the desired outcome. Although non-surgical breast augmentation with fat graft injections is not associated with implant-related medical complications (filler leakage, deflation, visibility, palpability,  capsular contracture ), the achievable breast volumes are physically limited; the large-volume, global bust augmentations realised with breast implants are not possible with the method of structural fat grafting. Global breast augmentation contrasts with the controlled breast augmentation of fat-graft injection, in the degree of control that the plastic surgeon has in achieving the desired breast contour and volume. The controlled augmentation is realised by infiltrating and diffusing the fat grafts throughout the breast; and it is feather-layered into the adjacent pectoral areas until achieving the desired outcome of breast volume and contour. Nonetheless, the physical fullness-of-breast achieved with injected fat-grafts does not visually translate into the type of buxom fullness achieved with breast implants; hence, patients who had plentiful fat-tissue to harvest attained a maximum breast augmentation of one bra cup size in one session of fat grafting to the breast. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9758", "text": "A contemporary woman's lifetime probability of developing breast cancer is approximately one in seven. [ 137 ]  However, there is no causal evidence that fat grafting to the breast might be more conducive to breast cancer than are other breast procedures; because incidences of fat  tissue  necrosis and calcification occur in every such procedure: breast  biopsy , implantation,  radiation therapy ,  breast reduction ,  breast reconstruction , and liposuction of the breast. Nonetheless, detecting breast cancer is primary, and calcification incidence is secondary; thus, the patient is counselled to learn self-palpation of the breast and to undergo periodic mammographic examinations. Although the mammogram is the superior diagnostic technique for distinguishing among cancerous and benign lesions to the breast, any questionable  lesion  can be visualized  ultrasonically  and  magnetically  (MRI);  biopsy  follows any clinically suspicious lesion or indeterminate abnormality appeared in a  radiograph . [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9759", "text": "Breast augmentation via autologous fat grafts allows the  oncological  breast surgeon to consider conservative breast surgery procedures that usually are precluded by the presence of alloplastic  breast implants , e.g.  lumpectomy , if cancer is detected in an implant-augmented breast. In previously augmented patients, aesthetic outcomes cannot be ensured without removing the implant and performing mastectomy. [ 138 ] [ 139 ]  Moreover,  radiotherapy  treatment is critical to reducing cancerous recurrence and to the maximal conservation of breast tissue; yet, radiotherapy of an implant-augmented breast much increases the incidence of  medical complications \u00a0\u2013  capsular contracture , infection, extrusion, and poor cosmetic outcome. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9760", "text": "After mastectomy,  surgical breast reconstruction  with autogenous  skin flaps  and with breast implants can produce subtle deformities and deficiencies resultant from such global breast augmentation, thus the  breast reconstruction  is incomplete. In which case, fat graft injection can provide the missing coverage and fullness, and might relax the  breast capsule . The fat can be injected as either large grafts or as small grafts, as required to correct difficult axillary deficiencies, improper breast contour, visible implant edges, capsular contracture, and tissue damage consequent to radiation therapy. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9761", "text": "Reduction mammoplasty  (also  breast reduction  and  reduction mammaplasty ) is the  plastic surgery  procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional  bust  that is proportionate to the patient's body, the critical corrective consideration is the  tissue viability  of the  nipple\u2013areola complex  (NAC), to ensure the functional sensitivity and  lactational  capability of the breasts. The indications for breast reduction surgery are three-fold \u2013 physical,  aesthetic , and psychological \u2013 the restoration of the bust, of the patient's  self-image , and of the patient's  mental health . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9762", "text": "In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to  mastopexy  (breast lift). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9763", "text": "The patient with  macromastia  presents heavy, enlarged breasts that sag and cause chronic pains to the head, neck, shoulders, and back; an oversized  bust  also causes secondary health problems, such as poor  blood circulation , impaired  breathing  (inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassi\u00e8re-strap indentations to the shoulders; and the improper fit of clothes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9764", "text": "In the patient affected by  gigantomastia  (>1,000 gm overweight per breast), the average breast-volume reduction diminished the oversized bust by three brassi\u00e8re cup-sizes. [ 4 ]  The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations imposed by a bodily disproportionate bust; thereby, it improves a patient's physical and  mental health . [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ]  Afterwards, the patient's ability to comfortably perform physical activities previously impeded by oversized breasts improves emotional health ( self-esteem ) by reducing  anxiety  and lessening  psychological depression . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9765", "text": "The medical history records the patient's age, the number of children the patient has borne, the patient's  breast-feeding  practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information are the patient's history of  tobacco smoking  and concomitant diseases, breast-surgery and breast-disease histories, family history of  breast cancer , and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9766", "text": "The physical examination records and establishes the accurate measures of the patient's  body mass index , vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of  breast ptosis , the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the  nipple\u2013areola complex  (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassi\u00e8re strap from the breast weight,  kyphosis  (excessive, backwards curvature of the  thoracic region  of the  spinal column ), skin irritation, and skin rash affecting the breast crease (IMF). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9767", "text": "Large breasts are usually developed during  thelarche  (the pubertal breast-development stage), but they can also develop postpartum, after gaining weight, at  menopause , and at any age. Macromastia usually develops in consequence to the  hypertrophy  (overdevelopment) of  adipose fat , rather than to milk-gland hypertrophy. Moreover, many are  genetically  predisposed to developing large breasts, the size and weight of which are often increased, either by  pregnancy , by weight gain, or by both conditions; there also exist  iatrogenic  (physician-caused) conditions such as post\u2013 mastectomy  and post\u2013 lumpectomy  asymmetry. Nonetheless, it is statistically rare for a young person to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrent  breast hypertrophy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9768", "text": "The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the  milk glands  or of the  adipose tissue , or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (<300 gm) to the moderate (ca. 300\u2013800 gm) to the severe (>800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging,  breast ptosis  that is determined by the degree to which the nipple has descended below the inframammary fold (IMF). [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9769", "text": "Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy, but a weight-reduction regimen for the certain patients can alleviate some of the excessive size and volume of abnormally enlarged breasts. [ 13 ]  Physical therapy provides some relief for neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9770", "text": "The traditional surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar \u2013 around the NAC, where the dark-to-light skin-color transition hides the surgical scar. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9771", "text": "A  reduction mammoplasty  to re-size enlarged breasts and to correct  breast ptosis  resects (cuts and removes) excess tissues ( glandular ,  adipose ,  skin ), overstretched  suspensory ligaments , and transposes the NAC higher upon the breast hemisphere. During  puberty , the breast grows in consequence to the influences of the  hormones   estrogen  and  progesterone ; as a  mammary gland , the breast is composed of lobules of glandular tissue, each of which is drained by a  lactiferous duct  that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules, except during  pregnancy  and  lactation , when  breast milk  constitutes most of the breast volume. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9772", "text": "Surgically, the breast is an  apocrine gland  overlaying the chest \u2013 attached at the nipple and suspended with ligaments from the chest \u2013 which is integral to the skin, the  body integument  of the individual. The dimensions and weight of the breasts vary with age and habitus (body build and physical constitution); hence, small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750\u20131,000 gm. [ 15 ] [ 16 ] [ 17 ]  Anatomically, the  breast topography  and the hemispheric locale of the NAC are particular to each individual; thus, the desirable, average measurements are a 21\u201323\u00a0cm sternal distance (nipple to sternum-bone notch), and a 5\u20137\u00a0cm inferior-limb distance (NAC to IMF)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9773", "text": "The  arterial blood  supply of the breast has medial and lateral vascular components; it is supplied with blood by the  internal mammary artery  (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th  intercostal perforating arteries . Drainage of  venous blood  from the breast is by the superficial vein system under the  dermis , and by the deep vein system parallel to the artery system. The primary  lymph  drainage system is the retromammary lymph plexus in the  pectoral fascia . Sensation in the breast is established by the  peripheral nervous system innervation  of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal  nerves , and  thoracic spinal nerve 4  ( T4 nerve ) innervates and supplies sensation to the NAC. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9774", "text": "In realizing the breast-reduction corrections, the plastic surgeon takes  anatomic  and  histologic  account of the  biomechanical , load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility ( Poisson's ratio of ~0.5 )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9775", "text": "Reduction mammoplasty , either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a patient affected with  macromastia  (>500 gm [ clarification needed ]  increase per breast) or with  gigantomastia  (>1,000 gm increase per breast). Breast reduction surgery has two technical aspects:  (i)  the  skin-incision pattern  and the  skin- and glandular-tissue excision technique  applied for access to and removal of breast  parenchyma  tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars;  (ii)  the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of  nerves  and blood vessels ( arterial  and  venous ) that ensure its  tissue viability . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9776", "text": "The specific reduction mammoplasty procedure is determined by the volume of breast tissues ( glandular ,  adipose ,  skin ) to be resected (cut and removed) from each breast, and the degree of breast ptosis present:  Pseudoptosis  (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold);  Grade I: Mild ptosis  (the nipple is below the IMF, but above the lower pole of the breast);  Grade II: Moderate ptosis  (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple);  Grade III: Severe ptosis  (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily proportionate bust becomes evident at 6-months to 1-year post-operative, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some patients may experience painful breast-enlargement during the first post-operative  menstruation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9777", "text": "Breast reduction surgery cannot be performed if the patient is  lactating , or has recently ceased lactating; if the patient's breasts contain unevaluated  tissue masses , or unidentified microcalcifications; if the patient has a  systemic illness ; if the patient is unable to understand the technical limitations of the plastic surgery; or, if the patient cannot accept the possible  medical complications  of the procedure. Additionally, recent research has indicated that mammograms should not be done with any increased frequency in patients undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9778", "text": "The  inferior pedicle  (central mound) features a blood vessel supply (arterial and venous) for the NAC from an inferior, centrally-based attachment to the chest wall. [ 22 ]  The skin pedicle maintains the  innervation  and  vascular  viability of the NAC, which produces a reduced, sensitive breast with full  lactational  capability and function. [ 23 ]  The volume and size reduction of  hypertrophied breasts  is performed with a periareolar incision to the NAC, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the NAC is transposed higher upon the breast hemisphere; thereby, the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the patients's person. Breast-reduction with an inferior pedicle occasionally produces breasts that appear squared; despite this, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9779", "text": "The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision  scars  and a NAC elevated by means of a pedicle (superior, medial, lateral) that maintains the  biologic  and  functional  viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9780", "text": "The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a NAC pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the anchor pattern). The horizontal-scar technique best applies to the patient whose oversized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9781", "text": "The breast reduction performed with the free nipple-graft technique transposes the NAC as a  tissue   graft  without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive NAC, and without  lactational  capability. The medically indicated candidates are: the patient whose health presents a high risk of  ischemia  (localized  tissue   anemia ) of the  NAC , which can cause  tissue necrosis ; the  diabetic  patient; the patient who is a  tobacco smoker ; the patient whose oversized breasts have an approximate NAC-to-IMF measure of 20\u00a0cm; and the patient who has macromastia, requiring much resecting of the breast tissues. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9782", "text": "The breast reduction performed with the  liposuction-only  technique usually applies to the patient whose oversized breasts require the removal of a medium volume of internal tissue, and to the patient whose health precludes the extended  anaesthesia  typical of surgical breast-reduction operations. The ideal lipectomy candidate is the patient whose low-density breasts are principally composed of  adipose tissue , have a relatively elastic skin envelope, and manifest mild  ptosis . The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior; hence, a shorter post-operative healing period for the incision scars. The therapeutic disadvantage is limited breast-reduction volumes. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9783", "text": "The  medical treatment records  for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the oversized breasts, the sternal-notch\u2013to-nipple distances, and the nipple-to\u2013inframammary-fold distances. The patient is instructed about the purposes of the breast reduction surgery; the achievable corrections; the expected final size, shape, and contour of the reduced breasts; the expected final appearance of the breast reduction  scars ; possible changes in the sensation of the  NAC ; possible changes in  breast-feeding  capability; and possible  medical complications . The patient also is instructed about post-operative matters, such as convalescence, and the proper care of the surgical wounds to the breasts. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9784", "text": "Incision-plan delineation: to the breasts of the standing patient, the plastic surgeon delineates the  mosque dome  skin-incision plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper edge of the (future) NAC is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) NAC is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9785", "text": "The patient is laid supine upon the operating table so that the surgeon can later raise them to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the NAC is transposed higher upon the breast hemisphere. The pillars of  parenchymal tissue  are approximated (joined), and the skin envelope is sutured. [ 24 ] [ 25 ] [ 26 ]  \nThere is no evidence to support using drains during breast reduction surgery. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9786", "text": "The patient is instructed to resume normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassi\u00e8re; the convalescence regimen is for three-months post-operative. The patient is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within one\u2013six months post-operative, but some cases may require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9787", "text": "Limited evidence shows no significant benefit in the use of wound drains after reduction mammoplasty. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9788", "text": "The post-operative complications occurred include  seroma ,  wound dehiscence ,  hematoma ; partial NAC  necrosis  occurred in 10 per cent of the reduced breasts, but, after refinement of the Lejour technique, the study  Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases  (1999) reported a reduced incidence rate of 7.0 percent in the 324 breast reductions performed in 167 patients. [ 29 ]  Moreover, the incidence of such post-operative complications is greater among the patients whose breasts required large-volume resection of the  parenchyma ; in patients who were  obese ; in patients who were  tobacco smokers ; and in young patients. [ 30 ] [ 31 ]  Furthermore, wound dehiscence, epidermolysis,  adipose tissue  necrosis, and  infection  occur less among patients who undergo Lejour-technique breast reduction than among patients who undergo a periareolar, anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 percent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 percent of patients, and total NAC insensitivity occurs in 1.0 per cent of women. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9789", "text": "The reliability of the lipectomy procedure was confirmed in two studies. The first,  Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction  (2000), reported that tumescent  liposuction  is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts. [ 33 ] [ 34 ]  The second study by Daniel Lanzer,  Breast Reduction with Liposuction  (2002), about a 250-patient cohort, reported that the application of tumescent liposuction, as the sole reduction-mammoplasty procedure, yielded consistent results wherein none of the patients had loose breast-skin envelopes, irregular breast-shape, permanent loss of sensation (either glandular, dermal, or of the NAC), scars, tissue  necrosis ,  or infection. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9790", "text": "After fat cells are suctioned away via  liposuction , it was quoted in the  Obesity journal  that overall  body fat  generally returned to the same level as before treatment, [ 36 ]  despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9791", "text": "The reduction of oversized breasts by liposuction only ( lipectomy ) is indicated when a minor-to-moderate volume-reduction is required, and there is no  breast ptosis  to correct.  However, in a 2001 study of 250 patients, nipple and breast elevation of between 3\u00a0cm and 15\u00a0cm was reported. [ 35 ]    Further indications for lipectomy are presented by: (i) the patient who requires a large-volume reduction, and wants un-scarred, sensate breasts, but will accept a degree of ptosis; (ii) the patient who requires a secondary mammoplasty to correct an asymmetric breast, by up to one brassi\u00e8re cup-size; and (iii) the patient affected by  virginal breast hypertrophy , as a temporary procedure performed before the conclusion of  thelarche  (the pubertal breast-growth phase), given the hypertrophy's high rate of recurrence. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9792", "text": "Breast reduction by liposuction only cannot be performed upon a patient whose  mammogram  indicates that the oversized breast is principally composed of hypertrophied  milk glands . Furthermore, liposuction mammoplasty also is contraindicated for any patient whose mammograms indicate the presence of unevaluated  neoplasms ; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9793", "text": "Consultation: the plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The patient is informed of the alternative,  surgical  reduction techniques available for diminishing oversized breasts; of the consequent surgical  scars ; of the possible loss of breast sensation; of the possible impairment of  lactation  capability; and of the possible impairment of  breast-feeding  functions. The patient is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the patient's questions to assist in establishing realistic expectations ( self-image ) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the breast volume, a secondary, surgical breast-reduction procedure can be performed later. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9794", "text": "The measures of the bust: a liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the patient's breasts, chest, and torso, but the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the  anaesthetized  patient is laid supine upon the operating table, arms laterally extended (abducted), in order to fully expose the breasts. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9795", "text": "Anaesthestic preparation: to limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast's circulatory system is established with an  anaesthetic  solution ( lidocaine  +  epinephrine  in  saline solution ) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation  cannula , the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient's physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9796", "text": "The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the  anaesthetic  solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate the  adipose fat . The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the  adipose fat  sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9797", "text": "After the liposuction, the superficial layer of  adipose fat  is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9798", "text": "Technical note: for the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of this incision later allows converting the lipectomy breast-reduction procedure into an  inferior-pedicle breast reduction  surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9799", "text": "The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the patient quickly recovers their health, usually resuming daily life activities at 14 to 28 days post-operative \u2013 when the breast-molding dressings are changed; the patient also resumes their personal hygiene regimen, to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the patient has continuously worn a strapless brassi\u00e8re to contain and immobilize the corrected breasts; afterwards, the patient continuously wears a strapped brassi\u00e8re for 30 days after the breast-reduction operation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9800", "text": "Early complications include  infection  and  hematoma  (blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either  surgical  or  liposuction  revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the  edema  usually subsides at 2\u20133 weeks post-operative. To date, no incidence of  tissue   necrosis  has been reported; likewise, there have been few reports of lessened nipple sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection. [ 13 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9801", "text": "Gluteoplasty  (Greek   glout\u03ccs ,  rump  +  plassein ,  to shape ) denotes the  plastic surgery  and the  liposuction  procedures for the correction of  congenital ,  traumatic , and acquired defects/deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement (by augmentation or by reduction) of the contour of the  buttocks . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9802", "text": "The corrective procedures for buttock augmentation and buttock repair include the  surgical  emplacement of a  gluteal implant  (buttock prosthesis);  liposculpture  (fat transfer and  liposuction ); and  body contouring  (surgery, liposculpture, and  Sculptra  injections) to resolve the patient's particular defect or deformity of the gluteal region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9803", "text": "Gluteoplasty has also been applied in the practice of  sexual reassignment surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9804", "text": "The functional purpose of the  buttocks musculature  is to establish a stable  gait  (balanced walk) for the person who requires the surgical correction of either a defect or a deformity of the gluteal region; therefore, the restoration of anatomic functionality is the therapeutic consideration that determines which  gluteoplasty  procedure will effectively correct the damaged muscles of the buttocks. The applicable techniques for  surgical  and correction include the surgical emplacement of gluteal implants;  autologous tissue-flaps ; the excision (cutting and removal) of damaged tissues; lipoinjection augmentation; and  liposuction  reduction\u2014to resolve the defect or deformity caused by a traumatic injury ( blunt ,  penetrating ,  blast ) to the buttocks muscles ( gluteus maximus ,  gluteus medius ,  gluteus minimus ), and any deformation of the anatomic contour of the buttocks. Likewise, the corrective techniques apply to resolving the sagging skin of the body, and the muscle and bone deformities presented by the formerly  obese  patient, after a massive weight loss (MWL)  bariatric surgery  procedure; and for resolving  congenital defects  and  congenital deformities  of the gluteal region. [ 2 ]  Known as the BBL \" Brazilian Butt Lift \" surgery mimicks what steotopygia a normal way people of afrodescent distribute fat around their lower body leading to large buttocks with a shelf like shape , steep triangular hips and large curvileaner  thighs"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9805", "text": "Anatomically, the mass of each  buttock  principally comprises two muscles\u2014the  gluteus maximus muscle  and the  gluteus medius muscle \u2014which are covered by a layer of  adipose body fat . The upper aspects of the buttocks end at the  iliac crest  (the upper edges of the wings of the  ilium , and the upper lateral margins of the  greater pelvis ), and the lower aspects of the buttocks end at the  horizontal gluteal crease , where the buttocks anatomy joins the rear, upper portion of the thighs. The gluteus maximus muscle has two points of insertion: (i) the one-third superior portion of the (coarse line)  linea aspera  of the thigh bone ( femur ), and (ii) the superior portion of the  iliotibial tract  (a long, fibrous reinforcement of the deep  fascia lata  of the thigh). The left and the right gluteus maximus muscles (the butt cheeks) are vertically divided by the  intergluteal cleft  (the butt-crack) which contains the  anus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9806", "text": "The  gluteus maximus muscle  is a large and very thick muscle (6\u20137\u00a0cm) located on the  sacrum , which is the large, triangular bone located at the base of the  vertebral column , and at the upper- and back-part of the  pelvic cavity , where it is inserted (like a wedge) between the two  hip bones . The upper part of the sacrum is connected to the final  lumbar vertebra  (L5), and to the bottom of the  coccyx  (tailbone). At its origin, the gluteus maximus muscle extends to include parts of the  iliac bone , the sacrum, the coccyx, the sacrosciatic ligament, and the  tuberosity of the ischium . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9807", "text": "Like every pelvic-area muscle, the gluteus maximus muscle originates from the pelvis; nonetheless, it is the sole pelvic muscle not inserted to the  trochanter  (head of the femur), and is approximately aligned to the  femur  and the  fascia lata  (the  deep fascia  of the thigh); the tissues of the gluteus maximus muscle cover only the rear, lateral face of the trochanter, and there form a bursa (purse) that faces the interior of the  thigh . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9808", "text": "The motor innervation of the gluteus maximus muscle is performed by the  inferior gluteal nerve  (a branch nerve of the  sacral plexus ) and extends from the pelvis to the gluteal region, then traverses the  greater sciatic foramen  (opening) from behind and to the middle to then join the  sciatic nerve . The inferior gluteal nerve divides into three collateral branches: (i) the  gluteus branch , (ii) the  perineal branch , and (iii) the  femoral branch . The first ramification\u2014the gluteus branch\u2014is a branch nerve that is very close to the emergence of the inferior gluteal nerve to the area, next to the inferior border of the  pyramidalis muscle . [ 5 ]  As it arises, the inferior gluteal nerve then divides into four or more  fillets  (bands of nerve fibres) that travel (in a crow's-foot configuration) between the gluteus maximus muscle and its (front) anterior fascia; the thickest nerve-bands are the superior-most and the inferior-most fillets. The superior-most fillet runs almost vertically, near the sacrum, and innervates the superior portion of the gluteus muscle; the inferior-most fillet, which has the greatest calibre, travels very close and parallel to the  sacrotuberous ligament ; the inferior-most fillet provides fine-gauge branch-nerve ramifications that innervate the gluteus muscle through its anterior (front) face. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9809", "text": "In surgical and body contouring praxis, the plastic surgeon creates the  implant-pocket \u2014either for the gluteal prosthesis or for the injections of autologous fat\u2014by undermining the gluteus maximus muscle with a dissection technique that avoids the  sacrum , the  sacrotuberous ligament , and the  tuberosity of the ischium ; which, if accidentally cut, might isolate the posterior (back) portion of the muscle and lead to denervation, the loss of nerve function and of innervation. [ 4 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9810", "text": "The  superior gluteal artery , the  inferior gluteal artery , the  superior gluteal veins , and the  inferior gluteal veins  irrigate the gluteus maximus muscle with  arterial  and  venous  blood. The vascularization, the entrance of the blood vessels to the muscle tissues, occurs at the anterior (front) face of the muscle, very close to the  sacrum . As the arteries and the veins enter the mass of the gluteal muscle, they divide into narrower blood-vessel ramifications (configured like the horizontal branches of a tree), most of which travel parallel to the muscle fibres. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9811", "text": "In surgical and body contouring praxis, the plastic surgeon effects the implant-pocket undermining of the gluteus maximus muscle by carefully separating the muscle fibres to avoid severing the pertinent blood vessels, which would interfere with the blood irrigation of the muscle tissue. Therefore, to create an implant-pocket, either for a gluteal prosthesis or for lipoinjection, a low-angle muscle-dissection is performed in order to avoid the risk of severing any major branch\u2014 superior  or  inferior \u2014of the gluteal artery, which travels very close to the  sacrum  and to the  sacrotuberous ligament . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9812", "text": "While the resolution of the defects and deformities of the  gluteal region  can be realized surgically, the assessment of the degree of severity of the injury organizes treatment therapies into three types: (i) buttocks augmentation,  (ii) buttocks reduction, and (iii) contour irregularity treatments that combine surgery and liposculpture ( liposuction  and fat-injection). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9813", "text": "The augmentation of the buttocks is realized with a  gluteal implant , which is emplaced under each  gluteus maximus muscle ; the insertion of the buttock prosthesis is through a midline incision (5\u20138-cm-wide) over the tailbone ( coccyx ). Augmentation with a gluteal implant is the method most effective for enlarging the buttocks of a patient whose body possesses few stores of excess  adipose fat  in the lower portion of the trunk, the  buttocks  and  thighs , the anatomic regions where the human body usually stores excess body fat. Post-operatively, because of the cutting (incising) into the flesh of the tailbone muscles, the full healing of the augmented tissues can be approximately 6\u20138 months, in the course of which the gluteal-muscle tissues relax, and the settled buttocks prostheses are integrated to the gluteal region. [ 8 ]  The implantation procedure can be performed upon a patient who is either  sedated  or  anaesthetized , either under  general anaesthesia  or under  local anaesthesia . The usual operating-room time for a buttocks augmentation procedure is approximately 2 hours. The procedure can be managed either as an overnight in-patient treatment or as a hospital outpatient treatment. Given the nature of the surgical incisions to the gluteus maximus muscles, the therapeutic management of post-surgical pain (at the surgical-wound sites) and normal tissue-healing usually require a 4\u20136-week convalescence, after which the patient resumes their normal-life activities. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9814", "text": "The augmentation and contouring of the buttocks with  autologous fat transfer  (lipoinjection) therapy is realized with the excess  adipose-fat tissue  harvested from the  abdomen , flanks, and  thighs  of the patient. In 1987 Dr. Eduardo Krulig, a Venezuelan plastic surgeon, described the technique, using the name \"lipoinjection\" for the first time, mentioning the regions of the body where the technique is useful. [ 9 ]  The gentle liposuction applied to harvest the autologous fat minimally disturbs the local tissues, especially the  connective-tissue layer  between the skin and the immediate subcutaneous muscle tissues. Then, the harvested fat is injected to the pertinent body area of the gluteal region, through a fine-gauge  cannula  inserted through a small surgical incision, which produces a short and narrow  scar . Lipoinjection contouring and augmentation with the patient's own body fat avoids the possibility of tissue rejection, and is physically less invasive than buttocks-implant surgery. Therefore, depending upon the health of the patient, the convalescence period allows them to resume daily, normal-life activities at 2-days post-operative, and the full spectrum of physical activity at 2-weeks post-operative. Furthermore, the liposuction harvesting of the patient's excess body fat improves the aesthetic appearance of the body fat donor-sites. [ 10 ]  Nonetheless,  physiologically , the human body's normal, health-management chemistry does resorb (break down and eliminate) some of the injected adipose-fat tissue, and so might diminish the augmentation. According to the degree of diminishment of the volume and contour caused by the fat-resorption, the patient might require additional sessions of fat-transfer therapy to achieve the desired size, shape, and contour of the buttocks. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9815", "text": "In common parlance, lipoinjection into the buttocks for aesthetic purposes is often called a \"Brazilian butt lift\" (BBL). [ 11 ]  This name is suggested to originate from the Brazilian surgeon  Ivo Pitanguy , who pioneered the surgery in the 1960s. The popularity of the surgery significantly increased during the 2010s as a result of social media trends. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9816", "text": "The augmentation of the buttocks, by rearranging and enhancing the pertinent muscle and fat tissues of the gluteal region, is realized with a combined gluteoplasty procedure of  surgery  (subcutaneous  dermal-fat flaps ) and  liposculpture  (fat-suction, fat-injection). Therapeutically, such a combined correction-and-enhancement procedure is a realistic and feasible lower-body-lift treatment for the patient who has undergone massive  weight loss  (MWL) in the course of resolving  obesity  with  bariatric surgery . [ 13 ] [ 14 ] [ 15 ]  In the case of the patient who presents under-projected, flat buttocks ( gluteal hypoplasia ), and a degree of gluteal-muscle ptosis (prolapsation, falling forward), wherein neither gluteal-implant surgery nor lipoinjection would be adequate to restoring the natural anatomic contour of the gluteal region, the application of a combined treatment of autologous dermal-fat flap surgery and lipoinjection can achieve the required functional correction and aesthetic contour. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9817", "text": "The methods for reducing the size of the buttocks include the varieties of  liposuction , such as  lipectomy  (with and without  ultrasonic  enhancement) to reduce excess body fat, and  superficial liposculpture , to reshape, refine, and re-establish the natural contour of the body. The usual buttocks-reduction treatment is lipectomy with applied  tumescence  and  anaesthesia , wherein the body fat is harvested by aspiration (suction) through a small-gauge cannula (2\u20134\u00a0mm) that is inserted through a small incision, either to the  intergluteal sulcus  (the butt-crack), or to the upper area of the  gluteus maximus muscle  proper. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9818", "text": "Ultrasonically assisted liposuction can quickly remove a large volume of  body fat  for the correction of a notable occurrence of  lipodystrophy , a deposit of adipose fat to the buttocks and related anatomic areas. The  ultrasonic  liposuction machine liquefies the excess fat tissue, and so more readily facilitates its removal with conventional suction-lipectomy. The quick fat-harvesting allowed by the ultrasonic lipectomy technique has eliminated the larger (long and wide) surgical incisions that once were required for removing a large volume of adipose tissue. Nonetheless, because of the sensitivity of the gluteal-region tissues, the skin of the pertinent donor-site is cooled in order to prevent ultrasonic heat damage caused by the liquefying and removal of the excess adipose fat. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9819", "text": "Reshaping the buttocks with liposculpture is performed with a small cannula (2\u00a0mm) specifically for contouring superficial body fat, the configuration of which (number of open ports) is determined by the type and the degree of gluteal correction to be realized. To sculpt rounded contours to square-shaped buttocks muscles, superficial liposculpture allows the plastic surgeon to control the injection-rate of the fat-volume. Moreover, superficial  liposuction  can be combined with other treatment methods for contouring the gluteal region to achieve the required functional, anatomic correction, and the aesthetic enhancement sought by the patient, such as reshaping the lateral area of the buttocks into an athletic form. [ 16 ] [ 17 ]  The study  Contouring the Gluteal Region with Tumescent Liposculpture  (2011) indicated that effective, gluteal-region contouring is best achieved by tailoring the liposuction-reduction and the lipoinjection-augmentation techniques to the anatomic topography of the body areas to be corrected. [ 18 ]  Furthermore, the study  Contouring of the Gluteal Region in Women: Enhancement and Augmentation  (2011) indicated that natural contours of the buttocks and the thighs are effectively achieved with a combined gluteoplasty of selective liposuction and lipoinjection, which reduces the need for aggressive surgical procedures, decreases the risk of medical complications, abbreviates wound-recovery-time, and lessens post-operative scarring. Combined with any buttocks-correction method, superficial liposculpture facilitates the treatment of contour irregularities, the surgical revision of scars, and the correction of gluteal-region contour depressions. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9820", "text": "To meet the functional requirements and the aesthetic expectations ( body image ) of the patient, the plastic surgeon establishes a realistic and feasible surgery plan by which to correct the anatomic contour deficiencies of the gluteal region. The surgeon and the patient determine the location of the surgical-wound  scars , and determine the best operative position, to allow the proper exposure of the pertinent anatomy to be corrected. Because the surgical procedure requires the  tumescence  and  anaesthesia  of the gluteal-region area to be corrected, the physician and the  anaesthesiologist  determine the volumes of the anaesthetic and  tumescent  fluids to be administered to the patient during the procedure, and so avoid the risks of drugs overdose and toxicity. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9821", "text": "Once the patient is atop the operating table, the surgeon positions him or her to best expose the pertinent gluteal-region area that is to be corrected or contoured, or both; the usual operative position is the prone (face down) position, but the patient can also be positioned laterally (on his or her side). The surgical correction plan can be delineated and marked to the patient's body when he or she is awake (before sedation or anaesthesia) or it can be delineated when the patient is on the operating table (already  sedated  or  anaesthetized ). In operative praxis, the second option allows the plastic surgeon greater freedom to properly manipulate the patient into the position best suited for performing the body-contouring surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9822", "text": "Once the patient is in the operative position, the surgeon begins the liposuction correction by making incisions to the marks of the surgical-correction plan, and then infiltrates (injects) a solution of anaesthesia- and tumescence-inducing drugs, usually a combination of  lidocaine  and  epinephrine . The volume of the anaesthetic-tumescent solution is gradually infiltrated to the pertinent gluteal area, in order to avoid the nerves and the deeper anatomic structures of the gluteus maximus muscle. The particular anatomic features to be contoured determine the types of cannula (gauge, size, grade) used to effect and control the harvesting of excess adipose fat from the patient's body. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9823", "text": "For a lipoinjection augmentation, the surgeon first dissects and prepares the augmentation-pocket to which will be injected the autologous fat-tissue. The surgical creation (muscle dissection) of the augmentation-pocket avoids the gluteal innervation ( superior gluteal nerve  and  inferior gluteal nerve ) and the vascular system ( venous  and  arterial ) of the  gluteus maximus muscle . Afterwards, the surgeon  sutures  the dissection-incision and secures it with adhesive tape to ensure that the augmentation-pocket remains open, as dissected, ready to receive the injections of adipose fat. For the revision of scars, with surgery and injections of autologous fat, or with allopathic synthetic fillers, the surgeon applies subcuticular closures to the incision wounds, which then are bandaged. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9824", "text": "After completing the surgical corrections and the lipoinjection contouring of the pertinent area(s) of the gluteal region, the surgeon thoroughly examines the patient to ensure his or her general recovery from the operation; and examines each surgical incision to ascertain that it is correctly sutured and taped, in order to facilitate the uneventful healing of the gluteus-muscle tissues, without medical complications. The patient is advised to avoid exercise and strenuous physical activity until 3-weeks post-operative; how to properly care for surgical-incision wounds; and how to wear a compression garment that will keep in place the surgically corrected tissues, and so ensure their healing as a whole anatomic unit of the gluteal region. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9825", "text": "The physician advises the patient who has undergone a  surgical contouring  of the buttocks with gluteal implants, that, although immediate results can be observed, the final, corrected body contour usually is observed at 6-months post-operative, and at 1-year post-operative, depending upon the tissue-healing capabilities of the patient's body. The  liposculpture  patient usually requires approximately 6 months, and occasionally 1 year before producing the final, corrected body contour. For both procedures, at approximately 1-month post-operative, marked aesthetic improvement is noticeable in the corrected body areas, as is the elimination of the initial, post-operative weight gain caused by the body's retention of the infiltrated,  anaesthetic  and  tumescent , fluids. The patient is advised to wear a compression garment to contain swelling and to immobilize the corrected tissues, so that they heal as one anatomic unit of the gluteal region. Moreover, throughout the convalescence, to facilitate shrinking the skin to the new, corrected body contour, and to resolve unevenness, wrinkles to the skin, and localized swelling, the continual application of massage and (occasional) ultrasound treatments can facilitate the diminishment of the post-operative conditions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9826", "text": "Of the three general methods of gluteal augmentation procedures, including implants, flaps and fat graft, a 2019 systemic literature review with meta-analysis of 46 publications revealed fat graft with the least complication rate (7%) while implants associated with highest complication rate (31%). [ 20 ]    The surgical and liposculpture contouring of the human body presents possible medical complications such as: the psychological\u2014unmet  body image  expectations of aesthetic improvement; the physical\u2014uneven contour, local and general; the physiologic\u2014toxic reactions to the  anaesthesic  and the  tumescent  drugs; and the nervous\u2014 paresthesia , localized areas of perduring numbness in the corrected portion(s) of the gluteal region. [ 2 ]  The medical complications possible to a  surgical buttocks augmentation  procedure, the submuscular emplacement of a gluteal implant, include  infection ,  surgical-wound dehiscence  that exposes the implant, revision surgery, rupture of the implant,  seroma  (a pocket of clear serous fluid),  capsular contracture , asymmetry of the corrected area, shifting of the implant, surgical over-correction, injury to the  sciatic nerve , and  paresthesia  (tingling skin). The medical complications possible to a  liposculpture buttocks augmentation  include the bodily resorption of some of the injected adipose fat, asymmetric contour of the corrected body area, an irregular contour to the body, seroma,  abscess  (pus enclosed by inflamed tissue),  cellulitis  (subcutaneous connective-tissue inflammation), and paresthesia. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9827", "text": "Like most medical procedures, buttock augmentation come with risks some of which can be life-threatening. A total of 413 Mexican plastic surgeons reported 64 deaths related to liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent) occurred during lipoinjection, whereas the remaining five (38.4 percent) occurred within the first 24 hours. In Colombia, six deaths (77.7 percent) occurred during surgery and three occurred (22.2 percent) immediately after surgery. [ 21 ]  Secondary lymphoedema of the lower extremities has been reported as an unusual side effect of liquid silicone injection on the hips and buttock while thromboembolism, implant displacement and explosion has also been listed as some of the dangers. [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9828", "text": "In the surgical praxis of body contouring therapy, the patient's  body-image  expectations can be different from the contoured body that is the outcome of the performed surgical operation. Such unmet aesthetic expectations can be avoided at the pre-operative consultation stage, whereby, with informed consent, the physician and the patient jointly establish a realistic and feasible surgery plan to achieve a mutually satisfactory corrective outcome (functional and aesthetic) of the operation to the gluteal region, the buttock- and thigh-areas. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9829", "text": "Contour problems of the corrected gluteal region can be prevented with the operational use of small-gauge cannulas (ca. 2.0\u00a0mm) specifically for superficial liposuction; and with the application of cross-pattern harvesting of the excess body fat, to avoid removing too much  adipose fat  tissue, which might disfigure the contour of the patient's fat-donor area. The possible contour problems that might arise from ultrasonic liposuction are skin burns and hypertrophic scarring, which might occur if the fat-donor area skin is not cooled and protected during the fat harvest. To that end, the infusion of a tumescence-inducing solution to the fat-donor area(s) assists in cooling the patient's skin during the ultrasonic lipo-harvesting; likewise, the application of moist towels, a skin protector, and the constant cooling-fluid infiltration of the cannula in an integrated sheath. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9830", "text": "The infiltration of a solution of  anaesthesia - and  tumescence -inducing drugs can present medical complications such as a fluid overload of the tissues, the inadequate replacement of the infiltrated solution, and the partitioning (separation) of a single infiltration into several pools, which then are removed by suction lipectomy. Moreover, during anaesthesia, maintaining the patient's stable blood pressure can be difficult, which increases the possibility of bleeding, and the possibility that  anaesthetic toxicity  can occur if excessive doses are administered by infiltration; the symptoms are manifested as  central nervous system  (CNS) occurrences of drug-induced  anxiety , apprehension, restlessness, nervousness, disorientation, confusion, dizziness, blurred vision, tremors,  nausea , vomiting, shivering, and seizures; likewise, as manifestations of drowsiness, unconsciousness, respiratory depression, and respiratory arrest. Furthermore, the toxicity symptoms of a tumescence-inducing drug (e.g.  epinephrine ) might cause such CNS symptoms, for which reason the operative application of a tumescent drug is limited throughout the operation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9831", "text": "Post-operatively, local areas of numbness ( paresthesia ) might occur in the contoured portion(s) of the gluteal region, and might perdure for a long time after the surgery. Hence, the patient is advised to facilitate the re-sensitizing of the numb area(s) with applications of gentle massage, to prevent the development of a  neuroma  complication, and to alleviate pain. Nonetheless, depending upon the tissue-healing capabilities of the patient, he or she can recover in full at 2-years post-operative. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9832", "text": "The outcome of a buttocks-contouring procedure depends upon the specific defect or deformity that can be effectively corrected with liposculpture,  ultrasonic  or not. Nonetheless, depressed scars and deep  morphological  defects are difficult to correct because of the curvature of the buttocks as an anatomic unit, and because of the scar-contracting elements of the tissues across the gluteal curvature. In such a case, although the injection of (autologous or artificial) tissue fillers to correct the defect or the deformity might be impermanent\u2014it usually will remedy the functional and aesthetic shortcoming(s) required by the patient, which is the therapeutic purpose of gluteoplasty. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9833", "text": "In common parlance, \"Brazilian butt lift\" (BBL) is often used to describe  lipoinjection  into the buttocks for aesthetic purposes. [ 24 ]  This name is suggested to originate from the Brazilian surgeon  Ivo Pitanguy , who pioneered the surgery in the 1960s. The popularity of the surgery significantly increased during the 2010s as a result of social media trends. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9834", "text": "Catherine Cando  (June 7, 1995 \u2013 January 10, 2015) was an  Ecuadorean  beauty queen who won the Queen of  Dur\u00e1n   pageant . A prize for the winner was a free  liposuction procedure . Cando died as a result of  complications  during the operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9835", "text": "Cando had no  weight problems  as child, and her sister-in law asked her to enter the Queen of Dur\u00e1n contest. There, she met Dr Ecuador, a  plastic surgeon  who worked with the Duran government and was a  judge  on the pageant's panel. Ecuador allegedly convinced Cando to undergo the liposuction after she had first refused, with promises that she might become his assistant at some later time (Cando wished to enter the medical field). Cando died on the operating table; Ecuador told Cando's family that the cause was brain  edema , but staff later stated the cause of death was  cardiac arrest  as the result of a botched operation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9836", "text": "Cando's death sparked outrage in Ecuador against plastic surgery. [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9837", "text": "This biographical article about a contestant in a beauty pageant is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9838", "text": "Cellulite  or  gynoid lipodystrophy  ( GLD ) is the  herniation  of subcutaneous  fat  within fibrous  connective tissue  that manifests as skin dimpling and  nodularity , often on the  pelvic  region (specifically the  buttocks ), lower limbs, and  abdomen . [ 1 ] [ 2 ]  Cellulite occurs in most postpubescent females. [ 3 ]  A review gives a prevalence of 85\u201398% of women of European descent, [ 4 ]  but it is considerably less common in women of East Asian descent. [ 5 ] [ 6 ]  It is believed to be  physiological  rather than  pathological . It can result from a complex combination of factors, including  diet ,  sedentary lifestyle ,  hormonal imbalance  or  heredity , among others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9839", "text": "The causes of cellulite include changes in  metabolism ,  physiology , diet and exercise habits, obesity, alteration of  connective tissue  structure,  hormonal  factors,  genetic  factors, the microcirculatory system, the  extracellular matrix , and subtle  inflammatory  alterations. [ 1 ] [ 3 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9840", "text": "Hormones play a dominant role in the formation of cellulite.  Estrogen  is thought to be an important hormone in the development of cellulite, and it has been proposed that an imbalance of  estrogen  relative to  progesterone  may be associated with cellulite. However, there has been no reliable clinical evidence to support the claim that  estrogen  levels are linked to cellulite, and many women with elevated estrogen levels do not get cellulite. [ 8 ]  Other hormones\u2014including  insulin , the  catecholamines   adrenaline ,  cortisol  and  noradrenaline ,  thyroid hormones , and  prolactin \u2014are believed to participate in the development of cellulite. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9841", "text": "There is a genetic element in individual susceptibility to cellulite. [ 1 ]  Researchers have traced the genetic component of cellulite to particular  polymorphisms  in the  angiotensin converting enzyme  ( ACE ) and  hypoxia-inducible factor 1A  ( HIF1a ) genes. [ 9 ]  Evidence for the heredity of cellulite is supported from studies showing that both the presence and degree of cellulite is similar between females within the same family. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9842", "text": "Several factors have been shown to affect the development of cellulite.  Sex ,  ethnicity ,  biotype , distribution of subcutaneous fat, and  predisposition  to  lymphatic  and circulatory insufficiency have all been shown to contribute to cellulite. [ 1 ]  It has been found to be considerably less common in women of East Asian descent, than in white women. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9843", "text": "A high- stress  lifestyle causes an increase in the level of  catecholamines , which have also been associated with the development of cellulite. [ 1 ]  Inactivity can cause vascular stasis, contributing to cellulite formation. [ 5 ]  Excessive carbohydrate consumption may also be related to cellulite in some instances. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9844", "text": "Cellulite can be resistant to a variety of treatments. [ 10 ]  Aside from \"topical\" products (creams,  ointments ) and injectables ( collagenase ), treatments for cellulite include  non-invasive therapy  such as mechanical suction or mechanical massage. Energy-based devices include  radio frequency  with deep penetration of the skin, ultrasound, [ 11 ]  cryotherapy chambers, [ 12 ]  laser and pulsed-light devices. [ 13 ] [ 14 ]  Combinations of mechanical treatments and energy-based procedures are widely used. [ 13 ]   Ionithermie , a form of  electrotherapy  using  electrical muscle stimulation , has been described as ineffective. [ 15 ] [ 16 ]  More invasive 'subcision' techniques utilize a needle-sized  microscalpel  to cut through the causative fibrous bands of connective tissue. Subcision procedures (manual, vacuum-assisted, or laser-assisted) are performed in specialist clinics with patients given local anaesthetic. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9845", "text": "In European populations, cellulite is thought to occur in 80\u201390% of post-adolescent females. [ 9 ] [ 17 ]  Its existence as a real disorder has been challenged, [ 18 ]  and the prevailing medical opinion is that it is merely the \"normal condition of many women\". [ 19 ]  It is rarely seen in males. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9846", "text": "The growing interest in cellulite has historically been linked to the growth of the cosmetic industry in the west, as well as globalization. The term was first used in the 1920s by spa and beauty services to promote their services, and began appearing in English-language publications in the late 1960s, with the earliest reference in  Vogue  magazine , \"Like a swift migrating fish, the word  cellulite  has suddenly crossed the Atlantic.\" [ 20 ]  According to Italian researcher Martina Grimaldi, cellulite has often been pathologized as a \"disease\" in Western European news media, and it has been shown that French magazines promoting this misinformation are often funded by pharmaceutical companies that manufacture anti-cellulite skincare products. [ 21 ]  American journalist  Susan Faludi  notes that the Western beauty advertisements have attempted to portray cellulite as a symptom of women's social progress; that cellulite is caused by being a working, independent woman. Faludi writes that such messaging is motivated by a fear within the cosmetic industry that women's social progress might lead to declining profits in the beauty industry as a whole, noting that profits did decline in the 1970s and 1980s, the era of  second-wave feminism . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9847", "text": "Circumcision  is a  procedure  that removes the  foreskin  from the  human penis . In the most common form of the operation, the foreskin is extended with  forceps , then a circumcision device may be placed, after which the foreskin is  excised . Topical or locally injected  anesthesia  is generally used to reduce pain and  physiologic stress . [ 1 ]  Circumcision is generally  electively performed , most commonly done as a form of  preventive healthcare , as a  religious obligation , or as a  cultural practice . [ 2 ]  It is also an option for cases of  phimosis , other  pathologies  that do not resolve with other treatments, and chronic  urinary tract infections  (UTIs). [ 3 ] [ 4 ]  The procedure is  contraindicated  in cases of certain genital structure abnormalities or poor general health. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9848", "text": "The procedure is associated with reduced rates of  sexually transmitted infections [ 6 ]  and  urinary tract infections . [ 1 ] [ 7 ] [ 8 ]  This includes reducing the incidence of  cancer-causing  forms of  human papillomavirus  (HPV) and reducing  HIV transmission  among  heterosexual men  in high-risk populations by up to 60%; [ 9 ] [ 10 ]  its prophylactic efficacy against HIV transmission in the  developed world  or among  men who have sex with men  is debated. [ 11 ] [ 12 ] [ 13 ]  Neonatal circumcision decreases the risk of  penile cancer . [ 14 ]  Complication rates increase significantly with age. [ 15 ]  Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications, while  meatal stenosis  is the most common long-term. [ 16 ]  There are various  cultural, social , and  ethical  views on circumcision. Major medical organizations hold variant views on the strength of circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while other medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. [ 17 ] [ 18 ] [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9849", "text": "Circumcision is one of the world's most common and oldest medical procedures. [ 2 ]  Prophylactic usage originated in  England  during the 1850s and subsequently widely spread, becoming predominately established as a way to prevent sexually transmitted infections. [ 21 ] [ 22 ]  Beyond use as a prophylactic or treatment option in healthcare, circumcision plays a major role in many of the world's cultures and religions, most prominently  Judaism  and  Islam . Circumcision is among the  most important commandments in Judaism . [ 23 ] [ 24 ]  In some  African  and  Eastern Christian denominations  male circumcision is an established practice, and require that their male members undergo circumcision. [ 25 ] [ 26 ]  It is widespread in Australia, Canada, the United States, South Korea, most of Africa, and parts of Asia. [ 2 ]  It is relatively rare for non-religious reasons in parts of Southern Africa, Latin America, Europe, and parts of Asia. [ 2 ]  The origin of circumcision is not known with certainty, but the oldest documentation comes from  ancient Egypt . [ 2 ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9850", "text": "Around half of all circumcisions worldwide are performed for reasons of prophylactic healthcare. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9851", "text": "There is a consensus among the world's major medical organizations and in the academic literature that circumcision is an efficacious intervention for HIV prevention in high-risk populations if carried out by medical professionals under safe conditions. [ 30 ] [ 12 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9852", "text": "In 2007, the WHO and the  Joint United Nations Programme on HIV/AIDS  (UNAIDS) stated that they recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes \" informed consent ,  confidentiality , and absence of  coercion \" \u2014 known as voluntary medical male circumcision, or VMMC. [ 30 ]  In 2010, this was expanded to routine neonatal circumcision, as long as those undergoing the procedure received assent from their parents. [ 18 ]  In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations. [ 30 ] [ 18 ]  The International Antiviral Society\u2013USA also suggests circumcision be discussed with  men who have insertive anal sex with men , especially in regions where HIV is common. [ 31 ]  There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9853", "text": "The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as an additional method of controlling the spread of HIV. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9854", "text": "Major medical organizations hold varying positions on the  prophylactic efficacy  of the elective circumcision of minors in the context of  developed countries . [ 19 ]  Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them. [ 20 ] [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9855", "text": "The  World Health Organization  (WHO),  UNAIDS , and American medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. [ 17 ] [ 18 ] [ 19 ] [ 20 ]  Advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is \"imperative\". [ 34 ]  They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications. [ 32 ]  The  American Academy of Pediatrics ,  American College of Obstetricians and Gynecologists ,  and  Centers for Disease Control and Prevention  stated that the potential benefits of circumcision outweigh the risks. [ 1 ] [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9856", "text": "The World Health Organization in 2010 stated: [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9857", "text": "There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9858", "text": "Circumcision is also used to treat various pathologies. These include pathological  phimosis , refractory  balanoposthitis  and chronic or recurrent  urinary tract infections  (UTIs). [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9859", "text": "Circumcision is  contraindicated  in certain cases. [ 5 ] [ 4 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9860", "text": "These include infants with certain  genital  structure abnormalities, such as a misplaced  urethral opening  (as in  hypospadias  and  epispadias ), curvature of the head of the penis ( chordee ), or  ambiguous genitalia , because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in  premature  infants and those who are not clinically stable and in good health. [ 5 ] [ 4 ] [ 37 ]  If an individual is known to have or has a family history of serious bleeding disorders such as  hemophilia , it is recommended that the blood be checked for normal  coagulation  properties before the procedure is attempted. [ 4 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9861", "text": "The  foreskin  is the double-layered fold of tissue at the distal end of the  human penis  that covers the  glans  and the  urinary meatus . [ 2 ]  For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9862", "text": "For infant circumcision,  devices  such as the  Gomco clamp ,  Plastibell  and  Mogen clamp  are commonly used in the USA. [ 1 ]   These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial  orifice  to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin ( preputial epithelium ) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a  dorsal slit ), which remains until blood flow has stopped. Finally, the foreskin is  amputated . [ 1 ]  For older babies and adults, circumcision is often performed surgically without specialized instruments, [ 37 ]  and alternatives such as  Unicirc  or the  Shang ring  are available. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9863", "text": "The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, [ 39 ]  so the use of  analgesia  is advocated. [ 1 ] [ 40 ]  Ordinary procedural pain may be managed in  pharmacological  and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. [ 1 ] [ 41 ] [ 42 ]  The  ring block  and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than  EMLA  (eutectic mixture of local anesthetics) cream, which is more effective than a  placebo . [ 41 ] [ 42 ]  Topical creams have been found to irritate the skin of  low birth weight  infants, so penile nerve block techniques are recommended in this group. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9864", "text": "For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a  sucrose  or non-sucrose pacifier are more effective at reducing pain than a placebo, [ 42 ]  but the  American Academy of Pediatrics  (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques. [ 1 ]  A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell. [ 42 ]  The available evidence does not indicate that post-procedure pain management is needed. [ 1 ]   For adults,  topical anesthesia , ring block, dorsal penile nerve block (DPNB) and  general anesthesia  are all options, [ 43 ]  and the procedure requires four to six weeks of abstinence from  masturbation  or intercourse to allow the wound to heal. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9865", "text": "Neonatal circumcision is generally a safe, low-risk procedure when done by an experienced practitioner. [ 44 ] [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9866", "text": "Male circumcision reduces the risk of  human immunodeficiency virus (HIV) transmission  from HIV positive women to men in high risk populations. [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9867", "text": "In 2020, the  World Health Organization  (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9868", "text": "Human papillomavirus  (HPV) is the most commonly transmitted  sexually transmitted infection , affecting both men and women. While most infections are  asymptomatic  and are cleared by the  immune system , some types of the virus cause  genital warts , and other types, if untreated, cause various forms of cancer, including  cervical cancer  and  penile cancer . Genital warts and cervical cancer are the two most common problems resulting from HPV. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9869", "text": "Circumcision is associated with a reduced  prevalence  of  oncogenic  types of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man. [ 53 ] [ 54 ]  It also decreases the likelihood of multiple infections. [ 7 ]  As of 2012 [update] , there was no strong evidence that it reduces the rate of new HPV infection, [ 8 ] [ 7 ] [ 55 ]  but the procedure is associated with increased  clearance  of the virus by the body, [ 8 ] [ 7 ]  which can account for the finding of reduced prevalence. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9870", "text": "Although genital warts are caused by a type of HPV, there is no  statistically significant relationship  between being circumcised and the presence of genital warts. [ 8 ] [ 54 ] [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9871", "text": "Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have, generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of  syphilis ,  chancroid , and possibly genital  herpes . [ 56 ]  A 2010 review found that circumcision reduced the incidence of  HSV -2 (herpes simplex virus, type 2) infections by 28%. [ 57 ]  The researchers found mixed results for protection against  trichomonas vaginalis  and  chlamydia trachomatis , and no evidence of protection against  gonorrhea  or syphilis. [ 57 ]  It may also possibly protect against syphilis in MSM. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9872", "text": "Phimosis is the inability to retract the foreskin over the glans penis. [ 59 ]  At birth, the foreskin cannot be retracted due to  adhesions  between the foreskin and glans, and this is considered normal (physiological phimosis). [ 59 ]  Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three. [ 59 ]  Less than one percent are still having problems at age 18. [ 59 ]  If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option. [ 3 ] [ 60 ]  This pathological phimosis may be due to scarring from the skin disease  balanitis xerotica obliterans  (BXO), repeated episodes of  balanoposthitis  or forced retraction of the foreskin. [ 61 ]   Steroid  creams are also a reasonable option and may prevent the need for surgery including in those with mild BXO. [ 61 ] [ 62 ]  The procedure may also be used to prevent the development of phimosis. [ 4 ]  Phimosis is also a complication that can result from circumcision. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9873", "text": "An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called  balanitis . [ 64 ] [ 65 ]  Most cases of these conditions occur in uncircumcised males, [ 66 ]  affecting 4\u201311% of that group. [ 59 ]  The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially  Candida albicans , are the most common penile infection and are rarely identified in samples taken from circumcised males. [ 66 ]  Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. [ 64 ] [ 65 ]  Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in the twenty-first century the availability of the other treatments has made it less necessary. [ 64 ] [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9874", "text": "A UTI affects parts of the  urinary system  including the  urethra ,  bladder , and  kidneys . There is about a one percent risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not  ideal evidence  that circumcision of babies reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3\u201310 times (100 circumcisions prevents one UTI). [ 1 ] [ 67 ] [ conflicted source ] [ 68 ]  Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects, [ 1 ]  and may be used to treat recurrent UTIs. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9875", "text": "There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the  urinary meatus ) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacterial population. [ 1 ] [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9876", "text": "Not being circumcised is the primary  risk factor  for  penile cancer . [ 69 ] [ 70 ]  Pre-adolescent circumcision has a strong protective effect against penile cancer in later life. [ 14 ]  Penile cancer is a rare disease in the  developed world  but much more prevalent in the  developing world . [ 14 ]  The penile tissue removed during circumcision is a potential origin for penile cancer. [ 71 ]  Risk-benefit considerations around the use of circumcision as a cancer-preventive measure are a source of debate. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9877", "text": "Penile cancer development can be detected in the carcinoma  in situ  (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage. [ 1 ]   There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself. [ 72 ]  Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9878", "text": "Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision. [ 72 ]  The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men. [ 1 ] [ 72 ]  Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men [ 7 ]  and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9879", "text": "There is some evidence that circumcision is associated with reduced risk of  prostate cancer . [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9880", "text": "A 2017 systematic review found consistent evidence that male circumcision prior to heterosexual contact was associated with a decreased risk of cervical cancer,  cervical dysplasia , HSV-2, chlamydia, and syphilis among women. The evidence was less consistent in regards to the potential association of circumcision with women's risk of HPV and HIV. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9881", "text": "The accumulated data show circumcision does not have an adverse physiological effect on sexual pleasure, function, desire, or fertility. [ 75 ] [ 76 ]  There is some evidence that circumcision has no effect on  pain with intercourse ,  premature ejaculation ,  intravaginal ejaculation latency time ,  erectile dysfunction  or difficulties with  orgasm . [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9882", "text": "According to a 2014 review, the effect of circumcision on sexual partners' experiences is unclear as this has not been well studied. [ 78 ]   According to a policy statement from the  Canadian Paediatric Society  that was reaffirmed in 2021, [ 79 ]  \"medical studies do not support circumcision as having an impact on sexual function or satisfaction for partners of circumcised individuals\". [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9883", "text": "There are popular misconceptions that circumcision benefits or adversely impacts the sexual pleasure of the circumcised person. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9884", "text": "The most common acute  complications  are bleeding, infection and the removal of either too much or too little foreskin. [ 1 ] [ 80 ]  These complications occur in approximately 0.13% of procedures, with bleeding being the most common acute complication in the United States. [ 80 ]  Minor complications are reported to occur in three percent of procedures. [ 45 ]  Severe complications are rare. [ 63 ]  A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification. [ 1 ]  Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age. [ 15 ]  Significant acute complications happen rarely, [ 1 ] [ 15 ]  occurring in about 1 in 500 newborn procedures in the United States. [ 1 ]  Severe to catastrophic complications, including death, are so rare that they are reported only as individual case reports. [ 1 ] [ 46 ]  Where a Plastibell device is used, the most common complication is the retention of the device occurring in around 3.5% of procedures. [ 16 ]  Other possible complications include  buried penis ,  chordee , phimosis,  skin bridges , urethral fistulas, and  meatal stenosis . [ 46 ]  These complications may be partly avoided with proper technique, and are often treatable without requiring surgical revision. [ 46 ]  The most common long-term complication is meatal stenosis, this is almost exclusively seen in circumcised children, it is thought to be caused by ammonia producing bacteria coming into contact with the meatus in circumcised infants. [ 16 ]  It can be treated by  meatotomy . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9885", "text": "Effective pain management should be used during the procedure. [ 1 ]  Inadequate pain relief may carry the risks of heightened pain response for newborns. [ 39 ]  Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed. [ 81 ]  For adult men who have been circumcised, there is a risk that the  circumcision scar  may be tender. [ 82 ]  There is no good evidence that circumcision affects cognitive abilities. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9886", "text": "Circumcision is the oldest known surgical procedure. [ 84 ]  Depictions of circumcised penises are found in  Paleolithic art , [ 85 ]  predating the earliest signs of  trepanation . [ 84 ] [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9887", "text": "The history of the migration and evolution of circumcision is known mainly from the cultures of two regions. In the lands south and east of the Mediterranean, starting with Central Sahara, Sudan and Ethiopia, the procedure was practiced by the  ancient Egyptians  and the  Semites , and then by the Jews and Muslims. In Oceania, circumcision is practiced by the  Australian Aboriginals  and  Polynesians . [ 87 ]  There is also evidence that circumcision was practiced among the  Aztec  and  Mayan  civilizations in the Americas, [ 2 ]  but little is known about that history. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9888", "text": "It has been speculated that circumcision originated as a substitute for  castration  of defeated enemies or as a  religious sacrifice . [ 28 ]  In many traditions, it acts as a  rite of passage  marking a boy's entrance into  adulthood . [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9889", "text": "At  Oued Djerat , in  Algeria , engraved rock art with masked bowmen, which feature male circumcision and may be a scene involving ritual, have been dated to earlier than 6000 BP amid the  Bubaline Period ; [ 88 ]  more specifically, while possibly dating much earlier than 10,000 BP, rock art walls from the Bubaline Period have been dated between 9200 BP and 5500 BP. [ 89 ]  The cultural practice of circumcision may have spread from the Central  Sahara , toward the south in  Sub-Saharan Africa  and toward the east in the region of the  Nile . [ 88 ]  Based on  engraved  evidence found on walls and evidence from  mummies , circumcision has been dated to at least as early as 6000 BCE in  ancient Egypt . [ 90 ]  Some  ancient Egyptian mummies , which have been dated as early as 4000 BCE, show evidence of circumcision. [ 87 ] :\u200a2\u20133\u200a [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9890", "text": "Evidence suggests that circumcision was practiced in the Middle East by the fourth millennium BCE, when the  Sumerians  and the Semites moved into the area that is modern-day Iraq from the North and West. [ 27 ]   The earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankh-Mahor at  Saqqara , dating to about 2400\u20132300 BCE. Circumcision was possibly done by the Egyptians for hygienic reasons, but also was part of their obsession with purity and was associated with spiritual and intellectual development.  No well-accepted theory explains the significance of circumcision to the Egyptians, but it appears to have been endowed with great honor and importance as a  rite of passage , performed in a public ceremony emphasizing the continuation of family generations and fertility.  It may have been a mark of distinction for the elite:  the Egyptian  Book of the Dead  describes the sun god  Ra  as having circumcised himself. [ 28 ] [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9891", "text": "Circumcision is prominent in the  Hebrew Bible . [ 92 ]  In addition to proposing that circumcision was adopted by the Israelites purely as a religious mandate, scholars have suggested that Judaism's patriarchs and their followers adopted circumcision to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice. [ 27 ] [ 87 ] [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9892", "text": "Historical campaigns of  ethnic, cultural, and religious persecution  frequently included bans on circumcision as a means of  forceful assimilation, conversion, and ethnocide . [ 94 ]   Alexander the Great  conquered the Middle East in the fourth century BCE, and in the following centuries ancient Greek cultures and values came to the Middle East. The Greeks abhorred circumcision, making life for circumcised Jews living among the Greeks and later the Romans very difficult. [ 94 ]   Restrictions on the Jewish practice  by European governments have occurred several times in world history, including the  Seleucid Empire  under  Antiochus IV  and the  Roman Empire  under  Hadrian , where it was used as a means of  forceful assimilation and conversion . [ 94 ]  Antiochus IV's restriction on Jewish circumcision was a major factor in the  Maccabean Revolt . [ 94 ]   Hadrian 's prohibition has also been considered by some to have been a contributing cause of the  Bar Kokhba revolt . [ 94 ]  According to Silverman (2006), these restrictions were part of a \"broad campaign\" by the Romans to \"civilize\" the Jewish people, viewing the practice as repulsive and analogous to  castration . [ 94 ]  His successor,  Antoninus Pius , altered the edict to permit  Brit Milah . [ 94 ]  During this period in history, Jewish circumcision called for the removal of only a part of the prepuce, and  Hellenized  Jews often attempted to look uncircumcised by stretching the extant parts of their foreskins. This was considered by the Jewish leaders to be a serious problem, and during the second century CE they changed the requirements of Jewish circumcision to call for the complete removal of the foreskin, [ 95 ]  emphasizing the Jewish view of circumcision as intended to be not just the fulfillment of a Biblical commandment but also an essential and permanent mark of membership in a people. [ 87 ] [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9893", "text": "A narrative in the Christian  Gospel of Luke  makes a brief mention of the  circumcision of Jesus , but physical circumcision is not part of the received teachings of Jesus.  Circumcision has  played an important role  in  Christian history  and  theology .  Paul the Apostle  reinterpreted circumcision as a spiritual concept, arguing literal circumcision to be unnecessary for Gentile converts to Christianity. The teaching that circumcision was unnecessary for membership in a divine covenant was instrumental to the separation of Christianity from Judaism. [ 96 ] [ 97 ]  While the circumcision of Jesus is celebrated as  a feast day  in the  liturgical calendar  of many  Christian denominations . [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9894", "text": "Although it is not explicitly mentioned in the  Quran  (early seventh century CE), circumcision is considered essential to Islam, and it is nearly universally performed among Muslims.  The practice of circumcision spread across the Middle East, North Africa, and Southern Europe with Islam. [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9895", "text": "Genghis Khan  and the following Yuan Emperors in China forbade Islamic practices such as  halal  butchering and circumcision. [ 99 ] [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9896", "text": "The practice of circumcision is thought to have been brought to the Bantu-speaking tribes of Africa by either the Jews after one of their many expulsions from European countries, or by Muslim Moors escaping after the 1492  reconquest  of Spain. In the second half of the first millennium CE, inhabitants from the Northeast of Africa moved south and encountered groups from Arabia, the Middle East, and West Africa. These people moved south and formed what is known today as the Bantu. Bantu tribes were observed to be upholding what was described as Jewish law, including circumcision, in the 16th century. Circumcision and elements of Jewish dietary restrictions are still found among Bantu tribes. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9897", "text": "Circumcision is practiced by some groups amongst  Australian Aboriginal  peoples,  Polynesians , and  Native Americans . [ 2 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9898", "text": "For Aboriginal Australians and Polynesians, circumcision likely started as a blood sacrifice and a test of bravery and became an initiation rite with attendant instruction in manhood in more recent centuries.  Often seashells were used to remove the foreskin, and the bleeding was stopped with  eucalyptus  smoke. [ 27 ] [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9899", "text": "Christopher Columbus  reported circumcision being practiced by Native Americans. [ 28 ]  It probably started among South American tribes as a blood sacrifice or ritual to test bravery and endurance, and later evolved into a rite of initiation. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9900", "text": "Circumcision began to be advocated as a means of  prophylaxis  in 1855, primarily as a means of preventing the transmission of sexually transmitted infections. At this time,  British  physician  Jonathan Hutchinson  published his findings that, among his venereal disease patients, Jews had a lower prevalence of  syphilis . [ 102 ] [ 103 ]  Hutchinson suggested that circumcision lowers the risk of contracting syphilis. [ 103 ]  Pursuing a successful career as a general practitioner, Hutchinson went on to advocate circumcision for health reasons for the next fifty years, [ 102 ]  eventually earned a  knighthood  for his contributions to medicine. His viewpoint that circumcision was prophylactic against disease was adopted by other medical professionals. [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9901", "text": "In 1870, orthopedic surgeon  Lewis Sayre , a founder of the  American Medical Association , introduced circumcision in the United States as a purported cure for several cases of young boys presenting with paralysis and other significant gross motor problems. He thought the procedure ameliorated such problems based on the then prominent \"reflex neurosis\" theory of disease, thinking that a tight foreskin inflamed the nerves and caused systemic problems. [ 105 ]  The use of circumcision to promote good health also fit the  germ theory of disease , which saw validation during the same period: the foreskin was thought to harbor infection-causing  smegma . [ 106 ] :\u200a106\u200a  Sayre published works on the subject and promoted it in speeches. [ 105 ]  Although later discredited, many contemporary physicians believed it could cure, reduce, or otherwise prevent a wide-ranging array of perceived medical problems and social ills, including that of  epilepsy ,  hernia ,  headache ,  masturbation ,  clubfoot ,  alcoholism  and  gout . Its popularity spread with publications such as Peter Charles Remondino's  History of Circumcision . [ 106 ] [ 107 ] [ 108 ]  By the late 19th century, circumcision had become common throughout the  Anglophonic world \u2014Australia, Canada, the United States, and the United Kingdom\u2014as well as the  Union of South Africa . In the United Kingdom and United States, it was universally recommended. [ 21 ] [ 106 ]  Some mainstream pediatric manuals in the US continued to recommend circumcision as a deterrent against masturbation until the 1950s. [ 107 ] :\u200a752"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9902", "text": "Historian  David Gollaher  proposes that \"Americans found circumcision appealing not merely on medical grounds, but also for its connotations of science, health, and cleanliness\u2014newly important class distinctions\" in a country where 17 million immigrants arrived between 1890 and 1914. [ 106 ] :\u200a106"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9903", "text": "During the  interwar period , medical organizations and doctors in  mainland Europe  experimented with the idea of routine circumcision for prophylactic reasons as well, alongside developments in the Anglophonic world. In France, the medical profession went so far as to recommend universal routine circumcision. However, prevalence in France and mainland Europe remained low. [ 19 ]  There is a lack of consensus in the academic literature on why this occurred. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9904", "text": "Yosha & Bolnick & Koyle  (2012) have suggested that a factor in its Anglophonic adoption and dismissal in mainland Europe relates to attitudes towards Judaism and Jewish practices. While many of these Anglophonic polities would not be considered tolerant by modern standards: the United Kingdom had  Benjamin Disraeli \u2014a Jew\u2014as  Prime Minister ;  Jews in the United States  were prominent and generally well-respected; while in Australia \"the racial issues of the time  involved primarily Aborigines and Chinese immigration , and Jews were essentially below the radar\". They argue that once \"a substantial proportion of the male population [was] circumcised, the idea that it [was] a Jewish practice [became] no longer relevant. In Britain this was aided by the fact that circumcision was well known to be as much a practice of the nobility as a Jewish religious rite, so that the racial-religious nexus was broken.\" These factors were absent in  continental Europe . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9905", "text": "Rates in the Anglophonic world began to sharply diverge after 1945. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9906", "text": "After the end of  World War II , Britain implemented a  National Health Service .  Douglas Gairdner 's 1949 article \"The Fate of the Foreskin\" argued that the evidence showed that the risks outweighed the benefits, leading to a significant reduction in circumcision incidence within the United Kingdom. [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9907", "text": "In contrast to Gairdner, American pediatrician  Benjamin Spock  argued in favor of circumcision in his popular  The Common Sense Book of Baby and Child Care  which led to rates in the United States significantly rising. In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision, leading to drops in the rates of both of those countries. The United States made similar statements in the 1970s but stopped short of recommending against it. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9908", "text": "An association between circumcision and reduced heterosexual HIV infection rates was first suggested in 1986. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9909", "text": "Experimental evidence was needed to establish a causal relationship, so three  randomized controlled trials  were commissioned to exclude other  confounding factors . [ 12 ]  Trials took place in South Africa, Kenya and Uganda. [ 12 ]  All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, so it was considered unethical to withhold the procedure, in light of strong evidence of prophylactic efficacy. [ 12 ] [ 111 ]  WHO assessed these as \"gold standard\" studies and found \"strong and consistent\" evidence from later studies that confirmed the results of the studies. [ 30 ]  A scientific consensus subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations; [ 13 ] [ 9 ] [ 112 ]  the WHO, along with other major medical organizations, have since promoted circumcision of high-risk populations as part of the program to reduce the spread of HIV. [ 30 ]  The  Male Circumcision Clearinghouse  website was created in 2009 by WHO, UNAIDS, FHI and AVAC to provide evidence-based guidance, information, and resources to support the delivery of safe male circumcision services in countries that choose to scale up the procedure as one component of comprehensive HIV prevention services. [ 113 ] [ 114 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9910", "text": "The word  circumcision  is from Latin  circumcidere , meaning \"to cut around\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9911", "text": "Many societies hold  cultural, ethical, or social views on the practice , with perspectives ranging widely. In some cultures, males are generally required to be circumcised shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic and  Druze  faiths and in  Coptic Christianity  and the  Ethiopian Orthodox Church  and the  Eritrean Orthodox Tewahedo Church . [ 19 ] [ 115 ] [ 116 ] [ 117 ] [ 118 ] [ 119 ] [ 120 ]  In contrast, some religions, such as  Mandaeism  and  Hinduism  and  Sikhism , strongly prohibit the practice of routine circumcision. [ 121 ] [ 122 ] [ 123 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9912", "text": "Circumcision is near-universal among Jews. [ 124 ]  The  mitzvah  of circumcision on the eighth day of life is considered among the  most important commandments in Judaism . Barring extraordinary circumstances, failure to undergo the rite is seen by followers of  Judaism  as leading to a state of  Kareth : the extinction of the  soul  and denial of a share in the  world to come . [ 23 ] [ 24 ] [ 94 ]  Reasons for biblical circumcision include to show off \"patrilineal descent, sexual fertility, male initiation, cleansing of birth impurity, and dedication to God\". [ 125 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9913", "text": "The basis for its observance is found in the  Torah  of the Hebrew Bible, in  Genesis chapter 17 , in which a covenant of circumcision is made with Abraham and his descendants. Jewish circumcision is part of the  brit milah  ritual, to be performed by a specialist ritual circumciser, a  mohel , on the eighth day of a newborn son's life, with certain exceptions for poor health. Jewish law requires that the circumcision leaves the glans bare when the penis is flaccid.  Converts to Conservative and Orthodox Judaism must also be circumcised; those who are already circumcised undergo a symbolic circumcision ritual. Circumcision is not required by Judaism for one to be considered Jewish, but mainstream Judaism foresees serious negative spiritual consequences if it is neglected. [ 115 ] [ 126 ]  Circumcision is not considered a  universal moral law  within Judaism. Rather, the commandment to circumcise is seen as only applying to Jewish people. Those who are Gentiles are believed to have a portion in the \"World to Come\" as long as they follow the tenets of the  Seven Laws of Noah . [ 127 ]  There are also certain exceptions for Jews with poor health. [ 128 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9914", "text": "According to traditional Jewish law, in the absence of an adult free Jewish male expert, a woman, a slave, or a child who has the required skills is also authorized to perform the circumcision, provided that they are Jewish. [ 129 ]  However, most streams of non-Orthodox Judaism allow female  mohels , called  mohalot  ( Hebrew :  \u05de\u05d5\u05b9\u05d4\u05b2\u05dc\u05d5\u05b9\u05ea , the plural of  \u05de\u05d5\u05b9\u05d4\u05b6\u05dc\u05b6\u05ea   mohelet , feminine of  mohel ), without restriction. In 1984 Deborah Cohen became the first certified Reform  mohelet ; she was certified by the Berit Mila program of Reform Judaism. [ 130 ]  An increasing number of Jews in the United States have chosen not to circumcise their sons. [ 131 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9915", "text": "All major rabbinical organizations make the recommendation that male infants should be circumcised. The issue of converts remains controversial in Reform and Reconstructionist Judaism; [ 132 ] [ 133 ]  circumcision of converts is not mandatory in either. [ 134 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9916", "text": "Islamic scholars have diverse opinions on the obligatory nature of male circumcision, with some considering it mandatory ( w\u0101jib ), while others view it as only being recommended ( sunnah ). [ 135 ]  According to  historians of religion  and scholars of  religious studies , the Islamic tradition of circumcision was derived from the  Pagan practices and rituals  of  pre-Islamic Arabia . [ 136 ]  Although there is some debate within Islam over whether it is a religious requirement or mere recommendation, circumcision (called  khitan ) is practiced nearly universally by Muslim males. Islam bases its practice of circumcision on the Genesis 17 narrative, the same Biblical chapter referred to by Jews. The procedure is not explicitly mentioned in the Quran, however, it is a tradition established by Islam's prophet  Muhammad  directly (following Abraham), and so its practice is considered a  sunnah  (prophet's tradition) and is very important in Islam. For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self ( nafs ). [ 117 ] [ 118 ] [ 137 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9917", "text": "There is no agreement across the many Islamic communities about the age at which circumcision should be performed. It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age. The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal. Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam. [ 117 ] [ 118 ] [ 137 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9918", "text": "Traditionally, circumcision has not been practiced by Christians for religious reasons, with the practice being viewed as succeeded by  Baptism , with the  New Testament  chapter  Acts 15  recording that Christianity did not require circumcision from new converts. [ 138 ]  Christian denominations generally hold a neutral position on circumcision for prophylactic, cultural, and social reasons, while strongly opposing it for religious reasons. This includes the  Catholic Church , which explicitly banned the practice of religious circumcision in the  Council of Florence , [ 139 ]  and maintains a neutral position on the practice of circumcision for other reasons. [ 140 ]  A majority of other  Christian denominations  take a similar position on circumcision, prohibiting it for religious observance, but neither explicitly supporting or forbidding it for other reasons. [ 140 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9919", "text": "Thus, circumcision rates of Christians are predominately determined by the surrounding cultures which they live in. In some  African  and  Eastern Christian denominations  circumcision is an established practice, [ 25 ] [ 141 ]  and generally boys undergo circumcision shortly after birth as part of a  rite of passage . [ 25 ]  Circumcision is near-universal among  Coptic Christians , [ 142 ]  and they practice circumcision as a rite of passage. [ 2 ] [ 116 ] [ 120 ] [ 143 ]  The  Ethiopian Orthodox Church  calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia. [ 2 ]   Eritrean Orthodox  practice circumcision as a rite of passage, and they circumcise their sons \"anywhere from the first week of life to the first few year\". [ 144 ]  Some Christian churches in South Africa disapprove of the practice, while others require it of their members. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9920", "text": "Circumcision is practiced in many predominantly  Christian countries  and Christian communities. [ 145 ] [ 146 ] [ 147 ]   Christian communities  in  Africa , [ 148 ] [ 149 ]  some  Anglosphere countries , the Philippines, the Middle East, [ 150 ] [ 151 ]  South Korea and  Oceania  have high circumcision rates, [ 152 ] [ 153 ]  while Christian communities in  Europe  and  South America  have low circumcision rates, although none of these are performed out of perceived religious obligation. [ 25 ] [ 154 ]  Scholar Heather L. Armstrong writes that, as of 2021, [update]  about half of Christian males worldwide are circumcised, with most of them being located in Africa, Anglosphere countries, and the Philippines. [ 155 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9921", "text": "Circumcision is widely practiced by the  Druze ; [ 156 ]  Druze practice Druzism, an  Abrahamic , [ 157 ] [ 158 ]   monotheistic ,  syncretic , and  ethnic religion . The procedure is practiced as a cultural tradition, and has no religious significance in the Druze faith. [ 159 ] [ 160 ]  There is no special date for this act in the  Druze faith : male Druze infants are usually circumcised shortly after birth, [ 161 ]  however some remain uncircumcised until the age of ten or older. [ 161 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9922", "text": "Some Druses do not circumcise their male children and refuse to observe this \"common Muslim practice\". [ 162 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9923", "text": "Like Judaism, the religion of  Samaritanism  requires ritual circumcision on the eighth day of life. [ 163 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9924", "text": "Circumcision is forbidden in  Mandaeism , [ 121 ] [ 164 ]  and the sign of the Jews given to  Abraham  by God, circumcision, is considered abhorrent by the  Mandaeans . [ 165 ]  According to Mandaean doctrine, a circumcised man cannot serve as a  Mandaean priest . [ 166 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9925", "text": "Circumcision is not required in  Yazidism , but is practised by some  Yazidis  due to regional customs. [ 167 ]  The ritual is usually performed soon after birth, it takes place on the knees of the ker\u00eef (approximately \"godfather\"), with whom the child will have a life-long formal relationship. [ 168 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9926", "text": "Sikhism  does not require the elective circumcision of its followers and strongly criticizes the practice. [ 123 ] [ 169 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9927", "text": "For example,  Bhagat Kabir  criticizes the practise of circumcision in the hymn of  Guru Granth Sahib . [ 170 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9928", "text": "Some  Australian Aborigines  use circumcision as a test of bravery and self-control as a part of a rite of passage into manhood, which results in full societal and ceremonial membership.  It may be accompanied by body  scarification  and the removal of teeth, and may be followed later by  penile subincision .  Circumcision is one of many trials and ceremonies required before a youth is considered to have become knowledgeable enough to maintain and pass on the cultural traditions.  During these trials, the maturing youth bonds in solidarity with the men.  Circumcision is also strongly associated with a man's family, and it is part of the process required to prepare a man to take a wife and produce his own family. [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9929", "text": "In the Philippines, circumcision is known as \"tuli\" and is generally viewed as a rite of passage. [ 172 ]  An overwhelming majority of Filipino men are circumcised. [ 172 ] [ a ]  Often this occurs, in April and May, when Filipino boys are taken by their parents. The practice dates back to the arrival of  Islam  in 1450. Pressure to be circumcised is even in the language: one  Tagalog profanity  for 'uncircumcised' is  supot , meaning 'coward' literally. A circumcised eight or ten year-old is no longer considered a boy and is given more adult roles in the family and society. [ 174 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9930", "text": "Worldwide, the large majority of polities do not have specific laws concerning the circumcision of males, [ 2 ]  with religious infant circumcision being legal in every country. [ 124 ] [ 179 ]  A few countries have passed legislation on the procedure: Germany allows routine circumcision, [ 180 ]  while non-religious routine circumcision is illegal in South Africa and Sweden. [ 2 ] [ 179 ]  No major medical organization recommends circumcising all males, and no major medical organization recommends banning the procedure. [ 19 ] [ 181 ] [ 124 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9931", "text": "In the academic literature, there is general agreement among both supporters and opponents of the practice that an outright ban would be predominately ineffective and \"harmful\". [ 19 ] [ 124 ] [ 182 ] [ 181 ]  A consensus to keep the procedure within the purview of medical professionals is found across all major medical organizations, who advise medical professionals to yield to some degree to parental preferences in their decision to agree to circumcise. [ 19 ] [ 124 ]  The Royal Dutch Medical Association, which expresses some of the strongest opposition to routine neonatal circumcision, argues that while there are valid reasons for banning it, doing so could lead parents who insist on the procedure to turn to poorly trained practitioners instead of medical professionals. [ 19 ] [ 179 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9932", "text": "During the 2010s, several  right-wing nationalist  parties prominently called for the banning of circumcision. [ 183 ]  Gressg\u00e5rd argued that politicians that supported Norway's proposed circumcision ban debated circumcision in a manner which constituted \" ethnocentrism \". [ 184 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9933", "text": "The cost-effectiveness of circumcision has been studied to determine whether a policy of circumcising all newborns or a policy of promoting and providing inexpensive or free access to circumcision for all adult men who choose it would result in lower overall societal healthcare costs. As  HIV/AIDS  is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce its spread in parts of Africa that have a relatively high infection rate and low circumcision prevalence. [ 185 ]  Several analyses have concluded that circumcision programs for adult men in Africa are cost-effective and in some cases are cost-saving. [ 186 ] [ 187 ]  In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult, [ 55 ] [ 188 ]  with the greatest savings achieved when the procedure is performed in the newborn period due to the lower cost per procedure and greater timeframe for HIV infection protection. [ 189 ] [ 188 ]  Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya, and Uganda, with cost savings estimated in the billions of US dollars over 20 years. [ 185 ]  Hankins  et al.  (2011) estimated that a $1.5 billion investment in circumcision for adults in 13 high-priority African countries would yield $16.5 billion in savings. [ 190 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9934", "text": "The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a different cost setting from Africa in areas such as public health infrastructure, availability of medications, and medical technology and the willingness to use it. [ 191 ]  A study by the CDC suggests that newborn circumcision would be societally cost-effective in the United States based on circumcision's efficacy against the transmission of HIV alone during  coitus , without considering any other cost benefits. [ 1 ]  The American Academy of Pediatrics (2012) recommends that neonatal circumcision in the United States be covered by third-party payers such as  Medicaid  and insurance. [ 1 ]  A 2014 review that considered reported benefits of circumcision such as reduced risks from HIV, HPV, and HSV-2 stated that circumcision is cost-effective in both the United States and Africa and may result in health care savings. [ 192 ]  A 2014 literature review found that there are significant gaps in the current literature on male and female sexual health that need to be addressed for the literature to be applicable to North American populations. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9935", "text": "Collagen induction therapy  ( CIT ), also known as  microneedling ,  dermarolling , or  skin needling , is a  cosmetic  procedure that involves repeatedly puncturing the  skin  with tiny, sterile needles (microneedling the skin). CIT should be separated from other contexts in which microneedling devices are used on the skin (e.g.,  transdermal  drug delivery,  vaccination )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9936", "text": "It is a technique for which research is ongoing, but has been used for a number of skin problems including scarring and  acne . [ 1 ]  Some studies have also shown that when combined with  minoxidil  treatment, microneedling is able to treat hair loss more effectively than minoxidil treatment alone. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9937", "text": "Platelet-rich plasma  (PRP) can be combined with collagen induction therapy treatment in a form of  dermatologic   autologous blood therapy . PRP is derived from the patient's own blood and may contain  growth factors  that increase collagen production. [ 3 ]  It can be applied topically to the entire treatment area during and after collagen induction therapy treatments or injected intradermally to scars. Efficacy of the combined treatments remains in question pending scientific studies. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9938", "text": "More serious safety concerns have been cited for these treatments, popularly known as  vampire facials , when performed in non-medical settings by people untrained in  infection control . [ 6 ] [ 7 ]  The New Mexico Department of Health issued a statement that at least one such business offering vampire facials \"could potentially spread blood-borne infections such as  HIV ,  hepatitis B  and  hepatitis C  to clients\". [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9939", "text": "In April 2024, the CDC announced that three women who had been patients at the Albuquerque, New Mexico, VIP Spa had been diagnosed with HIV after getting \"vampire facials\" there. Another almost 200 former clients and their sexual partners were also tested but were found to not have HIV. No mention was made of any testing for other possible blood-borne infections. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9940", "text": "A  corset  is a support  garment  worn to hold and train the  torso  into the desired shape and  posture . They are traditionally constructed out of fabric with boning made of  whalebone  or steel, a stiff panel in the front called a  busk  which holds the torso rigidly upright, and some form of lacing which allows the garment to be tightened. Corsets were an essential undergarment in European women's fashion from the 17th century to the early 20th century. In the 17th and 18th centuries they were commonly known as \"stays\" and had a more conical shape. This later evolved into the curvaceous 19th century form which is commonly associated with the corset today. By the beginning of the 20th century, shifting gender roles and the onsets of  World War I  and  II  (and the associated material shortages) led the corset to be largely discarded by mainstream fashion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9941", "text": "Since the corset fell out of use, the fashion industry has used the term \"corset\" to refer to undergarments or shirts which, to varying degrees, mimic the look of traditional corsets. While these modern  corsets  and  corset tops  often feature lacing or  boning , and generally imitate a historical style of corsets, they by-and-large have very little, if any, effect on the shape of the wearer's body. Elasticated garments such as girdles and waist trainers are still worn today and serve to compress the waist or hips, although they lack the rigidity of corsets. A  corset brace  is a type of  orthotic  resembling a traditional corset, used to support the lower back in patients with mild to moderate back pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9942", "text": "The word  corset  is a diminutive of the  Old French  word  cors  (meaning \"body\", and itself derived from the  Latin   corpus ): the word therefore means \"little body\". The craft of corset construction is known as  corsetry , as is the general wearing of them. (The word  corsetry  is sometimes also used as a collective plural form of corset). Someone who makes corsets is a  corsetier  or  corseti\u00e8re  (French terms for a man and for a woman maker, respectively), or sometimes simply a  corsetmaker ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9943", "text": "In 1828, the word corset came into general use in the English language. The word was used in  The Ladies Magazine [ 1 ]  to describe a \"quilted waistcoat\" that the French called  un corset.  It was used to differentiate the lighter corset from the heavier stays of the period."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9944", "text": "As the form and purpose of the corset was continually evolving throughout its time as a standard undergarment, there is no way to definitively state how it was worn. While the original purpose of stiffened undergarments was founded in the avoiding of creasing to costly, highly adorned outer garments, [ 2 ]  the most common and well-known use of corsets is to slim the body and make it conform to a fashionable silhouette. For women, this most frequently emphasizes a curvy figure by reducing the  waist  and thereby exaggerating the  bust  and  hips ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9945", "text": "However, in the  Tudor period , corsets, known then as \"bodies\", were worn to achieve a tubular straight-up-and-down shape, which involved minimizing the bust. These bodies, both women's and menswear, were worn into the 16th and 17th centuries and achieved their stiffened shaping through materials including steel, wood, or whalebone, and were constructed of two parts and fastened at the sides. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9946", "text": "These bodies evolved into the  stays  of the 17th century. [ 2 ]  The term corset emerged later, around the end of the 18th century. [ 3 ]  Stays were an integral part of fashionable women's underclothing in  the West . Shaping the body to fit the desired silhouette, which, for example, in the 1780s resembled a conical shape, stays of the 18th century ensured good posture \u2013 the central aim of such undergarments of this period, rather than accentuating the bust, for example. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9947", "text": "During the late 1700s up until the 1820s, in reflection of the neoclassical style of dress, the demi-corset or short stays were popularised, [ 3 ]  as the  empire line  of fashionable gowns did not require support or shaping to the waist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9948", "text": "For men, corsets were sporadically used to slim the figure. From around 1820 to 1835\u2014and even until the late 1840s in some instances\u2014a  wasp-waisted figure  (a small, nipped-in look to the  waist ) was also desirable for men; [ citation needed ]  wearing a corset sometimes served to achieve this. However, by the mid-1800s onward, men's corsets fell out of favor, and were generally considered effeminate and pretentious. [ 5 ] :\u200a227"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9949", "text": "An \"overbust corset\" encloses the torso, extending from just under the arms toward the hips. An \"underbust corset\" begins just under the breasts and extends down toward the hips. A \"longline corset\"\u2014either overbust or underbust\u2014extends past the  iliac crest , or the hip bone. A longline corset is ideal for those who want increased stability, have longer torsos, or want to smooth out or minimize the hips. This style was common during the 1910s, when slim hips came into vogue, and later evolved into the elasticated  girdle . [ 6 ]  A \"standard\" length corset will stop short of the iliac crest and is ideal for those who want increased flexibility or have a shorter torso. Some corsets, in very rare instances, reach the  knees . A shorter kind of corset that covers the  waist  area (from low on the ribs to just above the hips), is called a  waist cincher . A corset may also include  garters  to hold up  stockings ; alternatively, a separate  garter belt  may be worn."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9950", "text": "Traditionally, a corset supports the visible dress and spreads the pressure from large dresses, such as the  crinoline  and  bustle . At times, a corset cover is used to protect outer clothes from the corset and to smooth the lines of the corset. The original corset cover was worn under the corset to provide a layer between it and the body. Corsets were not worn next to the skin, possibly due to difficulties with laundering these items during the 19th century, as they had steel boning and metal eyelets that would rust. Light linen or cotton shifts (also called chemises) were worn beneath corsets to absorb sweat and protect the corset and wearer from each other, and also to function as underwear and protect other garments from the wearer and their sweat. The corset cover was generally in the form of a light chemisette, made from cotton lawn or silk. Modern corset wearers may wear corset liners for many of the same reasons. Those who lace their corsets tightly use the liners to prevent burn on their skin from the laces."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9951", "text": "Aside from fashion and medical uses, corsets are also used in  sexual fetishism , most notably in Bondage/Discipline/Sado-Masochism ( BDSM ). In BDSM, a  submissive  may be required to wear a corset, which would be laced very tightly and restrict the wearer to some degree. A  dominant  may also wear a corset, often black, but for entirely different reasons, such as aesthetics. A specially designed corset, in which the  breasts  and  vulva  are exposed, can be worn during \" vanilla sex \" or  BDSM  activities. Dress historian  David Kunzle  argues in his work  Fashion and Fetishism  that historical usage of the corset had a fetishistic dimension as some wearers reported feeling sexual pleasure from the use of the garment, and the corseted waist was highly sexualized by men and women alike. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9952", "text": "A  corset brace  is a  lumbar  support that is used in the prevention and treatment of lower-back pain. They can also be prescribed to patients healing from spinal surgery. A corset brace resembles a historical corset, but is typically made with elastic fabric and plastic boning to allow for more flexibility. Metal boning may be used if more rigidity is needed. [ 8 ] [ 9 ]  Artist  Andy Warhol  was shot in 1968 and never fully recovered; he wore a corset for the rest of his life. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9953", "text": "Corsets are typically constructed of a stiff material, such as buckram, structured with  boning  (also called ribs or stays) inserted into channels in the cloth or leather. In the 18th and early 19th century, thin strips of  baleen  (also known as whalebone) were favoured for the boning. [ 11 ] [ 12 ]   Plastic  is the most commonly used material for modern corsets and the majority of poor-quality corsets. Spring and/or spiral steel or synthetic whalebone is preferred for stronger and generally better quality corsets. Other materials used for boning have included  ivory ,  wood , and cane."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9954", "text": "Corsets are held together by lacing, usually (though not always) at the back. Tightening or loosening the lacing produces corresponding changes in the firmness of the corset. Depending on the desired effect and time period, corsets can be laced from the top down, from the bottom up, or both up from the bottom and down from the top, using the bunny ears lacing method. Victorian corsets also had a buttoned or hooked front opening called a  busk . If the corset was worn loosely, it was possible to leave the lacing as adjusted and take the corset on and off using the front opening. (If the corset is worn snugly, this method will damage the busk if the lacing is not significantly loosened beforehand)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9955", "text": "In the 1660s, the manufacture of stays, as they were known during the period, began to emerge as its own profession in France. These craftsmen were known as staymakers. The work was specialized and generally considered men's work, although women often assisted in the construction process sewing together pieces cut and fitted by men. Women were excluded from staymaker's guilds, and the work was considered too strenuous for women to do correctly. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9956", "text": "By the 19th century, corsets became one of the first garments to be manufactured in factories via assembly line. Each step was performed by a different group of people, often children. Heavy or messy work was done in house, such as cutting the fabric pieces and  japanning  the steels to prevent rust, and lighter work, such as sewing the bones in place, was taken home by  piece workers , generally women who enlisted their children to help them. Workers in corset factories were among the most poorly-paid in London, and frequently could not make enough to meet their daily living expenses. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9957", "text": "Although the corsetmaking industry was dominated by men, a number of woman designers and inventors became known for their work in this field. Among them included  Roxey Ann Caplin , who consulted her physician husband to create corsets with respect to modern knowledge of female  anatomy . The field of corsetmaking was one in which new designs were continually submitted and  patented , often with the desire to create ever stronger or stiffer corsets that were less likely to break. [ 5 ] :\u200a26\u201328"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9958", "text": "In the past, a woman's corset was usually worn over a  chemise , a sleeveless low-necked gown made of washable material (usually  cotton  or  linen ). It absorbed  perspiration  and kept the corset and the gown clean. In modern times, a tee shirt, camisole, or corset liner may be worn. In the late Victorian period, as anxiety around the health effects of corseting increased, the \"health corset\" became popularized, typically featuring woolen lining and other features such as elasticated panels or steel watch springs instead of steel strips for boning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9959", "text": "The invention of the steel  eyelet  in 1827 was a major turning point in the history of the corset, and allowed wearers to lace their corsets significantly more tightly without damaging the garment. [ 5 ] :\u200a13\u200a  Dress historian David Kunzle maintains that tightlacing was largely the domain of middle to lower-middle-class women hoping to increase their station in life; he estimates that the average corseted waist size of the 1880s was approximately 21 inches (53\u00a0cm), with an uncorseted waist size of about 27 inches (69\u00a0cm). [ 7 ]  A corseted waist of 19 inches (48\u00a0cm) was considered \"standard\" and one of 13 inches (33\u00a0cm) \"severe\" but not unheard of. [ 14 ] [ 15 ]   Statistics from 1888 indicate that the average waist size had decreased over the past 25 years, attributed to tightlacing itself as well as the lowered respiration and food intake permitted by tightlacing. [ 5 ] :\u200a248\u2013249\u200a  Modern wearers are unlikely to achieve the same degree of reduction that was recorded in historical usage since the corset was usually begun during the early teen years or even before. The slimmest waist sizes on record should be contextualized with the fact that they were seen in teenage girls, and may have been reserved for special occasions. [ 16 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9960", "text": "In 1895,  The West Australian  published an account purporting to be from the early 1860s, the diary of a student at an all-girls  boarding school  which described how their school madams trained girls to achieve waists ranging from 14 inches (36\u00a0cm) to 19 inches (48\u00a0cm); the narrator herself reports a reduction from 23 inches (58\u00a0cm) to 14 inches (36\u00a0cm), and a subsequent interview with a corsetmaking firm corroborated that such sizes were not unusual during that period. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9961", "text": "Until 1998, the  Guinness Book of World Records  listed  Ethel Granger  as having the smallest waist on record at 13 inches (33\u00a0cm). [ 17 ]  After 1998, the category changed to \"smallest waist on a living person\".  Cathie Jung  took the title with a waist measuring 15 inches (38\u00a0cm). Other women, such as  Polaire , also have achieved such reductions: 16 inches (41\u00a0cm) in her case.  Empress Sisi  of Austria was known to have a very slender waist at 16 inches."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9962", "text": "The negative physical effects of corseting have become widely known, including a variety of myths. For example, the idea that Victorian women frequently underwent  rib removal  to achieve a smaller waist is baseless. [ 13 ]  However, wearing a corset does affect a number of bodily functions and can be deleterious to the wearer's health, especially when worn regularly over a long period of time; during the Victorian era stays were typically begun at or before the onset of puberty, with reported ages ranging from 7 to 13. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9963", "text": "Moderately laced corsets have been demonstrated to reduce  lung capacity  anywhere from 2 to 29%, with an average of 9%, and can cause an increase in shortness of breath during moderate exercise such as dancing. Doctors warned corseted women against \"everything that [was] worthy of the name exercise\" to avoid strain, [ 13 ] :\u200a70\u201371\u200a  although some guides were written on light calisthenics to be done by young women who would presumably be wearing corsets. Typical exercises included stretching, dance steps, and skipping, largely focusing on moving the limbs and balancing. [ 18 ]  As women's social freedom increased during the second half of the 19th century, sport corsets began to be sold, designed for wear while  bicycling , playing  tennis , or horseback riding. These designs typically incorporated some form of elastic panelling or mesh. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9964", "text": "Corsets were widely thought to contribute to  tuberculosis . Prior to the advent of  germ theory , some thought corsets directly caused the disease, as women were significantly more likely to contract and die from the disease than men in this era. Others thought corsets contributed to TB deaths due to impairment of lung function. [ 14 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9965", "text": "Corsets are known to contribute significantly to  muscle wasting  in the core and back when worn over long periods of time. Although they temporarily relieve back pain, muscle atrophy due to disuse will lead to increased lower-back pain and eventually perpetual reliance on the corset. [ 13 ]   Forceps delivery  was standard during this period, which could be due to  atrophy  of the abdominal muscles caused by lifelong corset usage. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9966", "text": "Skeletal analyses have found that the usage of corsets had a significant effect on the form of the spine, ribs, and hips. [ 15 ] [ 19 ] [ 20 ]  However, the consequences of this change are not fully agreed upon by researchers. Underdevelopment of the pelvic inlet may have contributed to difficulties in birth. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9967", "text": "A significant source of the controversy surrounding corsets was their ability to affect the reproductive system due to the downward pressure created by displacement of organs. [ 5 ]  One Doctor Lewis writes in an 1882 edition of  The North American Review : [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9968", "text": "A girl who has indulged in tight lacing should not marry. She may be a very devoted wife, yet her husband will secretly regret his marriage. Physicians of experience know what is meant, while thousands of husbands will not only know, but deeply feel the meaning of this hint."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9969", "text": "This quote alludes to problems with the reproductive organs experienced by women who  tightlaced , and demonstrates the difficulties of explaining this issue due to  Victorian taboos  around discussing sexuality. Reformist and activist  Catharine Beecher  was one of the few to defy propriety norms and discuss in any detail the gynecological issues resulting from lifelong corset usage, in particular  uterine prolapse . [ 22 ] [ 23 ]  Corsets were usually worn during pregnancy, often as long as possible, to suppress and disguise the appearance of the growing fetus. [ 13 ] :\u200a76\u200a  Obstetrician and writer  Alice Bunker Stockham  campaigned against the widespread practice of wearing corsets during  pregnancy , writing sardonically: \"The corset should not be worn for two hundred years before pregnancy.\" [ 22 ]  Feminist historian Leigh Summers theorized that some of the moral panic came from the common but unspeakable idea that tightlacing could be used to induce an  abortion . [ 5 ]  Doctors often attributed the difficult births many Victorian women experienced to corsets, widely believing that \"primitive\" women who wore less restrictive garments had less painful births and were overall healthier and more vigorous. [ 5 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9970", "text": "Modern skeletal analyses indicate that corseting, particularly during pre-puberty (most girls began corseting around 7 or 8), led to underdevelopment of the  pelvic inlet , which is consistent with reported difficulties in birth, although studies into this topic have been mixed. [ 20 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9971", "text": "Uterine prolapse  was a significant danger exacerbated by corsets, the incidence of which correlated with widespread corset wearing. [ 13 ] [ 14 ]  Both  rectal  and uterine prolapse occurred at a higher incidence during the Victorian era than today, with occurrences declining as the corset fell out of fashion. [ 14 ]  An 1888 doctor reported that \u201cuterine derangement had increased fifty percent within the last fifteen years as a result of tight clothing, corsets and high heels.\" [ 5 ] :\u200a113\u200a  This era saw the development of a number of  pessaries  and other devices patented to support the prolapsed uterus, the insertion of which frequently led to further complications; the topic was a subject of wide professional discussion among  gynecologists . [ 5 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9972", "text": "Corset wearing is known to decrease the size of the stomach and disturb digestion, potentially leading to constipation or indigestion. The downward pressure on the pelvic floor can also lead to  urinary incontinence , similar to that experienced during pregnancy. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9973", "text": "Chlorosis is a now-outdated term which referred to a disease thought to be caused directly by corsets, now thought to be  hypochromic anemia . The illness, also known as green sickness, was associated with the onset of  menarche  and fell under the umbrella of \"female complaints\": problems attributed to the increasing demands that puberty brought onto the frail female body. [ 5 ]  The physician  Frederick Parkes Weber  posited that the disease may have been caused by corset wearing, noting that the illness never appeared in boys, that fat rather than thin girls were more likely to experience it, and that prolonged bed rest seemed to resolve the symptoms, while trips to the sea (during which corsets would still be worn) did not. [ 5 ] :\u200a111"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9974", "text": "For nearly 500 years, bodies, stays, or corsets with boning made of reeds,  whalebone , or metal were a standard part of European women's fashion. Researchers have found evidence of the use of corsets in the  Minoan civilization  of early  Crete . [ 25 ] :\u200a5"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9975", "text": "In the late 16th century, what would later be known as the corset was called \"a pair of bodys.\" [ 26 ]  It consisted of a simple  bodice , stiffened with boning of reed or whalebone. [ 25 ] :\u200a6\u200a  A busk made of wood, horn, whalebone, metal, or ivory further reinforced the central front and created an upright posture. It was most often laced in the back, and was, at first, a garment reserved for the aristocracy. Later, the term \"pair of bodies\" would be replaced with the term \"stays\" and was generally used during the 17th and 18th centuries. Stays shaped the upper torso into a cone or cylinder shape. [ 27 ]  In the 17th century, tabs (called \"fingers\") at the waist were added."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9976", "text": "Stays evolved in the 18th century, during which whalebone was used more, and increased boning was used in the garment. The shape of the stays changed as well. While they were low and wide in the front, they could reach as high as the upper shoulder in the back. Stays could be strapless or use shoulder straps. The straps of the stays were generally attached in the back and tied at the front."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9977", "text": "The purpose of 18th century stays was to support the bust and confer the fashionable conical torso shape, while drawing the shoulders back. At that time, the eyelets were reinforced with stitches and were not placed across from one another, but staggered. That allowed the stays to be spiral laced. One end of the stay lace was inserted into the bottom eyelet and knotted, and the other end was wound through the eyelets of the stays and tightened on the top. \"Jumps\" were a variant of stays, which were looser, had no boning, and sometimes had attached sleeves, like a jacket. [ 25 ] :\u200a27\u200a  Women of all levels of society wore stays or jumps, from ladies of the court to street vendors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9978", "text": "Corsets were originally quilted waistcoats, which French women wore as an alternative to stiff stays. [ 25 ] :\u200a29\u200a  They were only quilted linen, laced in the front, and unboned. That garment was meant to be worn on informal occasions, while stays were worn for court dress. In the 1790s, stays began to fall out of fashion. That coincided with the  French Revolution  and the adoption of  neoclassical  styles of dress. In the late 18th and early 19th centuries, some men were known to wear corsets, particularly the widely mocked  dandies . [ 25 ] :\u200a36"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9979", "text": "In the early 19th century, when gussets were added for room for the bust, stays became known as corsets. They also lengthened to the hip, and the lower tabs were replaced by gussets at the hip and had less boning. In the 1820s, fashion changed again, with the waistline lowered to almost the natural position. That was to allow for more ornamentation on the bodice, which, in turn, saw the return of the corset to modern fashion. Corsets began to be made with some padding, for a waist-slimming effect, and more boning. Some women made their own, while others bought their corsets. Corsets were one of the first mass-produced garments for women. They began to be more heavily boned in the 1840s, and the shoulder straps were eliminated. By 1850, steel boning became popular."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9980", "text": "With the advent of metal eyelets in 1827, tightlacing became possible. The position of the eyelets changed. They were situated opposite one another at the back. The front was fastened with a metal  busk . The corsets of the 1850s\u20131860s were shorter, because of a change in the silhouette of women's fashion, with the advent of the  hoop skirt  or  crinoline . After the 1860s, as the crinoline fell out of style, the corset became longer, to shape the abdomen, exposed by the new lines of the princess or  cuirass  style."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9981", "text": "In 1855, a woman named Frances Egbert had trouble with her corsets, due to the front steel pieces constantly breaking as a result of strain. [ 28 ]  Consequently, her husband, Samuel Barnes, designed \"reinforced steels\" for Egbert's corsets. Barnes filed a patent for the invention 11 years later, and Egbert collected the royalties on this patent for 15 years following his death. [ 28 ]  Following the case of  Egbert v. Lippmann , the US Supreme court deemed Barnes's and Egbert's  patent  as \"public\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9982", "text": "The new practice of  tight-lacing  instigated widespread controversy.  Dress reformists  claimed that the corset was prompted by vanity and foolishness, and harmful to health. The reported health risks included damaged and rearranged internal organs, compromised fertility; weakness and general depletion of health. Those who were pro-corset argued that it was required for stylish dress and had its own unique pleasures; dress historian David Kunzle theorized that some enthusiastic fans of tightlacing may have experienced sexual pleasure when tightlacing, or by  rubbing  against the front of the corset, which contributed to the moral outrage against the practice. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9983", "text": "The corset controversy was also closely tied to notions of  social Darwinism  and  eugenics . The potential damage to the uterus, ovaries, and fetus was frequently pointed to as a danger to the race; i.e., the  European  race. Western women were thought to be weaker and more prone to birth complications than the ostensibly more vigorous, healthier, \"primitive\" races who did not wear corsets. Dress reformers exhorted readers to loosen their corsets, or risk destroying the \"civilized\" races. [ 5 ] :\u200a135\u200a  On the other hand, those who argued for the importance of corsets cited Darwinism as well, specifically the notion that women were less evolved and thus frailer, in need of the external support of a corset."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9984", "text": "The reformers' critique of the corset was one part of a throng of voices clamoring against  tightlacing . Doctors counseled patients against it and  journalists  wrote articles condemning the vanity and frivolity of women who would sacrifice their health for the sake of fashion. Although for many, corseting was accepted as necessary for health, propriety, and an upright military-style  posture , dress reformers viewed tightlacing, especially at the height of the era of  Victorian morality , as a sign of moral indecency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9985", "text": "American women active in the  anti-slavery  and  temperance movements , with experience in public speaking and political agitation, advocated for and wore sensible clothing that would not restrict their movement, although corsets were a part of their wardrobe. [ 29 ]  While supporters of fashionable dress contended that corsets maintained an upright, \"good figure\", and were a necessary physical structure for a moral and well-ordered society, dress reformers maintained that women's fashions were not only physically detrimental, but \"the results of male conspiracy to make women subservient by cultivating them in slave psychology\". [ 30 ] [ 31 ]  They believed a change in fashions could change the position of women in society, allowing for greater social mobility, independence from men and marriage, and the ability to work for wages, as well as physical movement and comfort. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9986", "text": "In 1873,  Elizabeth Stuart Phelps Ward  wrote:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9987", "text": "Burn up the corsets! ... No, nor do you save the whalebones, you will never need whalebones again.  Make a bonfire of the cruel steels that have lorded it over your thorax and abdomens for so many years and heave a sigh of relief, for your emancipation I assure you, from this moment has begun. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9988", "text": "Despite those protests, little changed in fashion and undergarments up to 1900. The primary result of the dress reform movement was the evolution, rather than elimination, of the corset. Because of the public health outcry surrounding corsets and tightlacing, doctors took it upon themselves to become  corsetieres . Many doctors helped to fit their patients with corsets to avoid the dangers of ill-fitting corsets, and some doctors even designed corsets themselves.  Roxey Ann Caplin  became a widely renowned corset maker, enlisting the help of her husband, a physician, to create corsets which she purported to be more respectful of human anatomy. [ 5 ]  Health corsets and \"rational corsets\" became popular alternatives to the boned corset. They included features such as wool lining, [ 34 ]  watch springs as boning, elastic paneling, and other features purported to be less detrimental to one's health."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9989", "text": "In the 1890s,  In\u00e8s Gaches-Sarraute  designed the straight-front corset in response to her patients' gynecological issues which were attributed to wearing corsets. The design was intended to reduce pressure on the abdomen and improve overall health. The new S-curve silhouette created by this design quickly caught on among fashion houses in the early 20th century. [ 35 ]  The style was worn from 1900 to 1908. [ 25 ] :\u200a144"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9990", "text": "The corset reached its longest length in the early 20th century. At first, the longline corset reached from the bust down to the upper thigh. There was also a style of longline corset that started under the bust, and necessitated the wearing of a brassiere, a style that was meant to complement the new silhouette. It was a boneless style, much closer to a modern  girdle  than the traditional corset. From 1908 to 1914, the fashionable narrow-hipped and narrow-skirted silhouette necessitated the lengthening of the corset at its lower edge. Meanwhile, as  bras  began to catch on in the 1910s, fewer and fewer corsets included bust support. The fashionable corsets of this period covered the thighs and changed the position of the hips, making the waist appear higher and wider and the hips narrower, forecasting the \"flapper\" silhouette of the 1920s. [ 35 ]   The new fashion was considered uncomfortable, cumbersome, and required the use of strips of elastic fabric. The development of rubberized  elastic  materials in 1911 helped the girdle replace the corset. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9991", "text": "In 1910, the physician  Robert Latou Dickinson  published \"Toleration of the corset: Prescribing where one cannot proscribe\", in which he investigated the medical effects of corsets, including the displacement and deformation of internal organs. He found that, while some women could wear these garments without apparent harm, the vast majority of users sustained permanent deformations and damage to their health. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9992", "text": "The longline style was abandoned during World War I, in part to save materials for the war effort. In the late 1940s and early 1950s, there was a brief revival of the corset in the form of the  waist cincher  sometimes called a \"waspie\". This was used to give the hourglass figure as dictated by  Christian Dior 's \" New Look \". However, use of the waist cincher was restricted to  haute couture , and most women continued to use girdles. Waspies were also met with push-back from women's organizations in the United States, as well as female members of the British Parliament, because corsetry had been forbidden under rationing during  World War II . [ 34 ]  The revival ended when the New Look gave way to a less dramatically shaped silhouette."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9993", "text": "By the 1960s, the advent of  hippie culture  and youth rebellion led the wasp-waisted silhouette to fall out of favor. Feminist activists protested against the restrictive nature of Dior's designs. [ 38 ]  In 1968 at the feminist  Miss America protest , protestors symbolically threw a number of feminine products into a \"Freedom Trash Can.\" These included girdles and corsets, [ 39 ]  which were among items the protestors called \"instruments of female torture\". [ 40 ]  The 1960s and 1970s saw the rise of popular  fitness culture , and diet, plastic surgery (modern  liposuction  was invented in the mid-1970s), and  exercise  became the preferred methods of achieving a thin waist. [ 41 ]  The  sexual revolution  of the 1960s and 70s brought with it midriff-revealing styles like the  crop top , and many women chose to forgo supportive undergarments like girdles or corsets, preferring a more athletic figure. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9994", "text": "The corset has largely fallen out of mainstream fashion since the 1920s in Europe and North America, replaced by girdles and elastic  brassieres , but has survived as an article of costume. Originally an item of  lingerie , the corset has become a popular item of outerwear in the  fetish ,  BDSM , and  Goth  subcultures. In the fetish and BDSM literature, there is often much emphasis on  tightlacing , and many corset makers cater to the fetish market."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9995", "text": "Outside the fetish community, living history reenactors and historic costume enthusiasts still wear stays and corsets according to their original purpose to give the proper shape to the figure when wearing historic fashions. In this case, the corset is underwear rather than outerwear. Skilled corset makers are available to make reproductions of historic corset shapes or to design new styles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9996", "text": "Since the late 1980s, the corset has experienced periodic revivals, all which have usually originated in haute couture and have occasionally trickled through to mainstream fashion. Fashion designer  Vivienne Westwood 's use of corsets contributed to the push-up bust trend that lasted from the late 1980s throughout the 1990s. [ 34 ]  Those revivals focused on the corset as an item of outerwear rather than underwear. The strongest of the revivals was seen in the Autumn 2001 fashion collections and coincided with the release of the film  Moulin Rouge! , in which the costumes featured many corsets as characteristic of the era. Another fashion movement, which has renewed interest in the corset, is the  steampunk  subculture that utilizes late-Victorian fashion shapes in new ways. In the early 2020s, corset-inspired tops and dresses began to trend as part of the  regencycore  aesthetic, inspired by television series like  Bridgerton  and  The Gilded Age . These designs typically do not incorporate any form of boning. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9997", "text": "Modern historical fiction films and TV shows such as  Bridgerton  have renewed interest in corsets while also drawing attention to potential health risks as actresses including  Emma Stone ,  Cara Delevingne , and  Simone Ashley  have complained about discomfort wearing them during the course of their careers. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9998", "text": "There are some special types of corsets and corset-like devices which incorporate boning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_9999", "text": "A corset dress (also known as hobble corset because it produces similar restrictive effects to a  hobble skirt ) is a long corset. It is like an ordinary corset, but it is long enough to cover the legs, partially or totally. It thus looks like a dress, hence the name. A person wearing a corset dress can have great difficulty in walking up and down the stairs (especially if wearing high-heeled footwear) and may be unable to sit down if the boning is too stiff."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10000", "text": "Other types of corset dresses are created for unique high fashion looks by a few modern corset makers. These modern styles are functional as well as fashionable and are designed to be worn with comfort for a dramatic look."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10001", "text": "A  neck corset  is a type of  posture collar  incorporating  stays  and it is generally not considered to be a true corset. This type of corset and its purpose of improving posture does not have long term results. Since certain parts of the neck are being pulled towards the head, a band in the neck, called the platysmal band, will most likely disappear. [ 45 ]  Like the neck corset, a collar serves some of the same purposes. The neck collar can be worn to allow minimal neck movement after road accidents, and is more accessible and cheap than  physiotherapy . [ 46 ]  However, neck corsets and collars are more often used as a fashion statement or as an element of  BDSM  rather than physiotherapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10002", "text": "Cosmetic surgery , also referred to as  aesthetic surgery , is a surgical procedure which endeavours to improve the physical aspects of one's appearance to become more aesthetically pleasing. [ 1 ]  The continuously growing field of cosmetic surgery is closely linked with  plastic surgery , the difference being, cosmetic surgery is an elective surgery with the sole purpose to enhance the physical features of one's appearance. Plastic surgery is performed in order to rectify defects to reinstate normality to function and appearance. [ 2 ]  Cosmetic surgical procedures are generally performed on healthy functioning body parts, with the procedure being optional not medically necessary. The inevitable aim of cosmetic surgery is to enhance one's image, encompassing reducing the signs of  aging  and/or correction of a believed deviation on one's body in turn it is surrounded by  controversy . Although the implementation of cosmetic surgery within Australian society is growing, the trade has struggled to find its place within the  Australian culture ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10003", "text": "The word \"cosmetic\", originates from the  Greek  term Kosmetike, meaning the \"art of beautifying\". [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10004", "text": "The history of cosmetic surgery can be linked back to that of plastic surgery, as the debate persists, around the blurred lines of the two. [ 4 ]  Plastic surgery originated in 600 BC when  Hindu  surgeons performed  rhinoplasty  with the use of segments of  cheek tissue ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10005", "text": "At the end of the fifteenth century when  syphilis  was prevalent, came the introduction of debatable  reconstructive surgery  to rectify the ill shaped nose, a prominent feature of Syphilis sufferers. The sixteenth century saw an Italian by the name of  Gaspare Tagliacozzi  adopt the method of using upper arm tissue to reconstruct the nose during rhinoplasty, granting him the nickname 'the father of plastic surgery'. Although Tagliacozzi's approach left patients required to have their arm raised to their nose for several months, requiring numerous surgeries, with excessive  Scaring ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10006", "text": "England was exposed to the Hindu techniques of rhinoplasty by a practitioner in 1815, who clearly defined the use for the surgery, limited to those who were physically affected by the horrors of  Napoleonic Wars . Towards the end of the century in the 1880s John Orlando Roe, a New York surgeon, developed a technique which prevented scarring by operating from inside the nostrils."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10007", "text": "World War I  was the most costly war to Australia in regards to  fatality . The brutality sparked the generation of plastic surgery within Australia introduced by a man by the name of  Harold Gillies . Gillies oversaw the development of the first unit to treat the returned battle scared  veterans  of the war. This led to the relocation of the  Red Cross  to the Queen Mary Hospital in  Sidcup , England. The Queen Mary Hospital opened in 1917 was a six hundred bed hospital which focused solely on plastic surgery. It was here that Gillies trained not only Australian plastic surgeons but surgeons from all over the globe. The return of these surgeons to their home countries such as Australia, saw the spread of the plastic surgery trade across the globe. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10008", "text": "The war gave the dishonoured trade a respected name through the treatment and resurrection of returned war veterans, with shattered physical traits. The century gave rise to  anaesthetics  and  Antiseptics  prompting an increase in the number of surgeries being performed. But with this heroic status and development of techniques came the taboo ideology cast upon cosmetic surgery as the trade filtered into the population, with civilians un-pleased with their aesthetic appearance undergoing surgery. [ 5 ]  In turn the need for secrecy arose as people felt the need to hide the truth about their surgical endeavours. From here a surgeon by the name of Henry Junius Schireson, acquired his license to practice throughout multiple states of  America , who became known in 1923 when he performed rhinoplasty on a  Jewish  actress  Fanny Brice  in her New York apartment, [ 6 ]  giving birth to the booming trade of cosmetic surgery for everyday civilians."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10009", "text": "Benjamin Rank was an Australian trained by Gillies himself who in the 1940s governed the  Royal Melbourne Hospital  which was the first plastic surgery unit within Australia. It was in 1956 that plastic surgery was acknowledged by the Royal Australia College of Surgeons as a separate specialty trade of plastic surgery. [ 4 ]  Today, the Australian Society of Plastic Surgeons Inc. founded in 1917, commonly known as ASPS, was founded in 1970 with the aim to uphold the integrity of the plastic surgery field (inclusive of cosmetic and reconstructive surgery) within Australia. Today, the deliverance of the highest quality surgeries is at the forefront of their work. They govern the AMC accredited Surgical Education and Training (SET) Program within Australia. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10010", "text": "The development of different techniques within the field of cosmetic surgery has led to the  innovation  of  non-invasive methods . Nine percent of the Australian population have undergone a non-invasive form of cosmetic surgery. [ 7 ]  Numerous surgeries are now performed using these techniques as opposed to open surgery methods which have been used in the past. This adaptation has led to a reduction in cost, time, scarring and pain involved with these procedures. Through the development of aiding surgical instruments such as a viewing scope or  Lasers  (see below), this shift has been made possible, reducing the incision site resulting in a faster recovery time for patients. [ 8 ]  Examples of non-invasive surgeries are as muscle relaxants, such as  Botox  or  Dysport ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10011", "text": "Another form of laser treatment is  intense pulsed light  (IPL). IPL differs from laser treatment as unlike laser treatments, IPL will perform multiple treatments at once but only a few are capable of doing so with the same potency as a laser.  IPL is predominantly used for mild skin issues in comparison to laser being used for the more extreme cases. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10012", "text": "Due to cosmetic surgery being an elective surgical procedure it is of common assumption that the risk factors around these surgeries are lower than that of other surgeries. The invasive procedures have numerous risk factors as it is still a medical procedure, all of which come with a level of risk. The non-invasive treatments also come with a level of risk although lower than invasive methods. This common impression can be linked to the controversies surrounding the trade as critics struggle to see the link between the benefits and the risk facts. Surgeries are generally linked to, although not restricted to, risk factors affecting the area in which the surgery is performed. Some of the common risks are the development of a  hematoma , organ damage,  deep vein thrombosis ,  seroma , excessive bleeding, swelling, bruising,  ectropion  (optical), blindness (optical), obstruction of airways (nasal), loss of sensation, excessive scarring (including of  keloid scars ), a shift in position of hair line effecting symmetry and nerve damage. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10013", "text": "Most surgeons will suggest to patients electing to undergo cosmetic surgery to cease smoking for a period before and after their alterations. Generally a period of four weeks pre-operative and post operative, to aid in the recovery time and the healing of the wound. Just like other surgeries, cosmetic surgery may require incisions to be made to the skin, in one or more places of the body. These wounds will be required to heal post operation, therefore leaving the patient at risk of poor wound healing which may be due to numerous causes such as infection requiring  antibiotics . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10014", "text": "Medical conditions can impact on the level of risk involved with cosmetic surgery as there can be underlying effects caused by different medications. For example, blood thinning medication can cause excessive bleeding due to the bloods ability to clot being lowered by the medication. All medications prescribed to a patient are noted and discussed by the surgeons to reduce the chance of issues arising. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10015", "text": "The most common reason behind one's choice to undergo cosmetic surgery is due to dissatisfaction with their body image. Body image issues are commonly allied with lower levels of  self-esteem  and  psychological well-being . [ 10 ]  These issues are the cause of many women turning to cosmetic surgery. In today's world viewers are flooded with images and advertisements, showing generally, naturally unobtainable faces and bodies. There is a growing trend of reality television shows broadcasting makeovers of ordinary civilians undergoing cosmetic surgery to enhance their aesthetic image. Viewpoints grow around the link between the climbing figures of cosmetic surgery and the constantly changing world of media. There is a constant stream of connection developed via social media outlets such as Facebook and  Instagram  which hold a high level of importance within people lives. Other viewpoints circle the growth of public awareness of the topic is increasing becoming a direct link to this growth spurt in popularity of surgery. Many of the patients who undergo cosmetic surgery have been found to have low levels of self-esteem and use cosmetic surgery to rectify the issues they have with their body image. Numerous studies have focused on the final outcome of cosmetic procedures and the level of satisfaction which patients have with their results showing a large portion of patients look for additional surgeries to rectify the issue. Cosmetic surgery in a lot of cases will enhances the problems patients have with their self-esteem issues instead of depressing them as first desired. [ 10 ]  Studies show that patients who undergo cosmetic surgery who have been made aware of the risks involved along with the technical side of the procedure, have higher levels of satisfaction with their outcome post-surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10016", "text": "Body dysmorphic disorder  (BDD) is a condition of which people find their own image immensely flawed. It effects both men and women equally, with the average onset age of thirteen years of age. The condition is treatable although there is an alarmingly high rate of suicide within BDD sufferers, one in every three hundred and thirty diagnosed will end their own lives. [ 12 ]  Patients of BDD will commonly turn to cosmetic surgery to rectify these flaws resulting in unsatisfactory results due to their condition. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10017", "text": "Histrionic personality disorder  can be categorised as a person who thrives on being the center of attention in all social settings. They show signs of  attention seeking behaviour  along with instability emotionally. Immense discomfort is felt by the individual when they do not feel they are the epicenter of a group or one on one environment and often struggle when it comes to relationships with others, being both on a level of friendship and sexual relationships. [ 13 ]  Suggestions have been made in regards to the need for screening before cosmetic surgeries are performed on patients who suffer from disorders such as histrionic personality disorder as the level of satisfaction which is felt by individuals post-surgery is low, triggering the desire for additional treatments. The surgery impacts on their self-esteem leaving them higher levels of distressed post-op. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10018", "text": "The controversies surrounding cosmetic surgery are plentiful. The stigma that exists around the practice has been evident since its introduction into the  modern world . The taboo stigma around these types of surgery is beginning to fade as we see the trend of cosmetic surgery growing. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10019", "text": "The age limitations around cosmetic surgery within Australia is eighteen years of age until one is eligible to opt to undergo cosmetic surgery. [ 14 ]  There is numerous discussions occurring around the use of cosmetic surgery within children which have undergone extensive  trauma  due to a catastrophic life event or birth defects, in turn patients seek cosmetic surgery to rectify the issue. The debate around whether this is ethically correct exists with the viewpoint that this is unethical and the surgeries are for the purpose of vanity. Other sides of the debate argue for the lasting impacts on the children during adolescent years due to the dis-figuration causing prejudice and view the surgical procedures will attribute to the child's mental health in later years. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10020", "text": "In 2011, concerns were expressed as information arose in regards to the quality of the material being used in silicone breast implants. Industrial grade silicone was being used in the replacement of medical grade supplies by a French firm by the name of  Poly Implant Prothese  (PIP). The silicone being used was found to be suitable for uses within the production of mattresses. [ 15 ]  In 2011, it was reported that in twelve years of production, more than 300,000 PIP implants were sold globally. [ 16 ]  In the case of rupture the dispute around safety risks arose with parties debating the increase cancer risks due to the poor grade materials. To date there has been no scientific evidence proving the implants should cause safety concerns linking to toxicity or cancer. The debate surrounds whether the removal of the implants is required due to safety concerns around rupture and toxicity. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10021", "text": "Concerns are sparked within Australia around the level of regulation which exists around the implementation of laser and IPL treatments. The practice has little federal regulated with inconsistencies existing between the states within Australia. It is largely debated around the level of regulation in comparison to the heavy controls placed around the use of  schedule 4 drugs  such as Botox or Dysport. Many rally for the investigation into the uses of these techniques, claiming long term damage can be a result of mistreatment. The authority involved in the monitoring these regulations within Australia is the  Department of Health , the  Therapeutic Goods Administration . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10022", "text": "Cosmetic surgery  refers to the process, methods, and theories focusing on the enhancement of a person's physical appearance. [ 1 ] [ 2 ]  In  China , there are over 10 million people who have undergone cosmetic surgery, 8.5 million of them are under 30 years old. [ 3 ]  The intensifying fixation with physical beauty has escalated the demand for cosmetic surgery in recent years. The influence of Korean pop stars and other celebrities, and social media have significantly prompted young people to undergo these surgeries. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10023", "text": "The roots of modern cosmetic surgery in China goes back to a plastic surgeon called Song Ruyao. As a medical student during the  Second Sino-Japanese war , he was sent to the University of Pennsylvania in 1943 to study reconstructive  plastic surgery . He is considered the founder of the field in China, which would later include cosmetic surgery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10024", "text": "Very few cosmetic surgeries took place before the  Chinese Communist Revolution . During the  Cultural Revolution , cosmetic surgeries were condemned as \"bourgeois\" for its focus on exterior form over practicality or function. [ 5 ]  In the 1980s, as cosmetic surgeries started becoming more acceptable, they also saw a rapid increase. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10025", "text": "In 1994, cosmetic surgery was introduced in  Beijing  and since then, the market has significantly evolved. In 2004, a beauty pageant where only contestants who had gone under the knife could enter crowned China's first \"Miss Plastic Surgery\". [ 6 ] [ 7 ]  In 2010, Beijing's  China-Japan Friendship Hospital  catered to a total of 20,000 to 30,000 people in its  plastic surgery  department, and the numbers consistently rose over the years. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10026", "text": "Students make up the bulk of cosmetic surgery patients under 30 and estimates show that there are 20 million people in China who have had cosmetic surgery. [ citation needed ]  In 2014 alone, over 7 million people, mostly young women, had cosmetic surgery, when the country's cosmetic surgery industry was valued at RMB400 billion. [ 9 ]  For every 100 buyers of medical beauty products, 64% per were from the post \u201990s, followed by 19% of millennials. Reports also indicate an estimate of 100,000 cosmetic surgeons, of which only 10% were licensed. This signifies that 90% of facial surgery operations are carried out outside official medical systems. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10027", "text": "China\u2019s cosmetic surgery industry soared from RMB 87 billion in 2015 to RMB 176 billion in 2017 [ 11 ]  and currently continues to rise. It is the world\u2019s 3rd largest cosmetic surgery market in 2018 [ 12 ]  and recent studies conducted by  HSBC  foresee an increase in its market size by 2019. Forecasts also reveal a boost in total spending of up to 800 million  RMB  ($122 million US) with the potential to reach 20.6 billion U.S. dollars by 2020. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10028", "text": "The rise of the middle class in Chinese society is one reality behind China's escalating cosmetic surgery industry. The increase in the  purchasing power of over 350 million Chinese raised the level of people's standards of living allowing them to aspire for other luxuries and life standards. [ 14 ]  Based on statistics culled from the  Chinese Association of Plastics and Aesthetics  in November 2015, the country's plastic surgery sector has grown rapidly with an annual growth rate of 30%. Likewise, it has changed the definition of plastic surgery. The practice is no longer confined to improving the looks of people with disfigured faces resulting from accidents and injuries; it now like getting the \"icing on the cake\" for inherently good looking people. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10029", "text": "Another driver is pressure on social media. Beauty applications play an influential role in these \u201cmedia demands\u201d  as many of these platforms put forward  opportunities to alter or \u201cimprove\u201d one's  face. These application propose their own standard of beauty to users which all the more ignites the pressure that these people feel when they start comparing their \u2018before and after\u2019 photos. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10030", "text": "The influence of Korean culture is another dynamic prompting the high number of Chinese citizens to avail of cosmetic surgery. This is due to the increasing popularity of the  Korean Wave  through Korean dramas and television shows which have become a hit in China. Since cosmetic surgery is common in Korea, entertainment personalities\u2014with theirunbridled eyes [ clarification needed ] , V-shaped jaw, and prominent cheekbones\u2014have greatly influenced the Chinese people. These same Korean influences are found on the skin care market, where a perfect and white skin is a must for any woman wishing to convey a beautiful image of oneself. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10031", "text": "Cosmetic surgery  is voluntary or elective surgery for beauty enhancement. [ 1 ]  The motivation for plastic surgery has been debated throughout Korean society. Holliday and Elfving-Hwang suggest that the pressure of success in work and marriage is deeply rooted in one's ability to manage their body which is influenced by beauty. [ 2 ]  As companies helping with matchmaking for marriage and even job applications require a photo of the individual, Korean population inevitably feels pressure to undergo plastic surgery to achieve the \"natural beauty\". [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10032", "text": "South Korea has emerged as a major destination for medical tourism. Over the past four years, the number of foreign patients who visited plastic surgery clinics was 190,000, with Thailand and China accounting for the largest number. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10033", "text": "According to ISAPS data as of 2021, South Korea has estimated the highest number of plastic surgery cases per capita in the world. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10034", "text": "The modern Korean interest in appearance dates back to the 7th century, finding its roots in  physiognomy  ( gwansang) . The concept of connecting identity and appearance became stronger during the  Japanese colonial period in Korea , as Japanese rulers believed that certain facial features displayed greater intelligence and nobility. After that, plastic surgery technique brought by American doctors during the Korean War and accepted the Western notion that changing one's face would change one's destiny. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10035", "text": "Due to the  1997 Asian financial crisis , South Korea deregulated the labor market; [ 7 ]  Korean citizens tried all they could to get an edge over competitors for a job position, including cosmetic surgery. [ 6 ]  This still happens in the current day, as companies require a photo, height, and sometimes the family background of applicants as a part of the hiring process. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10036", "text": "Over the past few decades, plastic surgery has become more accepted in Korea. For example, 66% of respondents in 2015 expressed that a woman can get plastic surgery for marriage, compared to 38% in 1994. [ 9 ]  The proportion of women who reported that they had undergone plastic surgery also climbed from 5% in 1994 to 31% in 2015. Women consistently score higher and are more supportive about the procedures than men. According to a Statista survey in 2020 which interviewed a total of 1,500 people, plastic surgery is prevalent among young women in South Korea. Nearly 25% of women aged 19\u201329 have undergone plastic surgery, while men have only undergone surgery 2% of the time. This number increases to 31% of women and 4% of men among 30\u201339-year-olds. [ 10 ]  A case study by Allure Magazine noted that in recent years, the percentage rate of males who underwent plastic surgery increased and consisted as much as 30% of cases of those who underwent the procedure. [ 11 ]  The expectation of undergoing cosmetic surgery is not restricted to urban areas and has spread to rural towns, in part due to the popularity of  K-pop idols  such as  Wonder Girls  and  Girls' Generation . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10037", "text": "South Korea is frequently called the \"plastic surgery capital of the world\". [ 13 ] [ 14 ]  Cosmetic surgery in South Korea is commonplace, if not a common graduation gift. [ 15 ]  South Korea's cosmetic surgery is a market leader, with South Korea taking a 25% share in the global market. [ 16 ]  One in five Korean women have undergone plastic surgery, compared to just one in twenty in the United States. [ 17 ]  In 2018, a total of 464,452 patients visited South Korea for cosmetic surgery, a 16.7 percent increase from 2017. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10038", "text": "In the Korean surgery market, there are two providers: Hospitals and Specialty Clinics and Spas and Cosmetic Surgery Centers. [ clarification needed ]  In 2021, the market was valued to 1.95\u00a0billion US dollars. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10039", "text": "This form of cosmetic surgery is also known as the \" double eyelid surgery \". It is a surgery that reshapes the skin around the eye, resulting in a crease on the upper eyelid. The procedure is popular not just in South Korea but also other Asian countries like Taiwan and India."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10040", "text": "The double eyelid surgery can be done in several ways, with the main difference being the form of incision. The full incision is often done to patients with excess fat and skin in the upper eyelid, a partial incision is done when there is only excess fat in the eyelid, while there is no incision used when there is no excess fat and skin. The surgery is not considered painful and it can take up to 4 weeks to fully recover. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10041", "text": "Asian facial skeletal contouring surgeries, also known as V-Line surgeries, are often done to reduce the dimension or angularity of the cheekbones or the jaw in order to create a V shape. They are commonly found among young Korean pop stars and can give the face an elf- or childlike appeal. [ 12 ]   K-pop  groups like created a trend for the V-shaped face among young girls, as it is seen as an attractive feature. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10042", "text": "A surgery can involve several related procedures:  zygomatic reduction , V-Line surgery, mandibular contouring, and sagittal osteotomy of  mandible . Zygomatic reduction involves fracturing the  zygomatic arch , reshaping and re-orienting the bone so that it protrudes less to the side. During a V-Line surgery, incisions are made through the mouth. The chin is then fractured and reduced, and the jaw bone is shaved. Mandibular contouring is similar but does not involve the chin. Sagittal osteotomy reduces the width of the jaw bone. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10043", "text": "The pain following surgery ranges from mild to extreme. The jaws may be wired together for weeks, and it can take six months for the swelling to completely disappear, although it is most significant during the first 72 hours. [ 12 ] [ 21 ]  A maxillofacial surgeon and former professor at  Columbia University  said the V-Line surgery is complex and carries risks of permanent numbness and death. [ 12 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10044", "text": "Examples of Korean celebrities that have undergone a \" nose job \" include  Kim Hee-chul ,  Jessi , and  Soyou . [ 23 ]  A popular member from Apink Hyoyeon has undergone rhinoplasty and other procedures during her time as an idol. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10045", "text": "The surgery can be performed open and closed. The open procedure is the most popular as it gives the surgeon more visual context. It requires an incision in the  columella , which often heals without any issues and leaves a minor scar that should be difficult to spot. Once the procedure is done, it takes a few weeks to heal completely. [ 25 ]  In a closed surgery, all the incisions are made inside of the nose. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10046", "text": "In South Korea, rhinoplasty is the second least common surgery among ethnic Koreans. [ 27 ]  The procedure is sometimes be performed in a health context as well, as restructuring the nose can also make it easier to breathe. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10047", "text": "Face-whitening injections have also started becoming more popular as a pale skin fits within the  Korean beauty standards . [ 28 ]  The active ingredients in these injections is  glutathione . The procedure last 20 minutes. Some negative effects from the procedure are as following: low blood pressure, rash all over the body, and problems with the digestive system such as nausea or vomiting. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10048", "text": "Medical tourism is the act of attracting foreigners to undergo surgeries. With the rise of popularity of K-drama and K-pop around the world, numerous people opted South Korea to undergo cosmetic surgeries. \"South Korea's plastic surgery business is gaining popularity because of the country's quick, affordable, efficient, safe, and high-quality healthcare system.\" [ 30 ]  In 2019, a total of 211,218 tourists visited South Korea for plastic surgery. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10049", "text": "A  ghost surgery  is a surgery in which the person who performs the operation, the \"ghost doctor,\" is not the surgeon that was hired for and is credited with the operation. The ghost doctor substitutes the hired surgeon while the patient is unconscious from  anesthesia . [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10050", "text": "Ghost surgeries are \"rampant\" in the South Korean cosmetic surgery industry. [ 32 ] [ 33 ] [ 34 ]  Ghost doctors are often unlicensed and unqualified to perform the operations they are hired for, with some plastic surgeries being performed by dentists, nurses, or salespeople; one former ghost doctor reported that most substitutes were dentists. [ 32 ]  The Korean Society of Plastic Surgeons estimated that there were about 100,000 victims of ghost surgery in South Korea between 2008 and 2014. About five patients died during ghost surgeries between 2014 and 2022. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10051", "text": "Ghost surgery is illegal in South Korea, but as there is often no evidence a surgery was performed by a ghost doctor, it is rarely punished in court. [ 33 ]  Public backlash to ghost surgery has led to the mandating of security cameras in operating rooms in South Korea. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10052", "text": "Korea is often criticised for having unrealistic beauty standards, often expecting women to be very thin to the point where their weight can become unhealthy. The \"escape the corset\" movement goes directly against the country's beauty standards and active promotion of beauty products and surgery. [ 37 ]  The movement is intended to create body positivity and reduce the strict standards that women have to live up to in the country."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10053", "text": "A study made by Charlotte N. Markeya and Patrick M. Markeya show there is a correlation between reality television viewing and interest in cosmetic surgery. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10054", "text": "Another study made by Young A. Kim, Duckhee Chae and Hyunlye Kim about  \"Factors Affecting Acceptance of Cosmetic Surgery Among Undergraduate Students\" affirms that the rise of the beauty standards conveyed by television, internet, actors and stars of  K-pop  affect people's mental health by decreasing their self-esteem and increasing their anxiety. The socio-cultural message transmitted by peers reflects the high beauty standards are became the norms. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10055", "text": "A study at Miami University shows that the pressure to get the \"perfect\" appearance can stem from feelings of inferiority if someone sees themselves as less attractive. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10056", "text": "Let Me In  was a controversial South Korean television show that is focused on doing complete make-overs, including plastic surgery. [ 40 ]  Participants have to convince a panel that their appearance makes their life difficult, it even goes as far as making their parents apologise for appearance and lack of plastic surgery. Participants are presented to the audience after their make-over. The show was shut down in 2015 in a response to the amount of controversy and criticism, as the show was blamed for making plastic surgery more attractive to its viewers. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10057", "text": "Employment surgery is a common occurrence in South Korea. Due to a lot of competition in the job market, appearance is considered an important factor when hiring, which pressures people into undergoing surgery to get an edge over their competitors. [ 42 ]  People who are considered more appealing have statistically more chances to \"have\" the job than people who do not fit the beauty standards. This is well known by Koreans and can affect also the mental health of person who are looking for a job with the required qualification but not does not satisfy the beauty qualification. [ 43 ]  According to a 2006 survey, 92.2% of women in South Korea expect to be discriminated based on appearance during a job interview. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10058", "text": "In 2021, a bill was proposed that take action against this culture, banning companies from asking for photos at a r\u00e9sum\u00e9. A survey in 2006 showed that 80% of public companies require personal information like photos. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10059", "text": "Dermaordinology  (from Ancient Greek \u03b4\u03ad\u03c1\u03bc\u03b1 (derma) \u201cskin\u201d, Latin ordin\u0101re, \u201cto put in order\u201d and Ancient Greek \u03bb\u03cc\u03b3\u03bf\u03c2, \u201cknowledge/study\u201d) is a specialised field in  cosmetics  and  medicine  aimed at finding the optimal permanent solution to superficial  skin  defects, such as  hypertrichosis ,  hirsutism , couperosis,  acne ,  milia  and  fibromata . [ 1 ]  Combining findings from  endocrinology  and  dermatology , dermaordinology serves as the basis for the development of innovative micro-surgical methods to safely and painlessly remove these defects without damaging the surrounding skin tissue. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10060", "text": "This  dermatology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10061", "text": "Diary of a Facelift  is the second book by  Toyah Willcox , published in 2005 by  Michael O'Mara Books . It is an autobiographical account of her experiences with  cosmetic surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10062", "text": "Willcox had been contemplating cosmetic surgery ever since she was twenty-six. Her decision was eventually prompted in 2003, at the age of forty-five, when she took part in the  second series  of  I'm a Celebrity...Get Me Out of Here! , after which she received unfavourable media coverage referring to her appearance, particularly a derogatory comment by  Jonathan Ross  on his  BBC Radio 2  show. [ 1 ] [ 2 ]  For three years prior to her  facelift , Willcox had been having regular  botox  injections under her eyes. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10063", "text": "The singer underwent the surgery in Paris in February 2004. It involved lifting her jawline and operating skin around her eyes, and has reportedly cost \u00a37,500. [ 1 ]  Graphic descriptions of the procedure as well as photos of the singer's recovery were included in the book. The cover photos of Toyah were taken by Dean Stockings. Excerpts from the book were published in  The Daily Telegraph  in the lead-up to its official release. [ 4 ]  The book gained a large amount of media interest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10064", "text": "Diary of a Facelift  has generated mixed response in the media. It was described in  Glasgow Evening Times  as \"a truly remarkable account\". [ 5 ]  A negative opinion in  The Guardian  found it \"galling for such an admirable woman to be setting such a bad example to the sisterhood\". [ 6 ]  Despite the controversy, the book reached the top 10 in many booksellers' lists, including  Waterstones ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10065", "text": "EarFold  or  EarFold method  is a surgical method for pinning protruding ears. In contrast to all the other ear-pinning procedures ( otoplasty ), metal implants are used instead of  sutures . As far as the invasiveness of the surgery is concerned, the Earfold method ranks between the open, invasive conventional ear-pinning procedures (6, 7, 8, 9), and the closed, minimally invasive  stitch method  (4, 5) or other variations of minimally invasive procedures (10, 11, 12, 13, 14, 15, 16, 17, 18). The ears are cut open and the skin is detached from the  cartilage  as in conventional ear-pinning operations, but to a lesser extent. Occasionally, the cartilage under the detached skin is also scored or perforated with a needle to weaken it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10066", "text": "The Earfold technique was first described by Norbert V. Kang and Ryan L. Kerstein in 2016 (1). Kang and his colleagues reported on the results and possible complications of the method in 2018 (2)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10067", "text": "One or several incisions of approximately 1\u00a0cm in length are made in the skin on the front of the ear, depending on the number of metal implants to be inserted in the ear. Starting here, the skin on the front of the ear is raised from the cartilage to create pockets in which the metal implants are inserted with the aid of an Earfold introducer 3)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10068", "text": "The metal implants are called Earfolds. They are 5x15 mm large and 0.15\u00a0mm thick. They are made of  Nitinol , an alloy of titanium and nickel, and have a 24-carat gold plating. On the side facing the cartilage, the implants have short, triangular, thornlike tips that penetrate the cartilage and thus fix the implant in place after several weeks. Because of their U-shape, the implants reshape a poorly developed  antihelix  or create a new one if it is non-existent, thereby moving the ear towards the head. The ear cartilage lying beneath the implants is either left intact or is scored or perforated with a needle - the latter is done to weaken it. The patient is allowed to check the new position of his ears in a mirror before the operation by having a Prefold positioner, of the same size, shape and tension as the implant, placed temporarily on the antihelix fold. The extent of the ear pinning is determined by the curvature of the Earfolds and their position along the antihelix. The resulting new head-to-ear distance doesn\u2019t always meet the individual expectations of the patient because it is determined by the constant, preset curvature of the implant. The incisions in the skin are sewn up and covered with a strip of plaster.\nThe method is not suitable for all patients. If their ears have a large, deep Cavum conchae, which in combination with a poorly formed antihelix is often the cause of a protruding ear, ear pinning in the lower half of the ear is not possible or the ear-pinning result is unsatisfactory. Protruding earlobes can\u2019t be pinned.\nIn comparison to the conventional ear-pinning operations (see traditional  ear surgery  and  otoplasty ) and the  Stitch method , there are no publications available on long-term results. The authors of the Earfold method point out that late complications, such as relapse, secondary deformations, defects, shifts in position or rejection of the implants, could only be assessed to a limited degree due to the short follow-up time of the patients in the study carried out (1, 2)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10069", "text": "The patients should not sleep on their ears for the first 4 weeks, so that the metal implants are not shifted out of place. One may not smoke for 3 months, so that there are no circulatory disturbances leading to skin  erosion  of the very thin skin over the implant. Earrings should not be worn for 2 weeks. One should not swim during the first 4 weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10070", "text": "They are comparable to the methods of the traditional otoplasty: irregularities; undesired results; top of ear is pointed (the so-called Spock ear); post-operative bleeding with haematoma in the pockets of the skin; pain; infection; erosion of the skin; allergic reaction to the implants; rejection of the implants;  hypertrophic scars ;  keloid  on the skin incisions; cosmetically disfiguring edge formations on the front of the ear when the implants turn;  asymmetry  in the position of the ears; shifting of the implants in the first weeks when lying on the ears; visibility of the implants under the skin; removal of the implants more complex and difficult than removing sutures with other surgical methods."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10071", "text": "Reference List"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10072", "text": "Epicanthoplasty  is a rare  eye surgery  to modify the  epicanthal folds . It can be a challenging procedure because the epicanthal folds overlay the  lacrimal canaliculi  (tear drainage canals). [ 1 ] \nAlthough an epicanthic fold can also be associated with a less prominent upper eyelid crease (a feature commonly termed \"single eyelids\" as opposed to \"double eyelids\"), the two features are distinct; a person may have both epicanthal folds and an upper eyelid crease, one and not the other, or neither. [ 2 ]  Single eyelids are reshaped using  East Asian blepharoplasty . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10073", "text": "Epicanthoplasty may leave visible post-surgical scar lines. A common corrective technique involves using  Z-plasty .  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10074", "text": "Eyelash implants  are a form of  cosmetic surgery  involving  transplanting  additional  eyelashes  around the  eye .  The process typically involves removing a section of  hair  from the patient, typically from the back of the head, and  grafting  the hair to the eyelids, replacing the existing eyelashes.  The procedure typically involves 60 to 70 hairs per eye, and after removal and a thorough cleaning of the oil on the hair, they are reattached to patient by delicately sewing the lashes back on. Maintenance of the eyelashes is needed thereafter, as the hair continues to grow at the same rate as on other parts of the body. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10075", "text": "Eyelash transplantation is performed on outpatient basis under local anesthesia and takes two to three hours to complete. The steps involved in the surgery are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10076", "text": "Donor area preparation: Firstly donor area \u2013 usually back of the scalp \u2013 is shaved and cleansed to prepare it for the surgery.\nAdministration of anesthesia: Then local anesthesia is administered in the area around the eyelashes.\nHair extraction: After administration of anesthesia, hair follicles are extracted using follicular unit extraction. Grafts with 1 to 4 hair follicles are extracted for eyelash hair transplantation.\nRecipient area preparation: After extraction of hair, surgeon prepares recipient area by administering local anesthesia and making extremely small incisions for implantation of follicles. While preparing recipient site, direction and angle of eyelashes are kept in mind to produce natural looking results.\nGraft implantation: After preparing recipient site, surgeon implants 1 to 2 hair follicles at a time in specific directions. Single procedure usually involves implantation of 30 to 40 hair follicles to get desired density of eyelashes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10077", "text": "Fat transfer , also known as  fat graft ,  lipomodelling , or  fat injections , [ 1 ] [ 2 ]  is a surgical process in which a person's own fat is transferred from one area of the body to another area. The major aim of this procedure is to improve or augment the area that has irregularities and grooves. [ 3 ]  Carried out under either  general anesthesia  or  local anesthesia , [ 4 ]  the technique involves 3 main stages: fat harvesting (extracting adipose fat), fat processing (processing the extracted fat) and fat injection (reinjecting the purified fat into the area needing improvement). [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10078", "text": "Autologous fat transplantation is a widely used treatment modality because of its biocompatible properties and availability of fat for transplantation. [ 7 ]  The technique has become increasingly popular in recent years for soft tissue augmentation and volume replacement in both reconstructive and aesthetic plastic surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10079", "text": "Breast reconstruction is the surgical process of rebuilding the natural shape and look of a breast, using autologous tissue, prosthetic implants, or a combination of both. [ 8 ]  The procedure is most commonly performed in women - as part of their treatment - who have had  mastectomy  or surgery to treat  breast cancer . A doctor harvests fat from one or more areas of the patient's body where excess fat is available and grafts it to the breast for breast reconstruction surgery after a mastectomy or  lumpectomy . As the procedure uses the patient's own fat, the structural fat grafting for breast reconstruction surgery is a more natural process than implants and creates a smooth, more symmetrical, look. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10080", "text": "Fat transfer breast augmentation is a natural solution to restore shape and volume to the breasts, which may have been lost due to factors such as aging, pregnancy/breast feeding, or weight loss. [ 10 ]  Breast asymmetry can be corrected using the fat transfer procedure, and to give the breasts the same shape and size.  Breast augmentation  and correction of asymmetry using fat transfer is considered to be an overall safe procedure. [ medical citation needed ]  Any major weight gain or loss could have an impact of the procedure results because the fat transferred will behave like the fat in any other body part. The procedure is associated with certain risks such as  fat necrosis  or death of fat cells, a risk related to any type of fat grafting surgeries. Another risk is fat reabsorption, wherein the body may reabsorb the fat used (up to 50%) in the fat transfer augmentation procedure. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10081", "text": "Fat transfer in gluteal augmentation, also known as  buttock augmentation  with autologous fat grafting or gluteal lift (currently marketed as the \"Brazilian butt lift\"), represents one of the most rapidly evolving and increasingly popular operations in aesthetic surgery. [ 12 ]  This is a \"dual-benefit\" body contouring procedure, because fat is harvested from areas with surplus body fat to enhance contouring using  liposuction . [ 13 ] [ 14 ]  This fat is purified and prepared for transplantation into the gluteal region to increase buttock volume. The technique that can be performed under general and local anesthesia can also create an improvement in buttock shape, along with enhancing. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10082", "text": "The regenerative potential of lipofilling and the role of adipose-derived stem cells (ASCs) contribute to good results in facial fat transfer. In traditional techniques for facial rejuvenation, surgery was used involving the excision of muscle, skin, and/or fat. In contrast, modern techniques focus on using fat grafting [ 16 ]  to add volume to the \"empty\" facial compartments. Now, with more comprehensive understanding of facial aging constituents such as fat atrophy and ptosis of the facial compartments, fat grafting is considered a plausible facial rejuvenation technique, especially of the eyelids. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10083", "text": "Structural fat grafting can be an ideal option to treat the signs of aging or other appearance-related issues \u2013 such as prominent-looking veins and tendons, loss of fullness, thinning skin, arthritis and wasting of the hand. [ 18 ]  The procedure involves manually harvesting fat from one or more locations on the body via liposuction and placing it around the back of the patient's hand, and sculpting it into a smooth, uniform layer for an ideal appearance. [ 19 ]  To \"fine tune\" the results, additional fat transfer or injection of dermal filler products can be performed. [ 20 ]  Autologous fat transfer serves as a filler in the hand rejuvenation procedure. Besides, it also rejuvenates the soft tissue and skin on the posterior side of the hands. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10084", "text": "Autologous micro fat transplantation is often used to correct a low dorsum and a short nose. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10085", "text": "Scars and burns caused due to various reasons such as injuries, chicken pox, acne, sun or radiation exposure, and more can be repaired with structural fat grafting. [ 23 ]  The procedure harvests fat from one or more areas of the body and places it anywhere on the body where tissue has been damaged. [ 24 ]  Structural fat grafting can improve the quality of aged and scarred skin, reduce pain and itchiness, heal radiation damage, treat chronic ulcers and reduce the appearance of scars on the face and body - including dimpling and deep depressions, resulting in thicker, softer, healthier skin. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10086", "text": "To ensure survivability, the fat graft should not be manipulated too much and it must be quickly reinjected. Possible complications are swelling, bruising,  hematoma  formation,  paresthesia  or donor-site pain,  hypertrophic scarring , infection, contour irregularities, and injury caused by the cannula to the underlying structures. [ 16 ] [ 3 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10087", "text": "Hair transplantation  is a  surgical  technique that removes  hair follicles  from one part of the body, called the 'donor site', to a bald or balding part of the body known as the 'recipient site'. The technique is primarily used to treat  male pattern baldness . In this minimally invasive procedure, grafts containing hair follicles that are genetically resistant to balding (like the back of the head) are transplanted to the bald scalp."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10088", "text": "Hair transplantation can also be used to restore  eyelashes ,  eyebrows , beard hair, chest hair, pubic hair and to fill in scars caused by accidents or surgery such as face-lifts and previous hair transplants. Hair transplantation differs from  skin grafting  in that grafts contain almost all of the  epidermis  and  dermis  surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10089", "text": "Since hair naturally grows in groupings of 1 to 4 hairs, current techniques harvest and  transplant  hair \"follicular units\" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking original hair orientation. This hair transplant procedure is called  follicular unit transplantation  (FUT). Donor hair can be harvested in two different ways: strip harvesting, and  follicular unit extraction  (FUE)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10090", "text": "At an initial consultation, the surgeon analyzes the patient's scalp, discusses their preferences and expectations, and advises them on the best approach (e.g. single vs. multiple sessions) and what results might reasonably be expected.\n Laxometers  are used to measure the looseness (or more specifically,  laxity ) of the scalp. Pre-operative folliscopy will help to know the actual existing density of hair, so that postoperative results of newly transplanted hair grafts can be accurately assessed. Some patients may benefit with preoperative topical minoxidil application and vitamins. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10091", "text": "For several days prior to surgery the patient refrains from using any medicines which might result in intraoperative bleeding and resultant poor grafting. Alcohol and smoking can contribute to poor graft survival. Post operative  antibiotics  are commonly prescribed to prevent wound or graft  infections . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10092", "text": "Transplant operations are performed on an outpatient basis, with mild  sedation  (optional) and injected local  anesthesia . The scalp is shampooed and then treated with an antibacterial agent prior to the donor scalp being harvested. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10093", "text": "There are several different techniques for harvesting hair follicles, each with their own advantages and disadvantages. Regardless of the harvesting technique, proper extraction of the hair follicle is paramount to ensure the viability of the transplanted hair and avoid transection, the cutting of the hair shaft from the hair follicle. Hair follicles grow at a slight angle to the skin's surface, so transplanted tissue must be removed at a corresponding angle. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10094", "text": "There are two main ways in which donor grafts are extracted today: strip excision harvesting, and follicular unit extraction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10095", "text": "Strip harvesting (also known as  follicular unit transplantation  or FUT) is the most common technique for removing hair and follicles from a donor site. The surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. A single-, double-, or triple-bladed scalpel is used to remove strips of hair-bearing tissue from the donor site. Each incision is planned so that intact hair follicles are removed. The excised strip is about 1\u20131.5 x 15\u201330\u00a0cm in size. While closing the resulting wound, assistants begin to dissect individual follicular unit grafts, which are small, naturally formed groupings of hair follicles, from the strip. Working with binocular  Stereo-microscopes , they carefully remove excess fibrous and fatty tissue while trying to avoid damage to the follicular cells that will be used for grafting. The latest method of closure is called 'Trichophytic closure' which results in much finer scars at the donor area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10096", "text": "The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10097", "text": "Strip harvesting will leave a thin linear scar in the donor area, which is typically covered by a patient's hair even at relatively short lengths. The recovery period is around 2 weeks and will require the stitches/staples to be removed by medical personnel or sub cuticular suturing can be done."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10098", "text": "With Follicular Unit Extraction or FUE harvesting, individual follicular units containing 1 to 4 hairs are removed under local anesthesia; this micro removal typically uses tiny punches of between 0.6mm and 1.0mm in diameter. The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10099", "text": "FUE takes place in a single long session or multiple small sessions. The FUE procedure is more time-consuming than strip surgery. An FUE surgery time varies according to the surgeons experience, speed in harvesting and patient characteristics. The procedure can take anywhere from a couple hours to extract 200 grafts for a scar correction to a surgery over two consecutive days for a megasession of 2,500 to 3,000 grafts. [ 3 ]  With the FUE Hair Transplant procedure there are restrictions on patient candidacy. [ 4 ]  Clients are selected for FUE based on a fox test, [ 5 ]  though there is some debate about the usefulness of this in screening clients for FUE."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10100", "text": "FUE can give very natural results. The advantage over strip harvesting is that FUE harvesting negates the need for large areas of scalp tissue to be harvested, so there is no linear incision on the back of the head and it doesn't leave a linear scar. Because individual follicles are removed, only small, punctate scars remain which are virtually not visible and any post-surgical pain and discomfort is minimized. As no suture removal is required, recovery from Micro Grafting FUE is less than 7 days. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10101", "text": "Disadvantages include increased surgical times and higher cost to the patient. [ 7 ]   It is challenging for new surgeons because the procedure is physically demanding and the learning curve to acquire the skills necessary is lengthy and tough. [ citation needed ]  Some surgeons note that FUE can lead to a lower ratio of successfully transplanted follicles as compared to strip harvesting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10102", "text": "Robotic hair restoration devices utilize cameras and robotic arms to assist the surgeon with the FUE procedure. In 2009, NeoGraft became the first robotic surgical device FDA approved for hair restoration. [ 8 ]  The ARTAS System was FDA approved in 2011 for use in harvesting follicular units from brown-haired and black-haired men. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10103", "text": "There are a number of applications for hair transplant surgery, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10104", "text": "If donor hair numbers from the back of the head are insufficient, it is possible to perform body hair transplantation (BHT) on appropriate candidates who have available donor hair on the chest, back, shoulders, torso and/or legs. Body hair transplant surgery can only be performed by the FUE harvesting method and, so, requires the skills of an experienced FUE surgeon. However, there are several factors for a potential BHT candidate to consider prior to surgery. These include understanding the natural difference in textural characteristics between body hair and scalp hair, growth rates, and having realistic expectations about the results of BHT surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10105", "text": "The cost of hair transplantation depends on the individual hair loss and consequently on the number of necessary grafts. The average price per graft ranges between US$1.07 in  Turkey  up to US$7.00 in Canada. Some clinics also offer all-inclusive packages. [ 10 ] [ 11 ] \nIn the UK the cost can be between \u00a34000\u2013\u00a38000 depending on location and area of implant. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10106", "text": "Hair thinning, known as \"shock loss\", is a common side effect that is usually temporary. [ 13 ]  Bald patches are also common, as fifty to a hundred hairs can be lost each day."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10107", "text": "The use of both  scalp  flaps, in which a band of tissue with its original blood supply is  shifted  to the continue bald area, and free grafts dates back to the 19th century. In 1897, Menahem Hodara successfully implanted hair taken from the unaffected areas of the scalp on to the scars that were left bald by  favus . Modern transplant techniques began in Japan in the 1930s, [ 14 ]  where surgeons used small grafts, and even \"follicular unit grafts\" to replace damaged areas of  eyebrows  or lashes, but not to treat  baldness . Their efforts did not receive worldwide attention at the time, and the traumas of World War II kept their advances isolated for another two decades."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10108", "text": "The modern era of hair transplantation in the western world was ushered in the late 1950s, when New York  dermatologist   Norman Orentreich  began to experiment with free donor  grafts  to balding areas in patients with male pattern baldness. Previously it had been thought that transplanted hair would thrive no more than the original hair at the \"recipient\" site. Orentreich demonstrated that such grafts were \"donor dominant,\" as the new hairs grew and lasted just as they would have at their original home. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10109", "text": "Advancing the theory of donor dominance, Walter P. Unger, M.D. defined the parameters of the \"Safe Donor Zone\" from which the most permanent hair follicles could be extracted for hair transplantation. [ 16 ]  As transplanted hair will only grow in its new site for as long as it would have in its original one, these parameters continue to serve as the fundamental foundation for hair follicle harvesting, whether by strip method or FUE."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10110", "text": "For the next twenty years, surgeons worked on transplanting smaller grafts, but results were only minimally successful, with 2\u20134\u00a0mm \"plugs\" leading to a doll's head-like appearance. In the 1980s, strip excisions began to replace the plug technique, and Carlos Uebel in Brazil popularized using large numbers of small grafts, while in the United States William Rassman began using thousands of \"micrografts\" in a single session. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10111", "text": "In the late 1980s, B.L. Limmer introduced the use of the stereo-microscope to dissect a single donor strip into small micrografts. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10112", "text": "The follicular unit hair transplant procedure has continued to evolve, becoming more refined and minimally invasive as the size of the graft incisions have become smaller. These smaller and less invasive incisions enable surgeons to place a larger number of follicular unit grafts into a given area. With the new \"gold standard\" of ultra refined follicular unit hair transplantation, over 50 grafts can be placed per square centimeter, when appropriate for the patient. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10113", "text": "Surgeons have also devoted more attention to the angle and orientation of the transplanted grafts. The adoption of the \"lateral slit\" technique in the early 2000s enabled hair transplant surgeons to orient 2 to 4 hair follicular unit grafts so that they splay out across the scalp's surface. This enabled the transplanted hair to lie better on the scalp and provide better coverage to the bald areas. [ original research? ]  One disadvantage however, is that lateral incisions also tend to disrupt the scalp's vascularity more than sagittals. Thus sagittal incisions transect less hairs and blood vessels assuming the cutting instruments are of the same size. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10114", "text": "One of the advantages of sagittals is that they do a much better job of sliding in and around existing hairs to avoid follicle transection. [ original research? ]  This makes a strong case for physicians who do not require shaving of the recipient area. The lateral incisions bisect existing hairs perpendicular (horizontal) like a T while sagittal incisions run parallel (vertical) alongside and in between existing hairs. The use of perpendicular (lateral/coronal) slits versus parallel (sagittal) slits, however, has been heavily debated in patient-based hair transplant communities. Many elite hair transplant surgeons [ who? ]  typically adopt a combination of both methods based on what is best for the individual patient. [ original research? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10115", "text": "Stem cells and dermal papilla cells have been discovered in hair follicles. [ 19 ]  Research on these follicular cells may lead to successes in treating baldness through hair multiplication (HM), also known as  hair cloning . [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10116", "text": "The  incisionless Fritsch otoplasty  is a minimally invasive procedure for pinning  protruding ears ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10117", "text": "Michael H. Fritsch, MD, Professor, Indianapolis, Indiana, USA, named his method \u201cIncisionless Otoplasty\u201d and published it under this name in 1995, [ 1 ]  2004, [ 2 ]  2009 [ 3 ]  and 2013. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10118", "text": "The technique is used for protuberant \"lop\" ears to correct the problem in the least invasive way. From the back of the ear, permanent, non-absorbable sutures (called by Fritsch \"retention sutures\") are placed invisibly into the cartilage of the external ear pinna with a unique technique, whereby the stitch passes in and out of the same needle hole achieve the desired pathway for the suture to correct the protuberant ear. Kaye and others, made open micro-incisions to get the suture under the skin.  When the sutures are tightened, the ear moves towards the head. Patients were operated on using only the percutaneous incisionless technique. Fritsch pointed out that some ears needed not only re-creation of the antihelical fold of the pinna external ear, but also, a closer approximation of the conchal bowl to the mastoid process behind the ear; these retention sutures were also placed without incisions. Ears were satisfactorily corrected with this technique. This corresponds to the conventional Furnas Method, but without the large vertical access incision. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10119", "text": "Fritsch also sometimes combined with a technique of the traditional methods for correcting protruding earlobes, by opening the back of the earlobe and removing soft tissue from it. He found that his minimally invasive technique did not produce any satisfactory results in the case of pronounced conchal hyperplasia: \"Mega ear\".  This is how Fritsch described his method in 1995."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10120", "text": "In his later publications, the antihelical cartilage \"spring\" is scratched or scored, sometimes quite deeply, with only a needle and without incisions. Narrow tunnels in the auricular cartilage created micro-scarring bands to augment the retention sutures and permanently correct the conchal bowl correction and pinna antihelix.  Later, Fritsch sometimes removed excessively thick soft-tissue or bone between the conchal bowl and the mastoid through 2mm incisions.  In this way, the Fritsch technique became a combination of several minimally invasive methods. Others have adopted this technique and modified it according to their own insights."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10121", "text": "According to Fritsch:  Possibilities could include rare infection; bleeding;   hematoma ;  pain; discomfort; swelling; suture breakage; post-auricular suture bridging;  epithelial  inclusion with cyst formation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10122", "text": "According to Weerda: [ 6 ]  Cosmetically, the different procedures of all otoplasty surgery types can cause disfiguring cartilage edges along the anterior surface of the antihelix if the cartilage is scored too deeply or the perichondrium is injured; post-operative bleeding; hematoma; relapse (ears protruding again); hypersensitivity; pain with pressure and cold, pressure damage (necrosis) from too tightly fitting hard bandages; perichondritis (inflammation of the cartilage); stronger asymmetry of the ears (see also on  otoplasty )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10123", "text": "The  lip plate , also known as a  lip plug ,  lip disc , or  mouth plate , is a form of  body modification . Increasingly large discs (usually circular, and made from clay or wood) are inserted into a  pierced hole  in either the upper or lower  lip , or both, thereby  stretching  it. The term  labret  denotes all kinds of pierced-lip ornaments, including plates and plugs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10124", "text": "Archaeological evidence indicates that disk and plate labrets have been invented multiple times including in Africa (Sudan and Ethiopia; 5500\u20136000 BCE) [ 1 ]  Mesoamerica (1500 BCE), [ 1 ]  and coastal Ecuador (500 BCE). [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10125", "text": "In some African countries, a lower lip plate is usually combined with the dental extraction of two lower front teeth, sometimes all four.  Among the  Sara people  and  Lobi  of Chad, a plate is also inserted into the upper lip.  Other tribes, such as the  Makonde  of Tanzania and Mozambique, used to wear a plate in the upper lip only."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10126", "text": "Many sources have suggested that the plate's size was a sign of social or economical importance in some tribes. [ citation needed ]  However, because of natural mechanical attributes of human skin, the plate's size may often depend on the stage of stretching of the lip and the wishes of the wearer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10127", "text": "Among the  Surma  and  Mursi  people of the lower Omo River valley in Ethiopia, [ 3 ]  about 6 to 12 months before marriage, a young woman has her lip pierced by her mother or one of her kinswomen, usually at around the age of 15 to 18. The initial piercing is done as an incision of the lower lip of 1 to 2\u00a0cm length, and a simple wooden peg is inserted. After the wound has healed, which usually takes between two and three weeks, the peg is replaced with a slightly bigger one. At a diameter of about 4\u00a0cm, the first lip plate made of clay is inserted. Every woman crafts her own plate and takes pride in including some ornamentation. The final diameter ranges from about 8\u00a0cm to over 20\u00a0cm. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10128", "text": "In 1990 Beckwith and Carter claimed that for Mursi and Surma women, the size of their lip plate indicates the number of cattle paid as the  bride price . [ 5 ]  Anthropologist Turton, who studied the Mursi for 30 years, denies this. [ 6 ]  LaTosky, meanwhile, argues that most Mursi women use lip plates, and the value of the ornamentation lies within a discourse of female strength and self-esteem. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10129", "text": "In contemporary culture, most girls of age 13 to 18 appear to decide whether or not to wear a lip plate. This adornment has caused the Mursi and Surma women to be treated as if they are a tourist attraction. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10130", "text": "The largest lip plate recorded was in Ethiopia, measuring 59.5\u00a0cm (23.4\u00a0in) in circumference and 19.5\u00a0cm (7.6\u00a0in) wide, in 2014. It belongs to Ataye Eligidagne. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10131", "text": "In South America among some Amazonian tribes, young males traditionally have their lips pierced and begin to wear plates when they enter the men's house and leave the world of women. [ 10 ] [ 11 ]  Lip plates there are associated with oration and singing. [ citation needed ]  The largest plates are worn by the greatest orators and war chiefs,  [ citation needed ]  such as  Chief Raoni  of the  Kayapo  tribe, a well known environmental campaigner. In South America, lip plates are nearly always made from light wood."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10132", "text": "In the  Pacific Northwest  of North America, labrets have a long history of use, dating back at least five thousand years. At times they were used by both men and women, but in more recent times (e.g. 19th century) were associated with exclusive use by high ranking women. [ 12 ] \nAmong the  Haida ,  Tsimshian , and  Tlingit , they were once used by women to symbolize social maturity by indicating a girl's eligibility to be a wife.  [ citation needed ]  The installation of a girl's first plate was celebrated with a sumptuous feast. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10133", "text": "In western nations, some young people, including some members of the  Modern Primitive  movement, have adopted larger-gauge lip piercings, a few large enough for them to wear proper lip plates. Some examples are given on the  BME  website. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10134", "text": "This practice can lead to infections, especially during the process of perforation. \nIt also complicates normal mouth functions such as salivating and eating. Gum irritation can also arise as consequence from plate rubbing, leading to related gum diseases and infections. Teeth gapping and erosion could happen as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10135", "text": "For this reason, the  Ethiopian  government has put pressure on suppressing the practice. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10136", "text": "Tribes that are known for their traditional lip plates or labrets include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10137", "text": "In the late nineteenth and early twentieth centuries, African women wearing lip plates were brought to Europe and North America for exhibit in circuses and sideshows. Around 1930,  Ringling Brothers and Barnum & Bailey  promoted such women from the  French Congo  as members of the \"Ubangi\" tribe; the Ringling press agent admitted that he picked that name from a  map  for its exotic sound. [ 18 ]  The word was used in this way in the 1937  Marx Brothers  film  A Day at the Races . The word  Ubangi  was still given a definition as an African tribe in 2009 in some English-language dictionaries. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10138", "text": "Looksmaxxing  (sometimes spelled  looksmaxing ) is the process of maximizing one\u2019s own  physical attractiveness . The term originated on male  incel   message boards  in the 2010s. [ 1 ] [ 2 ]  In the 2020s, the term left relatively obscure internet forums, and was popularised on  TikTok . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10139", "text": "Proponents of \"looksmaxxing\" encourage practices as \"softmaxxing\", including proper hygiene, skincare, hairstyles suited to one's face shape, exercise routines, wearing fashionable clothing, as well as \" mewing \", a scientifically unsupported tongue posture practice purported to improve jaw structure. \"Hardmaxxing\" refers to more extreme and permanent methods, including undergoing cosmetic procedures such as  jaw surgery . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10140", "text": "While some looksmaxxing ideas have been deemed helpful for  self improvement , online forums have been criticized for contributing to  body dysmorphia . [ 1 ]  The spread of the concept on TikTok is said to exclude many of the \"toxic\" elements seen on forums. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10141", "text": "Softmaxxing, a variant of looksmaxxing, is a practice in which people perform several body care routines in an effort to improve ones physical appearance. Some of these practices are fairly common and standard, such as clearing up  facial acne , going to the gym, getting a new haircut, or  moisturizing . These practices are the most popular, and are considered \"softmaxxing\". Additional practices have been associated with looksmaxxing, with a popular example being the act of \" mewing \", which involves performing various exercises with one's tongue with the goal of achieving a \"square jawline\". [ 4 ] [ 5 ]  These methods are the most popular ones shared around  TikTok , where men are typically the ones giving the advice. These methods were previously popularized with magazines such as  GQ ,  Esquire , and  Men's Health  sharing around skincare and hairstyle advice. Some that partake in \"looksmaxxing\" consider themselves to be making \"facial gains\". [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10142", "text": "Some people who perform looksmaxxing have also performed more extreme methods. This has been coined as \"hardmaxxing\", and those who practice them refer to themselves as \"hardmaxxers\". Practices associated with hardmaxxing include getting implants or limb-lengthening surgeries, intentionally starving oneself (\"starvemaxxing\"), using moisturizers to attempt to appear more  white  (\"whitemaxxing\"), and withholding  sexual climax  in an effort to boost  testosterone  (\" edging \"). [ 4 ] [ 5 ]  An additional method, known as \" bonesmashing \u00a0[ Wikidata ] \", refers to the act of hitting one's face against objects such as a hammer in order to create a \"chiselled look\". While this practice is considered an inside joke and few have actually done it, it has been warned as  misinformation . [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10143", "text": "Some that partake in looksmaxxing also look for others to rate their appearance, with some engaging in anonymous message boards associated with  incel  sub-culture. This rating has been considered to be one's \"sexual market value\" (also known as SMV). [ 4 ] [ 6 ]  Those that determine this value usually check for a variety of different facial features. One of the most prominent features checked for is \"hunter eyes\", which refers to a positive  canthal tilt , resembling that of a predatorial animal. Additional features checked for include hollow cheeks and \"pursed lips\". [ 5 ] [ 6 ]  In order to achieve these features, some perform acts such as the aforementioned \"mewing\", rubbing against the orbital area, or even getting surgery. [ 6 ] [ 7 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10144", "text": "Those who receive a low rating are often harassed for their appearance afterwards, with some forms of harassment including suicide encouragement (known in some legal jurisdictions as \"Incitement to Suicide\"). [ 4 ]  Additional terms have been coined by these communities in an effort to \"dominate others\". These phrases include \"mogging\", which refers to asserting dominance over another person based on their appearance, and being \"Y-pilled\", which refers to one viewing themselves as more masculine than the other and is a spin on the phrase \" redpilled \". [ 5 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10145", "text": "The practice originated on \" manosphere \" message boards such as Lookism.net and Incels.me in the 2010s. [ 9 ] [ 10 ]  In 2015, a forum site named Looksmaxxxer.com was registered to the  Internet Archive , [ citation needed ]  coining the term \"looksmaxxing\" and inspiring its usage on anonymous imageboard websites such as  4chan . Looksmaxxing became a TikTok trend in the 2020s, amongst mostly teenagers. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10146", "text": "Looksmaxxing has been connected to incel sub-culture since its origins within it. [ 4 ] [ 5 ] [ 6 ]  Writing for  The Conversation , senior lecturer and researcher Jamilla Rosdahl of the  Australian College of Applied Psychology  considered the practice to convert young men into incels as a result of TikTok  algorithms . On the popularity of looksmaxxing amongst young people overall, she wrote that \"where young people feel like they can\u2019t control their environment, they may turn to trends such as looksmaxxing as something they can control,\" attributing several real world problems such as an unstable economy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10147", "text": "Several acts associated with looksmaxxing have been criticized by doctors and dismissed as misinformation, including mewing and bonesmashing. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10148", "text": "Neck rings , or  neck-rings , are any form of stiff  jewellery  worn as an ornament around the neck of an individual, as opposed to a loose  necklace . Many cultures and periods have made neck rings, with both males and females wearing them at various times."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10149", "text": "Of the two most notable types, one is the  torc , an often heavy and valuable ornament normally open at the throat.  These were worn by various early cultures but are especially associated with the ancient  Celts  of the  European Iron Age , where they were evidently a key  indicator of wealth and status , mostly worn by men."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10150", "text": "The other type is one or more spiral metal coils of many turns, often worn only by married women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10151", "text": "In a few African and Asian cultures, neck rings are worn usually to create the appearance that the neck has been stretched."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10152", "text": "The custom of wearing neck rings is related to an  ideal of beauty : an elongated neck. Neck rings push the  clavicle  and ribs down. [ 1 ]  The neck stretching is mostly illusory: the weight of the rings twists the  collarbone  and eventually the upper ribs at an angle 45 degrees lower than what is natural, causing the illusion of an elongated neck. The  vertebrae  do not elongate, though the space between them may increase as the  intervertebral discs  absorb liquid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10153", "text": "The custom requires that the girls who wear the neck rings start before  puberty , in order to get the body used to them. These heavy coils can weigh as much as 11 pounds (5\u00a0kg)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10154", "text": "Tourism  is often considered to encourage the use of neck rings  in Myanmar , as they are a popular attraction for tourists. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10155", "text": "Padaung  ( Kayan Lahwi ) women of the  Kayan people  begin to wear neck coils from as young as age two. The length of the coil is gradually increased to as much as twenty turns. The weight of the coils will eventually place sufficient pressure on the  clavicles  (collarbone) to cause them to deform and create an impression of a longer neck. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10156", "text": "Small Kayan girls may wear brass collars from the age of two to five years old, as it is more comfortable to deform the collarbone and upper ribs slowly. The alternative, an accelerated process at around the age of twelve, when girls first begin to compete for the attention of boys, is painful.  Marco Polo  first described the practice to Western culture in c. 1300. Refugee practitioners in  Thailand  were first accessible to tourists in 1984."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10157", "text": "The  South Ndebele peoples  of Africa also wear neck rings as part of their traditional dress and as a sign of wealth and status. Only married women are allowed to wear the rings, called  dzilla . Metal rings are also worn on different parts of the body, not just the neck. Traditionally these rings are given to a wife by her husband, and not removed until the husband's death; however, these rings are individual and do not function as a body modification. [ 4 ] [ 5 ]  The rings are usually made of copper or brass, usually stacked in multiples of three."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10158", "text": "Modupe Ozolua  (b. October 10, 1973) is a Lebanese-Nigerian-American philanthropist and entrepreneur. She was the CEO of Body Enhancement Ltd and is the founding president of Empower 54 Project Initiatives (Empower 54) formerly known as Body Enhancement Annual Reconstructive Surgery (BEARS) Foundation.  [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10159", "text": "Princess Ozolua is the youngest of four children born to Prince Julius I. Ozolua, an educationist, and Princess Olua Mary S. Ozolua ( n\u00e9e  Otaru), an entrepreneur from Ososo, Akoko-Edo LGA,  Edo State .  [ 1 ]  Her name \"Modupe\" means \"I give thanks\" in  Yoruba .  [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10160", "text": "She holds the traditional title \"The Oyimiz\u00e9 of Ososo Kingdom\" meaning \"The One We Choose\" from her mother's tribe."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10161", "text": "Ozolua studied business management in  Southwestern College , graduated with honors, was inducted into the Alpha Pi Epsilon, chapter of  Phi Theta Kappa  and recognized as an outstanding student by the Southwestern Dean's Honorary List and the National Dean's List (1994 - 1995).  [ 4 ]  Princess Modupe Ozolua further studied at DeVry University where she obtained her Bachelor of Science in Technical Business Management and graduated with Magna Cum Laude honors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10162", "text": "Ozolua returned to Nigeria in 2001 and started Body Enhancement Ltd, [ 5 ]  a cosmetic surgery company and aesthetic laser treatments in Nigeria. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10163", "text": "In 2003, she founded Empower 54, formerly known as Body Enhancement Foundation, or Body Enhancement Annual Reconstructive Surgery (BEARS), [ 4 ]  an international humanitarian organization dedicated to providing humanitarian assistance such as medical missions, hunger eradication, education, female empowerment, and refugee programs to underprivileged Africans. Archbishop  Desmond Tutu  was a patron of Empower 54 since the creation of the organization in 2003. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10164", "text": "All humanitarian aid rendered through Empower 54 is free to the beneficiaries. Empower 54's \"Rise Above Terror\" initiative has been active in rehabilitating women and children survivors of the  Boko Haram  terrorist group in Nigeria, through self-employment and education for the children at the IDP camps. Ozolua leads Empower 54 to enter communities attacked by Boko Haram in remote parts of North-East Nigeria and help survivors of insurgency attacks. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10165", "text": "During one of the foundation's missions, she discovered the extremely malnourished children rescued from Boko Haram's captivity and facilitated the collaboration between Empower 54 and the Borno State Government in evacuating them to Maiduguri for urgent CMAM treatment. 1,500 children were evacuated from Bama, along with their families. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10166", "text": "Princess Ozolua writes articles focused on politics, charity and lifestyle which are published in Nigerian national newspapers and magazines."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10167", "text": "Princess Ozolua married at 21 and divorced at the age of 23. She has a son. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10168", "text": "To improve the regulatory framework of CSOs in Nigeria, Princess Ozolua assumed the leadership position of Senior Special Assistant on NGOs and  People with Disabilities (PWD) in the Office of the Deputy President of the 9th Senate, National Assembly (Nigeria) from 2019 to 2023. In that role she was Chairperson, SOP on clearing charitable items into the Federal Republic of Nigeria (2020 - 2023). She initiated the project and oversaw implementation of the Standard Operating Procedure (SOP) Working Group's review, simplification, recommendations and harmonization of laws and policies relating to the clearing processes of charitable items into Nigeria. As Chair of the SOPWG, she was responsible for strategic inter-government negotiations and all stakeholders' support towards the creation of a new national SOP.\nThe SOPWG consisted of 130 members including National Assembly committee Chairs and Clerks; government ministries, agencies, security agencies, United Nations bodies, development partners, INGOs, CSOs, port service providers, diplomatic Corps and consultants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10169", "text": "CO-Chairperson, Technical Committee on the creation of an NGO National Database in Nigeria (2020 - Present). She initiated this project and oversaw the creation of the Nigerian government\u2019s first-ever national database of NGOs operating in Nigeria with capacity for real-time interface with all regulating MDAs online platforms for ease of verification, national mapping, communication and dissemination of information and changes in laws and policies regarding CSO engagement in the country."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10170", "text": "Ozolua successfully facilitated the partnership with the Federal Ministry of Finance, Budget and National Planning, negotiated inter-government and donors\u2019 participation, and is also a strategic member of the Steering Committee members which consist of government ministries, government agencies, United Nations bodies, development partners, INGOs and CSOs. She also got development partners to sponsor the creation of the Nigeria Government's first national NGO database which now domiciled with the Federal Ministry of Finance, Budget and National Planning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10171", "text": "Government and CSO Multi-Stakeholders\u2019 Forum\nInitiated project and oversee the creation of Nigeria\u2019s first government and Civil Society multi-stakeholders\u2019 forum domiciled at the Federal Ministry of Finance, Budget and National Planning with focus of enabling seamless communication and review of policies regarding civil society legal frameworks in the country. Members of the forum consist of National Assembly legislators, government ministries, agencies, security agencies, United Nations bodies, development partners, INGOs and CSOs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10172", "text": "Improved collaboration between Nigeria National Assembly and CSOs\nOzolua successfully facilitated relationships between the 9th Assembly Senate and House of Representatives Committee Chairpersons and CSOs which enabled opportunities for alliances on amendment of laws regulating the CSO sector."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10173", "text": "\"Official website\" .  Empower 54 ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10174", "text": "Perineoplasty  (also  perineorrhaphy ) denotes the plastic surgery procedures used to correct clinical conditions (damage, defect, deformity) of the  vagina  and the  anus . [ 1 ] [ 2 ] [ 3 ]  Among the vagino-anal conditions resolved by perineoplasty are  vaginal looseness ,  vaginal itching , damaged  perineum ,  fecal incontinence ,  genital warts ,  dyspareunia ,  vaginal stenosis ,  vaginismus ,  vulvar vestibulitis , and decreased sexual sensation. [ 4 ]  Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the  perineal muscles  and the vagina; the second, to loosen the perineal muscles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10175", "text": "A  perineoplasty  procedure repairs damage to the  perineum  and damage to the  vulva  that a woman might experience as a result of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10176", "text": "Clinically, the woman reports a feeling of physical looseness in her  vulvo-vaginal  area, which might be associated with decreased sexual satisfaction when compared to the degree of her sexual satisfaction before the incidence of the perineal damage. The indications can include detachment of the  anal sphincter  muscle, and the collapse of her rectum (rectocele). Perineoplasty is occasionally associated with posterior  colporrhaphy , and can be performed in conjunction with the procedure. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10177", "text": "A perineoplasty procedure first involves a V-shaped incision to the posterior wall of the  vagina . Incisions atop the V-incision can be flat, curved, or angled upwards, which incision is applied is determined by the degree of  vaginal tightening  to be achieved. [ 1 ] [ 2 ]  Once the incision is made, any existing  scar tissue  and abnormal tissue fixations that resulted from previous injury or surgery or injury are removed. Depending upon the degree of damage occurred to the perineum, the corrections can include the:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10178", "text": "Stitching of the muscles is carefully performed to avoid creating transverse ridges, and so produce a ridged interior surface in the vagina. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10179", "text": "A person who experiences painful sexual intercourse (dyspareunia), or who is afflicted with vaginismus (involuntary contraction of the puboccygeus muscles) can be treated with a variant perineoplasty procedure that loosens the over-tight vaginal introitus (entry). Some surgeons use a simple surface incision at the fourchette for such loosening, but generally is not the most effectively corrective surgical approach. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10180", "text": "To perform loosening perineoplasty, a triangle of skin is excised from below the vulvar vestibule with its base near the vestibule and its apex near the anus. This allows the removal of genital warts and the adjustment of musculature necessary to increase the size of the vagina. In this procedure, it is desirable to maintain the vaginal mucosa as much as possible. [ 6 ]  Recovery typically requires 4\u20136 weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10181", "text": "Perineoplasty is generally considered effective for treatment of dyspareunia, [ 6 ]  including that caused by  lichen sclerosus , [ 7 ]  and vaginismus. [ 6 ]  It is also considered an effective treatment for vulvar vestibulitis, although it is generally recommended following the failure of nonsurgical methods. [ 8 ] [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10182", "text": "Polypropylene breast implants , also known as  string breast implants , are a form of  breast implant  using  polypropylene  developed by Gerald W. Johnson.  Due to a number of  medical complications , the device has not been approved in the  European Union  or the  United States . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10183", "text": "Polypropylene implants absorb water very slowly, about <0.01% in 24 hours. [ 2 ]  The polypropylene, which is yarn-like, causes irritation to the implant pocket which causes the production of  serum  which fills the implant pocket on a continual basis. [ citation needed ]   This causes continuous expansion of the breast after surgery.   Growth can only be alleviated by removal of serum by syringe.  Problems can also arise if the breasts enlarge at different rates.  This can be corrected by removal of serum or introduction of sterile saline.  Continual breast growth will eventually result in \"extreme, almost cartoonish breast sizes.\" [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10184", "text": "String implants were only available for a very short time in the US before being removed from the market by the FDA around 2001. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10185", "text": "Polypropylene implants have created the largest recorded increases in breast size due to  surgical augmentation . They are rarely seen outside the  adult entertainment  industry.  Big-bust entertainers  Chelsea Charms , [ 5 ]   Maxi Mounds , [ 6 ]  Kayla Kleevage [ citation needed ] ,  Minka [ citation needed ] , Elizabeth Starr [ citation needed ] , and Teddi Barrett [ citation needed ]  are some recipients of polypropylene breast implants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10186", "text": "Scarless  Serdev Suture  suspension liftings  [1]  use percutaneous skeletal fixation of movable fascias without  incisions . In  Brazil  known as  fio elastico ., [ 1 ] [ 2 ]  are used to correct early  ptosis  and flabbiness in areas of face and body. The suture suspension techniques are described to lift, if necessary to form volume and to correct position of  soft tissue  without traditional incisions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10187", "text": "The techniques consist of passing closed  sutures , [ 3 ]  by needle perforations only, to lift movable fascias and fix them to non movable  skeletal structures   [2]  in several facial and body areas:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10188", "text": "In face areas: [ 4 ]  total ambulatory SMAS Lift, temporal and supra-temporal suture SMAS lift,  scarless  brow suture lift, lateral cantus lifting, mid face suture lift, cheekbone lift and augmentation, lower smas-platysma face and  neck lift  using skin perforations only or by using hidden retro-lobular incisions, chin enhancement, form and position correction by suture, Serdev sutures for: nasal tip refinement; nasal tip rotation; nasal alar base narrowing, scarless Serdev suture method in prominent ears, chin  dimples  and smiling dimples by suture, permanent block of glabella muscles etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10189", "text": "In body areas: scarless  breast lift  by suture and needle perforations only, scarless  buttock lift  by suture, abdominal flaccidity tightening by sutures, scarless inner thigh lift."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10190", "text": "Tumescent liposuction  is a technique that provides local anesthesia to large volumes of subcutaneous fat and thus permits  liposuction ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10191", "text": "While the suctioned fat cells are permanently gone, after a few months overall body fat generally returned to the same level as before treatment. [ 1 ]  This is despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack. Edit per the cited journal, the difference in visceral fat between control and intervention group was not significant  [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10192", "text": "The tumescent technique for liposuction provides for local anesthesia via  lidocaine , eliminating the need for the administration of  sedatives  or  narcotics  during surgery. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10193", "text": "A review published in 2011 stated tumescent liposuction was safe. [ 4 ]  During the first decade of the treatments use, deaths were reported with the treatment as the cause of death, dating back to 1999. [ 5 ]  By 2002, 23 deaths in five years had been reported in the European literature. [ 4 ]  Tierney  et al  (2011) said, \"The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism.\" [ 4 ]  Complications in this procedure are rare and typically minor. The most common include: skin irregularity, lumpiness, dimpling, loose skin, numbness, infections and scarring. However, these type of minor complications can easily be corrected in most cases. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10194", "text": "In many U.S. states, physicians are not required to have training to perform this cosmetic surgery procedure. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10195", "text": "Jeffrey Klein and Patrick Lillis, dermatologic surgeons, invented the tumescent technique. [ 8 ] [ 9 ]  The technique was developed in the 1980s, before it came to market in the 1990s. [ 8 ]  The technique was introduced to  Australia  in the early 1990s, with Daniel Lanzer named as one of the first to use the procedure in the country. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10196", "text": "Colorectal surgery  is a field in medicine dealing with disorders of the  rectum ,  anus , and  colon . [ 1 ]  The field is also known as  proctology , but this term is now used infrequently within medicine and is most often employed to identify practices relating to the anus and rectum in particular. [ clarification needed ]  The word  proctology  is derived from the  Greek  words  \u03c0\u03c1\u03c9\u03ba\u03c4\u03cc\u03c2   proktos , meaning \"anus\" or \"hindparts\", and  -\u03bb\u03bf\u03b3\u03af\u03b1   -logia , meaning \"science\" or \"study\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10197", "text": "Physicians specializing in this field of medicine are called colorectal surgeons or proctologists. In the United States, to become colorectal surgeons, surgical doctors have to complete a general surgery residency as well as a colorectal surgery fellowship, upon which they are eligible to be certified in their field of expertise by the  American Board of Colon and Rectal Surgery  or the  American Osteopathic Board of Proctology . In other countries,  certification  to practice proctology is given to surgeons at the end of a 2\u20133 year subspecialty  residency  by the country's board of surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10198", "text": "Colorectal surgical disorders include: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10199", "text": "Surgical forms of treatment for these conditions include:  colectomy , ileo/colostomy,  polypectomy ,  strictureplasty , hemorrhoidectomy (in severe cases of  hemorrhoids ), minimally invasive surgery, anoplasty, and more depending on the condition the patient has. Diagnostic procedures, such as a  colonoscopy , are very important in colorectal surgery, as they can tell the physician what type of diagnosis should be given and what procedure should be done to correct the condition. Other diagnostic procedures used by colorectal surgeons include:  proctoscopy ,  defecating proctography ,  sigmoidoscopy .   In recent times, the  laparoscopic  method of surgery has seen a surge of popularity, due to its lower risks, decreased recovery time, and smaller, more precise incisions achieved by using laparoscopic instruments. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10200", "text": "Mechanical bowel preparation (MBP) is a procedure lacking evidence in literature, [ 4 ]  wherein fecal matter is expelled from the bowel lumen prior to surgery, most commonly by using  sodium phosphate . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10201", "text": "Shafi Ahmed  is a chief surgeon, teacher,  futurist , innovator, professor and entrepreneur. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10202", "text": "Ahmed lives in London. He is married to Farzana Hussain, a  general practitioner , with whom he has two children. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10203", "text": "He was born on 26 January 1969 in  Sylhet District ,  East Pakistan  (now  Bangladesh ), and came to the United Kingdom as a child. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10204", "text": "Ahmed attended Chadwell Heath High School (now  Chadwell Heath Academy ) before attending the Redbridge technical college."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10205", "text": "From 1988 to 1993, he studied medicine at  King's College Hospital  School of Medicine. As the elected President of the Medical and Dental Society, he helped introduce medical ethics into the curriculum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10206", "text": "During his surgical training in London, he undertook a period of research at The  Royal London Hospital  and the  Queen Mary University of London . In 2010, he obtained a PhD with a thesis entitled \"The role of microarray profiling in predicting outcome in patients with colorectal cancer\". [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10207", "text": "Ahmed has been awarded four honorary PhDs (Honoris Causa) from Udabol University Bolivia, SIISDET Colombia, the University of Peru of Science and Informatics and EXIBED, Spain. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10208", "text": "In 2017, he was appointed as an honorary professor at The  University of Bradford  and awarded an Honorary Doctorate of Medicine in 2019. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10209", "text": "In 2020 he was awarded the Spinoza Honorary professorship at the  University of Amsterdam . [ 6 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10210", "text": "Ahmed is a specialist advisor to the Abu Dhabi Ministry of Health to help deliver innovation and  digital health . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10211", "text": "Ahmed works in the Academic Centre of Surgery and has established  minimally invasive   colorectal surgery  at the  Royal London Hospital ,  Barts Health NHS Trust . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10212", "text": "His main clinical interest is  colorectal cancer , and he performs surgery for primary and recurrent disease as well as multi-visceral resections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10213", "text": "He has pioneered single incision  laparoscopic  colorectal surgery (virtual scarless surgery) and also works with liver surgeons to perform simultaneous laparoscopic liver and  bowel resections  for cancer. His other clinical interest is advanced stage 3/4  endometriosis , performing laparoscopic surgery with  gynaecologists . This has led to the development and recognition of a national centre for endometriosis. In addition, he has specialist experience in complex abdominal wall  hernias  and reconstruction. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10214", "text": "From 2010 to 2015, Ahmed was the lead clinician and multi-disciplinary team lead for colorectal cancer at Barts Health NHS Trust. He was also a CQC specialist advisor in general surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10215", "text": "Ahmed was the Associate Dean for Barts and the London undergraduate medical students at  The Royal London Hospital  from 2010 to 2019 and was the lead for surgery. He was programme director for core surgical trainees for North East London 2012\u20132013 and Tutor in Surgery for the Royal London Hospital 2011\u20132013. He teaches innovation and digital transformation for surgeons at  Harvard Medical School  and  Imperial College London . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10216", "text": "He is the civilian advisor for the  British Armed forces  for general surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10217", "text": "From 2013 to 2019, Ahmed was elected to the council of the  Royal College of Surgeons of England . [ 10 ]  He had numerous roles and led the International Surgical Training Programme. He was part of the Cancer 2020, 5 Year Forward View Taskforce 2015. [ 11 ]  He is a member of the court of examiners and is an international convenor of the MRCS for Bangladesh. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10218", "text": "In 2007, Ahmed was appointed as a Consultant General, Laparoscopic and Colorectal surgeon to  The Royal London Hospital  and  St Bartholomew's Hospital ,  Barts Health NHS Trust ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10219", "text": "He was chosen to curate the  NHS  Twitter account from 27 February 2017 to 3 March 2017 and tweeted the world's first live operation via this account."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10220", "text": "He was the clinical lead for surgery at the  NHS Nightingale  Hospital at Excel London during the COVID-19 pandemic in 2020."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10221", "text": "Ahmed performed a live cancer operation at  The Royal London Hospital  on Channel 5 for the series  Operation Live  in 2018."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10222", "text": "Ahmed is the module lead for an innovative new course at Barts and the London Medical School which aims to teach the third year medical students about future medicine and how to generate ideas to improve clinical care. [ 13 ] [ 1 ]  The students are taught by  digital health  innovators and those involved in Medtech from the UK and US."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10223", "text": "Ahmed has been working on new technologies to enhance surgical education globally. His online videos have been watched hundreds of thousands of times, earning him the accolade of the most-watched surgeon in human history. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10224", "text": "He aims to teach surgery and surgical processes to thousands of students at a time using VR technology. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10225", "text": "Ahmed's company Virtual Medics developed the use of  wearable technology  in education and clinical practice. This has allowed the development of a web-placed platform to stream live and interactive teaching."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10226", "text": "In May 2014, using  Google Glass , he performed and streamed a live operation to 14 thousand students across 132 countries and 1100 cities. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10227", "text": "Ahmed is the co-founder of Medical Realities, a group offering surgical training products, specialising in virtual reality, augmented reality and  serious games . [ 17 ]  Through Medical Realities, he aims to provide tutorials in a modular format to teaching hospitals around the world. This will be made accessible to students and surgical trainees."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10228", "text": "On 14 April 2016, in collaboration with  Barts Health , Medical Realities and Mativision, he performed the world's first virtual reality operation recorded and streamed live in  360 degrees . [ 8 ] [ 17 ] [ 18 ] [ 19 ]  This was viewed by 55,000 people in 140 countries and 4000 cities and reached 4.6 million people on Twitter."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10229", "text": "This event was covered worldwide on over 400 newspaper/online articles and  BBC Click , Sky News, ARD German, TRT News, South American NTN,  ABC News ,  Aljazeera , and Press TV. [ 20 ] [ 21 ] [ 22 ] [ 23 ]  His work has been featured on  Wired ,  The Guardian ,  The Telegraph , ABC News,  CNET ,  The Verge ,  Huffington Post , and Tech China. [ 24 ] [ 25 ] [ 26 ] [ 27 ] [ 16 ] [ 28 ] [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10230", "text": "On 9 December 2016, he performed the world's first live operation using Snapchat Spectacles where he trained 200 medical students and surgical trainees, which was covered by  Time  magazine, and  BBC . [ 31 ] [ 32 ] [ 33 ]  The operation has been viewed over 100,000 times. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10231", "text": "He is a non-executive director of Medic creations, GPDQ and Imera. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10232", "text": "He is the chair of the GIANT (Global Innovation and New Technologies) Health Event in London and also the chair of the Webit Health conference in Sofia, Bulgaria, which showcases startups, innovation, technology and entrepreneurship. [ 36 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10233", "text": "Ahmed is a three time  TEDx  speaker and four times Wired Health and international  keynote speaker , and a member of the faculty at Exponential Medicine,  Singularity University ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10234", "text": "On 15 March 2017, Ahmed delivered the Cantor Technology Lecture at the  University of Bradford  and also delivered the public lecture to open the Digital Health Enterprise Zone. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10235", "text": "He is Vice-President of Proshanti, a local charity community project to set up a health programme in Bangladesh, He is an advisor to Beani Bazaar Cancer Hospital, Bangladesh. [ 48 ]  He also teaches and trains surgeons in Dhaka, Bangladesh where he is the Dean for education at Rahetid, a postgraduate surgical training centre. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10236", "text": "The  American Board of Colon and Rectal Surgery  ( ABCRS ) is a member of the  American Board of Medical Specialties  that issues certificates for practitioners of  Colorectal surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10237", "text": "The board was established in 1934 as the American Board of Proctology. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10238", "text": "This article about a United States health organization is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10239", "text": "The  American Osteopathic Board of Proctology  ( AOBPR ) is an organization that provides  board certification  to qualified  Doctors of Osteopathic Medicine  (D.O.) who specialize in the medical and surgical treatment of disorders of the  anus ,  colon , and  rectum  of the  gastrointestinal tract  ( proctologists ). The board is one of 18  medical specialty  certifying boards of the  American Osteopathic Association Bureau of Osteopathic Specialists  approved by the  American Osteopathic Association  (AOA), [ 3 ]  and was established in 1941. [ 1 ]  As of April 2011, there were 25 osteopathic proctologists certified by the AOBPR. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10240", "text": "To become board certified in proctology, candidates must have completed an AOA-approved  residency  in proctology and one year of practice as a licensed proctologist. [ 5 ]   Additionally, candidates must have successfully completed the required oral and written examinations. Since 2004, board certified osteopathic proctologists must renew their certification every ten years to avoid expiration of their board certified status. [ 6 ]  Physicians certified by the AOBPR are known as fellows of the American Osteopathic College of Proctology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10241", "text": "Anal dysplasia  is a pre-cancerous condition which occurs when the lining of the  anal canal  undergoes abnormal changes. It can be classified as  low grade squamous intraepithelial lesions  (LSIL) and high-grade squamous intraepithelial lesions (HSIL). [ 1 ]  \nMost cases are not associated with symptoms, but people may notice lumps in and around the  anus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10242", "text": "Anal dysplasia is most commonly linked to  human papillomavirus  (HPV), a usually  sexually-transmitted infection . [ 3 ]  HPV is the most common  sexually transmitted infection  in the United States [ 4 ]  while  genital herpes  ( HSV ) was the most common sexually transmitted infection globally. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10243", "text": "Anal fistula  is a chronic  abnormal communication  between the  anal canal  and the perianal skin. [ 1 ]  An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. [ 2 ]  Anal fistulae commonly occur in people with a history of  anal abscesses . They can form when anal abscesses do not heal properly. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10244", "text": "Anal fistulae originate from the  anal glands , which are located between the  internal  and  external anal sphincter  and drain into the  anal canal . [ 4 ]  If the outlet of these glands becomes blocked, an  abscess  can form which can eventually extend to the skin surface. The tract formed by this process is a fistula. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10245", "text": "Abscesses can recur if the fistula seals over, allowing the accumulation of  pus . It can then extend to the surface again \u2013 repeating the process. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10246", "text": "Anal fistulae  per se  do not generally harm, but can be very painful, and can be irritating because of the drainage of pus (it is also possible for formed stools to be passed through the fistula). Additionally, recurrent abscesses may lead to significant short term morbidity from pain and, importantly, create a starting point for systemic infection. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10247", "text": "Treatment, in the form of surgery, is considered essential to allow drainage and prevent infection. Repair of the fistula itself is considered an elective procedure which many patients opt for due to the discomfort and inconvenience associated with an actively draining fistula. [ 5 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10248", "text": "Anal fistulae can present with the following symptoms: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10249", "text": "Diagnosis is by examination, either in an  outpatient  setting or under  anaesthesia  (referred to as  EUA  or Examination Under Anaesthesia). The fistula may be explored by using a fistula probe (a narrow instrument). In this way, it may be possible to find both openings. The examination can be an  anoscopy . Diagnosis may be aided by performing a fistulogram, proctoscopy and/or sigmoidoscopy.\nPossible findings:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10250", "text": "Depending on their relationship with the  internal  and  external sphincter  muscles, fistulae are classified into five types:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10251", "text": "Other conditions in which infected perianal \"holes\" or openings may include  pilonidal cyst ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10252", "text": "There are several stages to treating an anal fistula:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10253", "text": "Definitive treatment of a fistula aims to stop it recurring.  Treatment depends on where the fistula lies, and which parts of the  internal  and  external anal sphincters  it crosses. However, treatment is challenging as complete eradication of the anal sphincters may lead to continence impairment, but failure to excise the affected areas results in recurrence. Those already treated for recurring anal fistula are at higher risk to experience re-recurrence of the disease.  [1]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10254", "text": "The VAAFT procedure is done in two phases, diagnostic and operative. Before the procedure, the patient is given a spinal or general anaesthetic and is placed in the lithotomy position (legs in stirrups with the perineum at the edge of the table).  In the diagnostic phase, the fistuloscope is inserted into the fistula to locate the internal opening in the anus and to identify any secondary tracts or abscess cavities. The anal canal is held open using a speculum and irrigation solution is used to give a clear view of the fistula tract. Light from the fistuloscope can be seen from inside the anal canal at the location of the internal opening of the fistula, which helps to locate the internal opening.  In the operative phase of the procedure, the fistula tract is cleaned and the internal opening of the fistula is sealed. To do this, the surgeon uses the unipolar electrode, under video guidance, to cauterise material in the fistula tract. Necrotic material is removed at the same time using the fistula brush and forceps, as well as by continuous irrigation. The surgeon then closes the internal opening from inside the anal canal using stitches and staples."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10255", "text": "Some people will have an active  infection  when they present with a fistula, and this requires clearing up before definitive treatment can be decided."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10256", "text": "Antibiotics  can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation.  This can be done with a  seton ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10257", "text": "A literature review published in 2018 showed an incidence as high as 21 people per 100,000. \"Anal fistulas are 2\u20136 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s.\" [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10258", "text": "Anal stricture  or  anal stenosis  is a narrowing of the anal canal. [ 1 ]  It can be caused by a number of surgical procedures including:  hemorrhoid  removal and following  anorectal wart  treatment. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10259", "text": "Anismus  or  dyssynergic defecation  is the failure of normal relaxation of  pelvic floor  muscles during attempted  defecation . It can occur in both children and adults, and in both men and women (although it is more common in women). It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with  parcopresis , or psychogenic fecal retention. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10260", "text": "Symptoms include  tenesmus  (the sensation of incomplete emptying of the rectum after defecation has occurred) and  constipation . Retention of stool may result in fecal loading (retention of a mass of stool of any consistency) or  fecal impaction  (retention of a mass of hard stool). This mass may stretch the walls of the rectum and colon, causing  megarectum  and/or  megacolon , respectively. Liquid stool may leak around a fecal impaction, possibly causing degrees of liquid fecal incontinence. This is usually termed  encopresis  or soiling in children, and  fecal leakage , soiling or liquid  fecal incontinence  in adults."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10261", "text": "Anismus is usually treated with dietary adjustments, such as  dietary fiber  supplementation. It can also be treated with a type of  biofeedback  therapy, during which a sensor probe is inserted into the person's  anal canal  in order to record the pressures exerted by the pelvic floor muscles. These pressures are visually fed back to the patient via a monitor who can regain the normal coordinated movement of the muscles after a few sessions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10262", "text": "Some researchers have suggested that anismus is an over-diagnosed condition, since the standard investigations or  digital rectal examination  and  anorectal manometry  were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence. [ 1 ]  Due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently compared to normal circumstances. These researchers went on to conclude that paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and fecal incontinence, and it represents a non-specific finding or laboratory artifact related to untoward conditions during examination, and that true anismus is actually rare."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10263", "text": "Symptoms include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10264", "text": "To understand the cause of anismus, an understanding of normal colorectal anatomy and physiology, including the normal defecation mechanism, is helpful. The relevant anatomy includes: the  rectum , the  anal canal  and the muscles of the  pelvic floor , especially  puborectalis  and the  external anal sphincter . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10265", "text": "The  rectum  is a section of bowel situated just above the anal canal and distal to the  sigmoid colon  of the  large intestine . It is believed to act as a reservoir to store stool until it fills past a certain volume, at which time the defecation reflexes are stimulated. [ 4 ]  In healthy individuals, defecation can be temporarily delayed until it is socially acceptable to  defecate . In continent individuals, the rectum can expand to a degree to accommodate this function. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10266", "text": "The anal canal is the short straight section of bowel between the rectum and the  anus . It can be defined functionally as the distance between the anorectal ring and the end of the  internal anal sphincter . The internal anal sphincter forms the walls of the anal canal. The internal anal sphincter is not under voluntary control, and in normal persons it is contracted at all times except when there is a need to defecate. This means that the internal anal sphincter contributes more to the resting tone of the anal canal than the external anal sphincter. The internal sphincter is responsible for creating a watertight seal, and therefore provides continence of liquid stool elements. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10267", "text": "The  puborectalis  muscle is one of the pelvic floor muscles. It is  skeletal muscle  and is therefore under voluntary control. The puborectalis originates on the posterior aspect of the  pubic bone , and runs backwards, looping around the bowel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10268", "text": "The point at which the rectum joins the anal canal is known as the anorectal ring, which is at the level that the puborectalis muscle loops around the bowel from in front. This arrangement means that when puborectalis is contracted, it pulls the junction of the rectum and the anal canal forwards, creating an angle in the bowel called the anorectal angle. This angle prevents the movement of stool stored in the rectum moving into the anal canal. It is thought to be responsible for gross continence of solid stool. Some believe the anorectal angle is one of the most important contributors to continence. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10269", "text": "Conversely, relaxation of the puborectalis reduces the pull on the junction of the rectum and the anal canal, causing the anorectal angle to straighten out. A  squatting posture  is also known to straighten the anorectal angle, meaning that less effort is required to defecate when in this position. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10270", "text": "Distension of the rectum normally causes the internal anal sphincter to relax (rectoanal inhibitory response, RAIR) and the external anal sphincter initially to contract (rectoanal excitatory reflex, RAER). The relaxation of the internal anal sphincter is an involuntary response. The external anal sphincter, by contrast, is made up of skeletal (or striated muscle) and is therefore under voluntary control. It can contract vigorously for a short time. Contraction of the external sphincter can defer defecation for a time by pushing stool from the anal canal back into the rectum. Once the voluntary signal to defecate is sent back from the brain, the abdominal muscles contract (straining) causing the intra-abdominal pressure to increase. The pelvic floor is lowered causing the anorectal angle to straighten out from ~90 o  to <15 o  and the external anal sphincter relaxes. The rectum now contracts and shortens in  peristaltic waves , thus forcing fecal material out of the rectum, through the anal canal and out of the anus. The internal and external anal sphincters along with the puborectalis muscle allow the feces to be passed by pulling the anus up over the exiting feces in shortening and contracting actions. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10271", "text": "In patients with anismus, the puborectalis and the external anal sphincter muscles fail to relax, with resultant failure of the anorectal angle to straighten out and facilitate evacuation of feces from the rectum. These muscles may even contract when they should relax (paradoxical contraction), and this not only fails to straighten out the anorectal angle, but causes it to become more acute and offer greater obstruction to evacuation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10272", "text": "As these muscles are under voluntary control, the failure of muscular relaxation or paradoxical contraction that is characteristic of anismus can be thought of as either maladaptive behavior or a loss of voluntary control of these muscles. Others claim that puborectalis can become  hypertrophied  (enlarged) or  fibrosis  (replacement of muscle tissue with a more fibrous tissue), which reduces voluntary control over the muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10273", "text": "Anismus could be thought of as the patient \"forgetting\" how to push correctly, i.e. straining against a contracted pelvic floor, instead of increasing abdominal cavity pressures and lowering pelvic cavity pressures. It may be that this scenario develops due to stress. For example, one study reported that anismus was strongly associated with sexual abuse in women. [ 7 ]  One paper stated that events such as pregnancy, childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis could lead to a \"functional  obstructed defecation syndrome \" (including anismus). [ 8 ]  Anismus may develop in persons with  extrapyramidal motor disturbance  due to  Parkinson's disease . [ 9 ]   This represents a type of  focal dystonia . [ 10 ]  Anismus may also occur with  anorectal malformation ,  rectocele , [ 11 ]   rectal prolapse [ 12 ]  and  rectal ulcer . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10274", "text": "In many cases however, the underlying pathophysiology in patients presenting with obstructed defecation cannot be determined. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10275", "text": "Some authors have commented that the \"puborectalis paradox\" and \"spastic pelvic floor\" concepts have no objective data to support their validity. They state that \"new evidence showing that defecation is an integrated process of colonic and rectal emptying suggests that anismus may be much more complex than a simple disorder of the pelvic floor muscles.\" [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10276", "text": "Persistent failure to fully evacuate stool may lead to retention of a mass of stool in the rectum (fecal loading), which can become hardened, forming a  fecal impaction  or even  fecaliths . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10277", "text": "Liquid stool elements may leak around the retained fecal mass, which may lead to paradoxical diarrhoea and/or fecal leakage (usually known as  encopresis  in children and  fecal leakage  in adults). [ 14 ] [ 15 ] [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10278", "text": "When anismus occurs in the context of intractable  encopresis  (as it often does), resolution of anismus may be insufficient to resolve encopresis. [ 18 ]  For this reason, and because biofeedback training is invasive, expensive, and labor-intensive, biofeedback training is not recommended for treatment of encopresis with anismus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10279", "text": "The walls of the rectum may become stretched, known as  megarectum . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10280", "text": "In the  Rome IV classification , diagnostic criteria for \"functional defecation disorders\" are as follows: [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10281", "text": "2 subcategories exist within the functional defecation disorders category:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10282", "text": "For all of these Rome-IV diagnoses, diagnostic criteria must have been fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. [ 20 ]  The subcategories F3a and F3b are defined by age- and gender-appropriate normal values for the technique. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10283", "text": "Previous Rome criteria recommended that anorectal testing is not usually indicated in patients with symptoms until patients have failed conservative treatment (e.g., increased dietary fiber and liquids; elimination of medications with constipating side effects\nwhenever possible). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10284", "text": "Several definitions have been offered:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10285", "text": "Physical examination can rule out anismus (by identifying another cause) but is not sufficient to diagnose anismus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10286", "text": "The measurement of  pressures  within the rectum and anus with a  manometer  (pressure-sensing probe)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10287", "text": "defecating proctogram , and  MRI defecography"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10288", "text": "Anismus can be subcategorized into 4 types based on the results of anorectal manometry testing: [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10289", "text": "Anismus is classified as a functional defecation disorder. It is also a type of rectal outlet obstruction (a functional outlet obstruction). Where anismus causes constipation, it is an example of  functional constipation . Many authors describe an \" obstructed defecation syndrome \", of which anismus is a cause. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10290", "text": "The  Rome II classification  functional defecation disorders were divided into 3 types, [ 25 ]  however the symptoms the patient experiences are identical. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10291", "text": "It can be seen from the above classification that many of the terms that have been used interchangeably with anismus are inappropriately specific and neglect the concept of impaired propulsion. Similarly, some of the definitions that have been offered are also too restrictive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10292", "text": "The rectal cooling test is suggested to differentiate between rectal inertia and impaired relaxation/paradoxical contraction  [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10293", "text": "Other techniques include  manometry ,  balloon expulsion test ,  evacuation proctography  (see  defecating proctogram ), and MRI defecography. [ 28 ]   Diagnostic criteria are:  fulfillment of criteria for  functional constipation , manometric and/or EMG and/or radiological evidence (2 out of 3), evidence of adequate expulsion force, and evidence of incomplete evacuation. [ 28 ]   Recent dynamic imaging studies have shown that in persons diagnosed with anismus the  anorectal angle  during attempted  defecation  is abnormal, and this is due to abnormal (paradoxical) movement of the  puborectalis muscle . [ 29 ] [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10294", "text": "Initial steps to alleviate anismus include dietary adjustments and simple adjustments when attempting to defecate. Supplementation with a  bulking agent  such as  psyllium  will make stool more bulky, which decreases the effort required to evacuate. [ 23 ]  Similarly, exercise and adequate hydration may help to optimise  stool form . The anorectal angle has been shown to flatten out when in a  squatting position , and is thus recommended for patients with functional outlet obstruction like anismus. [ 5 ]  If the patient is unable to assume a squatting postures due to mobility issues, a low stool can be used to raise the feet when sitting, which effectively achieves a similar position. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10295", "text": "Treatments for anismus include biofeedback retraining, botox injections, and surgical resection. Anismus sometimes occurs together with other conditions that limit (see  contraindication ) the choice of treatments.  Thus, thorough evaluation is recommended prior to treatment. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10296", "text": "Biofeedback  training for treatment of anismus is highly effective and considered the gold standard therapy by many. [ 18 ] [ 33 ] [ 34 ] \nOthers however, reported that biofeedback had a limited therapeutic effect. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10297", "text": "Injections of  botulin toxin type-A  into the  puborectalis muscle  are very effective in the short term, and somewhat effective in the long term. [ 36 ]  Injections may be helpful when used together with biofeedback training. [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10298", "text": "Historically, the standard treatment was  surgical resection  of the puborectalis muscle, which sometimes resulted in fecal incontinence. Recently, partial resection (partial division) has been reported to be effective in some cases. [ 35 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10299", "text": "Paradoxical anal contraction during attempted defecation in constipated patients was first described in a paper in 1985, when the term anismus was first used. [ 40 ]  The researchers drew analogies to a condition called  vaginismus , which involves paroxysmal (sudden and short lasting) contraction of  pubococcygeus  (another muscle of the pelvic floor).  These researchers felt that this condition was a spastic dysfunction of the anus, analogous to 'vaginismus'. However, the term anismus implies a psychogenic etiology, which is not true although psychological dysfunction has been described in these patients. Hence:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10300", "text": "Latin  ani  - \"of the anus\" \nLatin  spasmus  - \"spasm\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10301", "text": "(Derived by extrapolation with the term vaginismus, which in turn is from the Latin  vagina  - \"sheath\" +  spasmus  - \"spasm\")"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10302", "text": "Many terms have been used synonymously to refer to this condition, some inappropriately. The term \"anismus\" has been criticised as it implies a  psychogenic  cause. [ 41 ]  In the most widely accepted classification systems ( ICD-11  and  Rome-IV ), the term \"dyssynergic defecation\" is preferred. [ 21 ] [ 20 ]  As stated in the Rome II criteria, the term \"dyssynergic defecation\" is preferred to \"pelvic floor dyssynergia\" because many patients with dyssynergic defecation do not report sexual or urinary symptoms, [ 25 ]  meaning that only the defecation mechanism is affected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10303", "text": "Other synonyms include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10304", "text": "Anorectal anomalies  are congenital malformations of the  anus  and  rectum . [ 1 ]  One anal anomaly,  imperforate anus  has an estimated incidence of 1 in 5000 births. [ 2 ] [ 3 ]  It affects boys and girls with similar frequency. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10305", "text": "Examples of anorectal anomalies include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10306", "text": "This article about a  disease , disorder, or medical condition is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10307", "text": "Anorectal manometry  ( ARM ) is a  medical test  used to measure  pressures  in the  anus  and  rectum  and to assess their function. [ 1 ] [ 2 ]  The test is performed by inserting a  catheter , that contains a probe embedded with pressure sensors, through the anus and into the rectum. [ 3 ]  Patients may be asked to perform certain maneuvers, such as coughing or attempting to  defecate , to assess for pressure changes. [ 3 ]  Anorectal manometry is a safe [ 4 ]  and low risk [ 3 ]  procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10308", "text": "From 2014 to 2018, the international anorectal physiology working group (IAPWG) meet several times to develop consensus on  indications  for anorectal manometry. [ 5 ]  Their assessment concluded that anorectal manometry was indicated when used in assessment of  fecal incontinence ,  constipation , evacuation disorders (including  Hirschsprung's disease [ 6 ] ), functional anorectal pain and in the assessment of anorectal function  preoperatively  or after a traumatic  obstetric  injury. [ 5 ]  In addition to the indications outlined by the IAPWG, anorectal manometry has been used as a component of anorectal  biofeedback . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10309", "text": "Since its introduction in 2007,  high resolution  anorectal manometry (HR-ARM) has increasingly replaced conventional anorectal manometry as the standard. [ 7 ]  There has been increasing usage of high-definition (3D) anorectal manometry (HD-ARM) as well. [ 7 ]  Current advances in anorectal manometry include the development of  bedside  portable technology. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10310", "text": "After eliminating structural causes of  fecal incontinence  from the  differential diagnosis , anorectal manometry may be used to evaluate deficiencies in  sphincter  function or anorectal sensation. [ 4 ] [ 7 ]  An abnormal resting pressure or squeeze pressure may indicate problems with either the  internal anal sphincter  or the  external anal sphincter  respectively. [ 4 ]  Both increased and decreased anorectal sensation has also been detected in individuals with fecal incontinence. [ 6 ]  The use of HD-ARM can allow recognition of pressure asymmetry within the anorectum. [ 4 ]  Some patients with fecal incontinence benefit from muscle strength training which may make use of anorectal biofeedback. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10311", "text": "Anorectal manometry can be used in the diagnostic workup of individuals with  chronic constipation  without a known cause [ 8 ]  or with chronic constipation that has not improved on a trial of  laxatives  and/or  fiber . [ 9 ]  For example, on a  digital rectal exam , a physician may notice specific findings that point to  dyssynergic defecation , a cause of chronic constipation. [ 8 ]  In such instances, the physician may order an anorectal manometry study to verify their findings. [ 8 ]  Abnormal results, such as the presence of a  paradoxical  contraction of the anal sphincter muscles during  defecation  (i.e. the muscles are squeezing instead of relaxing), can also be used to guide treatment (e.g. anorectal  biofeedback ). [ 4 ] [ 8 ]  Other abnormal findings on manometry consistent with chronic constipation include an unsatisfactory generation of the propulsive  force  needed to defecate and a decreased movement of  pelvic floor  muscles. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10312", "text": "Anorectal manometry, especially HR-ARM and HD-ARM, has also been used to evaluate constipation due to structural causes such as a  rectocele , [ 2 ]  an  enterocele , or an intra-anal  intussusception . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10313", "text": "In infants and children, anorectal manometry may be used to assist in the diagnosis of  Hirschsprung's disease . [ 2 ]  The absence of the  rectoanal inhibitory reflex  (RAIR) is almost always  pathognomonic  for Hirschsprung's disease in this population. [ 6 ]  Anorectal manometry is not significantly less  sensitive and specific  when compared to the  gold standard  method of diagnosis, rectal suction  biopsy . [ 6 ]  In adults, the absence of the RAIR is less likely due to Hirschsprung's disease and may indicate the presence of  megarectum . [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10314", "text": "Functional anorectal pain includes disorders such as  levator ani syndrome ,  proctalgia fugax  and unspecified functional anorectal syndrome. [ 4 ]  Although diagnosis of these disorders is largely clinical, anorectal manometry may be used for further diagnostic assessment. [ 4 ]  For example, the degree of anal sphincter hypertension may be determined [ 7 ]  which may be useful information when treating functional anorectal pain with biofeedback therapy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10315", "text": "The goal of anorectal  biofeedback  is to help patients improve  defecating  behaviors by providing patients with visual and verbal feedback. [ 10 ]  Visual feedback tools, such as anorectal manometry, are often used to aid patients in learning how to modify their behaviors. [ 10 ]  Patients may work on improving muscle strength, muscle relaxation or sensation during defecation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10316", "text": "The effectiveness of anorectal biofeedback as a treatment remains an ongoing source of debate and research. A systemic review article [ 11 ]  concluded that although better than  placebo , there remained limited evidence demonstrating the effectiveness of anorectal biofeedback for chronic  idiopathic  constipation. [ 8 ]  In patients with  defecatory  disorders, including  dyssynergic defecation ,  pelvic floor  biofeedback therapy had been shown to be more effective than laxatives. [ 6 ] [ 9 ]  An American-European  Neurogastroenterology & Motility  task force (ANMS-ESNM) recommended the use of biofeedback in the short and long treatment of constipation with dyssynergic defecation and fecal incontinence. [ 10 ]  They did not recommend biofeedback treatment for constipation without dyssynergic defecation, nor in children with constipation. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10317", "text": "Types of anorectal manometry include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10318", "text": "HR-ARM and HD-ARM are newer methods that use multiple closely spaced sensors in the anus and rectum, compared to 3-6 widely spaced sensors used by non-HRM, to generate a more refined view. [ 3 ] [ 6 ]  An additional benefit to HR-ARM and HD-ARM is the increased ease in analyzing the results as pressure readings are displayed in both color and as a line plot. [ 3 ]  Accompanying the benefits shared by both high-resolution and high-definition methods, the HD-ARM method employs additional sensors placed circumferentially around the catheter allowing for closer interpretation of individual sensor pressure readings. [ 3 ]  In comparison to non-HRM, however, both of the newer methods utilize equipment that is more expensive and has a shorter  design life . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10319", "text": "The specifics of the equipment used for the procedure will ultimately depend on the type of manometry and the manufacturer of the device. Nonetheless, most share some common features: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10320", "text": "In 2019, the International Anorectal Physiology Working Group (IAPWG) released a standardized testing protocol for the use of anorectal manometry. [ 5 ]  One of the goals of this protocol was to standardize procedural techniques to better facilitate meaningful data sharing. [ 5 ]  This protocol is the most recent published guideline for anorectal manometry since the one published in 2002 [ 12 ]  which was not widely adopted. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10321", "text": "Fasting  is not a requirement for this procedure. [ 5 ]  Patients are  informed  as to how the procedure is performed, its benefits and risks. Risks include the possibility of developing discomfort, pain, minor bleeding, dizziness or a rare  perforation . [ 3 ] [ 13 ]  In the testing room, the patient is placed on their left side with their knees bent. [ 5 ]  A  digital rectal exam  is then performed prior to the procedure to evaluate initial anatomy and function, check for stool, and to assess patient's understanding of the verbal instructions employed during the procedure. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10322", "text": "Anorectal manometry is often performed alongside a rectal sensory test (RST) and a balloon expulsion test (BET). [ 5 ]  The RST is performed after the manometry while the BET may be performed immediately prior to the manometry or subsequent to the RST. [ 5 ]  The total time to conduct all three tests is 15 to 20 minutes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10323", "text": "This test takes approximately 10 minutes. [ 5 ]  With the use of a lubricant, an anorectal manometry catheter is introduced into the anus. [ 5 ]  The catheter is advanced until the base of the balloon is above the  anal canal  by 3\u20135\u00a0cm (1.2\u20132.0\u00a0in) and the most  distal  sensor is below the  anal verge . [ 5 ]  In order, the following maneuvers are then performed:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10324", "text": "During the rectal sensory test, air is placed into the catheter balloon and slowly inflated either continuously or step-wise. [ 5 ]  The patient is asked to verbalize when they first sense the balloon, when the urge to defecate is first present and when they can no longer tolerate the balloon. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10325", "text": "To perform the balloon expulsion test, a catheter with a balloon on its tip is introduced into the patient's anorectum. [ 5 ]  The balloon is then distended to 50ml with water. [ 5 ]  Patients are then instructed to transfer from lying on their side to sitting on a toilet. [ 5 ]  Next, patients are asked to push out the balloon as if they are defecating. [ 5 ]  The time it takes for the expulsion of the balloon is then recorded. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10326", "text": "The anal resting pressure is the recorded pressure within the anus during muscle relaxation. [ 6 ]  After insertion of the catheter, a short amount of time is allowed for the muscles to relax. Afterwards, pressures are recorded over 60 seconds. [ 5 ]  The  maximum  resting pressure is the highest pressure reached during this time period, while the  mean  resting pressure is the average pressure during this time period. In healthy individuals, women, especially older women, have an average lower anal resting pressures than men. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10327", "text": "The anal squeeze pressure is the recorded pressure within the anus during a voluntary contraction of the  external anal sphincter . [ 6 ]  Similar to resting pressures, squeeze pressures in healthy women are lower than healthy men. [ 6 ]  If using high-definition anorectal manometry, asymmetry in squeeze pressures can also be measured. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10328", "text": "During  defecation , the pressure in the anorectum should increase while the  external anal sphincter  should relax. If the pressure difference during defecation does not increase sufficiently, it may indicate poor propulsive force. [ 6 ] [ 14 ]  Additionally, inadequate relaxation of the sphincter during defecation is another abnormal finding. [ 6 ]  Another method to assess changes during defecation is to calculate an anorectal gradient (or defecation index) in one of two ways. [ 14 ]  The anorectal gradient is either calculated as a difference (rectal pressure - anal pressure) or as a  ratio  (rectal pressure / anal pressure). [ 14 ]  A positive difference or a ratio over 1 indicates normal findings. [ 14 ]  Abnormal findings on manometry does not definitively indicate illness as a significant number of healthy individuals have been found to have abnormal results. [ 6 ] [ 14 ]  Values recorded during a defecation trial are influenced by a number of factors including the degree of patient involvement in defecation efforts. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10329", "text": "In healthy individuals, in the process of defecating, the  internal anal sphincter  will  reflexively  relax. The lack of a  rectoanal inhibitory reflex  may indicate either the absence or the non-functionality of certain muscle or nerve structures involved in proper defecation. [ 3 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10330", "text": "Patients are assessed on their anorectal sensory perception via the inflation of a balloon. As the balloon is inflated, its volume is recorded at certain milestones: [ 5 ]  initial sensation of the equipment, start of the sensory urge to defecate and the point of maximum discomfort. [ 6 ] [ 3 ]  An increased level of sensation has been noted in disorders such as  fecal incontinence , while a decreased level of sensation has been seen in individuals with  dyssynergic defecation . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10331", "text": "As part of the 2020 IAPWG consensus manuscript, the group published the newly created London Classification for Disorders of Anorectal Function which aimed to standardize the interpretation of anorectal manometry findings. [ 5 ] [ 7 ]  The London Classification divided disorders into 4 parts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10332", "text": "Under each part, there are a list of diagnosis that are made based on manometry findings. For example, under part 2 (Disorders of anal tone and contractility), listed manometric diagnoses include: anal hypotension, anal hypertension, anal hypercontractility and combined anal hypertension and hypercontractility. [ 7 ]  Findings are also divided into: major findings, minor findings and inconclusive findings. [ 7 ]  Major findings are findings that are not present in healthy patient such as rectoanal areflexia, [ 7 ]  Minor findings are findings that are more commonly found in patients with anorectal disease compared to healthy patients, while inconclusive findings are findings that may be present in both groups. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10333", "text": "Centers rely on published data sets from healthy volunteers to evaluate test findings. [ 4 ]  However, the lack of standardization in equipment usage and procedural protocol, can in certain cases, impact the ability to determine what may be considered normal or abnormal values. [ 4 ]  This is further complicated by the limited amount of data on the impact of different epidemiological characteristics (such as age or gender) on said values. [ 4 ]  For an individual patient, findings on anorectal manometry, alone, does not dictate management. [ 7 ]  In addition to correlating manometry findings with clinical findings, as part of a diagnostic or evaluatory workup, the use of anorectal manometry may be complemented with other diagnostic tests such as  endoanal ultrasound ,  defecography  or gut transit studies. [ 7 ]  High resolution anorectal manometry also experiences pressure drift, variable linear changes in pressure readings over time, that could impact the clinical value of manometry findings in some specific situations. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10334", "text": "Anorectal varices  are  collateral  submucosal blood vessels  dilated  by backflow in the veins of the  rectum . [ 1 ]  Typically this occurs due to  portal hypertension  which shunts venous blood from the  portal system  through the  portosystemic anastomosis  present at this site into the  systemic venous system . [ 2 ] [ 3 ]  This can also occur in the  esophagus , causing  esophageal varices , and at the level of the  umbilicus , causing  caput medusae . [ 4 ]  Between 44% and 78% of patients with portal hypertension get anorectal varices. [ 3 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10335", "text": "Blood from the superior portion of the  rectum  normally drains into the  superior rectal vein  and via the  inferior mesenteric vein  to the  liver  as part of the  portal venous system . Blood from the middle and inferior portions of the  rectum  is drained via the  middle  and  inferior rectal veins . In  portal hypertension , venous resistance is increased within the  portal venous system ; when the pressure in the portal venous system increases above that of the  systemic , blood is shunted through the  portosystemic anastomoses . The shunting of blood and consequential increase of pressure through the collateral veins causes the  varicosities . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10336", "text": "The terms  rectal varices  and  haemorrhoids  are often used interchangeably, but this is not correct. [ 6 ]  Haemorrhoids are due to prolapse of the  rectal venous plexus  and are no more common in patients with portal hypertension than in those without. [ 7 ]  Rectal varices, however, are found only in patients with portal hypertension and are common in conditions such as  cirrhosis . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10337", "text": "Unlike esophageal varices, rectal varices are less prone to bleeding, are less serious when a bleed does occur, and are easier to treat because of the more accessible location. [ 9 ]  However, in some cases, rectal varices can result in severe bleeding.  [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10338", "text": "Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing. [ 5 ]  Insertion of a  transjugular intrahepatic portosystemic shunt  (TIPS) has been shown to alleviate varices caused by portal hypertension. [ 1 ]  Successful treatment of portal hypertension that subsequently reduces anorectal varices provides a confirmation of the initial diagnosis, allowing for a distinction between varices and hemorrhoids, which would not have been alleviated by reduction of portal hypertension. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10339", "text": "An  anoscopy  is a  medical examination  using a small, rigid, tubular instrument called an anoscope (also called a  rectal speculum ).  This is inserted a few inches into the  anus  in order to evaluate problems of the  anal canal . Anoscopy is used to diagnose  hemorrhoids ,  anal fissures  (tears in the lining of the anus), and some  cancers . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10340", "text": "This test is usually done in a doctor's office. The patient is required to remove their underwear, and must either lie on their side on top of an examining table, with their knees bent up towards the chest, or bend forward over the table. The anoscope is 3 to 4\u00a0inches long and the width of an average-to-large bowel movement. The doctor will coat the anoscope with a lubricant and then gently push it into the anus and rectum. The doctor may ask the patient to \"bear down\" or push as if they were going to have a bowel movement, and then relax. This helps the doctor insert the anoscope more easily and identify any bulges along the lining of the rectum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10341", "text": "By shining a light into this tube, the doctor will have a clear view of the lining of the lower rectum and anus. The anoscope is pulled out slowly once the test is finished."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10342", "text": "The patient will feel pressure during the examination, and the anoscope will make one feel as if they were about to have a bowel movement. This is normal, however, and many patients do not feel pain from anoscopy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10343", "text": "Anoscopy will permit  biopsies  to be taken, and is used when ligating prolapsed hemorrhoids. It is used in the treatment of warts produced by  HPV ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10344", "text": "The procedure is done on an outpatient basis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10345", "text": "A  cholecystoenterostomy  is a surgical procedure in which the  gall bladder  is joined to the  small intestine . It is performed in order to allow bile to pass from the  liver  to the  intestine  when the  common bile duct  is obstructed by an irremovable cause. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10346", "text": "A  cul-de-sac hernia  (also termed a  peritoneocele ) is a  herniation  of  peritoneal  folds into the  rectovaginal septum  (in females), [ 2 ]  or the  rectovesical septum  (in males). The herniated structure is the  recto-uterine pouch  (pouch of Douglas) in females, [ 2 ]  or the  rectovesical pouch  in males. The hernia descends below the proximal (upper) third of the vagina in females, [ 2 ]  or, according to another definition, below the pubococcygeal line (PCL). [ 3 ] [ note 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10347", "text": "According to a consensus statement by the USA, Australia and the UK, [ note 2 ]  a cul-de-sac hernia / peritoneocele is defined as \"a protrusion of the peritoneum between the rectum and vagina that does not contain any abdominal viscera\" (organs). [ 4 ]  An enterocele is defined as \"a protrusion of the peritoneum between the rectum and vagina containing the small intestine.\" [ 4 ]  A sigmoidocele is defined as \"a protrusion of the peritoneum between the rectum and vagina that contains the sigmoid colon.\" [ 4 ]  An omentocele is defined as \"a protrusion of the omentum between the rectum and the vagina.\" [ 4 ]  As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10348", "text": "This hernia is so named because it is a herniation of the recto-uterine pouch (pouch of Douglas), which is also sometimes called the \"cul-de-sac\". This is the pocket formed by the reflection of the peritoneum from the rectum and the posterior wall of the uterus. The equivalent structure in males is the rectovesical pouch, which is the pocket formed by the reflections of the peritoneum from the rectum to the male bladder. In terms of pelvic organ prolapse, a cul-de-sac hernia is located in the posterior compartment of the pelvis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10349", "text": "A true cul-de-sac hernia contains only  omental  fat, and often  intraperitoneal liquid. [ 6 ]  If the hernia contains omentum, sometimes the term \"omentocele\" is used. [ 7 ]  If the cul-de-sac hernia contains loops of small bowel, the term  enterocele  is used. [ 2 ]  If it contains sigmoid colon, the term  sigmoidocele  is used. [ 2 ]  It has been suggested that the terms enterocele and sigmoidocele are inaccurate, since hernias are usually named according to location and not according to contents. [ 8 ]  However, the terms are in widespread use. [ 8 ]  As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10350", "text": "Cul-de-sac hernias may be classified as rectal, septal, or vaginal depending on the structure they herniate into. Rectal cul-de-sac hernias herniate into an internal or external  rectal prolapse . Septal cul-de-sac hernias herniate into the recto-vaginal septum (rectovesical septum in males). Vaginal cul-de-sac hernias bulge into the vagina itself. Combinations of these types are also possible. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10351", "text": "Severity of the hernia may be classed as first degree if it is above the pubococcygeal line, second degree if it is below the pubococcygeal line but above the ischiococcygeal line, [ note 3 ]  or third degree if it is below the ischiococcygeal line. [ 9 ]  Severity may also be graded according the distance between the pubococcygeal line and the lowest point of the sac as follows: small (less than 3\u00a0cm), moderate (3\u20136\u00a0cm) or large (more than 6\u00a0cm). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10352", "text": "Cul-de-sac hernias may also be classified as primary and secondary. Primary cul-de-sac hernias are associated with factors such as  multiparity , old age, lack of elasticity,  obesity ,  constipation , and increased abdominal pressure are present. [ 8 ]  Secondary cul-de-sac hernias are those which develop after gynecologic procedures, especially after vaginal hysterectomy. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10353", "text": "Another classification of cul-de-sac hernias is internal, meaning those that are only visible on defecography, or external, which are associated with a clinically visible rectocele or rectal prolapse. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10354", "text": "Symptoms are variable, and depend on the exact location and severity of the hernia. [ 10 ]  Possible symptoms include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10355", "text": "Cul-de-sac hernias are the most difficult to diagnose during physical examination, and to distinguish from anterior  rectocele  or enterocele. [ 2 ]  Furthermore, rectocele and cul-de-sac hernia may occur together. [ 3 ]  Combined vaginal and rectal digital palpation may be used (examiner's thumb in vagina, index finger in anal canal). [ 11 ]  The peritoneal sac containing omentum may be palpable between the thumb and index finger. [ 11 ]  The prolapse may be detectable at the upper posterior vaginal wall during  Valsalva's maneuver . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10356", "text": "Imaging which may be used to detect cul-de-sac hernia includes standard  defecography , magnetic resonance defecography and  dynamic transperineal ultrasound . [ 5 ]  Cul-de-sac hernias usually only appear on such imagining at the end of the simulated defecation, and require complete or near complete evacuation of the rectum before they are visible. [ 3 ]  This feature may distinguish cul-de-sac hernia from rectocele. [ 1 ]  However, a large rectocele that retains contrast medium may hide a cul-de-sac hernia. [ 3 ]  Cul-de-sac hernia (peritoneocele / omentocele) may appear on fluoroscopic defecography as an un-opacified mass which deforms the anterior border of the rectum and the posterior border of the vagina, with widening of the recto-vaginal space in between. [ 1 ]  On magnetic resonance defecography, the vagina and rectum may appear clearly \"splayed\" apart. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10357", "text": "Risk factors include prior  hysterectomy  and  urethropexy  because of the damage caused to the  rectovaginal fascia . [ 2 ]  Hysterectomy also increases the size of the pouch of Douglas. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10358", "text": "Defecography  (also known as proctography, defecating/defecation proctography, evacuating/evacuation proctography or dynamic rectal examination) is a type of medical  radiological  imaging in which the mechanics of a patient's  defecation  are visualized in real time using a  fluoroscope . [ 1 ]  The anatomy and function of the anorectum and  pelvic floor  can be dynamically studied at various stages during defecation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10359", "text": "Defecating proctography was pioneered in 1945, during  World War II . The procedure gained popularity at this time in the midst of an outbreak of  whipworm , which is known to cause  rectal prolapse . [ 3 ]  It has since become used for diagnosis of various anorectal disorders, including  anismus  and other causes of  obstructed defecation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10360", "text": "It has fallen out of favor due to inadequate training in the technique. It is now only performed at a few institutions. Many radiology residents refer to the procedure as the \"Def Proc\", \"Defogram\", or \"Stool Finale\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10361", "text": "Defecography may be indicated for the following reasons:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10362", "text": "Specifically, defecography can differentiate between anterior and posterior  rectocele . [ 4 ]  Also, in external  rectal prolapse  that was not directly visualized during examination, this radiographic projection will demonstrate its presence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10363", "text": "In females, pre-procedural preparation involves smearing a small amount of  barium   contrast agent  in the vagina, which will help to identify if anterior  rectocele ,  enterocele  or  sigmoidocele  is present."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10364", "text": "The technique itself involves the insertion of a  caulking gun  device into the rectum with a subsequent manual infusion of barium paste until there is adequate distension. The patient is then transferred to a portable plastic commode which is situated next to a fluoroscope which records the defecation. Positioning of the X-ray camera is of paramount importance as visualization of the buttocks, rectal vault, and lower pelvis is critical."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10365", "text": "Anatomical and physiological parameters that can be objectively measured by this investigation include: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10366", "text": "Conditions which may be demonstrated include: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10367", "text": "The rectum may be seen to prolapse, whether internally or externally. There can be difficulty differentiating between internal intussusception and a normal rectal fold. The thickness of the intussusception is half the width of the intussusception (the intussusception is a doubled over layer of rectal wall). This is most likely to be seen during straining."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10368", "text": "Cinedefecography is a technique that is an evolution of defecography. The defecation cycle is recorded as a continuous series rather than individual still radiographs. [ 2 ]  More recent techniques involve the use of advanced, cross-sectional imaging modalities such as  magnetic resonance imaging . [ 6 ]  This is known as dynamic pelvic MRI, or MRI proctography. [ 2 ]  The MRI proctography also called MRI defecography is not as efficient as conventional X-ray defecography for some problems. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10369", "text": "Diseases of the Colon & Rectum  is a monthly  peer-reviewed   medical journal  covering  colorectal surgery . It was established in 1958 and is published by  Lippincott Williams and Wilkins  on behalf of the  American Society of Colon and Rectal Surgeons , of which it is the official journal. The  editor-in-chief  is Susan Galandiuk ( University of Louisville ). According to the  Journal Citation Reports , the journal has a 2016  impact factor  of 3.519. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10370", "text": "Endoanal ultrasound  is a type of medical investigation which images the structures of the  anal canal . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10371", "text": "It is used in the investigation of some anorectal symptoms, e.g.  fecal incontinence  or  obstructed defecation . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10372", "text": "This  gastroenterology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10373", "text": "Endodermal sinus tumor  ( EST ) is a member of the  germ cell tumor  group of  cancers . [ 1 ]  It is the most common testicular tumor in children under three, [ 2 ]  and is also known as  infantile embryonal carcinoma . This age group has a very good prognosis. In contrast to the pure form typical of infants, adult endodermal sinus tumors are often found in combination with other kinds of germ cell tumor, particularly  teratoma  and  embryonal carcinoma . While pure teratoma is usually  benign , endodermal sinus tumor is  malignant ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10374", "text": "Causes for this cancer are poorly understood. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10375", "text": "The  histology  of EST is variable, but usually includes malignant endodermal cells. These cells secrete  alpha-fetoprotein  (AFP), which can be detected in tumor tissue,  serum ,  cerebrospinal fluid ,  urine  and, in the rare case of fetal EST, in  amniotic fluid . When there is incongruence between  biopsy  and AFP test results for EST, the result indicating presence of EST dictates treatment. [ 3 ]  This is because EST often occurs as small \"malignant foci\" within a larger tumor, usually  teratoma , and biopsy is a sampling method; biopsy of the tumor may reveal only teratoma, whereas elevated AFP reveals that EST is also present. GATA-4, a  transcription factor , also may be useful in the diagnosis of EST. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10376", "text": "Diagnosis of EST in  pregnant women  and in  infants  is complicated by the extremely high levels of AFP in those two groups. Tumor surveillance by monitoring AFP requires accurate correction for gestational age in pregnant women, and age in infants. In pregnant women, this can be achieved simply by testing  maternal serum AFP  rather than  tumor marker AFP . In infants, the tumor marker test is used, but must be interpreted using a reference table or graph of normal AFP in infants. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10377", "text": "EST can have a multitude of morphologic patterns including: reticular, endodermal sinus-like, microcystic, papillary, solid, glandular, alveolar, polyvesicular vitelline, enteric and hepatoid. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10378", "text": "Schiller\u2013Duval bodies  on  histology  are  pathognomonic  and seen in the context of the endodermal sinus-like pattern. Rarely, it can be found in the vagina. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10379", "text": "Most treatments involve some combination of  surgery  and  chemotherapy . Treatment with  cisplatin ,  etoposide , and  bleomycin  has been described. [ 8 ]  Before modern chemotherapy, this type of neoplasm was highly lethal, but the prognosis has significantly improved since then. [ citation needed ]  When endodermal sinus tumors are treated promptly with surgery and chemotherapy, fatal outcomes are exceedingly rare. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10380", "text": "Germ cell tumor  ( GCT ) is a  neoplasm  derived from the  primordial germ cells . [ 1 ]  Germ-cell tumors can be  cancerous  or  benign . Germ cells normally occur inside the  gonads  ( ovary [ 2 ]  and  testis ).  GCTs that originate outside the gonads may be  birth defects  resulting from errors during  development  of the  embryo ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10381", "text": "GCTs are classified by their  histology , [ 4 ]  regardless of location in the body. However, as more information about the genetics of these tumors become available, they may be classified based on specific gene mutations that characterize specific tumors. [ 5 ]  They are broadly divided in two classes: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10382", "text": "The two classes reflect an important clinical difference. Compared with germinomatous tumors, nongerminomatous tumors tend to grow faster, have an earlier mean age at time of diagnosis (around 25 years versus 35 years, in the case of  testicular cancers ), and have a lower five-year survival rate.  The survival rate for germinomatous tumors is higher in part because these tumors are very sensitive to radiation, and they also respond well to chemotherapy.  The prognosis for nongerminomatous tumours has improved dramatically, however, due to the use of platinum-based chemotherapy regimens. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10383", "text": "Mixed germ cell tumors occur in many forms.  Among these, a common form is teratoma with endodermal sinus tumor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10384", "text": "Teratocarcinoma refers to a germ cell tumor that is a mixture of  teratoma  with  embryonal carcinoma , or with  choriocarcinoma , or with both. [ 9 ]   This kind of mixed germ cell tumor may be known simply as a teratoma with elements of embryonal carcinoma or choriocarcinoma, or simply by ignoring the teratoma component and referring only to its malignant component:  embryonal carcinoma and/or choriocarcinoma. They can present in the  anterior mediastinum . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10385", "text": "Some investigators suggest that this distribution arises as a consequence of abnormal migration of germ cells during embryogenesis. Others hypothesize a widespread distribution of germ cells to multiple sites during normal embryogenesis, with these cells conveying genetic information or providing regulatory functions at somatic sites. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10386", "text": "Extragonadal GCTs were thought initially to be isolated  metastases  from an undetected primary tumor in a  gonad , but many germ cell tumors are now known to be   congenital  and originate outside the gonads.  The most notable of these is  sacrococcygeal teratoma , the single most common tumor diagnosed in babies at birth. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10387", "text": "Of all anterior mediastinal tumors, 15\u201320% are GCTs of which about 50% are benign teratomas. [ 10 ]  Ovarian teratomas may be associated with  anti-NMDA receptor encephalitis . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10388", "text": "Despite their name, GCTs occur both within and outside the  ovary  and  testis . They are found in: [ citation needed ] }"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10389", "text": "In females, GCTs account for 30% of ovarian tumors, but only 1 to 3% of  ovarian cancers  in  North America . In younger women, they are more common, thus in patients under the age of 21, 60% of ovarian tumors are of the  germ-cell type , and up to one-third are  malignant . In males, GCTs of the testis occur typically after puberty and are malignant ( testicular cancer ).  In  neonates ,  infants , and  children  younger than 4 years, most are  sacrococcygeal teratomas . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10390", "text": "Males with  Klinefelter syndrome  have a 50 times greater risk of GSTs. [ 12 ]   In these persons, GSTs usually contain nonseminomatous elements, present at an earlier age, and seldom are gonadal in location. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10391", "text": "Women with benign GCTs such as  mature teratomas  (dermoid cysts) are cured by  ovarian cystectomy  or  oophorectomy . [ 13 ]  In general, all patients with malignant GCTs have the same staging surgery that is done for  epithelial ovarian cancer . [ 14 ]  If the patient is in her reproductive years, an alternative is unilateral  salpingoophorectomy , while the uterus, the ovary, and the fallopian tube on the opposite side can be left behind. This is not an option when the cancer is in both ovaries. If the patient has finished having children, the surgery involves complete staging, including salpingoophorectomy on both sides, as well as  hysterectomy . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10392", "text": "Patients with germ-cell cancer often need to be treated with combination  chemotherapy  for at least three cycles, but female patients with early-stage disease may not require this treatment. [ 15 ]  The  chemotherapy regimen  most commonly used in GCTs is called PEB (or BEP), and consists of  bleomycin ,  etoposide , and a  platinum-based antineoplastic  ( cisplatin ). [ 13 ]  Targeted treatments, such as immunotherapy, hormonal therapy and kinase inhibitors, are being evaluated for tumors that do not respond to chemotherapy. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10393", "text": "The 1997 International Germ Cell Consensus Classification [ 17 ]  is a tool for estimating the risk of relapse after treatment of malignant germ-cell tumor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10394", "text": "A small study of ovarian tumors in girls [ 18 ]  reports a correlation between  cystic  and benign tumors, and conversely, solid and malignant tumors.  Because the cystic extent of a tumor can be estimated by ultrasound, MRI, or CT scan before surgery, this permits selection of the most appropriate surgical plan to minimize risk of spillage of a malignant tumor. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10395", "text": "Access to appropriate treatment has a large effect on outcome.  A 1993 study of outcomes in Scotland found that for 454 men with nonseminomatous (nongerminomatous) GCTs diagnosed between 1975 and 1989, five-year survival increased over time and with earlier diagnosis.  Adjusting for these and other factors, survival was 60% higher for men treated in a cancer unit that treated the majority of these men,  though the unit treated more men with the worst prognosis. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10396", "text": "Choriocarcinoma  of the testicles has the worst prognosis of all germ-cell cancers. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10397", "text": "A  gonadoblastoma  is a complex  neoplasm  composed of a mixture of  gonadal  elements, [ 1 ]  such as large primordial  germ cells , immature  Sertoli cells  or  granulosa cells  of the  sex cord , and gonadal  stromal cells . Gonadoblastomas are by definition benign, but more than 50% have a co-existing  dysgerminoma  which is malignant, and an additional 10% have other more aggressive malignancies, and as such are often treated as malignant. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10398", "text": "Gonadoblastoma is most often associated with an abnormal chromosomal  karyotype , gonadal  dysgenesis , or the presence of a  Y chromosome  in over 90% of cases. Gonadoblastoma has been found in association with  androgen insensitivity syndrome ,  mixed gonadal dysgenesis  and  Turner syndrome , especially in the presence of Y chromosome-bearing cells. [ 3 ] [ 4 ]  Women with Turner syndrome whose karyotype includes a Y chromosome (as in 45,X/46,XY mosaicism) are at increased risk for gonadoblastoma. Because of the risk of gonadoblastoma, individuals with Turner syndrome with detectable Y chromosome material (Mosaic Turner syndrome) should have their gonads prophylactically removed. In a population-based study, the cumulative risk for women with Turner syndrome and Y chromosome material was 7.9 percent by age 25 years. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10399", "text": "Gonadoblastomas can contain elements of both germ cells and gonadal stroma. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10400", "text": "Formerly, gonadoblastoma was sometimes regarded as a subset of  dysgerminoma . In modern literature, it is sometimes considered to progress to dysgerminoma. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10401", "text": "Standard treatment would include surgical exploration via  laparotomy .  Laparoscopy  may be an option if the surgeon is particularly skilled in removing ovarian neoplasms via laparoscopy intact. If the diagnosis of gonadoblastoma is certain, a bilateral  salpingo-oophorectomy  (BSO) should be performed to remove both the primary tumor and the dysgenic contralateral ovary. If uninvolved, the  uterus  should be left intact. Modern reproductive endocrinology technology allows patients post BSO to achieve pregnancy via in-vitro fertilization ( IVF ) with a donor egg. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10402", "text": "Goodsall's rule  relates the external opening (in the perianal skin) of an  anal fistula  to its internal opening (in the anal canal). It states that if the perianal skin opening is posterior to the transverse anal line, the fistulous tract will open into the anal canal in the midline posteriorly, sometimes taking a curvilinear course. A perianal skin opening anterior to the transverse anal line (within 3cm radius) is usually associated with a radial fistulous tract but if it's beyond the 3 cm radius it will take a curvilinear course and open in the midline posterioly. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10403", "text": "Or in more direct terms, it means that anterior-opening fistulas tend to follow a simple, direct course if it is within the 3cm radius, beyond which it takes a curving path and opens in poster midline. The posterior-opening fistulas may follow a devious, curving path with some even being horseshoe-shaped before opening in the posterior midline. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10404", "text": "Fistulas  can be described as  anterior or posterior  relating to a line drawn in the  coronal plane  across the  anus , the so-called transverse anal line. Anterior fistulas will have a direct track into the anal canal. Posterior fistulas will have a curved track with their external opening lying in the posterior midline of the  anal canal . An exception to the rule are anterior fistulas lying more than 3.75\u00a0cm from the anus, which may have a curved track (similar to posterior fistulas) that opens into the posterior midline of the anal canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10405", "text": "According to a study on patients undergoing operations for cryptoglandular anal fistulas, 92.9% of fistulas within 1.5\u00a0cm followed the Goodsall rule, whereas only 47.4% followed it beyond 3.6\u00a0cm. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10406", "text": "In situations where there are multiple anal fistulae, the course would be similar to that of posterior-opening fistulae because of branching and communication between these openings. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10407", "text": "The investigation of choice for anal fistulas is  magnetic resonance imaging  (MRI). Fistulograms can be used to demonstrate the track of the fistula."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10408", "text": "Goodsall's rule is named after  David Henry Goodsall  who described it in 1900."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10409", "text": "Hemorrhoids  (or  haemorrhoids ), also known as  piles , are  vascular  structures in the  anal canal . [ 7 ] [ 8 ]  In their normal state, they are cushions that help with  stool  control. [ 2 ]  They become a disease when  swollen  or  inflamed ; the unqualified term  hemorrhoid  is often used to refer to the disease. [ 8 ]  The signs and symptoms of hemorrhoids depend on the type present. [ 4 ]  Internal hemorrhoids often result in painless, bright red  rectal bleeding  when  defecating . [ 3 ] [ 4 ]  External hemorrhoids often result in pain and swelling in the area of the  anus . [ 4 ]  If bleeding occurs, it is usually darker. [ 4 ]  Symptoms frequently get better after a few days. [ 3 ]  A  skin tag  may remain after the healing of an external hemorrhoid. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10410", "text": "While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved. [ 4 ]  This may include  constipation ,  diarrhea , and sitting on the  toilet  for long periods. [ 3 ]  Hemorrhoids are also more common during  pregnancy . [ 3 ]  Diagnosis is made by looking at the area. [ 3 ]  Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should not be ruled out. [ 2 ]   Colonoscopy  or  sigmoidoscopy  is reasonable to confirm the diagnosis and rule out more serious causes. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10411", "text": "Often, no specific treatment is needed. [ 9 ]  Initial measures consist of increasing  fiber  intake, drinking fluids to maintain hydration,  NSAIDs  to help with pain, and rest. [ 1 ]  Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence. [ 9 ]  A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. [ 6 ]   Hemorrhoidal artery embolization (HAE)  is a safe and effective  minimally invasive procedure  that can be performed and is typically better tolerated than traditional therapies. [ 10 ] [ 11 ] [ 12 ]  Surgery is reserved for those who fail to improve following these measures. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10412", "text": "Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives. [ 1 ] [ 3 ]  Males and females are both affected with about equal frequency. [ 1 ]  Hemorrhoids affect people most often between 45 and 65\u00a0years of age, [ 5 ]  and they are more common among the wealthy, [ 4 ]  although this may reflect differences in healthcare access rather than true prevalence. [ 13 ]  Outcomes are usually good. [ 3 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10413", "text": "The first known mention of the disease is from a 1700 BC Egyptian  papyrus . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10414", "text": "In about 40% of people with pathological hemorrhoids, there are no significant symptoms. [ 4 ]  Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. [ 8 ]  Bleeding enough to cause  anemia  is rare, [ 5 ]  and life-threatening bleeding is even more uncommon. [ 15 ]  Many people feel embarrassed when facing the problem [ 5 ]  and often seek medical care only when the case is advanced. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10415", "text": "If not  thrombosed ,  external hemorrhoids  may cause few problems. [ 16 ]  However, when thrombosed, hemorrhoids may be very painful. [ 1 ] [ 8 ]  Nevertheless, this pain typically resolves in two to three days. [ 5 ]  The swelling may, however, take a few weeks to disappear. [ 5 ]  A  skin tag  may remain after healing. [ 8 ]  If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10416", "text": "Internal hemorrhoids usually present with painless, bright red  rectal bleeding  during or following a bowel movement. [ 8 ]  The blood typically covers the stool (a condition known as  hematochezia ), is on the toilet paper, or drips into the toilet bowl. [ 8 ]  The stool itself is usually normally coloured. [ 8 ]  Other symptoms may include mucous discharge, a perianal mass if they  prolapse  through the anus,  itchiness , and  fecal incontinence . [ 15 ] [ 17 ]  Internal hemorrhoids are usually painful only if they become thrombosed or  necrotic . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10417", "text": "The exact cause of symptomatic hemorrhoids is unknown. [ 18 ]  A number of factors are believed to play a role, including irregular bowel habits ( constipation  or  diarrhea ), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining,  ascites , an intra-abdominal mass, or  pregnancy ), genetics, an absence of valves within the hemorrhoidal veins, and aging. [ 1 ] [ 5 ]  Other factors believed to increase risk include  obesity , prolonged sitting, [ 8 ] [ dubious  \u2013  discuss ]  a  chronic   cough , and  pelvic floor dysfunction . [ 2 ]  Squatting while defecating may also increase the risk of severe hemorrhoids. [ 19 ]  Evidence for these associations, however, is poor. [ 2 ]  Being a receptive partner in  anal intercourse  has been listed as a cause. [ 20 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10418", "text": "During pregnancy, pressure from the  fetus  on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. [ 23 ]  Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10419", "text": "Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. [ 8 ]  There are three main cushions present in the normal  anal canal . [ 1 ]  These are located classically at left lateral, right anterior, and right posterior positions. [ 5 ]  They are composed of neither  arteries  nor  veins , but blood vessels called  sinusoids ,  connective tissue , and  smooth muscle . [ 2 ] :\u200a175\u200a  Sinusoids do not have  muscle tissue  in their walls, as veins do. [ 8 ]  This set of blood vessels is known as the  hemorrhoidal plexus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10420", "text": "Hemorrhoid cushions are important for  continence . They contribute to 15\u201320% of anal closure pressure at rest and protect the  internal  and  external anal sphincter  muscles during the passage of stool. [ 8 ]  When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure. [ 5 ]  Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. [ 15 ]  Increased  internal  and  external anal sphincter  pressure may also be involved in hemorrhoid symptoms. [ 5 ]  Two types of hemorrhoids occur: internals from the  superior hemorrhoidal plexus  and externals from the inferior hemorrhoidal plexus. [ 5 ]  The  pectinate line  divides the two regions. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10421", "text": "Hemorrhoids are typically diagnosed by physical examination. [ 6 ]  A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. [ 8 ]  Visual confirmation of internal hemorrhoids, on the other hand, may require  anoscopy , insertion of a hollow tube device with a light attached at one end. [ 5 ]  A  digital rectal exam  (DRE) can also be performed to detect possible rectal  tumors ,  polyps , an enlarged  prostate , or  abscesses . [ 8 ]  This examination may not be possible without appropriate  sedation  because of pain, although most internal hemorrhoids are not associated with pain. [ 1 ]  If pain is present, the condition is more likely to be an  anal fissure  or external hemorrhoid rather than internal hemorrhoid. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10422", "text": "Internal hemorrhoids originate above the pectinate line. [ 16 ]  They are covered by  columnar epithelium , which lacks pain  receptors . [ 2 ]  They were classified in 1985 into four grades based on the degree of  prolapse : [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10423", "text": "External hemorrhoids  occur below the dentate (or pectinate) line. [ 16 ]  They are covered proximally by  anoderm  and distally by skin, both of which are sensitive to pain and temperature. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10424", "text": "Many anorectal problems, including  fissures ,  fistulae , abscesses,  colorectal cancer ,  rectal varices , and  itching  have similar symptoms and may be incorrectly referred to as hemorrhoids. [ 1 ]   Rectal bleeding  may also occur owing to colorectal cancer,  colitis  including  inflammatory bowel disease ,  diverticular disease , and  angiodysplasia . [ 6 ]  If  anemia  is present, other potential causes should be considered. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10425", "text": "Other conditions that produce an anal mass include  skin tags ,  anal warts ,  rectal prolapse ,  polyps , and enlarged anal papillae. [ 5 ]   Anorectal varices  due to  portal hypertension  (blood pressure in the  portal venous system ) may present similar to hemorrhoids but are a different condition. [ 5 ]  Portal hypertension does not increase the risk of hemorrhoids. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10426", "text": "A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise. [ 5 ] [ 24 ]  Spending less time attempting to  defecate , avoiding reading while on the toilet, [ 1 ]  and losing weight for overweight persons and avoiding heavy lifting are also recommended. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10427", "text": "Conservative treatment typically consists of foods rich in  dietary fiber , intake of oral fluids to maintain hydration,  nonsteroidal anti-inflammatory drugs ,  sitz baths , and rest. [ 1 ]  Increased fiber intake has been shown to improve outcomes [ 26 ]  and may be achieved by dietary alterations or the consumption of  fiber supplements . [ 1 ] [ 26 ]  Evidence for benefits from sitz baths during any point in treatment, however, is lacking. [ 27 ]  If they are used, they should be limited to 15 minutes at a time. [ 2 ] :\u200a182\u200a  Decreasing time spent on the toilet and not straining is also recommended. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10428", "text": "While many  topical agents  and  suppositories  are available for the treatment of hemorrhoids, little evidence supports their use. [ 1 ]  As such, they are not recommended by the  American Society of Colon and Rectal Surgeons . [ 29 ]   Steroid -containing agents should not be used for more than 14 days, as they may cause thinning of the skin. [ 1 ]  Most agents include a combination of active ingredients. [ 2 ]  These may include a barrier cream such as  petroleum jelly  or  zinc oxide , an analgesic agent such as  lidocaine , and a  vasoconstrictor  such as  epinephrine . [ 2 ]  Some contain  Balsam of Peru  to which certain people may be allergic. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10429", "text": "Flavonoids  are of questionable benefit, with potential side effects. [ 2 ] [ 32 ]  Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. [ 33 ]  Evidence does not support the use of  traditional Chinese herbal treatment . [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10430", "text": "The use of  phlebotonics  has been investigated in the treatment of low-grade hemorrhoids, [ 29 ] [ 35 ] [ 36 ] [ 37 ]  although these drugs are not approved for such use in the United States or Germany. [ 38 ] [ 39 ]  The use of phlebotonics for the treatment of chronic venous diseases is restricted in Spain. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10431", "text": "A number of office-based procedures may be performed. While generally safe, rare serious side effects such as  perianal sepsis  may occur. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10432", "text": "Hemorrhoidal artery embolization (HAE)  is an additional minimally invasive procedure performed by an  interventional radiologist . [ 10 ]  HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or  microparticles  to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding. [ 11 ]  HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10433", "text": "A number of surgical techniques may be used if conservative management and simple procedures fail. [ 6 ]  All surgical treatments are associated with some degree of complications, including bleeding, infection,  anal strictures , and  urinary retention , due to the close proximity of the rectum to the nerves that supply the bladder. [ 1 ]  Also, a small risk of  fecal incontinence  occurs, particularly of liquid, [ 2 ] [ 42 ]  with rates reported between 0% and 28%. [ 43 ]  Mucosal  ectropion  is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). [ 44 ]  This is where the anal mucosa becomes everted from the anus, similar to a very mild form of  rectal prolapse . [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10434", "text": "It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider. [ 15 ] [ 18 ]  However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time. [ 1 ]  Both sexes experience about the same incidence of the condition, [ 1 ]  with rates peaking between 45 and 65\u00a0years. [ 5 ]  Some studies have found that they are common in people of higher  socioeconomic status , [ 2 ]  however this may reflect differences in healthcare access rather than true prevalence. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10435", "text": "Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes. [ 15 ]  Only a small proportion of persons end up needing surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10436", "text": "The first known mention of this disease is from a 1700 BC Egyptian  papyrus , which advises: \"Thou shouldest give a recipe, an ointment of great protection;  acacia  leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately.\" [ 14 ]  In 460 BC, the  Hippocratic corpus  discusses a treatment similar to modern rubber band ligation: \"And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of  Hellebore .\" [ 14 ]  Hemorrhoids may have been described in the  Bible , with earlier English translations using the now-obsolete spelling \" emerods \". [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10437", "text": "Celsus  (25 BC \u2013 14 AD) described ligation and excision procedures and discussed the possible complications. [ 48 ]   Galen  advocated severing the connection of the arteries to veins, claiming it reduced both pain and the spread of gangrene. [ 48 ]  The  Susruta Samhita  (4th\u20135th century BC) is similar to the words of Hippocrates, but emphasizes wound cleanliness. [ 14 ]  In the 13th century, European surgeons such as  Lanfranc of Milan ,  Guy de Chauliac ,  Henri de Mondeville , and John of Ardene made great progress and development of the surgical techniques. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10438", "text": "In medieval times, hemorrhoids were also known as  Saint Fiacre 's curse after a sixth-century saint who developed them following tilling the soil. [ 49 ]  The first use of the word \"hemorrhoid\" in English occurs in 1398, derived from the  Old French  \"emorroides\", from  Latin   h\u00e6morrhoida , [ 50 ]  in turn from the Greek \u03b1\u1f31\u03bc\u03bf\u03c1\u03c1\u03bf\u0390\u03c2 ( haimorrhois ), \"liable to discharge blood\", from \u03b1\u1f37\u03bc\u03b1 ( haima ), \"blood\" [ 51 ]  and \u1fe5\u03cc\u03bf\u03c2 ( rhoos ), \"stream, flow, current\", [ 52 ]  itself from \u1fe5\u03ad\u03c9 ( rheo ), \"to flow, to stream\". [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10439", "text": "An  imperforate anus  or  anorectal malformations  ( ARMs ) are  birth defects  in which the  rectum  is malformed. ARMs are a spectrum of different congenital anomalies which vary from fairly minor  lesions  to complex anomalies. [ 1 ]  The cause of ARMs is unknown; the genetic basis of these anomalies is very complex because of their anatomical variability. In 8% of patients, genetic factors are clearly associated with ARMs. [ 2 ]   Anorectal malformation  in  Currarino syndrome  represents the only association for which the gene  HLXB9  has been identified. [ clarification needed ] [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10440", "text": "There are other forms of anorectal malformations though imperforate anus is most common. Other variants include  cloacal malformation , rectal atresia, rectal stenosis, and anterior ectopic anus. [ 4 ] [ 5 ]  This form is more commonly seen in females and presents with constipation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10441", "text": "There are several forms of imperforate anus and anorectal malformations. The new classification is in relation of the type of associated  fistula . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10442", "text": "The Wingspread classification was in low and high anomalies: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10443", "text": "Imperforate anus is usually present along with other birth defects\u2014 spinal  problems,  heart  problems,  tracheoesophageal fistula ,  esophageal atresia ,  renal  anomalies and  limb  anomalies are among the possibilities, collectively being called the  VACTERL association . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10444", "text": "Imperforate anus is associated with an increased incidence of some other specific anomalies as well, together being called the  VACTERL association . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10445", "text": "Other entities associated with an imperforate anus are trisomies 18 and 21, the  cat-eye syndrome  (partial  trisomy  or  tetrasomy  of a maternally derived  chromosome 22 ),  Baller\u2013Gerold syndrome ,  Currarino syndrome ,  caudal regression syndrome ,  FG syndrome ,  Johanson\u2013Blizzard syndrome ,  McKusick\u2013Kaufman syndrome ,  Pallister\u2013Hall syndrome ,  short rib\u2013polydactyly syndrome type 1 ,  Townes\u2013Brocks syndrome ,  13q deletion syndrome ,  urorectal septum malformation sequence  and the  OEIS complex  ( omphalocele ,  exstrophy  of the  cloaca , imperforate anus, spinal defects). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10446", "text": "When an infant is born with an anorectal malformation, it is usually detected quickly as it is a very obvious defect. Doctors will then determine the type of birth defect the child was born with and whether or not there are any associated malformations. Determining the presence of any associated defects during the newborn period in order to treat them early may avoid further  sequelae . There are two main categories of anorectal malformations: those that require a protective  colostomy  and those that do not. The decision to open a colostomy is usually taken within the first 24 hours of birth. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10447", "text": "Sonography  can be used to determine the type of imperforate anus. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10448", "text": "Imperforate anus usually requires immediate  surgery  to open a passage for  feces  unless a  fistula  can be relied on until corrective surgery takes place. Depending on the severity of the imperforate, it is treated either with a perineal  anoplasty [ 10 ]  or with a  colostomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10449", "text": "While many surgical techniques to definitively repair anorectal malformations have been described, the posterior sagittal approach (PSARP) has become the most popular. It involves dissection of the perineum without entry into the abdomen and 90% of defects in boys can be repaired this way. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10450", "text": "With a high lesion, many children have problems controlling bowel function and most also become  constipated . With a low lesion, children generally have good bowel control, but they may still become constipated. For children who have a poor outcome for continence and constipation from the initial surgery, further surgery to better establish the angle between the anus and the rectum may improve continence and, for those with a large rectum, surgery to remove that dilated segment may significantly improve the bowel control for the patient.  An antegrade enema mechanism can be established by joining the appendix to the skin (Malone stoma); however, establishing more normal anatomy is the priority. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10451", "text": "Imperforate anus has an estimated incidence of 1 in 5,000 births. [ 11 ] [ 12 ]  It affects boys and girls with similar frequency. [ 13 ]   However, imperforate anus will present as the low version 90% of the time in females and 50% of the time in males."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10452", "text": "Imperforate anus is an occasional complication of  sacrococcygeal teratoma . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10453", "text": "7th-century  Byzantine  physician  Paulus Aegineta  described a surgical treatment for imperforate anus for the first time. [ 15 ]  10th-century  Persian  physician  Haly Abbas  was the first to highlight preserving the  sphincter muscles  throughout the surgery and the prevention of strictures with a  stent . [ 15 ]  He has reported the use of wine for wound care in this surgery. Some reports of children surviving this surgery are available from the early  medieval Islamic era . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10454", "text": "Implantable bulking agents  are self-expanding solid  prostheses  which are implanted in the tissues around the  anal canal . [ 1 ]  It is a  surgical treatment for fecal incontinence  and represents a newer evolution of the similar procedure which uses  perianal injectable bulking agents ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10455", "text": "The implantable bulking agents represent the most recent stage of development of a similar procedure which uses  perianal injectable bulking agents . That procedure in turn was developed from use of injectable bulking agents in urology to treat  urinary incontinence . Many different injectable materials have been used. The biggest problem with injectable materials is that they seem to have only a temporary effect. Over time, the material degrades and may migrate away from the injection site. For example, one study investigated the outcome and ultrasound appearance of 3 of the commonly used injectable bulking agents (Durasphere, PTQ, Solesta) after an average of 7 years. The researchers reported that typically about 14% of the original volume of material was still identifiable on ultrasound, and that complete disappearance of the materials on ultrasound was correlated with poorer clinical outcomes. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10456", "text": "Implantable bulking agents use multiple cylindrical HYEXPAN ( polyacrylonitrile ) implants. Marketed as \"Gatekeeper\" by Medtronic, Minneapolis, USA, it was first used to treat  gastro-esophageal reflux disease . [ 1 ]  Production of the implant system was transferred to THD S.p.A., Correggio, Italy. Gatekeeper now has a  CE marking , and was registered for the treatment of fecal incontinence in 2010. [ 4 ]  The first publication describing use of these implants in FI was in 2011. [ 5 ]  Several other publications appeared and the results were initially promising. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10457", "text": "In the original description, Gatekeeper used four self-expandable, solid, thin cylinders. [ 4 ]  Subsequently, six of the prostheses were used. [ 6 ]  An advancement of the procedure was described in 2016, marketed as \"SphinKeeper\". [ 4 ]  SphinKeeper uses 10 prostheses which are slightly thicker and longer compared to those used in the Gatekeeper implant system. [ 4 ]  One publication stated that new generation SphinKeeper implant system has replaced use of Gatekeeper, and that the use of 10 prostheses represents change in the paradigm of injectable and implantable bulking agents. [ 3 ]  SphinKeeper is a permanent implantable device rather than a bulking agent, and aims to create a kind of artificial neosphincter. [ 3 ]  Previous techniques aimed to simply augment the internal anal sphincter. [ 3 ]  The first systematic review on implantable bulking agents was published in 2022. [ 4 ]  However, no randomized placebo controlled trials have been published yet."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10458", "text": "The implants are made of  polyacrylonitrile  (HYEXPAN). This material is inert, non-allergenic, non-immunogenic, nondegradable and noncarcinogenic. [ 1 ]  The material is hydrophilic, which allows the implants to slowly absorb water and change in dimensions, which occurs within 48 hours once they are implanted in the tissues. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10459", "text": "This polyacrylonitrile material is thought to meet the criteria for the \"ideal bulking agent\", and therefore may overcome the disadvantages of other bulking agents. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10460", "text": "Implantable bulking agents are indicated for passive fecal incontinence, caused by interior anal sphincter dysfunction or damage. [ 1 ]  The onset of incontinence should be at least 6 months ago. [ 6 ]  It has been recommended that this procedure should be attempted only if non-surgical options have failed (such as pharmacologic, behavioral, pelvic floor rehabilitation), [ 6 ]  and also if injectable bulking agents were unsuccessful. [ 1 ]  Researchers are investigating the use of GK and SK in patients with a wider range of causes of fecal incontinence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10461", "text": "Contraindications have been suggested by different authors, and include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10462", "text": "Diabetes mellitus ,  pudendal neuropathy , and previous implantation of  sacral nerve stimulation  device are not contraindications to the use of implantable bulking agents. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10463", "text": "The procedure is carried out under  local  or regional anesthesia ( Spinal anaesthesia ) with or without  sedation  or  general anesthesia . [ 1 ] [ 6 ] [ 3 ]  It takes 30-40 minutes and may be done as a  day case  on an outpatient basis. [ 1 ]  Intravenous  antibiotics  may given at the start of the procedure. [ 1 ]  The patient is usually put into the  lithotomy position . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10464", "text": "The surgeon identifies the interior anal sphincter and the intersphincteric groove while using an anal retractor such as the Eisenhammer retractor. 2 cm away from the anal verge a 2 mm incision is made in the perianal skin. [ 1 ]  This location may minimize the possibility of contamination of the wounds during bowel movements. [ 6 ]  The prostheses are implanted using a custom \"gun\" which consists of a delivery system and a dispenser which holds one prosthesis at a time. [ 1 ]  This device is specific to the type of implant being used: Gatekeeper or SphinKeeper. [ 6 ]  The needle (cannula / sheath) is inserted into the incision and pushed into the intersphincteric space through a short subcutaneous tunnel. [ 1 ] [ 6 ]  It is thought that the path of this created \"tunnel\" should not be a straight line, in order to prevent extrusion of the prosthesis along the insertion track. [ 6 ]  The needle is advanced to a depth just beyond the level of the  dentate line . [ 1 ]  This will correspond to the upper part of the anal canal, at the level of the  puborectalis muscle . [ 6 ]  The exact position of the needle tip is confirmed by direct vision or with the guidance of endoanal ultrasound. [ 1 ]  The procedure is described as relatively simple to perform from a technical perspective, [ 4 ]  and one author stated that ultrasound guidance during placement is not necessary if the surgeon is experienced. Firing the \"gun\" causes the cannula to retract completely into the delivery system, leaving the prosthesis in the target location. [ 6 ]  The prosthesis is then placed into the intersphincteric space. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10465", "text": "It is thought that placement of the implants in the intersphincteric space pushes the external anal sphincter outwards and the internal anal sphincter inwards. This may increase the length of the  sarcomeres , which theoretically increases the contractility of the muscle. In terms of physiological measurements, the resting anal pressure and the length of the high pressure zone in the anal canal may be improved. In other words, the bulking effect may improve the seal of the anal canal and the length of the anal canal. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10466", "text": "The surgical procedure is almost identical for Gatekeeper and SphinKeeper. The difference between Gatekeeper and SphinKeeper is in the size and number of the individual prostheses. Gatekeeper uses 4-6 prostheses. SphinKeeper uses up to 10 prostheses. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10467", "text": "Within 48 hours of implantation, the implant material absorbs water from the tissues because of its hydrophilic properties. Each prosthesis becomes thicker and shorter in shape. This rapid increase in volume allows the prostheses to self-fix in position and prevents displacement and migration (in most cases). [ 1 ]  The prostheses also become softer in consistency and compliant to external pressures, but are still able to maintain their original shape. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10468", "text": "In the dehydrated state, Gatekeeper prostheses are thin cylinders, 2 mm in diameter and 22 mm long. After implantation, they become 6.5 mm in diameter and 17 mm long. Their volume increases by 750% from 70 mm 3  to 500 mm 3 . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10469", "text": "SphinKeeper prostheses are slightly thicker and longer cylinders. In the dehydrated state, SphinKeeper prostheses are 3 mm in diameter and 29 mm long. After implantation, they become 7 mm in diameter and 23 mm long. [ 1 ]  SphinKeeper implants are long enough to restore the normal length of the anal canal. [ 6 ]  They are also wide enough to make sure there is good filling ability. Therefore, SphinKeeper allows for surgical correction of larger defects of the internal anal sphincter or external anal sphincter. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10470", "text": "The process is repeated for each individual prosthesis, placing them into incisions made at the intersphincteric groove at equidistant intervals depending upon the total number of prostheses to be deployed. [ 1 ]  For example, if 4 prostheses are to be used, incisions may be placed at 12, 3, 6, and 9 o\u2019clock. If 6 prostheses are to be used, incisions may be placed at 1, 3, 5, 7, 9, and 11 o\u2019clock. [ 6 ]  The exact number of prostheses used is arbitrary, but placing 10 prostheses enables the creation of a circumferential ring of prostheses around the anal canal in the intersphincteric space. This effectively creates a situation similar to an artificial anal sphincter. [ 1 ]  One publication reported improved outcome with Gatekeeper when more prostheses were used. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10471", "text": "Interestingly, it is thought that the exact spacing of the prostheses does not influence the outcome of the procedure, and the important factor appears to be that the prostheses are distributed equally around the anal canal. [ 6 ]  This is the case even in the presence of tears of the external anal sphincter or internal anal sphincter. [ 6 ]  Therefore, the implants are placed in the above locations for convenience of the surgeon, even for patients with a tear in a specific part of the sphincter. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10472", "text": "The incisions are closed with resorbable sutures. Endoanal ultrasound may be used to confirm the location of each prosthesis. A course of oral antibiotics (e.g. metronidazole) may be given after the procedure. Oral  laxatives  (e.g.  lactulose ) may be given, which prevents straining and constipation. Anal trauma (e.g. receptive anal intercourse) should be avoided for at least 72 hours after the procedure. [ 1 ]  Patients are usually advised to rest in bed, with the aim of reducing the risk of dislocation of the prostheses. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10473", "text": "After healing, the implants continue to be palpable and are visible on endoanal ultrasound. [ 1 ]  Each prosthesis appears as hyperechoic dot with a hypoechoic shadow behind it. [ 6 ]  Three dimensional endoanal ultrasound has also been used to visualize the implants, wherein the prostheses appear as a continuous hyperechoic line. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10474", "text": "Compared to other surgical treatment options for fecal incontinence, implantable bulking agents appear to be safe. [ 6 ]  Therefore, it is also suitable for elderly or frail patients. [ 6 ]  However, complications are sometimes reported. For example, acute sepsis (infection) at the implantation site has been rarely recorded. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10475", "text": "The most important complication is displacement of a prosthesis (also referred to as migration / dislocation / dislodgement / extrusion). [ 6 ]  The rate of displacement of at least 1 of the prostheses has been reported to be as low as 0%, or as high as 91% of cases. [ 4 ]  The patient may report pain, swelling and/or no improvement in symptoms when there is prosthesis displacement. [ 6 ]  This is potentially noteworthy, [ 7 ]  since improved symptoms after use of injectable bulking agents have been attributed at least in part to the  placebo effect . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10476", "text": "Placement in the intersphincteric space is thought to be less liable to extrusion or migration of the prostheses or other complications such as erosion, ulceration or fistula formation in the anal canal. [ 1 ] [ 6 ]  If the implants were in the submucosal layer, they would be more vulnerable to such complications. [ 1 ]  Furthermore, displacement is less likely because of the rapid increase in size of the prostheses, [ 4 ]  allowing them self-fix in position in most cases. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10477", "text": "A systematic review found that in total, migration / dislodgement / dislocation was reported in 41 out of 154 patients (26.6%) across 7 studies. [ 4 ]  The same researchers reported that some kind of adverse event occurred in 48 out of 166 patients (28.9%). [ 4 ]  Sometimes, a prosthesis had to be removed, [ 4 ]  however it is possible to implant a new one in the correct position. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10478", "text": "The first systematic review on GK and SK was published in 2022. It combined results from 8 studies published before 2020 \u2013 a total of 166 patients. All studies were judged to be at moderate to high risk of bias. The reviewers reported that severity of FI improved in 5 out of 7 of the studies which used the Cleveland Clinic FI Score and in 3 out of 5 of the studies which used the Vaizey score. Quality of life improved in 2 studies which measured that outcome. They concluded that GK and SK may be effective, safe and minimally invasive options for fecal incontinence in those cases where non surgical treatments have failed. The reviewers called for controlled trials to be conducted. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10479", "text": "A  keyhole defect  is a term used in medicine and in the  forensic sciences  to refer to the shape of an anomalous feature or traumatic lesion caused by a  gunshot wound ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10480", "text": "A keyhole defect is characteristic of a type of entrance wound caused by a bullet striking the surface of a flat bone (typically the  cranium ) at a shallow angle. [ 1 ]  The defect is characterized by a rounded portion with a clean margin where the bullet first perforates bone, and a wider area with external beveling on the opposite end.  The keyhole entrance wound can thus indicate the trajectory of the bullet at the time of impact."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10481", "text": "In  proctology , a keyhole defect may refer to a groove in the  anal canal  wall, which can occur after posterior midline  fissurectomy  or  fistulotomy  (surgical operations involving the anal canal), or with lateral internal anal sphincter defects. The keyhole defect is associated with minor degrees of  fecal incontinence , allowing seepage of liquid stool or mucus. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10482", "text": "This  human digestive system  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10483", "text": "LIFT technique  is the novel modified approach through the  intersphincteric  plane for the treatment of  fistula-in-ano , known as LIFT (ligation of intersphincteric fistula tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected  cryptoglandular  tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all  granulation tissue  in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. [ 1 ] \nThe procedure was developed by Thai colorectal surgeon, Arun Rojanasakul, Colorectal Division Department of Surgery,  Chulalongkorn University  in  Bangkok, Thailand . The first report of preliminary healing result from the procedure were 94% in 2007  [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10484", "text": "In 1993 Matos et al. described a technique of total anal sphincter preservation in high fistula in ano, which is based on the concept of excision of intersphincteric anal gland infection through the intersphincteric approach. [ 3 ]  This novel technique was also documented in Corman\u2019s textbook of colon and rectal surgery. [ 4 ]  However, the technique was not widely adopted. [ 5 ] \nBetween 2004 and 2005 there was a personal experience in the similar technique by group of surgeons. That technique included coring out the intersphinteric fistula tract from the external opening to the external sphincter, excision of the intersphincteric fistula tract and suture of the internal sphincter defect through the intersphincteric plane. The outcome in 20 patients was disappointing with only 9 (45%) successes. Surgeons proposed that the reasons for the unfavorable outcome include dissection in the intersphincteric plane damaging blood supply to the internal opening area, and suturing delicate ischemic areas with increased risk of suture break-down. Surgeons thought that ligation of the intersphincteric tract close to the internal opening might solve the problem. Surgeons noticed that during intersphincteric plane dissection if the internal sphincter was damaged and the anal mucosa breached, failure was common despite meticulous repair. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10485", "text": "Researchers of the procedure agree that the LIFT technique may cause some injury to internal sphincter, but theoretically LIFT causes less trauma of the internal sphincter than the other fistula operations.  Matos et al. reported the technique of excision of the whole fistula tract plus primary repair, with intersphincteric plane approach for excision of the fistula tract and suturing of the internal anal sphincter defect, in 1993. [ 3 ]  However, Rojanasakul reported the ligation of intersphincteric fistula tract in 2007 with apparent satisfactory results probably due to secured closure of the internal opening. [ 2 ]  This represents a significant change from the originally described technique with improved outcomes . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10486", "text": "Low anterior resection syndrome  is a  complication  of  lower anterior resection , a type of surgery performed to remove the  rectum , typically for  rectal cancer . It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as  fecal incontinence , incomplete defecation or the sensation of incomplete defecation ( rectal tenesmus ), changes in stool frequency or consistency, unpredictable bowel function, and painful defecation ( dyschezia ). [ 1 ]  Treatment options include symptom management, such as use of  enemas , or surgical management, such as creation of a  colostomy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10487", "text": "Low anterior resection syndrome falls into two groups. Fecal urgency,  incontinence , and increased frequency make up the first.  Constipation , a sense of incomplete evacuation, and trouble emptying the bowels are included in the second category. Some patients describe characteristics from both groups, either switching back and forth between the two patterns or going through both at once. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10488", "text": "Low anterior resection syndrome emerges after rectal resection. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10489", "text": "The two factors that negatively affect patients' bowel function after lower anterior resection are low tumor height and  radiation , either pre- or post-operative. Additionally linked to worse bowel function are  stomas  that are temporary in nature and those that have been in place for an extended length of time. This, however, is probably a reflection of the height of the tumor and potential surgical complications, which may also have a deleterious effect on bowel function. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10490", "text": "Multiple factors likely contribute to low anterior resection syndrome. During intersphincteric resection, the  internal anal sphincter  may sustain direct structural damage that leads to fecal  incontinence , or secondary damage from the insertion of an anastomotic device through the  anus  during low anterior resection. [ 6 ]  In particular, if the surgical approach reaches the posterolateral side of the  prostate  (in men), where both the  sympathetic  and  parasympathetic   nerve fibers  enter the rectal wall, damage to the  internal anal sphincter 's nerve supply may also result in dysfunction. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10491", "text": "When performing a low anterior resection, the conjoint longitudinal muscle may also sustain damage during the surgical dissection of the intersphincteric space. [ 3 ]  Furthermore, in order to achieve a sufficient horizontal marginanally, the  rectococcygeus muscle  is frequently divided, which impairs the muscle's functionality. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10492", "text": "A decrease in the maximum allowable rectal volume following low anterior resection and an increase in the false urge to urinate can result from poor compliance brought on by rectal volume loss. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10493", "text": "The extrinsic  spinal cord  nerves that mediate the rectoanal inhibitory reflex may also be injured during a low anterior resection, resulting in intestinal dysfunction. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10494", "text": "Low anterior resection syndrome can be assessed using two patient questionnaires that have been validated. [ 3 ]  After sphincter-preserving surgery, the 18-item validated  Memorial Sloan Kettering Cancer Center  Bowel Function Instrument (MSKCC-BFI) can be used to assess bowel function. It was developed in 2004. [ 12 ]  A 5-item validated questionnaire called the LARS score was developed in 2012 by Emmertsen et al. in a Danish population as a second scoring system to evaluate bowel function following sphincter-preserving surgery for rectal cancer. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10495", "text": "Anorectal manometry  objectively assesses anal sphincter function and rectal capacity by recording resting pressure, maximum squeezing pressure, rectoanal inhibitory reflex, rectal capacity, and compliance with a balloon catheter and pressure sensor. Although it can be used to direct and track the effectiveness of therapy,  anorectal manometry  is not necessary for the diagnosis of low anterior resection syndrome. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10496", "text": "Endoscopic rectal ultrasound  is a useful tool for evaluating the  pelvic floor  and sphincter complex structure. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10497", "text": "Fecoflowmetry is a valuable technique for evaluating anorectal motor function following surgery. It works by tracking changes in flow against time and analyzing the fecal flow rate, which is the result of rectal detrusor action against anorectal outlet resistance. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10498", "text": "The foundation of\u00a0treatment for low anterior resection syndrome is conservative therapy, including pelvic floor rehabilitation,\u00a0 colonic irrigation , or minimally invasive procedures, such as spinal nerve stimulation. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10499", "text": "For the short-term treatment of a single symptom, certain patients should be treated with loperamide or  antibiotics  like neomicine or  rifaximin  (in the event of proximal expansion of native gut microbes or  small-intestinal bacterial overgrowth  shown with the  lactulose  breath test). [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10500", "text": "Although  bile acid sequestrants  like  colesevelam  and  5-HT3 antagonists  like  ramosetron  have shown intriguing early results, more research is still needed. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10501", "text": "Transanal irrigation is an inexpensive and successful treatment for the high frequency of defecations and incontinence linked to low anterior resection syndrome. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10502", "text": "Sacral nerve stimulation  (SNS) is associated with improved fecal incontinence and deferred defecation among individuals with normal as well as impaired sphincters, as well as in patients with low anterior resection syndrome. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10503", "text": "When  fecal incontinence  becomes unmanageable, surgery may be a viable treatment option. When all other forms of treatment have been exhausted, a  stoma  should be taken into consideration. Sphincteric substitution and other advanced surgical techniques ought to be reserved for a very select group of patients. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10504", "text": "These procedures aim to inject  bio-compatible  material ( perianal injectable bulking agents , also termed  sphincter bulking agents [ 1 ]  or  biomaterial injectables ) [ 2 ]  into the walls of the anal canal, in order to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing  fecal incontinence . This procedure has many advantages over more invasive surgery, since there are rarely any serious complications. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10505", "text": "Originally, injectable bulking agents were used to treat  stress urinary incontinence  in females. [ 4 ]  The procedure aimed to bulk out the tissues of the neck of the bladder, and it was successful. [ 5 ]  The technique was first used for FI in 1993 by an Egyptian surgeon. [ 6 ]  He used  polytetrafluroethylene  (PTFE/polytef/Teflon) paste injected into the submucosal layer of anal canal. [ 5 ] [ 4 ]  Later publications described autologous transplantation of fat from the abdominal wall or the buttock. [ 5 ] [ 4 ]  After about the year 2000, many different materials started to be used as well as variations of the technique. Some of these materials were concurrently being used to treat urinary incontinence. The latest development of this technique is the  implantable bulking agents  \"Gatekeeper\" and \"Sphinkeeper\". [ 4 ]  These are not injectable materials but rather implants which expand after placement. [ 7 ]  As such, they are termed \"self-expandable prostheses\", and the term \"non-self-expandable prostheses\" is used to refer to older injectable materials. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10506", "text": "The exact methods of this procedure are not standardized and vary considerably, [ 8 ] [ 9 ]  for example the exact number and locations of the injections and the volume of the injected material. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10507", "text": "Before the operation, antibiotic prophylaxis may be given. [ 10 ]  The rectum is prepared with a phosphate enema at least 2 hours before the procedure. [ 10 ]  The procedure can be carried out under  local anesthetic  on an  out patient  basis, or with  caudal epidural anesthesia , [ 8 ]  or with  intravenous sedation , or under  general anesthesia . [ 3 ]   Ultrasound  guidance may be used during the injections, which is sometimes reported as being more effective than the surgeon simply  palpating  (feeling) and looking where to inject."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10508", "text": "The site of the bulking material can be inter-sphincteric (in the space between the IAS and the EAS), submucosal injections (under the mucosal layer, usually just above the dentate line), or within the IAS itself. [ 3 ] [ 4 ]  Injection of the material can be by the different routes: transanal route, trans-sphincteric, intersphincteric, perianal route (going through the muscle complex) or transcutaneous route. [ 3 ]  As such, there are several different variations of injection location and route: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10509", "text": "The perianal injection route (intersphincteric or transsphincteric) gives better results than the transanal route according to one review. [ 3 ]  Submucosal implant location may have a higher risk of erosion and sepsis. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10510", "text": "Many different materials have been used as perianal injectable bulking agents. [ 11 ]  The ideal injectable or implantable material would be biocompatible, non-migratory, non- allergenic , non- carcinogenic  and non-immunogenic (and therefore induce a minimal inflammatory and fibrotic reaction). [ 5 ] [ 4 ] [ 10 ]  The material should also be easy to inject. The particles should be greater than 80 \u03bcm in diameter in order to prevent migration away from the injection site. On the other hand, materials with particles small enough to be used in small caliber needles may be desirable, in order to leave a smaller needle track, which may reduce the chance of leakage of the material via the needle track. Alternatively, some materials are shape-retaining porous hydrogels with no particles. [ 5 ]  The ideal material should produce an improvement in continence not only in the short term, but in the long term, and repeated procedures should not be necessary. [ 4 ]  Technically, most materials are particles suspended in a carrier (excipient) solution, which is usually a biodegradable gel. [ 12 ] [ 10 ]  It is not known which of the available materials is the best. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10511", "text": "This was the original material used as a bulking agent, first used to treat urinary incontinence in 1964, and then about 20 years later it was the first material used as a bulking agent to treat FI.  Polytef paste is  polytetrafluoroethylene ,  glycerin  and  polysorbide . The particles are mostly very small in size (4\u201340-\u03bcm). Research in animals has shown that these particles migrate and may be found in lymph nodes, lungs, kidneys, spleen and brain. [ 5 ]  If the material mostly migrates away, any benefit will be temporary, and there are safety concerns that it could lead to the formation of foreign body  granulomas  and the development of  sarcoma . [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10512", "text": "This variation of the procedure uses the patient's own fat cells, and therefore is non-allergenic and non-immunogenic. [ 5 ]  The fat cells are taken from the abdominal wall by suction. Then they are purified and put into a saline solution before injection. [ 10 ]  When used in other fields such as urology or facial surgery, autologous fat transplants have very rarely been reported to cause  fat embolism  and  stroke . [ 4 ]  This material is also subject to rapid digestion and migration. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10513", "text": "This is a silicone biomaterial, marketed as \"PTQ\" or \"Bioplastique\". It is polydimethylsiloxane elastomer particles suspended in a biocompatible carrier hydrogel of  poly-N-vinyl-pyrrolidone  (povidone). Significantly more publications exist which investigate this material compared to the other materials, [ 4 ]  and it has been the most widely used bulking material used for FI. [ 10 ]  Publications used inter-sphincteric or  within IAS injection sites via the trans-sphincteric route. [ 4 ]  The particles are in the range 100\u2013450 \u03bcm with smaller particles in the gel. Therefore there is a possibility of migration and granuloma formation. There are also concerns about a link between autoimmune diseases and silicone. The bulking agent is very viscous which makes it difficult to inject. [ 5 ]  After injection there is irregular collagen deposition around and inside the implant. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10514", "text": "After PTQ, this material has most scientific publications. Publications described using it via the transmucosal or trans-sphincteric routes, with the end location of the material being the submucosa. It is composed of carbon-coated zirconium beads (pyrolytic carbon-coated beads) in a water-based carrier gel containing  \u03b2-glucan . [ 4 ]  Pyrolytic carbon is not biologically reactive and does not undergo degradation. It is used in various medical devices including heart valves. The particle size of Durasphere is in the range 212-500 \u03bcm, [ 5 ]  which is approximately 3 times the migration threshold of 80 \u03bcm. [ 10 ]  However, one report of the material as used in urology showed significant migration to local and distant lymph nodes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10515", "text": "This is a newer material which became more popular after 2011. [ 2 ]  It is marketed as NASHA Dx, Zuidex, or Solesta. [ 4 ]  As of 2022, NASHA Dx is the only material approved in the US by the U.S. Food and Drug Administration (FDA). [ 8 ]  This material is composed of crosslinked dextranomer (dextran) microspheres and non-animal stabilized sodium hyaluronate (NASHA) in phosphate-buffered 0.9%  sodium chloride  solution. [ 4 ]  The particles are 120 \u03bcm in diameter. The material is non-allergenic, non-immunogenic and non-migratory. After injection, the hyaluronic acid is degraded, and soft tissue fibrosis forms with ingrowth of fibroblasts, inflammatory cells, blood vessels and collagen. This means that even though the particles undergo degradation, the bulking effects may persist. [ 5 ]  There are several publications which report the use of this material. They used submucosal injection site via the transmucosal route. [ 4 ]  Uncertainty about indications, cost, and durability of the material in the long term stopped widespread adoption of this material. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10516", "text": "Marketed as \"Coaptite\", this is spherical particles of calcium hydroxylapatite ceramic suspended in a sodium carboxylmethylcellulose, glycerine and water carrier gel. [ 4 ]  This is a synthetic version of a compound that is a normal component of bones and teeth. It is non-antigenic and noninflammatory. The particle size is in the range 75\u2013125 \u03bcm and therefore should avoid migration away from the implant site.  Once in place, the particles are enmeshed in a non-encapsulated stable soft collagen matrix. This matrix maintains volume even after the solid particles have been degraded and resorbed. The material is radio-opaque (and therefore will be visible on x-rays). It has been used in dental and orthopedic reconstructive surgery, and for replacement heart valves. In the field of plastic surgery, it is termed Radiance FNTM. [ 5 ]  As of 2022 only one publication exists. The material was used in submucosal injection site via transsphincteric route. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10517", "text": "GAX (glutaraldehyde cross-linked) collagen is purified collagen from cow skin, marketed as Contigen. [ 5 ] [ 4 ]  Enzymes are used to remove  telopeptides , which reduces the antigenicity (the degree to which the body's immune cells will be able to recognize the material as a foreign body). About 5% of patients will have an immune reaction to this material, therefore allergy testing is carried out before the final procedure. There is also a concern about disease transmission. [ 5 ]  This material contains 95% collagen Type I and 1-5% of collagen Type III. [ 10 ]  Chemical cross-linking with glutaraldehyde is intended to stop the degradation of the material by collagenases. [ 5 ]  The carrier solution is physiological saline with phosphate. [ 10 ]  The material does not seem to be associated with formation of granulomas or migration, however it is subject to degradation over time. [ 5 ]  In publications is has been used with submucosal injection site via transmucosal route. [ 4 ]  This material has not achieved widespread use. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10518", "text": "Cross-linked porcine dermal collagen matrix (collagen from pig skin) has been used, marketed as Permacol. [ 5 ]  It consists of large particles of cross-linked porcine dermal collagen. [ 10 ]  It has been used for urinary incontinence and for facial contour augmentation, as well as for FI. It is biocompatible, non-allergenic and has improved durability due to revascularization and cell ingrowth following injection. [ 5 ]  In several publications where the material was used for FI, submucosal or intersphincteric injection site was used, via the transmucosal or intersphincteric routes. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10519", "text": "Marketed as Bulkamid, this material is a synthetic non-particulate hydrogel composed of water and cross-linked polyacrylamide (2.5%). [ 4 ]  The size of the molecules is large which makes it resistant to migration. Since it is a non particulate homogeneous hydrogel, it is thought to retain elasticity and does not lead to hard tissue fibrosis or cause other significant reaction in the surrounding tissues. [ 5 ] [ 10 ]  It is non-resorbable and non allergenic. In plastic surgery it is marketed as Aquamid. [ 5 ]  In one publication where it was used for FI, intersphincteric injection site was used via the intersphincteric route. [ 4 ]  This material has not achieved widespread use. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10520", "text": "ALTA injection is somewhat different to the other materials because it is a sclerosant (i.e. it is a type causes  sclerosis , or hardening of tissue). Therefore, it may be technically classified as a type of  sclerotherapy . This injectable material has been used for treatment of grade III to IV prolapsed internal  hemorrhoids , where it gives effects similar to  hemorrhoidectomy . It has also been used for treatment of  rectal prolapse  and  rectocele . [ 8 ]  The material causes a local inflammatory reaction, followed by sclerosis and retraction of tissues. This results in a chronic granulomatous inflammatory process and persistent  fibrosis . When used to treat rectal prolapse or mucosal prolapse, it is injected into a wider area (not just into the hemorrhoid cushions, but also into parts of the rectal mucosa), leading to thickening and toughening of the anal canal and rectal wall. This has been shown to increase the maximal resting pressure of the anal canal. Therefore, the result is thought to be similar to other injectable bulking agents, although it is claimed that there is no risk of dissipation and no need for repeated procedures. ALTA has the advantage that it may be used to treat related anorectal conditions which would be contraindications for other injectable bulking agents. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10521", "text": "8% ethylene vinyl alcohol co-polymer in dimethyl sulfoxide solution has been used. For FI it is marketed as Onyx34, and for gastroesophageal reflux disease it is marketed as Enteryx. [ 5 ] [ 4 ]  After injection, it forms a spongy solid mass via solidification of the hydrophobic copolymer. This occurs because the co-polymer is hydrophic, and the solvent is dissolved away upon contact with tissues. In one publication inter-sphincteric injection site was used via the inter-sphincteric route. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10522", "text": "Mesenchymal stem cells  (MSC) and  muscle-derived stem cells  (MDSC) have been used in urology to treat urinary incontinence.  Fibroblasts  in a collagen carrier were injected into the submucosa of the urethra, and  myoblasts  were injected into the urethral sphincter. The procedure was reported as being successful in most cases. [ 5 ]  Injection of MSCs may lead to engrafting and forming multinucleated myotubes, which helps to regeneration after injury. [ 10 ]  In theory, use of stem cells removes the problems of reabsorption and migration of the bulking material. [ 5 ]  There is similar research which aims to regenerate muscles and repair tissues by  cell therapy  to treat injuries of the external anal sphincter. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10523", "text": "The \"Gatekeeper\" and \"Sphinkeeper\" are related procedures. They are self-expandable prostheses which are implanted into the inter-sphincteric space of the anal canal using an applicator gun. [ 8 ] [ 2 ]  Gatekeeper is a solid  polyacrylonitrile  (hyexpan) cylinder which expands to approximately 720% original size within 24 hours after the implantation. [ 10 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10524", "text": "One review of 23 publications involved a total of 889 patients reported an overall rate of complications of 18%. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10525", "text": "Reported complications are mostly minor, and include: bleeding, perianal pain / discomfort (which may rarely be persistent), leakage of injected material, infection / abscess (which rarely may require drainage), mucosal erosion,  obstructed defecation , hypersensitivity reaction, hematoma, diarrhea,  pruritus ani ,  dermatitis , and bowel urgency (sudden strong urge to defecate). [ 3 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10526", "text": "A landmark randomized placebo control trial on NASHA Dx was published in 2011 in the Lancet. [ 13 ]  136 were given real injections and 70\npatients were given shame (fake) injections. 80% of the patients had no improvement 1 month after the procedure, and were given a second injection. [ 14 ]  After 6 months, 52% of patients who received real injections had improved symptoms. [ 15 ]  However, the patients who received fake injections reported over 30% improvement in symptoms, suggesting that patient psychology (i.e. the  placebo effect ) may be in part responsible for any positive results. [ 16 ]  6% of patients who received real injections were fully continent after 6 months. [ 14 ]  After publication of this study, the material was approved by the FDA in the USA in 2012. [ 14 ]  The material was aggressively marketed, and became popular for a time because of its potential as an in office treatment with low risks compared to other surgical options. [ 2 ]  However uncertainty about indications, cost, and long term durability stopped widespread adoption. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10527", "text": "A  Cochrane  systematic review of the efficacy of this type of treatment for FI was updated in 2013. The review included 5 randomized trials, which in total was 382 patients. 4 of the trials were assessed as uncertain or high risk of bias. [ 11 ]  Another commentator drew attention to the fact that all existing research on these procedures was driven by the companies who also marketed the treatments, and therefore the studies are indeed at high risk of bias. [ 16 ]  Another author in 2008 raised concern that 2 randomized placebo controlled trials had been conducted, but their results remained unpublished for unknown reasons. [ 9 ]  None of the studies in the Cochrane review reported long term follow up after 3, 6 or 12 months post procedure. Another problem with some of the trials is that they were too small. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10528", "text": "The Cochrane review found that most trials reported short term improvement following the procedure, regardless of which material was used. In some studies in the control groups, even placebo (sham) injections and saline injections lead to patients reporting improvement. One trial showed that dextranomer (NASHA Dx) was more effective six months after the procedure compared to placebo for just over half of patients. Another study showed that PTQ has some advantages and was safer than Durasphere in the short term. The authors concluded that due to the small amount of research available and its methodological weaknesses, further conclusions could not be made, especially regarding the long term effectiveness of the procedure. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10529", "text": "Another review which aimed to focus on the long term impact of the procedure included 889 patients across 23 studies. It reported a pooled improvement rate in measures of incontinence of 39.5%, on average 2 years after the procedure. [ 3 ]  In some cases there was no improvement after the procedure, and the injections needed to be repeated in up to 34% of cases. [ 3 ]  There can also be worsening of symptoms after an initial improvement period. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10530", "text": "A randomized trial by Dehli  et al . compared perianal injectable bulking agents to sphincter training and biofeedback, and found the former to be superior. Both methods lead to an improvement of FI, but comparisons of  St Mark's scores  between the groups showed no difference between treatments. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10531", "text": "Anal manometry  is sometimes used to investigate changes in the anal canal before and after the procedure. Usually mean anal resting pressure and mean anal squeeze pressure are the parameters used. [ 3 ]  Improvements in these measurements are often, but not always reported up to 3\u201312 months after the procedure. These improvements are not always maintained after 12 months. [ 3 ]  The length of the anal canal has also been reported to increase following the procedure. [ 3 ]  In one report, dextranomer did not increase anal resting or squeeze pressures. [ 15 ]  In the same study, dextranomer injections were found to be no different to  biofeedback . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10532", "text": "There is limited research available on this topic, and these publications are mostly of poor quality. [ 11 ]  Apart from the available research, most of the claims of benefit of these procedures is anecdotal. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10533", "text": "One author criticized these procedures, stating that simply narrowing the anal canal was an instinctive and na\u00efve solution which does not consider the complex pathopysiological mechanisms of FI. [ 16 ]  They suggested that these treatments are in theory suitable only for passive and minor forms of FI. [ 16 ]  Concerns have been raised about migration of the particles (in the case of Durasphere) away from the site of injection, or the total resorption of the material (in the case of hyaluronic acid and hydroxyl coaptite). [ 16 ]  Most research suggests that the positive effects of most of the bulking agents seem to reduce after 6 to 12 months. [ 8 ]  Endoanal ultrasound has sometimes been used to assess the presence of the material at follow up. At 6 months the material has been reported as missing or migrated in 18.4% of cases, at 3 years or more in 20.2% of cases. [ 3 ]  NASHA Dx and ALTA injection may have longer lasting effects, with most patients still having improvement after 3 years. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10534", "text": "The  pinworm  ( species   Enterobius vermicularis ), also known as  threadworm  (in the United Kingdom, Australia and New Zealand) or  seatworm , is a  parasitic worm .  It is a  nematode  (roundworm) and a common  intestinal parasite  or  helminth , especially in humans. [ 7 ]  The medical condition associated with pinworm infestation is known as  pinworm infection  ( enterobiasis ) [ 8 ]  (a type of  helminthiasis ) or less precisely as oxyuriasis in reference to the  family   Oxyuridae . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10535", "text": "Other than human,  Enterobius vermicularis  were reported from  bonnet macaque . [ 10 ]  Other species seen in  primates  include  Enterobius buckleyi  in  Orangutan [ 11 ]  and  Enterobius anthropopitheci  in  chimpanzee .   Enterobius vermicularis  is common in human children and transmitted via the faecal-oral route. Humans are the only natural host of   Enterobius vermicularis . [ 12 ]   Enterobius gregorii , another human species is morphologically indistinguishable from  Enterobius vermicularis  except the  spicule  size. [ 13 ]  Throughout this article, the word \"pinworm\" refers to  Enterobius . In British usage, however, pinworm refers to  Strongyloides , while  Enterobius  is called threadworm. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10536", "text": "The pinworm (genus  Enterobius ) is a type of  roundworm  (nematode), and three species of pinworm have been identified with certainty. [ 15 ]  Humans are hosts only to  Enterobius vermicularis  (formerly  Oxyurias vermicularis ). [ 16 ]   Chimpanzees  are host to  Enterobius anthropopitheci , which is  morphologically  distinguishable from the human pinworm. [ 5 ]  Hugot (1983) claims another species affects humans,  Enterobius gregorii , which is supposedly a  sister species  of  E. vermicularis , and has a slightly smaller  spicule  (i.e., sexual organ). [ 17 ]  Its existence is controversial, however; Totkova et al. (2003) consider the evidence to be insufficient, [ 6 ]  and Hasegawa et al. (2006) contend that  E. gregorii  is a younger stage of  E. vermicularis . [ 4 ] [ 5 ]  Regardless of its status as a distinct species,  E. gregorii  is considered clinically identical to  E. vermicularis . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10537", "text": "The adult female has a sharply pointed  posterior  end, is 8 to 13\u00a0mm long, and 0.5\u00a0mm thick. [ 18 ]  The adult male is considerably smaller, measuring 2 to 5\u00a0mm long and 0.2\u00a0mm thick, and has a curved posterior end. [ 18 ]  The eggs are  translucent [ 18 ]  and have a surface that adheres to objects. [ 19 ]  The eggs measure 50 to 60  \u03bcm  by 20 to 30 \u03bcm, and have a thick shell flattened on one side. [ 18 ]  The small size and colourlessness of the eggs make them invisible to the naked eye, except in barely visible clumps of thousands of eggs. Eggs may contain a developing  embryo  or a fully developed pinworm  larva . [ 18 ]  The larvae grow to 140\u2013150 \u03bcm in length. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10538", "text": "The entire life cycle, from egg to adult, takes place in the  human gastrointestinal tract  of a single host, [ 18 ] [ 19 ]  from about 2\u20134 weeks [ 20 ]  or about 4\u20138 weeks. [ 21 ]   E. vermicularis  molts four times; the first two within the egg before hatching and two before becoming an adult worm. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10539", "text": "Although infection often occurs via  ingestion  of embryonated eggs by inadequate hand washing or nail biting, inhalation followed by swallowing of airborne eggs may occur rarely. [ 19 ] [ 21 ]  The eggs hatch in the  duodenum  (i.e., first part of the  small intestine ). [ 23 ]  The emerging pinworm  larvae  grow rapidly to a size of 140 to 150 \u03bcm, [ 20 ]  and migrate through the small intestine towards the  colon . [ 19 ]  During this migration, they  moult  twice and become adults. [ 19 ] [ 21 ]  Females survive for 5 to 13 weeks, and males about 7 weeks. [ 19 ]  The male and female pinworms mate in the  ileum  (i.e., last part of the small intestine), [ 19 ]  whereafter the male pinworms usually die, [ 23 ]  and are passed out with stool. [ 24 ]  The gravid female pinworms settle in the  ileum ,  caecum  (i.e., beginning of the  large intestine ),  appendix  and  ascending colon , [ 19 ]  where they attach themselves to the  mucosa [ 21 ]  and ingest colonic contents. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10540", "text": "Almost the entire body of a  gravid  female becomes filled with eggs. [ 23 ]  The estimations of the number of eggs in a gravid female pinworm range from about 11,000 [ 19 ]  to 16,000. [ 21 ]  The egg-laying process begins about five weeks after initial ingestion of pinworm eggs by the human host. [ 19 ]  The gravid female pinworms migrate through the colon towards the  rectum  at a rate of 12 to 14\u00a0cm per hour. [ 19 ]  They emerge from the  anus , and while moving on the skin near the anus, the female pinworms deposit eggs either through (1) contracting and expelling the eggs, (2) dying and then disintegrating, or (3) bodily rupture due to the host scratching the worm. [ 23 ]  After depositing the eggs, the female becomes  opaque  and dies. [ 24 ]  The female emerges from the anus to obtain the oxygen necessary for the maturation of the eggs. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10541", "text": "E. vermicularis  causes the medical condition  pinworm infection  also known as  enterobiasis , whose primary symptom is  itching  in the anal area. [ 26 ]  Extraintestinal disease is rare and most commonly involves the female reproductive tract, [ 27 ]  but spleen abscess has also been reported. [ 28 ]  Enterobius vermicularis infections are found to be correlated with stunting and lower mean  I.Q.  among prepubescent children. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10542", "text": "The pinworm has a worldwide distribution, [ 25 ]  and is the cause of the most common  helminthiasis  ( parasitic worm  infection) in the United States, western Europe, and Oceania. [ 21 ]  In the United States, a study by the  Center of Disease Control  reported an overall  incidence rate  of 11.4% among children. [ 21 ]  Pinworms are particularly common in children, with  prevalence rates  in this age group having been reported as high as 61% in India, 50% in England, 39% in Thailand, 37% in Sweden, and 29% in Denmark. [ 21 ]   Finger sucking  has been shown to increase both incidence and relapse rates, [ 21 ]  and  nail biting  has been similarly associated. [ 31 ]  Because it spreads from host to host through  contamination , pinworms are common among people living in close contact, and tends to occur in all people within a household. [ 25 ]  The prevalence of pinworms is not associated with gender, [ 25 ]  nor with any particular social class,  race , or culture. [ 21 ]  Pinworms are an exception to the tenet that intestinal parasites are uncommon in affluent communities. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10543", "text": "A fossilized nematode egg was detected in 240 million-year-old fossil dung, [ 32 ]  showing that parasitic pinworms already infested pre-mammalian  cynodonts . The earliest known instance of the pinworms associated with humans is evidenced by pinworm eggs found in human  coprolites   carbon dated  to 7837 BC found in western  Utah . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10544", "text": "Pinworm infection  ( threadworm infection  in the UK), also known as  enterobiasis , is a  human parasitic disease  caused by the  pinworm ,  Enterobius vermicularis . [ 3 ]  The most common symptom is  pruritus ani , or  itching  in the  anal  area. [ 1 ]   The period of time from swallowing eggs to the appearance of new eggs around the anus is 4 to 8 weeks. [ 2 ]  Some people who are infected do not have symptoms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10545", "text": "The disease is spread between people by pinworm eggs. [ 1 ]  The eggs initially occur around the anus and can survive for up to three weeks in the environment. [ 1 ]  They may be swallowed following contamination of the hands, food, or other articles. [ 1 ]  Those at risk are those who go to school, live in a health care institution or prison, or take care of people who are infected. [ 1 ]  Other animals do not spread the disease. [ 1 ]  Diagnosis is by seeing the worms which are about one  centimetre  long or the eggs under a  microscope . [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10546", "text": "Treatment is typically with two doses of the medications  mebendazole ,  pyrantel pamoate , or  albendazole  two weeks apart. [ 4 ]  Everyone who lives with or takes care of an infected person should be treated at the same time. [ 1 ]  Washing personal items in hot water after each dose of medication is recommended. [ 1 ]  Good  handwashing , daily bathing in the morning, and daily changing of  underwear  can help prevent reinfection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10547", "text": "Pinworm infections commonly occur in all parts of the world. [ 1 ] [ 5 ]  They are the most common type of worm infection in  Western Europe ,  Northern Europe  and the  United States . [ 5 ]  School-aged children are the most commonly infected. [ 1 ]  In the United States about 20% of children will develop pinworm at some point. [ 3 ]  Infection rates among high-risk groups may be as high as 50%. [ 2 ]  It is not considered a serious disease. [ 5 ]  Pinworms are believed to have affected humans throughout history. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10548", "text": "One-third of individuals with pinworm infection are totally  asymptomatic . [ 8 ]  The main symptoms are  itching in and around the anus  and  perineum . [ 8 ] [ 9 ] [ 10 ]  The itching occurs mainly during the night, [ 9 ] [ 11 ]  and is caused by the female pinworms migrating to lay eggs around the anus. [ 12 ] [ 10 ]  Both the migrating females and the clumps of eggs are irritating, as well as the sticky substance that is produced by the worms when the eggs are laid. [ 11 ] [ 13 ]  The intensity of the itching varies, and it can be described as  tickling , crawling sensations, or even acute  pain . [ 14 ]  The itching leads to continuously scratching the area around the anus, which can further result in tearing of the skin and complications such as  secondary bacterial infections , including  bacterial   skin inflammation , and  hair follicle inflammation . [ 9 ] [ 10 ] [ 14 ]  General symptoms are  trouble sleeping , and  restlessness . [ 9 ]  A considerable proportion of children experience loss of appetite,  weight loss ,  irritability , emotional instability, and  bed wetting . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10549", "text": "Pinworms cannot damage the skin, [ 15 ]  and they do not normally migrate through  tissues . [ 10 ]  However, they may move onto the  vulva  and into the  vagina , from there moving to the  external orifice of the uterus , and onwards to the  uterine cavity ,  fallopian tubes ,  ovaries , and  peritoneal cavity . [ 15 ]  This can cause  inflammation of the vulva and vagina . [ 9 ] [ 10 ]  This causes  vaginal discharge  and  itchiness of the vulva . [ 9 ]  The pinworms can also enter the  urethra , and presumably, they carry intestinal bacteria with them. [ 15 ]  According to Gutierrez (2000), a statistically significant correlation between pinworm infection and  urinary tract infections  has been shown; [ 15 ]  however, Burkhart & Burkhart (2005) maintain that the incidence of pinworms as a cause of urinary tract infections remains unknown. [ 8 ]  One report indicated that 36% of young girls with a  urinary tract infection  also had pinworms. [ 8 ]   Painful urination  has been associated with pinworm infection. Sometimes, pinworms can be stopped before reaching the vaginal area  [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10550", "text": "The relationship between pinworm infestation and  appendicitis  (a condition in which the appendix becomes inflamed and filled with pus, causing pain) has been researched, but there is a lack of clear consensus on the matter: While Guti\u00e9rrez maintains that there exists a consensus that pinworms do not produce the inflammatory reaction, [ 16 ]  Cook (1994) states that it is controversial whether pinworms are causatively related to acute  appendicitis , [ 14 ]  and Burkhart & Burkhart (2004) state that pinworm infection causes symptoms of appendicitis to surface. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10551", "text": "The cause of a pinworm infection is the worm  Enterobius vermicularis .  The entire lifecycle \u2013 from egg to adult \u2013 takes place in the  human gastrointestinal tract  of a single human host. [ 12 ] [ 17 ]  This process is two to eight weeks. [ 18 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10552", "text": "Pinworm infection spreads through human-to-human  transmission , by swallowing infectious pinworm eggs. [ 18 ] [ 19 ]  The eggs are hardy and can remain infectious in a moist environment for up to three weeks, [ 11 ] [ 18 ]  though in a warm dry environment they usually last only 1\u20132 days. [ 20 ]  They do not tolerate heat well, but can survive in low temperatures: at \u22128 degrees Celsius (18\u00a0\u00b0F), two-thirds of the eggs are still viable after 18 hours. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10553", "text": "After the eggs have been initially deposited near the anus, they are readily transmitted to other surfaces through  contamination . [ 19 ]  The surface of the eggs is sticky when laid, [ 12 ] [ 11 ]  and the eggs are readily transmitted from their initial deposit near the anus to fingernails, hands, night-clothing and bed linen. [ 9 ]  From here, eggs are further transmitted to food, water, furniture, toys, bathroom  fixtures  and other objects. [ 12 ] [ 18 ] [ 19 ]  Household pets often carry the eggs in their fur, while not actually being infected. [ 21 ]  Dust containing eggs can become airborne and widely dispersed when dislodged from surfaces, for instance when shaking out bed clothes and linen. [ 11 ] [ 18 ] [ 21 ]  Consequently, the eggs can enter the mouth and nose through inhalation, and be swallowed later. [ 9 ] [ 11 ] [ 18 ] [ 19 ]  Although pinworms do not strictly multiply inside the body of their human host, [ 9 ]  some of the pinworm larvae may hatch on the anal  mucosa , and migrate up the  bowel  and back into the  gastrointestinal tract  of the original host. [ 9 ] [ 18 ]  This process is called  retroinfection . [ 11 ] [ 18 ]  According to Burkhart (2005), when this retroinfection occurs, it leads to a heavy  parasitic  load and ensures that the pinworm infestation continues. [ 18 ]  This statement is contradictory to a statement by Caldwell, who contends that retroinfection is rare and not clinically significant. [ 11 ]  Despite the limited, 13-week lifespan of individual pinworms, [ 12 ]   autoinfection  (infection from the original host to itself), either through the anus-to-mouth route or through retroinfection, causes the pinworms to inhabit the same host indefinitely. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10554", "text": "The life cycle begins with eggs being  ingested . [ 12 ]  The eggs hatch in the  duodenum  (first part of the  small intestine ). [ 19 ]  The emerging pinworm  larvae  grow rapidly to a size of 140 to 150 micrometres, [ 9 ]  and migrate through the small intestine towards the  colon . [ 12 ]  During this migration they  moult  twice and become adults. [ 12 ] [ 18 ]  Females survive for 5 to 13 weeks, and males about 7 weeks. [ 12 ]  The male and female pinworms mate in the  ileum  (last part of the small intestine), [ 12 ]  whereafter the male pinworms usually die, [ 19 ]  and are passed out with stool. [ 11 ]  The gravid female pinworms settle in the  ileum ,  caecum  (beginning of the  large intestine ),  appendix  and  ascending colon , [ 12 ]  where they attach themselves to the  mucosa [ 18 ]  and ingest colonic contents. [ 10 ]  Almost the entire body of a gravid female becomes filled with eggs. [ 19 ]  The estimations of the number of eggs in a gravid female pinworm ranges from about 11,000 [ 12 ]  to 16,000. [ 18 ]  The egg-laying process begins approximately five weeks after initial ingestion of pinworm eggs by the human host. [ 12 ]  The gravid female pinworms migrate through the  colon  towards the  rectum  at a rate of 12 to 14 centimetres per hour. [ 12 ]  They emerge from the  anus , and while moving on the skin near the anus, the female pinworms deposit eggs either through contracting and expelling the eggs, dying and then disintegrating, or bodily rupture due to the host scratching the worm. [ 19 ]  After depositing the eggs, the female becomes opaque and dies. [ 11 ]  The reason the female emerges from the anus is to obtain the oxygen necessary for the maturation of the eggs. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10555", "text": "Diagnosis relies on finding the eggs or the adult pinworms. [ 19 ]  Individual eggs are invisible to the naked eye, but they can be seen using a low-power  microscope . [ 21 ]  On the other hand, the light-yellowish thread-like adult pinworms are clearly visually detectable, usually during the night when they move near the anus, or on toilet paper. [ 8 ] [ 14 ] [ 21 ]  Shining a flashlight on the infected individual's anus about one hour after they fall asleep is one form of detection and may show worms crawling out of the anus. [ 22 ]  Another form of detection is the use of transparent  adhesive tape  (e.g.  Scotch Tape ) applied on the anal area which will pick up deposited eggs, and diagnosis can be made by examining the tape with a microscope. [ 16 ] [ 21 ]  This test is most successful if done every morning for several days, because the females do not lay eggs every day, and the number of eggs varies. [ 21 ]  A third method of diagnosis is examining a sample from under their fingernails under a microscope as itching around the anal area is common and therefore they may have collected some eggs under their nails as a result. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10556", "text": "Pinworms do not lay eggs in the  feces , [ 21 ]  but sometimes eggs are deposited in the intestine. [ 19 ]  As such, routine examination of fecal material gives a positive diagnosis in only 5 to 15% of infected subjects, [ 14 ]  and is therefore of little practical diagnostic use. [ 9 ]  In a heavy infection, female pinworms may adhere to  stools  that pass out through the anus, and they may thus be detected on the surface on the stool. [ 14 ] [ 19 ]  Adult pinworms are occasionally seen during  colonoscopy . [ 14 ]  On a microscopic level, pinworms have an identifying feature of  alae  (i.e., protruding ridges) running the length of the worm. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10557", "text": "Pinworm infection cannot be totally prevented under most circumstances. [ 25 ]  This is due to the prevalence of the parasite and the ease of transmission through soiled night clothes, airborne eggs, contaminated furniture, toys and other objects. [ 19 ]  Infection may occur in the highest strata of society, where hygiene and  nutritional  status are typically high. [ 26 ]  The stigma associated with pinworm infection is hence considered a possible over-emphasis. [ 26 ]   Counselling  is sometimes needed for upset parents who have discovered their children are infected, as they may not realize how prevalent the infection is. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10558", "text": "Preventive action revolves around  personal hygiene  and the cleanliness of the living quarters. [ 26 ]  The  rate  of reinfection can be reduced through hygienic measures, and this is recommended especially in recurring cases. [ 21 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10559", "text": "The main measures are keeping fingernails short, and washing and scrubbing hands and fingers carefully, especially after  defecation  and before meals. [ 26 ] [ 27 ]  Showering every morning is also highly recommended to wash off any eggs that may be still lying on the skin. [ 28 ]  Under ideal conditions, bed covers, sleeping garments, and hand towels should be changed daily [ 26 ]  and clothes and linens should be washed in hot water and then be placed in a hot dryer in order to kill off any eggs. [ 28 ]  Children can wear gloves while asleep, and the bedroom floor should be kept clean. [ 26 ]  Regular disinfection of kitchen and bathroom surfaces will help to prevent spread as well. [ 29 ]  Food should be covered to limit contamination with dust-borne parasite eggs. [ 26 ]  It is not recommended to shake clothes and bed linen as the eggs may detach and spread [ 26 ]  or to share clothes and towels. Nail biting and sucking on fingers is also discouraged."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10560", "text": "Medication  is the primary treatment for pinworm infection. [ 26 ]  However, reinfection is frequent regardless of the medication used. [ 8 ]  Total elimination of the parasite in a household may require repeated doses of medication for up to a year or more. [ 9 ]  Because the drugs kill the adult pinworms, but not the eggs, the first retreatment is recommended in two weeks. [ 21 ]  Also, if one household member spreads the eggs to another, it will be a matter of two or three weeks before those eggs become adult worms and thus amenable to treatment. [ 27 ]   Asymptomatic  infections, often in small children, can serve as reservoirs of infection, and therefore the entire household should be treated regardless of whether or not symptoms are present. [ 9 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10561", "text": "The  benzimidazole  compounds  albendazole  ( brand names  e.g.,  Albenza ,  Eskazole ,  Zentel  and  Andazol ) and  mebendazole  ( brand names  e.g.,  Ovex ,  Vermox ,  Antiox  and  Pripsen ) are the most effective. [ 26 ]  They work by inhibiting the  microtubule  function in the pinworm adults, causing  glycogen  depletion, [ 26 ]  thereby effectively starving the parasite. [ 27 ]  A single 100 milligram dose of  mebendazole  with one repetition after two weeks, is considered the safest, and is usually effective with cure rate of 96%. [ 8 ] [ 26 ]  Mebendazole has no serious  side effects , although  abdominal pain  and  diarrhea  have been reported. [ 26 ]   Pyrantel pamoate  (also called pyrantel embonate,  brand names  e.g.,  Reese's Pinworm Medicine ,  Pin-X ,  Combantrin ,  Anthel ,  Helmintox , and  Helmex ) kills adult pinworms through  neuromuscular blockade , [ 27 ]  and is considered as effective as the  benzimidazole  compounds and is used as a second-line medication. [ 9 ]  Pyrantel pamoate is available over the counter and does not require a prescription. Pinworms located in the  genitourinary system  (in this case, female genital area) may require other drug treatments. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10562", "text": "The available data on mebendazole, albendazole, and pyrantel pamoate use in pregnancy is limited and they are all assigned to  pregnancy category  level C. Treatment of a pinworm infection during pregnancy is only recommended for patients with significant symptoms that may be causing adverse effects to the pregnant woman such as loss of sleep and weight loss. [ 30 ] [ 31 ]  Pyrantel pamoate is the treatment of choice in pregnancy but should be used only after consultation with a health care practitioner rather than self-treatment. [ 30 ]  Treatment should be avoided in the first trimester, and if possible done in the third trimester. [ 32 ] [ 31 ]  If the pregnant woman is asymptomatic, then they should be treated after the baby is delivered. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10563", "text": "Mebendazole has less than 10% of the oral dose absorbed into systemic circulation with a clinically insignificant amount of drug excreted in breastmilk, and therefore treatment should not be withheld during breastfeeding. [ 31 ]  There is limited data on the use of pyrantel pamoate and albendazole in breastfeeding but  WHO  also classifies them as compatible with breastfeeding. This is due to the drugs acting mainly in the intestinal system of the mother with only a very small amount of drug being absorbed into the systemic circulation. [ 31 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10564", "text": "Pinworm infection occurs worldwide, [ 10 ]  and is the most common  helminth  (i.e., parasitic worm) infection in the United States and Western Europe. [ 18 ]  In the United States, a study by the  Center of Disease Control  reported an overall  incidence rate  of 11.4% among people of all ages. [ 18 ]  Pinworms are particularly common in children with approximately 30% of children being infected and most commonly seen in children between 7 and 11 years old. [ 34 ]  The  prevalence rates  in children having been reported as high as 61% in India, 50% in England, 39% in Thailand, 37% in Sweden, and 29% in Denmark. [ 18 ]   Finger sucking  has been shown to increase both incidence and relapse rates, [ 18 ]  and  nail biting  has been similarly associated. [ 14 ]  Because it spreads from host to host through  contamination , enterobiasis is common among people living in close contact, and tends to occur in all people within a household. [ 10 ]  The prevalence of pinworms is not associated with gender, [ 10 ]  nor with any particular  social class ,  race , or culture. [ 18 ]  Pinworms are an exception to the tenet that intestinal parasites are uncommon in affluent communities. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10565", "text": "The earliest known instance of pinworms is evidenced by pinworm eggs found in  coprolite ,  carbon dated  to 7837 BC at western  Utah . [ 12 ]  Pinworm infection is not classified as a  neglected tropical disease  unlike many other parasitic worm infections. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10566", "text": "Garlic  has been used as a treatment in the ancient cultures of China, India, Egypt, and Greece. [ 36 ]   Hippocrates  mentioned garlic as a remedy against intestinal parasites. [ 37 ]  German botanist  Adam Lonicer  also recommended garlic against parasitic worms. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10567", "text": "Proctoscopy , or  rectoscopy , is a common medical procedure in which an instrument called a proctoscope (also known as a  rectoscope , although the latter may be a bit longer) is used to examine the  anal cavity ,  rectum , or  sigmoid colon . A proctoscope is a short, straight, rigid, hollow metal tube, and usually has a small light bulb mounted at the end. It is approximately 15\u00a0cm (5\u00a0inches) long, while a rectoscope is approximately 25\u00a0cm (10\u00a0inches) long. [ 1 ]  During proctoscopy, the proctoscope is lubricated and inserted into the  rectum , and then the  obturator  is removed, allowing an unobstructed view of the interior of the rectal cavity. This procedure is normally done to inspect for  hemorrhoids  or rectal  polyps  and might be mildly uncomfortable as the proctoscope is inserted further into the rectum. Modern  fibre-optic  proctoscopes allow more extensive observation with less discomfort."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10568", "text": "A  proctoscope  is a hollow, tube-like  speculum  that is used for visual inspection of the rectum. [ 2 ] [ 3 ]  Both disposable and non-disposable proctoscopes are available for use. Out of these, the non-disposable Kelly's rectal speculum, [ 4 ]  named after the American gynecologist  Howard Atwood Kelly , is the most commonly used speculum for proctoscopy. Some proctoscopes have a light source for better visibility. The proctoscope is inserted into the  anal canal  with the patient in  Sims' position . Fibre optic proctoscopes are now available which cause less discomfort to the patient. \nThe proctoscope is used in the diagnosis of  hemorrhoids , carcinoma of anal canal or rectum and  rectal polyp . It is used therapeutically for  polypectomy  and rectal biopsy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10569", "text": "Disposable proctoscopes without light are also available.   The proctoscope also has a hollow channel through which other instruments may be inserted. For example, another instrument may be used to take a  biopsy  of a small amount of  tissue  for examination under a  microscope . Also, air may be injected through the proctoscope to help make viewing easier. Similar instruments, the  sigmoidoscope  and  colonoscope  may be used to visualize more proximal parts of the bowels."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10570", "text": "Rectal discharge  is intermittent or continuous expression of liquid from the anus ( per rectum ). Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of  fecal incontinence  (e.g., fecal leakage) but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10571", "text": "Different types of discharge are described. Generally \"rectal discharge\" refers to either a mucous or  purulent  discharge, but, depending upon what definition of rectal discharge is used, the following could be included:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10572", "text": "There are many different types of rectal discharge, but the most common presentation of a discharge is passage of mucus or pus wrapped around an otherwise normal bowel movement. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10573", "text": "Rectal discharge has many causes, and may present with other symptoms: [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10574", "text": "Pus  usually indicates  infection . Frequently medical sources do not differentiate between the two types of discharge, instead using the general term  mucopurulent discharge , which, strictly speaking, should only be used to refer to a discharge that contains both mucus and pus. Purulent discharges may be blood-streaked. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10575", "text": "Mucus  coats the walls of the  colon  in health, functioning as a protective barrier and also to aid  peristalsis  by  lubrication  of  stool . Mucous discharges can be thought of in three broad categories:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10576", "text": "A mucous rectal discharge may be blood-streaked. With some conditions, the blood can be homogenously mixed with the mucus, creating a pink goo. An example of this could be the so-called \"red currant jelly\" stools in  intussusception . This appearance refers to the mixture of sloughed  mucosa , mucus, and blood. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10577", "text": "Note : \"mucus\" is a noun, used to name the substance itself, and \"mucous\" is an adjective, used to describe a discharge. \"Mucoid\" is also an adjective and means mucus-like. \"Mucinous\" strictly speaking refers to something having a  mucin -like attribute, but it often is used interchangeably with the word \"mucous\" (as mucus usually contains a high percentage of mucin)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10578", "text": "The differential diagnosis of rectal discharge is extensive,  but the general  etiological  themes are  infection  and  inflammation . [ 11 ]   Some lesions can cause a discharge by mechanically interfering with, or preventing the complete closure of, the  anal canal . This type of lesion may not cause discharge intrinsically, but instead, allow transit of liquid stool components and mucus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10579", "text": "Perianal  Crohn's disease  is associated with fistulizing, fissuring and perianal abscess formation. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10580", "text": "After  colostomy , the distal section of bowel continues to produce mucus despite fecal diversion, often resulting in mucinous discharge. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10581", "text": "Occasionally,  intestinal parasitic  infection can present with discharge, for example  whipworm . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10582", "text": "Several pathologies can present with perianal discharge. Although not exactly the same as rectal discharge, perianal discharge can be misinterpreted as such, given the anatomical proximity. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10583", "text": "Fistulae  draining into the perianal region, as well as  pilonidal diseases , are the main entities that fall within this category. Perianal tumours can also discharge when they fungate or otherwise become cystic or necrotic. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10584", "text": "Proctitis is inflammation of the lining of the rectum [ 21 ]  including the  distal  15\u00a0cm (6\u00a0in) of the rectum. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10585", "text": "Proctitis  has many causes. Common infection causes include: sexual intercourse with someone who has a sexually transmitted disease (STD), infection from a foodborne illness, and strep throat (in children). [ 22 ]   Proctitis may also be caused by some types of inflammatory bowel disease, radiation therapy, injury to the rectum or anus, or some types of antibiotic. [ 22 ] [ clarification needed ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10586", "text": "Tuberculosis  proctitis can create a mucous discharge. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10587", "text": "Anal warts are irregular, verrucous lesions caused by  human papilloma virus . Anal warts are usually transmitted by unprotected,  anoreceptive intercourse .  Anal warts may be asymptomatic, [ 24 ]  or may cause rectal discharge, anal wetness,  rectal bleeding , and  pruritus ani . [ 14 ]  Lesions can also occur within the anal canal, where they are more likely to create symptoms. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10588", "text": "The bacterium  Chlamydia trachomatis  can cause 2 conditions in humans; viz.  trachoma  and  lymphogranuloma venereum . Trachoma can cause an asymptomatic  proctitis , but the symptoms of lymphogranuloma venereum are usually more severe, including  pruritus ani , purulent rectal\ndischarge,  hematochezia   rectal pain  and  diarrhea  or  constipation . [ 14 ] [ 24 ]  Lymphogranuloma venereum can cause  fistulas ,  strictures  and  anorectal abscesses  if left untreated. Hence, it can be confused with Crohn's disease. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10589", "text": "Rectal gonorrhea is caused by  Neisseria gonorrhoeae . [ 24 ]  The condition is usually asymptomatic, but symptoms can include rectal discharge (which can be creamy, purulent or bloody),  pruritus ani ,  tenesmus , and possibly  constipation . When symptomatic, these usually appear 5\u20137 days post-exposure. [ 14 ]  Discharge is the most common symptom, and it is usually a brownish mucopurulent consistency. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10590", "text": "Anorectal syphilis is caused by  Treponema pallidum  and is contracted through anoreceptive intercourse. Symptoms are usually minimal, but mucous discharge, bleeding, and  tenesmus  may be present. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10591", "text": "When the fecal stream is diverted as part of a  colostomy , a condition called  diversion colitis  may develop in the section of bowel that no longer is in contact with stool. The mucosal lining is nourished by short-chain fatty acids, which are produced as a result of bacterial fermentation in the gut. Long-term lack of exposure to these nutrients can cause inflammation of the colon (colitis). [ 28 ]  Symptoms include  rectal bleeding , mucous discharge,  tenesmus , and  abdominal pain . [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10592", "text": "Anal carcinoma is much less common than  colorectal cancer . The most common form is  squamous cell carcinoma , followed by  adenocarcinoma  and  melanoma . [ 29 ]  SCC usually occurs in the anal canal, and more rarely on the anal margin. Anal margin SCC presents as a lesion with rolled, everted edges and central ulceration. [ 27 ]  Symptoms include a painful lump, bleeding,  pruritus ani ,  tenesmus , discharge or possibly  fecal incontinence . SSC in the anal canal most commonly causes bleeding, but may also cause anal pain, a lump,  pruritus ani , discharge,  tenesmus , change in bowel habits and  fecal incontinence . Because these symptoms are so unspecific, and because symptoms of anal carcinoma may not always be typical, this can lead to delays in diagnosis. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10593", "text": "Rare neoplasms at this site that can give rise to discharge include Paget's disease (which is possibly a type of adenocarcinoma) and verrucous carcinoma. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10594", "text": "Adenoma  is the most common colorectal  polyp . Adenomas are not malignant, but rarely  adenocarcinoma  can develop from them. Large adenomas can cause  rectal bleeding , mucus discharge,  tenesmus , and a sensation of urgency. Mucus production may be so great that it can cause  electrolyte  disturbances in the blood. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10595", "text": "Juvenile polyps  may cause rectal discharge."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10596", "text": "A  rectal prolapse  occurs when walls of the  rectum  have  prolapsed  to such a degree that they protrude out of the  anus  and are visible outside the body. [ 2 ]  However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10597", "text": "Rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be  mucous discharge  (mucus coming from the anus),  rectal bleeding , degrees of  fecal incontinence , and  obstructed defecation  symptoms. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10598", "text": "Rectal prolapse is generally more common in elderly women, although it may occur at any age and in either sex. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated. [ 5 ]  Most external prolapse cases can be treated successfully, often with a surgical procedure. Internal prolapses are traditionally harder to treat and surgery may not be suitable for many patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10599", "text": "The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize some subtypes and others do not. Essentially, rectal prolapses may be: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10600", "text": "External (complete) rectal prolapse  (rectal procidentia, full thickness rectal prolapse, overt rectal prolapse [ 6 ] ) is\na full thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10601", "text": "Internal rectal intussusception  (occult rectal prolapse, internal procidentia) can be defined as a funnel shaped infolding of the upper rectal (or lower  sigmoid ) wall that can occur during  defecation . [ 9 ]  This infolding is perhaps best visualised as folding a sock inside out, [ 10 ]  creating \"a tube within a tube\". [ 11 ]  Another definition is \"where the rectum collapses but does not exit the anus\". [ 12 ]  Many sources differentiate between internal rectal intussusception and mucosal prolapse, implying that the former is a full thickness prolapse of rectal wall. However, a publication by the  American Society of Colon and Rectal Surgeons  stated that internal rectal intussusception involved the  mucosal  and  submucosal  layers separating from the underlying  muscularis mucosa  layer attachments, resulting in the separated portion of rectal lining \"sliding\" down. [ 5 ]  This may signify that authors use the terms internal rectal prolapse and internal mucosal prolapse to describe the same phenomena."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10602", "text": "Mucosal prolapse  (partial rectal mucosal prolapse) [ 13 ]  refers to prolapse of the loosening of the submucosal attachments to the muscularis propria of the distal rectummucosal layer of the rectal wall. Most sources define mucosal prolapse as an external, segmental prolapse which is easily confused with prolapsed (3rd or 4th degree)  hemorrhoids  (piles). [ 10 ]  However, both internal mucosal prolapse (see below) and circumferential mucosal prolapse are described by some. [ 13 ]  Others do not consider mucosal prolapse a true form of rectal prolapse. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10603", "text": "Internal mucosal prolapse  (rectal internal mucosal prolapse, RIMP) refers to prolapse of the mucosal layer of the rectal wall which does not protrude externally. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity. [ 15 ]  The term \"mucosal hemorrhoidal prolapse\" is also used. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10604", "text": "Solitary rectal ulcer syndrome  (SRUS, solitary rectal ulcer, SRU) occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions. [ 5 ]  It describes  ulceration  of the rectal lining caused by repeated frictional damage as the internal intussusception is forced into the anal canal during straining. SRUS can be considered a consequence of internal intussusception, which can be demonstrated in 94% of cases."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10605", "text": "Mucosal prolapse syndrome  (MPS) is recognized by some. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. [ 17 ] [ 18 ]  It is classified as a chronic benign inflammatory disorder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10606", "text": "Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation: [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10607", "text": "Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity: [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10608", "text": "The most widely used classification of internal rectal prolapse is according to the height on the rectal/sigmoid wall from which they originate and by whether the intussusceptum remains within the rectum or extends into the  anal canal . The height of intussusception from the anal canal is usually estimated by  defecography . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10609", "text": "Recto-rectal (high) intussusception  (intra-rectal intussusception) is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum. (i.e. the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum only). These are usually intussusceptions that originate in the upper rectum or lower  sigmoid . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10610", "text": "Recto-anal (low) intussusception  (intra-anal intussusception) is where the intussusception starts in the rectum and protrudes into the anal canal (i.e. the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10611", "text": "An Anatomico-Functional Classification of internal rectal intussusception has been described, [ 11 ]  with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology. The parameters of this classification are anatomic descent, diameter of intussuscepted bowel, associated rectal hyposensitivity and associated delayed colonic transit:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10612", "text": "Patients may have associated gynecological conditions which may require multidisciplinary management. [ 5 ]  History of  constipation  is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10613", "text": "Rectal prolapse may be confused easily with prolapsing hemorrhoids. [ 5 ]  Mucosal prolapse also differs from prolapsing (3rd or 4th degree) hemorrhoids, where there is a segmental prolapse of the hemorrhoidal tissues at the 3, 7 and 11 o'clock positions. [ 13 ]  Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential.  In mucosal prolapse, these folds are radially. [ 10 ]  The folds in mucosal prolapse are usually associated with internal hemorrhoids. Furthermore, in rectal prolapse, there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus. [ 3 ]  Prolapsed, incarcerated hemorrhoids are extremely painful, whereas as long as a rectal prolapse is not strangulated, it gives little pain and is easy to reduce. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10614", "text": "The prolapse may be obvious, or it may require straining and squatting to produce it. [ 5 ]  The anus is usually patulous, (loose, open) and has reduced resting and squeeze pressures. [ 5 ]  Sometimes it is necessary to observe the patient while they strain on a toilet to see the prolapse happen [ 21 ]  (the perineum can be seen with a mirror or by placing an endoscope in the bowl of the toilet). [ 10 ]  A phosphate enema may need to be used to induce straining. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10615", "text": "The perianal skin may be macerated (softening and whitening of skin that is kept constantly wet) and show  excoriation . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10616", "text": "These may reveal congestion and  edema  (swelling) of the distal rectal mucosa, [ 21 ]  and in 10-15% of cases there may be a solitary rectal ulcer on the anterior rectal wall. [ 5 ]  Localized inflammation or ulceration can be biopsied and may lead to a diagnosis of SRUS or colitis cystica profunda. [ 5 ]  Rarely, a  neoplasm  (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of  colorectal cancer . Full length colonoscopy is usually carried out in adults prior to any surgical intervention. [ 5 ]  These investigations may be used with contrast media ( barium enema ) which may show the associated mucosal abnormalities. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10617", "text": "This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination. [ 3 ]  It is usually not necessary with obvious external rectal prolapse. [ 10 ]   Defecography  may demonstrate associated conditions like  cystocele , vaginal vault prolapse or  enterocele . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10618", "text": "Colonic transit studies  may be used to rule out  colonic inertia  if there is a history of severe constipation. [ 3 ] [ 5 ]  Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10619", "text": "This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some. [ 10 ]  It may be used to assess for pelvic floor dyssenergia, [ 5 ]  ( anismus  is a contraindication for certain surgeries, e.g. STARR), and these patients may benefit from post-operative  biofeedback  therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse. [ 5 ]  Resting tone is usually preserved in patients with mucosal prolapse. [ 21 ]  In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10620", "text": "It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan. [ 5 ]  There may be denervation of striated musculature on the electromyogram. [ 21 ]  Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10621", "text": "Rectal prolapse is a \"falling down\" of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing. [ 10 ]  The symptoms can be socially debilitating without treatment, [ 5 ]  but it is rarely life-threatening. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10622", "text": "The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most affected people are elderly, the condition is generally under-reported. [ 22 ]  It may occur at any age, even in children, [ 23 ]  but there is peak onset in the fourth and seventh decades. [ 3 ]  Women over 50 are six times more likely to develop rectal prolapse than men. It is rare in men over 45 and in women under 20. [ 21 ]  When males are affected, they tend to be young and report significant bowel function symptoms, especially  obstructed defecation , [ 5 ]  or have a predisposing disorder (e.g., congenital  anal atresia ). [ 10 ]  When children are affected, they are usually under the age of 3."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10623", "text": "35% of women with rectal prolapse have never had children, [ 5 ]  suggesting that pregnancy and labor are not significant factors. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10624", "text": "Associated conditions, especially in younger patients include autism, developmental delay syndromes, and psychiatric conditions requiring several medications. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10625", "text": "Signs and symptoms include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10626", "text": "Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing, [ 5 ]  coughing or sneezing ( Valsalva  maneuvers). [ 3 ]  A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulceration and bleeding. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10627", "text": "If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation. [ 21 ]   This may require an urgent surgical operation if the prolapse cannot be manually reduced. [ 5 ]  Applying granulated sugar on the exposed rectal tissue can reduce the  edema  (swelling) and facilitate this. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10628", "text": "The precise cause is unknown, [ 3 ] [ 10 ] [ 9 ]  and has been much debated. [ 5 ]  In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic  fascial  defect. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10629", "text": "This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen. [ 5 ]   Other adjacent structures can sometimes be seen in addition to the rectal prolapse. [ 5 ]  Although a  pouch of Douglas   hernia , originating in the cul de sac of Douglas, may protrude from the anus (via the anterior rectal wall), [ 21 ]  this is a different situation from rectal prolapse."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10630", "text": "Shortly after the invention of  defecography , In 1968 Broden and Snellman used  cinedefecography  to show that rectal prolapse begins as a circumferential intussusception of the rectum, [ 3 ] [ 10 ]  which slowly increases over time. [ 21 ]  The leading edge of the intussusceptum may be located at 6\u20138\u00a0cm or at 15\u201318\u00a0cm from the  anal verge . [ 21 ]  This proved an older theory from the 18th century by  John Hunter  and  Albrecht von Haller  that this condition is essentially a full-thickness rectal intussusception, beginning about 3 inches above the  dentate line  and protruding externally. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10631", "text": "Since most patients with rectal prolapse have a long history of constipation, [ 10 ]  it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse. [ 3 ] [ 9 ] [ 21 ] [ 24 ] [ 25 ] [ 26 ]  Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy. [ 9 ]  This excessive straining may be due to predisposing pelvic floor dysfunction (e.g.  obstructed defecation ) and anatomical factors: [ 10 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10632", "text": "Some authors question whether these abnormalities are the cause, or secondary to the prolapse. [ 3 ]  Other predisposing factors/associated conditions include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10633", "text": "The association with uterine prolapse (10-25%) and cystocele (35%) may suggest that there is some underlying abnormality of the pelvic floor that affects multiple pelvic organs. [ 3 ]  Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence. [ 5 ]  This finding was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that  pudendal nerve  damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10634", "text": "Sphincter function in rectal prolapse is almost always reduced. [ 3 ]  This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex (RAIR - contraction of the external anal sphincter in response to stool in the rectum). The RAIR was shown to be absent or blunted. Squeeze (maximum voluntary contraction) pressures may be affected as well as the resting tone. This is most likely a denervation injury to the external anal sphincter. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10635", "text": "The assumed mechanism of  fecal incontinence  in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit (the intussusceptum) connecting rectum to the external environment which is not guarded by the sphincters. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10636", "text": "The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal's ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal  lumen , creating a blockage that straining, anismus and colonic dysmotility exacerbate. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10637", "text": "Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse. [ 30 ]  The factors that result in a patient progressing from internal intussusception to a full thickness rectal prolapse remain unknown. [ 5 ]  Defecography studies demonstrated that degrees of internal intussusception are present in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10638", "text": "Surgery is thought to be the only option to potentially cure a complete rectal prolapse. [ 7 ]  For people with medical problems that make them unfit for surgery, and those who have minimal symptoms, conservative measures may be beneficial. Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining. [ 7 ]  A bulk forming agent (e.g.  psyllium ) or stool softener can also reduce constipation. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10639", "text": "Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective, [ 7 ]  and there have been over 50 different operations described. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10640", "text": "Surgical approaches in rectal prolapse can be either perineal or abdominal. A perineal approach (or trans-perineal) refers to surgical access to the rectum and sigmoid colon via an incision around the anus and  perineum  (the area between the genitals and the anus). [ 32 ]  Abdominal approach (trans-abdominal approach) involves the surgeon cutting into the  abdomen  and gaining surgical access to the  pelvic cavity . Procedures for rectal prolapse may involve fixation of the bowel (rectopexy), or resection (a portion removed), or both. [ 7 ]  Trans-anal (endo-anal) procedures are also described where access to the internal rectum is gained through the anus itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10641", "text": "Abdominal procedures are associated with lower risk of postoperative recurrence of the prolapse, compared with perineal procedures (6.1% vs 16.3% in patients who are younger than 65 years of age at the time of surgery). [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10642", "text": "The abdominal approach carries a small risk of impotence in males (e.g. 1-2% in abdominal rectopexy). [ 10 ]  Abdominal operations may be open or  laparoscopic  (keyhole surgery). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10643", "text": "Laparoscopic procedures \nRecovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery. [ 32 ]  Instead of opening the pelvic cavity with a wide incision (laparotomy), a laparoscope (a thin, lighted tube) and surgical instruments are inserted into the pelvic cavity via small incisions. [ 32 ]  Rectopexy and anterior resection have been performed laparoscopically with good results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10644", "text": "The perineal approach generally results in less post-operative pain and complications, and a reduced length of hospital stay. These procedures generally carry a higher recurrence rate and poorer functional outcome. [ 5 ]  The perineal procedures include perineal rectosigmoidectomy and Delorme repair. [ 3 ]  Elderly, or other medically high-risk patients are usually treated by perineal procedures, [ 3 ]   as they can be performed under a  regional anesthetic , or even  local anesthetic  with  intravenous sedation , thus avoid the risks of a  general anesthetic . [ 10 ]  Alternatively, perineal procedures may be selected to reduce risk of nerve damage, for example in young male patients for whom sexual dysfunction may be a major concern. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10645", "text": "Perineal rectosigmoidectomy"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10646", "text": "The goal of Perineal rectosigmoidectomy is to resect or remove the redundant bowel. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse. [ 7 ]  The full thickness of the rectal wall is incised at a level just above the dentate line. Redundant rectal and sigmoid wall is removed and the new edge of colon is reconnected (anastomosed) with the anal canal with stitches or staples. [ 10 ]  This procedure may be combined with levatorplasty, to tighten the pelvic muscles. [ 7 ]  A combined a perineal proctosigmoidectomy with anterior levatorplasty is also called an Altemeier procedure. [ 3 ]  Levatorplasty is performed to correct levator diastasis which is commonly associated with rectal prolapse. [ 3 ]  Perineal rectosigmoidectomy was first introduced by Mikulicz in 1899, and it remained the preferred treatment in Europe for many years. [ 3 ]  It was Popularized by Altemeier. [ 10 ]  The procedure is simple, safe and effective. [ 3 ]  Continence levatorplasty may enhance restoration of continence (2/3 of patients). [ 3 ]  Complications occur in less than 10% of cases, and include pelvic bleeding, pelvic abscess and anastomotic dehiscence (splitting apart of the stitches inside), bleeding or leak at a dehiscence [ 3 ]  Mortality is low. [ 10 ]  Recurrence rates are higher than for abdominal repair, [ 3 ]  16-30%, but more recent studies give lower recurrence rates. [ 3 ]  Additional levatorplasty can reduce recurrence rates to 7%. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10647", "text": "Delorme Procedure"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10648", "text": "This is a modification of the perineal rectosigmoidectomy, differing in that only the mucosa and submucosa are excised from the prolapsed segment, rather than full thickness resection. [ 10 ]  The prolapse is exposed if it is not already present, and the mucosal and submucosal layers are stripped from the redundant length of bowel. The muscle layer that is left is plicated (folded) and placed as a buttress above the pelvic floor. [ 7 ]  The edges of the mucosal are then stitched back together. \"Mucosal proctectomy\" was first discussed by Delorme in 1900, [ 10 ]  now it is becoming more popular again as it has low morbidity and avoids an abdominal incision, while effectively repairing the prolapse. [ 3 ]  The procedure is ideally suited to those patients with full-thickness prolapse limited to partial circumference (e.g., anterior wall) or less-extensive prolapse (perineal rectosigmoidectomy may be difficult in this situation). [ 3 ] [ 10 ]  Fecal incontinence is improved following surgery (40%\u201375% of patients). [ 5 ] [ 10 ]  Post operatively, both mean resting and squeeze pressures were increased. [ 5 ]  Constipation is improved in 50% of cases, [ 5 ]  but often urgency and tenesmus are created. Complications, including infection, urinary retention, bleeding,  anastomotic  dehiscence (opening of the stitched edges inside),  rectal stricture  (narrowing of the gut lumen), diarrhea, and fecal impaction occur in 6-32% of cases. [ 5 ] [ 10 ]  Mortality occurs in 0\u20132.5% cases. [ 10 ]  There is a higher recurrence rate than abdominal approaches (7-26% cases). [ 5 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10649", "text": "Anal encirclement (Thirsch procedure)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10650", "text": "This procedure can be carried out under  local anaesthetic . After reduction of the prolapse, a subcutaneous suture (a stitch under the skin) or other material is placed encircling the anus, which is then made taut to prevent further prolapse. [ 7 ]  Placing silver wire around the anus first described by Thiersch in 1891. [ 10 ]  Materials used include nylon, silk, silastic rods, silicone, Marlex mesh, Mersilene mesh, fascia, tendon, and Dacron. [ 10 ]  This operation does not correct the prolapse itself, it merely supplements the anal sphincter, narrowing the anal canal with the aim of preventing the prolapse from becoming external, meaning it remains in the rectum. [ 10 ]  This goal is achieved in 54-100% cases. Complications include breakage of the encirclement material, fecal impaction, sepsis, and erosion into the skin or anal canal. Recurrence rates are higher than the other perineal procedures. This procedure is most often used for people who have a severe condition or who have a high risk of adverse effects from general anesthetic, [ 7 ]  and who may not tolerate other perineal procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10651", "text": "Internal rectal intussusception  (rectal intussusception, internal intussusception, internal rectal prolapse, occult rectal prolapse, internal rectal  procidentia  and rectal invagination) is a medical condition defined as a funnel shaped infolding of the  rectal  wall that can occur during  defecation . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10652", "text": "This phenomenon was first described in the late 1960s when  defecography  was first developed and became widespread. [ 5 ]  Degrees of internal intussusception have been demonstrated in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10653", "text": "Internal intussusception may be  asymptomatic , but common symptoms include: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10654", "text": "Recto-rectal  intussusceptions may be  asymptomatic , apart from mild obstructed defecation. \"interrupted defaecation\" in the morning is thought by some to be characteristic. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10655", "text": "Recto-anal  intussusceptions commonly give more severe symptoms of straining, incomplete evacuation, need for digital evacuation of stool, need for support of the  perineum  during defecation, urgency, frequency or intermittent  fecal incontinence . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10656", "text": "It has been observed that intussusceptions of thickness \u22653\u00a0mm, and those that appear to cause obstruction to rectal evacuation may give clinical symptoms. [ 36 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10657", "text": "There are two schools of thought regarding the nature of internal intussusception, viz: whether it is a primary phenomenon, or secondary to (a consequence of) another condition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10658", "text": "Some believe that it represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. The folding section of rectum can cause repeated trauma to the mucosa, and can cause  solitary rectal ulcer syndrome . [ 10 ]  However, internal intussusception rarely progress to external rectal prolapse. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10659", "text": "Others argue that the majority of patients appear to have rectal intussusception as a consequence of obstructed defecation rather than a cause, [ 38 ] [ 39 ]  possibly related to excessive straining in patients with obstructed defecation. [ 36 ]  Patients with other causes of obstructed defecation ( outlet obstruction ) like  anismus  also tend to have higher incidence of internal intussusception.  Enteroceles  are coexistent in 11% of patients with internal intussusception. [ 40 ]  Symptoms of internal intussusception overlap with those of  rectocele , indeed the 2 conditions can occur together. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10660", "text": "Patients with  solitary rectal ulcer syndrome  combined with internal intussusception (as 94% of SRUS patients have) were shown to have altered rectal wall biomechanics compared to patients with internal intussusception alone. [ 42 ]  The presumed mechanism of the  obstructed defecation  is by telescoping of the intussusceptum, occluding the rectal lumen during attempted defecation. [ 36 ]  One study analysed resected rectal wall specimens in patients with obstructed defecation associated with rectal intussusception undergoing  stapled trans-anal rectal resection . They reported abnormalities of the  enteric nervous system  and  estrogen receptors . [ 43 ]  One study concluded that intussusception of the  anterior  rectal wall shares the same cause as  rectocele , namely deficient recto-vaginal ligamentous support. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10661", "text": "The following conditions occur more commonly in patients with internal rectal intussusception than in the general population:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10662", "text": "Unlike external rectal prolapse, internal rectal intussusception is not visible externally, but it may still be diagnosed by  digital rectal examination , while the patient strains as if to defecate. [ 11 ]  Imaging such as a  defecating proctogram [ 47 ]  or dynamic MRI defecography can demonstrate the abnormal folding of the rectal wall. Some have advocated the use of anorectal physiology testing ( anorectal manometry ). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10663", "text": "Nonsurgical measures to treat internal intussusception include pelvic floor retraining, [ 48 ]  a  bulking agent  (e.g.  psyllium ),  suppositories  or  enemas  to relieve constipation and straining. [ 21 ]  If there is  incontinence  ( fecal leakage  or more severe FI), or paradoxical contraction of the pelvic floor ( anismus ), then biofeedback retraining is indicated. [ 49 ]  Some researchers advise that internal intussusception be managed conservatively, compared to external rectal prolapse which usually requires surgery. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10664", "text": "As with external rectal prolapse, there are a great many different surgical interventions described. Generally, a section of rectal wall can be  resected  (removed), or the rectum can be fixed (rectopexy) to its original position against the  sacral vertebrae , or a combination of both methods. Surgery for internal rectal prolapse can be via the abdominal approach or the transanal approach. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10665", "text": "It is clear that there is a wide spectrum of symptom severity, meaning that some patients may benefit from surgery and others may not. Many procedures receive conflicting reports of success, leading to a lack of any consensus about the best way to manage this problem. [ 49 ]  Relapse of the intussusception after treatment is a problem. Two of the most commonly employed procedures are discussed below."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10666", "text": "This procedure aims to \"[correct] the descent of the posterior and middle pelvic compartments combined with reinforcement of the rectovaginal septum\". [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10667", "text": "Rectopexy has been shown to improve anal incontinence ( fecal leakage ) in patients with rectal intussusception. [ 52 ]  The operation has been shown to have low recurrence rate (around 5%). [ 53 ]  It also improves obstructed defecation symptoms. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10668", "text": "Complications include constipation, which is reduced if the technique does not use posterior rectal mobilization (freeing the rectum from its attached back surface). [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10669", "text": "The advantage of the laparoscopic approach is decreased healing time and less complications. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10670", "text": "This operation aims to \"remove the anorectal mucosa circumferentially and reinforce the anterior anorectal junction wall with the use of a circular stapler\". [ 45 ] [ 46 ]  In contrast to other methods, STARR does not correct the descent of the rectum, it removes the redundant tissue. [ 51 ]  The technique was developed from a similar stapling procedure for prolapsing  hemorrhoids . Since, specialized circular staplers have been developed for use in external rectal prolapse and internal rectal intussusception. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10671", "text": "Complications, sometimes serious, have been reported following STARR, [ 57 ] [ 58 ] [ 59 ] [ 60 ] [ 61 ]   but the procedure is now considered safe and effective. [ 60 ]  STARR is   contraindicated  in patients with weak sphincters (fecal incontinence and urgency are a possible complication) and with  anismus  (paradoxical contraction of the pelvic floor during attempted defecation). [ 60 ]  The operation has been shown to improve rectal sensitivity and decrease rectal volume, the reason thought to create urgency. [ 51 ]  90% of patients do not report urgency 12 months after the operation. The anal sphincter may also be stretched during the operation. STARR was compared with biofeedback and found to be more effective at reducing symptoms and improving quality of life. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10672", "text": "Rectal mucosal prolapse  (mucosal prolapse, anal mucosal prolapse) is a sub-type of rectal prolapse, and refers to abnormal descent of the  rectal   mucosa  through the  anus . [ 21 ]  It is different to an internal intussusception (occult prolapse) or a complete rectal prolapse (external prolapse, procidentia) because these conditions involve the full thickness of the rectal wall, rather than only the mucosa (lining). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10673", "text": "Mucosal prolapse is a different condition to prolapsing (3rd or 4th degree)  hemorrhoids , [ 13 ]  although they may look similar."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10674", "text": "Rectal mucosal prolapse can be a cause of  obstructed defecation  (outlet obstruction). [ 9 ]  and rectal malodor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10675", "text": "Symptom severity increases with the size of the prolapse, and whether it spontaneously reduces after defecation, requires manual reduction by the patient, or becomes irreducible. The symptoms are identical to advanced hemorrhoidal disease, [ 13 ]  and include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10676", "text": "The condition, along with complete rectal prolapse and  internal rectal intussusception , is thought to be related to chronic straining during  defecation  and  constipation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10677", "text": "Mucosal prolapse occurs when the results from loosening of the submucosal attachments (between the mucosal layer and the  muscularis propria ) of the  distal   rectum . [ 3 ]  The section of prolapsed rectal mucosa can become ulcerated, leading to bleeding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10678", "text": "Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially. [ 10 ]  The folds in mucosal prolapse are usually associated with internal hemorrhoids. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10679", "text": "EUA  (examination under anesthesia) of anorectum and banding of the mucosa with rubber bands."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10680", "text": "Solitary rectal ulcer syndrome  (SRUS, SRU), is a disorder of the  rectum  and  anal canal , caused by straining and increased pressure during  defecation . This increased pressure causes the anterior portion of the rectal lining to be forced into the anal canal (an  internal rectal intussusception ). The lining of the rectum is repeatedly damaged by this friction, resulting in  ulceration . SRUS can therefore be considered to be a consequence of internal intussusception (a sub type of rectal prolapse), which can be demonstrated in 94% of cases. It may be  asymptomatic , but it can cause  rectal pain ,  rectal bleeding ,  rectal malodor , incomplete evacuation and  obstructed defecation  (rectal outlet obstruction)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10681", "text": "Symptoms include: [ 18 ] [ 21 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10682", "text": "The condition is thought to be uncommon. It usually occurs in young adults, but children can be affected too. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10683", "text": "The essential cause of SRUS is thought to be related to too much straining during defecation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10684", "text": "Overactivity of the anal sphincter during defecation causes the patient to require more effort to expel stool. This pressure is produced by the modified valsalva manovoure (attempted forced exhalation against a closed glottis, resulting in increased abdominal and intra-rectal pressure). Patiest with SRUS were shown to have higher intra-rectal pressures when straining than healthy controls. [ 65 ]  SRUS is also associated with prolonged and incomplete evacuation of stool. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10685", "text": "More effort is required because of concomitant  anismus , or non-relaxation/paradoxical contraction of  puborectalis  (which should normally relax during defecation). [ 67 ]  The increased pressure forces the anterior rectal lining against the contracted puborectalis and frequently the lining prolapses into the anal canal during straining and then returns to its normal position afterwards."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10686", "text": "The repeated trapping of the lining can cause the tissue to become swollen and congested. Ulceration is thought to be caused by resulting poor blood supply ( ischemia ), combined with repeated frictional trauma from the prolapsing lining, and exposure to increased pressure are thought to cause ulceration. Trauma from hard stools may also contribute."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10687", "text": "The site of the ulcer is typically on the  anterior  wall of the  rectal ampulla , about 7\u201310\u00a0cm from the anus. However, the area may of ulceration may be closer to the anus, deeper inside, or on the lateral or posterior rectal walls. The name \"solitary\" can be misleading since there may be more than one ulcer present. Furthermore, there is a \"preulcerative phase\" where there is no ulcer at all. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10688", "text": "Pathological specimens of sections of rectal wall taken from SRUS patients show thickening and replacement of muscle with fibrous tissue and excess collagen. [ 69 ]  Rarely, SRUS can present as polyps in the rectum. [ 70 ] [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10689", "text": "SRUS is therefore associated and with internal, and more rarely, external rectal prolapse. [ 66 ]  Some believe that SRUS represents a spectrum of different diseases with different causes. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10690", "text": "Another condition associated with internal intussusception is  colitis cystica profunda  (also known as CCP, or proctitis cystica profunda), which is  cystica profunda  in the rectum. Cystica profunda is characterized by formation of  mucin   cysts  in the muscle layers of the gut lining, and it can occur anywhere along the gastrointestinal tract. When it occurs in the rectum, some believe to be an interchangeable diagnosis with SRUS since the  histologic  features of the conditions overlap. [ 73 ] [ 74 ]  Indeed, CCP is managed identically to SRUS. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10691", "text": "Electromyography may show  pudendal nerve  motor latency. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10692", "text": "Complications are uncommon, but include massive rectal bleeding, ulceration into the prostate gland or formation of a  stricture . [ 76 ] [ 77 ] [ 78 ]  Very rarely, cancer can arise on the section of prolapsed rectal lining. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10693", "text": "SRUS is commonly misdiagnosed, and the diagnosis is not made for 5\u20137 years. [ 64 ]  Clinicians may not be familiar with the condition, and treat for Inflammatory bowel disease, or simple constipation. [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10694", "text": "The thickened lining or ulceration can also be mistaken for types of cancer. [ 81 ] [ 82 ] [ 83 ] [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10695", "text": "The differential diagnosis of SRUS (and CCP) includes: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10696", "text": "Defecography ,  sigmoidoscopy ,  transrectal  ultrasound , mucosal  biopsy , anorectal  manometry  and  electromyography  have all been used to diagnose and study SRUS. [ 18 ] [ 67 ]  Some recommend biopsy as essential for diagnosis since ulcerations may not always be present, and others state  defecography  as the investigation of choice to diagnose SRUS. [ 63 ] [ 74 ] [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10697", "text": "Although SRUS is not a medically serious disease, it can be the cause of significantly reduced  quality of life  for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10698", "text": "Stopping straining during bowel movements, by use of  correct posture ,  dietary fiber  intake (possibly included bulk forming  laxatives  such as  psyllium ), stool softeners (e.g.  polyethylene glycol , [ 85 ] [ 86 ]  and  biofeedback  retraining to coordinate pelvic floor during defecation. [ 87 ] [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10699", "text": "Surgery may be considered, but only if non surgical treatment has failed and the symptoms are severe enough to warrant the intervention. Improvement with surgery is about 55-60%. [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10700", "text": "Ulceration may persist even when symptoms resolve. [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10701", "text": "A group of conditions known as  Mucosal prolapse syndrome  (MPS) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. [ 17 ] [ 18 ]  It is classified as a chronic benign inflammatory disorder. The unifying feature is varying degrees of rectal prolapse, whether internal intussusception (occult prolapse) or external prolapse."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10702", "text": "Rectal prolapse affects less than 0.5% of the general population. [ 91 ]  It affects women more commonly, with a female to male ratio of 9:1. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10703", "text": "Rosebud pornography and prolapse pornography (or rosebudding or rectal prolapse pornography) is an anal sex practice that occurs in some extreme anal pornography wherein a pornographic actor or actress performs a rectal prolapse wherein the walls of the rectum slip out of the anus. Rectal prolapse is a serious medical condition that requires the attention of a medical professional. However, in rosebud pornography, it is performed deliberately. Michelle Lhooq, writing for VICE, argues that rosebudding is an example of producers making 'extreme' content due to the easy availability of free pornography on the internet. She also argues that rosebudding is a way for pornographic actors and actresses to distinguish themselves. [ 92 ]  Repeated rectal prolapses can cause bowel problems and anal leakage and therefore risk the health of pornographic actors or actresses who participate in them. [ 92 ]  Lhooq also argues that some who participate in this form of pornography are unaware of the consequences. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10704", "text": "Prolapse refers to \"the falling down or slipping of a body part from its usual position or relations\". It is derived from the Latin  pro-  - \"forward\" +  labi  - \"to slide\".  \"Prolapse\" .  Merriam-Webster.com Dictionary . Merriam-Webster.   Prolapse  can refer to many different medical conditions other than rectal prolapse."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10705", "text": "procidentia has a similar meaning to prolapse, referring to \"a sinking or prolapse of an organ or part\". It is derived from the Latin  procidere  - \"to fall forward\". [ 93 ]   Procidentia  usually refers to  uterine prolapse , but rectal procidentia can also be a synonym for rectal prolapse."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10706", "text": "Intussusception is defined as  invagination  (infolding), especially referring to \"the slipping of a length of intestine into an adjacent portion\". It is derived from the Latin  intus  - \"within\" and  susceptio  - \"action of undertaking\", from  suscipere  - \"to take up\".  \"Intussusception\" .  Merriam-Webster.com Dictionary . Merriam-Webster.  Rectal intussusception is not to be confused with other  intussusceptions  involving  colon  or  small intestine , which can sometimes be a medical emergency. Rectal intussusception by contrast is not life-threatening."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10707", "text": "Intussusceptum refers to the  proximal  section of rectal wall, which telescopes into the  lumen  of the  distal  section of  rectum  (termed the intussuscipiens). [ 10 ]  What results is 3 layers of rectal wall overlaid. From the lumen outwards, the first layer is the proximal wall of the intussusceptum, the middle is the wall of the intussusceptum folded back on itself, and the outer is the distal rectal wall, the intussuscipiens. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10708", "text": "A  rectal stricture  ( rectal stenosis ) [ 1 ]  is a chronic and abnormal narrowing or constriction of the  lumen  of the  rectum  which presents a partial or complete obstruction to the movement of bowel contents. A rectal stricture is located deeper inside the body compared to an  anal stricture . Sometimes other terms with wider meaning are used, such as  anorectal stricture ,  colorectal stricture  or  rectosigmoid stricture ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10709", "text": "Rectal stricture has been defined as the inability to pass a rigid  proctoscope  (12\u00a0mm diameter) or a rigid  sigmoidoscope  (19\u00a0mm diameter) through the affected cross-section of rectum. [ 1 ]  If the rectal stricture is accessible during digital rectal examination, a rectal stricture may be defined as narrowing to less than one-finger breadth. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10710", "text": "Anal strictures are usually located at the anal verge in a narrow band, but sometimes they involve the entire length of the anal canal. [ 1 ]  Surgeons and anatomists have different definitions of the anal canal. [ 3 ]  Surgically and clinically, the anal canal is usually defined as the zone from the anal verge to the anorectal ring (at the level of the external anal sphincter and the  puborectalis muscle ). The anorectal ring is easy to identify when patients are asked to squeeze during  digital rectal examination . [ 3 ]  Anatomically, the anal canal is defined as the zone from the anal verge to the dentate line ( pectinate line ). [ 3 ]  This is a line formed by the lower ends of the anal columns and represents the embryological junction between the  hindgut  and the  proctodeum . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10711", "text": "Both rectal stricture and  anal stricture  (anal stenosis) are types of colonic stricture. They both can also be more widely categorized as gastrointestinal strictures. However, rectal strictures behave differently to colonic strictures because of the proximity of the rectum to the anal canal and pelvic organs, and because of different blood supply. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10712", "text": "There may be no symptoms (clinically silent stricture), [ 4 ]  or only minor symptoms, but may get worse over time. [ 2 ]  On the other hand, acute  bowel obstruction  may develop as the first major sign of a stricture. This may be the case with malignant strictures, and the condition may be a medical emergency which requires urgent treatment in order to avoid serious complications such as  bowel perforation . [ 5 ]  When symptoms are caused, the term \"clinically relevant rectal stricture\" is used. [ 1 ]  Possible symptoms include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10713", "text": "The first step is exclusion of malignant causes. This may involve tissue  biopsy ,  endorectal ultrasound ,  computed tomography , and  magnetic resonance imaging . [ 1 ]  The next step is assessment of the stricture. The distance from the anal verge, the diameter of the narrowest point of the stricture, and the longitudinal length are ascertained. The degree of narrowing can be assessed with a water-soluble  contrast enema . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10714", "text": "Rectal strictures are usually classified as benign or malignant (associated with cancer)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10715", "text": "Benign rectal strictures can be further subcategorized as primary (caused by diseases) and secondary (caused by complication of surgery). Secondary strictures very often occur at the site of a previous surgical anastomosis. Primary strictures have various causes, including different inflammatory disease processes. Causes of benign strictures include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10716", "text": "Acute bowel obstruction is a common presenting manifestation of colorectal cancer which is locally advanced. [ 5 ]  Malignant strictures may also develop in the context of inflammatory bowel disease. Treatment for malignant strictures is ideally resection (surgical removal) with or without radiotherapy. If resection is not possible or not sensible, symptoms of the stricture may be palliated with radiotherapy, stents, or debulking. [ 1 ]  Possible malignant processes which may cause rectal stricture include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10717", "text": "The narrowing may be because of an intrinsic process occurring within the lumen of the rectum (luminal), within the wall of the rectum (mural), or it can be due to an extrinsic process that is compressing the rectum from the outside (extramural). [ 1 ] [ 8 ]  In the case of external compression of the bowel, the term pseudostricture may be used. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10718", "text": "According to one review of a total of 730 cases, those which formed after anastomosis represented 74% of all reported benign rectal strictures. [ 2 ]  The next most common cause of benign rectal stricture was inflammatory bowel disease, accounting for 20% of all cases. [ 2 ]  This means all other causes of rectal stricture are, by comparison, rare."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10719", "text": "Rectal stricture is reported to develop after colorectal resection at a rate of 3-30%. Such strictures mostly form after resection due to rectal cancer with colorectal or coloanal anastomosis. Stricture is also possible as a complication following resection because of diverticular disease. According to some reports, rectal strictures are more likely following stapled anastomosis compared to hand sutured anastomosis. [ 2 ]  However, a Cochrane review found no significant difference in the rate of rectal stricture between hand sewn and stapled  ileocolic anastomosis  (usually performed after right\u2010sided  colon cancer  and  Crohn's disease ). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10720", "text": "Inflammatory bowel diseases (IBD) include Crohn\u2019s disease, which affects only the colon, and ulcerative colitis, which may affect any section of the gastrointestinal tract. The relapsing-remitting, chronic inflammation in the bowel wall non uncommonly leads to the development of colonic strictures, including rectal strictures. [ 6 ]  Rectal strictures are more common in Crohn's disease than in ulcerative colitis. [ 2 ]  There is a risk of malignancy developing at the site of stricture. Therefore, tissue biopsy of strictures is carried out in order to check for dysplasia or malignancy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10721", "text": "Stricture may occur following trauma such as caustic burns caused by chemical agents. [ 11 ] [ 12 ]  If they cause inflammation, chronic use of  suppositories  may cause rectal stricture, [ 2 ]  but overall this is a safe method of drug delivery. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10722", "text": "Thermal burns are possible if hot water enemas are attempted by patients or practitioners of alternative medicine in the belief that they will provide a stronger stimulus for evacuation of stool. [ 11 ]  The rectal mucosa is vulnerable to thermal burns in such cases because it is sensitive only to distension (stretching) and not to thermal stimuli. [ 11 ]  Usually a burn of the rectal wall heals after 2\u20133 weeks without permanent stricture. Such burns may be treated with bowel resting, antibiotics, stool softeners, liquid diet and steroid suppository to reduce inflammation. [ 11 ]  Sometimes thermal burns progress to chronic stricture. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10723", "text": "The rectum is very close to the prostate in males and the uterus and cervix in females, and therefore it frequently receives radiation during radiotherapy for cancers in the pelvic region.  Radiation proctitis  (chronic radiation enterocolitis) usually appears after several months of treatment, and is characterized by rectal bleeding or obstructed defecation secondary to the formation of strictures. [ 7 ]  Such rectal strictures are usually located in the proximal rectum, and are one of the most common features of late radiation damage. [ 14 ]  The mechanism of stricture formation is  obliterative endarteritis , lymphatic dilation, and tissue ischemia and necrosis. [ 7 ]  Then there is collagen deposition and fibrosis in the submucosal layer. [ 7 ]  They are often associated with a fistula. [ 14 ]  Post-irradiation strictures may cause symptoms such as diarrhea, tenesmus, narrow feces, abdominal pain, and vomiting. [ 7 ]  The risk of intestinal obstruction due to strictures in patients receiving radiotherapy in the pelvis is reported as 1\u201315%. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10724", "text": "Sexually transmitted infections  may sometimes cause rectal strictures in persons who engage in anoreceptive sex. [ 2 ]   Lymphogranuloma venereum  usually affects the genital mucosa. However, it may rarely present as the anorectal variant, termed \"lymphogranuloma venereum proctitis\". Lymph nodes are enlarged and suppurative (produce pus). The condition is similar to Crohn's disease with rectal stricture formation (eventually), bowel perforation and fistulae. [ 15 ]  In one report,  herpes simplex virus 2  was implicated as the cause of a rectal stricture. [ 2 ]  Rarely, rectal stricture may develop in  actinomycosis  infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10725", "text": "If a foreign body becomes stuck there is reactive inflammation and fibrosis, which eventually may lead to the formation of a stricture. [ 2 ]  In  endometriosis , if ectopic endometrial tissue is present in the rectal wall it may cause rectal stricture. [ 2 ]   Solitary rectal ulcer syndrome  may also sometimes be associated with rectal stricture. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10726", "text": "Rectal stricture may sometimes be a complication of surgical procedures other than anastomosis. For example, endoscopic submucosal dissection, which is a minimally invasive treatment for colorectal cancer, may rarely cause development of a rectal stricture. [ 2 ]  Other surgical procedures which may cause the development of a stricture include  ventral rectopexy , [ 8 ]   Delorme\u2019s procedure , [ 16 ]  and  hemorrhoidectomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10727", "text": "How a rectal stricture is treated depends on the exact cause, the distance from the anal verge, the degree of narrowing, the severity of symptoms, and the health of the patient. [ 1 ]  Short strictures are more responsive to dilation. Longer strictures may require more significant surgical procedures. [ 1 ]  Generally, benign rectal strictures may not require treatment if they do not cause symptoms. [ 1 ]  For example, a non symptomatic stricture may be detected as an incidental finding during colonoscopy for an unrelated reason. [ 1 ]  Treatment options fall into 3 main categories: dilatation, stenting, or surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10728", "text": "The treatment depends on the cause. For example, strictures caused by infections may respond well to  antibiotics . [ 2 ]  Use of  stool softeners ,  laxatives  and high fiber diet is a general measure for most strictures, and is also sometimes advised for prevention of recurrence of stricture even after treatment. [ 2 ]  Non surgical treatment may be combined with other procedures such as dilation.  Steroids  may be injected into the stricture. It is unknown exactly how the steroid helps to prevent recurrence of the stricture, but it may involve inhibition of collagen formation and cross-linking, and increase of collagen breakdown. In combination, this reduces contraction of scar tissue. [ 7 ]   TNF inhibitors  such as  infliximab  have also been injected into strictures endoscopically. However, this is not a common treatment. [ 6 ]  Healing of rectal strictures in inflammatory bowel disease with TNF inhibitor occurs in 59% of cases. [ 2 ]   Mitomycin C  has been used as a topical application, in combination with manual dilation. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10729", "text": "For rectal strictures which are mild and close to the anal verge (<6\u00a0cm), digital dilation (with fingers) or dilation with instruments is possible. [ 1 ]  Such instruments include Hagar's dilators, esophageal dilators, St Marks anal dilators, and bougie dilators. [ 16 ] [ 1 ] [ 2 ]  Sometimes the patient can be shown how to perform this dilation at home, but this is may be difficult for them, and rarely gives good long term results. [ 16 ]  Dilation with instruments by the surgeon may be performed under sedation or under general aesthesia for moderate strictures. [ 16 ]  This treatment is often the first to be attempted, and is successful about 50% of the time. [ 2 ]  Hegar dilators come in multiple sizes with different diameters. This enables progressive dilation over time which reduces the risk of bowel perforation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10730", "text": "Balloon dilation is the most common method of mechanical dilation, [ 11 ]  and is also often considered the first line treatment. [ 2 ]  This treatment is simple, but repeat procedures may be needed. [ 11 ]  Balloon dilation may be combined with intralesional steroid injection. [ 7 ]  Injection of steroid seems to increase the effectiveness of balloon dilation, and increases the length of time before relapse. [ 7 ]  The success rate of balloon dilation for benign rectal strictures overall is about 78%. [ 2 ]  In rectal strictures in the context of Crohn's disease, the long-term success rate of balloon dilation is about 80%. However, it may be ineffective for very tight, fibrotic strictures. [ 17 ]  Fluoroscopic guidance can be used during the procedure to improve visualization. [ 2 ]  The risk of bowel perforation is about 1%. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10731", "text": "Surgical procedures are indicated if multiple other treatments have failed, or if the stricture involves a long section of bowel. [ 11 ]  Surgical procedures may be carried out by the transanal approach or via the transabdominal approach. [ 11 ]  Debulking of malignant strictures may be carried out with laser ablation or with argon beam plasma coagulation. [ 1 ]  Various procedures and methods have been used to surgically treat strictures, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10732", "text": "Self-expandable metallic stents  (SEMS) are sometimes used, but they are usually considered not suitable for very low rectal strictures. [ 14 ]  However, this view is now challenged. [ 18 ]  Stents may be used as the definitive treatment of a stricture, or as a temporary measure to stabilize a patient with acute obstruction before another procedure is carried out. [ 11 ]  Stents are not commonly used for benign rectal strictures. [ 11 ]  Sometimes they are used when strictures are associated with malignancy. In such cases, use of a stent may avoid or delay the need for  colostomy . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10733", "text": "A  rectovestibular fistula , also referred to simply as a  vestibular fistula , is an anorectal  congenital disorder  where an abnormal connection ( fistula ) exists between the  rectum  and the  vulval vestibule  of the female genitalia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10734", "text": "If the fistula occurs within the  hymen , it is known as a  rectovaginal fistula , a much rarer condition. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10735", "text": "If a colostomy is not performed immediately after birth, patients with rectovestibular fistulae may present later in life with complications including severe  constipation  and  megacolon  (abnormal dilation of the colon), requiring colostomy or further surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10736", "text": "A rectovestibular fistula occurs when the  colon  or  rectum  deviates anteriorly. [ 1 ]  This leads to the formation of an abnormal connection between the rectum and the  vulval vestibule , immediately posterior to the  hymen , so that an  ectopic anus  opens into the  fourchette , or frenulum, of the  labia minora . [ 3 ]  A common wall is shared between the rectum and  vagina  above the site of the fistula. [ 2 ]  Although the opening of the rectum into the  anal canal  is shorter and narrower than normal, the rectum itself is completely normal. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10737", "text": "The diagnosis of a rectovestibular fistula can be made in female newborns if the vulva is stained with  meconium  (the earliest form of  stool  in an infant). [ 3 ]  The opening of the  anus  may be difficult to see due to its small size and position, but it may be visible as a thickening of the median  perineal raphe  with an obvious anal dimple. [ 3 ] [ 2 ]  Patients with rectovestibular fistulae are commonly misdiagnosed with rectovaginal fistulae. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10738", "text": "Colostomy  is recommended by most surgeons, and has a good prognosis, with 90% of patients regaining normal bowel control. [ 4 ]  Since the rectal opening and  anal orifice  in a vestibular fistula tend to be short and narrow, a colostomy is usually performed to allow decompression of the bowel unless the orifice is wide enough to allow normal defecation. [ 2 ]  Colostomy is often followed by  posterior sagittal anorectoplasty  (PSARP), a surgical procedure to repair the anal orifice, at a later date. [ 4 ] [ 5 ]  Some surgeons prefer to perform an immediate PSARP without a colostomy first, while others perform neither a colostomy nor a PSARP and instead opt for a simple dilatation of the orifice to allow stool to pass and the bowel to decompress. [ 5 ]  It has been suggested that only experienced surgeons should perform repair without an initial colostomy. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10739", "text": "Rectovestibular fistula is the most common defect of the rectum and anal canal in females. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10740", "text": "Sigmoidocele  (also known as  pouch of Douglas  descent) is a medical condition in which a  herniation  of  peritoneum  containing loops of redundant  sigmoid colon  descends (prolapses) into the  rectouterine pouch  (in females), between the  rectum  and the  vagina . [ 1 ] [ 2 ]  This can obstruct the rectum and cause  obstructed defecation syndrome . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10741", "text": "Sigmoidocele may be internal if it is only detectable on  defecography , or external if it detectable without imaging and associated with a  rectocele  or  rectal prolapse . [ 2 ]  It is a type of posterior compartment prolapse. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10742", "text": "Sigmoidocele may be classified according to size relative to the pubococcygeal line. [ 2 ] [ note 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10743", "text": "The severity of sigmoidocele can be described with reference to the position of the lowest loop of the sigmoid relative to lines drawn on defecography:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10744", "text": "Sigmoidocele may not cause any symptoms. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10745", "text": "The phenomenon is caused by a weak section of   fascial supports  of the vagina (the uterosacral cardinal ligament complex and rectal vaginal septum), which allows a section of peritoneum containing the sigmoid colon to prolapse out of normal position and descend between the rectum and the vagina. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10746", "text": "The  mesentery  of the sigmoid colon (the structure which attaches the colon to the abdominal wall) is termed the mesosigmoid. This structure is very flexible, which means that the sigmoid colon is very mobile and may change position. During defecation it may be pushed down, eventually causing sigmoidocele. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10747", "text": "Sigmoidocele may be associated with  descending perineum syndrome . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10748", "text": "It is not possible to differentiate between a  rectocele  and a sigmoidocele on  vaginal examination .   Defecating proctography  will demonstrate a sigmoidocele during straining. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10749", "text": "Surgery is considered if there is a significant hernia combined with symptoms of obstructed defecation. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10750", "text": "Laparoscopic  ventral mesh rectopexy  has been used to correct sigmoidocele. [ 7 ]  This procedure involves inserting a mesh between the rectum and the vagina. The mesh is suspended from the sacral promontory without tension. This acts to support the recto-vaginal septum and elevate a deep pouch of Douglas. [ 7 ]  If there is prolapse of the middle compartment,  sacrocolpopexy  may be carried out to surgically correct all pelvic prolapse problems in the same procedure. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10751", "text": "Other treatment options are  anterior resection , [ 4 ]   sigmoidopexy  with rectocele repair, [ 4 ]  or  sigmoidectomy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10752", "text": "Sigmoidocele normally occurs in females, and is uncommon. [ 1 ]  Sigmoidocele is detected about 4-5% of the time when defecography is carried out. [ 3 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10753", "text": "Solitary rectal ulcer syndrome  ( SRUS  or  SRU ) is a chronic disorder of the rectal  mucosa  (the lining of the rectum). [ 1 ]  Very often but not always it occurs in association with varying degrees of  rectal prolapse . The condition is thought to be caused by different factors, such as long term  constipation , straining during defecation, and  dyssynergic defecation  (anismus). Treatment is by normalization of bowel habits,  biofeedback , and other conservative measures. In more severe cases, various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30\u201350. Females are affected slightly more often than males. The disorder can be confused clinically with  rectal cancer  or other conditions such as  inflammatory bowel disease , even when a  biopsy  is done. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10754", "text": "The signs and symptoms are variable, and in up to 25% of patients there may be no symptoms. [ 3 ]  The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases). [ 4 ]  According to one report, constipation is present in about 55% of cases, but diarrhea is present in 20%\u201340% of cases. [ 1 ]  Reported symptoms are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10755", "text": "The exact cause is unclear and the condition is not fully understood. [ 3 ]  There are thought to be multiple factors which simultaneously cause the condition. [ 3 ]  Long term injury to the rectal mucosa and ischemic trauma are thought to be the main mechanisms. [ 5 ]  In a report of 36 patients with SRUS, the underlying cause was internal prolapse (intussusception) in 20 patients, external rectal prolapse in 14 patients, and dyssynergic defecation (anismus) in 2 patients. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10756", "text": "Self-digitation is when individuals with constipation resort to inserting a finger into the rectum in order to \"hook out\" fecal pellets or to apply pressure to an obstructing lesion (see:  obstructed defecation ). The rectal mucosa is fragile and vulnerable to trauma when such manoeuvres are performed chronically. It is thought that this self-induced trauma is one possible mechanism of SRUS. [ 1 ]  However, since sometimes the location of SRUS lesion(s) is much further than a finger could reach means that this cannot be the only cause. [ 5 ]  In constipation, the stools may be very hard and this is another possible mechanism of trauma. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10757", "text": "People with constipation or certain anatomical anomalies are more likely to end up using excessive straining during defecation attempts. [ 5 ]  Prolonged straining may cause direct trauma to the rectal mucosa. [ 5 ]  Most patients with SRUS have  dyssynergic defecation  (previously termed anismus). [ 8 ]  This is a failure of relaxation (or paradoxical contraction) of the  puborectalis muscle  during defecation attempts. This pelvic floor muscle is normally supposed to relax, thereby straightening the anorectal angle and allowing rectal contents to be evacuated. Dyssynergic defecation causes high pressure in the rectum and in the anal canal, [ 1 ]  which causes lengthening [ 1 ]  and compression of the rectal tissues, which in turn leads to ischema of the mucosa. [ 8 ]  There is also a shearing movement of the rectum against the pelvic floor muscles. [ 8 ]  In the long term this leads to repeated mucosal damage. [ 8 ]  Inappropriate contraction of puborectalis in the squatting position causes traumatic compression of the rectal wall against the anal canal. [ 5 ]  Also, it is reported that individuals with SRUS have not only increased pressure when squeezing, but also higher resting pressure compared to normal controls. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10758", "text": "SRUS is usually accompanied by prolapse (e.g. external prolapse or rectoanal intussusception/internal prolapse) or other pelvic-floor disorders. [ 1 ] [ 7 ]  This is association is common, but not always present. [ 9 ]  Some state that if SRUS is not treated, it would always tend to progress to rectal prolapse. [ 5 ]  The relationship of SRUS with  rectal prolapse  and rectal cystitis profunda is debated. [ 8 ]  Some see SRUS and prolapse as synonymous, while others see them as separate entities, [ 8 ]  and state that they do not share the same physiology. [ 6 ]  For example, the mucosal changes that occur with external rectal prolapse can be separated from the mucosal changes seen in SRUS. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10759", "text": "The excessive pressure caused by straining (i.e. dyssynergic defecation and constipation) may in the long term lead to development of the spectrum of rectal prolapse conditions (mucosal versus full-thickness prolapse, internal versus external rectal prolapse). [ 5 ]  These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa, [ 1 ]  which predisposes it to ulceration, [ 8 ]  and pressure necrosis. [ 4 ]  Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region. [ 5 ]  This is the first stage of ulcer development. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10760", "text": "Psychological factors are also thought to be involved, since patients with SRUS sometimes have psychological disorders such as  obsessive-compulsive disorder . [ 1 ]  Also, some unknown factors may also be involved, such as hormonal factors related to pregnancy. [ 5 ]  Other possible factors are rectal hypersensitivity, [ 4 ]  and impaired rectal evacuation of stool. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10761", "text": "Diagnosis is difficult because of rarity of the condition and because of the variability of the symptoms and the histologic appearance. [ 1 ] [ 5 ]  The condition is sometimes misdiagnosed. [ 1 ]  Clinicians may not be familiar with the condition, and treat for  inflammatory bowel disease , or simple constipation. [ 10 ] [ 11 ]  Diagnosis may be delayed by many years as a result. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10762", "text": "The  differential diagnosis  is as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10763", "text": "Investigations used in the diagnosis of SRUS include  defecography ,  endoanal ultrasound ,  colonoscopy  and histological examination of a  biopsy . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10764", "text": "The macroscopic appearance of SRUS is very variable. [ 8 ]  Indeed, the condition has been referred to as \u201cthe three-lies disease\u201d, [ 4 ]  because the name of the condition is sometimes misleading. In reality, there may be more than one lesion, which may not be  ulcerative , [ 12 ]  and the condition may appear in different parts of the gastrointestinal tract (i.e. other than the  rectum ). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10765", "text": "Classically, there is a solitary ulcer. But only 20% of patients have a single ulcer whereas in other cases there may be multiple lesions. [ 6 ]  The size of the ulcers is usually 0.5\u20134\u00a0cm. [ 5 ]  The lesion is most often located on the anterior (front) or lateral (side) rectal wall, centered on a rectal fold, [ 1 ]  usually 10\u00a0cm from the anal verge. [ 8 ]  Less commonly there may be ulcers in the  anal canal  or even in the  sigmoid colon . [ 5 ]  The nature of the tissue changes can vary from simple  erythema  (redness) /  hyperaemia  (increased blood flow) of the mucosa in 18% of cases, [ 1 ]  to a chronic-appearing, small, shallow ulcer with nodular margins and a white or sloughing base. [ 8 ] [ 1 ]  In up to 33% of cases there is no ulceration but instead one or more well-developed polyps or mass lesions. [ 8 ] [ 5 ]  There is usually mild  proctitis  (inflammation of the rectal mucosa) surrounding the ulcer. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10766", "text": "Conventional defecography or magnetic resonance defecography may be used. [ 1 ]  Between 50-100% of patients with SRUS will have abnormal defecography results. [ 5 ]  Defecography findings in SRUS may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10767", "text": "Endoanal ultrasound  can determine the depth of the ulcer and the structure of the external and internal anal sphincters. [ 8 ]  Endoanal ultrasound findings in SRUS include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10768", "text": "As a diagnostic investigation, anorectal manometry can evaluate defecation function. It can highlight excessive and prolonged straining effort during defecation attempts, and also record any improvement in function before and after treatment interventions. [ 13 ]  It is uncommonly used to diagnose SRUS, although biofeedback is still commonly used as a treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10769", "text": "The histological appearance is as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10770", "text": "If the biopsy includes polypoid lesions, there are villiform structures visible. [ 5 ]  Gland entrapment in the submucosa is sometimes seen, which is termed  colitis cystica profunda . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10771", "text": "Treatment of SRUS is difficult and there is a lack of evidence-based guidelines. [ 4 ]  The treatment is based on the pathophysiology of SRUS, [ 5 ]  and the main aim is restoration of a normal pattern of defecation. [ 1 ]  The exact treatment depends on the severity of the symptoms, the severity/type of SRUS, and whether rectal prolapse is present or absent. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10772", "text": "Conservative measures are the first line treatment for patients with no symptoms or only mild to moderate symptoms, and those who have no significant anatomical defect. [ 1 ]  Conservative measures by themselves may improve symptoms and prevent the condition getting worse. [ 1 ]  Where conservative measures fail, or with severe disease and symptoms, or with significant anatomical defects, surgical options may be indicated. [ 5 ] [ 1 ]  Improvement in symptoms does not always equate to healing of the ulcer as seen on endoscopy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10773", "text": "Conservative management is focused on education of the patient and behavioral modification. Where indicated, conservative management may also involve treatment of psychological problems, [ 5 ]  and avoidance of anoreceptive sex (to prevent trauma to the rectum). [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10774", "text": "Biofeedback targets pelvic floor behaviors and enables a reprogramming of autonomic neurologic pathways associated with defecation. [ 8 ]  The treatment is particularly helpful for dyssynergic defecation (anismus). Research studies have shown that there is improved blood flow to the rectal mucosa after biofeedback therapy. [ 1 ]  The overall rate of complete resolution of both symptoms and ulceration varies at 50-75%. [ 8 ]  Stool frequency and straining effort decrease after this treatment. [ 1 ]  In about 56% of cases, biofeedback treatment stops rectal bleeding. [ 1 ]  Some patients are able to cease relying on digitation. [ 1 ]  Biofeedback is more effective in children with SRUS compared to adults. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10775", "text": "A randomized controlled study compared topical agents (dexamethasone, sucralfate and bismuth) with biofeedback. Overall, biofeedback gave 80% improvements in evacuation difficulty, need for digitation, sensation of incomplete evacuation, evacuation time, and appearance of mucosa on colonoscopy compared to the topical agents (50% improvement). [ 13 ]  However, the degree of long term improvement is not known. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10776", "text": "Several different topical treatments have been reported, with variable outcomes. [ 1 ]  These are substances applied directly to the ulcer, usually administered by enema. [ 8 ]  They may be helpful for short term management of acute symptoms in SRUS. [ 8 ]  They are thought to work by reducing inflammation and physically forming a barrier over the surface of the ulcer to protect it from irritants, thereby allowing it to heal. [ 4 ] [ 5 ]  However, the long term efficacy is unknown. According to a systematic review, 57% of SRUS patients who received medical treatment had resolution of ulceration. [ 4 ]  Topical agents which have been used for SRUS include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10777", "text": "According to one report, topical agents had an efficacy between 28 and 90%. Sucralfate had a 45-81% resolution rate compared to sulfasalazine (30-64%) and combination of other topical agents (20-79%). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10778", "text": "Surgery may be indicated for severe cases of SRUS (either severe symptoms, severe ulceration, or significant associated anatomical defect such as prolapse), or when conservative measures fail. [ 8 ] [ 5 ]  Some authors state that most patients do not benefit from surgery. [ 5 ]  Overall, up to 33% of SRUS patients end up requiring surgery. [ 8 ]  A systematic review reported that SRUS improved in 77% of patients who underwent any type of surgery. [ 6 ]  However, recurrence of the condition later developed in 52% of cases. [ 6 ]  It has been suggested that any treatment which only addresses the ulcer without correcting the underlying causes will typically lead to recurrence. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10779", "text": "There are multiple different surgical procedures which have been reported for SRUS, [ 5 ]  including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10780", "text": "Various local treatments for SRUS have been reported. According to one report, such measures have generally unfavorable results, and sometimes the ulcer returns deeper and larger than before the treatment. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10781", "text": "Excision (removal) of the ulcer and suturing the resulting defect with surrounding healthy mucosa has been reported. However, there may not be any long-term benefit. [ 8 ]  Ulcers in the upper part of the rectum may be accessible to local excision using a transanal minimally invasive approach (TAMIS). [ 8 ]  Excision with  neodymium yttrium-aluminium garnet laser  has also been reported. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10782", "text": "Rectopexy is a surgery for rectal prolapse. [ 3 ]  A newer version of the procedure is termed ventral mesh rectopexy, which has also been used for SRUS. [ 14 ]  It may be performed with or without anterior resection (removal of a portion of the front wall of the rectum). [ 9 ]  A mesh may be used to reinforce the anterior rectal wall. [ 8 ]  It can be done as an open procedure or with a laparoscopic abdominal approach. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10783", "text": "Some authors state rectopexy is suitable in highly select cases, [ 9 ]  while others say it is the procedure of choice, [ 7 ]  since it directly addresses the most likely cause. [ 8 ]  There is not much evidence for the use of laparoscopic ventral rectopexy to treat SRUS, [ 13 ]  but there is more evidence to support the its use compared to other surgical procedures. [ 8 ]  Approximately 55-83% of patients with SRUS get reduced symptoms after rectopexy, [ 8 ]  and these benefits appear to be long term. [ 3 ]  In one study, 11 people with SRUS underwent laparoscopic ventral rectopexy. All of the patients showed resolved symptoms and mucosal injury one year after the procedure. In the long term, 1 patient developed recurrence after 4 years, and the other 7 who were evaluated in the long term did not develop recurrence. [ 13 ]  Another study combined laparoscopic ventral rectopexy and biofeedback for 48 patients with SRUS. In all cases there was healing of the mucosa 3 months after the procedure. In 65% of cases there was improvement in symptoms of obstructed defecation and in 45% of cases there was improved quality of life. The rate of recurrence was 4-8% after an average follow up time of 33 months. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10784", "text": "The stapled transanal rectal resection (STARR) procedure has been used both as an alternative to ventral mesh rectopexy and as a secondary procedure when ventral mesh rectopexy failed to completely resolve the condition. [ 16 ]  In one study, STARR gave improvement in all cases where biofeedback had not worked. [ 13 ]  In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel  urgency , recurrence and other complications, some of which may be serious. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10785", "text": "The following \"last resort\" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10786", "text": "The condition is relatively rare, but the exact prevalence is not known. [ 3 ]  Prevalence has been estimated as 1 in 100,000 people per year. [ 3 ]  SRUS can occur at any age, but it is most common in adults aged between 30-50. [ 3 ]  Males and females are affected almost equally, [ 3 ]  or females slightly more. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10787", "text": "Misdiagnosis  as  inflammatory bowel disease  (IBD) or  rectal polyps  may hide the true prevalence of SRUS. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10788", "text": "Stapled hemorrhoidopexy  is a  surgical  procedure that involves the cutting and removal of anal hemorrhoidal vascular cushion, whose function is to help to seal stools and create continence. Procedure also removes abnormally enlarged  hemorrhoidal tissue , followed by the repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. Severe cases of hemorrhoidal prolapse will normally require surgery. Newer surgical procedures include  stapled transanal rectal resection  (STARR) and procedure for prolapse and hemorrhoids (PPH).  Both STARR and PPH are  contraindicated  in persons with either  enterocele  or  anismus . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10789", "text": "This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures. [ citation needed ]  During the procedure the external anal sphincter muscle is pulled in when the anal cushion is cut followed tight stapling with 2 rows of 28 staples so if external hemorrhoids are present they also get pulled in and get hidden inside and get tucked inside the anal canal and reappear when the staples fall after a few months when the external anal sphincter comes to its normal position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10790", "text": "Previously a lot of surgeons thought that this procedure is for external hemorrhoids also as they disappear but instead they are hidden inside and fool the eye and reappear after the staples fall off. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10791", "text": "Hemorrhoids  are amongst the most common anal disorders. Patients may complain of bleeding,  prolapse , personal discomfort and minor  anal leakage . Where traditional non-surgical measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments. Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without  anesthetics , the lasting effect of these conservative therapies has been questioned. Many patients treated with  rubber band ligation  or injection  sclerotherapy  require multiple treatments and there is high recurrence rate following these procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10792", "text": "Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period.  This can put a stress on a  general practitioner \u2019s resources, may alienate the patient and delays the patient's return to a full, normal lifestyle and the workplace. Because of this, surgeons will generally reserve formal  excision  for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10793", "text": "Obstructed defecation  syndrome (ODS) can be caused by structural deformities in the rectum resulting in chronic constipation. STARR can treat ODS using minimally invasive methods. STARR is a surgical procedure developed by Antonio Longo, an Italian surgeon, that is performed through the anus, requires no external incisions, and leaves no visible scars. Using a surgical stapler, the procedure removes the excess tissue in the rectum, reducing the anatomical defects that can cause ODS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10794", "text": "In a study of 90 patients undergoing the STARR procedure, patients were hospitalized one to three days, experienced minimal postoperative pain after the procedure, and resumed employment or normal activity in 6 to 15 days. In this study, most ODS patients experienced a significant improvement in their ODS symptoms following STARR.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10795", "text": "PPH uses a circular stapler to reduce the degree of prolapse. The procedure avoids the need for wounds in the sensitive perianal area thus reducing post-operative pain considerably, and facilitates a speedier return to normal activities. This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures.\n [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10796", "text": "This procedure was first described by an Italian surgeon \u2013 Dr.  Antonio Longo , Department of Surgery, University of Palermo \u2013 in 1993 and since then has been widely adopted through Europe. This procedure avoids the need for wounds in the sensitive perianal area and, as a result, has the advantage of significantly reducing the patient's post operative pain. [ 2 ] [ 3 ] [ 4 ]  Follow-up on relief of symptoms indicate a similar success rate to that achieved by conventional haemorrhoidectomy. [ 2 ] [ 5 ]  Since PPH was first introduced it has been the subject of numerous clinical trials and in 2003 the National Institute of Clinical Evidence (NICE) in the UK issued full guidance on the procedure stating it was  safe and efficacious ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10797", "text": "PPH is generally indicated for the more severe cases of internal hemorrhoidal prolapse (3rd and 4th degree) where surgery would normally be indicated. It may also be indicated for patients with minor degree haemorrhoids who have failed to respond to conservative treatments.  The procedure may be contra-indicated when only one cushion is prolapsed or in severe cases of fibrotic piles which cannot be physically repositioned."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10798", "text": "In addition to correcting the symptoms associated with the prolapse, problems with bleeding from the piles are also resolved by this excision.  Although the cushions may be totally or partially preserved, the blood supply is interrupted or venous drainage is improved by the repositioning.  Any external component which remains will usually regress over a period of 3\u20136 months.  Prominent skin tags may, on occasion, be removed during the operation but this may increase the postoperative pain so is not routinely performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10799", "text": "PPH employs a unique circular stapler which reduces the degree of prolapse by excising a circumferential strip of mucosa from the proximal anal canal.  This has the effect of pulling the hemorrhoidal cushions back up into their normal anatomical position.\nUsually, the patient will be under general anesthetic, but only for 20\u201330 minutes.  Many cases have been successfully performed under local or regional anesthesia and the procedure is suited to day case treatment.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10800", "text": "Due to the low level of post-operative pain and reduced analgesic use, patients will usually be discharged either the same day or on the day following surgery. Most patients can resume normal activities after a few days when they should be fit for work.  The first bowel motion is usually on day two and should not cause any great discomfort.  Staples may be passed from time to time during defecation.  This is normal and should not be a cause for concern. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10801", "text": "Since 2002 more than 100 articles have been published reporting complications during and after stapled hemorrhoidectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10802", "text": "Bleeding is the most common postoperative complication. Severe postoperative pain could be caused by dehiscence of the anastomosis or due to the fact that the anastomosis is too near to the linea dentata. [ citation needed ]  A rare complication stemming from PPH is intra- abdominal  bleeding. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10803", "text": "Many long-term complications have been described. Most of them are related to either an incorrect indication for surgery or technical errors. Several authors stated that although it seems to be an easy operation to perform, it should only be done by experienced surgeons. Severe complications leading to death have been described but are rare. Irreversible urge incontinence due to lesions of the sphincter muscle or a diminished rectal capacity due to resection of too much mucosa, are quite common complications if the procedure is not performed properly. Rectovaginal fistulas and anastomotic diverticula are very rare but possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10804", "text": "Steatorrhea  (or  steatorrhoea ) is the presence of excess  fat  in  feces . Stools may be bulky and difficult to flush, have a pale and oily appearance, and can be especially foul-smelling. [ 1 ]  An oily anal leakage or some level of  fecal incontinence  may occur. There is increased fat excretion, which can be measured by determining the fecal fat level. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10805", "text": "Impaired digestion or absorption can result in fatty stools.\nPossible causes include  exocrine pancreatic insufficiency , with poor digestion from lack of  lipases , loss of  bile salts , which reduces  micelle  formation, and small intestinal disease-producing  malabsorption . Various other causes include certain medicines that block fat absorption or indigestible or excess oil/fat in diet. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10806", "text": "The absence of  bile  secretion can cause the feces to turn gray or pale. Bile is responsible for the brownish color of feces. In addition to this, bile also plays a role in fat absorption, where dietary lipids are combined so that pancreatic lipases can hydrolyze them before going towards the small intestine. Without bile acids, this pathway would have a hard time occurring, which would lead to fat malabsorption and make steatorrhea more probable to occur. [ 2 ]  Other features of fat malabsorption may also occur such as reduced bone density, difficulty with vision under low light levels, bleeding, bruising, and slow blood clotting times. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10807", "text": "Orlistat  (also known by trade names Xenical and Alli) is a diet pill that works by blocking  the enzymes that digest fat . As a result, some fat cannot be absorbed from the gut and is excreted in the feces instead of being metabolically digested and absorbed, sometimes causing oily anal leakage. [ 6 ] [ 7 ] [ 8 ]  Vytorin (ezetimibe/simvastatin) tablets can cause steatorrhea in some people. [ 6 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10808", "text": "Some studies have shown that stool lipids are increased when whole nuts are eaten, compared to nut butters, oils or flour [ 9 ]  and that lipids from whole nuts are significantly less well absorbed. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10809", "text": "Consuming  jojoba oil  has been documented to cause steatorrhea and anal leakage because it is indigestible. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10810", "text": "Consuming  escolar  and  oilfish  (sometimes mislabelled as  butterfish ) will often cause steatorrhea, also referred to as gempylotoxism or gempylid fish poisoning or  keriorrhea . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10811", "text": "The fat substitute  Olestra , used to reduce digestible fat in some foods, was reported to cause leakage in some consumers during the test-marketing phase. As a result, the product was reformulated before general release to a hydrogenated form that is not liquid at physiologic temperature. The U.S.  Food and Drug Administration  warning indicated excessive consumption of Olestra could result in \"loose stools\"; however, this warning has not been required since 2003. [ 7 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10812", "text": "Steatorrhea should be suspected when the stools are bulky, floating and foul-smelling. [ 1 ]    Specific tests are needed to confirm that these properties are in fact due to excessive levels of fat.  Fats in feces can be measured over a defined time (often five days). [ 14 ]  Other tests include the (13)C-mixed triglycerides test and fecal  elastase , to detect possible fat maldigestion due to  exocrine pancreatic insufficiency , [ 14 ]  or various specific tests to detect other causes of  malabsorption  such as  celiac disease . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10813", "text": "Treatments are mainly correction of the underlying cause, as well as digestive enzyme supplements. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10814", "text": "In  fecal incontinence  (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10815", "text": "The relative effectiveness of surgical options for treating fecal incontinence is not known. [ 2 ]  A combination of different surgical and non-surgical therapies may be optimal. [ 2 ]  A surgical treatment algorithm has been proposed for FI, [ 3 ]  although this did not appear to include some surgical options. Isolated sphincter defects may be initially treated with sphincteroplasty and if this fails, the patient can be assessed for sacral nerve stimulation. Functional deficits of the external anal sphincter (EAS) and/or internal anal sphincter (IAS), i.e. where there is no structural defect, or only limited EAS structural defect, or with neurogenic incontinence, may be assessed for sacral nerve stimulation. If this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. Substantial muscular and/or neural defects may be treated with neosphincter initially."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10816", "text": "This operation aims to repair sphincter defects (which may be of unknown cause) or damage from trauma (usually caused by obstetric damage). Where the sphincter has separated from a tear, this procedure brings these ends back together. Primary sphincteroplasty is repair carried out soon after the trauma has occurred, whilst other repairs may be carried out years after the original trauma (secondary or delayed sphincter repair), usually because the trauma went unrecognised. Usually, sphincter defects are in the anterior position on the sphincter, when an anterior sphincteroplasty may be carried out. Where the sphincter defect is laterally or posteriorly placed, this carries a less successful outcome. [ 3 ] [ 4 ] [ 5 ]  Overlapping anterior sphincteroplasty is preceded by a bowel preparation and possibly antibiotics. Once the patient is under anesthesia, an incision is made in front of the anus (the anterior perineum). Scar tissue is removed and the mucosa of the anal canal separated from the damaged sphincter. The sphincter is cut and its ends overlapped and then stitched back together. The exact method of the procedure varies, e.g. the cut sphincter may be stitched back end to end, rather than overlapped, or the IAS and EAS may be repaired as separate stages. Sphincter repair may sometimes be combined with an anterior levatorplasty (an operation to tighten the pelvic floor). A surgical drain is left to prevent buildup of fluid. After the operation,  sitz baths  are recommended to maintain hygiene during healing, and laxatives prescribed to avoid hard stool. [ 5 ]  Overlapping anterior sphincteroplasty improves FI symptoms in the short term in most (50-80%) patients with sphincter defects. Thereafter, continence deteriorates. Most who undergo this operation are incontinent again after 5 years. Poor results with this procedure may be related to pelvic floor denervation (nerve damage). Primary sphincter repair is inadequate in most women with obstetric ruptures following vaginal delivery. Residual sphincter defects remain in most and around 50% remain incontinent. If there is a residual sphincter defect following the operation (as demonstrated by endoanal ultrasonography), then the procedure may be repeated. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10817", "text": "This procedure aims to improve FI by restoring the anorectal angle and lengthen the anal canal.  The main indication is denervation of the pelvic floor (e.g. descending perineum syndrome). After the patient is anesthetized, an incision is made posterior to (behind) the anus and a space between the EAS and IAS is opened up. This plane is followed, freeing the rectum from its attachment to the pelvic floor. Puborectalis and pubococcygeus are folded and held with stitches. These folds will lengthen the anal canal. It is safe and simple, but long term improvements in FI are poor (30-40%). Total pelvic floor repair refers to a procedure combining postanal and anterior anal repair. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10818", "text": "These procedures aim to inject  bio-compatible  material into the walls of the anal canal, aiming to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing FI. Originally, this technique was described for urinary incontinence, but was first used for FI in 1993, [ 6 ]  especially passive soiling due to IAS dysfunction. The procedure can be carried out under  local anesthetic  on an  out patient  basis, or with  caudal epidural anesthesia , [ 7 ]  or with  intravenous sedation , or under  general anesthesia . [ 8 ]  This measure has many advantages over more invasive surgery, since there are rarely any serious complications. [ 8 ]  Many different materials have been used as perianal injectable bulking agents. [ 9 ]  Of the available materials, which one is the best is not known. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10819", "text": "In 2013 a  Cochrane  systematic review included 5 randomized trials, which in total was 382 patients. None of the included studies reported long term follow up after 3, 6 or 12 months post procedure. [ 9 ]  In another review of 889 patients across 23 studies, a pooled improvement rate in measures of incontinence was 39.5%. [ 8 ]  In some cases there is no improvement after the procedure, and the injections are repeated in up to 34% of cases. [ 8 ]  There can also be worsening of symptoms after an initial improvement period. [ 8 ]  In one randomized control trial, the placebo treatment gave over 30% improvement in symptoms, suggesting that patient psychology (i.e. the  placebo effect ) may be in part responsible for any positive results. [ 10 ]  One author criticized these procedures, stating that simply narrowing the anal canal was an instinctive and naive solution which does not consider the complex pathopysiological mechanisms of FI. [ 10 ]  Concerns have been raised about migration of the particles (in the case of Durasphere) away from the site of injection, or the total resorption of the material (in the case of hyaluronic acid and hydroxyl coaptite). [ 10 ]  Most research suggests that the positive effects of most of the bulking agents seem to reduce after 6 to 12 months. [ 7 ]  At 6 months the material has been reported as missing or migrated in 18.4% of cases, at 3 years or more in 20.2% of cases. [ 8 ]  One author drew attention to the fact that all existing research on these procedures was driven by the companies who also marketed the treatments, and therefore the studies are at high risk of bias. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10820", "text": "Mesenchymal stem cells  (MSC) and  muscle-derived stem cells  (MDSC) have been used in urology to treat urinary incontinence.  Fibroblasts  in a collagen carrier were injected into the submucosa of the urethra, and  myoblasts  were injected into the urethral sphincter. The procedure was reported as being successful in most cases. [ 11 ]  Injection of MSCs may lead to engrafting and forming multinucleated myotubes, which helps to regeneration after injury. [ 12 ]  In theory, use of stem cells removes the problems of reabsorption and migration of the bulking material. [ 11 ]  There is similar research which aims to regenerate muscles and repair tissues by  cell therapy  to treat injuries of the external anal sphincter. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10821", "text": "The \"Gatekeeper\" and \"SphinKeeper\" are self-expandable prostheses which are implanted into the intersphincteric space of the anal canal. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10822", "text": "Sacral nerve stimulation  was originally used in urinary incontinence. It was first used to treat FI in 1995. The procedure involves implantation of an electrical device (an implanted pulse generator, IPG) which applies a low amplitude electric current to a  sacral  nerve (usually  S3 ). This appears to modulate the nerves and muscles of the pelvic floor and rectum. A  Cochrane  review of the efficacy of sacral nerve stimulation concluded that more research was needed, but can be helpful in selected people with FI, and reduce symptoms in selected people with constipation. [ 13 ]  It is possible to simulate the effect of SNS without surgery. This is trial usually lasts around 2\u20133 weeks, where a temporary percutaneous peripheral nerve electrode is placed in the lower back, and then connected to an external stimulator. This trial may not always accurately predict a successful outcome. If there is an improvement, a permanent electrode can be implanted on the sacrum and connected to an stimulator which is in turn implanted in the lower abdominal wall or in the buttock. Implanted stimulators usually last 8 years. The patients who may benefit from SNS include those with intact anal sphincters and those with a history of unsuccessful anal repair. [ 5 ]  Complications of the surgery are rare, including pain and infection, which may require implant removal in 5% of cases. The effects of SNS may include increased resting and squeeze anal tone, and improved rectal sensitivity. There is reported reduction of involuntary loss of bowel contents and increased ability to postpone defecation. A substantial percentage of patients regain full continence. Patient quality of life has also been shown to be improved after the procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10823", "text": "In the 1950s described an operation using the  gracilis muscle  from the inner thigh and wrapping it around the anus to function as a new anal sphincter (neosphincter). Non dynamic graciloplasty was not particularly successful because the gracilis is mostly composed of type II, fast-twitch, fatiguable muscle fibres, whereas the sphincter ideally needs to be able to automatically contract for long periods. A neurostimulation device with an impulse generator can be implanted to adapt the muscle to prolonged contraction (dynamic graciloplasty). Over time, the muscle becomes mostly composed of type I, slow twitch, fatigue resistant fibres. The patient uses an external magnetic programming device to deactivate the electrical stimulation, relaxing the muscular contraction and enabling defecation at a voluntary time. [ 3 ] [ 5 ]  Dynamic graciloplasty may be indicated for patients with a completely destroyed anal sphincter or a torn sphincter with a large gap between both ends that is not amenable to repair. The procedure involves detachment of the gracilis from the leg, preserving both its blood supply and innervation. The muscle is then moved to wrap around the anal canal completely, and also attached to the  periosteum  of the inferior ramus of the  pubic bone . Various arrangements are described, depending upon the length of the gracilis. The implanted stimulator electrode is placed intramuscularly (within the muscle), very close to the gracilis nerve, and the impulse generator is placed subcutaneously (under the skin). [ 3 ] [ 5 ]  The success rate of the operation is between 40 and 60%, and varies with surgeon experience. The complication rate is high, (infections 28%, device problems 15%, and\nleg pain 13%) but these are usually treatable without influence on the result. A second operation may be required for some complications. When dynamic graciloplasty is successful in curing FI, up to 50% of patients may develop signs and symptoms of  obstructed defecation . [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10824", "text": "This is also termed artificial anal sphincter or neosphincter. [ 14 ]  The usual surgical approach is through the  perineum  or alternatively via the vagina. The artificial bowel sphincter involves the implantation of 3 components: (i) A fluid filled silicone elastomer cuff placed around the anus, (ii) a liquid filled, pressure-regulating balloon positioned in the peritoneal fat, and (iii) a manual pump connecting these components (placed in either the  labia majora  or the  scrotum ). When the cuff is inflated, the anal canal sealed. The fluid is transferred to the balloon by the manual pump, resulting in deflation of the cuff, opening of the anal canal and allowing for defecation. [ 3 ] [ 4 ] [ 5 ]  This procedure improves FI scores and quality of life, and continence is excellent when the procedure works (successful outcome in 85% patients with a functioning device). The procedure is less technically demanding than the graciloplasty, but there is the disadvantage of using foreign material, which can erode through the anal canal. As with graciloplasty, obstructed defecation may develop with a working device, and may be treated with enemas. Complications include infection, which may warrant temporary removal of the device. [ 3 ] [ 4 ] [ 5 ]  Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior, [ 15 ]  however both methods have high rates of complications. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10825", "text": "This was originally described as a surgical management for  rectal prolapse . This operation essentially involves encircling the anal canal with implanted foreign material. Various materials have been used, including nylon, silk, fascia strips, silver wire, and\nsilastic bands. Anal encirclement effectively supplements the anal sphincter, narrowing the anal canal and its barrier function to stool, without altering voluntary control. Since complications are common, and can be serious (fecal impaction, infection, erosion of encirclement through anal canal), modern surgeons prefer to perform colostomy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10826", "text": "This refers to temperature-controlled radiofrequency energy being delivered to the anal canal, and is marketed as the SECCA procedure. This procedure aims to create a controlled scarring and  stricturing  of the anal canal. [ 1 ]  In theory, it is thought that radiofrequency induced IAS injury may cause collagen deposition and fibrosis (scarring), resulting in the affected area tightening. [ 17 ]  Specialized surgical instrument called a radiofrequency handpiece is used. It has 4 needles which enter the IAS and heat up to 85\u00a0\u00b0C. This causes the water molecules in the tissue to vibrate with subsequent frictional heating. The hand piece is cooled by water and monitors the temperature of the tissues it is applied to for safety. It is thought that the improvement in FI occurs over time as  collagen  is deposited and the tissues undergo remodeling. [ 18 ]  The procedure is carried out under  local anesthesia  (with or without  conscious sedation ) on an  outpatient  basis. [ 19 ]  There appear to be relatively few serious complications. [ 18 ] \nInitial studies of the SECCA procedure have shown promising improvements in quality of life and FI severity scores, however large  randomized control trials  and  systematic reviews  are currently lacking. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10827", "text": "This procedure involves the surgical creation of a stoma (either an appendicostomy, cecostomy, or sigmoidostomy), which thereafter functions as an irrigation port. This antegrade colonic irrigation aims to introduce fluid to wash out the colon at regular intervals. The idea is to ensure regular emptying of the colon and rectum and hopefully, prevent involuntary loss of bowel content. [ 3 ]  The  Malone antegrade continence enema  (MACE) is where an appendicostomy is created, i.e. the  vermiform appendix  is stitched to the abdominal wall to form a stoma. ACE is often necessary in addition to others when FI is complicated by  neuropathy  and/or an incomplete IAS. Patients may have persistent leakage of fluid per rectum for several hours following the irrigation. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10828", "text": "Diversion may be a temporary measure in the management of FI, e.g. to allow healing of another surgical procedure, or it may be a definitive procedure.  Stoma creation is considered to be the last resort treatment, [ 4 ]  when all other attempts to improve symptoms have been unsuccessful, although they are associated with many problems such as odor associated with leakage of stool and flatus from the stoma.  The  stoma  may be  colostomy  (where the colon is ended in a stoma) or  ileostomy  (where the  ileum  is ended in a stoma).  Both may involve the creation of an  internal waste-holding reservoir  in a procedure developed by Dr.  Nils Kock  in the late 1960s. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10829", "text": "Diversion colitis  is inflammation of the section of gut through which stool no longer passes. This condition arises because normally the lining of the gut obtains some of its nutrients from the fecal stream.  This condition may cause a foul-smelling, mucous  rectal discharge  from the distal, unused colon. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10830", "text": "Transanal irrigation  is medical procedure in which water is used to evacuate feces from the  rectum  and  descending colon  via the  anus . [ 5 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10831", "text": "Transanal irrigation uses a large volume water  enema  system. [ 2 ]  It is carried out every day (or every 2 days) by the patient or carer as a long term management for bowel dysfunction, including  fecal incontinence  and/or  constipation  (especially  obstructed defecation )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10832", "text": "Although the procedure and general goals may be similar, transanal irrigation is different from  colon cleansing  (colon hydrotherapy), which is a term used in alternative medicine. Transanal irrigation is used for medical conditions which affect defecation, such as  spinal cord injury  or  multiple sclerosis . Colon cleansing is used outside of mainstream medical supervision, and may be used in the belief that the procedure removes toxins from the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10833", "text": "The impact of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and other report little or no benefit. [ 5 ]  Evidence shows this treatment can be considered for children as well. [ 6 ] [ 7 ]  When diet and medication has proven ineffective, transanal irrigation may be used. [ 5 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10834", "text": "Transanal irrigation systems may use either a rectal balloon catheter or a cone-shaped colostomy tip. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10835", "text": "The catheter tip is inserted into the anal canal. Systems with balloon catheters require inflation of the balloon once the tip is in position. [ 9 ]  Cone shaped colostomy tip systems must be supported manually. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10836", "text": "Lukewarm tapwater (36-38\u00b0C) [ 4 ]  is used if it is drinkable. [ 9 ]   If tap water is not safe for drinking, a different source of clean water is needed. The irrigation bag is ideally placed or hung 1-1.5 m above the level of the toilet. The flow is switched on with a handheld valve. The flow rate of the water may be controlled by a manual pump or a battery pump. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10837", "text": "The volume of water used is normally about 1000 ml. [ 9 ]  Some sources recommend repeat irrigation with a higher volume up to 2300 ml. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10838", "text": "Transanal irrigation may be performed every day or every other day in order to simulate a normal defecation routine. [ 9 ]  Ideally, irrigation is performed at the same hour each day. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10839", "text": "The optimal volume and frequency may be determined by trail and error for each individual patient during the first few months of treatment. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10840", "text": "The time required for the procedure is in the range of 30\u2013120 min. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10841", "text": "Some individuals take oral constipating medications or oral laxative medications in addition to transanal irrigation. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10842", "text": "It is unclear whether the mechanism of action of irrigation is by simple mechanical washing out of the bowel, or by triggering of colonic mass movements, or both. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10843", "text": "Disadvantages of the treatment may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10844", "text": "Specific conditions for which transanal irrigatio has been used include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10845", "text": "A Cochrane review found evidence that transanal irrigation was more effective compared to conservative management in the management of spinal cord injury. There were more positive benefits for constipation scores, neurogenic bowel dysfunction scores, and fecal incontinence scores. Patients spent less time in total on bowel care and were more satisfied with the treatment. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10846", "text": "The treatment is generally considered safe. However, adverse effects are reported, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10847", "text": "Bowel perforation  is when the wall of the bowel ruptures. It is a potentially lethal complication [ 9 ]  which requires emergency surgery. 49 bowel perforations caused by transanal irrigation were reported between 2005 and 2013. [ 19 ]  This rate was used to calculate a risk of 2-6 perforations per 1 million procedures. [ 19 ]  This risk of perforation is significantly lower compared to other common medical procedures such as flexible sigmoidoscopy (1 perforation per 40000 procedures), colonoscopy (1 per 1000) and barium enema (1 per 10000). [ 10 ]  However, patients may need to conduct transanal irrigation daily or near-daily for many years, which increases their lifetime risk. [ 9 ]  Perforation is more likely in the first weeks after starting treatment. [ 19 ]  People who have had a surgical anastomosis (for example, after low anterior resection,  stapled transanal rectal resection ,  ventral mesh rectopexy , or other types of surgery for  rectal prolapse ) are more at risk of bowel perforation during transanal irrigation. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10848", "text": "One study reported before and after changes in anorectal physiology tests in patients with idiopathic faecal incontinence or chronic idiopathic constipation. The patients had all used transanal irrigation for at least 30 months. In the chronic idiopathic constipation group there was no reduction in anal sphincter function after long term use of transanal irrigation. In the idiopathic faecal incontinence group anal resting and squeeze pressures were lower after long term use of transanal irrigation. The researchers suggested that this was due to age related changes in sphincter function and the deterioration of the disease over time rather than due to the use of transanal irrigation. In both groups rectal urge volume increased after long term use of transanal irrigation. The researchers suggested that patients get accustomed to larger rectal volumes, and without the irrigation their everyday sensation of urge from the presence of stool in the rectum is decreased. This may encourage patients to continue using the irrigation. However, rectal compliance (how well the rectum can stretch and accommodate increasing volumes without triggering discomfort or pain) and biomechanical properties of the rectal wall were unchanged. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10849", "text": "Ventral rectopexy  is a surgical procedure for external  rectal prolapse , internal rectal prolapse (rectal intussusception), and sometimes other conditions such as  rectocele ,  obstructed defecation syndrome , or  solitary rectal ulcer syndrome . The  rectum  is fixed into the desired position, usually using a biological or synthetic  mesh  which is attached to the  sacral promontory . The effect of the procedure is correction of the abnormal descended position of the posterior compartment of the pelvis (i.e., the rectum), reinforcement of the anterior (front) surface of the rectum, and elevation of the  pelvic floor . [ 3 ]  In females, the rectal-vaginal septum is reinforced, and there is the opportunity to simultaneously correct any prolapse of the middle compartment (i.e., the  uterus ). [ 4 ]  In such cases, ventral rectopexy may be combined with  sacrocolpopexy . [ 5 ] [ 3 ]  The surgery is usually performed  laparoscopically  (via small openings made in the abdomen)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10850", "text": "There are over 300 different variations of surgical procedures described for rectal prolapse, and this area has seen rapid development. [ 3 ]  However, there is no clear consensus regarding the best method. [ 6 ]  Surgical treatment for rectal prolapse may be via the perineal or abdominal (transabdominal / peritoneal) approach. [ 5 ] [ 6 ]  Generally speaking, perineal procedures have less complications but higher rates of recurrence compared to abdominal procedures. [ 7 ]  Ventral rectopexy falls into the abdominal procedure category, and can be considered as a type of abdominal rectopexy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10851", "text": "Abdominal rectopexy encompasses several procedures which involve mobilization and fixation of the rectum, with or without resection, via abdominal approach. Some of types of abdominal rectopexy are now rarely or never performed. For example, the Ripstein rectopexy (anterior fixation of mesh below the sacral promontory) and the Wells procedure (involving detachment of the lateral ligaments of the rectum) have been abandoned. [ 8 ]  In general, abdominal rectopexy procedures have been associated with post-operative problems with defecation such as new or worsened constipation, obstructed defecation or fecal incontinence. [ 9 ] [ 2 ]  This does not seem to be a significant problem with ventral rectopexy, [ 2 ]  which represents the most recent development of abdominal rectopexy. In men, mobilization of the rectum may risk the development of  erectile dysfunction . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10852", "text": "Another way of categorizing surgery for prolapse of pelvic organs is suspensive or resective (involving removal of sections of the bowel wall). Ventral rectopexy alone is a syspensive type surgery, a category which also includes  colposacropexy . [ 10 ]  Resection rectopexy additionally involves removal of a section of the  sigmoid colon  ( sigmoidectomy ). It is thought to have decreased post operative problems of constipation, because the redundant colon is removed and therefore cannot \"kink\". However, there is no evidence that this improves the outcomes, and the necessary creation of an  anastomosis  (surgically created joining between two ends of bowel when a section of bowel is removed) increases the risk of severe complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10853", "text": "Ventral rectopexy with an  autologous graft  ( fascia lata ), [ 9 ]  and then with a synthetic mesh for external rectal prolapse was first reported in 1971. [ 11 ]  The Orr-Loygue procedure (lateral mesh rectopexy) was described in 1984. [ 12 ] [ 5 ]  The Orr-Loygue procedure involved anterior and posterior mobilization of the rectum to the level of the levator ani muscle and removal of the pouch of Douglas. Mesh was sutured to the lateral surfaces (sides) of the rectum. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10854", "text": "The Orr-Loygue procedure was modified by D'Hoore in 2004. [ 13 ]  In ventral rectopexy, there is no posterior dissection and mobilization of the rectum apart from to expose the sacral promontory. With no posterior (dorsal) or lateral dissection, damage to the autonomic nerves is minimized. As a result, there are less problems with post-operative constipation. There is no excision of the pouch of Douglas, and the mesh is placed directly onto the anterior (ventral) surface of the rectum. This procedure aims to suspend the middle and lower sections of the rectum. This modified procedure is now known as the anterior rectopexy or ventral rectopexy. [ 1 ]  D'Hoore also used a  laparoscopic  approach (laparoscopic ventral mesh rectopexy, LVMR). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10855", "text": "After 2002, the minimally invasive trans-anal approach known as  Stapled Trans-Anal Rectal Resection  (STARR) became popular for treating  obstructed defecation syndrome . However, over time, there has been a general trend away from STARR towards abdominal rectopexy for surgical treatment of obstructed defecation syndrome. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10856", "text": "Ventral mesh rectopexy has become the one of the most popular options for rectal prolapse. [ 16 ] [ 7 ]  Ventral rectopexy also provides the opportunity to simultaneously correct any prolapse of the middle compartment of the pelvis, [ 4 ]  and is sometimes combined with  sacrocolpopexy . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10857", "text": "There has been some controversy connected with transvaginal placement of mesh in the treatment of  pelvic organ prolapse  and  stress urinary incontinence . This is because there is a risk of erosion (tissue breakdown around the mesh) and sepsis (infection). [ 4 ]  In 2008 and 2016 the  US Food and Drug Administration  published guidance about potential serious complications caused by such meshes and upgraded their risk classification of such meshes from Class II (moderate risk) to Class III (high risk). Procedures involving transvaginal mesh have since decreased by 40\u201360% in the USA. [ 14 ]  In 2011, manufacturers of permanent transvaginal meshes withdrew the products from the market. [ 17 ]  In Europe, the  Scientific Committee on Emerging and Newly Identified Health Risks  (SCENIHR) stated in 2015 that implantation of any mesh via the vaginal route should be done only in complicated cases where a primary repair has failed. [ 14 ]  A  Cochrane review  in 2016 stated that the risks were higher with such meshes compared to native tissue repair (using the patient's own tissues instead of mesh). [ 17 ]  Transvaginal meshes have higher risk of repeat surgery, injury to the bladder, and stress urinary incontinence which appears after the surgery. [ 17 ]  They concluded that transvaginal meshes have limited benefit in the primary surgical management of pelvic organ prolapse and stress urinary incontinence. [ 17 ] [ needs update ]  The review was updated in 2024 with the same conclusions but based on newly available evidence. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10858", "text": "In response to the controversy connected with transvaginal meshes, the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland issued a position statement regarding the use of mesh in ventral rectopexy in 2020. They stated that meshes in ventral rectopexy are not the same because the mesh is inserted between the rectum and the vagina and not directly into the vagina as with transvaginal meshes. [ 14 ]  They also stated that according to current evidence ventral mesh rectopexy is the best available treatment to restore normal rectal function, and that the estimated overall risk of complications is about 2.5% based on the worst-case scenario. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10859", "text": "The definitive indication for ventral rectopexy is:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10860", "text": "Relative indications are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10861", "text": "Absolute contraindications are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10862", "text": "Relative contraindications are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10863", "text": "There are 3 options for surgical approach: open abdominal surgery, laparoscopic approach or  robotic surgery . The laparoscopic approach is safer than open surgery, [ 4 ]  and there is less risk of complications after the procedure. [ 23 ]  There is also less blood loss, less pain after the procedure, shorter average length of stay in hospital and faster recovery. [ 8 ] [ 23 ]  Rarely, the procedure must be converted into an open abdominal surgery. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10864", "text": "The procedure is still almost always carried out via laparoscopic approach. [ 14 ]  However, increasingly some surgeons use robotic surgery to conduct the procedure. [ 5 ]  Some surgeons claim that the use of robotic surgery makes ventral rectopexy less technically demanding, because it requires careful dissection and suture placement in a tight, narrow space. [ 1 ]  This is especially true in patients with a narrow pelvis. [ 16 ]  Laparoscopic ventral rectopexy is also difficult in patients who are obese. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10865", "text": "Robotic approach has the benefit of three-dimensional visualization, precise dissection and the possibility of refined, articulated movements suitable for a narrow conical space such as the pelvis. [ 16 ]  There is less trauma to the tissues and less blood loss compared to conventional laparoscopy. [ 8 ]  In the case of ventral rectopexy, which is considered a difficult procedure requiring a lot of training (100 cases), robotic surgery is reported to speed up the learning curve for surgeons (20 cases). [ 8 ]  Longer operation times are usually reported with robotic surgery, but operation time is less With surgeons who are experienced in using the robotic technique. [ 8 ]  The laparoscopic approach is cheaper than robotic surgery, [ 16 ]  but when considering the reduced hospital stay, robotic surgery may be cheaper overall. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10866", "text": "The choice of synthetic material used to perform the rectopexy may also vary and can include nylon, Teflon, Marlex, Ivalon, Gore\u2010Tex, Vicryl or Dexon. There is debate regarding the best mesh material, and whether a biologic or synthetic mesh is superior. One systematic review found no significant difference between biologic or synthetic mesh with regards to the rates of mesh erosion or recurrence of prolapse. [ 21 ]  However, a later systematic review reported lower rate of mesh erosion for biologic mesh (0.22%) compared to synthetic mesh (1.87%). [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10867", "text": "Usually one strip of mesh is placed, but sometimes two are used. [ 7 ]  The meshes are 15, 17 or 20\u00a0cm long. [ 7 ]  Tackers (Protack), titanium screw tacks, or sutures (absorbably or non-absorbable) are used to fix the mesh to the sacral promontory. [ 7 ]  Absorbable or non-absorbable sutures (Ethibond, prolypropylene), or 4mm titanium staples are used to fix the mesh to anterior rectal wall. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10868", "text": "After the procedure, patients are advised to avoid sex and lifting heavy weights, and to use laxatives for 6 weeks. [ 5 ]  Continuing pelvic floor physical therapy may be beneficial in those cases where people had symptoms of obstructed defecation or incontinence before the procedure. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10869", "text": "According to one publication, risk of a complication occurring is 14%. [ 5 ]  Another systematic review reported an average complication rate of 4.8%. [ 7 ]  Complications involving the urinary tract are most common and mesh related complications are less common. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10870", "text": "Recurrence of the prolapse after ventral rectopexy is possible. Recurrence rates are reported as between 1.4 and 9.7% of cases. Recurrence occurs sooner and the overall rate is higher when ventral rectopexy is performed on a prolapse which has already recurred in the past (25% of cases after 5 years). Risk factors for recurrence after ventral rectopexy include old age, male gender, higher  body mass index , higher Cleveland Clinic incontinence score, prolonged  pudendal nerve terminal motor latency , weak pelvic floor, [ 5 ] [ 7 ]   benign joint hypermobility syndrome , [ 4 ]  and excessive perineal descent associated with chronic straining. [ 4 ]  Mesh of 20\u00a0cm length has lower risk of recurrence than mesh of 15\u201317\u00a0cm. [ 5 ]  Recurrence may occur as either full thickness prolapse or mucosal prolapse. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10871", "text": "Recurrence may occur if the mesh slips from the sacral promontory. This may happen because of inadequate fixation and adherence of the mesh to the anterior rectal wall or to the sacral promontory, or incorrectly placed staples to the upper sacrum. [ 5 ] [ 7 ]  Another technical reason for relapse is inadequate dissection on the anterior aspect of the rectum. [ 7 ]  Recurrence can be a challenging situation for surgeons, [ 7 ]  and in this case the patient is re-evaluated for 6 months to identify the reason for the recurrence. [ 5 ]  A further surgical procedure to re-fix the mesh may be required. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10872", "text": "Overall risk of complications associated with the mesh have been reported as 2.5%. [ 14 ]  Such complications include detachment and migration of the mesh. This complication is reported at a rate of 4.6% of cases. [ 5 ]  The mesh can erode into the vagina (1.3% of cases), or into the rectum.  The risk of mesh complications appears to be low regardless of what mesh material is used. [ 21 ]  However, biologic mesh may have a lower risk of complications compared to synthetic mesh. [ 23 ]  When suturing synthetic mesh to the rectum, the use of absorbable sutures leads to lower risk of complications compared to non-resorbable sutures. [ 5 ]   When mesh erosion into the vagina occurs, a further surgical procedure is required to remove the tissue from the mesh and to close the vaginal wall over the defect. [ 5 ]  Most mesh-related complications can be treated successfully. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10873", "text": "At the site where the mesh is attached (lumbosacral region), vertebral  discitis  may occur. This is a rare but serious complication. In one case, the discitis may have been caused by the use of titanium screws. Signs and symptoms of discitis include chronic back pain and infection. Discitis is treated with intravenous antibiotics and possible removal of the mesh. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10874", "text": "Urinary-related complications include  urinary tract infection ,  urinary retention , damage to structures like the  ureter ,  bladder  or  vas deferens . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10875", "text": "Other possible complications are infection or hernia at the port site,  ileus  and small bowel injury. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10876", "text": "The average improvement in fecal incontinence is reported as 62.5 [ 7 ]  to 79.3%, [ 5 ]  and the average improvement in constipation from 76.6% [ 7 ]  to 71%. [ 5 ]  However, these conditions may not fully resolve after the procedure. [ 5 ]  Ventral rectopexy may be more effective as an initial surgical repair of a prolapse rather than treatment for a recurrent prolapse which was previously operated upon. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10877", "text": "One systematic review comparing laparoscopic ventral mesh rectopexy and robotic ventral mesh rectopexy concluded that robotic approach resulted in a longer operation time. [ 16 ]  However, this may be related to lack of operator experience with the robotic platform, and it has been suggested that a surgeon who is experienced with the robotic approach can perform the operation as fast or faster than a surgeon who is experienced with the laparoscopic approach. The robotic approach resulted in a shorter stay in hospital for patients, which balanced the increased cost of the robotic surgery itself. This may be because robotic surgery is more precise and leads to less bleeding and pain after the procedure. One study showed lower scores for obstructed defecation after robotic approach. In general, both approaches showed improvement in function and quality of life, but some studies reported robotic approach as giving slightly more improvement in quality of life. Both approaches resulted in similar long term outcome and recurrence rates. The review authors concluded that robotic ventral mesh rectopexy is safe and results in at least the same outcomes as laparoscopic approach. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10878", "text": "The most commonly used material for synthetic mesh is polypropylene. This material has a lower risk of mesh exposure compared to polyester. [ 19 ]  The two most common biologic mesh products are Permacol, which is cross-linked collagen, and Biodesign, which is non-cross linked. It is not known if one type of biologic mesh is better. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10879", "text": "In 2020 another systematic review compared the use of synthetic mesh and biologic mesh in ventral mesh rectopexy for external rectal prolapse or symptomatic internal rectal prolapse. [ 19 ]  The review included 32 studies containing a total of 4001 cases where synthetic mesh was used and 762 where biologic mesh was used. The rate of mesh-related complications ranged from 0 to 2.4% for synthetic mesh, with a pooled incidence rate of 1%. The rate of mesh-related complications ranged from 0 and 0.7% for biologic mesh. The rate of recurrence ranged from 1.1 to 18.8% for synthetic mesh. The rate of recurrence ranged from 0 to 15.4% for biologic mesh. The reviewers stated that the risk of mesh related complications are low for both synthetic and biologic mesh, and there may a small reduction in mesh-related complications with biologic mesh. However, due to lack of sufficient high quality data for biologic mesh, they were unable to make definitive conclusions. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10880", "text": "One systematic review compared laparoscopic suture rectopexy with laparoscopic mesh rectopexy in the treatment of full-thickness rectal prolapse (external rectal prolapse, complete rectal prolapse). Compared to suture rectopexy, mesh rectopexy had lower rate of recurrence and longer operation time. There were no differences in degree of improvement of constipation, incontinence, bleeding during the surgery, length of stay in hospital, and overall rate of complications after the surgery. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10881", "text": "The  American Board of Thoracic Surgery  is an  American  surgical  organization  devoted to  thoracic surgery. [ 1 ]  The ABTS will soon shut down their access to the Self-Education Self Assessment in Thoracic Surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10882", "text": "This article about a medical organization or association is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10883", "text": "The  Association of Cardiothoracic Surgical Assistants (ACSA)  is a professional body in the  United Kingdom  that ACSA represents a body of non-medical practitioners working in  cardiothoracic surgery , performing a range of skilled interventions. It was formed in 1997. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10884", "text": "The ACSA supports its members by providing educational meetings, discussion forums and professional advice. Members also can receive indemnity cover at a reduced cost from the  Medical Protection Society  and receive a newsletter, have access to a members' forum and to archived educational material. ACSA represents its members in the  Society of Cardiothoracic Surgery  and has helped to develop the  National Curriculum  framework for surgical care practitioners."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10885", "text": "In 1997, 12 surgical assistants from the UK met to discuss the future of cardiothoracic surgical assistants in the UK; a motion was passed to form the Association of Cardiothoracic Surgical Assistants (ACSA). Richard Ward was elected as its inaugural president, and the association identified the need for a support network and standard education and qualification practices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10886", "text": "The same year, the Society of Cardiothoracic Surgery, the Royal College of Surgeons of Great Britain and Ireland and ACSA formulated the Surgeons' Assistant Diploma in Cardiothoracic Surgery. In 1998, ACSA identified a need to run a revision course for future candidates for the diploma. This course has since run with great success."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10887", "text": "In 2004, the title of Surgical Practitioner was reviewed by the United Kingdom Department of Health. The title was later changed once again to \"Surgical Care Practitioner (SCP)\". This title is still used today although it should be said that it is still only a working title due to disputes with other groups. The same year, work began on the National Curriculum Framework for SCPs, started by the Department of Health."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10888", "text": "ACSA worked with many other organisations including the Royal College of Surgeons, the  National Association of Assistants in Surgical Practice , the  Association for Perioperative Practice , the  Association of Surgeons in Training , the  Association of Operating Department Practitioners , the  British Orthopaedic Trainees Association , and the  Royal College of Obstetricians and Gynaecologists ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10889", "text": "In 2006 the National Curriculum framework was published. In 2007 ACSA and SCTS decided to start holding their  Annual General Meetings  to coincide with each other."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10890", "text": "Steven Bryant went on to become president of ACSA for two years, during this time Steven attended many meetings at the RCS and other organisations such as the 'new ways of working' department, set up  by the last government to discuss the future development of the surgical assistant/care practitioner. He is widely credited as one of the leading lights in the profession and in 2011 became the first non-medically qualified practitioner to become an examiner for the RCS diploma. Steven Bryant continues to work at Papworth hospital in Cambridgeshire as the lead scp Papworth Hospital is regarded as one of the main training centres for SA/SCP  training in the UK and abroad."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10891", "text": "Cardiothoracic surgery  is the  field  of  medicine  involved in  surgical treatment  of organs inside the  thoracic cavity  \u2014 generally treatment of conditions of the  heart  ( heart disease ),  lungs  ( lung disease ), and other  pleural  or  mediastinal  structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10892", "text": "In most countries, cardiothoracic surgery is further  subspecialized  into  cardiac surgery  (involving the heart and the  great vessels ) and  thoracic surgery  (involving the lungs,  esophagus ,  thymus , etc.); the exceptions are the  United States ,  Australia ,  New Zealand , the  United Kingdom ,  India  and some  European Union  countries such as  Portugal . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10893", "text": "A cardiac surgery  residency  typically comprises anywhere from four to six years (or longer) of training to become a fully qualified surgeon. [ 2 ]  Cardiac surgery training may be combined with thoracic surgery and/or  vascular surgery  and called cardiovascular (CV) / cardiothoracic (CT) / cardiovascular thoracic (CVT) surgery. Cardiac surgeons may enter a cardiac surgery residency directly from  medical school , or first complete a  general surgery  residency followed by a  fellowship . Cardiac surgeons may further sub-specialize cardiac surgery by doing a fellowship in a variety of topics including  pediatric  cardiac surgery,  cardiac transplantation , adult-acquired heart disease, weak heart issues, and many more problems in the heart. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10894", "text": "The highly competitive Surgical Education and Training (SET) program in Cardiothoracic Surgery is six years in duration, usually commencing several years after completing medical school. Training is administered and supervised via a bi-national (Australia and New Zealand) training program. Multiple examinations take place throughout the course of training, culminating in a final fellowship exam in the final year of training.  Upon completion of training, surgeons are awarded a Fellowship of the  Royal Australasian College of Surgeons  (FRACS), denoting that they are qualified specialists.  Trainees having completed a training program in General Surgery and have obtained their FRACS will have the option to complete fellowship training in Cardiothoracic Surgery of four years in duration, subject to college approval. It takes around eight to ten years minimum of post-graduate (post-medical school) training to qualify as a cardiothoracic surgeon. Competition for training places and for public (teaching) hospital places is very high currently, leading to concerns regarding  workforce planning  in Australia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10895", "text": "Historically, cardiac surgeons in  Canada  completed general surgery followed by a fellowship in CV / CT / CVT.  During the 1990s, the Canadian cardiac surgery training programs changed to six-year \"direct-entry\" programs following medical school. The direct-entry format provides residents with experience related to cardiac surgery they would not receive in a general surgery program (e.g.  echocardiography ,  coronary care unit , cardiac catheterization etc.). Residents in this program will also spend time training in thoracic and  vascular surgery . Typically, this is followed by a fellowship in either Adult Cardiac Surgery, Heart Failure/Transplant, Minimally Invasive Cardiac Surgery, Aortic Surgery, Thoracic Surgery, Pediatric Cardiac Surgery or Cardiac ICU. Contemporary Canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the United States. The Royal College of Physicians and Surgeons of Canada also provides a three-year cardiac surgery fellowship for qualified general surgeons that is offered at several training sites including the  University of Alberta , the  University of British Columbia  and the  University of Toronto . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10896", "text": "Thoracic surgery is its own separate 2\u20133 year fellowship of general or cardiac surgery in Canada."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10897", "text": "Cardiac surgery programs in Canada: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10898", "text": "Cardiac surgery training in the  United States  is combined with general  thoracic surgery  and called cardiothoracic surgery or thoracic surgery.  A cardiothoracic surgeon in the U.S. is a physician who first completes a  general surgery  residency (typically 5\u20137 years), followed by a cardiothoracic surgery fellowship (typically 2\u20133 years). The cardiothoracic surgery fellowship typically spans two or three years, but certification is based on the number of surgeries performed as the operating surgeon, not the time spent in the program, in addition to passing rigorous board certification tests.  Two other pathways to shorten the duration of training have been developed: (1) a combined general-thoracic surgery residency consisting of four years of general surgery training and three years of cardiothoracic training at the same institution and (2) an integrated six-year cardiothoracic residency (in place of the general surgery residency plus cardiothoracic residency), which have each been established at many programs (over 20). [ 3 ]   Applicants match into the integrated six-year (I-6) programs directly out of medical school, and the application process has been extremely competitive for these positions as there were approximately 160 applicants for 10 spots in the U.S. in 2010.  As of May 2013, there are 20 approved programs, which include the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10899", "text": "Integrated six-year Cardiothoracic Surgery programs in the United States: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10900", "text": "The  American Board of Thoracic Surgery  offers a special pathway certificate in congenital cardiac surgery which typically requires an additional year of fellowship. This formal certificate is unique because congenital cardiac surgeons in other countries do not have formal evaluation and recognition of pediatric training by a licensing body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10901", "text": "The earliest operations on the  pericardium  (the sac that surrounds the heart) took place in the 19th century and were performed by  Francisco Romero  (1801) [ 4 ]   Dominique Jean Larrey ,  Henry Dalton , and  Daniel Hale Williams . [ 5 ]  The first surgery on the heart itself was performed by  Norwegian  surgeon  Axel Cappelen  on 4 September 1895 at  Rikshospitalet  in Kristiania, now  Oslo . He  ligated  a bleeding  coronary artery  in a 24-year-old man who had been stabbed in the left  axilla  and was in deep  shock  upon arrival. Access was through a left  thoracotomy . The patient awoke and seemed fine for 24 hours, but became ill with increasing temperature and he ultimately died from what the  post mortem  proved to be  mediastinitis  on the third postoperative day. [ 6 ] [ 7 ]  The first successful surgery of the heart, performed without any complications, was by  Ludwig Rehn  of  Frankfurt ,  Germany , who repaired a stab wound to the right  ventricle  on September 7, 1896. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10902", "text": "Surgery in  great vessels  ( aortic coarctation  repair,  Blalock-Taussig shunt  creation, closure of  patent ductus arteriosus ) became common after the turn of the century and falls in the domain of cardiac surgery, but technically cannot be considered heart surgery.  One of the more commonly known cardiac surgery procedures is the  coronary artery bypass graft (CABG) , also known as \"bypass surgery.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10903", "text": "In 1925 operations on the  heart valves  were unknown.  Henry Souttar  operated successfully on a young woman with  mitral stenosis . He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years [ 10 ]  but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10904", "text": "Cardiac surgery changed significantly after  World War II . In 1948 four surgeons carried out successful operations for  mitral stenosis  resulting from  rheumatic fever .  Horace Smithy  (1914\u20131948) revived an operation due to Dr  Dwight Harken  of the  Peter Bent Brigham Hospital  using a punch to remove a portion of the  mitral valve .  Charles Bailey  (1910\u20131993) at the  Hahnemann Hospital ,  Philadelphia ,  Dwight Harken  in  Boston  and  Russell Brock  at  Guy's Hospital  all adopted Souttar's method. All these men started work independently of each other, within a few months. This time Souttar's technique was widely adopted although there were modifications. [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10905", "text": "In 1947  Thomas Holmes Sellors  (1902\u20131987) of the  Middlesex Hospital  operated on a  Fallot's Tetralogy  patient with  pulmonary stenosis  and successfully divided the stenosed  pulmonary valve . In 1948,  Russell Brock , probably unaware of Sellor's work, used a specially designed dilator in three cases of  pulmonary stenosis . Later in 1948 he designed a punch to resect the  infundibular muscle   stenosis  which is often associated with  Fallot's Tetralogy . Many thousands of these \"blind\" operations were performed until the introduction of heart bypass made direct surgery on valves possible. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10906", "text": "Open heart surgery is a procedure in which the patient's heart is opened and surgery is performed on the internal structures of the heart. It was discovered by  Wilfred G. Bigelow  of the  University of Toronto  that the repair of intracardiac pathologies was better done with a bloodless and motionless environment, which means that the heart should be stopped and drained of blood. The first successful intracardiac correction of a  congenital heart defect  using  hypothermia  was performed by  C. Walton Lillehei  and  F. John Lewis  at the  University of Minnesota  on September 2, 1952. The following year,  Soviet  surgeon  Aleksandr Aleksandrovich Vishnevskiy  conducted the first cardiac surgery under  local anesthesia . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10907", "text": "Surgeons realized the limitations of hypothermia \u2013 complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the  brain . The patient needs the function of the heart and  lungs  provided by an artificial method, hence the term  cardiopulmonary bypass .  John Heysham Gibbon  at Jefferson Medical School in Philadelphia reported in 1953 the first successful use of extracorporeal circulation by means of an  oxygenator , but he abandoned the method, disappointed by subsequent failures. In 1954 Lillehei realized a successful series of operations with the controlled cross-circulation technique in which the patient's mother or father was used as a ' heart-lung machine '.  John W. Kirklin  at the  Mayo Clinic  in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and was soon followed by surgeons in various parts of the world. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10908", "text": "Nazih Zuhdi  performed the first total intentional hemodilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963. [ 13 ]  In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age  3 + 1 \u2044 2 , using the total intentional hemodilution machine. In 1985 Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, who had  cancer , died from an infection 54 days after surgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10909", "text": "Since the 1990s, surgeons have begun to perform \" off-pump bypass surgery \" \u2013 coronary artery bypass surgery without the aforementioned  cardiopulmonary bypass . In these operations, the heart is beating during surgery, but is stabilized to provide an almost still work area in which to connect the conduit vessel that bypasses the blockage; in the U.S., most conduit vessels are harvested endoscopically, using a technique known as  endoscopic vessel harvesting  (EVH). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10910", "text": "Some researchers believe that the off-pump approach results in fewer post-operative complications, such as  postperfusion syndrome , and better overall results. Study results are controversial as of 2007, the surgeon's preference and hospital results still play a major role. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10911", "text": "A new form of heart surgery that has grown in popularity is  robot-assisted heart surgery . This is where a machine is used to perform surgery while being controlled by the heart surgeon. The main advantage to this is the size of the incision made in the patient. Instead of an incision being at least big enough for the surgeon to put his hands inside, it does not have to be bigger than 3 small holes for the robot's much smaller \"hands\" to get through. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10912", "text": "Pediatric cardiovascular surgery is surgery of the heart of children. The first operations to repair cardio-vascular [ 15 ]  defects in children were performed by Clarence Crafoord in Sweden when he repaired coarctation of the aorta in a 12-year-old boy. [ 16 ]  The first attempts to palliate congenital heart disease were performed by Alfred Blalock with the assistance of William Longmire, Denton Cooley, and Blalock's experienced technician, Vivien Thomas in 1944 at Johns Hopkins Hospital. [ 17 ]   Techniques for repair of congenital heart defects without the use of a bypass machine were developed in the late 1940s and early 1950s.  Among them was an open repair of an atrial septal defect using hypothermia, inflow occlusion and direct vision in a 5-year-old child performed in 1952 by Lewis and Tauffe. C. Walter Lillihei used cross-circulation between a boy and his father to maintain perfusion while performing a direct repair of a ventricular septal defect in a 4-year-old child in 1954. [ 18 ]  He continued to use cross-circulation and performed the first corrections of tetralogy of Fallot and presented those results in 1955 at the American Surgical Association. In the long-run, pediatric cardiovascular surgery would rely on the cardiopulmonary bypass machine developed by Gibbon and Lillehei as noted above. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10913", "text": "The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the mortality rates of these surgeries to relatively low ranks. For instance, repairs of congenital heart defects are currently estimated to have 4\u20136% mortality rates. [ 19 ] [ 20 ]  A major concern with cardiac surgery is the incidence of  neurological  damage.  Stroke  occurs in 5% of all people undergoing cardiac surgery, and is higher in patients at risk for stroke. [ 21 ]  A more subtle constellation of  neurocognitive deficits  attributed to  cardiopulmonary bypass  is known as  postperfusion syndrome , sometimes called \"pumphead\". The symptoms of postperfusion syndrome were initially felt to be permanent, [ 22 ]  but were shown to be transient with no permanent neurological impairment. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10914", "text": "To assess the performance of surgical units and individual surgeons, a popular risk model has been created called the  EuroSCORE .  This takes a number of health factors from a patient and using precalculated logistic regression coefficients attempts to give a percentage chance of survival to discharge.  Within the UK this EuroSCORE was used to give a breakdown of all the centres for cardiothoracic surgery and to give some indication of whether the units and their individual surgeons performed within an acceptable range. The results are available on the CQC website. [ 24 ]   The precise methodology used has however not been published to date nor has the raw data on which the results are based. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10915", "text": "Infection represents the primary non-cardiac complication from cardiothoracic surgery. Infections include mediastinitis, infectious myo- or pericarditis, endocarditis, cardiac device infection, pneumonia, empyema, and bloodstream infections.  Clostridioides difficile  colitis can develop when prophylactic or post-operative antibiotics are used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10916", "text": "Post-operative patients of cardiothoracic surgery are at risk of nausea, vomiting, dysphagia, and aspiration pneumonia. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10917", "text": "A pleurectomy is a surgical procedure in which part of the  pleura  is removed. It is sometimes used in the treatment of  pneumothorax  and  mesothelioma . [ 26 ]  In case of pneumothorax, only the apical and the diaphragmatic portions of the parietal pleura are removed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10918", "text": "Lung volume reduction surgery, or LVRS, can improve the quality of life for certain patients with  COPD  of  emphysematous  type, when other treatment options are not enough. Parts of the  lung  that are particularly damaged by emphysema are removed, allowing the remaining, relatively good lung to expand and work more efficiently.  The beneficial effects are correlated with the achieved reduction in residual volume. [ 27 ]   Conventional LVRS involves  resection  of the most severely affected areas of emphysematous, non- bullous  lung (aim is for 20\u201330%). This is a surgical option involving a  mini-thoracotomy  for patients in end stage COPD due to underlying emphysema, and can improve lung  elastic recoil  as well as  diaphragmatic function . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10919", "text": "The National Emphysema Treatment Trial (NETT) was a large multicentre study (N = 1218) comparing LVRS with non-surgical treatment. Results suggested that there was no overall survival advantage in the LVRS group, except for mainly upper-lobe emphysema + poor exercise capacity, and significant improvements were seen in exercise capacity in the LVRS group. [ 28 ]  Later studies have shown a wider scope of treatment with better outcomes. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10920", "text": "Possible complications of LVRS include prolonged air leak (mean duration post surgery until all  chest tubes  removed is 10.9 \u00b1 8.0 days. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10921", "text": "In people who have a predominantly upper lobe emphysema, lung volume reduction surgery could result in better health status and lung function, though it also increases the risk of early mortality and adverse events. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10922", "text": "LVRS is used widely in Europe, though its application in the United States is mostly experimental. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10923", "text": "A less invasive treatment is available as a  bronchoscopic lung volume reduction  procedure. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10924", "text": "Not all lung cancers are suitable for surgery. The  stage , location and cell type are important limiting factors. In addition, people who are very ill with a poor  performance status  or who have inadequate pulmonary reserve would be unlikely to survive. Even with careful selection, the overall operative death rate is about 4.4%. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10925", "text": "In  non-small cell lung cancer staging , stages IA, IB, IIA, and IIB are suitable for surgical resection. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10926", "text": "Pulmonary reserve is measured by  spirometry . If there is no evidence of undue shortness of breath or  diffuse parenchymal lung disease , and the FEV 1  exceeds 2 litres or 80% of predicted, the person is fit for  pneumonectomy . If the FEV 1  exceeds 1.5 litres, the patient is fit for lobectomy. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10927", "text": "There is weak evidence to indicate that participation in exercise programs before lung cancer surgery may reduce the risk of complications after surgery. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10928", "text": "A prolonged air leak (PAL) can occur in 8\u201325% of people following lung cancer surgery. [ 38 ] [ 39 ]  This complication delays chest tube removal and is associated with an increased length of hospital stay following a lung resection (lung cancer surgery). [ 40 ] [ 41 ]  The use of  surgical sealants  may reduce the incidence of prolonged air leaks, however, this intervention alone has not been shown to results in a decreased length of hospital stay following lung cancer surgery. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10929", "text": "There is no strong evidence to support using  non-invasive positive pressure ventilation  following lung cancer surgery to reduce pulmonary complications. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10930", "text": "The  European Association for Cardio-Thoracic Surgery  ( EACTS ) is a membership organisation devoted to the practice of  cardiothoracic surgery . The mission statement of the association is to advance education in the field of cardiac, thoracic and vascular interventions; and promote research into cardiovascular and thoracic physiology, pathology and therapy, with the aim to correlate and disseminate the results for the public benefit. Within the EACTS there is a large number of committees working on various issues in order to improve cardio-thoracic surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10931", "text": "EACTS was founded as a  European  organisation. However, its membership is now spread all over the world in all continents representing some 70 countries. Since its foundation in 1986 more than 3500 members have been admitted, and the interest in applying for membership has grown considerably during the last few years. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10932", "text": "The EACTS Annual Meeting is the largest cardio-thoracic meeting in the world [ citation needed ]  focusing on scientific developments and research in the following specialities: Acquired Cardiac Disease, Congenital Heart Disease, Vascular Disease and Thoracic Disease. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10933", "text": "The EACTS publishes two journals focused on high-quality research and cardio thoracic surgery education and one website featuring video based cardio-thoracic tutorials these are:  European Journal of Cardio-Thoracic Surgery (EJCTS) ,  Interactive Cardiovascular and Thoracic Surgery (ICVTS) , and  Multimedia Manual of Cardio-Thoracic Surgery (MMCTS)   [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10934", "text": "The Quality Improvement Programme was launched in 2012 to facilitate continuing improvement of clinical outcomes in adult cardiac surgery through improving education, and various research initiatives. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10935", "text": "The organisation has collaborated with the  European Society of Cardiology , the  American Heart Association ,  Oxford University , and other organizations to produce clinical practice guidelines and consensus statements related to the treatment of cardiovascular disease. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10936", "text": "Hyperhidrosis  is a  medical condition  in which a person exhibits excessive  sweating , [ 1 ] [ 2 ]  more than is required for the  regulation of body temperature . [ 3 ]  Although it is primarily a physical burden, hyperhidrosis can deteriorate the quality of life of the people who are affected from a psychological, emotional, and social perspective. [ 4 ]  In fact, hyperhidrosis almost always leads to psychological as well as physical and social consequences. [ 5 ]  People suffering from it present difficulties in professional fields, more than 80% experiencing a moderate to severe emotional impact from the disease [ 6 ]  and half are subject to  depression ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10937", "text": "This excess of sweat happens even if the person is not engaging in tasks that require muscular effort, and it does not depend on the exposure to heat. [ 7 ]  Common places to sweat can include underarms, face, neck, back, groin, feet, and hands. It has been called by some researchers 'the silent handicap'. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10938", "text": "Both  diaphoresis  and  hidrosis  can mean either  perspiration  (in which  sense  they are  synonymous  with  sweating [ 9 ] [ 10 ] ) or  excessive perspiration , in which case they refer to a specific, narrowly defined, clinical disorder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10939", "text": "Hyperhidrosis can either be  generalized , or  localized  to specific parts of the body. Hands, feet, armpits, groin, and the facial area are among the most active regions of perspiration due to the high number of  sweat glands  ( eccrine glands  in particular) in these areas. When excessive sweating is localized (e.g. palms, soles, face, underarms, scalp) it is referred to as  primary  hyperhidrosis or  focal hyperhidrosis . Excessive sweating involving the whole body is termed  generalized  hyperhidrosis or secondary hyperhidrosis. It is usually the result of some other, underlying condition. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10940", "text": "Primary or  focal  hyperhidrosis may be further divided by the area affected, for instance, palmoplantar hyperhidrosis (symptomatic sweating of only the hands or feet) or  gustatory hyperhidrosis  (sweating of the face or chest a few moments after eating certain foods). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10941", "text": "Hyperhidrosis can also be classified by onset, either congenital (present at birth) or acquired (beginning later in life). Primary or  focal hyperhidrosis  usually starts during adolescence or even earlier and seems to be inherited as an  autosomal  dominant genetic trait. It must be distinguished from  secondary  hyperhidrosis, which can start at any point in life, but usually presents itself after 25 years of age. Secondary hyperhidrosis commonly accompanies conditions such as diabetes mellitus, Parkinson's disease, hyperthyroidism, hyperpituitarism, anxiety disorder, pheochromocytoma, and menopause. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10942", "text": "One classification scheme uses the amount of skin affected. [ 12 ]  In this scheme, excessive sweating in an area of 100\u00a0 cm 2  (16\u00a0 in 2 ) or more is differentiated from sweating that affects only a small area. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10943", "text": "Another classification scheme is based on possible causes of hyperhidrosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10944", "text": "The cause of primary hyperhidrosis is unknown.  Anxiety  or excitement can exacerbate the condition. A common complaint of people is a nervous condition associated with sweating, then  sweat more because the person is nervous . Other factors can play a role, including certain  foods  and  drinks ,  nicotine ,  caffeine , and  smells . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10945", "text": "Similarly, secondary (generalized) hyperhidrosis has many causes including certain types of  cancer , disturbances of the  endocrine system ,  infections , and medications. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10946", "text": "Primary (focal) hyperhidrosis has many causes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10947", "text": "A variety of cancers have been associated with the development of secondary hyperhidrosis including  lymphoma ,  pheochromocytoma ,  carcinoid  tumors (resulting in  carcinoid syndrome ), and tumors within the  thoracic cavity . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10948", "text": "Certain endocrine conditions are also known to cause secondary hyperhidrosis including  diabetes mellitus  (especially when  blood sugars are low ),  acromegaly ,  hyperpituitarism ,  pheochromocytoma  (tumor of the  adrenal glands , present in 71% of patients) and various forms of  thyroid disease . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10949", "text": "Use of  selective serotonin reuptake inhibitors  (e.g.,  sertraline ) is a common cause of medication-induced secondary hyperhidrosis. [ 4 ]  Other medications associated with secondary hyperhidrosis include  tricyclic antidepressants ,  stimulants ,  opioids ,  nonsteroidal anti-inflammatory drugs  (NSAIDs),  glyburide ,  insulin ,  anxiolytic  agents,  adrenergic agonists , and  cholinergic agonists . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10950", "text": "Symmetry of excessive sweating in hyperhidrosis is most consistent with primary hyperhidrosis. [ 4 ]  To diagnose this condition, a dermatologist gives the person a physical exam. This includes looking closely at the areas of the body that sweat excessively. A dermatologist also asks very specific questions. This helps the physician understand why the person has excessive sweating. Sometimes medical testing is necessary. Some patients require a test called the sweat test. This involves coating some of their skin with a powder that turns purple when the skin gets wet. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10951", "text": "Excessive sweating affecting only one side of the body is more suggestive of secondary hyperhidrosis and further investigation for a neurologic cause is recommended. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10952", "text": "Antihydral cream is one of the solutions prescribed for hyperhidrosis for palms. [ 14 ] [ 15 ]  Topical agents for hyperhidrosis therapy include  formaldehyde  lotion and topical anticholinergics. These agents reduce perspiration by  denaturing   keratin , in turn occluding the pores of the  sweat glands . They have a short-lasting effect. Formaldehyde is classified as a probable human  carcinogen . Contact sensitization is increased, especially with formalin.  Aluminium chlorohydrate  is used in regular  antiperspirants . However, hyperhidrosis requires solutions or gels with a much higher concentration. These antiperspirant solutions or hyperhidrosis gels are especially effective for treatment of  axillary  or underarm regions. It takes three to five days to see improvement. The most common side-effect is  skin irritation . For severe cases of plantar and palmar hyperhidrosis, there has been some success with conservative measures such as higher strength aluminium chloride antiperspirants. [ 16 ]  Treatment algorithms for hyperhidrosis recommend topical antiperspirants as the first line of therapy for hyperhidrosis. The International Hyperhidrosis Society has published evidence-based treatment guidelines for  focal  and generalized hyperhidrosis. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10953", "text": "Prescription medications called  anticholinergics , often taken by mouth, are sometimes used in the treatment of both generalized and focal hyperhidrosis. [ 18 ]  Anticholinergics used for hyperhidrosis include  propantheline ,  glycopyrronium bromide  or  glycopyrrolate ,  oxybutynin ,  methantheline , and  benzatropine . Use of these drugs can be limited, however, by side-effects, including dry mouth,  urinary retention , constipation, and visual disturbances such as  mydriasis  and  cycloplegia . For people who find their hyperhidrosis is made worse by anxiety-provoking situations ( public speaking , stage performances, special events such as weddings, etc.), taking an anticholinergic medicine before the event may help. [ 19 ]  In 2018, the U.S.  Food and Drug Administration  (FDA) approved the  topical  anticholinergic  glycopyrronium tosylate  for the treatment of primary axillary hyperhidrosis. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10954", "text": "For peripheral hyperhidrosis, some people have found relief by simply ingesting crushed ice water. Ice water helps to cool excessive body heat during its transport through the blood vessels to the extremities, effectively lowering overall body temperature to normal levels within ten to thirty minutes. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10955", "text": "Injections of  botulinum toxin  type A can be used to block neural control of sweat glands. The effect can last from 3\u20139 months depending on the site of injections. [ 23 ]  This use has been approved by the U.S.  Food and Drug Administration  (FDA). [ 24 ]  The duration of the beneficial effect in primary palmar hyperhidrosis has been found to increase with repetition of the injections. [ 25 ]  The Botox injections tend to be painful. Various measures have been tried to minimize the pain, one of which is the application of ice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10956", "text": "This was first demonstrated by Khalaf Bushara and colleagues as the first nonmuscular use of BTX-A in 1993. [ 26 ]  BTX-A has since been approved for the treatment of  severe primary axillary hyperhidrosis  (excessive underarm sweating of unknown cause), which cannot be managed by topical agents. [ when? ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10957", "text": "miraDry , a  microwave -based device, has been tried for excessive underarm perspiration and appears to show promise. [ 29 ]  With this device, rare but serious side effects exist and are reported in the literature, such as paralysis of the upper limbs and  brachial plexus . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10958", "text": "Tap water  iontophoresis  as a treatment for palmoplantar hyperhidrosis was originally described in the 1950s. [ 31 ]  Studies showed positive results and good safety with tap water iontophoresis. [ 32 ]  One trial found it decreased sweating by about 80%. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10959", "text": "Sweat gland removal or destruction is one surgical option available for axillary hyperhidrosis (excessive underarm perspiration). There are multiple methods for sweat gland removal or destruction, such as sweat gland suction, retrodermal curettage, and axillary liposuction, Vaser, or Laser Sweat Ablation. Sweat gland suction is a technique adapted for liposuction. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10960", "text": "The other main surgical option is  endoscopic thoracic sympathectomy  (ETS), which cuts, burns, or clamps the thoracic ganglion on the main sympathetic chain that runs alongside the spine. Clamping is intended to permit the reversal of the procedure. ETS is generally considered a \"safe, reproducible, and effective procedure and most patients are satisfied with the results of the surgery\". [ 35 ]  Satisfaction rates above 80% have been reported, and are higher for children. [ 36 ] [ 37 ]  The procedure brings relief from excessive hand sweating in about 85\u201395% of people. [ 38 ]  ETS may be helpful in treating axillary hyperhidrosis, facial blushing and facial sweating, but failure rates in people with facial blushing and/or excessive facial sweating are higher and such people may be more likely to experience unwanted side effects. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10961", "text": "ETS side-effects have been described as ranging from trivial to devastating. [ 40 ]  The most common side-effect of ETS is compensatory sweating (sweating in different areas than prior to the surgery). Major problems with compensatory sweating are seen in 20\u201380% of people undergoing the surgery. [ 41 ] [ 42 ] [ 43 ]  Most people find the compensatory sweating to be tolerable while 1\u201351% claim that their quality of life decreased as a result of  compensatory sweating .\" [ 36 ]  Total body perspiration in response to heat has been reported to increase after sympathectomy. [ 44 ]  The original sweating problem may recur due to nerve regeneration, sometimes as early as 6 months after the procedure. [ 41 ] [ 42 ] [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10962", "text": "Other possible side-effects include  Horner's Syndrome  (about 1%),  gustatory  sweating (less than 25%) and excessive dryness of the palms (sandpaper hands). [ 46 ]  Some people have experienced cardiac sympathetic denervation, which can result in a 10% decrease in heart rate both at rest and during exercise, resulting in decreased exercise tolerance. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10963", "text": "Percutaneous sympathectomy is a minimally invasive procedure similar to the botulinum method, in which nerves are blocked by an injection of  phenol . [ 48 ]  The procedure provides temporary relief in most cases. Some physicians advocate trying this more conservative procedure before resorting to surgical sympathectomy, the effects of which are usually not reversible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10964", "text": "Hyperhidrosis can have physiological consequences such as cold and clammy hands, dehydration, and skin infections secondary to maceration of the skin. Hyperhidrosis can also have devastating emotional effects on one's individual life. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10965", "text": "Those with hyperhidrosis may have greater stress levels and more frequent depression. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10966", "text": "Excessive sweating or focal hyperhidrosis of the hands interferes with many routine activities, [ 51 ]  such as securely grasping objects. Some people with focal hyperhidrosis sufferers avoid situations where they will come into physical contact with others, such as greeting a person with a handshake. Hiding embarrassing sweat spots under the armpits limits the affected person's arm movements and pose. In severe cases, shirts must be changed several times during the day and require additional showers both to remove sweat and control body odor issues or microbial problems such as acne, dandruff, or athlete's foot. Additionally, anxiety caused by self-consciousness to the sweating may aggravate the sweating. Excessive sweating of the feet makes it harder for people to wear slide-on or open-toe shoes, as the feet slide around in the shoe because of sweat. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10967", "text": "Some careers present challenges for people with hyperhidrosis. For example, careers that require the use of a knife may not be safely performed by people with excessive sweating of the hands. The risk of  dehydration  can limit the ability of some to function in extremely hot (especially if also humid) conditions. [ 53 ]  Even the playing of musical instruments can be uncomfortable or difficult because of sweaty hands. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10968", "text": "It is estimated that the incidence of focal hyperhidrosis may be as high as 2.8% of the population of the United States. [ 51 ]  It affects men and women equally, and most commonly occurs among people aged 25\u201364 years, though some may have been affected since early childhood. [ 51 ]  About 30\u201350% of people have another family member affected, implying a  genetic  predisposition. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10969", "text": "In 2006, researchers at  Saga University  in Japan reported that primary palmar hyperhidrosis maps to gene locus 14q11.2\u2013q13. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10970", "text": "The  Journal of Cardiothoracic Surgery  is an  open access ,  peer-reviewed  online journal that encompasses all aspects of research in  cardiothoracic surgery .The Journal publishes original scientific research related to all domains of cardiac, vascular and thoracic surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10971", "text": "1) Editorial Board:  https://cardiothoracicsurgery.biomedcentral.com/about/editorial-board"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10972", "text": "2) Instruction for Authors:  https://www.biomedcentral.com/about/foreditors"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10973", "text": "Lung surgery  is a type of  thoracic surgery  involving the repair or removal of  lung  tissue, [ 1 ]  and can be used to treat a variety of conditions ranging from  lung cancer  to  pulmonary hypertension . Common operations include anatomic and nonanatomic resections,  pleurodesis  and  lung transplants . Though records of lung surgery date back to the  Classical Age , new techniques such as  VATS  continue to be developed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10974", "text": "The first written records of lung surgery were provided by  Hippocrates , where he described a treatment for thoracic  empyema  by means of drainage. [ 2 ]  Thoracic procedures became more viable with the advent of  positive pressure ventilation , [ 3 ]  introduced by  Samuel Meltzer  in 1909. This technique enables surgeons to conduct open chest procedures without risking  hypoxia , [ 4 ]  significantly decreasing patient mortality and is presently used in conjunction with  double-lumen endotracheal intubation  to isolate the ventilation of the affected lung during surgery. [ 5 ]  The 20th century saw further innovation of new procedures, such as the first-ever  pneumonectomy  performed by  Evarts Graham  in 1933. [ 6 ]  A breakthrough in minimally invasive lung surgery was also achieved in the form of  thoracoscopy , developed by  Hans Christian Jacobaeus  in 1910 as a method to diagnose  tuberculosis . Thoracoscopy was later used by surgeons to perform chest operations without  open thoracotomy . [ 7 ]  However, the latter remains a widely used method to access the  pleural cavity . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10975", "text": "Before the advent of  tuberculosis chemotherapy  in the 1940s, the disease was treated via collapse therapy. [ 9 ]  This involved the creation of an artificial  pneumothorax , aimed at resting the infected lung to limit infection spread and accelerate healing. The traumatic nature of collapse therapy and the discovery of antituberculosis drugs has rendered the former obsolete. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10976", "text": "Lung cancer can be classified into two main types:  non-small cell lung cancer  (NSCLC) and  small cell lung cancer  (SCLC). NSCLC, the most common of the two types, is a group of cancers including  squamous cell carcinoma ,  adenocarcinoma  and  large cell carcinoma . [ 11 ]  SCLC is highly aggressive and consists of small ovoid cells. [ 12 ]  Surgical resection is used curatively in stage I-III NSCLC and  palliatively  in stage IV. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10977", "text": "A  pneumothorax , also known as a collapsed lung, is a collection of air outside the lung in the pleural cavity. [ 14 ]  Depending on etiology, a pneumothorax is classified as spontaneous, traumatic and  iatrogenic . A spontaneous pneumothorax is further classified as primary and secondary, with the former occurring in individuals with no clinical lung disease and the latter occurring as a complication of preexisting lung disease. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10978", "text": "Chronic obstructive pulmonary disease  (COPD) is a group of diseases that results in airflow blockage and therefore cause breathing-related issues. COPD includes  emphysema  as well as chronic  bronchitis . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10979", "text": "Cystic fibrosis  is a genetic disease, caused by a mutation that results in defects in movement of salt and water in and out of cells which can cause sticky mucus in the body\u2019s tubes and passageways such as in the lungs. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10980", "text": "Pulmonary hypertension  occurs as a result of excess pressure in the blood vessels from the heart to the lungs. An increased amount of muscle in the walls of the blood vessels to the lung is prominent in cases with pulmonary hypertension. Although there are treatments such as  oxygen therapy  and medicine that is given to reduce swelling, lung transplantation may be necessary in some extreme cases. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10981", "text": "Idiopathic pulmonary fibrosis  causes the lungs to become scarred which results in a difficulty in breathing. The causes are of this disease is still not fully known, however, prevention methods include self-care such as stopping smoking and exercising. Medicines such as  pirfenidone  and  nintedanib  are also commonly used in order to reduce the rate of scarring in the lungs. Lung transplantation is effective in certain cases, however this depends on the availability of healthy donor lungs. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10982", "text": "Anatomic resections refer to procedures where a section of the lung is removed with respect to lobar or segmental anatomy. [ 20 ]  These include pneumonectomies, lobectomies and segmentectomies and are commonly used for the treatment of NSCLC. Preoperative evaluations for resections include cancer  staging  via a chest  CT scan  and  PET scan , followed by assessments of pulmonary reserve volume and cardiac function to determine the amount of lung tissue that can be safely removed without developing pulmonary insufficiency. [ 21 ]  Following tissue removal, the resultant bronchial stumps are pressurised under water to check for air leaks before the resection is deemed complete. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10983", "text": "A  pneumonectomy  is the surgical removal of an entire lung. Due to the high morbidity and mortality of the procedure, its viability for treating lung cancer is a subject of debate. [ 23 ]  However, pneumonectomies are still used for lung carcinomas that are large and centrally located or have invaded the interlobar fissures. Another indication for the use this procedure is lung destruction due to chronic infections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10984", "text": "During a pneumonectomy, the pleural cavity is accessed through a  thoracotomy . With direct access to the tumour, the need for pneumonectomy is reassessed. After surgeons decide to proceed with the procedure, the  hilar structures  are dissected sequentially. The pulmonary artery, then the pulmonary veins, are divided via stapling. Next, the main bronchus is divided using a scalpel and the lung is removed from the pleural cavity. The bronchial stump is subsequently closed by  polyglactin   sutures . Finally,  mediastinal  lymph nodes are dissected. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10985", "text": "A  lobectomy  is the surgical removal of one of the five  lung lobes  (right upper, right middle, right lower, left upper and left lower lobes). [ 24 ]  Lobectomies are the most common type of lung surgery and the standard operation for most NSCLC patients. [ 25 ]  Though specific surgical techniques vary for each lobe, the general workflow is identical. The lobe to be resected is first visualized through  thoracotomy  or  thoracoscopy . Next, the surrounding  lymph nodes  are harvested to check for metastasis. After confirmation that no metastasis has taken place, the vasculature of the lobe is controlled by blood vessel division using a  stapler . Stapling is also used to divide the lobar bronchus and subsequently separate the lobe along the lung fissure(s). After the lobe is removed, lymph node dissection is completed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10986", "text": "Specific considerations exist for certain lobes. Right middle lobectomies are not usually carried out alone and are instead part of a bilobectomy alongside a right upper or lower lobectomy. Left upper lobectomies require additional caution to avoid arterial branches from the fissure and proximal  pulmonary artery . [ 21 ]  Another risk is the proximity of the  recurrent laryngeal nerve  to the upper mediastinal lymph nodes, which increases its risk of injury during lymph node dissection. [ 26 ]  Thus, a swallowing study is required if nerve damage is suspected postoperatively. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10987", "text": "A sleeve lobectomy is a lobectomy that is coupled with the removal of a part of the main bronchus. The ends of the bronchus are then rejoined to reattach any remaining lung lobes. [ 27 ]  This procedure is performed in lieu of pneumonectomy when surgeons determine the removal of the entire lung to be unnecessary for centrally located tumours. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10988", "text": "Segmentectomies  are the surgical removal of  bronchopulmonary segments  and often involve the removal of two adjacent segments. The pulmonary arterial branches to the segments are first identified then divided. Next, stapling is used to divide the segmental bronchi and separate the segments from the lung. [ 13 ]  Compared to lobectomies, this procedure has higher survivability for stage 1A patients with tumours \u2264 2\u00a0cm in diameter. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10989", "text": "Non-anatomic resections refer to the removal of lung tissue without respect to lobar or segmental anatomy. They can be used to treat a variety of lung diseases such as NSCLC and tuberculosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10990", "text": "A  wedge resection  is the non-anatomic removal of a triangular-shaped piece of tissue from the lungs. The utility of wedge resection in NSCLC is disputed. Wedge resection is currently used in NSCLC patients with low pulmonary function, or for pulmonary tuberculosis patients with multiple lesions which do not respect intersegmental boundaries. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10991", "text": "A bleb resection is the surgical removal of one or more  blebs , small collections of air between the lung and visceral pleura. Blebs may combine to form larger cysts named bullae. The rupture of blebs or bullae results in air leaking into the pleural space, causing a spontaneous pneumothorax. In most cases, patients will be unaware of blebs until they are detected by CT scans or cause noticeable symptoms such as chest pain. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10992", "text": "Bleb resections may be done via mini-thoracotomy or thoracoscopy. After inspection of the chest cavity, identified blebs are removed via dissection and stapling. To prevent future bleb formation, this procedure is often accompanied by pleurodesis. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10993", "text": "A pneumothorax is commonly treated with needle aspiration of air followed by  chest tube  drainage. In the case of a recurrent pneumothorax,  pleurodesis  may be used to prevent further air accumulation. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10994", "text": "Pleurodesis is the obliteration of the pleural space, achieved by adhering the visceral pleura on the lung surface to the costal pleura of the chest wall. Adhesion is caused by  inflammation  and subsequent scarring of the pleural layers. Inflammation may be induced by either physical or chemical irritation. The former is commonly used in younger patients and involves surgical abrasion. The latter involves the instillation of chemical sclerosant, usually sterile  talc , via a chest tube. Other sclerosing agents include  tetracycline  and  bleomycin . [ 30 ]  After sclerosant instillation, the patient may be moved through various positions to ensure even distribution. [ 13 ]  Due to the pain of this operation, it is accompanied by  local anaesthesia . Pleurodesis is also used in recurrent  pleural effusion , a common result of lung cancer. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10995", "text": "Lung transplant  is defined as \u2018an operation to remove and replace a diseased lung with a healthy human lung from a donor. A donor is most commonly known to be a deceased person, however, in very rare cases a section of the lung that is required for a patient can be transplanted from a living donor. Lung transplants are usually required when a patient has advanced lung disease whereby the disease is also unresponsive to other methods of treatment. Another significant reason for a lung transplant to be considered as a necessary option is if the patients\u2019 life expectancy is predicted to be under three years without the lung transplant procedure taking place. Typical conditions that are treated with a lung transplant include COPD, cystic fibrosis, pulmonary hypertension and idiopathic pulmonary fibrosis. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10996", "text": "Methods for the preservation of donor lungs are imperative in order to increase availability of lungs for transplantation which therefore increases the efficacy of the treatment as more available lungs for transplantation leads to more people being applicable to undergo the treatment/transplantation. Before an organ is removed from the donor for transplantation, the donor organ is commonly flushed free of blood with a preservation solution that is prepared to be ice-cold which also contains essential elements such as electrolytes and nutrients. Furthermore, when the organ is removed from the donor, it is packaged in wet ice for preservation of the organ. [ 32 ]  A therapy called  ex-vivo lung perfusion  that is commonly used for the donor lung just before transplantation provides an enhancement of the quality of the organ and can potentially make previously unsuitable organs, safe for transplantation. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10997", "text": "All lung surgeries breach the pleural cavity, which disrupts the negative intrapleural pressure and prevents normal breathing. [ 34 ]  Surgical trauma may also lead to  pleural effusion , further disrupting intrapleural pressure. [ 35 ]  To counteract these disruptions, a  chest tube  which is attached to a drainage system consisting of a collection chamber, one-way water valve and suction chamber is inserted into the patient. This enables air and fluid to be unidirectionally extracted from the pleural cavity. [ 36 ]  Chest tubes are usually removed one week after surgery along with any stitches or staples in the incisions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10998", "text": "Patients experiencing shortness of breath will be guided through deep breathing or coughing exercises by a physician or respiratory therapist. In severe cases, the patient will also receive oxygen supplementation through a mask or nostril tube. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_10999", "text": "A pneumonectomy comes with its own risks whereby the most common complications are  cardiac arrhythmia  as well as atrial fibrillation (or flutter), which commonly occurs in the first three days following the surgery. Furthermore, additional risks following this surgery include: cardiac herniation, pulmonary complications (e.g.  pneumonia ), bronchopleural fistula,  pulmonary oedema , multi-organ dysfunction, acute lung injury,  acute respiratory distress syndrome  (ARDS) and postoperative acute kidney injury. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11000", "text": "Lobectomies share many of the complications that come with a pneumonectomy. However, additional risks that can result from a lobectomy include  empyema , which is an area of pus in the chest cavity, as well as  pleural effusion , which occurs as a result of fluid in the space between the lung and inner chest wall. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11001", "text": "Similar to other anatomic resections, cardiac arrhythmia is a major complication for segmentectomy. Additionally,  hemorrhage  in the pleural cavity may occur due to injury to the pulmonary artery or its branches. Patients may also develop a  contralateral  pneumothorax, necessitating the placement of a chest tube to eliminate air within the pleural cavity. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11002", "text": "Wedge resections share the complications of anatomic resections. [ 41 ]  However, the former generally has lower patient mortality. [ 30 ]  The major complications of bleb resection are prolonged air leak and pneumothorax recurrence. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11003", "text": "Pleurodesis may lead to a fever due to the induced inflammatory response. [ 43 ]  Chemical pleurodesis, specifically that using talc, may also cause ARDS via the  systemic absorption  of sclerosant. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11004", "text": "Lung transplantation is an intricate treatment that can provide efficient results, however, there are risks that come with this procedure which include: bleeding, infection, blockage of the blood vessels to the new lungs, blockage of the airways, severe  pulmonary oedema  as well as potential blood clot formation. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11005", "text": "Lung surgeries can be perceived as invasive procedures that may cause side effects such as bruising, swelling, numbness, pain, scarring and infection. However, new methods such as  video-assisted thoracoscopic surgery  (VATS) provide a minimally invasive method which can eliminate diseased parts of the lungs and lymph nodes. A development of thoracoscopy, VATS utilizes small, high-resolution cameras which are inserted into the chest through small incisions. This grants surgeons a high degree of visibility into the pleural cavity despite making smaller incisions, resulting in quicker patient recovery. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11006", "text": "Moreover, treatment for lung cancer has been further developed with the use of  robotic surgery  as a method for treatment. This method involves the use of robotic arms which are manipulated by a surgeon at a console, enabling more precise movements and providing the surgeon with 3D vision of the surgical site. [ 47 ]  Similar to VATS, robotic surgery has also been found to be minimally invasive and is extremely useful for removing certain parts of lung tissue that are diseased as well as surrounding lymph nodes. [ 48 ]  However, comparisons of current robotic methods with VATS have shown no significant differences in patient outcome. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11007", "text": "Rib removal  is  surgery  to remove one or more  ribs .  Rib resection  is the removal of part of a rib. [ 1 ]  The procedures are done for various medical reasons. A number of celebrities have been falsely rumoured to have had ribs removed as a form of  body modification . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11008", "text": "Rib removal may be medically approved in several situations. If a rib is fractured in such a way that it might puncture a vital organ, it may be safer to remove it than wait for it to heal. [ 1 ]  A  cancerous rib  may be removed to stop the cancer from spreading. [ 1 ]  Rib bone material may be used for a  bone graft . [ 1 ]  The excess pressure of  thoracic outlet syndrome  may be reduced by rib removal. [ 1 ]  Major surgery to the thoracic cavity, such as  open heart surgery , may require removal of ribs to allow access to the organ being operated on. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11009", "text": "Victorian fashion  valued a  wasp waist  and  hourglass figure  for women. This was achieved through laced  corsets . Twentieth-century rumors hold that some women had their lower ribs removed to facilitate tighter lacing of the waist. In 1931, corset-maker Rosa Binner alleged that French actress  Polaire  had had her lowest rib removed in the 1890s. [ 3 ]   Germaine Greer 's  second-wave feminist  book  The Female Eunuch  gives the practice as an example of male-directed distortion of the female body. [ 4 ]  Valerie Steele's history of the corset finds no evidence of such a procedure, and with Lynne Kutsche argues the mortal danger of surgery of the era makes it extremely implausible. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11010", "text": "Barbara Mikkelson of  Snopes.com  suggests that  Florenz Ziegfeld  might have started such a rumor about his prot\u00e9g\u00e9e  Anna Held  to publicize her career. [ 6 ]   Similar stories have been spread about later celebrities.  Cher  hired a physician in 1990 to confirm that she has a full set of ribs. [ 6 ]  It was rumored that  Marilyn Manson  had ribs removed to facilitate  autofellatio . [ 7 ] \nInterviewed for a  Vogue  article in 2000, John E. Sherman of  Weill Cornell Medical College  said that while such a procedure was theoretically possible, there was no record of it in the medical literature. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11011", "text": "Amanda Lepore  claimed that she had skirted the law to obtain a similar surgery.  She was quoted saying \"'I've had my boobs done, and my lips done, my bottom lip reduced, and my bottom rib broken and pushed in\u2014I think  Raquel Welch  and  Cher  did that, too. It's illegal in the US, but I had it done in Mexico. They break the  floating rib  in the back and push it in, so there's no scar.\" in an interview. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11012", "text": "In October 2015, internet model and self-proclaimed \"living doll\"  Pixee Fox  documented the procedure to remove her six lower ribs on her  Tumblr  account. The procedure shortened rather than fully removed the ribs. [ 10 ]  In an interview with  Closer , she stated that it was difficult to find a doctor willing to perform the surgery. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11013", "text": "The Society of Thoracic Surgeons  is a Chicago, Illinois (US)-based  medical specialty   professional society  in the field of  cardiothoracic surgery . Membership worldwide includes more than 7,500 surgeons, researchers, and other health care professionals who are part of the cardiothoracic surgery team. The Society's official journal is  The Annals of Thoracic Surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11014", "text": "The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. The Database has four components\u2014the Adult Cardiac Surgery Database (ACSD), the General Thoracic Surgery Database (GTSD), the Congenital Heart Surgery Database (CHSD), and the Intermacs Database\u2014and now houses more than 7.5 million surgical records. The STS National Database has grown to be the largest database of its kind in medicine and is one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11015", "text": "In late 2010, the Society launched an initiative through which participants of the ACSD could voluntarily report their performance on coronary artery bypass grafting (CABG) surgeries. Since then, ACSD public reporting has evolved to include aortic valve replacement (AVR) surgery and CABG+AVR; outcomes for isolated mitral valve replacement or mitral valve repair (MVRR) and combined MVRR+CABG are planned to be reported in early 2019. Public reporting from the CHSD was added in 2015, and public reporting from the GTSD began in 2017.  Consumer Reports  and  U.S. News & World Report  have both relied upon STS Public Reporting Online data for their respective hospital ratings programs. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11016", "text": "To meet the needs of an expanding specialty, a group of established young thoracic surgeons, led primarily by  Dr. R. Adams Cowley  of Baltimore, met in the late 1950s to exchange ideas concerning the feasibility of another thoracic surgical society. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11017", "text": "By April 1963, a committee comprising Dr. Cowley (Chairman), Dr. Francis X. Byron of Los Angeles, Dr. Clifford F. Storey of San Diego, Dr. J. Maxwell Chamberlain of New York, Dr. John D. Steele of San Fernando, Calif., Dr. Byron H. Evans of Fresno, Calif., Dr. Edgar P. Mannix of Manhasset, NY, Dr. Earle B. Kay of Cleveland, and Dr. John E. Miller of Baltimore, recommended that the a new society for thoracic and cardiovascular surgery be established. [ 5 ]  A planning committee was appointed, and an STS constitution was finalized in August 1963 at the home or Dr. Robert K. Brown in Denver. Officers and councilors were elected on October 31, 1963, and included Dr. Paul C. Samson as president, Dr. Thomas H. Burford as vice president, Dr. Byron as secretary, and Dr. John E. Steele as editor of  The Annals of Thoracic Surgery . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11018", "text": "The first STS Annual Meeting was held in St. Louis in January 1965."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11019", "text": "The initial management activities of STS were conducted from the office of Dr. J. Maxwell Chamberlain in New York. By 1969, when membership in the Society had grown to approximately 700, it was decided that management activities would be handled by a professional management organization. Smith, Bucklin and Associates (SBA) managed STS from 1969 to 2002, but in the later years of the SBA era, the Society's leadership felt the organization had grown so robust that it was time to hire a staff of dedicated STS employees."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11020", "text": "The transition to self-management was successfully implemented under the direction of Mark B. Orringer, MD, who completed his term as STS President, and William A. Baumgartner, MD, his successor as President."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11021", "text": "On June 1, 2002, STS opened its headquarters office in the American College of Surgeons building in Chicago with 9.5 full-time employee equivalents, including Executive Director & General Counsel Robert A. Wynbrandt, and a membership that had grown to more than 4,100. In 2004, a dedicated STS office in Washington, DC, was established; by 2018, the STS staff in Chicago and Washington had grown to approximately more than 65 full-time employees, and membership had grown to more than 7,500."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11022", "text": "STS manages and provides staff support for five affiliate organizations, including its charitable arm, The Thoracic Surgery Foundation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11023", "text": "Oral and maxillofacial surgery  is a surgical specialty focusing on  reconstructive surgery  of the  face ,  facial trauma   surgery , the  mouth ,  head  and  neck , and  jaws , as well as facial  plastic surgery  including cleft lip and cleft palate surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11024", "text": "An oral and maxillofacial surgeon is a specialist  surgeon  who treats the entire  craniomaxillofacial complex :  anatomical  area of the  mouth ,  jaws ,  face , and  skull , head and neck as well as associated structures. Depending upon the national jurisdiction, oral and maxillofacial surgery may require a degree in  medicine ,  dentistry  or both."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11025", "text": "In the U.S., oral and maxillofacial surgeons, whether possessing a single or dual degree, may further specialize after residency, undergoing additional one or two year sub-specialty oral and maxillofacial surgery fellowship training in the following areas:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11026", "text": "In countries such as the UK and most of Europe, it is recognised as a  specialty of medicine  with a degree in medicine and an additional degree in dentistry being compulsory. [ 1 ]  The scope of practice is mainly  head and neck cancer ,  microvascular reconstruction ,  craniofacial surgery  and  cranio-maxillofacial trauma , skin cancer, facial deformity, cleft lip and palate, craniofacial surgery,  TMJ  surgery and  cosmetic facial surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11027", "text": "In the UK, Maxillofacial surgery is a specialty of the  Royal College of Surgeons of England ,  Royal College of Surgeons of Edinburgh . Intercollegiate Board Certification is provided through the JCIE, and is the same as Plastic Surgery, ENT, General Surgery, Orthopaedics, Paediatric Surgery, Neurosurgery and Cardiothoracic Surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11028", "text": "The FRCS (Fellowship of the Royal College of Surgeons) is the specialist exam at the end of surgical training, and is required to work as a Consultant Surgeon in Maxillofacial Surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11029", "text": "In the EU, OMFS is defined within Directive 2005/36 on professional qualifications (updated 2021). The two OMFS specialties are 'dual degree' dental, oral, and maxillofacial surgery (DOMFS) and 'single medical degree' maxillofacial surgery (MFS). In some cases a dental degree may be required to enter specialty training but in all cases the medical degree must be obtained before starting OMFS specialty training.  [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11030", "text": "In Poland, Maxillofacial Surgery has always been dominated by dentists and still the majority of current OMFS trainees are dental graduates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11031", "text": "Since 2019, Norway switched from dual degree requirement for Maxillofacial Surgery to medical degree only. Similarly, Sweden has started several Maxillofacial Surgery training programs for medical graduates.\n [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11032", "text": "In Asia, oral and maxillofacial surgery is also recognized as a dental specialty and requires a degree in dentistry prior to surgical residency training. The Canadian model is the same as the model used in the United States of America."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11033", "text": "In Pakistan, OMFS is recognized as specialty of dentistry which requires FCPS from CPSP after 4 years BDS degree and a one-year housejob. The candidate has to pass FCPS-1 in order to commence his/her training followed by PGMI Exam(not in all cases). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11034", "text": "Oral and maxillofacial surgery, also known as OMFS, is a branch recognized by DCI (Dental Council of India) in countries such as India. In India, becoming a maxillofacial surgeon requires a five-year dental degree followed by three years of post-graduate specialisation. In India, oral and maxillofacial surgery includes the treatment of complex dental surgery, including wisdom tooth removal, dental implant, craniomaxillofacial trauma, Orofacial pain (trigeminal neuralgia) and jaw joint pain (Temporomandibular disorder(TMD) or TMJ Pain) management, jaw joint(TMJ) replacement for TMJ ankylosis and deformed jaw joint cases, Lefort-3 distraction for Craniosynostosis case, jaw tumor and cyst removal surgery, head and neck cancer, facial aesthetic like rhinoplasty, eye and ear plastic surgery, Facial cosmetic surgery, microvascular surgery, and cleft and craniomaxillofacial surgery. In India, a Maxillofacial surgeon is considered one of the required members of the emergency team. Almost 20-25% of trauma patients usually have sustained facial trauma, and that needs urgent opinion and primary management that can be better managed by Maxillofacial experts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11035", "text": "In Australia and New Zealand, oral and maxillofacial surgery is recognised as both a specialty of medicine and dentistry. Degrees in both medicine and dentistry are compulsory prior to being accepted for surgical training. The scope of practice is broad and there is the ability to undertake subspecialty fellowships in areas such as head and neck surgery and microvascular reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11036", "text": "In other countries, oral and maxillofacial surgery as a specialty exists but under different forms, as the work is sometimes performed by a single or dual qualified specialist depending on each country's regulations and training opportunities available. In several countries, oral and maxillofacial surgery is a specialty recognized by a professional association, as is the case with the Dental Council of India, American Dental Association,  Royal College of Surgeons of England ,  Royal College of Surgeons of Edinburgh , Royal College of Dentists of Canada,  Royal Australasian College of Surgeons  and Brazilian Federal Council of Odontology (CFO)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11037", "text": "Oral and maxillofacial surgery is an internationally recognized surgical specialty. Oral and maxillofacial surgery is formally designated as either a medical, dental or dual (medical and dental) specialty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11038", "text": "In the United States, oral and maxillofacial surgery is a recognized  surgical specialty , formally designated as a dental specialty. A professional dental degree is required, [ 5 ]  a qualification in medicine may be undertaken optionally during residency training. In this respect, oral and maxillofacial surgery is  sui generis  among  surgical specialties . [ 6 ]  Oral and maxillofacial surgery requires an extensive 4-6 year surgical residency training covering the U.S. specialty's scope of practice: surgery of the oral cavity,  dental implant  surgery,  dentoalveolar  surgery, surgery of the  temporomandibular joint ,  general surgery ,  reconstructive surgery  of the  face ,  head and neck ,  mouth , and  jaws , facial  cosmetic surgery ,  facial deformity ,  craniofacial surgery , facial  skin cancer ,  head and neck cancer ,  microsurgery  free flap reconstruction,  facial trauma , facial  trauma surgery  and, uniquely, the administration of  general anesthesia  and deep  sedation . [ 7 ]  As is the norm among surgical specialists, oral and maxillofacial surgery residents typically serve as  Chief Resident  in their final year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11039", "text": "Following residency training, oral and maxillofacial surgeons, whether single or dual degree, have the option of undergoing 1-2 year surgical sub-specialty  fellowship  for further training in  head and neck cancer ,  microvascular reconstruction ,  cosmetic facial surgery ,  craniofacial surgery  and  cranio-maxillofacial trauma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11040", "text": "Board certification in the U.S. is governed by the American Board of Oral and Maxillofacial Surgery (ABOMS). [ 8 ]  Oral and maxillofacial surgery is among the fourteen  surgical specialties  recognized by the  American College of Surgeons . [ 9 ]  Oral and maxillofacial surgeons in the United States, whether single or dual degree, may become Fellows of the American College of Surgeons, \"FACS\" (Fellow, American College of Surgeons). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11041", "text": "The  American Association of Oral and Maxillofacial Surgeons  (AAOMS) is the chief professional organization representing the roughly 9,000 oral and maxillofacial surgeons in the United States. [ 11 ]  The American Association of Oral and Maxillofacial Surgeons publishes the peer-reviewed  Journal of Oral and Maxillofacial Surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11042", "text": "In the U.S., oral and maxillofacial surgeons are required to undergo five months of intensive general anesthesia training. An additional month of pediatric anesthesia training is also required. The  American Society of Anesthesiologists  published a  Statement on the Anesthesia Care Team  which specifies qualified anesthesia personnel and practitioners as anesthesiologists, anesthesiology fellows, anesthesiology residents, and oral and maxillofacial surgery residents. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11043", "text": "Unique among surgical specialists in the U.S., [ 13 ]  oral and maxillofacial surgeons are trained to administer  general anesthesia  and deep  sedation , and they are licensed to do so in both hospital and office settings. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11044", "text": "In the specialty's infancy, dental and oral surgeons were plenary in the introduction of  anesthesia  to modern  medicine  and the development of modern  surgery . In 1844, at  Harvard Medical School 's  Massachusetts General Hospital , dentist, Dr.  Horace Wells  was the first to use anesthesia, but with limited success. On 16 October 1846, Boston oral surgeon, Dr.  William Thomas Green Morton  gave a successful demonstration using  diethyl ether  to Harvard medical students at the same venue. In one of the most important and well documented events in American medical history, Morton was invited to Massachusetts General Hospital to demonstrate his technique for painless surgery. After Morton had induced anesthesia, Dr.  John Collins Warren , a founding member of Massachusetts General Hospital, the hospital's first surgeon, and the first Dean of Harvard Medical School, removed a  tumor  from the neck of patient,  Edward Gilbert Abbott . The demonstration was performed in the surgical amphitheater now called the  Ether Dome  at  Harvard . Massachusetts General Hospital views the demonstration as among the institution's most significant claims to fame. Upon the successful completion of Dr. Morton's demonstration, Dr. Warren famously proclaimed to the crowded, astonished and elated amphitheater, what would become likely the most famous words in modern medicine, \"Gentlemen, this is no humbug.\" Indeed, the event marked the beginning of modern anesthesia and surgical practice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11045", "text": "Immediately following the demonstration, in a congratulatory letter to Dr. William Thomas Green Morton,  polymath  and later Harvard Medical School Dean,  Oliver Wendell Holmes Sr. , father of Justice  Oliver Wendell Holmes Jr.  of the  Supreme Court of the United States , proposed naming the state produced \"anesthesia\", and the procedure an \"anesthetic.\" [ 15 ]  Holmes wrote to Morton, \"Everybody wants to have a hand in a great discovery. All I will do is to give a hint or two as to names\u2014or the name\u2014to be applied to the state produced and the agent. The state should, I think, be called 'Anaesthesia.' This signifies insensibility\u2014more particularly ... to objects of touch.\" Holmes added poetically that the new term \"will be repeated by the  tongues  of every civilized [member] of mankind.\" [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11046", "text": "Dr. Ferdinand Hasbrouck, a New York oral surgeon and an 1870 graduate of the  University of Pennsylvania School of Dental Medicine  was among the first practitioners to succeed in the regular and commercial use of anesthesia in private surgical practice. [ 17 ]  In 1893, U.S.  President Grover Cleveland  was diagnosed with an intraoral tumor. The President chose Dr. Hasbrouck to serve among his team of surgeons and simultaneously as  the   anesthesiologist  for the procedure. For political reasons, Cleveland did not want the public to know about his condition. [ 18 ]  The operation was performed in secret on the yacht  Oneida  in the Long Island Sound, NY. Dr. Hasbrouck, induced President Cleveland with  nitrous oxide  and extracted teeth from the corpus of the tumor. As Cleveland recovered from nitrous oxide, Dr. Hasbrouck began the administration of ether for the remainder of the procedure as he and the team performed the tumor surgery. [ 19 ]  The procedure was a milestone for the practice of anesthesia. [ 20 ]  Ferdinand Hasbrouck's son, James F. Hasbrouck, discussed below, was among the founders of the  Columbia University  College of Dental and Oral Surgeons in 1916. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11047", "text": "In 1945, oral and maxillofacial surgeon, Dr. Niels Jorgensen was first to develop intravenous moderate  sedation . His technique, administering  pentobarbital ,  meperidine  and  scopolamine  intravenously, was widely accepted and first taught at  Loma Linda University School of Medicine , beginning in 1945."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11048", "text": "In the United States, a close educational and professional relationship between oral and maxillofacial surgery and anesthesiology persists to the present day. [ 22 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11049", "text": "Oral and maxillofacial surgery stands as a pillar of the modern practice of  plastic surgery  and plastic surgery's recognition in 1941 [ 23 ]  as a surgical specialty in the United States. In the early 1900s, plastic surgery was founded by a professional organization of oral surgeons with elite training and an interest in plastic and reconstructive surgery, the American Association of Oral and Plastic Surgery. [ 24 ]  Over time, the exclusive organization began to elect a small number of non-oral surgeon members, the first of which was legendary general surgeon Dr. Vilray Blair of Washington University in St. Louis. The organization became the American Association of Plastic Surgeons in 1921. [ 25 ]  At  Harvard University , oral and maxillofacial surgeon, Dr.  Varaztad Kazanjian  pioneered plastic surgery and is considered to be a founder, if not,  the  founder of the modern practice of plastic surgery. He graduated from  Harvard School of Dental Medicine  in 1905. Dr. Kazanjian was Professor of Clinical Oral Surgery at Harvard from 1922 to 1941 when he was named Harvard's first Professor of Plastic Surgery. Dr. Kazanjian was instrumental in plastic surgery's formal recognition as an independent surgical specialty in 1941. Dr. Kazanjian joined the First Harvard Unit, serving with the British Forces in WWI, establishing the first dental and maxillofacial clinic in France, handling more than 3,000 cases of severe wounds to the face and jaws. He was honored for his surgical advances by British monarch  George V , who invested him Companion to the  Order of St Michael and St George . [ 26 ]  Kazanjian served as an early president of American Association of Plastic Surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11050", "text": "Another founder and god-father of plastic surgery was  University of Pennsylvania  oral surgeon, Dr.  Robert H. Ivy , an 1898  University of Pennsylvania School of Dental Medicine  graduate, developed the surgical treatment of  cleft lip  and  cleft palate . The inter-maxillary fixation technique, the  Ivy Loop  is named after him. Ivy is considered a pioneer and father of the modern practice of plastic surgery. Ivy was influenced by Dr. Vilray Blair of  Washington University School of Medicine . [ 25 ]  Ivy founded the  Journal of Plastic and Reconstructive Surgery , plastic surgery's premier peer-reviewed academic journal and the American Association of Oral and Plastic Surgeons and served as its president. In 1919, New York City oral and maxillofacial surgeon, Dr. Armin Wald, an 1896 graduate of  New York University College of Dentistry , was among the first in the United States [ 27 ]  to successfully demonstrate and publish a procedure for alveolectomy and  alveoloplasty , the surgical resection and smoothing of the ridge of the mandible and maxilla for cosmetic and prosthetic purposes. [ 28 ]  Once mastered, the innovative procedure was remarkably simple; to the present, the procedure is commonplace among oral, plastic and ENT surgeons performing  alveolar ridge  reconstruction and  bone grafting . Wald was influenced by his father, Henry Wald, M.D., [ 29 ]  an 1872  University of Vienna Faculty of Medicine  graduate [ 30 ]  and preceptor in surgery at  Columbia College   School of Medicine ; [ 31 ]  their nephew,  Charles A. Reich , became a law professor at  Yale . Wald's partner, [ 32 ]   New York University  oral and maxillofacial surgeon, Dr. James F. Hasbrouck, [ 33 ]  interested in the development of the surgical specialty in New York, [ 34 ]  was among the founders of the Columbia University College of Dental and Oral Surgery in 1916. [ 21 ]  In keeping with the ideals of the American Association of Oral and Plastic Surgeons, the first two years of coursework at the new college were fully unified with Columbia's College of Physicians and Surgeons, [ 35 ]  of which Hasbrouck was an 1894 graduate. [ 36 ]  Students devoted their entire second two years to specialization in surgery at Columbia Presbyterian Hospital, which provided extraordinary preparation for the possibility of post-graduate residency training in oral surgery. [ 35 ]  Hasbrouck was notable in the specialty for having received both a dental and medical degree prior to 1895. His father, oral surgeon, Ferdinand Hasbrouck, discussed above, was a pioneer in  anesthesiology . Hasbrouck's and Wald's sons, Theodore F. Hasbrouck and Arthur H. Wald [ 37 ]  both graduated from Columbia's College of Dental and Oral Surgery in 1937. [ 38 ]  Arthur Wald made further advances in  grafting  in oral, plastic and reconstructive surgery [ 39 ]  with the early use of  fibrin  foam and  thrombin  in the resection of large and rare mandibular tumors. [ 40 ]  He served in the  United States Army Air Forces  during  World War II  and owned a cosmetic practice in midtown  Manhattan . Globally, the role of oral and maxillofacial surgery was also profound in the founding of plastic surgery: outside the United States, fathers of plastic surgery include London based  otolaryngologist  Sir  Harold Gillies [ 41 ]  and his French mentor, the  oral and maxillofacial surgeon  Dr.  Hippolyte Morestin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11051", "text": "Oral and maxillofacial surgery's stature and clout in university hospitals can be traced to its plenary role in the development of modern medicine and surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11052", "text": "While a professional dental degree,  i.e. , D.D.S. or D.M.D. is mandatory in the U.S., oral and maxillofacial surgeons may possess various doctoral degree combinations,  e.g. , D.D.S., D.M.D., D.D.S./M.D., D.M.D./M.D., D.M.D./Ph.D. or D.D.S./Ph.D. Still, it is the completion of an oral and maxillofacial residency training program and corresponding certificate of specialty training that confers surgical specialty status and board eligibility, [ 42 ]  not the surgeon's professional degree or degree combination. [ 43 ]  Analogously, it is a certificate of specialty training and board eligibility that satisfies state licensure requirements to administer  general anesthesia [ 44 ]  and deep  sedation , not the surgeon's professional degree or degree combination. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11053", "text": "D.D.S. (Doctor of Dental Surgery) and D.M.D. (Doctor of Medicine in Dentistry or Doctor of Dental Medicine) are the same degrees. D.M.D. and D.D.S. represent the same education. The letters used are a function of university discretion, both degrees represent an identical curriculum, set of educational requirements and level of educational attainment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11054", "text": "Oral and maxillofacial surgery [ 45 ]  is assigned Health Care Provider Taxonomy Code: 204E00000X  [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11055", "text": "In the United States and globally, treatments may be performed on the  craniomaxillofacial complex : mouth, jaws, face, neck, and skull, and include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11056", "text": "Oral and maxillofacial surgery is intellectually and physically demanding and is among the most highly compensated  surgical specialties  in the United States [ 47 ]  with a 2008 average annual income of $568,968. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11057", "text": "The popularity of oral and maxillofacial surgery as a career for persons whose first degree was medicine, not dentistry, seems to be increasing. At least one program (University of Alabama at Birmingham) exists that allows highly qualified candidates whose first degree is in medicine, to earn the required dental degree, so as to qualify for entrance into oral and maxillofacial residency training programs and ultimately achieve board eligibility and certification in the surgical specialty. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11058", "text": "In the UK, Oral and maxillofacial surgery is one of the ten medical specialties, requiring MRCS and FRCS examinations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11059", "text": "In mainland Europe, its status, including whether or not oral surgery, maxillofacial surgery and stomatology are considered separate specialties, varies by country. The required qualifications (medical degree, dental degree, or both, as well as the required internship and residency programs) also vary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11060", "text": "In the US, Australia and South Africa, Oral and maxillofacial surgery is one of the ten dental specialties recognized by the  American Dental Association ,  Royal College of Dentists of Canada , and the  Royal Australasian College of Dental Surgeons . Oral and maxillofacial surgery requires four to six years of further formal university training after dental school ( i.e. , DDS, BDent, DMD or BDS)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11061", "text": "Residency training programs are either four or six years in duration. In the  United States , four-year  residency  programs grant a certificate of specialty training in oral and maxillofacial surgery. Six year programs granting an optional  MD degree  emerged in the early 1990s in the United States. Typically, Six-year residency programs grant the specialty certificate and an additional degree such as a medical degree (e.g.,  MD , MBBS, MBChB) or research degree (e.g., MS, MSc, MPhil, MDS, MSD, MDSc, DClinDent, DSc, DMSc, PhD). Both four\u2013 and six\u2013year graduates are designated US \"Board Eligible\" and those who earn \"Board Certification\" are Diplomats. Approximately 50% of the training programs in the US and 66% [ 50 ]  of Canadian training programs are \"dual-degree.\" The typical total length of education and training, post-secondary school is 12 to 14 years. Beyond these years, some sub-specialize, adding an additional 1-2 year fellowship."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11062", "text": "The typical training program for an oral and maxillofacial surgeon is:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11063", "text": "In addition, single and dual qualified graduates of oral and maxillofacial surgery training programs can pursue post-residency sub-specialty fellowships, typically 1\u20132 years in length, in the following areas:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11064", "text": "A number of notable philanthropic organizations provide humanitarian oral and maxillofacial surgery around the globe.  Smile Train  was created in 1998 by  Charles Wang  focusing on childhood facial deformity.  Operation Smile  focuses on correcting cleft lips and palates in children.  AboutFace , created by  Paul Stanley , of the rock band KISS, who was born with a facial deformity, focuses on  craniofacial  disfiguration."}
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{"_id": "WikiPedia_Surgical_specialties$$$corpus_11067", "text": "Alveolar cleft grafting  is a surgical procedure, used to repair the defect in the  upper jaw  that is associated with  cleft lip and palate , where the bone defect is filled with bone or bone substitute, and any holes between the mouth and the nose are closed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11068", "text": "An alveolar cleft is a failure of the  premaxilla  to fuse with the  upper jaw  leaving a defect in the bone. It is common in people with  cleft palate  and is also associated with  holes  between the mouth and the nose that affects speech, and allows fluid to move into the nose when eating and drinking. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11069", "text": "Surgeries on the  roof of the mouth  early in life typically close the larger hole between the mouth and the nose (caused by the cleft in the palate) but  do not repair the defect in the bone, or any holes further  forward  between the  palate  and the upper lip.  About the age of 8, just before the  eye teeth  are about to erupt into the bone defect (the cleft),  braces  are used to first widen the upper jaw,  and position the premaxilla. Then, a surgery places bone or a bone substitute in the defect to allow the premaxilla to fuse to the rest of the maxilla, provide  bone  for eruption of the  canine , and  close  any remaining holes between the mouth and nose.  If completed early, the canine teeth will erupt into the mouth with good bone support and remain healthy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11070", "text": "Alveolar cleft grafting is used primarily to allow the eruption of the  maxillary canines  into the mouth between the ages of 8 and 13 years old.  It is also used to close oranasal  fistulas , stop fluid reflux into the nose, improve speech, support the  maxillary lateral  teeth, and stabilize the jaw for  orthodontics  or  orthognathic surgery . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11071", "text": "In cleft palate patients bone grafting during the mixed dentition has been widely accepted since the mid-1960s.  The goals of surgery are to stabilize the  maxilla , facilitate the healthy eruption of teeth that are adjacent the cleft, improving the esthetics of the base of the nose, create a bone base for  dental implants , and to close any oro-nasal  fistulas . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11072", "text": "One of the most controversial topics in alveolar cleft grafting is the timing of treatment, however, most centres recommend grafting around the ages of 6\u20138 years old as the  lateral incisor  and  maxillary canine  near the cleft site. [ 3 ]   This is referred to as secondary grafting during  mixed dentition  (after eruption of the maxillary central incisors but before the eruption of the canine). [ 4 ]   A smaller proportion recommend primary grafting around the age of 2, but success rates are lower, and fewer patients are good candidates.  Late secondary grafting (after eruption of the canine) has also been advocated but has been largely abandoned due to the loss of tooth support. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11073", "text": "In secondary grafting, the dental age of the patient needs to be closely monitored for the eruption of the first maxillary molars in unilateral cases around the age of 6, and in bilateral cases the eruption of central incisors about the age of 8.  This timing is used because there is minimal growth of the upper jaw after ages 6\u20137, the patient is more compliant with orthodontics that is required prior to surgery for expansion, the donor site is better developed, and the grafting precedes the eruption of teeth into the site. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11074", "text": "In cases with a single cleft, 35-60% of  lateral incisors  are congenitally missing, [ 4 ]  and cannot be relied on for timing.  Instead, the eruption of the incisors and first molars is used as a queue to begin assessments.   With bilateral cases, the premaxilla must be repositioned before grafting and special consideration must be given.  During this time, the orthodontist must be wary of rotating teeth into the cleft site.  Last, the size of the patient, defect, and social issues must all be taken into consideration and is best assessed with a   CBCT  scan as the patient enters the  mixed dentition  phase of dental development. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11075", "text": "In cleft lip and palate cases, the  maxilla  is typically narrow compared to the lower jaw and must be expanded outward.  An expansion appliance is placed in the maxilla 6\u20139 months prior to correct any  crossbite  or upper arch constriction. [ 3 ]    This will widen the cleft size, and so that parents and patients need to be warned the symptoms such as fluid reflux may worsen, although some centres will expand the jaw after surgery is complete.  In the case of double clefts, expansion is typically before surgery because the  premaxilla  needs to be repositioned forward, which cannot occur until the upper jaw is widened to allow room. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11076", "text": "The goals of the surgery are to: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11077", "text": "At surgery, the gingiva is incised along the cleft margin to allow creation of pocket of tissue up towards the nose (recreating a nasal floor), and down towards the mouth (recreating a palate, and closing the palatal opening). The bony edges of the cleft are cleaned, and any extra teeth in the cleft are removed.  The gingiva along the  outside  part of the  upper jaw  is raised, so that it can be drawn forward to close the cleft.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11078", "text": "After creation of the pocket, but before suturing closed the gingiva a  bone graft  is placed into the bony defect.  This is most commonly harvested from the  anterior   hip  but can also be obtained from other sites, donor bone, or bioactive materials such as  bone morphogenic proteins .  Once packed the cleft is filled with bone material the gingiva is sutured closed to create a water tight closure between the mouth and the nose.   [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11079", "text": "The most common source of the bone graft is from the  iliac crest , [ 6 ]  harvested at the time of the cleft closure. Other sources such as the chin, and posterior iliac crest, or  skull  can also be used.  Artificial grafts such as  demineralized bone ,  recombinent bone morphogenic protein  or a mix of harvested bone and artificial grafts have also been used.   Insufficient data exists to show that one is beneficial over the other. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11080", "text": "The mouth wounds recover in 7\u201310 days with precautions for fluid only diet for 5 days, and not to increase pressure in the nose or sinuses for 2\u20133 weeks.  Evidence that the bone graft is forming will be seen on x-ray at about 8 weeks.  Movement of teeth into the graft can begin at 3 months once bone graft consolidation is seen on xray. [ 4 ]   Recovery from the bone harvest will vary depending on the site (if harvested) with the anterior iliac crest being sore for 2\u20133 weeks. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11081", "text": "Success of the bone graft with the first surgery are approximately 85% [ 7 ]  but may vary with technique and bone grafting material. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11082", "text": "Orthodontics after surgery can close the space between the  central incisor  and  maxillary canine  in 50-75% of cases, and for those who can't have the space closed the gap can be filled with a dental implant once growth has finished. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11083", "text": "The first attempts at bone grafting cleft patients were made by Lexer (1908) and Drachter (1914).  Between 1921 and 1952 various attempts were made to graft patients using the  turbinate ,  rib  and other harvest sites.  Schmid (1954) at meetings in 1951 and 1952 reported on the treatment of patients using iliac crest bone grafts but stated, \"The procedure has merely been presented for discussion\".  By 1964 the iliac crest bone graft had gained popularity and was presented at multiple meetings. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11084", "text": "Bioceramics  and  bioglasses  are  ceramic  materials that are  biocompatible . [ 1 ]  Bioceramics are an important subset of  biomaterials . [ 2 ] [ 3 ]  Bioceramics range in biocompatibility from the ceramic  oxides , which are inert in the body, to the other extreme of resorbable materials, which are eventually replaced by the body after they have assisted repair. Bioceramics are used in many types of medical procedures. Bioceramics are typically used as rigid materials in  surgical implants , though some bioceramics are flexible. The ceramic materials used are not the same as  porcelain  type ceramic materials. Rather, bioceramics are closely related to either the body's own materials or are extremely durable  metal oxides ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11085", "text": "Prior to 1925, the materials used in implant surgery were primarily relatively pure metals. The success of these materials was surprising considering the relatively primitive surgical techniques. The 1930s marked the beginning of the era of better surgical techniques as well as the first use of alloys such as  vitallium ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11086", "text": "In 1969, L. L. Hench and others discovered that various kinds of glasses and ceramics could bond to living bone. [ 4 ] [ 5 ]  Hench was inspired by the idea on his way to a conference on materials. He was seated next to a colonel who had just returned from the Vietnam War. The colonel shared that after an injury the bodies of soldiers would often reject the implant. Hench was intrigued and began to investigate materials that would be biocompatible. The final product was a new material which he called  bioglass . This work inspired a new field called bioceramics. [ 6 ]  With the discovery of bioglass, interest in bioceramics grew rapidly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11087", "text": "On April 26, 1988, the first international symposium on bioceramics was held in Kyoto, Japan. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11088", "text": "Ceramics are now commonly used as  dental  and  bone   implants . [ 8 ] [ 9 ]  Surgical  cermets  are used regularly. Joint replacements are commonly coated with bioceramic materials to reduce wear and inflammatory response. Other examples of medical uses for bioceramics are in  pacemakers , kidney dialysis machines, and respirators. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11089", "text": "Bioceramics are meant [ clarification needed ]  to be used in extracorporeal circulation systems ( kidney dialysis , for example) or engineered bioreactors; however, they are most common as  implants . [ 10 ]  Ceramics show numerous applications as biomaterials due to their physico-chemical properties. They have the advantage of being inert in the human body, and their hardness and resistance to abrasion makes them useful for bone and tooth replacement. Some ceramics also have excellent resistance to friction, making them useful as replacement materials for malfunctioning  joints . Properties such as appearance and electrical insulation are also a concern for specific biomedical applications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11090", "text": "Some bioceramics incorporate  alumina  (Al 2 O 3 ) as their lifespan is longer than that of the patient's. The material can be used in middle  ear ossicles , ocular prostheses, electrical insulation for pacemakers, catheter orifices and in numerous prototypes of implantable systems such as cardiac pumps. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11091", "text": "Aluminosilicates  are commonly used in dental prostheses, pure or in ceramic-polymer  composites . The ceramic-polymer composites are a potential way to fill cavities, replacing amalgams suspected to have toxic effects. The aluminosilicates also have a glassy structure. Unlike artificial teeth in resin, the colour of tooth ceramic remains stable. [ 10 ] [ 12 ]  Zirconia  doped  with  yttrium oxide  has been proposed as a substitute for alumina for osteoarticular prostheses. The main advantages are a greater failure strength, and a good resistance to fatigue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11092", "text": "Vitreous carbon  is also used as it is light, resistant to wear, and compatible with blood. It is mostly used in cardiac valve replacement. Diamond can be used for the same application, but in coating form. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11093", "text": "Calcium phosphate -based ceramics constitute, at present, the preferred bone substitute material in orthopaedic and maxillofacial applications, as they are similar to the main mineral phase of bone in structure and chemical composition. Such synthetic bone substitute or scaffold materials are typically porous, which provides an increased surface area that encourages osseointegration, involving cell colonisation and revascularisation. However, such porous materials generally exhibit lower mechanical strength compared to bone, making highly porous implants very delicate. Since the  elastic modulus  values of ceramic materials are generally higher than that of the surrounding bone tissue, the implant can cause mechanical stresses at the bone interface. [ 10 ]  Calcium phosphates usually found in bioceramics include hydroxyapatite (HAP) Ca 10 (PO 4 ) 6 (OH) 2 ; tricalcium phosphate \u03b2 (\u03b2 TCP): Ca 3  (PO 4 ) 2 ; and mixtures of HAP and \u03b2 TCP."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11094", "text": "A number of implanted ceramics have not actually been designed for specific biomedical applications. However, they manage to find their way into different implantable systems because of their properties and their good biocompatibility. Among these ceramics, we can cite  silicon carbide ,  titanium nitrides  and  carbides , and  boron nitride . TiN has been suggested as the friction surface in hip prostheses. While cell culture tests show a good biocompatibility, the analysis of implants shows significant  wear , related to a delaminating of the TiN layer. Silicon carbide is another modern-day ceramic which seems to provide good biocompatibility and can be used in bone implants. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11095", "text": "In addition to being used for their traditional properties, bioactive ceramics have seen specific use for due to their  biological activity . Calcium phosphates,  oxides , and  hydroxides  are common examples. Other natural materials \u2014 generally of animal origin \u2014 such as bioglass and other composites feature a combination of mineral-organic composite materials such as HAP, alumina, or titanium dioxide with the biocompatible polymers (polymethylmethacrylate): PMMA, poly(L-lactic) acid: PLLA, poly(ethylene). Composites can be differentiated as bioresorbable or non-bioresorbable, with the latter being the result of the combination of a bioresorbable calcium phosphate (HAP) with a non-bioresorbable  polymer  (PMMA, PE). These materials may become more widespread in the future, on account of the many combination possibilities and their aptitude at combining a biological activity with mechanical properties similar to those of the bone. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11096", "text": "Bioceramics' properties of being anticorrosive, biocompatible, and aesthetic make them quite suitable for medical usage.  Zirconia  ceramic has bioinertness and noncytotoxicity. Carbon is another alternative with similar mechanical properties to bone, and it also features blood compatibility, no tissue reaction, and non-toxicity to cells. Bioinert ceramics do not exhibit bonding with the bone, known as osseointegration. However, bioactivity of bioinert ceramics can be achieved by forming composites with bioactive ceramics. Bioactive ceramics, including bioglasses must be non-toxic, and form a bond with bone. In bone repair applications, i.e. scaffolds for bone regeneration, the solubility of bioceramics is an important parameter, and the slow dissolution rate of most bioceramics relative to bone growth rates remains a challenge in their remedial usage. Unsurprisingly, much focus is placed on improving dissolution characteristics of bioceramics while maintaining or improving their mechanical properties. Glass ceramics elicit  osteoinductive  properties, with higher dissolution rates relative to crystalline materials, while crystalline calcium phosphate ceramics also exhibit non-toxicity to tissues and bioresorption. The ceramic particulate reinforcement has led to the choice of more materials for implant applications that include ceramic/ceramic, ceramic/polymer, and ceramic/metal composites. Among these composites ceramic/polymer composites have been found to release toxic elements into the surrounding tissues.  Metals  face corrosion related problems, and ceramic coatings on metallic implants degrade over time during lengthy applications. Ceramic/ceramic composites enjoy superiority due to similarity to bone minerals, exhibiting biocompatibility and a readiness to be shaped. The biological activity of bioceramics has to be considered under various  in vitro  and  in vivo  studies. Performance needs must be considered in accordance with the particular site of implantation. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11097", "text": "Technically, ceramics are composed of raw materials such as powders and natural or synthetic  chemical additives , favouring either compaction (hot, cold or isostatic), setting (hydraulic or chemical), or accelerating  sintering  processes. According to the formulation and shaping process used, bioceramics can vary in density and porosity as  cements , ceramic depositions, or ceramic composites. Porosity is often desired in bioceramics including bioglasses. Towards improving the performance of transplanted porous bioceramics, numerous processing techniques are available for the control of  porosity , pore size distribution and pore alignment. For crystalline materials, grain size and crystalline defects provide further pathways to enhance biodegradation and osseointegration, which are key for effective bone graft and bone transplant materials. [ 10 ]  This can be achieved by the inclusion of grain refining dopants and by imparting defects in the crystalline structure through various physical means."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11098", "text": "A developing material processing technique based on the biomimetic processes aims to imitate natural and biological processes and offer the possibility of making bioceramics at ambient temperature rather than through conventional or hydrothermal processes [GRO 96]. The prospect of using these relatively low processing temperatures opens up possibilities for mineral organic combinations with improved biological properties through the addition of proteins and biologically active molecules (growth factors, antibiotics, anti-tumor agents, etc.). However, these materials have poor mechanical properties which can be improved, partially, by combining them with bonding proteins. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11099", "text": "Common bioactive materials available commercially for clinical use include 45S5 bioactive glass, A/W bioactive glass ceramic, dense synthetic HA, and bioactive composites such as a  polyethylene \u2013HA mixture. All these materials form an interfacial bond with adjacent tissue. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11100", "text": "High-purity alumina bioceramics are currently commercially available from various producers. U.K. manufacturer Morgan Advanced Ceramics (MAC) began manufacturing orthopaedic devices in 1985 and quickly became a recognised supplier of ceramic femoral heads for hip replacements. MAC Bioceramics has the longest clinical history for alumina ceramic materials, manufacturing HIP Vitox\u00ae alumina since 1985. [ 13 ]  Some calcium-deficient phosphates with an apatite structure were thus commercialised as \"tricalcium phosphate\" even though they did not exhibit the expected crystalline structure of tricalcium phosphate. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11101", "text": "Currently, numerous commercial products described as HA are available in various physical forms (e.g. granules, specially designed blocks for specific applications). HA/polymer composite (HA/polyethyelene, HAPEXTM) is also commercially available for ear implants, abrasives, and plasma-sprayed coating for orthopedic and dental implants. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11102", "text": "Bioceramics are also been used in cannabis or delta 8 devices as wicks for the vaporization of such extracts. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11103", "text": "Bioceramics have been proposed as a possible treatment for  cancer . Two methods of treatment have been proposed:  hyperthermia  and  radiotherapy .  Hyperthermia treatment  involves implanting a bioceramic material that contains a ferrite or other magnetic material. [ 15 ]  The area is then exposed to an alternating magnetic field, which causes the implant and surrounding area to heat up. Alternatively, the bioceramic materials can be doped with \u03b2-emitting materials and implanted into the cancerous area. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11104", "text": "Other trends include engineering bioceramics for specific tasks. Ongoing research involves the chemistry, composition, and micro- and nanostructures of the materials to improve their biocompatibility. [ 16 ] [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11105", "text": "Bone grafting  is a surgical procedure that replaces missing bone in order to repair  bone fractures  that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured without bone grafting, but the risk is greater for large fractures like compound fractures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11106", "text": "Bone generally has the ability to regenerate completely but requires a very small fracture space or some sort of scaffold to do so. Bone grafts may be autologous (bone harvested from the patient's own body, often from the  iliac crest ), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often made of  hydroxyapatite  or other naturally occurring and  biocompatible  substances) with similar mechanical properties to bone. Most bone grafts are expected to be resorbed and replaced as the natural bone heals over a few months' time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11107", "text": "The principles involved in successful bone grafts include osteoconduction (guiding the reparative growth of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblasts), and osteogenesis (living bone cells in the graft material contribute to bone remodeling). Osteogenesis only occurs with autograft tissue and allograft cellular bone matrices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11108", "text": "Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11109", "text": "Osteoconduction is termed as \"the property of a material to support tissue ingrowth, osteoprogenitor cell growth, and development for bone formation to occur\". [ 2 ]  In the context of bone grafting it occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone.  Osteoblasts  from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. [ 1 ]  Osteoblasts do not originate from the donor tissue, but through the internal ingrowing of the host's cells. [ 3 ]  The proper bonding of bioactive chemicals (Beta-Tricalcium Phosphate) in implants used in bone grafting surgery allow the promotion of  osteoconductivity  in the area of a defect. [ 2 ]  In the very least, a bone graft material should be osteoconductive by being made up of these bioactive chemicals."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11110", "text": "Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators is  bone morphogenetic proteins  (BMPs). [ 1 ]  A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11111", "text": "Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example,  enamel matrix derivative  has been shown to enhance the osteoinductive effect of  demineralized freeze dried bone allograft  (DFDBA), but will not stimulate new bone growth alone. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11112", "text": "Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11113", "text": "Depending on where the bone graft is needed, a different doctor may be requested to do the surgery. Doctors and physicians that perform bone graft procedures are commonly  orthopedic surgeons ,  otolaryngology head and neck surgeon ,  neurosurgeons ,  craniofacial surgeons ,  oral and maxillofacial surgeons ,  podiatric surgeons  and  periodontists ,  dental surgeons ,  oral surgeons  and  implantologists . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11114", "text": "Autologous  (or autogenous) bone grafting involves utilizing bone obtained from the same individual receiving the graft. Bone can be harvested from non-essential bones, such as from the  iliac crest , or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the  coronoid process ); this is particularly true for  block grafts , in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body. [ 6 ]  As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post-operative pain and complications. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11115", "text": "Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources as the  iliac crest , the  fibula , the  ribs , the  mandible  and even parts of the  skull . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11116", "text": "All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the  periosteum  and accompanying blood vessels along with donor bone is required. This kind of graft is known as a  vital bone graft . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11117", "text": "An autograft may also be performed without a solid bony structure, for example, using bone reamed from the  anterior superior iliac spine . In this case, there is an osteoinductive and osteogenic action, however, there is no osteoconductive action, as there is no solid bony structure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11118", "text": "Chin offers a large amount of cortico-cancellous autograft and easy access among all the intraoral sites. It can be easily harvested in the office settings under local anaesthesia on an outpatient basis. Proximity of the donor and recipient sites reduce operative time and cost. Convenient surgical access, low morbidity, elimination of hospital stay, minimal donor site discomfort and avoidance of cutaneous scars are the added advantages. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11119", "text": "Dentin  bone, made from extracted teeth, [ 8 ]  comprises more than 85% of tooth structure, the enamel consists of HA mineral and comprises 10% of tooth structure. Dentin is similar to bone in its chemical composition, by volume 70\u201375% is HA mineral and 20% organic matrix, mostly fibrous type I collagen. [ 9 ]  Dentin, like bone, may release growth and differentiating factors while being resorbed by osteoclasts. In order to make the dentin graft usable and bacteria-free, some companies have developed clinical procedures which include grinding, sorting and cleaning of the teeth for immediate or future use. In Korea, the Korea Tooth Bank performed bio-recycling of 38 000 patients' own teeth from January 2009 until October 2012. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11120", "text": "Allograft  bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone can be taken from  cadavers  that have donated their bone so that it can be used for living people who are in need of it; it is typically sourced from a  bone bank . Bone banks also supply allograft bone sourced from  living  human bone donors (usually hospital inpatients) who are undergoing elective total hip arthroplasty (total hip replacement surgery). During total hip replacement, the orthopaedic surgeon removes the patient's femoral head, as a necessary part of the process of inserting the artificial hip prosthesis. The femoral head is a roughly spherical area of bone, located at the proximal end of the femur, with a diameter of 45\u00a0mm to 56\u00a0mm in adult humans. The patient's femoral head is most frequently discarded to hospital waste at the end of the surgical procedure. However, if a patient satisfies a number of stringent regulatory, medical and social history criteria, and provides informed consent, their femoral head may be deposited in the hospital's bone bank."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11121", "text": "There are three types of bone allograft available: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11122", "text": "Alloplastic grafts may be made from  hydroxyapatite , a naturally occurring mineral that is also the main mineral component of bone. They may be made from  bioactive glass . Hydroxylapatite is a synthetic bone graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Tricalcium phosphate which is now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability. Polymers such as some  microporous  grades of  PMMA  and various other acrylates (such as polyhydroxylethylmethacrylate aka PHEMA), coated with calcium hydroxide for adhesion, are also used as alloplastic grafts for their inhibition of infection and their mechanical resilience and biocompatibility. [ 11 ]  Calcifying marine algae such as  Corallina officinalis  have a fluorohydroxyapatitic composition whose structure is similar to human bone and offers gradual resorption, thus it is treated and standardized as \"FHA (Fluoro-hydroxy-apatitic) biomaterial\" alloplastic bone grafts. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11123", "text": "Artificial bone  can be created from ceramics such as calcium phosphates (e.g.  hydroxyapatite  and  tricalcium phosphate ),  Bioglass  and  calcium sulfate ; all of which are biologically active to different degrees depending on solubility in the physiological environment. [ 13 ]  These materials can be doped with  growth factors , ions such as  strontium [ 14 ]  or mixed with  bone marrow  aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting; [ 6 ]  however, infection and rejection of the graft is much less of a risk, and the mechanical properties such as  Young's modulus  are comparable to bone. The presence of elements such as  strontium  can result in higher  bone mineral density  and enhanced  osteoblast  proliferation  in vivo . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11124", "text": "A synthetic material may be used as a temporary antibiotic spacer before being replaced by a more permanent material. For example, the  Masquelet procedure  consists of initially using PMMA mixed with an  antibiotic  ( vancomycin  or  gentamicin ) for 4\u201312 weeks, and then replacing the space with an autologous bone graft. [ 15 ]  It can be used to treat posttraumatic bone defects. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11125", "text": "Bone xenografts are an alternative form of bone grafts that involve transplanting different animal species cells into humans. This graft can range from orthopedic to dental uses. Most xenografts are derived from bovine sources such as cows or pigs and are sterilized and processed for safe implantation into human tissue. They can be  freeze dried  or demineralized and deproteinized. Xenografts are usually only distributed as a calcified matrix. Madrepore and or millepore type of  corals  are harvested and treated to become 'coral derived granules' (CDG) [ 16 ]  and other types of coralline xenografts. [ 17 ]  Coral based xenografts are mainly  calcium carbonate  (and an important proportion of fluorides, useful in the context of grafting to promote bone development) while natural human bone is made of hydroxyapatite along with calcium phosphate and carbonate: the coral material is thus either transformed industrially into hydroxyapatite through a  hydrothermal  process, yielding a non-resorbable xenograft, or simply the process is omitted and the coralline material remains in its calcium carbonate state for better resorption of the graft by the natural bone. The coral xenograft is then saturated with growth-enhancing gels and solutions. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11126", "text": "Studies show that xenografts can be used, however they are closely monitored due to their risk of rejection.  Zoonoses , which are diseases that arise from the crossing of animal and human tissue, pose a threat to the success of xenograft implantation. Specifically, these diseases are referenced as \"xenozoonoses\". They can be categorized in 3 different groups: viral infection, prion-mediated infection, and bacterial infection. They have the potential to create a public health risk if they are not closely monitored, as they can cause diseases to be more easily transmissible through different species. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11127", "text": "Growth Factor  enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens ( Bone Morphogenic Proteins  in conjunction with a carrier medium, such as collagen)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11128", "text": "The time it takes for an individual to recover depends on the severity of the injury being treated and lasts anywhere from two weeks to two months, with a possibility of vigorous exercise being barred for up to six months. Distal femoral bone graft takes up to six months to heal. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11129", "text": "The most common use of bone grafting is in the application of  dental implants  to restore the  edentulous  area of a missing tooth. Dental implants require bones underneath them for support and  proper integration  into the mouth. As mentioned earlier bone grafts come in various forms such as autologous (from the same person), Allograft, Xenograft (mainly bovine bone), and Alloplastic materials. Bone grafts can be used prior to implant placement or simultaneously. [ 20 ]  People who have been edentulous (without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, autologous bone can be taken from the chin, from the pilot holes for the implants, or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant. Alternatively, exogenous bone can be used: xenograft is the most commonly used, because it offers the advantage of exceptional volume stability over time. Allograft offers the best regeneration quality but has lower volume stability. Often a mix of different kinds of bone grafts is used. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11130", "text": "In general, bone graft is either used en bloc (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11131", "text": "Dental bone grafting is a specialized oral surgical procedure that has been developed to reestablish lost jawbone. This loss can be a result of  dental infection of abscess ,  periodontal disease , trauma, or the natural process of aging. There are various reasons for replacing lost bone tissue and encouraging natural bone growth, and each technique tackles jawbone defects differently. Reasons that bone grafting might be needed include  sinus augmentation ,  socket preservation , ridge augmentation, or regeneration. There is currently some evidence supporting the use of autologous platelet concentrates (cell fragments containing growth factors to promote tissue regeneration) when bone grafting is used to treat gum disease. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11132", "text": "Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11133", "text": "Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no  graft rejection . [ 19 ]  Besides the main use of bone grafting \u2013 dental implants \u2013 this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed. [ 19 ]  Furthermore, bone grafts or substitutes are widely used for augmentation of spinal fusion procedures. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11134", "text": "As with any procedure, there are risks involved; these include reactions to medicine, problems breathing,  bleeding , and  infection . [ 19 ]  Infection is reported to occur in less than 1% of cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher risk of getting an infection as opposed to those who are overall healthy. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11135", "text": "Some of the potential risks and complications of bone grafts employing the  iliac crest  as a donor site include: [ 23 ] [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11136", "text": "Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia. [ 31 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11137", "text": "Bone graft procedures consist of more than just the surgery itself. The complete three-month total cost of a complex posterolateral lumbar spine fusion bone graft supplemented with graft extenders ranges from a mean of approximately US$33,860 to US$37,227. [ 33 ]  This price includes all visits in and out of the hospital for three months. Besides the cost of the bone graft itself (ranging from US$250 to US$900) other expenses for the procedure include: outpatient rehabilitation fees (US$5,000 to US$7,000), screws and rods (US$7,500), room and board (US$5,000), operating room (US$3,500), sterile supplies (US$1,100), physical therapy (US$1,000), surgeon's fees (average US$3,500),  anesthesiologist  fees (approximately US$350 to US$400 per hour), medication charges (US$1,000), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11138", "text": "Bone segment navigation  is a surgical method used to find the anatomical position of displaced bone fragments in  fractures , or to position surgically created fragments in  craniofacial surgery .  Such fragments are later fixed in position by  osteosynthesis . It has been developed for use in craniofacial and  oral and maxillofacial surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11139", "text": "Bone segment navigation is a patented  [ 1 ] [ 2 ]  surgical procedure, using a frameless and markerless registration technique. It uses for the first time natural registration surfaces instead of single artificial x-ray visible markers, in order to achieve a higher precision (1 mm and better). [ 3 ]  Previous methods of Cutting and Watzinger do not meet the criteria of bone segment navigation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11140", "text": "After an accident or injury, a fracture can be produced and the resulting bony fragments can be displaced. In the oral and maxillofacial area, such a displacement could have a major effect both on facial aesthetics and organ function: a fracture occurring in a bone that delimits the  orbit  can lead to  diplopia ; a  mandibular  fracture can induce significant modifications of the  dental occlusion ; in the same manner, a skull ( neurocranium ) fracture can produce an increased  intracranial pressure . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11141", "text": "In severe congenital malformations of the facial skeleton surgical creation of usually multiple [ 5 ] [ 6 ]  bone segments is required with precise movement of these segments to produce a more normal face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11142", "text": "An  osteotomy  is a surgical intervention that consists of cutting through bone and repositioning the resulting fragments in the correct anatomical place. To insure optimal repositioning of the bony structures by  osteotomy , the intervention can be planned in advance and simulated.  The surgical simulation is a key factor in reducing the actual operating time. Often, during this kind of operation, the surgical access to the bone segments is very limited by the presence of the soft tissues: muscles, fat tissue and skin - thus, the correct anatomical repositioning is very difficult to assess, or even impossible. Preoperative planning and simulation on models of the bare bony structures can be done.  An alternate strategy is to plan the procedure entirely on a CT scan generated model and output the movement specifications purely numerically. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11143", "text": "The osteotomies performed in  orthognathic surgery  are classically planned on cast models of the tooth-bearing jaws, fixed in an  articulator . For  edentulous  patients, the surgical planning may be made by using  stereolithographic models . These tridimensional models are then cut along the planned osteotomy line, slid and fixed in the new position.\nSince the 1990s, modern techniques of presurgical planning were developed \u2013 allowing the surgeon to plan and simulate the osteotomy in a virtual environment, based on a preoperative  CT  or  MRI ; this procedure reduces the costs and the duration of creating, positioning, cutting, repositioning and refixing the cast models for each patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11144", "text": "The usefulness of the preoperative planning, no matter how accurate, depends on the accuracy of the reproduction of the simulated  osteotomy  in the surgical field. The transfer of the planning was mainly based on the surgeon's visual skills. Different guiding headframes were further developed to mechanically guide bone fragment repositioning.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11145", "text": "Such a headframe is attached to the patient's head, during CT or MRI, and surgery. There are certain difficulties in using this device. First, exact reproducibility of the headframe position on the patient's head is needed, both during CT or MRI registration, and during surgery. The headframe is relatively uncomfortable to wear, and very difficult or even impossible to use on small children, who can be uncooperative during medical procedures.  For this reason headframes have been abandoned in favor of frameless stereotaxy of the mobilized segments with respect to the skull base.  Intraoperative registration of the patient's anatomy with the computer model is done such that pre-CT placement of fiducial points is not necessary. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11146", "text": "Initial bone fragment positioning efforts using an electro-magnetic system were abandoned due to the need for an environment without ferrous metals. [ 8 ]   In 1991 Taylor at IBM working in collaboration with the craniofacial surgery team at New York University developed a bone fragment tracking system based on an  infrared (IR)  camera and IR  transmitters  attached to the skull. [ 9 ] [ 10 ]   This system was patented by IBM in 1994. [ 11 ]   At least three IR transmitters are attached in the  neurocranium  area to compensate the movements of the patient's head. There are three or more IR transmitters are attached to the bones where the osteotomy and bone repositioning is about to be performed onto. The  3D  position of each transmitter is measured by the IR camera, using the same principle as in  satellite navigation . A computer workstation is constantly visualizing the actual position of the bone fragments, compared with the predetermined position, and also makes real-time spatial determinations of the free-moving bony segments resulting from the osteotomy.\nThus, fragments can be very accurately positioned into the target position, predetermined by surgical simulation.  More recently a similar system, the  Surgical Segment Navigator  (SSN), was developed in 1997 at the   University of Regensburg, Germany , with the support of the  Carl Zeiss Company . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11147", "text": "The  Bonwill Triangle  is a triangle formed by the contact point of the  mandibular central incisors  and the right\u00a0and\u00a0left\u00a0 mandibular\u00a0condyles . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11148", "text": "The distance between those points is equal in most humans and amounts on average to about 10 cm. [ 2 ]  The triangle is therefore an  equilateral triangle  in those cases.  William Gibson Arlington Bonwill  (1833\u20131899) was the first to describe this. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11149", "text": "Two variants of the Bonwill Triangle have been described that differ in the exact location of the points on the condyles. In one the points are located on the articulating\u00a0surfaces\u00a0of the condyles whilst in the other they are located\u00a0centrally\u00a0within the heads of the mandible. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11150", "text": "In terms of practical application, the Bonwill Triangle is utilized in the construction and correct application of fixed  articulators , which (in contrast to fully- and semi-adjustable articulators) are a type of articulator that does not allow for adjustments to imitate the specific movements of an individual's jaw. Instead, these articulators are designed to replicate the average movements of the jaw, and among others the Bonwill Triangle relationship is used to achieve this result. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11151", "text": "Cheek augmentation  is a   cosmetic surgical procedure  that is intended to emphasize the  cheeks  on a person's face. To augment the cheeks, a plastic surgeon may place a solid implant over the  cheekbone . Injections with the patients' own fat or a soft tissue filler, like  Restylane , are also popular. Rarely, various  cuts  to the  zygomatic bone  (cheekbone) may be performed. Cheek augmentation is commonly combined with other procedures, such as a  face lift  or  chin augmentation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11152", "text": "Cheek implants can be made of a variety of materials. The most common material is solid  silicone . In addition, two popular options are high-density porous  polyethylene , marketed as  Medpor , and ePTFE (expanded  polytetrafluoroethylene ), better known as  Gore-Tex . Both Medpor and ePTFE are  inert  substances, providing better integration with the underlying tissue and bone than solid silicone. However, in the case of Medpor, the implants' integration and ingrowth with the underlying tissue causes difficulty removing the implant if revisions are needed. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11153", "text": "There are three general shapes to cheek implants:  malar ,  submalar , or  combined . Malar implants, the most common shape, are placed directly on the cheekbones. The result is more projection to the cheekbones, providing a \"higher\" contour to the side of the face. In contrast, submalar implants are not placed on the cheekbones. They are intended to augment the midface, especially if the person has a gaunt or \"sunken\" appearance to this area. Combined implants or  malar/submalar combination , are an extended implant intended to augment both the midface and the cheekbones. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11154", "text": "A surgeon will usually make an incision in the upper mouth near the top of the gum line and slide the implants into place.  Another method is to make an external incision near the eye,  but most patients do not choose this method since it can create a visible scar.  However, the intraoral (inside the mouth) approach carries a higher risk of infection since the mouth contains more  bacteria . Cheek implant surgery is usually performed under sedation or  general anesthesia  and take about one to two hours.  Recovery from this surgery usually takes about ten days. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11155", "text": "As with any surgery there is a risk of  infection , postoperative bleeding, formation of a  blood clot , and severe swelling. Asymmetry is a risk with all forms of cheek augmentation. This can occur due to uneven resorption, implant  displacement , or shifting. This shift can happen due to swelling, trauma or scarring. Although a temporary  loss of sensation  is common, an extended loss of sensation can occur with any surgery, especially cosmetic plastic surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11156", "text": "Injections to the cheekbones to provide a less invasive and less expensive approach to cheek augmentation. A  hyaluronic acid , such as  Restylane  or  Juvederm , can be injected to the cheek area.  Autologous  fat is considered a \"more permanent\" option, but all are eventually completely resorbed. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11157", "text": "A zygomatic \"sandwich\" osteotomy is far less common. The procedure is often indicated during reconstructive surgery for  birth defects  or traumatic  injury . During this procedure, the zygoma, or cheekbone, is separated by bone cuts near the  orbital rim  and  maxilla . The bone is then moved outward and a solid material, such as  hydroxylapatite , is wedged in place to hold the new position of the zygoma. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11158", "text": "The cheek  constitutes the facial periphery and plays a key role in the maintenance of oral competence and mastication. It is also involved in the facial manifestation of human emotion and supports neighboring primary structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11159", "text": "The most common causes of acquired cheek defects are  tumors , burns, and trauma. Congenital abnormalities in cheek contour may be due to facial clefts, vascular anomalies, or facial wasting syndromes. The repair of these defects seeks to achieve aesthetic and functional ends that must be carefully considered by the reconstructive surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11160", "text": "The face can be divided into six  facial aesthetic units , with unique anatomic and aesthetic features. There are three central and three peripheral aesthetic units: eyelids, nose and lips; and forehead, cheek and chin, respectively. The aesthetic surface anatomy characteristics of the cheek have been described by Menick:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11161", "text": "\"The face can be divided into adjacent topographic areas of characteristic skin quality (color, texture, hair bearing), outline, and contour that define its regional units. The skin quality of the cheek matches the face in color and texture. The peripheral outline of the cheek unit is formed by the contours of the bordering units (forehead, eyelids, nose, lips, neck, and ear). Its outline follows the pre-auricular contours of the tragus and helix; goes around the sideburn, across the zygomatic arch, and into the lower eyelid-cheek junction; and then passes inferiorly along the nasal sidewall into the nasolabial fold and marionette line, around the chin and toward the submental crease. It then extends laterally along the jawline, passing superiorly up the angle of the jaw and back to the ear. In contour, the cheek is a relatively flat, expensive surface, except for the soft roundness of the nasolabial folds and cheek prominences.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11162", "text": "The  external carotid artery  (ECA), with contributions from the  internal carotid artery  (ICA) system, is the predominant arterial blood supply to the skin and muscles of the cheek. The greatest contribution is from the  facial artery  which traverses the face obliquely and terminates in the angular artery. The dorsal nasal artery runs along the nose and is the terminal branch of the  ophthalmic artery , which is a terminal branch of the ICA. Many smaller branches and communications also exist. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11163", "text": "The venous drainage system of the cheek is predominantly formed by the  anterior facial vein , which subsequently communicates with the  internal jugular vein . However, substantial drainage via the ophthalmic, infraorbital, and deep facial veins communicates with the cavernous sinus  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11164", "text": "The most important lymph nodes in the area are the intraparotid, submandibular and the submental lymph nodes. The inferior and medial parts usually drain to the submandibular nodes while the lateral and upper parts to the parotid nodes. Other lymphatic nodes include buccal nodes and submental nodes. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11165", "text": "The nerve supply of the cheek can be divided into sensory and motor systems. Sensation to the cheek is carried primarily by the second (maxillary) and third (mandibular) divisions of the trigeminal nerve (cranial nerve V). The facial nerve (cranial nerve VII) provides motor innervation to the muscles of facial expression. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11166", "text": "The primary goals of cheek reconstruction include the restoration of native function, maximization of aesthetic outcome, and limitation of repair related morbidity. Implicit in this statement is the intent to re-established both internal and external coverage, expressivity, masticatory function and aesthetic contour and quality."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11167", "text": "The advantages of this flap is that there is no need to skin graft the donor site and scars are placed at the natural skin folds. This flap is used for posterior and moderate-sized anterior cheek defects. Lower eyelid  ectropion  should be prevented, by minimizing tension and by overcorrection and suspension of the cheek flap to the lateral orbital rim. This anterior-based flap is supplied by the facial and submental arteries and advances upward from the cervical area and rotates forward."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11168", "text": "A posterior-based cervicofacial cheek flap is used for small and moderate-sized anterior cheek defects. This flap is used for reconstruction of small medial cheek defects next to the nose or lips. The flap is supplied by the superficial temporal artery and vessels in the pre-auriculair region. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11169", "text": "Larger posterior or lower cheek defects up to 10\u00a0cm can be closed if the incision of an anterior-based cervicofacial flap is extended, converting it into a cervicopectoral flap, which moves neck and chest skin to the face. This flap is vascularized by the internal mammary perforators. Advantages of this flap are its good skin color, texture, hair-bearing match and the location of the scars at natural folds."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11170", "text": "For larger anterior cheek defects, the posterior-based cervicofacial flap is continued inferiorly along the sternum, then laterally down across the chest, above the nipple and toward the axilla. This flap is supplied by the superficial temporal artery and vessels, the vertebral and occipital arteries and the perforators of the trapezius muscle. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11171", "text": "This flap can be used for various defects in the head and neck area. Based on the dominant blood supply there are three different variations of the PMF: superior, posterior or inferior based. Only the superior and posterior based PMF is suitable for oral and facial reconstruction. The thin, quadrangular shaped, and paired platysma muscles lie in the superficial fascia of the neck."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11172", "text": "The dominant blood supply is from the submental branch of the facial artery and the venous drainage of the v. submentalis. The arc of rotation is suitable for reconstruction of the anterior and lateral  floor of mouth , buccal mucosa, retromolar trigone, and skin of the lower cheek and parotid region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11173", "text": "This flap receives its blood supply primarily from branches of the a. occipitalis. Venous drainage is the v. jugularis interna."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11174", "text": "The arc of rotation is suitable for reconstruction of the lower lip, floor of mouth, ventral tongue, and lower one third of the face. For the proper arc of rotation an adequate exposure of the muscle is necessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11175", "text": "Advantages of the PMF is that the platysma flap has an appropriate thickness, minimal donor- site morbidity, acceptable scar and colour match and it is easy and faster to harvest. During the procedure the neck is in a hyperextended position. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11176", "text": "An adjunct to the utilization of local and locoregional flaps is the option of tissue expanders. They effectively increase the net skin surface area and provide skin that has the same texture, colour, and hair bearing qualities as the recipient site. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11177", "text": "Pedicled flaps are used when regional tissue is not available, for example because of burns or radiation. There are two pedicled flaps that are sometimes used for reconstruction of cheek defects with or without pre-expansion:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11178", "text": "The supraclavicular flap, also known as the \"epaulette\" flap is vascularized by the supraclavicular artery, which branches off the transverse cervical artery. The vessels can be found using a hand held doppler in the triangle between the dorsal edge of the sternocleidomastoid muscle, the external jugular vein, and the medial part of the clavicle. The flap can be raised as an island flap as well as a pedicled flap."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11179", "text": "The deltopectoral flap is beneficial for reconstruction of significant cheek defects, offering up to 250 cm2  of transferable cutaneous tissue to allow reconstruction of the entire cheek. The deltopectoral flap tolerates folding very well and allows movement in wide directions. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11180", "text": "Thanks to further refinements of microvascular techniques in the past three decades, transfer of a free flap is now a routine procedure. Free flaps are the first choice in case of complex, composite, and through-through cheek defects with exposed bone, sinuses, orbit or dura. Advantages of free flaps are their reliable blood supply and freedom of planning. Potential disadvantages are the mismatch of colour, texture, facial shape and thickness."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11181", "text": "Whereas a multitude of free flaps are available, the radial forearm, anterolateral thigh, scapular, and lateral arm flap are most useful in cheek reconstruction. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11182", "text": "Prefabrication of flaps opens interesting new possibilities. It is primarily used for reconstruction of complex defects where conventional techniques are not available (in burn patients where common donor sites may have been damaged or destroyed). Flap prefabrication starts with introduction of a vascular pedicle to a desired donor tissue that on its own does not possess an axial blood supply. After a period of neovascularization of at least 8 weeks, this donor tissue can then be transferred to the recipient defect based on the newly acquired axial vasculature. This process can be combined with the use of tissue expanders. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11183", "text": "Careful patient selection is essential for a successful outcome. Donor site morbidity, patient characteristics such as skin laxity, age, tobacco use and sun exposure, potential radiotherapy, planned lymph node dissection, the size of the defect, structural involvement (skin, muscle, nerves, bone), functional concerns like maintaining  oral hygiene , swallowing, mouth opening, aesthetic concerns, experience of the surgeon are all factors that influence the kind of reconstructive technique that should be chosen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11184", "text": "Cordectomy  is the surgical removal of a cord. It usually refers to removal of one or both  vocal cords , often for the purpose of treating  laryngeal cancer . [ 1 ] [ 2 ]  The word is derived from the  Greek , combining  chorde  and  ektome  meaning excision. It can be carried out by traditional surgical techniques or, increasingly, by  carbon dioxide laser . [ 3 ]  CO 2  laser cordectomy has allowed the treatment of glottic carcinoma as a day case procedure. [ 4 ]  The procedure has also been carried out by veterinarians to reduce the volume of incessant barking by  dogs , where it is called  debarking . [ 5 ]  In humans, this type of operation is usually done by  otolaryngologists ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11185", "text": "Prior to surgery, the patient must be informed of serious, debilitating, and permanent consequences of surgery, most notably the loss of speaking capacity with severity correlating to the portion of vocal cords removed. A patient will be incapable of producing most vocal sounds following total cordectomy, although deep guttural screams may still be produced, and with the patient almost always retaining the ability to speak in whispers. There is little to no chance of a patient recovering their voice following a complete or near-complete cordectomy as the procedure literally removes the organs responsible for vocal utterances, and patients with a less-than-entire cordectomy will always lose some or most of their vocal range (again corresponding to the section and amount of removed vocal cords). Doctors are encouraged to explore alternative communication technologies with patients (such as  electrolarynxes , whisper-amplifying devices, and  text-to-speech  software) prior to determining the acceptability of the procedure. Patients should be made to understand that the procedure is absolutely permanent and their vocal capacity (with current technology) will never recover to its range prior to the surgery, and patients with small percentages of cord removals will experience disproportionately severe loss of vocal range compared to the loss suffered by patients who have undergone a near-entire cordectomy procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11186", "text": "The indications being Carcinoma of Vocal cords and Early Glottic Carcinoma etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11187", "text": "According to the European Laryngeal Society, Cordectomy is classified into the following types:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11188", "text": "Craniofacial prostheses  are  prostheses  made by individuals trained in  anaplastology  or  maxillofacial prosthodontics  who medically help rehabilitate those with facial defects caused by  disease  (mostly progressed forms of  skin cancer , and  head and neck cancer ), trauma ( outer ear trauma ,  eye trauma ) or  birth defects  ( microtia ,  anophthalmia ).  They have the ability to replace almost any part of the face, but most commonly the  ear ,  nose  or  eye / eyelids .  An  ocular prosthesis  and  hair prosthesis  can also be classified as craniofacial prostheses.  Prostheses are held in place either by biocompatible drying  adhesives ,  osseointegrated implants ,  magnets , or another mechanical means (although rare) such as glasses or straps. Prostheses are designed to be as similar as possible to the natural anatomy of each individual.  Their purpose is to cover, protect, and disguise facial disfigurements or underdevelopments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11189", "text": "When surgical reconstruction is not ideal, craniofacial prosthetics are favored when they can better restore the form and function of the absent facial feature.  Craniofacial prosthetics are not wholly considered  cosmetic [ 1 ] [ 2 ]  because they replace the physical  form  and  functional  mechanics  of the absent anatomy and serve a significant role in the emotional stability and rehabilitation of those with facial defects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11190", "text": "Cranioplasty  is a  surgical operation  on the repairing of  cranial  defects caused by previous  injuries  or operations, such as  decompressive craniectomy . It is performed by filling the defective area with a range of materials, usually a bone piece from the patient or a synthetic material. Cranioplasty is carried out by incision and reflection of the  scalp  after applying anaesthetics and antibiotics to the patient. The  temporalis muscle  is reflected, and all surrounding  soft tissues  are removed, thus completely exposing the cranial defect. The cranioplasty flap is placed and secured on the cranial defect. The wound is then sealed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11191", "text": "Cranioplasty was closely related to  trephination , and the earliest operation is dated to 3000 BC. [ 2 ]  Currently, the procedure is performed for both cosmetic and functional purposes. Cranioplasty can restore the normal shape of the  skull  and prevent other complications caused by a sunken scalp, such as the \"syndrome of the trephined\". [ 3 ]  Cranioplasty is a risky operation, with potential risks such as  bacterial infection  and  bone flap resorption . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11192", "text": "The word  cranioplasty  can be broken down into two parts: cranio- and -plasty. Cranio- originates from the Ancient  Greek  word \u03ba\u03c1\u03b1\u03bd\u03af\u03bf\u03bd, meaning \" cranium \", while -plasty comes from the Ancient  Greek  word \u03c0\u03bb\u03b1\u03c3\u03c4\u03cc\u03c2, meaning \"moulded\" or \"fashioned\". [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11193", "text": "The operation has its cosmetic value as the normal shape of the cranium of patients is restored instead of the presence of a sunken skin flap, which may affect the confidence of patients. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11194", "text": "It also has its therapeutic value as the operation provides structure to the skull and protection to the brain from physical damage. [ 1 ] [ 6 ]  The surgery restores regular  cerebrospinal fluid (CSF)  and  cerebral  blood flow dynamics, along with normal  intracranial pressure . [ 1 ] [ 3 ]  Cranioplasty may improve  neurological  function in some individuals. Furthermore, it can reduce the occurrence of  headaches  caused by injury or previous surgery. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11195", "text": "The optimal timing of cranioplasty is controversial. Some experts put the time between a  craniectomy  and a cranioplasty at usually between 6 months and a year, [ 1 ]  while others say that the two operations should be more than a year apart. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11196", "text": "The timing of cranioplasty is affected by multiple factors. Sufficient time is required for the recovery of the incision from the previous operation, as well as to clear any infections (both  systemic  and cranial). [ 1 ]  Some findings showed that a greater infection rate is associated with early cranioplasty due to interruption of wound healing, [ 8 ]  as well as an increased incidence of  hydrocephalus . [ 9 ]  Contrarily, there is evidence of early cranioplasty limiting complications caused by \"syndrome of the trephined\", including changes in  cerebral blood flow  and abnormal  cerebrospinal fluid  hydrodynamics. [ 8 ]  Other researchers have reported no significant difference in infection rate with different operational timings. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11197", "text": "Contraindications  for cranioplasty include the presence of  bacterial infection ,  brain swelling , and  hydrocephalus . [ 10 ]  Cranioplasty is withheld until all contraindications are cleared. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11198", "text": "Before the operation,  CT scans  and  MRIs  are taken to study the cranial defect. The patient is given antibiotics to prevent bacterial infection. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11199", "text": "The patient is situated on a  foam donut  or a  horseshoe head holder  for the operation. The patient is then  anaesthetised  and an incision is made following the incision of the previous operation. The  scalp  and the  temporalis muscle  is reflected to completely reveal the cranial defect. Significant blood loss is observed as new  blood vessels  formed in  scar tissues  are damaged by incision. Any  soft tissues  at the edge of the defect are removed and the defect is cleaned. The cranioplasty material is placed on the defect and is fixed to the surrounding  skull  with standard titanium plate and screws.  CSF  may be drained from the brain to reduce  herniation . Small holes may be drilled on the bone graft or the prosthesis to prevent the  accumulation of fluid  under the repaired defect.  Soft tissues ,  temporalis , and the scalp are then fixed back in place.  Subgaleal  drain and  dressing  are applied to control facial swelling. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11200", "text": "After the operation, a  CT scan  is taken and patients may stay in intensive care for at least a night for better neurological status observation, or be placed in a regular care unit. The  subgaleal  drain and  dressing  are removed before the patient is dispatched. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11201", "text": "Special considerations to children undergoing cranioplasty are made to accommodate for their growing  cranium . Certain materials are more favoured when compared to adult cranioplasty. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11202", "text": "Autologous bone grafts  are the most preferred materials for  paediatric  cranioplasty, as they are accepted by the host and the bone flap can be integrated into the body of the host. [ 10 ]  However, autologous bone pieces may be unavailable or unsuitable in certain occasions. The body size of children may be not enough to have bone flaps to be stored in their  subcutaneous  spaces, while  cryopreservation  facilities for bone grafts are not widely available. [ 11 ] [ 12 ]  The use of  autograft  is also associated with a high rate of  bone resorption . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11203", "text": "Synthetic materials are used for paediatric cranioplasty when the use of  autografts  is not available or not recommended.  Hydroxyapatite  is another option for children cranioplasty as it allows the expansion of cranium for children and its ability to be moulded smoothly. It is less commonly used than autografts due to its brittle nature, high infection rate, and poor ability to integrate with the human  cranium . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11204", "text": "Bilateral cranioplasties are more prone to complications compared to unilateral cranioplasties in children. This may be explained by its larger scalp wound area, a higher volume of blood loss, and the higher complexity and duration of the operation. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11205", "text": "Cranioplasty's complication risk ranges from 15% to 41%. [ 4 ]  The cause for such a high risk compared to that borne by other  neurosurgical  operations is unclear. Male patients and older patients are groups with higher rates of complication. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11206", "text": "Complications occurring after cranioplasty include  bacterial infection ,  bone flap resorption ,  wound dehiscence ,  hematoma ,  seizures ,  hygroma , and  cerebrospinal fluid (CSF) leakage . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11207", "text": "The risk of bacterial infections in performing cranioplasty ranges from 5 to 12.8%. [ 1 ]  Multiple factors are affecting the risk of infection, one being the materials used for the operation. Using  titanium , whether being custom-made or using a  mesh , is associated with a lower infection rate; [ 1 ] [ 13 ]  on the other hand, materials such as  methyl methacrylate  and autologous bone is associated with a higher infection rate. [ 1 ]  Another risk factor for bacterial infection is the location of the operation. Bifrontal cranioplasties are associated with significantly higher infection rates and higher rates for reoperation. [ 9 ] [ 14 ]  Other risk factors for infection include previous infections, contact between  sinuses  and operation site, devascularized scalp (loss of blood supply in the scalp), previous operations, and type of injury. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11208", "text": "Bone resorption  is another complication of cranioplasty with a complication rate of 0.7-17.4%. [ 1 ]  Bone resorption occurs when the  autologous graft  does not have blood supply due to  devitalisation , or when  scar tissues  or  soft tissues  remain on the edge of the cranial defect during cranioplasty. [ 1 ]   Paediatric  patients have a higher risk of resorption, [ 1 ] [ 4 ] [ 9 ]  with a resorption rate up to 50%. [ 4 ]   Bone resorption  is more likely to occur in this group of patients when their cranioplasty is carried out over 6 weeks after their previous operation. [ 9 ]  Fragmented bone flaps, as well as large bone flaps (>70\u00a0cm 2 ), are associated with a higher resorption rate. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11209", "text": "The earliest cranioplasty operation is dated to 3000 BC in the  Pre-Columbian Peruvian civilisation , where precious metals, gourds, and shells were found next to  trepanned  skulls in graveyards, suggesting that cranioplasty had been performed. [ 2 ]  In the Paracas region of present-day  Peru , a skull from 2000 BC with a thin plate of gold covering a cranial defect was found. [ 2 ]  Moreover, defective skulls were found covered with coconut shells or  palm  leaves in ancient tribes of the  Polynesian Islands . [ 15 ]  Sanan and Haines stated that the materials being used for cranioplasty were associated with the status of the patient. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11210", "text": "Research on cranioplasty was not emphasised among early surgical authors in ancient  Asia ,  Egypt ,  Greece , and  Rome , although there were research and practice on  trephination  in ancient  Greece  and  Rome . More emphasis was placed on developing skills in applying  dressing  on an open wound. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11211", "text": "The earliest modern description of cranioplasty was written by surgeon  Ibrahim bin Abdullah  of the  Ottoman Empire , in his surgical book  Al\u00e2im-i Cerr\u00e2h\u00een  in 1505. The book mentioned the use of  xenografts  from  Kangal dogs  or goats as materials for cranioplasty. Such materials were used due to the accessibility of these animals near battlefields, where the procedure is likely to be performed. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11212", "text": "The first true description of cranioplasty in Europe was made by  Fallopius  in the 16th century, stating that the fractured  cranium  should be removed and be reinserted with a gold plate if the  dura  was damaged. This was questioned by other practitioners at his time, concerning that surgeons may keep the gold instead of using it for surgery. The first cranioplasty was reported by the Dutch surgeon  Job Janszoon van Meekeren . The report described the use of a segment of a  canine   cranium  as a material for cranioplasty on a  nobleman  in  Moscow . The operation was successful, but its use of canine bone was not accepted by the church and the man was forced to leave Russia. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11213", "text": "Since the first operation, bones from more animal species were used as xenografts for cranioplasty. These include  dogs ,  apes ,  geese ,  rabbits ,  calves ,  eagles ,  oxen , and  buffalos . In 1917,  William Wayne Babcock  reported the use of \"soup bone\", a piece of cooked and  perforated  animal bone as a xenograft. [ 2 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11214", "text": "The prevalence of  head injuries  increased in the 20th century with the advancement of armaments, particularly the use of  hand grenades  in  trench warfare  during  World War I . [ 17 ]  Along with a decreased mortality from suffering such injuries due to the development of cell debris removal, wound closing, and the use of  antibiotics , cranioplasty techniques were therefore improved. [ 17 ]   Autografts ,  allografts  and synthetic materials are the main types of materials used for cranioplasty. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11215", "text": "Autografts, or autologous grafts, are body tissues taken from the patient. The first successful cranioplasty using an autograft was recorded in 1821, with the bone piece being reinserted into the cranium. The operation achieved partial healing. [ 2 ] [ 10 ]  Subsequently, more studies and operations were carried out with autografts. A successful case of reimplantation of cranial bone was reported by  Sir William Macewen  in 1885, popularising autografts to be material for cranioplasty. Succeeding operations involved autografts taken from different parts of the patient's body, such as the  tibia  (leg bone),  scapula  (shoulder blade),  ilium  (hip bone),  sternum  (chest bone), along with  fat tissues  and  fascia . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11216", "text": "Allografts are tissues from another individual of the same species. The first use of allografts was reported in 1915 with  cadaver   cartilage  by Morestin. [ 3 ] [ 10 ]  Subsequently, another 32 cases of cranioplasties performed with cadaver cartilage were reported by Gosset in 1916. [ 2 ]  The use of  cadaver   cartilage  was favoured during  World War I  due to its  malleability  and resistance to infection. Its use declined because of its lack of significant  calcification  and strength. [ 2 ]   Cadaver   skull  was another type of allograft reported to be used as a cranioplasty material multiple times by Sicard and Dambrin from 1917 to 1919. [ 2 ] [ 3 ] [ 10 ]  The material was not favoured due to the high infection rate with its use. In the 1980s, the use of cadaver allograft disc for filling in small holes received a satisfactory result, and there was a resurgence of the use of  cadaver  bone. [ 2 ]  However, cadaver bones and allografts, in general, are not the preferred materials in modern operations. [ 2 ] [ 3 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11217", "text": "The use of  methyl methacrylate (PMMA)  for cranioplasty has been developed since  World War II , when there was a high demand for it to treat  combat injuries , and used extensively since 1954. [ 2 ] [ 17 ] [ 10 ] [ 18 ]  PMMA becomes malleable when an  exothermic reaction  occurs between its powder form and  benzoyl peroxide , allowing it to be moulded to the cranial defect. [ 1 ]  Advantages of using it are its malleability, low cost, high strength and high durability. Disadvantages include its vulnerability to  infection , as  bacteria  may adhere to its  fibrous  layer, as well as its brittle nature and absence of growth potential. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11218", "text": "Other common synthetic materials for cranioplasty include  titanium  and  hydroxyapatite . Titanium was first used for cranioplasty in 1965. [ 2 ]  It can be used as a plate or a mesh and be 3D printed as a porous form. [ 19 ]  Titanium is non- ferromagnetic  and non- corrosive , making the host free from  inflammatory reactions . [ 1 ]  It is also robust, thus preventing patients from trauma. [ 19 ]  The use of titanium is associated with a lower infection rate. [ 10 ]  Disadvantages of using titanium include its high cost, poor malleability, and disruption to  CT scan  images. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11219", "text": "Hydroxyapatite is a compound of  calcium phosphate  being arranged in a  hexagonal  structure. [ 2 ] [ 18 ]  It bonds well chemically with bones and inflicts little inflammatory reaction by the host, and has good  osteointegration . [ 1 ] [ 2 ] [ 10 ] [ 18 ]  It can be expanded and is used in  paediatric  cranioplasty. [ 1 ] [ 10 ]  It can be moulded smoothly and has appealing cosmetic results. [ 10 ]  However, the material is brittle and has low  tensile strength , and so is only suitable to be used for small cranial defects. [ 1 ] [ 2 ] [ 10 ] [ 18 ]  Its use is also associated with a high infection rate. [ 10 ]  Hydroxyapatite is often used with a titanium mesh to prevent fractures and for better osteointegration. [ 1 ] [ 10 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11220", "text": "Distraction osteogenesis  ( DO ), also called  callus distraction ,  callotasis  and  osteodistraction , is a process used in  orthopedic surgery , podiatric surgery, and  oral and maxillofacial surgery  to repair  skeletal   deformities  and in reconstructive surgery. [ 1 ] [ 2 ]   The procedure involves cutting and slowly separating bone, allowing the bone healing process to fill in the gap. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11221", "text": "Distraction osteogenesis (DO) is used in   orthopedic surgery , and  oral and maxillofacial surgery  to repair  skeletal   deformities  and in reconstructive surgery. [ 1 ] [ 2 ] [ 3 ]  It was originally used to treat problems like  unequal leg length , but since the 1980s is most commonly used to treat issues like  hemifacial microsomia ,  micrognathism  (chin so small it causes health problems),  craniofrontonasal dysplasias ,  craniosynostosis , as well as  airway obstruction  in babies caused by  glossoptosis  (tongue recessed too far back in the mouth) or micrognathism. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11222", "text": "In 2016, a systematic review of papers describing bone and soft tissue outcomes of DO procedures on the  lower jawbone  was published; the authors had planned to do a meta-analysis but found the studies were too poor in quality and too heterogeneous to pool. [ 4 ]   From what they were able to generalize, the authors found there was significant relapse in the vertical plane for bone, and a higher risk of relapse when there was an initial high  gonial angle  or Jarabak ratio (sella\u2013gonion/nasion\u2013menton). [ 4 ]   For soft tissue, little evidence was available regarding the vertical dimension, while a 90% correspondence between skeletal and soft tissue was found for sagittal positioning; the dental-to-soft tissue agreement was  around 20%. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11223", "text": "A 2018  Cochrane  review of DO on the  upper jawbone  to treat  cleft lip  and  cleft palate  compared with  orthognathic surgery  found only one study, involving 47 participants and performed between 2002 and 2008 at the University of Hong Kong. [ 5 ]  This was not sufficient evidence from which to generalize, but the authors noted that while both procedures produced notable hard and soft tissue improvements, the DO group had greater advancement of the maxillary and less horizontal relapse five years after surgery. [ 5 ]  There was no difference in speech or nasal emissions outcomes nor in adverse effects; the DO group had lower satisfaction at three months after surgery but higher at two years. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11224", "text": "In the first phase, called the \"osteotomy/surgical phase\", the bone is cut, either partially, only  through the hard exterior , or  completely , and a device is fitted which will be used in the next phases. In the second phase, the latency period, which lasts generally seven days, the appliance is not activated and early stages of bone healing are allowed.  In the third phase, the \"distraction phase\", the device, which is mounted to the bone on each side of the cut, is used to gradually separate the two pieces, allowing  new bone  to form in the gap. When the desired or possible length is reached, which usually takes three to seven days, a  consolidation phase  follows in which the device keeps the bone stable to allow the bone to fully heal.  After the consolidation phase, the device is removed in a second surgical procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11225", "text": "The device is usually manually operated by twisting a rod that separates the bone using a  rack and pinion  or similar system\u00a0; the rate of separation is carefully determined because going too quickly can cause  nonunion , in which unstable  fibrous connective tissue  is formed instead of bone, and going too slowly can allow premature union to occur.  Generally the rate is about a millimeter per day, achieved in two steps per day.  The frequency of steps and how much the device is moved at each step, is called the \"rhythm\".  The devices sometimes contain a spring that provides tension to continually separate the bones, instead of being manually operated at set intervals. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11226", "text": "In addition to these manually operated systems, there are also motorized systems like the Fitbone from Wittenstein. The Fitbone is a fully implantable, motorized, lengthening and correction nail. [ 6 ]  Advantages of this device are accurate deformity correction, low scar tissue formation, and reduced risk of infection. [ 7 ] [ 8 ]  Furthermore, the patients describe the procedure as more comfortable than limb lengthening with mechanical systems. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11227", "text": "Risks include infection (5% overall, with 1% of those requiring pin removal and the bone becoming infected in 0.5%), failure of bone to grow in the desired direction (between 7 and 9%),  hardware failure (between 3 and 4.5%), failure to follow the distraction protocol (4.5% overall; too slow 2% and too fast 0.5%), 1% pain due to distraction ending the procedure; damage to the inferior alveolar nerve occurs in 3.5% of mandibular distraction, tooth bud injury in 2%, and facial nerve injury in 0.5% of cases. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11228", "text": "The procedure was first proposed by  Bernhard von Langenbeck  in 1869, but the first publication of efforts to implement it clinically was by  Alessandro Codivilla  in 1905. [ 1 ]   The paper presented the results of efforts to treat 26 people who were born with malformed legs; Codivilla cut the femur, put a pin in the  heel bone , and applied  traction  to each person. [ 1 ] [ 10 ]   His paper showed high levels of complications, including infection, tissue death, and bones that failed to join, and his methods were not adopted. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11229", "text": "The Russian orthopedic surgeon  Gavriil Ilizarov  studied DO methods in over 15,000 people starting in the 1950s; he developed external fixation devices and methods to separate severed leg bones gradually, and using them he determined optimal rates of separation.  His work led to widespread use of DO. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11230", "text": "The first use in the jaw was pioneered by  Wolfgang Rosenthal  in 1930 but it was not further explored until the 1980s; the first paper of the modern era describing clinical use was published in 1992. [ 1 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11231", "text": "In  India , cosmetic limb-lengthening surgery is a high demand but also unregulated industry. [ 12 ] [ 13 ]  Height is highly attractive in India and cosmetic limb-lengthening has been used by some young Indians to improve marriage and career prospects. [ 14 ]  Others have used it in preparation for a new job in another country such as the United States. [ 13 ]  American and British men (with average heights of 5 feet 9.5 inches and 5 feet 9.75 inches, respectively) are around 5 inches taller than Indian men. [ 12 ]  One surgeon in India stated: \"This is one of the most difficult cosmetic surgeries to perform, and people are doing it after just one or two months' fellowship, following a doctor who is probably experimenting himself. There are no colleges, no proper training, nothing.\" [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11232", "text": "People as young as 13 or 14 have undergone the procedure in India. Some patients have received infections and had to undergo additional surgeries months later to regain the ability to walk, while others found that they gained less height than expected. [ 13 ]  Other patients have said the surgeons had misled them about the potential complications and dangers of the surgery. [ 12 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11233", "text": "In 2006, limb lengthening was banned by  China's Ministry of Health  after a series of operations resulting in serious side-effects. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11234", "text": "The plot of the 1997 American dystopian science fiction film  Gattaca  involves one character assuming the identity of another and leg lengthening is depicted as part of the elaborate ploy to achieve this subterfuge, along with the use of various bodily fluids to avoid detection by DNA sequencing. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11235", "text": "As of 2013, work was underway on distraction devices using  Shape-memory alloy  that could precisely separate bone without the need for intervention, as well as springs and motors; the use of biopharmaceuticals like  BMP  in combination with devices was also being explored. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11236", "text": "As of 2016, work was underway developing devices and techniques that would allow DO in more directions simultaneously. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11237", "text": "Endoscopic nasopharyngectomy  is a form of  endoscopic  surgery to treat  nasopharyngeal carcinoma . [ 1 ]  This type of  cancer  is commonly treated with  radiation therapy  and  chemotherapy , but endoscopic operation offers an alternative treatment especially when the radiation therapy fails. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11238", "text": "In the early stages oncology, endoscopic surgeries were considered to be radical treatment [ 3 ]  despite the surgery being minimally invasive. [ 4 ]  The surgery is effective the treatment of recently diagnosed localized nasopharyngeal cancer for stage I patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11239", "text": "Patient selection is extremely important in order to avoid surgical complications. Patients diagnosed with rT1 or rT2 tumors, and some rT3 tumors may be candidates for the surgery. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11240", "text": "A  face transplant  is a  medical procedure to replace  all or part of a person's  face  using  tissue  from a donor. Part\nof a field called \"Vascularized Composite Tissue Allotransplantation\" (VCA) it involves the transplantation of facial  skin , the nasal structure, the  nose , the  lips , the  muscles  of facial movement used for expression, the  nerves  that provide sensation, and, potentially, the  bones  that support the face. The recipient of a face transplant will take life-long medications to suppress the  immune system  and fight off  rejection . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11241", "text": "The world's first partial face transplant on a living human was carried out in France in 2005. [ 2 ]  The world's first full face transplant was completed in Spain in 2010. [ 3 ]  Turkey, [ 4 ]  France, the United States, and Spain (in order of total number of successful face transplants performed) are considered the leading countries in the research into the procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11242", "text": "People with faces  disfigured  by  trauma ,  burns , disease, or  birth defects  might aesthetically benefit from the procedure. [ 5 ]  Professor  Peter Butler  at the  Royal Free Hospital  first suggested this approach in treating people with facial disfigurement in a  Lancet  article in 2002. [ 6 ]  This suggestion caused considerable debate at the time concerning the ethics of this procedure. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11243", "text": "An alternative to a face transplant is facial reconstruction, which typically involves moving the patient's own skin from their back, buttocks, thighs, or chest to their face in a series of as many as 50 operations to regain even limited functionality, and a face that is often likened to a mask or a living  quilt ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11244", "text": "The world's first full-face replant operation was on 9-year-old Sandeep Kaur, whose face was ripped off when her hair was caught in a  thresher . Sandeep's mother witnessed the accident. Sandeep arrived at the hospital unconscious with her face in two pieces in a plastic bag. An article in  The Guardian  recounts: \"In 1994, a nine-year-old child in northern India lost her face and scalp in a  threshing machine  accident. Her parents raced to the hospital with her face in a plastic bag and a surgeon managed to reconnect the arteries and replant the skin.\" [ 12 ]  The operation was successful, although the child was left with some muscle damage as well as scarring around the perimeter where the facial skin was sutured back on. Sandeep's doctor was  Abraham Thomas , one of India's top  microsurgeons . In 2004, Sandeep was training to be a nurse. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11245", "text": "In 1996, a similar operation was performed in the Australian state of  Victoria , when a woman's face and scalp, torn off in a similar accident, was packed in ice and successfully reattached. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11246", "text": "The world's first partial face transplant on a living human was carried out on 27 November 2005 [ 15 ] [ 16 ]  by  Bernard Devauchelle , an  oral and maxillofacial surgeon , Benoit Lengel\u00e9, a Belgian plastic surgeon, and  Jean-Michel Dubernard  in  Amiens , France. [ 17 ]   Isabelle Dinoire [ 15 ]  underwent surgery to replace her original face, which had been mauled by her dog. A triangle of face tissue from a brain-dead woman's nose and mouth was grafted onto the patient. On 13 December 2007, the first detailed report of the progress of this transplant after 18 months was released in the  New England Journal of Medicine  and documents that the patient was happy with the results but also that the journey has been very difficult, especially with respect to her immune system's response. [ 18 ] [ 19 ]  Dinoire died on 22 April 2016\nat the age of 49 following cancer from medications. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11247", "text": "A 29-year-old French man underwent surgery in 2007. He had a facial tumor called a  neurofibroma  caused by a genetic disorder. The tumor was so massive that the man could not eat or speak properly. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11248", "text": "In March 2008, the treatment of 30-year-old Pascal Coler of France, who has neurofibromatosis, ended after he received what his doctors call the world's first successful almost full face transplant. [ 21 ] [ 22 ]  The operation, which lasted approximately 20 hours, was designed and performed by Laurent Lantieri and his team (Jean-Paul Meningaud, Antonios Paraskevas and Fabio Ingallina)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11249", "text": "In April 2006, Guo Shuzhong at the Xijing military hospital in  Xi'an , transplanted the cheek, upper lip, and nose of Li Guoxing, who was mauled by an  Asiatic black bear  while protecting his sheep. [ 23 ] [ 24 ]  On 21 December 2008, it was reported that Li had died in July in his home village in  Yunnan . Prior to his death, a documentary on the  Discovery Channel  showed he had stopped taking immuno-suppressant drugs in favour of herbal medication; a decision that was likely a contributing factor to his death, according to his surgeon. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11250", "text": "Selahattin \u00d6zmen  performed a partial face transplant on 17 March 2012 on Hatice Nergis, a twenty-year-old woman at  Gazi University 's hospital in  Ankara . It was Turkey's third, the first woman-to-woman and the first three-dimensional with bone tissue. The patient from  Kahramanmara\u015f  had lost her upper jaw six years prior in a firearm accident, including her mouth, lips, palate, teeth and nasal cavity, and was since then unable to eat. She had undergone around 35 reconstructive plastic surgery operations. The donor was a 28-year-old Turkish woman of Moldavian origin in  Istanbul , who had died by suicide. [ 26 ] [ 27 ] [ 28 ]  Nergis died in  Ankara  on 15 November 2016 after she was hospitalized two days prior complaining about acute pain. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11251", "text": "In December 2011, a 54-year-old man underwent a partial face transplant to the lower two-thirds of the face (including bone) after a ballistic accident. The operation was performed by a multidisciplinary team led by plastic surgeon Phillip Blondeel; Hubert Vermeersch, Nathalie Roche and Filip Stillaert were other members of the surgical team. For the first time 3D CT planning was used to plan the operation that lasted 20 hours. As of 2014 the patient is alive, with \"good recovery of motor and sensory function and social reintegration\". [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11252", "text": "In September 2018, a 49-year-old woman affected by Neurofibromatosis type I received a partial face transplant from a 21-year-old girl at Sant'Andrea Hospital of Sapienza University in Rome. The procedure took 27 hours and was carried out by two teams led by Fabio Santanelli di Pompeo and Benedetto Longo. [ 31 ]  The patient had a complication and after two days the surgeons had to replace the facial graft with autologous tissue. The patient is still alive and waiting for a second face transplantation. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11253", "text": "In May 2018, the first Canadian complete face transplant was performed under the leadership of  plastic surgeon   Daniel Borsuk  at the Hopital Maisonneuve Rosemont, in  Montreal ,  Quebec . [ 33 ] [ 34 ]  The transplant took over 30 hours and replaced the upper and lower jaws, nose, lips and teeth on  Maurice Desjardins , a 64-year-old man that shot himself in a hunting accident. At that time, Mr. Desjardins was the oldest person to benefit from a face transplant. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11254", "text": "On 20 March 2010, a team of 30 Spanish doctors led by plastic surgeon Joan Pere Barret at the  Vall d'Hebron University Hospital  in  Barcelona  carried out the world's first full face transplant, on a man injured in a shooting accident. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11255", "text": "On 8 July 2010, the French media reported that a full face transplant, including tear ducts and eyelids, was carried out at the  Henri-Mondor hospital  in  Cr\u00e9teil . [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11256", "text": "In March 2011, a surgical team, led by  Bohdan Pomaha\u010d  at  Brigham and Women's Hospital  in  Boston, Massachusetts , performed a full face transplant on  Dallas Wiens , who was badly disfigured in a power line accident that left him blind and without lips, nose or eyebrows. The patient's sight couldn't be recovered but he has been able to talk on the phone and smell. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11257", "text": "In April 2011, less than one month after the hospital performed the first full face transplant in the country, the  Brigham and Women's Hospital  face transplant team, led by Bohdan Pomaha\u010d, performed the nation's second full face transplant on patient Mitch Hunter of Speedway, Indiana. It was the third face transplant procedure to be performed at BWH and the fourth face transplant in the country. The team of more than 30 physicians, nurses, anesthesiologists and residents worked for more than 14 hours to replace the full facial area of the patient, including the nose, muscles of facial animation and the nerves that power them and provide sensation. Hunter had a severe shock from a high voltage electrical wire following a car accident in 2001. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11258", "text": "On 15 May 2013, at the  Maria Sk\u0142odowska-Curie Institute of Oncology  branch in  Gliwice , Poland, an entire face was transplanted onto a male patient, Grzegorz (aged 33) after he lost the front of his head in a machine accident at work. The surgery took 27 hours and was directed by Professor Adam Maciejewski. There had not been much planning or prep time before the surgery, which was performed about one month after the accident, because the transplantation was done as an urgent life-saving surgery due to the patient's difficulty in eating and breathing. Shortly after the donor's death, the decision to perform the surgery was made and his body was transported hundreds of kilometers to Gliwice once his relatives gave their consent. The doctors believe that their patient has an excellent chance to live a normal, active life after surgery, and that his face should operate more or less normally (his eyes survived the accident untouched). [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11259", "text": "Seven months later, on 4 December, the same Polish medical team in Gliwice transplanted a face onto a 26-year-old female patient with  neurofibromatosis . Two months after the operation, she left the hospital. [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11260", "text": "On 21 January 2012, Turkish surgeon  \u00d6mer \u00d6zkan  and his team successfully performed a full face transplant at  Akdeniz University 's hospital in  Antalya . The 19-year-old patient, U\u011fur Acar, was badly burnt in a house fire when he was a baby. The donor was 39-year-old Ahmet Kaya, who died on 20 January. [ 44 ]  The Turkish doctors declared that his body had accepted the new tissue. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11261", "text": "Almost one month later on 24 February 2012, a surgical team led by  Serdar Nas\u0131r  conducted the country's second successful full face transplant at  Hacettepe University 's hospital in  Ankara  on 25-year-old Cengiz G\u00fcl. The patient's face was badly burned in a  television tube implosion  accident when he was two years old. The donor was a undisclosed 40-year-old (the donor's family did not permit the identity of the donor to be revealed), who experienced  brain death  two days before the surgery following a motorcycle accident that occurred on 17 February. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11262", "text": "On 16 May 2012, surgeon \u00d6mer \u00d6zkan and his team at the Akdeniz University Hospital performed the country's fourth and their second full face transplant. The face and ears of 27-year-old patient Turan \u00c7olak from  \u0130zmir  were burnt when he fell into an oven when he was three and half years old. The donor was Tevfik Y\u0131lmaz, a 19-year-old man from  U\u015fak  who had attempted suicide on 8 May. He was declared brain dead in the evening hours of 15 May after having been in intensive care for seven days. His parents donated all his organs. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11263", "text": "On 18 July 2013, the face of a Polish man was successfully given to a Turkish man in a transplant performed by \u00d6zkan, at Akdeniz University hospital following a 6.5-hour operation, making it the fifth such operation to take place in the country. It was the 25th face transplant operation in the world. The donor was Andrzej Kucza, a 42-year-old Polish tourist who was declared brain dead following a heart attack on 14 July while swimming in Turkey's sea resort  Mu\u011fla . The receiver was 27-year-old patient Recep Sert from  Bursa . [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11264", "text": "On 23 August 2013, surgeon \u00d6mer \u00d6zkan and his team at Akdeniz University performed the sixth face transplant surgery in Turkey. Salih \u00dcst\u00fcn (54) received the scalp, eyelids, jaw and maxilla, nose and the half tongue of 31-year-old Muhittin Turan, who was declared brain dead after a motorcycle accident that took place two days before. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11265", "text": "On 30 December 2013, \u00d6zkan and his team conducted their fifth and Turkey's seventh face transplant surgery at the hospital of Akdeniz University. The nose, upper lip, upper jaw and maxilla of brain dead Ali Emre K\u00fc\u00e7\u00fck, aged 34, were successfully transplanted to 22-year-old Recep Kaya, whose face was badly deformed in a shotgun accident. While Kaya was flown from  K\u0131rklareli  to Antalya via Istanbul in four hours, the donor's organs were transported from  Edirne  by an ambulance airplane. The surgery took 4 hours and 10 minutes. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11266", "text": "In October 2006, surgeon  Peter Butler  at London's  Royal Free Hospital  in the UK was given permission by the  NHS  ethics board to carry out face transplants. His team will select four adult patients (children cannot be selected due to concerns over consent), with operations being carried out at six-month intervals. [ 51 ]  As of 2022, neither Butler nor any other UK surgeon has performed a face transplant. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11267", "text": "In 2004, the  Cleveland Clinic  became the first institution to approve this surgery and test it on cadavers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11268", "text": "In 2005, the Cleveland Clinic became the first US hospital to approve the procedure. In December 2008, a team at the Cleveland Clinic, led by  Maria Siemionow  and including a group of supporting doctors and six plastic surgeons (Steven Bernard, Dr Mark Hendrickson, Robert Lohman, Dan Alam and Francis Papay) performed the first face transplant in the US on a woman named  Connie Culp . [ 53 ] [ 54 ] [ 55 ]  It was the world's first near-total facial transplant and the fourth known facial transplant to have been successfully performed to date. This operation was the first facial transplant known to have included bones, along with muscle, skin, blood vessels, and nerves. The woman received a nose, most of the sinuses around the nose, the upper jaw, and even some teeth from a brain-dead donor. As doctors recovered the donor's facial tissue, they paid special attention to maintaining arteries, veins, and nerves, as well as soft tissue and bony structures. The surgeons then connected facial graft vessels to the patient's blood vessels in order to restore blood circulation in the reconstructed face before connecting arteries, veins and nerves in the 22-hour procedure. She had been disfigured to the point where she could not eat or breathe on her own as a result of a traumatic injury several years ago, which had left her without a nose, right eye and upper jaw. Doctors hoped the operation would allow her to regain her sense of smell and ability to smile, and said she had a \"clear understanding\" of the risks involved. Connie died 29 July 2020.\nThe second partial face transplant in the US took place at  Brigham and Women's Hospital  in Boston on 9 April 2009. During a 17-hour operation, a surgical team led by  Bohdan Pomaha\u010d , replaced the nose, upper lip, cheeks, and roof of the mouth \u2013 along with corresponding muscles, bones and nerves \u2013 of James Maki, age 59. Maki's face was severely injured after falling onto the electrified third rail at a Boston subway station in 2005. In May 2009, he made a public media appearance and declared he was happy with the result. [ 56 ]  This procedure was also shown in the eighth episode of the ABC documentary series  Boston Med ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11269", "text": "The first full face transplant performed in the US was done on a construction worker named  Dallas Wiens  in March 2011. He was burned in an electrical accident in 2008. This operation, performed by Bohdan Pomaha\u010d and BWH plastic surgery team, [ 57 ]  was paid for with the help of the US defense department. They hope to learn from this procedure and use what they learn to help soldiers with facial injuries. [ 58 ]  One of the top benefits of the surgery was that Dallas has regained his sense of smell. [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11270", "text": "The  Brigham and Women's Hospital  transplant team led by Bohdan Pomaha\u010d, performed the nation's second full face transplant on patient Mitch Hunter of Speedway, Indiana. Hunter, who is a US war veteran, was left disfigured in a car accident, burning about 94% of his face. It was the third face transplant procedure to be performed at BWH and the fourth face transplant in the country. The team of more than 30 physicians, nurses, anesthesiologists and residents worked for more than 14 hours to replace the full facial area of patient Mitch Hunter including the nose, eyelids, muscles of facial animation and the nerves that power them and provide sensation. Mitch Hunter was a passenger in a single cab pick-up truck, upon exiting the vehicle and pulling another passenger off a downed line, Hunter was then struck by a 10,000-volt 7-amp power line for a little under five minutes. The electricity entered his lower left leg, with the majority exiting his face, leaving him severely disfigured. He also lost part of his lower left leg, below the knee, and lost two digits on his right hand (pinkie and ring finger). Hunter has regained almost 100% of his normal sensation back in his face and his only complaint is that he looks too much like his older brother. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11271", "text": "57-year-old  Charla Nash , who was mauled by a chimpanzee named Travis in 2009, after the owner gave the chimp  Xanax  and wine. She underwent a 20-hour full face transplant in May 2011 at  Brigham and Women's Hospital  in  Boston . Nash's full face transplant was the third surgery of its kind performed in the United States, all at the same hospital. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11272", "text": "In March 2012, a face transplant was completed at the University of Maryland Medical Center and R Adams Cowley Shock Trauma Center under the leadership of plastic surgeon  Eduardo Rodriguez  and his team (Amir Dorafshar, Michael Christy, Branko Bojovic and  Daniel Borsuk [ 60 ] ). [ 61 ]  The recipient was 37-year-old Richard Norris, who had sustained a facial gunshot injury in 1997. This transplant included all facial and anterior neck skin, both jaws, and the tongue. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11273", "text": "In September 2014, another face transplant was performed by the Cleveland Clinic group. The patient had had complex trauma that masked the development of a rare type of autoimmune disease (granulomatosis with polyangiitis and pyoderma gengrenosum) affecting the face. It was the first face transplant in a patient with an autoimmune disease involving the craniofacial region. Prior to surgery, an analysis of renal transplant outcomes in granulomatosis with polyangiitis was conducted to evaluate allograft outcomes in these cohorts. That literature established feasibility and encouraged the Cleveland Clinic team to proceed with the surgery. The intervention was reported successful up to three years post-transplantation. [ 63 ] [ 64 ] [ 65 ] [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11274", "text": "In August 2015, a face transplant was completed at the NYU Langone Medical Center under the leadership of the chair of plastic surgery  Eduardo D. Rodriguez  and his team. A 41-year-old retired fireman named Patrick Hardison received the face of cyclist David Rodebaugh. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11275", "text": "In June 2016, a multidisciplinary team of surgeons, physicians and other health professionals completed a near-total face transplant at  Mayo Clinic 's Rochester campus. Patient Andrew Sandness, a 32-year-old from eastern Wyoming, had devastating facial injuries from a self-inflicted gunshot wound in 2006. The surgery, which spanned more than 50 hours, restored Sandness' nose, upper and lower jaw, palate, teeth, cheeks, facial muscles, oral mucosa, some of the salivary glands and the skin of his face (from below the eyelids to the neck and from ear to ear). The care team led by Samir Mardini, and Hatem Amer, the surgical director and medical director, respectively, for the Mayo Clinic Essam and Dalal Obaid Center for Reconstructive Transplant Surgery, devoted more than 50 Saturdays over  3 + 1 \u2044 2  years to rehearsing the surgery, using sets of cadaver heads to transplant the face of one to the other. They used 3-D imaging and virtual surgery to plot out the bony cuts so the donor's face would fit perfectly on the transplant recipient. Today, in addition to his physical transformation, Sandness can smell again, breathe normally and eat foods that were off-limits for a decade. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11276", "text": "In a 31-hour operation starting on 4 May 2017, surgeons at the Cleveland Clinic transplanted a face donated from Adrea Schneider, who had died of a drug overdose, to Katie Stubblefield, whose face had been disfigured in a suicide attempt by rifle on 25 March 2014. As of 2018 [update] , Katie is the youngest person in the United States to have had a face transplant, age 21 at the time. Surgeons originally planned to leave her cheeks, eyebrows, eyelids, most of her forehead, and the sides of her face alone. However, because the donor face was larger and darker than Katie's, they made the decision to transplant the donor's full face. This holds the risk that in case of acute  rejection  in which the face must be removed, she would not have enough tissue for reconstructive surgery. Katie was featured on the cover of  National Geographic  in September 2018 for an article entitled \"The Story of a Face.\" [ 69 ] [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11277", "text": "In July 2019, 68-year-old Robert Chelsea became the oldest person, as well as the first black person in the world, to receive a full face transplant. On 6 August 2013, Robert was involved in an horrific car accident, leaving burns over 75% of his body. The severe damage meant that Robert was missing significant facial elements such as a part of his nose, which limited his ability to eat and drink. Functionality was important to Robert and was a key reason behind his pursuit of the surgery. In 2016, a face transplant was first discussed. Yet, health care disparities have led to a lack of black organ donations. This meant that Robert waited two years to find a face that matched something close to his own complexion. [ 71 ]  The surgery was performed on 27 July 2019 at Brigham and Women's Hospital. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11278", "text": "In February 2024, 30-year-old Derek Pfaff received a full-face transplant from an anonymous donor. Pfaff had previously shot himself in the face during a suicide attempt in March 2014, 10 years prior to the surgery. The results of the surgery were later revealed in November 2024. [ 73 ] [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11279", "text": "A number of combined VCA procedures, such as bilateral  hand transplants , have been described in the literature and media sources. These combined procedures also include attempts at triple-limb [ 75 ] [ 76 ]  and quadruple-limb [ 77 ]  transplants, however, only three face transplants have been attempted in combination with other allografts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11280", "text": "In 2009, Laurent Lantieri and his team attempted a face and bilateral hand transplant on a 37-year-old man who sustained extensive injuries during a self-immolation attempt one year prior. The patient ultimately died of anoxic brain injury two months after his initial transplant during surgical management of infectious and vascular complications. Autopsy revealed no signs of rejection in any of the allografts. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11281", "text": "On 12 August 2020, at NYU Langone Health in New York, New York,  Eduardo D. Rodriguez  led a team of over 140 personnel in successfully transplanting the face and bilateral hands of a brain dead donor onto 22-year-old Joe DiMeo, who sustained disfiguring burns after a car accident in 2018. [ 79 ] [ 80 ]  The procedure lasted approximately 23 hours, and involved the entire facial soft tissue (extending from the anterior hairline to the neck, including the eyelids, nose, lips, and ears, along with strategic skeletal components), as well as both hands at the distal forearm level. [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11282", "text": "Charla Nash's face transplant, described above, also initially included bilateral hands from the same donor. Circulation to Nash's transplanted hands was compromised after she was started on  vasopressors  as part of treatment for sepsis. [ 78 ]  The hands were ultimately amputated, however the patient survived, as did her facial allograft."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11283", "text": "In May 2023, a team of 140 doctors at  NYU Langone Health  successfully conducted the first combination eye transplant and partial face transplant. The patient, a 46-year-old linesman, was electrocuted by high voltage wires in 2021 causing the loss of the lower portion of his face and his left eye. The eye, while not restoring vision to the patient, has successfully received blood flow to the retina. [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11284", "text": "The procedure consists of a series of operations requiring rotating teams of specialists. With issues of tissue type, age, sex, and skin color taken into consideration, the patient's face is removed and replaced (sometimes including the underlying fat, nerves, blood vessels, bones, and/or musculature). The surgery may last anywhere from 8 to 36 hours, followed by a 10- to 14-day hospital stay."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11285", "text": "There has been a substantial amount of ethical debate surrounding the operation and its performance. [ 83 ]  The main issue is that, as noted below, the procedure entails submitting otherwise physically healthy people to potentially fatal, lifelong immunosuppressant therapy. So far, four people have died of complications related to the procedure. Citing the comments of various plastic surgeons and medical professionals from France and Mexico, anthropologist Samuel Taylor-Alexander suggests that the operation has been infused with nationalist import, which is ultimately influencing the decision-making and ethical judgements of the involved parties. [ 84 ]  His most recent research suggests the face transplant community needs to do more in order to ensure that the experiential knowledge of face transplant recipients is included in the ongoing evaluation of the field. [ 85 ]  As of October 2019, the  AboutFace Project   Archived  1 February 2021 at the  Wayback Machine , funded by a  UKRI Future Leaders Fellowship  awarded to  Dr Fay Bound Alberti , is exploring these debates as part of its wider research into the emotional and cultural history of face transplants. [ 86 ]  The AboutFace project has entered its second phase as  Interface , a research project which explores the relationship between identity, emotion, and communication, as revealed through the human face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11286", "text": "After the procedure, a lifelong regimen of  immunosuppressive  drugs is necessary to suppress the patient's own  immune systems  and prevent rejection. [ 87 ]  Long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage, and cancer. The surgery may result in complications such as infections that could damage the transplanted face and require a second transplant or reconstruction with skin grafts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11287", "text": "A  facial cleft  is an opening or gap in the  face , or a malformation of a part of the face. Facial clefts is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. Facial clefts are extremely rare  congenital anomalies . There are many variations of a type of clefting and classifications are needed to describe and classify all types of clefting. Facial clefts hardly ever occur isolated; most of the time there is an overlap of adjacent facial clefts. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11288", "text": "There are different classifications about facial clefts. Two of the most used classifications are the  Tessier classification [ 2 ]  and the  Van der Meulen classification . [ 3 ]  Tessier is based on the anatomical position of the cleft and Van der Meulen classification is based on the embryogenesis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11289", "text": "In 1976  Paul Tessier  published a classification on facial clefts based on the anatomical position of the clefts. The different types of Tessier clefts are numbered 0 to 14. These 15 different types of clefts can be put into 4 groups, based on their position: [ 4 ]  midline clefts, paramedian clefts, orbital clefts and lateral clefts. The Tessier classification describes the clefts at soft tissue level as well as at bone level, because it appears that the soft tissue clefts can have a slightly different location on the face than the bony clefts. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11290", "text": "The midline clefts are Tessier number 0 (\"median craniofacial dysplasia\"), number 14 ( frontonasal dysplasia ), and number 30 (\"lower midline facial cleft\", also known as \"median mandibular cleft\"). These clefts bisect the face vertically through the midline. Tessier number 0 bisects the  maxilla  and the nose, Tessier number 14 comes between the nose and the  frontal bone . The Tessier number 30 facial cleft is through the tongue, lower lip and  mandible . The tongue may be absent, hypoplastic, bifid, or even duplicated. [ 5 ]  People with this condition may be  tongue-tied . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11291", "text": "Tessier number 1, 2, 12 and 13 are the paramedian clefts. These clefts are quite similar to the midline clefts, but they are further away from the midline of the face. Tessier number 1 and 2 both come through the maxilla and the nose, in which Tessier number 2 is further from the midline ( lateral ) than number 1. Tessier number 12 is in extent of number 2, positioned between nose and frontal bone, while Tessier number 13 is in extent of number 1, also running between nose and forehead. Both 12 and 13 run between the midline and the orbit. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11292", "text": "Tessier number 3, 4, 5, 9, 10 and 11 are orbital clefts. These clefts all have the involvement of the  orbit . Tessier number 3, 4, and 5 are positioned through the maxilla and the orbital floor. Tessier number 9, 10 and 11 are positioned between the upper side of the orbit and the forehead or between the upper side of the orbit and the  temple  of the head. \nLike the other clefts, Tessier number 11 is in extent to number 3, number 10 is in extent to number 4 and number 9 is in extent to number 5."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11293", "text": "The lateral clefts are the clefts which are positioned horizontally on the face. These are Tessier number 6, 7 and 8. Tessier number 6 runs from the orbit to the cheek bone. Tessier number 7 is positioned on the line between the corner of the mouth and the ear. A possible lateral cleft comes from the corner of the mouth towards the ear, which gives the impression that the mouth is bigger. It's also possible that the cleft begins at the ear and runs towards the mouth. Tessier number 8 runs from the outer corner of the eye towards the ear. \nThe combination of a Tessier number 6-7-8 is seen in the  Treacher Collins syndrome . Tessier number 7 is more related to  hemifacial microsomia  and number 8 is more related to  Goldenhar syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11294", "text": "Van der Meulen classification divides different types of clefts based on where the development arrest occurs in the  embryogenesis . A primary cleft can occur in an early stage of the development of the face (17\u00a0mm length of the embryo). The developments arrests can be divided in four different location groups: internasal,  nasal , nasalmaxillar and maxillar. The maxillar location can be subdivided in  median  and lateral clefts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11295", "text": "Internasal  dysplasia  is caused by a development arrest before the union of the two nasal halves. These clefts are characterized by a median cleft lip, a median notch of the  cupid's bow  or a duplication of the labial  frenulum . Besides the median cleft lip,  hypertelorism  can be seen in these clefts. Also sometimes there can be an underdevelopment of the  premaxilla ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11296", "text": "Nasal dysplasia or nasoschisis is caused by a development arrest of the lateral side of the nose, resulting in a cleft in one of the nasal halves. The nasal septum and cavity can be involved, though this is rare. Nasoschisis is also characterized by hypertelorism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11297", "text": "Nasomaxillary dysplasia is caused by a development arrest at the junction of the lateral side of the nose and the maxilla, which results in a complete or non-complete cleft between the nose and the orbital floor (nasoocular cleft) or between the mouth, nose and the orbital floor (oronasal-ocular cleft). The development of the lip is normal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11298", "text": "Maxillary dysplasia can manifest itself on two different locations in the maxilla: in the medial or the lateral part of the maxilla."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11299", "text": "It is possible that facial clefts are caused by a disorder in the migration of  neural crest cells . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11300", "text": "Another theory is that facial clefts are caused by failure of the fusion process and failure of inwards growth of the  mesoderm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11301", "text": "Other theories are that genetics play a part in the development of facial clefts [ 7 ]  or that they are caused by amniotic bands. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11302", "text": "Around one in 700 individuals are born with craniofacial clefts. [ 9 ]  There are multiple genetic and environmental factors which contribute to craniofacial development. Within craniofacial disorders and  abnormalities , orofacial clefts, and specifically  cleft lip  (CL) and  cleft palate  (CP) are the most common in humans. [ 9 ]  Occurrences of CL/P are most often (around seventy percent of cases) isolated and nonsyndromic, meaning they are not associated with a syndrome or inherited genetic conditions. [ 9 ] [ 10 ]  Around thirty percent occur with other structural variances, and over 500 syndromes have been identified in which clefting is a principal feature. [ 9 ] [ 10 ]  Clefting can result from  teratogens , an agent that disrupts embryo development such as, radiation, maternal infection, chemicals, or drugs. [ 9 ] [ 10 ]   Chromosomal abnormalities  or  mutations  at single gene loci have also contributed to clefting development. [ 9 ] [ 10 ]  Genetic causes are linked with most craniofacial syndromes, and CL/P and other orofacial clefts are recognized as  heterogeneous disorders , meaning there are multiple recognized causes. [ 9 ] [ 11 ]  Orofacial clefts have great phenotypic diversity, and their associated genetic environments have called for vast research and investigation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11303", "text": "Craniofacial disorders have high variance in phenotypic expression, and researchers have suggested this variance could be due to interactions between the mutated/deviated genes and other genes, along with interactions with environmental factors. [ 12 ] [ 13 ]  Environmental causes have been found to contribute to craniofacial clefting, however, these are still influenced by and supported by genetic factors. Many studies, for example, have linked maternal smoking to increased CLP risk; however, the increased risk suggests that genes in metabolic pathways could still contribute to susceptibility or formation of CL/P. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11304", "text": "The craniofacial complex begins its progress in the fourth week of development, and results from  neural crest  cells migrating to form and fuse the facial primordia. [ 9 ] [ 10 ]  Failures or deviations in this process result in craniofacial clefts, either CL or CP. [ 6 ]  The range of variation in phenotype aligns with ancestry. [ 9 ] [ 14 ]  Studies have found increased amounts of clefting in the relatives of patients with clefts, suggesting genetic factors are the underlying cause for CL/P. [ 9 ]  Inheritance has a known and significant role in human craniofacial morphology. This is supported through cephalometric and anthropometric comparisons of family members including between triplets, twins, siblings, and parents and children. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11305", "text": "Genetic factors of craniofacial clefting can be investigated and tracked through several methods including  sequencing  in humans,  Genome-wide association studies  (GWAs),  fate mapping , expression analysis, and animal studies (knockout experiments or models with clefting from chemical mutagenesis). [ 16 ]   Twin studies  and familial clustering have also revealed that facial structure and formation are genetically linked. Several genes have been associated with craniofacial disorders through experimentation, including sequencing Mendelian clefting syndromes. [ 9 ]  Over 25 loci have been identified as potential influencers of craniofacial clefts across populations. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11306", "text": "The  transforming growth factor  ( TGF ) family has provided multiple candidate genes linked with craniofacial development and malformation. [ 17 ] [ 18 ] [ 14 ] [ 10 ]   TGF  is involved in cell migration, differentiation, and proliferation, as well as regulating the extracellular matrix. [ 17 ]  Another gene that has been flagged as causal for craniofacial disorders, including CL/P, is  interferon regulatory factor 6  or,  IRF6 . [ 9 ] [ 14 ] [ 19 ]  Mutations in  IRF6  cause  Van der Woude syndrome , the most common clefting syndrome. [ 9 ]   Ventral anterior homeobox 1 ,  VAX1,  and  noggin ,  NOG , were identified with genome-wide significance for contributing to CL/P. [ 14 ]  Additionally, mutations in  SPECC1L  have recently been identified as influential to facial structure formation, and as causal for syndromic facial clefting. [ 19 ] [ 20 ]  Nonsyndromic CL/P has been associated with the transcription factor  forkhead box protein E1  ( FOXE1 ), as mutations have resulted in cases of CL/P in mice. [ 10 ]  Other genes which have been found to interact with or contribute to craniofacial clefting include  FGFR s,  TWIST ,  MSX s,  GREM1 ,  TCOF1 ,  PAX s,  MAFB ,  ABCA4,  and  WNT  allowing great cause for more research into the genetic basis for craniofacial disorders. [ 11 ] [ 18 ] [ 12 ] [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11307", "text": "Because the cause of facial clefts still is unclear, it is difficult to say what may prevent children being born with facial clefts. It seems that  folic acid  contributes to lowering the risk of a child being born with a facial cleft. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11308", "text": "There is no single strategy for treatment of facial clefts, because of the large amount of variation in these clefts. Which kind of surgery is used depends on the type of clefting and which structures are involved. There is much discussion about the timing of reconstruction of bone and soft tissue. The problem with early reconstruction is the recurrence of the deformity due to the intrinsic restricted growth. This requires additional operations at a later age to make sure all parts of the face are in proportion. [ 22 ]  A disadvantage of early bone reconstruction is the chance to damage the tooth germs, which are located in the maxilla, just under the orbit. The soft tissue reconstruction can be done at an early age, but only if the used skin flap can be used again during a second operation. The timing of the operation depends on the urgency of the underlying condition. If the operation is necessary to function properly, it should be done at early age. The best aesthetic result is achieved when the incisions are positioned in areas which attract the least attention (they cover up the scars). If, however, the function of a part of the face isn't damaged, the operation depends on psychological factors and the facial area of reconstruction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11309", "text": "The treatment plan of a facial cleft is planned right after diagnosis. This plan includes every operation needed in the first 18 years of the patients life to reconstruct the face fully. \nIn this plan, a difference is made between problems that need to be solved to improve the health of the patient (coloboma) and problems that need to be solved for a better cosmetic result (hypertelorism)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11310", "text": "The treatment of the facial clefts can be divided in different areas of the face: the cranial anomalies, the orbital and eye anomalies, the nose anomalies, the midface anomalies and the mouth anomalies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11311", "text": "The most common cranial anomaly seen in combination with facial clefts is  encephalocele ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11312", "text": "The treatment of encephalocele is based on surgery to repair the bony gap and provide adequate protection of the underlying brain. The question remains if the external brain tissue should be put back into the skull or if it is possible to cut off that piece of brain tissue, because its claimed that the external piece of brain tissue often isn't functional, [ 23 ]  with the exception of a basal encephalocele, in which the pituitary gland can be found in the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11313", "text": "The most common orbital /eye anomalies seen in children with facial clefts are colobomas and vertical dystopia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11314", "text": "The coloboma which occurs often in facial clefts is a cleft in the lower or upper eyelid. This should be closed as soon as possible, to prevent drought of the eye and a consecutive loss of vision. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11315", "text": "Vertical orbital dystopia can occur in facial clefts when the orbital floor and/or the maxilla is involved in the cleft. Vertical orbital dystopia means that the eyes do not lay on the same horizontal line in the face (one eye is positioned lower than the other). The treatment is based on the reconstruction of this orbital floor, by either closing the boney cleft or reconstructing the orbital floor using a  bone graft . [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11316", "text": "There are many types of operations which can be performed to treat a hypertelorism. 2 options are: box osteotomy and facial bipartition [ 26 ]  (also referred to as a median fasciotomy).\nThe goal of the box osteotomy is to bring the orbits closer together by removing a part of the bone between the orbits, to detach both orbits from the surrounding bone structures and move both orbits more to the centre of the face. \nThe goal of the facial bipartition is not only to bring the orbits closer together, but also to create more space in the maxilla. This can be done by splitting the maxilla and the frontal bone, remove a triangular shaped piece of bone from the forehead and nasal bones and pulling the two pieces of forehead together. Not only will the hypertelorism be solved by pulling the frontal bone closer together, but because of this pulling, the space between the both parts of the maxilla will become wider."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11317", "text": "The nose anomalies found in facial clefts vary. The main goal of the treatment is to reconstruct the nose to get a functional and esthetic acceptable result. A few possible treatment options are to reconstruct the nose with a forehead flap or reconstruct the nasal dorsum with a bone graft, for example a rib graft. The  nasal reconstruction  with a forehead flap is based on the repositioning of a skin flap from the forehead to the nose. A possible downside of this reconstruction is that once you performed it at a younger age, you can't lengthen the flap at a later stage. A second operation is often needed if the operation is done on early age, because the nose has a restricted growth in the cleft area. Repair of the  ala  (wing of the nose) often requires the inset of cartilage graft, commonly taken from the ear. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11318", "text": "The treatment of soft tissue parts of midface anomalies is often a reconstruction from a skin flap of the cheek. This skinflap can be used for other operations in the further, as it can be raised again and transposed again. In the treatment of midface anomalies there are generally more operations needed. Bone tissue reconstruction of the midface often occurs later than the soft tissue reconstruction. The most common method to reconstruct the midface is by using the fracture/ incision lines described by  Ren\u00e9 Le Fort . When the cleft involves the maxilla, it is likely that the impaired growth will result in a smaller maxillary bone in all 3 dimensions (height, projection, width)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11319", "text": "There are several options for treatment of mouth anomalies like Tessier cleft number 2-3-7 . These clefts are also seen in various syndromes like Treacher Collins syndrome and hemifacial microsomia, which makes the treatment much more complicated. In this case, treatment of mouth anomalies is a part of the treatment of the syndrome."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11320", "text": "Related articles"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11321", "text": "Syndromes"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11322", "text": "Joel Ferri  is a  French   Stomatologist , Oral and Maxillofacial Surgeon,  academic  and  author . He is the chairman and head of the Department of Oral and Maxillofacial Surgery at the Lille Medical School. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11323", "text": "Ferri is most known for his contributions to  stomatology  and maxillofacial surgery outcomes, with a special involvement in bone surgery ( orthognathic surgery , bone reconstruction, TMJ prosthesis). Among his notable works are his publications in academic journals, including the  American Journal of Orthodontics and Dentofacial Orthopedics  and  Journal of Oral and Maxillofacial Surgery  as well as an edited book titled  Preprosthetic and Maxillofacial Surgery: Biomaterials, Bone Grafting and Tissue Engineering . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11324", "text": "Ferri earned his  medical degree  from  Nantes University  in 1990. Additionally, he acquired a Specialized  Diploma  in  Stomatology  and Maxillofacial Surgery, along with a diploma in Facial and Neck Surgery. Subsequently, in 1996, he successfully completed his  Ph.D . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11325", "text": "Ferri was appointed as a  professor  in the Department of Oral and Maxillofacial Surgery at the  University of Lille  in 1997. From 2004 to 2008, he served as the president of the International Bone Research Association and as the president of the French Society of Stomatology and Maxillofacial Surgery in 2011. In 2022 as a result of his involvement of the head and neck malformations he was admitted as a member of the Undiagnosed Disease Network International (UDNI). He was admitted as a member of the European Society of TMJ Surgeons (ESTMJS) and was appointed president of this society in 2017. Moreover, he has been serving as the chairman and head of the Department of Oral and Maxillofacial Surgery at the Lille medical school since 1997. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11326", "text": "Ferri's early research was focused on the bone of the maxillo-facial area. He conducted a retrospective study comparing the advantages and disadvantages of mandibular reconstruction using a fibula free flap versus other techniques. The study found that while the fibula flap offers benefits like bone length and low donor site morbidity, it may not be suitable for large soft tissue defects, with the conclusion that it is satisfactory for defects over 20\u00a0cm in size. [ 3 ]  While investigating the relationship between the fiber-type composition of the masseter muscle and different bite patterns in individuals undergoing surgical correction of malocclusion, his 2005 research revealed significant associations between muscle composition and vertical bite characteristics, particularly in Class III subjects. [ 4 ]  In the same year, through his research, he presented a surgical protocol utilizing bimaxillary advancement and adjunctive procedures for the treatment of obstructive sleep apnea syndrome (OSAS) in patients affected by facial or mandible retrusion, demonstrating a high success rate in reducing the apnea/hypopnea index and improving patient outcomes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11327", "text": "Ferri's 2010 work examined the impact of orthognathic surgery on temporomandibular joint (TMJ) disorders, finding that while the surgery significantly reduces TMJ symptoms in patients with pre-operative symptoms, there is a risk of new onset of TMJ symptoms post-surgery, albeit with a low occurrence rate. [ 6 ]  In 2011, he co-edited the book titled  Reprosthetic and Maxillofacial Surgery: Biomaterials, Bone Grafting and Tissue Engineering , wherein he provided a comprehensive overview of preprosthetic and maxillofacial surgery, focusing on bone grafting, reconstructive surgery, and tissue engineering to enhance dental implant success and patient rehabilitation. [ 2 ]  His 2014 work with Andreas Neff and others evaluated treatment strategies for mandibular condylar fractures, finding a growing consensus among experts favouring open reduction with internal fixation (ORIF) as the gold standard, especially for displaced fractures, with considerations for endoscopic approaches and pediatric cases. [ 7 ]  In 2016, he reported a case of osteochimionecrosis on a fibula flap transferred for mandibular reconstruction, demonstrating that the transferred bone behaved similarly to the original one, thereby proving that environmental factors dictate bone behavior and pathophysiology regardless of its original nature. [ 8 ]  His 2017 work was a retrospective study comparing recurrence rates of ameloblastoma following conservative and radical treatments, revealing a significantly higher recurrence rate in the conservative treatment group, suggesting treatment should be tailored based on tumor characteristics and patient factors. [ 9 ]  More recently in 2022, he explored the regeneration potential of bone substitutes using a rabbit model with two different types of critical-sized defects, validating the model for calvaria defects but not for mandibular defects, and suggesting further research to improve mandibular defect design. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11328", "text": "Genioglossus advancement  ( GA ) is a  surgical procedure  or  sleep surgery  in which the base of the  tongue  is pulled forward. [ 1 ]  It is usually to increase airway size due to deformity or a  sleep breathing disorder . This procedure is frequently performed with either  uvulopalatopharyngoplasty  or  maxillomandibular advancement  surgeries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11329", "text": "Tongue muscles (genioglossus, geniohyoid and others) are attached to the lower jaw below the teeth. During a genioglossus advancement procedure, a small window or bone cut is made in the front part of the lower jaw (mandible) at the level of the geniotubercle which is where the genioglossus muscle is attached. This piece of bone along with the attachment for the tongue (genial tubercle) is pulled forward and is subsequently secured to the lower jaw, usually with a single screw or with a plate(s) and screws."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11330", "text": "This procedure is often combined with other surgeries such as uvulopalatopharyngoplasties or maxillomandibular advancement surgeries. It is rare to have this procedure performed as the only surgical treatment for sleep apnea, as obstruction in sleep apnea is most often at multiple levels (nose, palate, tongue, etc.)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11331", "text": "Hyoid suspension , also known as hyoid myotomy and suspension or hyoid advancement, is a  surgical procedure  or  sleep surgery  in which the  hyoid bone  and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway (airway behind and below the base of tongue). The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for  obstructive sleep apnea  (OSA). This procedure is frequently performed with a  uvulopalatopharyngoplasty  (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's  apnea-hypopnea index  is significantly reduced after surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11332", "text": "The American Academy of Otolaryngology\u2013Head and Neck Surgery position statement considers hyoid suspension \"effective and non-investigational with proven clinical results when considered as part of the comprehensive surgical management of symptomatic adult patients with mild obstructive sleep apnea (OSA) and adult patients with moderate and severe OSA assessed as having tongue base or hypopharyngeal obstruction.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11333", "text": "The  American Sleep Apnea Association  (ASAA) website  describes  hyoid suspension as a minimally invasive procedure where: \"Success from this procedure has been outstanding and is becoming a valuable tool in the surgeon's armamentarium.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11334", "text": "Hyo-mandibular advancement along with genioglossus advancement was originally described by in 1984. [ 2 ]   Published clinical experience with hyoid suspension can be summarized into three different approaches to the hyoid suspension procedure: hyo-mandibular suspension, hyo-thyroid suspension, and genioglossus advancement and hyoid myotomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11335", "text": "In hyo-mandibular suspension, sutures are looped around the anterior section of the hyoid bone, the hyoid is advanced typically 2\u20133 centimeters (until the muscle attachments to the hyoid are tensioned) using the sutures, and the hyoid advancement is locked into place and secured via bone anchors on the front lower inside portion of the jaw. This procedure is typically performed with two incisions, one incision under the chin for placement of bone anchors into the jaw and one incision directly over the hyoid bone for the most direct access to the bone.  Some surgeons perform the procedure from only the single incision below the chin. Potential complications and side effects from the procedure include neck seromas, edema, and surgical site infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11336", "text": "In hyo-thyroid suspension, sutures are looped around the hyoid, and the hyoid bone is advanced using the sutures to the upper edge of the thyroid cartilage where it is sutured and tied to the top of the thyroid cartilage. This procedure is typically performed from a single incision directly over the hyoid bone. Potential complications and side effects from the procedure include neck seromas, edema, transient dysphagia, and surgical site infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11337", "text": "In genioglossus advancement and hyoid myotomy (GAHM), a genioglossus advancement is performed at the same time as either a hyo-mandibular or hyo-thyroid suspension. Potential complications and side effects from the procedure include lip and chin hypoanesthesia, seromas, edema, transient dysphagia and aspiration, and surgical site infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11338", "text": "Published clinical results for hyoid suspension performed with a UPPP are presented in the table below. [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ]  Surgical success typically means that the AHI is reduced at least 50% and that the post-operative AHI is less than 20."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11339", "text": "Published clinical information for the three hyoid suspension variations without a UPPP is very limited. [ 20 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11340", "text": "For many years, a genioglossus advancement was consistently performed with a hyoid suspension where the more invasive and morbid genioglossus advancement was considered a necessary component for the overall success of the tongue base intervention. Hyo-thyroid suspension published evidence comes entirely from Europe where the low cost, reduced morbidity, and nearly equivalent results to GAHM have made it the preferred technique. \nRecent publications have suggested that hyo-mandibular suspension may be the most effective hyoid suspension technique in treating tongue base and hypopharyngeal obstructions. [ 23 ]   The technique is similarly invasive to hyo-thyroid suspension and available clinical data shows 25% greater efficacy for the reduction of AHI when compared to hyo-thyroid suspension. Data available for hyo-mandibular suspension also shows similar superior efficacy to the GAHM procedure. Hyo-mandibular suspension requires a surgical kit and implants ( Siesta Medical Encore  or  Medtronic Airvance ) which make the procedure marginally more expensive than hyo-thyroid suspension."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11341", "text": "A  labial frenectomy  is a form of  frenectomy  performed on the lip."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11342", "text": "The  labial   frenulum , also known as lip-tie, often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front  tooth gap . When a  denture  patient's lips move, the frenulum pulls and loosens the denture, which can be uncomfortable. This surgery is often done to help dentures fit better. [ 1 ]  A labial frenectomy can result in significant improvement in  breastfeeding  outcomes. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11343", "text": "Laboratory Unit for Computer Assisted Surgery   is a system used for virtual  surgical planning . Starting with 1998, LUCAS was developed at the  University of Regensburg, Germany , with the support of the  Carl Zeiss Company . The resulting surgical planning is then  reproduced  onto the patient by using a  navigation system . In fact, LUCAS is integrated into the same  platform  together with the  Surgical Segment Navigator (SSN) , the Surgical Tool Navigator (STN), the Surgical Microscope Navigator (SMN) and the 6 DOF  Manipulator (or, in German, \"Mehrkoordinatenmanipulator\" - MKM), also from the  Carl Zeiss Company ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11344", "text": "Data from separate  bidimensional  slices generated by a  CT  or  MRI  scan are uploaded into the LUCAS system. The resulting  dataset  is then processed, in order to eliminate  image noise , and to enhance the anatomical contours and also the general contrast of the images. The next step is to create a virtual  3D  model from the gathered collection of  2D  images. The bone segment that is to be repositioned is marked, on the 3D grid reconstructed model; then, the actual repositioning of that bone segment is done on the virtual model, until the optimal anatomical position is obtained. The criteria for the optimal position of the bone segment are: symmetry with the opposite side, the continuity of the normal bone contours, or the normal volume of an anatomical region (such as the  Orbit . Afterwards, a  textured  final image is rendered. The calculated vectors for the bone segment repositioning, together with the whole virtual model are finally transferred to the  Surgical Segment Navigator ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11345", "text": "The  Le Fort  (or  LeFort )  fractures  are a pattern of midface fractures originally described by the French surgeon,  Ren\u00e9 Le Fort , in the early 1900s. [ 1 ]  He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing  facial trauma  for communication, documentation, and  surgical planning . [ 2 ]  Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including  maxillomandibular fixation (MMF)  and  open reduction and internal fixation (ORIF) . The main goal of any surgical intervention is to re-establish  occlusion , or the alignment of upper and lower teeth, to ensure the patient is able to eat. [ 2 ]  Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11346", "text": "When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11347", "text": "The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It comprises the  maxillary bone ,  palatine bones ,  zygomas ,  zygomatic processes (of the temporal bone) ,  ethmoid bone ,  vomer ,  nasal concha ,  nasal bones , and  pterygoid processes (of the sphenoid bone) . [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11348", "text": "The maxillary bone contains important anatomical structures which are prone to injury during trauma. The  maxillary sinuses  are housed within the maxillary bone, and traumatic injury to these sinuses may cause  sinus infections , and changes in eye placement and movement. [ 4 ]  The  infraorbital nerve  (a terminal branch of  CNV2 ) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition).  Occlusion , or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11349", "text": "Facial  biomechanics , or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing. [ 2 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11350", "text": "The Le Fort fractures are a pattern of midface fractures originally described by the French surgeon,  Ren\u00e9 Le Fort , in the early 1900s. [ 1 ]  Le Fort studied the effect of  facial trauma  by dropping cadavers from various heights and recording the different fracture patterns observed. [ 2 ]  Today, with the evolution of high-speed  motor vehicle accidents  and advancements in  medical imaging  and surgical techniques, the low-speed fracture patterns originally described by Le Fort are not always applicable. [ 7 ]  Modern midface fractures typically do not neatly fit into one of the Le Fort classifications and often occur in combination with other  craniofacial trauma . [ 1 ]  Nevertheless, the Le Fort type fracture classification is still used today as a starting point for describing midface fractures for communication, documentation, and treatment planning. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11351", "text": "Traditionally, Le Fort described three types of fractures. All three fractures involve the  nasal septum  and the  pterygoid plates . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11352", "text": "Every trauma patient presenting to the hospital should first be evaluated according to the  Advanced Trauma Life Support (ATLS) protocol , which follows the ABC's ( airway ,  breathing ,  circulation ) of trauma. This includes ensuring the patient is able to breathe, confirming that the patient is actively  breathing , and identifying and minimizing major bleeding. [ 1 ] [ 2 ] [ 6 ]  Le Fort fractures have the potential to obstruct a patient's  airway  for a variety of reasons, preventing him or her from being able to breathe. [ 1 ] [ 6 ]  Medical providers should be prepared for  emergency airway management  should the patient develop an obstructed airway due to bleeding or swelling. [ 6 ]  Other life-threatening injuries, including those to the  brain ,  spine , or  abdomen , should receive prompt evaluation by the appropriate  medical specialist . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11353", "text": "After the initial evaluation is complete and the patient is  stable , the patient should be evaluated by a surgeon that specializes in facial trauma, such as a  plastic surgeon , an  otolaryngologist  (ear, nose, and throat surgeon), or an  oral and maxillofacial surgeon  (OMFS). The surgeon will perform a thorough facial exam, paying special attention to any new-onset facial asymmetry or distortion. [ 1 ]  Facial swelling and bruising is very common in Le Fort fractures and can make evaluation of facial changes challenging. [ 6 ]  It can be helpful to have a picture of the patient prior to his or her facial trauma as a comparison."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11354", "text": "If the surgeon suspects a Le Fort fracture, they may test for abnormal movement of the  maxillary bone  by planting one hand on the patient's forehead and using the other hand to press on the roof of the patient's mouth. [ 1 ]  Movement in the  maxillary bone  either in isolation or with the nose is suggestive of a Le Fort I or II fracture, respectively. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11355", "text": "The  cranial nerves (CNs)  should be  examined  if the patient is awake and able to participate in the exam process. [ 2 ]  The  CN exam  evaluates facial movement and sensation. Special attention should be made to the  fifth CN (CNV)  as one of its branches (the  infraorbital nerve ) courses through the  maxillary bone . [ 2 ]  If this nerve is injured during trauma, it can result in numbness or tingling around the nose or within the mouth. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11356", "text": "The surgeon will also examine the patient's mouth for bleeding, swelling, cuts, foreign objects, changes in bite, and newly lost teeth. Additionally, an eye exam assessing vision and  pupillary response  may be warranted, especially in Le Fort II and III fractures due to the involvement of the  orbit . [ 2 ]  If there is suspicion that the  skull base has been injured , such as during a Le Fort III fracture, the patient should be examined for clear drainage from the ear or nose which may be caused by a  cerebrospinal fluid (CSF) leak . [ 2 ] [ 6 ]  Abnormal findings during these mouth, eye, ear, or nose exams may require further evaluation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11357", "text": "If it was determined that the patient lost a tooth during the inciting trauma, the tooth's location should be identified as it could have become lodged in the airway,  aspirated into the lungs , or swallowed. [ 1 ]  If there is concern for an  aspirated  tooth, an  x-ray  can confirm the tooth's location. [ 1 ] [ 6 ]  If the eye exam reveals abnormalities in either vision or the  pupillary response , prompt evaluation by a  neurosurgeon  and an  ophthalmologist  should occur. [ 2 ]   Skull base injuries  can result in a  cerebrospinal fluid (CSF) leak , which can present as a clear, metallic-tasting liquid draining from the  nose  or the ear. [ 2 ]  If a CSF leak is suspected, the patient should be evaluated by a  neurosurgeon . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11358", "text": "Although diagnosis can be suspected by history and physical exam, imaging is required for an accurate diagnosis. A  computed tomography (CT)  of the face and skull is the imaging of choice for diagnosing Le Fort fractures. [ 5 ] [ 7 ]  CT imaging has greatly replaced the use of  plain x-ray  as CTs are significantly more likely to show when a fracture is present compared to an x-ray. [ 7 ]  Additionally, CT imaging is far more useful in visualizing the skeletal injuries in Le Fort fractures than  magnetic resonance imaging (MRI) . [ 7 ]  However, MRIs may be useful if there is extensive  soft tissue injuries . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11359", "text": "Surgical  treatment of Le Fort fractures is almost always necessary, especially if the fractures are displaced or impact facial functions like eating and speaking. [ 6 ]  Fractures can be repaired through  maxillomandibular fixation (MMF)  and/or  open reduction and internal fixation (ORIF)  after life-threatening injuries have been addressed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11360", "text": "The primary goal of any intervention is to ensure that a patient is able to eat and speak. This is done by re-establishing  occlusion  (alignment of upper and lower teeth) and stabilizing  facial biomechanics  (via the vertical and horizontal facial buttresses discussed previously) to support chewing. [ 1 ]  Other goals of intervention include restoring cosmetic deformities from the trauma, but this should never be prioritized over re-establishing occlusion. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11361", "text": "Maxillomandibular fixation (MMF) , also known as intermaxiallary fixation (IMF), is a surgical procedure to re-establish  occlusion  by fixating the upper and lower teeth in their correct position. It can be used in isolation or in combination with  open reduction and internal fixation (ORIF)  in treating Le Fort fractures. [ 6 ]  Several surgical techniques exist for establishing MMF, with selection relying on the individual patient injury and surgeon preference. [ 1 ] [ 2 ]  MMF involves fixation of the upper and lower teeth for 6-8 weeks, which limits a patient's ability to speak, eat, breathe through their mouth, and maintain adequate  oral hygiene . [ 1 ]  MMF patients should be provided with wire cutters or scissors for emergency situations. [ 1 ]  A patient in MMF will be placed on a liquid-only diet during the entirety of their treatment, which may result in weight changes. [ 1 ] [ 8 ]  MMF has some effect on a patient's ability to breathe through their mouth while in place, so patients with a history of  pulmonary disease  who rely on mouth breathing may not qualify for MMF. [ 8 ]   Additionally, patients with psychological or seizure disorders may not be good MMF candidates. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11362", "text": "Open reduction and internal fixation (ORIF)  is a surgical term that refers to open surgical repair of broken bones. It is required for correction of complex Le Fort fractures affecting facial function or involving neurological complications (visual changes,  CSF leak ). [ 6 ]  ORIF is especially important for repairing unstable facial buttresses in order to allow the patient to tolerate chewing. Plates and screws are often permanently fixated to facial bones to stabilize the lateral and medial vertical buttresses bilaterally. [ 2 ]  Bone grafts may also be required to stabilize the buttresses. [ 2 ]  ORIF can be used in isolation or in combination with  maxillomandibular fixation (MMF)  in treating Le Fort fractures. [ 6 ]  Following surgery, patients may require up to six weeks of rest before they are able to return to the demands of their daily life. [ 6 ]  As all patients heal slightly differently, ORIF may result in a less-than-ideal correction of facial bones, resulting in poor  occlusion  or facial asymmetries. Furthermore, as with any surgery, ORIF comes with risk of scarring, nerve injury, and infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11363", "text": "The role of  antibiotics  in midface trauma is a complex and highly patient-dependent topic. Facial trauma patients with  lacerations  (or wounds) to the inner lining ( mucosa ) of the  mouth  or the  nose  traditionally have been started on antibiotics as soon as they enter the hospital and have remained on antibiotics for a minimum of 24 hours after surgery. [ 2 ]  However, some preliminary studies on  preoperative  antibiotic use suggest that they may not be necessary to prevent  bacterial infections , though these are based on small patient populations and are not strong enough studies to set specific recommendations regarding preoperative antibiotic use. [ 9 ]  Therefore, patients are still often placed on antibiotics before surgery, especially if they are at an increased risk of developing infection (including, but not limited to, patients that are elderly,  tobacco users ,  diabetic , and/or  immunocompromised ). [ 9 ] [ 10 ]  If a patient is begun on antibiotics, it is difficult to determine how long they should remain on antibiotics  postoperatively . [ 10 ]  Although multiple studies have been performed examining postoperative antibiotic use, they have come to contradicting conclusions. [ 11 ]  The more recent studies have suggested that antibiotics may not have any advantage in preventing postoperative bacterial infections. [ 10 ] [ 11 ]  However, these studies acknowledge that their results are based predominantly on the young, healthy, male patients with non-specific  facial trauma  that make up the majority of the studies' participants and may not be applicable to the everyone experiencing midface trauma. [ 10 ]  With limited studies specifically on midface trauma, no standards for postoperative antibiotic use has been determined. The use of postoperative antibiotics relies on the surgeon's clinical recommendations and individual patient risk factors. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11364", "text": "Longterm outcomes of Le Fort fractures depend on the severity and location of the fracture. The most common complication of Le Fort fractures include imperfect fracture reduction resulting in poor  dental occlusion . [ 2 ]  Other longterm effects of Le Fort fractures include various nerve injuries, either from the inciting injury or from surgical correction, resulting in facial movement and sensory deficits. [ 2 ]  If one or both of the  maxillary sinuses  are injured during the trauma, it can result in  chronic sinus infections  or injuries to the eye which may require further surgical correction. [ 2 ]  Le Fort III fractures that injure the  optic nerve  or the  extraocular muscles  that move the eye may result in visual defects. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11365", "text": "The  Le Fort III Osteotomy  for  oral and maxillofacial surgery , is used to correct generalised growth failure of the midface involving the upper jaw nose and cheek bones ( zygomas ). [ 1 ]  The surgical approach and post operative management is similar as for the Le Fort II procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11366", "text": "Brow lift procedures may be carried out at the same time as  Le Fort II  and Le Fort III osteotomies. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11367", "text": "A  Le Fort osteotomy  is the name for three types of  osteotomies  of the jaw and face. They are based on [ 1 ]  the  analogous bone fractures  described by the French surgeon and physician  Ren\u00e9 Le Fort . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11368", "text": "A Le Fort I osteotomy surgically advances the upper jaw to correct misalignment and deformities. It is used in the treatment for several conditions, including skeletal  class II malocclusion ,  cleft lip and cleft palate ,  vertical maxillary excess  (VME) or deficiency, and some specific types of  facial trauma , particularly those affecting the mid-face. The procedure involves separating the upper jaw, repositioning it forward, and then securing it with plates and screws. [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11369", "text": "The Le Fort II osteotomy treats maxillary fractures. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11370", "text": "The Le Fort III osteotomy treats midfacial abnormalities and deficiencies. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11371", "text": "\"Le Fort IV\" has been used to describe a monobloc frontofacial osteotomy in 2000s French literature, but the use is heavily disputed. [ 6 ]  In 2014, the same term was used by a Japanese group to describe a \"monobloc minus Le Fort I\" osteotomy. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11372", "text": "Lifestyle Lift  (stylized in uppercase in its logo) was a national facial  cosmetic surgery  practice with headquarters in  Troy, Michigan , United States. The company's name in all caps is a  trademarked  brand name [ 1 ]  used to market a particular type of facial surgery called the lifestyle lift. In 2012,  Debby Boone  became the spokesperson for the company in its television commercials and its half-hour  infomercial . [ 2 ]  The company discontinued using Boone in late 2013 shifting to a new advertising campaign. [ 3 ]   The company abruptly closed all its offices in early March 2015 and announced its intention to declare bankruptcy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11373", "text": "The procedure is advertised as a minimally invasive, short-flap  face lift  performed under  local anesthesia .  The procedure involves the excess skin and  superficial muscular aponeurotic system  (SMAS) layer. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11374", "text": "Lifestyle Lift was founded by Dr. David Kent, whose previous medical practice focused on  otolaryngology  head and neck surgery, facial plastic surgery and hair replacement.  Kent completed an  osteopathic residency  in otolaryngology-head and neck surgery and facial plastic surgery.  He is a member of the  American Academy of Facial Plastic and Reconstructive Surgery [ 6 ]  and board certified by the  American Osteopathic College of Otolaryngology - Head and Neck Surgery . [ 7 ]  Kent was recently named Ernst & Young's 2012 Entrepreneur of the Year. He started Lifestyle Lift in 2001 with one office and has grown it to over 50 surgical, consultation and affiliated offices with more than 100 physicians. [ 8 ]  R. James Koch joined Lifestyle Lift in 2006 as medical director and oversaw medical training for the company.  Prior to joining Lifestyle Lift, Koch was a full-time faculty member at the  Stanford University School of Medicine  where he served as associate professor, co-director of the Division of Facial Plastic Surgery, and co-director of the Fellowship for Advanced Facial Plastic & Reconstructive Surgery. [ 9 ] [ unreliable source? ]  Koch resigned from the organization in 2010 and was replaced by three regional medical directors that same year and who were subsequently named medical directors in 2012: David Santos, Pacific and Mountain Regions; Jason Swerdloff, Southeast and Northeast Regions; Carlos Farias, Midwest and Northeast Regions. [ 10 ]  The company closed its operations and filed for bankruptcy on March 2, 2015. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11375", "text": "The company website lists 172,255 completed surgeries as of 5 February 2014. [ 12 ]   There are almost 200 reviews of the company out of over 150,000 customers\u2014some of them negative\u2014on  RealSelf .com, which Lifestyle Lift sued for trademark infringement (the case was settled). [ 13 ]  Lifestyle Lift has attempted to sue other companies based on trademark infringement, including informercialscams.com (now defunct). In 2008, Lifestyle Lift was the subject of an eight-part mini-series by the  CBS  affiliate in  Atlanta  featuring three dissatisfied Lifestyle Lift patients, and former employees and their complaints against the company. [ 14 ] [ 15 ]  In 2009, a Florida woman died just hours after undergoing a cosmetic facial surgery at a Lifestyle Lift center in Maitland, Florida. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11376", "text": "Lifestyle Lift\u00ae and/or its doctors have been the subject of multiple alleged malpractice claims in the state of Florida. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11377", "text": "In 2009 Lifestyle Lift reached a settlement with  New York  state over claims it had posted false customer endorsements on third-party websites, including RealSelf.com, [ 18 ]  and on some websites the company had created for the purpose. [ 19 ]  Lifestyle Lift was ordered to pay $300,000 to the state, and it agreed to cease the practice. [ 18 ] \nIn 2013, after a three-year review of all aspects of Lifestyle Lift marketing, the Florida Attorney General found that Lifestyle Lift was compliant with all state regulations. As a result, no fines were levied, but Lifestyle Lift reimbursed the State of Florida for costs of the investigation and made a donation to a Florida Attorney General sponsored charity. During the course of the investigation, Lifestyle Lift voluntarily made several minor changes to its marketing materials to ensure clarity for consumers. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11378", "text": "In 2008, an  Orlando, Florida , plastic surgeon filed a complaint with the Florida Board of Medicine, seeking payment for emergency room services he provided to a Lifestyle Lift patient; the company denied that it was negligent. [ 19 ]  Lifestyle Lift was also the subject of a March 2010 lawsuit filed by the family of a Massachusetts patient who died as a result of complications with local anesthesia in July 2009. The suit alleged that doctors failed to monitor the woman's vital signs during the procedure; in a statement, Lifestyle Lift responded that the woman had failed to disclose pertinent medical information. [ 21 ]  In an August 2011 lawsuit filed in  Broward County, Florida , a patient claimed she developed  keloid  scars within days following a Lifestyle Lift facelift, and that the doctor had lied about the risks of scarring. [ 22 ]  In a statement to the press, Lifestyle Lift indicated disagreement with the \"accounting of events\" described in the suit, and said it remained supportive of its surgeon. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11379", "text": "The procedure involves an incision made along the temple hairline and continuing down around the front of the ear or following the natural curves of the ear. The typical incision makes an S shape although the incision length and type can differ between surgeons and is individualized for each patient. The incision is made in front of and behind each ear.  Once these cuts are made, the deeper muscle or SMAS tissue is pulled up and back (and possibly trimmed) and sutured into place.  The excess skin is then trimmed off and the incision is closed.  Liposuction may be used to reduce fat from under the chin.  In addition, the muscle bands in the neck may be sutured together to lessen their appearance. \nLifestyle Lift surgeons also perform eyelid surgeries, brow lifting, fractional CO 2  laser skin resurfacing, fat grafting, and chin augmentation. [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11380", "text": "Maxillofacial prosthetist and technologist  is the term used in the  United Kingdom  for a specialist who delivers  facial ,  ocular  and other  prostheses  which restore form and function to the  body ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11381", "text": "In the  United States , this specialty is known as  anaplastology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11382", "text": "In the UK, [ 1 ]  the main governing body for the practice of  maxillofacial  prosthetics is the Institute of Maxillofacial Prosthetics and Technologists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11383", "text": "Maxillomandibular advancement  ( MMA ) or  orthognathic surgery , also sometimes called  bimaxillary advancement  ( Bi-Max ), or  maxillomandibular osteotomy  ( MMO ), is a surgical procedure or  sleep surgery  which moves the upper jaw ( maxilla ) and the lower jaw ( mandible ) forward.\nThe procedure was first used to correct deformities of the facial skeleton to include  malocclusion . In the late 1970s advancement of the lower jaw (mandibular advancement) was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with  obstructive sleep apnea ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11384", "text": "Currently, maxillomandibular advancement surgery is often performed simultaneously with  genioglossus advancement  (tongue advancement). The genioglossus advancement pulls the tongue forward in a manner that decreases the amount of tongue blockage during sleep. MMA has been demonstrated to be one of the most effective surgical treatments for sleep apnea, due to its high success rate. Nonetheless, the procedure is often used after other forms of treatment have failed (nasal surgeries,  tonsillectomy ,  uvulopalatopharyngoplasty , tongue reduction surgeries).  There is a longer recovery when compared to other sleep apnea surgeries, since the bones of the face have to heal into their new position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11385", "text": "An  oral medicine  or  stomatology  doctor/dentist (or stomatologist) has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities (growths, ulcers, infection, allergies, immune-mediated and autoimmune disorders) including oral cancer, salivary gland disorders, temporomandibular disorders (e.g.: problems with the TMJ) and facial pain (due to musculoskeletal or neurologic conditions), taste and smell disorders; and recognition of the oral manifestations of systemic and infectious diseases. It lies at the interface between  medicine  and  dentistry . An oral medicine doctor is trained to diagnose and manage patients with disorders of the orofacial region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11386", "text": "The importance of the mouth in medicine has been recognized since the earliest known medical writings. For example,  Hippocrates ,  Galen  and others considered the tongue to be a \" barometer \" of health, and emphasized the diagnostic and prognostic importance of the tongue. [ 1 ]  However, oral medicine as a specialization is a relatively new subject area. [ 2 ] :\u200a2\u200a  It used to be termed \"stomatology\" (- stomato-  +  -ology ). [ 2 ] :\u200a1"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11387", "text": "In some institutions, it is termed \"oral medicine and oral diagnosis\". [ 2 ] :\u200a1\u200a  American physician and dentist,  Thomas E Bond  authored the first book on oral and maxillofacial pathology in 1848, entitled \"A Practical Treatise on Dental Medicine\". [ 2 ] :\u200a2\u200a [ 3 ]  The term \"oral medicine\" was not used again until 1868. [ 3 ]   Jonathan Hutchinson  is also considered the father of oral medicine by some. [ 2 ] :\u200a2"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11388", "text": "Oral medicine grew from a group of New York dentists (primarily periodontists), who were interested in the interactions between medicine and dentistry in the 1940s. [ 4 ]  Before becoming its own specialty in the United States, oral medicine was historically once a subset of the specialty of  periodontics , with many  periodontists  achieving board certification in oral medicine as well as periodontics.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11389", "text": "Oral medicine is concerned with clinical diagnosis and non-surgical management of non-dental pathologies affecting the orofacial region (the mouth and the lower face)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11390", "text": "Many systemic diseases have signs or symptoms that manifest in the orofacial region. Pathologically, the mouth may be affected by many cutaneous and gastrointestinal conditions. There is also the unique situation of hard tissues penetrating the epithelial continuity (hair and nails are intra-epithelial tissues). The biofilm that covers teeth therefore causes unique pathologic entities known as plaque-induced diseases."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11391", "text": "Example conditions that oral medicine is concerned with are lichen planus, Beh\u00e7et's disease and pemphigus vulgaris. Moreover, it involves the diagnosis and follow-up of pre-malignant lesions of the oral cavity, such as leukoplakias or erythroplakias and of chronic and acute pain conditions such as paroxysmal neuralgias, continuous neuralgias, myofascial pain, atypical facial pain, autonomic cephalalgias, headaches and migraines. Another aspect of the field is managing the dental and oral condition of medically compromised patients such as cancer patients with related oral mucositis, bisphosphonate-related osteonecrosis of the jaws or oral pathology related to radiation therapy. Additionally, it is involved in the diagnosis and management of dry mouth conditions (such as Sj\u00f6gren's syndrome) and non-dental chronic orofacial pain, such as burning mouth syndrome, trigeminal neuralgia and temporomandibular joint disorder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11392", "text": "It is not uncommon for an individual to experience a lump/swelling in the oral environment. The overall presentation is highly variable and the progression of these lesions can also differ, for example: development of a lesion into a bulla or a malignant neoplasm. Lumps and swellings can occur due to a variety of conditions, both benign and malignant such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11393", "text": "So as seen above the list is extensive and by no means is this a complete and comprehensive representation of all the possible lumps/swellings that can occur in the mouth as to the means of acquiring a swelling in the mouth. When considering what a lump might be caused by the site of which it has appeared can be of significance. Below are some examples of swellings/lumps which usually are present as specific locations in the oral cavity: [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11394", "text": "If there is any suspect or unknown reason as to why a lump has arisen in an individual's mouth it is important to establish when this first was noticed and the accompanied symptoms if any. On examination ensure that there is not an obvious cause to the swelling/lump via a thorough: medical, social, dental and family history, followed by an oral examination. Whilst examining the suspected lesion there are some diagnostic aids to note which can be used to formulate a provisional diagnosis. [ 9 ]  There are many factors taken into consideration in this diagnosis, such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11395", "text": "Once the surrounding tissues and the immediate management of any lumps/swellings are taken care of, an image of the full extent of the lesion is needed. This is done to establish what the lump/swelling is associated with and to ensure that any damaging probability is kept to a minimum. There are a variety of imaging technique options which are chosen based on the lesion: size, location, growth pattern etc. Some examples of images used are: DPT,  Scintigraphy ,  Sialography ,  Computed Tomography ,  Magnetic Resonance Imaging  and  Ultrasound ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11396", "text": "As described some lumps or swellings can be in close relation to anatomical structures. Commonly, Teeth are associated in a lesion which brings about the question \u2013 \u201care they still vital?\u201d In order to clarify, any tooth that is associated with a lump or swelling is vitality tested, examined for any pathology or restorative deficiencies in order to determine the long term prognosis of this tooth and how this might affect treatment of the lump/swelling at hand."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11397", "text": "Alongside any radiographs which may be justified, Blood tests may be needed in order to obtain a definitive diagnosis if there is a suspicion of potential  blood dyscrasias  or any endocrinopathy involvement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11398", "text": "Finally, a particularly vital means of diagnosis is a biopsy. These tend to be regularly done in the cases of singular, chronic lesions and are carried out in an urgent manner as lesions of this category have a significant malignant potential. The indications to carry out a biopsy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11399", "text": "Once a small piece of tissue is removed for the biopsy, it is then microscopically histopathologically examined. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11400", "text": "Australian programs are accredited by the Australian Dental Council (ADC). They are three years in length and culminate with either a master's degree (MDS) or a Doctor of Clinical Dentistry degree (DClinDent). Fellowship can then be obtained with the  Royal Australasian College of Dental Surgeons , FRACDS (Oral Med) and or the  Royal College of Pathologists of Australasia , RCPA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11401", "text": "Canadian programs are accredited by the Canadian Commission on Dental Accreditation (CDAC). They are a minimum of three years in length and usually culminate with a master's (MSc) degree. Currently, only the  University of Toronto ,  McGill University , the  University of Alberta , and the  University of British Columbia  offer programs leading to the specialty. Most residents combine oral medicine programs with oral and maxillofacial pathology programs leading to a dual specialty. Graduates are then eligible to sit for the Fellowship exams with the Royal College of Dentists of Canada (FRCD(C))."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11402", "text": "Indian programs are accredited by the Dental Council of India (DCI).Oral Medicine is in conjunction with oral radiology in India and it is taught in both graduate and post graduate levels as Oral Medicine and Radiology. They are three years in length and culminate with a master's degree (MDS) in Oral Medicine and Radiology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11403", "text": "New Zealand has traditionally followed the UK system of dual training (dentistry and medicine) as a requisite for specialty practice; the  University of Otago Faculty of Dentistry  currently offers a 5-year intercalated clinical doctorate/medical degree (DClinDent/MBChB) program. On 9 July 2013, the dental council of New Zealand proposed that the prescribed qualifications for oral medicine be changed to include the new DClinDent in addition to a medical degree, with no requirement for a standard dental degree. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11404", "text": "In the UK, oral medicine is one of the 13 specialties of dentistry recognized by the  General Dental Council  (GDC). [ 11 ]  The GDC defines oral medicine as: \"[concerned with] oral health care of patients with chronic recurrent and medically related disorders of the mouth and with their diagnosis and non-surgical management.\" [ 12 ]  Unlike many other countries, oral medicine physicians in the UK do not usually partake in the dental management of their patients. [ citation needed ]  Some UK oral medicine specialists have dual qualification with both medical and dental degrees. [ 13 ]  However, in 2010 the GDC approved a new curriculum for oral medicine, and a medical degree is no longer a prerequisite for entry into specialist training. [ 14 ]  Specialist training is normally 5 years, although this may be reduced to a minimum of 3 years in recognition of previous training, such as a medical degree. [ 14 ]  In the UK, oral medicine is one of the smallest dental specialties. [ 15 ]  According to the GDC, as of December 2014 there were 69 clinicians registered as specialists in oral medicine. [ 16 ]  As of 2012, there were 16 oral medicine units across the UK, mostly based in  dental teaching hospitals , [ 14 ]  and around 40 practising consultants. [ 15 ]   The British & Irish Society for Oral Medicine  has suggested that there are not enough oral medicine specialists, and that there should be one consultant per million population. [ 15 ]  Competition for the few training posts is keen, although new posts are being created and the number of trainees increased. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11405", "text": "The  American Dental Association  (CODA) accredited programs are a minimum of two years in length. Oral medicine, is an  American Dental Association  recognized speciality, and many oral medicine specialists fulfil a very important role by teaching at dental schools and graduate programs to ensure dentists and other dental specialists receive excellent training in medical topics pertinent to the dental practice. The ADA has recently started a dental practice parameters for world-class quality services. [1]   Archived  2014-05-07 at the  Wayback Machine"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11406", "text": "Osseointegration  (from Latin  osseus  \" bony \" and  integrare  \"to make whole\") is the direct structural and functional connection between living  bone  and the surface of a load-bearing  artificial implant  (\"load-bearing\" as defined by  Albrektsson  et al. in 1981). A more recent definition (by  Schroeder  et al.) defines osseointegration as \"functional  ankylosis  (bone adherence)\", where new bone is laid down directly on the implant surface and the implant exhibits  mechanical stability  (i.e., resistance to destabilization by  mechanical agitation  or  shear forces ). Osseointegration has enhanced the science of  medical  bone and  joint replacement  techniques as well as  dental implants  and improving  prosthetics  for  amputees . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11407", "text": "Osseointegration is also defined as: \"the formation of a direct interface between an implant and bone, without intervening soft tissue\". [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11408", "text": "An  osseointegrated implant  is a type of  implant  defined as \"an endosteal implant containing pores into which osteoblasts and supporting connective tissue can migrate\". [ 2 ]  Applied to oral implantology, this refers to  bone  grown right up to the  implant  surface without interposed soft tissue layer. No  scar tissue ,  cartilage  or  ligament  fibers are present between the  bone  and implant surface. The direct contact of bone and implant surface can be verified  microscopically . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11409", "text": "Osseointegration may also be defined as: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11410", "text": "Osseointegration was first observed\u2014albeit not explicitly stated\u2014by Bothe, Beaton, and Davenport in 1940. [ 3 ] [ 4 ]  Bothe et al. were the first researchers to implant titanium in an animal and remarked how it tended to fuse with bone. [ 3 ] [ 4 ]   Bothe et al. reported that due to the elemental nature of the titanium, its strength, and its hardness, it had great potential to be used as future prosthesis material. [ 3 ] [ 4 ]  Gottlieb Leventhal later described osseointegration in 1951. [ 3 ] [ 5 ]  Leventhal placed titanium screws in rat femurs and said, \"At the end of 6 weeks, the screws were slightly tighter than when originally put in; at 12 weeks, the screws were more difficult to remove; and at the end of 16 weeks, the screws were so tight that in one specimen the femur was fractured when an attempt was made to remove the screw. Microscopic examinations of the bone structure revealed no reaction to the implants, the trabeculation appeared to be perfectly normal.\" [ 3 ] [ 5 ]  The reactions described by Leventhal and Bothe et al. would later be coined into the term \"osseointegration\" by  Per-Ingvar Br\u00e5nemark  of Sweden. In 1952, Br\u00e5nemark did an experiment where he used a titanium implant chamber to study blood flow in rabbit bone. At the end of the experiment, when it became time to remove the titanium chambers from the bone, he discovered that the bone had integrated so completely with the implant that the chamber could not be removed. Br\u00e5nemark called this \"osseointegration\", and, like Bothe et al. and Leventhal before him, saw the possibilities for human use. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11411", "text": "In  dentistry  the implementation of osseointegration started in the mid-1960s as a result of Br\u00e5nemark's work. [ 6 ] [ 7 ] [ 8 ] [ 9 ]   In 1965 Br\u00e5nemark, who was at the time Professor of Anatomy at  University of Gothenburg , placed  dental implants  into the first human patient\u2014G\u00f6sta Larsson. This patient had a cleft palate defect and needed implants to support a  palatal obturator . G\u00f6sta Larsson died in 2005, with the original implants still in place after 40 years of function. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11412", "text": "In the mid-1970s Br\u00e5nemark entered into a commercial partnership with the Swedish defense company  Bofors  to manufacture dental implants and the instrumentation required for their placement. Eventually an offshoot of Bofors, Nobel Pharma, was created to concentrate on this product line.  Nobel Pharma subsequently became Nobel Biocare. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11413", "text": "Br\u00e5nemark spent almost 30 years fighting the scientific community for acceptance of osseointegration as a viable treatment. In Sweden he was often openly ridiculed at science conferences. His university stopped funding for his research, forcing him to open a private clinic to continue treating patients. Eventually an emerging breed of young academics started to notice the work being done in Sweden. Toronto's George Zarb, a Maltese-born Canadian prosthodontist, was instrumental in bringing the concept of osseointegration to the wider world. The 1983 Toronto Conference is generally considered to be the turning point, when finally the worldwide scientific community accepted Br\u00e5nemark's work. Osseointegration is now a highly predictable and common treatment modality. [ 10 ]  Since 2010,  Professor Munjed Al Muderis  in Sydney, Australia, used a high tensile strength titanium implant with plasma sprayed surface as an intramedullary prosthesis that is inserted into the bone residuum of amputees and then connect through an opening in the skin to a robotic limb prosthesis. This lets amputees mobilize with more comfort and less energy consumption. Al Muderis also published the first series of combining osseointegration prosthesis with Joint replacement enabling below knee amputees with knee arthritis or short residual bone to walk without needing a socket prosthesis. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11414", "text": "On December 7, 2015, two Operation Iraqi Freedom/Operation Enduring Freedom veterans, Bryant Jacobs and Ed Salau, became the first in America to get a  percutaneous  osseointegrated  prosthesis . [ 12 ]  In the first stage, doctors at Salt Lake Veterans Affairs Hospital embedded a titanium stud in the femur of each patient. About six weeks later, they went back and attached the docking mechanism for the prosthesis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11415", "text": "In 2021 Professor Al Muderis published a thesis for the requirements for the  Doctor of Medical Science  discussing  Osseointegration for Amputees: Past, Present and Future  -  Basic Science, Innovations in Surgical Technique, Implant Design and Rehabilitation Strategies. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11416", "text": "Osseointegration is a dynamic process in which characteristics of the implant (i.e. macrogeometry, surface properties, etc.) play a role in modulating molecular and cellular behavior. [ 14 ]  While osseointegration has been observed using different materials, it is most often used to describe the reaction of bone tissues to titanium, or titanium coated with calcium phosphate derivatives. [ 15 ]  It was previously thought that titanium implants were retained in bone through the action of mechanical stabilization or interfacial bonding. Alternatively, calcium phosphate coated implants were thought to be stabilized via chemical bonding.  It is now known that both calcium phosphate coated implants and titanium implants are stabilized chemically with bone, either through direct contact between calcium and titanium atoms, or by the bonding to a cement line-like layer at the implant/bone interface. [ 16 ] [ 17 ]  While there are some differences (e.g. like the lack of chondrogenic progenitors), osseointegration occurs through the same mechanisms as bone fracture healing. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11417", "text": "For osseointegrated  dental implants , metallic, ceramic, and polymeric materials have been used, [ 2 ]  in particular  titanium . [ 20 ]  To be termed osseointegration the connection between the bone and the implant need not be 100%, and the essence of osseointegration derives more from the stability of the fixation than the degree of contact in histologic terms. In short it is a process where clinically asymptomatic rigid fixation of alloplastic materials is achieved, and maintained, in bone during functional loading. [ 21 ]  Implant healing time and initial stability are a function of implant characteristics. For example, implants using a screw-root form design achieve high initial mechanical stability through the action of their screws against bone. Following placement of the implant, healing typically takes several weeks or months before the implant is fully integrated into the bone. [ 22 ] [ 23 ] [ 24 ]  First evidence of integration occurs after a few weeks, while more robust connection is progressively effected over the next months or years. [ 25 ]   Implants that have a screw-root form design result in bone resorption followed by interfacial bone remodeling and growth around the implant. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11418", "text": "Implants using a plateau-root form design (or screw-root form implants with a wide enough gap between the pitch of the screws) undergo a different mode of peri-implant ossification. Unlike the aforementioned screw-root form implants, plateau-root form implants exhibit de novo bone formation on the implant surface. [ 27 ]  The type of bone healing exhibited by plateau-root form implants is known as intramembranous-like healing. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11419", "text": "Though the osseointegrated interface becomes resistant to external shocks over time, it may be damaged by prolonged adverse stimuli and overload, which may cause implant failure. [ 28 ] [ 29 ]   In studies done using \"Mini dental implants,\" it was noted that the absence of micromotion at the bone-implant interface was needed to enable proper osseointegration. [ 30 ]  It was also noted that there is a critical threshold of micromotion above which a fibrous encapsulation process occurs, rather than osseointegration. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11420", "text": "Other complications may arise even in the absence of external impact. One issue is growth of  cement . [ 32 ]  In normal cases, absence of cementum on the implant surface prevents attachment of  collagen  fibers. This is normally the case due to the absence of cementum progenitor cells in the area receiving the implant. However, when such cells are present, cement may form on or around the implant surface, and a functional collagen attachment may attach to it. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11421", "text": "Since 2005, a number of orthopedic device makers have introduced products with  porous metal construction . [ 34 ] [ 35 ] [ 36 ]  Clinical studies on mammals have shown that porous metals, such as titanium foam, may allow formation of vascular systems within the porous area. [ 37 ]  For orthopedic uses, metals such as  tantalum  or  titanium  are often used, as these metals have high  tensile strength  and corrosion resistance with excellent  biocompatibility . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11422", "text": "The process of osseointegration in metal foams is similar to that in  bone grafts .  The porous bone-like properties of the metal foam contribute to extensive bone infiltration, allowing  osteoblast  activity to take place.  In addition, the porous structure allows for soft tissue adherence and  vascularization  within the implant.  These materials are currently deployed in  hip replacement ,  knee replacement  and  dental implant  surgeries. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11423", "text": "There are a number of methods used to gauge the level of osseointegration and the subsequent stability of an implant. One widely used diagnostic procedure is percussion analysis, where a dental instrument is tapped against the implant carrier. [ 38 ]  The nature of the ringing that results is used as a qualitative measure of the implant's stability. An integrated implant will elicit a higher pitched \"crystal\" sound, whereas a non-integrated implant will elicit a dull, low-pitched sound. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11424", "text": "Another method is a reverse torque test, in which the implant carrier is unscrewed. If it fails to unscrew under the reverse torque pressure, the implant is stable. If the implant rotates under the pressure it is deemed a failure and removed. [ 40 ]  This method comes at the risk of fracturing bone that is mid-way in the process of osseointegration. [ 38 ]  It is also unreliable in determining the osseointegration potential of a bone region, as tests have yielded that a rotating implant can go on to be successfully integrated. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11425", "text": "A non-invasive and increasingly implemented diagnostic method is  resonance frequency analysis  (RFA). [ 38 ]  A resonance frequency analyzer device prompts vibrations in a small metal rod temporarily attached to the implant. As the rod vibrates, the probe reads its resonance frequency and translates it into an  implant stability quotient  (ISQ), which ranges from 1\u2013100, with 100 indicating the highest stability state. Values ranging between 57 and 82 are generally considered stable, though each case must be considered independently. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11426", "text": "One of the peculiarities of osseointegrated  prostheses  is that mechanical events at the prosthesis (e.g. touch) are transferred as vibrations through the bone. [ 42 ] \nThis \"osseoperception\" means that the prosthesis user regains a more accurate sense of how the prosthesis is interacting with the world. Users of bone-anchored lower limb prostheses report, for example, that they can tell which type of soil they are walking on due to osseoperception. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11427", "text": "Recent research on users of bone-anchored upper and lower limb prostheses showed that this osseoperception is not only mediated by  mechanoreceptors  but also by  auditory receptors . [ 44 ] [ 45 ]  This means that, rather than just feeling mechanical influences on the device, users also hear the movements of their prosthesis. This joint mechanical and auditory sensory perception is likely responsible for the improved environment perception of users of osseointegrated prostheses compared to traditional socket suspended devices. It is not clear, however, to what extent this implicit sensory feedback actually influences prosthesis users in everyday life. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11428", "text": "An  osteotomy  is a surgical  operation  whereby a  bone  is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a  hallux valgus , or to straighten a bone that has healed crookedly following a  fracture . It is also used to correct a  coxa vara ,  genu valgum , and  genu varum . The operation is done under a  general anaesthetic . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11429", "text": "Osteotomy is one method to relieve pain of arthritis, especially of the hip and knee. It is being replaced by joint replacement in the older patient. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11430", "text": "Due to the serious nature of this procedure, recovery may be extensive. Careful consultation with a physician is important in order to ensure proper planning during a recovery phase. Tools exist to assist recovering patients who may have non\u2013 weight bearing  requirements and include bedpans, dressing sticks, long-handled shoe-horns, grabbers/reachers and specialized walkers and wheelchairs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11431", "text": "Two main types of osteotomies are used in the correction of hip dysplasias and deformities to improve alignment/interaction of  acetabulum  \u2013 (socket) \u2013 and femoral head ( femur head ) \u2013  (ball),  innominate osteotomies  and  femoral osteotomies . The bones are cut, reshaped or partially removed to realign the load-bearing surfaces of the joint. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11432", "text": "Adjustments are made to part of the  hip-bone . Many operating methods and variations have been developed.  They are defined by the type of cut and adjustment made. Some acetabular procedures are named after the surgeons who first described them as Salter (R. Salter), Dega (W. Dega), Sutherland (D.H. Sutherland), Chiari (K. Chiari): other names one may encounter are Ludlov, P. Pemberton, and James B. Steele. Some are named after the shape of cut (e.g. Chevron, Wedge) or the way the bones are aligned (Dial=old style rotary dial phone)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11433", "text": "A femoral derotation osteotomy can be performed to correct version abnormalities such as excessive anteversion or retroversion of the hip joint. Excessive anteversion of the femur results in anterior instability of the hip joint while excessive retroversion results in femoroacetabular hip impingement. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11434", "text": "A subtrochanteric blade plate or an intramedullary rod can be used to stabilize the osteotomy site in a femoral derotation osteotomy until compete bone healing is achieved; an approach employing an intramedullary rod is much less invasive than one using a subtrochanteric blade plate. [ citation needed ] }"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11435", "text": "Femoral osteotomies, as the name indicates, involves adjustments made to the femur head and/or the  femur . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11436", "text": "Knee osteotomy is commonly used to realign arthritic damage on one side of the knee. The goal is to shift the patient's body weight off the damaged area to the other side of the knee, where the cartilage is still healthy. Surgeons remove a wedge of the tibia from underneath the healthy side of the knee, which allows the tibia and femur to bend away from the damaged cartilage. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11437", "text": "A model for this is the hinges on a door. When the door is shut, the hinges are flush against the wall. As the door swings open, one side of the door remains pressed against the wall as space opens up on the other side. Removing just a small wedge of bone can \"swing\" the knee open, pressing the healthy tissue together as space opens up between the femur and tibia on the damaged side so that the arthritic surfaces do not rub against each other. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11438", "text": "Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11439", "text": "The location of the removed wedge of bone depends on where osteoarthritis has damaged the knee cartilage. The most common type of osteotomy performed on arthritic knees is a high tibial osteotomy, which addresses cartilage damage on the inside (medial) portion of the knee. The procedure usually takes 60 to 90 minutes to perform. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11440", "text": "During a high tibial osteotomy, surgeons remove a wedge of bone from the outside of the knee, which causes the leg to bend slightly inward. This resembles the realigning of a bowlegged knee to a knock-kneed position. The patient's weight is transferred to the outside (lateral) portion of the knee, where the cartilage is still healthy. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11441", "text": "After regional or general anesthesia is administered, the surgical team sterilizes the leg with antibacterial solution.\nSurgeons map out the exact size of the bone wedge they will remove, using an X-ray, CT scan, or 3D computer modeling.\nA four- to five-inch incision is made down the front and outside of the knee, starting below the kneecap and extending below the top of the shinbone.Guide wires are drilled into the top of the shinbone (tibia plateau) from the outside (lateral side) of the knee. The wires usually outline a triangle form in the shinbone. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11442", "text": "A standard oscillating saw is run along the guide wires, removing most of the bone wedge from underneath the outside of the knee, below the healthy cartilage. The cartilage surface on the top of the outside (lateral side) of the shinbone is left intact.  The top of the shinbone is then lowered on the outside and attached with surgical staples or screws, depending on the size of the wedge that was removed.  The layers of tissue in the knee are stitched together, usually with absorbable sutures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11443", "text": "A fall or torque to the leg during the first two months after surgery may jeopardize healing. Patients must exercise extreme caution during all activities, including walking, until healing is complete. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11444", "text": "After rehabilitation, preventing osteoarthritis involves slowing the progression and spread of the disease. Maintaining aerobic cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic knee than occasional, heavy exercise. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11445", "text": "It is especially important to avoid any serious knee injuries, such as torn ligaments or fractured bones, because arthritis can complicate knee injury treatment. High-impact or repetitive stress sports, like football and distance running, should be avoided."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11446", "text": "Because osteoarthritis has multiple causes and may be related to genetic factors, no universal prevention tactic exists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11447", "text": "General recommendations include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11448", "text": "This is performed to realign the  mandible  (lower jaw) or  maxilla  (upper jaw) with the rest of the skull and/or teeth. This is usually performed to correct skeletal malocclusions, that is discrepancies in tooth position that cannot be corrected by simple orthodontic movement, and realignment of the  temporomandibular joints , or to correct facial deformities such as mandibular retrognathia. [ 12 ]  There is little scarring, and all of the surgery takes places inside of the mouth.  Orthodontic braces  may have to be worn pre- and post- operation to realign the  teeth  to match the newly realigned jaw."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11449", "text": "Chin osteotomy is most often done to correct a vertically short chin.  As opposed to putting an implant on top of the chin bone to bring it forward, an alternative approach is to cut the chin bone itself and bring it forward or other directions as well. It can also be used to lengthen the chin (which is more difficult with an implant) or to shorten or narrow a chin. (which is impossible with an implant). [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11450", "text": "Chin osteotomies (cutting the bone and moving it) are done through an incision inside the mouth. It is technically more difficult than an implant and has more swelling and recovery than a simple chin implant. Also, there is usually temporary loss of feeling of the lip and chin after that takes several weeks to months for full return of sensation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11451", "text": "In veterinary medicine, osteotomies are frequently performed to address rupture of the canine cranial cruciate ligament, which is analogous to the anterior cruciate ligament. The  tibial plateau leveling osteotomy  and  tibial tuberosity advancement  are two of the most common osteotomy procedures performed in the United States.  Recovery is often 6\u20138 weeks and the osteotomy can be filled with autologous bone grafts, scaffolds (hydroxyapatite, TR Matrix, etc.) or ceramics. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11452", "text": "Commonly known as a  dental cyst , the  periapical cyst  is the most common  odontogenic cyst .  It may develop rapidly from a  periapical granuloma , as a consequence of untreated chronic  periapical periodontitis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11453", "text": "Periapical is defined as \"the tissues surrounding the  apex  of the root of a  tooth \" and a  cyst  is \"a pathological cavity lined by  epithelium , having fluid or gaseous content that is not created by the accumulation of pus.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11454", "text": "Most frequently located in the maxillary anterior region, the cyst is caused by  pulpal   necrosis  secondary to  dental caries  or  trauma . Its lining is derived from the  epithelial cell rests of Malassez  which proliferate to form the cyst. [ 2 ]  Such cysts are very common. Although initially asymptomatic, they are clinically significant because secondary  infection  can cause  pain  and damage. In  radiographs , the cyst appears as a radiolucency (dark area) around the apex of a tooth's root. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11455", "text": "Periapical cysts begin as asymptomatic and progress slowly. Subsequent infection of the cyst causes swelling and pain. Initially, the cyst swells to a round hard protrusion, but later on the body resorbs some of the cyst wall, leaving a softer accumulation of fluid underneath the mucous membrane. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11456", "text": "Secondary [ clarification needed ]  symptoms of periapical cysts include inflammation and infection of the  pulp  causing dental caries. This infection is what causes  necrosis of the pulp . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11457", "text": "Larger cysts may cause bone expansion or displace roots. Discoloration of the affected tooth may also occur. Patient will present negative results to electric and ice test of the affected tooth but will be sensitive to percussion. Surrounding gingival tissue may experience  lymphadenopathy . The  alveolar plate  may exhibit  crepitus  when palpated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11458", "text": "Expansion of the cyst causes erosion of the floor of the maxillary sinus. As soon as it enters the maxillary antrum, the expansion rate increases due to available space for expansion. Performing a percussion test by tapping the affected teeth will cause shooting pain. This is often clinically diagnostic of pulpal infection. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11459", "text": "Dental cysts are usually caused due to root infection involving  tooth decay . Untreated dental  caries  then allow bacteria to reach the level of the pulp, causing infection. The bacteria gains access to the periapical region of the tooth through deeper infection of the pulp, traveling through the roots. The resulting pulpal  necrosis  causes proliferation of epithelial rests of Malassez which release toxins at the apex of the tooth. The body's inflammatory response will attack the source of the toxins, leading to periapical inflammation. The many cells and proteins that rush to an area of infection create osmotic tension in the periapex which is the source of internal pressure increase at the cyst site."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11460", "text": "These lesions can grow large because they apply pressure over the bone, causing  resorption .  The toxins released by the breakdown of granulation tissue are one of the common causes of bone resorption."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11461", "text": "There are two schools of thought regarding cyst expansion. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11462", "text": "Periapical cysts develop due to an inflammatory stimulus in 3 stages: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11463", "text": "The definitive mechanism by which cysts grow is under debate; several theories exist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11464", "text": "Pressure and concentration differences between the cystic cavity and the growth surroundings influence fluid movement into the cyst, causing size increase."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11465", "text": "a.  Collagenase  (breakdown of collagen) in the jaw bone leads to bone degeneration, providing room for cysts to develop. Substances released by the body's immune system as a result of the connective tissue breakdown, such as  cytokines  and growth factors, contribute to the mobilization and proliferation of epithelial cells in the area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11466", "text": "b. Bone resorption caused by metabolism of acidic substances produced by cysts contributes to cyst growth. Such substances include  Prostaglandin-2  and  Interleukin-1  which are both produced by the cyst itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11467", "text": "Epithelial cells will form a mass inside the cavity and the innermost cells become deprived of nutrients because they are far from the source of nutrients (the blood vessels). The innermost cells die and form an aggregate of dead tissue.  The inner cells undergo ischemic liquefactive necrosis which creates the cavity space surrounded by growing epithelial cells. This theory is unlikely in the absence of malignant transformation of epithelial cells as it does not follow the existing relationship between connective tissue and epithelium. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11468", "text": "Epithelial cells have an inherent quality to reproduce and cover any connective tissue that is not already lined with epithelia. Formation of an abscess must precede the epithelial proliferation in order for the cells to carry out this tendency. This theory explains why cysts are lined in epithelia but not why the initial cysts itself forms. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11469", "text": "A non-vital tooth is necessary for the diagnosis of a periapical cyst, meaning the nerve has been removed by root canal therapy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11470", "text": "The surrounding intraoral anatomical structures should be palpated to identify the presence of bone expansion or displacement of tooth roots as well as  crepitus  noises during examination, indicating extensive bone damage. Bulging of the buccal or lingual cortical plates [ 7 ]  may be present. Age of occurrence in the patient, the location of the cyst, the edges of cystic contours, and the impact that the cyst has on adjacent structures must all be considered for proper diagnosis. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11471", "text": "Several lesions can appear similarly in radiographic appearance. [ 2 ]  Intraoral X-rays or a 3-D cone beam scan of the affected area can be used to obtain radiological images and confirm diagnosis of cysts in the periapical area. Circular or ovoid radiolucency surrounding the root tip of approximately 1-1.5\u00a0cm in diameter is indicative of the presence of a periapical cyst. [ 2 ]  The border of the cyst is seen as a narrow opaque margin contiguous with the  lamina dura . In cysts that are actively enlarging, peripheral areas of the margin may not be present. Periapical cysts have a characteristic   unilocular [ 8 ]  shape on radiographs. There is also a severe border of cortication [ 9 ]  between the cyst and surrounding bone. Pseudocysts, on the other hand, have a fluid filled cavity but are not lined by epithelium, therefore they have a less severe and more blurred border between the fluid and bony surroundings. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11472", "text": "In  light microscopy , periapical cysts show: [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11473", "text": "They sometimes have the following features: [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11474", "text": "Periapical cysts exist in two structurally distinct classes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11475", "text": "Radiographically , it is virtually impossible to differentiate  granuloma  from a cyst. [ 2 ]  If the lesion is large it is more likely to be a cyst. Radiographically, both granulomas and cysts appear radiolucent. Many lesions of the mandible in particular appear cystlike in appearance. It is often necessary to obtain a biopsy and evaluate the tissue under a microscope to accurately identify the lesion. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11476", "text": "The infected tissue of the periapical cyst must be entirely removed, including the epithelium of the cyst wall; otherwise, a relapse is likely to occur. Root canal treatment should be performed on the tooth if it is determined that previous therapy was unsuccessful. Removal of the necrotic pulp and the inflamed tissue as well as proper sealing of the canals and an appropriately fitting crown will allow the tooth to heal under uninfected conditions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11477", "text": "Surgical options for previously treated teeth that would not benefit from root canal therapy include cystectomy [ 12 ]  and cystostomy. [ 12 ]  This route of treatment is recommended upon discovery of the cyst after inadequate root canal treatment. A cystectomy is the removal of a cyst followed by mucosa and wound closure to reduce chances of cyst regeneration. This type of treatment is more ideal for small cysts. [ citation needed ] \nA cystostomy is recommended for larger cysts that compromise important adjacent anatomy. The cyst is tamponaded to allow for the cyst contents to escape the bone. Over time, the cyst decreases in size and bone regenerates in the cavity space."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11478", "text": "Marsupialization  could also be performed, which involves suturing the edges of the gingiva surrounding the cyst to remain open. The cyst then drains its contents and heal without being prematurely closed. The end result is the same as the cystostomy, bone regeneration. For both a cystostomy and marsupialization, root resectioning may also be required in cases where root resorption has occurred. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11479", "text": "Periapical cysts comprise approximately 75% of the types of cysts found in the oral region. The ratio of individuals diagnosed with periapical cysts is 3:2 male to female, as well as individuals between 20 and 60 years old. Periapical cysts occur worldwide."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11480", "text": "Types of Periapical cysts:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11481", "text": "Apical: 70%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11482", "text": "Lateral: 20%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11483", "text": "Residual: 10%"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11484", "text": "ReSurge International , formerly known as  Interplast , is an international humanitarian organization that provides free reconstructive surgery in developing countries, primarily to children with  cleft lip and palate  and  burn scar contractures ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11485", "text": "ReSurge International, Interplast at the time, was founded in 1969 by  Stanford  plastic surgeon  Donald Laub , and as of 2023, has treated more than 124,000 patients worldwide. The first patient was a 13-year-old boy who had come to  Stanford University Medical Center  from his home in  Mexicali ,  Mexico , to receive surgery to repair his cleft lip and palate. Soon after, Laub and other surgeons began organizing regular trips to a charity hospital in Mexicali to treat children with disabling deformities."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11486", "text": "Inherent in the goals of organizations such as ReSurge Inter-national is the supposition that many such disabling conditions can be greatly alleviated or even resolved through plastic surgical intervention. [ 1 ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11487", "text": "Interplast was the subject of \" A Story of Healing \", winner of the 1997  Academy Award for Documentary Short Subject . Interplast still exists under the Interplast name in Australia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11488", "text": "The  splint activator  of Soulet-Besombes is a removable appliance for the treatment of dental and jaw anomalies. It is basically a stylized  Activator appliance , which is however not fitted individually, but is mass-produced in various shapes and sizes. The device is also known as  Position Trainer  or  Kaukraft-Kiefer-Former  (bite-force jaw former, K3F)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11489", "text": "The device is made from flexible material as one single piece. At its center, it is completely even and approximates the shape of an ideal dental arch. This flat part is surrounded by ramp-shaped walls. The teeth of the upper and lower jaw bite into the space between these walls accordingly. Normally, there are no individual tooth slots, with the prominent exception of the Australian  Myobrace  design."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11490", "text": "The appliance sits passively between the upper and lower jaw, and does not exercise any force by itself to the teeth. When the patient bites together, the teeth standing out of line collide with ramp-shaped walls and are moved into their correct position over time. This works due to the principle of the  inclined plane  and the spring force of the elastic deformation of the device. By biting more or less intensively, the patient can determine themselves how much force is applied."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11491", "text": "When the appliance is worn, the lower jaw is positioned into  Angle class  1 relation towards the upper jaw. This is supposed to get the jaw muscles used to this position, and to let the patient learn the correct swallowing pattern. The teeth that in this jaw position do not reach the central plane are allowed to erupt, the same way as they would do with a  bite-plate  applied."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11492", "text": "There are special modifications for the treatment of overbite and underbite, however they usually only differ in the shape of the dental arch and in stronger or longer walls."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11493", "text": "The device has to be worn at night as well as one hour during daytime. The effect can be increased by doing bite exercises during this time. The wearing comfort is pretty high, however talking is completely impossible. In order to wear the device the patient must be able to breathe through the nose. During the first days, it can fall out of the mouth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11494", "text": "As with any intra-oral appliance, wearing it should not cause sore spots on the  gingiva , as this could lead to permanent tissue damage. If it does cause sores, the parts of the device causing the damage have to be cut off as soon as possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11495", "text": "In the early 1950s, the French  orthodontists  Prof.  Ren\u00e9 Soulet  and Prof.  Andr\u00e9 Besombes  removed the fixed braces of their patients for the time of the summer holidays. In order to stabilize the results achieved so far, they gave them a confectioned rubber retainer to wear at night. To their own surprise, they discovered afterwards that the tooth and jaw anomalies had not only not worsened but even become better during this time. So they improved their construction and called it  Conformateur ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11496", "text": "The splint activator is a rather exotic appliance, albeit in recent times, the  Trainer for Kids  (T4K) made by the Australian company  Myofunctional Research  has gained some acceptance in the early treatment of young patients. Some very few practitioners claim that they can successfully treat patients of any age using the splint activator."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11497", "text": "Surgical planning  is the preoperative method of pre-visualising a surgical intervention, in order to predefine the surgical steps and furthermore the  bone segment navigation  in the context of  computer-assisted surgery . [ 1 ] \nThe surgical planning is most important in  neurosurgery  and  oral and maxillofacial surgery . The transfer of the surgical planning to the patient is generally made using a  medical navigation system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11498", "text": "The imagistic  dataset  used for surgical planning is mainly based on a  CT  or  MRI . In  oral and maxillofacial surgery , a different, more \"traditional\" surgical planning can be used for  orthognatic surgery , based on cast models fixed into an  articulator . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11499", "text": "In order to make a surgical planning, one would need a  3D  image of the patient. The starting point was made by  G. Hounsfield  in the 1970s, by using  CT  in order to record data about the anatomical situation of the patients. [ 2 ]  In the 1980s, advances were made by the radiologist  M. Vannier  and his team, by creating the first computed three-dimensional reconstruction from a  CT  dataset. [ 3 ]  In the early 1990s, the surgical planning was performed by using  stereolithographic models . [ 4 ]  During the late 1990s, the first  full computer-based  virtual surgical planning was made for  osteotomies , and then transferred to the operating theatre by a  navigation system . [ 5 ]  Currently 3D Printed models are also used to plan a procedure and improve patient outcomes. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11500", "text": "The first commercially available neurosurgical planning systems appeared in the 1990s (the StealthStation by  Medtronic , [ 7 ]  the VectorVision by  Brainlab [ 8 ] ). As newer imaging modalities emerged providing increasing anatomical and functional detail for the patient in the 2000s, these surgical planning systems started to incorporate  virtual reality  technology to facilitate the visualisation and manipulation of the 3D data. One example of such systems is the  Dextroscope , manufactured by  Volume Interactions Pte Ltd . The Dextroscope is mostly used in the planning of complex neurosurgical procedures. [ 9 ] [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11501", "text": "The  surgical segment navigator (SSN)  is a computer-based system for use in  surgical navigation . It is integrated into a common  platform , together with the surgical tool navigator (STN), the surgical microscope navigator (SMN) and the 6 DOF  manipulator (MKM), developed by  Carl Zeiss ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11502", "text": "The  SSN  has been developed as a computer system for  bone segment navigation  in  oral and maxillofacial surgery . [ 1 ]  It allows a very precise repositioning of bone fragments, with the advent of preoperative simulation and  surgical planning . [ 2 ]  The system has been developed since 1997 at the  University of Regensburg, Germany , with the support of the  Carl Zeiss Company . Its principle is based on an infrared localisation system, composed of an  infrared  camera and at least three infrared  transmitters  attached to each bony fragment. The SSN is mainly used in  orthognatic surgery  (surgical correction of dysgnathia), but also for the surgical reconstruction of the orbit, or other surgical interventions to the midface."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11503", "text": "Since 2001, at the  University of Heidelberg, Germany , the  SSN++  has been developed, a markerless- registration  navigation system, based on a native (=markerless)  CT  or  MRI . In this case, the  patient registration  is obtained on the operating table, using a surface scanner. [ 3 ]  The SSN++ correlates the surface scan data (gathered on the operating table) with the skin surface reconstruction from the  dataset  obtained preoperatively by  CT  or  MRI . This principle complies with the  terrain contour matching  principle described for flying objects. The advantage of the new method is that the  registration of the patient's position  becomes a simple automated procedure; on the other hand, the radiation load for the patient is reduced, compared to the method using markers. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11504", "text": "The  zygomaticomaxillary complex fracture , also known as a  quadripod fracture ,  quadramalar fracture , and formerly referred to as a  tripod fracture  or  trimalar fracture , has four components, three of which are directly related to connections between the zygoma and the face, and the fourth being the orbital floor. Its specific locations are the lateral orbital wall (at its superior junction with the  zygomaticofrontal suture  or its inferior junction with the  zygomaticosphenoid suture  at the  sphenoid greater wing ), separation of the maxilla and zygoma at the anterior maxilla (near the  zygomaticomaxillary suture ), the  zygomatic arch , and the  orbital floor  near the  infraorbital canal ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11505", "text": "On physical exam, the fracture appears as a loss of cheek projection with increased width of the face. In most cases, there is loss of sensation in the cheek and upper lip due to infraorbital nerve injury. Facial bruising, periorbital ecchymosis, soft tissue gas, swelling,  trismus , altered  mastication ,  diplopia , and   ophthalmoplegia  are other indirect features of the injury. [ 1 ]  The zygomatic arch usually fractures at its weakest point, 1.5\u00a0cm behind the zygomaticotemporal suture. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11506", "text": "The cause is usually a direct blow to the  malar eminence  of the cheek during assault. The paired  zygomas  each have two attachments to the cranium, and two attachments to the  maxilla , making up the  orbital floors and lateral walls . These complexes are referred to as the zygomaticomaxillary complex. The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11507", "text": "The formerly used 'tripod fracture' refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11508", "text": "There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11509", "text": "ZMC complex fractures involve the lateral vertical buttress of the ZMC complex (lateral maxillary sinus and lateral orbital wall) and the upper transverse buttress (inferior orbital rim and floor, also including the zygomatic arch). Three of its four components are directly related to connections between the zygoma and the face."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11510", "text": "Two of its components are connections between the orbit and mid-face at the orbital medial wall and floor. Unlike an orbital blow out fracture, however, the orbital rim can be involved.  The posterior vertical buttress is usually spared, and is more commonly involved in  Lefort fractures ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11511", "text": "Specifically, one of two positions at the lateral orbital wall can be involved, either above at its superior junction with the zygomaticofrontal suture or below at its inferior junction with the zygomaticosphenoid suture at the sphenoid greater wing. Separation of the maxilla and zygoma at the anterior maxilla is also seen near the zygomaticomaxillary suture. The zygomatic arch itself is also transcortically involved, and the orbital floor near the infraorbital canal is disrupted. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11512", "text": "Non-displaced or minimally displaced fractures may be treated conservatively. Open reduction and internal fixation is reserved for cases that are severely angulated or  comminuted . The purpose of fixation is to restore the normal appearance of the face. Specific attention is given to the position of the  malar eminence  and reduction of  orbital  volume by realigning the zygoma and sphenoid. Failure to correct can result in rotational deformity and increase the volume of the orbit, causing the  eye to sink inwards . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11513", "text": "Fractures with displacement require surgery consisting of fracture reduction with miniplates, microplates and screws. Gillie's approach is used for depressed zygomatic fractures. [ 5 ]  The prognosis of tripod fractures is generally good. In some cases there may be persistent post-surgical facial asymmetry, which can require further treatment. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11514", "text": "Digestive system surgery , or  gastrointestinal surgery , can be divided into upper GI surgery and lower GI surgery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11515", "text": "Upper gastrointestinal surgery , often referred to as  upper GI surgery , refers to a practice of  surgery  that focuses on the upper parts of the  gastrointestinal tract . There are many operations relevant to the upper gastrointestinal tract that are best done only by those who keep constant practice, owing to their complexity. Consequently, a  general surgeon  may specialise in 'upper GI' by attempting to maintain currency in those skills."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11516", "text": "Upper GI surgeons would have an interest in, and may exclusively perform, the following operations:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11517", "text": "Surgery on the digestive system's organs is referred to as digestive system surgery, gastrointestinal surgery, or gastrointestinal (GI) surgery. Nutrients from the food we eat are processed and absorbed by the digestive system. Surgery could be required to remedy or treat certain problems or diseases that affect the digestive tract."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11518", "text": "There are many different types of digestive system operations, some of the more popular ones being:\n1. Appendectomy: The surgical removal of the appendix, typically as a result of acute appendicitis, an appendix inflammation.\n2. Gastric bypass: A weight-loss procedure that includes separating the stomach into an upper pouch that is smaller and a lower pouch that is bigger. Then, a section of the stomach and small intestine are skipped in favor of rearranging the small intestine to link to both pouches. As a result, the stomach can contain less food and nutrients are not as well absorbed, which causes weight loss.\n3. Cholecystectomy: Surgically removing the gallbladder, frequently as a result of painful gallstones or other problems.\n4. Colectomy: The removal of the colon (large intestine) whole or in part. This procedure is typically done to address problems including colorectal cancer, diverticular disease, or inflammatory bowel disease.\n5. Resection of the liver in part: This procedure is frequently carried out to treat liver tumors or to remove damaged liver tissue.\n6. Esophagectomy: Removal of the esophagus in whole or in part, usually to treat esophageal cancer.\n7. Pancreatic Surgery: procedures involving the pancreas, such as the Whipple surgery (pancreaticoduodenectomy), which is used to treat some forms of pancreatic cancer and other serious pancreatic diseases.\n8. Hernia Repair: A hernia, which is the protrusion of an organ or tissue through a weak spot in the abdominal wall, is treated surgically."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11519", "text": "These operations can be carried out using conventional open surgical procedures or minimally invasive techniques like laparoscopic or robotic-assisted surgery, which require smaller incisions and result in quicker recoveries. Surgery of the digestive system is a complicated topic that calls for specialized education and experience. To make educated decisions regarding their healthcare, individuals must speak with a trained surgeon about their unique situation, treatment options, and potential hazards."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11520", "text": "1-800-GET-THIN  was an American marketing company with headquarters at  Beverly Hills , California. It sold weight-loss products and was a  vanity 800 number  as well as a trademarked brand name used to market \"insurance services, namely, insurance eligibility review and verification in the health industry.\" [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11521", "text": "Robert Silverman incorporated 1-800-GET-THIN in February 2010. According to Silverman, the goal of 1-800-GET-THIN was \"'assisting individuals [to] overcome their battle with obesity, which has reached world-wide epidemic status.'\"  Robert Silverman resigned as company president on 28 February 2012 \"to pursue other career opportunities.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11522", "text": "On February 2, 2012  Allergan , the manufacturer of  Lap-Band , announced it would no longer sell the device to companies affiliated with 1-800-GET-THIN. [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11523", "text": "On 7 February 2012, two clinics affiliated with 1-800-GET-THIN halted Lap-Band surgeries. [ 6 ] [ 7 ]  Shortly after that, all previous advertisements, including commercials, were scrubbed off clinic websites and their Youtube channel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11524", "text": "U.S. House  members called for a congressional investigation in 2012 into 1-800-GET-THIN. [ 8 ] [ 9 ] [ 10 ]  The  California Department of Insurance  is investigating surgery centers that are contracted with 1-800-GET-THIN for alleged insurance fraud. [ 11 ] [ 12 ] [ 13 ] [ 14 ]   Published reports and lawsuits speculate that one of the principal surgeons at this enterprise owned and controlled all of the surgery centers, as well as the 1-800-GET-THIN marketing firm. The documents also speculate that ownership of the centers and the marketing firm, 1-800-GET-THIN, are in part controlled by Kambiz Beniamia Omidi. [ 6 ] [ 7 ] [ 14 ] [ 15 ]  In October 2012, the FDA confirmed that members of the 1-800-GET-THIN ad campaign are the subjects of a criminal investigation, involving several federal and state law enforcement agencies, according to a court filing. The investigation is focused on numerous \"Potential violations of federal law, including conspiracy, healthcare fraud, wire fraud, mail fraud, tax violations, identity theft, and money laundering,\" Samanta Kelley, a special agent for the Food and Drug Administration's criminal division, said in an affidavit filed at the federal courthouse in Los Angeles. She also stated that the  FBI  investigated blackmail against 1-800-Get-Thin. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11525", "text": "A former 1-800-GET-THIN client testified in a deposition for a lawsuit that he knew about six or seven deaths that occurred before October 6, 2010, when he says he quit. Two reported deaths occurred after that date, including one still under investigation by the Los Angeles coroner.\" [ 17 ]  The death still under investigation was that of Paula Rojeski, who died on September 8, 2010, after she underwent a Lap-Band operation at the Valley Surgical Center in West Hills."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11526", "text": "No doctors were found of any wrongdoings. As a result, Rojeski's lawsuit was dismissed in 2017."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11527", "text": "In 2011, a  class action  lawsuit was filed by relatives of two patients who died after Lap-Band surgeries at clinics affiliated with the 1-800-GET-THIN campaign.  The complaint alleged false advertising and sought damages from the owners and several companies allegedly controlled by them. In April 2013, a settlement was reached to pay approximately $1.3 million to fund compensation for members of the plaintiff class and to fund a billboard campaign warning of the risks of the surgeries. Other lawsuits remain unresolved. [ 18 ]  To this day, no doctor associated with the 1-800-GET-THIN campaign was found guilty of any of the five patient deaths. In addition, there were no medical board accusations alleging wrongdoing by physicians."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11528", "text": "From 2011-12, the  U.S. Food and Drug Administration  found that 1-800-GET-THIN's advertisements, LapBandVIP's advertisements, and O-Band's advertisements were all simultaneously misleading and failed to provide accurate information about the potential risks involved in using the product. [ 19 ] [ 20 ]  In 2014 federal prosecutors seized more than $100 million in assets asserted to be related to the business, and in February 2018 Julian Omidi and Mirali Zarrabi were arrested after a federal grand jury indicted them on multiple counts relating to the business' allegedly fraudulent conduct. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11529", "text": "An  abdomino   perineal   resection , formally known as  abdominoperineal resection of the rectum  and  abdominoperineal excision of the  rectum  is a  surgery  for  rectal cancer  or  anal cancer . It is frequently  abbreviated  as  AP resection ,  APR  and  APER ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11530", "text": "See image on National Cancer Institute website \nThe principal indication for AP resection is a rectal carcinoma situated in the distal (lower) one-third of the rectum. [ 1 ]  Other indications include recurrent or residual anal carcinoma ( squamous cell carcinoma ) following initial, usually definitive combination chemoradiotherapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11531", "text": "APRs involves removal of the  anus , the  rectum  and part of the  sigmoid colon  along with the associated (regional)  lymph nodes , through incisions made in the  abdomen  and  perineum . The end of the remaining  sigmoid colon  is brought out permanently as an opening, called a  stoma , which is used by the patient in conjunction with a  colostomy  pouch, on the surface of the abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11532", "text": "This operation is one of the less commonly performed by  general surgeons , although they are specifically trained to perform this operation. As low case volumes in rectal surgery have been found to be associated with higher complication rates, [ 2 ] [ 3 ]  it is often centralised in larger centres, [ 4 ]  where case volumes are higher."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11533", "text": "There are several advantages in terms of outcomes if the surgery can be performed laparoscopically [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11534", "text": "An APR, generally, results in a worse  quality of life  than the less invasive  lower anterior resection  (LAR). [ 6 ] [ 7 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11535", "text": "William Ernest Miles  (1869\u20131947), an English surgeon first performed the surgery of removing the rectum in 1907. He assumed that the rectal cancer can spread in both upwards and downward directions, thus necessitating the removal of the entire rectum together with the anal sphincters, resulting in a permanent stoma by connecting the proximal end of the descending colon to the skin. Mile's operation became the gold standard for treating rectal cancer because his technique successfully reduced the rate of cancer recurrence. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11536", "text": "To reduce the incidence of death and suffering of the patients associated with the APR procedure,  Henri Albert Hartmann  introduced the anterior resection of the rectum by preserving the distal rectum and anal sphincters, while producing end-sigmoid colostomy. There were attempts to restore bowel continuity by joining the proximal colon with the rectum, but the high incidence of leakage from the anastomotic site caused an increased risk of death to patients. It was only in 1948, Claude Dixon successfully connected the proximal bowel to the rectum, thus allowing patients to have a 64% 5-year survival rate. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11537", "text": "Anal sphincterotomy  is a surgical procedure that involves treating mucosal fissures from the anal canal/ sphincter . [ 1 ] [ 2 ]  The word is formed from sphincter + otomy (to cut, to separate). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11538", "text": "Antrectomy , also called  distal   gastrectomy , is a type of gastric  resection  surgery that involves the removal of the  stomach   antrum  to treat  gastric diseases  causing the damage,  bleeding , or  blockage  of the stomach. [ 1 ] [ 2 ]  This is performed using either the  Billroth I (BI)  or  Billroth II (BII)  reconstruction method. Quite often, antrectomy is used alongside  vagotomy  to maximise its safety and effectiveness. [ 3 ]  Modern antrectomies typically have a high success rate and low  mortality rate , but the exact numbers depend on the specific  conditions  being treated. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11539", "text": "The history of antrectomy traces back to the 19th century, starting with the first successful  gastric resection  in 1810. Since then, antrectomy has undergone a magnitude of changes, where development in the field continues to this day. Even though antrectomy paired with vagotomy and anastomosis is now the established  gold standard , its  side effects  and  clinical relevance  remains a controversial subject. With advancements in alternative surgeries and other non-invasive treatments, antrectomy is less common nowadays."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11540", "text": "Generally, an antrectomy is performed to treat  bleeding  and  blockage  of the  stomach . [ 2 ]  This could be caused by a variety of gastric disorders, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11541", "text": "The  diagnosis  of  stomach  disorders begins with the examination of the patient\u2019s  history  and  family history , and supplemented with a  physical exam . [ 7 ]  Old age and recent significant weight loss would suggest the possibility of  gastric cancer . [ 7 ]  A family history of  duodenal or gastric ulcers  would require the patient to describe the type of discomfort he/she is experiencing. [ 7 ]  Different  stomach disorders  manifest  pain  at different time periods. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11542", "text": "The most common diagnostic tests for stomach disorders include  endoscopy , double-contrast  barium x-ray  study of the upper GI tract, and the detection of  H. pylori  infection . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11543", "text": "A midline  epigastric  incision is first made from the  xiphoid process  of the  sternum  to the  umbilicus . [ 8 ]  The opening can be widened by extending the incision inferiorly. [ 8 ]  When the abdominal organs are exposed, thorough exploration is undertaken to assess the extent of disease and, in the case of  stomach cancer , to confirm resectability. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11544", "text": "Two surgical methods can then be used to perform antrectomy: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11545", "text": "The  gastrocolic ligament  of the  greater omentum  is incised at the middle of the  greater curvature  of the stomach, which opens the  lesser sac . [ 9 ]  The dissection for  gastric ulcers  can be done between the  gastroepiploic vessels  and the gastric wall. [ 9 ]  In carcinoma, the greater omentum corresponding to the extent of the resection of the greater curvature must be removed at the same time. [ 9 ]  The incision continues along the greater curvature towards the duodenum. [ 9 ]  Near the  pylorus  of the stomach, the greater omentum becomes thick and divides into the front and back layer. [ 9 ]  Dissection should be continued bluntly and the right gastroepiploic vessels running between the two layers are ligated. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11546", "text": "The  Kocher manoeuver  is used at a position above or just below the descending (second) part of the duodenum from a lateral direction. [ 9 ]  The duodenum is mobilised to achieve a good general exposure, which facilitates the subsequent gastroduodenostomy. [ 9 ]  The preparation of the free superior (first) part of the duodenum is then continued. [ 9 ]  By stretching the stomach, the dissection proceeds along the greater curvature toward the left medial duodenal wall, then toward the back wall, and finally toward the lateral duodenal wall of the superior part as far as the beginning of the  hepatoduodenal ligament . [ 9 ]  This way, 3 to 5\u00a0cm of the back wall of the duodenum can be exposed. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11547", "text": "Dissection is then performed along the lesser curvature of the stomach. [ 9 ]  The  right gastric artery  is divided between  clamps  and ligated. [ 9 ]  The front and back layer of the  lesser (gastrohepatic) omentum  is severed individually. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11548", "text": "The actual resection starts with the cutting of the duodenum between  holding or guy sutures . [ 9 ]  The duodenum is temporarily closed with a sponge; the resection borders of the stomach are then determined. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11549", "text": "A sewing instrument facilitates the final step of stomach removal. [ 9 ]  The incision follows at an angle of 45 degrees to the lesser curvature. [ 9 ]  The staple line can, but need not, be oversewn. [ 9 ]  After removal of the distal portion (including the antrum and the  pylorus ) of the stomach, a clamp is fitted at right angles to the greater curvature. [ 9 ]  The clamp is pushed far enough orally (towards the mouth) for the removal level to correspond in size to the duodenal lumen. [ 9 ]  The remaining aboral (away from the mouth) end is cut off after stay sutures are placed at each cut edge. [ 9 ]  The anastomosis should be performed without clamps. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11550", "text": "The end-to-end gastroduodenostomy is accomplished by anastomosing the duodenum to the end of the greater curvature. [ 9 ]  For this purpose, the two cut surfaces are placed adjacent to each other and two corner stitches are placed, starting at the stomach through the seromuscular layers with tangential grasping of the  mucosa . [ 9 ]  At the duodenum, this stitch is done from inside to outside. [ 9 ]  The corner suture at the lesser curvature is tied, whereas the suture on the opposite side is left open. [ 9 ]  The back wall is reconstructed by interrupted back stitches. [ 9 ]  These stitches start through all layers of the back wall at the cut edge of the lesser curvature from inside to outside and go through all layers of the posterior wall of the duodenum from outside to inside. [ 9 ]  The suture is led back grasping only the mucosa, first of the duodenum and then of the stomach. [ 9 ]  Knotting these sutures leads to an exact coaptation, especially at the level of the mucosa. [ 9 ]  The front wall is best closed with one row of interrupted sutures through all layers with tangential stitches of the mucosa with the same technique as the corner stitches. [ 9 ]  Special attention must be paid to the Jammerecke (angle of sorrow) on the lesser curvature. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11551", "text": "Finally, the anastomosis is checked for patency with the thumb and index finger. [ 9 ]  The position of the  stomach tube  is also checked to ensure it crosses the anastomosis. [ 9 ]  A double-lumen gastric tube is placed across the anastomosis for 2 to 3 days, allowing early enteral nutrition via the distal lumen. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11552", "text": "In difficult duodenal ulcers, it can be impossible to preserve enough duodenal wall to be able to construct a tension-free anastomosis. [ 9 ]  In this situation, it is safer to staple close the duodenum and reconstruct the intestinal passage by end-to-side anastomosis. [ 9 ]  For this purpose, the stomach is removed as previously described; the dissected stomach lumen is then anastomosed onto the front wall of the duodenum. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11553", "text": "Usually, an oblique incision should be made on the duodenal front wall so that the incision level starts from oral\u2013medial and goes to aboral\u2013lateral. [ 9 ]  The suturing technique is the same as for the end-to-side anastomosis. [ 9 ]  In technically difficult duodenal stump closures, additional coverage of the stump with the back wall of the stomach can be obtained. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11554", "text": "Both the left gastric and left gastroepiploic artery are preserved in this method, although the resection is more extended. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11555", "text": "At the oral margin of the dissection line, usually covering two-thirds of the stomach, the resection is completed by transverse application of a linear stapler in a way that the complete stomach is divided between one stapler application. [ 9 ]  The staple line can be oversewn. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11556", "text": "The first or second loop of the  jejunum  is then mobilised and placed tension-free and in a retrocolonic fashion opposite the greater curvature of the remaining stomach. [ 9 ]  The loop should be long enough and should have a Braun jejunojejunostomy between the ascending and the descending loop. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11557", "text": "The last 4 to 5\u00a0cm of the stapler line towards the greater curvature should be excised with the help of an electrocautery device in order to form a slim opening for the subsequent gastrojejunostomy. [ 9 ]   Stay sutures  are placed on both sides of the anastomosis. [ 9 ]  The jejunum is incised with the electrocautery device opposite the  mesentery . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11558", "text": "The gastrojejunostomy is performed by single interrupted sutures with resorbable suture material and, as the anastomosis cannot be turned, the back wall is sutured by interrupted mattress sutures and the front wall by extramucosal interrupted sutures. [ 9 ]  Alternatively, continuous suturing with a monofilament resorbable thread on both sides of the anastomosis is possible. [ 9 ]  Before finalisation of the front wall, a double-lumen gastric tube is placed distally to the anastomosis, allowing early enteral nutrition. [ 9 ]  In order to prevent enterogastric (bile) reflux, the formation of a jejunojejunostomosis (Braun anastomosis), side-to-side, and 30\u00a0cm aborally of the gastrojejunostomy is mandatory. [ 9 ]  This anastomosis can be either hand-sewn (interrupted or continuous technique, resorbable suture material) or stapled. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11559", "text": "Supplementary operations can be applied alongside antrectomy to maximise its success and effectiveness. One commonly performed is vagotomy (the removal of the vagus nerve), since the  vagus nerve  also plays a key role in gastric juice regulation. While performed separately, vagotomy and antrectomy reduce stomach acid secretion by up to 60%. [ 10 ]  Combining both practices could reduce stomach acid secretion by up to 80% through an  additive effect . [ 10 ]  In some cases, antrectomy can be used alongside  laparoscopic   sleeve gastrectomy  to facilitate weight loss. [ 11 ]  Yet, the clinical relevance of including antrectomy in this procedure remains to be seen. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11560", "text": "The success rate of antrectomy is dependent on the rationale of the surgery. For example, antrectomies that are done to overcome peptic ulcer disease (PUD) have a 95% success rate, while the percentage is higher for  gastric antral vascular ectasia syndrome (GAVE) . [ 4 ]  However, antrectomies that deal with  gastric cancer  or penetrative wounds are not as successful. [ 4 ]  One possible explanation is that these symptoms are usually more severe and therefore harder to treat, no matter the kinds of surgery used. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11561", "text": "Nowadays, the mortality rates for antrectomy are typically low. The death rate of antrectomy for ulcer treatment is 1-2%, while it is 1-3% for gastric cancer. [ 4 ]  Similarly, the chances of developing complications after surgery depend on the reason for the surgery and the type of complication in question. For example, antrectomy for peptic ulcers has a 1-5% chance for the condition to recur, a 12% chance of developing  diarrhea , and a 30-35% chance of developing  Dumping syndromes . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11562", "text": "The clinical basis of antrectomy was laid in the 19th century with the birth of its father -  gastric resection . The first attempt at gastric resection was by German professor and surgeon  Christian Michaelis , whose experiment on removing pylorus in animals to resolve  gastric obstruction  failed. [ 12 ]  In 1810, his student  Daniel Merrem  successfully performed the resection of the  distal   stomach  and reconnected the  duodenum  to the  stomach  in animal experiments. [ 12 ]  The first clinical attempt of a gastric resection occurred in 1879 by French surgeon  Jules-\u00c9mile P\u00e9an , who unsuccessfully carried out a pylo-rectomy for a cancer patient. [ 12 ]  This was followed by the attempt of Polish surgeon  Ludwik Rydygier , whose gastric resection also ended in the death of his patient. [ 12 ]  It was not until 1881 was the first successful gastrectomy carried out by German physician Theodor Billroth . Billroth first tested gastrectomy surgery on animals in an experiment known as \u2018Billroth I gastrectomy\u2019, which resulted in the long-term survival of two out of seven dogs. [ 12 ]  This eventually led to the first successful gastric resection in a patient with stomach cancer, in which the duodenum was cut 1.5\u00a0cm away from the tumor and reattached to the stomach with carbolized silk. [ 12 ]  The practice was then quickly applied to Billroth\u2019s clinics, with 19 successful operations out of 41 gastrectomies by 1890. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11563", "text": "Following the success of the first gastric resection, the birth of antrectomy is attributed to a better understanding of the gastrointestinal system in the early 20th century. Upon the discovery of gastrin by  John S. Edkins  in 1906,  E. Klein  published the first report combining  vagotomy  with  gastrectomy  to ease symptoms of excessive gastric juice secretion. [ 13 ]  By 1946, American physicians  Farmer  and  Smithwick  performed the first vagotomy with hemigastrectomy (the removal of one-half of the stomach). [ 13 ]  In the following year,  Herrington  of Vanderbilt University similarly combined vagotomy with the removal of the lower stomach to improve operational effectiveness, sparking the earliest resemblance to the antrectomy performed today. [ 13 ]  During the same period, other variations of Billroth's gastrectomy such as concurrent  gastrojejunal anastomosis  were also transforming the landscape of gastrectomy, with the most notable contributions by surgeons Hofmeister, Polya, von Haberer, and Finsterer. [ 12 ]  These variations influenced the way antrectomy is practiced, specifically the type of surgeries that antrectomy is paired with."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11564", "text": "In the subsequent decades, antrectomy continued to evolve with advancements in surgical techniques. The 1950s marked the popularization of diagnostic and operational  laparoscopy  in hospitals and medical training. [ 14 ]  This meant that antrectomy could be performed in a minimally invasive manner. However, complications such as diarrhea in antrectomy continue to be a problem, with a 1952 edition of The  Lancet Review  commenting, 'fashions in the treatment of peptic ulcer come and go, and the surgical problem remains unsolved.' [ 15 ]  Hence the 1950s and 60s also marked the era of comparative studies of stomach surgery in an attempt of finding an effective method with the least side effects. Most notably, the 1968  Leads-York controlled trial  published by The British Medical Journal found that the combination of vagotomy and gastrectomy is superior to other forms of surgery such as gastroenterostomy on the  Visick grading  (scoring system to quantify the symptomatic outcome of peptic ulcer surgery). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11565", "text": "The decades leading up to the present featured shifting applications of antrectomy. With the commercialization of acid-reducing medications such as  antacids  in the late 1970s, the incidence and prevalence of gastric ulcers fell, hence reducing the need for antrectomy. At the same time, British physician David Cowley became the first person to diagnose and treat pseudo- Zollinger-Ellison syndromes  (stomach ulceration and excessive gastric acid production) using antrectomy and vagotomy. [ 17 ]  In the subsequent decades, a better understanding of the Zollinger-Ellison syndrome led to antrectomy becoming one of the key treatment methods for the ailment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11566", "text": "Despite this, advent of newer non-invasive methods of resolving gastric disorders have made antrectomy less relevant nowadays. By 2003, antrectomy is no longer recognized as the first-line treatment for  gastric antral vascular ectasia  (watermelon stomach) and  peptic ulcer disease . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11567", "text": "Antrectomy can reduce  acid secretion  in  PUD  and remove premalignant tissue to reduce gastric cancer odds. [ 1 ]  This offers a permanent method that has a 95% success rate. It also alleviates pain,  hemorrhage , and  anemia  from recurring  stomach   ulcers . For localized cancer cases, antrectomy can eliminate early-stage cancer in the third (lower) portion of the stomach. Moreover, antrectomy is able to treat PUD and  GOO  by the removal of malignant tissues which controls early-stage gastric cancer while retaining sufficient portions of the stomach for adequate digestion and nutrition uptake. Furthermore, treating  obesity  with antrectomy is also becoming more common. Antrectomy is also the immediate and only approach to reconstructing organs from injuries such as stabbing in the lower portion of the stomach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11568", "text": "Antrectomy results in the removal of parts of the stomach, reducing the functions of a normal stomach. Around 30% of patients develop  Dumping syndrome , a condition where food entering the stomach enters the  intestines  prematurely due to a partially removed stomach not maximizing its digestive function. It causes  heartburn ,  nausea ,  fatigue , and  vomiting  after meals. [ 4 ]  In addition, other side effects include  dysphagia , which is when digestive juices in the  duodenum  flow upward to the esophagus, thus  esophageal  lining is irritated. Diarrhea is common, especially in patients who had vagotomy in addition to an antrectomy because the damage of nerves to the  liver  and  gallbladder  causes excess  bile salt  release."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11569", "text": "Due to a decrease in gastric function, patients have to adjust to a diet composed of high  protein  and low  carbohydrates . [ 4 ]  They must take more liquids when eating and have small and frequent meals. The decreased gastric function also leads to  malabsorption  and  malnutrition , especially for  iron ,  folate , and  calcium  because acid is important for assimilating these substances. [ 18 ]  Therefore,  weight loss  due to decreased food intake and malnutrition is common in patients in recovery, especially in elderly patients. Additionally,  Bezoar development obstruction  of the digestive tract is also seen in postoperative patients because the fiber and more solid food are not fully digested by the shrunk stomach. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11570", "text": "Other than side effects, the success of antrectomy in treating the target condition is also debatable. Antrectomy removing a part of the stomach does not treat later-stage cancer. [ 19 ]  For PUD patients, antrectomy alone could still cause the recurrence of gastric ulcers, [ 18 ]  even if paired with a vagotomy. Leakage from anastomosis of the resected stomach and small intestines can also occur in some patients"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11571", "text": "Antrectomy is an invasive surgery that is only performed when patients experience  bleeding ,  perforation ,  obstruction , and  malignancy . Treatment alternatives are based on their diagnosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11572", "text": "For  gastric outlet obstruction (GOO) ,  balloon dilation  is a new option for treatment.  Endoscopic stenting  is also used as an alternative but due to the chance of re-obstruction and stent migration, [ 20 ]  it is usually performed on patients with shorter life expectancies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11573", "text": "Antrectomy is often not considered a first-line treatment for  PUD  due to the high success rate with usage of  antibiotics  and other medications, [ 21 ]  described below. Suitable candidates for antrectomy are those who failed to recover from treatment with over-the-counter NSAIDs and have severe damage to the  stomach lining . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11574", "text": "\"Triple therapy\" is a combination of medications to kill bacteria, reduce stomach acid production, and protect the stomach lining. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11575", "text": "For  cancer ,  chemotherapy  is the most common alternative to antrectomy. Antrectomy is suitable for early-stage gastric cancer as complete removal can stop cancer spread. With advancements in endoscopic surgeries,  endoscopic mucosal resection  (EMR) is a  non-invasive  choice that is safer than antrectomy for small tumor removals in the  distal  portion of the stomach. [ 19 ]  For late-stage cancer where malignancy is spread to other organs, chemotherapy is preferred as surgery cannot eliminate cancer. [ 4 ]  Cancer patients\u2019 condition is also considered when making surgical decisions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11576", "text": "Other surgeries can manage GOO. Surgical approaches are decided based on the patient\u2019s condition and the development of the condition. Enteral stents are used to expand the obstruction of the pylorus. Medication is used to protect the stomach lining."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11577", "text": "Other medications including  acupuncture ,  ayurvedic medication , and  herbal preparations  used based on the individual\u2019s physique are given as non-invasive treatments in Asian countries and have successful outcomes. [ 4 ]  To manage pain from ulcer and obstruction symptoms, herbalist approaches include  licorice ,  bupleurum ,  fennel ,  fenugreek ,  slippery elm , and  marshmallow root . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11578", "text": "With advancements in endoscopy, traditional antrectomy is a less popular surgical choice for  gastric outlet obstruction (GOO)  and  peptic ulcer disease (PUD) . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11579", "text": "In the past, 89-90% of ulcer-related GOO patients required surgery. [ 24 ]  As the development of  endoscopic procedures  advances, recent reports suggest that endoscopic balloon dilation is an effective treatment option for GOO and PUD."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11580", "text": "For Type I, II, and III ulcers,  robot-assisted  gastric antrectomy and  vagotomy  are gaining popularity. This method reduces blood loss and length of stay but the operation duration is longer. [ 21 ]  It carries out exact dissections in a scarred  stomach  and  duodenum  and offers magnification and smooth articulation of instruments. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11581", "text": "Robotic antrectomy first involves a  dissection  along the  greater curvature  of the stomach, from the  pylorus  to the  cephalad  followed by mobilizing the  lesser curvature  and  ligating  the  right gastric artery . [ 25 ]  The duodenal bulb is removed from the pancreas. [ 25 ]  At this point, the proximal transection should extend from the indentation of the  lesser curvature  to the terminal branch of the  right gastroepiploic artery  on the  greater curvature . [ 25 ]  The  distal  transection should be done on the duodenum. [ 25 ]  The antrectomy ends by creating an  anastomosis  for gastrointestinal continuity, usually gastroduodenal or gastrojejunal anastomosis. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11582", "text": "As robotic antrectomy is not popularized in most hospitals,  intracorporeal  antrectomy and anastomosis are the most common for tumor removal and curing complicated PUD as it is comparatively less invasive and minimizes blood loss. The first case of single-incision  laparoscopic antrectomy  for  type I gastric neuroendocrine tumor  was reported in 2021. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11583", "text": "In recent years, antrectomy has been used to control  obesity . [ 27 ]  There are debates on the safety and efficiency of this procedure regarding the distance from the pylorus of which the resection takes place. Trials and reviews have been done on exploring the postoperative effects,  nausea  and  vomiting , and chance of leakage from anastomosis when antrectomy is done 2\u00a0cm or less from the pylorus. [ 28 ]  Developments aim to reduce the  stomach  volume in obese patients while retaining digestive function and ensuring safety."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11584", "text": "An  appendectomy  ( American English ) or  appendicectomy  ( British English ) is a  surgical operation  in which the  vermiform appendix  (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute  appendicitis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11585", "text": "Appendectomy may be performed  laparoscopically  (as  minimally invasive surgery ) or as an open operation. [ 2 ]  Over the 2010s, surgical practice has increasingly moved towards routinely offering laparoscopic appendicectomy; for example in the  United Kingdom  over 95% of adult appendicectomies are planned as laparoscopic procedures. [ 3 ]  Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline  laparotomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11586", "text": "Complicated (perforated) appendicitis should undergo prompt surgical intervention. [ 1 ]   There has been significant recent trial evidence that uncomplicated appendicitis can be treated with either antibiotics or appendicectomy, [ 4 ] [ 5 ]  with 51% of those treated with antibiotics avoiding an appendectomy after 3 years. [ 6 ]  After appendicectomy the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours post-operatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days. [ 1 ]  An interval appendectomy is generally performed 6\u20138 weeks after conservative management with antibiotics for special cases, such as perforated appendicitis. [ 7 ]  Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not shown to increase risk of perforation or other complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11587", "text": "In general terms, the procedure for an open appendectomy is:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11588", "text": "The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ. [ 9 ]  A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11589", "text": "These incisions are placed for appendectomy:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11590", "text": "Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better  cosmesis ; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. [ 10 ]  Recent research has led to the development of  natural orifice transluminal endoscopic surgery  (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11591", "text": "Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar  et al.  described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2\u2013 or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates  et al.  and Roberts  et al.  have described variants of an  intracorporeal  sling-based single-port laparoscopic appendectomy with good clinical results. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11592", "text": "Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. [ 12 ]  With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. [ 11 ]   The additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11593", "text": "Pediatric patients have a mobile cecum, which allows externalization of the cecal appendix through the umbilicus in most cases. This has led to the development of surgical techniques such as laparoscopic-assisted transumbilical appendectomy, which allows the entire surgery to be performed with a single umbilical incision and has significant advantages in terms of both recovery and aesthetic outcome. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11594", "text": "Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy. [ 14 ]  These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester. [ 2 ]  If appendicitis develops in a  pregnant  woman, an appendectomy is usually performed and should not harm the  fetus . [ 15 ]  The risk of premature delivery is about 10%. [ 16 ]  The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11595", "text": "There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11596", "text": "Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11597", "text": "One area of concern related to the LA during pregnancy is  pneumoperitoneum . This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11598", "text": "A study from 2010 found that the average hospital stay for people with appendicitis in the United States was 1.8 days. For people with a perforated (ruptured) appendix, the average length of stay was 5.2 days. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11599", "text": "Recovery time from the operation varies from person to person. Some take up to three weeks before being completely active; for others, it can be a matter of days. In the case of a laparoscopic operation, the patient has three stapled scars of about an inch (2.5\u00a0cm) in length, between the navel and pubic hair line. When an open appendectomy has been performed, the patient has a 2\u2013 to 3-inch (5\u20137.5\u00a0cm) scar, which will initially be heavily bruised. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11600", "text": "One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI). [ 20 ]  Signs and symptoms indicative of a superficial SSI are redness, swelling, and tenderness surrounding the incision and are most likely to arise on post-operative day 4 or 5. These symptoms oftentimes precede fluid drainage from the incision. Tenderness extending beyond the redness that surrounds the incision, in addition to the development of cutaneous  vesicles  or bullae may be indicative of a deep SSI. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11601", "text": "Patients with complicated appendicitis (perforated appendicitis) are more likely to develop a SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital in addition to increased cost of the operation. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11602", "text": "About 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating-room procedures in 2011. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11603", "text": "The first recorded successful appendectomy was performed in September 1731 by English surgeon William Cookesley on Abraham Pike, a chimney sweep. [ 23 ] [ 24 ]  The second was on December 6, 1735, at  St. George's Hospital  in London, when French surgeon  Claudius Amyand  described the presence of a perforated appendix within the  inguinal hernial  sac of an 11-year-old boy. [ 8 ]  The organ had apparently been perforated by a pin the boy had swallowed. The patient, Hanvil Andersen, made a recovery and was discharged a month later. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11604", "text": "Harry Hancock performed the first  abdominal surgery  for appendicitis in 1848, but he did not remove the appendix. [ 26 ]  In 1889 in New York City,  Charles McBurney  described the presentation and pathogenesis of appendicitis accurately and developed the teaching that an early appendectomy was the best treatment to avoid perforation and  peritonitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11605", "text": "Some cases of autoappendectomies have occurred. One was attempted by  Evan O'Neill Kane  in 1921, but the operation was completed by his assistants. Another was  Leonid Rogozov , who in 1961 had to perform the operation on himself as he was the only doctor on a remote Antarctic base. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11606", "text": "On September 13, 1980,  Kurt Semm  performed the first  laparoscopic  appendectomy, opening up the path for a much wider application of minimally invasive surgery. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11607", "text": "While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study  analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined \"only uncomplicated episodes of acute appendicitis\" that involved \"visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home.\" The lowest charge for removal of an appendix was $1,529 and the highest $182,955, almost 120 times greater. The median charge was $33,611. [ 31 ] [ 32 ]  While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some sort of  medical insurance . [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11608", "text": "A study by the  Agency for Healthcare Research and Quality  found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11609", "text": "Billroth I , more formally  Billroth's operation I , is an  operation  in which the  pylorus  is removed and the distal  stomach  is  anastomosed  directly to the  duodenum . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11610", "text": "The operation is most closely associated with  Theodor Billroth , but was first described by  Polish   surgeon   Ludwik Rydygier . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11611", "text": "The surgical procedure is called a  gastroduodenostomy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11612", "text": "Billroth II , more formally  Billroth's operation II , is an  operation  in which a partial gastrectomy (removal of the stomach) is performed and the cut end of the stomach is closed.  The   greater curvature  of the stomach (not involved with the previous closure of the stomach) is then connected to the first part of the  jejunum  in end-to-side anastomosis.  The Billroth II always follows resection of the lower part of the  stomach  ( antrum ). The surgical procedure is called a partial gastrectomy and gastrojejunostomy. The Billroth II is often indicated in refractory  peptic ulcer disease  and  gastric adenocarcinoma . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11613", "text": "Over the years, the Billroth II operation has been colloquially referred to as any partial removal of the stomach with an end to side connection to the stomach as shown in the picture; however, technically, this picture is a modification of Billroth's operation called a partial gastrectomy with a Kronelein anastomosis where the divided end of the stomach is directly anastomosed to the side of the jejunal loop."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11614", "text": "Von Hacker was the first person to refer to the Billroth II partial gastrectomy operation writing from Billroth's clinic in 1885."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11615", "text": "A  Collis gastroplasty  is a  surgical procedure  performed when the surgeon desires to create a  Nissen fundoplication , but the portion of  esophagus  inferior to the  diaphragm  is too short. Thus, there is not enough esophagus to wrap. A vertical incision is made in the stomach parallel to the left border of the esophagus. This effectively lengthens the esophagus.  The  stomach fundus  can then be wrapped around the neo-esophagus, thus reducing  reflux  of  stomach acid  into the esophagus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11616", "text": "In fact, gastroplasty can be used when the length of the intra-abdominal esophagus is short and for anti-reflux action such as Nissen fundoplication, it is necessary to increase the intra-abdominal length of the esophagus.\nAt this time, part of the upper part of the stomach is separated by a stepper, i.e. the stapler fires longitudinally along the esophagus and increases the length of the stomach inside the abdomen.\nAt this time, a tongue is created from the stomach that can be easily rotated on the new esophagus and all kinds of fundoplication operations such as Nissen fundoplication can be done easily. [ 1 ] \nIt was devised by John Leigh Collis (1911\u20132003), [ 2 ]  a British cardiothoracic surgeon, in 1957. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11617", "text": "Coloanal anastomosis  (also known as  coloanal pull-through ) is a  surgical procedure  in which the  colon  is attached to the  anus  after the  rectum  has been removed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11618", "text": "Colonic polypectomy  is the removal of  colorectal polyps  in order to prevent them from turning  cancerous ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11619", "text": "Gastrointestinal polyps can be removed endoscopically through  colonoscopy  or  esophagogastroduodenoscopy , or  surgically  if the polyp is too large to be removed endoscopically. The method used to perform colonic polypectomies during  colonoscopy  depends on the size, shape and histological type of the polyp to be removed. Prior to performing polypectomy, polyps can be biopsied and examined histologically to determine the need to perform polypectomy. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11620", "text": "Prior to resection, assessment of the polyp should include: polyp size,  morphology , location, and accessibility. [ 3 ]  If there are features that suggest of cancer is present in the polyp, then either  endoscopic submucosal dissection  or surgery should be considered. [ 3 ]  If the polyp appears benign, but the risk of progression to cancer is negligible, then resection is not necessary. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11621", "text": "Large sessile polyps are more difficult to remove endoscopically, and polypectomy in these cases has a higher risk of complication. Sessile polyps up to 10mm can often be removed by snare polypectomy. Polyps over 10mm may have to be removed piecemeal by snare polypectomy. The use of electrocautery over a large area has a significant risk of causing colonic perforation; to reduce this chance, and to facilitate the polypectomy, sterile fluid (saline or colloid, with  methylene blue  dye added) can be injected under the base of the polyp to raise it away from the muscular layers of the colon. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11622", "text": "Pedunculated polyps can be removed by snare polypectomy. When the polyp is identified, a polypectomy snare is passed over the polyp and around the stalk of the polyp. The loop of the snare is then tightened to grip the polyp stalk, and the polyp is pulled away from the wall of the colon. An electric current is then passed through the snare loop to cut through the polyp stalk, providing electrocautery at the same time. The polyp can then be retrieved using the snare or an endoscopy basket, and removed by withdrawing the colonoscope."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11623", "text": "Polyps may be removed using cold biopsy forceps, cold snare polypectomy, hot biopsy forceps, hot snare polypectomy,  endoscopic mucosal resection , or  endoscopic submucosal dissection . Cold biopsy forceps may be used for small (diminutive) polyps 1-3 mm in size. [ 3 ]  Cold snare polypectomy has the advantage of avoiding the risk of delayed bleeding, postpolypectomy coagulation syndrome, and perforation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11624", "text": "The most common complications of colonic polypectomy are  bleeding  and colonic  perforation . Rarely,  postpolypectomy coagulation syndrome  may occur following removal of large polyps with  electrocautery . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11625", "text": "A  colostomy  is an opening ( stoma ) in the  large intestine  (colon), or the  surgical procedure  that creates one. The opening is formed by drawing the healthy end of the colon through an  incision  in the anterior  abdominal wall  and  suturing  it into place. This opening, often in conjunction with an attached  ostomy system , provides an alternative channel for  feces  to leave the body. Thus if the natural  anus  is unavailable for that function (for example, in cases where it has been removed as part of treatment for  colorectal cancer  or  ulcerative colitis ), an artificial anus takes over. It may be  reversible  or irreversible, depending on the circumstances."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11626", "text": "There are many reasons for this procedure.  Some common reasons are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11627", "text": "Types of colostomy include: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11628", "text": "Colostomy surgery that is planned usually has a higher rate of long-term success than surgery performed in an emergency situation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11629", "text": "A colostomy may be temporary; and  reversed  at a later date; or permanent."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11630", "text": "Colostomy or  ileostomy  is now rarely performed for rectal cancer, with surgeons usually preferring primary  resection  and internal  anastomosis , [ 3 ]  e.g. an  ileo-anal pouch . In place of an external  appliance , an internal ileo-anal pouch is constructed using a portion of the patient's lower intestine, to act as a new  rectum  to replace the removed original."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11631", "text": "Placement of the stoma on the  abdomen  can occur at any location along the colon, but the most common placement is on the lower left side near the  sigmoid  where a majority of colon cancers occur. Other locations include the  ascending ,  transverse , and  descending  sections of the colon. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11632", "text": "Pouches and the stick-on appliances to which they attach must be changed regularly. Sometimes an odor neutralizer and lubricant is squirted into a new pouch before it is attached. Two types of pouches are available: one disposable and one drainable. Most pouches are opaque and filter out air through a charcoal filter. The recommended practice is to empty such pouches when one-third full. [ 5 ]  Appliances, in contrast with pouches, are usually replaced every three to seven days except in cases where their seals have broken contact with the skin, when they should be replaced immediately. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11633", "text": "Even as long ago as the 1940s, surgeons conducting a  review  at the  Cleveland Clinic  (Jones and Kehm, 1946) [ 6 ]  could summarize the routine care of the permanent colostomy as usually quite satisfactory, stating that after patients recover from the initial worry prompted by the need for a colostomy, most of them learn to manage their colostomy quite well. [ 6 ]  \"These patients come from all walks of life and carry on their daily work as usual. One patient stated that he could see no advantage of the normal anus over a colostomy. While this may be somewhat overstated, it is true that most people with a permanent colostomy can live a useful, happy life.\" [ 6 ]  They found that, just as in anyone else, dietary indiscretion was the usual factor in occasional bowel habit disruption. [ 6 ]  This historical experience has been borne out, as today the conclusion still stands that most patients can successfully manage a colostomy as part of their  activities of daily living ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11634", "text": "Jones and Kehm preferred tissue paper as a colostomy cover (held in place with a band or garment) rather than a colostomy bag. [ 6 ]  They found that irrigation of the colostomy varied with each patient's bowel habit but that most patients developed a routine of every-other-day irrigation, whereas a few needed no irrigation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11635", "text": "People with colostomies must wear an  ostomy pouching system  to collect intestinal waste.  Ordinarily, the pouch must be emptied or changed a couple of times a day depending on the frequency of activity; in general the further from the  anus  (i.e., the further 'up' the intestinal tract) the ostomy is located the greater the output and more frequent the need to empty or change the pouch. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11636", "text": "People with colostomies who have ostomies of the  sigmoid colon  or  descending colon  may have the option of irrigation, which allows for the person to not wear a pouch, but rather just a gauze cap over the stoma, and to schedule irrigation for times that are convenient. [ 8 ]  To irrigate, a  catheter  is placed inside the stoma, and flushed with water, which allows the feces to come out of the body into an irrigation sleeve. [ 9 ]  Most colostomates irrigate once a day or every other day, though this depends on the person, their food intake, and their health."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11637", "text": "Parastomal hernia (PH) is the most common late complication of stomata through the  abdominal wall , occurring in 10-25% of patients, [ 10 ]  even up to 50% by some estimates. [ 11 ]   Prolapse  of bowel wall through the stoma occasionally happens and can require reoperation to repair. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11638", "text": "Clinical  pilates -based exercises have been demonstrated to improve patients' core abdominal strength and to reduce the risk of a hernia worsening. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11639", "text": "Other common complications of colostomy are high output, skin irritation, prolapse, retraction, and ischemia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11640", "text": "A  colostomy reversal , also known as a  colostomy takedown , is a reversal [ 1 ]  of the  colostomy  process by which the colon is reattached by  anastomosis  to the  rectum  or  anus , providing for the reestablishment of flow of  waste  through the  gastrointestinal tract . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11641", "text": "Indications for the surgery include patient pain or discomfort caused by the colostomy, frequent skin breakdown or infection, and herniation at the colostomy site. The technical aspects of the surgery depend on the amount of remaining colon and rectum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11642", "text": "Cystogastrostomy  is a surgery to create an opening between a  pancreatic pseudocyst  and the stomach when the cyst is in a suitable position to be drained into the stomach. [ 1 ]  This conserves  pancreatic juices  that would otherwise be lost. [ 2 ]  This surgery is performed by a pancreatic surgeon to avoid a life-threatening rupture of the pancreatic pseudocyst. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11643", "text": "Symptomatic pancreatic pseudocysts are an indication a cystogastrostomy needs to be performed.  Pancreatic pseudocysts are chronic collections of  pancreatic  fluid encased by a wall of nonepithelialized granulation tissue and  fibrosis . They can be caused by leakage of the  pancreatic duct , or as a result of inflammatory  pancreatitis . [ 4 ]  Symptoms of this include abdominal bloating, difficulty eating and digesting food, and constant pain or deep ache in the abdomen.  A lump can be felt in the middle or left upper abdomen if a pseudocyst is present.  To further diagnose a pancreatic pseudocyst an abdominal  CT scan ,  MRI  or  ultrasound  can be used. [ 5 ]   Emergency surgery may need to be performed if there is a rupture of the pseudocyst. This can be detected from symptoms of bleeding, shock, fainting, fever and chills, rapid heartbeat, or severe abdominal pain. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11644", "text": "Surgical repair is carried out through an  incision  in the abdomen. After locating the pseudocyst, it is attached to the wall of the stomach and the cystogastrostomy is created. Although it has a high success rate, it is infrequently used because of the recovery period. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11645", "text": "A relatively new and less-invasive method involving  endoscopic ultrasound  (EUS) guidance and  fluoroscopy . A large bore needle is used to access the identified pseudocyst, creating a  fistula  between the cystic cavity and either the stomach or the  duodenum . [ 6 ]  Plastic stents may be placed to facilitate drainage from the pseudocyst. [ 4 ]  The success rate of endoscopic treatment of pseudocysts may be greater than 70%. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11646", "text": "This method is the second of two less invasive surgeries used to drain pseudocysts and can be performed by a single surgeon because of the advanced tools. The pseudocyst is identified and accessed using  laparoscopic techniques . Once the pseudocyst cavity is located, it is entered and aspirated, and an opening is created into the stomach for drainage. Laparoscopic drainage may result in better cosmetic appearance and decreased pain following surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11647", "text": "Cystogastrostomy can lead to  pancreatic abscess [ 9 ]  and pancreatic duct leak. Stents can become blocked, leading to infection of the pseudocyst. [ 6 ]  Other complications include those normally associated with surgery and anesthesia, including bleeding. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11648", "text": "Jedlicka first described the procedure. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11649", "text": "Enterotomy  is the surgical incision into an intestine. It may be purposeful or a complication of an  abdominal surgery , such as exploratory  laparotomies  or  hernia repair . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11650", "text": "An enterotomy can be done to remove an obstruction or foreign body from the intestine. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11651", "text": "If an accidental enterotomy is not noticed during surgery, it can take days to become apparent. Surgical repair is required. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11652", "text": "Esophagogastric dissociation  is a surgical procedure that is sometimes used to treat  gastroesophageal reflux , mainly in neurologically impaired children. [ 1 ]  It has been suggested as an alternative to  Nissen fundoplication  for these cases. [ 2 ] [ 3 ]  Preliminary studies have shown it may have a lower failure rate [ 4 ]  and a lower incidence of recurrent reflux. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11653", "text": "An  exploratory  laparotomy  is a general surgical operation where the  abdomen  is opened and the abdominal  organs  are examined for injury or disease. It is the standard of care in various  blunt  and  penetrating  trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the  staging  of some cancers. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11654", "text": "During an exploratory laparotomy, a large  incision  is made vertically in the middle of the abdomen to access the  peritoneal  cavity, then each of the  quadrants of the abdomen  is examined. [ 1 ]  Various other maneuvers, such as the  Kocher maneuver , or other procedures may be performed concurrently. Overall operative mortality ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [ 3 ] [ 4 ] [ 5 ]  Recovery typically involves a prolonged hospital stay, sometimes in the  intensive care unit , and may include rehabilitation with one or more therapies. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11655", "text": "A database that tracks exploratory laparotomies performed in the United Kingdom estimates that about 30,000 are done across England and Wales each year out of a population of 59.5 million people. [ 6 ]  Reasons why a patient may require an exploratory laparotomy include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11656", "text": "A vertical cut, or  incision , is made in the middle of the abdomen. This midline incision extends from the  xiphoid process  at the bottom of the chest to the  pubic symphysis  at the bottom of the pelvis.  The fibrous tissue of the  linea alba , which separates the right and the left  abdominal muscles , serves as a guide for where to cut. After opening the  fascia , the abdominal cavity, or  peritoneum , is entered. The surgeon then looks for evidence of injury, infection, or disease. In trauma exploratory laparotomy, any immediate, life-threatening bleeding is first identified and controlled. In these cases, sponges are often packed in the spaces around the  liver  and the  spleen  to slow bleeding until a source can be found. This allows the surgeon to focus on one area at a time by removing the sponges from that  quadrant . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11657", "text": "A systematic approach is taken to examining the abdominal organs for disease. The  small bowel  is \"run\", or looked at segment by segment, along its entire length from the  ligament of Treitz  to the  terminal ileum . The  gastrocolic ligament  is incised and the  lesser sac  is explored, including the posterior  stomach  and the anterior  pancreas . The surfaces of the  spleen  and the  liver  also are examined for injury. [ 1 ]  If being performed for cancer staging, special attention will be paid during the exploratory laparotomy to the  lymph nodes , which may be  biopsied , or removed and assessed with a microscope or other special tests to see whether they contain cancerous cells indicative of cancer spread. [ 7 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11658", "text": "If necessary, several other surgical maneuvers or procedures may be performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11659", "text": "Based on where and what injury or disease is identified, one or more additional procedures may be performed during an exploratory laparotomy, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11660", "text": "Depending on the stability of the patient following an exploratory laparotomy, the abdomen may be sutured back together (\"primary closure\") or one or more tissue layers may be left open (\"open abdomen\") to facilitate further non-surgical  resuscitation . In cases where the abdomen is left open, a  vacuum dressing , a  saline bag , or towel clips may be placed to protect the internal organs until the patient is stable enough to return to the operating room for definitive closure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11661", "text": "The likelihood of death after an exploratory laparotomy depends on several factors including the age of the patient, injury or disease severity, other  comorbid  medical conditions, the skill of the surgeon, and what resources are available in the hospital. [ 6 ] [ 17 ]  Overall, the mortality rate typically ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [ 3 ] [ 4 ] [ 5 ]  It is lower for scheduled ( elective ) exploratory laparotomies, since patients are typically less sick and more optimized when procedures are able to be planned ahead of time. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11662", "text": "Like with any major surgery, a variety of  complications  may occur during and after an exploratory laparotomy. These include minor problems, such as  superficial skin infection  or  delayed bowel motility , and major problems, such as bleeding, blood clots in the  legs  or in the  lungs ,  stroke ,  deep intraabdominal infection  which can lead to  sepsis , and  reopening of the wound  due to a failure to heal properly. [ 17 ]  A minority of patients will require reoperation for complications of exploratory laparotomy. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11663", "text": "Most patients spend at least several days in the hospital after having an exploratory laparotomy, sometimes in the  intensive care unit , depending on the severity of the injury, infection, or disease. It can take weeks or months to heal completely. During the recovery period, there may be restrictions on activities such as driving, exercising, lifting, swimming, and showering. Depending on how long they were in the hospital, how severe their illness was, and whether they sustained other injuries or complications, some patients may require rehabilitation with  physical therapy ,  occupational therapy , or  speech-language pathology . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11664", "text": "Exploratory laparotomy originated as a technique for the treatment of acute trauma. In 1881, Dr.  George E. Goodfellow  performed the first documented exploratory laparotomy for a  ballistic injury , however the use of the procedure for blunt trauma has been described previously. [ 19 ]  In 1888, Dr. Henry O. Marcy first discussed using exploratory laparotomy as a means of diagnosing acute nontraumatic abdominal and pelvic problems at the 39th Annual Meeting of the American Medical Association, citing how improvements in safe surgical methods \"so greatly increased the utility of the operation\". [ 20 ]  Since the early 2000s, the opposite trend has been seen thanks to improvements in laboratory testing;  CT ,  MRI , and other  medical imaging ; and less invasive  laparoscopic  surgical techniques, all of which have made exploratory laparotomy less common for diagnostic purposes outside of the severe trauma setting. [ 21 ] [ 22 ] [ 8 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11665", "text": "A  gastrectomy  is a partial or total surgical removal of the  stomach ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11666", "text": "Gastrectomies are performed to treat  stomach cancer  and  perforations  of the stomach wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11667", "text": "For severe  duodenal ulcers , it may be necessary to remove the  lower portion of the stomach  and the  upper portion of the small intestine . If there is a sufficient portion of the upper duodenum remaining, a  Billroth I procedure  is performed, where the remaining portion of the stomach is reattached to the duodenum before the  common bile duct . If the stomach cannot be reattached to the duodenum, a  Billroth II  is performed, wherein the remaining portion of the duodenum is sealed off, a hole is cut into the next section of the small intestine (called the  jejunum ), and the stomach is reattached at this hole. As the pylorus is used to grind food and slowly release the food into the small intestine, removal of the pylorus can cause food to move into the small intestine faster than normal, leading to  gastric dumping syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11668", "text": "Also known as the Reichel\u2013Polya operation, this is a type of posterior gastroenterostomy which is a modification of the Billroth II operation [ 1 ]  developed by  Eugen P\u00f3lya  and  Friedrich Paul Reichel . It involves a resection of 2/3 of the  stomach  with blind closure of the duodenal stump, and a  retrocolic gastrojejunostomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11669", "text": "The most obvious effect of the removal of the stomach is the loss of a storage place for food while it is being digested. Since only a small amount of food can be allowed into the small intestine at a time, the patient will have to eat small amounts of food regularly in order to prevent  gastric dumping syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11670", "text": "Another major effect is the loss of the  intrinsic-factor -secreting  parietal cells  in the stomach lining. Intrinsic factor is essential for the uptake of  vitamin B 12  in the  terminal ileum , and without it the patient will develop a  vitamin B 12  deficiency . This can lead to a type of  anaemia  known as  megaloblastic anaemia  (can also be caused by  folate deficiency , or  autoimmune disease  where it is specifically known as  pernicious anaemia ) which severely reduces red-blood cell synthesis (known as  erythropoiesis , as well as other haematological  cell lineages  if severe enough but the red cell is the first to be affected). This can be treated by giving the patient direct injections of vitamin B 12 .   Iron-deficiency anemia  can occur as the stomach normally converts iron into its absorbable form. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11671", "text": "Another side effect is the loss of  ghrelin  production, which has been shown to be compensated after a while. [ 3 ]  Lastly, this procedure is post-operatively associated with decreased bone density and higher incidence of bone fractures.  This may be due to the importance of gastric acid in  calcium  absorption. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11672", "text": "Post-operatively, up to 70% of patients undergoing total gastrectomy develop complications such as dumping syndrome and reflux esophagitis. [ 5 ]  A meta-analysis of 25 studies found that construction of a \"pouch\", which serves as a \"stomach substitute\", reduced the incidence of dumping syndrome and reflux esophagitis by 73% and 63% respectively, and led to improvements in quality-of-life, nutritional outcomes, and body mass index. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11673", "text": "After Bilroth II surgery, a small amount of residual gastric tissue may remain in the duodenum. The alkaline environment causes the retained gastric tissue to produce acid, which may result in ulcers in a rare complication known as  retained antrum syndrome ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11674", "text": "All patients lose weight after gastrectomy, although the extent of weight loss is dependent on the extent of surgery (total gastrectomy vs partial gastrectomy) and the pre-operative BMI.  Maximum weight loss occurs by 12 months and many patients regain weight afterwards. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11675", "text": "The first successful gastrectomy was performed by  Theodor Billroth  in 1881 for cancer of the stomach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11676", "text": "Historically, gastrectomies were used to treat  peptic ulcers . [ 7 ]   These are now usually treated with  antibiotics , as it was recognized that they are usually due to  Helicobacter pylori  infection or chemical imbalances in the gastric juices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11677", "text": "In the past a gastrectomy for peptic ulcer disease was often accompanied by a  vagotomy , to reduce acid production.  This problem is now managed with  proton pump inhibitors ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11678", "text": "Gastroduodenostomy  is a surgical procedure where the doctor creates a new connection between the  stomach  and the  duodenum . [ 1 ]  This procedure may be performed in cases of  stomach cancer  or in the case of a malfunctioning  pyloric valve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11679", "text": "A  gastroenterostomy  is the surgical creation of a connection between the  stomach  and the  jejunum . The operation can sometimes be performed at the same time as a partial  gastrectomy  (the removal of part of the stomach). Gastroenterostomy was in the past typically performed to treat  peptic ulcers , but today it is usually carried out to enable food to pass directly to the middle section of the  small intestine  when it is necessary to bypass the first section (the  duodenum ) because of duodenal damage. The procedure is still being used to treat  gastroparesis  that is  refractory  to other treatments, but it is now rarely used to treat peptic ulcers because most cases thereof are bacterial in nature (due to  Helicobacter pylori ) and there are many new drugs available to treat the  gastric reflux  often experienced with peptic ulcer disease. Reported cure rates for  H. pylori  infection range from 70% to 90% after  antibiotic treatment . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11680", "text": "Gastropexy  is a  surgical operation  in which the  stomach  is  sutured  to the  abdominal wall [ 1 ]  or the  diaphragm . Gastropexies in which the stomach is sutured to the diaphragm are sometimes performed as a treatment of  GERD  to prevent the stomach from moving up into the chest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11681", "text": "A  Graham patch  is a  surgical technique  that is used to close  duodenal perforations . A piece of  omentum  is used to cover the perforation. This patch is typically used for holes with a size of 5mm or less. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11682", "text": "An appropriately-sized tongue of tension-free, well-vascularized omentum is used to plug the perforation. The omental patch is held in place by interrupted  sutures  placed through healthy  duodenum  on either side of the perforation. Once the patch is secure, the seal can be tested by submerging the site under irrigation fluid and injecting air into the patient's  nasogastric tube . The absence of air bubbles indicates that the seal is intact. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11683", "text": "Hassab's decongestion operation  is an elective  surgical procedure  to treat  esophageal varices  in patients with  portal hypertension  as a result of  cirrhosis  of the  liver . It was created by Dr.  Mohammed Aboul-Fotouh Hassab , a professor of surgery at  Alexandria University  in  Egypt ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11684", "text": "The approach is abdominal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11685", "text": "Heineke\u2013Mikulicz Strictureplasty  is the most common among the conventional  strictureplasties . Emmanuel Lee introduced this strictureplasty for the treatment of  Crohn's disease  in 1976. [ 1 ]  A similar technique for tubercular strictures of the terminal ileum was reported by RN Katariya et al. in 1977 [ 2 ]  This technique is similar to a Heineke\u2013Mikulicz  pyloroplasty  from which it derives its name. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11686", "text": "The technique is optimal to address short strictures (\u22647\u00a0cm). This technique is performed by making a longitudinal incision on the antimesenteric side of the bowel, extending from 2\u00a0cm proximal to 2\u00a0cm distal to the stricture. [ 3 ]  The  enterotomy  is then closed in a transverse fashion in one or two layers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11687", "text": "Strictureplasties  are categorized into three groups: Conventional, intermediate, and complex procedures. The Heineke\u2013Mikulicz strictureplasty is the most common among the conventional stricutreplasties, the  Finney strictureplasty  is the most common intermediate strictureplasty, and the most common complex strictureplasty is the  Michelassi strictureplasty . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11688", "text": "Heller myotomy  is a  surgical  procedure [ 1 ]  in which the  muscles  of the  cardia  ( lower esophageal sphincter  or LES) are cut, allowing food and liquids to pass to the  stomach .  It is used to treat  achalasia , a disorder in which the lower esophageal  sphincter  fails to relax properly, making it difficult for food and liquids to reach the stomach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11689", "text": "It was first performed by Ernst Heller (1877\u20131964) in 1913.  Then and until recently, this surgery was performed using an open procedure, either through the chest ( thoracotomy ) or through the abdomen ( laparotomy ).  However, open procedures involve greater recovery times. [ 2 ]  Modern Heller myotomy is normally performed using  minimally invasive   laparoscopic  techniques, which minimize risks and speeds recovery significantly. The 100th anniversary of Heller's description of the surgical treatment of patients with achalasia was celebrated in 2014. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11690", "text": "During the procedure, the patient is put under  general anaesthesia . Five or six small incisions are made in the  abdominal wall  and laparoscopic instruments are inserted.  The myotomy is a lengthwise cut along the  esophagus , starting usually about 6 cm above the lower esophageal sphincter and extending down onto the stomach approximately 2-2.5 cm.  The oesophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact. This procedure can also be performed robotically."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11691", "text": "There is a small risk of perforation during the myotomy.  A gastrografin swallow is performed after the surgery to check for leaks.  If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11692", "text": "Food can easily pass downward after the myotomy has cut through the lower oesophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial  fundoplication  to reduce the incidence of postoperative  acid reflux .  In Dor or anterior fundoplication, [ 4 ]  which is the most common method, part of the stomach (the  fundus ) is laid over the front of the oesophagus and stitched into place so that whenever the stomach contracts, it also closes off the oesophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the oesophagus instead.  Nissen or complete  fundoplication  (wrapping the fundus all the way around the oesophagus) is generally not considered advisable because  peristalsis  is absent in achalasia patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11693", "text": "This is a somewhat challenging operation, and surgeons have reported improved outcomes after their first 50 patients.  An author search at  Google Scholar  can be used to find studies on a surgeon's past experience with achalasia patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11694", "text": "After laparoscopic surgery, most patients can take clear liquids later the same day, start a  soft diet  within 2\u20133 days, and return to a normal diet after one month.  The typical hospital stay is 2\u20133 days, and many patients can return to work after two weeks.  If the surgery is done open instead of laparoscopically, patients may need to take a month off work.  Heavy lifting is typically restricted for six weeks or more."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11695", "text": "The Heller myotomy is a long-term treatment, and many patients do not require any further treatment. However, some will eventually need  pneumatic dilation , repeat myotomy (usually performed as an open procedure the second time around), or  oesophagectomy .  It is important to monitor changes in the shape and function of the esophagus with an annual timed  barium swallow .  Regular  endoscopy  may also be useful to monitor changes in the tissue of the oesophagus, since reflux may damage the oesophagus over time, potentially causing the return of  dysphagia , or a  premalignant condition  known as  Barrett's esophagus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11696", "text": "Though this surgery does not correct the underlying cause and does not eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink.  It is considered the definitive treatment for achalasia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11697", "text": "Hemorrhoidal artery embolization  (HAE, or hemorrhoid artery embolization) is a non-surgical treatment of internal  hemorrhoids. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11698", "text": "The procedure involves blocking the abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or  microparticles  to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding. [ 2 ]  It is a  minimally invasive therapy  that can be performed as an outpatient procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11699", "text": "HAE begins when a  catheter  is inserted into the femoral or radial artery through a small incision. The catheter is then carefully navigated through the arterial system with  x-ray  guidance until it reaches the branches of the  superior rectal artery  that supply blood to the hemorrhoidal plexus. [ 3 ]  Once in position,  microparticles  and/or microcoils are injected through the catheter to block these arteries, thereby reducing the blood supply to the hemorrhoids. This causes the hemorrhoidal tissue to shrink over time, alleviating symptoms such as pain, bleeding, and swelling. [ 1 ] [ 2 ] [ 4 ]  Post-procedure, patients are monitored for a brief period to ensure stability before being discharged with instructions for managing any minor discomfort or symptoms that may occur during the recovery period."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11700", "text": "HAE offers several benefits as a minimally invasive treatment for symptomatic hemorrhoids. Firstly, HAE effectively reduces blood flow to the hemorrhoidal tissue, leading to significant shrinkage and resolution of symptoms such as pain, bleeding, and prolapse. [ 2 ] [ 4 ]  This approach has been shown to provide long-lasting relief comparable to surgical methods but with potentially lower complication rates and faster recovery times. [ 5 ]  Additionally, HAE is associated with minimal post-procedural pain and allows for quicker return to daily activities, making it an attractive option for patients seeking less invasive treatment options. [ 5 ]  Moreover, its safety profile and efficacy have been supported by clinical trials, demonstrating its potential as a preferred alternative for managing hemorrhoidal disease. [ 6 ] [ 7 ] [ 8 ]  HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11701", "text": "The incidence of adverse events with HAE is very low. Rare arterial access site complications may occur. [ 2 ]   Although minor anal discomfort can occur in a minority of patients, there have been no reports of anorectal complications when embolization is performed primarily with microcoils [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11702", "text": "Hernia repair  is a  surgical operation  for the correction of a  hernia \u2014a bulging of  internal organs  or  tissues  through the  wall  that contains it. It can be of two different types:  herniorrhaphy ; or  hernioplasty . [ 1 ]  This operation may be performed to correct hernias of the  abdomen ,  groin ,  diaphragm ,  brain , or at  the site of a previous operation . Hernia repair is often performed as an  ambulatory procedure ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11703", "text": "The first differentiating factor in hernia repair is whether the surgery is done open, or laparoscopically. Open hernia repair is when an incision is made in the skin directly over the hernia. Laparoscopic hernia repair is when minimally invasive cameras and equipment are used and the hernia is repaired with only small incisions adjacent to the hernia. These techniques are similar to the techniques used in laparoscopic gallbladder surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11704", "text": "An operation in which the hernia sac is removed without any repair of the  inguinal canal  is described as a herniotomy. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with  autogenous  (patient's own tissue) or  heterogeneous  material such as  prolene  mesh, it is termed hernioplasty as opposed to herniorrhaphy, in which no autogenous or heterogeneous material is used for reinforcement. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11705", "text": "The Stoppa procedure is a  tension -free type of hernia repair. It is performed by wrapping the lower part of the  parietal peritoneum  with  prosthetic  mesh and placing it at a  preperitoneal  level over Fruchaud's myopectineal  orifice . It was first described in 1975 by Rene Stoppa. [ 2 ]  This operation is also known as \"giant prosthetic reinforcement of the  visceral   sac \" (GPRVS). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11706", "text": "This technique has met particular success in the repair of bilateral hernias, large  scrotal hernias , and recurrent or rerecurrent hernias in which conventional repair is difficult and which carries a high  morbidity  and failure rate. [ 4 ]  The most recent reported recurrence rate (involving 230 patients with 420 hernias and a maximum of 8 years follow-up) was 0.71%. [ 5 ]  The totally extra-peritoneal repair (TEP) uses exactly the same principles as the Stoppa repair, except that it is performed  laparoscopically . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11707", "text": "Robotic-assisted hernia repair has gained popularity due to its precision, smaller incisions, and quicker recovery times. Using robotic systems, surgeons have greater flexibility and control during the procedure. Although its use is still more expensive and requires specialized equipment, early studies suggest that robotic hernia repair may offer improved outcomes in complex cases, such as large or recurrent hernias. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11708", "text": "A  Hill repair  is an anti- acid reflux  procedure. [ 1 ]   It is similar to the  Nissen fundoplication .  Though far less common owing to a greater degree of difficulty, studies indicate a similar rate of efficacy.  It is performed almost exclusively in the  Pacific Northwest . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11709", "text": "The  Hofmeister\u2013Finsterer operation  is a partial  gastrectomy , devised by  Franz von Hofmeister , based upon a procedure by  Eugen P\u00f3lya . It was later refined by  Hans Finsterer  and became known as the Hofmeister\u2013Finsterer gastrectomy.\nHere upper part of the cut end of the stomach is closed and remaining lower portion is anastomosed with jejunum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11710", "text": "In  medicine , the  ileal pouch\u2013anal anastomosis  ( IPAA ), also known as  restorative proctocolectomy  ( RPC ),  ileal-anal reservoir  ( IAR ), an  ileo-anal pouch ,  ileal-anal pullthrough , or sometimes referred to as a  J-pouch ,  S-pouch ,  W-pouch , or a  pelvic pouch , is an  anastomosis  of a reservoir pouch made from  ileum  (small intestine) to the  anus , bypassing the former site of the  colon  in cases where the colon and rectum have been removed. The pouch retains and restores functionality of the anus, with stools passed under voluntary control of the person, preventing  fecal incontinence  and serving as an alternative to a total proctocolectomy with  ileostomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11711", "text": "During a total proctocolectomy, a surgeon removes a person's diseased colon, rectum, and anus. [ citation needed ]   For the ileostomy, the end of the small intestine is brought to the surface of the body through an opening in the abdominal wall for waste to be removed.  People with ileostomies wear an external bag, also known as an  ostomy system  or stoma appliance, to collect waste which can be emptied and changed as needed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11712", "text": "With an optional ileo-anal pouch procedure, the pouch component is a surgically constructed internal intestinal reservoir; usually situated near where the  rectum  would normally be. It is formed by folding loops of small intestine (the  ileum ) back on themselves and stitching or stapling them together. The internal walls are then removed thus forming a reservoir often referred to as a 'pouch'. The reservoir is then stitched or stapled into anal area where the bottom of the rectum was.  The first pouch anal-anastomosis surgery in the world was performed by British surgeon  Sir Alan Parks  in 1976 at the London Hospital (called the  Royal London Hospital  since 1990).  After the first surgery, he continued to develop the procedure at  St Mark's Hospital  in London along with his colleague  John Nicholls . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11713", "text": "Pouch surgery is elective, meaning it is entirely optional, and should be done on the basis of choice by people who doctors deem suitable for a pouch after medical evaluations.  Pouch surgery is considered reconstructive with the benefit being for quality of life and not disease removal, similar in theory to a breast reconstruction after a mastectomy removes diseased breast tissue.  Before a pouch is created, a person's diseased colon and rectum are removed.  After disease removal, standard medical screening exams for pouch candidates include but are not limited to biopsies, radiology imaging, sphincter function tests, fertility consultations for people of childbearing age with the wish to get pregnant, and psychological support due to intensity of the pouch operations. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11714", "text": "A similar ileal pouch without the anal anastomosis is a  Kock pouch .  A Kock pouch is also called a 'continent ileostomy' because while a person has a pouch constructed inside their body, it is located near the abdominal wall and empties via a stoma from the ileum at the person's convenience. [ 3 ]   A Kock pouch does not restore the anal function.  The procedure was first premiered by Finnish surgeon  Nils Kock  in Sweden during 1969.  It was an evolution in bowel surgery because it created an ileum pouch for storage of waste inside the body eliminating the need for an external bag for waste collection.  An  ileostomy  without a Kock pouch functions constantly, meaning, a patient with ileostomy by itself is incontinent because waste is always moving down the bowel and thus the need for an external appliance bag.  Kock pouch surgery is also elective surgery that only provides a reconstructive benefit after disease removal.  It should be the patient's optional choice based on how a person wants to live their life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11715", "text": "Ileo-anal pouches are constructed for people who have had their  colon  and  rectum  surgically removed due to disease, injury, or infection. Several diseases and conditions may trigger the need for surgical removal. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11716", "text": "There is debate about whether patients with  Crohn's disease  and  indeterminate colitis  are suitable candidates for an ileo-anal pouch due to the risk of the disease occurring in the pouch. Crohn's disease can manifest in many different parts of the digestive tract, so the removal of the colon and creation of a pouch, while alleviating symptoms that occurred in the large intestine plus possibly the rectum, does not eliminate Crohn's disease. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11717", "text": "Additional contradictions that may prevent a person from being able to undergo pouch surgery include but are not limited to weak sphincter muscles, advanced age (elderly) due to the higher risk of fecal incontinence, pelvic radiation therapy, and women with a history of obstetric complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11718", "text": "Ileum pouch surgery (Kock and IPAA) are  reconstructive procedures .  Reconstructive procedures do not cure disease.  Since they are not  curative , reconstructive surgeries are not medically necessary, meaning they are elective operations.  Several words can be used to describe an ' elective surgery ' including optional and patient's choice.  Pouch reconstruction should never be offered as the only option to a person because it is elective and should be a voluntary choice offered alongside other options that are safe for the person's individual circumstances. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11719", "text": "While both  ulcerative colitis  (UC) and  familial adenomatous polyposis  (FAP) patients and are sometimes controversially considered cured of problematic symptoms after pouch creation due to the removal of disease activity in the colon and rectum, there are still many complications that can arise. While life with a pouch is typically viewed by some people plus some medical professionals as a significant improvement compared to life with an ileostomy, patients living with a pouch may still face daily pains and discomforts including the inability to sleep through the night, a changed diet, severe or frequent gas pain, nutrient deficiencies, and the inability to digest certain foods."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11720", "text": "With regards to  ulcerative colitis  (UC), the disease is a systemic  immune mediated inflammatory disease , also often referred to as an  autoimmune  condition. [ 10 ]   The main risk UC presents is typically inflammation that causes ulcers in the lining of the colon and rectum.  This common expression happens in the mucosal layer of the intestine that is only present in the colon and rectum (not the small intestine), which is why the disease was named 'ulcerative colitis'.  Therefore, ulcerative colitis is considered 'cured' of the problematic disease activity in the colon and rectum only, after both the large intestine and rectum are removed.  Reasons to remove this mucosal layer include severe discomfort that reduces quality of life, bowel perforation from inflammation, and development of tumors that are cancerous from long-term inflammation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11721", "text": "Even after a person has their colon and rectum removed, the circumstances that created ulcerative colitis still lives on inside that person's body because it is a systemic  immune mediated  condition.  These conditions occasionally manifest in other ways including additional illnesses considered related to ulcerative colitis like  primary sclerosing cholangitis  (PSC) in the liver, the eye condition  uveitis , and certain forms of  arthritis  throughout the body."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11722", "text": "It is important to understand that pouch surgery does not cure a patient of ulcerative colitis, removal of the diseased mucosal layer in the colon and rectum cures the disease in the colon and rectum only, if the entire colon and full rectum are removed.  For example, if a rectal remnant remains, UC disease can be retained in the small remnant.  Active disease feels similar to ulcerative proctosis when the full natural rectum was in place.  It is also medically treated the same way ulcerative proctosis was before any surgery.  Even if the entire colon and rectum are removed to stop disease activity in this area, the underlying reasons for the expression of the disease in the large bowel and rectum's mucosal layer remain with the person. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11723", "text": "A pouch should never be offered as the only treatment option due to the fact it is  reconstructive  and not  curative .  People who need to have their colon and rectum removed are usually presented with several options including total proctocolectomy with end ileostomy (\"Barbie\" or \"Ken\" butt), colectomy with rectum left in place, pelvic pouch (ileo-anal pouch / IPAA), ileo-rectum anastomosis (IRA), or continent ileostomy such as a Kock pouch, for example, if someone has weak  sphincter  muscles or a diseased anus.  The end decision should always be the patient's choice, based on if their health permits the option to have a good outcome. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11724", "text": "Pouch surgery comes with a number of well known complications that a person will not be able to imagine as possibilities themselves, therefore, as part of the education and  informed consent  process before pouch creation surgery is scheduled, risks, complications, and safe alternatives need to be communicated. [ 14 ] [ 15 ]   If a person has  indeterminate colitis , they should also be informed before a pouch is recommended and created that their pathology is unknown due to the even higher risk indeterminate folks face. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11725", "text": "The most common complication of pouch surgery is an umbrella term called pouchitis that encompasses many causes of inflammation of the pouch.  The word 'pouchitis' simply means 'pouch inflammation' similar to 'tonsillitis' meaning 'tonsil inflammation' or 'sinusitis' meaning 'sinus inflammation'.  While ulcerative colitis pouch patients may experience a dysbiosis sparked type of inflammation more than people who get a pouch because of cancer or FAP, pouchitis can be caused by a number of factors in any pouch. [ 18 ]   Pouchitis is grouped into four main categories of origin: inflammatory, mechanical, surgical, or functional.  Pouchitis, meaning pouch inflammation from various root causes, can be a driver of pouch dysfunction for some. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11726", "text": "The surgical procedure for forming an ileal pouch-anal anastomosis (IPAA) was pioneered by  Sir Alan Parks  at the London Hospital, today called the  Royal London Hospital , in 1976."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11727", "text": "Parks' pouch surgery was originally envisioned as a quality of life enhancing procedure for people who needed to have their colon and rectum removed.  People who opted to have the procedure would be able to avoid an ileostomy by restoring intestinal continuity with elective, or optional, ileo-anal pouch surgery.  Shortly after performing the world's first few pouch procedures in 1976, Sir Alan along with  John Nicholls  joined  St Mark's Hospital  also in London where they continued to develop the intestinal pouch procedure.  The pair first published details of the procedure in the  British Medical Journal  in 1978 with the article \"Proctocolectomy without ileostomy for ulcerative colitis\". [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11728", "text": "Sir Alan Parks' ileo pouch-anal anastomosis (IPAA), was a surgical advancement from the ileoanal anastomosis procedure developed in the 1940s.  With an ileum-anal anastomosis, the entire colon and rectum were removed.  Next a surgical join (anastomosis) was used to connect the end of the small intestine (ileum) to the anus.  It was described by the German surgeon Nissen in 1934 and American surgeons Ravitch and Sabiston in 1947.  The ileum-anal anastomisis [ check spelling ]  was reported to have a high of frequency of liquid movements making it uncomfortable for many people. [ 21 ]   It was also a surgical advancement from the  Kock pouch  first performed in Sweden by Finnish surgeon  Nils Kock  in 1969 because Parks' ileum pouch-anal anastomosis (IPAA), unlike Kock's 'continent ileostomy' allowed for restoration of anal evacuation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11729", "text": "The original Sir Alan S-pouches had a bit of intestine at the bottom of the design that often made them difficult to evacuate.  Some patients later underwent advancement surgery to remove the extra tip of small intestine and lower the pouch directly onto the anus to remedy evacuation difficulties. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11730", "text": "In 1980, surgeons in Japan published the first study on the J-shaped pouch. J. Utunomiya is created with its creation. [ 23 ]   The J-shaped pouch design eliminated the 'conduit' or bit of intestine at the bottom of Sir Alan Parks' S-pouch formation making it easier for people to empty a J-pouch.  As intestinal pouch surgery became more common, the J-pouch eventually became the dominant shape.  J-pouches are easier for surgeons to construct than the hand sewn S or W formations because the Js are from two loops of ileum plus with the invention of the stapler, Js could be stapled, instead of hand-sewn.  J-pouches are considered faster and easier to make over Ss and Ws. [ 24 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11731", "text": "The same year as Sir Alan Parks' unexpected death in 1982, his St Mark's Hospital colleague,  John Nicholls  premiered the W-pouch which was an augmentation of the J-pouch made to expand the pouch's capacity and reduce the person's frequency of bowel movements. [ 26 ]   Nicholls' W-pouch is explained as two J-pouches placed together to make the higher capacity W-pouch."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11732", "text": "The W-pouch was entirely hand-sewn and required a very experienced and highly skilled surgeon plus more time in the operating room. [ 27 ] [ 28 ]   A J-pouch was not as technical and therefore, more surgeons could perform the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11733", "text": "In the United States, Australian born colorectal surgeon  Victor Warren Fazio  was a driving force behind the procedure's adaptation into American colorectal surgery offerings.  He established the  Cleveland Clinic 's prestigious pouch practice in 1983 when the clinic performed its first pouch surgery.  In 2002 the Cleveland Clinic opened the world's first pouch center with its \"Ileal Pouch Center\"."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11734", "text": "About the same time as the Cleveland Clinic began offering the restorative proctocolectomy procedure (RPC), surgeons at the  Mayo Clinic  in Minnesota also started offering it to suitable patients including Roger R. Dozois who published several early studies on the pouch operation in the United States. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11735", "text": "By the early 1980s, the ileal pouch procedure had become part of specialist colorectal surgical practices not just in the United Kingdom and United States but worldwide.  Following the unexpected death of  Sir Alan Parks  in 1982, his colleague  John Nicholls  along with the pouch surgery team at  St Marks Hospital  collaborated with a number of leading hospitals globally to share pouch surgery knowledge Zane Cohen is credited with being a leader in Canada's development of pouch surgery. [ 31 ] [ 32 ]  Rolland Parc was a force behind its early evolution in France. [ 33 ]  Gilberto Poggioli is credited with being at the forefront of establishing the pouch a surgical offering in Italy. [ 34 ] [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11736", "text": "It is generally considered best practice to create and manage ileum pouches at a facility that has specialized and experienced clinicians specifically for intestinal pouch care.  Individual doctors and facilities can communicate their level of pouch experience to potential pouchees, people already living with a pouch interested in continued care, or loved ones who care for a person eligible for pouch construction surgery, or for loved ones already with a pouch.  Colorectal ,  coloproctology , and/or  proctology surgeons  should be able to communicate their pouch surgery success and failure rates.  Gastroenterologists  and surgeons should also be able to refer people to pouch specialists for a second opinion on an existing recommendation or for continued pouch care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11737", "text": "Intestinal pouches are considered optional reconstructive procedures to be done by the patient's choice since pouch surgery itself does not cure disease.  Pouch surgery can only take place after disease is removed.  Many national gastroenterology associations including the  British Society of Gastroenterology  (BSG) [ 37 ]  and the European Crohn's and Colitis Organisation (ECCO) [ 38 ]  recommend that pouches should ideally be created at facilities that have specialized pouch centers when possible due to the high level of technical skill required for multidisciplinary management of a pouch.  Numerous studies also show that there is a direct relation between the success of a pouch and the experience a surgeon has with previous pouch creations. [ 39 ] [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11738", "text": "In addition to specialized doctors for colorectal surgery, gastroenterology, pathology, radiology, gynecology and urology, fertility, psychology, nutrition, and rehabilitation including physiotherapy, facilities with pouch centers often also have a specialized pouch nurse or pouch nursing team.  The pouch nurse is usually an extension of the IBD nursing team or stoma nurse team.  However, pouch nurses are also trained for pouches created from injury, infection, FAP, cancer and other reasons.  Pouch nurses provide healthcare, advice, and support specific to the concerns of pouch patients before and after surgery. [ 41 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11739", "text": "In this elective and reconstructive  surgical procedure , a pouch, or intestinal reservoir, made from  ileum  (small intestine) is attached to the  anus  after the  colon  (large intestine) and  rectum  have been removed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11740", "text": "The entire procedure can be performed in one operation, but is usually split into two or three procedures based on the person's overall health at the time of surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11741", "text": "If a colectomy is planned, and not done as an emergency due to severe injury or illness and the person is in good health, some surgeons will recommend a two-step procedure.  When done as a two-step, the first operation (step one) involves a  proctocolectomy  (removal of the large intestine and rectum), and fashioning of the pouch. The patient is given a temporary defunctioning  ileostomy  (also known as a \"loop ileostomy\"). After a healing period determined by the surgeon based on the individual patient, the second step is performed, in which the ileostomy is reversed. This step is referred to as ileostomy reversal or takedown.  The reason for the temporary ileostomy is to allow the newly constructed pouch to fully heal without waste passing through it, thus avoiding leaks that can lead to infection. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11742", "text": "When a colectomy is performed as an emergency (which can arise from  toxic megacolon  and other complications including infection), or when the patient is extremely ill, the colectomy and pouch construction are performed in separate stages, resulting in a three-part surgery. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11743", "text": "Outside of serious illness, some surgeons also prefer to perform a  subtotal colectomy  (removing all the colon except the  rectum ) first, since removal of the rectum can lead to complications with the anal  sphincters . After the subtotal colectomy, the second operation consists of pouch creation with installation of a double or loop ileostomy to protect the pouch while it heals.  Waste continues to exit through an opening in the abdominal wall.  Then usually three to six months later when surgeons feel the pouch has healed, the loop stoma is reversed and the pouch becomes fully operational restoring intestinal continuity. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11744", "text": "Just as debate continues on which formation of pouch functions best, there is also an ongoing discussion about the pouch's type of anal anastomosis - or method used to attach the pouch to the anal canal.  Both methods have risks and benefits."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11745", "text": "The pouch can also be formed as part of a three step procedure for people of childbearing age who have not completed their family planning.  When there is a wish for pregnancy, the process can be paused after subtotal colectomy until family planning is complete if doctors feel remaining disease in the rectum, if any, can be safely managed until removal during pouch creation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11746", "text": "A fall in female fertility was reported in a Danish study by Olsen et al. in 1999 showing a drop after pouch surgery to less than 50% of the normal population. [ 51 ]   There are well researched risks to fertility for both men and women.  Highly specialized pouch centers globally typically offer fertility counselling as part of their patient selection and informed consent process. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11747", "text": "A rare risk to male fertility is nerve damage that impairs or prevents ejaculation.  Risks to fertility for women include removal of the rectum reducing fertility by at least 50%, a dysfunctional pouch sparking a hostile environment in the pelvis preventing embryo implementation in the uterus and scar tissue formation over fallopian tubes blocking ovulation, although, scar tissue formation appears to be less likely with laparoscopic than open surgery. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11748", "text": "Women who choose the option to undergo pouch surgery before childbirth, should also undergo a fertility evaluation before surgery that includes an egg preservation consultation especially if she is over the age of 35 years.  With the pouch surgery potentially reducing fertility, the  in vitro  fertilization  (IVF) treatment a younger woman experiencing pouch related infertility may need to rely on to conceive, may not legally be available to the older woman if she later learns past the cutoff-age that her situation requires IVF to get pregnant.  Most women are not aware of age limits to IVF treatment using their own eggs - especially if they are living, studying, or working away from their hometown or abroad at the time of their operations. [ 54 ] [ 55 ] [ 56 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11749", "text": "The general public's lack of widespread knowledge about IVF regulations also applies to child adoption laws.  Most men and women are not aware that some countries place age bans on adopting newborns.  For example, in Germany adoption of an infant is prohibited if a parent is over the age of 40 years.  These adoption age bans combined with the risk of pouch related fertility complications, plus potential IVF age cut-off limits then increases the need for a person to plan to preserve fertility before pouch surgery commences in order to improve chances of later completing a wish for a family. [ 58 ] [ 59 ] [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11750", "text": "While most people who undergo elective reconstructive pouch surgery have either no issues or occasional minor discomfort, some pouches experience more serious complications that need medical management with a variety of therapies including medication and/or additional surgery. \n [ 61 ] [ 62 ] [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11751", "text": "Pouchitis  is a general term that refers to a wide spectrum of diseases and conditions that cause inflammation of the pouch. It is a common complication after IPAA/RPC. People report many symptoms including abdominal pain or cramps, increased bowel frequency, urgency of movements, strong evacuation urges, daytime incontinence, nocturnal seepage, and/or rectal bleeding. Studies show pouchitis occurs more often in people who got their pouch because of ulcerative colitis rather than familial adenomatous polyposis (FAP) which suggests that the pathogenic (microbial) background of UC may contribute to the development of pouchitis in some pouches. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11752", "text": "Diagnosis of pouchitis: \nPouchitis is diagnosed based on the presence of symptoms together with endoscopic and histological evidence of pouch inflammation. For example, biopsies may be taken during a pouchoscopy (a camera exam like a colonoscopy but for the pouch) to rule out infection from  Clostridioides difficile  infection  (C-diff) or  Cytomegalovirus  (CMV). Treatment of infections usually begins with antibiotics and may also include multi-strain probiotics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11753", "text": "After exams and tests, pouchitis is divided into two categories based on findings: idiopathic or secondary. In idiopathic pouchitis, the cause of inflammation is still unclear. With secondary pouchitis, there is an association with a specific causative or pathogenetic factor. Secondary pouchitis can be classified into subgroups. It is possible to have one or more causes of pouch inflammation at the same time. [ 64 ] [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11754", "text": "Antibiotic therapy for pouchitis: \nStandard treatment of pouchitis when first reported (acute pouchitis) without any other obvious cause identified such as infection or anal join leak (fistula) is oral antibiotics for two weeks, typically ciprofloxacin 500\u00a0mg every 12 hours.  Alternatives to ciprofloxacin for initial therapy include metronidazole 500\u00a0mg (twice daily) or tinidazole 500\u00a0mg (twice daily). [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11755", "text": "For pouches with acute idiopathic pouchitis, response to antibiotic therapy is typically examined clinically by asking the patient if they have experienced an improvement with their symptoms plus looking endoscopically using a pouchoscopy after completing antibiotic therapy. While endoscopic mucosal healing may lag behind symptomatic improvement, mucosal healing is a treatment target for patients with pouchitis. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11756", "text": "Cuffitis: \nCuffitis is inflammation of the retained rectal 'cuff' usually in a stapled pouch-anal anastomosis or the spot where the intestinal pouch was attached to the anus to restore anal evacuation.  Symptoms are typically similar to ulcerative proctosis for ulcerative colitis pouches including burning in the anal canal, a change in bowel movements, and sometimes rectal bleeding. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11757", "text": "Cuffitis diagnosis: \nMost expert pouch centers plus national gastroenterology society guidelines worldwide recommend a cuff be no longer than 2\u00a0cm with the aim to staple the pouch at the level of the anorectal junction, [ 48 ] [ 68 ]  leaving about 1\u00a0cm of rectum or mucus layer behind for the staple to attach the pouch to the anus. [ 69 ] [ 67 ] [ 70 ]   This retained 1 to 2\u00a0cm of rectum can therefore, sometimes retain ulcerative colitis in UC pouches.  In contrast, hand sewn pouch-anal anastomosis' typically do not retain any mucus layer but sometimes a cuff is also used and it might cause discomfort for some hand sewn pouches.  Cuffitis is clinically diagnosed by symptoms plus endoscopically (pouchoscopy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11758", "text": "Treatment of cuffitis: \nFirst-line therapy for acute cuffitis due to retained rectal mucosal layer is usually similar to the treatment for ulcerative proctosis that ulcerative colitis patients would have likely used before pouch surgery.  Mesalazine  suppositories or enemas are sometimes prescribed first (brand names include Asacol, Canasa, and Pentasa).  If those do not provide enough relief then treatment might be escalated to corticosteroid suppositories or enemas such as Budesonide.  Biological therapy may be prescribed if all other medical therapies fail to manage cuffitis and the person either is not suitable for or does not want to undergo a revision operation to remove the retained cuff and hand sew the pouch on the level of the dentate line (spot where anal skin changes to rectal mucus layer). [ 67 ] [ 71 ] [ 72 ] [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11759", "text": "Crohn's disease of the pouch: \nSome people undergoing IPAA/RPC may be later diagnosed with underlying Crohn's disease because the disease likely had not fully expressed itself at the time of surgery.  Crohn's disease of the pouch is associated with high failure rates.  Pouches may experience fistula leaks that cause pelvic sepsis and other complications. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11760", "text": "Treatment of Crohn's disease of the pouch: \nIf a person later diagnosed with Crohn's disease of the pouch wishes to keep their pouch operational, in some circumstances medical management might be possible.  Typically this is done with the prescription of biologics.  It may take more than one drug prescription to find a suitable biologic that encourages the desired anti-inflammatory response."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11761", "text": "Celiac disease: \n Celiac disease  is an autoimmune condition that causes inflammation in the small intestine after gluten is eaten.  It can cause pouchitis symptoms and discomfort.  Some pouches that are celiac initially get misdiagnosed with Crohn's of the pouch.  Celiac disease is typically diagnosed by biopsy of the pouch. [ 75 ] [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11762", "text": "Treatment of Celiac disease: \nTypically, the first therapy approach to manage Celiac disease in person with an ileum pouch is dietary modification to reduce and/or eliminate gluten."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11763", "text": "Other inflammatory conditions including IgG and IgG4: \nImmunoglobulin related diseases can also cause problems for a pouch.  The two most common that are biopsied for are IgG and IgG4.  IgG molecules can initiate inflammatory reactions, both good and bad.  When the autoimmune reaction is inappropriate, a pouch might have problems with IgG.\nIgG4 is a subclass of IgG.  IgG4 disease is a chronic immune-mediated fibroinflammatory disorder that can manifest with painless enlargement of organs or tumor-like masses. [ 77 ] [ 78 ] [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11764", "text": "Biopsies of the pouch should confirm if an infection is the root cause of pouch inflammation. If an infection from  Clostridioides difficile  (C-diff) or  Cytomegalovirus  (CMV) is found, initial therapy is usually antibiotics. [ 81 ] [ 82 ]  Certain infections such as a  Clostridioides difficile  (C-diff) might also be treated with probiotics just as a C-diff infection in a person who still has their colon would be treated. Probiotics that are prescribed for pouchitis (specifically pouchitis diagnosed as being caused by dysbiosis) are often also prescribed for C-diff. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11765", "text": "The pouch surgery itself can be the reason for some complications. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11766", "text": "Anastomotic leaks: \nAnastomotic leaks occur on the lines where the pouch was sutured or stapled.  They usually occur close to the time of surgery but can appear months or years later.  When an anastomotic leak occurs, it can form a fistula or tract of fluid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11767", "text": "Fistulas: \nMost fistulas will connect from an anastomotic leak to another area of the body such as a pouch-vagina fistula, perianal fistula, or presacral fistula with pelvic collection.  In some circumstances fistulas develop years after pouch creation due to the development of Crohn's disease.  Fistula's caused by Crohn's disease are often treated with biological therapy while a fistula from an anastomotic leak requires different therapies as biologics rarely help close a leak in a surgical suture or staple line of the pouch.  Different potential treatment options for an anastomotic fistula depend on the leak's location and include but are not limited to ENDO-Vac sponge, needle-knife therapy, draining seton, or cutting seton. [ 84 ] [ 85 ] [ 86 ] [ 87 ] [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11768", "text": "Pelvic collection/sinus: \nA pelvic collection or collection of fluid anywhere from a leak is called a sinus.  When an anastomotic leak is not treated promptly or does not heal it can cause pelvic sepsis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11769", "text": "Pelvic sepsis: \nPelvic sepsis also called peri pouch sepsis is a main cause of pouch failure and it creates conditions that make major revisionary surgery difficult."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11770", "text": "Large or small pouch: \nStandard guidelines for J-pouch construction is to use two loops of 15\u201320\u00a0cm ileum.  If the pouch is too small, the pouch will have a small volume.  This will increase the frequency of moments and could also be a cause of pouch failure. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11771", "text": "Pouch prolapse: \nA pouch can either tilt or twist when stapled onto the anus causing prolapse. Pouch prolapse is also sometimes referred to as a floppy pouch. [ 90 ]   Pouch prolapse from a pouch being tilted or twisted can also cause pouch fistulas to develop, especially pouch-vagina fistulas.  Prolapse can also happen after the pouch is already in use.  With symptoms for pouch prolapse, a person typically has evacuation difficulties, seepage, pain, nausea, abdominal pain, or overt external prolapse of tissue. [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11772", "text": "Strictures or stenosis \nNarrowing of the anal canal under the pouch can cause evacuation difficulties.  Anal stricture can be a cause of pouch failure if not managed properly.  Anal stricture is a common complication of pouch surgery.  It is treated with dilatation or stretching under anesthesia.  Some people are also prescribed home dilatation routine using a  Hegar dilator  to manage chronic stenosis that keeps returning after dilatation. [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11773", "text": "U-bend: \nThis happens when the surgeon fires the linear stapler and it malfunctions.  Usually the flaw is not noticed until after surgery is complete during first pouchoscopy.  The pouch is called a \"U\" bend because instead of stapling the two full sections of ileum together into a \"J\", the stapler does not create the 'J' but instead retains the shape of a 'U'."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11774", "text": "Pelvic floor dysfunction and evacuation difficulties \nPelvic floor dysfunction is a common complication of pelvic surgery.  The Mayo Clinic believes it is an under reported complication of IPAA/RPC surgery with up to 75% of pouch patients experiencing non-relaxing pelvic floor dysfunction.  Biofeedback therapy is the main treatment for pelvic floor dysfunction. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11775", "text": "Cancer is a rare event after a pouch is created.  However, retained rectal mucosa can develop dysplasia over time especially if cuffitis is an ongoing complication.  Cancer can also develop in the pouch when there has been long-term pouchitis (inflammation of the pouch for any reason).  People who got their pouch as a result of bowel cancer may also experience cancer of the pouch. [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11776", "text": "Removal of the entire large intestine (colon) and amounts of the terminal ileum at the end of the small intestine leads to fluid and nutritional absorption issues for all pouches.  The colon absorbs water, salts, and some key nutrients.  Dehydration can occur if a person does not get enough fluids."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11777", "text": "The importance of ileum is that it absorbs key vitamins and minerals including  B12 ,  potassium , and  magnesium . In medical terms, low potassium is called  hypokalemia .  When a pouch is constructed small amounts of ileum are lost to the stomas and any stoma revisions.  The pouch itself is also made from ileum.  If a pouch is defunctioned (also explained as disconnected and/or pouch failure) the person also loses this extra amount of ileum when the pouch is disconnected from the digestive tract."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11778", "text": "People with a pouch are at a further health risk if they experience excessive potassium loss due to things like vomiting, diarrhea, and prescription medications that increase urination. This is because potassium is a key electrolyte that helps regulate the heart and if levels become too low, a person can quickly become life-threateningly ill.  When levels are dangerously low, medical intervention with supplementation either orally or intravenously becomes necessary. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11779", "text": "Intestinal obstruction after ileal pouch-anal anastomosis (IPAA) surgery can occur due to various reasons such as adhesions (scar tissue ), strictures (narrowing at the anastomosis site), and Pouchitis (inflammation of the ileal pouch). [ 97 ]  Perforation at the site of attachment of the ileum to the rectum, or near the J-pouch, is a serious complication. [ 98 ] [ 99 ]  It can occur due to several reasons. But sometimes when pouchitis is not treated well, it gradually weakens the intestinal wall, which can eventually perforate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11780", "text": "When a pouch fails, suitable patients can choose to undergo surgery to repair the pouch or completely redo a pouch's anal-anastomosis or redo the entire pouch (if enough terminal ileum remains to produce a second pouch). [ 100 ] [ 101 ]   The cause of the problem that triggered a person's need for pouch salvage surgery will determine which method an experienced revision surgeon recommends as the surgical approach most likely to produce the best result possible.  Revisional surgeries are considered highly specialized. [ 102 ]   They require a skilled surgeon with complex revisional experience for the best chance at a good result.  Many expert pouch surgeons advocate for early referrals to specialists for best outcomes. [ 103 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11781", "text": "Sometimes the root cause of pouch dysfunction can be managed with more conservative methods such as using an ENDO-Vac sponge for an anastomotic defect that leaks, needle knife therapy for fistulas and sinuses, or cutting seton for a low lying peri-anal fistula that does not impact the pouch's anal anastomosis (and many not even be related to the pouch itself).  When a more conservative method will not work or an attempt fails, bigger surgicial salvage procedures are then recommended, if the operation will have a chance to succeed and restore quality of life. [ 104 ] [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11782", "text": "If a pouch has a troubled anal-anastomosis that leaks and causes sepsis or if a person retained more than the recommended amount of rectum (a rectal cuff of no more than 2\u00a0cm follows global colorectal surgery recommendations for an ulcerative colitis person), then an experience surgeon may be able to 'redo' the anal anastomosis by removing excess rectum.  Similarly, if a standard cuff of 1\u20132\u00a0cm was used, a revision surgeon still might be able to remove that and lower the pouch onto the anus.  In this scenario, the surgeon typically tries to save and reuse the existing pouch, but this is not always possible if the pouch is also damaged from complications or has technical flaws.  It might not be possible for an experienced salvage surgeon to redo an anal-anastomosis that has already been hand sewn or has a complication like a fistula or sepsis damage too close to the anus because this presents a surgical situation that is high risk to not heal properly and cause more complications. [ 106 ] [ 104 ] [ 107 ] [ 108 ] [ 109 ] [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11783", "text": "If a person's pouch body is troubled, then an experienced pouch surgeon may be able to make a second pouch if the person's previous surgeries retained enough ileum to still safely create a second pouch.  Experienced revision surgeons will not create a second pouch if it risks putting the person into nutritional difficulties (including  short bowel syndrome ) because too much small bowel would be lost. [ 106 ] [ 104 ] [ 107 ] [ 108 ] [ 109 ] [ 105 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11784", "text": "Occasionally, an experienced revision surgeon may need to alter the shape of the original pouch they are attempting to rescue.  For example, when there is not enough ileum to create a second pouch or if the person's anatomy (mesentery and/or vascular supply) does not allow for the pouch to reach to the anus.  This means the shape of a J-pouch may be transformed into an S, W, or even an H to repurpose functional ileum from the primary, or first pouch surgery, when retaining the original shape would not be successful but altering it could rescue the pouch situation. [ 110 ] [ 111 ] [ 112 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11785", "text": "People can also choose to convert their failed ileo pouch-anal anastomosis (IPAA) to a continent ileostomy such as a  Kock pouch  in some circumstances. [ 113 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11786", "text": "If a repair or redo can not be undertaken because of factors like severe disease, or a repeat surgery fails, or a patient wishes to have their pouch removed with undergoing additional surgery, a pouch excision operation can be performed to remove the pouch.  Removal of a pouch is a big operation that comes with complication risks. [ 114 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11787", "text": "Ileo pouch-anal anastomosis surgery (IPAA) also called Reconstructive Proctocolectomy (RPC) was originally designed and premiered to improve quality of life for people who needed to have their colon and rectum removed because it avoided the need for stool collection in an external bag and restored the anal evacuation route."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11788", "text": "The surgical evolution of the anal pouch also empowered people who were forced to lose their colon and rectum because of disease with choice: they could decide to live their life with an ileostomy or undergo reconstructive surgery to restore anal evacuation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11789", "text": "Ileo pouch-anal anastomosis (IPAA) surgery is generally viewed as providing benefits over living with an ileostomy from a total proctocolectomy.  However, not all people may consider extra surgery as a 'benefit' and therefore, some people opt to forgo the pouch option and remain living with an ileostomy after disease removal.  Pouches are the individual's choice based on how a person wants to live their life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11790", "text": "After the colon is removed a person does not have the ability to form solid stool.  Because waste will always be liquid, people experience several movements per day when their pouch's capacity is full.  The aim of pouch surgery is 4-8 movements per day, although, some people experience many more.  The number of movements per day may seem similar to when someone was in an  ulcerative colitis  (UC) flare, for people who got their pouch as a result of UC.  People with a small volume pouch will likely experience more movements. [ 115 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11791", "text": "Additionally, liquid stool directly from the ileum no longer benefits from the colon removing digestive enzymes before a bowel movement.  This means liquid stool produced by the ileum can be aggressive on the skin around the anus.  Discomfort, including experiencing itching and/or burning around the anus' opening, can be treated with creams, by using a squirt water bottle or hand bidet after each movement to wash away enzymes, or by placing a piece of gauze between buttocks to prevent seepage from irritating the skin around the anus. [ 116 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11792", "text": "The experience of learning how to use a newly functional anal pouch can be distressing for some.  Sharp pains, explosive moments, and anal seepage are common initial sensations.  Specialized pouch centers often have a pouch nurse that educates a person for how to safely empty the pouch without causing avoidable complications like incisional hernias after reversal or takedown surgery. [ 117 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11793", "text": "The process of adjusting to life with an anal pouch can take many months.  Mayo Clinic research estimates that up to 75% of people with a pouch might experience some level of pelvic floor dysfunction after pouch surgery. [ 118 ]  For pouches that are difficult to evacuate or experience anal seepage, biofeedback therapy can be prescribed. [ 119 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11794", "text": "Water and salts are typically reabsorbed into the body by the colon or  large intestine .  However, people with an ileum pouch have lost their entire colon and at least small amounts of  ileum .  Experiences like having sudden  diarrhea ,  vomiting  from sickness,  sweating  in hot weather, sweating from  physical exercise , or from not drinking enough  fluids  can all cause dehydration.  Having an episode of pouchitis, or pouch inflammation, can also cause dehydration for some if the episode causes an increase in bowel movements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11795", "text": "This experiences mean that people with pouches, like people with ileostomies, will require drinking more fluids and eating more salt to not become dehydrated.  Dehydration  can cause feelings of  dizziness ,  physical weakness , and/or  fatigue . People may also notice that urine has changed from light yellow and become darker and more concentrated. [ 120 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11796", "text": "It is important that people with pouches maintain healthy  fluid  and  salt levels  because chronic dehydration increases the risk for  kidney stones  and even  kidney failure .  If a person becomes severely dehydrated, hospital admission for intravenous administration of fluids to restore hydration safely may be required. [ 116 ] [ 121 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11797", "text": "Many people with a pouch eat their normal diet after surgery while others have to alter their diet due to discomfort when digesting certain foods.  Others experience more watery output after eating specific foods like processed sugary snacks which may require some people with pouches to use dietary or medical interventions like fiber products or doctor prescribed tablets to control watery stool and prevent dehydration. [ 122 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11798", "text": "People with a pouch can follow any diet they choose while monitoring their overall nutritional status due to the loss of bowel causing absorption issues.  People diagnosed with vitamin or mineral deficiencies may be prescribed injections or tablets.  Others may be referred to a nutritionist to design meals that provide additional amounts of needed vitamins and minerals. Studies show that some foods may also contribute to pouch inflammation. [ 123 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11799", "text": "Having an intestinal pouch is considered a rare condition.  Some national organizations and specialist charities usually associated with inflammatory bowel disease (IBD) or ostomies provide some information to people considering or who have chosen to undergo elective pouch surgery. Some of the larger national organizations globally include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11800", "text": "Ileostomy  is a  stoma  (surgical opening) constructed by bringing the end or loop of  small intestine  (the  ileum ) out onto the surface of the skin, or the surgical procedure which creates this opening. [ 1 ]   Intestinal waste passes out of the ileostomy and is collected in an external  ostomy system  which is placed next to the opening.  Ileostomies are usually sited above the  groin  on the right hand side of the  abdomen ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11801", "text": "Ileostomies are necessary where injury or a surgical response to disease has meant the  large intestine  cannot safely process waste, typically because the  colon  and  rectum  have been partially or wholly removed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11802", "text": "Diseases of the large intestine which may require surgical removal include  Crohn's disease ,  ulcerative colitis ,  familial adenomatous polyposis , and total colonic  Hirschsprung's disease . [ 2 ]   An ileostomy may also be necessary in the treatment of  colorectal cancer  or  ovarian cancer .  One example is a situation where the cancer  tumor  is causing a blockage (obstruction). [ 3 ]   In such a case, the ileostomy may be temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining sections of colon or rectum following removal of the tumor provided that enough of the rectum remains intact to preserve  internal / external anal sphincter  function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11803", "text": "In an  end ileostomy , the end of the ileum is everted (turned inside out) to create a spout and the edges are sutured under the skin to anchor the ileum in place.  Permanent ileostomies are usually done this way.  An end ileostomy may be temporary, notably if some of the large intestine was removed and the bowel or overall health is not considered amenable to tolerating further surgery, such as an  anastomosis  to rejoin the small and large intestines."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11804", "text": "In a  temporary  or  loop ileostomy , a loop of the ileum is surgically brought through the skin creating a stoma, but keeping the lower portion of the ileum for future reattachment in cases where the entire colon and rectum are not removed but need time to heal.  Temporary ileostomies are also often made as the first stage in surgical construction of an  ileo-anal pouch , so  fecal  material does not enter the newly made pouch until it heals and has been tested for leaks\u2014usually requiring a period of eight to ten weeks. When healing is complete the temporary ileostomy is then \"taken down\" (or reversed) by surgically repairing the loop of intestine which made the temporary stoma and closing the skin incision. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11805", "text": "People with ileostomies must use an  ostomy pouch  to collect intestinal waste.  People with ileostomies typically use an open-ended (referred to as a \"drainable\") one- or two-piece pouch that is secured at the lower end with a leakproof clip, or velcro fastener.  The alternative is the closed-end pouch that must be thrown away when full.  Ordinarily, the pouch must be emptied five to eight times a day. [ 5 ] [ 6 ]  If the bag stays empty for more than four to six hours, individuals should contact their healthcare provider, as this may indicate intestinal blockage. [ 6 ]  The pouch and flange (both one and two piece pouches) are usually changed every 2\u20135 days. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11806", "text": "Ostomy pouches fit close to the body and are usually not visible under regular clothing unless the pouch becomes too full.  It is necessary to measure the stoma regularly as it changes shape after the initial surgery. The stomal- or colorectal-nurse does this initially for a patient and advises them on the exact size required for the pouch's opening. Changes in size and shape can indicate a problem and may signal a need to call a healthcare provider. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11807", "text": "Some people find they must make adjustments to their diet after having an ileostomy. It is important for individuals to consult with their healthcare providers. [ 6 ]   Tough or high- fiber  foods (for example: potato skins, tomato skins, and raw vegetables) are hard to  digest  in the small intestine and may cause blockages or discomfort when passing through the stoma.  Chewing food thoroughly can reduce such problems. [ 6 ]   Some people find that certain foods cause annoying gas or  diarrhea . [ 8 ]   Many foods can change the color of the intestinal output, causing alarm; beetroot, for instance, produces a red output that may appear to be blood. [ 8 ]   Nevertheless, people who have an ileostomy as treatment for  inflammatory bowel disease  typically find they can enjoy a more \"normal\" diet than they could before surgery.  Correct dietary advice is essential in combination with the patient's gastroenterologist and hospital-approved dietician.  Supplementary foods may be prescribed and liquid intake and output monitored to correct and control output. If the output contains blood, an ileostomate (patient) is advised to visit an emergency department. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11808", "text": "After having ileostomies, people may continue to take baths and showers and have an active lifestyle. [ 6 ] [ 10 ]  These and other topics are important to discuss with healthcare providers. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11809", "text": "Complications can include  kidney stones ,  gallstones , and  post-surgical adhesions . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11810", "text": "In some patients with Crohn's disease, a procedure called an  ileoanal anastomosis  is done if the disease affects the entire colon and rectum, but leaves the anus unaffected. In this procedure, the entire large intestine and rectum is surgically removed, and the ileum is then stitched to the anus to allow fecal matter to go through the ileum just as it did when the patient had a large intestine. This procedure requires a temporary loop ileostomy to allow the anastomosis to heal. With lifestyle adjustments, those who have had this procedure for their Crohn's disease can resume normal bowel movements without artificial appliances. However, there is always the possibility of disease relapse, as Crohn's can affect mouth to anus. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11811", "text": "Since the late 1970s, an increasingly popular alternative to an ileostomy has been the  Barnett continent intestinal reservoir  (or BCIR).  The formation of this pouch (made possible through a procedure first pioneered by  Nils Kock  in 1969), involves the creation of an internal reservoir which is formed using the  ileum  and connecting it through the abdominal wall in a very similar fashion to a standard \"Brooke\" ileostomy. [ 14 ]   The BCIR procedure should not be confused with a  J-pouch , which is also an ileal reservoir, but is connected directly to the  anus \u2014after removal of the  colon  and  rectum \u2014avoiding the need for subsequent use of external appliances. [ 13 ]  Because continent ileostomies can cause problems and may need redoing, they are not often done. [ 1 ]  However, continent ileostomies can be considered depending on surgeon experience, patient characteristics, and other factors. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11812", "text": "The Barnett continent intestinal reservoir (BCIR) is a type of an appliance-free intestinal  ostomy .  The BCIR was a modified  Kock pouch  procedure pioneered by William O. Barnett.  It is a surgically created pouch, or reservoir, on the inside of the  abdomen , made from the last part of the  small intestine  (the  ileum ), [ 16 ]  and is used for the storage of intestinal  waste .  The pouch is internal, so the BCIR does not require wearing an appliance or  ostomy bag ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11813", "text": "The pouch works by storing the liquid waste, which is drained several times a day using a small silicone tube called a  catheter .  The catheter is inserted through the surgically created opening on the abdomen into the pouch called a  stoma .  The capacity of the internal pouch increases steadily after surgery: from 50\u00a0cm 3 , when first constructed, to 600\u20131000\u00a0cm 3  over a period of months, when the pouch fully matures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11814", "text": "The opening through which the catheter is introduced into the pouch is called the  stoma .  It is a small, flat, button-hole opening on the abdomen.  Most patients cover the stoma site with a small pad or bandage to absorb the  mucus  that accumulates at the opening. [ 17 ] [ Note 1 ]   This mucus formation is natural, and makes insertion of the catheter easier.  The BCIR requires no external appliance and it can be drained whenever it is convenient. Most people report draining the pouch 2\u20134 times a day, and most times they sleep through the night. This can vary depending on what kinds and quantities of food eaten. The process of draining the pouch is simple and quickly mastered. The stoma has no nerve endings, and inserting the catheter is not painful. The process of inserting the catheter and draining the pouch is called  intubation  and takes just a few minutes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11815", "text": "Finnish surgeon  Nils Kock  developed the first intra-abdominal continent ileostomy in 1969. This was the first continent intestinal reservoir. By the early 1970s, several major medical centers in the United States were performing Kock pouch ileostomies on patients with ulcerative colitis and familial polyposis.  One problem with these early Kock pouches was valve slippage, [ 18 ]  which often resulted in difficulty  intubating  and an  incontinent pouch . As a result, many of these pouches had to be revised or removed to allow a better  quality of life ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11816", "text": "William O. Barnett began modifying the Kock pouch in 1979. He believed in the concept of the continent reservoir, but was disappointed with the valve's relatively high failure rate. Barnett was intent on solving the problem. [ 18 ] [ Note 2 ]  His first change was in the construction of the nipple valve. He changed the direction of flow within this segment of intestine to keep the valve in place. This greatly improved the success rate. [ 17 ] [ Note 3 ]  In addition, he used a plastic material called  Marlex  to form a collar around the valve. [ 18 ]  This further stabilized and supported the valve, decreasing valve slippage. This technique worked well, but after several years, the intestine reacted to the Marlex by forming  fistulae  (abnormal connections) into the valve.  Dr. Barnett continued his investigation in an effort to improve these results.  After much effort, the idea came to him\u2014a \"living collar\" constructed from the small intestine itself.  This technique made the valve more stable and eliminated the problems the Marlex collars had presented. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11817", "text": "After a test series of over 300 patients, Barnett moved to  St. Petersburg, Florida  where he joined the staff of  Palms of Pasadena Hospital , where he trained other surgeons to perform his continent intestinal reservoir procedure.  With the assistance of James Pollack, the first BCIR Program was established.  Both surgeons further enhanced the procedure to bring it to where it is today.  These modifications included reconfiguring the pouch to decrease the number of  suture lines  from three to one (this allowed the pouch to heal faster and reduced the chance of developing fistulae); and creating a  serosal  patch over the suture lines which prevented leakage. [ 17 ] [ Note 4 ]   The end result of these developments has been a continent intestinal reservoir with minimal complications and satisfactory function. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11818", "text": "Ulcerative colitis [ 20 ]  and familial adenomatous polyposis [ 21 ]  are the two main health conditions that lead to removal of the entire  colon  (large intestine) and  rectum , which leads to the need for an ileostomy. [ 22 ] [ 23 ] [ Note 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11819", "text": "Candidates for BCIR include: people who are dissatisfied with the results of an alternate procedure (whether a conventional Brooke ileostomy or another procedure); patients with a malfunctioning/failed Kock pouch or  IPAA/J-pouch ; and individuals with poor  internal / external anal sphincter  control who either elect not to have the J-pouch (IPAA) or are not a good candidate for IPAA. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11820", "text": "There are, however, some contraindications for having the BCIR surgery. BCIR is not for people who have or need a  colostomy , people with [active]  Crohn's disease , mesenteric  desmoids ,  obesity , advanced age, or poor motivation. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11821", "text": "When Crohn's disease only affects the colon, it may, in select cases, be appropriate to perform a BCIR as an alternative to a conventional ileostomy.  If the small intestine is affected, however, it is not safe to have the BCIR (because the internal pouch is created out of the small intestine, which must be healthy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11822", "text": "A patient must have an adequate length of  small intestine  to be considered a potential candidate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11823", "text": "A 1995 study by the  American Society of Colon and Rectal Surgeons  included 510 patients who received the BCIR procedure between January 1988 and December 1991.  All patients were between 1\u20135 years post-op with an admitting diagnosis of ulcerative colitis or familial polyposis.  The study was published in  Diseases of the Colon and Rectum  in June 1995. [ 24 ]    The study found that:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11824", "text": "The study concluded: \"BCIR represents a successful alternative to patients with a conventional Brooke ileostomy or those who are not candidates for the  IPAA .\" [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11825", "text": "In 1999, American Society of Colon and Rectal Surgeons published a unique study on 42 patients with a failed  IPAA/J-pouch  who converted to the Barnett modification of the Kock pouch (BCIR).  The authors noted that their study was significant in the very large number of patients, [ 26 ]  approximately 6 times more than studied by any previous author. [ 27 ]   The study was published in  Diseases of the Colon and Rectum  in April 1999. [ 27 ]   The study found:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11826", "text": "The study concluded: \"The continent ileostomy offers an alternative with a high degree of patient satisfaction, to those patients who face the loss of an  IPAA .\" [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11827", "text": "Inguinal hernia surgery  is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the  inguinal canal  in the groin region."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11828", "text": "There are two different clusters of hernia: groin and ventral (abdominal) wall. Groin hernia includes femoral, obturator, and inguinal. [ 1 ]  Inguinal hernia is the most common type of hernia and consist of about 75% of all hernia surgery cases in the US. Inguinal hernia, which results from lower abdominal wall weakness or defect, [ 2 ]  is more common among men with about 90% of total cases. [ 3 ] [ 4 ]  In the inguinal hernia, fatty tissue or a part of the small intestine gets inserted into the inguinal canal. [ 5 ]  Other structures that are uncommon but may get stuck in inguinal hernia can be the appendix, caecum, and transverse colon. [ 6 ]  Hernias can be asymptomatic, incarcerated, or strangled. [ 3 ]  Incarcerated hernia leads to impairment of intestinal flow, and strangled hernia obstructs blood flow in addition to intestinal flow. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11829", "text": "Inguinal hernia can make a small lump in the groin region which can be detected during a physical exam and verified by imaging techniques such as computed tomography (CT). This lump can disappear by lying down and reappear through physical activities, laughing, crying, or forceful bowel movement. Other symptoms can include pain around the groin, an increase in the size of bulge over the time, pain while lifting, and a dull aching sensation. [ 5 ]  In occult (hidden) hernia, the bulge cannot be detected by physical examination and magnetic resonance imaging (MRI) can be more helpful in this situation. [ 7 ]  Males who have asymptomatic inguinal hernia and pregnant women with uncomplicated inguinal hernia can be observed, but the definitive treatment is mostly surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11830", "text": "Surgery remains the ultimate treatment for all types of  hernias  as they will not get better on their own, however not all require immediate repair. [ 9 ] [ 10 ]   Elective surgery  is offered to most patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health. [ 9 ]  Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when  intra-abdominal fat  or small intestine becomes stuck within the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation as a result of restricted blood supply to the trapped segment of small intestine causing that portion to die. [ 11 ]  Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11831", "text": "Surgical repair of inguinal hernias is one of the most commonly performed operations worldwide and the most commonly performed surgery within the United States. A combined 20 million cases of both inguinal and  femoral hernia  repair are performed every year around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year. [ 13 ]  Groin hernias account for almost 75% of all abdominal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men account for nearly 90% of all repairs performed and have a  bimodal incidence  of inguinal hernias peaking at 1 year of age and again in those over the age of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most common subtype of groin hernia in both males and females. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11832", "text": "Inguinal hernia surgery is also one of the most common surgical procedures, with an estimated incidence of 0.8-2% and increasing up to 20% in preterm children. [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11833", "text": "Surgical intervention for hernias is guided by various factors, including the severity of symptoms, hernia type, medical history, hernia size, bowel incarceration (bowel can no longer return to the abdomen) and the overall general health of the person. [ 12 ] [ 9 ] [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11834", "text": "Elective surgery  is planned in order to help relieve symptoms, respect the person's preference, and prevent future complications that may require emergency surgery. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11835", "text": "Surgery is offered to the majority of people who:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11836", "text": "Symptomatic hernias tend to cause pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to be most prominent at the end of the day as well as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11837", "text": "A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include: [ 19 ] [ 11 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11838", "text": "Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of the intestine. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11839", "text": "Although pediatric inguinal hernias sometimes present asymptomatically, surgical repair is still the standard of care to prevent hernia incarceration, which for children who are born with hernias has a risk of 12% in full-term children and 39% in preterm children. [ 22 ]  In preterm neonates, the timing for intervention appears to be of utter importance as surgical  hernia repair after neonatal intensive care unit (NICU) discharge might decrease recurrence and anesthesia-induced respiratory difficulties compared to surgery before NICU discharge. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11840", "text": "The person with the hernia should be given an opportunity to participate in the  shared decision-making  with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such that elective repair is no longer in a person's best interest. Such cases include: [ 21 ] [ 10 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11841", "text": "Additionally, certain medical conditions can prevent people from being candidates for laparoscopic approaches to repair. Examples of such include: [ 19 ] [ 10 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11842", "text": "Techniques to repair inguinal hernias fall into two broad categories termed \"open\" and \" laparoscopic \". Surgeons tailor their approach by taking into account factors such as their own experience with either techniques, the features of the hernia itself, and the person's anesthetic needs. [ 19 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11843", "text": "The cost associated with either approach varies widely across regions, but updated guidelines published by the International Endohernia Society (IES) cast doubt on the comprehensiveness of cost comparison studies due in part to the complexity inherent in calculating costs across institutions. [ citation needed ]  The IES asserts that hospital and societal costs are lower for laparoscopic repairs as compared to open approaches. They recommend the routine use of reusable instruments as well as improving the proficiency of surgeons to help further decrease costs as well as time spent in the OR. [ 24 ]  However, as an example, the  UK 's  National Health Service  spends \u00a356 million a year in repairing inguinal hernias, 96% of which were repaired via the open mesh approach while only 4% were done laparoscopically. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11844", "text": "All techniques involve an approximate 10-cm incision in the groin. Once exposed, the hernia sac is returned to the abdominal cavity  or excised and the abdominal wall is very often reinforced with  mesh . [ 11 ]  There are many techniques that do not utilize mesh and have their own situations where they are preferable. [ 25 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11845", "text": "Open repairs are classified via whether prosthetic mesh is utilized or whether the patient's own tissue is used to repair the weakness. Prosthetic repairs enable surgeons to repair a hernia without causing undue tension in the surrounding tissues while reinforcing the abdominal wall. Repairs with undue tension have been shown to increase the likelihood that the hernia will recur. Repairs not using prosthetic mesh are preferable options in patients with an above-average risk of infection such as cases where the bowel has become strangulated (blood supply lost due to constriction). [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11846", "text": "One large benefit of this approach lies in its ability to tailor anesthesia to a person's needs. People can be administered  local anesthesia , a  spinal block , as well as  general anesthesia . [ 19 ]  Local anesthesia has been shown to cause less pain after surgery, shorten operating times, shorten recovery times as well as decrease the need to return to the hospital. However, people who undergo general anesthesia tend to be able to go home faster and experience fewer complications. [ 26 ] [ 27 ] [ 10 ]  The European Hernia Society recommends the use of local anesthesia particularly for people with ongoing medical conditions. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11847", "text": "Repairs that utilize mesh are usually the first recommendation for the vast majority of patients including those that undergo laparoscopic repair. [ 12 ]  Procedures that employ mesh are the most commonly performed as they have been able to demonstrate better results compared to non-mesh repairs. [ 21 ]  Approaches utilizing mesh have been able to demonstrate faster return to usual activity, lower rates of persistent pain, shorter hospital stays, and a lower likelihood that the hernia will recur. [ 29 ] [ 12 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11848", "text": "Options for mesh include either  synthetic  or  biologic . Synthetic mesh provides the option of using \"heavyweight\" as well as \"lightweight\" variations according to the diameter and number of mesh fibers. [ 34 ]  Lightweight mesh has been shown to have fewer complications related to the mesh itself than its heavyweight counterparts. [ 35 ]  It was additionally correlated with lower rates of chronic pain while sharing the same rates of hernia recurrence as compared to heavyweight options. [ 36 ] [ 37 ] [ 38 ]  This has led to the adoption of lightweight mesh for minimizing the chance of chronic pain after surgery. [ 21 ]  Biologic mesh is indicated in cases where the risk of infection is a major concern such as cases in which the bowel has become strangulated. They tend to have lower  tensile strength  than their synthetic counterparts lending them to higher rates of mesh rupture. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11849", "text": "Biomeshes are increasingly popular since their first use in 1999 [ 40 ]  and their subsequent introduction to the market in 2003. Some have a similar price to high end synthetic meshes. They can be produced from absorbable, animal-sourced  extra cellular matrix , or by other means. Synthetic absorbable meshes are also available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11850", "text": "Meshes made of  mosquito net  cloth, in  copolymer  of  polyethylene  and  polypropylene  have been used for low-income patients in rural  India  and  Ghana . [ 41 ]  Each piece costs $0.01, 3700 times cheaper than an equivalent commercial mesh. [ 42 ] [ 43 ]  They give results identical to commercial meshes in terms of infection and recurrence rate at 5 years. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11851", "text": "The Lichtenstein tension-free repair has persisted as one of the most commonly performed procedures in the world. The European Hernia Society recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method. [ 12 ]  Recent studies have indicated that mesh attachment with the use of  adhesive glue  is faster and less likely to cause post-op pain as compared to attachment via suture material. [ 44 ] [ 45 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11852", "text": "The plug and patch tension-free technique has fallen out of favor due to higher rates of mesh shift along with its tendency to irritate surrounding tissue. This has led to the European Hernia Society recommending that the technique not be used in most cases. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11853", "text": "A variety of other tension-free techniques have been developed and include: [ 19 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11854", "text": "Techniques in which mesh is not used are referred to as tissue repair technique, suture technique, and tension technique. All involve bringing together the tissue with sutures and are a viable alternative when mesh placement is contraindicated. [ 19 ]  Such situations are most commonly due to concerns of contamination in cases where there are infections of the groin, strangulation or perforation of the bowel. [ 21 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11855", "text": "The Shouldice technique is the most effective non-mesh repair thus making it one of the most commonly utilized methods. [ 29 ]  Numerous studies have been able to validate the conclusion that patients have lower rates of hernia recurrence with the Shouldice technique as compared to other non-mesh repair techniques. [ 48 ]  However this method frequently experiences longer procedure times and length of hospital stay. Despite being the superior non-mesh technique, the Shouldice method results much higher rates of hernia recurrence in patients when compared to repairs that utilize mesh. [ 12 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11856", "text": "The Bassini technique, described by  Edoardo Bassini  in the 1880s, was the first efficient inguinal hernia repair. [ 49 ] [ 50 ]  In this technique, the  conjoint tendon  (formed by the distal ends of the  transversus abdominis  and  internal oblique  muscles) is approximated to the  inguinal ligament  and closed. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11857", "text": "The Shouldice technique was itself an evolution of prior techniques that had greatly advanced the field of inguinal hernia surgery. Such classic open non-mesh repairs include: [ 21 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11858", "text": "There are two main methods of laparoscopic repair:  transabdominal preperitoneal  ( TAPP ) and  totally extra-peritoneal  ( TEP ) repair. When performed by a surgeon experienced in hernia repair,  laparoscopic  repair causes fewer complications than Lichtenstein, particularly less  chronic pain . However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. All that said, many surgeons are shifting to using laparoscopic techniques as they require smaller incisions, and result in less bleeding, lower infection rates, faster recovery, shorter hospitalization periods, and reduced chronic pain. [ 65 ] [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11859", "text": "Recurrence rates are identical when laparoscopy is performed by an experienced surgeon. [ 66 ]  When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11860", "text": "Robot assisted repair of inguinal hernias has demonstrated safety and efficacy in surgeries repairing inguinal hernias that present on both sides of the pubic bone (bilateral) as well as inguinal hernias that present on one side (unilateral). [ 69 ]  In comparing robot assisted repair of inguinal hernias to traditional laparoscopic techniques, robot assisted surgeries repairing inguinal hernias have longer operating times and can be more costly. However, measures of safety, complication rates, and readmission rates did not significantly differ between robot assisted repair and traditional laparoscopic repair. [ 70 ] [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11861", "text": "Studies have demonstrated that men whose hernias cause little to no symptoms can safely continue to delay surgery until a time that is most convenient for patients and their healthcare team. Research shows that the risk of inguinal hernia complications remains under 1% within the population. [ 81 ] [ 20 ] [ 9 ] [ 21 ]  Watchful waiting requires that patients maintain a close follow-up schedule with providers to monitor the course of their hernia for any changes in symptoms and can be safely offered for up to 2 years. [ 82 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11862", "text": "Patients who do elect watchful waiting eventually undergo repair within five years as 25% will experience a progression of symptoms such as worsening of pain. Elective repair discussions should be revisited if patients begin to avoid aspects of their normal routine due to their hernia. [ 12 ] [ 83 ] [ 10 ]  After 1 year it is estimated that 16% of patients who initially opted for watchful waiting will eventually undergo surgery. Furthermore, 54% and 72% will undergo repair at 5-year and 7.5-year marks respectively. [ 84 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11863", "text": "The use of a  truss  is an additional non-surgical option for men. It resembles a jock-strap that utilizes a pad to exert pressure at the site of the hernia in order prevent excursion of the hernia sack. It has little evidence to support its routine use and has not been shown to prevent complications such as incarceration (bowel can no longer slide back into abdomen) or strangulation of bowel (constriction causing loss of blood supply). However some patients do report a soothing of symptoms when utilized. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11864", "text": "Inguinal hernia repair complications are unusual, and the procedure as a whole proves to be relatively safe for the majority of patients. Risks inherent in almost all surgical procedures include: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11865", "text": "Risks that are specific to inguinal hernia repairs include such things as: [ 9 ] [ 17 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11866", "text": "Post-herniorrhaphy inguinodynia  is a condition where 10-12% of patients experience severe pain after inguinal hernia repair, due to a complex combination of different  forms of pain signals . [ 87 ] [ 88 ] [ 12 ]  It can occur with any inguinal hernia repair technique, and if unresponsive to pain medications, further surgical intervention is often required. [ 89 ]  Removal of the implanted mesh, in combination with  bisection of regional nerves , is commonly performed to address such cases. [ 90 ] [ 91 ] [ 92 ]  There remains ongoing discussion amongst surgeons regarding the utility of planned resections of regional nerves as an attempt to prevent its occurrence. [ 92 ] [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11867", "text": "Mortality rates for non-urgent, elective procedures was demonstrated as 0.1%, and around 3% for procedures performed urgently. [ 94 ] [ 10 ]  Other than urgent repair, risk factors that were also associated with increased mortality included being female, requiring a femoral hernia repair, and older age. [ 95 ] [ 96 ] [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11868", "text": "Upon awakening from anesthesia, patients are monitored for their ability to drink fluids, produce urine, as well as their ability to walk after surgery. Most patients are then able to return home once those conditions are met. [ 17 ]  It is not uncommon for patients to experience residual soreness for a couple of days after surgery. [ 98 ] [ 25 ]  Patients are encouraged to make strong efforts in getting up and walking around the day after surgery. [ 12 ]  Most patients can resume their normal routine of daily living within the week such as driving, showering, light lifting, as well as sexual activity. [ 9 ]  Long work absences are rarely necessary and length of sick days tend to be dictated by respective employment policies. [ 12 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11869", "text": "In general, it is not recommended to administer antibiotics as prophylaxis after elective inguinal hernia repair. However, the rate of wound infection determines the appropriate use of the antibiotics. [ 99 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11870", "text": "Post-op development of any of the following should warrant timely reporting via phone: [ 25 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11871", "text": "Most indirect inguinal hernias in the abdominal wall are not preventable. Direct inguinal hernias may be prevented by maintaining a healthy weight, refraining from smoking, preventing straining during bowel movements, and maintaining proper lifting techniques when heavy lifting. [ 17 ] [ 9 ]  There is no evidence that indicates physicians should routinely  screen  for asymptomatic inguinal hernias during patient visits. [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11872", "text": "Intestine transplantation  ( intestinal transplantation,  or  small bowel transplantation ) is the  surgical   replacement  of the  small intestine  for  chronic  and  acute  cases of intestinal  failure . While intestinal failure can oftentimes be treated with alternative therapies such as  parenteral nutrition  (PN), complications such as PN-associated  liver disease  and  short bowel syndrome  may make transplantation the only viable option. One of the rarest type of  organ  transplantation performed, intestine transplantation is becoming increasingly prevalent as a therapeutic option due to improvements in  immunosuppressive regimens , surgical technique, PN, and the clinical management of pre and post-transplant patients. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11873", "text": "Intestine transplantation dates back to 1959, when a team of surgeons at the  University of Minnesota  led by Richard C. Lillehei reported successful transplantation of the small intestine in dogs. Five years later in 1964, Ralph Deterling in  Boston  attempted the first human intestinal transplant, albeit unsuccessfully. For the next two decades, attempts at transplanting the small intestine in humans were met with universal failure, and patients died of technical complications,  sepsis , or  graft rejection . However, the discovery of the immunosuppressant  ciclosporin  in 1972 triggered a revolution in the field of transplant medicine. Due to this discovery, in 1988, the first successful intestinal transplant was performed in Germany by E. Deltz, followed shortly by teams in France and Canada. Intestinal transplantation was no longer an experimental procedure, but rather a life-saving therapy. In 1990, a newer immunosuppressant drug,  tacrolimus , appeared on the market as a superior alternative to ciclosporin. In the two decades since, intestine transplant efforts have improved tremendously in both number and outcomes. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11874", "text": "Failure of the small intestine is life-threatening due to the inability to absorb  nutrients ,  fluids , and  electrolytes  from food. Without these essential substances and the ability to maintain  energy balances ,  homeostasis  cannot be maintained and one's  prognosis  will be dismal. Causes of intestinal failure may be clinically complex, and may result from a combination of nutritional,  infectious ,  traumatic , and  metabolic  complications that affect ordinary  anatomy  and  physiology . [ 3 ]  Many underlying conditions that serve as precursors to failure are genetic or congenital in nature. For example, severe  inflammation ,  ulceration ,  bowel obstruction ,  fistulation ,  perforation , or other pathologies of  Crohn's disease  may severely compromise intestinal function. [ 4 ]  Despite the danger these conditions may pose in themselves, they may lead to even further, more serious complications that necessitate replacement of the diseased intestine. The single leading cause for an intestinal transplant is affliction with  short bowel syndrome , oftentimes a secondary condition of some other form of intestinal disease. [ 5 ] [ 6 ]  Short-bowel syndrome was the cause for 73% of American intestinal transplantations in 2008, followed by functional bowel problems for 15% and other causes representing 12% of cases. [ 7 ]  Natural SBS is mercifully rare, estimated to be 3 per 100,000 births. [ 8 ]  Surgical removal is the most common cause, performed as a treatment for various  gastroenterological  and  congenital  conditions such as Crohn's disease,  necrotizing enterocolitis ,  mesenteric ischemia ,  motility disorder ,  omphalocele / gastroschisis ,  tumors , and  volvulus . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11875", "text": "Regardless of the underlying condition, the loss of intestinal function does not necessarily necessitate a transplant. Several conditions, such as necrotizing enterocolitis or volvulus, may be adequately resolved by other surgical and nonsurgical treatments, especially if SBS never develops. An individual can obtain nutrients intravenously through PN, bypassing food consumption entirely and its subsequent  digestion . Long-term survival with SBS and without PN is possible with  enteral nutrition , but this is inadequate for many patients as it depends on the remaining intestine's ability to adapt and increase its absorptive capacity. [ 3 ]  Although more complicated and expensive to perform, any person may receive PN. Although PN can meet all energy, fluid, and nutrient needs and can be performed at home,  quality of life  can be significantly decreased. On average, PN takes 10 to 16 hours to administer but can take up to 24. Over this time frame, daily life can be significantly hindered as a consequence of attachment to the  IV pump . [ 5 ] [ 10 ]  Over long periods of time, PN can lead to numerous health conditions, including severe  dehydration ,  catheter -related infections, and liver disease. [ 2 ] [ 11 ]  PN-associated liver disease strikes up to 50% of patients within 5\u20137 years, correlated with a mortality rate of 2\u201350%. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11876", "text": "Another alternative treatment to transplant for patients with SBS is surgical bowel lengthening via either  serial transverse enteroplasty  (STEP) or the older  longitudinal intestinal lengthening and tailoring  (LILT) technique. Although both procedures contribute to an approximate 70% increase in length, STEP appears somewhat more favorable in terms of lower mortality and progression to transplant. [ 12 ]  Nevertheless, a positive reception to either procedure may reduce the level of PN required, if not negate its required use altogether. [ 8 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11877", "text": "There are four  Medicare  and  Medicaid -approved  indications  for intestine transplantation: a loss of two of the six major routes of  venous access , multiple episodes of  catheter -associated life-threatening sepsis, fluid and electrolyte abnormalities in the face of maximal medical therapy, and PN-associated liver disease. Transplants may also be performed if the growth and development of a  pediatric  patient fails to ensue, or in extreme circumstances for patients with an exceptionally low quality of life on PN. [ 14 ] [ 15 ]  A multidisciplinary team consisting of  transplant surgeons ,  gastroenterologists ,  dieticians ,  anesthesiologists ,  psychiatrists , financial representatives, and other  specialists  should be consulted to evaluate the treatment plan and ensure transplantation is the patient's best option.  Psychological  preparations should be made for the transplant team and patient as well. Early referral requires trust between all parties involved in the operation to ensure that a rush to judgment does not lead to a premature transplant. [ 11 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11878", "text": "Other  absolute contraindications  to receiving an intestinal transplant include the presence of  systemic  and untreated local infections, malignant cancer, severe  neurological impairment , and severe  cardiac  and/or  pulmonary disease .  These criteria are similar to established guidelines for transplants of other organ types. [ 17 ]  HIV infection is a  relative contraindication  for intestine transplantation; desperate terminal patients may accept a transplant from a HIV-positive donor if they are willing to expose themselves to HIV. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11879", "text": "There are three major types of intestine transplants: an isolated intestinal  graft , a combined intestinal-liver graft, and a  multivisceral graft  in which other  abdominal  organs may be transplanted as well. In the most basic and common graft, an isolated intestinal graft, only sections of the  jejunum  and  ileum  are transplanted. [ 18 ]  These are performed in the absence of liver failure. In the event of severe liver dysfunction due to PN,  enzyme  deficiencies, or other underlying factors, the liver may be transplanted along with the intestine. In a multivisceral graft, the  stomach ,  duodenum ,  pancreas , and/or  colon  may be included in the graft. Multivisceral grafts are considered when the underlying condition significantly compromises other sections of the digestive system, such as intra-abdominal tumors that have not yet  metastasized , extensive venous  thrombosis  or  arterial   ischemia  of the  mesentery , and motility syndromes. [ 11 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11880", "text": "Donated  intestines, like all organs, should be matched to a recipient prior to recovery, as to prepare him or her and minimize the time the organ spends outside the  body . [ 5 ]  Potential recipients are placed on the  International Intestinal Transplant Registry  (ITR), where they contribute to the world's growing understanding of intestine transplantation. Before a transplant may be performed, an organ must first be located. In the United States, the matching of all organs is coordinated by the  United Network for Organ Sharing  (UNOS). The standard intestinal donor is deceased with a diagnosis of  brain death . [ 19 ]  In terms of transplant outcomes, brain-dead donors are highly preferable to donors who have suffered  cardiopulmonary death . If respiration can be assisted by a  ventilator , brain-dead donors may exhibit maintainable  cardiac ,  endocrine , and  excretory  function. If appropriately managed, the continuation of  blood flow  and bodily metabolism allows for healthier organs for procurement and additional time to prepare recipients for transplant. [ 20 ]  Furthermore, terminal ileum recovery from living donors is possible., [ 21 ]  and a  laparoscopic technique  is being developed to harvest limited sections of small bowel from living donors. [ 22 ]  When determining potential donor-recipient matches, important characteristics include donor size, age,  tissue  quality, and  ABO  and  histo-compatibility . [ 11 ] [ 21 ]  If the intestine is too large, it may be not transplantable into young or small patients. Ideally, intestines should be selected from donors of lighter weight than the proposed recipients to ensure simple closure of the abdominal wound. [ 23 ]  If a patient is too young or too old, they may not be hardy enough to survive the operation and recovery period. [ 11 ]  If the donor and recipient organs do not meet compatibility requirements, the threat of  organ rejection  by the body is all but certain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11881", "text": "Organ rejection is the unfortunate circumstance of the host  immune system  recognizing the transplanted organ as foreign. This is the most notable complication facing transplant recipients. Through  T-cell receptors ,  T-lymphocytes  are able to distinguish between self and non-self by recognizing  human leukocyte antigens  (HLA) bound to the  major histocompatibility complex  (MHC)  protein  located on the surface of organ  cells . Once identified as foreign, the immune system proceeds to destroy the transplanted tissue. The  panel-reactive antibody  (PRA) test measures the proportion of the population to which a recipient will react via pre-existing  antibodies  to various HLA  antigens ; in other words, how likely a patient is to acutely reject their new transplant. Therefore, it is essential that HLA and PRA statuses are tested for and demonstrate low immunoreactivity of the patient to the graft. [ 2 ] [ 21 ] [ 24 ]  In some cases, a recipient may suffer from  graft-versus-host disease , in which cells of the transplanted organ attack the recipient's cells. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11882", "text": "To ensure proper histocompatibility, tissue quality, and safety from infection,  blood work  should be collected and tested in the laboratory. In addition to HLA and PRA typing, the  complete blood count  (CBC),  coagulation  profile,  complete metabolic panel , and  ABO blood group  determination tests should be performed for both the donor and recipient. [ 2 ]  ABO-incompatible grafts can sometimes be performed on very young pediatric patients, as their immune systems have not fully developed and for whom waiting list mortality remains high. [ 14 ]  Additionally, blood  serum  should be  tested  for the presence of  viruses , including HIV,  hepatitis B  and  C ,  cytomegalovirus  (CMV), and  Epstein\u2013Barr virus  (EBV) antibodies to prevent infection. [ 24 ]  Particularly in the immunocompromised system necessitated by the transplant, these viruses can wreak havoc on the body and become extremely dangerous, even fatal. Even with healthy physiological levels, ABO and HLA compatibilities, and no signs of bacterial, viral, and  fungal  infections, organ transplantation is not without extrasurgical risk. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11883", "text": "A major challenge facing the intestinal transplant enterprise is meeting the need for transplantable intestines, particularly in the United States where the majority of intestinal transplants take place. [ 9 ]  There exists a narrow timeslot between procurement and transplantation that any organ remains viable, and logistical challenges are faced regarding bringing organ and recipient together. During procurement, organs that are being recovered are cooled and  perfused  with preservation solution. This slows organ activity and increases the time they remain viable for transplant. [ 2 ]  Although chilling and perfusion may extend intestinal lifespans by several hours, failure is still imminent unless transplanted. This duration between the cooling of the organ during procurement and the restoration of physiological temperature during implantation is the  cold ischemic time . Due to the sensitivity of the intestine to ischemic injury, many potential donor intestines are lost to the events following brain death and trauma. Furthermore, irreversible intestinal damage is seen after approximately only 5 hours of cold ischemia in the form of  mucosal  damage and bacterial translocation outside the  gastrointestinal tract . Therefore, ensuring cardiac survival and nearby donor-recipient proximity before procurement are essential so organs do not wait too long outside the body and without blood flow. [ 11 ]  Not only is there a lack of transplantable intestines, but a deficiency in the number of centers possessing the capability to carry out the complicated transplant procedure as well. As of 2005 [update] , there were only 61 medical centers in the world capable of executing an intestinal transplant. [ 9 ]  Furthermore, many young, small children, particularly those weighing less than 5  kg , cannot find a transplant due to the lack of size-matched donors. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11884", "text": "Despite these challenges, obtaining an intestine for transplant is rather probable in the United States. In 2008, there were 212 people on the U.S. intestinal transplant waitlist, 94% of whom were U.S. citizens. [ 7 ]  Regardless of transplant type, over half of new registrants are 5 years of age or younger.  Adults  compromise the next largest cohort, followed by pediatric patients aged 6 and older. In 2008, the  ethnic  composition of the intestinal transplant waitlist was 65%  White , 18%  Black , 16%  Hispanic , 1%  Asian , and 0.5% other or  mixed race , resembling the  demographics  of the American general population at the time aside from a below-average Asian cohort. ABO blood types also matched the general population, with 31% A, 14% B, 5% AB, and 50% O. [ 7 ]  In 2004, the average waiting period to receive a transplant was 220 days, [ 21 ]  with a  median  of 142 days in 2008. [ 7 ]  The rate of waitlist additions has shifted from year to year; gains increased until 2006 (with 317 added), but then decreased in 2012 (to 124 added). [ 26 ]  In 2007, only 9% of patients on the U.S. waitlist died while waiting for a transplant. [ 7 ]  Waitlist mortality peaked around 2002 and was highest for liver-intestine (pediatric) patients. Deaths among all pediatric groups awaiting intestine-liver transplants have decreased in the years leading up to 2014 whereas adult intestine-liver deaths have dropped less dramatically. The decrease in recent years is likely due to improved care of infants with intestinal failure and subsequently a decrease in referrals for transplant. [ 26 ]  Although many improvements have been made in the States, outcomes everywhere still demonstrate much room for improvement. Worldwide, 25% of pediatric patients on the waitlist for an intestinal transplant die before they can receive one. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11885", "text": "Following matching of the organ, the complicated procurement of the small bowel can be performed by a team of abdominal transplant surgeons. Once a donor has been selected and approved for donation, several pretreatments may be initiated to destroy  microorganisms  and  immune cells . The donor intestine must be  decontaminated  with several  antibiotics , including  neomycin ,  erythromycin ,  amphotericin B , and  cephalosporin . [ 18 ]  They may also be treated with anti- lymphocyte  antibodies ( anti-thymocyte globulin ,  alemtuzumab ),  irradiation  directed against excessive mesenteric  lymphatic tissue , and have their bowel  irrigated . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11886", "text": "Once donor preparation is accomplished, procurement can begin by utilizing the same standard techniques for all abdominal organ procurements. The team exposes the abdominal cavity and inserts two  cannulae  for the  infusion  of  University of Wisconsin   organ preservation solution  into the  aorta  and  inferior mesenteric vein . As the abdominal organs are cooled  in situ , the surrounding tissue is  dissected  so that they may be quickly extracted. In the next step, the aorta is  cross-clamped , cutting off blood supply to the organs. Once blood and oxygen supply to an organ is cut off, organ death will approach swiftly unless steps are taken to preserve them until transplant. Organs are therefore fully  drained of blood , flushed with cool preservation solution, and removed from the body. [ 2 ] [ 18 ]  In an isolated intestinal transplant, the  colon will be detached  from the small intestine. The  cecum  and  ascending colon  are devascularized, while care is taken to preserve major  vasculature  in the ileum. The jejunum will be separated from the duodenum while preserving the vasculature of the jejunum, ileum, mesentery, and the pancreas. If healthy, the pancreas can oftentimes be retrieved as an additional isolated procurement. The intestinal allograft, when ready to be extracted, is attached by the mesenteric  pedicle , where the vessels converge out of the intestinal system. This pedicle will be  stapled  closed, and can be separated from the body via a  transverse  cut to create a vascular cuff. The complete intestinal allograft can then be removed and wrapped in a surgical  towel . [ 18 ]  The protocols for combined liver and multivisceral procurements are far more complicated and meticulous than isolated intestine alone. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11887", "text": "First, any abdominal  scar tissue  from previous surgeries must be removed. The aorta and  vena cava  are dissected in preparation for vascular  anastomosis , followed by dissection of the  proximal  and  distal  ends of the digestive tract. Anastomosis is then performed to revascularize the graft. Arterial vessels are connected to the abdominal aorta, below the  kidneys . However, venous drainage, or the reattachment of the transplanted organ to the venous system, may be performed differently depending on the unique intra-abdominal vasculature of the recipient. The graft is usually drained systemically into the  infrarenal  vena cava, [ 15 ]  but may also be drained  portally  into the  hepatic portal  or  superior mesenteric vein . [ 17 ]  The graft is then reperfused with blood and any bleeding is stopped before the proximal and distal ends of the transplant bowel are connected to the original digestive tract. A loop  ileostomy  is then created as to provide easy access for future  endoscopic  observation and  biopsies . A  gastronomy  or  jejunostomy   feeding tube  may be placed before the abdominal wall is closed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11888", "text": "When a liver is being transplanted in conjunction with the intestine, the recipient must first have their own  liver removed . Following this, the aorta, cava, and portal veins of the donor and recipient are anastomosed. The graft is then flushed before the caval  clamps  are removed. The intestine is then reconstructed as in an isolated intestinal transplant, before being connected to the  bile duct  servicing the new liver. [ 17 ]   Multivisceral transplants  are especially difficult and susceptible to complications because all organs must survive a conjoined procurement, transport, and transplantation. All three of these measures are tailored to the individual needs of the recipient. [ 18 ]  Preservation of the native  spleen , pancreas, and duodenum during a multivisceral transplant can reduce the risk of additional complications related to these structures. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11889", "text": "Following the procedure, the patient is actively monitored in an  intensive care unit  (ICU).  Broad-spectrum antibiotics  are administered, bleeding monitored, and serum  pH  and  lactate  levels measured for evidence of intestinal ischemia. The patient's immune system is strongly modulated immediately post-operation. The  initial phase of treatment  consists of the administration of tacrolimus with  corticosteroids  to suppress T-lymphocyte activation. Next, various assortments of  interleukin-2  (IL-2)  receptor   antagonists  ( daclizumab ,  basiliximab ), anti-proliferation agents ( azathioprine ,  mycophenolate mofetil ), and the drugs  cyclophosphamide  and  sirolimus  are administered on an individual patient basis to further suppress the immune system. [ 11 ]  The  bioavailability  of these drugs is dependent on intestinal  surface area  and transit time, and therefore the length of the allograft determines the immunosuppression regimen. [ 2 ]  Intravenous administration of  prostaglandin E1  is occasionally performed for the first 5 to 10 days following transplant to improve intestinal circulation and a potential dispensing of immunosuppressive effects. [ 2 ] [ 11 ]  The gut is selectively decontaminated against high-risk  flora  and  preventative care  is taken against CMV and fungal infections. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11890", "text": "It is ideal to commence enteral nutrition as early as possible following transplantation. Therefore, a feeding tube connecting to the stomach or jejunum is quickly placed to facilitate rehabilitation. [ 11 ]  If gastrointestinal function is restored, a diet can be reestablished and cautiously advanced as tolerated. Most patients are weaned from PN within 4 weeks of transplantation, and nearly all are free from additional enteral supplementation by one year. [ 14 ]  Evidence for the restoration of function includes decreasing gastrostomy tube returns and increasing  gas  and enteric contents in the ileostomy. [ 2 ]  Routine surveillance endoscopy and biopsies via the ileostomy should be performed with decreasing frequency over several months to observe signs of rejection, ideally before clinical symptoms present themselves. Should the patient continue to perform well through the first post-transplant year, the ileostomy would generally be closed. Should rejection be suspected in the future, endoscopies would be performed and an appropriate antirejection therapy will be tailored. The median time for hospital  discharge  varies between procedures. The median times for isolated intestine, intestine-liver, and multivisceral transplants are 30, 60, and 40 days post-operation respectively. [ 14 ]  Within the first several months,  carbohydrate  and  amino acid  absorptive capacity should normalize, followed by the absorptive capacity for fats. Once enteral nutrition is capable of providing all nutritional needs, PN can be discontinued. [ 2 ]  Nearly all patients with a successful transplant are free of PN within one year. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11891", "text": "Intestinal transplantation is the least performed type of transplant due to a number of unique obstacles. The most major of these is the profound immunosuppression required due to the ability of the intestine to elicit strong immune responses. Because of exposure to a wide range of gut flora and material consumed by the body, the intestinal  epithelium  possesses a highly developed  innate immune system  and  antigen-presenting  abilities. Immunosuppression is the primary determinant of outcome in small bowel transplantation; the risk for graft rejection is increased by under-immunosuppression and for local and systemic infection with over-immunosuppression. [ 11 ]  Ensuring an appropriate dose of immunosuppressant can therefore be difficult, especially as both ciclosporin (14\u201336%) and tacrolimus (8.5\u201322%) have generally low bioavailabilities. [ 27 ]  A major problem due to immunosuppression in intestinal transplant patients is post-transplant  lymphoproliferative disorder , in which B-lymphocytes excessively proliferate due to infection by EBV and result in infectious  mononucleosis -like lesions. [ 7 ]  Intestinal transplant recipients are also at risk for chronic  renal failure  because  calcineurin  inhibitors are  toxic  to the kidneys. A transplant recipient must remain on immunosuppressants for the rest of his or her life. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11892", "text": "Intestinal transplants are highly susceptible to infection even more so than the standard immunocompromised recipient of other organs due to the great composition and variety of the gut flora. [ 11 ]  A complex assortment of microorganisms inhabits the human digestive tract, with concentrations of up to 10 4 \u201310 7   CFU /mL in the jejunoileum and 10 11 \u201310 12  CFU/mL in the colon. [ 28 ]  While suppression of the immune system may prevent immune attack on the new allograft, it may also prevent the immune system's ability to keep certain gut microbial populations in line. Despite pre and post-decontamination of the transplant, recipients are at risk of local and systemic infection by both natural and external flora. The common symptom of graft dysfunction, whether due to infection, rejection, or some other condition, is  diarrhea . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11893", "text": "Intestinal transplant outcomes have improved significantly in recent years. Despite mild incongruities in survival rate percentages between centers in North America, Europe, Australia, and elsewhere, intestinal transplantations mostly approach survivorship rates of  lung transplantation . [ 11 ]  At one-year, graft survival rates for isolated intestine currently waver around 80%, and 70% for intestine-liver and multivisceral. Over the same time period, patient survival for isolated intestine patients may even exceed 90%, while the more complicated multiorgan transplants do not show any increase in patient survival when compared to patients surviving with the intestinal graft alone. [ 14 ]  The five-year survival rate for patients and transplants ranges from 50 to 80% (overall mean 60%), depending on underlying disease and presurgical  morbidity . Very young (<1 year) and very old (>60 years) patients receiving a transplant have pronounced rates of mortality. [ 14 ] [ 15 ]  After 4 years, pediatric survival significantly worsens compared to adults. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11894", "text": "Several factors relating to superior patient and graft prognosis have proven to be statistically significant. Patients who have been admitted for transplant directly from home rather than the hospital, younger patients over one year of age, those receiving their first transplant, those receiving transplants at experienced transplant centers, and who receive antibody or sirolimus-based induction therapies have increased rates of survival. [ 9 ] [ 15 ]  Furthermore, underlying  etiology , [ 29 ]  the presence of  comorbidity , the frequency of previous surgery, nutritional status, and the level of liver function have been found to affect patient-graft survival . [ 30 ]  Patients with a pre-transplant diagnosis of volvulus were found to possess a lower risk of mortality. [ 29 ]  As of 2008, the longest recorded surviving transplant survived for 18 years. [ 14 ]  Between 1999 and 2008, 131 retransplant procedures were performed in the United States. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11895", "text": "The improvement to quality of life following an intestinal transplantation is significant. Of living patients 6 months after transplant, 70% are considered to have regained full intestinal function, 15% are at partial function, and 15% have had their grafts removed. [ 9 ] [ 14 ]  For those with full function, enteral nutritional  autonomy  is high. [ 7 ]  The ability to resume regular activities such as the ability to consume food and exert control over digestive function is certainly a welcome return for patients. The low quality of life induced by intestinal failure is oftentimes further supplemented by significant  psychosocial   disability  and  narcotic   dependence . Following transplantation, these have been found to generally decrease. [ 15 ]  According to surveys comparing patients who have undergone transplants and those that have not, there seems to be a remarkable improvement for transplant recipients in such areas as  anxiety , depression,  appearance ,  stress ,  parenting ,  impulsiveness ,  optimism ,  medical compliance , and the quality of  relationships . [ 14 ] [ 15 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11896", "text": "Receiving an organ transplant of any kind is a highly significant investment financially, but a successful, well-functioning transplant can be very  cost-efficient  relative to alternate therapies. Total charges to maintain PN at home can reach upwards of $150,000 a year, even though the actual cost of nutrition is typically only $18 to $22 a day. [ 5 ] [ 14 ]  This excludes the cost for additional home support, equipment, and the care of PN-related complications. The cost involved in undergoing intestinal transplantation, including the initial hospitalization for the transplant, can range from $150,000 to $400,000, and reoccurring hospitalizations are common up through the second year. Two to three years post-transplant, the financial cost of transplantation reaches parity with PN and is more cost-effective thereafter. [ 11 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11897", "text": "Jejunojejunostomy  is a surgical technique used in an  anastomosis  between two portions of the  jejunum . [ 1 ]  It is a type of  bypass  occurring in the  intestine . It may lead to marked reduction in the functional volume of the intestine. This technique is also performed using  Laparoscopic  surgery. [ 2 ]  The surgical procedure can lead to complications including  infections ,  hemorrhage ,  strictures ,  ulcers ,  intestinal obstruction ,  thromboembolism  and  malnutrition . [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11898", "text": "Jejunostomy  is the surgical creation of an opening (stoma) through the skin at the front of the abdomen and the wall of the  jejunum  (part of the  small intestine ). It can be performed either  endoscopically , or with  open surgery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11899", "text": "A jejunostomy may be formed following  bowel resection  in cases where there is a need to bypass the distal small bowel and/or colon due to a bowel leak or perforation. Depending on the length of jejunum resected or bypassed the patient may have resultant  short bowel syndrome  and require  parenteral nutrition . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11900", "text": "A jejunostomy is different from a jejunal  feeding tube . A jejunal feeding tube is an alternative to a  gastrostomy   feeding tube  and is commonly used when gastric enteral feeding is contraindicated or carries significant risks.  The advantage over a gastrostomy is its low risk of  aspiration  due to its distal placement. Disadvantages include  small bowel  obstruction,  ischemia , and requirement for continuous feeding. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11901", "text": "The  Witzel jejunostomy  is the most common method of jejunostomy creation. [ 4 ]   It is an open technique where the jejunosotomy is sited 30\u00a0cm distal to the  Ligament of Treitz  on the antimesenteric border, with the catheter tunneled in a seromuscular groove. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11902", "text": "Laparoscopy  (from  Ancient Greek     \u03bb\u03b1\u03c0\u03ac\u03c1\u03b1  ( lap\u00e1ra ) \u00a0'flank, side' and    \u03c3\u03ba\u03bf\u03c0\u03ad\u03c9  ( skop\u00e9\u014d ) \u00a0'to see') is an operation performed in the  abdomen  or  pelvis  using small  incisions  (usually 0.5\u20131.5\u00a0cm) with the aid of a camera. The laparoscope aids  diagnosis  or therapeutic interventions with a few small cuts in the abdomen. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11903", "text": "Laparoscopic surgery, also called  minimally invasive procedure , bandaid surgery, or keyhole surgery, is a modern  surgical  technique. There are a number of advantages to the patient with laparoscopic surgery versus an  exploratory laparotomy . These include reduced pain due to smaller incisions, reduced  hemorrhaging , and shorter recovery time. The key element is the use of a  laparoscope , a long fiber optic cable system that allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11904", "text": "Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Specific surgical instruments used in laparoscopic surgery include  obstetrical forceps , scissors, probes, dissectors, hooks, and retractors. Laparoscopic and thoracoscopic surgery belong to the broader field of  endoscopy . The first laparoscopic procedure was performed by German surgeon  Georg Kelling  in 1901."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11905", "text": "There are two types of laparoscope: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11906", "text": "The mechanism mentioned in the second type is mainly used to improve the image quality of flexible endoscopes, replacing conventional  fiberscopes . Nevertheless, laparoscopes are rigid endoscopes. Rigidity is required in clinical practice. The rod-lens-based laparoscopes dominate overwhelmingly in practice, due to their fine optical resolution (50\u00a0\u03bcm typically, dependent on the aperture size used in the objective lens), and the image quality can be better than that of the digital camera if necessary. The second type of laparoscope is very rare in the laparoscope market and in hospitals. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11907", "text": "Also attached is a  fiber optic  cable system connected to a \"cold\" light source ( halogen  or  xenon ) to illuminate the operative field, which is inserted through a 5\u00a0mm or 10\u00a0mm  cannula  or  trocar . The  abdomen  is usually  insufflated  with  carbon dioxide  gas. This elevates the abdominal wall above the internal organs to create a working and viewing space. CO 2  is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11908", "text": "During the laparoscopic procedure, the position of the patient is either in  Trendelenburg position  or in reverse Trendelenburg. These positions have an effect on cardiopulmonary function. In Trendelenburg's position, there is an increased  preload  due to an increase in the venous return from lower extremities. This position results in cephalic shifting of the viscera, which accentuates the pressure on the diaphragm. In the case of reverse Trendelenburg position, pulmonary function tends to improve as there is a caudal shifting of viscera, which improves tidal volume by a decrease in the pressure on the diaphragm. This position also decreases the preload on the heart and causes a decrease in the venous return leading to hypotension. The pooling of blood in the lower extremities increases the stasis and predisposes the patient to develop deep vein thrombosis (DVT). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11909", "text": "Rather than a minimum 20\u00a0cm incision as in traditional (open)  cholecystectomy , four incisions of 0.5\u20131.0\u00a0cm, or, beginning in the second decade of the 21st century, a single incision of 1.5\u20132.0\u00a0cm, [ 5 ]  will be sufficient to perform a laparoscopic removal of a  gallbladder .\nSince the gallbladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1\u00a0cm incision at the patient's navel.\nThe length of postoperative stay in the hospital is minimal,\nand most patients can be safely discharged from the hospital the same day. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11910", "text": "In certain advanced laparoscopic procedures, where the specimen removed is too large to pull through a trocar site (as is done with gallbladders), an incision larger than 10\u00a0mm must be made. The most common of these procedures are removal of all or part of the colon ( colectomy ), or removal of the kidney ( nephrectomy ). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an  anastomosis ). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO 2  will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events (e.g., uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11911", "text": "Conceptually, the laparoscopic approach is intended to minimise post-operative  pain  and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes in the early 21st century, laparoscopic surgery has been adopted by various surgical sub-specialties, including gastrointestinal surgery (including bariatric procedures for  morbid obesity ), gynecologic surgery, and urology. Based on numerous prospective  randomized controlled trials , the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional  hernias  (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11912", "text": "The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception, and the limited working area are factors adding to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery gain additional laparoscopic surgery training during one or two years of fellowship after completing their basic surgical residency. In OB-GYN residency programs, the average laparoscopy-to-laparotomy quotient (LPQ) is 0.55. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11913", "text": "Laparoscopic techniques have also been developed in the field of  veterinary medicine . Due to the relatively high cost of the equipment required, it has not become commonplace in most traditional practices today but rather limited to specialty practices. Many of the same surgeries performed in humans can be applied to animal cases\u00a0\u2013 everything from an egg-bound tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA (Journal of the American Veterinary Medical Association) in 2005 showed that dogs spayed laparoscopically experienced significantly less pain (65%) than those that were spayed with traditional \"open\" methods. [ 11 ]   Arthroscopy , thoracoscopy, and cystoscopy are all performed in veterinary medicine today."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11914", "text": "There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11915", "text": "Although laparoscopy in adults is widely accepted, its advantages in children are questioned. [ 19 ] [ 20 ]  Benefits of laparoscopy appear to recede with younger age. Efficacy of laparoscopy is inferior to open surgery in certain conditions such as  pyloromyotomy  for infantile hypertrophic  pyloric stenosis . Although laparoscopic  appendectomy  has less wound problems than open surgery, the former is associated with more intra-abdominal  abscesses . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11916", "text": "While laparoscopic surgery is clearly advantageous in terms of patient outcomes, the procedure is more difficult from the surgeon's perspective when compared to conventional, open surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11917", "text": "Some of the risks are briefly described below:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11918", "text": "In recent years, electronic tools have been developed to aid surgeons. Some of the features include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11919", "text": "Robotic surgery has been touted as a solution to  underdeveloped nations , whereby a single central hospital can operate several remote machines at distant locations. The potential for  robotic surgery  has had a strong military interest as well, with the intention of providing mobile  medical care  while keeping trained doctors safe from battle.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11920", "text": "In January 2022, a robot performed the first ever successful laparoscopic surgery without the help of a human. The robot performed the surgery on the soft tissue of a pig. It succeeded at intestinal anastomosis, a procedure that involves connecting two ends of an intestine. The robot, named the Smart Tissue Autonomous Robot (STAR), was designed by a team of Johns Hopkins University researchers. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11921", "text": "There are also user-friendly nonrobotic assistance systems that are single-hand guided devices with a high potential to save time and money. These assistance devices are not bound by the restrictions of common medical robotic systems. The systems enhance the manual possibilities of the surgeon and his/her team, regarding the need of replacing static holding force during the intervention. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11922", "text": "With laparoscopy providing tissue diagnosis and helping to achieve the final diagnosis without any significant complication and less operative time, it can be safely concluded that diagnostic laparoscopy is a safe, quick, and effective adjunct to non\u2011surgical diagnostic modalities, for establishing a conclusive diagnosis, but whether it will replace imaging studies as a primary modality for diagnosis needs more evidence. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11923", "text": "It is difficult to credit one individual with the pioneering of the laparoscopic approach. In 1901,  Georg Kelling  of  Dresden , Germany, performed the first laparoscopic procedure in dogs, and, in 1910,  Hans Christian Jacobaeus  of Sweden performed the first laparoscopic operation in humans. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11924", "text": "In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. The advent of computer chip-based television cameras was a seminal event in the field of laparoscopy. This technological innovation provided the means to project a magnified view of the operative field onto a monitor and, at the same time, freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11925", "text": "The first publication on modern diagnostic laparoscopy by  Raoul Palmer  appeared in 1947, [ 45 ]  followed by the publication of  Hans Frangenheim  and  Kurt Semm , who both practised  CO 2  hysteroscopy from the mid-1970s. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11926", "text": "Patrick Steptoe , one of the pioneers of  IVF , was important in popularizing laparoscopy in the UK. He published a textbook,  Laparoscopy in Gynaecology,  in 1967. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11927", "text": "In 1972, H. Courtenay Clarke invented, published, patented, presented, and recorded on film laparoscopic surgery, with instruments he invented and were marketed by the Ven Instrument Company of  Buffalo, New York . [ 48 ]   He was the first to perform a surgical laparoscopic process with standard sutures [ 49 ]  and simple instruments This was meant to facilitate the application of laparoscopic surgery to all economic sectors by avoiding expensive materials and devices. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11928", "text": "In 1975, Tarasconi, from the Department of Ob-Gyn of the University of Passo Fundo Medical School (Passo Fundo, RS, Brazil), started his experience with organ resection by laparoscopy (Salpingectomy), first reported in the Third AAGL Meeting, Hyatt Regency Atlanta, November 1976 and later published in The Journal of Reproductive Medicine in 1981. [ 51 ] \nThis laparoscopic surgical procedure was the first laparoscopic organ resection reported in medical literature."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11929", "text": "In 1981, Semm, from the gynecological clinic of Kiel University, Germany, performed the first  laparoscopic   appendectomy . Following his lecture on laparoscopic appendectomy, the president of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society suggesting suspension of Semm from medical practice. Subsequently, Semm submitted a paper on laparoscopic appendectomy to the  American Journal of Obstetrics and Gynecology , at first rejected as unacceptable for publication on the grounds that the technique reported on was \"unethical,\" but finally published in the journal  Endoscopy . The abstract of his paper on endoscopic appendectomy can be found at the journal site. [ 46 ] [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11930", "text": "Semm established several standard procedures that were regularly performed, such as  ovarian cyst  enucleation,  myomectomy , treatment of  ectopic pregnancy  and finally laparoscopic-assisted vaginal  hysterectomy  (also termed cervical intra-fascial Semm hysterectomy). He also developed a medical instrument company Wisap in  Munich ,  Germany , which still produces various endoscopic instruments. In 1985, he constructed the pelvi-trainer = laparo-trainer, a practical surgical model whereby colleagues could practice laparoscopic techniques. Semm published over 1000 papers in various journals. He also produced over 30 endoscopic films and more than 20,000 colored slides to teach and inform interested colleagues about his technique. His first atlas,  More Details on Pelviscopy and Hysteroscopy  was published in 1976, a slide atlas on pelviscopy, hysteroscopy, and fetoscopy in 1979, and his books on gynecological endoscopic surgery in German, English, and many other languages in 1984, 1987, and 2002. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11931", "text": "In 1985,  Erich M\u00fche , professor of surgery in Germany, performed the first laparoscopic  cholecystectomy . [ 53 ]  Afterward, laparoscopy gained rapid acceptance for non-gynecologic applications. The first video-assisted laparoscopic surgery was performed in 1987, a laparoscopic cholecystectomy. [ 54 ]  Before this time, the  operating field  was visualised by surgeons directly via a laparoscope."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11932", "text": "In 1987,  Alfred Cuschieri  performed the first minimally invasive surgery in the UK with his team at  Ninewells Hospital  after working with multiple researchers from across the world, including  Patrick Steptoe . Cuschieri took advantage of smaller cameras to perform operations with smaller cuts and shorter recovery times. After some controversy and patient deaths, new laparoscopic training centres were set up as most surgeons lacked the necessary specialised training to perform laparoscopic surgery. The first opened in Dundee in 1991 and became the Cuschieri Skills Centre at Ninewells Hospital in 2004. As of 2008, 40 specialist centres around the world base their laparoscopic training on the Cuschieri Skills Centre. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11933", "text": "Prior to M\u00fche, the only specialty performing laparoscopy on a widespread basis was gynecology, mostly for relatively short, simple procedures such as a diagnostic laparoscopy or tubal ligation. The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made general surgeons more comfortable with making the leap to laparoscopic cholecystectomies ( gall bladder removal). On the other hand, some surgeons continue to use the single clip appliers as they save as much as $200 per case for the patient, detract nothing from the quality of the clip ligation, and add only seconds to case lengths. Both laparoscopy tubal ligations and cholecystectomies may be performed using suturing and tying, thus further reducing the expensive cost of single and multiclips (when compared to suture). Once again this may increase case lengths but costs are greatly reduced (ideal for developing countries) and widespread accidents of loose clips are eliminated. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11934", "text": "The  first transatlantic surgery  performed was a laparoscopic  gallbladder  removal in 2001. The first robotic advanced  pediatric surgery  series were performed overseas in Egypt at  Cairo University . [ 56 ] [ 57 ]   Remote surgeries  and  robotic surgeries  have since become more common and are typically laparoscopic procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11935", "text": "There are many International and American Surgical Associations involved in surgical education and training for laparoscopy, thoracoscopy and many minimally invasive procedures for both adults and pediatrics. These societies include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11936", "text": "In gynecology, diagnostic laparoscopy may be used to inspect the outside of the  uterus ,  ovaries , and  fallopian tubes , as, for example, in the diagnosis of  female infertility . [ 60 ]  Usually, one incision is placed near the navel and a second near the  pubic hairline . A special type of laparoscope called a  fertiloscope , which is modified for  transvaginal  application, can be used. A dye test may be performed to detect any blockage in the reproductive tract, wherein a dark blue dye is passed up through the  cervix  and is followed with the laparoscope through its passage out into the fallopian tubes to the ovaries. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11937", "text": "A  laparotomy  is a  surgical  procedure involving a surgical incision through the  abdominal wall  to gain access into the  abdominal cavity . It is also known as a  celiotomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11938", "text": "The first successful laparotomy was performed without anesthesia by  Ephraim McDowell  in 1809 in  Danville, Kentucky . On July 13, 1881,  George E. Goodfellow  treated a miner outside  Tombstone , Arizona Territory, who had been shot in the abdomen with a .32-caliber Colt revolver. Goodfellow was able to operate on the man nine days after he was shot, when he performed the first laparotomy to treat a bullet wound. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11939", "text": "The term comes from the Greek word \u03bb\u1fb0\u03c0\u03ac\u03c1\u1fb1 (lapara) 'the soft part of the body between the ribs and hip, flank' [ 2 ]  and the suffix  -tomy , from the Greek word \u03c4\u03bf\u03bc\u03ae (tome) '(surgical) cut'."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11940", "text": "In  diagnostic laparotomy (most often referred to as an  exploratory laparotomy  and abbreviated ex-lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11941", "text": "In therapeutic laparotomy, a cause has been identified (e.g.  colon cancer ) and the operation is required for its therapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11942", "text": "Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11943", "text": "Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11944", "text": "The most common incision for laparotomy is a vertical incision in the middle of the abdomen which follows the  linea alba . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11945", "text": "Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11946", "text": "Other common laparotomy incisions include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11947", "text": "Globally, there are few studies comparing perioperative mortality following laparotomy across different health systems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11948", "text": "A study in the UK with more than 180,000 patients aimed to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the United Kingdom National Emergency Laparotomy Audit (NELA) database. A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013\u2013December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Results showed that quantitative futility occurred in 4% of patients (7442/180,987) and median age was 74 years. Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality and surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery. These findings suggest that quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively and should be incorporated into shared decision-making discussions with extremely high-risk patients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11949", "text": "There are also several national studies looking at 30-day mortality in various health systems including the United Kingdom (the National Emergency Laparotomy Audit- NELA) and Australia and New Zealand (ANZELA). One major prospective study of 10,745 adult patients undergoing emergency laparotomy from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high- HDI  countries even when adjusted for prognostic factors. [ 12 ]  In this study the overall global mortality rate was 1.6 percent at 24\u2009hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent; P < 0.001), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent; P < 0.001). Of the 578 patients who died, 404 (69.9 percent) did so between 24\u2009h and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the  WHO Surgical Safety Checklist  associated with reduced mortality at 30 days. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11950", "text": "Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed in these settings. Internationally, the most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11951", "text": "Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11952", "text": "A related procedure is  laparoscopy , where cameras and other instruments are inserted into the  peritoneal cavity  via small holes in the abdomen. For example, an  appendectomy  can be done either by a laparotomy or by a  laparoscopic  approach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11953", "text": "There is no evidence of short-term or long-term advantages for peritoneal closure during laparotomy. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11954", "text": "Lateral internal sphincterotomy  is an  operation  performed on the  internal anal sphincter  muscle for the treatment of chronic  anal fissure . The internal anal sphincter is one of two muscles that comprise the anal  sphincter  which controls the passage of  feces . The procedure helps by lowering the resting pressure of the internal anal sphincter, which improves blood supply to the fissure and allows faster healing. [ 1 ]  The procedure has been shown to be very effective, with 96% of fissures healing at a median of 3 weeks in one trial. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11955", "text": "Lateral internal sphincterotomy is the preferred method of surgery for persons with chronic anal fissures, and is generally used when medical therapy has failed. [ 1 ]  It is associated with a lower rate of side effects than older techniques such as posterior internal sphincterotomy and anoplasty, [ 3 ]  and has also been shown to be superior to topical  glyceryl trinitrate  (GTN 0.2% ointment) in long term healing of fissures, with no difference in fecal continence. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11956", "text": "Lateral internal sphincterotomy is a minor operation which can be carried out under either  local  or  general anaesthesia ; a report in 1981 showed that general anaesthesia is preferable due to high rates of fissure recurrence in patients treated under local anaesthesia. [ 5 ]  This operation is generally carried out as a day case procedure. It can be performed with either \"open\" or \"closed\" techniques: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11957", "text": "In both techniques the lower one third to one half of the internal sphincter is divided, to lower the resting pressure without destroying the effect of the sphincter. The closed technique results in a smaller wound, but both techniques appear to be similarly effective. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11958", "text": "The  longitudinal intestinal lengthening and tailoring  (Bianchi) procedure is a form of autologous intestinal reconstruction. The small bowel is divided longitudinally in the midline, preserving one leaf of mesentery with its blood supply to each half. This results in two vascularized segments of small bowel which can then be rejoined end-to-end to restore continuity of the small bowel. There are also another ways of performing this procedure. [ 1 ]  it is one of the surgical therapeutic options along with other surgical options such as small bowel  segmental reversal ,  artificial intestinal valve construction ,  electrical pacing of the small bowel ,  serial transverse enteroplasty , or  transplantation  in treatment of  short gut syndrome . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11959", "text": "The procedure was first described by Bianchi in 1980 in a porcine model and first applied clinically by Boeckman and Traylor in 1981. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11960", "text": "A  lower anterior resection , formally known as  anterior resection of the rectum and colon  and  anterior excision of the rectum  or simply  anterior resection  (less precise), is a common surgery for  rectal cancer  and occasionally is performed to remove a diseased or ruptured portion of the intestine in cases of  diverticulitis . It is commonly  abbreviated  as  LAR . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11961", "text": "LARs are for cancer in the  proximal  (upper) two-thirds of the rectum which lends itself well to resection while leaving the rectal sphincter intact. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11962", "text": "LARs, generally, give a better  quality of life  than  abdominoperineal resections  (APRs). [ 2 ] [ 3 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible. APRs lead to a permanent colostomy and do not spare the sphincters. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11963", "text": "Low anterior resection syndrome (LARS) comprises a collection of symptoms mainly affecting patients after surgery for rectal cancer characterized by fecal incontinence (stool and gases), fecal urgency, frequent bowel movements and bowel fragmentation, while some patients only experience constipation and a  feeling of incomplete bowel emptying . [ 4 ] [ 5 ] [ 6 ]    The cause is unclear, and has been thought to be due to nerve damage, or possibly due to loss of the  rectoanal inhibitory reflex. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11964", "text": "Many of the symptoms of LAR syndrome improve over a period of many months. [ 7 ]  The nerves that control the natural contractions of the colon and rectum run along the colon and can be damaged or cut during the surgery. [ citation needed ]   After such damage, the nerves can regrow, but only slowly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11965", "text": "Natural orifice transluminal endoscopic surgery  ( NOTES ) is a  surgical  technique whereby \"scarless\"  abdominal  operations can be performed with an  endoscope  passed through a natural orifice ( mouth ,  urethra ,  anus ,  vagina , etc.) then through an internal  incision  in the  stomach ,  vagina ,  bladder  or  colon , thus avoiding any external incisions or  scars . [ 1 ] [ 2 ]   Memic's hominis robotic system is the first and only FDA-authorized surgical robotic platform for NOTES procedures. The system is currently at use for transvaginal  hysterectomies  through the  rectouterine pouch  - the removal of the uterus, along with one or both of the  fallopian tubes  and  ovaries , in cases where there is no cancer present, as well as with the removal of  ovarian cysts   [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11966", "text": "Ralph John Nicholls  (born 20 May 1943), FRCS (Eng), EBSQ is a retired British colorectal surgeon, Emeritus Consultant Surgeon at  St Mark's Hospital  London and Professor of Colorectal Surgery,  Imperial College London . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11967", "text": "R. John Nicholls is best known for his work in the development of ileal pouch surgery. With the advancement of  ileal-anal pouch surgery , selected patients with  ulcerative colitis  and  familial adenomatous polyposis (FAP)  requiring surgery can be treated by removing the diseased  colon  also known as the large intestine and  rectum  while preserving the anus, thereby avoiding a permanent stoma ( ileostomy ). This revolutionary operation challenged the conventional procedure used at the time,  total procotocolectomy , which included removal of the  anal sphincter  leaving the patient with an ileostomy for life. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11968", "text": "The technique of  ileal pouch-anal anastomosis (IPAA)  surgery, also known as restorative procotocolectomy (RPC) consists of removal of the diseased colon and rectum, immediately followed by the creation of a surgical join ( anastomosis ) between the small intestine ( ileum ) above and the  anus  below. The reservoir function of the rectum lost by its removal was replaced by the surgical construction of a 'new' rectum made from the ileum to form a so-called \"ileal pouch\". This enabled the patient requiring surgery for ulcerative colitis and some with familial adenomatous polyposis to avoid a permanent ileostomy by enabling the storage of stool in the pouch as would normally occur in the rectum to be followed by defaecation through the anus at the patient's convenience. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11969", "text": "The drive behind creating and developing  ileo-anal pouch  surgery was to improve the quality of life for select patients who required surgery for their condition and were medically suitable to undergo the procedure.  The decision to undergo the pouch operation was made by the patient based on objective information and their preference between life with a permanent ileostomy or the preservation of defaecation through the anus, in each case with the removal of the disease. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11970", "text": "The pouch operation with anal anastomosis was designed to be the patient's choice between life with an ileostomy or they could choose an elective/optional pouch reconstruction after the colon and rectum needed to be removed due to disease.  The  Kock pouch  procedure developed by Finnish surgeon  Nils Kock  first reported in Sweden in 1969 which is a continent ileostomy, was also an attempt to improve the patient's quality of life, but it still required an opening of the bowel onto the abdominal wall, rather than preservation of the normal route of defaecation through the anus as in restorative proctocolectomy. [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11971", "text": "Born in Wilby, England, Nicholls attended  Felsted School  and went on to study medicine at Gonville and Caius College in the  University of Cambridge . [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11972", "text": "He completed his clinical training and surgical residency at the London Hospital (known from 1990 as the  Royal London Hospital ) and became a Fellow of the  Royal College of Surgeons in England  in 1972. It was at the London Hospital, that Nicholls trained under British surgeon  Sir Alan Parks . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11973", "text": "Parks operated on his first  ileo-anal pouch  patient in 1976 at the London Hospital and subsequently at  St Mark's Hospital  where he was also a consultant. [ 12 ] [ 13 ]   Nicholls was his first assistant having spent 1976 carrying out research under Fritz Linder [ 14 ]  on an Alexander von Humboldt Fellowship in the Department of Surgery at the  Heidelberg University  in Germany. Nicholls became a Resident Surgical Officer at St Mark's on his return to the UK in 1977. He was also a consultant surgeon to  St Thomas' Hospital , London, from 1982 to 1993 when he left to become Dean of St Mark's."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11974", "text": "The  ileal pouch-anal anastomosis  (IPAA) procedure was an advancement from the \"straight\" ileoanal anastomosis procedure original described by the German surgeon  Nissen  in 1934 and resurrected by the Americans  Ravitch  and  Sabiston  in 1947. [ 15 ]   They described the total removal of the colon and rectum with restoration of intestinal continuity by means of an ileo-anal anastomosis without any formation of an ileal pouch or reservoir.  They procedure resulted in high frequency and urgency of defaecation day and night which made life difficult for many patients. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11975", "text": "Finnish surgeon  Nils Kock  premiered his continent ileostomy procedure in Sweden in 1969.  The procedure known as a  Kock pouch  involved first the removal of the colon, rectum, and anus.  Next, using the last 45 centimetres of the ileum, the construction of an ileal pouch with a valve designed only to allow drainage of its contents when a  catheter  was passed through the stoma on the  abdominal wall .  This allowed many patients to have control over their life by being able to evacuate stool at a time of their choosing. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11976", "text": "When Koch showed that the creation of an ileal reservoir in humans did not compromise the patient's health,  Alan Parks  recognised that the combination of total surgical removal of the disease by excision of the colon and rectum combined with an ileal pouch to replace the lost reservoir of the rectum might achieve the two aims of cure of the disease and acceptable bowel function. Parks then constructed a reservoir or \"pouch\" made from the last 40\u201350 centimetres of the small bowel (ileum) after excision of the colon and rectum and joined this to the anus to form an ileo-anal anastomosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11977", "text": "This not only preserved anal function but the creation of a reservoir was intended to improve the patient's function by reducing the frequency of defaecation as much as was possible. The operation is known by several names globally today including ileal pouch, Parks' pouch, pelvic pouch, S-pouch, J-pouch, W-pouch, Ileal Pouch Anal Anastomosis (IPAA) and restorative proctocolectomy (RPC).  It is also now performed for a number of conditions beyond ulcerative colitis and familial adenomatous polyposis (FAP) including accident or injury, infection, allergic reaction, toxic mega colon, and cancer among others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11978", "text": "Parks and Nicholls published the seminal article on  ileo-anal pouch  surgery entitled \"Proctocolectomy without ileostomy for ulcerative colitis\" in 1978 published by the British Medical Journal. [ 16 ]   Articles that followed in the surgical literature mainly centred on clinical results including complications and function.  This was followed by period of time during which the shape and size of the reservoir became and area of interest. [ 17 ]  Parks' original design, the so-called \"S-pouch\", was often followed by difficulty in evacuation of stool due to the retention of a short segment of ileum anastomosed at the anal canal.  The \"J-pouch\" described by Utsunomiya in 1980 largely avoided this problem. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11979", "text": "The demonstration of an inverse relationship between the capacity of the pouch and the frequency of defaecation led to further designs including the W-pouch described by Nicholls led to further designs including the W-pouch he described in 1987 which was free from defaecation difficulty and appeared also to be followed by fewer bowel actions per 24 hours than the J-pouch. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11980", "text": "Following the unexpected death of Alan Parks on November 3, 1982, [ 20 ]  John Nicholls became the most active pouch surgeon in the United Kingdom. At this time he was still a mid-career surgeon but he had been working with the operation since its inception when he was still a senior registrar (chief resident)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11981", "text": "By the early 1980s, the ileal pouch procedure had become part of specialist colorectal surgical practices worldwide. In the United States the Australian-born surgeon  Victor Warren Fazio  at the  Cleveland Clinic  and Roger Dozois [ 21 ] [ 22 ]  at the  Mayo Clinic  began publishing on the operation in the early 1980s greatly increasing its diffusion and there was generous co-operation among these units, St Mark's and colorectal departments in Canada (Zane Cohen), [ 23 ] [ 24 ]  France (Rolland Parc) [ 25 ]  and Italy (Gilberto Poggioli). [ 26 ] [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11982", "text": "Nicholls' other contributions to coloproctology include aspects of rectal cancer related to staging, local surgery, and radiotherapy and his collaboration with Professor Michael Kamm in the field of incontinence. [ 29 ] [ 30 ]   He was a founding member of the European Society of Coloproctology and was first secretary of the Division of Colorectal Surgery of the Union Europ\u00e9enne des M\u00e9decins Specialistes (UEMS) which instigated accreditation and certification for  colorectal surgery . [ 31 ]   He was the founder of the International Journal of Colorectal Disease and was its editor from 1986 to 1999.  He then established the journal Colorectal Disease of which he was Editor-in-Chief until his retirement in 2014, during which time the Impact Factor rose to be the second of colorectal journals worldwide. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11983", "text": "Nicholls became Dean of St Mark's from 1987 and held the position until 1997.  From 1997 to 2001, he was the Clinical Director of St Mark's Hospital.  During this time (from 1997 to 2001), Nicholls was additionally a member of the Specialist Advisory Committee in General Surgery for Higher Surgical Training in Great Britain and Ireland. In 1993 he with his colleague James Thomson, the Clinical Director of St Mark's at the time, created the St Mark's Academic Institute. [ 34 ]   He was appointed Professor of Colorectal Surgery in Imperial College London in 1997 and was Chairman of the Board of Trustees of Northwick Park Institute for Medical Research from 2008 to 2016. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11984", "text": "Fellowships have been awarded to him by many professional bodies including the  Royal College of Physicians  of London, the  American College of Surgeons , the  American Society of Colon and Rectal Surgeons , the surgical Royal Colleges of Edinburgh, Ireland and Glasgow, l'Academie Nationale de Chirurgie, the  British Society of Gastroenterology  (BSG) and the national colorectal societies in Italy, France, Brazil, Spain, Austria, Switzerland, Yugoslavia, Chile, Argentina, Canada, Australia and Poland. He was able to lecture in French, German and Italian. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11985", "text": "Nicholls was the President of the Association of Coloproctology of Great Britain and Ireland in 2000 and of the European Association of Coloproctology in 2004.  With the formation of the European Society of Coloproctology in 2005, which he joined as a founder, he became the Chairman of the Scientific Committee responsible for he scientific programme of the meetings. [ 37 ] [ 38 ]  Nicholls retired from NHS practice in 2006 but kept active in the field of colorectal surgery until his full retirement in 2014.  He has authored over 300 publications and four books. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11986", "text": "Nicholls remains a Patron of the Red Lion Group (RLG), a national support group and charity for people with pouches founded by a group of St Mark's staff and patients in 1994. Nicholls' had an instrumental role in the launch of the Red Lion's Group helping it to be based at St Mark's Hospital and served as the first President of the Red Lion Group from 1994 until Nicholls' retirement from the  National Health Service (NHS)  in 2006. Thereafter, he remained active in research and teaching until his full retirement in 2014. [ 40 ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11987", "text": "A  Nissen fundoplication , or  laparoscopic Nissen fundoplication  when performed via  laparoscopic surgery , is a  surgical procedure  to treat  gastroesophageal reflux disease  (GERD) and  hiatal hernia . In GERD, it is usually performed when medical therapy has failed; but, with a  Type II (paraesophageal) hiatus hernia , it is the first-line procedure. The Nissen fundoplication is total (360\u00b0), but partial fundoplications known as Thal (270\u00b0 anterior), Belsey (270\u00b0 anterior transthoracic), Dor (anterior 180\u2013200\u00b0), Lind (300\u00b0 posterior), and Toupet fundoplications (posterior 270\u00b0) are alternative procedures with somewhat different indications and outcomes. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11988", "text": "Dr. Rudolph Nissen  (1896\u20131981) first performed the procedure in 1955 and published the results of two cases in a 1956  Swiss Medical Weekly . [ 2 ]  In 1961 he published a more detailed overview of the procedure. [ 3 ]   Nissen originally called the surgery \"gastroplication\". The procedure has  borne his name  since it gained popularity in the 1970s. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11989", "text": "The most common indication for a fundoplication is GERD that has failed lifestyle modification and medical management. [ 5 ]  Patients that continue to have reflux symptoms or that have had uncontrolled reflux symptoms for more than 5 years are also candidates for surgical management. [ 6 ]  Complications that arise from long term  GERD  such as severe esophagitis,  stricture  formation, and  ulcer  development, all of which can be seen on  endoscopy , warrant surgical intervention. Presence of  Barrett's esophagus  is not an indication, as the benefit of a fundoplication in preventing progression into  adenocarcinoma  is controversial. [ 6 ]  Respiratory symptoms and upper airway symptoms such as cough,  asthma , hoarseness are also indications for surgical intervention. [ 7 ]  In the pediatric population, infants who fail to thrive or have inadequate weight gain despite  proton-pump inhibitor  (PPI) therapy may also benefit from fundoplication. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11990", "text": "In a  fundoplication , the  gastric fundus  (upper part) of the  stomach  is wrapped, or plicated, around the lower end of the  esophagus  and stitched in place, reinforcing the closing function of the  lower esophageal sphincter  (LES). The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged  esophageal hiatus  of the  diaphragm .\nThe surgeon should begin with ligating and dividing the  short gastric arteries . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11991", "text": "In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 360 degrees around the esophagus. In contrast, surgery for  achalasia  is generally accompanied by either a  Dor  or  Toupet  partial fundoplication, which is less likely than a Nissen wrap to aggravate the  dysphagia  that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11992", "text": "The procedure can be performed with open surgery but is now routinely performed  laparoscopically , as laparoscopic surgery has decreased post-operative complications and decreased hospital stay. [ 10 ]  When used to alleviate gastroesophageal reflux symptoms in patients with  delayed gastric emptying , it is frequently combined with modification of the  pylorus  via  pyloromyotomy  or  pyloroplasty . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11993", "text": "This procedure can also be completed robotically. Outcomes comparing laparoscopic fundoplication to robotic fundoplication show similar clinical outcomes, but robotic fundoplication is more likely to have an increased length of operative time and financial cost. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11994", "text": "Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it.  This prevents the reflux of  gastric acid  (in GERD). Although antacids and  PPI  drug therapy can reduce the effects of reflux acid, successful surgical treatment has the advantage of eliminating drug side-effects and damaging effects from other components of reflux such as bile or gastric contents. [ 1 ]  The Nissen fundoplication reduces reflux by reinforcing the  LES  by increasing LES pressure and increasing the LES length. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11995", "text": "Nissen (complete) fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1% and many of the most common post-operative complications minimized or eliminated by the partial fundoplication procedures now more commonly used. Studies have shown that after 10 years, 89.5% of patients are still symptom-free. When compared to stand alone medical therapy with PPIs, Nissen fundoplication has been found to be superior in reducing acid reflux as well as the symptoms associated with reflux. [ 12 ]  Fundoplication was found to be better at increasing  LES  pressure than  PPI  therapy, whilst having similar risk for adverse events. [ 13 ]  In patients with non-acid reflux, a  hiatal hernia , or respiratory symptoms, surgical intervention was found to be more effective at controlling symptoms than  PPIs  alone. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11996", "text": "Complications include \"gas bloat syndrome\",  dysphagia  (trouble swallowing),  dumping syndrome , excessive scarring, vagus nerve injury and, rarely,  achalasia . [ 14 ]  The fundoplication can also come undone over time in about 5\u201310% of cases, leading to recurrence of symptoms. If the symptoms warrant a repeat surgery, the surgeon may use  Marlex  or another form of artificial mesh to strengthen the connection. [ 15 ]  Postoperative  ileus , which is common after abdominal surgery, is possible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11997", "text": "In \"gas bloat syndrome\", fundoplication can alter the mechanical ability of the stomach to eliminate swallowed air by  belching , leading to an accumulation of gas in the  stomach  or small intestine. Data varies, but some degree of gas-bloat may occur in as many as 41% of Nissen patients, whereas the occurrence is less with patients undergoing partial anterior fundoplication. [ 16 ]   Gas bloat syndrome is usually self-limiting within 2 to 4 weeks, but in some it may persist.  The offending gas may also come from dietary sources (especially carbonated beverages), or involuntary swallowing of air ( aerophagia ).  If postoperative gas-bloat syndrome does not resolve with time, dietary restrictions, counseling regarding aerophagia, medications, and correction \u2013 either by  endoscopic balloon dilatation [ citation needed ]  or repeat surgery to revise the Nissen fundoplication to a partial fundoplication \u2013 may be necessary. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11998", "text": "Acute  dysphagia  or short term trouble swallowing is a symptom that most patients will have after having a fundoplication. Patients who have  dysphagia  prior to surgery are more likely to have some  dysphagia  post-operatively. [ 17 ]  Symptoms of  dysphagia  will often resolve on their own within a few months. [ 18 ]  Short term  dysphagia  is controlled by modifying diet to include more easily swallowed food such as liquids and soft foods. [ 19 ]   Dysphagia  that persists longer than 3 months will need further evaluation, typically with a  barium swallow study ,  esophageal manometry , or  endoscopy . [ 20 ]  Structural changes such as movement of the wrap,  herniation , development of stenosis or stricture may lead to persistent  dysphagia . [ 19 ]  Previously undiagnosed achalasia or a wrap that is too tight may also lead to persistent  dysphagia . [ 18 ]  Depending on the etiology of persistent dysphagia, a trial of  PPI  therapy, endoscopic dilation, or surgical revision may be necessary. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_11999", "text": "Vomiting is sometimes impossible or, if not, very painful after a fundoplication, with the likelihood of this complication typically decreasing in the months after surgery. In some cases, the purpose of this operation is to correct excessive vomiting. Initially, vomiting is impossible; however, small amounts of vomit may be produced after the wrap settles over time, and in extreme cases such as  alcohol poisoning  or  food poisoning , the patient may be able to vomit freely with some amount of pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12000", "text": "Omentopexy  is a  surgical  procedure whereby the  greater omentum  is sutured to a nearby organ. Suture to the  abdominal wall  is used to induce circulation away from the portal circulation into caval circulation. It may also be sutured to another organ to increase  arterial  circulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12001", "text": "Partial ileal bypass surgery  is a  surgical procedure  which involves shortening the  ileum  to shorten the total  small intestinal  length. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12002", "text": "First introduced in 1962 by Professor  Henry Buchwald  of the University of Minnesota, [ 2 ]  the procedure is used to treat a number of  hyperlipidemias  including  familial hypercholesterolemia . [ 3 ] [ 4 ]  The only  randomized controlled trial  comparing bypass surgery with standard management was the POSCH trial, which was conducted by Buchwald and his team. The trial ran between 1975 and 1983 and included 838 men who had survived a  heart attack . This trial initially failed to show any benefit on mortality, but in 1998 follow-up results indicated that in addition to its known benefit on cholesterol levels and disease events it had also decreased mortality in the treatment group. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12003", "text": "Ileal bypass surgery was mainly performed prior to the introduction of effective oral medication for the most common hypercholesterolemias. [ 6 ]  It is occasionally used in the surgical treatment of  obesity . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12004", "text": "As with any ileal resection, a possible complication is mild  steatorrhea  due to a reduced uptake of bile acids by the ileum."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12005", "text": "Percutaneous endoscopic gastrostomy  ( PEG ) is an  endoscopic   medical procedure  in which a tube ( PEG tube ) is passed into a patient's stomach through the  abdominal wall , most commonly to provide a means of feeding when  oral  intake is not adequate (for example, because of  dysphagia  or  sedation ). This provides  enteral  nutrition (making use of the natural  digestion  process of the  gastrointestinal tract ) despite bypassing the mouth; enteral nutrition is generally preferable to  parenteral nutrition  (which is only used when the GI tract must be avoided). The PEG procedure is an alternative to open surgical  gastrostomy  insertion, and does not require a  general anesthetic ;  mild sedation  is typically used. PEG tubes may also be extended into the  small intestine  by passing a jejunal extension tube ( PEG-J tube ) through the PEG tube and into the  jejunum  via the  pylorus . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12006", "text": "PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many  stroke  patients, for example, are at risk of  aspiration pneumonia  due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the  stomach  in cases of  gastric volvulus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12007", "text": "Gastrostomy may be indicated in numerous situations, usually those in which normal (or  nasogastric ) feeding is impossible. The causes for these situations may be neurological (e.g.  stroke ), anatomical (e.g.  cleft lip and palate  during the process of correction) or other (e.g.  radiation therapy  for tumors in head & neck region). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12008", "text": "In certain situations where normal or nasogastric feeding is not possible, gastrostomy may be of no clinical benefit. In advanced  dementia , studies show that PEG placement does not in fact prolong life. [ 3 ]  Instead, oral  assisted feeding  is preferable. [ 4 ]  Quality improvement protocols have been developed with the aim of reducing the number of non-beneficial gastrostomies in patients with dementia. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12009", "text": "A gastrostomy can be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a \"venting PEG\" and is placed to prevent and manage nausea and vomiting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12010", "text": "A gastrostomy can also be used to treat  volvulus  of the stomach, where the stomach twists along one of its axes.  The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12011", "text": "A PEG tube can be used in providing gastric or post-surgical drainage. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12012", "text": "Two major techniques for placing PEGs have been described in the literature."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12013", "text": "The Gauderer-Ponsky technique involves performing a  gastroscopy  to evaluate the  anatomy  of the  stomach .  The anterior stomach wall is identified and techniques are used to ensure that there is no  organ  between the wall and the  skin :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12014", "text": "An  angiocath  is used to puncture the abdominal wall through a small  incision , and a soft guidewire is inserted through this and pulled out of the  mouth .  The feeding tube is attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of the incision. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12015", "text": "In the Russell introducer technique, the  Seldinger technique  is used to place a wire into the stomach, and a series of dilators are used to increase the size of the  gastrostomy .  The tube is then pushed in over the wire. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12016", "text": "There are several techniques such as moderate sedation with left transversus abdominis plane block, and moderate sedation with local anesthetic infiltration at feeding tube site. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12017", "text": "As with other types of feeding tubes, care must be made to place PEGs into an appropriate population.  The following are contraindications to PEG use: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12018", "text": "The  American Medical Directors Association , the  American Geriatrics Society  and the  American Academy of Hospice and Palliative Medicine  recommend against inserting percutaneous feeding tubes in individuals with advanced dementia and, instead, recommend oral assisted feedings. Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia. It may increase the risk of the patient inhaling food, it does not reduce suffering, it may cause fluid overload, diarrhea, abdominal pain and local complications, and it can reduce the amount of human interaction the patient experiences. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12019", "text": "PEG tubes with rigid, fixed \"bumpers\" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the esophagus and removed through the mouth. The PEG site heals without intervention. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12020", "text": "PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12021", "text": "The first percutaneous endoscopic gastrostomy performed on a child was on June 12, 1979, at the  Rainbow Babies & Children's Hospital ,  University Hospitals of Cleveland . Michael W.L. Gauderer, pediatric surgeon, Jeffrey Ponsky, endoscopist, and James Bekeny, surgical resident, performed the procedure on a  4 + 1 \u2044 2 -month-old child with inadequate oral intake. [ 15 ]  The authors of the technique, Michael W.L. Gauderer and Jeffrey Ponsky, first published the technique in 1980. [ 15 ]  In 2001, the details of the development of the procedure were published, the first author being the originator of the technique itself. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12022", "text": "Proctocolectomy  is the  surgical  removal of the entire  colon  and  rectum  from the human body, leaving the patients  small intestine  disconnected from their  anus . [ 1 ]  It is a major surgery that is performed by  colorectal surgeons , however some portions of the surgery, specifically the  colectomy  (removal of the colon) may be performed by  general surgeons . [ 2 ]  It was first performed in 1978 and since that time, medical advancements have led to the surgery being less invasive with great improvements in patient outcomes. [ 3 ]  The procedure is most commonly indicated for severe forms of  inflammatory bowel disease  such as  ulcerative colitis  and  Crohn's disease . It is also the treatment of choice for patients with  familial adenomatous polyposis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12023", "text": "According to the guidelines published by the American Society of Colon and rectal surgery, a proctocolectomy can be considered in patients who are suffering from severe ulcerative colitis (UC), a form of inflammatory bowel disease. [ 5 ]  This procedure is considered curative for this condition because UC only affects the large colon and rectum. [ 6 ]  Proctocolectomy may also be performed for severe Crohn\u2019s disease, another form of inflammatory bowel disease, however this intervention is not considered curative. Surgical intervention for Crohn's disease is only pursued when medications are no longer effective or when extensive damage to the large colon and rectum has occurred. [ 7 ]  The final most common indication for proctocolectomy is for individuals who suffer from Familial Adenomatous Polyposis. [ 4 ]  This is a condition that is inherited from past generations and leads to dozens or even thousands of polyps inside the colon and rectum that can then become cancerous. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12024", "text": "The surgical removal of the entire colon and rectum is a major surgery with many complex steps involved. In brief, the surgeon will begin by making an incision in the patient\u2019s belly and then expose the colon (large intestine). They will then remove the entire large intestine being careful not to damage any other nearby internal organs. [ 9 ]  Next the surgeon will remove the patient\u2019s rectum. Lastly the surgeon will connect the patient\u2019s small intestine to their anus so that they will be able continue having bowel movements from their bottom. This is known as an ileoanal anastomosis. [ 9 ]  It is important to note that the surgeon preserves the patient\u2019s anus and sphincter muscles in order to prevent fecal incontinence when the small intestine is connected to the anus. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12025", "text": "As previously stated, a proctocolectomy is a major surgery and with that comes the risk of complications. The major risks of the surgery include damage to nearby organs and nerves within the body, infection, scar tissue within the belly that can lead to small intestine blockage, poor absorption of nutrients and incisional hernias. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12026", "text": "A  pull-through procedure  is the definitive operation for  Hirschsprung disease , involving the removal of the abnormal segment of  bowel  that has no nerves, pulling through the normal bowel and  connecting  it to the  anus . Several types of pull-through procedures exist including the Soave,  Swenson  and Duhamel. It can be performed using an open or  minimally invasive approach . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12027", "text": "A pull-through procedure is the definitive treatment for Hirschsprung's disease, with the aim of removing the abnormal part of the bowel and joining the normal part of the intestine with the anus. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12028", "text": "The original pull-through procedure was designed by  Orvar Swenson  and his colleague Alexander Bill. The abnormal aganglionic part of the bowel is resected down to the  sigmoid colon  and  rectum , and the normal colon and the low rectum are subsequently  joined . [ 1 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12029", "text": "The Duhamel pull-through is a modified Swenson's pull-through, first described in 1956. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12030", "text": "The Soave procedure involves resecting the mucosa and submucosa of the rectum and pulling through the normal ganglionic bowel through the aganglionic muscular cuff of the rectum. It was introduced in the 1960s and initially did not include a formal join. It depended on scar tissue formation between the pull-through segment and the surrounding aganglionic bowel. The procedure was later modified by Boley. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12031", "text": "If the segment of Hirschsprung's is short, anorectal myomectomy maybe an alternative surgical option. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12032", "text": "Georgeson  first described laparoscopic surgical treatment of Hirschsprung's in 1999. [ 1 ]  Transanal pull-through procedures do not require an intra-abdominal dissection. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12033", "text": "Complications include anaesthetic risks, infection,  bleeding  and  perforation of the bowel . [ 5 ]  Frequent loose stools may cause nappy rash. Toilet training may also pose problems. Occasionally a temporary  stoma  is required. [ 6 ]  A pull-through may sometimes fail if some of the abnormal bowel is left behind. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12034", "text": "Pyloromyotomy  is a surgical procedure in which a portion of the muscle fibers of the  pyloric muscle  are cut. This is typically done in cases where the contents from the stomach are inappropriately stopped by the pyloric muscle, causing the stomach contents to build up in the stomach and unable to be appropriately digested. The procedure is typically performed in cases of \" hypertrophic pyloric stenosis \" in young children. [ 1 ]  In most cases, the procedure can be performed with either an open approach or a laparoscopic approach [ 2 ]  and the patients typically have good outcomes with minimal complications. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12035", "text": "The development of the procedure has attributed to Dr.  Conrad Ramstedt  in 1911, who originally named the procedure Ramstedt's Operation. However, the procedure was truly performed about 17 months earlier by Sir  Harold Stiles \u00a0 in 1910 at the  Royal Hospital for sick children . [ 4 ]  In 1991, the first laparoscopic pyloromyotomy was performed by Dr. Alain and Dr. Grousseau. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12036", "text": "After pyloric stenosis is identified in a patient, and any electrolyte and fluid imbalances are stabilized, the surgeon will perform the procedure. [ 4 ] [ 1 ]  During which, the surgeon must access the pylorus through the  abdominal wall . This can either be done  laparoscopically  or with an \"open\" procedure. In either case, the once the pylorus is accessed, the surgeon will visualize the  hypertrophied  pyloric muscle. Then, the surgeon will carefully cut through the outer layers of tissue and through the pyloric muscle to the  mucosa , which is the layer of tissue facing the inside of the gastrointestinal tract. From there, the two portions of the pyloric muscle are tested for mobility and the mucosal layer is inspected for any unintentional damage. Depending on the approach, the pylorus, stomach, and  gastrointestinal tract  are returned to their appropriate place in the  abdominal cavity  and the medical equipment is removed. Finally, each of the surgical incisions are stitched closed and the patient is taken back to post-operative area for monitoring. [ 5 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12037", "text": "Laparoscopic approach:  In the laparoscopic approach, the appropriate area of the gastrointestinal tract is accessed in a minimally invasive manner. [ 5 ]  This approach may be chosen due to the reduced hospital stay, quicker recovery time, and higher satisfaction with the appearance of the surgical site after the patient has healed when compared to the older open approach. [ 2 ]  Typically, two to three  trocars , a medical device used to penetrate the abdominal wall in laparoscopic medical procedures, are placed in their appropriate positions. This is typically done by making a small cut for each trocar in the abdominal wall before placing the trocar into the cut. The abdomen is then filled with a gas, such as carbon dioxide to increase visibility with the laparoscopic camera and increase working space. [ 1 ]  Once the laparoscopic instruments and camera are place through the trocars, the hypertrophied pylorus is visualized. Then, the pyloric muscle is cut down to the mucosa and the muscle fibers are spread apart using the laparoscopic instruments. From there, the two pyloric sections are tested independently for appropriate movement. After that, the mucosa is inspected for any unintentional damaged. This is done by inflating the patient's stomach and looking for the formation of bubbles along the mucosa. [ 4 ]  If a leak is identified it is typically repaired with  sutures  if determined to be appropriate. Finally, all instruments and trocars are removed before the surgical wound sites are repaired with stitches. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12038", "text": "Open approach:  In the older open pyloromyotomy, the appropriate area of the gastrointestinal tract is accessed by creating a single cut on the abdomen of the patient and the pylorus and stomach are gently pulled through the opening for the procedure. [ 5 ]  This approach may be chosen due to patient/parent preference or if determined by the surgeon to be more appropriate. [ 6 ]  Once the initial cut on the abdomen is made, a layer of  connective tissue  between the abdomen and stomach is cut through. Then, the stomach and pylorus are carefully pulled through the opening created by the initial cut and the hypertrophied pylorus is identified by the surgeon. After that, the pyloric muscle is cut down to the mucosa and the muscle fibers are spread apart using a pyloric spreader. The newly separated pyloric sections are tested for adequate movement and the mucosa is tested for holes or other damage, which are repaired using suture as appropriate. Finally, the stomach and pylorus are carefully placed back into the abdominal cavity and the various tissue layers are repaired with stitches. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12039", "text": "The pyloromyotomy is primarily indicated by the presence of hypertrophic pyloric stenosis. [ 5 ] [ 1 ]  Hypertrophic Pyloric stenosis is a gastrointestinal tract defect, most commonly seen in young children, typically in the first few months of life, caused by enlargement of the tissue in the pyloric muscle. [ 5 ] [ 4 ] [ 1 ]  This causes the contents of the stomach to be unable to empty leading to pain after eating, electrolyte abnormalities, and projectile vomiting among other clinical signs and symptoms. [ 7 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12040", "text": "While the procedure has been proven to be highly effective at treating pyloric stenosis, there are still several complications that may occur as a result of the procedure. [ 1 ] [ 3 ] [ 7 ]  The rate that any complications may occur as a result of the surgery are estimated to be 4.6\u201312% of cases. [ 3 ]  The most common complications include incomplete pyloromyotomy, perforation of the mucosa, and infection of the surgical site. [ 3 ]  Other complications reported to be related to the procedure, in addition to those stated above, are listed below:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12041", "text": "The result of the surgery is typically successful at treating the patient's pyloric stenosis nearly 100% of the time with a quick recovery for most patients. [ 1 ] [ 7 ]  Typically, the patient will have a special liquid diet for a few feedings following the procedure. In most cases the patient can be expected to be able to resume feedings with breast milk within 1 day of the procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12042", "text": "In  general surgery , a  Roux-en-Y anastomosis , or  Roux-en-Y , is an end-to-side  surgical anastomosis  of  bowel  used to reconstruct the  gastrointestinal tract .  Typically, it is between  stomach  and small bowel that is  distal  (or further down the  gastrointestinal tract ) from the cut end. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12043", "text": "The name is derived from the  surgeon  who first described it ( C\u00e9sar Roux ) [ 1 ]  and the  stick-figure  representation.  Diagrammatically , the Roux-en-Y anastomosis looks a little like the  letter   Y . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12044", "text": "Typically, the two upper limbs of the Y represent (1) the  proximal  segment of stomach and the distal small bowel it joins with and (2) the blind end that is surgically divided off, and the lower part of the Y is formed by the  distal  small bowel beyond the anastomosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12045", "text": "Roux-en-Ys are used in several operations and collectively called  Roux operations . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12046", "text": "When describing the surgery, the  Roux limb  is the  efferent  or antegrade limb that serves as the primary recipient of food after the surgery, while the  hepatobiliary  or  afferent  limb that anastomoses with the biliary system serves as the recipient for biliary secretions, which then travel through the excluded small bowel to the distal anastomosis at the mid jejunum to aid digestion. The altered anatomy can contribute to indigestion following surgery. [ 2 ]  The procedure has also been associated with an increased incidence of  iron-deficiency anemia . Iron-deficiency anemia develops in up to 45% of people who have had a Roux-en-Y anastomosis. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12047", "text": "Rubber band ligation  (RBL) [ 1 ]  is an outpatient treatment procedure for internal  hemorrhoids  of any grade. [ 2 ]  There are several different devices a physician may use to perform the procedure, including the traditional metal devices, endoscopic banding, and the CRH O'Regan System."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12048", "text": "With rubber band ligation, a small band is applied to the base of the hemorrhoid, stopping the blood supply to the hemorrhoidal mass. The hemorrhoid will shrink and fibrose within a few days with shriveled hemorrhoidal tissue and band falling off during normal  bowel movements  - likely without the patient noticing. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12049", "text": "Rubber band ligation is a popular  procedure for the treatment of hemorrhoids, as it involves a much lower risk of pain than surgical treatments of hemorrhoids, as well as a shorter recovery period (if any at all). It is a very effective procedure and there are multiple methods available. When done with the CRH O\u2019Regan System, it is also associated with a recurrence rate of 5% at 2 years. [ 4 ]  The procedure is typically performed by gastroenterologists, colorectal surgeons, and general surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12050", "text": "Ligation  of hemorrhoids was first recorded by  Hippocrates  in 460 BC, who wrote about using thread to tie off hemorrhoids. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12051", "text": "In modern history, ligation using rubber band was introduced in 1958 by  Blaisdell  and refined in 1963 by  Barron , who introduced a mechanical, metal device called the  Barron ligator  (similar to the McGivney)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12052", "text": "Dr. Patrick J. O\u2019Regan, a laparoscopic surgeon, invented the disposable CRH O\u2019Regan System. In 1997, the ligator was approved by the FDA for the treatment of hemorrhoids. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12053", "text": "Rubber band ligation procedure is as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12054", "text": "Possible complications from rubber band ligation include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12055", "text": "Serial transverse enteroplasty (STEP)  is a surgical procedure used primarily in the treatment of  short bowel syndrome  (SBS). In STEP, by making cuts in the intestine and creating a zigzag pattern, surgeons lengthen the amount of bowel available to absorb nutrients. The procedure was first performed in 2003 and more than 100 patients had undergone the surgery by 2013."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12056", "text": "Short bowel syndrome (SBS) is the condition in which a patient cannot absorb adequate nutrients because a portion of the small intestine is damaged or absent. SBS commonly affects pediatric patients who have undergone surgery, such as premature infants with  necrotizing enterocolitis  and infants with gastrointestinal defects such as  gastroschisis . In adults,  Crohn's disease  is a possible cause of SBS. If they are unable to absorb nutrients in the gut, patients must be given  parenteral nutrition  (PN) intravenously, but long-term PN can be associated with liver failure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12057", "text": "The procedure was studied by researchers in Boston utilizing a group of ten young pigs. Five of the pigs underwent removal of 90 percent of the bowel followed by STEP. The other pigs underwent the bowel resection without the STEP procedure, serving as control subjects. STEP was shown to lengthen the bowel from 105.2 \u00b1 7.7\u00a0cm to 152.2 \u00b1 8.3\u00a0cm. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12058", "text": "STEP was first performed on a human patient, a two-year-old who had been born with gastroschisis, in 2003. [ 3 ]   By 2010, it had been utilized by more than 20 hospitals, mostly in the United States. [ 4 ]  In addition to its use in treating SBS, STEP has been utilized to treat bacterial overgrowth in a dilated bowel loop and to prevent SBS upon the initial repair of certain types of intestinal atresia. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12059", "text": "In 2004, the International Serial Transverse Enteroplasty (STEP) Data Registry was created to serve as an online database to study outcomes following STEP. By 2013, 111 patients had been entered into the database, though 14 had been lost to follow-up. At that time, 11 patients had died and five had received intestinal transplants. 47% had attained enteral autonomy (sufficient bowel function). Pre-STEP bowel length was found to be inversely proportional to the likelihood of transplant or death. Pre-STEP  direct bilirubin  levels were found to be proportional to the likelihood of transplant or death. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12060", "text": "In STEP, the bowel is dilated and then partially transected (cut) at certain points, creating a zigzag pattern to the bowel that results in lengthening of the surface area available for digestion. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12061", "text": "Longitudinal intestinal lengthening and tapering (LILT), also known as the Bianchi procedure, is a surgical alternative to STEP. LILT and STEP have similar outcomes. With each procedure, more than half of patients gain the ability to absorb sufficient nutrients in the intestine. A single-center study compared STEP and LILT, reporting fewer complications with LILT. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12062", "text": "Strictureplasty  (also spelled  Stricturoplasty ) is a surgical procedure performed to alleviate bowel narrowing due to scar tissue that has built up in the intestinal wall from inflammatory bowel conditions such as Crohn's disease. The scar tissue accumulates as a result of repeated damage and healing, with the scarring causing a stricture (a narrowing of the lumen of the bowel). The narrowing can force bowel contents into fissures and ulcers at the site, causing additional damage and narrowing. The surgery restores free flow through the bowel without the need for removing bowel segments (i.e., without bowel resection)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12063", "text": "The first strictureplasty for Crohn's disease was performed by Emanoel Lee in 1976 and was reported in 1982. [ 1 ]  The course of the following two decades several papers demonstrated that strictureplasties were safe and effective. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12064", "text": "Strictureplasties are categorized into three groups: Conventional, intermediate, and complex procedures.  The  Heineke-Mikulicz Strictureplasty  is the most common among the conventional stricutreplasties. Best-suited for short (up to 7 centimeters) strictures, the H-M Strictureplasty is performed by making a cut lengthwise along one side of the bowel, pushing the two ends of the cut together and then suturing the bowel widthwise  (picture) , thus, having the effect of widening the segment of narrowed bowel, therefore resolving the stricture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12065", "text": "The  Finney Strictureplasty  is the most common intermediate strictureplasty. Indicated for strictures up to 15 centimeters, the Finney Strictureplasty is performed by folding the diseased bowel on itself and creating a large opening between the two loops."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12066", "text": "For multiple strictures or for longer strictures neither the conventional nor the intermediate strictureplasties are suitable. In these cases surgeons need to use complex procedures. The most common complex strictureplasty is the  Michelassi Strictureplasty . [ 3 ]  In this strictureplasty the long loop of the bowel affected by Crohn's is first divided at its midpoint. The two halves are then moved side to side. A very long opening is created between the two loops, which are then sutured together  (Figure 1) ,  (Figure 2) ,  (Figure 3) ,  (Figure 4) ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12067", "text": "Multiple strictureplasty can be performed in the same patient.  All strictureplasty techniques spare the patient from bowel resections, an important consideration in a chronic recurrent intestinal condition or in patients with short gut. In addition, recent data suggests that strictureplasty has a protective effect on disease recurrence.  [ 4 ]   Because of the reconfiguration of the bowel, strictureplasty causes slight discontinuities in peristalsis, visible in some imaging tests.  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12068", "text": "Total mesorectal excision  ( TME ) is a standard surgical technique for treatment of  rectal cancer , first described in 1982 by Professor Bill Heald at the UK's  Basingstoke  District Hospital. [ 1 ] [ 2 ]  It is a precise dissection of the  mesorectal  envelope comprising rectum containing the tumour together with all the surrounding fatty tissue and the sheet of tissue that contains lymph nodes and blood vessels. Dissection is along the avascular alveolar plane between the  presacral  and mesorectal fascia, described as  holy plane  (Heald's \" holy plane \"). [ 3 ]  Dissection along this plane facilitates a straightforward dissection and preserves the sacral vessels and  hypogastric nerves  and is a  sphincter -sparing resection and decreases permanent  stoma  rates. [ 4 ]  It is possible to rejoin the two ends of the colon; however, most patients require a temporary  ileostomy  pouch to bypass the colon, allowing it to heal with less risk of infection, perforation or leakage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12069", "text": "TME has become the \"gold standard\" treatment for rectal cancer Worldwide. [ 5 ] [ 6 ]  The operation can be done by  open  surgery,  laparoscopic  or  Robot-assisted . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12070", "text": "For lower down tumours in the middle and lower third of the rectum a new procedure has been developed known as  Transanal-Total Mesorectal Excision (TaTME) . Instead of the dissection via the abdomen TaTME combines an abdominal and transanal endoscopic approach (endoscopic instruments are inserted into the anus) allowing easier dissection of the most difficult part of the surgery deep down in the pelvis (particularly in male patients or patients with visceral obesity or a narrow pelvis). The perceived benefits of this technique may include ease of procedure due to better views, decreased operative time and reduced complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12071", "text": "An occasional side effect of the operation is the formation and tangling of fibrous bands from near the site of the operation with other parts of the bowel.  These can lead to  bowel infarction  if not operated on. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12072", "text": "TME results in a lower recurrence rate than traditional approaches and a lower rate of permanent  colostomy . Postoperative recuperation is somewhat increased over competing methods. When practiced with diligent attention to anatomy there is no evidence of increased risk of urinary incontinence or sexual dysfunction. [ 9 ]   However, there can be partial fecal incontinence and/or \"clustering\" \u2013 a series of urgent trips to the toilet separated by a few minutes, each trip producing only a very small yield. [ 10 ]  Other long-term bowel dysfunction symptoms may include fecal and gas incontinence, urgency, frequent bowel movements, and difficulty emptying. The symptoms collectively are referred to as low anterior resection syndrome (LARS) and adversely affect quality of life, sometimes so much so that some patients even prefer to have their stoma-reversal itself reversed, and to live with a permanent colonostomy or iliostomy. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12073", "text": "Depending on the  staging , size and location of the tumour,  neoadjuvant   radiotherapy  often combined with  chemotherapy  may be used to shrink the tumour prior to surgery and prevent further  spread .  Adjuvant  chemotherapy may also be used post-surgery to prevent further disease spread [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12074", "text": "Transanal hemorrhoidal dearterialization (THD)  is a minimally invasive  surgical  procedure for the treatment of internal hemorrhoids."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12075", "text": "In 1995, Morinaga et al. [ 1 ]  developed a non-excisional surgical technique for the treatment of internal  hemorrhoids .  Dal Monte et al. further refined this technique, introducing transanal hemorrhoidal dearterialization (THD). THD belongs to the category of minimally invasive surgery, since the procedure does not comprise incisions or removal of the hemorrhoidal tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12076", "text": "Hemorrhoids are normal vascular cushions found in the anal canal. 15% of a human's continence mechanism is attributed to the hemorrhoidal plexus. When a person coughs, for instance, the hemorrhoids will engorge with blood and increase one's ability to hold gas and stool. They are termed internal and external based on their positioning to an embryological line termed the  pectinate line . Hemorrhoids above the pectinate line are considered \"internal\" and those below it \"external\". [ 2 ] [ unreliable source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12077", "text": "Hemorrhoids are fed by arteries and drained by veins. The arterial blood supply is based on the superior rectal (hemorrhoidal) artery. Just as veins in the leg weaken and become prominent, hemorrhoidal veins also may become varicose, resulting in internal hemorrhoids or \u201cpiles\u201d. Internal hemorrhoids are divided into four grades. Grade I hemorrhoids are composed of prominent vessels, without protrusion. Grade II hemorrhoids demonstrate prolapse upon straining, with spontaneous reduction. Grade III hemorrhoids demonstrate prolapse upon straining and require manual reduction. Grade IV hemorrhoids prolapse and cannot be manually reduced. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12078", "text": "THD [ 3 ]  uses a specially developed  anoscope  combined with a  Doppler transducer  to identify the hemorrhoidal arteries (originating from the  superior rectal artery ) 2\u20133\u00a0cm above the pectinate line. Once the superior rectal arteries are identified through the Doppler, a suture ligation is performed to effectively decrease the blood flow to the hemorrhoidal plexus. \nIn case of redundant prolapse, the prolapsed mucosal membrane is lifted and sutured (with the last suture minimum 5\u00a0mm above the pectinate line [ 4 ] ), repositioning hemorrhoidal cushions in situ.\nThis is different from a traditional hemorrhoidectomy, which focused on excising the hemorrhoidal bundle. In this procedure, there is no tissue excision. Because the suture line is above the pectinate line, post-operative pain is minimized for patients. THD can be performed with  conscious sedation ,  local [ 5 ]  or  general anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12079", "text": "After the operation, a  high-fiber diet  with plenty of liquids (approximately two litres per day) is recommended.\nFor most patients, the procedure can be performed in a day-surgery setting [ 6 ]  and normal activities can be resumed on average between two and three days post-operatively. [ 7 ] \nThe affected areas usually restore their normal anatomy after two to three months. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12080", "text": "Reports on this procedure showed low complication rates and lower postoperative pain. Postoperative bleeding and constipation were included among some of the arising complications. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12081", "text": "The term  abdominal surgery  broadly covers  surgical  procedures that involve opening the  abdomen  ( laparotomy ).  Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see  stomach ,  kidney ,  liver , etc.) Diseases affecting the abdominal cavity are dealt with generally under their own names."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12082", "text": "The most common abdominal surgeries are described below."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12083", "text": "Complications of abdominal surgery include, but are not limited to:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12084", "text": "Sterile technique,  aseptic  post-operative care,  antibiotics , use of the  WHO Surgical Safety Checklist , and vigilant post-operative monitoring greatly reduce the risk of these complications.  Planned surgery performed under sterile conditions is much less risky than that performed under emergency or unsterile conditions.  The contents of the bowel are unsterile, and thus leakage of bowel contents, as from trauma, substantially increases the risk of infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12085", "text": "Globally, there are few studies comparing  perioperative mortality  following abdominal surgery across different health systems. One major prospective study of 10,745 adult patients undergoing emergency  laparotomy  from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. [ 2 ]  In this study the overall global mortality rate was 1.6 percent at 24\u2009hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent). Of the 578 patients who died, 404 (69.9 percent) did so between 24\u2009hours and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12086", "text": "Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1,000 procedures performed in these settings. Internationally, the most common operations performed were  appendectomy ,  small bowel resection ,  pyloromyotomy  and correction of  intussusception . After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23)) and middle-HDI (4.42 (1.44 to 13.56)) countries compared with high-HDI countries. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12087", "text": "Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12088", "text": "There is low-certainty evidence that there is no difference between using scalpel and  electrosurgery  in infection rates during major abdominal surgeries. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12089", "text": "Bariatric surgery  (also known as  metabolic surgery  or  weight loss surgery ) is a surgical procedure used to manage  obesity  and obesity-related conditions. [ 1 ] [ 2 ]  Long term weight loss with bariatric surgery may be achieved through alteration of gut hormones, physical reduction of stomach size ( stomach reduction surgery ), [ 3 ]  reduction of nutrient absorption, or a combination of these. [ 2 ] [ 4 ]   Standard of care  procedures include  Roux en-Y bypass ,  sleeve gastrectomy , and  biliopancreatic diversion with duodenal switch , from which weight loss is largely achieved by altering gut hormone levels responsible for hunger and satiety, leading to a new hormonal weight  set point . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12090", "text": "In morbidly obese people, bariatric surgery is the most effective treatment for weight loss and reducing complications. [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ]  A 2021  meta-analysis  found that bariatric surgery was associated with reduction in  all-cause mortality  among obese adults with or without  type 2 diabetes . [ 10 ]  This meta-analysis also found that median life-expectancy was 9.3 years longer for obese adults with diabetes who received bariatric surgery as compared to routine (non-surgical) care, whereas the life expectancy gain was 5.1 years longer for obese adults without diabetes. [ 10 ]  The risk of death in the period following surgery is less than 1 in 1,000. [ 11 ]  A 2016 review estimated bariatric surgery could reduce all-cause mortality by 30-50% in obese people. [ 1 ]  Bariatric surgery may also lower disease risk, including improvement in  cardiovascular disease   risk factors ,  fatty liver disease , and diabetes management. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12091", "text": "Stomach reduction surgery is frequently used for cases where traditional weight loss approaches, consisting of diet and physical activity, have proven insufficient, or when  obesity  already significantly affects well-being and general health. [ 3 ] [ 13 ]  The weight-loss procedure involves reducing food intake. Some individuals might suppress bodily functions to reduce the absorption of  carbohydrates , fats,  calories , and  proteins . The outcome is a significant reduction in  BMI . [ 3 ]  The efficacy of stomach reduction surgery varies depending on the specific type of procedure. [ 13 ]  There are two primary divisions of surgery, specifically  gastric sleeve  surgery and  gastric bypass  surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12092", "text": "As of October\u00a02022, [update]  the American Society of Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity recommended consideration of bariatric surgery for adults meeting two specific criteria: people with a  body mass index  (BMI) of more than 35 whether or not they have an obesity-associated condition, and people with a BMI of 30\u201335 who have  metabolic syndrome . [ 12 ] [ 14 ]  However, these designated BMI ranges do not hold the same meaning in particular populations, such as among Asian individuals, for whom bariatric surgery may be considered when a BMI is more than 27.5. [ 12 ]  Similarly, the  American Academy of Pediatrics  recommends bariatric surgery for adolescents 13 and older with a BMI greater than 120% of the 95th percentile for age and sex. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12093", "text": "As of October\u00a02024, [update]  there has been a reported 30% drop in bariatric surgeries in the United States during the past year, and this can be attributed to GLP-1s such as  Novo Nordisk 's  Ozempic and Wegovy . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12094", "text": "Bariatric surgery has proven to be the most effective obesity treatment option for enduring weight loss. [ 17 ]  Along with this weight reduction, the procedure reduces risk of cardiovascular diseases, type 2 diabetes, fatty liver disease, depression syndromes, among others. [ 18 ]  While often effective, numerous barriers to  shared decision making  between the medical provider and person affected include lack of insurance coverage or understanding how it functions, a lack of knowledge about procedures, conflicts with organizational priorities and  care coordination , and tools supporting people who need the surgery. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12095", "text": "Historically, eligibility for bariatric surgery was defined as a BMI greater than 40, or a BMI more than 35 with an obesity-associated comorbidity, as based on the 1991 NIH Consensus Statement. [ 12 ]  In the three decades that followed, obesity rates continued to rise,  laparoscopic  surgical techniques made the procedure safer, and high-quality research showed effectiveness at improving health among various conditions. [ 14 ]  In October 2022, ASMBS/IFSO revised the eligibility criteria, which include all adult patients with a BMI greater than 35, and those with a BMI more than 30 with  metabolic syndrome . [ 14 ]  However, BMI is a limited measurement, for which factors such as ethnicity are not used in the BMI calculation. Eligibility criteria for bariatric surgery are modified for people who identify as a part of the Asian population with a BMI of more than 27.5. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12096", "text": "Stomach reduction surgeries were highly recommended for patients who meet these criteria: BMI>40 (type 3 obesity), BMI>35 (type 2 obesity), with specific  comorbid  conditions such as  type 2 diabetes ,  hypertension ,  dyslipidemia , etc. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12097", "text": "As of 2019, [update]  the  American Academy of Pediatrics  recommended bariatric surgery without age-based eligibility limits under the following indications: BMI  more than 35 with severe comorbidity, such as  obstructive sleep apnea  (Apnea-Hypopnea Index above 0.5), type 2 diabetes,  idiopathic intracranial hypertension ,  nonalcoholic steatohepatitis ,  Blount disease ,  slipped capital femoral epiphysis ,  gastroesophageal reflux disease , and idiopathic hypertension or a BMI above 40 without comorbidities. [ 21 ]  Surgery is contraindicated with a medically correctable cause of obesity, substance abuse, concurrent or planned pregnancy,  eating disorder , or inability to adhere to postoperative recommendations and mandatory lifestyle changes. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12098", "text": "When counseling a patient on bariatric procedures, providers take an interdisciplinary approach. Psychiatric screening is also critical for determining postoperative success. [ 22 ] [ 23 ]  People with a BMI of 40 or greater have a 5-fold risk of depression, and half of bariatric surgery candidates are depressed. [ 22 ] [ 23 ]  Among bariatric surgery candidates and those who undergo bariatric surgery, mental health-related conditions including  anxiety disorders ,  eating disorders , and  substance use  are also more commonly reported. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12099", "text": "Elderly patients will face higher  postoperative  complications due to  frailty  of elderly patients. The  adolescents  who performed stomach reduction surgery showed better results and there is no negative impact on linear/ puberty  growth. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12100", "text": "Stomach reduction surgery is not suitable for people with the following conditions:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12101", "text": "In adults, malabsorptive procedures lead to more weight loss than restrictive procedures, but they have a higher risk profile. [ 27 ]  Gastric banding is the least invasive, so it may offer fewer complications, while gastric bypass may offer the highest initial and most sustainable weight loss. [ 27 ]  A single protocol is not superior to the other. In one 2019 systematic review, estimated weight loss (EWL) for each surgical protocol is as follows: 56.7% for gastric bypass, 45.9% for gastric banding, 74.1% for biliopancreatic bypass +/- duodenal switch and 58.3% for sleeve gastrectomy. [ 28 ]  Most patients do remain obese (BMI 25-35) following surgery despite significant weight loss, and patients with BMI over 40 tended to lose more weight than those with BMI under 40. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12102", "text": "Concerning  metabolic syndrome , bariatric surgery patients were able to achieve remission 2.4 times as often as those who underwent nonsurgical treatment. [ 31 ] [ 29 ]  No significant difference was noted for changes in cholesterol, or LDL, but HDL did increase in the surgical groups, and reduction in blood pressure was variable between studies. [ 31 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12103", "text": "Studies of bariatric surgery for type 2 diabetes ( T2DM ) within the obese population show that 58% prioritize the improvement of diabetes, while 33% pursued surgery for weight loss alone. [ 32 ]  While weight loss is essential in T2DM management, sustaining improvements long-term is challenging; 50% to 90% of people struggle to achieve adequate diabetes control, suggesting the need for alternative interventions. [ 33 ] [ 34 ]  In this context, studies have reported an 85.3\u201390% resolution of T2DM after bariatric surgery, measured by reductions in fasting plasma glucose and  HbA1C  levels, and remission rates of up to 74% two years post-surgery. [ 33 ] [ 34 ]  Furthermore, there is a difference in effectiveness between bariatric surgery and traditional interventions. The Swedish Obese Subjects (SOS) study demonstrated the difference in T2DM remission rates between conventional medical therapy and bariatric surgery: while conventional methods achieved a 21% remission at two years and 12% at 10 years, bariatric surgery exhibited a 72% remission at two years and 37% at 10 years. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12104", "text": "The relative risk reductions associated with bariatric surgery are 61%, 64%, and 77% for the development of T2DM, hypertension, and dyslipidemia, respectively, highlighting the efficacy of bariatric surgery in prevention as well as resolution of chronic obesity. [ 30 ]  Predictors for post-operative diabetes resolution include the current method of diabetes control, adequate blood sugar control, age, duration of diabetes, and waist circumference. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12105", "text": "Bariatric surgery likewise plays a role in the reduction of medication use. [ 33 ] [ 30 ]  During postoperative follow-up, 76% of people discontinued the use of insulin, while 62% no longer required T2DM medications at all. [ 33 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12106", "text": "Bariatric surgery is also considered for individuals with new-onset T2DM and obesity, although the level of improvement may be slightly less. [ 34 ] [ 30 ] [ 33 ]  The International Diabetes Federation Task recommends bariatric surgery under certain circumstances, including failure of conventional weight and T2DM therapy in individuals with a BMI of 30\u201335. [ 34 ]  The Centers for Medicare and Medicaid Services, however, maintain their recommendation of bariatric surgery for only those of BMI above 35. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12107", "text": "A 2021 meta-analysis found that bariatric surgery was associated with 59% and 30% reductions in all-cause mortality among obese adults with or without  type 2 diabetes  respectively. [ 10 ]  It also found that median life expectancy was 9 years longer for obese adults with diabetes who received bariatric surgery as compared to routine (non-surgical) care, whereas the life expectancy gain was 5 years longer for obese adults without diabetes. [ 10 ]  The overall cancer risk in bariatric surgery patients was decreased by 44%, especially in colorectal, endometrial, breast, and ovarian cancer. [ 35 ]  Improvements in cardiovascular health are the most well-described changes after bariatric surgery, with notable reductions in the incidence of stroke (except in patients with T2DM), heart attack, atrial fibrillation, all-cause cardiovascular mortality, and ischemic heart disease. [ 35 ] [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12108", "text": "Bariatric surgery in older patients is a safety concern; the relative benefits and risks in this population are not known. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12109", "text": "The position of the  American Society for Metabolic and Bariatric Surgery as of 2017 [update]  was that it was not clearly understood whether medical weight-loss treatments or bariatric surgery had an effect responsiveness to subsequent treatments for infertility in both men and women. [ 37 ]  Bariatric surgery reduces the risk of  gestational diabetes  and  hypertensive disorders of pregnancy  in women who later become pregnant, but increases the risk of  preterm birth , and maternal anemia. [ 35 ] [ 38 ]  For women with  PCOS , post-operatively there tends to be a reduction in menstrual irregularity,  hirsutism , infertility, and the overall prevalence of PCOS is reduced at 12 and 23 months. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12110", "text": "Among people seeking bariatric surgery, pre-operative mental health disorders are commonly reported. [ 39 ] [ 24 ]  Some studies indicate that psychological health can improve after bariatric surgery, due in part to improved body image, self-esteem, and change in self-concept; these findings were found in children (see Considerations in adolescent patients below). [ 40 ]  Bariatric surgery has consistently been associated with postoperative decreases in depression symptoms and reduced severity. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12111", "text": "Weight loss surgery in adults is associated with an elevated risk of complications compared to nonsurgical treatments for obesity. [ 41 ] [ 42 ]  can be separated into 2 stages, early complication (within 30 days after surgeries) and late complications (after 30 days). [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12112", "text": "The overall risk of mortality is low in bariatric surgery at 0 to .01%. Severe complications, such as gastric perforation or necrosis, have been significantly reduced by improved surgical experience and training. Bariatric surgery morbidity is also low at 5%. [ 27 ] [ 31 ] [ 35 ]  In fact, several studies have reported a reduced overall long-term all-cause mortality compared to controls. [ 27 ] [ 31 ] [ 35 ]  However, obese populations maintain an elevated risk of disease and mortality compared to the general population even after surgery, therefore elevated mortality after surgery may be related to the ongoing complications of existing obesity-related disease. [ 27 ] [ 31 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12113", "text": "The percentage of procedures requiring reoperations due to complications was 8% for  adjustable gastric banding , 6% after  Roux-en-Y gastric bypass , 1% for  sleeve gastrectomy , and 5% after biliopancreatic diversion. [ 29 ]  Over a 10-year study while using a common data model to allow for comparisons, 9% of patients who received a sleeve gastrectomy required some form of reoperation within 5 years compared to 12% of patients who received a Roux-en-Y gastric bypass. Both of the effects were fewer than those reported with adjustable gastric banding. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12114", "text": "Laparoscopic  bariatric surgery requires an average hospital stay of 2\u20135 days, barring potential complications. [ 45 ]  Minimally invasive procedures (i.e.  adjustable gastric band ) tend to have less complications than open procedures (i.e.  Roux-en-Y ). [ 27 ] [ 35 ]  Similar to other surgical procedures, there is a risk of atelectasis (collapse of small airways) and pleural effusion (fluid buildup in lungs), and pneumonia which tends to be less associated with minimally invasive procedures. [ 27 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12115", "text": "Complications specific to the laparoscopic gastric band procedure include esophageal perforation from the advancement of the calibration probe, gastric perforation from the creation of a retrograde gastric tunnel, esophageal dilation, and acute dilation of the gastric pouch due to malpositioning of the gastric band. [ 27 ]  Gastric band malpositioning can be devastating, leading to gastric prolapse, overdistention, and resultingly, gastric ischemia and necrosis. [ 27 ]  Erosion and migration of the band may also occur post-operatively, in which case, if over 50% of the circumference of the band migrates, then surgical repositioning is necessary. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12116", "text": "Risks of Roux-en-Y gastric bypass include anastomotic stenosis (narrowing of the intestine where the two segments are rejoined), bleeding, leaks,  fistula  formation, ulcers (ulcers near the rejoined segment), internal hernia,  small bowel obstruction , kidney stones, and gallstones. [ 27 ]  Bowel obstruction tends to be more difficult to diagnose in post-bariatric surgery patients due to their reduced ability to vomit; symptoms mainly involve abdominal pain and are intermittent due to twisting and untwisting of the intestinal  mesentery . [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12117", "text": "Sleeve gastrectomy also carries a small risk of stenosis, staple line leak, stricture formation, leaks, fistula formation, bleeding, and  gastro-esophageal reflux disease  (also known as GERD or heartburn). [ 18 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12118", "text": "Deficiencies of  micronutrients  like iron (15%), vitamin D, vitamin B12, fat-soluble vitamins, thiamine, and folate are common after bariatric procedures. [ 27 ] [ 29 ]  Such deficiencies are potentiated by alterations in absorption and lack of appetite and often require supplementation.  Notably, chronic vitamin D deficiency may contribute to  osteoporosis ; insufficiency fractures, especially of the upper extremity, are of higher incidence in bariatric surgery patients. [ 27 ] [ 35 ]  Sleeve gastrectomy leads to fewer long-term vitamin deficiencies compared to gastric banding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12119", "text": "Early complication:  Bleeding  is present in approximately 5% of cases of sleeve gastrectomy. Symptoms can vary widely, ranging from gastrointestinal bleeding to  internal  bleeding.  Venous thromboembolism  (VTE) may occur, causing a decrease in flow through the  splenic  system, potentially leading to system collapse or death. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12120", "text": "Late complications: They include gastric  stenosis ,  nutrient deficiencies , and  Gastroesophageal  reflux disease. For gastric stenosis, the symptoms are  food intolerance  and vomiting. [ 43 ]  For the  gastroesophageal reflux disease , which due to post-surgery changes of reduced lower  esophageal   sphincter  tension and increased  intragastric  pressure. Patients may suffer from  heartburn  after eating or upper  abdominal pain . [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12121", "text": "An early complication of Roux-En-Y Gastric Bypass:  Small bowel obstruction , which can be caused by the internal  hernias  due to the laparoscopic RYGB surgery techniques that were used. And it is life-threatening to patients since it is hard to diagnose through clinical or  radiographic  imaging. [ 47 ]  The symptoms included vomiting, abdominal pain and  peritonitis . Common complications such as internal  gastrointestinal hemorrhage  (bleeding) and staple line  leakage  occur in both surgeries. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12122", "text": "Late complication: For the anastomotic stricture, [ 48 ]  there is a 2.9%-23% chance for patients to experience  gastrojejunal   anastomosis . [ 47 ]  This complication more often occurs in the  laparoscopic  era than open RYGB surgery. Symptoms such as difficulty  swallowing  and  vomiting . [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12123", "text": "The most common complication, especially after sleeve gastrectomy, is GERD, which may occur in up to 25% of cases. [ 49 ]  Dumping syndrome (rapid emptying of undigested stomach contents) is another common complication of bariatric surgery, especially after Roux-en-Y, which is further classified into early and late dumping syndrome. [ 49 ]  Dumping syndrome in some cases may be associated with more efficient weight loss, however, it can be uncomfortable. [ 49 ]  Symptoms of dumping syndrome include nausea, diarrhea, painful abdominal cramps, bloating, and autonomic symptoms such as tachycardia, palpitations, flushing, and sweating. [ 49 ]  Early dumping syndrome (emptying within 1 hour of eating) is also associated with a rapid drop in blood pressure, which may cause fainting. [ 49 ]  Late dumping syndrome is characterized by low blood sugar 1\u20133 hours after a meal, presenting with palpitations, tremors, sweating, a feeling of faintness, and irritability. [ 49 ]  Dumping syndrome is best mitigated by consuming small meals and avoiding high carb or high-fat foods. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12124", "text": "Rapid weight loss after obesity surgery can contribute to the development of  gallstones , especially at 6 and 18 months. [ 27 ] [ 29 ]  Estimates for prevalence of symptomatic gallstones after Roux-En-Y gastric bypass range from 3\u201313%. [ 18 ]  The risk of gallstones following bariatric surgery has shown to be higher among those of the female sex. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12125", "text": "Kidney stones  are common after Roux-En-Y gastric bypass, with estimates of prevalence ranging from 7-11%. [ 18 ]  All surgical modalities are associated with a significant increase in the risk of kidney stones compared to nonsurgical weight loss treatment, with biliopancreatic diversion being the most associated at a ten-fold increase in one study. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12126", "text": "Bariatric surgery as a treatment for obesity can lead to vitamin deficiencies. Long-term follow-up reported deficiencies for vitamins D, E, A, K and B12. [ 52 ]  There are guidelines for multivitamin supplementation, but adherence rates are reported to be less than 20%. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12127", "text": "Pregnancy in patients post-bariatric surgery must be carefully monitored. Infant mortality, preterm birth, small fetal size, congenital anomalies, and NICU admission are all elevated in bariatric surgery patients. This elevation in adverse outcomes is thought to be because of malnutrition. [ 54 ]  Most notably, a reduction in serum folate and iron are well-established correlates to neural tube defects and preterm birth, respectively. People considering pregnancy should consult with their physician before conceiving to optimize their health and nutritional status before pregnancy. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12128", "text": "Bariatric procedures function by a variety of mechanisms, such as alteration of gut hormones, reduction of the gut size (reducing the amount of food that may pass through), and reduction or blockage of nutrient absorption. [ 2 ] [ 55 ]  The distinction in these mechanisms, and which are at work for a particular bariatric procedure is not always clearly defined, as multiple mechanisms may be used by a single procedure. [ 2 ] [ 4 ]  For instance, while sleeve gastrectomy (discussed below) was initially thought to work simply by reducing the size of the stomach, research has begun to elucidate changes in gut hormone signaling as well. [ 18 ]  The two most frequently performed procedures are sleeve gastrectomy and Roux-en-Y gastric bypass (also called gastric bypass), with sleeve gastrectomy accounting for more than half of all procedures since 2014. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12129", "text": "Studies have shown that bariatric procedures may have additional effects on the hormones that affect hunger and satiety (such as  ghrelin  and  leptin ), despite initial development to target reduction of food intake and/or nutrient absorption. [ 2 ] [ 18 ] [ 56 ]  This is especially important when considering the durability of weight loss compared to lifestyle changes. While diet and exercise are essential for maintaining a healthy weight and physical fitness, metabolism typically slows as the individual loses weight, a process known as  metabolic adaptation . [ 56 ]  Thus, efforts for obese individuals to lose weight often stall, or result in weight re-gain. Bariatric surgery is thought to affect the weight \"set point,\" leading to a more durable weight loss. This is not completely understood but may involve the cell-signaling pathways and hunger/satiety hormones. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12130", "text": "Procedures may reduce food intake by reducing the size of the stomach that is available to hold a meal (see below: gastric sleeve or stomach folding). Filling the stomach faster enables an individual to feel more full after a smaller meal. [ 2 ] [ 4 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12131", "text": "Procedures may reduce the amount of intestine that food passes through to decrease the absorption of nutrients from food. [ 2 ] [ 4 ]  For example, a Roux-en-Y gastric bypass connects the stomach to a more distal part of the intestine, which reduces the ability of the intestines to absorb nutrients from the food. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12132", "text": "Sleeve gastrectomy , also known as a gastric sleeve, is a surgical  weight-loss  procedure where the  stomach  size is reduced by the surgical removal of a large portion of the stomach, following  along the major curve  of the stomach. [ 2 ]  The open edges are then attached (typically with  surgical staples , sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12133", "text": "The procedure is performed  laparoscopically  and is not reversible. It has been found to produce a weight loss comparable to that of  Roux-en-Y gastric bypass . [ 18 ]  The risk of ulcers or narrowing of the gut due to intestinal strictures is less so with sleeve gastrectomy versus Roux-en-Y gastric bypass, but it is not as effective at treating  GERD  or type 2 diabetes. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12134", "text": "This was the most commonly performed bariatric surgery as of 2021 [update]  in the United States, and is one of the two most commonly performed bariatric surgeries in the world. [ 2 ] [ 4 ]  Though initially thought to work strictly by reducing the size of the stomach, recent research has shown that there are also changes in gut signaling hormones with this procedure leading to weight loss. [ 2 ] [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12135", "text": "The sleeve gastrectomy mechanism works by creating a narrow gastric  lumen  which restricts food intake and prevents receptive relaxation, alongside ongoing research into  hormonal  changes, and  gastrointestinal   motility . [ 58 ] [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12136", "text": "The physical mechanism that will make the SG stand out to other  bariatric surgery  is its reduction of the storage of the stomach significantly, allowing patients to control their calorie intakes. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12137", "text": "The mechanism related to hormone regulation, SG can help to improve  Insulin  sensitivity, aiming for better  glucose  regulation and contributing to the remission of  type 2 diabetes  in many patients. The levels of gut hormones such as  GLP-1  and  PYY  increase after operation of SG. [ 59 ]  GLP-1 enhances  insulin  secretion and has a satiety-inducing effect, while PYY helps reduce  appetite . These hormonal changes are  pivotal  in the  metabolic  improvements observed after SG, including better control of  blood sugar levels  and reduced hunger. [ 58 ] [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12138", "text": "SG will affect the  metabolism  and absorption of  nutrients , hence causing an effect on nutrient dynamics.  Postoperative  observation shows patients' nutrient levels of\u00a0 Vitamin B1  and  B12  have significantly declined, necessitating careful postoperative nutritional management to prevent deficiencies. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12139", "text": "Research suggests SG surgery can alter the composition of the  gut microbiota , which plays a role in obesity and metabolic health. Changes in the gut microbial community post-SG may influence  energy  harvest from the diet, impact  inflammatory  pathways, and affect the  host 's metabolic profile. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12140", "text": "The key mechanism is  gastrointestinal   motility  adjustment of SG surgery, which impacts the speed and efficiency of food processing. [ 58 ]  Studies have observed a modification in the pressure of the lower  esophageal sphincter  and an increase in  intragastric  pressure post-surgery, which collectively impact the gastrointestinal motility. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12141", "text": "Techniques:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12142", "text": "After 1-3 postoperative days, patients begin oral intake, contingent on a successful  gastrografin  leak test, and receive continuous metabolic monitoring. [ 61 ]  To reduce early respiratory risk,  prophylactic  measures such as oxygen support and  ultrasound  evaluations are employed. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12143", "text": "Late postoperative care involves careful observation for  anastomotic  leaks, patient change to a clear liquid diet, and managing potential  nausea  and  vomiting . [ 61 ]  After discharge, the focus shifts to dietary management, starting with a full liquid diet and gradually incorporating soft, solid foods. Monitoring includes regular check-ups for  weight  and  blood pressure , along with comprehensive lab tests to ensure optimal recovery. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12144", "text": "Roux-en-Y gastric bypass surgery  involves the creation of a new connection in the  gastrointestinal tract , from a smaller portion of the stomach to the middle of the  small intestine . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12145", "text": "The surgery is a permanent procedure that aims to decrease the absorption of nutrients due to the new, limited connection created. [ 4 ]  The surgery also works by affecting gut hormones, resetting hunger and satiety levels. [ 4 ]   The physically smaller stomach and increase in baseline satiety hormones help people to feel full with less food after the surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12146", "text": "This is the most commonly performed operation for weight loss in the United States, with approximately 140,000 gastric bypass procedures performed in 2005. [ 18 ]  A 2021 evidence update comparing the benefits and harms of bariatric procedures found that Roux-en-Y gastric bypass surgery and sleeve gastrectomy both effectively reduced weight and led to Type 2 diabetes remission. After five years, Roux-en-Y resulted in greater weight loss (26% compared to 19% for sleeve gastrectomy) and a 25% lower rate of diabetes relapse. However, Roux-en-Y patients had a higher likelihood of hospitalization and additional abdominal surgeries compared to sleeve gastrectomy. [ 62 ]  Though, since 2013, sleeve gastrectomy has overtaken RYGB as the most common bariatric procedure. [ 18 ]  RYGB remains one of the two most commonly performed bariatric surgeries in the world. [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12147", "text": "Gastric bypass  is the most frequently employed technique for weight reduction, the abnormal absorption in the  intestines  and the physical restriction of the stomach. [ 3 ] [ 13 ]  The types of surgeries can be categorized by the effects and the changes made. Reconstruction of the small intestine to reduce the  mucosal  area which is used to absorb nutrients is called the  Malabsorption  operation. [ 13 ]  The  jejunoileal bypass  (JIB) is the most traditional technique for gastric bypass. [ 63 ]  This procedure has no limitations in the flow and processing of food; [ 63 ]  it only allows the transport of nutrients from the small intestine to the surrounding areas of the intestine. [ 63 ]  The impact of weight loss is apparent and remarkable. [ 13 ]  Individuals who undergo  ROUX-en-Y gastric bypass  (RYGB) consume fewer snacks and meals compared to those who undergo JIB. [ 13 ]  The RYGB procedure has been proved to be the most effective medical treatment for  type 2 diabetes  and weight loss. After performing gastric bypass surgery, the two hormones related to obesity,  leptin  and  insulin , fall in levels and while lose weight. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12148", "text": "Roux-en-Y (RYGB) offers two surgical approaches for processing: an open technique or the  laparoscopic  technique. The majority of cases are still performed with laparoscopy. [ 13 ]  The laparoscopic approach is a safe procedure that is associated with fewer problems resulting from wound  inflammation . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12149", "text": "There are three main areas of techniques for performing laparoscopic RYGB: (1) Anastomotic technique [ 64 ]  including Linear Circular stapler. 2)  Alimentary limb configuration , such as Antecolic or  Retrocolic  and Antegastric or Retrogastric. 3)\u00a0 Limb-length of the bilio- pancreatic  (BP) limb. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12150", "text": "Linear stapling: this technique has two variations. 1) Perform the  jejuno -jejunal (JJ)  anastomosis , then act on the gastro-jejunal (GJ) anastomosis. 2) reverse the first process. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12151", "text": "Jejuno-jejunal first: This technique is prevalent within gastric bypass surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12152", "text": "Other techniques include the  Omega   Loop  Technique and  Trans-abdominal  technique employ different operating approaches along with different process orders. All of them will show positive weight loss results. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12153", "text": "The duration of the recuperation phase typically ranges from 2 to 4 weeks. The length of the period is dependent upon the self-perception of the patients and their future state of mental and physical ability. For patients to resume their normal activities, a minimum of 3-5 weeks recovery period is required. Doctors should determine the length of the recovery period based on a range of  body mass index . [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12154", "text": "The  biliopancreatic diversion with duodenal switch  (BPD/DS) is a slightly less common bariatric procedure, but is increasing in use with proven efficacy for sustainable weight loss. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12155", "text": "This procedure has multiple steps. First, a  sleeve gastrectomy  (see above section) is performed. This part of the procedure causes food intake restriction due to the physical reduction of the stomach size, and is permanent. [ 65 ]  Next, the stomach is then disconnected from the upper part of the  small intestine  and connected to a farther part of the  small intestine (ileum) , creating the alimentary limb. [ 65 ]  The leftover section of the far part of the small intestine is then used to make a connection that brings digestive fluids from the  gallbladder  and  pancreas  to the alimentary limb. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12156", "text": "Weight loss following the surgery is largely due to the alteration of gut hormones that control hunger and satiety, as well as the physical restriction of the stomach and decrease in nutrient absorption. [ 66 ]  Compared to the sleeve gastrectomy and Roux-en-Y gastric bypass, BPD/DS produces better results with lasting weight loss and resolution of type 2 diabetes. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12157", "text": "Vertical banded gastroplasty  was more commonly used in the 1980s, and is not typically performed in the 21st century. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12158", "text": "In the vertical banded gastroplasty, a part of the stomach is permanently stapled to create a smaller, new stomach. [ 68 ]  This new stomach is physically restricted, allowing people to feel full with smaller meals. [ 69 ]  Short-term weight loss is similar to other bariatric procedures, but long-term complications may be higher. [ 69 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12159", "text": "This procedure is similar to the sleeve gastrectomy surgery, but a sleeve is created by  suturing , rather than physically removing stomach tissue. [ 70 ]  This allows for the natural ability of the stomach to absorb nutrients to remain intact. [ 70 ]  This procedure is reversible, is a less invasive procedure, and does not use hardware or staples. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12160", "text": "Gastric plication significantly reduces the volume of the patient's stomach, so smaller amounts of food provide a feeling of satiety. [ 71 ]  In a 2020 review and meta-analysis, long-term weight loss was not as durable as other, more common bariatric techniques. [ 71 ]  Gastric plication has not performed as well as the sleeve gastrectomy, with the sleeve gastrectomy associated with greater weight loss and fewer complications. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12161", "text": "The restriction of the stomach also can be created using a silicone band, which can be adjusted by the addition or removal of saline through a port placed just under the skin, a procedure called  adjustable gastric band  surgery. [ 36 ]   This operation can be performed laparoscopically, and is commonly referred to as a \"lap band\". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. [ 36 ]  It is considered somewhat of a safe surgical procedure, with a mortality rate of 0.05%. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12162", "text": "Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space, resulting in the feeling of fullness after a smaller meal. [ 72 ] [ 73 ]   The balloon can be left in the stomach for a maximum of 6 months and results in weight loss of 3 BMI or 3\u20138\u00a0kg within several study ranges. [ 72 ] [ 73 ]  Weight loss with the gastric balloon tends to be more modest than other interventions. The intragastric balloon may be used before another bariatric surgery to assist the patient in reaching a weight that is suitable for surgery but can be used repeatedly and unrelated to other procedures. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12163", "text": "This procedure where a device similar to a heart pacemaker that is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, was under preliminary research in 2015. [ 74 ]  Electrical stimulation is thought to modify the activity of the  enteric nervous system  of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12164", "text": "People are followed closely both before and after bariatric procedures by a healthcare team. The care team may include people in a variety of disciplines, such as social workers, dietitians, and medical  weight management  specialists. [ 36 ]  Follow-up after surgery is typically focused on helping avoid complications and tracking the progress toward body weight goals. [ 36 ]  Having a structure of social support in the post-operative time may be beneficial as people work through the changes that present physically and emotionally following surgery. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12165", "text": "Dietary restrictions after recovery from surgery depend in part on the type of surgery. In general, immediately after bariatric surgery, the person is restricted to a clear liquid diet, which includes foods such as  broth , diluted fruit juices, or sugar-free drinks. [ 75 ]  This diet is continued until the gastrointestinal tract begins to recover approximately 2\u20133 weeks after surgery. [ 75 ]  The next stage provides a  pur\u00e9ed  liquid or soft-solid diet that is slightly increased in viscosity. This may consist of high protein, liquid, or soft foods such as protein shakes, soft meats, and dairy products. [ 36 ] [ 75 ]  People in recovery are encouraged to compose their diet mainly of  plant-based foods  and soft proteins (1.0\u20131.5g/kg/day). [ 36 ] [ 75 ]  During recovery, people must adapt to eating more slowly and avoid eating past fullness; overeating may lead to nausea and vomiting. [ 36 ] [ 75 ]  Alcohol is avoided completely in the first 6 months to 1 year after surgery. [ 75 ]  Some people may take a daily  multivitamin  to compensate for reduced absorption of essential nutrients. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12166", "text": "In general, women are advised to avoid pregnancy for 12\u201324 months after bariatric surgery to reduce the possibility of  intrauterine growth restriction  or nutrient deficiency, since a person having bariatric surgery will likely undergo significant weight loss and changes in metabolism. Over many years, the rates of potential adverse maternal and fetal outcomes have been reduced for mothers following bariatric surgery. [ 35 ] [ 38 ] [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12167", "text": "After a person successfully loses weight following bariatric surgery, excess skin may occur. [ 76 ]  Bariatric  plastic surgery  procedures, sometimes called body contouring, may be an option for people wishing to remove excess skin following the large change in weight. [ 77 ]   Targeted areas include the arms, buttocks and thighs, abdomen, and breasts, with changes occurring slowly over years. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12168", "text": "The rising  prevalence  of  lawsuits  related to gastric bypass surgery is a legal concern in different countries. [ 79 ]  The causes are complex, including the immature characteristics of this technology and an increasing number of patients. In the future, the number of emergent patients who have stomach reduction surgery, long-term complications, and the number of lawsuits due to non-eligible surgery will increase. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12169", "text": "In the 21st century, obesity rates increased globally, and with this, a proportional rise in related diseases and complication. [ 18 ] [ 80 ]  In the United States during 2017-20, an estimated 40% of adults were obese, up from 30% in 1999-2000. [ 18 ]  The costs of treating obesity and related conditions has a large economic impact globally. [ 81 ] [ 82 ]  This  economic impact  results from direct treatment of obesity, treatment of obesity-related conditions, as well as other economic losses from decreased workforce productivity. [ 18 ] [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12170", "text": "Bariatric surgery is cost-effective when compared to savings estimated from treatment or prevention of obesity-related conditions. [ 82 ]  Cost-effectiveness occurs at the individual level due to fewer healthcare expenses for medications, and nationally with a reduction in the overall lifetime healthcare costs. [ 83 ] [ 82 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12171", "text": "During the early 21st century, obesity among children and adolescents increased globally, as did treatment options including lifestyle changes, drug treatments, and surgical procedures. [ 84 ] [ 85 ]  The medical complications and health concerns associated with  childhood obesity  may have short or long-term effects, with a growing concern of a potential decline in overall  life expectancy . [ 85 ] [ 86 ]  Childhood obesity may affect mental health and impact eating practices. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12172", "text": "Difficulties surrounding obesity treatment selection among children and adolescents include ethical considerations when obtaining consent from those who may be unable to do so without adult guidance or understanding the potential lasting effects of invasive procedures. [ 84 ] [ 87 ]  Among high-quality randomized control trial data for surgical treatment of obesity, many studies are not specific to children and adolescents. [ 88 ]  Concerns for  bullying  about overweight or body image exist for those with childhood obesity; self-harm among children and adolescents bullied for their weight also occurs. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12173", "text": "Bariatric surgical procedures available to adolescents include: Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and adjustable gastric banding. [ 89 ]  Multiple organizations have created guidelines for bariatric surgery indications in children and adolescents. In 2022-23, such guidelines overlapped with recommendations for potential bariatric surgical management in children and adolescents with a BMI of 40 or higher, or a BMI of 35 or higher while also experiencing related experiences. [ 90 ] [ 12 ] [ 91 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12174", "text": "Reviews have shown similar weight loss in adolescents following bariatric surgery as in adults. [ 92 ]  Reduction of eating disorders for several years after bariatric surgery has also been shown in adolescents after bariatric surgery. [ 92 ]  Long-term reduction in or resolution of weight-related conditions, such as diabetes and  high blood pressure , occurred in adolescents after bariatric surgery. [ 93 ]  Long-term effects of bariatric surgery in adolescents remains under research, as of 2023. [ 92 ] [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12175", "text": "Techniques for weight loss have been reported for decades, with a more formal transition to noting weight loss following surgical intervention in the 1950s when subsequent weight loss after surgical shortening of the small intestine in dogs and people was observed. [ 94 ] [ 95 ]  Specifically,  anastomosis  between upper and lower portions of the small intestine to skip, or bypass, part of the small intestine led to what was called the  jejuno-ileal bypass . [ 95 ]  A modified version of this procedure showed long-term improvement of lipid levels in people with known  high levels of cholesterol  following the procedure. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12176", "text": "Further modification of the bypass procedure achieved weight loss in obesity, during which an  anastomosis  between the small intestine and upper lower intestine, known as a  jejunocolic bypass , was performed. [ 94 ]  During the late 1960s, the initiation of bariatric surgery followed the development of a procedure to bypass portions of the stomach \u2013 the  gastric bypass . [ 94 ] [ 95 ] [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12177", "text": "Sleeve gastrectomy  (SG), is one of the most popular stomach reduction surgeries and was earliest performed in 1990 as a first-stage operation of  duodenal switch  (DS) surgery. Patients who go through SG typically experience substantial weight loss, preventing the need for the second phase of DS. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12178", "text": "Laparoscopic  techniques revolutionized bariatric surgery, making procedures less invasive and recovery quicker. The first laparoscopic gastric bypass performed by Alan Wittgrove in 1994 exemplifies this leap in  surgical innovation . [ 96 ] The SG laparoscopic version was first performed in 1999. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12179", "text": "Historically, the RYGBP is the best bariatric surgery for obese patients, but now being rivalled by the SG. The complication of RYGBP leads people to find less intricate and safer surgeries, the complication including internal  hernias  and  anastomotic  complications. [ 13 ]  Nowadays, SG has a lower risk of complication, and the  mortality  rate has become the more favorable option for the patients. [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12180", "text": "Eye surgery , also known as  ophthalmic surgery  or  ocular surgery , is  surgery  performed on the  eye  or its  adnexa . [ 1 ]  Eye surgery is part of  ophthalmology  and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. [ 2 ]  It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12181", "text": "Since the eye is heavily supplied by nerves,  anesthesia  is essential.  Local anesthesia  is most commonly used.  Topical anesthesia  using  lidocaine  topical gel is often used for quick procedures. Since topical anesthesia requires cooperation from the patient,  general anesthesia  is often used for children, traumatic eye injuries, or major orbitotomies, and for apprehensive patients. The  physician administering anesthesia , or a  nurse anesthetist  or  anesthetist assistant  with expertise in anesthesia of the eye, monitors the patient's cardiovascular status. Sterile precautions are taken to prepare the area for surgery and lower the risk of infection. These precautions include the use of  antiseptics , such as  povidone-iodine , and sterile drapes, gowns, and gloves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12182", "text": "Although the terms laser eye surgery and  refractive surgery  are commonly used as if they were interchangeable, this is not the case. Lasers may be used to treat nonrefractive conditions (e.g. to seal a retinal tear). [ 3 ]  Laser eye surgery or laser corneal surgery is a medical procedure that uses a laser to reshape the surface of the eye to correct  myopia  (short-sightedness),  hypermetropia  (long-sightedness), and  astigmatism  (uneven curvature of the eye's surface). Importantly, refractive surgery is not compatible with everyone, and people may find on occasion that eyewear is still needed after surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12183", "text": "Recent developments also include procedures that can change eye color from brown to blue. [ 5 ] [ 6 ]  Before proceeding with laser surgery, the eye specialist needs to certify that the patient is a suitable candidate for the surgery and there are several factors to be considered before doing laser surgery. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12184", "text": "A  cataract  is an opacification or cloudiness of the eye's  crystalline lens  due to aging, disease, or trauma that typically prevents light from forming a clear image on the  retina . If  visual loss  is significant, surgical removal of the lens may be warranted, with lost  optical power  usually replaced with a plastic  intraocular lens . Owing to the high prevalence of cataracts, cataract extraction is the most common eye surgery. Rest after surgery is recommended. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12185", "text": "Glaucoma  is a group of diseases affecting the  optic nerve  that results in  vision loss  and is frequently characterized by raised  intraocular pressure . Many types of glaucoma surgery exist, and variations or combinations of those types can facilitate the escape of excess  aqueous humor  from the eye to lower intraocular pressure, and a few that lower it by decreasing the production of aqueous humor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12186", "text": "Canaloplasty  is an advanced, nonpenetrating procedure designed to enhance drainage through the eye's natural drainage system to provide sustained reduction of intraocular pressure. Canaloplasty uses microcatheter technology in a simple and minimally invasive procedure.\nTo perform a canaloplasty, an ophthalmologist creates a tiny incision to gain access to a canal in the eye. A microcatheter circumnavigates the canal around the iris, enlarging the main drainage channel and its smaller collector channels through the injection of a sterile, gel-like material called viscoelastic. [ clarification needed ]  The catheter is then removed and a suture is placed within the canal and tightened. [ clarification needed ]  By opening up the canal, the pressure inside the eye can be reduced. [ clarification needed ] [ 9 ] [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12187", "text": "Refractive surgery aims to correct errors of refraction in the eye, reducing or eliminating the need for corrective lenses."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12188", "text": "Corneal surgery  includes most refractive surgery, as well as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12189", "text": "Vitreoretinal surgery includes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12190", "text": "With about 1.2 million procedures each year,  extraocular muscle  surgery is the third-most common eye surgery in the United States.\n [1]   Archived  2016-08-18 at the  Wayback Machine"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12191", "text": "Oculoplastic surgery, or oculoplastics, is the subspecialty of  ophthalmology  that deals with the reconstruction of the eye and associated structures. Oculoplastic surgeons perform procedures such as the repair of droopy eyelids ( blepharoplasty ), [ 30 ]  repair of tear duct obstructions, orbital fracture repairs, removal of tumors in and around the eyes, and facial rejuvenation procedures including laser skin resurfacing, eye lifts, brow lifts, and even facelifts. Common procedures are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12192", "text": "Many of these described procedures are historical and are not recommended due to a risk of complications. Particularly, these include operations done on ciliary body in an attempt to control glaucoma, since highly safer surgeries for glaucoma, including lasers, nonpenetrating surgery, guarded filtration surgery, and seton valve implants have been invented."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12193", "text": "' General'  surgery  is a  surgical specialty  that focuses on  alimentary canal  and  abdominal  contents including the  esophagus ,  stomach ,  small intestine ,  large intestine ,  liver ,  pancreas ,  gallbladder ,  appendix  and  bile ducts , and often the  thyroid gland . General surgeons also deal with diseases involving the  skin ,  breast ,  soft tissue ,  trauma ,  peripheral artery disease  and  hernias  and perform  endoscopic  as such as  gastroscopy ,  colonoscopy  and laparoscopic procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12194", "text": "General surgeons may sub-specialise into one or more of the following disciplines: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12195", "text": "In many parts of the world including  North America ,  Australia  and the  United Kingdom , the overall responsibility for  trauma care  falls under the auspices of general surgery. Some general surgeons obtain advanced training in this field (most commonly surgical critical care) and specialty certification surgical critical care. General surgeons must be able to deal initially with almost any surgical emergency. Often, they are the first port of call to critically ill or gravely injured patients, and must perform a variety of procedures to stabilize such patients, such as thoracostomy,  cricothyroidotomy , compartment fasciotomies and emergency  laparotomy  or  thoracotomy  to  stanch  bleeding. They are also called upon to staff surgical intensive care units or trauma intensive care units. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12196", "text": "All general surgeons are trained in emergency surgery. Bleeding, infections, bowel obstructions and organ perforations are the main problems they deal with.  Cholecystectomy , the surgical removal of the gallbladder, is one of the most common surgical procedures done worldwide. This is most often done electively, but the gallbladder can become acutely inflamed and require an emergency operation. Infections and rupture of the  appendix  and small bowel obstructions are other common emergencies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12197", "text": "This is a relatively new specialty dealing with  minimal access techniques  using cameras and small instruments inserted through 3- to 15-mm  incisions.  Robotic surgery  is now evolving from this concept (see below). Gallbladders, appendices, and colons can all be removed with this technique. Hernias are also able to be repaired laparoscopically.  Bariatric surgery  can be performed laparoscopically and there a benefits of doing so to reduce wound complications in  obese  patients. General surgeons that are trained today are expected to be proficient in laparoscopic procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12198", "text": "General surgeons treat a wide variety of major and minor colon and rectal diseases including inflammatory bowel diseases (such as  ulcerative colitis  or  Crohn's disease ),  diverticulitis , colon and rectal cancer, gastrointestinal bleeding and hemorrhoids."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12199", "text": "General surgeons can specialise in Upper Gastro-intestinal (or  foregut ) surgery, which includes the surgical treatment of diseases of the  stomach  and  oesophagus ,  liver ,  pancreas  and  gallbladder . [ 2 ]  In the UK, Upper GI surgeons can subspecialise further as benign surgeons, dealing with  hiatus hernias  and gallbladder diseases, bariatric surgeons, providing surgical care for  weight management  and metabolic diseases, or oesophago-gastric surgeons, dealing with complex problems related to the upper gastrointestinal tract (the foregut), including cancer. Surgical care of complex liver and pancreatic problems (including  liver cancer  and  pancreatic cancer ) is undertaken by  Hepatobiliary and Pancreatic Surgery  sub-specialists."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12200", "text": "General surgeons perform a majority of all non-cosmetic breast surgery from lumpectomy to  mastectomy , especially pertaining to the evaluation, diagnosis and treatment of  breast cancer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12201", "text": "General surgeons can perform vascular surgery if they receive special training and certification in vascular surgery. Otherwise, these procedures are typically performed by vascular surgery specialists. However, general surgeons are capable of treating minor vascular disorders."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12202", "text": "General surgeons are trained to remove all or part of the thyroid and  parathyroid glands  in the neck and the  adrenal glands  just above each  kidney  in the abdomen. In many communities, they are the only surgeon trained to do this. In communities that have a number of subspecialists, other subspecialty surgeons may assume responsibility for these procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12203", "text": "Responsible for all aspects of pre-operative, operative, and post-operative care of abdominal organ transplant patients.  Transplanted organs include liver, kidney, pancreas, and more rarely small bowel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12204", "text": "Surgical oncologist refers to a general surgical oncologist (a specialty of a general surgeon), but thoracic surgical oncologists, gynecologist and so forth can all be considered surgeons who specialize in treating cancer patients.  The importance of training surgeons who sub-specialize in cancer surgery lies in evidence, supported by a number of clinical trials, that outcomes in surgical cancer care are positively associated to surgeon volume (i.e., the more cancer cases a surgeon treats, the more proficient he or she becomes, and his or her patients experience improved survival rates as a result). This is another controversial point, but it is generally accepted, even as common sense, that a surgeon who performs a given operation more often, will achieve superior results when compared with a surgeon who rarely performs the same procedure. This is particularly true of complex cancer resections such as  pancreaticoduodenectomy  for pancreatic cancer, and  gastrectomy  with extended (D2) lymphadenectomy for gastric cancer. Surgical oncology is generally a 2-year fellowship following completion of a general surgery residency (5\u20137 years)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12205", "text": "Most cardiothoracic surgeons in the U.S. (D.O. or M.D.) first complete a general surgery residency (typically 5\u20137 years), followed by a cardiothoracic surgery fellowship (typically 2\u20133 years). However, new programmes are currently offering cardiothoracic surgery as a residency (6\u20138 years)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12206", "text": "Pediatric surgery is a subspecialty of general surgery. Pediatric surgeons do surgery on patients under age 18. Pediatric surgery is 5\u20137 years of residency and a 2-3 year fellowship."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12207", "text": "In the 2000s,  minimally invasive surgery  became more prevalent. Considerable enthusiasm has been built around  robot-assisted surgery  (also known as  robotic surgery ), despite a lack of data suggesting it has significant benefits that justify its cost. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12208", "text": "In Canada, Australia, New Zealand, and the United States general surgery is a five to seven year  residency  and follows completion of  medical school , either  MD, MBBS, MBChB , or  DO  degrees. In Australia and New Zealand, a residency leads to eligibility for Fellowship of the  Royal Australasian College of Surgeons . In Canada, residency leads to eligibility for certification by and Fellowship of the  Royal College of Physicians and Surgeons of Canada , while in the United States, completion of a residency in general surgery leads to eligibility for board certification by the  American Board of Surgery  or the  American Osteopathic Board of Surgery  which is also required upon completion of training for a general surgeon to have operating privileges at most hospitals in the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12209", "text": "In the  United Kingdom , surgical trainees may apply to enter training after five years of medical school and two years of the  Foundation Programme . During the two year core surgical training programme (\"phase 1\"), doctors are required to sit the Membership of the  Royal College of Surgeons  (MRCS) examination. On award of the MRCS by one of the four surgical colleges, surgeons may hold the title ' Mister ' or ' Miss / Ms. / Mrs ' rather than doctor. This tradition dates back hundreds of years in the United Kingdom from when only physicians attended medical school and surgeons did not, but were rather associated with  barbers  in the  Barber Surgeon's  Guild. The tradition is also present in many  Commonwealth  countries including  New Zealand  and some states of  Australia . After completion of phase 1 training, trainees may apply for a nationally awarded Higher Surgical Training (HST) programme, which lasts six years and is now divided into two further phases (phases 2 and 3). Trainees are expected to declare a sub-specialty before the end of phase 2, and training during phase 3 focuses on that sub-specialty. Before the end of HST, the examination for  Fellowship of the Royal College of Surgeons  (FRCS) must be taken in general surgery plus the subspeciality. Upon completion of training, the surgeon will be eligible for entry on the  GMC  Specialist Register. They may then apply to work both in the  NHS  and independent sector as a consultant surgeon, although many trainees complete further fellowships. [ 4 ]  The implementation of the European Working Time Directive limited UK surgical residents to an average 48-hour working week. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12210", "text": "Oculoplasty , or oculoplastic surgery, involves medical and surgical treatment for deformities and abnormalities of the eyelids, lacrimal (tear) system, orbit (bony cavity around the eye), and the adjacent face. This specialized branch of ophthalmology requires adherence to strict medical guidelines and legal frameworks to ensure patient safety and professional accountability. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12211", "text": "Ophthalmology  ( / \u02cc \u0252 f \u03b8 \u00e6 l \u02c8 m \u0252 l \u0259 d\u0292 i / ,  OFF -thal- MOL -\u0259-jee ) [ 1 ]  is a  clinical  and  surgical  specialty within  medicine  that deals with the diagnosis and treatment of  eye  disorders. [ 2 ]  A former term is  oculism ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12212", "text": "An  ophthalmologist  is a physician who undergoes subspecialty training in medical and surgical eye care. [ 3 ]  Following a  medical degree , a doctor specialising in ophthalmology must pursue additional postgraduate  residency training  specific to that field. This may include a one-year integrated internship that involves more general medical training in other fields such as internal medicine or general surgery. Following residency, additional specialty training (or fellowship) may be sought in a particular aspect of eye pathology. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12213", "text": "Ophthalmologists prescribe medications to treat ailments, such as eye diseases, implement laser therapy, and perform surgery when needed. [ 5 ]   Ophthalmologists provide both primary and specialty eye care\u2014medical and surgical. [ 5 ]  Most ophthalmologists participate in academic research on eye diseases at some point in their training and many include research as part of their career. [ 6 ] \nOphthalmology has always been at the forefront of medical research with a long history of advancement and innovation in eye care. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12214", "text": "A brief list of some of the most common diseases treated by ophthalmologists: [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12215", "text": "The most valued pharmaceutical companies worldwide whose leading products are in Ophthalmology are  Regeneron  (United States) for  Macular degeneration (AMD)  treatment and  Bausch Health  (Canada) for Front of eye. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12216", "text": "Following are examples of examination methods performed during an  eye examination  that enables diagnosis [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12217", "text": "Optical coherence tomography  (OCT)  is a medical technological platform used to assess ocular structures. The information is then used by physicians to assess staging of pathological processes and confirm clinical diagnoses. Subsequent OCT scans are used to assess the efficacy of managing diabetic retinopathy, age-related macular degeneration, and glaucoma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12218", "text": "Optical coherence tomography angiography  (OCTA)  and  Fluorescein angiography  to visualize the vascular networks of the retina and choroid."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12219", "text": "Electroretinography   (ERG)  measures the electrical responses of various cell types in the  retina , including the  photoreceptors  ( rods  and  cones ), inner retinal cells ( bipolar  and  amacrine  cells), and the  ganglion cells ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12220", "text": "Electrooculography  ( EOG ) is a technique for measuring the corneo-retinal standing potential that exists between the front and the back of the human eye. The resulting signal is called the electrooculogram. Primary applications are in ophthalmological  diagnosis  and in recording  eye movements ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12221", "text": "Visual field testing  to detect dysfunction in central and  peripheral vision  which may be caused by various medical conditions such as  glaucoma ,  stroke ,  pituitary disease ,  brain tumours  or other neurological deficits."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12222", "text": "Corneal topography  is a  non-invasive   medical imaging  technique for mapping the anterior curvature of the  cornea , the outer structure of the  eye ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12223", "text": "Ultrasonography  of the eyes may be performed by an ophthalmologist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12224", "text": "Eye surgery , also known as ocular surgery, is surgery performed on the eye or its adnexa by an ophthalmologist. The eye is a fragile organ, and requires extreme care before, during, and after a surgical procedure. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient and for taking the necessary safety precautions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12225", "text": "Ophthalmology includes subspecialities that deal either with certain diseases or diseases of certain parts of the eye. Some of them are: [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12226", "text": "Medical retina and vitreo-retinal surgery sometimes are combined and together they are called  posterior segment  subspecialisation"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12227", "text": "The  Greek  roots of the word ophthalmology are \u1f40\u03c6\u03b8\u03b1\u03bb\u03bc\u03cc\u03c2 ( ophthalmos , \"eye\") and -\u03bbo\u03b3\u03af\u03b1 (- logia , \"study, discourse\"), [ 14 ] [ 15 ]  i.e., \"the study of eyes\". The discipline applies to all animal eyes, whether human or not, since the practice and procedures are quite similar with respect to disease processes, although there are differences in the anatomy or disease prevalence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12228", "text": "In the  Ebers Papyrus  from ancient Egypt dating to 1550 BC, a section is devoted to eye diseases. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12229", "text": "Prior to  Hippocrates , physicians largely based their anatomical conceptions of the eye on speculation, rather than  empiricism . [ 2 ]  They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by  Alcamaeon  (fifth century BC) and others, that this fluid was the medium of vision and flowed from the eye to the brain by a tube.  Aristotle  advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He and his contemporaries further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12230", "text": "The Greek physician  Rufus of Ephesus  (first century AD) recognised a more modern concept of the eye, with  conjunctiva , extending as a fourth epithelial layer over the eye. [ 2 ]  Rufus was the first to recognise a two-chambered eye, with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with a substance resembling egg whites)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12231", "text": "Celsus  the Greek philosopher of the second century AD gave a detailed description of cataract surgery by the  couching  method."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12232", "text": "The Greek physician  Galen  (second century AD) remedied some mistaken descriptions, including about the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a  posterior chamber . Although this model was a roughly correct modern model of the eye, it contained errors. Still, it was not advanced upon again until after  Vesalius . A  ciliary body  was then discovered and the sclera, retina, choroid, and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid, as well as the lens being attached to the choroid. Galen continued the notion of a central canal, but he dissected the optic nerve and saw that it was solid. He mistakenly counted seven optical muscles, one too many. He also knew of the  tear ducts ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12233", "text": "The Indian surgeon  Sushruta  wrote the  Sushruta Samhita  in  Sanskrit  in approximately the sixth century BC, [ 16 ]  which describes 76 ocular diseases (of these, 51 surgical) as well as several ophthalmological surgical instruments and techniques. [ 17 ] [ 18 ]  His description of  cataract surgery  was compatible with the method of  couching . [ 19 ]  He has been described as one of the first cataract surgeons. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12234", "text": "Medieval Islamic Arabic and Persian scientists (unlike their classical predecessors) considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore, found it natural to combine the study of the eye with the practical application of that knowledge. [ 22 ]   Hunayn ibn Ishaq , and others beginning with the medieval Arabic period, taught that the crystalline lens is in the exact center of the eye. [ 23 ]  This idea was propagated until the end of the 1500s. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12235", "text": "Ibn al-Nafis , an Arabic native of Damascus, wrote a large textbook,  The Polished Book on Experimental Ophthalmology , divided into two parts,  On the Theory of Ophthalmology  and  Simple and Compounded Ophthalmic Drugs . [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12236", "text": "Avicenna  wrote in his Canon \"rescheth\", which means \"retiformis\", and  Gerard of Cremona  translated this at approximately 1150 into the new term \"retina\". [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12237", "text": "In the seventeenth and eighteenth centuries,  hand lenses  were used by  Malpighi ,  microscopes  by  Leeuwenhoek , preparations for fixing the eye for study by  Ruysch , and later the freezing of the eye by  Petit . This allowed for detailed study of the eye and an advanced model. Some mistakes persisted, such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the  posterior chamber , and the nature of the retina. Unaware of their functions,  Leeuwenhoek  noted the existence of photoreceptors, [ 26 ]  however, they were not properly described until  Gottfried Reinhold Treviranus  in 1834."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12238", "text": "Jacques Daviel  performed the first documented planned primary cataract extraction on Sep. 18, 1750 in Cologne. [ 27 ] \n Georg Joseph Beer  (1763\u20131821) was an Austrian ophthalmologist and leader of the First Viennese School of Medicine. He introduced a flap operation for treatment of  cataract  (Beer's operation), as well as having popularized the instrument used to perform the surgery (Beer's knife). [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12239", "text": "In North America, indigenous healers treated some eye diseases by rubbing or scraping the eyes or eyelids. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12240", "text": "The first ophthalmic surgeon in the UK was  John Freke , appointed to the position by the governors of  St. Bartholomew's Hospital  in 1727. A major breakthrough came with the appointment of Baron de Wenzel (1724\u201390), a German who became the oculist to  King George III  of Great Britain in 1772. His skill at removing cataracts legitimized the field. [ 30 ]  The first dedicated ophthalmic hospital opened in 1805 in London; it is now called  Moorfields Eye Hospital .  Clinical developments at Moorfields and the founding of the Institute of Ophthalmology (now part of the  University College London ) by  Sir Stewart Duke-Elder  established the site as the largest eye hospital in the world and a nexus for ophthalmic research. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12241", "text": "In Berlin, ophthalmologist  Albrecht von Graefe  introduced  iridectomy  as a treatment for glaucoma and improved cataract surgery, he is also considered the founding father of the German Ophthalmological Society."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12242", "text": "Numerous ophthalmologists fled Germany after 1933 as the Nazis began to persecute those of Jewish descent. A representative leader was  Joseph Igersheimer  (1879\u20131965), best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to  Turkey  in 1933. As one of eight emigrant directors in the Faculty of Medicine at the  University of Istanbul , he built a modern clinic and trained students. In 1939, he went to the United States, becoming a professor at  Tufts University . [ 32 ]  German ophthalmologist,  Gerhard Meyer-Schwickerath  is widely credited with developing the predecessor of laser coagulation, photocoagulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12243", "text": "In 1946, Igersheimer conducted the first experiments on light coagulation. In 1949, he performed the first successful treatment of a retinal detachment with a light beam (light coagulation) with a self-constructed device on the roof of the ophthalmic clinic at the  University of Hamburg-Eppendorf . [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12244", "text": "Polish ophthalmology dates to the thirteenth century. The Polish Ophthalmological Society was founded in 1911. A representative leader was  Adam Zamenhof  (1888\u20131940), who introduced certain diagnostic, surgical, and nonsurgical eye-care procedures. He was executed by the German Nazis in 1940. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12245", "text": "Zofia Falkowska (1915\u201393) head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12246", "text": "The prominent physicists of the late nineteenth and early twentieth centuries included  Ernst Abbe  (1840\u20131905), a co-owner of at the Zeiss Jena factories in Germany, where he developed numerous optical instruments.  Hermann von Helmholtz  (1821\u20131894) was a polymath who made contributions to many fields of science and invented the  ophthalmoscope  in 1851. They both made theoretical calculations on image formation in optical systems and also had studied the optics of the eye."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12247", "text": "Ophthalmologists are  physicians  ( MD/DO in the U.S. or MBBS in the UK and elsewhere  or  DO /DOMS/DNB, who typically complete an undergraduate degree, general medical school, followed by a residency in ophthalmology. Ophthalmologists typically perform optical, medical and surgical eye care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12248", "text": "In  Australia  and  New Zealand , the FRACO or FRANZCO is the equivalent postgraduate specialist qualification. The structured training system takes place over five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST or CCT, usually are deemed to be comparable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12249", "text": "In  Bangladesh  to be an ophthalmologist the basic degree is an MBBS. Then they have to obtain a postgraduate degree or diploma in an ophthalmology specialty. In Bangladesh, these are diploma in ophthalmology, diploma in community ophthalmology, fellow or member of the College of Physicians and Surgeons in ophthalmology, and Master of Science in ophthalmology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12250", "text": "In  Canada , after medical school an ophthalmology residency is undertaken. The residency typically lasts five years, which culminates in fellowship of the Royal College of Surgeons of Canada (FRCSC). Subspecialty training is undertaken by approximately 30% of fellows (FRCSC) in a variety of fields from  anterior segment ,  cornea ,  glaucoma ,  vision rehabilitation ,  uveitis ,  oculoplastics , medical and surgical retina,  ocular oncology ,  Ocular pathology , or  neuro-ophthalmology . Approximately 35 vacancies open per year for ophthalmology residency training in all of Canada. These numbers fluctuate per year, ranging from 30 to 37 spots. Of these, up to ten spots are at French-speaking universities in Quebec. At the end of the five years, the graduating ophthalmologist must pass the oral and written portions of the  Royal College  exam in either English or French."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12251", "text": "In  India , after completing MBBS degree, postgraduate study in ophthalmology is required. The degrees are doctor of medicine, master of surgery, diploma in ophthalmic medicine and surgery, and diplomate of national board. The concurrent training and work experience are in the form of a junior residency at a medical college, eye hospital, or institution under the supervision of experienced faculty. Further work experience in the form of fellowship, registrar, or senior resident refines the skills of these eye surgeons. All members of the India Ophthalmologist Society and various state-level ophthalmologist societies hold regular conferences and actively promote continuing medical education."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12252", "text": "In  Nepal , to become an ophthalmologist, three years of postgraduate study is required after completing an MBBS degree. The postgraduate degree in ophthalmology is called medical doctor in ophthalmology. Currently, this degree is provided by Tilganga Institute of Ophthalmology, Tilganga, Kathmandu, BPKLCO, Institute of Medicine, TU, Kathmandu, BP Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel, and National Academy of Medical Science, Kathmandu. A few Nepalese citizens also study this subject in Bangladesh, China, India, Pakistan, and other countries. All graduates have to pass the Nepal Medical Council Licensing Exam to become a registered ophthalmologists in Nepal. The concurrent residency training is in the form of a PG student (resident) at a medical college, eye hospital, or institution according to the degree providing university's rules and regulations. Nepal Ophthalmic Society holds regular conferences and actively promotes continuing medical education."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12253", "text": "In  Ireland , the  Royal College of Surgeons of Ireland  grants membership (MRCSI (Ophth)) and fellowship (FRCSI (Ophth)) qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of three years of basic surgical training, and a further 4.5 years of higher surgical training. Clinical training takes place within public,  Health Service Executive -funded hospitals in  Dublin ,  Sligo ,  Limerick ,  Galway ,  Waterford , and  Cork . A minimum of 8.5 years of training is required before eligibility to work in  consultant  posts. Some trainees take extra time to obtain  MSc ,  MD  or  PhD  degrees and to undertake clinical fellowships in the UK, Australia, and the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12254", "text": "In  Pakistan , after MBBS, a four-year full-time residency program leads to an exit-level FCPS examination in ophthalmology, held under the auspices of the College of Physicians and Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani and eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12255", "text": "Moreover, a two-and-a-half-year residency program leads to an MCPS while a two-year training of DOMS is also being offered. [ 36 ]  For candidates in the military, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12256", "text": "The M.S. in ophthalmology is also one of the specialty programs. In addition to programs for physicians, various diplomas and degrees for allied eyecare personnel are also being offered to produce competent optometrists, orthoptists, ophthalmic nurses, ophthalmic technologists, and ophthalmic technicians in this field. These programs are being offered, notably by the  College of Ophthalmology and Allied Vision Sciences , in  Lahore  and the Pakistan Institute of Community Ophthalmology in Peshawar. [ 37 ]  Subspecialty fellowships also are being offered in the fields of  pediatric ophthalmology  and vitreoretinal ophthalmology.  King Edward Medical University , Al Shifa Trust Eye Hospital Rawalpindi, and Al- Ibrahim Eye Hospital Karachi also have started a degree program in this field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12257", "text": "In the Philippines, Ophthalmology is considered a medical specialty that uses medicine and surgery to treat diseases of the eye. There is only one professional organization in the country that is duly recognized by the PMA and the PCS: the Philippine Academy of Ophthalmology (PAO). [ 38 ]  PAO and the state-standard Philippine Board of Ophthalmology (PBO) regulates ophthalmology residency programs and board certification. To become a general ophthalmologist in the Philippines, a candidate must have completed a doctor of medicine degree (MD) or its equivalent (e.g. MBBS), have completed an internship in Medicine, have passed the physician licensure exam, and have completed residency training at a hospital accredited by the Philippine Board of Ophthalmology (accrediting arm of PAO). [ 39 ]  Attainment of board certification in ophthalmology from the PBO is essential in acquiring privileges in most major health institutions. Graduates of residency programs can receive further training in ophthalmology subspecialties, such as neuro-ophthalmology, retina, etc. by completing a fellowship program that varies in length depending on each program's requirements."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12258", "text": "In the  United Kingdom , three colleges grant postgraduate degrees in ophthalmology. The  Royal College of Ophthalmologists  (RCOphth) and the  Royal College of Surgeons of Edinburgh  grant MRCOphth/FRCOphth and MRCSEd/FRCSEd, (although membership is no longer a prerequisite for fellowship), the  Royal College  of Glasgow grants FRCS. Postgraduate work as a  specialist registrar  and one of these degrees is required for specialization in  eye diseases . Such clinical work is within the NHS, with supplementary private work for some consultants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12259", "text": "Only 2.3 ophthalmologists exist per 100,000 population in the UK \u2013 fewer  pro rata  than in any nations in the European Union. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12260", "text": "Ophthalmologists typically complete four years of undergraduate studies, four years of medical school and four years of eye-specific training (residency). Some pursue additional training, known as a fellowship - typically one to two years. Ophthalmologists are physicians who specialize in the eye and related structures. They perform medical and surgical eye care and may also write prescriptions for corrective lenses. They often manage late stage eye disease, which typically involves surgery. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12261", "text": "Ophthalmologists must complete the requirements of  continuing medical education  to maintain licensure and for recertification."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12262", "text": "The following is a list of physicians who have significantly contributed to the field of ophthalmology:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12263", "text": "1. LeFort I \n2. Bilateral Sagittal Split\n3. Genioplasty \n4. IMDO\n5. GenioPaully\n6. Custom PEEK\n7. SARME\n8. Custom BIMAX"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12264", "text": "Orthognathic surgery  ( / \u02cc \u0254\u02d0r \u03b8 \u0259 \u0261 \u02c8 n \u00e6 \u03b8 \u026a k / ), also known as  corrective jaw surgery  or simply  jaw surgery , is  surgery  designed to correct conditions of the  jaw  and lower  face  related to structure, growth, airway issues including  sleep apnea ,  TMJ  disorders,  malocclusion  problems primarily arising from skeletal disharmonies, and other  orthodontic  dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics  [ 1 ]  and self-esteem."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12265", "text": "The origins of orthognathic surgery belong in oral surgery, and the basic operations related to the surgical removal of impacted or displaced teeth \u2013 especially where indicated by orthodontics to enhance dental treatments of malocclusion and dental crowding. One of the first published cases of orthognathic surgery was the one from Dr.  Simon P. Hullihen  in 1849."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12266", "text": "Originally coined by Harold Hargis, it was more widely popularised first in Germany and then most famously by Hugo Obwegeser who developed the bilateral sagittal split osteotomy (BSSO). This surgery is also used to treat congenital conditions such as  cleft palate . [ 2 ]  Typically surgery is performed via the mouth, where jaw bone is cut, moved, modified, and realigned to correct malocclusion or  dentofacial deformity . The word \"osteotomy\" means the division of bone by means of a surgical cut."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12267", "text": "The \"jaw osteotomy\", either to the upper jaw or lower jaw (and usually both) allows (typically) an oral and maxillofacial surgeon to surgically align an arch of teeth, or the segment of a dental arch with its associated jawbone, relative to other segments of the dental arches. Working with orthodontists, the coordination of dental arches has primarily been directed to create a working occlusion. As such, orthognathic surgery is seen a secondary procedure supporting a more fundamental orthodontic objective."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12268", "text": "It is only recently, and especially with the evolution of oral and maxillofacial surgery in establishing itself as a primary medical specialty \u2013 as opposed to its long term status as a dental speciality \u2013 that orthognathic surgery has increasingly emerged as a primary treatment for obstructive sleep apnoea, as well as for primary facial proportionality or symmetry correction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12269", "text": "The primary use of surgery to correct jaw disproportion or malocclusion is rare in most countries due to private health insurance and public hospital funding and health access issues. A small number of mostly heavily socialist funded countries report that jaw correction procedures occur in some form or other in about 5% of a general population, but this figure would be at the extreme end of service  [ 3 ] [ 4 ] [ 5 ]  presenting with dentofacial  deformities  like maxillary prognathisms, mandibular prognathisms, open bites, difficulty chewing, difficulty swallowing,  temporomandibular joint dysfunction  pains, excessive wear of the teeth, and receding chins."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12270", "text": "Increasingly, as people are more able to self-fund surgery, 3D facial diagnostic and design systems have emerged, as well as new operations that enable for a broad range of jaw correction procedures that have become readily accessible; in particularly in private maxillofacial surgical practice. These procedures include IMDO, SARME, GenioPaully, custom BIMAX, and custom PEEK procedures. These procedures are replacing the traditional role of certain orthognathic surgery operations that have for decades served wholly and primarily orthodontic or dental purposes. [ 6 ]  Another development in the field is the new index called the index of orthognathic functional treatment need (IOFTN) that detects patients with the greatest need for orthognathic surgery as a part of their comprehensive treatment. [ 7 ]  IOFTN has been validated internationally and detected over 90% of patients with greatest need for orthognathic surgery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12271", "text": "It is estimated that nearly 5% of the UK or US population present with dentofacial deformities that are not amenable to orthodontic treatment requiring orthognathic surgery as a part of their definitive treatment. [ 9 ] [ 4 ] [ 5 ]  Orthognathic surgery can be used to correct:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12272", "text": "A disproportionately grown upper or lower jaw causes dentofacial deformities. Chewing becomes problematic, and may also cause pain due to straining of the jaw muscle and bone. Deformities range from  micrognathia , which is when the mandible does not grow far forward enough (over bite), and when the mandible grows too much, causing an under bite; all of which are uncomfortable. Also, a total  maxilla  osteotomy is used to treat the \"long face syndrome\", known as the skeptical open bite, idiopathic long face, hyper divergent face, total maxillary alveolar hyperplasia, and vertical maxillary excess. Prior to surgery, surgeons should take  x-rays  of the patient's jaw to determine the  deformity , and to make a plan of procedures. [ 11 ]   Mandible  osteotomies, or corrective jaw surgeries, benefit individuals who have difficulty chewing, swallowing,  TMJ  pains, excessive wear of the teeth, open bites,  overbites ,  underbites , or a receding chin. [ citation needed ]  The deformities listed above can be perfected by an osteotomy surgery of either the maxilla or mandible (whichever the deformity calls for), which is performed by an oral surgeon who is specialized in the working with both the upper and lower jaws. [ 12 ]  Orthognathic surgery is also available as a very successful treatment (90\u2013100%) for obstructive sleep apnea. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12273", "text": "Orthognathic surgery is a well established and widely used treatment option for insufficient growth of the  maxilla  in patients with an  orofacial cleft . [ 14 ]  There is some debate regarding the timing of orthognathic procedures, to maximise the potential for natural growth of the facial skeleton. [ 15 ]  Patient reported aesthetic outcomes of orthognathic surgery for cleft lip and palate appear to be of overall satisfaction, [ 16 ] [ 17 ]  despite complications that may arise. A potentially significant long-term outcome of orthognathic surgery is impaired maxillary growth, due to scar tissue formation. [ 18 ]  A 2013 systematic review comparing traditional orthognathic surgery with maxillary  distraction osteogenesis  found that the evidence was of low quality; it appeared that both procedures might be effective, but suggested distraction osteogenesis might reduce the incidence of long-term relapse. [ 19 ]  The most common causes of cleft lip and palate are genetic and environmental factors. Clefts are known to occur due to folic acid deficiency, iron and iodine deficiency [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12274", "text": "Although infrequent, there can be complications such as bleeding, swelling, infection, nausea and vomiting. [ 21 ]  Infection rates of up to 7% are reported after orthognathic surgery; antibiotic prophylaxis reduces the risk of surgical site infections when the antibiotics are given during surgery and continued for longer than a day after the operation. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12275", "text": "There can also be some post operative facial numbness due to nerve damage. [ 23 ]  Diagnostics for nerve damage consist of: brush-stroke directional discrimination (BSD), touch detection threshold (TD), warm/cold (W/C) and sharp/blunt discrimination (S/B), electrophysiological tests (mental nerve blink reflex (BR), nerve conduction study (NCS), and cold (CDT) and warm (WDT) detection thresholds. [ 24 ]  The  inferior alveolar nerve , which is a branch of the  mandibular nerve , must be identified during surgery and worked around carefully in order to minimize  nerve  damage. The numbness may be either temporary, or more rarely, permanent. [ 25 ]  Recovery from the nerve damage typically occurs within three months after repair. Some 3D movements are considered riskier than other ones, such as maxillary impaction.  [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12276", "text": "Orthognathic surgery is performed by maxillofacial or an  oral surgeon  or a plastic surgeon in collaboration with an  orthodontist . It often includes braces before and after surgery, and retainers after the final removal of braces. Orthognathic surgery is often needed after reconstruction of cleft palate or other major  craniofacial  anomalies. Careful coordination between the surgeon and orthodontist is essential to ensure that the teeth will fit correctly after the surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12277", "text": "Planning for the surgery usually involves input from a multidisciplinary team, including oral and maxillofacial surgeons, orthodontists, and occasionally a speech and language therapist. Although it depends on the reason for surgery, working with a speech and language therapist in advance can help minimize potential relapse. The surgery usually results in a noticeable change in the patient's face; a psychological assessment is occasionally required to assess patient's need for surgery and its predicted effect on the patient.\nRadiographs and photographs are taken to help in the planning. There is also advanced software that can predict the shape of the patient's face after surgery, [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ]  which is useful for the planning and also explaining the surgery to the patient and the patient's family. [ 32 ]  Great care needs to be taken during the planning phase to maximize airway patency."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12278", "text": "Orthodontics are a critical component of orthognathic surgery. Traditionally the presurgical orthodontic phase can take as long as one year and undertaken with conventional metal braces. [ 33 ]  However, these days new approaches and paradigms exist including surgery-first  [ 34 ]  And using clear aligner orthodontia (like Invisalign) [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12279", "text": "This procedure is used to correct  mandible  retrusion and  mandibular prognathism  (over and under bite).\nFirst, a  horizontal  cut is made on the inner side of the  ramus mandibulae , extending anterally to the  anterior  portion of the ascending  ramus . The cut is then made inferiorly on the ascending ramus to the descending ramus, extending to the lateral border of the mandible in the area between the first and  second molar . At this time, a  vertical  cut is made extending inferior to the body of the mandible, to the inferior border of the mandible.\nAll cuts are made into the middle of the bone, where  bone marrow  is present. Then, a chisel is inserted into the pre existing cuts and tapped gently in all areas to split the mandible of the left and right side. From here, the mandible can be moved either forwards or backwards. If sliding backwards, the distal segment must be trimmed to provide room in order to slide the mandible backwards. Lastly, the jaw is stabilized using stabilizing screws that are inserted extra-orally. The jaw is then wired shut for approximately 4\u20135 weeks. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12280", "text": "This procedure is used for the advancement (movement forward) or retraction (movement backwards) of the chin.\nFirst, incisions are made from the  first bicuspid  to the first bicuspid, exposing the  mandible . Then, soft tissue of the mandible is detached from the bone; done by stripping attaching tissues. A horizontal incision is then made inferior to the first bicuspids, bilaterally, where bone cuts (osteotomies) are made vertically inferior, extending to the inferior border of the mandible, thereby detaching the bony segments of the mandible. The bony segments are stabilized with titanium plates; no fixation (binding of the jaw) necessary. If advancement is indicated for the chin, there are inert products available to implant onto the mandible, utilizing titanium screws, bypassing bone cuts. [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12281", "text": "When a patient has a constricted (oval shape)  maxilla , but normal  mandible , many  orthodontists  request a rapid  palatal  expansion.\nThis consists of the surgeon making horizontal cuts on the lateral board of the maxilla, extending anterally to the inferior border of the  nasal cavity . At this time, a chisel designed for the  nasal septum  is utilized to detach the maxilla from the  cranial  base. Then, a pterygoid chisel, which is a curved chisel, is used on the left and right side of the maxilla to detach the pterygoid palates. Care must be taken as to not injure the inferior palatine artery. Prior to the procedure, the orthodontist has an  orthopedic  appliance attached to the maxilla teeth, bilaterally, extending over the  palate  with an attachment so the surgeon may use a hex-like screw to place into the device to push from anterior to posterior to start spreading the bony segments. [ 37 ]  The expansion of the maxilla may take up to eight weeks with the surgeon advancing the expander hex lock, sideways (\u2190 \u2192), once a week."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12282", "text": "After orthognathic surgery, patients are often required to adhere to an all-liquid diet for a time. Weight loss due to lack of appetite and the liquid diet is common. Normal recovery time can range from a few weeks for minor surgery, to up to a year for more complicated surgery. For some surgeries, pain may be minimal due to minor nerve damage and lack of feeling. Doctors will prescribe pain medication and prophylactic antibiotics to the patient. There is often a large amount of swelling around the jaw area, and in some cases bruising. Most of the swelling will disappear in the first few weeks, but some may remain for a few months."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12283", "text": "All dentofacial osteotomies require an initial healing time of 2\u20136 weeks with secondary healing (complete bony union and bone remodeling) taking an additional 2\u20134 months. The jaw is sometimes immobilized (movement restricted by wires or elastics) for approximately 1\u20134 weeks. However, the jaw will still require two to three months for proper healing. Lastly, if screws were inserted in the jaw, bone will typically grow over them during the two to three month healing period. Patients also may not drive or operate vehicles or large machinery during the consumption of painkillers, which are typically taken for six to eight days after the surgery, depending on the pain experienced. Immediately after surgery, patients must adhere to certain infection preventing instructions such as daily cleaning, and the consumption of  antibiotics . Cleaning of the mouth should always be done regardless of surgery to ensure healthy, strong teeth. Patients are able to return to work 2\u20136 weeks after the surgery, but must follow the specific rules for recovery for ~8 weeks. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12284", "text": "Mandible  and  maxilla  osteotomies date to the 1940s. They were used to correct dentofacial  deformities  like a  malocclusion , and a  prognathism . [ 41 ]  Advances have been made in the procedures, and in the  anesthesia  used. In 1985, mandible and maxilla osteotomies were effectively used to correct more extreme deformities like receding chins, and to relieve pain from  temporomandibular joint disorder  (TMJ)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12285", "text": "Prior to 1991, some patients undergoing a dentofacial osteotomy still had  third molars  (wisdom teeth), and had them removed during surgery. An extensive study done by Dr. M Lacy and Dr. R Colcleugh, was used to identify threats of combining the two surgeries used 83 patients from the time span of 1987 and 1991. Patients were reviewed, and divided into two groups; those who had, and those who did not have their third molars extracted during the dentofacial Osteotomy. The study showed that 73% of patients developed an infection of the hardware inserted into the jaw when having their third molars removed during an osteotomy. The data indicated that getting the osteotomy and the  third molar   extraction  at the same time highly increases the chances of infection development. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12286", "text": "Advances in the surgical techniques allow surgeons to perform the surgery under  local anesthesia  with assistance from  intravenous  sedation. Dr. Raffaini introduced this technique in 2002 after a four-year study done with local anesthesia and assistance from intravenous sedation. Prior to this, surgeons would fully  sedate  patients, hospitalizing them shortly after the surgery for a 2\u20133 day recovery, specifically from the  anesthesia . Advancements allow surgeons to expand the use of an osteotomy on more parts of the jaws with faster recovery time, less pain, and no hospitalization, making the surgery more effective with respect to time and recovery. [ 43 ] \nThe procedure, which is strictly used for a mandibular (jaw) deformity and mobilization, has advanced from similar, very effective procedures performed since 1985. The original mandible and maxilla osteotomy procedure still remains almost unchanged, as it is the simplest and still the most effective for dentofacial deformity correction."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12287", "text": "Prophylactic surgery  (also known as  preventive surgery  or  risk-reducing surgery ) is a form of  surgery  most commonly intended to minimize or eliminate the risk of the patient developing cancer in an organ or  gland  before development occurs. This can be a life-saving procedure for those at high risk of developing cancer in certain organs. [ 1 ] [ 2 ] [ 3 ]  This category of surgery may include  mastectomies ,  oophorectomies ,  colectomies  and surgical corrections for conditions that include  cryptorchidism   ( undescended testis) . [ 4 ]  Another, less common use of prophylactic surgery is in the prevention of other  diseases  or to seek better health outcomes. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12288", "text": "Throughout most of history, preventive medical techniques have been largely ignored and mostly only relegated to scarce occurrences. Despite the prevalence of diseases such as  syphilis ,  leprosy  and the  black plague  throughout the  late Middle Ages , the concepts of preventive medicine was largely ignored despite advancements in  quarantining  and  sanitary techniques . [ 7 ]  Furthermore, the high  mortality rate  of surgeries both during operation and post-operation deemed these procedures to be too high of a risk to take for a preventive measure. [ 8 ]  This changed however with the introduction of  anesthesia , advancements in  anatomy  and with the introduction  antiseptic  or  aseptic techniques  alongside further advancements in sanitary techniques in the 19th to 20th century allowed surgeons to consider prophylactic surgeries without running the high risks previously experienced. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12289", "text": "One may choose to undergo prophylactic surgery if they believe that it is within their best interest to undergo a procedure in order to remove a high-risk  organ  or  gland . There are several types of preventable surgeries that are known to substantially decrease the risk of future disease. Since prophylactic surgeries are usually permanent and  irreversible , the pros and cons must be carefully weighed by individuals considering the procedure. There are a  myriad  of  ethical ,  physiological, \u2063  and  psychological  considerations to be made before taking such a procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12290", "text": "There are both physical and mental implications that come with committing to a prophylactic surgery; often, alongside the initial disadvantages that are associated with any procedure, such as cost, time lost, recovery, and more, there are other reasons for opting out of an operation. Ethical and religious reasons are commonly considered, especially when in regard to the  reproductive system  and its function. Concerns about sexual and reproductive function and self-image are rather common on clear external surgeries or sexual/ reproductive related surgeries. [ 10 ]  Furthermore, depending on the surgery, there may be certain unknown or unique risks attached depending on the cancer or surgical area. Additionally, undertaking a prophylactic surgery does not guarantee that the patient will never develop cancer later. [ 11 ]  Ultimately, it is a very complex and personal question when it comes to making the decision on whether to operate. Individuals whom do request prophylactic surgeries can be under the influence of  anxiety ,  uncertainty  and  irrational fear  as a result of a test or  hereditary disease  may incite these fears in the individual. It is important to consider the person's opinion, as well as those of their families and surgeon's first before committing to a prophylactic surgery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12291", "text": "Prophylactic surgery in children has largely been justified through two grounds, the best interest of the child and  public health . Since children are unlikely to be able to provide a meaningfully informed  consent , it is an  ethical  subject discussed and heavily contested by various  bioethics  committees and the public. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12292", "text": "Depending on the situation, the type of prophylactic surgery performed may be relegated to match with relevant primary, secondary or tertiary  preventive measures . A primary prevention's goal is to prevent a disease or injury before it has occurred, secondary prevention's goal is to minimize the effects of an illness after it has occurred, and tertiary prevention aims to manage the effects of an illness in the long term. [ 12 ]  Depending on the stage of the illness or whether the patient has had an illness, a different type of procedure may be required. If a cancer has not appeared already then a preventive surgery including the considerations of issues associated with  metastatic breast cancer  will not be considered, instead operations that conserve tissue can be discussed without considerations in case of  metastasis  and the patient may choose, under the context of breast cancer, may undergo a skin sparing or  nipple sparing mastectomy  instead of a  total mastectomy . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12293", "text": "Mastectomies, especially under the context of cancer, are the most well-known form of prophylactic surgery, however there are still a multitude of other forms of surgery used to prevent other diseases. Prophylactic surgery is not only restricted to the prevention of cancer but can also include surgery whose intended purpose is to prevent any disease or unwanted consequence surgically. [ 5 ]  These can include prophylactic  appendectomy ,  circumcision  and even cosmetic surgeries as forms of prophylactic surgery. However, the terms usage is largely associated and most commonly interpreted as the prevention of cancer surgically. [ 11 ] [ 3 ] \nThere are several examples and types of prophylactic surgery, for both cancer related and cancer unrelated diseases. In cancer related prophylactic surgeries, most individuals required to do these surgeries have either already been effected by a related cancer or have an inherited cancer. These  hereditary cancer syndromes  contribute to 5-10 percent of all cancers. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12294", "text": "Prophylactic  mastectomy  is the surgical removal of breast tissue to remove cells that are at risk of developing cancer. These are most commonly done in women whom have  BRCA1  or  BRCA2  mutations discovered from gene testing, have already had cancer in one breast, have a family history of breast cancer or have undergone radiation therapy to their chest, increasing their risk of developing breast cancer. Instances of post-surgery complications are common, with two-thirds of women experiencing at least one complication post-surgery. However, women whom have opted for simultaneous reconstruction after surgery have shown a slightly significant lower risk of  complication at 64%. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12295", "text": "Prophylactic  salpingectomy  is the surgical removal of the  Fallopian tube  which, when done as a preventive measure, may be done to prevent pregnancies as a form of  contraception , or as a method to prevent cancer. Women who underwent prophylactic salpingectomy have shown to have a lower incidence of ovarian cancer compared to women who have not undergone the procedure, from 2.2% to 13% and from 4.75% to 24.4%. Furthermore, it has been shown that salpingectomy may reduce 29.2% to up to 64% of ovarian cancer incidence. [ spelling? ]  For most women, it has been shown to have no significant effect on ovarian function, quality of life, sexuality, and its cost-effective profile. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12296", "text": "Prophylactic  oophorectomy  is the removal of the ovaries and is either done as a planned response to the genetic risk of ovarian or breast cancer, especially among women whom have a hereditary family history of ovarian cancer, have the BRCA1 or BRCA2 mutations,  [ 17 ]  or have developed breast cancer in the past. [ 18 ]  Oophorectomy when done alongside salpingectomy as a bilateral  salpingo-oophorectomy ,  [ 17 ]  or alongside  hysterectomy  or all together, have shown to significant decrease instances of ovarian cancer if the individual has a known history of  BRCA1 or BRCA2  mutations and if they have an identified genetic risk of breast and ovarian cancer. However, hormone replacement therapy and less invasive methods of treating  menorrhagia  and  fibroids  have become more common, making prophylactic oophorectomy a less common choice in unaffected women without a hereditary history of breast or ovarian cancer. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12297", "text": "Prophylactic  Colectomy  is the removal of part or all of the colon in an effort to prevent cancer in the colon. [ 20 ]  This is especially prevalent in individuals with hereditary colorectal cancer syndromes like  hereditary non-polyposis colorectal cancer [ 4 ]  or  familial adenomatous polyposis . [ 21 ]   Individuals affected by these inherited cancers can carry a risk of 80% to up to nearly 100% in some cases within their lifetime. Prophylactic Colectomy have shown to greatly minimize this risk with minimal disturbance to the  bowel . [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12298", "text": "Prophylactic  appendectomy  is the removal of the  appendix  in order to remove the chances of developing  appendicitis  as the leading cause of acute intra-abdominal disease in more than 50% of all cases. [ 23 ]  Prophylactic Appendectomy is one of the most common preventive surgeries and is the most common emergency surgery performed in the  USA . [ 24 ]  The procedure is very safe when performed safely under optimal conditions with little to no  adverse effects  on the operated individuals. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12299", "text": "In  medicine ,  traumatology  (from Greek  trauma , meaning injury or wound) is the study of  wounds  and  injuries  caused by  accidents  or  violence  to a person, and the  surgical therapy  and repair of the damage. Traumatology is a branch of  medicine . It is often considered a subset of  surgery  and in countries without the specialty of  trauma surgery  it is most often a sub-specialty to  orthopedic surgery . Traumatology may also be known as  accident surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12300", "text": "Branches of traumatology include medical traumatology and  psychological traumatology . Medical traumatology can be defined as the study of specializing in the treatment of wounds and injuries caused by violence or general accidents. This type of traumatology focuses on the surgical procedures and future  physical therapy  a patient needs to repair the damage and recover properly. Psychological traumatology is a type of damage to one's mind due to a  distressing  event. This type of trauma can also be the result of overwhelming amounts of stress in one's life. Psychological trauma usually involves some type of physical trauma that poses as a threat to one's sense of security and survival. Psychological trauma often leaves people feeling overwhelmed,  anxious , and threatened. [ 1 ] \nTrauma can also be classified as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12301", "text": "Secondary or vicarious trauma, is another form of trauma in which a person develops trauma symptoms from close contact with someone who has experienced a traumatic event. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12302", "text": "When it comes to types of trauma, medical and psychological traumatology go hand in hand. Types of trauma include  car accidents ,  gunshot wounds ,  concussions ,  PTSD  from incidents, etc. Medical traumas are repaired with surgeries; however, they can still cause psychological trauma and other stress factors. For example, a teenager in a car accident who broke his  wrist  and needed extensive surgery to save his arm may experience  anxiety  when driving in a car post-accident. PTSD can be diagnosed after a person experiences one or more intense and traumatic events and react with fear with complaints from three categorical symptoms lasting one month or longer. These categories are: re-experiencing the traumatic event, avoiding anything associated with the trauma, and increased symptoms of increased psychological  arousal . [ 3 ] :\u200a555"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12303", "text": "Airway management , monitoring, and management of injuries are all key guidelines when it comes to medical trauma care. Airway management is a key component of emergency on-scene care. Using a systematic approach, first responders must assess that a patient's airway is not blocked in order to ensure the patient gets enough  circulation  and remain as calm as they can. [ 4 ] :\u200a19\u200a  Monitoring patients and making sure their body does not go into  shock  is another essential guideline when it comes to medical trauma care. Nurses are required to watch over patients and check  blood pressure ,  heart rate , etc. to make sure that patients are doing well and are not  crashing . When it comes to managing injuries, head and neck injuries require the most care post surgery.  Head injuries  are one of the major causes of trauma related death and disabilities worldwide. It is important for patients of head trauma to get  CT scans  post surgery to insure that there are no problems. [ 4 ] :\u200a28\u201330"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12304", "text": "There is a range of approaches to assist victims to overcome the anxiety and stress that follows  psychological trauma . Affected persons can also follow  self-care  such as exercise and socializing with familiar and safe associates and family members. Trauma disturbs the body's natural equilibrium by putting it in a state of fear and hyper-arousal. [ 1 ]  Exercising for thirty minutes a day facilitated the nervous system to \"unfreeze\" from a traumatic state. Being surrounded by a good support system is a powerful factor in treating psychological trauma. Participating in social activities, volunteering, and making new friends are all ways to help forget about or cope with traumatic events. Coming to terms with  childhood trauma  is especially challenging. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12305", "text": "Factors in the  assessment of wounds  are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12306", "text": "Forensic physicians, as well as pathologists may also be required to examine ( traumatic ) wounds on people."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12307", "text": "Urogynecology  or  urogynaecology  is a surgical sub-specialty of  urology  and  gynecology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12308", "text": "In 1893,  Howard Kelly , a gynecologist and pioneering urogynecologist, invented an air  cystoscope  which was simply a handheld, hollow tube with a glass partition. [ 1 ]  When the American Surgical Society, later the  American College of Surgeons , met in Baltimore in 1900, a contest was held between  Howard Kelly  and  Hugh Hampton Young , who is often considered the father of modern urology. [ 2 ]  Using his air cystoscope, Kelly inserted ureteral catheters in a female patient in just 3 minutes. Young equaled this time in a male patient. [ 3 ]  So began the friendly competitive rivalry between gynecologists and urologists in the area of female urology and urogynecology. This friendly competition continued for decades. In modern times, the mutual interest of obstetricians, gynecologists, and urologists in pelvic floor problems in women has led to a more collaborative effort."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12309", "text": "Urogynecologists are medical professionals who have been to medical school and achieved their basic medical degree, followed by postgraduate training in Obstetrics and Gynaecology (OB-GYN).  They then undertake further training in Urogynecology to achieve accreditation/board certification in this subspecialty. Training programme requirements and duration varies from country to country but usually tend to be around 2\u20133 years in most places. Urogynaecology fellowship programmes are available in some countries, but not all and the levels of formal accreditation and certification vary from country to country."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12310", "text": "The International Urogynecological Association (IUGA) is a global body for professionals practising in the field of urogynaecology and female pelvic medicine and reconstructive surgery.  IUGA facilitates training for physicians from countries which do not have formal training programmes by maintaining and publishing a directory of fellowship programmes. IUGA also  provides educational opportunities for urogynecologists both online and in-person, develops terminology and standardization for the field. The International Continence Society (ICS) is another global organization which strives to improve the quality of life for people affected by urinary, bowel and pelvic floor disorders through education, and research."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12311", "text": "Urogynecology is a sub-specialty of Gynecology, and in some countries is also known as Female Pelvic Medicine and Reconstructive Surgery.  A urogynecologist manages clinical problems associated with dysfunction of the pelvic floor and bladder.  Pelvic floor disorders affect the bladder, reproductive organs, and bowels.  Common pelvic floor disorders include urinary incontinence, pelvic organ prolapse and fecal incontinence.  Increasingly, Urogynecologists are also responsible for the care of women who have experienced trauma to the perineum during childbirth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12312", "text": "There is some crossover with the subspecialty of Female Urology - these doctors are urologists who undergo additional training to be able to manage female urinary incontinence, pelvic organ prolapse and interstitial cystitis/PBS.  In addition, there are colorectal surgeons who have a special interest in anal incontinence and pelvic floor dysfunction related to rectal function.  Contemporary urogynecological practice encourages multidisciplinary teams working in the care of patients, with collaborative input from urogynecologists, urologists, colorectal surgeons,  elderly care  physicians, and physiotherapists.  This is especially important in the care of patients with complex problems, e.g. those who have undergone previous surgery or who have combined incontinence and prolapse, or combined urinary and bowel problems.  Multidisciplinary team meetings are an important part of the management pathway of these women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12313", "text": "Urogynaecologists manage women with urinary incontinence and pelvic floor dysfunction.  The clinical conditions that a urogynecologist may see include stress incontinence, overactive bladder, voiding difficulty, bladder pain, urethral pain, vaginal or uterine prolapse, obstructed defecation, anal incontinence, and perineal injury.  They may also care for women with  vesicovaginal  or rectovaginal fistulae with specialist training, and in conjunction with other specialties."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12314", "text": "Patients will usually be assessed using a combination of history taking, examination (including pelvic examination and assessment of prolapse using validated systems such as the  Pelvic Organ Prolapse Quantification System  and assessment of quality of life impact using validated questionnaires, including the assessment of sexual function, using Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA- Revised [PISQ-IR].  A bladder diary is often used to quantify an individual's fluid intake, and the number of voids per day and night, as well as the volume the bladder can hold on a day-to-day basis.  Further investigations might include urodynamics or a cystoscopy.  Treatment usually starts with conservative measures such as pelvic floor muscle training, fluid and food modification or bladder training.  Drug therapies can be used for overactive bladder, which may include antimuscarinic drugs or beta 3 receptor agonists - both of these help to control the urgency that is the key component of overactive bladder. If medications fail, more invasive options such as injections of botulinum toxin into the bladder muscle, or neuromodulation are other options for symptom relief.  Surgical treatments can be offered for stress incontinence and/or uterovaginal prolapse if pelvic floor muscle training is unsuccessful."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12315", "text": "Urogynecological problems are seldom life-threatening, but they do have a major impact on the quality of life of affected individuals.  Urogynecologists will usually use quality of life improvement as a treatment goal, and there is a major focus on optimising symptoms using conservative measures before embarking on more invasive treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12316", "text": "Some conditions treated in urogynecology practice include: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12317", "text": "Diagnostic tests and procedures performed include: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12318", "text": "Specialty treatments available include: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12319", "text": "Urology  (from  Greek   \u03bf\u1f56\u03c1\u03bf\u03bd   ouron  \"urine\" and  -\u03bb\u03bf\u03b3\u03af\u03b1   -logia  \"study of\"), also known as  genitourinary surgery , is the branch of  medicine  that focuses on surgical and medical diseases of the  urinary system  and the  reproductive organs . Organs under the domain of urology include the  kidneys ,  adrenal glands ,  ureters ,  urinary bladder ,  urethra , and the male reproductive organs ( testes ,  epididymides ,  vasa deferentia ,  seminal vesicles ,  prostate , and  penis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12320", "text": "The urinary and reproductive tracts are closely linked, and disorders of one often affect the other. Thus a major spectrum of the conditions managed in urology exists under the domain of  genitourinary disorders . Urology combines the management of medical (i.e., non-surgical) conditions, such as  urinary-tract infections  and  benign prostatic hyperplasia , with the management of surgical conditions such as bladder or  prostate cancer ,  kidney stones , congenital abnormalities, traumatic injury, and  stress incontinence . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12321", "text": "Urological techniques include minimally invasive  robotic  and  laparoscopic surgery , laser-assisted surgeries, and other scope-guided procedures. Urologists receive training in open and minimally invasive surgical techniques, employing real-time ultrasound guidance, fiber-optic endoscopic equipment, and various lasers in the treatment of multiple benign and malignant conditions. [ 2 ] [ 3 ]  Urology is closely related to (and urologists often collaborate with the practitioners of)  oncology ,  nephrology ,  gynaecology ,  andrology ,  pediatric surgery ,  colorectal surgery ,  gastroenterology , and  endocrinology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12322", "text": "Urology is one of the most competitive and highly sought surgical specialties for  physicians , with new urologists comprising less than 1.5% of United States medical-school graduates each year. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12323", "text": "Urologists are physicians which have specialized in the field after completing their general degree in medicine. Upon successful completion of a residency program, many urologists choose to undergo further advanced training in a subspecialty area of expertise through a fellowship lasting an additional 12 to 36 months. Subspecialties may include: urologic surgery, urologic oncology and urologic oncological surgery, endourology and endourologic surgery,  urogynecology  and urogynecologic surgery, reconstructive urologic surgery (a form of  reconstructive surgery ), minimally-invasive urologic surgery,  pediatric urology  and pediatric urologic surgery (including adolescent urology, the treatment of premature or delayed puberty, and the treatment of congenital urological syndromes, malformations, and deformations),  transplant  urology (the field of transplant medicine and surgery concerned with transplantation of organs such as the kidneys, bladder tissue, ureters, and, recently, penises),  voiding dysfunction ,  paruresis ,  neurourology , and androurology and  sexual medicine . Additionally, some urologists supplement their fellowships with a master's degree (2\u20133 years) or with a Ph.D. (4\u20136 years) in related topics to prepare them for academic as well as focused clinical employment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12324", "text": "As of 2022, there are 146  residency  programs that offered 356 categorical positions. [ 6 ]  Urology is one of the early match programs, with results given to applicants by early February (6 weeks before NRMP match). Applications are accepted starting Sep 1, with some programs accepting applications until early Jan. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12325", "text": "It is a relatively competitive specialty to match into, with only 65.6% of US seniors matching in the 2022 match cycle. [ 8 ]  The number of positions has grown from 278 in 2012 to 356 in 2022. Matching is significantly more difficult for IMGs and students who have a year or more off before residency - match rates were 27% and 55% respectively in 2012. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12326", "text": "The medical school environment may also be a factor. A study in 2012 also showed after an analysis of match rates from schools between 2005 and 2009 that 20 schools sent more than 15 students into urology (1  standard deviation  above the  median ), with Northwestern University sending 44 students over those five years. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12327", "text": "After urology residency, there are seven subspecialties recognized by the AUA (American Urological Association):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12328", "text": "Training is completed through the  Royal Australasian College of Surgeons [ 12 ]  (RACS). The program requires six years of full-time training (for those who commenced prior to 2016), or five years for those who commenced after 2016. [ 13 ]  The program is accredited by the  Australian Medical Council . [ 12 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12329", "text": "In Nepal, the formal urologist degree awarded is MCh (Magister Chirurgiae). [ 15 ]  This is a three years course post masters and includes thesis and a mandatory publication. This degree is awarded after completing MBBS (four and half year plus a one-year rotatory internship) and MS (Mastery of surgery) in general surgery (three years course). Till now [ when? ]  two universities Tribhuvan University and Kathmandu University as well as two Autonomous institutes BP Koirala Institute of health sciences and National Academy of Medical Sciences (Bir Hospital) run the MCh Urology programme. [ 16 ] [ 17 ]  This degree is equivalent to Clinical PhD and called as \"Chikitsa Bidhyabaridhi\" by Tribhuvan University (Government University) and is considered to be the highest degree among the surgical discipline degrees."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12330", "text": "In Ethiopia, in 2001, there were only five qualified urologists. All trained abroad, in countries like India, Tanzania and Hungary. Before this chapter all urology cases were managed by general surgeons. The only urological unit in the country was at Tikur Anbessa Tertiary Hospital. The services provided included  ESWL  and endo-urology. The urology training program was started in 2009 with a curriculum for general surgeons which had a three-year training program. Up to 2019, six urologists have graduated by this program for general surgeons. The first residency program started accepting general practitioners in 2010 for a five-year program. [ 18 ]  The first two years were trainings in general surgery, the next three years were dedicated urology training program, which included the same three-year training as of the general surgeons three year curriculum. It started with two residents who graduated in 2015 with a certificate in specialty of urology. Up to 2019, seventeen urologists have graduated from this five-year residency program. From the start these programs in 2009 up to 2019, a total of 23 urologists have been trained in Tikur Anbessa Tertioary Hospital. As of 2020, there were 26 trainees in the programme. All of the urologists who graduated from Tikur Anbessa Tertioary Hospital were as of 2020 working in different parts of the country. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12331", "text": "As a medical discipline that involves the care of many organs and physiological systems, urology can be broken down into several subdisciplines. At many larger academic centers and university hospitals that excel in patient care and clinical research, urologists often specialize in a particular sub discipline."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12332", "text": "Endourology is the branch of urology that deals with the closed manipulation of the urinary tract. [ 19 ]  It has lately grown to include all minimally invasive urologic surgical procedures. As opposed to open surgery, endourology is performed using small cameras and instruments inserted into the urinary tract. Transurethral surgery has been the cornerstone of endourology. Most of the urinary tract can be reached via the urethra, enabling prostate surgery, surgery of tumors of the  urothelium , stone surgery, and simple urethral and ureteral procedures. Recently, the addition of laparoscopy and robotics has further subdivided this branch of urology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12333", "text": "Laparoscopy  is a rapidly evolving branch of urology and has replaced some open surgical procedures.  Robot-assisted surgery  of the prostate, kidney, and ureter has been expanding this field. Today, many prostatectomies in the United States are carried out by so-called robotic assistance. This has created controversy, however, as robotics greatly increase the cost of surgery and the benefit for the patient may or may not be proportional to the extra cost. Moreover, current (2011) market situation for robotic equipment is a de facto monopoly of one publicly held corporation [ 20 ]  which further fuels the cost-effectiveness controversy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12334", "text": "Urologic oncology concerns the surgical treatment of malignant genitourinary diseases such as cancer of the prostate, adrenal glands, bladder, kidneys, ureters, testicles, and penis, as well as the skin and subcutaneous tissue and muscle and fascia of those areas (that particular subspecialty overlaps with dermatological oncology and related areas of oncology). The treatment of genitourinary cancer is managed by either a urologist or an oncologist, depending on the treatment type (surgical or medical). Most urologic oncologists in Western countries use minimally invasive techniques (laparoscopy or endourology, robotic-assisted surgery) to manage urologic cancers amenable to surgical management."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12335", "text": "Neurourology concerns  nervous system  control of the genitourinary system, and of conditions causing abnormal  urination . Neurological diseases and disorders such as a stroke,  multiple sclerosis ,  Parkinson's disease , and  spinal cord injury  can disrupt the lower urinary tract and result in conditions such as  urinary incontinence ,  detrusor  overactivity,  urinary retention , and  detrusor sphincter dyssynergia .  Urodynamic studies  play an important diagnostic role in neurourology. Therapy for nervous system disorders includes clean intermittent self-catheterization of the bladder, anticholinergic drugs, injection of Botulinum toxin into the bladder wall and advanced and less commonly used therapies such as sacral  neuromodulation .\nLess marked neurological abnormalities can cause urological disorders as well\u2014for example, abnormalities of the sensory nervous system are thought by many researchers to play a role in disorders of painful or frequent urination (e.g. painful bladder syndrome also known as  interstitial cystitis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12336", "text": "Pediatric  urology concerns urologic disorders in  children . Such disorders include  cryptorchidism  (undescended testes), congenital abnormalities of the genitourinary tract,  enuresis , underdeveloped genitalia (due to delayed growth or delayed puberty, often an endocrinological problem), and  vesicoureteral reflux ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12337", "text": "Andrology  is the medical specialty that deals with male health, particularly relating to the problems of the male reproductive system and urological problems that are unique to men such as prostate cancer, male fertility problems, and surgery of the male reproductive system. It is the counterpart to gynaecology, which deals with medical issues that are specific to female health, especially reproductive and urologic health."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12338", "text": "Reconstructive urology is a highly specialized field of male urology that restores both structure and function to the genitourinary tract.  Prostate procedures, full or partial hysterectomies, trauma (auto accidents, gunshot wounds, industrial accidents, straddle injuries, etc.), disease, obstructions, blockages (e.g., urethral strictures), and occasionally, childbirth, can necessitate reconstructive surgery. The urinary bladder, ureters (the tubes that lead from the kidneys to the urinary bladder) and genitalia are other examples of reconstructive urology."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12339", "text": "Female urology is a branch of urology dealing with  overactive bladder ,  pelvic organ prolapse , and  urinary incontinence . Many of these physicians also practice neurourology and reconstructive urology as mentioned above. Female urologists (many of whom are men) complete a 1\u20133-year fellowship after completion of a 5\u20136-year urology residency. [ 21 ]  Thorough knowledge of the female pelvic floor together with intimate understanding of the physiology and pathology of voiding are necessary to diagnose and treat these disorders. Depending on the cause of the individual problem, a medical or surgical treatment can be the solution. Their field of practice heavily overlaps with that of urogynecologists, physicians in a sub-discipline of gynecology, who have done a three-year fellowship after a four-year OBGYN residency. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12340", "text": "There are a number of peer-reviewed journals and publications about urology, including  The Journal of Urology ,  European Urology , the  African Journal of Urology ,  British Journal of Urology International ,  BMC Urology ,  Indian Journal of Urology ,  Nature Reviews Urology , and  Urology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12341", "text": "There are national organizations such as the  American Urological Association , the American Association of Clinical Urologists, [ 22 ]   European Association of Urology , the Large Urology Group Practice Association (LUGPA), [ 22 ]  and  The Society for Basic Urologic Research . Urology is also included under the auspices of the  International Continence Society ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12342", "text": "Teaching organizations include the  European Board of Urology , as well as the  Vattikuti Urology Institute  in  Detroit , which also hosts an annual  International Robotic Urology Symposium  devoted to new technologies. The American non-profit  IVUMed  teaches urology in  developing countries ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12343", "text": "Veterinary surgery  is  surgery  performed on non-human animals by  veterinarians , whereby the procedures fall into three broad categories: orthopaedics (bones, joints, muscles), soft tissue surgery (skin, body cavities, cardiovascular system, GI/urogenital/respiratory tracts), and neurosurgery.  Advanced surgical procedures such as joint replacement (total hip, knee and elbow replacement), fracture repair, stabilization of cranial cruciate ligament deficiency, oncologic (cancer) surgery, herniated disc treatment, complicated gastrointestinal or urogenital procedures, kidney transplant, skin grafts, complicated wound management, and minimally invasive procedures ( arthroscopy ,  laparoscopy ,  thoracoscopy ) are performed by veterinary surgeons (as registered in their jurisdiction). Most general practice veterinarians perform routine surgeries such as  neuters  and minor mass excisions; some also perform additional procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12344", "text": "The goal of veterinary surgery may be quite different in  pets  and in  farm animals . In the former, the situation is more close to that with human beings, where the benefit to the patient is the important factor. In the latter, the economic benefit is more important."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12345", "text": "In the United States, Canada and  Europe , veterinary surgery is one of 22  veterinary specialties  recognized by the  American Veterinary Medical Association [ 1 ]  respectively the European Board of Veterinary Specialisation. [ 2 ]  Those wishing to become board certified must undergo a one-year clinical internship program followed by three years of intensive training in a residency program under direct supervision of board certified veterinary surgeons, including performance of a large number of surgical procedures in such categories as  abdominal surgery , surgical treatment of angular limb deformities,  arthroscopic surgery , surgery of the foot, fracture fixation,  ophthalmic surgery , urogenital surgery, and upper respiratory surgery, etc. Once the minimum requirements of training are met, residents are required to pass a rigorous certification examination before being admitted as members (diplomates) of the  American College of Veterinary Surgeons [ 3 ]  or European College of Veterinary Surgeons. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12346", "text": "Anesthesia  in animals has many similarities to human anesthesia, but some differences as well.   Local anesthesia  is primarily used for wound closure and removal of small tumors.  Lidocaine ,  mepivacaine , and  bupivacaine  are the most commonly used  local anesthetics  used in veterinary medicine. [ 5 ]   Sedation  without general anesthesia is used for more involved procedures. Sedatives commonly used include  acepromazine ,  hydromorphone ,  midazolam ,  diazepam ,  xylazine , and  medetomidine .  \u03b12   agonists  like xylazine and medetomidine are especially useful because they can be reversed, xylazine by  yohimbine  and medetomidine by  atipamezole .  Xylazine is approved for use in dogs, cats, horses,  deer , and  elk  in the United States, while medetomidine is only approved for dogs. [ 6 ]   Most surgeries in  ruminants  can be performed with  regional anesthesia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12347", "text": "General anesthesia  is commonly used in animals for major surgery. Animals are often premedicated intravenously or intramuscularly with a sedative,  analgesic , and  anticholinergic  agent (dogs frequently receive  buprenorphine  and acepromazine). The next step is induction, usually with an  intravenous  drug.  Dogs and cats commonly receive  thiopental  (no longer allowed in the UK),  ketamine  with diazepam,  tiletamine  with  zolazepam  (usually just in cats), and/or  propofol .  Alfaxalone  is a  steroid  anaesthetic used in many practices in the UK to induce anaesthesia in  cats  and sometimes  dogs . It is similar in physiological effect but different in composition to the now withdrawn  Saffan . [ 7 ]   Horses commonly receive thiopental and  guaifenesin . [ 5 ]   Following induction, the animal is  intubated  with an  endotracheal tube  and maintained on a gas anesthetic.  The most common gas anesthetics in use in veterinary medicine are  isoflurane ,  enflurane , and  halothane , although  desflurane  and  sevoflurane  are becoming more popular due to rapid induction and recovery. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12348", "text": "Elective procedures are those performed on a non-emergency basis, and which do not involve immediately life-threatening conditions. These are in contrast to  emergency  procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12349", "text": "One of the most common elective surgical procedures in animals are those that render animals incapable of reproducing.  Neutering in animals describes  spaying or castration  (also please see  castration ).  To spay (medical term:  ovariectomy  or ovario-hysterectomy) is to completely remove the  ovaries  and often the  uterus  of a female animal.  In a  dog , this is accomplished through a  ventral  midline incision into the  abdomen . In a  cat , this is accomplished either by a  ventral  midline abdominal incision, or by a flank incision (more common in the UK). With an  ovariectomy ,  ligatures  are placed on the blood vessels above and below the ovary and the organ is removed. With an ovariohysterectomy, the ligaments of the uterus and ovaries are broken down and the blood vessels are  ligated  and both organs are removed.  The body wall,  subcutis , and skin are  sutured .  To castrate (medical term:  orchiectomy ) is to remove the  testicles  of a male animal.  Different techniques are used depending on the type of animal, including ligation of the  spermatic cord  with suture material, placing a rubber band around the cord to restrict blood flow to the testes, or crushing the cord with a specialized instrument like the  Burdizzo ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12350", "text": "Neutering is usually performed to prevent breeding, prevent unwanted behavior, or decrease risk of future medical problems.  Neutering is also performed as an emergency procedure to treat certain reproductive diseases, like  pyometra  and  testicular torsion , and it is used to treat  ovarian ,  uterine , and  testicular cancer .  It is also recommended in cases of  cryptorchidism  to prevent torsion and  malignant transformation  of the testicles. Please see  spaying and neutering  for more information on the advantages and disadvantages of this procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12351", "text": "Laser surgery  offers a number of benefits, [ 9 ] [ 10 ]  including reduced risk of  infection , less post-operative pain and  swelling , reduced  bleeding  and improved visibility of the surgical field. Better  hemostasis  and visibility can in some cases minimize the need for  anesthesia  and/or reduce overall surgical time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12352", "text": "Other common elective surgical procedures in the United States are declawing in cats ( onychectomy ),  ear-cropping  in dogs,  tail docking  in dogs,  horses , and dairy cattle, and  livestock dehorning  in cattle, sheep, and goats.  These procedures have been controversial and recently debated among breeders, veterinary organizations, and animal welfare scientists. The controversy is different for each procedure, but issues arise based on reasons to perform the procedure, differing opinions on techniques and methods, perceived long-term benefits in individual animals, and the development of alternatives. Declawing, for example, consists of removal of the  distal phalanges  using either a  scalpel ,  scissors  or  laser . It is typically performed to prevent property damage in house cats, but may also be performed in purebred dogs to meet certain show requirements. Some procedures are illegal in some countries (in the UK, declawing is illegal and tail docking is only allowed in working dogs) and face ethical challenges in others."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12353", "text": "Common dental surgical procedures:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12354", "text": "In older dogs and cats  tumors  are a common occurrence, and may involve any or multiple body systems: skin, musculoskeletal, gastrointestinal tract, urogenital tract, reproductive tract, cardiovascular system, spinal cord and peripheral nerves, the spleen and the lining of body cavities.  Common skin tumors include  lipomas ,  mast cell tumors ,  melanomas ,  squamous cell carcinomas ,  basal cell carcinomas ,  fibrosarcomas , and  histiocytomas .  Skin tumors are removed through either simple excisions or through excisions needing reconstructive  plastic  surgery.  Common oral tumors include melanomas, fibrosarcomas, and squamous cell carcinomas, which are removed with as much surrounding tissue as possible, including parts of the  mandible  and  maxilla .  Other types of cancer requiring surgery include  osteosarcomas , stomach and intestinal tumors,  splenic masses , and  urinary bladder  tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12355", "text": "Common ophthalmic surgeries in animals include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12356", "text": "Common orthopedic surgeries in animals include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12357", "text": "Common cardiology surgeries in animals include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12358", "text": "Caesarean sections  are commonly performed in dogs, cats, horses, sheep, and cattle. Usually it is done as an emergency surgery due to difficulties in the birthing process. Certain dog breeds such as  Bulldogs  often need to have this surgery because of the size of the puppy's head relative to the width of the bitch's birth canal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12359", "text": "Gastric dilatation volvulus  (bloat) is a common condition in dogs in which the stomach fills with gas, and can become torsed. This requires immediate surgical intervention to prevent  necrosis  of the stomach wall and death of the dog. During surgery, the stomach is deflated and put back into its normal position. A  gastropexy  may be performed, whereby the stomach is attached to the body wall to prevent this condition from recurring. A  splenectomy  or partial  gastrectomy  may also be required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12360", "text": "A  cystotomy  is a surgical opening of the  urinary bladder . It is commonly performed in dogs and cats to remove  bladder stones  or tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12361", "text": "Bite wounds from other animals (and rarely humans) are a common occurrence.  Wounds from objects that the animal may step on or run into are also common.  Usually these wounds are simple  lacerations  that can be easily cleaned and sutured, sometimes using a  local anesthetic .  Bite wounds, however, involve compressive and tensile forces in addition to shearing forces, and can cause separation of the skin from the underlying tissue and  avulsion  of underlying muscles.  Deep puncture wounds are especially prone to infection.  Deeper wounds are assessed under  anesthesia  and explored,  lavaged , and  debrided .  Primary wound closure is used if all remaining tissue is healthy and free of contamination.  Small puncture wounds may be left open, bandaged, and allowed to  heal  without surgery.  A third alternative is delayed primary closure, which involves bandaging and reevaluation and surgery in three to five days. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12362", "text": "Wounds occurring in the  udder  and  teats  of  cows  are more difficult to repair, due to the difficult access and sensitivity of the organ, and because deep anaesthesia may not be applied to cows. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12363", "text": "A variety of non-edible objects are commonly swallowed by dogs, cats, and cattle.  These  foreign bodies  can cause obstruction of the  gastrointestinal tract  causing severe vomiting and resulting  electrolyte  imbalances.  The stomach (gastrotomy) or intestine (enterotomy) can be surgically opened to remove the foreign body.  Necrotic intestine can be removed (enterectomy) and repaired with  intestinal anastomosis .  Foreign bodies can also be removed by  endoscopy , which although requires general anesthesia does not require surgery and significantly decreases recovery time. [ 19 ]  However, endoscopic foreign body retrieval is anatomically limited to objects lodged in the esophagus, the stomach or the colon. The condition in cattle is known as  hardware disease ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12364", "text": "Advanced trauma life support  ( ATLS ) is a training program for medical providers in the management of acute  trauma  cases, developed by the  American College of Surgeons . Similar programs exist for immediate care providers such as paramedics. The program has been adopted worldwide in over 60 countries, [ 2 ]  sometimes under the name of  Early Management of Severe Trauma , especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in  trauma centers . The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most  time-critical  interventions performed early. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12365", "text": "The American College of Surgeons Committee on Trauma has taught the ATLS course to over 1 million doctors in more than 80 countries. ATLS has become the foundation of care for injured patients by teaching a common language and a common approach. [ 3 ]  However, there is no high-quality evidence to show that ATLS improves patient outcomes as it has not been studied. If it were studied, this would be known. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12366", "text": "The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously  resuscitation  is begun. A simple mnemonic,  ABCDE , is used as a  mnemonic  for the order in which problems should be addressed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12367", "text": "Cervical spine stabilization is the first step, after that follow ABCD. The first stage of the primary survey is to  assess the airway . If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or  jaw thrust . Airway adjuncts may be required. If the airway is blocked (e.g., by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of suctioning instruments. In the case of obstruction, pass an  endotracheal tube . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12368", "text": "The chest must be examined by inspection,  palpation ,  percussion  and  auscultation .  Subcutaneous emphysema  and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as  Airway Obstruction , Tension  Pneumothorax , Massive  Haemothorax ,  Open Pneumothorax ,  Flail chest  segment with  Pulmonary Contusion  and  Cardiac Tamponade .  Flail chest , tracheal deviation, penetrating injuries and bruising can be recognized by inspection.  Subcutaneous emphysema  can be recognized by palpation. Tension  Pneumothorax  and  Haemothorax  can be recognized by percussion and auscultation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12369", "text": "Hemorrhage  is the predominant cause of preventable post-injury deaths.  Hypovolemic shock  is caused by significant blood loss. Two large-bore intravenous lines are established and  crystalloid solution  may be given. If the person does not respond to this, type-specific blood, or  O-negative  if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12370", "text": "During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction,  lateralizing signs , and  spinal cord injury  level."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12371", "text": "The  Glasgow Coma Scale  is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status.  Hypoglycemia  and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to  traumatic brain injury  until proven otherwise."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12372", "text": "The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent  hypothermia  in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12373", "text": "When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete  history  and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained. If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present. The person should be removed from the hard  spine board  and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause  skin breakdown  and pain while a firm mattress provides equivalent stability for potential spinal fractures. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12374", "text": "A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management. The rate of delayed diagnosis may be as high as 10%. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12375", "text": "Mannequin surgical simulators are widely used in the United States as alternatives to the use of live animals in ATLS courses. In 2014,  PETA  announced that it was donating surgical simulators to ATLS training centers in 9 countries that agreed to switch from animal use to training on the simulators. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12376", "text": "Additionally, Anaesthesia Trauma and Critical Care (ATACC) is an international trauma course based in the United Kingdom that teaches an advanced trauma course and represents the next level for trauma care and trauma patient management post ATLS certification. Accredited by two  Royal Colleges  and numerous emergency services, the course runs numerous times per year for candidates drawn from all areas of medicine and trauma care. [ 9 ]  Specific injuries, such as major  burn  injury, may be better managed by other more programs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12377", "text": "In military medicine, the ATLS protocol has been modified to the Battlefield Advanced Trauma Life Support (BATLS) protocol. The treatment procedure is cABCDE. Added c = Catastrophic bleeding (massive external bleeding). [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12378", "text": "ATLS has its origins in the United States in 1976, when  James K. Styner , an  orthopedic surgeon  piloting a light aircraft, crashed his plane into a field in  Nebraska . His wife Charlene was killed instantly and three of his four children, Ken, Randy, and Kim sustained critical injuries. His son Chris suffered a broken arm. He carried out the initial  triage  of his children at the crash site. Styner had to flag down a car to transport him to the nearest hospital in  Hebron ; upon arrival, he found it closed. Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate. [ 11 ]  Upon returning to  Lincoln , Styner declared: \"When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed.\" [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12379", "text": "Upon returning to work, he set about developing a system for saving lives in medical trauma situations. Styner and his colleague Paul 'Skip' Collicott, with assistance from  advanced cardiac life support  personnel and the Lincoln Medical Education Foundation, produced the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international dissemination of the course. Styner himself recently recertified as an ATLS instructor, teaching his Instructor Candidate course in Nottingham in the UK, July 2007, [ 13 ]  and then in the Netherlands. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12380", "text": "Since its inception, ATLS has become the standard for trauma care in American emergency departments and advanced paramedical services. Since emergency physicians, paramedics and other advanced practitioners use ATLS as their model for trauma care it makes sense that programs for other providers caring for trauma would be designed to interface well with ATLS. The Society of Trauma Nurses has developed the Advanced Trauma Care for Nurses (ATCN) course for  registered nurses . ATCN meets concurrently with ATLS and shares some of the lecture portions. This approach allows for medical and nursing care to be well-coordinated with one another as both the medical and nursing care providers have been trained in essentially the same model of care. Similarly, the  National Association of Emergency Medical Technicians  has developed the Prehospital Trauma Life Support (PHTLS) course for basic Emergency Medical Technicians (EMT)s and a more advanced level class for Paramedics. The International Trauma Life Support committee publishes the ITLS-Basic and ITLS-Advanced courses for prehospital professionals as well. This course is based around ATLS and allows the PHTLS-trained EMTs to work alongside paramedics and to transition smoothly into the care provided by the ATLS and ATCN-trained providers in the hospital. On March 22, 2013, the American College of Surgeons Committee on Trauma renamed their annual Award for Meritorious Service in ATLS to the James K. Styner Award for Meritorious Service in honor of Styner's contributions to trauma care. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12381", "text": "The  Australasian Trauma Society  (ATS) [ 1 ]  is a medical specialist interest group for  medical  and  paramedical  individuals working in the area of  traumatic injury .  It was begun in 1997 by a group of health professionals from  Australia  and  New Zealand  involved in  trauma  care. In 2022 the ATS was renamed the Australian and New Zealand Trauma Society (ANZTS)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12382", "text": "The stated aims of the ATS are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12383", "text": "Membership of the Society is open to  doctors ,  nurses  and  paramedical personnel  from both Australia and New Zealand. Associate membership is open to others outside of those categories."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12384", "text": "The ATS runs an annual scientific meeting either alone or in combination with other organisations such as the Trauma Association of Canada. [ 2 ]  It also provides financial and other support for the  Australasian  National Trauma Registry consortium. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12385", "text": "An annual travelling fellowship is offered to a member to allow them to further their  trauma  care knowledge."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12386", "text": "The medical journal  Injury [ 4 ]  is the journal for both the ATS and the British Trauma Society. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12387", "text": "Battle's sign , also known as  mastoid ecchymosis , is an indication of  fracture  of  middle cranial fossa  of the  skull . These fractures may be associated with underlying  brain trauma . Battle's sign consists of bruising over the  mastoid process  as a result of  extravasation  of blood along the path of the  posterior auricular artery . [ 1 ]  The sign is named after  William Henry Battle . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12388", "text": "Battle's sign takes at least one day to appear after the initial traumatic  basilar skull fracture , similar to  raccoon eyes . [ 3 ]  It is usually seen after head injuries resulting in injury to mastoid process leading to bruising."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12389", "text": "Battle's sign may be confused with a spreading  hematoma  from a  fracture of the mandibular condyle , [ 4 ]   which is a less serious injury."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12390", "text": "Complex post-traumatic stress disorder  ( CPTSD ,  cPTSD , or hyphenated  C-PTSD ) is a  stress-related   mental  and  behavioral   disorder  generally occurring in response to  complex traumas [ 1 ]  (i.e., commonly prolonged or repetitive exposures to a series of  traumatic events , from which one sees little or no chance to escape). [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12391", "text": "In the  ICD-11  classification, C-PTSD is a category of  post-traumatic stress disorder  (PTSD) with three additional clusters of significant symptoms:  emotional dysregulation , negative self-beliefs (e.g., shame, guilt, failure for wrong reasons), and interpersonal difficulties. [ 5 ] [ 6 ] [ 3 ]  C-PTSD's symptoms include prolonged feelings of terror, worthlessness, helplessness, distortions in identity or  sense of self , and  hypervigilance . [ 5 ] [ 6 ] [ 3 ]  Although early descriptions of CPTSD specified the type of trauma (i.e. prolonged, repetitive), in the  ICD-11  there is no requirement of a specific trauma type. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12392", "text": "The  World Health Organization  (WHO)'s  International Statistical Classification of Diseases  has included C-PTSD since its eleventh revision that was published in 2018 and came into effect in 2022 ( ICD-11 ). The previous edition ( ICD-10 ) proposed a diagnosis of  Enduring Personality Change after Catastrophic Event  ( EPCACE ), which was an ancestor of C-PTSD. [ 3 ] [ 2 ] [ 8 ]   Healthdirect Australia  (HDA) and the British  National Health Service  (NHS) have also acknowledged C-PTSD as mental disorder. [ 9 ] [ 10 ]  However, the  American Psychiatric Association  (APA) has not included C-PTSD in the  Diagnostic and Statistical Manual of Mental Disorders . The related disorder,  Disorders of Extreme Stress \u2013 not otherwise specified  ( DESNOS ) was studied for inclusion in the  DSM-IV , but not ultimately included. Instead, the symptoms of PTSD were expanded in the DSM-IV and then DSM-5 to better capture the range of symptoms that can follow from all types of trauma. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12393", "text": "The diagnosis of  PTSD  was originally given to adults who had suffered because of a trauma (e.g., during a  war ,  rape ). [ 12 ]  However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver. [ 13 ]  In many cases, it is the child's caregiver who causes the trauma. [ 12 ]  The diagnosis of PTSD does not take into account how the  developmental stages  of children may affect their symptoms and how trauma can affect a child's development. [ 12 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12394", "text": "The term  developmental trauma disorder  ( DTD ) has been proposed as the childhood equivalent of C-PTSD. [ 13 ]  This developmental form of trauma places children at risk for developing psychiatric and medical disorders. [ 13 ] [ 14 ]   Bessel van der Kolk  explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12395", "text": "Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. [ 15 ]  Cook and others describe symptoms and behavioral characteristics in seven domains: [ 16 ] [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12396", "text": "Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon. [ 17 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12397", "text": "Earlier descriptions of CPTSD suggested six clusters of symptoms: [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12398", "text": "Experiences in these areas may include: [ 4 ] :\u200a199\u2013122"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12399", "text": "C-PTSD was considered for inclusion in the  DSM-IV  but was excluded from the 1994 publication. [ 4 ]  It was also excluded from the  DSM-5 , which lists post-traumatic stress disorder. [ 22 ]  The  ICD-11  has included C-PTSD since its initial publication in 2018 and a validated self-report measure exists for assessing the ICD-11 C-PTSD, [ 2 ]  which is the International Trauma Questionnaire (ITQ). [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12400", "text": "In the ICD-11, there are two paired diagnoses, PTSD and CPTSD. A person can only be diagnosed with one or the other. A diagnosis of PTSD is made if a person has experienced a trauma and also experiences 1) re-experiencing the event in the form of intrusive memories, nightmares, or flashbacks, 2) avoidance of memories of the event or of people, places, and situations that remind them of it, and 3) perceptions of heightened current threat (e.g., hypervigilance, enhanced startle reaction). These symptoms must cause impairment in important areas of functioning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12401", "text": "In contrast, a diagnosis of CPTSD is made if the person meets all of the above criteria in addition to 1) difficulties in regulating emotions, 2) changes in beliefs about oneself such as feeling worthless with significant shame, and 3) difficulties in maintaining close relationships with important people. Again, these symptoms must cause significant impairment to be considered CPTSD."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12402", "text": "In the DSM-5, many of the symptoms of complex PTSD are now captured in the symptoms of PTSD, which are much broader than the PTSD symptoms in the ICD-11. Moreover, the DSM-5 also includes a dissociative symptom subtype. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12403", "text": "Earlier descriptions of CPTSD were broader but may no longer apply clinically:For instance, CPTSD was described to include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be  revictimized . Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD. [ 4 ] :\u200a199\u2013122\u200a  C-PTSD has also been characterized by  attachment disorder , particularly the  pervasive insecure , or  disorganized-type attachment . [ 24 ]   Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12404", "text": "Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987, [ 25 ]  differs from C-PTSD. [ citation needed ] [ how? ]  It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with  civil conflict  and  political repression . The term is applicable to the effects of exposure to contexts in which  gang violence  and  crime  are endemic as well as to the effects of ongoing exposure to life threats in  high-risk occupations  such as  police, fire and emergency services . It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12405", "text": "Traumatic grief [ 27 ] [ 28 ] [ 29 ] [ 30 ]  or complicated mourning [ 31 ]  are conditions [ 32 ]  where trauma and  grief  coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. [ 33 ]  If a traumatic event was  life-threatening , but did not result in a  death , then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence. [ 34 ] [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12406", "text": "For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of  stepchildren  is referred to as the  Cinderella effect ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12407", "text": "C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). [ 36 ] [ 37 ]  However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12408", "text": "It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of  Bessel A. van der Kolk  together with an understanding drawn from a description of BPD:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12409", "text": "Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently  harass , beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional,  physiologic , and  neuroendocrinologic  levels. Repetition on these different levels causes a large variety of individual and social suffering."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12410", "text": "25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed as such [ citation needed ]  compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that \"genetic factors play a major role in individual differences of borderline personality disorder features in Western society.\" [ 39 ]  A 2014 study published in the  European Journal of Psychotraumatology  was able to compare and contrast C-PTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. [ 40 ]  BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to have PTSD or to have some history of trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12411", "text": "In  Trauma and Recovery , Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently ' dependent ', ' masochistic ', or ' self-defeating ', comparing this attitude to the historical misdiagnosis of  female hysteria . [ 4 ]  However, those who develop C-PTSD do so as a result of the intensity of the  traumatic bond  \u2014 in which someone becomes tightly biochemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, embedded in their personality over the years of trauma \u2014 a normal reaction to an abnormal situation. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12412", "text": "While standard evidence-based treatments may be effective for treating  post-traumatic stress disorder , treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12413", "text": "The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Julian Ford and  Bessel van der Kolk  have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of  developmental trauma disorder  (DTD). [ 42 ] :\u200a60\u200a  According to Courtois and Ford, for DTD to be diagnosed it requires a"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12414", "text": "history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12415", "text": "Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12416", "text": "A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field: [ 42 ] :\u200a67"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12417", "text": "Judith Lewis Herman, in her book,  Trauma and Recovery , proposed a complex trauma recovery model that occurs in three stages:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12418", "text": "Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of \"relationship\", however, and can also include relationships with friends, co-workers, one's relatives or children, and the  therapeutic relationship . [ 4 ]  However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12419", "text": "Securing a safe environment requires strategic attention to the patient's economic and social ecosystem. The patient must become aware of her own resources for practical and emotional support as well as the realistic dangers and vulnerabilities in her social situation. Many patients are unable to move forward in their recovery because of their present involvement in unsafe or oppressive relationships. In order to gain their autonomy and their peace of mind, survivors may have to make difficult and painful life choices. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. The social obstacles to recovery are not generally recognized, but they must be identified and adequately addressed in order for recovery to proceed. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12420", "text": "It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation,  dissociation , and interpersonal problems. [ 24 ]  Six suggested core components of complex trauma treatment include: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12421", "text": "The above components can be conceptualized as a model with three phases. Not every case will be the same, but the first phase will emphasize the acquisition and strengthening of adequate coping strategies as well as addressing safety issues and concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12422", "text": "In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. [ 45 ]  Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. [ 46 ] [ 47 ]  Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. [ 46 ]  For example, it is well established that the development of  dissociative identity disorder  among women is often associated with early childhood sexual abuse. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12423", "text": "Cognitive behavioral therapy ,  prolonged exposure therapy  and  dialectical behavioral therapy  are well established forms of evidence-based intervention. These treatments are approved and endorsed by the  American Psychiatric Association , the  American Psychological Association  and the Veteran's Administration. There is a question as to whether these PTSD treatments can also treat CPTSD. Given that the ICD-11 CPTSD diagnosis is relatively young, it will be years before this is adequately studied. However, some preliminary studies have examined whether PTSD treatments work equally well in those with PTSD or CPTSD. [ 48 ]  Two different studies of phase-based PTSD treatment found that both standard PTSD treatment and phased treatment worked equally well whether participants had a diagnosis of PTSD or CPTSD (per the ITQ). [ 49 ] [ 50 ] [ 51 ]  Another study of an existing European intensive trauma treatment combining Prolonged Exposure and EMDR found that people with PTSD and CPTSD and comparable decreases in PTSD and CPTSD (though they had more severe PTSD at baseline). [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12424", "text": "One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of  therapy  or  intervention  are reimbursed by insurance companies who use  evidence-based practice  as a criterion for reimbursement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12425", "text": "It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. [ citation needed ]  There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12426", "text": "Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12427", "text": "Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including  Bessel van der Kolk  and  Bruce D. Perry ) who argue:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12428", "text": "Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, \"dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing.\" [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12429", "text": "Complex post-traumatic stress disorder is a long term mental health condition which often requires treatment by highly skilled mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12430", "text": "There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy [ 55 ] ) there are many therapeutic interventions used by mental health professionals to treat PTSD. As of February\u00a02017 [update] , the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD: [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12431", "text": "The American Psychological Association also conditionally recommends [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12432", "text": "While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating C-PTSD symptoms like PTSD, depression and anxiety. [ 63 ] [ 64 ]  For example, in a 2016, meta-analysis, four out of eight EMDR studies resulted in statistical significance, indicating the potential effectiveness of EMDR in treating certain conditions. Additionally, subjects from two of the studies continued to benefit from the treatment months later. Seven of the studies that employed psychometric tests showed that EMDR led to a reduction in depression symptoms compared to those in the placebo group. [ 65 ]   Mindfulness  and  relaxation  is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse. [ 63 ] [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12433", "text": "Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12434", "text": "Judith Lewis Herman  of Harvard University was the first psychiatrist and scholar to conceptualise complex post-traumatic stress disorder (C-PTSD) as a (new) mental health condition in 1992, within her book  Trauma & Recovery  and an accompanying article. [ 4 ] [ 17 ]  In 1988, Herman suggested that a new diagnosis of complex post-traumatic stress disorder (C-PTSD) was needed to describe the symptoms and psychological and emotional effects of long-term trauma. Over the years, the definition of CPTSD has shifted (including a proposal for DESNOS in DSM-IV and a diagnosis of EPCACE in ICD-10), with a different definition in the ICD-11 than per Dr. Herman's initial conceptualization. [ 74 ]  The ICD-11 definition of CPTSD overlaps more with DSM-5 PTSD than earlier definitions of PTSD. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12435", "text": "Though acceptance of the idea of complex PTSD has increased with mental health professionals, the research required for the proper validation of a new disorder was considered insufficient to include CPTSD as a separate disorder in the DSM-IV and DSM-5. [ 75 ] [ 11 ]  The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the  DSM-IV  but was rejected by members of the  Diagnostic and Statistical Manual of Mental Disorders  (DSM) committee of the  American Psychiatric Association  for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12436", "text": "Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. [ 76 ]  Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of  DSM-5  refused to include DTD due to a perceived lack of sufficient research."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12437", "text": "One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. [ 17 ]  Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. [ 77 ]  Conversely, an article published in  BioMed Central  has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12438", "text": "Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences. [ 78 ]  In the diagnosis of PTSD, the definition of the stressor event is limited to life-threatening or sexually violent events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. [ 5 ]  By broadening the stressor criterion, an article published by the  Child and Youth Care Forum  claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12439", "text": "Direct therapeutic exposure  ( DTE ) is a  behavior therapy  technique pioneered by Patrick A. Boudewyns, where  stressors  are vividly and safely confronted to help combat  veterans , and patients with  posttraumatic stress disorder  (PTSD),  panic disorder , or  phobias .  Exposure therapy  has supporting evidence with both simple and complex traumas. [ 1 ]  A similar therapy is  Eye Movement Desensitization and Reprocessing  (EMDR).  First known publication in book form is  Flooding and Implosive Therapy: Direct Therapeutic Exposure in Clinical Practice  by Patrick A. Boudewyns, Robert H. Shipley.  1983.  ISBN \u00a0 0-306-41155-5 ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12440", "text": "It is not uncommon to combine DTE treatment with other therapies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12441", "text": "Direct exposure has been used with a variety of populations including agoraphobia [ 2 ]  and chronic PTSD [ 3 ]  It involves as the name applies placing the client either real or imaginally in the feared situation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12442", "text": "Other techniques for treating PTSD:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12443", "text": "Endovascular and hybrid trauma and bleeding management   is a new and rapidly evolving concept within medical healthcare and endovascular  resuscitation . It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. [ 1 ] [ 2 ] [ 3 ]  It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12444", "text": "The fundamental principles of  trauma care  are built around  advanced trauma life support  (ATLS) guidelines using the mnemonic  ABCDE  for early assessment of the patient and detection of airway and circulatory problems. This way, life-threatening conditions are identified and resuscitation may be initiated, despite the lack of definitive diagnosis. [ 5 ]  The EVTM concept of acute trauma care incorporates modern endovascular techniques and procedures as additional adjuncts to this well-established protocol. [ 1 ] [ 2 ] [ 3 ] [ 4 ]  The new suggested algorithm of  A ABCDE has emerged for EVTM enabled providers. The additional \u201cA\u201d stands for  A ccess, indicating the importance of gaining early vascular access to the  femoral artery  (and  vein ), and is fundamental to this concept of trauma care. [ 6 ]  As with traditional trauma care, vascular access in the peripheral or central veins allows for blood sampling and administration of drugs or fluids. However, for EVTM enabled providers, early femoral arterial access provides the possibility to use potentially lifesaving endovascular diagnostic and therapeutic tools for temporary management and bridge to definitive endovascular or open surgical treatment, in addition to arterial blood sampling and invasive blood pressure monitoring. [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12445", "text": "One of the major elements of EVTM is the multidisciplinary team approach. By combining the expertise present allows for optimal treatment not just at the time of patient arrival but also in the pre-hospital setting and later in the operating suite. It is all about teamwork with a common goal, to save the patient. It allows for the hybrid use of open surgery and endovascular methods for hemorrhage control and definitive treatment. In a hemodynamically unstable bleeding patient, traditional treatment is  laparotomy  with abdominal packing, but an EVTM team might simultaneously gain vascular access and perform REBOA for proximal control or embolization as a part in definitive treatment. An EVTM multidisciplinary approach requires complete transparency, good communication and leadership. It is however also important to remember that just because you can, doesn't mean that you should use an EVTM approach. EVTM should always be considered but only used in the optimally selected patient at the right time if the expertise and equipment is present to do it safely. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12446", "text": "In the acute setting, the femoral artery is most often the easiest to identify and access thanks to its typically reasonable size. This is however obviously relative to individual anatomical differences and hemodynamic state of the patient. It is in general beneficial to gain early vascular access as the inguinal area is seldom occupied and, if possible, attempt to do this on the contralateral side to a major lower extremity injury. Access may be attempted by ultrasound-guided or blind puncture and surgical cut-down, where ultrasound-guided is the safest and most reasonable alternative for the less experienced. Vascular access is based on the  Seldinger technique . After puncturing the vessel with a needle and confirmation of arterial access a wire is advanced, the needle removed and a vascular sheath is introduced. The access is then ready to use. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12447", "text": "The use of endovascular modalities for bleeding control and treatment on hemodynamically unstable trauma patients is increasing. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for hemorrhage control, angioembolization and stent grafts are highly established tools used for both arterial and venous hemorrhage in both traumatic and non-traumatic patients. [ 4 ] [ 9 ] [ 10 ] [ 11 ]  To be able to provide an endovascular opportunity for resuscitation requires good organization and a well-established endovascular team. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12448", "text": "Acute care of a hemodynamically unstable trauma patient is never an ideal task. [ 12 ] [ 13 ]  The emphasis is on stopping blood extravasation and hemodynamic stabilisation without delay, despite if it is pre-hospital, in the emergency department or in a hybrid operating suite. REBOA, also called Aortic Balloon Occlusion (ABO), is a powerful endovascular tool that inflates an intra-aortic balloon occluding the lumen of the vessel and decreased or completely prevents blood flow to the more distal parts. If inflated in the aorta proximal to the identified source of bleeding it may help to diminish or stop blood extravasation, also potentially aiding to increase cardiac afterload. This should increase the central pressure and secure adequate myocardial and cerebral perfusion, hopefully rendering the patient, at least temporarily, more hemodynamically stable. REBOA is used as an endovascular tool for hemodynamic control and as a resuscitation adjunct that may prolong the life of the critical patient. REBOA is not only used from an endovascular resuscitation aspect, but may also to help by allowing more time for definitive treatment. [ 6 ] [ 9 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ excessive citations ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12449", "text": "Embolization  is a minimally invasive technique used in EVTM of selected hemodynamically unstable patients with both  traumatic  and non-traumatic injuries. It is the artificial creation of a thrombus by the introduction of various substances to intentionally occlude a vessel with the aim to stop or diminish blood extravasation and is a critical part of the modern management of arterial injuries. [ 6 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12450", "text": "Stent grafts , or endo-grafts, are a more permanent solution in the hemodynamically unstable patient and are an important part of the tool kit for EVTM. They are self-expanding artificial reconstructions of vessels with fabric coating deployed inside the original vessel and help to gain temporary control, stop the hemorrhage and repair the damaged vessel wall. They can be used and positioned, by an experienced surgeon, in every major vessel in the body. [ 6 ] [ 11 ] [ 20 ] [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12451", "text": "The  Journal of Endovascular Resuscitation and Trauma Management  (JEVTM) is an open access platform for publishing  peer-reviewed research  regarding endovascular hybrid hemorrhage control. The first issue was published August 2017 with continued publications quarterly. The editorial board is made up by clinicians and scientists who are experts within the field. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12452", "text": "Focused assessment with sonography in trauma  (commonly  abbreviated  as  FAST )  is a rapid bedside  ultrasound  examination performed by surgeons, emergency physicians, and paramedics as a  screening test  for blood around the heart ( pericardial effusion ) or abdominal organs ( hemoperitoneum ) after  trauma . [ 1 ] [ 2 ]  There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12453", "text": "The four classic areas that are examined for free fluid are the perihepatic space (including Morison's pouch or the  hepatorenal recess ), peri splenic  space,  pericardium , and the  pelvis .  With this technique it is possible to identify the presence of intraperitoneal or pericardial free fluid. In the context of traumatic injury, this fluid will usually be due to  bleeding ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12454", "text": "Reasons a FAST or eFAST would be performed would be:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12455", "text": "Since the FAST/eFAST is performed with ultrasound, there is very little risk to the patient as ultrasounds only emit sound waves and record the echo to create a picture. [ 5 ]  The most common contraindication would be delay of definitive care such as surgical intervention in the setting of obvious trauma or resuscitative efforts in an extreme scenario. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12456", "text": "The eFAST allows for the examination of both  lungs  by adding bilateral anterior thoracic  sonography  to the FAST exam. This allows for the detection of a  pneumothorax  with the absence of normal \u2018lung-sliding\u2019 and \u2018comet-tail\u2019 artifact (seen on the ultrasound screen). Compared with supine  chest radiography , with  CT  or clinical course as the gold standard, bedside sonography has superior  sensitivity  (49\u201399% versus 27\u201375%), similar  specificity  (95\u2013100%), and can be performed in under a minute. [ 6 ]  Several recent prospective studies have validated its use in the setting of trauma resuscitation, and have also shown that ultrasound can provide an accurate estimation of pneumothorax size. [ 7 ] [ 8 ]  Although radiography or CT scanning is generally feasible, immediate bedside detection of a pneumothorax confirms what are often ambiguous physical findings in unstable patients, and guides immediate  chest decompression . In addition, in the patient undergoing  positive-pressure ventilation , the detection of an otherwise \u2018occult\u2019 pneumothorax prior to CT scanning may hasten treatment and subsequently prevent development of a  tension pneumothorax , a deadly complication if not treated immediately, and deterioration in the  radiology  suite (in the CT scanner). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12457", "text": "There are five components to the eFAST exam:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12458", "text": "eFAST (extended focused assessment with sonography for trauma) allows an emergency physician or a surgeon the ability to determine whether a patient has  pneumothorax ,  hemothorax ,  pleural effusion , mass/tumor, or a lodged foreign body. The exam allows for visualization of the echogenic tissue, ribs, and lung tissue. Few radiographic signs are important in any trauma and they include the  stratosphere sign , the  sliding or seashore sign , and the  sinusoid sign."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12459", "text": "Stratosphere sign  is a clinical medical  ultrasound  finding usually in an eFAST examination that can prove presence of a  pneumothorax . The sign is an imaging finding using a 3.5\u20137.5  MHz  ultrasound probe in the fourth and fifth intercostal spaces in the anterior clavicular line using the M-Mode of the machine. This finding is seen in the M-mode tracing as pleura and lung being indistinguishable as linear hyperechogenic lines and is fairly reliable for diagnosis of a pneumothorax. Even though the stratospheric sign can be an indication of pneumothorax its absence is not at all reliable to rule out pneumothorax as definitive diagnosis usually requires X-ray or  CT  of thorax. [ 11 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12460", "text": "Seashore sign  is another eFAST finding usually in the lungs in the M-mode that depicts the glandular echogenicity of the lung abutted by the linear appearance of the visceral pleura. This sign is a normal finding. In absence of a seashore sign or presence of a stratosphere sign, pneumothorax is likely.  B-lines  or \"comet trails\" are echogenic bright linear reflections beneath the pleura that are usually lost with any air between the probe and the lung tissue and therefore whose presence with seashore sign indicates absence of a pneumothorax. [ 11 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12461", "text": "Sinusoid sign  is another  M-mode  finding indicating presence of pleural effusion. Due to the cyclical movement of the lung in inspiration and expiration, the motion-time tracing (M-mode) ultrasound shows a sinusoid appearance between the fluid and the line tissue. This finding indicates a possible  pleural effusion ,  empyema , blood in pleural space (hemothorax). [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12462", "text": "FAST is less invasive than  diagnostic peritoneal lavage , involves no exposure to radiation and is cheaper compared to  computed tomography , but achieves a similar accuracy. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12463", "text": "Numerous studies have shown FAST is useful in evaluating trauma patients. [ 15 ] [ 16 ] [ 17 ] [ 18 ]  It also appears to make  emergency department  care faster and better. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12464", "text": "FAST is most useful in trauma patients who are hemodynamically unstable. A positive FAST result is defined as the appearance of a dark (\"anechoic\") strip in the dependent areas of the  peritoneum . In the right upper quadrant this typically appears in  Morison's Pouch  (between the  liver  and  kidney ). This location is most useful as it is the place where fluid will collect with a supine patient. In the left upper quadrant, blood may collect anywhere around the  spleen  (perisplenic space). In the  pelvis , blood generally pools behind the  bladder  (in the rectovesicular space). A positive result suggests hemoperitoneum; often  CT scan  will be performed if the patient is stable [ 22 ]  or a  laparotomy  if unstable. In those with a negative FAST result, a search for extra-abdominal sources of bleeding may still need to be performed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12465", "text": "Geriatric trauma  refers to a  traumatic injury  that occurs to an  elderly  person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of  population aging  is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. [ 1 ]  While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the  Emergency Department  following traumatic injury. [ 2 ]  In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12466", "text": "Trauma is a leading cause of  morbidity  and mortality across all age groups, however, geriatric populations are unique compared to younger counterparts in the amount of existing health issues and inherent risk of  disability  and  death . [ 4 ]  As a whole, older populations are more vulnerable to trauma from minor mechanisms of injury and less able to recover following injury. [ 5 ]  At the same time,  medications  to manage existing  chronic conditions  and co-morbidities may negatively affect older adults\u2019 physiological responses to traumatic injuries and increase the risk for complications later on. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12467", "text": "A progressive decline in  central nervous system  function leads to a loss of  proprioception ,  balance  and overall  motor coordination , as well as a reduction in  eye\u2013hand coordination ,  reaction time  and an unsteady  gait . [ 7 ]  These degenerative changes are often accompanied by  osteoarthritis  (degenerative joint disease), which leads to a reduction in the  range of motion  of the head, neck and extremities. Furthermore, elderly people frequently take multiple  medications  for control of various diseases and conditions. The side effects of some of these medications may either predispose to injury, or may cause a minor trauma to result in a much more severe condition. For example, a person taking  warfarin  (Coumadin) and/or  clopidogrel  (Plavix) may experience a life-threatening  intracranial hemorrhage  after sustaining a relatively minor  closed head injury , as a result of the defect in the  hemostatic mechanism  caused by such medications. The combined effects of these changes greatly predisposes elderly people to traumatic injury. Both the incidence of falls and the severity of associated complications increase with advancing age. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12468", "text": "Virtually all organ systems experience a progressive decline in function as a result of the  aging  process. [ 8 ] [ 9 ]  One example is a decline in  circulatory system  function caused in part by thickening of the  cardiac muscle . This can lead to  congestive heart failure  or  pulmonary edema . [ 10 ] [ 11 ]  Another example is the decline in muscle mass, which although highly variable among individuals, rapidly speeds up in older age and can decreases up to 50% when compared to the weight of the individual. [ 12 ]  This loss of muscle mass can compromise the elderly adult's ability to maintain a straight posture. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12469", "text": "Atrophy  of the brain begins to accelerate at around seventy years of age, [ 11 ]  which leads to a significant reduction in brain mass. Since the skull does not decrease in size with the brain, there is significant space between the two when this occurs which puts the elderly at a higher risk of a  subdural hematoma  after sustaining a closed head injury. [ 9 ]  The reduction of brain size can lead to issues with  eyesight ,  cognition  and  hearing . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12470", "text": "Because  falls  are the most common mechanism of injury in severely injured geriatric patients, [ 14 ]  the risk factors for geriatric trauma overlap significantly with those that predispose older adults to falls. Falls may often be described as \u201cmechanical\u201d or \u201cnon-mechanical.\u201d A \u201cmechanical fall\u201d implies that an object or force in the patient's external environment caused the fall to occur. However, the use of this term may result in a failure to conduct a thorough evaluation of intrinsic factors related to the fall. Even in cases of community-dwelling older adults experiencing falls related to slipping, tripping, or stumbling, the patients\u2019 co-morbidities and health status are often involved. In addition, a proportion of patients with reported \u201cnon-mechanical falls\u201d have been shown to have environmental factors. [ 15 ]  For this reason, it is crucial to consider the interactions between environmental hazards and increased individual susceptibility from the accumulated effects of intrinsic risk factors when evaluating why a fall occurred in an older adult."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12471", "text": "From a meta-analysis examining risk factors for falls in both community-dwelling and institutionalized populations, the most common intrinsic determinants of falls risks include: [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12472", "text": "Other important intrinsic risk factors for falls indicated by other studies include peripheral nerve dysfunction with postural instability, [ 17 ]  use of  sedatives ,  hypnotics ,  antidepressants ,  benzodiazepines , [ 18 ]  and  vasodilators , [ 19 ]  and  history of problem drinking . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12473", "text": "Lastly, in one study, home modifications like adding handrails for outside and inside stairs, grab rails for bathrooms, outdoor lighting, and slip-resistant floors was shown to cause a 26% reduction in the rate of injuries caused by falls at home per year compared to a control group without these interventions. This demonstrates the value in creating a more accommodating and safe home environment for a community-dwelling elder, especially if they have several intrinsic risk factors for falls. [ 21 ]  Another study found a lower risk of falls associated with wearing athletic shoes and canvas shoes compared to other types of footwear including slippers, sandals, and high heels. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12474", "text": "Motor vehicle crashes are the second most frequent mechanism of injury to explain trauma in older adults. [ 23 ]  Risk factors that affect driving performance in older adults include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12475", "text": "Although the survivability of  burn  injuries continues to improve across all age groups, this improvement may be less for older burn victims. This observation may be attributable to a greater degree of co-morbidities and slow wound healing that result in an increased length of stay and higher mortality in the elderly compared to patients less than 60 years. [ 31 ]  Therefore, it is important to recognize and address risk factors that predispose older adults to burns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12476", "text": "Factors that increase the risk of incurring burn injury in older adults include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12477", "text": "Geriatric trauma may be caused by  elder physical, emotional, or sexual abuse , resulting in an increased risk of death at the end of a 13-year follow-up period in one study. [ 35 ]  According to a published uniform definition from the National Center for Injury Prevention and Control, Division of Violence Prevention, elder abuse is \u201can intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.\u201d [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12478", "text": "To prevent or identify patients who may experience elder abuse, it is crucial to identify which older adults are at an increased risk. Some findings correlated with risk of elder mistreatment are presented below:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12479", "text": "Falls and motor vehicle crashes are the most common types of injuries among geriatric adults. As a whole, older populations are more vulnerable to mortality from all causes of trauma given that they are less able to compensate following injury. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12480", "text": "Falls  account for three-quarters of all trauma in this population. [ 14 ]  In one review, the estimated probability of falling at least once in any given year for individuals 65 years and older was 27%. [ 41 ]  One out of five falls causes a serious injury such as broken bones or a head injury. [ 42 ]  In the United States, over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12481", "text": "Motor vehicle crashes  are the second most common mechanism of injury among geriatric adults, and the most common cause of traumatic mortality. [ 44 ]  Of the possible injuries, older adults are especially at risk of chest injuries (such as rib fractures) which may negatively interact with existing cardiopulmonary comorbidities\u2014increasing the risk of complications like pneumonia and respiratory failure. [ 45 ]  In addition, the highest mortality rate in geriatric trauma is among older pedestrians struck by a vehicle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12482", "text": "Burns  are also especially dangerous in geriatric populations. Relating back to physiology, comorbidities and slow wound healing can result in an increase length of stay, and higher mortality in the elderly compared to patients less than 60 yr of age. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12483", "text": "Falls  are the most common cause of injury in older adults. According to the Behavior Risk Factor Surveillance System in 2018, approximately 28 percent of individuals aver 65 years old reported a fall within the last year. This would account for approximately 36 million falls, of which approximately 8.4 million resulted in injuries. [ 47 ]  These falls are often underreported and can significantly threaten the individual's independence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12484", "text": "Every year, about 5 percent of falls result in hospitalizations in the geriatric population. These injuries lead to an increase in morbidity and a greater likelihood that they will be admitted to a nursing home. [ 48 ]  Approximately 95 percent of all hip fractures reported are due to an unforeseen fall and 25-75 percent of those do not recover fully to the mobility they had prior to the fall. [ 49 ]  Of those older adults who fall, only about half are able to stand back up on their own, the other half experience a \u201clong lie\u201d which makes them more likely to experience a steeper decline on their activities of daily living than those who are able to stand back up on their own. [ 50 ]  Furthermore, the medical complications arising from these falls make it so that they become the leading cause of death from injury in populations over 65 years old and fifth overall cause of death."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12485", "text": "As a result of a fall, older adults can also experience post-fall anxiety syndrome. This fear of falling was present in 60 percent of community dwelling geriatric populations, and was demonstrated by their reduction in levels of activity; 15 percent of which severely restricted their mobility out of fear of having another fall. [ 51 ]  This further contributes to morbidity because it can contribute to cognitive impairment, depression, isolation, increase in rates of obesity, and further mobility impairment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12486", "text": "Source: [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12487", "text": "The geriatric population is at increased risk for burn injury. While geriatric burns account for less than 5% of burns in developing countries, nearly 20% of burns in developed countries are experienced by the geriatric population. These burn injuries tend to occur at home\u2014particularly in the kitchen or the bathroom\u2014and most commonly consist of flame and scald burns."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12488", "text": "Importantly, geriatric patients are at increased risk for downstream complications. This is in part due to limited mobility, decreased ability to react rapidly to threats, and pre-existing medical problems such as vision impairment and medication side effects. Additionally, due to the natural processes of aging, the skin of geriatric patients has impaired mechanisms to protect against burns, including impaired neurosensory sensitivity, skin permeability, and regeneration capacity. These impairments lead to deeper wounds, prolonged wound healing, and lower potential for complete recovery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12489", "text": "Fluid resuscitation  and  pain control  are key components of burn treatment. In the geriatric population, extra care must be paid to provide appropriate fluids, as age is significantly associated with increased volume requirement in the first 48 hours post-injury. Additionally, geriatric patients are often not provided with adequate pain control management, in part due to a misconception that pain decreases with age (there is no evidence to support this claim). Appropriate pain management is critical for recovery, and must consider patients' co-morbidities, organ functions, and current medications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12490", "text": "Skin-grafting  is another important form of treatment for burns. However, age is a risk factor for unsuccessful grafting due to the natural thinning of the skin that occurs with age. Other risk factors for failed skin relevant to the geriatric population for unsuccessful skin grafting include being over age 55, peripheral vascular disease, diabetes mellitus, and related problems of limb ischemia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12491", "text": "Studies suggest that few geriatric patients return to their previous state of health following burn injury. Long-term consequences in this population include exacerbation of pre-existing conditions, decreased mobility, loss of independence, worsened nutrition, pain, and psychological sequelae including depression."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12492", "text": "One significant problem in the acute assessment of geriatric trauma patients is under- triage .  Trauma team activation  (TTA) must be done liberally due to limited costs and resources. Therefore, the criteria for TTA is established by the  American College of Surgeons  and individual  trauma centers . The criteria used to identify patients with a greater need for high level care include  vital signs  ( systolic blood pressure  below 90 mmHg or  heart rate  above 120 bpm),  level of consciousness , and mechanism of injury. However, elderly patients with severe trauma often do not meet the standard TTA criteria due to normal age-related changes and reduced physiologic capacities. For example, older adults have a less profound  tachycardic  response to  hemorrhage ,  pain , or  anxiety  following trauma. This explains why mortality increases in the elderly above a heart rate of 90 bpm, an association not observed until heart rate of 130 bpm in younger patients. Similarly, in older adults,  systemic vascular resistance  is increased, which may result in baseline  hypertension . In the setting of  shock , expected declines in blood pressure may not occur, leading to misinterpretation of the geriatric patient's condition. This supports why mortality significantly increases with systolic blood pressure below 110 mmHg in older adults but not until 95 mmHg in younger patients. [ 53 ] [ 54 ]  This is why several centers and studies support using older age as a TTA criterion as a means to reduce mortality in this population, regardless of the mechanism of injury. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12493", "text": "An  injury  is any  physiological  damage to living tissue [ 1 ]  caused by immediate physical stress. Injuries to humans can occur  intentionally  or  unintentionally  and may be caused by  blunt trauma ,  penetrating trauma ,  burning ,  toxic exposure ,  asphyxiation , or  overexertion . Injuries can occur in any part of the body, and different symptoms are associated with different injuries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12494", "text": "Treatment of a major injury is typically carried out by a  health professional  and varies greatly depending on the nature of the injury.  Traffic collisions  are the most common cause of accidental injury and injury-related death among humans. Injuries are distinct from  chronic conditions ,  psychological trauma ,  infections , or  medical procedures , though injury can be a contributing factor to any of these."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12495", "text": "Several major health organizations have established systems for the classification and description of human injuries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12496", "text": "Injuries may be intentional or unintentional. Intentional injuries may be acts of violence against others or  self-inflicted  against one's own person. Accidental injuries may be unforeseeable, or they may be caused by  negligence . In order, the most common types of unintentional injuries are traffic accidents, falls,  drowning , burns, and accidental poisoning. Certain types of injuries are more common in  developed countries  or  developing countries . Traffic injuries are more likely to kill pedestrians than drivers in developing countries. Scalding burns are more common in developed countries, while open-flame injuries are more common in developing countries. [ clarification needed ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12497", "text": "As of 2021, approximately 4.4 million people are killed due to injuries each year worldwide, constituting nearly 8% of all deaths. 3.16 million of these injuries are unintentional, and 1.25 million are intentional. Traffic accidents are the most common form of deadly injury, causing about one-third of injury-related deaths. One-sixth are caused by suicide, and one-tenth are caused by homicide. Tens of millions of individuals require medical treatment for nonfatal injuries each year, and injuries are responsible for about 10% of all years lived with disability. Men are twice as likely to be killed through injury than women. [ 3 ]  In 2013, 367,000 children under the age of five died from injuries, down from 766,000 in 1990. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12498", "text": "The  World Health Organization  (WHO) developed the  International Classification of External Causes of Injury  (ICECI). Under this system, injuries are classified by mechanism of injury, objects/substances producing injury, place of occurrence, activity when injured, the role of human intent, and additional modules. These codes allow the identification of distributions of injuries in specific populations and case identification for more detailed research on causes and preventive efforts. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12499", "text": "The United States  Bureau of Labor Statistics  developed the Occupational Injury and Illness Classification System (OIICS). Under this system injuries are classified by nature, part of body affected, source and secondary source, and event or exposure. The OIICS was first published in 1992 and has been updated several times since. [ 6 ]   The Orchard Sports Injury and Illness Classification System (OSIICS) , previously OSICS, is used to classify injuries to enable research into specific  sports injuries . [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12500", "text": "The  injury severity score  (ISS) is a medical score to assess trauma severity. [ 9 ] [ 10 ]  It correlates with mortality, morbidity, and hospitalization time after trauma. It is used to define the term  major trauma  ( polytrauma ), recognized when the ISS is greater than 15. [ 10 ]  The AIS Committee of the  Association for the Advancement of Automotive Medicine  designed and updates the scale."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12501", "text": "Traumatic injury is caused by an external object making forceful contact with the body, resulting in a  wound .  Major trauma  is a severe traumatic injury that has the potential to cause  disability  or  death . Serious traumatic injury most often occurs as a result of traffic collisions. [ 11 ]  Traumatic injury is the leading cause of death in people under the age of 45. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12502", "text": "Blunt trauma injuries are caused by the forceful impact of an external object. Injuries from blunt trauma may cause  internal bleeding  and  bruising  from ruptured  capillaries  beneath the skin, abrasion from scraping against the superficial  epidermis , lacerated tears on the skin or internal organs, or  bone fractures .  Crush injuries  are a severe form of blunt trauma damage that apply large force to a large area over a longer period of time. [ 11 ]  Penetrating trauma injuries are caused by external objects entering the  tissue  of the body through the  skin . Low-velocity penetration injuries are caused by sharp objects, such as  stab wounds , while high-velocity penetration injuries are caused by ballistic projectiles, such as  gunshot wounds  or injuries caused by  shell fragments . [ 13 ]  Perforated injuries result in an entry wound and an exit wound, while puncture wounds result only in an entry wound. Puncture injuries result in a cavity in the tissue. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12503", "text": "Burn injury is caused by contact with extreme temperature, chemicals, or radiation. The effects of burns vary depending on the depth and size. Superficial or first-degree burns only affect the  epidermis , causing pain for a short period of time. Superficial partial-thickness burns cause weeping  blisters  and require dressing. Deep partial-thickness burns are dry and less painful due to the burning away of the skin and require surgery. Full-thickness or third-degree burns affect the entire  dermis  and is susceptible to  infection . Fourth-degree burns reach deep tissues such as muscles and bones, causing loss of the affected area. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12504", "text": "Thermal burns  are the most common type of burn, caused by contact with excessive heat, including contact with flame, contact with hot surfaces, or  scalding  burns caused by contact with hot water or steam.  Frostbite  is a type of burn caused by contact with excessive cold, causing cellular injury and deep tissue damage through the crystallization of water in the tissue.  Friction burns  are caused by  friction  with external objects, resulting in a burn and abrasion. [ 15 ]   Radiation burns  are caused by exposure to  ionizing radiation . Most radiation burns are  sunburns  caused by  ultraviolet  radiation or high exposure to radiation through medical treatments such as repeated  radiography  or  radiation therapy . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12505", "text": "Electrical burns  are caused by contact with  electricity  as it enters and passes through the body. They are often deeper than other burns, affecting lower tissues as electricity penetrates the skin, and the full extent of electrical burns are often obscured. They will also cause extensive destruction of tissue at the entry and exit points. Electrical injuries in the home are often minor, while high tension power cables cause serious electrical injuries in the workplace.  Lightning strikes  can also cause severe electrical injuries. Fatal electrical injuries are often caused by tetanic spasm inducing  respiratory arrest  or interference with the heart causing  cardiac arrest . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12506", "text": "Chemical burns  are caused by contact with  corrosive substances  such as  acid  or  alkali . Chemical burns are rarer than most other burns, though there are many chemicals that can damage tissue. The most common chemical-related injuries are those caused by  carbon monoxide ,  ammonia ,  chlorine ,  hydrochloric acid , and  sulfuric acid . Some  chemical weapons  induce chemical burns, such as  white phosphorus . Most chemical burns are treated with extensive application of water to remove the chemical contaminant, though some burn-inducing chemicals react with water to create more severe injuries. [ 18 ]  The ingestion of corrosive substances can cause chemical burns to the larynx and stomach. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12507", "text": "Toxic injury  is caused by the ingestion, inhalation, injection, or absorption of a  toxin . This may occur through an interaction caused by a  drug  or the ingestion of a  poison . Different toxins may cause different types of injuries, and many will cause injury to specific organs. [ 20 ]  Toxins in gases, dusts, aerosols, and smoke can be inhaled, potentially causing respiratory failure. Respiratory toxins can be released by structural fires, industrial accidents, domestic mishaps, or through chemical weapons. Some toxicants may affect other parts of the body after inhalation, such as carbon monoxide. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12508", "text": "Asphyxia causes injury to the body from a lack of oxygen. It can be caused by  drowning ,  inhalation  of certain substances,  strangulation ,  blockage of the airway , traumatic injury to the airway,  apnea , and other means. The most immediate injury caused by asphyxia is  hypoxia , which can in turn cause acute lung injury or  acute respiratory distress syndrome  as well as damage to the circulatory system. The most severe injury associated with asphyxiation is cerebral  hypoxia  and  ischemia , in which the brain receives insufficient oxygen or blood, resulting in neurological damage or death. Specific injuries are associated with water inhalation, including alveolar collapse,  atelectasis ,  intrapulmonary shunting , and  ventilation perfusion mismatch . [ 22 ]  Simple asphyxia is caused by a lack of external oxygen supply. Systemic asphyxia is caused by exposure to a compound that prevents oxygen from being transported or used by the body. This can be caused by  azides , carbon monoxide,  cyanide ,  smoke inhalation ,  hydrogen sulfide ,  methemoglobinemia -inducing substances,  opioids , or other systemic asphyxiants. Ventilation and oxygenation are necessary for treatment of asphyxiation, and some asphyxiants can be treated with antidotes. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12509", "text": "Injuries of overuse or overexertion can occur when the body is strained through use, affecting the bones, muscles, ligaments, or tendons.  Sports injuries  are often overuse injuries such as  tendinopathy . [ 24 ]  Over-extension of the ligaments and tendons can result in  sprains  and  strains , respectively. [ 25 ]  Repetitive sedentary behaviors such as extended use of a computer or a physically repetitive occupation may cause a  repetitive strain injury . [ 26 ]  Extended use of brightly lit screens may also cause  eye strain . [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12510", "text": "Abdominal trauma  includes injuries to the  stomach ,  intestines ,  liver ,  pancreas ,  kidneys ,  gallbladder , and  spleen . Abdominal injuries are typically caused by traffic accidents, assaults, falls, and work-related injuries, and physical examination is often unreliable in diagnosing blunt abdominal trauma.  Splenic injury  can cause  low blood volume  or  blood in the peritoneal cavity . The treatment and prognosis of splenic injuries are dependent on cardiovascular stability. [ 28 ]  The gallbladder is rarely injured in blunt trauma, occurring in about 2% of blunt abdominal trauma cases. Injuries to the gallbladder are typically associated with injuries to other abdominal organs. [ 29 ]  The intestines are susceptible to injury following blunt abdominal trauma. [ 30 ]  The kidneys are protected by other structures in the abdomen, and most injuries to the kidney are a result of blunt trauma. [ 31 ]  Kidney injuries typically cause blood in the urine. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12511", "text": "Due to its location in the body,  pancreatic injury  is relatively uncommon but more difficult to diagnose. Most injuries to the pancreas are caused by penetrative trauma, such as gunshot wounds and stab wounds. Pancreatic injuries occur in under 5% of blunt abdominal trauma cases. The severity of pancreatic injury depends primarily on the amount of harm caused to the  pancreatic duct . [ 33 ]  The stomach is also well protected from injury due to its heavy layering, its extensive blood supply, and its position relative to the  rib cage . As with pancreatic injuries, most traumatic stomach injuries are caused by penetrative trauma, and most civilian weapons do not cause long-term tissue damage to the stomach. Blunt trauma injuries to the stomach are typically caused by traffic accidents. [ 34 ]  Ingestion of corrosive substances can cause chemical burns to the stomach. [ 19 ]   Liver injury  is the most common type of organ damage in cases of abdominal trauma. [ 35 ]  The liver's size and location in the body makes injury relatively common compared to other abdominal organs, and blunt trauma injury to the liver is typically treated with nonoperative management. [ 36 ]  Liver injuries are rarely serious, though most injuries to the liver are concomitant with other injuries, particularly to the spleen, ribs, pelvis, or spinal cord. [ 35 ]  The liver is also susceptible to toxic injury, with overdose of  paracetamol  being a common cause of liver failure. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12512", "text": "Facial trauma  may affect the  eyes ,  nose ,  ears , or  mouth . Nasal trauma is a common injury and the most common type of facial injury. [ 38 ]  Oral injuries are typically caused by traffic accidents or alcohol-related violence, though falls are a more common cause in young children. The primary concerns regarding oral injuries are that the airway is clear and that there are no concurrent injuries to other parts of the head or neck. Oral injuries may occur in the soft tissue of the face, the hard tissue of the mandible, or as  dental trauma . [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12513", "text": "The ear is susceptible to trauma in head injuries due to its prominent location and exposed structure. Ear injuries may be internal or external. Injuries of the external ear are typically lacerations of the cartilage or the formation of a hematoma. Injuries of the middle and internal ear may include a  perforated eardrum  or trauma caused by extreme pressure changes. The ear is also highly sensitive to  blast injury . The bones of the ear are connected to facial nerves, and ear injuries can cause paralysis of the face. Trauma to the ear can cause  hearing loss . [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12514", "text": "Eye injuries  often take place in the  cornea , and they have the potential to permanently damage vision.  Corneal abrasions  are a common injury caused by contact with foreign objects. The eye can also be injured by a foreign object remaining in the cornea. Radiation damage can be caused by exposure to excessive light, often caused by  welding  without eye protection or being exposed to excessive ultraviolet radiation, such as  sunlight . Exposure to corrosive chemicals can permanently damage the eyes, causing  blindness  if not sufficiently irrigated. The eye is protected from most blunt injuries by the  infraorbital margin , but in some cases blunt force may cause an eye to hemorrhage or tear. [ 41 ]  Overuse of the eyes can cause eye strain, particularly when looking at brightly lit screens for an extended period. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12515", "text": "Cardiac injuries affect the  heart  and  blood vessels .  Blunt cardiac injury  in a common injury caused by blunt trauma to the heart. It can be difficult to diagnose, and it can have many effects on the heart, including contusions, ruptures, acute valvular disorders,  arrhythmia , or  heart failure . [ 42 ]  Penetrative trauma to the heart is typically caused by stab wounds or gunshot wounds. Accidental cardiac penetration can also occur in rare cases from a fractured sternum or rib. Stab wounds to the heart are typically survivable with medical attention, though gunshot wounds to the heart are not. The  right ventricle  is most susceptible to injury due to its prominent location. The two primary consequences of traumatic injury to the heart are severe hemorrhaging and  fluid buildup  around the heart. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12516", "text": "Musculoskeletal injuries  affect the  skeleton  and the  muscular system .  Soft tissue injuries  affect the  skeletal muscles ,  ligaments , and  tendons . Ligament and tendon injuries account for half of all musculoskeletal injuries. Ligament sprains and tendon strains are common injuries that do not require intervention, but the healing process is slow.  Physical therapy  can be used to assist reconstruction and use of injured ligaments and tendons. Torn ligaments or tendons typically require surgery. [ 25 ]  Skeletal muscles are abundant in the body and commonly injured when engaging in athletic activity. Muscle injuries trigger an inflammatory response to facilitate healing. Blunt trauma to the muscles can cause contusions and  hematomas . Excessive tensile strength can overstretch a muscle, causing a strain. Strains may present with torn muscle fibers, hemorrhaging, or  fluid in the muscles . Severe muscle injuries in which a tear extends across the muscle can cause total loss of function. Penetrative trauma can cause laceration to muscles, which may take an extended time to heal. Unlike contusions and strains, lacerations are uncommon in sports injuries. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12517", "text": "Traumatic injury may cause various  bone fractures  depending on the amount of force, direction of the force, and width of the area affected.  Pathologic fractures  occur when a previous condition weakens the bone until it can be easily fractured.  Stress fractures  occur when the bone is overused or suffers under excessive or traumatic pressure, often during athletic activity. Hematomas occur immediately following a bone fracture, and the healing process often takes from six weeks to three months to complete, though continued use of the fractured bone will prevent healing. [ 45 ]   Articular cartilage damage  may also affect function of the skeletal system, and it can cause posttraumatic  osteoarthritis . Unlike most bodily structures, cartilage cannot be healed once it is damaged. [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12518", "text": "Injuries to the  nervous system  include  brain injury ,  spinal cord injury , and  nerve injury . Trauma to the  brain  causes  traumatic brain injury  (TBI), causing \"long-term physical, emotional, behavioral, and cognitive consequences\". Mild TBI, including  concussion , often occurs during athletic activity, military service, or as a result of untreated  epilepsy , and its effects are typically short-term. More severe injuries to the brain cause moderate TBI, which may cause confusion or lethargy, or severe TBI, which may result in a  coma  or a secondary brain injury. TBI is a leading cause of mortality. [ 47 ]  Approximately half of all trauma-related deaths involve TBI. [ 12 ]  Non-traumatic injuries to the brain cause  acquired brain injury  (ABI). This can be caused by  stroke , a  brain tumor , poison, infection, cerebral hypoxia, drug use, or the secondary effect of a TBI. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12519", "text": "Injury to the  spinal cord  is not immediately terminal, but it is associated with concomitant injuries, lifelong medical complications, and reduction in life expectancy. It may result in complications in several major organ systems and a significant reduction in mobility or paralysis.  Spinal shock  causes temporary paralysis and loss of reflexes. [ 49 ]  Unlike most other injuries, damage to the  peripheral nerves  is not healed through cellular proliferation. Following nerve injury, the nerves undergo degeneration before regenerating, and other pathways can be strengthened or reprogrammed to make up for lost function. The most common form of peripheral nerve injury is stretching, due to their inherent elasticity. Nerve injuries may also be caused by laceration or compression. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12520", "text": "Injuries to the  pelvic area  include injuries to the  bladder ,  rectum ,  colon , and  reproductive organs . Traumatic injury to the bladder is rare and often occurs with other injuries to the abdomen and pelvis. The bladder is protected by the  peritoneum , and most cases of bladder injury are concurrent with a fracture of the  pelvis . Bladder trauma typically causes  hematuria , or blood in the urine. Ingestion of alcohol may cause distension of the bladder, increasing the risk of injury. A  catheter  may be used to extract blood from the bladder in the case of hemorrhaging, though injuries that break the peritoneum typically require surgery. [ 51 ]  The colon is rarely injured by blunt trauma, with most cases occurring from penetrative trauma through the abdomen. Rectal injury is less common than injury to the colon, though the rectum is more susceptible to injury following blunt force trauma to the pelvis. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12521", "text": "Injuries to the  male reproductive system  are rarely fatal and typically treatable through grafts and reconstruction. The elastic nature of the  scrotum  makes it resistant to injury, accounting for 1% of traumatic injuries. Trauma to the scrotum may cause damage to the  testis  or the  spermatic cord . Trauma to the  penis  can cause  penile fracture , typically as a result of vigorous  intercourse . [ 53 ]  Injuries to the  female reproductive system  are often a result of  pregnancy  and  childbirth  or sexual activity. They are rarely fatal, but they can produce a variety of complications, such as chronic discomfort,  dyspareunia ,  infertility , or the formation of  fistulas . Age can greatly affect the nature of genital injuries in women due to changes in hormone composition. Childbirth is the most common cause of genital injury to women of reproductive age. Many cultures practice  female genital mutilation , which is estimated to affect over 125 million women and girls worldwide as of 2018. [ 54 ]  Tears and abrasions to the  vagina  are common during sexual intercourse, and these may be exacerbated in instances of non-consensual sexual activity. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12522", "text": "Injuries to the  respiratory tract  affect the  lungs ,  diaphragm ,  trachea ,  bronchus ,  pharynx , or  larynx .  Tracheobronchial injuries  are rare and often associated with other injuries.  Bronchoscopy  is necessary for an accurate diagnosis of tracheobronchial injury. [ 56 ]  The neck, including the pharynx and larynx, is highly vulnerable to injury due to its complex, compacted anatomy. Injuries to this area can cause  airway obstruction . [ 57 ]  Ingestion of corrosive chemicals can cause chemical burns to the larynx. [ 19 ]  Inhalation of toxic materials can also cause serious  injury  to the respiratory tract. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12523", "text": "Severe trauma to the chest can cause damage to the lungs, including  pulmonary contusions ,  accumulation of blood , or a  collapsed lung . The  inflammation  response to a lung injury can cause acute respiratory distress syndrome. Injuries to the lungs may cause symptoms ranging from  shortness of breath  to terminal  respiratory failure . Injuries to the lungs are often fatal, and survivors often have a reduced quality of life. [ 58 ]  Injuries to the diaphragm are uncommon and rarely serious, but blunt trauma to the diaphragm can result in the formation of a  hernia  over time. [ 59 ]  Injuries to the diaphragm may present in many ways, including abnormal blood pressure, cardiac arrest, gastroinetestinal obstruction, and respiratory insufficiency. Injuries to the diaphragm are often associated with other injuries in the chest or abdomen, and its position between two major cavities of the human body may complicate diagnosis. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12524", "text": "Most injuries to the skin are minor and do not require specialist treatment. Lacerations of the skin are typically repaired with  sutures ,  staples , or adhesives. The skin is susceptible to burns, and burns to the skin often cause blistering. Abrasive trauma scrapes or rubs off the skin, and severe abrasions require  skin grafting  to repair. Skin tears involve the removal of the epidermis or dermis through friction or shearing forces, often in vulnerable populations such as the elderly. Skin injuries are potentially complicated by foreign bodies such as glass, metal, or dirt that entered the wound, and skin wounds often require cleaning. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12525", "text": "Much of  medical practice  is dedicated to the treatment of injuries.  Traumatology  is the study of traumatic injuries and injury repair. Certain injuries may be treated by  specialists . Serious injuries sometimes require  trauma surgery . Following serious injuries, physical therapy and  occupational therapy  are sometimes used for rehabilitation.  Medication  is commonly used to treat injuries. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12526", "text": "Emergency medicine  during major trauma prioritizes the immediate consideration of life-threatening injuries that can be quickly addressed. The airway is evaluated, clearing bodily fluids with suctioning or creating an artificial airway if necessary. Breathing is evaluated by evaluating motion of the chest wall and checking for  blood  or  air  in the  pleural cavity . Circulation is evaluated to resuscitate the patient, including the application of  intravenous therapy . Disability is evaluated by checking for responsiveness and reflexes. Exposure is then used to examine the patient for external injury. Following immediate life-saving procedures, a  CT scan  is used for a more thorough diagnosis. Further resuscitation may be required, including ongoing blood transfusion, mechanical ventilation and nutritional support. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12527", "text": "Pain management  is another aspect of injury treatment.  Pain  serves as an indicator to determine the nature and severity of an injury, but it can also worsen an injury, reduce mobility, and affect quality of life.  Analgesic  drugs are used to reduce the pain associated with injuries, depending on the person's age, the severity of the injury, and previous medical conditions that may affect pain relief.  NSAIDs  such as  aspirin  and  ibuprofen  are commonly used for acute pain. Opioid medications such as  fentanyl ,  methadone , and  morphine  are used to treat severe pain in major trauma, but their use is limited due to associated long-term risks such as addiction. [ 62 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12528", "text": "Complications  may arise as a result of certain injuries, increasing the recovery time, further exasperating the symptoms, or potentially causing death. The extent of the injury and the age of the injured person may contribute to the likelihood of complications. Infection of wounds is a common complication in traumatic injury, resulting in diagnoses such as  pneumonia  or  sepsis . [ 63 ]  Wound infection prevents the healing process from taking place and can cause further damage to the body. A majority of wounds are contaminated with microbes from other parts of the body, and infection takes place when the immune system is unable to address this contamination. The surgical removing of devitalized tissue and the use of topical antimicrobial agents can prevent infection. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12529", "text": "Hemorrhaging of blood is a common result of injuries, and it can cause several complications. Pooling of blood under the skin can cause a  hematoma , particularly after blunt trauma or the suture of a laceration. Hematomas are susceptible to infection and are typically treated compression, though surgery is necessary in severe cases. [ 65 ]  Excessive blood loss can cause  hypovolemic shock  in which cellular oxygenation can no longer take place. This can cause  tachycardia ,  hypotension , coma, or  organ failure .  Fluid replacement  is often necessary to treat blood loss. [ 66 ]  Other complications of injuries include cavitation, development of fistulas, and organ failure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12530", "text": "Injuries often cause psychological harm in addition to physical harm. Traumatic injuries are associated with psychological trauma and distress, and some victims of traumatic injuries will display symptoms of  post-traumatic stress disorder  during and after the recovery of the injury. The specific symptoms and their  triggers  vary depending on the nature of the injury. [ 67 ]   Body image  and  self-esteem  can also be affected by injury. Injuries that cause permanent disabilities, such as spinal cord injuries, can have severe effects on self-esteem. [ 68 ] [ 69 ]  Disfiguring injuries can negatively affect body image, leading to a lower quality of life. Burn injuries in particular can cause dramatic changes in a person's appearance that may negatively affect body image. [ 70 ] [ 71 ] [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12531", "text": "Severe injury can also cause social harm. Disfiguring injuries may also result in stigma due to scarring or other changes in appearance. [ 73 ] [ 74 ]  Certain injuries may necessitate a change in occupation or prevent employment entirely. Leisure activities are similarly limited, and athletic activities in particular may be impossible following severe injury. In some cases, the effects of injury may strain personal relationships, such as marriages. [ 75 ]  Psychological and social variables have been found to affect the likelihood of injuries among athletes. Increased life stress can cause an increase in the likelihood of athletic injury, while  social support  can decrease the likelihood of injury. [ 76 ] [ 77 ]  Social support also assists in the recovery process after athletic injuries occur. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12532", "text": "Major trauma  is any  injury  that has the potential to cause prolonged  disability  or  death . [ 1 ]  There are many causes of major trauma,  blunt  and  penetrating , including  falls ,  motor vehicle collisions ,  stabbing wounds , and  gunshot wounds . Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility (called a  trauma center ) may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12533", "text": "In 2002, unintentional and intentional injuries were the fifth and seventh leading causes of deaths worldwide, accounting for 6.23% and 2.84% of all deaths. For research purposes the definition often is based on an  Injury Severity Score  (ISS) of greater than 15. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12534", "text": "Injuries generally are classified by either severity, the location of damage, or a combination of both. [ 3 ]  Trauma also may be classified by  demographic group , such as age or gender. [ 4 ]  It also may be classified by the type of force applied to the body, such as  blunt trauma  or  penetrating trauma . For research purposes injury may be classified using the  Barell matrix , which is based on  ICD-9-CM . The purpose of the matrix is for international standardization of the classification of trauma. [ 5 ]  Major trauma sometimes is classified by body area; injuries affecting 40% are  polytrauma , 30%  head injuries , 20%  chest trauma , 10%,  abdominal trauma , and 2%,  extremity  trauma. [ 4 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12535", "text": "Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value may be used for  triaging  a patient or for statistical analysis. Injury scales measure damage to anatomical parts, physiological values (blood pressure etc.),  comorbidities , or a combination of those. The  Abbreviated Injury Scale  and the  Glasgow Coma Scale  are used commonly to quantify injuries for the purpose of triaging and allow a system to monitor or \"trend\" a patient's condition in a clinical setting. [ 7 ]  The data also may be used in epidemiological investigations and for research purposes. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12536", "text": "Approximately 2% of those who have experienced significant trauma have a spinal cord injury. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12537", "text": "Injuries may be caused by any combination of external forces that act physically against the body. [ 10 ]  The leading causes of traumatic death are  blunt trauma ,  motor vehicle collisions , and  falls , followed by  penetrating trauma  such as  stab wounds  or impaled objects. [ 11 ]  Subsets of blunt trauma are both the number one and two causes of traumatic death. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12538", "text": "For statistical purposes, injuries are classified as either intentional such as suicide, or unintentional, such as a motor vehicle collision. Intentional injury is a common cause of traumas. [ 13 ]  Penetrating trauma is caused when a  foreign body  such as a bullet or a knife enters the  body tissue , creating an open wound. In the United States, most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms. [ 14 ]   Blast injury  is a complex cause of trauma because it commonly includes both blunt and penetrating trauma, and also may be accompanied by a  burn injury . Trauma also may be associated with a particular activity, such as an  occupational  or  sports injury . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12539", "text": "The body responds to traumatic injury both systemically and at the injury site. [ 16 ]  This response attempts to protect vital organs such as the liver, to allow further cell duplication and to heal the damage. [ 17 ]  The healing time of an injury depends on various factors including sex, age, and the severity of injury. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12540", "text": "The symptoms of injury may manifest in many different ways, including: [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12541", "text": "Various organ systems respond to injury to restore  homeostasis  by maintaining perfusion to the heart and brain. [ 20 ]   Inflammation  after injury occurs to protect against further damage and starts the healing process. Prolonged inflammation may cause  multiple organ dysfunction syndrome  or  systemic inflammatory response syndrome . [ 21 ]  Immediately after injury, the body increases production of glucose through  gluconeogenesis  and its consumption of fat via  lipolysis . Next, the body tries to replenish its energy stores of glucose and protein via  anabolism . In this state the body will temporarily increase its maximum expenditure for the purpose of healing injured cells. [ 18 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12542", "text": "The initial assessment is critical in determining the extent of injuries and what will be needed to manage an injury, and for treating immediate life threats."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12543", "text": "Primary  physical examination  is undertaken to identify any life-threatening problems, after which the secondary examination is carried out. This may occur during transportation or upon arrival at the hospital. The secondary examination consists of a systematic assessment of the  abdominal ,  pelvic , and  thoracic  areas, a complete inspection of the body surface to find all injuries, and a  neurological examination . Injuries that may manifest themselves later may be missed during the initial assessment, such as when a patient is brought into a hospital's emergency department. [ 23 ]  Generally, the physical examination is performed in a systematic way that first checks for any immediate life threats (primary survey), and then taking a more in-depth examination (secondary survey). [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12544", "text": "Persons with major trauma commonly have chest and pelvic  x-rays  taken, [ 6 ]  and, depending on the mechanism of injury and presentation, a  focused assessment with sonography for trauma  (FAST) exam to check for internal bleeding. For those with relatively stable blood pressure, heart rate, and sufficient  oxygenation ,  CT scans  are useful. [ 6 ] [ 25 ]   Full-body CT scans , known as pan-scans, improve the survival rate of those who have suffered major trauma. [ 26 ] [ 27 ]  These scans use intravenous injections for the  radiocontrast  agent, but not oral administration. [ 28 ]  There are concerns that intravenous contrast administration in trauma situations without confirming adequate renal function may cause damage to kidneys, but this does not appear to be significant. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12545", "text": "In the U.S., CT or  MRI  scans are performed on 15% of those with trauma in  emergency departments . [ 29 ]  Where blood pressure is low or the heart rate is increased\u2014likely from bleeding in the abdomen\u2014immediate surgery bypassing a CT scan is recommended. [ 30 ]  Modern 64-slice CT scans are able to rule out, with a high degree of accuracy, significant injuries to the neck following blunt trauma. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12546", "text": "Surgical techniques, using a tube or catheter to  drain fluid from the peritoneum ,  chest , or the  pericardium around the heart , often are used in cases of severe blunt trauma to the chest or abdomen, especially when a person is experiencing early signs of  shock . In those with  low blood-pressure , likely because of bleeding in the abdominal cavity,  cutting through the abdominal wall surgically  is indicated. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12547", "text": "By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems may help to enhance the overall health of a population. [ 32 ]  Injury prevention strategies are commonly used to prevent injuries in children, who are a high risk population. [ 33 ]  Injury prevention strategies generally involve educating the general public about specific risk factors and developing strategies to avoid or reduce injuries. [ 34 ]  Legislation intended to prevent injury typically involves seatbelts, child car-seats, helmets, alcohol control, and increased enforcement of the legislation. [ citation needed ]  Other controllable factors, such as the use of drugs including  alcohol  or  cocaine , increases the risk of trauma by increasing the likelihood of traffic collisions, violence, and abuse occurring. [ 6 ]  Prescription drugs such as  benzodiazepines  may increase the risk of trauma in  elderly  people. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12548", "text": "The care of acutely injured people in a public health system requires the involvement of bystanders, community members, health care professionals, and health care systems. It encompasses  pre-hospital trauma assessment  and care by  emergency medical services  personnel, emergency department assessment, treatment, stabilization, and in-hospital care among all age groups. [ 35 ]  An established trauma system network is also an important component of community disaster preparedness, facilitating the care of people who have been involved in disasters that cause large numbers of casualties, such as earthquakes. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12549", "text": "The pre-hospital use of  stabilization  techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a  trauma center  as well as provide primary stabilization by checking and treating  airway, breathing, and circulation  as well as assessing for disability and gaining exposure to check for other injuries. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12550", "text": "Spinal motion restriction  by securing the neck with a  cervical collar  and placing the person on a  long spine board  was of high importance in the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favor. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to indicate the need of these adjuncts. [ 36 ] [ 37 ]  This may be accomplished with other medical transport devices, such as a   Kendrick extrication device , before moving the person. [ 38 ]  It is important to quickly control severe bleeding with direct pressure to the wound and consider the use of  hemostatic agents  or  tourniquets  if the bleeding continues. [ 39 ]  Conditions such as impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear, however, if this is best performed before reaching hospital or in the hospital. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12551", "text": "Rapid transportation of severely injured patients improves the outcome in trauma. [ 6 ] [ 23 ]  Helicopter EMS transport reduces mortality compared to ground-based transport in adult trauma patients. [ 41 ]  Before arrival at the hospital, the availability of  advanced life support  does not greatly improve the outcome for major trauma when compared to the administration of  basic life support . [ 42 ] [ 43 ]  Evidence is inconclusive in determining support for pre-hospital  intravenous fluid resuscitation  while some evidence has found it may be harmful. [ 44 ]  Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them, [ 6 ]  and outcomes may improve when persons who have experienced trauma are transferred directly to a trauma center. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12552", "text": "Improvements in pre-hospital care have led to \"unexpected survivors\", where patients survive trauma when they would have previously been expected to die. [ 46 ]  However these patients may struggle to rehabilitate. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12553", "text": "Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status. [ 48 ]  These steps may happen simultaneously or depend on the most pressing concern such as a  tension pneumothorax  or major arterial bleed. The primary survey generally includes assessment of the cervical spine, though  clearing  it is often not possible until after imaging, or the person has improved. After immediate life threats are controlled, a person is either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey is performed that is a more detailed head-to-toe assessment of the person. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12554", "text": "Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure. [ 50 ]  Examples of these indications include penetrating neck trauma, expanding neck hematoma, and being unconscious. In general, the method of intubation used is  rapid sequence intubation  followed by ventilation, though intubating in shock due to bleeding can lead to arrest, and should be done after some resuscitation whenever possible. Trauma resuscitation includes control of active bleeding. When a person is first brought in, vital signs are checked, an  ECG  is performed, and, if needed, vascular access is obtained. Other tests should be performed to get a baseline measurement of their current blood chemistry, such as an  arterial blood gas  or  thromboelastography . [ 51 ]  In those with  cardiac arrest  due to trauma chest compressions are considered futile, but still recommended. [ 52 ]  Correcting the underlying cause such as a  pneumothorax  or  pericardial tamponade , if present, may help. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12555", "text": "A  FAST  exam may help assess for internal bleeding. In certain traumas, such as  maxillofacial  trauma, it may be beneficial to have a highly trained health care provider available to maintain airway, breathing, and circulation. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12556", "text": "Traditionally, high-volume  intravenous fluids  were given to people who had poor perfusion due to trauma. [ 54 ]  This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. [ 55 ]  In general, however, giving lots of fluids appears to increase the risk of death. [ 56 ]  Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. [ 4 ] [ 55 ]  Targets include a  mean arterial pressure  of 60\u00a0mmHg, a  systolic blood pressure  of 70\u201390\u00a0mmHg, [ 54 ] [ 57 ]  or the re-establishment of peripheral pulses and adequate ability to think. [ 54 ]   Hypertonic saline  has been studied and found to be of little difference from normal saline. [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12557", "text": "As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed  Lactated Ringer's solution  continues to be the solution of choice. [ 54 ]  If blood products are needed, a greater use of  fresh frozen plasma  and  platelets  instead of only  packed red blood cells  has been found to improve survival and lower overall blood product use; [ 59 ]  a ratio of 1:1:1 is recommended. [ 57 ]  The success of platelets has been attributed to the fact that they may prevent  coagulopathy  from developing. [ 60 ]   Cell salvage and autotransfusion  also may be used. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12558", "text": "Blood substitutes  such as  hemoglobin-based oxygen carriers  are in development; however, as of 2013 there are none available for commercial use in North America or Europe. [ 54 ] [ 61 ] [ 62 ]  These products are only available for general use in South Africa and Russia. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12559", "text": "Tranexamic acid  decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on CT scan. [ 63 ] [ 64 ] [ 65 ]  It  only appears to be beneficial, however, if administered within the first three hours after trauma. [ 66 ]  For severe bleeding, for example from  bleeding disorders ,  recombinant factor VIIa \u2014a protein that assists blood clotting\u2014may be appropriate. [ 6 ] [ 55 ]  While it decreases blood use, it does not appear to decrease the mortality rate. [ 67 ]  In those without previous factor VII deficiency, its use is not recommended outside of trial situations. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12560", "text": "Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury. [ 4 ]  While positive  inotropic medications  such as  norepinephrine  sometimes are used in hemorrhagic shock as a result of trauma, there is a lack of evidence for their use. [ 69 ]  Therefore, as of 2012 they have not been recommended. [ 58 ]  Allowing a low blood pressure may be preferred in some situations. [ 70 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12561", "text": "The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur. [ 71 ]   Damage control surgery  is used to manage severe trauma in which there is a  cycle  of  metabolic acidosis ,  hypothermia , and  hypotension  that may lead to death, if not corrected. [ 6 ]  The main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable. [ 6 ]  Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding. [ 72 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12562", "text": "Trauma deaths occur in immediate, early, or late stages. Immediate deaths usually are due to  apnea , severe brain or high spinal cord injury, or rupture of the heart or of large blood vessels. Early deaths occur within minutes to hours and often are due to  hemorrhages in the outer meningeal layer of the brain ,  torn arteries ,  blood around the lungs ,  air around the lungs ,  ruptured spleen ,  liver laceration , or  pelvic fracture . Immediate access to care may be crucial to prevent death in persons experiencing major trauma. Late deaths occur days or weeks after the injury [ 23 ]  and often are related to infection. [ 73 ]  Prognosis is better in countries with a dedicated trauma system where injured persons are provided quick and effective access to proper treatment facilities. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12563", "text": "Long-term prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain one year after injury. [ 74 ]  Many also experience a reduced  quality of life  years after an injury, [ 75 ]  with 20% of victims sustaining some form of disability. [ 76 ] \nPhysical trauma may lead to development of  post-traumatic stress disorder  (PTSD). [ 77 ]  One study has found no correlation between the severity of trauma and the development of PTSD. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12564", "text": "Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. [ 80 ] [ 81 ]  It is the fifth leading cause of significant disability. [ 80 ]  About half of trauma deaths are in people aged between 15 and 45 years and trauma is the leading cause of death in this age group. [ 81 ]  Injury affects more males; 68% of injuries occur in males [ 82 ]  and death from trauma is twice as common in males as it is in females, this is believed to be because males are much more willing to engage in risk-taking activities. [ 81 ]  Teenagers and young adults are more likely to need hospitalization from injuries than other age groups. [ 83 ]  While elderly persons are less likely to be injured, they are more likely to die from injuries sustained due to various physiological differences that make it more difficult for the body to compensate for the injuries. [ 83 ]  The primary causes of traumatic death are central nervous system injuries and  substantial blood loss . [ 80 ]  Various classification scales exist for use with trauma to determine the severity of injuries, which are used to determine the resources used and, for statistical collection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12565", "text": "The human remains discovered at the site of  Nataruk  in  Turkana , Kenya, are claimed to show major trauma\u2014both blunt and penetrating\u2014caused by violent trauma to the head, neck, ribs, knees, and hands, which has been interpreted by some researchers as establishing the existence of warfare between two groups of hunter-gatherers 10,000 years ago. [ 84 ]  The evidence for blunt-force trauma at Nataruk has been challenged, however, and the interpretation that the site represents an early example of warfare has been questioned. [ 85 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12566", "text": "The financial cost of trauma includes both the amount of money spent on treatment and the loss of potential economic gain through absence from work. The average financial cost for the treatment of traumatic injury in the United States is approximately  US$334,000  per person, making it costlier than the treatment of cancer and  cardiovascular diseases . [ 86 ]  One reason for the high cost of the treatment for trauma is the increased possibility of complications, which leads to the need for more interventions. [ 87 ]  Maintaining a trauma center is costly because they are open continuously and maintain a state of readiness to receive patients, even if there are none. [ 88 ]  In addition to the direct costs of the treatment, there also is a burden on the economy due to lost wages and productivity, which in 2009, accounted for approximately  US$693.5 billion  in the United States. [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12567", "text": "Citizens of  low-  and  middle-income  countries (LMICs) often have higher mortality rates from injury. These countries accounted for 89% of all deaths from injury worldwide. [ 82 ]  Many of these countries do not have access to sufficient surgical care and many do not have a trauma system in place. In addition, most LMICs do not have a pre-hospital care system that treats injured persons initially and transports them to hospital quickly, resulting in most casualty patients being transported by private vehicles. Also, their hospitals lack the appropriate equipment, organizational resources, or trained staff. [ 90 ] [ 91 ]  By 2020, the amount of trauma-related deaths is expected to decline in  high-income countries , while in low- to middle-income countries it is expected to increase. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12568", "text": "260,000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12569", "text": "175,000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12570", "text": "96,000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12571", "text": "47,000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12572", "text": "45,000"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12573", "text": "Due to anatomical and physiological differences, injuries in children need to be approached differently from those in adults. [ 92 ]  Accidents are the leading cause of death in children between 1 and 14 years old. [ 76 ]  In the United States, approximately sixteen million children go to an emergency department due to some form of injury every year, [ 76 ]  with boys being more frequently injured than girls by a ratio of 2:1. [ 76 ]  The world's five most common unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning. [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12574", "text": "Weight estimation  is an important part of managing trauma in children because the accurate dosing of medicine may be critical for resuscitative efforts. [ 94 ]  A number of methods to estimate weight, including the  Broselow tape ,  Leffler formula , and  Theron formula  exist. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12575", "text": "Trauma occurs in approximately 5% of all pregnancies, [ 96 ]  and is the leading cause of maternal death. Additionally, pregnant women may experience  placental abruption ,  pre-term labor , and  uterine rupture . [ 96 ]  There are diagnostic issues during pregnancy;  ionizing radiation  has been shown to cause birth defects, [ 4 ]  although the doses used for typical exams generally are considered safe. [ 96 ]  Due to normal  physiological changes that occur during pregnancy , shock may be more difficult to diagnose. [ 4 ] [ 97 ]  Where the woman is more than 23 weeks pregnant, it is recommended that the fetus be monitored for at least four hours by  cardiotocography . [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12576", "text": "A number of treatments beyond typical trauma care may be needed when the patient is pregnant. Because the weight of the uterus on the  inferior vena cava  may decrease blood return to the heart, it may be very beneficial to lay a woman in late pregnancy on her left side. [ 96 ]  also recommended are  Rho(D) immune globulin  in those who are rh negative,  corticosteroids  in those who are 24 to 34 weeks and may need delivery or a  caesarean section  in the event of cardiac arrest. [ 96 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12577", "text": "Most research on trauma occurs during war and military conflicts as militaries will increase trauma research spending in order to prevent combat related deaths. [ 98 ]  Some research is being conducted on patients who were admitted into an  intensive care unit  or trauma center, and received a trauma diagnosis that caused a negative change in their health-related quality of life, with a potential to create anxiety and symptoms of depression. [ 99 ]  New preserved blood products also are being researched for use in pre-hospital care; it is impractical to use the currently available blood products in a timely fashion in remote, rural settings or in theaters of war. [ 100 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12578", "text": "A  medical surge  occurs when \"patient volumes challenge or exceed a hospital's servicing capacity\"\u2014often but not always tied to high volume of patients in a hospital's  emergency room . [ 1 ]  Medical surges can occur after a  mass casualty incident . [ 2 ]  In a poll by the  American College of Emergency Physicians  (ACEP) in May 2018, 93% of doctors said their US emergency rooms were not fully prepared for medical surges. 6% said their emergency departments were fully prepared. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12579", "text": "Hospitals preparation to manage an increase in patient volumes has been highlighted in recent times due to different man-made or natural-caused disasters. The Covid-19 pandemic is a recent well-known disaster situation and has made a big impact on the preparedness work.  But hospital disaster preparation is at least described in the Second World War. [ 4 ]  Some hospitals, such as  San Francisco General Hospital , have medical surge exercises to train staff. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12580", "text": "In February 2019, the  American Hospital Association  released a report that medical surge capacity was one of four major challenges threatening rural hospitals' ability to provide care, along with the \"opioid epidemic,\" violence in the community, and cyber threats. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12581", "text": "Surge capacity is described as \"the ability to expand care capabilities in response to sudden or more prolonged demand.\" [ 7 ]  The requirements of surge may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations. This is related to patients volume and  identifying numbers of hospital beds, personnel, supplies, and equipment should be identified and addressed.\" [ 8 ]  These factors are often described as the 4S; Staff, Stuff, Structure and Systems. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12582", "text": "According to the U.S. Department of Health & Human Services, medical surge capability required \"special intervention to protect medical providers, other patients, and the integrity of the HCO. This is also the ability to manage patients requiring specialized medical care and evaluation.\" Notable examples include influxes of patients with  SARS . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12583", "text": "The  National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR)  is an orthopedic hospital and undergraduate & post-graduate institute in  Sher-e-Bangla Nagar ,  Dhaka ,  Bangladesh . It was established in 1972 by the  Government of Bangladesh  as the Shaheed Suhrawardy Hospital. In October 2002 the name of the institute was changed to National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR). [ 1 ]  NITOR is affiliated previously  to       Dhaka University  and now to  Bangabandhu Sheikh Mujib Medical University ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12584", "text": "Master of Surgery (MS) (Orthopedics) and D. Ortho. awarded by NITOR, a post-graduate institute, are recognized by the  Bangladesh Medical and Dental Council ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12585", "text": "23\u00b043\u203232\u2033N   90\u00b023\u203253\u2033E \ufeff / \ufeff 23.72556\u00b0N 90.39806\u00b0E \ufeff /  23.72556; 90.39806"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12586", "text": "This article about a hospital in Bangladesh is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12587", "text": "The  National Trauma Data Bank  ( NTDB ), also called the  American College of Surgeons National Trauma Data Bank , is a compilation of information about  traumatic injuries and outcomes  in the  United States . Hospital  emergency rooms  and other institutions such as  trauma centers  which are participants submit data and receive in return access to reports analyzing data about both their own operations and trauma medicine in the United States as a whole. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12588", "text": "Annual reports, an annual report and a pediatric report, which include  demographic  information is issued. Access to data sets is available to researchers who apply and are approved. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12589", "text": "Penetrating trauma  is an  open wound   injury  that occurs when an object pierces the  skin  and enters a  tissue  of the body, creating a deep but relatively narrow entry  wound . In contrast, a  blunt or  non-penetrating  trauma  may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment.  The penetrating object may  remain in the tissues , come back out the path it entered, or pass through the full thickness of the tissues and exit from another area. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12590", "text": "A penetrating injury in which an object enters the body or a structure and passes all the way through an exit wound is called a  perforating trauma , while the term  penetrating trauma  implies that the object does not perforate wholly through. [ 2 ]  In  gunshot wounds , perforating trauma is associated with an entrance wound and an often larger exit wound."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12591", "text": "Penetrating trauma can be caused by a foreign object or by fragments of a broken bone.  Usually occurring in  violent crime  or  armed combat , [ 3 ]  penetrating injuries are commonly caused by  gunshots  and  stabbings . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12592", "text": "Penetrating trauma can be serious because it can damage internal organs and presents a risk of  shock  and  infection .  The severity of the injury varies widely depending on the body parts involved, the characteristics of the penetrating object, and the amount of  energy  transmitted to the tissues. [ 4 ]   Assessment may involve  X-rays  or  CT scans , and treatment may involve surgery, for example to repair damaged structures or to remove foreign objects. Following penetrating trauma,  spinal motion restriction  is associated with worse outcomes and therefore it should not be done routinely. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12593", "text": "As a missile passes through tissue, it  decelerates , dissipating and transferring  kinetic energy  to the tissues. [ 1 ]  The  velocity  of the projectile is a more important factor than its mass in determining how much damage is done; [ 1 ]  kinetic energy increases with the square of the velocity.  In addition to injury caused directly by the object that enters the body, penetrating injuries may be associated with secondary injuries, due for example to a  blast injury . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12594", "text": "The path of a projectile can be estimated by imagining a line from the entrance wound to the exit wound, but the actual trajectory may vary due to  ricochet  or differences in tissue density. [ 4 ]  In a cut, the discolouration and the swelling of the skin from a blow happens because of the ruptured blood vessels and escape of blood and fluid and other injuries that interrupt the circulation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12595", "text": "Low-velocity items, such as knives and swords, are usually propelled by a person's hand, and usually do damage only to the area that is directly contacted by the object. [ 7 ]  The space left by tissue that is destroyed by the penetrating object as it passes through forms a cavity; this is called  permanent cavitation . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12596", "text": "High-velocity objects are usually  projectiles  such as  bullets  from high-powered rifles, such as  assault rifles [ 7 ]  or  sniper rifles .  Bullets classed as medium-velocity projectiles include those from  handguns ,  shotguns , [ 7 ]  and  submachine guns . In addition to causing damage to the tissues they contact, medium- and high-velocity projectiles cause a secondary cavitation injury: as the object enters the body, it creates a  pressure wave  which forces tissue out of the way, creating a cavity which can be much larger than the object itself; this is called \"temporary cavitation\". [ 8 ]  The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12597", "text": "The characteristics of the tissue injured also help determine the severity of the injury; for example, the denser the tissue, the greater the amount of energy transmitted to it. [ 8 ]  Skin, muscles, and intestines absorb energy and so are resistant to the development of temporary cavitation, while organs such as the liver, spleen, kidney, and brain, which have relatively low tensile strength, are likely to split or shatter because of temporary cavitation. [ 10 ]  Flexible elastic soft tissues, such as muscle, intestine, skin, and blood vessels, are good energy absorbers and are resistant to tissue stretch.  If enough energy is transferred, the liver may disintegrate. [ 9 ]  Temporary cavitation can be especially damaging when it affects delicate tissues such as the  brain , as occurs in penetrating head trauma. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12598", "text": "While  penetrating head trauma  accounts for only a small percentage of all  traumatic brain injuries  (TBI), it is associated with a high  mortality rate , and only a third of people with penetrating  head trauma  survive long enough to arrive at a hospital. Injuries from firearms are the leading cause of TBI-related deaths. Penetrating head trauma can cause  cerebral contusions  and lacerations,  intracranial hematomas ,  pseudoaneurysms , and  arteriovenous fistulas . The prognosis for penetrating head injuries varies widely. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12599", "text": "Penetrating  facial trauma  can pose a risk to the  airway  and  breathing ; airway obstruction can occur later due to  swelling  or bleeding. [ 12 ]  Penetrating  eye trauma  can cause the globe of the  eye  to rupture or  vitreous humor  to leak from it, and presents a serious threat to eyesight. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12600", "text": "Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%. [ 14 ]  Penetrating  chest trauma  can injure vital organs such as the heart and lungs and can interfere with breathing and circulation.  Lung injuries that can be caused by penetrating trauma include  pulmonary laceration  (a cut or tear)  pulmonary contusion  (a bruise),  hemothorax  (an accumulation of blood in the chest cavity outside of the lung),  pneumothorax  (an accumulation of air in the chest cavity) and  hemopneumothorax  (accumulation of both blood and air).   Sucking chest wounds  and  tension pneumothorax  may result. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12601", "text": "Penetrating trauma can also cause injuries to the heart and circulatory system. When the heart is punctured, it may bleed profusely into the chest cavity if the membrane around it (the  pericardium ) is significantly torn, or it may cause  pericardial tamponade  if the pericardium is not disrupted. [ 15 ]   In pericardial tamponade, blood escapes from the heart but is trapped within the pericardium, so pressure builds up between the pericardium and the heart, compressing the latter and interfering with its pumping. [ 15 ]   Fractures of the ribs  commonly produce penetrating chest trauma when sharp bone ends pierce tissues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12602", "text": "Penetrating  abdominal trauma  (PAT) typically arises from stabbings, ballistic injuries (shootings), or industrial accidents. [ 16 ]  PAT can be life-threatening because abdominal organs, especially those in the  retroperitoneal space , can bleed profusely, and the space can hold a large volume of blood. [ 2 ]  If the pancreas is injured, it may be further injured by its own  secretions , in a process called  autodigestion . [ 2 ]  Injuries of the  liver , common because of the size and location of the organ, present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. [ 2 ]  The intestines, taking a large part of the lower abdomen, are also at risk of  perforation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12603", "text": "People with penetrating abdominal trauma may have signs of  hypovolemic shock  (insufficient blood in the  circulatory system ) and  peritonitis  (an inflammation of the  peritoneum , the membrane that lines the  abdominal cavity ). [ 2 ]  Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause  bruits  (a distinctive sound similar to  heart murmurs ) to be audible. [ 2 ]  Percussion of the abdomen may reveal  hyperresonance  (indicating air in the abdominal cavity) or dullness (indicating a buildup of blood). [ 2 ]  The abdomen may be distended or tender, signs which indicate an urgent need for surgery. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12604", "text": "The standard management of penetrating abdominal trauma was for many years mandatory  laparotomy . A greater understanding of mechanisms of injury, outcomes from surgery, improved imaging and interventional radiology has led to more conservative operative strategies being adopted. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12605", "text": "Assessment can be difficult because much of the damage is often internal and not visible. [ 4 ]  The patient is thoroughly examined. [ 2 ]  X-ray and  CT scanning  may be used to identify the type and location of potentially lethal injuries. [ 2 ]  Sometimes before an X-ray is performed on a person with penetrating trauma from a projectile, a paper clip is taped over entry and exit wounds to show their location on the film. [ 2 ]  The patient is given  intravenous  fluids to replace lost blood. [ 2 ]  Surgery may be required;  impaled  objects are secured into place so that they do not move and cause further injury, and they are removed in an  operating room . [ 2 ]  If the location of the injury is not obvious, a surgical operation called an  exploratory laparotomy  may be required to look for internal damage to the organs in the  abdomen . [ 17 ]  Foreign bodies such as bullets may be removed, but they may also be left in place if the surgery necessary to get them out would cause more damage than would leaving them. [ 12 ]  Wounds are  debrided  to remove tissue that cannot survive and other material that presents risk for infection. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12606", "text": "Negative pressure wound therapy is no more effective in preventing wound infection than standard care when used on open traumatic wounds. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12607", "text": "Before the 17th\u00a0century, medical practitioners poured hot oil into wounds in order to  cauterize  damaged blood vessels, but the French surgeon  Ambroise Par\u00e9  challenged the use of this method in 1545. [ 19 ]  Par\u00e9 was the first to  propose controlling bleeding using  ligature . [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12608", "text": "During the  American Civil War ,  chloroform  was used during surgery to reduce pain and allow more time for operations. [ 2 ]  Due in part to the lack of  sterile technique  in hospitals, infection was the leading cause of death for wounded soldiers. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12609", "text": "In  World War I , doctors began replacing patients' lost fluid with salt solutions. [ 2 ]  With  World War II  came the idea of  blood banking , having quantities of  donated blood  available to replace lost fluids.  The use of  antibiotics  also came into practice in World War II. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12610", "text": "Perpetrator trauma , also known as  perpetration-  or  participation-induced traumatic stress  , both abbreviated to PITS, occurs when the symptoms of  posttraumatic stress disorder  (PTSD) are caused by an act or acts of killing or similar horrific violence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12611", "text": "Perpetrator trauma is similar but distinct from  moral injury , which focuses on the psychological, cultural, and spiritual aspects of a perceived moral transgression which produces profound shame."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12612", "text": "The  DSM-5  addresses the idea of active participation as a cause of  trauma  under the discussion accompanying its definition of PTSD, and adds to the list of causal factors: \"for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12613", "text": "There has been some study with  combat veterans , [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  people who carry out  executions  or  torture , police who shoot in the line of duty, people who commit criminal  homicide , and others. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12614", "text": "All studies that have considered the question of severity, have indicated that symptoms tend to be more severe for those who have killed, than for other causes of traumatization. One study [ 6 ]  using the U.S. government database of  American veterans of Vietnam [ 7 ]  has suggested that the pattern of symptoms in combat veterans may be different in those who said they had killed, as opposed to those who said they had not. Symptoms include intrusive imagery,  dreams ,  flashbacks , unwanted thoughts, being more prominent, along with explosive outbursts of  anger , and  concentration  and  memory problems  being less prominent. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12615", "text": "To a lesser extent,  hypervigilance , a sense of  alienation , and the non-PTSD symptom of a sense of disintegration were found to be greater for those who answered yes on killing.  Alcohol  and  cocaine use disorder  appeared to be more severe. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12616", "text": "Compared to the victim form of being traumatized, there are different dream motifs reported. While the eidetic dreams \u2013 that is, those that are like a video of the event playing in the head \u2013 can be experienced as they are with traumatized victims, other motifs also appear more commonly. [ 1 ] [ 12 ] [ 13 ] \nOne is of having the tables turned and being the one killed, or being very vulnerable in the same situation. Another motif is that of the victims accusing the dreaming person, or demanding to know why he or she did it.  Also possible, is a motif of the self being split in two, so that the killer part of the person is seen as actually being a different person."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12617", "text": "Therapies that have shown some effectiveness in the treatment of perpetrator trauma include  group therapy ,  eye movement desensitization and reprocessing , [ 14 ]  Time Perspective Therapy [ 15 ]  and understanding how common the problem is. [ 16 ]  Those who suffer, many of whom participated in violence as a matter of social expectation, find it beneficial to know that they are having a normal reaction to an abnormal situation, and are not uniquely cowardly or crazy. Traditional remedies of  atonement ,  forgiveness , and bearing witness have also stood the test of time as being helpful. [ 17 ] \nMore vigorous studies are needed for all these suggestions, as well as common PTSD therapies that have not yet been thoroughly explored, with the distinction of perpetration versus victimization in mind."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12618", "text": "Other proposed treatments have been proven to be ineffective. The \"flooding\" technique, technically called  Prolonged Exposure , which desensitizes the sufferer of trauma by repeated exposure to reminders of it in controlled settings, appears to be a bad idea, counter-indicated when the trauma involved being active in inflicting harm. [ 18 ]  It may be that expressive writing, which most people find helpful in working through their traumas, instead increases anger in soldiers. [ 19 ]  Differences in what physiological mechanisms in what pharmaceutical drugs might be useful in therapy are not yet known."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12619", "text": "In the 11th century, soldiers involved in the  Norman conquest of England , took part in the church administered  Ermenfrid Penitential , to atone for, and mentally process the violence they participated in. [ 20 ] :\u200a225"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12620", "text": "Several of the symptoms are capable of causing or allowing for renewed acts of violence. [ 1 ] [ 21 ]  The outbursts of anger can have an impact in  domestic violence  and  street crime . The sense of  emotional numbing ,  detachment  and estrangement from other people can contribute to these, along with contributing to participation in further battle activities or to  apathetic  reactions when violence is done by others. Associated  substance use disorders  may also have connections to acts of violence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12621", "text": "Perpetrator trauma has been documented among the perpetrators of  the Holocaust , [ 22 ]  the  Indonesian Communist Purges , [ 23 ]  the  Cambodian genocide , [ 24 ]  the South African  apartheid , [ 25 ]  and among  slaughterhouse workers . [ 26 ] [ better\u00a0source\u00a0needed ] [ 27 ] \nIn writing about the experiences of American soldiers during the  Iraq War , the psychiatrist R. J. Lifton claims in the aftermath of the  Haditha massacre :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12622", "text": "The alleged crimes in Iraq, like My Lai, are examples of what I call an atrocity-producing situation\u2014one so structured, psychologically and militarily, that ordinary people, men or women no better or worse than you or I, can commit atrocities. A major factor in all of these events was the emotional state of US soldiers as they struggled with angry grief over buddies killed by invisible adversaries, with a desperate need to identify an 'enemy.' [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12623", "text": "Referring to the definition of \"atrocity-producing situation\", Morag (2013) was one of the first scholars to theorize perpetrator trauma and delineate the victim-perpetrator distinction in the context of the twenty-first century new war on terror. [ 29 ]  According to Morag's theorization, perpetrator trauma as an ethical trauma has been documented among Israeli soldiers during the Intifada as well US soldiers in Iraq and Afghanistan. [ 30 ]  Authors from the PTSD Journal have documented perpetrator trauma among slaughterhouse workers, stating that \"these employees are hired to kill animals, such as pigs and cows that are largely gentle creatures. Carrying out this action requires workers to disconnect from what they are doing and from the creature standing before them. This emotional dissonance can lead to consequences such as domestic violence, social withdrawal, anxiety, substance use, and PTSD.\" [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12624", "text": "Polytrauma  and  multiple trauma  are medical terms describing the condition of a person who has been subjected to multiple  traumatic injuries , such as a serious head injury in addition to a serious burn. The term is defined via an  Injury Severity Score  (ISS) equal to or greater than 16. [ 1 ]  It has become a commonly applied term by  US military  physicians in describing the seriously injured soldiers returning from  Operation Iraqi Freedom  in  Iraq  and  Operation Enduring Freedom  in  Afghanistan . The term is generic, however, and has been in use for a long time for any case involving multiple trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12625", "text": "In civilian life, polytraumas often are associated with  motor vehicle crashes . This is because car crashes often occur at high velocities, causing multiple injuries. On admission to hospital any trauma patient should immediately undergo  x-ray  diagnosis of their  cervical spine ,  chest , and  pelvis , commonly known as a 'trauma series', to ascertain possible life-threatening injuries. (Where available, a CT trauma series for head, neck, thorax, abdomen and pelvis may be the imaging modality of first choice). Examples would be a fractured cervical  vertebra , a severely fractured pelvis, or a  haemothorax . Once this initial survey is complete, x-rays may be taken of the limbs to assess the possibility of other fractures. It also is quite common in severe trauma for patients to be sent directly to  CT  or a  surgery theatre , if they require emergency treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12626", "text": "Extracorporeal membrane oxygenation  (ECMO) may be effective in treating some polytrauma patients with pulmonary or cardiopulmonary failure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12627", "text": "Polytrauma often results from blast injuries sustained from  improvised explosive devices , or by a hit with a  rocket-propelled grenade , with  \"Improvised explosive devices, blasts, landmines, and fragments account[ing] for 65 percent of combat injuries\u00a0...\" . [ 3 ]  The combination of high-pressure waves, explosive fragments, and falling debris may produce multiple injuries including  brain injury ,  loss of limbs ,  burns ,  fractures ,  blindness , and  hearing loss , [ 4 ]  with 60 percent of those injured in this way, having some degree of traumatic brain injury. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12628", "text": "In some respects, the high incidence of polytrauma in military medicine is, in fact, a sign of medical advancement. In previous wars most soldiers with such multiple injuries simply did not survive, even if quickly transferred into hospital care. Today many polytrauma victims never fully regain their previous physical capacity, and are more susceptible to psychological complications, such as  PTSD . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12629", "text": "As of 2013, there were five rehabilitation centers in the U.S. specialising in polytrauma. They are managed by the  United States Department of Veterans Affairs  and are located in  Minneapolis, Minnesota ;  Palo Alto, California ;  Richmond, Virginia ;  San Antonio, Texas , and  Tampa, Florida . [ 4 ]  In addition to the intensive care, insofar as still required, these hospitals mainly specialize in  rehabilitative treatment . In addition the Department of Veterans Affairs has 22 polytrauma network sites, located throughout the country."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12630", "text": "Veterans Health Administration (VHA) developed a screening and evaluation process to ensure that OEF/OIF/OND Veterans with TBI are identified, and that they receive appropriate treatments and services. This includes mandatory screening for deployment-related TBI of all OEF/OIF/OND Veterans upon their initial entry into VHA for services. Veterans with positive screens are referred for a comprehensive evaluation by TBI specialists for diagnostic and treatment recommendations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12631", "text": "Based on extensive research, the VA-TBI Screening Tool has revealed high sensitivity and moderate specificity allowing VA to identify symptomatic Veterans and develop an appropriate plan of care. From 2007 to 2015, over 900,000 Veterans have been screened for possible OEF/OIF/OND deployment related TBI. Of those, approximately 20 percent had positive screens and were referred for further evaluation.  [1]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12632", "text": "OEF/OIF/OND veterans have a high polytrauma rate. [ 5 ] [ 6 ] [ 7 ]  Respectfully, a study exhibited findings with a population of 16,590 OEF/OIF/OND veterans, in which 27.66% met the criteria for poly trauma. [ 7 ]  Those within this subpopulation were most likely male (92.9%) and White (71.0%). Similar findings in a sample of 2,441,698 OEF/OIF/OND active duty found that the rate of poly trauma was 5.99 per 1,000 individuals. [ 6 ]  Of those with polytrauma, 52.15% were most likely between the ages of 20\u201329 years, male (89.93%), White (69.07%), married (64.18%), and enlisted in the Army (74.71%). Furthermore, the rate of polytrauma among a sample of 613,391 OEF/OIF/OND veterans was 6% (36,800). [ 8 ]  Additional research has concluded that in a selection of 340 OEF/OIF/OND veterans, 42.1% exhibited symptoms of poly trauma. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12633", "text": "As of April 2007, the Department of Veterans Affairs has treated more than 350 service members in their inpatient centers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12634", "text": "The treatment and rehabilitative care for polytrauma  patients  is a very extensive and time-consuming activity. The recommended staffing numbers (FTE = Full Time Equivalent) for six rehabilitation treatment beds are: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12635", "text": "In other words, 2.8 people are required full-time (24h), for every patient, often for months, while some care may be required for life."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12636", "text": "Psychological trauma  in adults   who are older  (usually more than 60 years), [ 1 ]  is the overall prevalence and occurrence of trauma symptoms within the  older adult population . (The term  psychological trauma  is sometimes hereinafter referred to as  trauma ). This should not be confused with  geriatric trauma . Although there is a 90% likelihood of an older adult experiencing a traumatic event, [ 2 ]  there is a lack of research on trauma in older adult populations. This makes research trends on the complex interaction between traumatic symptom presentation and considerations specifically related to the older  adult  population (e.g., the  aging  process, a lifetime prevalence of traumatic symptoms [otherwise known as lifetime trauma], etc.) difficult to pinpoint. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]  This article reviews the existing literature and briefly introduces various ways, apart from the occurrence of  elder abuse , that psychological trauma impacts the older adult population."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12637", "text": "Psychological trauma in older adults can present differently depending on the type of traumatic experience and when it took place. [ 8 ]  If the traumatic experiences of an older adult were recurrent in childhood (see  childhood trauma  or  complex trauma ) or in adulthood, the experiences can have varying but lasting detrimental effects on an older adult's psychological well-being, [ 6 ] [ 8 ]  health, [ 2 ] [ 9 ] [ 10 ]  and cognition. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12638", "text": "Older adults who experienced childhood-based trauma have a long-term trauma history, which increases their likelihood of experiencing more severe negative psychological, health, and cognitive symptoms. [ 9 ] [ 10 ] [ 11 ]  Additionally, the timing of trauma exposure has the potential to influence both the manifestation of  post-traumatic stress disorder (PTSD)  symptoms and the psychosocial functioning of older adults. Generally, older adults who identify their most distressing traumatic event as occurring during childhood tend to exhibit more severe symptoms of PTSD and report reduced subjective happiness compared to older adults who have experienced trauma later in life. [ 12 ]  A specific example is the intersection between recurrent interpersonal trauma and PTSD symptoms as an older adult. Research suggests that this intersection in older adults can lead to a perpetuating cycle where both components contribute to the experience of chronic pain later in life. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12639", "text": "Adulthood-based trauma considerations introduce the complexity of the interaction between an older adult's trauma presentation and potential neurocognitive components. [ 3 ]  Research indicates that older adults who have had PTSD are more likely to develop dementia  than those who did not have PTSD. [ 3 ] [ 14 ]   The neurocognitive effects of PTSD symptoms can also look similar to the neurocognitive effects of cognitive impairment in older adults. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12640", "text": "Psychological trauma diagnosis in older adults is considered less common than in younger adults. [ 3 ] [ 8 ] [ 9 ]  However, older adults' symptom presentations may make it more difficult for healthcare providers to identify trauma as the cause of an individual's symptoms (e.g., if the individual exhibits somatic representations of trauma symptoms; see  psychosomatic disorders ). [ 3 ] [ 8 ] [ 9 ] [ 11 ]  Some older adults may be more likely to report non-psychological symptoms and may not be aware that they may be experiencing trauma symptoms. [ 3 ]  Some trauma symptoms may emerge later on in life (known as Late-Onset Stress Symptomatology), [ 11 ]  which could make pinpointing a potential cause even more difficult. [ 11 ] [ 15 ]  Considering cohort factors is also important. [ 16 ]  The majority of today's older adults grew up during a time when psychological trauma was just starting to be acknowledged. [ 16 ]  This can make identifying and treating trauma within this population more difficult because there may be a lack of awareness or willingness to perceive their symptoms from a different perspective. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12641", "text": "Older adults who experienced trauma in their later years may also retain harmful symptoms associated with the normal aging process (see  old age ). [ 17 ]  For example, there are several research studies on older adults potentially developing PTSD after experiencing a fall. [ 17 ]  As people get older, they tend to experience more falls, leading to a  fear of falling . [ 18 ]  A meta-analysis of these studies revealed that female older adults who were more frail had a greater likelihood of developing PTSD following a fall, compared to older adults who were less frail and had higher levels of psychological resilience. [ 17 ]  Older adults' past experiences paired with current perceptions and health conditions are likely to perpetuate various psychological disorders (i.e., depression, anxiety, and phobias related to older adult considerations such as falling) [ 18 ] [ 14 ]  as well as worsen existing PTSD symptoms. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12642", "text": "Research on psychological trauma in older adults is sparse, [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 13 ]  with some individual studies lacking empirical reliability and validity. [ 7 ]  In order to assess and treat psychological trauma in older adults, strong research is needed within  scientific  literature. This will help in creating  psychological screeners  for trauma, which can aid in differentiating trauma symptom from other health or psychological disorders. [ 7 ]  Trauma symptoms can manifest differently among older adults. While there isn't a PTSD screener specifically designed for the general older adult population, certain PTSD  screeners  have been successfully tested with  veteran  older adults and can effectively screen for PTSD. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12643", "text": "In fact, most of the research on psychological trauma in older adults stems from the veteran population. [ 8 ] [ 11 ] [ 14 ]  PTSD in the older adult veteran population is a focal point of research with Veterans Affairs (VA; see  Veterans Health Administration ). The VA has been considered a leader in trauma research for decades. [ 19 ]  Considering that the concept of trauma originated with soldiers' experiences in war (i.e., trauma was labelled as \"shell shock\" or \"war neurosis\"), [ 16 ]  the VA closely monitors trauma development and treatment for veterans of all ages and identities. [ 20 ]   The results with aging veterans highlights the need to further understand psychological trauma within older adults more generally, including how it impacts their quality of life. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12644", "text": "Research on trauma in older adults is relevant and applicable in clinical settings as well. The National Center for PTSD (NCPTSD) [ 19 ]  conducts clinical research through the VA by implementing and providing psychological treatment for veterans who have experienced trauma. [ 21 ]  This includes research into such treatments as  cognitive processing therapy  (CPT),  eye movement desensitization reprocessing  (EMDR), and  prolonged exposure therapy  (PE). [ 9 ] [ 21 ]  The NCPTSD claims these three therapeutic orientations have a 53% success rate in PTSD symptom remission. [ 19 ]  Although research indicates that exposure therapies generally show effectiveness for treating trauma in older adults, [ 7 ] [ 9 ]  PE has been specifically identified as a reliable therapeutic approach for this population. [ 9 ]  If an older adult has both psychological trauma and cognitive impairment, it is recommended to provide them with an adapted or modified version of an evidence-based therapeutic treatment. [ 3 ]  If an older adult with psychological trauma is considering taking medication concurrently with and as a supplement for therapy, the VA has identified four medications for PTSD treatment:  fluoxetine ,  paroxetine ,  sertraline , and  venlafaxine . [ 19 ]  While there is limited research on medication specifically for treating trauma in older adults, medication use in general (see  pharmacotherapy ) can be beneficial for psychological and health treatment. [ 18 ]  It is crucial to monitor medication half-lives and potential harmful interactions when taking multiple medications. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12645", "text": "Psychotraumatology  is the study of  psychological trauma . [ 1 ]  Specifically, this discipline is involved with researching, preventing, and treating traumatic situations and people's reactions to them. [ 1 ] [ 2 ]  It focuses on the study and treatment of  post-traumatic stress disorder (PTSD)  and  acute stress disorder (ASD) , but encompasses any adverse reaction after experiencing traumatic events, including  dissociative disorders . Since 2021, Certified Trauma Professionals who have achieved a major level of training and clinical expertise can use the abbreviation PsyT [ 3 ]  after their names as a standard of recognition in the trauma field. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12646", "text": "The emergence of psychotraumatology as a field begins with the legitimization of PTSD as a psychological disorder. Symptoms of PTSD have been continuously reported in the context of war since the 6th century B.C., but it was not officially recognized as a valid disorder until it finally classified by the  American Psychiatric Association (APA)  in 1980. [ 1 ]  Once it was officially recognized as an issue, clinical research on PTSD increased dramatically, giving way to the field of  psychotraumatology. [ 1 ]  The term \"psychotraumatology\" was coined by George S. Everly, Jr. and Jeffrey M. Lating in the text entitled \"Psychotraumatology\" (1995). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12647", "text": "Donovan ( 1991) suggested that the term traumatology be used to unite the various endeavors within the field of traumatic stress studies.  As Donovan notes, however, the term traumatology also denotes the branch of medicine that deals with wounds and serious injuries. Schnitt (1993) expressed concern over Donovan's choice of a term that has at least two meanings. He urged clarity of communications as this new field expands; indeed, expansion is often built upon and facilitated by clarity of communications fostered by sematic precision. In a rebuttal of sorts, Donovan (1993) argued for a term broader in scope than traumatic stress studies, the phrase that has been used historically to unite the field. Clearly Schnitt's (1993) commentary offers insight to be considered. There is significant potential for ambiguity in the use of traumatology as a unifying term for the field of psychological trauma. Donovan (1993) argues that the term is \"socially influential as well as conceptually and pragmatically useful\" (p. 41 0). The potential ambiguity serves to diminish the promised pragmatics, but the lack of sematic precision is easily corrected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12648", "text": "In 1995, the addition of the prefix psycho- to the root traumatology appears to clarify potential ambiguities and more clearly defines the conduct at hand. Such reasoning serves as the foundation for the choice of psychotraumatology as the title of this field published in the Volume of Psychotraumatology. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12649", "text": "There are three main categories that are looked at in psychotrauamatology: the factors before, during, and after a psychologically traumatizing event has occurred. [ 1 ]  Such factors include: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12650", "text": "The term psychotraumatology is used in the present context to define or order the conduct of inquiry and the categorization of information relevant to psychological trauma. Psychotraumatology may be defined as the study of psychological trauma; more specifically, the study of the processes and factors that lie (a) antecedent to, (b) concomitant with, and (c) subsequent to psychological traumatization (Everly, 1992; 1993)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12651", "text": "Since the adoption of new evidence based models in trauma treatment a new specialization in psychotherapy has emerged, the psychotraumatologist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12652", "text": "According to the International Psychotraumatology Association a Psychotraumatologist standard of education and ethics:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12653", "text": "A Licensed Clinical Psychotherapist or Psychiatrist with knowledge and training:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12654", "text": "There are three main sub-specialization in the psychotraumatology field:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12655", "text": "Railway spine  was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in  railroad accidents ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12656", "text": "The first full-length medical study of the condition was  John Eric Erichsen 's classic book,  On Railway and Other Injuries of the Nervous System . [ 1 ]  For this reason, railway spine is often known as  Erichsen's disease ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12657", "text": "Railway collisions were a frequent occurrence in the early 19th century.  Exacerbating the problem was that railway cars were flimsy, wooden structures with no protection for the occupants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12658", "text": "Soon a group of people started coming forward who claimed that they had been injured in train crashes, but had no obvious evidence of injury. The railroads rejected these claims as fake, sometimes belittling people's pain as  litigation neurosis , implying that the only real problem was the injured person making a legal claim. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12659", "text": "The nature of symptoms caused by \"railway spine\" was hotly debated in the late 19th century, notably at the meetings of the (Austrian) Imperial Society of Physicians in Vienna, 1886. Germany's leading neurologist,  Hermann Oppenheim , claimed that all railway spine symptoms were due to physical damage to the spine or brain, whereas French and British scholars, notably  Jean-Martin Charcot  and Herbert Page, insisted that some symptoms could be caused by  hysteria  (now known as  conversion disorder ). [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12660", "text": "Erichsen observed that those most likely to be injured in a railway crash were those sitting with their backs to the acceleration. This is the same injury mechanism found in  whiplash . As with automobile accidents, railway and airplane accidents are now known to cause  posttraumatic stress disorder  (PTSD) and other  psychosomatic  symptoms in addition to physical trauma. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12661", "text": "Rape trauma syndrome  ( RTS ) is the  psychological trauma  experienced by a  rape  survivor that includes disruptions to normal physical, emotional, cognitive, and interpersonal behavior. The theory was first described by nurse  Ann Wolbert Burgess  and sociologist Lynda Lytle Holmstrom in 1974. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12662", "text": "RTS is a cluster of psychological and physical signs, symptoms and reactions common to most rape victims immediately following a rape, but which can also occur for months or years afterwards. [ 2 ]  While most research into RTS has focused on female victims, sexually abused males (whether by male or female perpetrators)  also exhibit RTS symptoms. [ 3 ] [ 4 ]  RTS paved the way for consideration of  complex post-traumatic stress disorder , which can more accurately describe the consequences of protracted trauma than  post-traumatic stress disorder  alone. [ 5 ]  The symptoms of RTS and post-traumatic stress syndrome overlap.  As might be expected, a person who has been raped will generally experience high levels of distress immediately afterward. These feelings may subside over time for some people; however, individually each syndrome can have long devastating effects on rape victims and some victims will continue to experience some form of psychological distress for months or years. Rape survivors are at high risk for developing  substance use disorders ,  major depression ,  generalized anxiety disorder , and  obsessive-compulsive disorder . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12663", "text": "RTS identifies three stages of  psychological trauma  a rape survivor goes through: the acute stage, the outer adjustment stage, and the renormalization stage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12664", "text": "The acute stage occurs in the days or weeks after a rape. Durations vary as to the amount of time the victim may remain in the acute stage. The immediate symptoms may last a few days to a few weeks and may overlap with the outward adjustment stage.\nAccording to Scarse, [ 7 ]  there is no \"typical\" response amongst rape victims. However, the U.S.  Rape Abuse and Incest National Network [ 8 ]  (RAINN) asserts that, in most cases, a rape victim's acute stage can be classified as one of three responses: expressed (\"He or she may appear agitated or hysterical, [and] may suffer from crying spells or anxiety attacks\"); controlled (\"the survivor appears to be without emotion and acts as if 'nothing happened' and 'everything is fine'\"); or shock/disbelief (\"the survivor reacts with a strong sense of disorientation. They may have difficulty concentrating, making decisions, or doing everyday tasks. They may also have poor recall of the assault\"). Not all rape survivors show their emotions outwardly. Some may appear calm and unaffected by the assault. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12665", "text": "Behaviors  present in the acute stage can include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12666", "text": "Survivors in this stage seem to have resumed their normal lifestyle. However, they simultaneously suffer profound internal turmoil, which may manifest in a variety of ways as the survivor copes with the long-term trauma of a rape. In a 1976 paper, Burgess and Holmstrom [ 10 ]  note that all but 1 of their 92 subjects exhibited maladaptive coping mechanisms after a rape. The outward adjustment stage may last from several months to many years after a rape."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12667", "text": "RAINN [ 8 ]  identifies five main coping strategies during the outward adjustment phase:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12668", "text": "Other  coping mechanisms  that may appear during the outward adjustment phase include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12669", "text": "Survivors in this stage can have their lifestyle affected in some of the following ways:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12670", "text": "Some rape survivors may see the world as a more threatening place to live in, so they will place restrictions on their lives, interrupting their normal activity. For example, they may discontinue previously active involvements in societies, groups or clubs, or a parent who was a survivor of rape may place restrictions on the freedom of their children."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12671", "text": "Whether or not they were injured during a  sexual assault , survivors exhibit higher rates of poor health in the months and years after an assault, [ 4 ]  including acute  somatoform disorders  (physical symptoms with no identifiable cause). [ 1 ]   Physiological  reactions such as  tension headaches ,  fatigue , general feelings of soreness or localized pain in the chest, throat, arms or legs. Specific symptoms may occur that relate to the area of the body assaulted. Survivors of oral rape may have a variety of mouth and throat complaints, while survivors of vaginal or anal rape have physical reactions related to these areas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12672", "text": "A common psychological defense that is seen in rape survivors is the development of fears and  phobias  specific to the circumstances of the rape, for example:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12673", "text": "In this stage, the survivor begins to recognize their adjustment phase.   Recognizing the impact of the rape for survivors who were in  denial , and recognizing the secondary damage of any counterproductive coping tactics (e.g., recognizing that one's drug abuse began to help cope with the aftermath of a rape) is particularly important.  Male survivors typically do not seek psychotherapy for a long time after the sexual assault\u2014according to Lacey and Roberts, [ 19 ]  less than half of male survivors sought therapy within six months and the average interval between assault and therapy was 2.5 years; King and Woollett's [ 20 ]  study of over 100 male rape survivors found that the mean interval between assault and therapy was 16.4 years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12674", "text": "During renormalization, survivors integrate the sexual assault into their lives so that the rape is no longer the central focus of their lives; negative feelings such as  guilt  and  shame  become resolved, and survivors no longer blame themselves for the attack."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12675", "text": "Prosecutors sometimes use RTS evidence to disabuse jurors of prejudicial misconceptions arising from a victim's ostensibly unusual post-rape behavior. The RTS testimony helps educate the jury about the psychological consequences surrounding rape and functions to dispel  rape myths  by explaining counterintuitive post-rape behavior."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12676", "text": "Especially in cases in which prosecutors have introduced RTS testimony, defendants have also sometimes proffered RTS evidence, a practice that has been criticized as undermining core values embodied in  rape shield laws , since it can involve subjecting victims to compelled psychological evaluations and searching cross-examination regarding past sexual history. Since social scientists have difficulty distinguishing symptoms attributable to rape-related PTSD from those induced by previous traumatic events, rape defendants sometimes argue that an alternative traumatic event, such as a previous rape, could be the source of the victim's symptoms. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12677", "text": "A criticism of rape trauma syndrome as currently conceptualized is that it delegitimizes a person's reaction to rape by describing their coping mechanisms, including their rational attempts to struggle through, survive the pain of sexual assault, and to adapt to a violent world, as symptoms of disorder. People who installed locks and purchased security devices, took self-defense classes, carried mace, changed residence, and expressed anger at the criminal justice system, for example, were characterized as exhibiting pathological symptoms and \"adjustment difficulties\". According to this criticism, RTS removes a person's pain and anger from their social and political context, attributing a person's anguish, humiliation, anger, and despair after being raped to a disorder caused by the actions of the rapist, rather than to, say, insensitive treatment by the police,  examining physicians , and the judicial system; or to family reactions permeated with rape mythology. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12678", "text": "Another criticism is that the literature on RTS constructs rape survivors as passive, disordered victims, even though much of the behavior that serves as the basis for RTS could be considered the product of strength. Words like \"fear\" are replaced with words like \"phobia\", with its connotations of irrationality. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12679", "text": "Criticisms of the scientific validity of the RTS construct are that it is vague in important details; it is unclear what its boundary conditions are; it uses unclear terms that do not have a basis in psychological science; it fails to specify key quantitative relationships; it has not undergone subsequent scientific evaluation since the 1974 Burgess and Holstrom study; there are theoretical  allegiance effects ; it has not achieved a consensus in the field; it is not falsifiable; it ignores possible mediators; it is not  culturally sensitive ; and it is not suitable for being used to infer that rape has or has not occurred. PTSD has been described as a superior model since unlike RTS, empirical examination of the PTSD model has been extensive, both conceptually and empirically. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12680", "text": "Suicide and trauma  is the increased risk of  suicide  that is caused by  psychological trauma ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12681", "text": "The National Institute of Mental Health  defines suicide as a self-inflicted act of  violence  with the intention of  death  that leads to the actual death of oneself. [ 1 ]  Although  rates of suicide  vary worldwide, suicide ranks as the tenth leading cause of death in the  United States  with rates increasing on average by one to two percent per year between 1999 and 2018, with the later years within that time span increasing at the greater rate. [ 2 ] [ 3 ] [ 4 ]  In 2017, the United States alone accounted for 2,813,503 deaths by suicide. [ 4 ]  Existing research has identified risk factors for suicide and the impacts of a suicide by a close other on a surviving individual."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12682", "text": "Suicide research has commonly identified  psychiatric disorders , particularly  depression , as major risk factors for suicide. [ 5 ] [ 6 ]  A systematic review found that more severe cases of depression and high levels of  hopelessness  indicate greater risk for suicide. [ 6 ]  Other factors identified with increased suicide risk include being of the male gender, having a family history of mental illness and/or suicide, having previously attempted suicide and/or engaged in  self-harming  behaviors, having co-morbid mental disorders, having been recently released from  inpatient care  for mental health, and being in the period just prior to beginning and/or just following initiation of  antidepressant  treatment or  psychotherapy . [ 2 ] [ 7 ]  Employment status, physical illness, major life events, recent exposure to suicidal acts, and access to means are also known factors to generally increase the risk for suicide. [ 2 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12683", "text": "Despite the variation in  suicide methods  used across countries and between cultures, common methods identified include the use of  firearms ,  poison  by  drugs , poison by  pesticides , jumping from heights,  hanging , and  suffocation . [ 10 ] [ 4 ]  Prevalence of pesticide suicide has been shown to be higher in  Asian  countries, whereas suicide by firearms is more prevalent in the United States and some  European  countries where ownership of firearms is common within the home. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12684", "text": "Research has given particular consideration to the impacts of suicide within a  family , whether by  spouse ,  parent , or  child . [ 11 ]  However, most studies have not examined the quality of the relationships within the family or the effect of different family members\u2019 reactions on the others. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12685", "text": "Suicide by a spouse has been associated with greater risk for mental illness, including depression,  PTSD , and engagement in self-harming behaviors. [ 12 ]  Spousal suicide has also been associated with adverse changes in physical health and social functioning, mortality, increased risk of suicide, and increased utilization of  mental health  services. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12686", "text": "Changes in family dynamics and functioning has been reported in the context of suicide by a child, which researchers note may affect relationships and bonding with surviving children within a family. [ 14 ]  More extreme types of family functioning with regard to cohesion and adaptability were associated with greater susceptibility to stress related to the death of a child such as the  anniversary of one's birth  and  death  and decisions regarding one's belongings. [ 14 ]  Many families must also navigate other stressors such as addressing the needs of surviving children and family members, which researchers assert can place the family at risk for additional health implications. [ 14 ]  Increases in utilization of mental health services and risk of suicide in parents has also been linked to experiencing suicide of a child. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12687", "text": "Studies have also shown the experience of a suicide or  suicide attempt  within a family is associated with greater engagement in risky behaviors in  adolescents  such as  substance use , self-harm, and one's own  suicidal ideation  and attempts, and higher rates of depression in suicide-bereaved children relative to their non-suicide-bereaved counterparts. [ 15 ] [ 16 ] [ 17 ]  Children of parents who have attempted suicide are at six times greater risk of attempting themselves. [ 18 ]  Although most suicides and suicidal behaviors within the family occur in the context of  mood disorders  transmitted within the family, mood disorders do not account for the totality of this phenomenon. [ 18 ]  Studies show increased risk of suicide and suicidal behaviors remain evident, despite familial transmission of mental illness. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12688", "text": "Exposure to suicide increases risk for  mental illness  and subsequent suicides. [ 11 ]   Prevention  efforts have focused on identifying at-risk groups. [ 5 ] [ 2 ]  Suicide researchers have suggested providers monitor individuals'  impulsivity , hopelessness, and access to means to increase prevention of suicidal acts. [ 10 ] [ 5 ]  Detection and management of mental illness has also been suggested to be an effective method aimed at reducing rates of suicide. [ 5 ]  In the context of exposure to suicide within a family, researchers have suggested providers aim to improve family functioning and responsiveness to suicide-related stressors and advocate for families\u2019 mental health care and access to other services when indicated. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12689", "text": "Psychological trauma often occurs when an individual faces an extensive degree of  stress  in which they are unable to cope with, resulting in difficulties processing and integrating the stressful event. [ 19 ]  Definitions of trauma have been extended over the past few decades to include a wider range of traumatic experiences, including the sudden or unexpected death of a close other (e.g. suicide). [ 20 ]  More recent definitions of trauma have also evolved such that greater emphasis is placed on the individual's perceptions of the traumatic event as opposed to its objective features, giving rise to the notion that similar events can lead to grossly different outcomes across individuals. [ 20 ]  Despite high rates of exposure to trauma, only a small percentage of those exposed go on to develop clinically significant symptoms of post-traumatic stress disorder, achieving criteria for a full diagnosis. [ 20 ]  However, studies have demonstrated a connection between exposure to traumatic events and negative mental health outcomes, including depression,  anxiety , substance use, and other externalizing disorders. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12690", "text": "While the act of suicide itself is often an independent act, suicide has the ability to affect broader social networks such as family,  friends , and the community and can be experienced as traumatic. [ 22 ] [ 11 ]  Exposure to violent deaths, such as suicide, have been associated with  grief  and trauma, and traumatic events as such may create a greater risk for the development of post-traumatic stress disorder. [ 14 ] [ 23 ]  Consideration has also been given to the impact of client suicide on providers such as  mental health professionals . [ 24 ]  A review of 57 studies revealed that the nature of the relationship between the departed and the surviving individual or individuals is associated with the adverse outcomes in the latter's mental and  social health . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12691", "text": "The  semicircular canal dehiscence  ( SCD ) is a category of rare  neurotological   diseases/disorders  affecting the  inner ears , which gathers the superior SCD, lateral SCD and posterior SCD. These SCDs induce SCD syndromes (SCDSs), which define specific sets of hearing and balance symptoms. [ 1 ] [ 2 ]  This entry mainly deals with the superior SCDS."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12692", "text": "The  superior semicircular canal dehiscence syndrome  ( SSCDS ) is a set of hearing and balance symptoms that a rare disease/disorder of the  inner ear 's  superior semicircular canal/duct  induces. [ 3 ] [ 4 ] [ 5 ]   The symptoms are caused by a thinning or complete absence of the part of the  temporal bone  overlying the  superior semicircular canal  of the  vestibular system . There is evidence that this rare defect, or susceptibility, is congenital. [ 6 ] [ 7 ]  There are also numerous cases of symptoms arising after physical trauma to the head. It was first described in 1998 by  Lloyd B. Minor  of  Johns Hopkins University  in  Baltimore . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12693", "text": "The superior canal  dehiscence  can affect both hearing and balance to different extents in different people. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12694", "text": "Symptoms of the SCDS include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12695", "text": "According to current research, in approximately 2.5% of the general population the bones of the head develop to only 60\u201370% of their normal thickness in the months following birth. This genetic predisposition may explain why the section of temporal bone separating the superior semicircular canal from the  cranial cavity , normally 0.8\u00a0mm thick, shows a thickness of only 0.5\u00a0mm, making it more fragile and susceptible to damage through physical head trauma or from slow erosion. An explanation for this erosion of the bone has not yet been found. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12696", "text": "The presence of dehiscence can be detected by a high definition (0.6\u00a0mm or less) coronal  CT scan  of the  temporal bone , currently the most reliable way to distinguish between superior canal dehiscence syndrome (SCDS) and other conditions of the inner ear involving similar symptoms such as  M\u00e9ni\u00e8re's disease ,  perilymphatic fistula  and  cochlea-facial nerve dehiscence . [ 10 ] [ 11 ]  Other diagnostic tools include the  vestibular evoked myogenic potential  or  VEMP  test,  videonystagmography  ( VNG ),  electrocochleography  (ECOG) and the rotational chair test. An accurate diagnosis is of great significance as unnecessary exploratory middle ear surgery may thus be avoided. Several of the symptoms typical to SCDS (e.g. vertigo and  Tullio ) may also be present singly or as part of M\u00e9ni\u00e8re's disease, sometimes causing the one illness to be confused with the other. There are reported cases of patients being affected by both M\u00e9ni\u00e8re's disease and SCDS concurrently. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12697", "text": "As SCDS is a very rare and still a relatively unknown condition, obtaining an accurate diagnosis of this distressing (and even disabling) disease may take some time as many health care professionals are not yet aware of its existence and frequently dismiss symptoms as being mental health-related. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12698", "text": "Once diagnosed, the gap in the temporal bone can be repaired by surgical resurfacing of the affected bone or plugging of the superior semicircular canal. [ 13 ] [ unreliable source? ] [ 14 ]  These techniques are performed by accessing the site of the dehiscence either via a middle fossa  craniotomy  or via a canal drilled through the  transmastoid bone  behind the affected ear. Bone cement has been the material most often used, in spite of its tendency to slippage and resorption, and a consequent high failure rate; recently, soft tissue grafts have been substituted. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12699", "text": "Occasionally this disorder has been referred to as  Minor's syndrome,  after its discoverer,  Lloyd B. Minor . However, that eponym has also been given to an unrelated condition, the paralysis and anaesthesia following a spinal injury, which is named after the Russian neurologist,  Lazar Minor  (1855\u20131942). In the latter case this term is now nearly obsolete. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12700", "text": "Trauma in children , also known as  pediatric trauma , refers to a  traumatic  injury that happens to an  infant ,  child  or  adolescent . Because of  anatomical  and  physiological  differences between children and  adults  the care and management of this population differs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12701", "text": "There are significant anatomical and physiological differences between children and adults. For example, the  internal organs  are closer in proximity to each other in children than in adults; this places children at higher risk of traumatic injury. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12702", "text": "Children present a unique challenge in trauma care because they are so different from adults - anatomically, developmentally, physiologically and emotionally. A 2006 study concluded that the risk of death for injured children is lower when care is provided in pediatric trauma centers rather than in non-pediatric trauma centers. Yet about 10% of injured children are treated at pediatric trauma centers. The highest mortality rates occur in children who are treated in rural areas without access trauma centers. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12703", "text": "An important part of managing trauma in children is  weight estimation . A number of methods to estimate weight exist, including the Broselow tape, Leffler formula, and Theron formula. [ 3 ]  Of these three methods, the Broselow tape is the most accurate for weight estimation in children \u226425\u00a0kg, [ 3 ]  while the Theron formula performs better with patients weighing >40\u00a0kg. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12704", "text": "Due to basic  geometry , a child's weight to surface area ratio is lower than an adult's, children more readily lose their body heat through radiation and have a higher risk of becoming  hypothermic . [ 4 ] [ 5 ]  Smaller body size in children often makes them more prone to  poly traumatic  injury. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12705", "text": "Several classification systems have been developed that use some combination of subjective and objective data in an effort to quantify the severity of trauma. Examples include the  Injury Severity Score [ 7 ] [ 8 ]  and a modified version of the  Glasgow Coma Scale . [ 9 ]  More complex classification systems, such as the  Revised Trauma Score ,  APACHE II , [ 10 ]  and  SAPS II [ 11 ]  add physiologic data to the equation in an attempt to more precisely define the severity, which can be useful in triaging casualties as well as in determining medical management and predicting prognosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12706", "text": "Though useful, all of these measures have significant limitations when applied to pediatric patients. For this reason, health care providers often employ classification systems that have been modified or even specifically developed for use in the pediatric population. For example, the  Pediatric Glasgow Coma Scale  is a modification of the Glasgow Coma Scale that is useful in patients who have not yet developed language skills. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12707", "text": "Emphasizing the importance of body weight and airway diameter, the Pediatric Trauma Score (PTS) was developed to specifically reflect the vulnerability of children to traumatic injury. The minimal score is -6 and the maximum score is +12. There is a linear relationship between the decrease in PTS and the mortality risk (i.e. the lower the PTS, the higher the mortality risk). [ 12 ]  Mortality is estimated at 9% with a PTS > 8, and at 100% with a PTS \u2264 0. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12708", "text": "In most cases the severity of a pediatric trauma injury is determined by the pediatric trauma score [ 4 ]  despite the fact that some research has shown there is no benefit between it and the revised trauma scale. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12709", "text": "The management of pediatric trauma depends on a knowledge of the physiological, anatomical, and developmental differences in comparison to an adult patient, this requires expertise in this area. [ 14 ]  In the pre-hospital setting issues may arise with the treatment of pediatric patients due to a lack of knowledge and resources involved in the treatment of these injuries. [ 15 ]  Despite the fact there is only a slight variation in outcomes in adult trauma centers, definitive care is best reached at a pediatric trauma center. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12710", "text": "Based on the  Centers for Disease Control and Prevention 's (CDC) WISQARS database for the latest year of data (2010), serious injury kills nearly 10,000 children in America each year. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12711", "text": "Pediatric trauma accounted for 59.5% of all mortality for children under 18 in 2004. [ 1 ] [ 19 ]  Injury is the leading cause of death in this age group in the  United States \u2014greater than all other causes combined. [ 20 ]  It is also the leading cause of permanent paralysis for children. [ 21 ] [ 22 ]  In the US approximately 16,000,000 children go to a hospital  emergency room  due to some kind of injury every year. [ 4 ]  Male children are more frequently injured than female children by a ratio of two to one. [ 4 ]  Some injuries, including  chemical eye burns , are more common among young children than among their adult counterparts; these are largely due to cleaning supplies and similar  chemicals  commonly found around the home. [ 23 ]  Similarly, penetrating injuries in children is because of  writing utensils  and other common household objects as many are readily available to children in the course of their day. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12712", "text": "The  Trauma Quality Improvement Program  ( TQIP ) was initiated in 2008 by the  American College of Surgeons  Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult  trauma  outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals to objectively evaluate their trauma centers' performance relative to other hospitals. TQIP's administrative costs are less than those of other programs, making it an accessible tool for assessing performance and enhancing quality of trauma care."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12713", "text": "Morbidity and mortality rates are variable across United States  trauma centers . Institutional variations can be attributed to differences in both patient population and quality of care at each institution. [ 1 ]  The  Institute of Medicine  (IOM) report  To Err is Human: Building A Safer Health System  emphasized the importance of recognizing variability and inefficiencies in the  United States healthcare  system. [ 2 ] [ 3 ]  To address these discrepancies, John Fildes, MD, FACS created an  ad hoc  work group to create and implement an outcomes-based, validated, risk-adjusted trauma quality improvement system. The goal was to utilize existing trauma infrastructures to measure and continually improve the quality of trauma care. This was done by accessing each hospital's registry database using the National Trauma Data Standard (NTDS) from the  National Trauma Data Bank  (NTDB), resulting in the creation of the Trauma Quality Improvement Program (TQIP) by the  American College of Surgeons  (ACS). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12714", "text": "TQIP was preceded by surgical indicators that included the Optimal Resources for the Care of the Injured reference document, published by the ACS Committee on Trauma in 1979. The document created a framework for the trauma center verification review process with a  systems approach  to trauma care. [ 4 ]  The Major Trauma Outcome Study (MTOS) of 1982\u20131989 subsequently established the national standards for trauma care. The MTOS database also facilitated the creation of a methodology to estimate an individual trauma patient's survival probability, also known as the Trauma Injury Severity Score (TRISS). [ 1 ]  Other studies, such as the 2006 National Study of the Costs and Outcomes of Trauma (NSCOT), aimed to identify differences in expenditures and outcomes at various hospitals. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12715", "text": "A  pilot study  was initiated in June 2008 to refine the methodology and assess the feasibility of applying TQIP for quality improvement at different trauma centers. Twenty-three Level I and II trauma centers volunteered and were selected to participate in the study with ACS verification. Most Level I centers are university-based trauma centers with comprehensive services. Level II centers were included to increase geographic and patient diversity, as well as the statistical power of any analyses. Each participating center received a registrar training course that included information about TQIP objectives and infrastructures, critical data collection fields, and NTDS data definitions. Webinars with conference calls and test case data abstraction were used for follow-up training. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12716", "text": "Using NTDB data from patients admitted to trauma centers between January 1 and December 1, 2007, three cohorts were created. The first cohort included patients with blunt multisystem or blunt mechanism traumas with an  Abbreviated Injury Scale  (AIS) score \u2265 3 in two or more regions including the head, face, neck, thorax, abdomen, spine, and extremities. The second cohort was composed of trauma patients with penetrating truncal injuries with an AIS score \u2265 3 in at least one region including the neck, thorax, and abdomen. Patients in the third cohort had a blunt single-system injury with an AIS score \u2265 3 in only one AIS body region, with the remaining regions having a maximum AIS score of 2. The outcomes of interest were death during hospitalization as evidenced by an  emergency department  (ED) discharge disposition of \u201cdeath\u201d or hospital discharge disposition of \u201cexpired,\u201d as well as the prevalence of inpatient complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12717", "text": "Data reports were created and distributed to each participating trauma center in June 2009. Results were consistent with the previous year's baseline findings. Cohorts of similar verified trauma centers had differences in risk-adjusted mortality rates with a large amount of variance between low-outlier and high-outlier trauma centers. The aggregate group had a relative risk-mortality of 3.3, while the single-system trauma cohort had a mortality 5.9 times higher for high-outlier facilities. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12718", "text": "The TQIP pilot results gave each trauma center feedback regarding their trauma outcomes relative to other hospitals. The results also shed light on appropriate actions to undertake in order to improve quality, such as by illuminating local or regional collaborative efforts that could implemented. Overall, the pilot study demonstrated that TQIP's anonymous measures of relative performance could successfully allow trauma centers to identify shortcomings and facilitate quality improvement using existing resources and systems at local, regional, and national levels. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12719", "text": "TQIP utilizes a  retrospective cohort  of trauma patients in designated and ACS-verified Level I and II hospitals in the United States and Canada. There is no minimum sample size requirement for a trauma center to participate in the program. As of 2014 [update] , over 200 participating Level I and II trauma centers that vary in type (public, private teaching university, teaching community, etc.) and region participate in TQIP. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12720", "text": "To participate in the program, patients must meet the following inclusion criteria: be an adult greater than sixteen years of age with at least one valid  ICD 9 CM  diagnosis code, history of blunt or penetrating mechanisms of injury, or have an AIS score \u2265 3. Eligible patients also must have emergency department or hospital dispositions available. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12721", "text": "Patients are excluded from the program if they have a pre-existing  advance directive  to withhold life-sustaining measures or are older than 65 years of age and have an isolated hip fracture. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12722", "text": "The program categorizes patients into different cohorts in order to evaluate different aspects of trauma care. [ 2 ]  The cohorts are as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12723", "text": "This program focuses on mortality, complications, and resource use. Mortality is further subdivided into on arrival, in the emergency department, and in-hospital. Complications are further subdivided into  urinary tract infections , deep  venous thrombosis ,  ventilator-associated pneumonia ,  central line -related  bacteremia ,  renal failure , and  surgical site infections .  Resource use is measured via  length of stay  in the hospital, length of stay in the  intensive care unit , and number of days that a patient is on a  ventilator . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12724", "text": "TQIP addresses quality issues by explicitly addressing certain care metrics, including monitoring  intracranial pressure  in patients with  traumatic brain injuries , measuring time to operations, measuring the placement and timing of  tracheostomies , measuring the time to  hemorrhage  control, and documenting the use of  venous thromboembolism   prophylaxis . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12725", "text": "TQIP helps ensure the quality of data by providing training for trauma registrars and data abstractors. TQIP administrators hold monthly activities, such as webinars and quizzes, to educate registrars on the importance of data quality. Administrators assess outlier values, perform internal and external validation, and perform data logic checks. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12726", "text": "TQIP measures multiple variables in its risk-adjustment models. These variables include factors such as age, race, gender, initial pulse rate in the emergency department, the mechanism of injury, etc. An 18 variable multivariable logistic regression model is used to estimate risk-adjusted mortality for trauma patients. Results provide observed-to-expected ratios and a 90%  confidence interval  of a trauma center's data compared to other de-identified trauma centers in order to gauge relative variability. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12727", "text": "TQIP is designed to give each hospital an objective measure of its trauma center's performance compared to that of other trauma centers. It is meant as a self-reflective tool to be used in determining how to improve outcomes and decrease costs by understanding the reasons for variability and identifying best practices. Results are not intended to be used for marketing purposes or bestowing competitive advantages. [ 1 ]  TQIP reports allow hospitals to focus on outcomes and workflows, including care coordination, in-hospital processes, and resource allocation. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12728", "text": "TQIP's external benchmarking utilizes NTDB data collection and NTDS with specific enhancements. Deliverables comprise risk adjusted hospital comparisons in the form of one annual benchmark report as well as two separate annual reports related to a topic of interest and the TQIP online analysis tool. Education and training are delivered via the annual meeting, online training, monthly educational experiences for abstractors, and monthly open forum calls for registry staff. Data are submitted quarterly and quality is monitored through a data validation site visit, a TQIP validator, and data quality reporting. Feedback to participating trauma centers about their relative performance encourages the sharing of practices during the annual meeting with emphasis on high performers and web conferences. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12729", "text": "The TQIP annual fee is $9,000 and includes the deliverables above. Additional costs include the salary of the registrar and trauma registry software. As the compilation and maintenance of the trauma registry are required for verification, the additional cost to a currently verified trauma center is for participation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12730", "text": "TQIP's outcome estimates are heavily dependent on data quality and sample size for each participating trauma center. Despite the development of sophisticated statistical models which attempt to mitigate errors in precision, the small sample sizes of highly specific trauma patient populations will inevitably skew results. Similarly, centers reporting data need to be hyper-aware of their reporting for data fields for certain patient populations susceptible to biased or missing data (e.g., high prevalence of low  Injury Severity Scores  for patients with early death who did not receive complete diagnostic testing or autopsies). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12731", "text": "As of 2013 [update] , TQIP has not incorporated measures related to racial disparities in trauma outcomes. However, there is evidence to suggest that differences in trauma outcomes are due to the overall quality of hospitals serving higher proportions of minority patients, rather than being due to discriminatory delivery of care; that is, these hospitals are less likely to provide recommended care to patients. [ 7 ]  In fact, almost 80% of trauma centers serving primarily minority patients are classified as high mortality trauma centers due to their ratios of observed-to-expected survival rates. Patients from all racial and ethnic backgrounds appear to be 40% more likely to survive when treated at low mortality trauma centers when compared with patients of the same race and ethnicity with the same injuries being treated at high mortality trauma centers. [ 8 ]  Differences between groups are relatively small compared to overall discrepancies between recommended and observed care. [ 9 ]  Still, high mortality status is not universal among institutions treating predominantly minority patients, and TQIP has not addressed this inequity. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12732", "text": "TQIP excludes from statistical analyses all  dead on arrival  (DOA) patients and those who expire in the emergency department. This is done out of concern regarding varying patient transit times among trauma centers located in more urban vs. rural environments as well as the severity of injuries more likely to be present at certain trauma centers. However, this practice has the potential to remove a sizable number of patients from a trauma center's mortality index (for example, if a trauma center that is exceptionally skillful at the resuscitation phase of care may receive no credit), thus impeding analysis of a vital component of trauma care. Similarly, there can be great variation in how trauma centers classify DOA patients, leading to differences in treatment (e.g., resuscitation attempts or other invasive procedures). While independent researchers have found that inclusion of ED deaths in statistical analyses yields only small, insignificant changes in TQIP outcomes, doing so eliminates bias that might otherwise be introduced. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12733", "text": "As of 2014 [update] , over 200 Level I or Level II trauma centers are participating in TQIP, which is facilitating the identification of high performers. Enrollment is done on a rolling basis that allows hospitals to join at any time. Additionally, a pediatric TQIP pilot with thirty-eight participating centers is currently underway and external data validation has been implemented. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12734", "text": "In psychology,  Trauma-informed feminist therapy  is a model of trauma for both men and women that incorporates the client's  sociopolitical  context."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12735", "text": "In  feminist therapy , the therapist views the client's trauma experience through a sociopolitical lens.  In other words, the therapist must consider how the client's social and political environment could have contributed to their trauma or perpetuated it. Feminist theory argues that certain traumas are produced and maintained by  institutionalized discrimination  and  social hierarchies . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12736", "text": "The diagnosis of  Post-traumatic stress disorder , or PTSD, was first recognized in 1980 and published in the third edition of the  Diagnostic and Statistical Manual of Mental Disorders . [ 2 ] [ 3 ]  The original PTSD diagnosis was formulated to fit the  symptomology  of veterans returning home from combat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12737", "text": "Feminist psychologists modified the diagnosis when treating patients with exposure to childhood sexual assault, chronic  abuse , and gender-based trauma. [ 4 ]   Trauma-informed feminist therapy challenged both the traditional conceptualization of the PTSD diagnosis, as well as the overall standard approach to trauma treatment, by proposing new models of trauma that incorporate sociopolitical context. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12738", "text": "Feminist therapy began in the 1960s during the  second wave of feminism .  According to its proponents, a  sexist  power structure in American psychotherapy was harmful to women suffering trauma.   Initially, groups of women began to meet at leader-less \" consciousness-raising ,\" meetings where women shared their experiences with sexism in therapy.  Many women evoked opinions that  oppressive  cultural norms  affect mental health.  To them,  the groups acted as a way to both draw attention to the oppression within the mental health system, as well as a way to empower women. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12739", "text": "The original consciousness-raising meetings evolved into an integrated set of principles to be applied in therapy.  Today, feminist therapy has expanded to reflect the ideas of the  third wave of feminism , that the patriarchy is harmful to both men and women. [ 7 ]   Another part of feminist therapy is a focus on social justice issues for people,  regardless of their gender, culture,  sexuality , social class,  phenotype , or national origin. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12740", "text": "Feminist theory argues that certain traumas are produced and maintained by institutionalized discrimination and social hierarchies  [ 1 ]  Root (1992) coined the term \"insidious traumatization,\" to describe the distress that builds when one is the member of a  marginalized group  and subjected to constant threat of  discrimination . [ 9 ]  Exposure to insidious trauma is thought to creates both unique vulnerabilities and unique strengths. Feminist theory argues that insidious traumatization can lead to full blown PTSD symptoms. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12741", "text": "Freyd (1996) expanded the idea of insidious traumatization to include the term \"betrayal trauma,\" to describe the specific kind of trauma that occurs when a child is abused by their  caregivers ; Feminist theory argues that betrayal trauma is inherently different from single-incident trauma, mainly because betrayal trauma tends to manifest specifically as interpersonal difficulties and  dissociative symptoms , while traditional intrusive symptoms are usually not present. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12742", "text": "Overall, feminist theory argues against the use of diagnoses, except in instances where a  diagnosis  would assist the service user in gaining access to  mental health care . [ 12 ]  Feminist therapy aims to move away from pathologizing responses to trauma in favor of framing responses as \"survival techniques.\""}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12743", "text": "For example, in regard to diagnoses that relate to trauma, feminist theory takes issue with the diagnosis  Borderline Personality Disorder  (BPD), a disorder that is often linked to severe  childhood trauma . [ 13 ]  Feminist theory posits that a diagnosis of BPD, unnecessarily pathologizes  normative  and adaptive responses to betrayal trauma. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12744", "text": "In addition, feminist theory argues that chronic exposure to inescapable trauma, such as childhood abuse, is better captured by the diagnosis of  Complex Post-Traumatic Stress Disorder  (CPTSD); [ 15 ]  CPTSD has been proposed as an alternative diagnosis for those responding to sever trauma with BPD-like symptoms, in an attempt to view symptoms as a survival response as opposed to a  personality disorder ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12745", "text": "Trauma-informed feminist therapy encourages therapists to take an eclectic approach to trauma treatment, allowing the service user to be the expert of their own experience. [ 16 ] [ 17 ]  Feminist therapy seeks to break down what it terms the inherent power differential between  clinician  and client, by actively constructing an egalitarian relationship. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12746", "text": "In addition, feminist therapists strive to understand their client's experience with trauma by acknowledging and exploring how  social structure  influenced the trauma. [ 19 ]  Trauma-informed feminist therapy argues that successful treatment is not about creating an absence of symptoms; instead feminist therapy aims to assist trauma survivors in creating a non-blaming view of their traumatic experience from which they can gain a sense of  empowerment . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12747", "text": "Traumatic cardiac arrest  ( TCA ) is a condition in which the  heart  has  ceased  to beat due to  blunt  or  penetrating trauma , such as a  stab wound  to the  thoracic  area. [ 1 ]  It is a  medical emergency  which will always result in death without prompt advanced medical care.  Even with prompt medical intervention, survival without  neurological  complications is rare. [ 2 ]  In recent years, protocols have been proposed to improve survival rate in patients with traumatic cardiac arrest, though the variable causes of this condition as well as many coexisting injuries can make these protocols difficult to standardize. [ 3 ]  Traumatic cardiac arrest is a complex form of  cardiac arrest  often derailing from  advanced cardiac life support  in the sense that the emergency team must first establish the cause of the traumatic arrest and reverse these effects, for example hypovolemia and haemorrhagic shock due to a penetrating injury. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12748", "text": "Traumatic cardiac arrest can occur in patients following any severe blunt or penetrating  injury to the chest . Following the traumatic event, the heart ceases to pump blood through the body. Unlike medical cardiac arrest, there are several potentially reversible causes that may result in cardiac arrest in the setting of trauma. Clinicians will rapidly assess for these causes, and interventions will be directed to the specific cause. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12749", "text": "In both blunt and penetrating trauma, massive  internal  or  external bleeding  may decrease the volume of blood is available to be pumped by the heart to the body. This is considered  preload  dependent arrest. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12750", "text": "Tension pneumothorax  is caused when air is able to enter the space between the  lung  and the  chest wall , but is not able to escape. The increasing pressure within the chest cavity prevents blood from returning from the body to fill the heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12751", "text": "Hemothorax  occurs when injury to the chest results in bleeding into the thoracic cavity. Similar to tension pneumothorax, increasing pressure prevents the return of blood from circulation to the heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12752", "text": "In the setting of trauma,  cardiac tamponade  results from an acute  pericardial effusion , the accumulation of blood within the sac that surrounds the heart. As this sac is filled with fluid, the pressure on the heart is increased, and the chambers of the heart are unable to fill with blood."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12753", "text": "Inability to maintain  oxygenation  in trauma patients may be a result of  airway  compromise due to mechanical injury or obstruction or due to loss of the  respiratory drive  from  cervical spine  or  peripheral nerve injury . [ 4 ]  These conditions result in the  hypoxia  that may lead to cardiac arrest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12754", "text": "Patients will present following a traumatic event most often with  pulseless electrical activity  (PEA). Patients will exhibit low blood pressure with pulses that cannot be palpated. Patients will progress into  asystole  if the underlying condition is not reversed. Other non-specific signs and symptoms associated with impending traumatic cardiac arrest may include sweating,  altered mental status ,  rapid  or  slow breathing , and signs of trauma (bruising,  laceration , fractures, etc.). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12755", "text": "Diagnosis of traumatic cardiac arrest is initially made with  electrocardiogram  with EMS or in the emergency department. Clinicians will also order diagnostic testing that may include  chest x-ray , bedside ultrasound and  echocardiogram , and blood gas levels. A  type and cross  will be ordered to match the patient to receive blood transfusion if necessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12756", "text": "Other work-up involved in diagnosis of a trauma patient may include  e-FAST ,  RUSH exam ,  CBC , pelvic X-ray, and  CT  of the head, neck, chest, abdomen, and pelvis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12757", "text": "Treatment of traumatic cardiac arrest is guided by  advanced trauma life support guidelines . Standard advanced cardiac life support guidelines are inappropriate for use in traumatic cardiac arrest, as they are directed primarily at treating pathology originating within the heart itself. [ 5 ]  As clinicians begin to intervene, they will simultaneously seek reversible causes of the arrest. Management begins by establishing multiple points of IV access and evaluating the patient's airway and breathing. Other interventions may include  thoracostomy  and  thoracotomy , as well as treatment of the underlying cause of arrest."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12758", "text": "Basic life support  is commonly initiated by bystanders and first responders, but the role of basic life support in traumatic cardiac arrest is unclear. Basic life support is targeted to maintain oxygenation and circulation throughout the body, which can be lifesaving in cases of medical cardiac arrest, but does not address the frequent large volume blood loss encounters in many cases of traumatic cardiac arrest. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12759", "text": "Chest compressions  are considered the most important initial intervention in cases of medical cardiac arrest, however studies evaluating their efficacy have excluded patients with traumatic cardiac arrest. Chest compressions work to replace the cardiac function of pumping blood throughout the body, however cases where the heart is either unable to fill with blood or the total blood volume is depleted, this intervention may be ineffective. Additionally, as many of the interventions targeted at specific causes of arrest are centered around procedures performed around the patient's chest, head, and neck, compressions may interfere with definitive management. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12760", "text": "Current guidelines tailored to treatment of specific causes of traumatic cardiac arrest have improved outcomes for patients, however these guidelines may be difficult to apply in a standardized manner due to differences in pre-hospital care and the wide variety of causes of traumatic cardiac arrest compared to medical cardiac arrest. [ 3 ]  Evolving algorithms are directed at quickly identifying incidences of cardiac arrest with a traumatic source and rapidly intervening to address reversible causes. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12761", "text": "Historically, traumatic cardiac arrest was thought to lead invariably to death. More recently, evolutions of advanced trauma life support guidelines and improved understanding of the underlying causes of traumatic cardiac arrest have improved outcomes for patients. [ 5 ]  Recent studies suggest that the survival rate for traumatic cardiac arrest is similar to that of all-cause cardiac arrest. [ 6 ]  There is wide variability in the estimated survival rate based on factors that include initiation of pre-hospital care and nature of injury. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12762", "text": "Many patients who survive traumatic cardiac arrest may develop long-term neurological damage resulting from lack of circulation to the nervous system during the arrest. This damage may range from moderate disability to a persistent vegetative state. A 2012 review suggests that while survival rates of traumatic cardiac arrest are higher in children, so is the incidence of neurological complication. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12763", "text": "Traumatic asphyxia , or  Perte's syndrome , [ 1 ]  is a medical emergency caused by an intense compression of the  thoracic cavity , causing  venous  back-flow from the right side of the heart into the veins of the neck and the brain. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12764", "text": "Traumatic asphyxia is characterized by  cyanosis  in the upper extremities, neck, and head as well as  petechiae  in the  conjunctiva .  Patients can also display  jugular venous distention  and facial  edema . [ 3 ]  Associated injuries include  pulmonary contusion ,  myocardial contusion ,  hemo / pneumothorax , and  broken ribs . [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12765", "text": "Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in  motor vehicle accidents , as well as industrial and farming accidents. However, it can be present anytime a significant pressure is applied to the thorax."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12766", "text": "The sudden impact on the thorax causes an increase in  intrathoracic pressure . [ 4 ]   In order for traumatic asphyxia to occur, a  Valsalva maneuver  is required when the traumatic force is applied. [ 6 ]  Exhalation against the closed glottis along with the traumatic event causes air that cannot escape from the thoracic cavity. Instead, the air causes increased venous back-pressure, which is transferred back to the heart through the  right atrium , to the  superior vena cava  and to the head and neck veins and capillaries. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12767", "text": "Patients are seen with a cyanotic discoloration of the shoulder skin and neck and face, jugular distention, bulging of the eyeballs, and swelling of the tongue and lips. The latter two are resultants of edema, caused by excessive blood accumulating in the veins of the head and neck and venous stasis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12768", "text": "For individuals who survive the initial crush injury, survival rates are high for traumatic asphyxia. [ 4 ] [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12769", "text": "The Traumatology Institute (Canada)  is an international mental health consulting and training organization focused on after trauma care located in  Toronto, Ontario , Canada."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12770", "text": "The mandate of the Traumatology Institute is to raise awareness about Post-Traumatic Stress and trauma informed care options. [ 1 ]  It was established following intensive course development at  Florida State University  in 1997 with Dr. Anna B. Baranowsky, Dr. J. Eric Gentry,  Dr. Charles Figley , and Kathleen Dunning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12771", "text": "Baranowsky established the Traumatology Institute (Canada) in 1998. [ 2 ] [ 3 ] [ 4 ]  The curriculum leads to competency in Field Trauma Response, Clinical Traumatology, Community & Workplace Traumatology, Compassion Fatigue Care, School Crisis Response Certificate Program, Justice/Corrections Traumatologist and the Trauma Recovery Program Online."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12772", "text": "The Traumatology Institute Training Curriculum (TITC) provided foundational training for those Certified Traumatologists involved in recovery interventions for over 4,700 people following the September 11, 2001 terrorist attacks in New York City and thousands of traumatologists nationally and internationally. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12773", "text": "Baranowsky is the author of  Trauma Practice: Tools for Stabilization & Recovery  (2015, 3rd Ed., Baranowsky & Gentry) [ 6 ]  and  What is PTSD? 3 Steps to Healing Trauma  (2012, Baranowsky & Lauer), a 2013 International Book Award finalist (Health category). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12774", "text": "Wound contracture  is a process that may occur during  wound healing  when an excess of  wound contraction , a normal healing process, leads to physical deformity characterized by skin constriction and functional limitations. [ 1 ] [ 2 ] [ 3 ]  Wound contractures may be seen after serious burns and may occur on the palms, the soles, and the anterior thorax. [ 2 ]  For example, scars that prevent joints from extending or scars that cause an  ectropion  are considered wound contractures. [ 1 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12775", "text": "ABCD rating , also called the  Jewett staging system  or the  Whitmore-Jewett staging system , is a staging system for  prostate cancer  that uses the letters  A ,  B ,  C , and  D ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12776", "text": "Climacturia  is  urinary incontinence  at the moment of sexual climax ( orgasm ).  It can be a result of radical  prostatectomy  to treat  prostate cancer . It is uncomfortable at times, but usually harmless. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12777", "text": "This  sexuality -related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12778", "text": "A Colour Atlas of Urology  is a medical textbook of  urology  images first published by Wolfe Medical Publications in 1983. It is co-authored by  Reginald Wyndham Lloyd-Davies , James G. Gow and D. R. Davies. 1,188 Images include those of pathological specimens, photographs at  endoscopy of the bladder  and diagrams that explain urological diagnostic procedures. 70 images relate to lesions of the  penis  and  scrotum . A second edition was published in 1994."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12779", "text": "A review in the  Postgraduate Medical Journal  noted that the X-ray of  lung metastases  was back to front. Another review considered it a complete work covering everything a urologist could possibly see in their profession. The  British Journal of Venereal Disease  noted that the book was aimed at urologists but suggested that genitourinary physicians might be interested in it. All three reviews reported that the book was expensive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12780", "text": "A Colour Atlas of Urology  is co-authored by  Reginald Wyndham Lloyd-Davies ,  James G. Gow  and D. R. Davies, and was first published by Wolfe Medical Publications in 1983 at a cost of \u00a348. [ 1 ]  A second edition, with co-author  Helen Parkhouse , was published in 1994. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12781", "text": "1,188 images include those of pathological specimens, photographs at endoscopy of the  bladder  and diagrams that explain urological diagnostic procedures. [ 3 ] [ 4 ]  It contains a collection of  X-rays  including a comparison of  spread to bone  from  prostate cancer  and  Paget's disease . [ 4 ]  70 images relate to lesions of the  penis  and  scrotum . [ 1 ]  These include  priapism ,  spermatocele , [ 5 ]  and  hydrocele . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12782", "text": "J. P. Hopewell, in the  Postgraduate Medical Journal , called the book \"impressive and interesting\" but noted that the X-ray of  lung metastases  was back to front and felt that improvement could have been made on the X-rays of   polycystic kidney disease . [ 4 ]  W. Hendry, in the  British Journal of Surgery , considered it a complete work covering everything a urologist could possibly see in their profession. [ 3 ]  A. McMillan, in the  British Journal of Venereal Disease  noted that the book was aimed at urologists but suggested that genitourinary physicians might be interested in it. [ 1 ]  All three reviews reported that the book was expensive. [ 1 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12783", "text": "The  cystocele , also known as a  prolapsed bladder , is a medical condition in which a woman's  bladder  bulges into her  vagina . [ 1 ] [ 5 ]  Some may have no symptoms. [ 6 ]  Others may have trouble starting urination,  urinary incontinence , or  frequent urination . [ 1 ]  Complications may include recurrent  urinary tract infections  and  urinary retention . [ 1 ] [ 7 ]  Cystocele and a  prolapsed urethra  often occur together and is called a cystourethrocele. [ 8 ]  Cystocele can negatively affect  quality of life . [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12784", "text": "Causes include  childbirth ,  constipation ,  chronic cough , heavy lifting,  hysterectomy ,  genetics , and being  overweight . [ 1 ] [ 2 ] [ 6 ]  The underlying mechanism involves weakening of  muscles  and  connective tissue  between the bladder and vagina. [ 1 ]  Diagnosis is often based on symptoms and examination. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12785", "text": "If the cystocele causes few symptoms, avoiding heavy lifting or straining may be all that is recommended. [ 1 ]  In those with more significant symptoms a vaginal  pessary ,  pelvic muscle exercises , or surgery may be recommended. [ 1 ]  The type of surgery typically done is known as a  colporrhaphy . [ 11 ]  The condition becomes more common with age. [ 1 ]  About a third of women over the age of 50 are affected to some degree. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12786", "text": "The symptoms of a cystocele may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12787", "text": "A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12788", "text": "Complications may include  urinary retention , recurring urinary tract infections and incontinence. [ 1 ] [ 7 ]  The anterior vaginal wall may actually protrude though the vaginal introitus (opening). This can interfere with sexual activity. [ 6 ]  Recurrent urinary tract infections are common for those who have urinary retention. [ 15 ]  In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystocele may affect the quality of life, women who have cystocele tend to avoid leaving their home and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12789", "text": "A cystocele occurs when the muscles,  fascia ,  tendons  and  connective tissues  between a woman's bladder and vagina weaken, or detach. [ 2 ] [ 16 ]  The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the  arcus tendineus fascia pelvis ; the transverse defect is when the  pubocervical fascia  becomes detached from the top (apex) of the vagina. [ 2 ]  There is some pelvic prolapse in 40\u201360% of women who have given birth. [ 17 ] [ 18 ]  Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12790", "text": "Some women with connective tissue disorders are predisposed to developing anterior vaginal wall collapse. Up to one third of women with  Marfan syndrome  have a history of vaginal wall collapse.  Ehlers-Danlos  syndrome in women is associated with a rate of 3 out of 4. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12791", "text": "Risk factors for developing a cystocele are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12792", "text": "Connective tissue disorders predispose women to developing cystocele and other pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12793", "text": "There are two types of cystocele. The first is distension. This is thought to be due to the overstretching of the vaginal wall and is most often associated with aging, menopause and vaginal delivery. It can be observed when the  rugae  are less visible or even absent. The second type is displacement. Displacement is the detachment or abnormal elongation of supportive tissue. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12794", "text": "The initial assessment of cystocele can include a  pelvic exam  to evaluate leakage of urine when the women is asked to bear down or give a strong cough ( Valsalva maneuver ), and the anterior vaginal wall measured and evaluated for the appearance of a cystocele. [ 26 ] [ 27 ]  If a woman has difficulty emptying her bladder, the clinician may measure the amount of urine left in the woman's bladder after she urinates called the postvoid residual. This is measured by  ultrasound . A  voiding cystourethrogram  is a test that involves taking x-rays of the bladder during urination. This  x-ray  shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. [ 1 ]  A urine culture and sensitivity test will assess the presence of a urinary tract infection that may be related to urinary retention. [ 12 ]  Other tests may be needed to find or rule out problems in other parts of the urinary system. [ 1 ]  Differential diagnosis will be improved by identifying possible inflammation of the  Skene's glands  and  Bartholin glands . [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12795", "text": "A number of scales exist to grade the severity of a cystocele. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12796", "text": "The  pelvic organ prolapse quantification  (POP-Q) assessment, developed in 1996, quantifies the descent of the cystocele into the vagina. [ 6 ] [ 13 ]  The POP-Q provides reliable description of the support of the anterior, posterior and apical vaginal wall. It uses objective and precise measurements to the reference point, the  hymen . Cystocele and prolapse of the vagina from other causes is staged using POP-Q criteria can range from good support (no descent into the vagina) reported as a POP-Q stage 0 or I to a POP-Q score of IV which includes prolapse beyond the hymen. It also used to quantifies the movement of other structures into the vaginal  lumen  and their descent. [ 6 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12797", "text": "The Baden\u2013Walker Halfway Scoring System\u00a0is used as the second most used system and assigns the classifications as mild (grade 1) when the bladder droops only a short way into the vagina; (grade 2) cystocele, the bladder sinks far enough to reach the opening of the vagina; and (grade 3) when the bladder bulges out through the opening of the vagina. [ 1 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12798", "text": "Cystocele can be further described as being apical, medial, or lateral. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12799", "text": "Apical cystocele  is located upper third of the vagina. The structures involved are the  endopelvic fascia  and  ligaments . The  cardinal ligaments  and the  uterosacral ligaments  suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect. [ 16 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12800", "text": "Medial cystocele  forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and  pubocervical fascia . The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by  MRI . [ 16 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12801", "text": "Lateral cystocele  forms when both the pelviperineal muscle and its ligamentous\u2013fascial develop a defect. The ligamentous\u2013 fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system results in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the  arcus tendineus fasciae  pelvis \u2013 the essential ligament structure. [ 16 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12802", "text": "Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12803", "text": "Treatment options range from no treatment for a mild cystocele to  surgery  for a more extensive cystocele. [ 1 ]  If a cystocele is not bothersome, the clinician may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a  pessary , a device placed in the vagina to hold the bladder in place and to block protrusion. [ 12 ] [ 23 ]  Treatment can consist of a combination of non-surgical and surgical management. Treatment choice is also related to age, desire to have children, severity of impairment, desire to continue sexual intercourse and other diseases that a woman may have. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12804", "text": "Cystocele is often treated by non-surgical means:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12805", "text": "The surgery to repair the anterior vaginal wall may be combined with other procedures that will repair the other points of pelvic organ support such as anterior-posterior repair and anterior colporrhaphy. [ 12 ]  Treatment of cystocele often accompanies the more invasive hysterectomy. [ 32 ]  Since the failure rate in cystocele repair remains high, additional surgery may be needed. [ 13 ]  Women who have surgery to repair a cystocele have a 17% of needing another operation within the next ten years. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12806", "text": "The surgical treatment of cystocele will depend on the cause of the defect and whether it occurs at the top (apex), middle, or lower part of the anterior vaginal wall. The type of surgery will also depend on the type of damage that exists between supporting structures and the vaginal wall. [ 2 ]  One of the most common surgical repairs is  colporrhaphy . [ 32 ]  This surgical procedure consists of making a longitudinal folding of the vaginal tissue, suturing it into place and creating a stronger point of resistance to the intruding bladder wall.  Surgical mesh  is sometimes used to strengthen the anterior vaginal wall. [ 6 ]  It has a 10\u201350% failure rate. [ 34 ] [ 32 ]  In some cases a surgeon may choose to use  surgical mesh  to strengthen the repair. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12807", "text": "During surgery, the repair of the vaginal wall consists of folding over and then suturing the existing tissue between the vagina and bladder to strengthen it. [ 1 ] [ 11 ]  This tightens the layers of tissue to promote the replacement of the pelvic organs into their normal place. The surgery also provides more support for the bladder. This surgery is done by a surgeon specializing in gynecology and is performed in a hospital.  Anesthesia  varies according to the needs of each woman. Recovery may take four to six weeks. [ 1 ]  Other surgical treatment may be performed to treat cystocele. Support for the vaginal wall is accomplished with the paravaginal defect repair. This is a surgery, usually  laproscopic , that is done to the ligaments and fascia through the abdomen. The lateral ligaments and supportive structures are repaired, sometimes shortened to provide additional support to the vaginal wall. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12808", "text": "Sacrocolpopexy  is a procedure that stabilizes the vaginal vault (the uppermost portion of the vagina) and is often chosen as the treatment for cystocele, especially if previous surgeries were not successful. The procedure consists of attaching the vaginal vault to the sacrum. It has a success rate of 90%. [ 32 ]  Some women choose not to have surgery to close the vagina. This surgery, called  colpocleisis , treats cystocele by closing the vaginal opening. This can be an option for women who no longer want to have vaginal intercourse. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12809", "text": "If an  enterocele / sigmoidocele , or prolapse of the rectum/colon, is also present, the surgical treatment will take this concurrent condition into account while planning and performing the repairs. [ 2 ]  Estrogen that is administered vaginally before surgical repair can strengthen the vaginal tissue providing a more successful outcome when mesh or sutures are used for the repair. Vaginal thickness increases after estrogen therapy. [ 33 ]  Another review on the surgical management of cystocele describes a more successful treatment that more strongly attaches the ligaments and fascia to the vagina to lift and stabilize it. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12810", "text": "Post surgical complications can develop. The complications following surgical treatment of cystocele are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12811", "text": "After surgery, a woman is instructed to restrict her activities and monitor herself for signs of infection such as an elevated temperature, discharge with a foul odor and consistent pain. Clinicians may recommend that sneezing, coughing, and constipation are to be avoided. Splinting the abdomen while coughing provides support to an incised area and decreases pain on coughing. [ 12 ]  This is accomplished by applying gentle pressure to the surgical site for bracing during a cough. [ 36 ] [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12812", "text": "Recurrent surgery on the pelvic organs may not be due to a failure of the surgery to correct the cystocele. Subsequent surgeries can be directly or indirectly relating to the primary surgery. [ 13 ]  Prolapse can occur at a different site in the vagina. Further surgery after the initial repair can be to treat complications of mesh displacement, pain, or bleeding. Further surgery may be needed to treat incontinence. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12813", "text": "One goal of surgical treatment is to restore the vagina and other pelvic organs to their anatomically normal positions. This may not be the outcome that is most important to the woman being treated who may only want relief of symptoms and an improvement in her quality of life. The International Urogynecological Association (IUGA) has recommended that the data collected regarding the success of cystocele and pelvic organ repairs include the presence or absence of symptoms, satisfaction and Quality of Life. Other measures of a successful outcome should include perioperative data, such as operative time and hospital stay.  Standardized Healthcare Quality of Life  should be part of the measure of a successful resolution of cystocele. Data regarding short- and long-term complications is included in the recommendations of the IUGA to better assess the risk\u2013benefit ratio of each procedure. [ 13 ]  Current investigations into the superiority of using biological grafting versus native tissue or surgical mesh indicates that using grafts provides better results. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12814", "text": "A large study found a rate of 29% over the lifetime of a woman. Other studies indicate a recurrence rate as low as 3%. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12815", "text": "In the US, greater than 200,000 surgeries are performed each year for pelvic organ prolapse and 81% of these are to correct cystocele. [ 14 ] [ 11 ]  Cystocele occurs most frequently compared to the prolapse of other pelvic organs and structure. [ 13 ] [ 14 ]  Cystocele is found to be three times as common as vaginal vault prolapse and twice as often as posterior vaginal wall defects. The incidence of cystocele is around 9 per 100 women-years. The highest incidence of symptoms occurs between ages of 70 and 79 years. Based on population growth statistics, the number of women with prolapse will increase by a minimum of 46% by the year 2050 in the US. Surgery to correct prolapse after hysterectomy is 3.6 per 1,000 women-years. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12816", "text": "Notable is the mention of cystocele in many older cultures and locations. [ 39 ]  In 1500 B.C. Egyptians wrote about the \"falling of the womb\". In 400 B.C. a Greek physician documented his observations and treatments:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12817", "text": "\"After the patient had been tied to a ladder-like frame, she was tipped upward so that her head was toward the bottom of the frame. The frame was then moved upward and downward more or less rapidly for approximately 3\u20135 min. As the patient was in an inverted position, it was thought that the prolapsing organs of the genital tract would be returned to their normal position by the force of gravity and the shaking motion.\" [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12818", "text": "Hippocrates  had his own theories regarding the cause of prolapse. He thought that recent childbirth, wet feet, 'sexual excesses', exertion, and fatigue may have contributed to the condition.  Polybus , Hippocrates's son-in-law, wrote: \"a prolapsed uterus was treated by using local astringent lotions, a natural sponge packed into the vagina, or placement of half a pomegranate in the vagina.\" In 350 A.D., another practitioner named Soranus described his treatments which stated that the pomegranate should be dipped into vinegar before insertion. Success could be enhanced if the woman was on bed rest and reduced intake of fluid and food. If the treatment was still not successful, the woman's legs were tied together for three days. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12819", "text": "In 1521,  Berengario da Carpi  performed the first surgical treatment for prolapse. This was to tie a rope around the prolapse, tighten it for two days until it was no longer viable and cut it off. Wine, aloe, and honey were then applied to the stump. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12820", "text": "In the 1700s, a Swiss gynecologist, Peyer, published a description of a cystocele. He was able to describe and document both cystocele and uterine prolapse. In 1730, Halder associated cystocele with childbirth. During this same time, efforts began to standardize the terminology that is still familiar today. In the 1800s, the surgical advancements of anesthesia, suturing, suturing materials and acceptance of  Joseph Lister's  theories of  antisepsis  improved outcomes for women with cystocele. The first surgical techniques were practiced on female cadavers. In 1823, Geradin proposed that an incision and resection may provide treatment. In 1830, the first dissection of the vagina was performed by Dieffenbach on a living woman. In 1834, Mend\u00e9 proposed that dissecting and repair of the edges of the tissues could be done. In 1859, Huguier proposed the amputation of the cervix was going to solve the problem for elongation. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12821", "text": "In 1866, a method of correcting a cystocele was proposed that resembled current procedures. Sim subsequently developed another procedure that did not require the full-thickness dissection of the vaginal wall. In 1888, another method of treating anterior vaginal wall Manchester combined an anterior vaginal wall repair with an amputation of the cervix and a perineorrhaphy. In 1909, White noted the high rate of recurrence of cystocele repair. At this time it was proposed that reattaching the vagina to support structures was more successful and resulted in less recurrence. This same proposal was proposed again in 1976 but further studies indicated that the recurrence rate was not better. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12822", "text": "In 1888, treatments were tried that entered the abdomen to make reattachments. Some did not agree with this and suggested an approach through the  inguinal canal . In 1898, further abdominal approaches were proposed. No further advances have been noted until 1961 when reattachment of the anterior vaginal wall to  Cooper's ligament  began to be used. Unfortunately, posterior vaginal wall prolapse occurred in some patients even though the anterior repair was successful. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12823", "text": "In 1955, using mesh to support pelvic structures came into use. In 1970, tissue from pigs began to be used to strengthen the anterior vaginal wall in surgery. Beginning in 1976, improvement in suturing began along with the surgical removal of the vagina being used to treat prolapse of the bladder. In 1991, assumptions about the detailed anatomy of the pelvic support structures began to be questioned regarding the existence of some pelvic structures and the non-existence of others. More recently, the use of stem cells, robot-assisted laparoscopic surgery are being used to treat cystocele. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12824", "text": "Dapoxetine , sold under the brand name  Priligy  among others, is a  selective serotonin reuptake inhibitor  (SSRI) used for the treatment of  premature ejaculation  (PE) in men ages 18 to 64 years old. [ 3 ] [ 4 ] [ 5 ]  Dapoxetine works by inhibiting the  serotonin transporter , increasing serotonin's action at the postsynaptic cleft, and as a consequence promoting ejaculatory delay. [ 6 ]  As a member of the SSRI family, dapoxetine was initially created as an  antidepressant . However, unlike other SSRIs, dapoxetine is absorbed and eliminated rapidly in the body. Its fast-acting property makes it suitable for the treatment of PE, but not as an antidepressant. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12825", "text": "Originally created by  Eli Lilly  pharmaceutical company, dapoxetine was sold to  Johnson & Johnson  in 2003 and submitted as a  New Drug Application  to the US Food and Drug Administration  (FDA) for the treatment of PE in 2004. [ 8 ]  Dapoxetine is sold in several European and Asian countries, and in Mexico. In the US, dapoxetine has been in phase III development. In May 2012, US-based Furiex Pharmaceuticals reached an agreement with ALZA Corp and Janssen Pharmaceuticals to market dapoxetine in the United States, Japan, and Canada, while selling the rights to market the drug in Europe, most of Asia, Africa, Latin America, and the Middle East to  Menarini . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12826", "text": "Randomized, double-blind, placebo-controlled trials have confirmed the efficacy of dapoxetine for the treatment of PE. [ 10 ]  Different dosages have different impacts on different types of PE. Dapoxetine 60\u00a0mg significantly improves the mean  intravaginal ejaculation latency time  (IELT) compared to that of dapoxetine 30\u00a0mg in men with lifelong PE, but no difference is seen in men with acquired PE. [ 11 ]  Dapoxetine, given 1\u20133 hours before sexual episode, prolongs IELT and increases the sense of control and sexual satisfaction in men of 18 to 64 years of age with PE. Since PE is associated with personal distress and interrelationship difficulty, dapoxetine provides help for men with PE to overcome this condition. [ 12 ] \nWith no drug approved specifically for treatment for PE in the US and some other countries, other SSRIs such as  fluoxetine ,  paroxetine ,  sertraline ,  fluvoxamine , and  citalopram  have been used off-label to treat PE. Waldinger's meta-analysis shows that the use of these conventional antidepressants increases IELT two- to nine-fold above baseline, compared to three- to eight-fold when dapoxetine is used. [ 11 ]  However, these SSRIs may need to be taken daily  to achieve meaningful efficacy, and their comparatively longer half-lives increase the risk of drug accumulation and a corresponding increase of adverse effects such as reduced libido. [ 13 ]  Dapoxetine, though, is generally categorized as a fast-acting SSRI. It is more rapidly absorbed and mostly eliminated from the body within a few hours. These pharmacokinetics are more favorable in that they might minimize drug accumulation in the body, habituation, and side effects. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12827", "text": "Although it was initially thought of as unsuccessful in its intended use as an antidepressant, dapoxetine has been more recently investigated as a possible aid to one approach to depression treatment focused on stress reduction, based on an animal model of depression. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12828", "text": "Dapoxetine should not be used in men with moderate to severe hepatic impairment and in those receiving CYP3A4 inhibitors such as  ketoconazole ,  ritonavir , and  telithromycin . Dapoxetine also cannot be used in patients with heart failure, permanent pacemaker, or other significant ischemic heart disease. Caution is advised in men receiving  thioridazine ,  monoamine oxidase inhibitors , SSRIs,  serotonin-norepinephrine reuptake inhibitors , or  tricyclic antidepressants . If a patient stops taking one of these drugs, he should wait for 14 days before taking dapoxetine. If a patient stops taking dapoxetine, he should wait for 7 days before receiving these drugs. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12829", "text": "The most common effects when taking dapoxetine are nausea, dizziness, dry mouth, headache, diarrhea, and  insomnia . [ 16 ] [ 17 ]  Discontinuation rates due to adverse effects and costs are very high. A recent study in Asia showed that cumulative discontinuation rates within one year are as high as 87%. [ 18 ]  Unlike other SSRIs used to treat depression, which have been associated with high incidences of  sexual dysfunction , [ 19 ]  dapoxetine is associated with low rates of sexual dysfunction. Taken as needed, dapoxetine has very mild adverse effects of decreased libido (<1%) and erectile dysfunction (<4%). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12830", "text": "No case of drug overdose has been reported during clinical trials. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12831", "text": "Many men who have PE also suffer from  erectile dysfunction  (ED). Treatment for these patients should consider the drug\u2013drug interaction between dapoxetine and PDE5 inhibitors such as  tadalafil  (Cialis) or  sildenafil  (Viagra). In Dresser study (2006), plasma concentration of 24 subjects was obtained. Half of the sample pool were treated with dapoxetine 60\u00a0mg plus tadalafil 20\u00a0mg; the other half were treated with dapoxetine 60\u00a0mg plus sildenafil 100\u00a0mg. These plasma samples were then analyzed using liquid chromatography-tandem mass spectrometry. The results showed that dapoxetine does not alter the pharmacokinetic of tadalafil or sildenafil. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12832", "text": "Alcohol  does not affect the pharmacokinetics of dapoxetine when taking concurrently. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12833", "text": "The mechanism through which dapoxetine affects premature ejaculation is still unclear, but dapoxetine is presumed to work by inhibiting  serotonin transporter  (SERT) and subsequently increasing serotonin's action at pre- and postsynaptic receptors. [ 22 ]  Human ejaculation is regulated by various areas in the  central nervous system  (CNS). [ 23 ]  The ejaculatory pathway originates from spinal reflex at the thoracolumbar and lumbosacral level of spinal cord activated by stimuli from male genitalia. These signals are passed on to the  brain stem , which then is influenced by a number of nuclei in the brain such as medial preoptic and paraventricular nuclei. [ 24 ]  Clement's study performed on anaesthetized male rats showed that acute administration of dapoxetine inhibits ejaculatory expulsion reflex at supraspinal level by modulating activity of lateral paragigantocellular nucleus (LPGi) neurons. These effects cause an increase in pudendal motoneuron reflex discharge (PMRD) latency, though whether dapoxetine acts directly on LPGi or on the descending pathway in which LPGi located is unclear. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12834", "text": "Dapoxetine is a white, powdery, water-insoluble substance. Taken one to three hours before sexual activity, it is rapidly absorbed in the body. Its  maximum plasma concentration  (C max ) is reached one to two hours after oral administration. The C max  and  AUC  (area under the plasma vs. time curve) is dose dependent. The C max  and Tm (time needed to obtain the maximum plasma concentration) after single doses of dapoxetine 30\u00a0mg and 60\u00a0mg are 297 and 498\u00a0ng/ml at 1.01 and 1.27 hours, respectively.\nA high-fat meal does reduce the C max  slightly, but it is insignificant. In fact, food does not alter dapoxetine pharmacokinetics. It can be taken with or without food. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12835", "text": "Dapoxetine is absorbed and distributed rapidly in the body. Greater than 99% of dapoxetine is bound to the plasma protein. The mean steady-state volume is 162 L. Its initial half-life is 1.31 hours (30\u00a0mg dose) and 1.42 hours (60\u00a0mg dose), and its terminal half life is 18.7 hours (30\u00a0mg dose) and 21.9 hours (60\u00a0mg dose). [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12836", "text": "Dapoxetine is  metabolized  extensively in the liver and kidney by multiple  enzymes  such as CYP2D6, CYP3A4, and flavin monooxygenase 1. The major product at the end of the metabolic pathway is circulating dapoxetine N-oxide, which is a weak SSRI and contributes no clinical effect. The other products presented less than 3% in the plasma are desmethyldapoxetine and didesmethydapoxetine. Desmethyldapoxetine is roughly equipotent to dapoxetine. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12837", "text": "The  metabolites  of dapoxetine are eliminated rapidly in the urine with a terminal half-life of 18.7 and 21.9 hours for a single dose of 30\u00a0mg and 60\u00a0mg, respectively. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12838", "text": "The cardiovascular safety profile of dapoxetine has been studied extensively during the  drug development . Phase I trials showed that dapoxetine had neither clinically significant electrocardiographic effects nor delayed repolarization effects, with dosing up to four-fold greater than the maximum recommended dosage, which is 60\u00a0mg. Phase III studies in men with PE showed a safety and well tolerated profile of dapoxetine with dosing of 30 and 60\u00a0mg. No cardiovascular adverse had been found. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12839", "text": "Studies of SSRIs in patients with major  psychiatric disorders  prove that SSRIs are potentially associated with certain neurocognitive adverse effects such as  anxiety ,  akathisia ,  hypomania , changes in mood, or suicidal thought. [ 30 ] [ 31 ]  No study on the effects of SSRIs in men with PE has been done.  McMahon's study in 2012 showed that dapoxetine has no effect on mood and is not associated with anxiety or suicidality. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12840", "text": "The incidence of  antidepressant discontinuation syndrome  symptoms in men using dapoxetine to treat PE has been described by reviewers as low or no different from the incidence of such symptoms in men withdrawn from placebo treatment. [ 33 ] [ 34 ]  The lack of chronic serotonergic stimulation with on-demand dapoxetine minimizes the potentiation action of serotonin at synaptic cleft, thus decreasing the risk of discontinuation symptoms. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12841", "text": "Currently, very few methods are used to synthesize ( S )-dapoxetine. This novel approach consists of only six steps in which three main steps are shown above. The initial reactant is  trans -cinnamyl alcohol, which is commercially available.  Sharpless asymmetric epoxidation  and  Mitsunobu reaction  have been used to produce expected ( S )-dapoxetine. The overall yield is 35%. This method is considered a good choice compared to the known methods due to high yield and easily obtainable reactants. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12842", "text": "Dapoxetine was created by Eli Lilly and in phase I clinical trial as an antidepressant. It never worked out well as a medication for the treatment of depression, though, and was shelved for a while before subsequently developed to treat PE. In December 2003, Eli Lilly sold the patent for dapoxetine to  Pharmaceutical Product Development  (PPD) for US$65 million. Eli Lilly may also receive royalties payment from PPD if the sale exceeds a certain amount. Research into the effectiveness of dapoxetine was revisited in 2020. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12843", "text": "ALZA is the current owner of dapoxetine, but PPD will receive milestone payments and drug royalties from ALZA. If approved, dapoxetine will be marketed in the US by Ortho McNeil pharmaceutical, Inc. Ortho McNeil and Janssen-Ortho Inc, or Janssen-Cilag are all units of Johnson & Johnson.\nAs at 2005, dapoxetine was in phase III clinical trials, pending review by the FDA. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12844", "text": "Dapoxetine has been marketed and approved in more than 50 countries. [ 39 ]  Dapoxetine has been approved in Italy, Spain, Mexico, South Korea, and New Zealand in 2009 and 2010; marketed in Sweden, Austria, Germany, Finland, Spain, Portugal, and Italy. It has also been approved in France, Russia, Malaysia, Philippines, Argentina, and Uruguay. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12845", "text": "William P. Didusch  (1895-1981) was a  scientific illustrator  known for his work for the  American Urological Association . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12846", "text": "Ejaculation  is the discharge of  semen  (the  ejaculate ; normally containing  sperm ) from the  penis  through the  urethra . [ 1 ] [ 2 ] [ 3 ]  It is the final stage and natural objective of male  sexual stimulation , and an essential component of  natural conception . After forming an  erection , many men emit  pre-ejaculatory fluid  during stimulation prior to ejaculating. Ejaculation involves involuntary  contractions  of the  pelvic floor  and is normally linked with  orgasm . It is a normal part of male  human sexual development ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12847", "text": "It can occur spontaneously during  sleep  (a  nocturnal emission  or \"wet dream\"). In rare cases, ejaculation occurs because of  prostatic  disease.  Anejaculation  is the condition of being unable to ejaculate.  Dysejaculation  is an ejaculation that is painful or uncomfortable.  Retrograde ejaculation  is the backward flow of semen into the  bladder  rather than out of the urethra.  Premature ejaculation  happens shortly after initiating sexual activity, and hinders prolonged  sexual intercourse . A  vasectomy  alters the composition of the ejaculate as a form of  birth control ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12848", "text": "The normal precursor to ejaculation is  sexual arousal  of the male, leading to the  erection  of the  penis , though not all arousals or erections lead to ejaculation, and ejaculation does not require erection. Penile sexual stimulation during  masturbation  or  vaginal ,  anal ,  oral ,  manual , or  non-penetrative  sexual activity may provide the necessary stimulus for a man to achieve  orgasm  and ejaculation. With regard to  intravaginal ejaculation latency , men typically reach orgasm five to seven minutes after the start of penile-vaginal  intercourse , taking into account their desire and that of their partners, but 10 minutes is also a common intravaginal ejaculation latency. [ 4 ] [ 5 ]  Prolonged stimulation either through  foreplay  (kissing, petting and direct stimulation of erogenous zones before penetration during intercourse) or stroking (during masturbation) leads to adequate arousal and production of  pre-ejaculatory fluid . Infectious agents (including  HIV ) can be present in pre-ejaculate. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12849", "text": "Once the penis has achieved sufficient stimulation for the man to reach orgasm, ejaculation begins. [ 7 ]  The initial stage of ejaculation, called emission, is controlled by a reflex in the sympathetic spinal cord. Sperm undergo their final developmental changes within the  epididymis , where they are held until being ejaculated. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12850", "text": "Ejaculation reaches its peak in the expulsion phase, which involves the discharge of semen from the urethral opening. This ejection is driven by coordinated contractions of the pelvic muscles, including the  bulbospongiosus  and  pubococcygeus  muscles. For the semen to be expelled out of the penis, the bladder neck stays shut while the external  urethral sphincter  is relaxed. These rhythmic contractions are part of the male orgasm [ 9 ]  under the control of a  spinal reflex  at the level of the  spinal nerves  S2\u20134 via the  pudendal nerve . Although the external sphincter and pelvic muscles can be voluntarily controlled, any voluntary control during semen expulsion is not evident. The expulsion phase is considered an extension of the emission phase, triggered by reaching a certain level of spinal nerve activation. [ 10 ]  The typical male orgasm lasts several seconds."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12851", "text": "Premature ejaculation  is when ejaculation occurs before it is desired. Otherwise, if a man is unable to ejaculate after prolonged sexual stimulation in spite of his desire, it is called  delayed ejaculation  or  anorgasmia . An orgasm that is not accompanied by ejaculation is known as a  dry orgasm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12852", "text": "At start of orgasm, pulses of semen begin to flow from the urethra, reach a peak of discharge and then diminish in flow. The typical orgasm consists of 10 to 15 contractions, although the man may not be consciously aware of so many. After the first contraction, ejaculation continues to completion involuntarily. During this stage ejaculation cannot be stopped. The rate of contractions gradually slows throughout the orgasm. Initial contractions occur on average every 0.6 seconds with an increasing increment of 0.1 seconds per contraction. Contractions of most men proceed at regular rhythmic intervals through their duration. Many men also experience irregular contractions at the end of the orgasm. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12853", "text": "Ejaculation usually begins during the first or second contraction of orgasm. For most men, the first ejection occurs during the second contraction, which is typically the largest, expelling 40% or more of total semen discharge. After this peak, the quantity of semen emitted by the penis diminishes as the contractions lessen in intensity. The muscle contractions of the orgasm can continue after ejaculation with no additional semen discharge. A small sample study of seven men showed an average of seven spurts of semen followed by an average of 10 more contractions with no semen expelled. This study also found a high correlation between number of spurts of semen and total ejaculate volume, i.e., larger semen volumes resulted from additional pulses of semen rather than larger individual spurts. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12854", "text": "Alfred Kinsey  measured the distance of ejaculation, in \"some hundreds\" of men. In three-quarters of men tested, ejaculate \"is propelled with so little force that the liquid is not carried more than a minute distance beyond the tip of the penis.\" In contrast to those test subjects, Kinsey noted \"In other males the semen may be propelled from a matter of some inches to a foot or two, or even as far as five or six and (rarely) eight feet\". [ 13 ]   Masters and Johnson  report ejaculation distance to be no greater than 30\u201360\u00a0cm (12\u201324\u00a0in). [ 14 ]  During the series of contractions that accompany ejaculation, semen is propelled from the urethra at 500\u00a0cm/s (200\u00a0in/s), close to 18\u00a0km/h (11\u00a0mph). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12855", "text": "Most men experience a  refractory period  immediately following an orgasm, during which they are unable to achieve another erection, and a longer period before they are capable of achieving another ejaculation. During this time a male feels a deep and often pleasurable sense of relaxation, usually in the groin and thighs. The length of the refractory period varies considerably, even for a given individual. Age affects the recovery time, with younger men recovering faster than older men, though not always. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12856", "text": "Whereas some men have refractory periods of 15 minutes or more, others are able to experience sexual arousal immediately after ejaculation. A short recovery period may allow partners to continue sexual play relatively uninterrupted by ejaculation. Some men may experience their penis becoming hypersensitive to stimulation after ejaculation, which can make sexual stimulation unpleasant even while they may be sexually aroused."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12857", "text": "Some men are able to achieve multiple orgasms, with or without the typical sequence of ejaculation and refractory period. Some of those men report not noticing refractory periods, or are able to maintain erection by \"sustaining sexual activity with a full erection until they passed their refractory time for orgasm when they proceeded to have a second or third orgasm\". [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12858", "text": "The force and amount of semen that is ejected during ejaculation varies widely among men, containing between 0.1 and 10  milliliters [ 16 ]  (for comparison, a  teaspoon  holds 5 ml and a tablespoon, 15 ml). Adult semen volume is affected by the time that has passed since his previous ejaculation; larger semen volumes develop with longer abstinence. The duration of the stimulation leading to ejaculation can affect the volume. [ 17 ]  Abnormally low semen volume is known as  hypospermia  and abnormally high semen volume is called  hyperspermia . One possible underlying cause of low volume or complete lack of semen is  ejaculatory duct obstruction . It is normal for the amount of semen to diminish with age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12859", "text": "The number of sperm in an ejaculation varies widely, depending on many factors including the time since the previous ejaculation, [ 18 ]  age, stress levels, [ 19 ]  and  testosterone . Longer time of sexual stimulation immediately preceding ejaculation can result in higher concentration of sperm. [ 17 ]  An unusually low sperm count, distinguished from low semen volume, is known as  oligospermia , and the absence of any sperm from the semen is termed  azoospermia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12860", "text": "The first ejaculation in males often occurs about 12 months after the onset of  puberty , generally through  masturbation  or  nocturnal emission  (wet dreams). This first  semen  volume is small. The typical ejaculation over the following three months produces less than 1 ml of semen. The semen produced during early puberty is also typically clear. After ejaculation this early semen remains jellylike and, unlike semen from mature males, fails to  liquefy . A summary of semen development is shown in Table 1."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12861", "text": "Most first ejaculations (90%) lack sperm. Of the few early ejaculations that do contain sperm, the majority of sperm (97%) lack motion. The remaining sperm (3%) have abnormal motion. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12862", "text": "As the male proceeds through puberty, the semen develops mature characteristics with increasing quantities of normal sperm. Semen produced 12 to 14 months after the first ejaculation liquefies after a short period of time. Within 24 months of the first ejaculation, the semen volume and the quantity and characteristics of the sperm match that of adult male semen. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12863", "text": "^a  Ejaculate is jellylike and fails to liquefy. \n ^b  Most samples liquefy. Some remain jellylike. \n ^c  Ejaculate liquefies within an hour."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12864", "text": "There is a  central pattern generator  in the  spinal cord , made up of groups of  spinal interneurons , that is involved in the rhythmic response of ejaculation. This is known as the  spinal generator for ejaculation . [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12865", "text": "To map the neuronal activation of the brain during the ejaculatory response, researchers have studied the expression of  c-Fos , a  proto-oncogene  expressed in neurons in response to stimulation by hormones and neurotransmitters. [ 22 ]  Expression of c-Fos in the following areas has been observed: [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12866", "text": "Although uncommon, some men can achieve ejaculations during masturbation without any manual stimulation. Such men usually do it by tensing and flexing their abdominal and buttocks muscles along with vigorous fantasizing. Others may do it by relaxing the area around the  penis , which may result in harder erections especially when extremely aroused. [ 25 ]  Hands-free ejaculation can also be achieved by prostate stimulation alone, either  internally  (with the use of  sex toys , fingers or performing  anal sex  or  pegging ) or externally (such as  perineum  massages), [ 26 ] [ 27 ]  although  prostate orgasms  without ejaculation (dry orgasms) are also possible. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12867", "text": "Perineum  pressing results in an ejaculation which is purposefully held back by pressing on either the perineum or the urethra to force the seminal fluid to remain inside. In such a scenario, the seminal fluid stays inside the body and goes to the  bladder . Some people do this to avoid making a mess by keeping all the semen inside. [ 29 ]  As a medical condition, it is called  retrograde ejaculation . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12868", "text": "For most men, no detrimental health effects have been determined from ejaculation itself or from frequent ejaculations, [ citation needed ]  though sexual activity in general can have health or psychological consequences. A small fraction of men have a disease called  postorgasmic illness syndrome  (POIS), which causes severe muscle pain throughout the body and other symptoms immediately following ejaculation. The symptoms last for up to a week. [ 31 ] [ 32 ] [ 33 ]  Some doctors speculate that the frequency of POIS \"in the population may be greater than has been reported in the academic literature\", [ 34 ]  and that many POIS sufferers are undiagnosed. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12869", "text": "It is not clear whether frequent ejaculation has any effect on the risk of  prostate cancer . [ 36 ] [ 37 ] [ 38 ]  Two large studies examining the issue were [ 39 ] [ 40 ] [ 41 ]  \"Ejaculation Frequency and Subsequent Risk of Prostate Cancer\" [ 42 ]  and \"Sexual Factors and Prostate Cancer\". [ 43 ]  These suggest that frequent ejaculation after puberty offers some reduction of the risk of prostate cancer. The US study involving 29,342 US men aged 46 to 81 years [ 42 ]  suggested that \"high ejaculation frequency was related to decreased risk of total prostate cancer\". [ 42 ]  An Australian study involving 1,079 men with prostate cancer and 1,259 healthy men found that \"there is evidence that the more frequently men ejaculate between the ages of 20 and 50, the less likely they are to develop prostate cancer\":"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12870", "text": "[T]he protective effect of ejaculation is greatest when men in their twenties ejaculated on average seven or more times a week. This group were one-third less likely to develop aggressive prostate cancer when compared with men who ejaculated less than three times a week at this age. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12871", "text": "In mammals and birds, multiple ejaculation is commonplace. [ 45 ] [ 46 ] [ clarification needed ]  During copulation, the two sides of a  short-beaked echidna 's penis are used sequentially. Alternating between the two sides allows for persistent stimulation to induce ejaculation without impeding the refractory period. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12872", "text": "In  stallions , ejaculation is accompanied by a motion of the tail known as \"tail flagging\". [ 48 ]  When a male  wolf  ejaculates, his final  pelvic thrust  may be slightly prolonged. [ 49 ]  A male  rhesus monkey  usually ejaculates less than 15 seconds after  sexual penetration . [ 50 ]  The first report and footage of  spontaneous ejaculation  in an aquatic mammal was recorded in a wild  Indo-Pacific bottlenose dolphin  near  Mikura Island , Japan, in 2012. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12873", "text": "In horses, sheep, and cattle, ejaculation occurs within a few seconds, but in  boars , it can last for five to thirty [ 52 ]  minutes. [ 53 ]  Ejaculation in boars is stimulated when the spiral-shaped penis interlocks with the female's cervix. [ 54 ]  A mature boar can produce 250\u2013300\u00a0ml (8.8\u201310.6\u00a0imp\u00a0fl\u00a0oz; 8.5\u201310.1\u00a0US\u00a0fl\u00a0oz) of semen during one ejaculation. [ 53 ]  In llamas and alpacas, ejaculation occurs continuously during copulation. [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12874", "text": "The semen of male dogs is ejaculated in three separate phases. [ 56 ]  The last phase of a male canine's ejaculation occurs during the  copulatory tie , and contains mostly prostatic fluid. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12875", "text": "Frequent urination , or  urinary frequency  (sometimes called  pollakiuria ), is the need to  urinate  more often than usual.  Diuretics  are medications that increase urinary frequency.  Nocturia  is the need of frequent urination at night. [ 1 ]  The most common cause of this condition for women and children is a  urinary tract infection . The most common cause of urinary frequency in older men is an  enlarged prostate . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12876", "text": "Frequent urination is strongly associated with frequent incidents of  urinary urgency , which is the sudden need to urinate.  It is often, though not necessarily, associated with  urinary incontinence  and  polyuria  (large total volume of urine). However, in other cases, urinary frequency involves only normal volumes of urine overall. [ 3 ]   [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12877", "text": "The normal number of times varies according to the age of the person. Among young children, urinating 8 to 14 times each day is typical. This decreases to 6\u201312 times per day for older children, and to 4\u20136 times per day among teenagers. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12878", "text": "The most common causes of frequent urination are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12879", "text": "Less common causes of frequent urination are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12880", "text": "Diagnosis of the underlying cause requires a careful and thorough evaluation. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12881", "text": "Treatment depends on the underlying cause or condition. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12882", "text": "Glans insufficiency syndrome , also known as  soft glans ,  cold glans , or  glans insufficiency , is a medical condition that affects male individuals. This condition is characterized by the persistent inability of the  glans penis  to achieve and maintain an  erect  or turgid state during  sexual arousal , remaining soft and cold. This condition can have an impact on a person's  sexual function , including decreased sensitivity, difficulty in  maintaining an erection , and overall quality of life. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12883", "text": "This condition is typically diagnosed among individuals who have undergone  penile implant  surgery, and is often underdiagnosed in the general population due to its complexity and the lack of clear nomenclature."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12884", "text": "Most commonly three distinct pathophysiologies have been hypothesized: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12885", "text": "The exact causes of soft glans syndrome remain complex and multifactorial, potentially involving issues related to blood flow, nervous system function, hormonal imbalances, medication side effects, or trauma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12886", "text": "Possible explanation of lack of glanular engorgement is that the pressure within the glans penis during an erection is consistently lower than that within the  corpora cavernosa . Glans engorgement does not typically occur in response to  intracavernous injections  of vasoactive agents, and it is frequently absent following the implantation of a penile prosthesis. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12887", "text": "Patients who have undergone urethroplasty and  penile implantation  may encounter the glans remaining soft and cold despite the expected response to sexual stimulation. [ 5 ] \nIt has been reported that from 4 to 60% of people who underwent anterior urethroplasty surgery had a glans insufficiency syndrome. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12888", "text": "Treatment options may include mechanical, pharmacologic, or surgical approaches. Surgical interventions may involve ligation of veins and closure of iatrogenic shunts, but their effectiveness remains a subject of limited research."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12889", "text": "In people who had received penile implantation, the problem was addressed through a combination of penile implant revision and a glanular enhancement procedure, which improved the outcome by alleviating cold glans syndrome. The method included venous stripping procedure of the retrocoronal plexus, followed by ligation of the  dorsal deep vein  (DDV) and circumflex veins (CVs) at the penile hilum. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12890", "text": "In a 1990 study, a treatment approach was used to repair isolated glans insufficiency due to venous leakage. The diagnosis was established by observing the rapid drainage of a  contrast agent  through the deep dorsal vein while conducting  pharmacodynamic   ultrasonography . The treatment involved the  surgical resection  and  ligation  of a segment of the deep dorsal vein, a procedure that aimed to reduce pathologic venous outflow from the glans during erections. This treatment effectively restored normal glans tumescence. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12891", "text": "The  Gleason grading system  is used to help evaluate the  prognosis  of men with  prostate cancer  using samples from a  prostate biopsy . Together with other parameters, it is incorporated into a strategy of  prostate cancer staging  which predicts prognosis and helps guide therapy. A Gleason score is given to  prostate  cancer based upon its  microscopic  appearance. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12892", "text": "Cancers  with a higher Gleason score are more aggressive and have a worse prognosis. Pathological scores range from 2 to 10, with higher numbers indicating greater risks and higher mortality. The system is widely accepted and used for clinical decision making even as it is recognised that certain biomarkers, like ACP1 expression, might yield higher predictive value for future disease course. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12893", "text": "The  histopathologic diagnosis of prostate cancer  has implications for the possibility and methodology of Gleason scoring. [ 3 ]  For example, it is not recommended in signet-ring adenocarcinoma or urothelial carcinoma of the prostate, and the scoring should discount the foamy cytoplasms seen in foamy gland carcinoma. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12894", "text": "A total score is calculated based on how  cells look under a microscope , with the first half of the score based on the dominant, or most common cell morphology (scored 1 to 5), and the second half based on the non-dominant cell pattern with the highest grade (scored 1 to 5). These two numbers are then combined to produce a total score for the cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12895", "text": "Most often, a  urologist  or  radiologist  will remove a cylindrical sample ( biopsy ) of prostate tissue through the  rectum  (or, sometimes the  perineum ), using hollow needles, and biomedical scientists in a histology laboratory prepare microscope slides for  H&E staining  and  immunohistochemistry  for diagnosis by a pathologist. If the prostate is surgically removed, a  pathologist  will slice the prostate for a final examination. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12896", "text": "A pathologist  microscopically  examines the biopsy specimen for certain \"Gleason\" patterns. These Gleason patterns are associated with the following features: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12897", "text": "In the present form of the Gleason system, prostate cancer of Gleason patterns 1 and 2 are rarely seen. Gleason pattern 3 is by far the most common. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12898", "text": "After analyzing the tissue samples, the pathologist then assigns a grade to the observed patterns of the tumor specimen. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12899", "text": "The pathologist then sums the pattern-number of the primary and secondary grades to obtain the final Gleason score. If only two patterns are seen, the first number of the score is that of the  tumor's  primary grade while the second number is that of the secondary grade, as described in the previous section. If three patterns are seen, the first number of the score would be the primary grade and the second number the pattern with the  highest  grade."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12900", "text": "For example, if the primary tumor grade was 2 and the secondary tumor grade was 3 but some cells were found to be grade 4, the Gleason score would be 2+4=6. This is a slight change from the pre-2005 Gleason system where the second number was the secondary grade (i.e., the grade of the second-most common cell line pattern). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12901", "text": "Key- blue: Gleason pattern 3 region, yellow: Gleason pattern 4 region, red: Gleason pattern 5 region"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12902", "text": "Gleason scores range from 2 to 10, with 2 representing the most well-differentiated tumors and 10 the least-differentiated tumors. Gleason scores have often been categorized into groups that show similar biologic behavior: low-grade (well-differentiated), intermediate-grade, moderate to poorly differentiated or high-grade. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12903", "text": "More recently, an investigation of the Johns Hopkins Radical Prostatectomy Database (1982-2011) led to the proposed reporting of Gleason grades and  prognostic  grade groups as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12904", "text": "Prostate cancers with a Gleason score \u2264 6 usually have rather good prognoses."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12905", "text": "The Gleason grade of architectural pattern is sometimes referred to as the Gleason architectural pattern. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12906", "text": "The Gleason grade is based on tissue architectural patterns rather than purely cytological changes. These tissue patterns are classified into 5 grades, numbered 1 though 5. Lower numbers indicate more differentiation, with pattern 5 being the least differentiated. [ 4 ] [ 7 ]  Differentiation is the degree to which the tissue, in this case the tumor, resembles native tissue. Greater resemblance (lower grade) is typically associated with a better prognosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12907", "text": "However, the Gleason score is not simply the highest grade (least differentiated) pattern within the tumor. Rather, it is a combination of the most two most frequent patterns seen. This recognizes that prostatic carcinomas have multiple patterns and that prognosis is more accurately determined by adding the scores of the two most prevalent patterns. Using this system, the grades of the most prevalent and second most prevalent patterns (if at least 5% of the total), are added together to yield the overall Gleason score. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12908", "text": "For example, if the most prevalent pattern/grade is 2, and the second most prevalent grade is 1, then the Gleason score is 2+1=3. If the neoplasm has only one pattern, the grade of that pattern is doubled to obtain the score. For example, if a tumor is entirely grade 1, the Gleason score would be 1+1=2. The most differentiated tumor would have the lowest score, Gleason 2 (1+1), while the most undifferentiated neoplasm (not resembling native prostate tissue) would have the highest score, Gleason 10 (5+5). Gleason scores range from 2 to 10; by definition there is no score of 0 or 1. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12909", "text": "Cytological differences between normal prostate and neoplastic glands are evident in changes to the typical two cell layers of the gland. In prostatic adenocarcinoma, the basal (bottom, usually cuboidal type) cell layer is lost, with only the top layer (usually columnar to pseudostratified) remaining. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12910", "text": "Using this system, the most well-differentiated tumors have a Gleason score/grade of 2, and the least-differentiated tumors a score of 10. Range by definition is from 2-10, with architectural type from 1-5, and always added together or doubled, as described above. Gleason scores are often grouped together, based on similar behaviour: Grade 2-4 as well-differentiated, Grade 5-6 as intermediately-differentiated, Grade 7 as moderately to poorly differentiated (either 3+4=7, where the majority is pattern 3, or 4+3=7 in which pattern 4 dominates and indicates less differentiation., [ 6 ]  and Grade 8-10 as \"high-grade.\" [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12911", "text": "Gleason pattern 1 is the most well-differentiated tumor pattern. It is a well-defined nodule of single/separate, closely/densely packed, back-to-back gland pattern that does not invade into adjacent healthy prostatic tissue. The glands are round to oval shaped and proportionally large, compared to Gleason pattern 3 tumors, and are approximately equal in size and shape to one another. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12912", "text": "Gleason 2 is fairly well-circumscribed nodules of single, separate glands. However, the glands are looser in arrangement and not as uniform as in pattern 1. Minimal invasion by neoplastic glands into the surrounding healthy prostate tissue may be seen. Similar to Gleason 1, the glands are usually larger than those of Gleason 3 patterns, and are round to oval in shape. Thus the main difference between Gleason 1 and 2 is the density of packing of the glands seen; invasion is possible in Gleason 2, but by definition not in Gleason 1. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12913", "text": "Gleason 3 is a clearly infiltrative neoplasm, with extension into adjacent healthy prostate tissue. The glands alternate in size and shape, and are often long/angular. They are usually small/micro-glandular in comparison to Gleason 1 or 2 grades. However, some may be medium to large in size. The small glands of Gleason 3, in comparison to the small and poorly defined glands of pattern 4, are distinct glandular units. Mentally you could draw a circle around each of the glandular units in Gleason 3. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12914", "text": "Gleason pattern 4 glands are no longer single/separated glands like those seen in patterns 1-3. They look fused together, difficult to distinguish, with rare lumen formation vs Gleason 1-3 which usually all have open lumens (spaces) within the glands, or can be cribriform-(resembling the cribriform plate/similar to a sieve: an item with many perforations). Fused glands are chains, nests, or groups of glands that are no longer entirely separated by stroma-(connective tissue that normally separates individual glands in this case). Fused glands contain occasional stroma giving the appearance of \"partial\" separation of the glands. Due to this partial separation, fused glands sometimes have a scalloped (think looking at a slice of bread with bite taken out of it) appearance at their edges. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12915", "text": "Neoplasms have no glandular differentiation (thus not resembling normal prostate tissue at all). It is composed of sheets (groups of cells almost planar in appearance (like the top of a box), solid cords (group of cells in a rope like fashion running through other tissue/cell patterns seen), or individual cells. You should not see round glands with lumenal spaces that can be seen in the other types that resemble more the normal prostate gland appearance. [ 4 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12916", "text": "Gleason scores 2-4 are typically found in smaller tumors located in the transitional zone (around the urethra). These are typically found incidentally on surgery for benign prostatic hyperplasia, which is not itself a precursor lesion for prostatic carcinoma. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12917", "text": "The majority of treatable/treated cancers are of Gleason scores 5-7 and are detected due to biopsy after abnormal  digital rectal exam  or  prostate specific antigen  evaluation.  The cancer is typically located in the peripheral zone usually the posterior portion, explaining the rationale of performing the digital rectal exam. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12918", "text": "Tumors with Gleason scores 8-10 tend to be advanced neoplasms that are unlikely to be cured. Although some evidence suggests that prostate cancers will become more aggressive over time, Gleason scores typically remain stable for several years. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12919", "text": "The Gleason scores then become part of the TNM or Whitmore-Jewett  prostate cancer staging  system to provide prognosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12920", "text": "The Gleason scoring system takes its name from  Donald Gleason , a pathologist at the Minneapolis Veterans Affairs Hospital, who developed it with colleagues at that facility in the 1960s. [ 8 ] [ 9 ] \nIn 2005 the International Society of Urological Pathology altered the Gleason system, refining the criteria and changing the attribution of certain patterns. [ 4 ]  It has been shown that this \"modified Gleason score\" has higher performance than the original one, and is currently assumed standard in urological pathology. In this form, it remains an important tool. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12921", "text": "However, problematic aspects of the original Gleason grading system still characterize the 2005 revision. The predominant lowest score assigned is Gleason 3+3 = 6. Patients who are told their Gleason score is 6 out of 10 may interpret that they have a more aggressive intermediate cancer and experience greater  anxiety . [ 11 ]  More importantly, some classification systems fail to clearly distinguish between Gleason 3+4 = 7 and Gleason 4+3 = 7, with the latter having a worse prognosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12922", "text": "Therefore, in 2014 an international multidisciplinary conference was convened to revise the 2005 system. A 5-point Gleason Grade grouping similar to those such as  PI-RADS  used with prostate MRI evaluations was proposed to denote prognostically distinct stratification. Grade 1 would indicate the lowest-risk cancer while Grade 5 would indicate the most aggressive disease. The system was tested and validated against 20,000 prostatectomy specimens and at least 16,000 biopsy samples."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12923", "text": "The majority of conference participants concurred on the superiority of the scale over the 2005 Gleason grading system, pointing to the likelihood that  overtreatment  could be avoided for those patients whose cancer was assigned Grade 1. The  World Health Organization 's 2016 edition of  Pathology and Genetics: Tumours of the Urinary System and Male Genital Organs  has accepted the 2014 system, which can be used in conjunction with the 2005 Gleason system. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12924", "text": "The  Gold Cystoscope Award  founded in 1936, revised in 1977, and named after the  cystoscope , is awarded annually by the  American Urological Association . The first recipient was Donald G. Skinner. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12925", "text": "This  medical  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12926", "text": "This  award -related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12927", "text": "Dr.  Mohan S. Gundeti  is an Indian pediatric urological surgeon and professor of surgery. Gundeti has served as the Chief of Pediatric Urology at the  University of Chicago  Comer Children\u2019s Hospital in Chicago, Illinois since 2007."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12928", "text": "Prior to his appointment at The University of Chicago, Gundeti was a locum consultant in pediatric urological surgery at the  Great Ormond Street Hospital for Children  and  Guy\u2019s and St. Thomas\u2019 Hospital  in London, where he worked and trained from 1999 to 2005."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12929", "text": "At The University of Chicago, in 2008, Gundeti (as team leader) performed the world\u2019s first robot-assisted bladder reconstructive surgery. [ 1 ]  for a pediatric patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12930", "text": "Gundeti has co-authored and edited several textbooks and publications, including the \u201cRobotic Urological Surgery\u201d Textbook [ 2 ]  published in 2022."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12931", "text": "Gundeti has developed multiple robotic surgical techniques for pediatric urology. The first is The University of Chicago RALIMA (Robot Assisted Laparoscopic Bladder Augmentation Ileocystoplasty with Mitrofanoff Appendicovesicostomy) Technique. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12932", "text": "In 2011, Gundeti began developing the  LUAA \"Gundeti\" Technique  for surgical correction of vesicoureteral reflux. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12933", "text": "Gundeti\u2019s research in clinical outcomes of complex urological surgery have been recognized by the  American Urological Association (AUA)  and  European Society of Pediatric Urology (ESPU) . He is now researching applications of Machine Learning to aid in diagnosing kidney diseases through funding from the  Chicago Institute for Translational Medicine (ITM)  Pilot Awards Program along with  Maryellen Giger."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12934", "text": "Gundeti is the author and editor of the educational textbooks \u201cBlackwell Wiley Pediatric Robotic and Reconstructive Urology: A Comprehensive Guide\u201d [ 7 ]  published in 2012, and \u201cSurgical Techniques in Pediatric and Adolescent Urology\", [ 8 ]  published in 2020. Gundeti was also the co-editor and co-author of the \"Robotic Urological Surgery\" [ 9 ]  textbook which was published in 2022."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12935", "text": "He co-edited and authored an online textbook, the \"Pediatric Urology Book\" [ 10 ]  in order to reduce restrictions to access, which was published in 2023. In addition to these major publications, Gundeti has co-authored over 200 publications, [ 11 ] [ 12 ]  including book chapters, peer-reviewed journal articles, and review articles."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12936", "text": "Between the years of 2013 and 2021, Gundeti was the Consulting Editor of  the British Journal of Urology International (BJUI) , and is presently an Associate Editor of the Urology Video Journal [ 13 ]  and JU Open Plus. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12937", "text": "2012: Third Prize Basis Research Award for Clinical Research study entitled \u201cIs Pelvic Plexus Nerve Identification possible during the Robotic Assisted Laparoscopic Ureteric Reimplantation (RALUR)\u201d [ 15 ]  awarded by the European Society of Pediatric Urology (ESPU)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12938", "text": "2014: Recognized as one of America\u2019s Top Doctors and Best Doctor in Chicago by Castle Connolly [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12939", "text": "2016: Hans Marberger Award [ 17 ]  awarded by the  European Association of Urology  (EAU)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12940", "text": "The  International Prostate Symptom Score (IPSS)  is an eight-question written  screening  tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the  lower urinary tract symptoms  of  benign prostatic hyperplasia  (BPH)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12941", "text": "It contains seven questions related to symptoms related to BPH and one question related to the patient's perceived  quality of life . Created in 1992 by the  American Urological Association , it originally lacked the eighth quality of life question, hence its original name: the American Urological Association symptom score (AUA-7). [ 1 ]  World Health Organization International Consultation on BPH adopted the \"eight question\" index and labeled it the IPSS. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12942", "text": "The seven questions relating to symptoms experienced in the last month include  feeling of incomplete bladder emptying ,  frequency of urination ,  intermittency of urine stream ,  urgency of urination , weak stream, straining and  waking at night to urinate . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12943", "text": "The IPSS was designed to be self-administered by the patient, with speed and ease in mind. Hence, it can be used in both urology clinics as well as the clinics of primary care physicians (i.e. by general practitioners) for the screening and diagnosis of BPH. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12944", "text": "Additionally, the IPSS can be performed multiple times to compare the progression of symptoms and their severity over months and years. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12945", "text": "In addition to diagnosis and charting disease progression, the IPSS is effective in helping to determine treatment for patients. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12946", "text": "The symptoms must have been experienced in the last month and each answer is scored from 0 to 5 for a maximum score of 35 points. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12947", "text": "The first six questions are scored based on the following: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12948", "text": "The seventh question, relating to nocturia, is scored from 0 to 5 based on how many times the patient gets up at night to urinate (viz. 1 is scored for one time per night and 5 for five times per night). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12949", "text": "The eighth, and final question (not included in the main IPSS score), relating to the patient's perceived  quality of life , is assigned a score of 0 (delighted) to 6 (terrible). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12950", "text": "The  mnemonic  \"FUN WISE\" can be used to remember the seven questions relating to symptoms of BPH. They are as follows:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12951", "text": "In research, the IPSS is used to standardise patients' complaints and symptoms. However, a meta-analysis on the subject of the influence of position (whether standing or sitting) on  urodynamics  (that is, on tests of how completely the bladder, sphincter and urethra store and release urine) noted that, in most cases, physicians either did not use the IPSS, or did not use it adequately. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12952", "text": "Intravesical drug delivery  is the  delivery of medications  directly into the  bladder  by  urinary catheter . This method of drug delivery is used to directly target diseases of the bladder such as  interstitial cystitis  and  bladder cancer , but currently faces obstacles such as low drug retention time due to washing out with urine and issues with the low permeability of the bladder wall itself. Due to the advantages of directly targeting the bladder, as well as the effectiveness of  permeability enhancers , advances in intravesical  drug carriers , and  mucoadhesive , intravesical drug delivery is becoming more effective and of increased interest in the medical community."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12953", "text": "Delivering drugs directly to the target bladder site allows for maximizing drug delivery while minimizing  systemic effects .  \nDelivering the treatment directly to the site allows for more effective dosages to be given since high concentrations of drug in the bladder can be reached. [ 1 ]  This becomes especially important when patients have a  urinary bladder disease  that is  drug resistant . The delivery of drugs directly to the bladder is a large improvement over systemic delivery which only allows a small fraction of the drug to reach the bladder, causing lower concentrations of drug leading to systemic treatments being ineffective. [ 1 ]  The smaller fraction of drug reaching its target with systemic delivery means more drugs must be administered which can lead to problems with systemic  toxicity . This is not the case when drug is administered directly to the bladder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12954", "text": "The layer of the bladder which comes into contact with urine, the urothelium (the  transitional epithelium  of the bladder, is a mostly impermeable barrier which stops molecules in the urine from being reabsorbed and prevents molecules from being secreted directly into the bladder as well. [ 1 ]   The bladder\u2019s impermeability means that any drug delivered intravesical will not absorb into the bloodstream well through the bladder wall, causing fewer systemic effects. This impermeability also causes treatment of bladder diseases to be more difficult to treat as drugs do not absorb well into the bladder wall. Intravesical drug delivery has been identified as an ideal way to treat most urinary disorders, including bladder tumors and  bladder cancers ,  interstitial cystitis , and  urinary incontinence . [ 1 ] [ 2 ] \n [ 3 ] [ 4 ] [ 5 ]  There is currently a lack of interest in treating  urinary tract infections  using intravesical delivery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12955", "text": "While intravesical delivery shows distinct advantages over systemic drug delivery it has several problems to overcome. When giving a drug intravesically it is  diluted  by urine and washed out when urine is voided. [ 1 ] [ 2 ] [ 3 ]  Additionally, the low permeability of the urothelium which lines the bladder creates a hurdle that must be overcome if the bladder wall needs to be treated. [ 3 ]  These issues create the need for more frequent dosing, which causes urinary catheter site irritation and compliance issues with treatments. [ 2 ]  \nIntravesical drug dilution occurs as urine accumulates in the bladder, lowering the concentration of drug in the bladder as overall volume increases. The  voiding  of drug with urine when using traditional drug formulations in the bladder has become a hurdle to overcome as well, since  residence time  of the drug inside the bladder is directly tied to the treatment\u2019s  efficacy . [ 1 ]  Creating  formulations  which adhere to the bladder wall has been targeted as one way to improve intravesical dug efficacy,. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  The low adherence of drugs to the bladder wall and low permeability into the bladder wall contributes to low drug retention in the bladder. [ 1 ]  When modifying drug formulations for intravesical delivery gels or  viscosity  increasing formulations are sometimes used to increase retention, though this can cause issues with  urethra obstruction , an additional hurdle in intravesical drug delivery. [ 2 ]  \nPermeability issues with the bladder wall can be attributed to the urothelium, the lining of the bladder wall made up of  umbrella cells , intermediate cells, and basal cells.,. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  The impermeability can be attributed to the umbrella cells which form tight junctions with each other to make up the innermost layer of the urothelium and have the ability to change shape to adapt to the bladder\u2019s varying size. [ 1 ] [ 2 ]  The umbrella cells are covered in a dense layer of plaques which further prevents the absorption of particles through the urothelium and a layer of  mucin  composed of  glycosaminoglycans  (GAGs) which prevents both hydrophobic and negatively charged molecules from adhering to the bladder wall. [ 1 ] [ 4 ]  Overcoming the impermeability of the mucin layer and the urothelium is a large focus of many intravesical drug formulations, and is key to an efficacious intravesical treatment [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12956", "text": "The main ways researchers are currently overcoming the problems in intravesical drug delivery are through developing formulations using  mucoadhesives ,  nanoparticles ,  liposomes , polymeric  hydrogel , expandable delivery devices, and electromotive drug administration. [ 1 ] [ 2 ] [ 3 ]  These methods each serve to improve retention time, drug permeability through the urothelium, or some combination of the two."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12957", "text": "Enhancing Drug retention can be achieved through changing formulation and delivery device. Often drug retention and permeability enhancement are tied, as drugs which permeate the urothelium will suffer fewer effects from urine dilution and voiding. Two of the most common methods to improve drug retention are by using a  mucoadhesive  formulation or using polymeric  hydrogels  that form in the bladder, or  in situ  gelling hydrogels. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12958", "text": "Mucoadhesive formulations can be made with both  biopolymers  and  synthetic polymers , and usually contain polymers that are  hydrophilic  and can form many  hydrogen bonds  with the  GAG-mucin . [ 1 ]  Positively charged molecules typically make far better mucoadhesive as the mucin layer is negatively charged. [ 6 ]  By forming these bonds, the mucoadhesive, and the drug it carries, can maintain sustained contact with the bladder wall, enhancing retention of the drug in the bladder. Among mucoadhesive materials  Chitosan  often stands out due to its  biocompatibility ,  biodegradability , and permeability enhancing factors. [ 3 ]  In experiments with chitosan, it has been shown that the mucoadhesive properties of a molecule likely increase as the  molecular weight  is increased. [ 7 ]  Studies have also found that the modification of chitosan formulations with  thiomers , which can form covalent bonds with mucus, can significantly improve the mucoadhesion of the chitosan formulations [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12959", "text": "Polymeric  hydrogels  for intravesical drug delivery take advantage of characteristics of the bladder or urine to gel, or may use external manipulation to cause the hydrogel to form. [ 1 ] [ 9 ]  These gels can take advantage of pH or temperature differences, or external input like  UV  lasers, to form gels inside the bladder after instillation of the formulation in liquid form. [ 9 ]  If these gels are made to be mucoadhesive they stick to the bladder wall and do not wash out or cause urethral obstruction. Polymeric hydrogels have also been formulated to float on top of the urine to avoid wash out and obstruction without having to adhere to the bladder wall. [ 10 ]  Drawbacks of using polymeric hydrogel formulations include the concern of urethral obstruction, the varying conditions of the urine which make pH or ionic controlled gelling formulations less controlled, and the  bladder wall inflammation  which can occur with mucoadhesive polymeric hydrogels. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12960", "text": "Enhancing drug permeability can be done through physical or chemical methods, and is also achieved through  nanoparticle  and  liposome   drug carriers . [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  Physical methods include electromotive drug administration, radiofrequency-induced chemotherapeutic effect, and conductive hyperthermic  chemotherapy , but electromotive drug administration seems to be the most prevalent in recent research and clinical trial focus. [ 1 ] [ 2 ] [ 3 ] [ 5 ] [ 11 ]  Chemical methods revolve around adding a chemical agent to enhance drug uptake and increase permeability. To enhance drug permeability through physical or chemical methods both the  mucin layer  and the  umbrella cells  of the urothelium must undergo a structural or chemical change. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12961", "text": "Electromotive drug administration utilizes a small  electric current  flowing across the bladder wall between two  electrodes , one on the skin and one placed inside the bladder via  catheterization , to enhance permeability of  aqueous  solutions. [ 1 ] [ 2 ] [ 3 ]  Electromotive drug administration best enhances  ionized  formulations, which diffuse poorly using standard  passive diffusion . [ 3 ]  This allows it to potentially assist in the delivery of many drugs that usually perform poorly in the bladder without having to change their formulations heavily. Across multiple studies and clinical trials electromotive drug administration has been shown to increase the uptake of many drugs, showing potential use in  bladder cancer ,  urinary incontinence ,  urinary cystitis  and pain management. [ 1 ] [ 2 ] [ 3 ] [ 5 ]  Cost of  local anesthesia  for bladder distention using electromotive drug administration in combination with  lidocaine  has been shown to be cheaper and more practical than  general anesthesia  or  spinal anesthesia . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12962", "text": "To enhance the permeability of the bladder wall, specifically the urothelium, to drugs administered locally to the bladder four chemical agents are most commonly used:  DMSO ,  protamine sulphate ,  Hyaluronidase , and  chitosan . DMSO is already widely used to directly treat urinary cystitis due to its  anti-inflammatory  and  antibacterial  properties. [ 1 ] [ 3 ]  DMSO can penetrate tissues without causing any damage to them. [ 1 ] [ 3 ]  This property of DMSO made it of particular interest as a chemical enhancer and it has been shown to increase the uptake of several chemotherapeutics used intravesically. [ 12 ]  Protamine sulphate causes disruption to the mucus layer of the urothelium and can cause large disruption of bladder permeability which can be modified by adding  defibrotide . [ 1 ] [ 3 ]  Hyaluronidase breaks down  Hyaluronic acid , a GAG molecule important to the  mucin layer , causing enhanced permeability of the mucin layer to drugs administered concurrently with hyaluronidase. [ 1 ]  Conversely, hyaluronic acid can be used to treat  interstitial cystitis  as it helps to repair damaged mucin layers. [ 3 ]  Chitosan is thought to function as a permeability enhancer by binding to the mucin layer and negatively affecting tight junctions between  umbrella cells  in the urothelium. [ 1 ]  It has been shown that chitosan increases bladder wall permeability but its effectiveness as a permeability enhancer decreases as calcium ion concentration increases. [ 13 ]  Chemically enhancing bladder permeability can lead to negative side effects such as  incontinence , pain, and uncontrolled leakage of molecules other than intended drug from the urine into the bladder wall. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12963", "text": "Nanoparticle  and  liposome   drug carrier  formulations allow for increased drug uptake, especially in the case of liposomes which allow for greater uptake via  endocytosis . [ 1 ] [ 2 ] [ 3 ] [ 5 ]  Liposomes generally must be shielded via modification with a  Polyethylene glycol  molecule to overcome issues with instability and  aggregation  in urine. [ 4 ]  Nanoparticle and Liposome drug carriers can be loaded into a  in situ  forming hydrogel to gain the advantages of mucoadhesive properties [ 4 ]  Empty liposomes by themselves have been noted to improve interstitial cystitis, most likely due to formation of a lipid film on damaged urothelium. [ 3 ] [ 5 ]  The variety of types of nanoparticles which can be made to carry drugs in intravesical formulations, combined with the tunability of many of these particles in regards to drug loading and release rates makes nanoparticles and liposomes a highly versatile and useful tool in intravesical drug delivery. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12964", "text": "This is a  list of recipients of the  St Peter's Medal , the highest award of the  British Association of Urological Surgeons  (BAUS). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12965", "text": "The  maiden waist deformity  is a  radiologic sign  associated with  retroperitoneal fibrosis , a condition resulting from the abnormal proliferation of fibrous tissue in the  retroperitoneal space . The fibrosis can extend to adjacent anatomical structures, frequently encompassing and obstructing the  ureters . [ 1 ]  This sign refers to the alteration in the normal course of the ureters: when the fibrosis causes both ureters to be pulled medially, they may form the appearance of a \"narrow-waisted maiden\". [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12966", "text": "Male contraceptives , also known as  male birth control , are methods of preventing  pregnancy  by interrupting the function of sperm. [ 1 ]  The main forms of male  contraception  available today are  condoms ,  vasectomy , and  withdrawal , which together represented 20% of global contraceptive use in 2019. [ 2 ] [ 3 ] [ 4 ] [ 5 ]   New forms of male contraception are in  clinical  and  preclinical  stages of  research and development , but as of 2024, none have reached  regulatory approval  for widespread use. [ 6 ] [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12967", "text": "These new methods include topical creams, daily pills, injections, long-acting implants, and external devices, and these products have both hormonal and non-hormonal mechanisms of action. [ 6 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ]   Some of these new contraceptives could even be  unisex , or usable by any person, because they could theoretically incapacitate mature sperm in the man's body before  ejaculation , or incapacitate sperm in the body of a woman after  insemination . [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12968", "text": "In the 21st century, surveys indicated that around half of men in countries across the world have been interested in using a variety of novel contraceptive methods, [ 18 ] [ 19 ] [ 20 ] [ 21 ]  and men in clinical trials for male contraceptives have reported high levels of satisfaction with the products. [ 12 ] [ 22 ]   Women worldwide have also shown a high level of interest in new male contraceptives, and though both male and female partners could use their own contraceptives simultaneously, women in long-term relationships have indicated a high degree of trust in their male partner's ability to successfully manage contraceptive use. [ 18 ] [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12969", "text": "A modelling study from 2018 suggested that even partial adoption of new male contraceptives would significantly reduce  unintended pregnancy  rates around the globe, [ 25 ]  which remain at nearly 50%, even in developed countries where women have access to modern contraceptives. [ 26 ] [ 27 ] [ 28 ]   Unintended pregnancies  are associated with negative socioeconomic, educational, and health outcomes for women, men, and the resulting children (especially in historically marginalized communities), [ 27 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ 34 ]  and 60% of unintended pregnancies end in  abortions , [ 35 ] [ 36 ]  many of which are  unsafe  and can lead to women's harm or death. [ 37 ] [ 38 ] [ 39 ] [ 40 ]   Therefore, the development of new male contraceptives has the potential to improve racial, economic, and gender equality across the world, advance  reproductive justice  and  reproductive autonomy  for all people, and save lives."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12970", "text": "Vasectomy is surgical procedure for permanent male  sterilization  usually performed in a physician's office in an outpatient procedure. [ 41 ]  During the procedure, the  vasa deferentia  of a patient are severed, and then tied or sealed to prevent sperm from being released during ejaculation. [ 42 ]  Vasectomy is an effective procedure, with less than 0.15% of partners becoming pregnant within the first 12 months after the procedure. [ 43 ]  Vasectomy is also a widely reliable and safe method of contraception, and complications are both rare and minor. [ 44 ] [ 45 ]   Vasectomies can be reversed, though rates of  successful reversal  decline as the time since vasectomy increases, and the procedure is technically difficult and often costly. [ 42 ] [ 46 ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12971", "text": "A condom is a  barrier device  made of  latex  or thin plastic film that is rolled onto an erect  penis  before intercourse and retains ejaculated  semen , thereby preventing pregnancy. [ 47 ]  Condoms are less effective at preventing pregnancy than vasectomy or modern methods of female contraception, with a real-world failure rate of 13%. [ 43 ]  However, condoms have the advantage of providing protection against some  sexually transmitted infections  such as  HIV/AIDS . [ 48 ] [ 49 ]  Condoms may be combined with other forms of contraception (such as  spermicide ) for greater protection. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12972", "text": "The withdrawal method, also known as  coitus interruptus  or pulling out, is a behavior that involves halting penile-vaginal intercourse to remove the penis out and away from the  vagina  prior to ejaculation. [ 51 ] [ 52 ]  Withdrawal is considered a less-effective contraceptive method, with typical-use failure rates around 20%. [ 41 ] [ 43 ]  However, it requires no equipment or medical procedures. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12973", "text": "Researchers have been working to generate novel male contraceptives with diverse mechanisms of action and possible delivery methods, including  long-acting reversible contraceptives  (LARCs), daily  transdermal gels , daily and on-demand oral pills, monthly  injectables , and  implants. [ 53 ] [ 54 ] [ 55 ]  Efforts to develop male contraceptives have been ongoing for many decades, but progress has been slowed by a lack of funding and industry involvement. As of 2024, most funding for male contraceptive research is derived from government or philanthropic sources. [ 56 ] [ 57 ] [ 58 ] [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12974", "text": "Novel male contraceptives could work by blocking various steps of the  sperm development process , blocking sperm release, or interfering with any of the sperm functions necessary to reach and fertilize an egg in the female reproductive tract. [ 60 ]   Advantages and disadvantages of each of these approaches will be discussed below, along with relevant examples of products in development."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12975", "text": "These methods work by preventing the testes from producing sperm, or interfering with sperm production in a way that leads to the production of nonfunctional sperm. [ 61 ]   This approach can be accomplished by either  hormonal  or nonhormonal small-molecule drugs, or potentially by thermal methods.  The effectiveness of contraceptives in this group can be easily assessed microscopically, by measuring sperm count or abnormalities in sperm shape, but because  spermatogenesis  takes approximately 70 days to complete, [ 62 ]  these methods are likely to require approximately three months of use before they become effective, and approaches that halt sperm production at an early stage of the process may result in reduced testicular size. [ 63 ]  Methods have been suggested in the 1980s. [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12976", "text": "Hormonal contraceptives for men work similarly to  hormonal female methods , using  steroids  to interrupt the  hypothalamic-pituitary-gonadal axis  and thereby block sperm production. Administering external  androgens  and  progestogens  suppresses secretion of the  gonadotropins   LH  and  FSH , which impairs  testosterone  production and sperm generation in the testes, leading to reduced sperm counts in ejaculates within 4\u201312 weeks of use. [ 65 ]  However, since the contraceptives contain testosterone or related androgens, the levels of androgens in the blood remain relatively constant, thereby limiting side effects and maintaining masculine  secondary sex characteristics  like muscle mass and hair growth. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12977", "text": "Multiple methods of male hormonal contraception have been tested in  clinical trials  since the 1990s, and although one trial was halted early, leading to a large amount of press attention, [ 66 ] [ 67 ] [ 68 ] [ 69 ] [ 70 ]  most hormonal male contraceptives have been found to be effective, reversible, and well-tolerated. [ 71 ] [ 72 ] [ 73 ] [ 74 ] [ 75 ] [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12978", "text": "As of 2024 [update] , the following hormonal male contraceptive products are in clinical trials:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12979", "text": "Some anabolic steroids may exhibit suppressive effects on spermatogenesis, but none are being investigated for use as a male contraceptive. [ 84 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12980", "text": "Non-hormonal contraceptives for men are a diverse group of molecules that act by inhibiting any of the many  proteins  involved in sperm production, release, or function.  Because sperm cells are highly specialized, they express many proteins that are rare in the rest of the human body. [ 85 ] [ 86 ] [ 87 ]   This suggests the possibility that non-hormonal contraceptives that specifically block these sperm proteins could have fewer side effects than hormonal contraceptives, since sex steroid receptors are found in tissues throughout the body. [ 88 ]   Non-hormonal contraceptives can work by blocking spermatogenesis, sperm release, or mature sperm function, resulting in products with a wide variety of usage patterns, from slow onset to on-demand usage. [ 89 ]   Contraceptives targeting mature sperm functions could even be taken by both sperm-producing and egg producing people. [ 17 ] [ 16 ]   Challenges of non-hormonal contraceptive development include  bioavailability  and delivery past the  blood-testis barrier . [ 90 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12981", "text": "As of 2024 [update] , the following non-hormonal male contraceptive product is in clinical trials:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12982", "text": "As of 2024 [update] , the following non-hormonal male contraceptive products are in  preclinical development :"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12983", "text": "Prolonged testicular heating had been shown to reduce sperm counts in 1941, [ 115 ]  considered as a method of birth control after 1968 and in the 1980s [ 116 ] [ 117 ]  No modern clinical trials have demonstrated the safety, contraceptive effectiveness, or reversibility of this approach. Various devices are in early preclinical stages of development, and as of 2017 some approaches have been used by men through  self-experimentation . [ 14 ] [ 118 ]   As of 2015, the mechanism by which heating disrupts spermatogenesis was still not fully understood. [ 119 ]  There have been theoretical  concerns that prolonged heating could increase the risk of  testicular cancer  since the inborn birth defect of  cryptorchidism  carries a risk of testicular cancer [ 120 ]  or that heating could damage sperm DNA, resulting in harm to potential offspring. [ 121 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12984", "text": "These approaches work by either physically or chemically preventing the emission of sperm during ejaculation, and are likely to be effective on-demand."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12985", "text": "\u03b11-adrenoceptor antagonists  and  P2X1  antagonists have been shown to inhibit  smooth muscle  contractions in the  vas deferens  during ejaculation, and therefore prevent the release of semen and sperm while maintaining the sensation of  orgasm . [ 122 ] [ 123 ] [ 124 ]  Various molecules in these categories are under consideration as possible on-demand male contraceptives."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12986", "text": "Vas-occlusive contraception  is a form of male  contraception  that blocks  sperm  transport in the  vas deferens , the tubes that carry sperm from the  epididymis  to the  ejaculatory ducts ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12987", "text": "Vas-occlusive contraception  provides a contraceptive effect through physical blockage of the  vas deferens , the  duct  connecting the  epididymis  to the  urethra . While a  vasectomy  excises, or removes, a piece of each vas deferens and occludes the remaining open ends of the duct, vas-occlusive methods aim to block the duct while leaving it intact.  Vas-occlusive methods generally aim to create  long-acting reversible  options, through a second procedure that removes the blockage. [ 138 ]   However, full reversibility remains questionable, since animal and human studies have shown sperm abnormalities, incomplete recovery of sperm parameters, and the development of fertility-impairing  antibodies  against one's own sperm after blockage removal. [ 111 ] [ 139 ] [ 140 ] [ 141 ] [ 142 ] [ 143 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12988", "text": "As of 2024 [update] , the following vas-occlusive male contraceptive products are in clinical trials:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12989", "text": "As of 2024 [update] , the following vas-occlusive male contraceptive products are in preclinical development:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12990", "text": "Research into new, more acceptable designs of condoms is ongoing. [ 164 ] [ 165 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12991", "text": "These approaches work by blocking functions that mature sperm need in order to reach and fertilize an egg in the female reproductive tract, such as  motility ,  capacitation , semen liquification, or  fertilization .  Drugs or devices that target mature sperm are likely to be effective on-demand (taken just before intercourse), and could even be delivered either in sperm-producing or egg-producing bodies, leading to unisex contraceptives. [ 17 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12992", "text": "As of 2024 [update] , the following non-hormonal male contraceptive approaches are in  preclinical  or early development:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12993", "text": "Although some people question whether men would be interested in managing their own contraceptives [ 188 ]  or whether women would trust their male partners to do so successfully, [ 189 ]  studies consistently show that men around the world have significant levels of interest in novel forms of male contraception [ 18 ] [ 23 ] [ 190 ] [ 19 ] [ 191 ] [ 192 ]  and that women in committed relationships would generally trust their male partners to manage the contraceptive burden in the relationship. [ 23 ]   Additionally, males participating in various contraceptive clinical trials have reported high satisfaction with the products they were using. [ 81 ] [ 12 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12994", "text": "Studies on potential uptake indicate that in most countries, more than half of men surveyed would be willing to use a new method of male contraception. [ 18 ] [ 20 ] [ 190 ] [ 193 ] [ 194 ] [ 195 ]   Interestingly, some of the highest rates were reported in low-income countries like Nigeria and Bangladesh where 76% of men surveyed indicated that they would be willing to use a new method within the first 12 months that it is available. [ 18 ]  This is particularly compelling, since it has been estimated that a mere 10% uptake of new male contraceptive methods could avert nearly 40% of unintended pregnancies in Nigeria. [ 25 ]   Across the world, many young and middle-aged men especially want the ability to control their own fertility, and are not well-served by existing family planning programs. [ 196 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12995", "text": "Although a phase II trial for an injectable male contraceptive was halted in 2011 by an independent data safety monitoring board due likely to rare adverse effects experienced by some participants, [ 197 ] [ 67 ]  leading many popular articles to suggest men could not tolerate side effects similar to those that many women endure on hormonal birth control, [ 70 ] [ 198 ]  in reality more than 80% of the study's male participants stated at the end of the trial that they were satisfied with the contraceptive injection, and would be willing to use the method if it were available. [ 199 ]   Subsequent hormonal male contraceptive clinical trials have progressed successfully, showing high levels of efficacy and acceptability among the participants. [ 12 ] [ 22 ] [ 81 ] [ 200 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12996", "text": "It is sometimes assumed that women won\u2019t trust men to take contraceptives, since women would bear the consequences of a male partner's missed dose or misuse. [ 189 ]   Of course, male contraceptive options would not have to replace female contraceptives, and in casual sexual encounters both partners may prefer to independently control their own contraceptive methods.  On the other hand, some long-term couples might want only one partner to bear the contraceptive burden. Indeed, there is evidence that a large proportion of women in relationships in many countries around the world would trust their partners to take a potential male method, [ 24 ] [ 18 ]  and many women want more male partner involvement in their own reproductive health services. [ 201 ]   Further, current contraceptive use data show that more than a quarter of women worldwide already rely on male-controlled methods for contraception (such as condoms and vasectomy), [ 202 ]  and this figure could grow as more male contraceptive methods become available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12997", "text": "Despite the fact that modern female pharmaceutical contraception has been on the market since the 1960s, [ 203 ]  40-50% of pregnancies are still  unintended  worldwide, leading to an approximate total of 121 million  unintended pregnancies  annually. [ 204 ] [ 205 ] [ 206 ]   Importantly, most studies on unintended pregnancies only measure women's intentions about the pregnancy, and so pregnancies that were unintended by men are understudied and may be under-reported. [ 207 ]   Unintended pregnancies have been shown to be linked with a wide variety of negative outcomes on mental and physical health, as well as educational and socioeconomic attainment in both parents and the children born of unintended pregnancies. [ 27 ] [ 29 ] [ 30 ] [ 32 ] [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12998", "text": "Surprisingly, although the rate of unintended pregnancies (per 1000 women of childbearing age) is higher in  developing countries , [ 205 ] [ 208 ] [ 209 ]  the percentage of pregnancies that are unintended is actually higher in  developed countries , since a lower proportion of women in developed countries are intending to conceive at any given time. [ 205 ]   Research indicates that unmet need for modern contraception is the cause of 84% of unintended pregnancies in developing countries. [ 210 ]   In the United States, which has a higher unintended pregnancy rate than many other developed nations, [ 211 ]  one important reason that women cite for nonuse of contraceptives is concerns about the side effects of existing products. [ 212 ]   Taken together, these statistics suggests that the current suite of contraceptives is insufficient to meet the fertility planning needs of people across the world, and therefore the introduction of new male contraceptives is likely to decrease the stubbornly high global rates of unintended pregnancy. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_12999", "text": "International market research indicates that 49% of men in the United states and 76% of men in Nigeria would try a novel male contraceptive within the first year of its existence. [ 18 ]   Independent modelling predicts that even if real-world usage is only 10% as high as the market research suggests, the introduction of a male contraceptive would avert roughly 200,000 unintended pregnancies per year in the USA and Nigeria each. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13000", "text": "Fathers with unintended births report lower proportions of happiness than in fathers with intentional births [ 213 ]  and unintended fatherhood for men in their early 30's is associated with a significant increase in depressive symptoms. [ 214 ]   In addition, men in insecure financial situations are more likely to report a recent unintended pregnancy, [ 207 ]  and supporting and raising a child brings significant costs that can exacerbate financial insecurity. [ 215 ] [ 216 ]   More broadly, access to effective and reliable contraception would advance men's ability to \"maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities\" in accordance with the principles of  Reproductive Justice . [ 217 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13001", "text": "Family planning has been found to be associated with overall well-being and is one of the most efficient tools for women's empowerment. [ 218 ] [ 219 ] [ 220 ]  Positive outcomes of effective birth control include improvements in women's health, self-agency, education, labor force participation, financial stability, as well as decreases in pregnancy-related deaths, [ 221 ] [ 222 ] [ 223 ]  and these positive social and health impacts may be further realized by the addition of novel male and unisex methods. [ 25 ] [ 18 ]  New male contraceptive options would not come at the expense of women\u2019s reproductive autonomy, since women would still be able to take advantage of all of the contraceptive methods available to them, choose to have both partners use their own contraceptive methods at the same time, or rely solely on their male partners\u2019 form of contraception."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13002", "text": "Interventions encouraging male engagement in couples' reproductive health and decisionmaking have shown positive outcomes related to promoting more equitable gender norms in the context of family planning, [ 224 ]  and increased joint decision making in couples. It is reasonable to assume from these data that increasing male involvement as contraceptive users will further improve gender equity. [ 225 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13003", "text": "While this article has used the term \"male\" contraception for clarity, these contraceptives are most accurately described as \"sperm-targeting\" contraceptives, since they would work effectively in any body that produces sperm, regardless of that person's gender identity or external genitalia. [ 17 ]   Importantly, contraceptives that block functions of mature sperm could be delivered in a  unisex  manner, incapacitating sperm before ejaculation in sperm-producing people, or after sperm arrives in the body of egg-producing people. [ 16 ] [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13004", "text": "Transgender ,  nonbinary , and  intersex  people are underserved by current contraceptive options.  For example, many trans men can become pregnant (both intentionally and unintentionally), [ 226 ] \u00a0but may prefer not to use  estrogen - or  progestin -containing hormonal birth control (both because of the social classification of these hormones as \"female sex hormones\" and because of a fear they will interfere with  masculinizing hormone therapy , although the American College of Obstetricians and Gynecologists states that these hormonal contraceptives have little effect on masculinization.) [ 227 ] [ 228 ] [ 229 ]  Trans women who have not had  gender-affirming genital surgery  may have similar unmet contraceptive needs as those of  cisgender  men, since gender-affirming hormonal therapy is not effective contraception. [ 229 ]   Nonbinary and intersex people may be less likely to use current methods of birth control, since they are popularly categorized by the labels \"male\" and \"female\", which may not match an individual's gender identity or may invoke feelings of  gender dysphoria . [ 228 ]   This dynamic may contribute to the higher rates of unintended pregnancies seen in the  LGBTQ+  community as compared to  heterosexual  peers, [ 230 ] [ 231 ] [ 232 ]  which could in theory be ameliorated by the introduction of  unisex  contraceptives."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13005", "text": "Novel male contraceptive options are predicted to reduce the incidence unintended pregnancies, [ 25 ] [ 18 ]  and being the product of an intended rather than unintended pregnancy has been shown to correlate with improved health and wellbeing outcomes in children. [ 31 ] [ 222 ] [ 233 ] [ 234 ]   Additionally, reduced family size correlates with improved educational outcomes, [ 235 ]  and children born after the introduction of family planning programs in the USA experienced a reduction in poverty rates, both in childhood and adulthood. [ 236 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13006", "text": "Unintended pregnancies rates increase as income decreases, both between countries [ 36 ]  and between socioeconomic and racial groups within a given country. [ 211 ] [ 237 ]  \u00a0Women of color, especially Black women, in the United States and other developed countries have dramatically higher rates of  death during and after birth  and worse maternal health outcomes, due in part to  systemic discrimination . [ 238 ] [ 222 ]  \u00a0Since unintended pregnancies can have negative effects on an individual's physical and mental health, educational attainment, and economic prospects, these higher unintended pregnancy rates likely contribute to the persistent socioeconomic gaps within and between societies. [ 27 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ 34 ]   \u00a0 It\u2019s therefore possible that the introduction of new male contraceptives would not only mitigate gender inequities, as discussed above, but racial and income inequities as well, by providing more ways for individuals to avoid unintended pregnancies. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13007", "text": "In addition to the personal financial savings of avoiding unintended pregnancy mentioned above, on a societal level, contraceptives are a public health intervention with a high return on investment: for every dollar the United States government spends on family planning programs, it saves $7.09, for a total of over $13 billion per year. [ 239 ]   Unintended pregnancies in the United States are estimated to cause $4.5 billion in direct medical costs. [ 34 ] [ 32 ]   New male contraceptives are likely to prevent some unintended pregnancies [ 25 ]  and therefore reduce these costs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13008", "text": "61% of unintended pregnancies end in  abortion , [ 35 ]  whereas only 20% of all pregnancies end in abortion. [ 240 ]  Interestingly, unintended pregnancy rates are higher in countries where abortion is illegal than those where abortion is legal, yet the incidence of abortion is similar between these groups of countries. [ 35 ] [ 241 ]   Illegal abortions are more likely to be  unsafe , and there are an estimated 25 million unsafe abortions globally each year, leading to 50,000 - 70,000 yearly deaths and 5 million people with long-term health consequences. [ 37 ] [ 38 ] [ 39 ] [ 40 ]    Importantly, increases in the prevalence and uptake of modern contraceptives have been shown to decrease unintended pregnancy and abortion rates when fertility rates are constant. [ 242 ] [ 243 ] [ 244 ]   This suggests that the introduction of new forms of male contraception could prevent a significant number of abortions, save lives, and avoid unnecessary suffering."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13009", "text": "A variety of plant extracts have been used throughout history in attempts to prevent pregnancy, though most were used by women, and the efficacy and safety of these methods is questionable. [ 245 ] [ 246 ] [ 247 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13010", "text": "Condoms  made of animal organs or fabric have been in documented use since at least the 16th century, [ 248 ]  and various types of penile coverings have been depicted and referenced in materials from cultures around the world as early as 3000  BCE , though it is not always clear that these coverings were used for birth control or protection from sexually transmitted infections. [ 249 ]   The 1800's saw the development of thick reusable rubber condoms, [ 248 ] [ 249 ]  and thinner disposable latex rubber condoms entered production in the 1920s. [ 250 ] [ 251 ] [ 252 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13011", "text": "Vasectomy  was first performed in humans in the late 1800s, but not initially as a method of voluntary birth control.  Instead, it was first used as an attempted treatment (later proved to be ineffective) for  enlarged prostates , and within a few years, one-sided vasectomy became popular as a supposed method of sexual rejuvenation in older men. [ 253 ] [ 254 ]   Although this rejuvenation treatment was ineffective  pseudoscience  and any perceived effects were likely due only to the  placebo effect , many prominent men, such as Sigmund Freud and W.B. Yeats, sought out the procedure. [ 255 ]   In the early 1900s, the use of vasectomy took a darker turn, and it became widely promoted and practiced as a means of  eugenic  involuntary sterilization. [ 254 ] [ 253 ]   It was not until the 1950s that vasectomy became widely used as a method for voluntary sterilization and family planning. [ 254 ] [ 253 ]   Since then, vasectomy has undergone extensive technical improvements and innovations, such that it is no longer a single procedure, but a  family of related procedures . [ 253 ] [ 256 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13012", "text": "In the 1990s, and into the early 2000s, major pharmaceutical companies  Organon ,  Wyeth , and  Schering  were pursuing preclinical and clinical development of various male contraceptive products, but in 2006, all three companies ceased development of these products within a short time of each other, for reasons that have not been publicly released. [ 257 ] [ 110 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13013", "text": "In 2013, the Male Contraceptive Initiative was founded with the goal of funding and supporting the development of new male contraceptives. [ 258 ] [ 259 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13014", "text": "In 2020,  Dr. Polina Lishko  was awarded the  MacArthur \"Genius\" Fellowship  for her contributions to the understanding of sperm physiology, with the award specifically noting her work on \"opening up new avenues in ... the development of male-specific or unisex contraceptives.\" [ 260 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13015", "text": "Many researchers have attempted to develop male contraceptive products over the last hundred years.  A selection of these efforts (that are no longer in development as of 2024) are listed below."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13016", "text": "In  urology , the  Mitrofanoff principle  is the creation of a passageway for  urine  or  enema  fluid that, by its ( surgical ) construction, has a  valve  mechanism to allow  continence . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13017", "text": "Procedures which make use of the Mitrofanoff principle:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13018", "text": "It is named after the  French   urologist  (Mitrofanoff) who popularized it. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13019", "text": "Nocturnal enuresis  ( NE ), also informally called  bedwetting , is  involuntary urination  while  asleep  after the age at which  bladder  control usually begins. [ 1 ]  Bedwetting in children and adults can result in emotional stress. [ 2 ]  Complications can include  urinary tract infections . [ 2 ] [ 3 ] [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13020", "text": "Most bedwetting is a  developmental delay \u2014not an emotional problem or physical illness. Only a small percentage (5 to 10%) of bedwetting cases have a specific medical cause. [ 6 ]  Bedwetting is commonly associated with a  family history  of the condition. [ 7 ]  Nocturnal  enuresis  is considered  primary  when a child has not yet had a prolonged period of being dry.  Secondary  nocturnal enuresis is when a child or adult begins wetting again after having stayed dry."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13021", "text": "Treatments range from  behavioral therapy , such as  bedwetting alarms , to medication, [ 8 ] [ 9 ]  such as  hormone replacement , and even surgery such as  urethral dilatation . Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve  self-esteem . [ 6 ]  Treatment guidelines recommend that the physician counsel the parents, [ 10 ]  warning about psychological consequences caused by pressure, shaming, or punishment for a condition children cannot control. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13022", "text": "Bedwetting is the most common childhood complaint. [ 11 ] [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13023", "text": "A review of medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. \"It is often the child's and family members' reaction to bedwetting that determines whether it is a problem or not.\" [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13024", "text": "Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13025", "text": "Children questioned in one study ranked bedwetting as the third most stressful life event, after \"parental war of words\", divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13026", "text": "Bedwetters face problems ranging from being teased by siblings, being punished by parents, the embarrassment of still having to wear diapers, and being afraid that friends will find out."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13027", "text": "Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Key factors are: [ 16 ] [ unreliable medical source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13028", "text": "Studies indicate that children with behavioral problems are more likely to wet their beds. For children who have developmental problems, the behavioral problems and the bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting. [ 16 ] [ unreliable medical source? ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13029", "text": "As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13030", "text": "Medical literature states, and studies show, that punishing or shaming a child for bedwetting will frequently make the situation worse. It is best described as a downward cycle, where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13031", "text": "In the United States, about 25% of enuretic children are punished for wetting the bed. [ 18 ]  In Hong Kong, 57% of enuretic children are punished for wetting. [ 19 ]  Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13032", "text": "In  Korea  and in small parts of  Japan , there is a folk tradition whereby bedwetters are made to wear a  winnowing basket  on their head and sent to ask their neighbors for salt. This is motivated in part by a desire to publicly embarrass the child into compliance, as neighbors would recognize why the child was knocking on their door. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13033", "text": "Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, diapers, and mattress replacement. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13034", "text": "Despite these stressful effects, doctors emphasize that parents should react patiently and supportively. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13035", "text": "Bedwetting does  not  indicate a greater possibility of being a  sociopath , as long as caregivers do not cause trauma by shaming or punishing a bedwetting child. Bedwetting was part of the  Macdonald triad , a set of three behavioral characteristics described by  John Macdonald  in 1963. [ 22 ]  The other two characteristics were  firestarting  and  animal abuse . Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying  sociopathic  criminal behavior. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13036", "text": "Up to 60% of multiple murderers, according to some estimates, wet their beds post-adolescence. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13037", "text": "Enuresis is an \"unconscious, involuntary [...] act\". [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13038", "text": "Bedwetting can be connected to past emotions and identity. Children under substantial stress, particularly in their home environment, frequently engage in bedwetting, in order to alleviate the stress produced by their surroundings. [ citation needed ]  Trauma can also trigger a return to bedwetting (secondary enuresis) in both children and adults."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13039", "text": "It is not bedwetting that increases the chance of criminal behavior, but the associated trauma. [ 26 ]  Parental cruelty can result in \"homicidal proneness\". [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13040", "text": "The  etiology  of NE is not fully understood, although there are three common causes: excessive urine volume, poor sleep arousal, and bladder contractions. Differentiation of cause is mainly based on patient history and fluid charts completed by the parent or carer to inform management options. [ 28 ] [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13041", "text": "Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13042", "text": "These first two factors (aetiology and genetic component) are the most common in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and  genetic testing  offers little or no benefit. As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13043", "text": "In some bedwetting children there is no increase in ADH (antidiuretic hormone) production, while other children may produce an increased amount of ADH but their response is insufficient. [ 28 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13044", "text": "Two physical functions prevent bedwetting. The first is a  hormone  that reduces  urine  production at night. The second is the ability to wake up when the  bladder  is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some  hereditary  factors in how and when these develop. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13045", "text": "The first ability is a  hormone  cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of  antidiuretic hormone  (also known as arginine vasopressin or AVP). This hormone burst reduces the  kidney 's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of  puberty , and some not at all. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13046", "text": "The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13047", "text": "The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13048", "text": "Thorough history regarding frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, and encopresis should be sought."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13049", "text": "Nocturnal urinary continence is dependent on three factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will experience nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13050", "text": "Primary nocturnal enuresis is the most common form of bedwetting. Bedwetting becomes a disorder when it persists after the age at which bladder control usually occurs (4\u20137 years), and is either resulting in an average of at least two wet nights a week with no long periods of dryness or not able to sleep dry without being taken to the toilet by another person."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13051", "text": "New studies show that anti-psychotic drugs can have a side effect of causing enuresis. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13052", "text": "It has been shown that diet impacts enuresis in children.  Constipation  from a poor diet can result in impacted stool in the colon putting undue pressure on the bladder creating loss of bladder control ( overflow incontinence ). [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13053", "text": "Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning 7 years old. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13054", "text": "Secondary enuresis occurs  after  a patient goes through an extended period of dryness at night (six months or more) and then  reverts  to night-time wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection. [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13055", "text": "Psychologists are usually allowed to diagnose and write a prescription for diapers if nocturnal enuresis causes the patient significant distress. [ 57 ]  Psychiatists may instead use a definition from the  DSM-IV , defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week or more for at least three consecutive months in a child of at least 5 years of age and not due to either a  drug side effect  or a  medical condition ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13056", "text": "There are a number of management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes. Treatment is recommended when there is a specific medical condition such as  bladder  abnormalities,  infection , or  diabetes . It is also considered when bedwetting may harm the child's  self-esteem  or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's  emotional  welfare. Behavioral treatment of bedwetting overall tends to show increased self-esteem for children. [ 58 ] [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13057", "text": "Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13058", "text": "Punishment is not effective and can interfere with treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13059", "text": "Simple behavioral methods are recommended as initial treatment. [ 61 ]  Other treatment methods include the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13060", "text": "Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 17 years old have a spontaneous cure rate of 16% per year. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13061", "text": "As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 17 are likely to deal with bedwetting throughout their lives. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13062", "text": "Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 20- to 79-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13063", "text": "In the first century B.C., at lines 1026-29 of the fourth book of his  On the Nature of Things ,  Lucretius  gave a high-style description of bed-wetting: [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13064", "text": "An early psychological perspective on bedwetting was given in 1025 by  Avicenna  in  The Canon of Medicine : [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13065", "text": "Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. However, more recent research and medical literature states that this is very rare. [ 82 ] [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13066", "text": "PC3  ( PC-3 ) is a human  prostate cancer   cell line  used in prostate cancer research and drug development. [ 1 ]  PC3 cells are useful in investigating biochemical changes in advanced prostate cancer cells and in assessing their response to  chemotherapeutic agents . PC3 cells are also used to study viral infection in mammalian cells that exhibit an immune response. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13067", "text": "The PC3 cell line was established in 1979 from bone metastasis of grade IV of  prostate  cancer in a 62-year-old Caucasian male. [ 3 ]  These cells do not respond to androgens, glucocorticoids or fibroblast growth factors, [ 4 ]  but results suggest that the cells are influenced by epidermal growth factors. [ 5 ]  PC3 cells can be used to create subcutaneous tumor  xenografts  in mice to investigate the tumor environment and therapeutic drug functionality. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13068", "text": "PC3 cells have high  metastatic  potential compared to other pancreatic cells of  DU145  cells, which have a moderate metastatic potential, and to  LNCaP  cells, which have low metastatic potential. [ citation needed ]  Comparisons of the  protein expression  of PC3, LNCaP, and other cells have shown that PC3 is characteristic of small cell neuroendocrine carcinoma. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13069", "text": "PC3 cells have low  testosterone - 5-alpha reductase  and  acidic phosphatase  activity, and do not express PSA ( prostate-specific antigen ). Furthermore,  karyotypic  analysis has shown that PC3 are near-triploid, having 62 chromosomes. Q-band analysis showed no Y chromosome. From a morphological point of view,  electron microscopy  revealed that PC3 cells show characteristics of a poorly-differentiated  adenocarcinoma . They have features common to neoplastic cells of epithelial origins, such as numerous microvilli, junctional complexes, abnormal nuclei and nucleoli, abnormal mitochondria, annulate lamellae, and lipoidal bodies. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13070", "text": "There are a variety of Different PC3 cell lines derived from the original PC3 cell line. The most common include PC3-PR Cells, PC-3M Cells, PC3-EGFP Cells, PC3-Dox Cells, PC3-LacZ Cells, PC3-AR Cells. Each of these have different morphological and physiological properties but they all originate from the original PC3 cell derived from the 62-year old caucasian male. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13071", "text": "C3-PR cells are Paclitaxel-Resistant cells that, unlike PC3 cells, are resistant with  Paclitaxel  (PTX). In these cells PTX is unable to stimulate p21 and acetylated \u03b1-tubulin expression of PC3-PR cells. Though  Cabazitaxel  and  HDAC  inhibitors were able to induce p21 and \u03b1-tubulin, these equally suppress PC3-PR cells. Due to the suppression ability of Cabazitaxel and HDAC, these drugs are able to replace the common chemotherapy drug in PC3-PR cells. [ 7 ]  These cells allow researchers to develop strategies in order to treat prostate cancer that is resistant to traditional chemotherapy drugs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13072", "text": "PC-3M Cells (Metastatic)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13073", "text": "PC-3-M cells are a highly metastatic form of PC3 cells. They metastasize in a much more prolific fashion than regular PC3 cells. These cells are used in research to study the potential treatments of PC\u2019s that are highly metastatic. PC3-M is used in research from in-vitro to in-vivo model animals for cancer research. [ 8 ]  This cell line is able to research the most dangerous, advanced forms of pancreatic cancer, as the high metastasis potential will allow these cells to spread throughout the body in a rapid fashion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13074", "text": "PC3-EGFP Cells (Enhanced Green Fluorescent Protein)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13075", "text": "PC3-EGFP are PC3 cells that have been modified in order to express green fluorescent proteins at a higher rate. This is visible when EGFP expression levels are analyzed. [ 9 ]  This allows for live tracking of PC3 cells as well as real time imaging. This can be especially useful when studying the proliferation as well as the drug response in PC3 cells."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13076", "text": "PC3-Dox Cells"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13077", "text": "PC3-Dox cells are modified to be resistant to Doxorubicin. This cell line is used to study multidrug resistance (MDR) in PC3. Specifically miR-21 research is based on this lineage of cells in order to determine if it is possible to reverse (MDR) through the employment of this drug. Additionally these cells look at if it is possible to resensitize PC3 cells to Doxorubicin. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13078", "text": "PC3-Ras Cells \nPC3-Ras cells are modified in order to express the oncogene ras. Ras is involved in the activation of downstream effectors that play a role in DNA transcription. This modification allows researchers to study the role of Ras signaling in prostate cancer. This is very important to studying the processes of tumor progression, metastasis, and drug resistance in pancreatic cancer cells, as it is tied to mitosis. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13079", "text": "Prostate cancer (PC) is the most common form of non-cutaneous malignant cancer in males, and is the second leading cause of cancer deaths in males. [ 12 ]  PC3 cells have been utilized to research aggressive and castration-resistant forms of pancreatic cancer. The androgen-independence of these cells during cell division makes them invaluable for studying the molecular mechanisms embedded in studying advanced prostate cancer.  [ 13 ]  PC3 cells have been involved in research regarding the prevention and treatment of prostate cancer. PC3 cells have been used in research surrounding Methylene Blue Photodynamic Laser Therapy (MB-PDT) and  Sulforaphane (SFN) . Research published in 2023 utilizing PC3 cells illustrated that MB-PDT treatment decreased the antioxidant potential and increased lipid peroxidation, decreasing the viability and metastatic capacity of PC3 cells. The results from this study further support other research that MB-PDT can be used in conjunction with traditional therapies to treat aggressive versions of prostate cancers. [ 14 ]  SFN treatments have been used to treat prostate cancer as well as many other tumors. SFN is a plant-derived chemical present in many plants, especially broccoli and broccoli sprouts; though there are concerns about the bioavailability of SFN supplements.  [ 15 ]  Nevertheless, many prostate cancer patients have turned to SFN to prevent growth of PCs resistant to many of the traditional forms of treatment. Experimentation in 2020 linked SFN to a decrease in prostate cancer proliferation and growth, using PC3 cells alongside  DU145 . These studies found that using treatments as low as 1 \u00b5M of SFN decreased PC3 cell count by 50% in-vitro.  [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13080", "text": "This  cell biology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13081", "text": "Pediatric urology  is a surgical subspecialty of medicine dealing with the disorders of children's genitourinary systems. Pediatric urologists provide care for both boys and girls ranging from birth to early adult age. The most common problems are those involving disorders of urination, reproductive organs and testes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13082", "text": "Some of the problems they deal with are: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13083", "text": "In North America, most pediatric urologists are associated with  children's hospitals . Training for  board certification  in pediatric urology typically consists of a surgery internship as part of a urology  residency  followed by subspecialty training in pediatric urology at a major children's hospital. In India, Pediatric Urology is practiced by Pediatric Surgeons with a special interest/ training in pediatric urology as well as by adult urologists who get trained in Pediatric Urology. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13084", "text": "Pelvic compression syndrome  is characterized by intermittent or persisting pain in the  abdomen , which is  exacerbated  by abdominal pressure. A swelling of the  veins  in the valveless  pampiniform plexus  causes it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13085", "text": "While  varicocele  is the diagnostic term for swelling in the valveless venous distribution of the male  pampiniform plexus , this  embryological  structure, common to males and females, is often incidentally noted to be swollen during  laparoscopic  examinations in both  symptomatic  and  asymptomatic  females. [ 1 ]  Diagnosis of female varicocele, properly called pelvic compression syndrome, should be expected to be as frequent as male varicocele (15% of healthy asymptomatic men, which are thought to develop primarily during puberty and prevalence increases approximately 10% per decade of life  [ 2 ] )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13086", "text": "While one may expect the female to have an equal  prevalence  of pelvic compression syndrome due to the identical  embryological  origin of the valveless  pampiniform plexus , this condition is thought to be underdiagnosed due to the broad differential of the pain pattern:  unilateral or bilateral  pain, dull to sharp, constant to intermittent pain worsening with any increase in  abdominal pressure . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13087", "text": "Physical exam has a specificity of 77% and sensitivity of nearly 94% when the patient is noted to be tender over  adnexa  during physical examination with a history of postcoital pain for differentiating  pelvic congestion syndrome  from other  pathologies  of pelvic origin. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13088", "text": "Confirmatory imaging requires  ultrasound  while performing a  Valsalva maneuver , while the gold standard remains  ovarian  and iliac  catheter   venography  showing veins 5-10mm in diameter during the Valsalva maneuver."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13089", "text": "Complete resolution of symptoms after  menopause  indicates the influence of hormones on  pelvic congestion syndrome .  Estrogen  is a venous dilator and can thus produce the venous dilation implicated in the  pathophysiology  of the PCS. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13090", "text": "Penis  clamp  is an external penis compression  device  that treats male  urinary incontinence . Incontinence clamps for men are applied to compress the  urethra  to compensate for the malfunctioning of the natural  urinary sphincter , preventing leakage from the  bladder  with minimal restriction of blood flow."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13091", "text": "These devices are crafted to block or compress the urethra, thus preventing urine leakage. They are applied externally and are typically user-friendly and comfortable to use. Compression devices may vary in shape and size, but they are generally made of flexible and soft materials that adapt to the anatomical contour. Some models come with adjustable settings to customize the level of compression according to individual needs. There were models of urethra clamping devices that date back from the 1920s. They are most commonly made from stainless steel and plastic on the outer surface and  silicone  or  rubber  on the inner surface. They are usually applied as a cost-effective solution to urinary incontinence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13092", "text": "Cunningham Penile Clamp: This type of clamp is placed around the penis. It helps to stop urine leakage by compressing the urethra, the tube through which urine exits. This is achieved by controlled squeezing, preventing urine from escaping."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13093", "text": "Flexible Uriclak Device: Another type of clamp that is also placed on the penis. It functions similarly to the Cunningham penile clamp by compressing the urethra, but in this case, it does not have closures. It is flexible and comfortably adapts to halt urine flow."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13094", "text": "Non-invasive: These devices do not require surgery or invasive procedures, making them an attractive option for individuals looking to avoid surgical interventions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13095", "text": "Customization: Penile clamps allow for personalized adjustments to cater to individual needs and preferences."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13096", "text": "Independence and Freedom: By offering greater control over urinary incontinence, incontinence devices help individuals maintain an active lifestyle and engage in various activities without worries."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13097", "text": "Effectiveness: Many users have experienced a significant reduction in urine leaks and an improvement in their quality of life after using penile devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13098", "text": "Usually, these devices are safe and effective. However, none of the penile compression devices cause sustained irritation or  impaired blood flow , and generally, patients yield good recovery around 40 minutes after the removal of the devices. [ 2 ]  It is recommended to de-clamp these devices at a regular interval of four hours. [ 1 ] \nIn the instruction manuals, manufacturers allow continuous use of penis clamps and recommend repositioning them every 2-3 hours (each time after urination).  [ 3 ] \n [ 4 ] \n [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13099", "text": "Customers should not buy this type of health products on non-specialized websites. Patients may incur serious risks. Urinary clamps imported directly from Asia may not have passed the necessary medical checks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13100", "text": "A  penis extender  is an external  medical device  with tentative evidence as of 2019 for  Peyronie's disease . It acts as a  mechanical ,  traction  device that stretches the  human penis  in the flaccid state to make it longer. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13101", "text": "Penis extenders usually have a  plastic  ring that sits at the base of a  flaccid penis , and another ring before the  glans penis , with a traction device that runs along the sides of the organ. The wearer adjusts springs, which pull the  penile shaft  with the intention of stretching the flaccid penis to become longer. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13102", "text": "There is tentative evidence for use in  Peyronie's disease . [ 1 ]  As of 2019, studies have been small in size; many had difficulty carrying out the treatment during the study period, and people were not blinded to the treatment that they were receiving. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13103", "text": "Adverse effects are not extensively reported in the literature, and they are usually mild and self-limiting, in part caused by lack of patient compliance with penile traction therapy (PTT). The most commonly reported symptoms with PTT include  pain ,  erythema ,  ecchymoses , and  pruritus . Another reported symptom was  edema  to the  pubic bone , which is associated with vigorous usage. All of these adverse events are generally self-limited and resolve with discontinuation of PTT. [ 1 ]  Seek advice on  how to use the penis extender  safely, and correctly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13104", "text": "It should not be used if penile wounds, lacerations, or infected zones have not fully healed, and by those suffering certain diseases or disorders. [ 2 ]  Aggressive or incorrect uses of penis extenders can cause damage to skin and blood vessels, among other possible issues. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13105", "text": "The  penrig  is a  unit  of  tumescence , specifically for the tumescence of the human  penis . It is defined as the tumescence that will raise 100\u00a0 grams  of penile tissue through one millimetre. [ 1 ] [ 2 ] [ 3 ]  The word is formed from PENis RIGidity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13106", "text": "Perineology  is a speciality dealing with the functional troubles of the three axes ( urological ,  gynaecological  and  coloproctological ) of the female  perineum . [ 1 ]  The perineologist takes a  holistic approach , using defect-specific and mini-invasive treatments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13107", "text": "The word perineology represents a  neologism . It was invented for the occasion of the 1st International Symposium on Perineology, held in  Venice  in 1990 to reflect an integrated view of the anatomy, physiology and pathology of the pelvic floor. [ 2 ]  It was popularized by the Italian journal Rivista Italiana di Colon-Proctologia. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13108", "text": "Some physicians in France and Italy prefer to use the broader term \u201cpelviperineology\u201d, which reflect a broader multidisciplinary approach to all the aspects of the management of the pelvic floor. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13109", "text": "In 2010, an International Society for Pelviperineology was formed. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13110", "text": "Postorgasmic illness syndrome  ( POIS ) is a  syndrome  in which human males have chronic physical and cognitive symptoms following  ejaculation . [ 1 ]  The symptoms usually onset within seconds, minutes, or hours, and last for up to a week. [ 1 ]  The cause and prevalence are unknown; [ 2 ]  it is considered a  rare disease . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13111", "text": "The distinguishing characteristics of POIS are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13112", "text": "POIS symptoms, which are called a \"POIS attack\", [ 1 ]  can include some combination of the following: cognitive dysfunction,  aphasia , severe  muscle pain  throughout the body, severe  fatigue , weakness, and flu-like or allergy-like symptoms, [ 4 ]  such as sneezing, itchy eyes, and nasal irritation. [ 5 ] [ 2 ] [ 6 ]  Additional symptoms include headache, dizziness, lightheadedness, extreme hunger, sensory and motor problems, intense discomfort, irritability,  anxiety ,  gastrointestinal  disturbances, craving for relief, susceptibility to nervous system stresses, depressed mood, and difficulty communicating, remembering words, reading and retaining information, concentrating, and socializing. [ 5 ] [ 7 ]  Affected individuals may also experience intense warmth or cold. [ 4 ]  An online anonymous self-report study found that 80% of respondents always experienced the symptom cluster involving fatigue, insomnia, irritation, and concentration difficulties. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13113", "text": "The symptoms usually begin within 30 minutes of  ejaculation , [ 5 ]  and can last for several days, sometimes up to a week. [ 4 ]  In some cases, symptoms may be delayed by 2 to 3 days or may last up to 2 weeks. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13114", "text": "In some men, the onset of POIS is in puberty, while in others, the onset is later in life. [ 10 ]  POIS that is manifest from the first ejaculations in adolescence is called  primary type ; POIS that starts later in life is called  secondary type . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13115", "text": "Many individuals with POIS report lifelong  premature ejaculation , with  intravaginal ejaculation latency time  (IELT) of less than one minute. [ 1 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13116", "text": "The 7 clusters of symptoms of criterion 1: [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13117", "text": "POIS has been called by a number of other names, including \"postejaculatory syndrome\", [ 4 ]  \"postorgasm illness syndrome\", [ 11 ]  \"post ejaculation sickness\", [ 12 ]  and \"post orgasmic sick syndrome\". [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13118", "text": "Dhat syndrome  is a condition ,  N. N. Wig  first coined the term and described in 1960 in India, [ 13 ]  with symptoms similar to POIS. [ 11 ]  Dhat syndrome is thought to be a  culture-bound   psychiatric  condition and is treated with  cognitive behavioral therapy  along with anti-anxiety and antidepressant drugs. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13119", "text": "Post-coital tristesse  (PCT) is a feeling of  melancholy  and  anxiety  after sexual intercourse that lasts anywhere from five minutes to two hours. PCT, which affects both men and women, occurs only after sexual intercourse and does not require an orgasm to occur, and in that its effects are primarily emotional rather than physiological. By contrast, POIS affects only men, consists primarily of physiological symptoms that are triggered by ejaculation and that can last, in some people, for up to a week. While PCT and POIS are distinct conditions, some doctors speculate that they could be related. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13120", "text": "An array of more subtle and lingering symptoms after orgasm, which do not constitute POIS, may contribute to habituation between mates. They may show up as restlessness, irritability, increased sexual frustration, apathy, sluggishness, neediness, dissatisfaction with a mate, or weepiness [ 15 ]  over the days or weeks after intense sexual stimulation. Such phenomena may be part of  human mating physiology  itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13121", "text": "Sexual headache  is a distinct condition characterized by headaches that usually begin before or during orgasm. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13122", "text": "The cause of POIS is unknown. Some doctors hypothesize that POIS is caused by an  auto-immune reaction . [ 17 ]  Other doctors suspect a  hormone imbalance  as the cause. Different causes have also been proposed. None of the proposed causes can fully explain the disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13123", "text": "According to one hypothesis, \"POIS is caused by  Type-I  and  Type-IV  allergy to the males' own semen\". [ 1 ] [ 18 ] [ 19 ]  This was conditioned by another study stating \" IgE -mediated semen allergy in men may not be the potential mechanism of POIS\". [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13124", "text": "Alternatively, POIS could be caused by an auto-immune reaction not to semen, but to a different substance released during ejaculation, such as  cytokines . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13125", "text": "According to another hypothesis, POIS is caused by a hormone imbalance, such as low  progesterone , [ medical citation needed ]  low  cortisol , low  testosterone , elevated  prolactin ,  hypothyroidism , or low  DHEA . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13126", "text": "POIS could be caused by a defect in  neurosteroid  precursor synthesis. If so, the same treatment may not be effective for all individuals. Different individuals could have different missing precursors leading to a deficiency of the same neurosteroid, causing similar symptoms. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13127", "text": "The majority of POIS symptoms like fatigue, muscle pains, sweating, mood disturbances, irritability, and poor concentration are also caused by  withdrawal  from different drug classes [ 21 ]  and natural reinforcers. [ 22 ]  It is  unknown whether there is a relationship between  hypersexuality ,  pornography addiction ,  compulsive sexual behavior  and POIS. Some evidence indicates that POIS patients have a history of excessive masturbation, suggesting that POIS could be a consequence of sex addiction. There is anecdotal evidence on porn addiction internet forums, that many men experience POIS like symptoms after ejaculation. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13128", "text": "POIS could be caused by  hyperglycemia [ 20 ]  or by chemical imbalances in the brain. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13129", "text": "Sexual activity for the first time  may set the stage for an associated  asthma  attack or may aggravate pre-existing asthma. Intense emotional stimuli during sexual intercourse can lead to autonomic imbalance with parasympathetic over-reactivity, releasing  mast cell  mediators that can provoke postcoital asthma and / or  rhinitis  in these patients. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13130", "text": "It is also possible that the causes of POIS are different in different individuals. POIS could represent \"a spectrum of syndromes of differing\" causes. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13131", "text": "None of the proposed causes for POIS can fully explain the connection between POIS and  lifelong premature ejaculation . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13132", "text": "There is no generally agreed upon diagnostic criteria for POIS. One group has developed five preliminary criteria for diagnosing POIS. These are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13133", "text": "POIS is prone to being erroneously ascribed to psychological factors such as  hypochondriasis  or  somatic symptom disorder . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13134", "text": "An online survey study suggested that only a small number of self-reported POIS fulfill entirely the five criteria. This study proposed to change the Criterion 3 with \u201cIn at least one ejaculatory setting (sex, masturbation, or nocturnal emission), symptoms occur after all or almost all ejaculations.\u201d [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13135", "text": "There is no standard method of treating or managing POIS. Patients need to be thoroughly examined in an attempt to find the causes of their POIS symptoms, which are often difficult to determine, and which vary across patients. Once a cause is hypothesized, an appropriate treatment can be attempted. At times, more than one treatment is attempted, until one that works is found. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13136", "text": "Affected individuals typically avoid sexual activity, [ 4 ]  especially ejaculation, [ 1 ]  or schedule it for times when they can rest and recover for several days afterwards. [ 5 ]  In case  post-coital tristesse  (PCT) is suspected, patients could be treated with  selective serotonin reuptake inhibitors . [ 11 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13137", "text": "In one patient, the POIS symptoms were so severe, that he decided to undergo removal of the testicles, prostate, and seminal vesicles in order to relieve them. The POIS symptoms were cured by this. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13138", "text": "Another patient, in whom POIS was suspected to be caused by cytokine release, was successfully treated with  nonsteroidal anti-inflammatory drugs  (NSAIDs) just prior to and for a day or two after ejaculation. The patient took  diclofenac  75\u00a0mg 1 to 2 hours prior to sexual activity with orgasm, and continued twice daily for 24 to 48 hours. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13139", "text": "One POIS patient with  erectile dysfunction  and  premature ejaculation  had much lower severity of symptoms on those occasions when he was able to maintain penile erection long enough to achieve vaginal penetration and ejaculate inside his partner. The patient took  tadalafil  to treat his erectile dysfunction and premature ejaculation. This increased the number of occasions on which he was able to ejaculate inside his partner, and decreased the number of occasions on which he experienced POIS symptoms. This patient is thought to have  Dhat syndrome  rather than true POIS. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13140", "text": "Two patients, in whom POIS was suspected to be caused by auto-immune reaction to their own semen, were successfully treated by  allergen immunotherapy  with their own autologous semen. They were given multiple subcutaneous injections of their own semen for three years. [ 1 ]  Treatment with autologous semen \"might take 3 to 5 years before any clinically relevant symptom reduction would become manifest\". [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13141", "text": "Treatments are not always successful, especially when the cause of POIS in a particular patient has not been determined. In one patient, all of whose  routine laboratory tests  were normal, the following were attempted, all without success:  ibuprofen , 400\u00a0mg on demand;  tramadol  50\u00a0mg one hour pre-coitally; and  escitalopram  10\u00a0mg daily at bedtime for 3 months. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13142", "text": "The prevalence of POIS is unknown. [ 2 ]  POIS is listed as a  rare disease  by the American  National Institutes of Health [ 3 ]  and the European  Orphanet . [ 28 ]  It is thought to be underdiagnosed and underreported. [ 7 ]  POIS seems to affect mostly men from around the world, of various ages and relationship statuses. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13143", "text": "It is possible that a similar disease exists in women, though, as of 2016, there is only one documented female patient. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13144", "text": "2ZCH ,  2ZCK ,  2ZCL ,  3QUM"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13145", "text": "354"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13146", "text": "18048"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13147", "text": "ENSG00000142515"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13148", "text": "ENSMUSG00000066513"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13149", "text": "P07288"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13150", "text": "P00757"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13151", "text": "NM_145864"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13152", "text": "NM_010915"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13153", "text": "NP_001025218 NP_001025219 NP_001639"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13154", "text": "NP_035045"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13155", "text": "Prostate-specific antigen  ( PSA ), also known as  gamma-seminoprotein  or  kallikrein-3  ( KLK3 ), P-30 antigen, is a  glycoprotein   enzyme  encoded in humans by the  KLK3   gene . PSA is a member of the  kallikrein -related  peptidase  family and is secreted by the  epithelial cells  of the  prostate  gland in men and the  paraurethral glands  in women. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13156", "text": "PSA is produced for the  ejaculate , where it liquefies  semen  in the seminal coagulum and allows  sperm  to swim freely. [ 6 ]  It is also believed to be instrumental in dissolving  cervical mucus , allowing the entry of sperm into the  uterus . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13157", "text": "PSA is present in small quantities in the  serum  of men with healthy prostates, but is often elevated in the presence of  prostate cancer  or other prostate disorders. [ 8 ]  PSA is not uniquely an indicator of prostate cancer, but may also detect  prostatitis  or  benign prostatic hyperplasia . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13158", "text": "Clinical practice guidelines  for prostate cancer  screening  vary and are controversial, in part due to uncertainty as to whether the benefits of screening ultimately outweigh the risks of  overdiagnosis  and overtreatment. [ 10 ]  In the United States, the  Food and Drug Administration  (FDA) has approved the PSA test for annual screening of prostate cancer in men of age 50 and older. [ medical citation needed ]  The patient is required to be informed of the risks and benefits of PSA testing prior to performing the test. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13159", "text": "In the United Kingdom, the  National Health Service  (NHS) as of 2018 [update]  does not mandate, nor advise for PSA test, but allows patients to decide based on their doctor's advice. [ 11 ]  The NHS does not offer general PSA screening, for similar reasons. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13160", "text": "PSA levels between 4 and 10 \u00a0 ng/mL (nanograms per milliliter) are considered to be suspicious, and consideration should be given to confirming the abnormal PSA with a repeat test. If indicated,  prostate biopsy  is performed to obtain a tissue sample for histopathological analysis.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13161", "text": "While PSA testing may help 1 in 1,000 avoid death due to prostate cancer, 4 to 5 in 1,000 would die from prostate cancer after 10 years even with screening. This means that PSA screening may reduce mortality from prostate cancer by up to 25%. Expected harms include anxiety for 100\u2013120 receiving false positives, biopsy pain, and other complications from biopsy for false positive tests. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13162", "text": "Use of PSA screening tests is also controversial due to questionable test accuracy. The screening can present abnormal results even when a man does not have cancer (known as a  false-positive  result ), or normal results even when a man does have cancer (known as a  false-negative  result ). [ 13 ]  False-positive test results can cause confusion and anxiety in men, and can lead to unnecessary prostate  biopsies , a procedure which causes risk of pain, infection, and  hemorrhage . False-negative results can give men a false sense of security, though they may actually have cancer. [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13163", "text": "Of those found to have prostate cancer, overtreatment is common because most cases of prostate cancer are not expected to cause any symptoms due to low rate of growth of the prostate tumor. Therefore, many will experience the side effects of treatment, such as for every 1000 men screened, 29 will experience erectile dysfunction, 18 will develop urinary incontinence, two  will have serious cardiovascular events, one will develop pulmonary embolus or deep venous thrombosis, and one perioperative death. [ failed verification ]  Since the expected harms relative to risk of death are perceived by patients as minimal, men found to have prostate cancer usually (up to 90% of cases) elect to receive treatment. [ 14 ] [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13164", "text": "Men with prostate cancer may be characterized as low, intermediate, or high risk for having/developing metastatic disease or dying of prostate cancer. PSA level is one of three variables on which the risk stratification is based; the others are the grade of prostate cancer ( Gleason grading system ) and the stage of cancer based on physical examination and imaging studies. D'Amico criteria for each risk category are: [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13165", "text": "Given the relative simplicity of the 1998 D'Amico criteria (above), other predictive models of risk stratification based on  mathematical probability  constructs exist or have been proposed to allow for better matching of treatment decisions with disease features. [ 18 ] \nStudies are being conducted into the incorporation of multiparametric  MRI  imaging results into  nomograms  that rely on PSA, Gleason grade, and tumor stage. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13166", "text": "PSA levels are monitored periodically (e.g., every 6\u201336 months) after treatment for prostate cancer \u2013 more frequently in patients with high-risk disease, less frequently in patients with lower-risk disease. If surgical therapy (i.e., radical prostatectomy) is successful at removing all prostate tissue (and prostate cancer), PSA becomes undetectable within a few weeks. A subsequent rise in PSA level above 0.2 \u00a0 ng/mL [ 20 ]  L [ disputed  \u2013  discuss ]  is generally regarded as evidence of recurrent prostate cancer after a radical prostatectomy; less commonly, it may simply indicate residual benign prostate tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13167", "text": "Following radiation therapy of any type for prostate cancer, some PSA levels might be detected, even when the treatment ultimately proves to be successful. This makes  interpreting the relationship between PSA levels and recurrence/persistence of prostate cancer after radiation therapy more difficult. PSA levels may continue to decrease for several years after radiation therapy. The lowest level is referred to as the PSA nadir. A subsequent increase in PSA levels by 2.0 \u00a0 ng/mL [ disputed  \u2013  discuss ]  above the nadir is the currently accepted definition of prostate cancer recurrence after radiation therapy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13168", "text": "Recurrent prostate cancer detected by a rise in PSA levels after curative treatment is referred to as a \" biochemical recurrence \". The likelihood of developing recurrent prostate cancer after curative treatment is related to the pre-operative variables described in the preceding section (PSA level and grade/stage of cancer). Low-risk cancers are the least likely to recur, but they are also the least likely to have required treatment in the first place. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13169", "text": "PSA levels increase in the setting of prostate infection/inflammation (prostatitis), often markedly (> 100)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13170", "text": "PSA was first identified by researchers attempting to find a substance in seminal fluid that would aid in the investigation of rape cases. [ 21 ]  PSA is used to indicate the presence of  semen  in forensic  serology . [ 22 ]  The semen of adult males has PSA levels far in excess of those found in other tissues; therefore, a high level of PSA found in a sample is an indicator that semen may be present. Because PSA is a  biomarker  that is expressed independently of  spermatozoa , it remains useful in identifying semen from  vasectomized  and  azoospermic  males. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13171", "text": "PSA can also be found at low levels in other body fluids, such as urine and breast milk, thus setting a high minimum threshold of interpretation to rule out  false positive  results and conclusively state that semen is present. [ 24 ]  While traditional tests such as crossover  electrophoresis  have a sufficiently low sensitivity to detect only seminal PSA, newer diagnostics tests developed from clinical  prostate cancer screening  methods have lowered the threshold of detection down to 4 \u00a0 ng/mL. [ 25 ]  This level of antigen has been shown to be present in the peripheral blood of males with prostate cancer, and rarely in female urine samples and breast milk. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13172", "text": "PSA is produced in the  epithelial  cells of the prostate, and can be demonstrated in biopsy samples or other  histological  specimens using  immunohistochemistry . Disruption of this epithelium, for example in inflammation or  benign prostatic hyperplasia , may lead to some diffusion of the antigen into the tissue around the epithelium, and is the cause of elevated blood levels of PSA in these conditions. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13173", "text": "More significantly, PSA remains present in prostate cells after they become malignant. Prostate cancer cells generally have variable or weak staining for PSA, due to the disruption of their normal functioning. Thus, individual prostate cancer cells produce less PSA than healthy cells; the raised serum levels in prostate cancer patients is due to the greatly increased number of such cells, not their individual activity. In most cases of prostate cancer, though, the cells remain positive for the antigen, which can then be used to identify  metastasis . Since some high-grade prostate cancers may be entirely negative for PSA, however, histological analysis to identify such cases usually uses PSA in combination with other antibodies, such as  prostatic acid phosphatase  and  CD57 . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13174", "text": "The physiological function of KLK3 is the dissolution of the coagulum, the sperm-entrapping gel composed of  semenogelins  and  fibronectin . Its proteolytic action is effective in liquefying the coagulum so that the sperm can be liberated. The activity of PSA is well regulated. In the prostate, it is present as an inactive pro-form, which is activated through the action of  KLK2 , another kallikrein-related peptidase. In the prostate, zinc ion concentrations are 10 times higher than in other bodily fluids. Zinc ions have a strong inhibitory effect on the activity of PSA and on that of KLK2, so that PSA is totally inactive. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13175", "text": "Further regulation is achieved through pH variations. Although its activity is increased by higher pH, the inhibitory effect of zinc also increases. The pH of semen is slightly alkaline and the concentrations of zinc are high. On ejaculation, semen is exposed to the acidic pH of the  vagina , due to the presence of  lactic acid . In fertile couples, the final vaginal pH after coitus approaches the 6-7 levels, which coincides well with reduced zinc inhibition of PSA. At these pH levels, the reduced PSA activity is countered by a decrease in zinc inhibition. Thus, the coagulum is slowly liquefied, releasing the sperm in a well-regulated manner. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13176", "text": "Prostate-specific antigen (PSA, also known as kallikrein III, seminin, semenogelase, \u03b3-seminoprotein and P-30 antigen) is a 34- kD   glycoprotein  produced almost exclusively by the  prostate gland . It is a  serine protease  ( EC   3.4.21.77 )  enzyme , the  gene  of which is located on the 19th  chromosome  (19q13) in humans. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13177", "text": "The discovery of prostate-specific antigen (PSA) is beset with controversy; as PSA is present in prostatic tissue and semen, it was independently discovered and given different names, thus adding to the controversy. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13178", "text": "Flocks was the first to experiment with antigens in the prostate [ 30 ]  and 10 years later  Ablin  reported the presence of precipitation antigens in the prostate. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13179", "text": "In 1971, Mitsuwo Hara characterized a unique protein in the semen fluid, gamma-seminoprotein. Li and Beling, in 1973, isolated a protein, E1, from human semen in an attempt to find a novel method to achieve fertility control. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13180", "text": "In 1978, Sensabaugh identified semen-specific protein p30, but proved that it was similar to E1 protein, and that prostate was the source. [ 34 ]  In 1979, Wang purified a tissue-specific antigen from the prostate ('prostate antigen'). [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13181", "text": "PSA was first measured quantitatively in the blood by Papsidero in 1980, [ 36 ]  and Stamey carried out the initial work on the clinical use of PSA as a marker of prostate cancer. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13182", "text": "PSA is normally present in the  blood  at very low levels. The  reference range  of less than 4 \u00a0 ng/mL for the first commercial PSA test, the Hybritech Tandem-R PSA test released in February 1986, was based on a study that found 99% of 472 apparently healthy men had a total PSA level below 4 \u00a0 ng/mL. [ 37 ] [ 38 ] [ 39 ] [ 40 ] [ 41 ] [ 42 ] [ 43 ] [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13183", "text": "Increased levels of PSA may suggest the presence of prostate cancer. However, prostate cancer can also be present in the complete absence of an elevated PSA level, in which case the test result would be a  false negative . [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13184", "text": "Obesity  has been reported to reduce serum PSA levels. [ 46 ]  Delayed early detection may partially explain worse outcomes in obese men with early prostate cancer. [ 47 ]  After treatment, higher BMI also correlates to higher risk of recurrence. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13185", "text": "PSA levels can be also increased by  prostatitis , irritation,  benign prostatic hyperplasia  (BPH), and recent ejaculation, [ 49 ] [ 50 ]  producing a  false positive  result. Digital  rectal examination  (DRE) has been shown in several studies [ 51 ] [ 52 ] [ 53 ] [ 54 ]  to produce an increase in PSA. However, the effect is clinically insignificant, since DRE causes the most substantial increases in patients with PSA levels already elevated over 4.0 \u00a0 ng/mL. PSA levels are higher during the summer than during the rest of the year. [ 55 ] [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13186", "text": "The \"normal\"  reference ranges  for prostate-specific antigen increase with age, as do the usual ranges in cancer (per associated table). [ 57 ] [ 58 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13187", "text": "Despite earlier findings, [ 59 ]  recent research suggests that the rate of increase of PSA (e.g. >0.35 \u00a0 ng/mL/yr, the 'PSA velocity' [ 60 ] ) is not a more specific marker for prostate cancer than the serum level of PSA. [ 61 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13188", "text": "However, the PSA rate of rise may have value in prostate cancer prognosis. Men with prostate cancer whose PSA level increased by more than 2.0 \u00a0 ng per milliliter during the year before the diagnosis of prostate cancer have a higher risk of death from prostate cancer despite undergoing  radical prostatectomy . [ 62 ]  PSA velocity (PSAV) was found in a 2008 study to be more useful than the PSA doubling time (PSA DT) to help identify those men with life-threatening disease before start of treatment. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13189", "text": "Men who are known to be at risk for prostate cancer, and who decide to plot their PSA values as a function of time (i.e., years), may choose to use a  semi-log plot . An exponential growth in PSA values appears as a straight line [ 64 ]  on a semi-log plot, so that a new PSA value significantly above the straight line signals a  switch  to a new and significantly higher growth rate, [ 64 ]  i.e., a higher PSA velocity."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13190", "text": "Most PSA in the blood is bound to serum proteins. A small amount is not protein-bound and is called 'free PSA'. In men with prostate cancer, the ratio of free (unbound) PSA to total PSA is decreased. The risk of cancer increases if the free to total ratio is less than 25%. (See graph) The lower the ratio is, the greater the probability of prostate cancer. Measuring the ratio of free to total PSA appears to be particularly promising for eliminating unnecessary  biopsies  in men with PSA levels between 4 and 10 \u00a0 ng/mL. [ 66 ]  However, both total and free PSA increase immediately after ejaculation, returning slowly to baseline levels within 24 hours. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13191", "text": "The PSA test in 1994 failed to differentiate between prostate cancer and benign prostate hyperplasia (BPH) and the commercial assay kits for PSA did not provide correct PSA values. [ 67 ]  Thus with the introduction of the ratio of free-to-total PSA, the reliability of the test has improved. Measuring the activity of the enzyme could add to the ratio of free-to-total PSA and further improve the diagnostic value of test. [ 68 ]  Proteolytically active PSA has been shown to have an anti-angiogenic effect  [ 69 ]  and certain inactive subforms may be associated with prostate cancer, as shown by MAb 5D3D11, an antibody able to detect forms abundantly represented in sera from cancer patients. [ 70 ] \nThe presence of inactive proenzyme forms of PSA is another potential indicator of disease. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13192", "text": "PSA exists in serum in the free (unbound) form and in a complex with  alpha 1-antichymotrypsin ; research has been conducted to see if measurements of complexed PSA are more specific and sensitive biomarkers for prostate cancer than other approaches. [ 72 ] [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13193", "text": "The term prostate-specific antigen is a  misnomer : it is an  antigen  but is not specific to the prostate. Although present in large amounts in prostatic tissue and semen, it has been detected in other body fluids and tissues. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13194", "text": "In women, PSA is found in  female ejaculate  at concentrations roughly equal to that found in male semen. [ 5 ]  Other than semen and female ejaculate, the greatest concentrations of PSA in biological fluids are detected in breast milk and amniotic fluid. Low concentrations of PSA have been identified in the urethral glands, endometrium, normal breast tissue and salivary gland tissue. PSA also is found in the serum of women with breast, lung, or uterine cancer and in some patients with renal cancer. [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13195", "text": "Tissue samples can be stained for the presence of PSA in order to determine the origin of malignant cells that have metastasized. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13196", "text": "Prostate-specific antigen has been shown to  interact  with  protein C inhibitor . [ 76 ] [ 77 ] \nProstate-specific antigen interacts with and activates the vascular endothelial growth factors  VEGF-C  and  VEGF-D , which are involved in tumor  angiogenesis  and in the lymphatic  metastasis  of tumors. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13197", "text": "Sexual health clinics  specialize in the prevention and treatment of  sexually transmitted infections ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13198", "text": "Sexual health clinics are also called  sexually transmitted disease  (STD) clinics ,  sexually transmitted infection (STI) clinics ,  venereal disease (VD) clinics , or  genitourinary medicine  (GUM) clinics . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13199", "text": "Sexual health clinics differ from  reproductive health  and  family planning  clinics. Sexual health clinics offer only some reproductive health services. Reproductive health clinics, such as  Planned Parenthood , offer most of the services of sexual health clinics. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13200", "text": "Sexual health clinics provide some or all of the following: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13201", "text": "Many clinics provide vaccinations to prevent  infections  from the  hepatitis A  and  B   viruses . [ 1 ] \nYoung women may receive vaccinations to prevent infection from some strains of the  human papillomavirus  (HPV). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13202", "text": "Many clinics provide  interpreting  for the hearing impaired or speakers of other languages. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13203", "text": "Many clinics will help patients tell their sexual contacts if they have a sexually transmitted infection, anonymously if needed. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13204", "text": "Public governmental and  non-profit  clinics often provide services for free or adjust the fee based on a patient's ability to pay.\nSexual health clinics often offer services without appointments. Some clinics open evenings or weekends. Some clinics have separate hours or facilities for men and women. Some clinics serve only specific populations such as women, men,  MSM ,  youths ,  LGBT , ethnic groups, the poor, or students. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13205", "text": "With the patient's  consent , a  clinician  will inspect the patient visually and by touch. If needed, the clinician will take samples to  test  for  sexually transmitted infections . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13206", "text": "In a private room or space, the patient will partially undress. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13207", "text": "The clinician may inspect the patient's: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13208", "text": "The clinician may swab the patient's:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13209", "text": "The clinician may take small blood samples by  pricking a finger  or from a  vein [ 4 ]  to test for  HIV ,  syphilis , and possibly  herpes [ 5 ]  and  hepatitis C . [ 6 ] [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13210", "text": "The clinician may ask for a small  urine  sample, given in private, to test for  chlamydia  and possibly  gonorrhea .\nThe inspections and taking samples do not hurt, but swabbing the urethra and cervix, and a finger prick blood sample feel uncomfortable.\nWomen will often receive a  pelvic exam , both external and internal, but usually less thorough than a reproductive health exam.\nA patient can choose a female or male clinician if available.\nA patient can have a  chaperone .\nSome clinics have separate hours or facilities for men and women. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13211", "text": "Medical  confidentiality  is an important part of the  medical ethics  of a  doctor\u2013patient relationship . Sexual health clinics follow local standards of medical confidentiality to protect the privacy of patients. Some clinics provide anonymous services or protect confidentiality by having a patient use a number or a pseudonym. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13212", "text": "Additional privacy protections sometimes apply to matters of sexuality and reproduction, since these areas are sensitive in many cultures. The  diagnosis of HIV/AIDS  has legal restrictions in patient confidentiality, and some clinics use  rapid antibody tests  to provide results to a patient within 30 minutes, without holding the patient's records. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13213", "text": "In the United States, clinics receiving federal funding from  Medicaid  or  Title X  of the  Public Health Service Act  must treat all patients confidentially. Thus minors can receive services without parental notification or consent. [ 10 ] [ 11 ] [ 12 ]  Additionally, medical records for all patients age 18 and above are strictly confidential under  HIPAA . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13214", "text": "Medical standards of  informed consent  apply to sexual health clinics. A patient needs information about the purposes and consequences of examinations, tests, treatments, and other procedures. A patient may then choose whether to consent to these procedures. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13215", "text": "A  minor  may consent to receive some or all of the procedures at many sexual health clinics. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13216", "text": "In  physiology ,  splay  is the difference between urine threshold (the amount of a substance required in the  kidneys  before it appears in the  urine ) and saturation, or T M,  where saturation is the exhausted supply of  renal  reabsorption carriers. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  In simpler terms, splay is the concentration difference between a substance's maximum renal reabsorption vs. appearance in the urine. [ 6 ]  Splay is usually used in reference to glucose; [ 1 ]  other substances, such as  phosphate , have virtually no splay at all."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13217", "text": "The splay in the glucose titration curve is likely a result of both anatomical and kinetic difference"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13218", "text": "One study found that glucose reabsorption exhibited low splay and another also found that the  titration curves  for glycine showed a large amount of splay whereas those for lysine showed none [ 13 ]  and the kinetics of carrier-mediated glucose transport possibly explains the level of splay in renal titration curves. As splay can be clinically important, patients with proximal tubule disease, mainly caused by hereditary nature and often in children, have a lower threshold but a normal Tm. Therefore, splay is suggested, probably because \"some individual cotransporters have a low glucose affinity but maximal transport rate (renal glycosuria). [ 14 ]  Studies also show that if  sulfate  is reabsorbed by a Tm-limited process, it will have low splay and, in animals, the limits of  citrate  concentration normal in the body, citrate titration curves show a large amount of splay therefore a Tm for citrate reabsorption may actually happen. Also, tubular transport is Tm-limited and the reabsorption mechanism being saturated at a plasma concentration more than 20 times than usual shows a low level of splay. [ 13 ]  Renal abnormalities of glucose excretion, causing  glycosuria , [ 15 ]  may happen as either a result of reduced Tm for glucose or because of an abnormally wide range of nephron heterogeneity so splay of the glucose excretion curve is increased. [ 16 ] [ 17 ]  Two causes are also listed for splay: \"heteroginicity in glomerular size, proximal tubular length and number of carrier proteins for glucose reabsorption\" and variability of TmG nephrons. [ 18 ]  Splay also occurs between 180 and 350\u00a0mg/dL\u00a0%. [ 18 ] [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13219", "text": "The  St Paul's Medal , established by British urologist  Richard Turner-Warwick  in 1989, is awarded annually by the  British Association of Urological Surgeons  (BAUS) for contributions to the surgical field of  urology  by a person from outside of the United Kingdom. Awardees include  Mohamed Ghoneim ,  Mark Soloway ,  Anthony J. Costello ,  Culley C. Carson III ,  Indy Gill , and  Mani Menon . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13220", "text": "The  St Peter's Medal  is awarded annually by the  British Association of Urological Surgeons  (BAUS) for contributions to the surgical field of  urology ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13221", "text": "The medal was designed and produced by sculptor  William Bloye  of the  Birmingham School of Art  and presented to the BAUS in 1948 by  Bernard Joseph Ward , the BAUS's first vice-president. The first medal was awarded in 1949 to  J. B. Macalpine  who was the first to report bladder cancers associated with the  dye  industry. St Peter on the medal is identified by a key engraved on the bible that he holds. On the reverse is a  laurel wreath  within which the recipient's name is engraved, and around the circumference are the names of  Edwin Hurry Fenwick ,  Peter Freyer  and  John Thomson-Walker ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13222", "text": "The St Peter's Medal was designed and produced by sculptor  William Bloye  of the  Birmingham School of Art , for the purpose of being awarded to a person who has made significant contributions to the field of  urology  and is a member of the  British Isles  or  Commonwealth . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13223", "text": "The stamping die for the medal was presented to the  British Association of Urological Surgeons  (BAUS) in 1948 by  Bernard Joseph Ward , the BAUS's first vice-president and urologist at Queen Elizabeth Hospital. [ 2 ] [ 3 ] [ 4 ]  The first medal was awarded in 1949 to  J. B. Macalpine  who first reported bladder cancers associated with the  dye  industry. [ 5 ] [ 6 ]  It has subsequently been awarded annually by the BAUS, usually to one recipient, apart from 1951, 1999, 2005, 2006, 2007 and 2014, when there were two recipients. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13224", "text": "The medal is engraved with the names of the three teachers who influenced Bernard Ward:  Edwin Hurry Fenwick ,  Peter Freyer  and  John Thomson-Walker . [ 4 ]  On presenting the medal in 1948, Ward stated in his speech that \"although they were individually attached to other hospitals, they all came together in one hospital,  St. Peter's ; and the suggestion therefore was that in order to honour all three of them, we should call it the St. Peter's Medal. [ 4 ]  The hospital, the first urological hospital in Britain, was named after  Saint Peter , whose name derives from the Latin for rock,  petrus , and who was said by Christ to be the foundation upon which the Christian church was to be constructed. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13225", "text": "St Peter on the medal is identified by the iconography of a key engraved on the bible that he holds. [ 4 ]  On the reverse of the medal is a  laurel wreath , within which the recipient's name is engraved, and around the wreath are the names of Fenwick, Freyer and Thomson-Walker. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13226", "text": "In 1951, the medal was presented for the second time, and for the first time to two recipients, when  Ronald Ogier Ward  and  Terence J. Millin were given the award . [ 9 ]  In 1959 the medal was awarded to  Harold H. Hopkins , a physicist, [ 10 ]  and in 2006 to  Alison Brading , a physiologist. [ 11 ]  Other recipients have included  Sir Michael Woodruff ,  Richard Turner-Warwick ,  John Wickham ,  Howard Kynaston ,  Geoffrey Chisholm ,  John M. Fitzpatrick ,  Roger Kirby  and  Prokar Dasgupta . [ 2 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13227", "text": "In 1975 the  International Medical Society of Paraplegia  proposed to offer a similar award based on the BAUS's St Peter's Medal. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13228", "text": "Summer penile syndrome  (also known as 'Lions Mane Penis') [ 1 ]  is a seasonal pediatric medical condition characterized by redness, swelling ( edema ), and itching ( pruritus ) of the penile skin. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13229", "text": "Summer penile syndrome is usually caused by  chigger  bites on the penis, or, more rarely by exposure of the genital region to plants like poison ivy, sumac, and oak. [ 2 ] [ 3 ]  The majority of cases occur in the summer months, with the clothing associated with warmer weather making penis-arachnid and penis-plant contact more likely. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13230", "text": "First line treatments for Summer penile syndrome include oral  antihistamines  and  cold compresses . In extreme cases where the sufferer is in severe pain or is unable to pass urine, systemic  corticosteroids  are considered. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13231", "text": "This cutaneous condition article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13232", "text": "Tubular fluid  is the fluid in the  tubules  of the  kidney . It starts as a  renal ultrafiltrate  in the  glomerulus , changes composition through the  nephron , and ends up as  urine  leaving through the  ureters ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13233", "text": "The composition of tubular fluid changes throughout the nephron, from the  proximal tubule  to the  collecting duct  and then as it exits the body, from the ureter."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13234", "text": "A  ureteric balloon catheter  is a  balloon catheter  intended for treating  strictures of the ureter . In fact it is a  double J stent  on which a balloon is mounted. It is connected to a delivery device (pusher) to introduce it from the  bladder  into the  ureter .\nThe system comprises a non-return valve device, and a pusher with a stylet and two ports. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13235", "text": "The side port is for injecting  contrast agent  to inflate the balloon, while the straight port is for the guidewire. The catheter has a relatively large-diameter central lumen and a shaft of 2\u00a0mm (6 Fr.). The balloon is in two sections: a long narrow section or shaft and a larger cranial bulb. The larger cranial bulb prevents distal migration, while the longer narrow section maintains the increased diameter of a predilated stricture in the ureter section."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13236", "text": "A guide wire has to be placed in the ureter. After dilatation of the ureteric stricture with a high pressure dilatation balloon the guidewire remains in place to bring in the ureteric balloon catheter. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13237", "text": "The balloon is inflated by an injection of contrast medium via side port of the pusher and remains in situ while the expanded  urothelium  heals. The stylet is used to detach the balloon catheter from the pusher. During the healing process urine drains through the wide central lumen while the balloon remains inflated. The ureteric balloon catheter may be used in conjunction with a  double J stent  for additional drainage. To remove the catheter after several weeks the balloon is deflated by snipping the distal end of the catheter.\nThe catheter can then safely be pulled out. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13238", "text": "The ureteric balloon catheter is intended to cure two major types of diseases:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13239", "text": "An intervention according to this Overtoom procedure is significantly less invasive than the alternative treatments. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13240", "text": "The balloon is not intended to be used in case of obstructions by stones or  malignancies . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13241", "text": "Ureteric stricture (ureteral stricture)  is the  pathological  narrowing of the  ureter  which may lead to serious complications such as  kidney  failure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13242", "text": "Several conditions have been identified to cause  strictures  such as impacted ureteric stones,  iatrogenic  injuries, tumours and radiotherapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13243", "text": "Endoscopic   urological  procedures are common with the advancement of medical  technology  which allows endoscopic procedures to be among the main operative modalities in  urology . However,  complications  can occur, and iatrogenic injury is disruption of healthy tissue which might lead to local  inflammation  in the process of healing and scarring which can result in ureteric stricture."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13244", "text": "Non-endoscopic open surgical procedures such as colon surgery where the operation field is very close to the adjacent retro peritoneal  ureter is a well-known procedure where ureters can be injured, especially when surgical plans are distorted in conditions such as tethered  colon cancer  or advanced  inflammatory bowel disease . In the same way  gynaecological  operations near the ureters can lead to their injury, one of the common conditions where surgical plans are not clear is the presence of advanced  endometriosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13245", "text": "Radiotherapy  had been identified as a cause of ureteric strictures formation. Damage occur as a result of both direct and indirect insults such as direct injury to  cell  proteins and  DNA  or  mutation  of the DNA which leads to future insults respectively. [ 1 ]  This is not surprising as in the same way radiotherapy is expected to treat cancer and hence collateral damage can occur hence  it can be challenging to treat as blood supply and vascularity are believed to be affected when stricture repair is intended. [ 2 ]  For instance, Radiotherapy of  cervical cancer  can cause ureteric stricture in 2.2% of patients at 10 years. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13246", "text": "Radiotherapy had been identified as a modality of treatment of several cancers in the pelvis and the abdomen which may lead to ureteric stricture formation among other urological adverse effects too such as radiation induced  cystitis . Among those cancers are; / colon  and  Anorectal  cancer,  cervical cancer ,  endometrial cancer  and  prostate cancer ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13247", "text": "Kidney stones  are becoming more common with time, and their incidence is believed to increase recently due to unhealthy diet habits. The passage of kidney stones into ureters might lead to their impaction and the development of local  inflammatory process  around the stone in addition to the obstruction of the  ipsilateral  kidney and build up of pressure manifested as hydronephrosis. Several studies were conducted to find stricture rates which varies from one to another but it seems that modern technology and treatment approaches are minimising the chances for stricture development post impacted stone treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13248", "text": "The  symptoms  of ureteric stricture varies from one patient to another, onset;  acute  or  chronic , mode of injury or concurrent complications play a significant role as most other conditions. It can be associated with  ipsilateral  (same side) kidney obstruction and  hydronephrosis , hence loin pain resulting from hydronephrosis and building up of pressure in the renal pelvis from obstructed urine flow which leads to its statics and pain."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13249", "text": "Other symptoms related to ureteric strictures can be those related to complications such as recurrent UTI."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13250", "text": "Ureteric strictures can be diagnosed using both imaging modalities and under direct vision through endoscopic procedures such as  Ureteroscopy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13251", "text": "Several  radiological studies  can be used to detect such a stricture.  Ultrasound Scans  can show signs of obstruction such as  hydronephrosis , while a  CT scans  can show the same and can locate the stricture or narrowing especially if used with  contrast  (CT Urogram), it can delineate other  pathologies  that might contribute to stricture such as  Tumours  or impacted stones."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13252", "text": "Nuclear imaging  plays a significant role to diagnose difficult cases and to evaluate the ipsilateral  kidney function , such as  MAG3  studies. Dynamic imaging are well known to play an essential diagnostic rule too such as  Whitaker test . Overall, national and local guidelines, surgeon preferences and availability of the diagnostic modality plays a rule in choosing the diagnostic modalities used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13253", "text": "Treatment of ureteric strictures varies from one patient to another depending on the level, cause and extent of stricture in addition to patient factors such as comorbidities and preferences. Treatment options include  minimally invasive   palliative  procedures such as  Nephrostomy  tube insertion or  ureteric stents  insertion or  ureteral balloon  catheter dilatation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13254", "text": "Various surgical techniques are employed to restore urine flow or repair damaged ureters when conservative treatments are insufficient. These reconstructive procedures address issues such as obstructions, trauma, surgical injury, or diseases that compromise the integrity of the urinary tract. The choice of technique depends on the nature and extent of the damage, the location of the ureteral defect, and the patient\u2019s overall condition. [ 4 ]  Procedures such as  Rendez-vous  and  reconstructive surgeries  such as  flaps  or using  ileum [ 5 ]  to reconstruct ureters are used and had various success rates. Ureter reimplantation, for example, repositions the ureters to correct flow abnormalities. Surgical techniques such as the psoas hitch procedure involve mobilizing the bladder to bridge a gap in the ureter by securing it to the psoas muscle for added stability. [ 6 ]  The Boari flap technique reshapes part of the bladder wall into a tube to replace a damaged ureter segment, while appendiceal ureter interposition uses the appendix as a substitute for the ureter. For more extensive reconstruction, the ileal ureter approach repurposes a segment of the small intestine (ileum) to create a new channel for urine flow, often draining into an external pouch."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13255", "text": "Technology is driving more hope finding more treatment options, laparoscopic assisted robotic techniques are developing and been reported while  tissue engineering  for reconstruction is not developed yet as it is in other urological reconstruction topics. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13256", "text": "A  ureterosigmoidostomy  is a  surgical  procedure wherein the  ureters , which carry urine from the  kidneys , are diverted into the  sigmoid colon . It is performed as a secondary treatment in  bladder cancer  patients who have undergone  cystectomy . Rarely, the cancer can present in children between the ages of 2 & 10 years old as an aggressive  rhabdomyosarcoma , although there have been diagnoses of children as young as 3 months old. The procedure was also used several decades ago as a correctional procedure for patients born with  bladder exstrophy . In the case of some bladder exstrophy patients, occasional bowel  incontinence  (in this case, a mixture of urine and feces similar to diarrhea) at night is one uncontrollable consequence. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13257", "text": "Another consequence of this procedure is an increased risk of kidney infections ( nephritis ) due to  bacteria  from  faeces  travelling back up the ureters (reflux). Patients are commonly put on oral prophylactic antibiotics to combat infections in the ureteral tract and kidneys, but this can lead to tolerance of the antibiotic. Consequently, the patient can build up tolerance to a large number of oral antibiotics, leading to the need for inpatient administration of IV (intravenous) antibiotics. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13258", "text": "Additionally, the urine entering the colon can cause diarrhea and salt imbalance due to the  sodium  and  chloride  in the urine.  Urea  levels in the  blood  are higher due to urea crossing the colon wall. In the  large intestine , sodium is swapped for  potassium , and chloride for  bicarbonate . This causes  hypokalaemia  and  acidosis . Many patients take sodium bicarbonate to combat this. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13259", "text": "Patients with ureterosigmoidostomy have a 100 times greater chance of developing  carcinoma of the colon  after living with the modification for a number of years (an average of 20\u201330 years after the operation), 24% of patients go on to develop carcinoma of the bowel. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13260", "text": "This operation is no longer popular in many countries, with an  ileal conduit  (where the ureters lead into a loop of  small intestine ) being preferred. However, ureterosigmoidostomy is still popular in developing countries, as the maintenance of an ileal conduit or catheter is seen to be more difficult. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13261", "text": "A  urethral bulking injection  is a gynecological procedure and medical treatment used to treat involuntary leakage of urine: urinary incontinence in women. Injectional materials are used to control stress incontinence. Bulking agents are injected into the mucosa surrounding the bladder neck and proximal urethra. This reduces the diameter of the urethra and creates resistance to urine leakage. After the procedure, the pressure forcing the urine from the bladder through the urethra is resisted by the addition of the bulking agent in the tissue surrounding the proximal urethra. Most of the time this procedure prevents urinary stress incontinence in women."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13262", "text": "A urethral bulking injection is one type of treatment for  incontinence  in women. Urethral bulking injections are considered by a  clinician  when the woman has  urinary sphincter  dysfunction,  urethral hypermobility , persistent stress urinary incontinence after a  urethral sling  or urethropexy, or stress urinary incontinence in women who cannot undergo surgery due to other illnesses or conditions. It restores the ability to retain urine during coughing, laughing and other normal occurrences that increase inter-abdominal pressure [ 1 ]  Some women choose to have urethral bulking injections because they wish to avoid surgery or the use of mesh material. Another reason other treatments may not be chosen include the desire to maintain fertility. Woman who benefit most from this treatment are those who have a stable bladder neck and an inadequate muscle strength of the sphincter muscles that close the urethra. Urethral instability is identified by the angle of the urethra. This can be evaluated when the woman lies on her back and the angle of the urethral is greater than 30\u00b0 during coughing. Tests are performed to confirm the diagnosis of stress urinary incontinence such as the bladder capacity to hold urine and the strength of the bladder muscle contractions. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13263", "text": "Diagnosis is aided before the procedure by a thorough evaluation of the woman. Information that is gathered prior to the injection includes consists of a medical history and physical exam. The residual, postvoid residual urine determination and urinalysis and urine culture help in the diagnosis. The surgeon will ask the woman to keep a diary of urine output and frequency. The physician may order a urodynamic evaluation to establish the diagnosis of intrinsic sphincter deficiency. A voiding diary and/or a measured voided volume gives an estimate of bladder capacity. A free-flow uroflowmetric examination gives additional information about flow rate, voided time and volume. A cystometrogram will evaluate detrusor over-activity, bladder compliance, bladder capacity, and abdominal (Valsalva) leak pressure. Another diagnostic tool is the urethral pressure profile. This measures the maximum urethral closure strength. The physician will use instrumentation and do a visual examination called a urethroscopic visualization. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13264", "text": "A woman may not be a good candidate for the procedure. Contraindications for this treatment are having a current urinary tract infection, having difficulty emptying the bladder, having a urethral stricture, having a urethral obstruction or having fragile or sensitive tissue where the injections are to be placed. In some women, cancer treatments may have created changes in the urethra, bladder and sphincter muscles which would prevent the success of the treatment. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13265", "text": "These are the most popular urethral bulking agents in the United States [ as of? ]  now that Contigen is no longer available. The ideal bulking material should be non allergic, tissue friendly, not migrate and be long-lasting. However, this has not been found, and despite a prolonged search, nothing financially feasible as yet appeared to be better than the available bulking agents. Urolastic is a new injectable product that seems to be a good candidate to become the ideal product for a minimal invasive and outpatient treatment of stress urinary incontinence since it is not degraded by the body and maintains form. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13266", "text": "Urethral bulking agents were first used in 1938 and incorporated morrhuate sodium as the injection material. Bovine collagen use began after 1989 and was considered the best example of treatment. All subsequent studies afterwards were compared with this agent. Its use was stopped in 2011. Other bulking agents have been in use since the 1990s. The use of some was discontinued due to complications, the 'unpleasantness' of the procedure and the cost of the procedure. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13267", "text": "Improved materials continue to be investigated. A successful bulking agent should be readily available, non-inflammatory, easy to inject, easy to prepare, efficacious, durable, inexpensive, biocompatible, nonimmunological, long-lasting, non-migrating (the size of the particles should be larger than 80 \u03bcm)   adult stem cell injection therapy using autologous muscle-derived stem cells for the regenerative repair of an impaired sphincter is currently at the forefront of incontinence research. The implanted cells fuse with muscle and release trophic factors promoting nerve and muscle integration. Small pilot studies have suggested restoration of the urethral sphincter over several months' time. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13268", "text": "Urethral hypermobility  is a condition of excessive movement of the female  urethra  due to a weakened urogenital diaphragm. It describes the instability of the urethra in relation to the pelvic floor muscles. A weakened  pelvic floor muscle  fails to adequately close the urethra and hence can cause stress  urinary incontinence . This condition may be diagnosed by primary care providers or urologists. Treatment may include  pelvic floor muscle exercises , surgery (e.g.  urethral sling ), or minimally invasive procedures (e.g.  urethral bulking injections ). [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13269", "text": "The urethra is held in place in relationship to the  pelvic bones  and  bladder  by a combination of ligaments, pelvic floor muscles, and surrounding connective tissue known as the urogenital diaphragm. Damage to any of these structures, or the nerves that control them can cause the urethra to be displaced from its normal position or to have increased range of motion. This can result in lack of effective closure of the urethra and thus urinary leakage, especially when pressure from the abdomen is increased during physical exertion and cough, sneeze, or  valsalva maneuvers . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13270", "text": "Changes during pregnancy and physical trauma during childbirth can cause damage to the pubosacral ligament, uterosacral ligament, and pelvic floor muscles, and the connection of the pubic bone itself. Any of these changes may contribute to urethral hypermobility. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13271", "text": "Males have a lower incidence of urethral hypermobility than females, but  prostatectomy  is one risk factor urethral hypermobility and stress incontinence. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13272", "text": "Urethral hypermobility is often diagnosed indirectly by achieving a diagnosis of stress urinary incontinence. This could include ruling out other types of incontinence and other abnormalities, and specific tests for stress incontinence, for example testing for urinary leakage during cough. Specialized testing to further characterize the degree of urethral hypermobility may include  urodynamic testing ,  voiding cystourethrography ,  pelvic ultrasound , and  electromyography . [ 5 ]  These modalities are only recommended for people who experience ongoing symptoms despite an adequate trial of pelvic floor muscle training. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13273", "text": "The first line treatment for urethral hypermobility is  pelvic floor exercises  under supervision of a  physical therapist . However, there is no consensus on which training regiments are most effective, and studies have not determined which mechanisms improve the function of the pelvic floor muscles (e.g. improving reflex action of muscles in response to abdominal pressure vs. increasing urethral closing pressure). [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13274", "text": "Loss of 5-10% of weight has been shown to result in mild improvement in symptoms that was persistent across follow-up periods of 1-3 years. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13275", "text": "Duloxetine  is a medication in the  Serotonin\u2013norepinephrine reuptake inhibitor  class which is approved in Europe for treatment of stress urinary incontinence and used  off-label  in America for the treatment of stress urinary incontinence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13276", "text": "Several surgical procedures are available to treat urethral hypermobility. These procedures use combinations of sutures, implanted synthetic mesh, and  autotransplanted  tissue to support and reposition the urethra in relation to the pubic bone and other pelvic structures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13277", "text": "Surgical meshes have come to the public attention due to safety concerns with  vaginal mesh used to treat pelvic organ prolapse , however, the urethral sling surgeries have been demonstrated to be highly effective with low risk of adverse events. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13278", "text": "Urethral bulking involves injecting an inert material into the wall of the urethra to relieve the symptoms of urethral hypermobility. This technique is less invasive than surgery with lower risk of adverse events, however it has a lower cure rate for stress incontinence than other methods. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13279", "text": "Lifestyle interventions such as limiting water intake and scheduling urination are not proven to be effective. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13280", "text": "Stem-cell therapy  and  Electrical muscle stimulation  are being explored to assist regeneration of damaged tissue and muscle growth in the urogenital diaphragm. These trials have been explored in animals  in vivo  and  In vitro  studies, but have not yet been explored in humans. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13281", "text": "A  urethral sling  is a device that is surgically implanted to stabilize the pelvic tissues and organs of women. The surgery that implants this device can help treat  urinary incontinence  and uterine prolapse. An alternative treatment to the placement of the urethral sling is  urethral bulking injections . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13282", "text": "Urinary anti-infective agent , also known as urinary  antiseptic , is medication that can eliminate  microorganisms  causing  urinary tract infection  (UTI). UTI can be categorized into two primary types:  cystitis , which refers to lower urinary tract or bladder infection, and  pyelonephritis , which indicates upper urinary tract or kidney infection. [ 1 ] \n Escherichia coli  (E. Coli) is the predominant microbial trigger of UTIs, accounting for 75% to 95% of reported cases. Other  pathogens  such as  Proteus mirabilis ,  Klebsiella pneumoniae , and  Staphylococcus saprophyticus  can also cause UTIs . [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13283", "text": "The use of antimicrobial therapy to treat UTIs started in the 20th century.  Nitrofurantoin ,  trimethoprim-sulfamethoxazole  (TMP/SMX),  fosfomycin , and  pivmecillinam  are currently the first-line agents for  empiric therapy  of simple cystitis. [ 4 ]  On the other hand, the choice of empiric antimicrobial therapy for pyelonephritis depends on the severity of illness, specific  host factors , and the presence of resistant bacteria.  Ceftriaxone  is often considered for  parenteral treatment , while oral or parenteral  fluoroquinolones , such as  levofloxacin  and  ciprofloxacin , are suitable alternatives for treating pyelonephritis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13284", "text": "Antimicrobial therapy  should be tailored to the individual, considering factors like the severity of illness, specific host factors, and  pathogen resistance  in the local community. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13285", "text": "Urinary antiseptics are medications that target bacteria in the urinary tract. [ 6 ]  They can be divided into two groups:  bactericidal  agents, and  bacteriostatic  agents. These antiseptics help prevent infections by effectively eliminating UTI symptoms through their action on microorganisms. [ 7 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13286", "text": "Nitrofurantoin  is regarded as the first-line agent for simple  cystitis , with an efficacy rate ranging from 88% to 92%. [ 9 ]  It can also be a prophylactic agent to prevent long-term UTIs. [ 10 ]  This antibacterial medication is effective against both  gram-positive  and  gram-negative bacteria . [ 11 ]  Nitrofurantoin exhibits its bactericidal activity through various mechanisms, including inhibiting  ribosomal   translation , causing bacterial  DNA damage  and interfering with the  citric acid cycle . However, the specific role of each mechanism remains to be further explored. [ 9 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13287", "text": "When nitrofurantoin is metabolized, it converts into a reactive intermediate that attacks bacterial  ribosomes , inhibiting bacterial protein synthesis. [ 9 ] [ 11 ]  This medication is typically taken orally and has minimal systemic absorption, reducing potential side effects. [ 12 ]  Common adverse reactions associated with nitrofurantoin include brown urine discoloration, nausea, vomiting, loss of appetite, rash, and  peripheral neuropathy . [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13288", "text": "Fosfomycin  is a  phosphonic acid  bactericidal agent. It is commonly used as the first-line treatment for acute simple cystitis, demonstrating a 91% cure rate. [ 4 ] [ 9 ]  It is administered orally as a single dose; In more complicated UTIs, the dose is adjusted to be repeated every three days to achieve successful eradication. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13289", "text": "The bactericidal effect of fosfomycin is attributed to its capability to inhibit bacterial wall synthesis by inactivating an enzyme called  pyruvyl transferase , which is responsible for microbial cell wall synthesis. [ 9 ]  Fosfomycin acts against gram-positive and  gram-negative  bacteria. Administration of fosfomycin may lead to side effects such as headache, dizziness,  nausea , vomiting, and abdominal cramps. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13290", "text": "Beta-lactam antibiotics  are often considered as a second-line option for treating UTIs due to their lower effectiveness compared to other antibiotics and their potential adverse effects. [ 14 ] [ 15 ]  Commonly used beta-lactam antibiotics for UTIs include  cephalosporins  and  penicillin . By binding to penicillin-binding proteins through their beta-lactam rings, beta-lactam antibiotics disrupt the normal function of these proteins, inhibiting bacterial  cell wall  synthesis, ultimately resulting in cell death. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13291", "text": "Cephalosporins are a subclass of beta-lactam family with broad-spectrum activity against gram-positive and gram-negative bacteria. [ 12 ]  They are categorized into five generations. [ 16 ]  First and third-generation cephalosporins, like  cefalexin  and ceftriaxone, are more commonly used in clinical practice. [ 17 ]  \u00a0Common adverse effects associated with cephalosporins include  hypersensitivity , rash,  anaphylaxis , and  seizures . [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13292", "text": "Penicillin is another widely used subclass that effectively targets various bacteria. [ 18 ]  However, it is not regarded as the first-line treatment for uncomplicated cystitis because of the high prevalence of penicillin-resistant E. coli strains. [ 12 ]  Within the penicillin class, pivmecillinam is considered the first-line empiric treatment for acute cystitis due to its wide spectrum of activity against gram-negative bacteria and its specific efficacy in the urinary tract. It has consistently demonstrated a high cure rate of over 85% for UTIs and a low resistance rate among E. coli strains. [ 4 ] [ 19 ] [ 20 ]  Amoxicillin-clavulanate combination, which enhances the effectiveness of  amoxicillin , is often used as an alternative for cystitis treatment when other options cannot be used. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13293", "text": "Fluoroquinolones  are a class of antimicrobial agents known for their high efficacy and broad spectrum activity against aerobic gram-positive and gram-negative bacteria. [ 12 ] [ 22 ]  These potent antibiotics exert their bactericidal effects by selectively inhibiting the activity of  type II DNA topoisomerases , which effectively halt the replication of bacterial DNA, leading to bacterial death. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13294", "text": "Among the fluoroquinolones,  ciprofloxacin  and  levofloxacin  are used more frequently for the treatment of UTIs. These agents are well-absorbed orally and achieve significant concentrations in urine and various tissues. [ 12 ]  However, fluoroquinolones administration carries risk of GI symptoms, confusion, hypersensitivity,  tendinopathy , and  neuropathy . [ 23 ]  Additionally, the extensive use of fluoroquinolones has contributed to the prevalence of antimicrobial resistance in some areas. As a result, fluoroquinolones are generally reserved for more serious UTIs or when there are no better anti urinary-infective agent options. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13295", "text": "Sulfonamide is a bacteriostatic agent that competitively inhibits the bacterial enzyme  dihydropteroate synthase . By acting as a substrate analog of  para-aminobenzoic acid , sulfonamide inhibits  folic acid  production. [ 24 ]  TMP/SMX is a combination of two antibacterial agents that work synergistically to combat a wide range of urinary tract pathogens. [ 25 ]  TMP/SMX is commonly used due to its ability to achieve high concentrations in urinary tract tissues and urine. This antibiotic combination demonstrates notable efficacy in both the treatment and prophylaxis of recurrent urinary tract infections. [ 12 ]  Common adverse effects include nausea, vomiting, rash, pruritus , and  photosensitivity . [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13296", "text": "Kidney disease  can affect  drug elimination , absorption, and distribution in the body, leading to altered serum drug concentrations. This can increase the risk of drug toxicity or suboptimal therapeutic effects. As a result, dosage adjustments are necessary for patients who fail to achieve the desired therapeutic serum drug levels. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13297", "text": "The choice of urinary anti-infective agents for patients with renal dysfunction is generally similar to that for individuals with normal kidney function. However, in cases where the patient's  glomerular filtration rate  (GFR) decreases to less than 20 mL/min, drug dosages adjustment is necessary because achieving the desired therapeutic serum drug levels becomes challenging in such patients. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13298", "text": "Some drugs need to be used with caution in patients with renal dysfunction. The use of nitrofurantoin is contraindicated in patients with an estimated GFR of less than 30 mL/min/1.73m 2  as drug accumulation can lead to increased side effects and impaired recovery of the urinary tract, increasing the risk of treatment failure. [ 29 ]  The use of TMP/SMX also raises concerns in patients with kidney disease. In patients with creatinine clearance less than 50 mL/min, the urine concentrations of SMX may decrease to subtherapeutic levels. Therefore, in patients with low  creatinine  clearance, it is recommended to prescribe a reduced dosage of TMP alone. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13299", "text": "Pregnant women with UTIs are at a higher risk of experiencing recurrent bacteriuria and developing pyelonephritis compared to non-pregnant individuals. [ 31 ]  Untreated UTIs during pregnancy can lead to adverse outcomes, including  preterm birth  and low birth weight infants. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13300", "text": "Antimicrobial treatment  should be adjusted for UTIs in pregnant women to avoid potential side effects brought to fetus. [ 34 ]  For acute cystitis and pyelonephritis in pregnant women, empiric antibiotic treatment is often initiated. Commonly used antibiotics for uncomplicated cystitis include amoxicillin-clavulanate and fosfomycin, while parenteral beta-lactams are preferred for acute  pyelonephritis . These options are chosen because they are considered safer in pregnancy and have a relatively broad spectrum of activity. Typically, an antimicrobial course of five to seven days is given. This duration is chosen to minimize fetal exposure to antimicrobials while ensuring optimal treatment outcomes. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13301", "text": "The type of urinary anti-infective agents should be carefully chosen for pregnant women with UTIs due to the potential impact on fetal development. Penicillins, cephalosporins, and fosfomycin are safe options during pregnancy. [ 35 ]  Nitrofurantoin is typically avoided during the first trimester due to uncertain associations with  congenital anomalies . [ 36 ]  TMP/SMX should also be avoided as it may be associated with impaired folate metabolism, which increases the risk of  neural tube defects . [ 37 ] [ 38 ]  \u00a0However, when all alternative antibiotics are contraindicated, nitrofurantoin and TMP/SMX become the last resort at the expense of the fetus. [ 39 ]  Fluoroquinolones should be avoided during pregnancy as they are associated with bone and cartilage toxicity in developing fetuses. [ 40 ] [ 41 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13302", "text": "Urinary tract infection in pediatric patients is a significant clinical issue, affecting approximately 7% of fevered infants and children. [ 43 ]  If left untreated, the infection can ascend from the bladder to the kidneys, resulting in acute pyelonephritis, which leads to  hypertension ,  kidney scarring , and  end-stage kidney disease . [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13303", "text": "The choice of urinary anti-infective agents used in pediatric patients and the duration of therapy depend on the types of UTIs they are suffering from. It is important to note that the dosage of antibiotics used in children is typically weight-dependent. Generally, oral or parenteral cephalosporins are recommended as the first-line agent for children older than two months. [ 45 ] [ 46 ]  Second-line therapy should be considered for patients who have poor response to first-line treatment. Alternative choices include amoxicillin-clavulanate, nitrofurantoin, TMP/SMX, and ciprofloxacin. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13304", "text": "For the treatment of simple cystitis in children, a five-day oral course of cephalexin is the preferred choice. As for children with suspected pyelonephritis, a ten-day treatment regimen is recommended. In such cases, a third-generation cephalosporin, such as cefdinir, is suggested as an appropriate option. If second-line therapy is initiated in pediatric patients with suspected pyelonephritis, ciprofloxacin should be the preferred option among the four alternatives. Nitrofurantoin may not be adequate in treating upper urinary tract infections, while TMP/SMX and amoxicillin-clavulanate should be used with caution due to the risk of kidney scarring in these patients. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13305", "text": "The choice of urinary anti-infective agents in pediatric patients may differ from that in adults due to the potential harm they can cause to children. For example, the systemic use of fluoroquinolones is not appropriate in pediatric patients due to the potential risk of musculoskeletal toxicity. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13306", "text": "The discovery of antimicrobial agents contributed significantly to UTI management during the 20th century. Nitrofurantoin emerged as the first practical and safe urinary antimicrobial agent, but it was with limited spectrum of activity. [ 48 ]  Subsequently, in the 1970s,  beta-lactam antibiotics  and TMP/SMX became available for UTI therapy. [ 48 ]   Antimicrobial resistance  was developed to these agents due to their widespread and extensive usage, which restricted their clinical efficacy in UTI management. Fluoroquinolones emerged during the 1980s and were recommended as an alternative when resistance to TMP/SMX reaches 10% or higher. [ 48 ]  The evolving landscape of drug resistance will continue to influence the development and application of antimicrobial agents in UTI therapy. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13307", "text": "In  urinary catheterization , a  latex ,  polyurethane , or  silicone  tube known as a urinary  catheter  is inserted into the  bladder  through the  urethra  to allow  urine  to drain from the bladder for collection. It may also be used to inject liquids used for treatment or diagnosis of bladder conditions. A  clinician , often a  nurse , usually performs the procedure, but self-catheterization is also possible. A catheter may be in place for long periods of time (indwelling catheter) or removed after each use ( intermittent catheterization )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13308", "text": "Catheters come in several basic designs: [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13309", "text": "Catheter diameters are sized by the  French catheter scale  (F). The most common sizes are 10\u00a0F (3.3mm) to 28\u00a0F (9.3mm). The clinician selects a size large enough to allow free flow of urine, and large enough to control leakage of urine around the catheter. A larger size is necessary when the urine is thick, bloody, or contains large amounts of  sediment . Larger catheters, however, are more likely to damage the urethra. Some people develop allergies or sensitivities to latex after long-term latex catheter use making it necessary to use silicone or Teflon types. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13310", "text": "Evidence does not support an important decrease in the risk of  urinary tract infections  when silver-alloy catheters are used. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13311", "text": "Common indications for urinary catheterization include acute or chronic  urinary retention  (which can damage the kidneys) from conditions such as  benign prostatic hyperplasia , orthopedic procedures that may limit a patient's movement, the need for accurate monitoring of input and output (such as in an  ICU ), urinary incontinence that may compromise the ability to heal wounds, and the effects of various surgical interventions involving the bladder, prostate, or bowel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13312", "text": "Intermittent self-catheterization may be indicated in cases of  neurogenic bladder  due to damage to the spinal cord or brain. This can be performed by the patient four to six times a day, using a clean technique. Nurses use a sterile technique to perform intermittent catheterization in hospital settings. For patients with  neurogenic bladder  due to spinal cord injury, intermittent catheterization (IC) is a standard method for bladder emptying. The technique is safe and effective and results in improved kidney and upper urinary tract status, lessening of  vesicoureteral reflux  and amelioration of continence. [ 5 ]  In addition to the clinical benefits, patient quality of life is enhanced by the increased independence and security offered by self-catheterization. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13313", "text": "A catheter that is left in place for more than a short period of time is generally attached to a drainage bag to collect the urine. This also allows for measurement of urine volume. There are three types of drainage bags: The first is a leg bag, a smaller drainage device that attaches by  elastic  bands to the leg. A leg bag is usually worn during the day, as it fits discreetly under pants or skirts, and is easily emptied into a toilet. The second type of drainage bag is a larger device called a down drain that may be used overnight. This device is hung on a hook under the patient's bed\u2014never placed on the floor, due to the risk of bacterial infection. The third is called a belly bag and is secured around the waist. This bag can be worn at all times. It can be worn under the patient's underwear to provide a totally undetectable look."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13314", "text": "During long-term use, the catheter may be left in place all the time, or a patient may be instructed on a procedure for placing a catheter just long enough to empty the bladder and then removing it (known as  intermittent self-catheterization ). Patients undergoing major  surgery  are often catheterized and may remain so for some time. The patient may require irrigation of the bladder with sterile saline injected through the catheter to flush out clots or other matter that does not drain. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13315", "text": "Catheterization can have short and long term complications. Generally long-term catheterization carries higher risk of complications. Long-term catheterization carries a significant risk of  urinary tract infection .  [ citation needed ]  Because of this risk catheterization is a last resort for the management of incontinence where other measures have proved unsuccessful.  [ citation needed ]  Other long term complications may include blood infections ( sepsis ),  urethral injury , skin breakdown,  bladder stones , and blood in the urine ( hematuria ).  [ citation needed ]  After many years of catheter use,  bladder cancer  may also develop.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13316", "text": "Some people experience  bladder spasms  with catheterization, which may be more common in males. If bladder spasms occur, or there is no urine in the drainage bag, the catheter may be blocked by blood, thick sediment, or a kink in the catheter or drainage tubing. Sometimes spasms are caused by the catheter irritating the bladder,  prostate / Skene's glands , or  penis / vulva . Such spasms can be controlled with medication such as  butylscopolamine , although most patients eventually adjust to the irritation and the spasms go away. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13317", "text": "Everyday care of the catheter and drainage bag is important to reduce the risk of infection. Such precautions include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13318", "text": "There is no clear evidence that any one catheter type or insertion technique is superior compared to another in preventing infections or complications. [ 10 ]  In the UK it is generally accepted that cleaning the area surrounding the urethral meatus with 0.9% sodium chloride solution is sufficient for catheterized patients regardless of their genitalia, as there is no reliable evidence to suggest that the use of antiseptic agents reduces the risk of  urinary tract infection . [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13319", "text": "Recent developments in the field of the temporary  prostatic stent  have been viewed as a possible alternative to indwelling catheterization and the infections associated with their use. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13320", "text": "Ancient Egyptian  and  Roman  physicians have been described using  reeds  as urinary catheters to overcome blockages, and catheterization to relieve urinary retention has also been described in ancient Indian and Chinese texts. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13321", "text": "Urination  is the release of  urine  from the  bladder  to the outside of the body. Urine is released through the  urethra  and exits the  penis  or  vulva  through the  urinary meatus  in  placental mammals , [ 1 ] [ 2 ] :\u200a38,\u200a364\u200a  but is released through the  cloaca  in other  vertebrates . [ 3 ] [ 1 ]  It is the  urinary system 's form of  excretion . It is also known medically as  micturition , [ 4 ]   voiding ,  uresis , or, rarely,  emiction , and known colloquially by various names including  peeing ,  weeing ,  pissing , and euphemistically  number one . The process of urination is under voluntary control in healthy humans and  other animals , but may occur as a  reflex  in infants, some elderly individuals, and those with neurological injury. It is normal for adult humans to urinate up to seven times during the day. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13322", "text": "In some animals, in addition to expelling waste material, urination  can mark territory or express submissiveness . Physiologically, urination involves coordination between the  central ,  autonomic , and  somatic nervous systems . Brain centres that regulate urination include the  pontine micturition center ,  periaqueductal gray , and the  cerebral cortex ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13323", "text": "The main organs involved in urination are the  urinary bladder  and the  urethra . The  smooth muscle  of the bladder, known as the  detrusor , is innervated by  sympathetic nervous system  fibers from the  lumbar   spinal cord  and  parasympathetic  fibers from the  sacral  spinal cord. [ 6 ]  Fibers in the  pelvic nerves  constitute the main afferent limb of the voiding reflex; the parasympathetic fibers to the bladder that constitute the excitatory efferent limb also travel in these nerves. Part of the urethra is surrounded by the  male  or  female external urethral sphincter , which is innervated by the somatic  pudendal nerve  originating in the cord, in an area termed  Onuf's nucleus . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13324", "text": "Smooth muscle bundles pass on either side of the urethra, and these fibers are sometimes called the  internal urethral sphincter , although they do not encircle the urethra. Further along the urethra is a sphincter of skeletal muscle, the sphincter of the membranous urethra (external urethral sphincter). The bladder's epithelium is termed  transitional epithelium  which contains a superficial layer of dome-like cells and multiple layers of stratified cuboidal cells underneath when evacuated. When the bladder is fully distended the superficial cells become squamous (flat) and the stratification of the cuboidal cells is reduced in order to provide lateral stretching."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13325", "text": "The physiology of micturition and the physiologic basis of its disorders are subjects about which there is much confusion, especially at the supraspinal level. Micturition is fundamentally a spinobulbospinal reflex facilitated and inhibited by higher brain centers such as the  pontine micturition center  and, like  defecation , subject to voluntary facilitation and inhibition. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13326", "text": "In healthy individuals, the lower urinary tract has two discrete phases of activity: the storage (or guarding) phase, when urine is stored in the bladder; and the voiding phase, when urine is released through the urethra. The state of the reflex system is dependent on both a conscious signal from the brain and the firing rate of sensory fibers from the bladder and urethra. [ 10 ]  At low bladder volumes, afferent firing is low, resulting in excitation of the outlet (the sphincter and urethra), and relaxation of the bladder. [ 11 ]  At high bladder volumes, afferent firing increases, causing a conscious sensation of urinary urge. Individual  ready to urinate consciously initiates voiding, causing the bladder to contract and the outlet to relax. Voiding continues until the bladder empties completely, at which point the bladder relaxes and the outlet contracts to re-initiate storage. [ 10 ]  The muscles controlling micturition are controlled by the  autonomic  and somatic nervous systems. During the storage phase, the internal urethral sphincter remains tense and the detrusor muscle relaxed by  sympathetic  stimulation. During micturition,  parasympathetic  stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. The external urethral sphincter (sphincter urethrae) is under somatic control and is consciously relaxed during micturition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13327", "text": "In infants, voiding occurs involuntarily (as a reflex). The ability to voluntarily inhibit micturition develops by the age of two\u2013three years, as control at higher levels of the central nervous system develops. In the adult, the volume of urine in the bladder that normally initiates a reflex contraction is about 300\u2013400 millilitres (11\u201314\u00a0imp\u00a0fl\u00a0oz; 10\u201314\u00a0US\u00a0fl\u00a0oz)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13328", "text": "During storage, bladder pressure stays low, because of the bladder's highly compliant nature. A plot of bladder (intravesical) pressure against the depressant of fluid in the bladder (called a  cystometrogram ), will show a very slight rise as the bladder is filled. This phenomenon is a manifestation of the  law of Laplace , which states that the pressure in a spherical viscus is equal to twice the wall tension divided by the radius. In the case of the bladder, the tension increases as the organ fills, but so does the radius. Therefore, the pressure increase is slight until the organ is relatively full. The bladder's smooth muscle has some inherent contractile activity; however, when its nerve supply is intact, stretch receptors in the bladder wall initiate a reflex contraction that has a lower threshold than the inherent contractile response of the muscle."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13329", "text": "Action potentials carried by sensory neurons from stretch receptors in the urinary bladder wall travel to the sacral segments of the spinal cord through the pelvic nerves. [ 10 ]  Since bladder wall stretch is low during the storage phase, these afferent neurons fire at low frequencies. Low-frequency afferent signals cause relaxation of the bladder by inhibiting sacral parasympathetic preganglionic neurons and exciting lumbar sympathetic preganglionic neurons. Conversely, afferent input causes contraction of the sphincter through excitation of Onuf's nucleus, and contraction of the bladder neck and urethra through excitation of the sympathetic preganglionic neurons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13330", "text": "Diuresis  (production of urine by the kidney) occurs constantly, and as the bladder becomes full, afferent firing increases, yet the micturition reflex can be voluntarily inhibited until it is appropriate to begin voiding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13331", "text": "Voiding begins when a voluntary signal is sent from the brain to begin urination, and continues until the bladder is empty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13332", "text": "Bladder afferent signals ascend the spinal cord to the  periaqueductal gray , where they project both to the  pontine micturition center  and to the cerebrum. [ 15 ]  At a certain level of afferent activity, the conscious  urge to void  or  urination urgency ,  becomes difficult to ignore. Once the voluntary signal to begin voiding has been issued, neurons in the pontine micturition center fire maximally, causing excitation of sacral preganglionic neurons. The firing of these neurons causes the wall of the bladder to contract; as a result, a sudden, sharp rise in intravesical pressure occurs. The pontine micturition center also causes inhibition of Onuf's nucleus, resulting in relaxation of the external urinary sphincter. [ 16 ]  When the external urinary sphincter is relaxed urine is released from the urinary bladder when the pressure there is great enough to force urine to flow out of the urethra. The micturition reflex normally produces a series of contractions of the urinary bladder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13333", "text": "The flow of urine through the urethra has an overall excitatory role in micturition, which helps sustain voiding until the bladder is empty. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13334", "text": "Many men, and some women, may sometimes  briefly shiver  after or during urination. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13335", "text": "After urination, the  female urethra  empties partially by gravity, with assistance from muscles. [ clarification needed ]  Urine remaining in the  male urethra  is expelled by several contractions of the  bulbospongiosus muscle , and, by some men, manual squeezing along the length of the penis to expel the rest of the urine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13336", "text": "For land mammals over 1 kilogram, the duration of urination does not vary with body mass, being dispersed around an average of 21 seconds (standard deviation 13 seconds), despite a 4 order of magnitude (1000\u00d7) difference in bladder volume. [ 19 ] [ 20 ]  This is due to increased urethra length of large animals, which amplifies gravitational force (hence flow rate), and increased urethra width, which increases flow rate. For smaller mammals a different phenomenon occurs, where urine is discharged as droplets, and urination in smaller mammals, such as mice and rats, can occur in less than a second. [ 20 ]  The posited benefits of faster voiding are decreased risk of predation (while voiding) and decreased risk of urinary tract infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13337", "text": "The mechanism by which voluntary urination is initiated remains unsettled. [ 23 ]  One possibility is that the voluntary relaxation of the muscles of the pelvic floor causes a sufficient downward tug on the  detrusor muscle  to initiate its contraction. [ 24 ]  Another possibility is the excitation or disinhibition of neurons in the pontine micturition center, which causes concurrent contraction of the bladder and relaxation of the sphincter. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13338", "text": "There is an inhibitory area for micturition in the midbrain. After transection of the brain stem just above the pons, the threshold is lowered and less bladder filling is required to trigger it, whereas after transection at the top of the midbrain, the threshold for the reflex is essentially normal. There is another facilitatory area in the posterior hypothalamus. In humans with lesions in the superior frontal gyrus, the desire to urinate is reduced and there is also difficulty in stopping micturition once it has commenced. However, stimulation experiments in animals indicate that other cortical areas also affect the process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13339", "text": "The bladder can be made to contract by voluntary facilitation of the spinal voiding reflex when it contains only a few milliliters of urine. Voluntary contraction of the  abdominal muscles  aids the expulsion of urine by increasing the pressure applied to the urinary bladder wall, but voiding can be initiated without straining even when the bladder is nearly empty.\nVoiding can also be consciously interrupted once it has begun, through a contraction of the perineal muscles. The external sphincter can be contracted voluntarily, which will prevent urine from passing down the urethra."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13340", "text": "The need to urinate is experienced as an uncomfortable, full feeling. It is highly correlated with the fullness of the bladder. [ 26 ]  In many males the feeling of the need to urinate can be sensed at the base of the penis as well as the bladder, even though the neural activity associated with a full bladder comes from the bladder itself, and can be felt there as well. In females the need to urinate is felt in the lower abdomen region when the bladder is full. When the bladder becomes too full, the sphincter muscles will involuntarily relax, allowing urine to pass from the bladder. Release of urine is experienced as a lessening of the discomfort."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13341", "text": "Many clinical conditions can cause disturbances to normal urination, including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13342", "text": "A drug that increases urination is called a  diuretic , whereas  antidiuretics  decrease the production of urine by the kidneys."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13343", "text": "There are three major types of bladder dysfunction due to neural lesions: (1) the type due to interruption of the afferent nerves from the bladder; (2) the type due to interruption of both afferent and efferent nerves; and (3) the type due to interruption of facilitatory and inhibitory pathways descending from the brain. In all three types the bladder contracts, but the contractions are generally not sufficient to empty the viscus completely, and residual urine is left in the bladder.  Paruresis , also known as shy bladder syndrome, is an example of a bladder interruption from the brain that often causes total interruption until the person has left a public area. These people (males) may have difficulty urinating in the presence of others and will consequently avoid using urinals without dividers or those directly adjacent to another person. Alternatively, they may opt for the privacy of a stall or simply avoid public toilets altogether."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13344", "text": "When the sacral dorsal roots are cut in experimental animals or interrupted by diseases of the dorsal roots such as  tabes dorsalis  in humans, all reflex contractions of the bladder are abolished. The bladder becomes distended, thin-walled, and hypotonic, but there are some contractions because of the intrinsic response of the smooth muscle to stretch."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13345", "text": "When the afferent and efferent nerves are both destroyed, as they may be by tumors of the  cauda equina  or  filum terminale , the bladder is flaccid and distended for a while. Gradually, however, the muscle of the \"decentralized bladder\" becomes active, with many contraction waves that expel dribbles of urine out of the urethra. The bladder becomes shrunken and the bladder wall hypertrophied. The reason for the difference between the small, hypertrophic bladder seen in this condition and the distended, hypotonic bladder seen when only the afferent nerves are interrupted is not known. The hyperactive state in the former condition suggests the development of denervation hypersensitization even though the neurons interrupted are  preganglionic  rather than  postganglionic ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13346", "text": "During  spinal shock , the bladder is flaccid and unresponsive. It becomes overfilled, and urine dribbles through the sphincters ( overflow incontinence ). After spinal shock has passed, a spinally mediated voiding reflex ensues, although there is no voluntary control and no inhibition or facilitation from higher centers. Some paraplegic patients train themselves to initiate voiding by pinching or stroking their thighs, provoking a mild mass reflex. In some instances, the voiding reflex becomes hyperactive. Bladder capacity is reduced and the wall becomes hypertrophied. This type of bladder is sometimes called the spastic neurogenic bladder. The reflex hyperactivity is made worse, and may be caused, by infection in the bladder wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13347", "text": "A common technique used in many developing nations involves holding the child by the backs of the thighs, above the ground, facing outward, in order to urinate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13348", "text": "The fetus urinates hourly and produces most of the  amniotic fluid  in the second and third trimester of pregnancy. The amniotic fluid is then recycled by fetal swallowing. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13349", "text": "Occasionally, if a male's penis is damaged or removed, or a  female's genitals /urinary tract is damaged, other urination techniques must be used. Most often in such cases, doctors will reposition the urethra to a location where urination can still be accomplished, usually in a position that would promote urination only while seated/squatting, though a permanent  urinary catheter  may be used in rare cases. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13350", "text": "Sometimes urination is done in a container such as a bottle,  urinal , bedpan, or  chamber pot  (also known as a  gazunder ). A container or wearable  urine collection device  may be used so that the urine can be examined for medical reasons or for a  drug test , for a  bedridden  patient, when no toilet is available, or there is no other possibility to dispose of the urine immediately."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13351", "text": "An alternative solution (for traveling,  stakeouts , etc.) is a special disposable bag containing absorbent material that solidifies the urine within seconds, making it convenient and safe to store and dispose of later. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13352", "text": "It is possible for both sexes to urinate into bottles in case of emergencies. The technique can help children to urinate discreetly inside cars and in other places without being seen by others. [ 28 ]  A  female urination device  can assist women and girls in urinating while standing or into a bottle. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13353", "text": "In  microgravity , excrement tends to float freely, so astronauts use a specially designed  space toilet , which uses suction to collect and recycle urine; the space toilet also has a receptacle for defecation. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13354", "text": "A  puer mingens [ 31 ]  is a figure in a work of art depicted as a prepubescent boy in the act of urinating, either actual or simulated. The puer mingens could represent anything from whimsy and boyish innocence to erotic symbols of virility and masculine bravado. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13355", "text": "Babies have little socialized control over urination within traditions or families that do not practice  elimination communication  and instead use  diapers .  Toilet training  is the process of learning to restrict urination to socially approved times and situations. Consequently, young children sometimes develop  nocturnal enuresis . [ 33 ] [ full citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13356", "text": "It is socially more accepted and more environmentally hygienic for those who are able, especially when indoors and in outdoor urban or suburban areas, to urinate in a  toilet . Public toilets may have  urinals , usually for males, although  female urinals  exist, designed to be used in various ways. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13357", "text": "Acceptability of outdoor urination in a public place other than at a  public urinal  varies with the situation and with customs. Potential disadvantages include a dislike of the smell of urine, and exposure of genitals. [ 35 ]  It can be avoided or mitigated by going to a quiet place and/or facing a tree or wall if urinating standing up, or while squatting, hiding the back behind walls, bushes, or a tree. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13358", "text": "Portable toilets  (port-a-potties) are frequently placed in outdoor situations where no immediate facility is available. These need to be serviced (cleaned out) on a regular basis. Urination in a heavily wooded area is generally harmless, actually saves water, and may be condoned for males (and less commonly, females) in certain situations as long as common sense is used. Examples (depending on circumstances) include activities such as camping, hiking, delivery driving, cross country running, rural fishing, amateur baseball, golf, etc."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13359", "text": "The more developed and crowded a place is, the more public urination tends to be objectionable. In the countryside, it is more acceptable than in a street in a town, where it may be a common transgression. Often this is done after the consumption of  alcoholic beverages , which causes production of additional urine as well as a reduction of  inhibitions . One proposed way to inhibit public urination due to drunkenness is the  Urilift , which is disguised as a normal manhole by day but raises out of the ground at night to provide a public restroom for bar-goers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13360", "text": "In many places, public urination is punishable by fines, though attitudes vary widely by country. In general, females are less likely to urinate in public than males. Women and girls, unlike men and boys, are restricted in where they can urinate conveniently and discreetly. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13361", "text": "The 5th-century BC historian  Herodotus , writing on the culture of the  ancient Persians  and highlighting the differences with those of the  Greeks , noted that to urinate in the presence of others was prohibited among Persians. [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13362", "text": "There was [ when? ]  a popular belief in the UK, that it was legal for a man to urinate in public so long as it occurred on the rear wheel of his vehicle and he had his right hand on the vehicle, but this is not true. [ 39 ]  Public urination still remains more accepted by males in the UK, although British cultural tradition itself seems to find such practices objectionable. [ 40 ] \nIn  Islamic toilet etiquette , it is  haram  to urinate while facing the  Qibla , or to turn one's back to it when urinating or relieving bowels, but modesty requirements for females make it impossible for girls to relieve themselves without facilities. [ 41 ] [ 42 ]  When toilets are unavailable, females can relieve themselves in  Laos ,  Russia  and  Mongolia  in emergency, [ citation needed ]  but it remains less accepted for females in  India  even when circumstances make this a highly desirable option. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13363", "text": "Women generally need to urinate more frequently than men, but as opposed to the common misconception, it is not due to having smaller bladders. [ 44 ]  Resisting the urge to urinate because of lack of facilities can promote  urinary tract infections  which can lead to more serious infections and, in rare situations, can cause  renal damage  in women. [ 45 ] [ 46 ]   Female urination devices  are available to help women to urinate discreetly, as well to help them urinate while standing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13364", "text": "Techniques and body postures while urinating vary across cultures. Different anatomical conditions in men and women may presume different postures, yet these are largely shaped by cultural norms, types of clothing, and the sanitary facilities available. While sitting toilets are the most common form in Western countries, squat toilets are common in  Asia ,  Africa , and the  Arab world . Urinals for men are widespread worldwide, although  women's urinals  are available in some countries, recently becoming more common in Western countries. With the spread of pants among women, a standing posture became impractical, but in some regions where women wear traditional skirts or robes, an upright posture is common. [ 47 ] [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13365", "text": "Cultures around the world differ regarding socially accepted voiding positions and preferences: in the Middle-East and Asia, the  squatting position  was more prevalent, while in the Western world the standing and sitting positions were more common. [ 49 ]  For practising  Muslim  men, the genital  modesty  of squatting is also associated with proper  cleanliness  requirements or  awrah . [ 50 ]  In Western culture, the  standing position  is regarded as the more efficient option among healthy males. [ citation needed ]  In restrooms without urinals, and sometimes at home, men may be urged to use the sitting position as to diminish spattering of urine. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13366", "text": "Elderly males with  prostate gland  enlargement may benefit from sitting down to urinate, with the seated voiding position found superior as compared with standing in elderly males with  benign prostate hyperplasia . [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13367", "text": "In Western culture, females usually sit or squat for urination, depending on what type of toilet they use; a  squat toilet  is used for urination in a squatting position. Women averting contact with a  toilet seat  may employ a partial  squatting position  (or \"hovering\"), similar to using a  female urinal . However, this may not completely void the  bladder . [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13368", "text": "Females may also urinate while standing, and while clothed. [ 34 ]  It is common for women in various regions of Africa to use this position when they urinate, [ 53 ] [ 54 ]  as do women in  Laos . [ 55 ]   Herodotus  described a similar custom in  ancient Egypt . [ 56 ]  An alternative method for women voiding while standing is to use a  female urination device  to assist. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13369", "text": "In many societies and in many social classes, even mentioning the need to urinate is seen as a social transgression, despite it being a universal need. Many adults avoid stating that they need to urinate. [ 58 ] [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13370", "text": "Many expressions exist, some  euphemistic  and some vulgar. For example, centuries ago the standard English word (both noun and verb, for the product and the activity) was \" piss \", but subsequently \"pee\", formerly associated with children, has become more common in general public speech. Since elimination of bodily wastes is, of necessity, a subject talked about with toddlers during  toilet training , other expressions considered suitable for use by and with children exist, and some continue to be used by adults, e.g. \"weeing\", \"doing/having a wee-wee\", \"to tinkle\", \" go potty \", \"go pee pee\". [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13371", "text": "Other expressions include \"squirting\" and \"taking a leak\", and, predominantly by younger persons for outdoor female urination, \"popping a squat\", referring to the position many women adopt in such circumstances. National  varieties of English  show creativity.  American English  uses \"to whiz\". [ 60 ]   Australian English  has coined \"I am off to take a  Chinese singing  lesson\", derived from the tinkling sound of urination against the China porcelain of a toilet bowl. [ 61 ]   British English  uses \"going to see my aunt\", \"going to  see a man about a dog \", \"to piddle\", \"to splash (one's) boots\", as well as \"to have a slash\", which originates from the  Scottish term  for a large splash of liquid. [ 62 ]  One of the most common, albeit old-fashioned, euphemisms in British English is \"to spend a penny\", a reference to coin-operated  pay toilets , which used ( pre-decimalisation ) to charge that sum. [ 63 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13372", "text": "References to urination are commonly used in  slang . Usage in English includes:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13373", "text": "Urolagnia , a  paraphilia , is an inclination to obtain  sexual enjoyment  by looking at or thinking of urine or urination. [ 65 ]  Urine may be consumed, or the person may bathe in it; this is known colloquially as a  golden shower . Drinking urine is known as  urophagia , though uraphagia refers to the consumption of urine regardless of whether the context is sexual. Involuntary urination during sexual intercourse is common, but rarely acknowledged. In one survey, 24% of women reported involuntary urination during sexual intercourse; in 66% of patients urination occurred on  penetration , while in 33% urine leakage was restricted to orgasm. [ 66 ] \nFemale  kob  may exhibit urolagnia during sex; one female will  urinate  while the other sticks her nose in the stream. [ 67 ] [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13374", "text": "Some mammals  urinate on themselves  in order to attract mates during the  rut  or urinate on other individuals before mating with them. [ 69 ]  A male  Patagonian mara , a type of rodent, will stand on his hind legs and urinate on a female's rump, to which the female may respond by spraying a jet of urine backwards into the face of the male. [ 70 ]  The male's urination is meant to repel other males from his partner while the female's urination is a rejection of any approaching male when she is not receptive. [ 70 ]  Both anal digging and urination are more frequent during the breeding season and are more commonly done by males. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13375", "text": "A male porcupine urinates on a female porcupine prior to mating, spraying the urine at high velocity. [ 72 ] [ 73 ] [ 74 ] [ 75 ] [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13376", "text": "In 2008 in London, a person died when they were urinating alongside a railway track at a train station and they received an electric shock. [ 77 ] [ 78 ]  The person received the electric shock when their stream of urine connected with the electric current from the live third rail. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13377", "text": "In 2010 in Washington state, a person who had died had received burns injuries on their body that were related to receiving an electric shock. [ 79 ]   It is thought that an electric current had traveled through their stream of urine and into their body. [ 79 ]   It is thought that the person had urinated into a roadside ditch and a live wire that was lying in the ditch gave the person an electric shock. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13378", "text": "In 2014 in Spain, a person died while urinating on a lamp post when he received an electric shock, which may have traveled through the stream of urine and into his body. [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13379", "text": "While the primary purpose of urination is the same across the  animal kingdom , urination often serves a social purpose beyond the expulsion of waste material. [ 81 ] [ 82 ]  In dogs and other animals, urination can  mark territory  or express submissiveness. [ 64 ]  In small  rodents  such as rats and mice, it marks familiar paths."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13380", "text": "The urine of animals of differing  physiology  or  sex  sometimes has different characteristics. For example, the urine of birds and reptiles is whitish, consisting of a pastelike suspension of uric acid crystals, and discharged with the  feces  of the animal via the  cloaca , whereas mammals' urine is a yellowish colour, with mostly  urea  instead of uric acid, and is discharged via the urethra, separately from the  feces . Some animals' (example:  carnivores ') urine possesses a strong odour, especially when it is used to mark territory or  communicate in other ways. [ clarify ] [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13381", "text": "Felids [ 12 ] [ 83 ] [ 84 ]  and  canids   [ 8 ] [ 85 ]  scent-mark their territories using urine.   Wolves mark their territories  by urinating in a raised-leg posture and release  preputial gland  secretions in their urine. Male  dogs mark their territories  with urine more frequently than females. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13382", "text": "Young cattle can be toilet-trained to urinate in a \"latrine\" where their urine can be collected for  wastewater treatment , [ 86 ] [ 87 ]  which could be used to reduce  greenhouse gas emissions  from the animals' urine in countries such as the Netherlands, the United States, and New Zealand. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13383", "text": "A  urine collection device  or  UCD  is a device that allows the collection of urine for analysis (as in  medical  or  forensic   urinalysis ) or for purposes of simple elimination (as in vehicles engaged in long voyages and not equipped with  toilets , particularly  aircraft  and  spacecraft ).  UCDs of the latter type are sometimes called  piddle packs . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13384", "text": "Similar devices are used, primarily by men, to manage  urinary incontinence . These devices are attached to the outside of the penile area and direct urine into a separate collection chamber such as a leg or bedside bag. There are several varieties of external urine collection devices on the market today including male external catheters also known as  urisheaths  or  Texas/condom catheters ,  urinals  and  hydrocolloid -based devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13385", "text": "External products should not be used by any individual who experiences  urinary retention  without  overflow incontinence . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13386", "text": "A urine collection device allows an individual to empty their  bladder  into a container hygienically and without spilling  urine ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13387", "text": "Condom  catheters , also known as  male external catheters ,  urisheaths , or  Texas catheters , are made of silicone or latex (depending on the brand/manufacturer) and cover the penis just like a condom but with an opening at the end to allow the connection to the urine bag. The sheath is worn over the penis and looks like a  condom  (hence the name). It stays in place by use of an adhesive, that can either be built into the sheath or come as a separate adhesive liner. The urine gets funneled away from the body, keeping the skin dry at all times. The urine runs into a urine bag that is attached at the bottom of the external catheter. During the day, a drainable leg bag can be used, and at night it is recommended to use a large-capacity bedside drainage bag. Male external catheters are designed to be worn 24/7 and changed daily \u2013 and can be used by men with both light and severe incontinence. Male external catheters come in several sizes and lengths to accommodate anatomical variation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13388", "text": "It is very important that the male external catheter/urisheath fits well \u2013 both the diameter and the length. Different manufacturers have small measuring guides that can be used to measure what size is needed before ordering a sample. If the user does not get measured correctly leakage and skin irritation can occur."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13389", "text": "Urinals  are a class of device that does not attach to the body. Instead, these external collection systems can be placed against the  urinary opening  during voiding and removed once voiding is complete. These are commonly used by hunters and sportsmen who may spend long periods away from a bathroom. These are not appropriate for men with urinary retention or who experience involuntary urine leakage. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13390", "text": "Penile external catheters/urisheaths combined with urine bags are preferred over absorbent products \u2013 in particular when it comes to 'limitations to daily activities'. [ 2 ]  Advantages also include discretion, less water retention at the skin surface, and the potential for 24 hour use. Complications can increase in severity and frequency over time. Up to 40% of condom catheter users will develop a urinary tract infection with long-term use. [ 3 ]  15% of long term users may develop skin injuries, including inflammation, ulceration, necrosis, gangrene and constriction of the penis. [ 4 ]  Sizing can also prove difficult for some men, leading to dislodgement of the catheter and urine spillage during voiding (commonly referred to as pop-offs or blow-offs). 1.3% of condom catheter users will develop a bladder or renal stone requiring medical treatment. [ 5 ]  While the line of causation is not well established, urinary retention from inefficient elimination while catheterized may allow more mineral buildup and encourage crystal growth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13391", "text": "Special UCDs exist for the collection of urine samples for subsequent urinalysis. They range from a simple plastic cup to elaborate devices designed to collect specific volumes or types of urine samples at various points in the micturition process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13392", "text": "A common use of UCDs is in military  fighter aircraft . Small aircraft such as fighter planes are not equipped with toilets, but pilots are sometimes required to fly them for several hours continuously. Since most people produce enough urine to fill their bladders after only a few hours under normal conditions, some method must be provided to allow a pilot to urinate without leaving their seat in the  cockpit . A UCD makes this possible. UCDs are also used on  spacecraft  and occasionally in other vehicles, for the same reasons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13393", "text": "A typical UCD consists of a small container with a dehydrated  sponge  inside, connected to a tube that in turn is connected to a funnel-like orifice that is adapted to the user's anatomy. The user simply holds the funnel near or on their urethral opening and urinates into the tube, with the collected urine saturating the sponge (which may be impregnated with disinfectants and odor-control substances) and filling the container. UCDs are designed to be used in cramped quarters without requiring that the user rise from his seated position in the cockpit. In most cases, the user wears special clothing that can easily be opened to permit use of the UCD (e.g., special  zippers  in  flight suits )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13394", "text": "By 2008 [update] , technologies that did not require opening of the flight suit began to emerge, such as the \"Advanced Mission Extender Device\" (AMXD), which includes a pump for draining urine into a collection bag. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13395", "text": "The first  American crewed mission  did not utilise a urine collection device, with  NASA  having passed over the idea, as the  MR-3  flight was expected to be too short for it to be necessary. Astronaut  Alan Shepard  faced a lengthy delay on the launchpad however, and was forced to urinate in his pressure suit. This short-circuited electrodes that had been designed to measure vital signs. A purpose built system was in place for  MR-5  utilising a condom and an external storage container. Similar systems have been used in spaceflight since. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13396", "text": "A  stadium buddy  is an apparatus that consists of a collecting bag fastened around the leg and tubing that attaches to a  condom catheter .  The hood attaches over the  penis  but, unlike a condom, has a plug for the tube where the condom's reservoir tip would normally be.  This apparatus allows an individual to \"conveniently\"  urinate  without having to make use of a  restroom . Stadium buddies have been used by sports and concert attendees for over two decades [ clarification needed ] , and are also used by pilots when flying aircraft too small to carry a restroom. Some aircraft have a tube in the seat for attaching to the condom catheter, and this tube drains out the bottom of the aircraft in flight. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13397", "text": "Urology Robotics , or  URobotics , is a new interdisciplinary field for the application of robots in urology and for the development of such systems and novel technologies in this clinical discipline. [ 1 ] [ 2 ]   Urology  is among the medical fields with the highest rate of technology advances, which for several years has included the use medical  robots . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13398", "text": "The first surgical robot approved by the FDA is the  da Vinci  system. [ 4 ]  Even though this was designed to assist in general  Laparoscopy , most of its application are in the urology field for  radical prostatectomy . Pioneered at the  Vattikuti Urology Institute , robotic radical prostatectomy has now become the gold standard for the treatment of prostate cancer. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13399", "text": "Other, URobotic systems are under development. These include image-guided robots that, in addition to the direct visual feedback, use medical images for guiding the intervention. Since  MRI  provides enhanced visualization of soft-tissues compared to  x-ray -based imaging,  MRI compatible robots  are being developed to assist the physician in performing the intervention  in the MRI scanner . If prostate cancer lesions can be delineated in the image, robots can accurately target those lesions for  biopsy  or focal  ablations ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13400", "text": "This robotics-related article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13401", "text": "This article related to  medical technology  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13402", "text": "Urostealith  is a  fatty  or  resinous  substance identified by the  Austrian   chemist   J. F. Heller  in 1845 as the main constituent of some  bladder stones . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13403", "text": "According to Heller's and other contemporary descriptions, urostealith is a soft brown substance, insoluble in water, sparingly soluble in  alcohol  and easily soluble in  ether .  Upon heating it softens at first, then expands and carbonizes before melting. It dissolves in solutions of  sodium carbonate , and the latter was successfully used by Heller to dissolve and break up stones in a patient's bladder."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13404", "text": "Urostealith stones seem to be very rare. [ 2 ]   The circumstances that lead to their formation, as well as the composition of the substance, are still obscure, and little has been published on the topic. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13405", "text": "Venous leak , also called  venogenic erectile dysfunction  and  penile venous insufficiency , is one category of vasculogenic impotence \u2014 a cause of  erectile dysfunction  in males. [ 2 ]  It affects all ages, being particularly awkward in young men. [ 3 ]  Much about venous leaks has not reached a consensus among the  medical community , and many aspects of the condition, particularly its treatment strategies, are controversial. The prevalence of the condition is still unknown, although some sources claim it to be a common cause of erectile dysfunction. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13406", "text": "Many men with venogenic erectile dysfunction start having trouble with their erections from a young age. [ 5 ]  Common complaints include a chronic soft erection insufficient for sexual intercourse, position-dependent erectile rigidity, difficulty achieving erections, difficulty maintaining erections without constant manual stimulation, loss of penile length and girth, and a soft  glans of the penis  during erection that is not fully engorged (also known as  cold glans syndrome )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13407", "text": "Physicians often look for signs that suggest an organic cause of erectile dysfunction rather than a psycho-osmotic cause in making a diagnosis of venous leak. Such suggestive signs include (1) erectile dysfunction that is persistent on all occasions where an erection is required, including with a partner and without a partner during masturbation, (2) Loss of quality of  morning erections , (3) Loss of quality of spontaneous erections, and (4) multi-treatment resistance to traditional erectile dysfunction medications including  sildenafil  and  intracavernosal injection  therapy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13408", "text": "Venous leak is an inability to maintain an erection in the presence of sufficient arterial blood flow through the cavernosal arteries of the penis. [ 6 ]  The defect lies in the excessive drainage of veins in the cavernosal tissue of the penis, which undermines normal erectile function. This provides extraordinary venous drainage from the corpora cavernosa of the penis despite the existence of a rigid erection and fails to adequately trap blood inside the  corporeal chambers  to maintain an erection of adequate strength or adequate length of time. It is still disputed as to what causes the excessive leakiness that is characteristic of the condition. However, it is mostly thought that the defect is in the connective tissue of the  tunica albuginea  surrounding the penile veins, most importantly, the  deep dorsal vein of the penis , a pair of cavernosal veins, and two pairs of para-arterial veins between the  Buck's fascia  and the  tunica albuginea  of the penis. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13409", "text": "Recently  hemodynamic  studies were conducted in both fresh and defrosted human  cadavers  in which a rigid erection was without exception attainable despite cavernosal tissue having lost its extensibility in cadaveric sinusoids. This implies a rigid penile erection is just a mechanical event and, consequently, that penile veins play a pivotal role in achieving a rigid erection. This is clearly a ramification of endorsing the determinant role of the erection-related veins in human erectile function. [ 8 ] [ citation needed ] [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13410", "text": "Furthermore, cavernosograms demonstrate that excessively  leaky veins  can cause drainage of the  corpora cavernosa . Histological specimens of cavernosal tissue in patients with confirmed  veno-occlusive disease  (VOD) show changes in the structure of  collagen  and  elastin  making up the connective tissue of the penis when compared to a control group. [ 7 ]  These changes may be responsible for such symptoms. In addition, other possible causes include  psychological stress ,  testosterone deficiency ,  neurotic deficit , a  drug's adverse influence ,  iatrogenic , and chronic  systemic diseases  such as  diabetes  and low urinary tract symptoms. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13411", "text": "Since 1873, when a  hypertonic solution  was injected into the large penile vein in an attempt to treat impotence and resulting in reduced venous drainage away from the corpora cavernosa, there has been much controversy concerning the most ideal milieu for applying  Pascal's law  as it relates to this area of study. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13412", "text": "Because many males are not responding to standard medical therapy (including  PDE-5 inhibitor , intracavernosal injection therapy, and coil embolization etc.), a penile  venous stripping  seems to be a unique treatment. Nevertheless, for those with erectile dysfunction that remains resistant to less-invasive treatments,  penile implant  remains the solution. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13413", "text": "One of the collection of Didusch drawings displayed in  William P. Didusch Center for Urologic History ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13414", "text": "page   image ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13415", "text": "Drawing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13416", "text": "The image's resolution is high enough to be recognizable, but not high enough to produce counterfeit and therefore does not impair the copyright holder's ability to profit from the work."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13417", "text": "William P. Didusch Center for Urologic History"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13418", "text": "Yes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13419", "text": "This image is used to demonstrate  the collection of drawings, photographs, and instruments of historical importance to  urology  displayed in  William P. Didusch Center for Urologic History"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13420", "text": "No free alternative."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13421", "text": "qualifies as  fair use  under  United States copyright law ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13422", "text": "Any other use of this image, whether on Wikipedia or elsewhere, could potentially constitute a  copyright infringement . For further information, please refer to  Wikipedia's guidelines on non-free content . \n Fair use \n //en.wikipedia.org/wiki/File:William_P._Didusch_Center_for_Urologic_History_1925.jpeg"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13423", "text": "An  abscess  is a collection of  pus  that has built up within the  tissue  of the body, usually caused by bacterial infection. [ 6 ] [ 7 ]  Signs and symptoms of abscesses include redness, pain, warmth, and swelling. [ 1 ]  The swelling may feel fluid-filled when pressed. [ 1 ]  The area of redness often extends beyond the swelling. [ 8 ]   Carbuncles  and  boils  are types of abscess that often involve  hair follicles , with carbuncles being larger. [ 9 ]  A  cyst  is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall. Abscesses can also form internally on internal organs and after surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13424", "text": "They are usually caused by a  bacterial infection . [ 10 ]  Often many different types of bacteria are involved in a single infection. [ 8 ]  In many areas of the world, the most common bacteria present is  methicillin-resistant Staphylococcus aureus . [ 1 ]  Rarely,  parasites  can cause abscesses; this is more common in the  developing world . [ 3 ]  Diagnosis of a skin abscess is usually made based on what it looks like and is confirmed by cutting it open. [ 1 ]   Ultrasound  imaging may be useful in cases in which the diagnosis is not clear. [ 1 ]  In abscesses around the  anus ,  computer tomography  (CT) may be important to look for deeper infection. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13425", "text": "Standard treatment for most skin or soft tissue abscesses is cutting it open and drainage. [ 4 ]  There appears to be some benefit from also using  antibiotics . [ 11 ]  A small amount of evidence supports not packing the cavity that remains with  gauze  after drainage. [ 1 ]  Closing this cavity right after draining it rather than leaving it open may speed healing without increasing the risk of the abscess returning. [ 12 ]  Sucking out the pus with a needle is often not sufficient. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13426", "text": "Skin abscesses are common and have become more common in recent years. [ 1 ]  Risk factors include  intravenous drug use , with rates reported as high as 65% among users. [ 2 ]  In 2005, 3.2 million people went to American emergency departments for abscesses. [ 5 ]  In Australia, around 13,000 people were hospitalized in 2008 with the condition. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13427", "text": "Abscesses may occur in any kind of tissue but most frequently within the skin surface (where they may be superficial pustules known as  boils  or deep skin abscesses), in the  lungs ,  brain ,  teeth , kidneys, and tonsils. Major complications may include spreading of the abscess material to adjacent or remote tissues, and extensive regional tissue death ( gangrene ). [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13428", "text": "The main symptoms and signs of a skin abscess are  redness , heat, swelling, pain, and loss of function. There may also be high temperature (fever) and chills. [ 15 ]  If superficial, abscesses may be fluctuant when  palpated ; this wave-like motion is caused by movement of the pus inside the abscess. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13429", "text": "An internal abscess is more difficult to identify and depend on the location of the abscess and the type of infection. General signs include pain in the affected area, a high temperature, and generally feeling unwell. [ 17 ] \nInternal abscesses rarely heal themselves, so prompt medical attention is indicated if such an abscess is suspected. An abscess can potentially be fatal depending on where it is located. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13430", "text": "Risk factors for abscess formation include  intravenous drug use . [ 20 ]  Another possible risk factor is a prior history of disc  herniation  or other spinal abnormality, [ 21 ]  though this has not been proven."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13431", "text": "Abscesses are caused by  bacterial infection , parasites, or foreign substances.\nBacterial infection is the most common cause, particularly  Staphylococcus aureus . The more invasive  methicillin-resistant Staphylococcus aureus  (MRSA) may also be a source of infection, though is much rarer. [ 22 ]  Among spinal subdural abscesses, methicillin-sensitive  Staphylococcus aureus  is the most common organism involved. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13432", "text": "Rarely  parasites  can cause abscesses and this is more common in the developing world. [ 3 ]  Specific parasites known to do this include  dracunculiasis  and  myiasis . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13433", "text": "Anorectal abscesses can be caused by non-specific obstruction and ensuing infection of the glandular crypts inside of the  anus  or  rectum . Other causes include  cancer , trauma, or  inflammatory bowel diseases .  [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13434", "text": "An  incisional abscess  is one that develops as a complication secondary to a  surgical incision . It presents as redness and warmth at the margins of the incision with purulent drainage from it. [ 24 ]  If the diagnosis is uncertain, the wound should be aspirated with a needle, with aspiration of pus confirming the diagnosis and availing for  Gram stain  and  bacterial culture . [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13435", "text": "Abscesses can form inside the body. The cause can be from trauma, surgery, an infection, or a pre-existing condition. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13436", "text": "An abscess is a  defensive reaction  of the tissue to prevent the spread of infectious materials to other parts of the body. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13437", "text": "Organisms or foreign materials destroy the local  cells , which results in the release of  cytokines . The cytokines trigger an  inflammatory response , which draws large numbers of  white blood cells  to the area and increases the regional blood flow. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13438", "text": "The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13439", "text": "An abscess is a localized collection of pus (purulent inflammatory tissue) caused by suppuration buried in a tissue, an organ, or a confined space, lined by the pyogenic membrane. [ 28 ]   Ultrasound  imaging can help in a diagnosis. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13440", "text": "Abscesses may be classified as either  skin abscesses  or  internal abscesses . Skin abscesses are common; internal abscesses tend to be harder to diagnose, and more serious. [ 15 ]  Skin abscesses are also called cutaneous or subcutaneous abscesses. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13441", "text": "For those with a history of intravenous drug use, an  X-ray  is recommended before treatment to verify that no needle fragments are present. [ 20 ]  If there is also a fever present in this population,  infectious endocarditis  should be considered. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13442", "text": "Abscesses should be differentiated from  empyemas , which are accumulations of pus in a preexisting, rather than a newly formed, anatomical cavity. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13443", "text": "Other conditions that can cause similar symptoms include:  cellulitis , a  sebaceous cyst , and  necrotising fasciitis . [ 3 ]  Cellulitis typically also has an erythematous reaction, but does not confer any purulent drainage. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13444", "text": "The standard treatment for an uncomplicated skin or soft tissue abscess is the act of opening and draining. [ 4 ]  There does not appear to be any benefit from also using  antibiotics  in most cases. [ 1 ]  A small amount of evidence did not find a benefit from packing the abscess with gauze. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13445", "text": "The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, incising and draining the abscess is standard treatment. [ 4 ] [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13446", "text": "Most people who have an uncomplicated skin abscess should not use antibiotics. [ 4 ]  Antibiotics in addition to standard incision and drainage is recommended in persons with severe abscesses, many sites of infection, rapid disease progression, the presence of  cellulitis , symptoms indicating bacterial illness throughout the body, or a health condition causing  immunosuppression . [ 1 ]  People who are very young or very old may also need antibiotics. [ 1 ]  If the abscess does not heal only with incision and drainage, or if the abscess is in a place that is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13447", "text": "In those cases of abscess which do require antibiotic treatment,  Staphylococcus aureus  bacteria is a common cause and an anti-staphylococcus antibiotic such as  flucloxacillin  or  dicloxacillin  is used. The  Infectious Diseases Society of America  advises that the draining of an abscess is not enough to address community-acquired  methicillin-resistant  Staphylococcus aureus  (MRSA), and in those cases, traditional antibiotics may be ineffective. [ 1 ]  Alternative antibiotics effective against community-acquired MRSA often include  clindamycin ,  doxycycline ,  minocycline , and  trimethoprim-sulfamethoxazole . [ 1 ]  The  American College of Emergency Physicians  advises that typical cases of abscess from MRSA get no benefit from having antibiotic treatment in addition to the standard treatment. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13448", "text": "Culturing the wound  is not needed if standard follow-up care can be provided after the incision and drainage. [ 4 ]  Performing a wound culture is unnecessary because it rarely gives information which can be used to guide treatment. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13449", "text": "In North America, after drainage, an abscess cavity is usually packed, often with special iodoform-treated cloth. This is done to absorb and neutralize any remaining exudate as well as to promote draining and prevent premature closure. Prolonged draining is thought to promote healing. The hypothesis is that though the heart's pumping action can deliver immune and regenerative cells to the edge of an injury, an abscess is by definition a void in which no blood vessels are present. Packing is thought to provide a wicking action that continuously draws beneficial factors and cells from the body into the void that must be healed. Discharge is then absorbed by cutaneous bandages and further wicking promoted by changing these bandages regularly. However, evidence from emergency medicine literature reports that packing wounds after draining, especially smaller wounds, causes pain to the person and does not decrease the rate of recurrence, nor bring faster healing, or fewer physician visits. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13450", "text": "More recently, several North American hospitals have opted for less-invasive loop drainage over standard drainage and wound packing. In one study of 143 pediatric outcomes, a failure rate of 1.4% was reported in the loop group versus 10.5% in the packing group (P<.030), [ 34 ]  while a separate study reported a 5.5% failure rate among the loop group. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13451", "text": "Closing an abscess immediately after draining it appears to speed healing without increasing the risk of recurrence. [ 12 ]  This may not apply to anorectal abscesses as while they may heal faster, there may be a higher rate of recurrence than those left open. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13452", "text": "Appendiceal abscess are complications of appendicitis where there is an infected mass on the appendix. This condition is estimated to occur in 2\u201310% of appendicitis cases and is usually treated by surgical removal of the appendix (appendicectomy). [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13453", "text": "Even without treatment, skin abscesses rarely result in death, as they will naturally break through the skin. [ 3 ]  Other types of abscess are more dangerous. Brain abscesses may be fatal if untreated. When treated, the mortality rate reduces to 5\u201310%, but is higher if the abscess ruptures. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13454", "text": "Skin abscesses are common and have become more common in recent years. [ 1 ]  Risk factors include  intravenous drug use , with rates reported as high as 65% among users. [ 2 ]  In 2005, in the United States 3.2 million people went to the emergency department for an abscess. [ 5 ]  In Australia around 13,000 people were hospitalized in 2008 for the disease. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13455", "text": "The  Latin  medical  aphorism  \" ubi pus, ibi evacua \" expresses \"where there is pus, there evacuate it\" and is classical advice in the culture of Western medicine. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13456", "text": "Needle exchange programmes  often administer or provide referrals for abscess treatment to  injection drug users  as part of a  harm reduction  public health strategy. [ 40 ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13457", "text": "An abscess is so called \"abscess\" because there is an  abscessus  (a going away or departure) of portions of the animal tissue from each other to make room for the suppurated matter lodged between them. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13458", "text": "The word carbuncle is believed to have originated from the Latin:  carbunculus , originally a small coal; diminutive of  carbon- ,  carbo : charcoal or ember, but also a  carbuncle stone , \"precious stones of a red or fiery colour\", usually  garnets . [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13459", "text": "The following types of abscess are listed in the medical dictionary: [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13460", "text": "An  accessory  bile duct  is a  conduit  that transports  bile  and is considered to be  supernumerary  or auxiliary to the  biliary tree . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13461", "text": "It may be described by its location relative to the  gallbladder  as supravesicular [ 2 ] [ 3 ]  (superior to the gallbladder body) or subvesicular [ 4 ] [ 5 ]  (inferior to the gallbladder body)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13462", "text": "In the surgical literature, the term  duct of Luschka  is used to refer to an accessory bile duct.  They are small ducts that distinctly enter the gallbladder bed, or small tributaries of minor intrahepatic radicals of the right hepatic ductal system. [ 6 ]  Originating from the hepatic parenchyma the accessory bile duct may enter a large bile duct or the gallbladder at any location. [ 7 ]  Rarely it is found to be connected directly to the GIT. [ 8 ]  They may not always drain bile and sometimes can have blind distal ends. [ 2 ]  One study showed them originating from the liver parenchyma of the right anterior inferior dorsal subsegment or from the connective tissue of the gallbladder bed. The study showed the distal connections ending at the hepatic right anterior inferior dorsal branch, hepatic right anterior branch, right hepatic duct, or common hepatic duct. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13463", "text": "The term  duct of Luschka  is ambiguous, as it may refer to supravesicular [ 2 ] [ 3 ]  or subvesicular ducts. [ 4 ] [ 5 ]  Supravesicular ducts are typically in the gallbladder bed. A 2012 review suggested that the term  duct of Luschka  should be abandoned because of this ambiguity and replaced by the more specific term  subvesical bile duct . [ 9 ]  As well, the exact origin and drainage locations of the relevant duct(s) varied greatly between patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13464", "text": "Of 116 articles, 54 provided detailed anatomic information identifying 238 subvesical ducts, most of which represented accessory ducts. The origin and drainage of these ducts were limited primarily to the right lobe of the liver, but great variation was seen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13465", "text": "Although they may not drain any liver  parenchyma , they can be a source of a bile leak or biliary  peritonitis  after  cholecystectomy  in both adults and children. If an accessory bile duct goes unrecognized at the time of the gallbladder removal, 5\u20137 days post-operative the patient will develop bile  peritonitis , [ 10 ]  an easily treatable complication with a morbidity rate of 44% if left untreated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13466", "text": "Often diagnosed by  HIDA scan , a bile leak from an accessory bile duct post-op can be treated with a temporary biliary stent [ citation needed ]  to redirect the bile from the liver into the intestine and allow the accessory duct to spontaneously seal itself or using a drainage guided by radiology. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13467", "text": "The term is named after German anatomist  Hubert von Luschka  (1820-1875) [ 12 ] [ 13 ]  who described the first case in 1863. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13468", "text": "An  acute abdomen  refers to a sudden, severe  abdominal pain . [ 1 ]  It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate  surgical treatment ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13469", "text": "Common causes of an acute abdomen include a  gastrointestinal perforation ,  peptic ulcer disease ,  mesenteric ischemia ,  acute cholecystitis ,  appendicitis ,  diverticulitis ,  pancreatitis , and an abdominal hemorrhage. However, this is a non-exhaustative list and other less common causes may also lead to an acute abdomen. [ 2 ]  In pregnant patient, a  tubo-ovarian abscess , ruptured ovarian cyst or a ruptured  ectopic pregnancy  are common causes of an acute abdomen. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13470", "text": "Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries (SMA and IMA respectively), both of which are direct branches of the aorta. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13471", "text": "Clinically, patients present with diffuse abdominal pain, bowel distention, and bloody diarrhea. On physical exam, bowel sounds will be absent. Laboratory tests reveal a neutrophilic leukocytosis, sometimes with a left shift, and increased serum amylase. Abdominal radiography will show many air-fluid levels, as well as widespread edema. Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone  infarction , and subsequent  anastomosis  of the remaining healthy tissue. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13472", "text": "Traditionally, the use of  opiates  or other pain medications in patients with an acute abdomen has been discouraged before the clinical examination because of the concern that pain medications may mask the signs and symptoms of the condition and therefore may lead to a delay in diagnosis. However, the scientific literature has shown that early administration of pain medications, including opiates, in those with acute abdomen does not lead to delayed diagnosis, delayed treatment or errors in management (the incorrect surgical treatment administered or performing un-necessary surgery). [ 5 ] [ 6 ] [ 2 ]  In a meta-analysis of those with acute appendicitis, early administration of opiates was found to alter treatment approach (with a slightly higher rate of appendectomy in those who received opiates) but diagnostic accuracy and surgical outcomes were unaffected by pain medication use. [ 7 ]  Clinical guidelines also recommend early analgesic use before a cause is established. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13473", "text": "Medical imaging  aids in the diagnosis of potential causes of an acute abdomen. A  CT scan  or  ultrasound  of the abdomen and pelvis are the preferred imaging modalities in the evaluate of an acute abdomen. [ 8 ]  The use of  radiocontrast agents  with CT scans improve diagnostic accuracy. [ 2 ]  Some authors advocate for the use of  CT angiography  with contrast of the abdomen and pelvis as the preferred imaging modality. [ 2 ]  An ultrasound is the preferred imaging modality in pregnant patients as CT scans expose the fetus to ionizing radiation which may lead to adverse pregnancy outcomes. [ 2 ]  An  abdominal x-ray  may show  free air  in the abdominal cavity due to a perforation in the gastrointestinal tract. However, abdominal x-ray is not recommended as part of the diagnostic evaluation in acute abdomen due to its low sensitivity and specificity. [ 8 ] [ 2 ]  Delays in medical imaging acquisition and interpretation greater than 2 hours are associated with an increased risk of complications and death. [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13474", "text": "In a population based study of  Medicare  patients in the United States, Black patients who were admitted to the hospital for an acute abdomen requiring general surgery consultation were 14% less likely to receive surgical consultation as compared to White patients. These racial disparities in care persisted (with an 11% difference) when socioeconomic factors were standardized. [ 10 ]  In another population based study in the United States, Black patients and patients from other racial minority groups were 22-30% less likely to receive pain medication for an acute abdomen as compared to White patients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13475", "text": "The  Alvarado score  is a clinical scoring system used in the diagnosis of  appendicitis . [ 1 ]   Alvarado scoring has largely been superseded as a clinical prediction tool by the  Appendicitis Inflammatory Response score . [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13476", "text": "Also known by the  mnemonic  MANTRELS, the scale has 6 clinical items (3  signs  and 3  symptoms ) and 2 laboratory measurements, each given an additive point score, with a maximum of 10 points possible. [ 5 ]   It was introduced in 1986 by Dr. Alfredo Alvarado and although meant for pregnant females, it has been extensively validated in the non-pregnant population.  A known limitation of the score is that only 20% of elderly patients present with classic findings on which the score focuses. [ 5 ]  A modified Alvarado score is at present in use. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13477", "text": "Elements from the person's  history , the  physical examination  and from laboratory tests: [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13478", "text": "The two most important factors, tenderness in the right lower quadrant and leukocytosis, are assigned two points, and the six other factors are assigned one point each, for a possible total score of ten points. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13479", "text": "A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates probable appendicitis, and a score of 9 or 10 indicates very probable acute appendicitis. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13480", "text": "The original Alvarado score describes a possible total of 10 points, but those medical facilities that are unable to perform a differential white blood cell count, are using a Modified Alvarado Score with a total of 9 points which could be not as accurate as the original score. The high diagnostic value of the score has been confirmed in a number of studies across the world. The consensus is that the Alvarado score is a noninvasive, safe, diagnostic method, which is simple, reliable, repeatable, and able to guide the clinician in the management of the case. However, a recent study demonstrated a sensitivity of only 72% of the Modified Alvarado Score for detection of appendicitis which has led to criticism of the usefulness of the score. Scores of less than five in children were useful for eliminating appendicitis from the differential diagnosis. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13481", "text": "It carries high significance in the diagnosis of acute appendicitis. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13482", "text": "Online calculator of the Alvarado Score"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13483", "text": "Appendicitis  is  inflammation  of the  appendix . [ 2 ]  Symptoms commonly include right lower  abdominal pain ,  nausea ,  vomiting , and  decreased appetite . [ 2 ]  However, approximately 40% of people do not have these typical symptoms. [ 2 ]  Severe complications of a ruptured appendix include widespread, painful  inflammation of the inner lining of the abdominal wall  and  sepsis . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13484", "text": "Appendicitis is primarily caused by a blockage of the  hollow portion  in the appendix. [ 10 ]  This blockage typically results from a  faecolith , a calcified \"stone\" made of feces. [ 6 ]  Some studies show a correlation between appendicoliths and disease severity. [ 11 ]  Other factors such as inflamed  lymphoid tissue  from a viral infection,  intestinal parasites ,  gallstone , or  tumors  may also lead to this blockage. [ 6 ]  When the appendix becomes blocked, it experiences increased pressure, reduced blood flow, and bacterial growth, resulting in inflammation. [ 6 ] [ 12 ]  This combination of factors causes tissue injury and, ultimately, tissue death. [ 13 ]  If this process is left untreated, it can lead to the appendix rupturing, which releases bacteria into the  abdominal cavity , potentially leading to severe complications. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13485", "text": "The diagnosis of appendicitis is largely based on the person's signs and symptoms. [ 12 ]  In cases where the diagnosis is unclear, close observation,  medical imaging , and laboratory tests can be helpful. [ 4 ]  The two most commonly used imaging tests for diagnosing appendicitis are ultrasound and computed tomography (CT scan). [ 4 ]  CT scan is more accurate than ultrasound in detecting acute appendicitis. [ 15 ]  However, ultrasound may be preferred as the first imaging test in children and pregnant women because of the risks associated with radiation exposure from CT scans. [ 4 ]  Although ultrasound may aid in diagnosis, its main role is in identifying important differentials, such as ovarian pathology in females or mesenteric adenitis in children."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13486", "text": "The standard treatment for acute appendicitis involves the  surgical removal of the inflamed appendix . [ 6 ] [ 12 ]  This procedure can be performed either through an open incision in the abdomen ( laparotomy ) or using minimally invasive techniques with small incisions and cameras ( laparoscopy ). Surgery is essential to reduce the risk of complications or potential death associated with the rupture of the appendix. [ 3 ]   Antibiotics  may be equally effective in certain cases of non-ruptured appendicitis, [ 16 ] [ 7 ] [ 17 ]  but 31% will undergo appendectomy within one year. [ 18 ]  It is one of the most common and significant causes of sudden abdominal  pain . In 2015, approximately 11.6 million cases of appendicitis were reported, resulting in around 50,100 deaths worldwide. [ 8 ] [ 9 ]  In the United States, appendicitis is one of the most common causes of sudden abdominal pain requiring surgery. [ 2 ]  Annually, more than 300,000 individuals in the United States undergo surgical removal of their appendix. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13487", "text": "The presentation of acute appendicitis includes acute abdominal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins to irritate the adjoining abdominal wall. This leads the pain to localize at  the right lower quadrant . This classic migration of pain may not appear in children under three years. This pain can be triggered by a sharp pain feeling. Pain from appendicitis may begin as dull pain around the navel. After several hours, the pain usually migrates towards the right lower quadrant, where it becomes localized. Symptoms include localized findings in the right  iliac fossa . The abdominal wall becomes very sensitive to gentle pressure ( palpation ). There is pain in the sudden release of deep tension in the lower abdomen ( Blumberg's sign ). If the appendix is retrocecal (localized behind the  cecum ), even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix). This is because the  cecum , distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is typically a complete absence of abdominal rigidity. In such cases, a digital  rectal examination  elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area ( McBurney's point ), called  Dunphy's sign . [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13488", "text": "Acute appendicitis seems to be the result of a primary obstruction of the  appendix . [ 20 ] [ 10 ]  Once this obstruction occurs, the appendix becomes filled with  mucus  and swells. This continued production of mucus leads to increased pressures within the lumen and the walls of the appendix. The increased pressure results in  thrombosis  and  occlusion  of the small vessels, and stasis of  lymphatic flow . At this point, spontaneous recovery rarely occurs. As the occlusion of blood vessels progresses, the appendix becomes  ischemic  and then  necrotic . As  bacteria  begin to leak out through the dying walls,  pus  forms within and around the appendix (suppuration). The result is appendiceal rupture (a 'burst appendix') causing  peritonitis , which may lead to  sepsis  and in rare cases,  death . These events are responsible for the slowly evolving abdominal pain and other commonly associated symptoms. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13489", "text": "The causative agents include  bezoars , foreign bodies,  trauma , [ 21 ] [ 22 ]   lymphadenitis  and, most commonly, calcified fecal deposits that are known as  appendicoliths  or  fecaliths . [ 23 ] [ 24 ]  The occurrence of  obstructing fecaliths  has attracted attention since their presence in people with appendicitis is higher in developed than in developing countries. [ 25 ]  In addition, an appendiceal fecalith is commonly associated with complicated appendicitis. [ 26 ]  Fecal stasis and arrest may play a role, as demonstrated by people with acute appendicitis having fewer bowel movements per week compared with healthy controls. [ 24 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13490", "text": "The occurrence of a fecalith in the appendix was thought to be attributed to a right-sided fecal retention reservoir in the colon and a prolonged transit time. However, a prolonged transit time was not observed in subsequent studies. [ 28 ]   Diverticular disease  and  adenomatous polyps  was historically unknown and  colon cancer  was exceedingly rare in communities where appendicitis itself was rare or absent, such as various African communities. Studies have implicated a transition to a  Western diet  lower in  fiber  in rising frequencies of appendicitis as well as the other aforementioned colonic diseases in these communities. [ 29 ] [ 30 ]  And acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. [ 31 ]  Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis. [ 32 ] [ 33 ] [ 34 ]  This low intake of dietary fiber is in accordance with the occurrence of a right-sided fecal reservoir and the fact that dietary fiber reduces transit time. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13491", "text": "The physician will ask questions to get the  health history , assess the patient's  symptoms , do a complete  physical exam , and order both laboratory and imaging tests. [ 36 ]  Appendicitis symptoms fall into two categories, typical and atypical. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13492", "text": "Typical appendicitis is characterized by a migratory  right iliac fossa  pain associated with nausea, and anorexia, which can occur with or without vomiting and localized muscle stiffness/ generalized  guarding . [ 37 ]  It is possible the pain could localize to  the left lower quadrant  in people with  situs inversus totalis . [ 38 ]  The combination of migrated  umbilical  pain to the right  lower quadrant , loss of appetite for food, nausea, unsustained  vomiting , and mild  fever  is classic. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13493", "text": "Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Irritation of the peritoneum (inside lining of the abdominal wall) can lead to increased pain on movement, or jolting, for example going over  speed bumps . [ 39 ]  Atypical histories often require imaging with ultrasound or CT scanning. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13494", "text": "During the early stages of appendicitis diagnosis, it is common for  physical exams  to present inconspicuous findings. Signs of inflammation become noticeable as the disease progresses. These signs may include [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13495", "text": "While there is no laboratory test specific for appendicitis, a  complete blood count  (CBC) is done to check for signs of infection or inflammation. Although 70\u201390 percent of people with appendicitis may have an elevated  white blood cell (WBC) count , many other abdominal and pelvic conditions can cause the WBC count to be elevated. [ 48 ]  However, a high  WBC count  may not alone represent a solid indicator of appendicitis but rather an inflammation  [ 15 ]  but the neutrophil ratio was more sensitive and specific for acute appendicitis. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13496", "text": "In children,  neutrophil-lymphocyte ratio (NLR) \ndemonstrates a high degree of accuracy in the diagnosis of acute appendicitis and distinguishes complicated appendicitis from the simple one. [ 50 ] \n75\u201378 percent of the patients have  neutrophilia . [ 42 ]  Delta-neutrophil index (DNI) is a valuable parameter\u00a0that helps in the diagnosis of histologically normal appendicitis and distinguishing\u00a0between simple and complicated appendicitis. [ 51 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13497", "text": "A  C-reactive protein (CRP) blood test  will be ordered by the doctor to find out if there are any further causes of inflammation. [ 36 ]  The C-reactive protein/albumin (CRP/ALB) ratio can be a reliable predictor of complicated appendicitis. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13498", "text": "The  urinalysis  is important for ruling out a urinary tract infection as the cause of abdominal pain. The presence of more than 20 WBC per high-power field in the urine is more suggestive of a urinary tract disorder. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13499", "text": "If the patient is a female, a  pregnancy test  will be ordered. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13500", "text": "In children, the clinical examination is important to determine which children with abdominal pain should receive immediate surgical consultation and which should receive diagnostic imaging. [ 53 ]  Because of the health risks of exposing children to radiation, ultrasound is the preferred first choice with CT scan being a legitimate follow-up if the ultrasound is inconclusive. [ 54 ] [ 55 ] [ 56 ]  CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a  sensitivity  of 94%,  specificity  of 95%. Ultrasonography had an overall  sensitivity  of 86%, a  specificity  of 81%. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13501", "text": "Abdominal ultrasonography , preferably with  doppler sonography , is useful to detect appendicitis, especially in children. Ultrasound can show the free fluid collection in the right iliac fossa, along with a visible appendix with increased blood flow when using color Doppler, and noncompressibility of the appendix, as it is essentially a walled-off abscess. Other secondary sonographic signs of acute appendicitis include the presence of echogenic mesenteric fat surrounding the appendix and the acoustic shadowing of an appendicolith. [ 58 ]  In some cases (approximately 5%), [ 59 ]  ultrasonography of the  iliac fossa  does not reveal any abnormalities despite the presence of appendicitis. This false-negative finding is especially true of early appendicitis before the appendix has become significantly distended. Also, false-negative findings are more common in adults where larger amounts of fat and bowel gas make visualizing the appendix technically difficult. Despite these limitations, sonographic imaging with experienced hands can often distinguish between appendicitis and other diseases with similar symptoms. Some of these conditions include  inflammation  of  lymph nodes  near the appendix or pain originating from other pelvic organs such as the ovaries or Fallopian tubes. Ultrasounds may be either done by the radiology department or by the emergency physician. [ 60 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13502", "text": "Where it is readily available,  computed tomography  (CT) has become frequently used, especially in people whose diagnosis is not obvious on history and physical examination. Although some concerns about interpretation are identified, a 2019 Cochrane review found that the sensitivity and specificity of CT for the diagnosis of acute appendicitis in adults was high. [ 62 ]   Concerns about radiation tend to limit use of CT in pregnant women and in children, especially with the increasingly widespread usage of MRI. [ 63 ] [ 64 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13503", "text": "The accurate diagnosis of appendicitis is multi-tiered, with the size of the appendix having the strongest  positive predictive value , while indirect features can either increase or decrease sensitivity and specificity. A size of over 6\u00a0mm is both 95% sensitive and specific for appendicitis. [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13504", "text": "However, because the appendix can be filled with fecal material, causing intraluminal distention, this criterion has shown limited utility in more recent meta-analyses. [ 66 ]  This is as opposed to ultrasound, in which the wall of the appendix can be more easily distinguished from intraluminal feces. In such scenarios, ancillary features such as increased wall enhancement as compared to adjacent bowel and inflammation of the surrounding fat, or fat stranding, can be supportive of the diagnosis. However, their absence does not preclude it. In severe cases with perforation, an adjacent  phlegmon  or  abscess  can be seen. Dense fluid layering in the pelvis can also result, related to either  pus  or  enteric spillage . When patients are thin or younger, the relative absence of fat can make the appendix and surrounding fat stranding difficult to see. [ 66 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13505", "text": "Magnetic resonance imaging  (MRI) use has become increasingly common for diagnosis of appendicitis in children and pregnant patients due to the radiation dosage that, while of nearly negligible risk in healthy adults, can be harmful to children or the developing baby. [ 67 ]  In pregnancy, it is more useful during the second and third trimester, particularly as the enlargening uterus displaces the appendix, making it difficult to find by ultrasound. The periappendiceal stranding that is reflected on CT by fat stranding on MRI appears as an increased fluid signal on T2 weighted sequences. First-trimester pregnancies are usually not candidates for MRI, as the fetus is still undergoing  organogenesis , and there are no long-term studies to date regarding its potential risks or side effects. [ 68 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13506", "text": "In general, plain abdominal radiography (PAR) is not useful in making the diagnosis of appendicitis and should not be routinely obtained from a person being evaluated for appendicitis. [ 69 ] [ 70 ]  Plain abdominal films may be useful for the detection of  ureteral   calculi ,  small bowel obstruction , or  perforated ulcer , but these conditions are rarely confused with appendicitis. [ 71 ]  An opaque  fecalith  can be identified in the right lower quadrant in fewer than 5% of people being evaluated for appendicitis. [ 48 ]  A  barium enema  has proven to be a poor diagnostic tool for appendicitis. While failure of the appendix to fill during a barium enema has been associated with appendicitis, up to 20% of normal appendices do not fill. [ 71 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13507", "text": "Several scoring systems have been developed to try to identify people who are likely to have appendicitis. [ 72 ]  The performance of scores such as the  Alvarado score  and the Pediatric Appendicitis Score, however, are variable. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13508", "text": "The Alvarado score is the most known scoring system. A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan or ultrasound exam may be used to reduce the rate of negative appendectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13509", "text": "Even for clinically certain appendicitis, routine  histopathology  examination of appendectomy specimens is of value for identifying unsuspected pathologies requiring further postoperative management. [ 74 ]  Notably,  appendix cancer  is found incidentally in about 1% of appendectomy specimens. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13510", "text": "Pathology diagnosis of appendicitis can be made by detecting a  neutrophilic  infiltrate of the  muscularis propria ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13511", "text": "Periappendicitis (inflammation of tissues around the appendix) is often found in conjunction with other abdominal pathology. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13512", "text": "Children:  Gastroenteritis ,  mesenteric adenitis ,  Meckel's diverticulitis ,  intussusception ,  Henoch\u2013Sch\u00f6nlein purpura , lobar  pneumonia ,  urinary tract infection  (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset  Crohn's disease  or  ulcerative colitis ,  pancreatitis , and abdominal trauma from  child abuse ;  distal intestinal obstruction syndrome  in children with cystic fibrosis;  typhlitis  in children with leukemia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13513", "text": "Women: A pregnancy test is important for all women of childbearing age since an  ectopic pregnancy  can have signs and symptoms similar to those of appendicitis. Other obstetrical/ gynecological causes of similar abdominal pain in women include  pelvic inflammatory disease ,  ovarian torsion ,  menarche , dysmenorrhea,  endometriosis , and  Mittelschmerz  (the passing of an egg in the ovaries approximately two weeks before menstruation). [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13514", "text": "Men:  testicular torsion"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13515", "text": "Adults: new-onset  Crohn disease ,  ulcerative colitis , regional enteritis,  cholecystitis ,  renal colic , perforated  peptic ulcer ,  pancreatitis ,  rectus sheath hematoma  and  epiploic appendagitis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13516", "text": "Elderly:  diverticulitis , intestinal obstruction,  colonic carcinoma ,  mesenteric ischemia , leaking  aortic aneurysm ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13517", "text": "The term \" pseudoappendicitis \" is used to describe a condition mimicking appendicitis. [ 79 ]  It can be associated with  Yersinia enterocolitica . [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13518", "text": "Acute appendicitis [ 81 ]  is typically managed by  surgery . While antibiotics are safe and effective for treating uncomplicated appendicitis, [ 16 ] [ 7 ] [ 82 ]  31% of people had a recurrence within a year and required an eventual appendectomy. [ 83 ]  Antibiotics are less effective if an  appendicolith  is present. [ 84 ]  While 51% of patients who were treated with antibiotics did not need an appendectomy three years after treatment, [ 85 ]  the cost effectiveness of surgery versus antibiotics is unclear [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13519", "text": "Using antibiotics to prevent potential postoperative complications in emergency appendectomy procedures is recommended, and the antibiotics are effective when given to a person before, during, or after surgery. [ 87 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13520", "text": "Pain medications (such as  morphine ) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the patient's care. [ 88 ]  Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children, and some recommended that they not be given until the surgeon was able to examine the person. [ 88 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13521", "text": "The  surgical  procedure for the removal of the appendix is called an  appendectomy . Appendectomy can be performed through open or laparoscopic surgery. Laparoscopic appendectomy has several advantages over open appendectomy as an intervention for acute appendicitis. [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13522", "text": "For over a century, laparotomy (open appendectomy) was the standard treatment for acute appendicitis. [ 90 ]  This procedure consists of the removal of the infected appendix through a single large incision in the lower right area of the abdomen. [ 91 ]  The incision in a laparotomy is usually 2 to 3 inches (51 to 76\u00a0mm) long."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13523", "text": "During an open appendectomy, the person with suspected appendicitis is placed under general  anesthesia  to keep the muscles completely relaxed and to keep the person unconscious. The incision is two to three inches (76\u00a0mm) long, and it is made in the right lower abdomen, several inches above the  hip bone . Once the incision opens the abdomen cavity, and the appendix is identified, the  surgeon  removes the infected tissue and cuts the appendix from the surrounding tissue. After careful and close inspection of the infected area, and ensuring there are no signs that surrounding tissues are damaged or infected.  In case of complicated appendicitis managed by an emergency open appendectomy, abdominal drainage (a temporary tube from the abdomen to the outside to avoid abscess formation) may be inserted, but this may increase the hospital stay. [ 92 ] [ needs update ]  The surgeon will start closing the incision. This means sewing the muscles and using  surgical staples  or  stitches  to close the skin up. To prevent infections, the incision is covered with a  sterile bandage  or surgical adhesive."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13524", "text": "Laparoscopic appendectomy was introduced in 1983 and has become an increasingly prevalent intervention for acute appendicitis. [ 93 ]  This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7\u00a0mm) long. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body, and it is designed to help the surgeon inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using  surgical instruments . Laparoscopic surgery requires  general anesthesia , and it can last up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including a shorter post-operative recovery, less post-operative pain, and a lower superficial surgical site infection rate. However, the occurrence of an intra-abdominal abscess is almost three times more prevalent in laparoscopic appendectomy than open appendectomy. [ 94 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13525", "text": "In pediatric patients, the high mobility of the cecum allows externalization of the appendix through the umbilicus, and the entire procedure can be performed with a single incision. Laparoscopic-assisted transumbilical appendectomy is a relatively recent technique but with a long published series and very good surgical and aesthetic results. [ 95 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13526", "text": "The treatment begins by  keeping the person who will be having surgery from eating or drinking  for a given period, usually overnight. An  intravenous drip  is used to hydrate the person who will be having surgery.  Antibiotics  given intravenously such as  cefuroxime  and  metronidazole  may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours), general anaesthesia is usually used. Otherwise,  spinal anaesthesia  may be used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13527", "text": "Once the decision to perform an  appendectomy  has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. (With all surgeries there are risks that must be evaluated before performing the procedures.) The risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%. [ 96 ]  The most usual complications that can occur are pneumonia,  hernia  of the incision,  thrombophlebitis , bleeding and  adhesions . Evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in outcomes to the person with appendicitis. [ 97 ] [ 98 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13528", "text": "The surgeon will explain how long the recovery process should take. Abdomen hair is usually removed to avoid complications that may appear regarding the incision."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13529", "text": "In most cases, patients going in for surgery experience nausea or vomiting that require medication before surgery. Antibiotics, along with pain medication, may be administered before appendectomies."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13530", "text": "Hospital lengths of stay typically range from a few hours to a few days but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition: if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally much faster if the appendix does not rupture. [ 99 ]  It is important that people undergoing surgery respect their doctor's advice and limit their physical activity so the tissues can heal. Recovery after an appendectomy may not require diet changes or a lifestyle change."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13531", "text": "The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in 2010, the average appendicitis hospital stay was 1.8 days. For stays where the person's appendix had ruptured, the average length of stay was 5.2 days. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13532", "text": "After surgery, the patient will be transferred to a  postanesthesia care unit , so their vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function correctly. Patients are recommended to sit on the edge of the bed and walk short distances several times a day. Moving is mandatory, and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks but can be prolonged to up to eight weeks if the appendix has ruptured."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13533", "text": "Most people with appendicitis recover quickly after surgical treatment, but complications can occur if treatment is delayed or if  peritonitis  occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around ten years old), the recovery takes three weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13534", "text": "The possibility of peritonitis is the reason why acute appendicitis warrants rapid evaluation and treatment. People with suspected appendicitis may have to undergo a  medical evacuation . Appendectomies have occasionally been performed in emergency conditions (i.e., not in a proper hospital) when a timely medical evacuation was impossible."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13535", "text": "Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more challenging to diagnose and is more apt to be complicated even when operated early. In either condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13536", "text": "Another entity known as the appendicular lump is talked about. It happens when the appendix is not removed early during infection, and the omentum and intestine adhere to it, forming a palpable lump. During this period, surgery is risky unless there is pus formation evident by fever and toxicity or by ultrasound. Medical management treats the condition."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13537", "text": "An unusual complication of an appendectomy is \"stump appendicitis\": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy. [ 100 ]  Stump appendicitis can occur months to years after initial appendectomy and can be identified with imaging modalities such as ultrasound. [ 101 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13538", "text": "The history of appendicitis traces back to ancient medical texts, though its clear clinical understanding emerged in the 19th century. Berengario da Carpi provided the first recorded description of the appendix in the 16th century, followed by  Andreas Vesalius  and  Gabriele Falloppio . Clinical understanding progressed in the 18th and 19th centuries, marked by Lorenz Heister's autopsy findings, Claudius Aymand's surgical intervention, and J. Mestivier's operation for appendicitis. Prior to the use of the term  appendicitis , it was described with terms including  perityphlitis ,  typhlitis ,  paratyphlitis , and  extra-peritoneal abscess of the right iliac fossa . [ 102 ]  The term \"appendicitis\" was coined by the American physician  Reginald Heber Fitz  in 1886, leading to standardized diagnosis and treatment, including Charles McBurney's identification of McBurney's point. Modern appendectomy techniques evolved in the early 20th century, coinciding with advancements in pathology, notably demonstrated by Ludwig Aschoff in 1908. [ 103 ] [ 104 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13539", "text": "Appendicitis is most common between the ages of 5 and 40. [ 106 ]  In 2013, it resulted in 72,000 deaths globally, down from 88,000 in 1990. [ 107 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13540", "text": "In the United States, there were nearly 293,000 hospitalizations involving appendicitis in 2010. [ 14 ]  Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization among children ages 5\u201317 years in the United States. [ 108 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13541", "text": "Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without. [ 109 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13542", "text": "Bowel obstruction , also known as  intestinal obstruction , is a mechanical or  functional obstruction  of the  intestines  which prevents the normal movement of the products of  digestion . [ 2 ] [ 5 ]  Either the  small bowel  or  large bowel  may be affected. [ 1 ]  Signs and symptoms include  abdominal pain ,  vomiting ,  bloating  and not passing  gas . [ 1 ]  Mechanical obstruction is the cause of about 5 to 15% of cases of  severe abdominal pain of sudden onset  requiring admission to hospital. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13543", "text": "Causes of bowel obstruction include  adhesions ,  hernias ,  volvulus ,  endometriosis ,  inflammatory bowel disease ,  appendicitis ,  tumors ,  diverticulitis ,  ischemic bowel ,  tuberculosis  and  intussusception . [ 1 ] [ 2 ]  Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and volvulus. [ 1 ] [ 2 ]  The diagnosis may be made on plain  X-rays ; however,  CT scan  is more accurate. [ 1 ]   Ultrasound  or  MRI  may help in the diagnosis of children or  pregnant  women. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13544", "text": "The condition may be treated conservatively or with  surgery . [ 2 ]  Typically  intravenous fluids  are given, a  nasogastric (NG) tube is placed through the nose into the stomach  to decompress the intestines, and  pain medications  are given. [ 2 ]   Antibiotics  are often given. [ 2 ]  In small bowel obstruction about 25% require surgery. [ 6 ]  Complications may include  sepsis , bowel  ischemia  and  bowel perforation . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13545", "text": "About 3.2 million cases of bowel obstruction occurred in 2015 which resulted in 264,000 deaths. [ 3 ] [ 7 ]  Both sexes are equally affected and the condition can occur at any age. [ 6 ]  Bowel obstruction has been documented throughout history, with cases detailed in the  Ebers Papyrus  of 1550 BC and by  Hippocrates . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13546", "text": "Depending on the level of obstruction, bowel obstruction can present with  abdominal pain ,  abdominal distension , and  constipation . Bowel obstruction may be complicated by  dehydration  and  electrolyte abnormalities  due to vomiting; respiratory compromise from pressure on the  diaphragm  by a distended abdomen, or  aspiration  of vomitus; bowel  ischemia  or  perforation  from prolonged distension or pressure from a foreign body and subsequently  sepsis  due to  bowel flora . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13547", "text": "In small bowel obstruction, the  pain  tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation. [ 10 ]  Common physical exam findings may include signs of  dehydration , abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13548", "text": "In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation. [ 12 ]  Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. [ 13 ]  Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of  volvulus  and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable  hernia , abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13549", "text": "The main diagnostic tools are  blood tests ,  X-rays  of the abdomen, CT scanning, and  ultrasound . If a mass is identified,  biopsy  may determine the nature of the mass. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13550", "text": "Radiological  signs of bowel obstruction include bowel distension (small bowel loops dilated >3 cm) and the presence of multiple (more than 2) air-fluid levels on supine and erect abdominal  radiographs . [ 16 ]  Ultrasounds may be as useful as CT scanning to make the diagnosis. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13551", "text": "Contrast enema  or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with  sensitivity  of 97% and  specificity  of 96%. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13552", "text": "Colonoscopy , small bowel investigation with ingested camera or push  endoscopy , and  laparoscopy  are other diagnostic options."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13553", "text": "Differential diagnoses  of bowel obstruction include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13554", "text": "Causes of  small bowel  obstruction include: [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13555", "text": "After abdominal surgery, the incidence of small bowel obstruction from any cause is 9%. In those where the cause of the obstruction was clear, adhesions are the single most common cause (more than half). [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13556", "text": "Causes of large bowel obstruction include: [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13557", "text": "Outlet obstruction is a sub-type of large bowel obstruction and refers to conditions affecting the anorectal region that obstruct  defecation , specifically conditions of the pelvic floor and anal sphincters. Outlet obstruction can be classified into four groups. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13558", "text": "Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management. [ 25 ] [ 26 ]  Patients are monitored by the surgical team for signs of improvement and resolution of the obstruction on imaging; if the obstruction does not clear then surgical management for the treatment of the causative lesion is required. [ 27 ]  In malignant large bowel obstruction, endoscopically placed self-expanding metal  stents  may be used to temporarily relieve the obstruction as a bridge to surgery, [ 28 ]  or as  palliation . [ 29 ]  Diagnosis of the type of bowel obstruction is normally conducted through initial plain  radiograph  of the abdomen, luminal contrast studies,  computed tomography scan , or  ultrasonography  prior to determining the best type of treatment. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13559", "text": "Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13560", "text": "In the management of small bowel obstructions, a commonly quoted surgical aphorism is: \"never let the sun rise or set on small-bowel obstruction\" [ 32 ]  because about 5.5% [ 32 ]  of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies ( volvulus , closed-loop obstructions,  ischemic bowel , incarcerated  hernias , etc.). [ 2 ]  Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of  peritonitis  such as rebound tenderness,  elevated heart rate , fever, and elevated inflammatory markers on lab work, such as  lactic acid . [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13561", "text": "A small flexible tube ( nasogastric tube ) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting.  Intravenous therapy  is utilized and the urine output may be monitored with a  catheter  in the  bladder . [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13562", "text": "Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and  X-ray images  are made to ensure he or she is not getting clinically worse. [ 37 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13563", "text": "Conservative treatment involves insertion of a  nasogastric tube , correction of dehydration and  electrolyte  abnormalities.  Opioid  pain relievers may be used for patients with severe pain but alternate pain relievers are preferred as opioids can decrease bowel motility. [ 38 ] Antiemetics  may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13564", "text": "Most patients improve with conservative care in 2\u20135 days. When the obstruction is cancer, surgery is the only treatment. Those with  bowel resection  or  lysis  of adhesions usually stay in the hospital a few more days until they can eat and walk. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13565", "text": "Small bowel obstruction caused by  Crohn's disease , peritoneal  carcinomatosis , sclerosing  peritonitis ,  radiation enteritis , and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13566", "text": "The prognosis for non-ischemic cases of SBO is good with mortality rates of 3\u20135%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13567", "text": "Cases of SBO related to cancer are more complicated and require additional intervention to address the  malignancy , recurrence, and  metastasis , and thus are associated with a more poor prognosis. [ 41 ]  Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction. [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13568", "text": "All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery. [ 43 ]  More than 90% of patients also form adhesions after major abdominal surgery. [ 44 ] \nCommon consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility. [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13569", "text": "Endoscopic stenting  is a medical procedure by which a  stent , a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by  endoscopy . They are usually inserted when a disease process has led to narrowing or obstruction of the organ in question, such as the  esophagus  or the  colon ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13570", "text": "There are various types of endoscopic stents: plastic stents, uncovered self-expandable metallic stents, partially covered self-expandable metallic stents, and fully covered self-expandable metallic stents. [ 1 ]   Self-expandable metallic stents  \"play an important role in the management of malignant obstructing lesions in the gastrointestinal tract.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13571", "text": "A stent may be inserted into the  common bile duct  during an  endoscopic retrograde cholangiopancreatography , especially if  gallstone  removal is deemed too risky. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13572", "text": "Some complications of metallic stents are: stent migration (occurring in 20 to 40% of the cases). Stents with anchoring flaps or flared ends can reduce the risk of migration. Cholecystitis can be a complication for stenting of malignant biliary stricture. Stent occlusion may occur from tumor or tissue overgrowth, or due to sludge deposits, causing the development of cholangitis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13573", "text": "An  epidural abscess  refers to a collection of pus and infectious material located in the  epidural space  superficial to the  dura mater  which surrounds the  central nervous system . Due to its location adjacent to brain or spinal cord, epidural abscesses have the potential to cause weakness, pain, and paralysis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13574", "text": "A  spinal epidural abscess  (SEA) is a collection of pus or inflammatory granulation between the  dura mater  and the  vertebral column . [ 1 ]   Currently the annual incidence rate of SEAs is estimated to be 2.5\u20133 per 10,000 hospital admissions.  Incidence of SEA is on the rise, due to factors such as an aging population, increase in use of invasive spinal instrumentation, growing number of patients with risk factors such as diabetes and intravenous drug use. [ 1 ]   SEAs are more common in posterior than anterior areas, [ 2 ]  and the most common location is the  thoracolumbar  area, where  epidural space  is larger and contains more fat tissue. [ 3 ] \nSEAs are more common in males, and can occur in all ages, although highest prevalence is during the fifth and seventh decades of life. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13575", "text": "Combined treatment of emergency surgery and antibiotics is the preferred treatment for the spinal epidural abscess, removing existing pus (which is tested for microorganisms to select the most appropriate antibiotic) and removing pressure from the spinal cord and nerve roots. Antibiotic therapy should start after obtaining pus for microbiological investigation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13576", "text": "A  cranial epidural abscess  involves pus and granulation tissue accumulation in between the dura mater and cranial bone. These typically arise (along with  osteomyelitis  of a cranial bone) from infections of the ear or paranasal sinuses. They rarely can be caused by distant infection or an infected  cerebral venous sinus thrombosis .  Staphylococcus aureus  is the most common pathogen. Symptoms include pain at the forehead or ear, pus draining from the ear or sinuses, tenderness overlying the infectious site, fever, neck stiffness, and in rare cases focal seizures.  Treatment requires a combination of antibiotics and surgical removal of infected bone. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13577", "text": "article/232570  at  eMedicine"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13578", "text": "A  gastrojejunocolic fistula  is a disorder of the human  gastrointestinal tract . It may form between the transverse colon and the upper  jejunum  after a  Billroth II  surgical procedure.  (The Billroth procedure attaches the jejunum to the remainder of the stomach.) Fecal matter thereby passes improperly from the colon to the stomach, and causes  halitosis . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13579", "text": "Patients may present with  diarrhea , [ 1 ]   weight loss  and  halitosis  as a result of fecal matter passing through the  fistula  from the colon into the stomach."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13580", "text": "A  glomectomy  is an excision of a  glomus body  or a  glomus cell , usually in the case of a  glomus tumor . This operation was formerly performed for the treatment of severe, chronic  asthma , [ 1 ]  but has since been abandoned for this purpose due to its lack of efficacy. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13581", "text": "In  human anatomy , the  greater sac , also known as the  general cavity (of the abdomen)  or  peritoneum of the  peritoneal cavity  proper , is the cavity in the  abdomen  that is inside the peritoneum but outside the  lesser sac ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13582", "text": "It is connected with the lesser sac via the  omental foramen , also known as the  foramen of Winslow  or  epiploic foramen , which is anteriorly bounded by the portal triad \u2013  portal vein ,  hepatic artery , and  common bile duct ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13583", "text": "The  ileojejunal bypass  is an  experimental   surgery  designed as a remedy for  morbid obesity . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13584", "text": "It was first performed on a series of patients at White Memorial Hospital,  Los Angeles, California , in the mid-to-late 1970s. It has since been discarded, as the complications from the surgery, including malnutrition, vitamin deficiencies, protein and albumin deficiency, liver and renal failure, and kidney stones, highly outweighed the benefits. Many patients who received this surgery consequently underwent reversal surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13585", "text": "Intra-abdominal infection  ( IAI , also spelled  intraabdominal ) is a group of  infections  that occur within the  abdominal cavity . They vary from  appendicitis  to  fecal peritonitis . [ 1 ]  Risk of death despite treatment is often high. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13586", "text": "IAIs can be classified into uncomplicated and complicated infections. Uncomplicated infections often involved the infection of single organ and can be controlled by surgical removal of the source of infection, and antibiotics is not required after the surgery to control the infection. In complicated infections, the infection spread to a part or to the whole of the  peritoneum , causing  peritonitis . Meanwhile, peritonitis can be classified into primary, secondary, and tertiary peritonitis. Primary peritonitis is the diffuse bacterial infection of the peritoneum while the integrity of the gastrointestinal tract is preserved (in cases of  ascites ); secondary peritonitis is the infection of peritoneum where the integrity of gastrointestinal tract is compromised; tertiary peritonitis is reinfection of peritoneum 48 hours after apparently good surgical control of secondary peritonitis. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13587", "text": "Those with suspected with IAIs usually have acute onset of abdominal pain with signs of local or generalised  inflammations  such as pain,  tenderness  (pain on touching), fever,  tachycardia  (increased heart rate), or  tachypnea  (increased breathing rate). In more severe cases, such as organ failure, signs such as  hypotension  (low blood pressure),  oliguria  (reduced urine output), sudden onset of  altered level of consciousness , and  lactic acidosis  will appear. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13588", "text": "In case of  appendicitis , signs such as fever, positive  psoas sign , migration of pain from umbilicus to the  right iliac fossa  increases the likelihood of the disease; while signs such as vomiting before the pain reduces its likelihood to occur. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13589", "text": "CT scan and ultrasound has been used routinely to complete the assessment of IAIs. CT scan has higher sensitivity and specificity than ultrasound to access the condition. However, CT scan poses radiation risk to the subject. [ 2 ]  MRI scan is less readily available than CT scan or ultrasound in hospitals to diagnose IAIs. However, it has been proposed to be used in those who are pregnant and have inconclusive findings on ultrasound. The sensitivity and specificity of MRI in diagnosing acute appendicitis are 94% and 96% respectively. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13590", "text": "Laparoscopic surgery has also been used to diagnose the cause of IAIs when imaging is unhelpful. Besides, the laparoscopic surgery can also initiate treatment in the same setting. The accuracy is very high, in the range of 86 to 100%. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13591", "text": "The  lesser sac , also known as the  omental bursa , is a part of the  peritoneal cavity  that is formed by the  lesser  and  greater omentum .  Usually found in mammals, it is connected with the  greater sac  via the  omental foramen  or  Foramen of Winslow . In mammals, it is common for the lesser sac to contain considerable amounts of fat."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13592", "text": "If any of the marginal structures rupture their contents could leak into the lesser sac. If the stomach were to rupture on its anterior side though the leak would collect in the  greater sac . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13593", "text": "The lesser sac is formed during  embryogenesis  from an infolding of the greater omentum. The open end of the infolding, known as the  omental foramen  is usually close to the stomach. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13594", "text": "A  Meckel's diverticulum , a true  congenital   diverticulum , is a slight bulge in the  small intestine  present at birth and a  vestigial  remnant of the  vitelline duct . It is the most common malformation of the  gastrointestinal tract  and is present in approximately 2% of the population, [ 1 ]  with males more frequently experiencing symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13595", "text": "Meckel's diverticulum was first explained by  Fabricius Hildanus  in the sixteenth century and later named after  Johann Friedrich Meckel , who described the embryological origin of this type of diverticulum in 1809. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13596", "text": "The majority of people with a Meckel's diverticulum are  asymptomatic . An asymptomatic Meckel's diverticulum is called a  silent  Meckel's diverticulum. [ 4 ]  If symptoms do occur, they typically appear before the age of two years. [ 5 ]  The most common presenting symptom is painless  rectal bleeding  such as  melaena -like black offensive stools, followed by  intestinal obstruction ,  volvulus  and  intussusception . Occasionally, Meckel's diverticulitis may present with all the features of  acute appendicitis . [ 6 ]  Also, severe pain in the  epigastric region  is experienced by the person along with bloating in the epigastric and umbilical regions. At times, the symptoms are so painful that they may cause sleepless nights with acute pain felt in the foregut region, specifically in the  epigastric  and  umbilical  regions. [ citation needed ]  In some cases, bleeding occurs without warning and may stop spontaneously. The symptoms can be extremely painful, often mistaken as just stomach pain resulting from not eating or constipation. [ citation needed ]  Rarely, a Meckel's diverticulum containing ectopic pancreatic tissue can present with abdominal pain and increased serum amylase levels, mimicking acute pancreatitis. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13597", "text": "The lifetime risk for a person with Meckel's diverticulum to develop certain  complications  is about 4\u20136%. Gastrointestinal bleeding,  peritonitis  or  intestinal obstruction  may occur in 15\u201330% of symptomatic people (Table 1). On rare occasions the diverticulum can herniate through the abdominal wall also known as a  Littre hernia.  Only 6.4% of all complications require surgical treatment, and untreated Meckel's diverticulum has a  mortality rate  of 2.5\u201315%. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13598", "text": "Table 1 \u2013 Complications of Meckel's Diverticulum: [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13599", "text": "Bleeding of the diverticulum is most common in young children, especially in males who are less than 2 years of age. [ 10 ]  Symptoms may include bright red blood in stools ( hematochezia ), weakness, abdominal tenderness or pain, and even  anaemia  in some cases. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13600", "text": "Bleeding may be caused by:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13601", "text": "The appearance of stools may indicate the nature of the bleeding:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13602", "text": "Inflammation of the diverticulum can mimic symptoms of appendicitis, i.e., periumbilical tenderness and intermittent crampy abdominal pain. Perforation of the inflamed diverticulum can result in peritonitis. Diverticulitis can also cause  adhesions , leading to intestinal obstruction. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13603", "text": "Diverticulitis may result from:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13604", "text": "Symptoms:  Vomiting, abdominal pain and severe or complete  constipation . [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13605", "text": "Anomalies between the diverticulum and umbilicus may include the presence of a fibrous cord,  cyst , fistula, or sinus, leading to: [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13606", "text": "Neoplasms  (tumors) in Meckel's diverticulum may cause bleeding, acute abdominal pain, gastrointestinal obstruction, perforation or intussusception. They may be  benign  or  malignant . [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13607", "text": "The omphalomesenteric duct (omphaloenteric duct, vitelline duct, or yolk stalk) normally connects the embryonic midgut to the yolk sac ventrally, providing nutrients to the midgut during embryonic development. The vitelline duct narrows progressively and disappears between the 5th and 8th weeks of gestation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13608", "text": "In Meckel's diverticulum, the proximal part of vitelline duct fails to regress and involute, which remains as a remnant of variable length and location. [ 16 ]  The solitary diverticulum lies on the antimesenteric border of the ileum (opposite to the  mesenteric attachment ) and extends into the umbilical cord of the embryo. [ 8 ]  The left and right vitelline arteries originate from the primitive  dorsal aorta , and travel with the vitelline duct. The right becomes the  superior mesenteric artery  that supplies a terminal branch to the diverticulum, while the left involutes. [ 17 ]  Having its own blood supply, Meckel's diverticulum is susceptible to obstruction or infection."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13609", "text": "Meckel's diverticulum is located in the  distal   ileum , usually within 60\u2013100\u00a0cm (2\u00a0feet) of the  ileocecal valve . This  blind segment  or small pouch is about 3\u20136\u00a0cm (2\u00a0inch) long and may have a greater  lumen  diameter than that of the  ileum . [ 20 ]  It runs antimesenterically and has its own blood supply. It is a remnant of the connection from the  yolk sac  to the small intestine present during  embryonic development . It is a  true diverticulum , consisting of all three layers of the  bowel  wall:  mucosa ,  submucosa  and  muscularis propria . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13610", "text": "As the vitelline duct is made up of  pluripotent  cell lining, Meckel's diverticulum may harbor abnormal tissues, containing embryonic remnants of other tissue types.  Jejunal ,  duodenal  mucosa or  Brunner's tissue  were each found in 2% of  ectopic  cases.  Heterotopic  rests of  gastric  mucosa and  pancreatic  tissue are seen in 60% and 6% of cases respectively. Heterotopic means the displacement of an organ from its normal anatomic location. [ 21 ]  Inflammation of this Meckel's diverticulum may mimic appendicitis. Therefore, during appendectomy, ileum should be checked for the presence of Meckel's diverticulum, if it is found to be present it should be removed along with appendix. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13611", "text": "A  memory aid  is the rule of 2s: [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13612", "text": "However, the exact values for the above criteria range from 0.2\u20135 (for example, prevalence is probably 0.2\u20134%). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13613", "text": "It can also be present as an indirect  hernia , typically on the right side, where it is known as a \" Hernia of  Littr\u00e9 \". A case report of strangulated  umbilical hernia  with Meckel's diverticulum has also been published in the literature. [ 23 ]  Furthermore, it can be attached to the umbilical region by the vitelline ligament, with the possibility of vitelline cysts, or even a patent vitelline canal forming a vitelline  fistula  when the umbilical cord is cut. Torsions of intestine around the intestinal stalk may also occur, leading to obstruction,  ischemia , and  necrosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13614", "text": "A  technetium-99m  ( 99mTc )  pertechnetate  scan, also called Meckel scan or nuclear scintigraphy scan, is the investigation of choice to diagnose Meckel's diverticula in children. This scan detects  gastric mucosa ; since approximately 50% of symptomatic Meckel's diverticula have ectopic gastric or pancreatic cells contained within them, [ 24 ]  this is displayed as a spot on the scan distant from the stomach itself. In children, this scan is highly accurate and  noninvasive , with 95% specificity and 85% sensitivity; [ 17 ]  however, in adults the test is only 9% specific and 62% sensitive. [ 25 ]  This scan is more accurate in children because gastric mucosa is found in 90% of bleeding diverticula; which is the most common symptom in children, not adults.  [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13615", "text": "Patients with these misplaced gastric cells may experience  peptic ulcers  as a consequence. Therefore, other tests such as  colonoscopy  and screenings for  bleeding disorders  should be performed, and  angiography  can assist in determining the location and severity of bleeding. Colonoscopy might be helpful to rule out other sources of bleeding but it is not used as an identification tool. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13616", "text": "Angiography  might identify brisk bleeding in patients with Meckel's diverticulum. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13617", "text": "Ultrasonography  could demonstrate omphaloenteric duct remnants or cysts. [ 27 ]   Computed tomography  (CT scan) might be a useful tool to demonstrate a blind ended and inflamed structure in the mid-abdominal cavity, which is not an appendix. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13618", "text": "In asymptomatic patients, Meckel's diverticulum is often diagnosed as an incidental finding during  laparoscopy  or  laparotomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13619", "text": "Treatment is surgical, potentially with a laparoscopic  resection . [ 17 ]  In patients with bleeding, strangulation of bowel, bowel perforation or  bowel obstruction , treatment involves surgical resection of both the Meckel's diverticulum itself along with the adjacent bowel segment, and this procedure is called a \"small bowel resection\". [ 17 ]  In patients without any of the aforementioned complications, treatment involves surgical resection of the Meckel's diverticulum only, and this procedure is called a simple  diverticulectomy . [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13620", "text": "With regards to asymptomatic Meckel's diverticulum, some recommend that a search for Meckel's diverticulum should be conducted in every case of  appendectomy /laparotomy done for  acute abdomen , and if found, Meckel's diverticulectomy or resection should be performed to avoid secondary complications arising from it. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13621", "text": "Meckel's diverticulum occurs in about 2% of the population. [ 21 ]  Prevalence in males is 3\u20135 times higher than in females. [ 20 ]  Only 2% of cases are symptomatic, which usually presents among children at the age of 2. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13622", "text": "Most cases of Meckel's diverticulum are diagnosed when complications manifest or incidentally in unrelated conditions such as laparotomy, laparoscopy or contrast study of the small intestine. Classic presentation in adults includes intestinal obstruction and inflammation of the diverticulum (diverticulitis). Painless rectal bleeding most commonly occurs in toddlers. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13623", "text": "Inflammation in the ileal diverticulum has symptoms that mimic appendicitis, therefore its diagnosis is of clinical importance. Detailed knowledge of the pathophysiological properties is essential in dealing with the life-threatening complications of Meckel's diverticulum. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13624", "text": "In  human anatomy , the  omental foramen  ( epiploic foramen ,  foramen of Winslow  after the anatomist  Jacob B. Winslow , or uncommonly  aditus ;  Latin :  Foramen epiploicum ) is the passage of communication, or foramen, between the  greater sac , and the  lesser sac  of the  peritoneal cavity ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13625", "text": "It has the following borders:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13626", "text": "As the portal vein is the most posterior structure in the hepatoduodenal ligament, and the inferior vena cava lies under the posterior wall, the epiploic foramen can be remembered as lying between the two great veins of the abdomen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13627", "text": "This article incorporates text in the  public domain  from  page 1156  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13628", "text": "A  Paget's abscess , named by eminent British surgeon and pathologist Sir  James Paget , is an  abscess  that recurs at the site of a former abscess which had resolved. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13629", "text": "Pelvic abscess  is a  collection of pus  in the  pelvis , typically occurring following lower abdominal  surgical procedures , or as a complication of  pelvic inflammatory disease  (PID),  appendicitis , or lower genital tract infections. [ 1 ]  Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  It can lead to sepsis and death. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13630", "text": "Blood tests typically show a  raised white cell count . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Ultrasound ,  CT-scan  or  MRI  may be used to locate the abscess and assess its dimensions. [ 1 ]  Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT . [ 3 ]  Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13631", "text": "Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  There may be urinary frequency,  diarrhoea , or persistent  feeling of needing to pass stool . [ 4 ]  Other symptoms may include fatigue, nausea, and vomiting. [ 2 ]  Clinical features might not be apparent until the pelvic abscess has grown in size. [ 2 ]  The lower abdomen is generally tender; one or both sides. [ 2 ]  A bulging of the front wall of the rectum might be felt on digital examination via the rectum or vagina. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13632", "text": "Complications include sepsis and  peritonitis . [ 1 ]  In the longterm, a  fistula  may develop. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13633", "text": "Pelvic abscess typically occurs following  gynecological surgery  and  abdominal surgery ; hysterectomy, laparotomy, caesarian section, and induced abortion. [ 1 ]   It may occur as a complication of  pelvic inflammatory disease  (PID),  appendicitis ,  diverticulitis ,  inflammatory bowel disease  (IBD), trauma, pelvic organ cancer, or lower genital tract infections. [ 1 ] [ 3 ]  The abscess may be in the  pouch of Douglas ,  fallopian tube ,  ovary , or  parametrium . [ 1 ]  It begins as inflammation or a  collection of blood  in the pelvis. [ 1 ]  Other risk factors include immunodeficiency, pregnancy,  hydrosalpinx ,  endometrioma , poorly controlled  diabetes ,  kidney disease ,  obesity , and genital tract abnormalities. [ 1 ] [ 2 ]  Opening the rectum to resect a  rectal cancer  may lead to developing a pelvic abscess. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13634", "text": "PID in females may lead to a  tubo-ovarian abscess , where the abscess may be in the  fallopian tube  or  ovary . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13635", "text": "In children, it is more frequently associated with IBD and appendicitis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13636", "text": "Blood tests typically show a  raised white cell count , often with a high  ESR  and  C-reactive protein . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Medical imaging  to assess the dimensions and locate the abscess may include  ultrasound ,  CT-scan  or  MRI . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13637", "text": "Other conditions that appear similar include  ectopic pregnancy , PID, appendicitis,  kidney stone ,  bowel obstruction , and sepsis following  miscarriage  or  termination of pregnancy . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13638", "text": "Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT ,  through the skin ,  via the rectum , or  transvaginal  routes. [ 3 ]  Occasionally antibiotics may be used without surgery; if the abscess is at a very stage and small. [ 2 ]  Until sensitivities are received, a broad spectrum antibiotic is generally required. [ 2 ]  Sometimes, a laparotomy of laparoscopy is required. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13639", "text": "Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]  Treatment also includes  adequate hydration . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13640", "text": "Further surgery such as is sometimes required to treat the underlying cause; such as salpingo-oophorectomy for tubo-ovarian abscess. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13641", "text": "Pelvic abscess responds well to antibiotics and hydration. [ 1 ]  The outcome is less successful in the presence of fistula. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13642", "text": "It is uncommon. [ 2 ]  The incidence of pelvic abscess is less than 1% in an individual undergoing obstetric and gynecological operative procedure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13643", "text": "A  retrograde appendicectomy  is a form of  surgery  to remove an  appendix  that is retrocaecal and adherent [ 1 ]  or otherwise inaccessible, so that the  appendicectomy  is performed in a retrograde fashion. [ 2 ]  In cases of acute appendicitis, antegrade appendicectomy is the preferred option, but in cases where the base of the appendix is accessible but is difficult to identify or deliver its more distal portion, a retrograde appendicectomy becomes necessary. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13644", "text": "Firstly, the base is divided between artery forceps then the appendiceal vessels are then ligated, the stump ligated and invaginated, and gentle traction on the caecum will enable the surgeon to deliver the body of the appendix, which is then removed from base to tip. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13645", "text": "Subphrenic abscess  is a disease characterized by an accumulation of infected fluid between the  diaphragm ,  liver , and  spleen . [ 2 ]   This  abscess  develops after surgical operations like  splenectomy .\nPresents with cough, increased respiratory rate with shallow respiration, diminished or absent breath sounds, hiccups, dullness in percussion, tenderness over the 8th\u201311th ribs, fever, chills, anorexia and shoulder tip pain on the affected side. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death.\nPatients who develop peritonitis may get localized abscesses in the right or left subphrenic space. The right side is more common due to the high frequency of ruptured appendices and perforated duodenal ulcers.\nTwo common approaches to draining a subphrenic abscess are 1) incision inferior to or through the bed of the 12th rib (no need to create an opening in the pleura or peritoneum) 2) an anterior subphrenic abscess is often drained through a subcostal incision located inferior and parallel to the right costal margin.  [ 3 ]  It is also associated with  peritonitis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13646", "text": "This article related to  pathology  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13647", "text": "This article about a medical condition affecting the respiratory system is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13648", "text": "A  tracheo-esophageal puncture  (or  tracheoesophageal puncture ) is a surgically created hole between the  trachea  (windpipe) and the  esophagus  (food pipe) in a person who has had a total  laryngectomy , a surgery where the  larynx  (voice box) is removed. The purpose of the puncture is to restore a person\u2019s ability to speak after the vocal cords have been removed. This involves creation of a  fistula  between the trachea and the esophagus, puncturing the short segment of tissue or \u201ccommon wall\u201d that typically separates these two structures.  A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for  esophageal speech ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13649", "text": "A laryngectomized person is required to breathe through a permanent breathing hole in the neck, called a  tracheostoma . When a laryngectomized person occludes the tracheostoma, completely blocking exhaled air to leave the body through that pathway, exhaled air is directed through the voice prosthesis. This air enters the esophagus and escapes through the mouth. During this process, as the air passes through the upper tissues of the esophagus and lower throat, it allows for vibration of the tissues of the pharyngo-esophageal segment (also called PE-segment, neoglottis or pseudoglottis). This vibration creates a sound that serves to replace the sound the  vocal cords  previously produced. Other methods of  alaryngeal speech  (speech without vocal cords) are esophageal speech, and  electrolaryngeal speech . Studies show that tracheo-esophageal speech is found to be closer to normal speech than esophageal speech [ 1 ] [ 2 ] [ 3 ]  and is often reported to be better, both in terms of naturalness as well as how well it is understood, when compared to esophageal speech [ 4 ] [ 5 ]   and electrolarynx speech. [ 6 ] \nThe first report on a tracheo-esophageal puncture dates back to 1932 [ 7 ]  when a laryngectomized patient was said to use a hot ice pick to create a tracheo-esophageal puncture in himself. This enabled him to speak by forcing air through the puncture when closing off the tracheostoma with a finger."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13650", "text": "There are two tracheo-esophageal puncture procedure types: Primary and secondary puncture. Initially, the procedure was described as a secondary procedure [ 8 ]  and later also as a primary procedure. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13651", "text": "This procedure is performed during the total laryngectomy surgery. After removal of the larynx and creation of the tracheostoma, the puncture is made through the back wall of the trachea into the front wall of the esophagus. The main advantages of a primary puncture are: 1) that a second surgery to create the puncture is avoided (including the related costs and risks) and: 2) that the patient will be able to speak within a few weeks after total laryngectomy. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13652", "text": "There are cases where a primary procedure cannot be performed. For example, this procedure cannot be used when there is complete separation of the tracheo-esophageal wall where the puncture would otherwise be placed (for example, in case a portion of the esophagus is removed requiring an anastomosis, or \u201creconnection\u201d of structures in the region).  In that case, a sufficient period of recovery and wound healing would be required. A secondary puncture could then be placed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13653", "text": "This procedure refers to a puncture that is placed anytime after the total laryngectomy surgery. The decision to use a primary or secondary puncture can vary greatly. Secondary puncture can be performed when: 1) primary puncture was not possible, 2) for re-puncture after closure of a previous tracheo-esophageal puncture, 3) because of physician or patient preference, and 4) in case failure of esophageal or electrolarynx speech if this was chosen as the initial speech option. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13654", "text": "There are two different methods that can be used to place the  voice prosthesis :\nPrimary placement: A voice prosthesis is placed into the puncture [ 12 ] [ 13 ]  immediately after it is created. During the immediate postoperative period, the patient is fed through a feeding tube, either inserted directly into the stomach or through a more temporary version than extends from the nose into the stomach. This tube is removed when the patient is able to eat enough by mouth to maintain nutritional needs; this can be as early as the second day following surgery. [ 11 ]  Speech production with the voice prosthesis is initiated when the surgical area has healed, after clearance by the surgeon. The advantages of this method are:\n1) the voice prosthesis stabilizes the TE wall,\n2) the flanges of the device protect the puncture against leakage of fluids, stomach acids and other stomach contents,\n3) there is no irritation or pressure from a stenting catheter, used to maintain the puncture opening until a voice prosthesis can be placed,\n4) patients become quickly familiar with their prosthesis care as they receive instructions while hospitalized,\n5) the patient will not have to undergo an outpatient procedure during which the voice prosthesis needs to be fitted,\n6) many patients can learn to speak before the start of any post-operative radiation therapy (if indicated)\n7) the patient can focus on voice production immediately, as wound healing allows. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13655", "text": "Another advantage is that generally, the voice prosthesis placed at the time of surgery lasts relatively long and requires no early frequent replacements. [ 14 ] [ 15 ]  The only disadvantage is that the patient will need to use a feeding tube for a few days."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13656", "text": "Delayed placement: Instead of the voice prosthesis, a catheter (red rubber, Silastic Foley catheter,  Ryle's tube ) is introduced through the puncture into esophagus. [ 10 ]  The tube is sometimes utilized for feeding the patient during the immediate post operative period, or the patient has a standard feeding tube for feeding. The voice prosthesis is placed after the patient is able to eat sufficiently by mouth and speech production is initiated when healing has completed, after clearance by the surgeon. The advantage of this method is that the patient may be fed through the catheter, not requiring standard tube feeding. The primary disadvantage is that the patient will have to undergo an outpatient procedure to have the voice prosthesis placed. Another disadvantage can be the need for more frequent replacements early after fitting of the voice prosthesis due to changes in the length of the puncture. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13657", "text": "Indications  include voice rehabilitation for patients who are undergoing a total laryngectomy (primary puncture) or patients who have had a total laryngectomy in the past (secondary puncture).\n Contra-indications  are mainly related to the use of the voice prosthesis and not the puncture procedure itself. It is important to have healthy tissue at the puncture site. This  will help ensure the voice prosthesis is properly supported. Poor tissue condition at the puncture site can be a contra-indication for TE puncture. It is also important that the patient candidacy be taken into account. Patients must be able to understand and manage proper prosthesis maintenance and monitor for complications or device problems. Bleeding disorders, anxiety disorders, dementia, poor vision and poor manual dexterity are all factors that may negatively interfere with successful voice restoration using tracheo-esophageal techniques and should be discussed further with an appropriate healthcare provider who is knowledgeable in this topic. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13658", "text": "Gynecological surgery  refers to surgery on the  female reproductive system  usually performed by  gynecologists . It includes procedures for  benign  conditions,  cancer ,  infertility , and incontinence. [ 1 ]  Gynecological surgery may occasionally be performed for optional or  cosmetic purposes , such as  hymenoplasty  or  labiaplasty ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13659", "text": "Following are different types of gynecologic procedures- [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13660", "text": "Gynecological surgery includes: [ medical citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13661", "text": "With the advancement of technology there has been robot-assisted surgery in many areas. [ 3 ]  It helps in avoiding extra testing and other instruments. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13662", "text": "Cervical cerclage , also known as a  cervical stitch , is a treatment for  cervical weakness , when the  cervix  starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth. In women with a prior spontaneous preterm birth and who are pregnant with one baby, and have shortening of the cervical length less than 25\u00a0mm, a cerclage prevents a  preterm birth  and reduces death and illness in the baby. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13663", "text": "The treatment consists of a strong  suture  sewn into and around the cervix early in the pregnancy, usually between weeks 12 to 14, and then removed towards the end of the pregnancy when the greatest risk of miscarriage has passed. The procedure is performed under local  anaesthesia , usually by way of a  spinal block . It is typically performed on an outpatient basis by an  obstetrician-gynecologist . Usually the treatment is done in the first or second trimester of pregnancy, for a woman who has had one or more late miscarriages in the past. [ 2 ]  The word \"cerclage\" means encircling, hooping or banding in French. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13664", "text": "The success rate for cervical cerclage is approximately 80\u201390% for elective cerclages, and 40\u201360% for emergency cerclages. A cerclage is considered successful if labor and delivery is delayed to at least 37 weeks (full term). After the cerclage has been placed, the patient will be observed for at least several hours (sometimes overnight) to ensure that she does not go into premature labor. The patient will then be allowed to return home, but will be instructed to remain in bed or avoid physical activity (including sexual intercourse) for two to three days, or up to two weeks. Follow-up appointments will usually take place so that her doctor can monitor the cervix and stitch and watch for signs of premature labor. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13665", "text": "For women who are pregnant with one baby (a singleton pregnancy) and at risk for a preterm birth, when cerclage is compared with no treatment, there is a reduction in preterm birth and there may be a reduction in the number of babies who die ( perinatal mortality ) [ 2 ]  There is no evidence that cerclage is effective in a multiple gestation pregnancy for preventing preterm births and reducing perinatal deaths or neonatal morbidity. [ 4 ]  Various studies have been undertaken to investigate whether cervical cerclage is more effective when combined with other treatments, such as antibiotics or vaginal pessary, but the evidence remains uncertain. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13666", "text": "There are three types of cerclage: [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13667", "text": "While cerclage is generally a safe procedure, there are a number of potential complications that may arise during or after surgery. These include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13668", "text": "The Arabin Pessary is a silicone device that has been suggested to prevent spontaneous preterm birth without the need for surgery. [ 11 ]  The leading hypotheses for its mechanisms were that it could help keep the cervix closed similarly to the cerclage, as well as change the inclination of the cervical canal so that the pregnancy weight is not directly above the internal  os . However, large randomized clinical trials in singleton [ 12 ]  and twin pregnancies [ 13 ]  found that the cervical  pessary  did not result in a lower rate of spontaneous early preterm birth. Therefore, the Society for Maternal-Fetal Medicine recommendation is that placement of cervical pessary in pregnancy to decrease preterm birth, should be used only in the context of a clinical trial or research protocol. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13669", "text": "Chromopertubation  is a method for the study of  fallopian tube   patency  (a state of being open or unobstructed) for suspected infertility in women caused by  fallopian tube obstruction . Occlusion or pathology of the fallopian tubes is the most common cause of suspected infertility. [ 1 ]  Chromopertubation is sometimes commonly referred to a \"laparoscopy and dye\" test. [ 2 ]  It is currently one of the standard procedures in this field. [ 3 ]  In most cases, chromopertubation is performed to assess and determine the cause of someone's difficulties in getting pregnant. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13670", "text": "Chromopertubation is a medical procedure in which blue dye is injected into the fallopian tubes to detect if there are any blockages. It is performed as a  laparoscopy , a minimally invasive procedure with small incisions. A laparoscope, a long, fine instrument is inserted into the abdomen close to the umbilicus in order to see one's internal organs, in particular the fallopian tubes. There is also a device called a uterine manipulator that is placed through the vagina and cervix into the uterus. [ 5 ]  As part of a laparoscopy, a blue dye solution ( methylene blue  or  indigo carmine ) is introduced into the uterine cavity. The dye solution will help determine if the fallopian tubes are open or blocked. If the fallopian tubes are open, the dye solution will enter and drain out into the pelvic cavity through the ends of the tubes. A tubular blockage is suspected if the fluid does not enter into the fallopian tubes or enters, but does not drain out of the fallopian tubes. [ 5 ]  Blocked fallopian tubes can be a factor of infertility in which the fallopian tubes will not allow the egg and sperm to meet."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13671", "text": "Chromopertubation with laparoscopy is considered the \"gold standard\" to evaluate tubal patency. [ 6 ]  It is the most accurate way to look at the abdominal cavity and other pelvic structures. Other problems that can be viewed during the procedure are malformations of the uterus, adhesions, blocked fallopian tubes, or  endometriosis . Slight adhesions inside a fallopian tube can be observed by the flow of dye solution and removed during the procedure. [ 6 ]  Other findings, such as endometriotic lesions, may also be treated as part of laparoscopy. [ 6 ]   If laparoscopy with chromopertubation shows a mild blockage within one or both of the fallopian tubes, surgical reconstruction of the tubes can be performed. [ 2 ]  Studies have shown that tubal flushing with a contrast medium could be used as a treatment for infertility, as it was noted that many women were able to conceive within the first 3\u20136 months after the procedure. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13672", "text": "Oil-based contrast medium is typically used in hysterosalpingography (HSG), while water-based contrast medium is regularly used in hystero contrast sonography (HyCoSy), hysterosalpingo-foam sonography (HyFoSy), laparoscopy with chromopertubation, and HSG. [ 8 ]  A meta-analysis that combined the results of five studies found that tubal flushing in HSG with an oil-based contrast medium moderately increased the odds of having a live-birth within six months. [ 8 ]  The benefit of a water-soluble contrast medium in tubal flushing is unclear. [ 7 ]  The effects of tubal flushing with either type of contrast media beyond six months are unknown and more research is needed to see if there is a difference in contrast media when used for tubal flushing in laparoscopy with chromopertubation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13673", "text": "Chromopertubation is done during laparoscopy, which requires  general anesthesia . General anesthesia is usually safe, but problems, such as pain, nausea and vomiting, sore throat, and muscle aches may arise. Around the small incisions on the abdomen, there will be some pain and may also be some bruising around the lower abdomen. [ 5 ]  There is a risk of procedural complications, such as bleeding or abdominal injury, which may result in longer recovery times. [ 6 ]  Also, some bleeding in the vagina can be from the placement of the instrument during the dye test. Minor bleeds should stop within a couple of days. [ 5 ]  Another issue is the chance of cornual spasms, which often occur if the injection of dye is done too quickly. [ 1 ]  These spasms, or contractions, can block off the interstitial region (proximal portion) of the fallopian tubes, leading to an incorrect diagnosis of proximal tube occlusion. [ 1 ]  Furthermore, the insertion of the instruments into the abdomen can potentially injure major abdominal organs, such as the small and large intestines, bladder, and blood vessels. Previous surgeries or procedures, such as Caesarean surgery, ovarian cyst removal, bladder surgery, or appendix removal can increase the chances of abdominal organs damage during chromopertubation. Difficulties with the insertion of the laparoscope can rarely happen. These difficulties usually occur in those who are overweight or who have had previous abdomen scarring from another procedure. If the instrument cannot be inserted into the abdominal cavity, chromopertubation will not be recommended. Instead, alternative methods of checking the fallopian tubes will be taken into consideration. Because laparoscopy with chromopertubation is a more time intensive diagnostic procedure, if no significant findings are found, then there may be a delay in starting other infertility therapies. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13674", "text": "Allergic-like reactions and  methemoglobinemia  have been documented after the use of methylene blue dye in chromopertubation. [ 9 ]  These reported symptoms vary from blue discoloration of body fluids to anaphylactic shock. [ 10 ]  Methemoglobinemia is a blood disorder that can potentially result in various levels of  cyanosis . [ 11 ]  High levels of methylene blue dye can also result in  hemolysis . In particular, methylene blue dye should be avoided in people using serotonergic drugs, such as  selective serotonin reuptake inhibitors (SSRIs)  and antidepressants, since this interaction may cause fatal  serotonergic syndrome . [ 12 ]  Serotonergic syndrome presents as changes in mental status, in addition to overactivation of the neuromuscular and nervous systems. [ 13 ]  Common symptoms of fatal serotonergic syndrome include high fevers, seizures, and tremors. [ 14 ]  Other reported features of fatal serotonergic syndrome include  hyperthermia , respiratory failure,  rhabdomyolysis ,  metabolic acidosis ,  myoglobinuria , renal failure, coma, and death. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13675", "text": "While there have been recent studies showing an increased odds of clinical pregnancy when an oil-based contrast medium is used for tubal flushing, there is also an increased risk for intravasation. [ 15 ]  Intravasation of oil-based contrast is the process of small oil droplets entering the blood circulation and causing inflammation of blood vessels or blocking blood vessels, potentially in the lungs or brain. [ 15 ]  Oil-based contrast medium also has a higher amount of iodine, as compared to water-based contrast medium, and this higher iodine exposure could lead to subclinical hypothyroidism. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13676", "text": "The cost of fallopian tube surgeries can range from $3,000 to up to about $13,000. [ 16 ]  The costs of the procedures and surgeries depends on insurance coverage, complications, and the type of fallopian tube surgery. In the female reproductive system, the fallopian tubes are one of the most important parts because the tubes connect to the ovaries where the eggs are released. To check if the fallopian tubes are blocked or damaged, a laparoscopy will cost from $1,700 to $5,000. [ 17 ]  If the fallopian tubes are blocked, there will be no fertilization and therefore, the egg and sperm cannot meet. If an individual wants to open up their fallopian tubes, a procedure called fallopian tube recanalization can be performed. During this procedure, cuts or incisions are not necessary, instead a catheter is inserted into the womb and fallopian tubes to make sure a blockage is confirmed, and then a second catheter is inserted to clear that blockage. This can cost about $3,000\u2013$5,000. [ 16 ]  In addition, there is another procedure called salpingostomy when the fallopian tubes are filled with fluid. This procedure costs about $5,000\u2013$7,000. The doctor opens the tube to remove the blockage, but does not disturb the position of the fallopian tube. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13677", "text": "There are also other procedures to determine whether or not someone's fallopian tubes are blocked. While laparoscopy with chromopertubation is considered to be the first-line practice for the diagnosis of tubal occlusion, it is generally a more expensive and invasive procedure, and it is recommended for women with comorbidities of both tubal occlusion and another pelvic pathology. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13678", "text": "Hysterosalpingography  (HSG), a different diagnostic procedure for tubal occlusion, is commonly performed in women without suspected comorbidities. [ 18 ]  HSG is done initially with an X-ray examination performed by a radiologist. While the main purpose of HSG is to evaluate the fallopian tubes, HSG does not provide an explanation for why the tubes are blocked. The examination should be scheduled between 7\u201312 days of an individual's menstrual cycle. [ 19 ]  Ideally, it should be completed within 2\u20135 days after menses is over. [ 1 ]  Radiographic dye is used to assess the uterine cavity and fallopian tubes. It can be used to study suspected infertility, as well as tubal disease. [ 20 ]  During a HSG procedure, the uterus is injected with contrast dye, which can be observed via fluoroscopy. [ 21 ]  The test results are normal if the X-ray shows a normal uterine shape, and the dye spills out from the ends of the fallopian tubes. There may be a problem if the dye shows an abnormally shaped uterus, and the dye does not flow freely from the fallopian tubes. [ 19 ]  While this method can be completed relatively quickly since anesthesia is not needed, there is a risk of tubal spasm, which typically occurs during injection of the contrast dye due to increased pressure. [ 20 ]  With tubal spasm, the fallopian tubes can close, and this may give a false diagnosis of tubal occlusion. [ 20 ]  While both HSG and chromopertubation can cause spasms, it is more likely to happen with HSG. [ 1 ]  HSG also has the disadvantage of exposing the patient to radiation from the X-ray that is performed. [ 2 ]  The radiographic dye, which is iodine-based, can also cause allergic reactions. [ 22 ]  Though this generally does not occur, there is an increased risk of genital tract infections so patients may be prescribed antibiotics."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13679", "text": "Sonohysterosalpingography (SHG), a type of ultrasound exam, is another procedure that assesses patency through the use of  varying contrast medium. One method is to introduce air into the uterine cavity and observe air bubbles in the fallopian tubes. [ 11 ]  The second method is to use distilled water or normal saline to observe the movement of fluid through the tubes. [ 23 ]  Here, fluid enters the uterus through the cervix via a plastic tube. [ 24 ]  The last method involves combining air with saline to make it easier to see on ultrasound. [ 23 ]  Images of the uterus lining are created through the use of sound waves, and the fluid introduced into the uterus serves to enhance the images. [ 24 ]  Side effects of this exam include cramping and a rare possibility of pelvic infection. [ 24 ]  Generally this procedure can be done quickly since no sedation is required and it tends to be a cheaper alternative compared to the other methods. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13680", "text": "Hystero contrast sonography  (HyCoSy) is another alternative to chromopertubation that allows for visualization of the uterine cavity, ovaries, and fallopian tubes. However, it is generally used as a screening test to assess the need for laparoscopy. [ 22 ]  The procedure includes an initial vaginal scan, with a subsequent injection of contrast agent via an intrauterine catheter. The contrast agent is taken up by the fallopian tubes. [ 22 ]  Since HyCoSy is performed using  transvaginal ultrasound , it is less invasive than chromopertubation. Using a contrast agent, the ultrasound image can be used to detect whether and how the contrast medium flows through the fallopian tubes. The contrast medium used is often a manufactured product with microbubbles or a gel-based product that creates foam when passing through the tubes. [ 23 ]  While the contrast medium is generally safe, there can still be allergic reactions as well as adverse effects. [ 22 ]  A positive result is recorded when contrast is not observed to pass through the fallopian tubes. In this case, laparoscopy can be considered as the next step to verify the diagnosis of tubal occlusion. [ 22 ]  This procedure does have contraindications which include reproductive tract cancer and current infections. [ 22 ]  One downside is that this method tends to be more challenging to interpret so it is more accurate when done by experienced sonographers. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13681", "text": "This method is often used as an alternative to hysterosalpingography. Using this method, a  Trocar  along with a scope is inserted into the vagina and allows for visualization of the fallopian tubes and the uterine cavity. [ 25 ]  Unlike HSG which visualizes the fallopian tubes using X-rays, transvaginal hydrolaparoscopy provides a closer look at the fallopian tubes since the scope can be threaded directly through the tubes. [ 25 ]  This procedure allows clinicians the ability to look at the inner structure of the tubes. During the procedure, topical anesthesia is often given before insertion of a needle into the vagina. [ 25 ]  Saline is flushed through the needle and the needle is replaced by the trocar. [ 25 ]  Depending on the clinician, Lactated Ringer's may be used instead of saline. [ 26 ]  Once the trocar is placed, an optic scope is inserted. [ 25 ]  Upon completion of the procedure, some patients may require sutures to stop any remaining bleeding. [ 25 ]  This method tends to be better for classifying tubal disease as inspection of the inner structure allows for visualization of any lesions, adhesions, and endometriomas. [ 26 ]  One benefit of this procedure is that no incisions are required and it can be completed in a clinic office. [ 25 ]  The disadvantages are the risk of bleeding, abdominal tenderness, and that insertion of the vaginal trocar can cause possible rectal injury. [ 26 ]  When the needle is initially inserted, it is also possible for accidental perforation to the uterus wall or bowels, though this is less likely to happen. [ 26 ]  While this method is extremely helpful, those with increased risk of bleeding, infections, or ovarian cysts should not undergo this procedure. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13682", "text": "Chlamydia  immunoglobulin G antibody tests (CAT) are used to explore tubal occlusions and injuries that may be caused by  Chlamydia trachomatis . [ 1 ]  These assays include  immunofluorescence  tests (including microimmunofluorescence) and  ELISA . [ 27 ]  While this method is noninvasive and easy to carry out, there is a chance of false-positive results. These tests can recognize antibodies to different species of  Chlamydia  as well as even other gram-negative bacteria. [ 28 ]  Therefore, these tests are usually used as a screening test. If negative, unnecessary testing is avoided; if positive, more invasive tests are required.  [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13683", "text": "Colpocleisis  is a procedure involving closure of the  vagina , used to treat  vaginal prolapse . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13684", "text": "In women who are no longer sexually active, a simple procedure for reducing prolapse is a partial colpocleisis. The procedure was described by Le Fort [ citation needed ]  and involves the removal of strip of anterior and posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other. This procedure may be performed whether or not the  uterus  and  cervix  are present. When it is completed, a small vaginal canal exists on either side of the septum, produced by the suturing of the lateral margins of the excision. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13685", "text": "Dr.  Nathan Bozeman  and Prof. Gustave Simon had a controversial dispute in the 1870s, about the \"wide and indiscriminate\" use of the procedure that existed at that time. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13686", "text": "Comprehensive Gynecology  (4th\u00a0ed.). Stenchever-Droegermueller. pp.\u00a0 580\u2013 581."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13687", "text": "Colporrhaphy  (also  vaginal wall repair ,  anterior and/or posterior colporrhaphy ,  anterior and/or posterior vaginal wall repair , or simply  A/P repair  or  A&P repair ) is a  surgical procedure  in women that repairs a defect in the wall of the  vagina . It is the surgical intervention for both  cystocele  (protrusion of the  urinary bladder  into the vagina) and  rectocele  (protrusion of the  rectum  into the vagina). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13688", "text": "The repair may be to either or both of the anterior (front) or posterior (rear) vaginal walls, thus the origin of some of its alternative names. [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13689", "text": "Culdoscopy  is an  endoscopic   procedure  performed to examine the  rectouterine pouch  and  pelvic viscera  by the introduction of a  culdoscope  through the  posterior   vaginal  wall. [ 1 ]  The word culdoscopy (and  culdoscope ) is derived from the term  cul-de-sac , which means literally in  French  \"bottom of a sac\", and refers to the  rectouterine pouch  (or called the  pouch of Douglas ). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13690", "text": "The culdoscope is a non-flexible endoscope, basically a modified laparoscope. [ 3 ]  A  trocar  is first inserted through the vagina into the posterior cul-de-sac, the space behind the  cervix , allowing then the entry of the culdoscope. Due to the position of the patient intestines fall away from the pelvic organs which can then be inspected. Conditions diagnosable by culdoscopy include tubal adhesions (causing sterility),  ectopic pregnancy , and  salpingitis . Culdoscopy allows the performance of minor procedures such as  tubal sterilization . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13691", "text": "Culdoscopy is performed with the patient in a  knee chest position  under local or general anesthesia. There is no insufflation of the abdomen as necessary in laparoscopy. There is no abdominal incision, the entry point in the vagina is closed with a suture. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13692", "text": "The procedure was inaugurated by Albert Decker in 1939 [ 3 ]  and became popular after his reported experience in 1944. [ 5 ]  Decker had his culdoscope made by American Cystoscope Makers (ACM). He published a textbook about culdoscopy in 1952. [ 6 ] \nThe use of culdoscopy faded in the 1970s as the laparoscopic approach was recognized to be superior due to technological advancements. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13693", "text": "Endocervical curettage  is a procedure in which the  mucous membrane  of the  cervical canal  is scraped using a spoon-shaped instrument called a  curette . The procedure is used to test for abnormal, precancerous conditions, or cervical cancer. [ 1 ]  The procedure is generally performed after an abnormal  pap smear  to further assess the tissue. Other common indications to perform endocervical curettage include evaluation of persistent  human papillomavirus infection  infections, workup of unexplained  abnormal uterine bleeding , and follow up of inconclusive  colposcopy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13694", "text": "Colposcopy  was first performed by physician Hans Hinselmann, a German  gynecologist , in 1925. He utilized a bright light and low-power microscope to directly visualize atypical cervical cells. [ 2 ]  However, the first use of endocervical curettage is not clearly delineated in the medical literature. The use of curettage as a method to extract biological tissue dates back to the 19th century. Dr.  Ernst Wertheim , an Austrian gynecologist, who pioneered many surgical interventions and techniques in  gynecology  may have been the first to implement endocervical curettage in its earliest forms. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13695", "text": "Use of endocervical curettage became widespread by the mid-20th century as understanding and methods of cervical pathology rapidly advanced. Over the decades endocervical curettage and its inclusion in guidelines have been the subject of debate by medical societies, with some arguing its diagnostic use is limited. [ 4 ]  However, endocervical curettage  has retained its value as a less invasive method to biopsy the endocervical canal. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13696", "text": "Endocervical curettage is a medical procedure used to extract cells of the endocervix to visualize under a microscope. Direct cervical visualization, colposcopy, and even endocervical colposcopy are not enough to fully analyze all areas of the endocervical epithelium and thus endocervical curettage is the method of choice in cases where this is necessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13697", "text": "Generally the next step in workup of an abnormal pap smear includes a colposcopy which involves the direct visualization of the cervix. However, the cervical epithelium of the endocervix cannot be visualized and endocervical curettage may be used to biopsy the endocervix epithelium. Endocervical curettage is particularly useful in cases of colposcopy where the squamocolumnar junction is not visualized. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13698", "text": "The indications to perform endocervical curettage vary by medical society recommendations but some commonly accepted indications include: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13699", "text": "The efficacy of endocervical curettage has long been debated with discussions around its value dating back to when its use first became widespread back in the mid-20th century. Numerous studies and meta-analyses have been performed over the centuries to assess the diagnostic value of endocervical curettage in the workup of cervical dysplasia and to determine its sensitivity and specificity. Most recent studies retain its value in the diagnostic workup as an intermediate step between pap smear and cone biopsy. It also maintains value as a less invasive method to analyze the endocervical canal. [ 5 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13700", "text": "Endocervical curettage is a type of cervical biopsy that is performed with a curette to scrape cells from endocervical canal. The procedure is generally performed in the outpatient setting and begins with the patient laying flat on their back with feet usually in  stirrups . This is the position for most  pelvic exams. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13701", "text": "The provider will first use a  speculum , which is inserted in the vaginal canal, for visualization of the cervix. Anesthetics should be used to ensure that the patient is comfortable during the procedure. A colposcope, a magnifying tool, is used to directly visualize the cervical, vaginal, or vulvar tissue under a low-powered microscope. Once the entire cervix is visualized, an acetic acid solution or lugol's iodine solution may be applied to the cervical canal to identify abnormal lesions. Forceps can be used during the procedure to grasp the cervix. Once these steps of the colposcopy are completed, the provider will proceed with endocervical curettage if the findings indicate that biopsy of the endocervical canal is necessary. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13702", "text": "Endocervical curettage is generally the last step of the colposcopy procedure. It is when the curette is inserted and passed through the  cervical os , the opening in the cervix that leads into the uterus, and used to scrape cells from the inside of the cervical canal. The curette is firmly held like a pen, and should scrape the endocervical canal in small strokes. [ 7 ]   The curette should be carefully removed from the canal once the entire area is sampled so the sample is not lost. These biopsied cells should be immediately placed into  formalin  to ensure their preservation. They are then later viewed under a microscope by a  pathologist  to assess for any abnormalities. [ 9 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13703", "text": "Guidelines reveal good evidence that endocervical curettage is contraindicated in pregnancy. [ 10 ]  There is a risk of damage to fetal membranes or placenta along with an increased risk of cervical perforation due to the softening of the cervix during pregnancy. [ 6 ]  For these reasons, pregnancy is a well established contraindication to performing endocervical curettage. [ 10 ]  Other relative contraindications to the procedure include severe cervical stenosis and acute uterine or cervical infections."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13704", "text": "Rare risks of the procedure include cervical perforation though the incidence of perforation is extremely low. Other risks for the procedure include bleeding, infection, and pain. [ 9 ]  Though sterilization techniques, anesthetics, and hemostasis tools greatly mitigate these risks and the procedure is generally very tolerated aside from discomfort."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13705", "text": "After endocervical curettage, cells are viewed under a high-powered microscope by a pathologist. The pathologist analyzes the cells for any atypical features such as  hyperplasia ,  dysplasia , or  neoplasm . [ 12 ]  Features that are analyzed include nuclear size, evidence of  pleomorphism , anisokaryosis, hyperchromasia, and mitotic features."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13706", "text": "Grades for  cervical dysplasia  include low-grade squamous intraepithelial lesion to high-grade squamous intraepithelial lesion. The dysplasia can be rated on the Bethesda System of cervical grades of increasing atypical nature summarized below: [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13707", "text": "Ratings of cervical intraepithelial neoplasia are also commonly used to grade cytology of cervical epithelium. Cervical intraepithelial neoplasia 1 is the most moderate and are low-grade squamous intraepithelial lesions while cervical intraepithelial neoplasia 2 and 3 are moderate to severe and are high-grade squamous intraepithelial lesions. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13708", "text": "Endometrial ablation  is a surgical procedure that is used to remove ( ablate ) or destroy the  endometrial lining  of the  uterus . The goal of the procedure is to decrease the amount of blood loss during  menstruation  (periods). Endometrial ablation is most often employed in people with excessive menstrual bleeding following unsuccessful medical therapy. [ 1 ]  It is less effective than  hysterectomy , but with a lower risk of adverse events. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13709", "text": "Endometrial ablation is typically done in a  minimally invasive  manner with no external incisions. Slender tools are inserted through the vagina and into the uterus. In some forms of the procedure, one of these tools may be a camera ( hysteroscope ) to assist with visualization. Other tools include those that harness  electricity ,  high-energy radio waves , heated fluids, or  cold temperature  to destroy the endometrial lining. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13710", "text": "The procedure is almost always performed as an  outpatient  treatment, either at a hospital, ambulatory surgery center, or physician office. Patients will most commonly undergo local and/or light sedative  anesthesia , or if necessary, general or spinal anesthesia. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13711", "text": "After the procedure, the endometrium heals by  scarring  over, thus reducing or eliminating future uterine bleeding. [ 5 ]  The patient's hormonal functions will remain unaffected because the  ovaries  are left intact. Due to the uterine changes that take place after undergoing ablation, patients are unlikely to be able to become  pregnant  after the procedure, and of pregnancies that do occur, complication risk is high. To reduce the associated mortality risks, it is often recommended for patients to adhere to  birth control  methods after undergoing endometrial ablation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13712", "text": "The primary  indication  for endometrial ablation is abnormal uterine bleeding, including chronic heavy menstrual bleeding, in premenopausal patients. [ 6 ]  Typically, these are patients for whom first-line medical therapy was unsuccessful or  contraindicated . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13713", "text": "In some cases, endometrial ablation is use to treat small  uterine fibroids . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13714", "text": "Absolute contraindications for undergoing endometrial ablation include endometrial  carcinoma , current pregnancy, and desire for future pregnancy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13715", "text": "Prior to undergoing endometrial ablation, patients will go through a pre-procedure evaluation and risk assessment. Components of this often include  informed consent , anesthesia evaluation, and a  pregnancy test  (as current pregnancy is a contraindication to the procedure). All patients will undergo endometrial  sampling  to test for endometrial carcinoma, as this is an absolute contraindication to endometrial ablation. Some patients may also require further assessment of the uterus through  hysteroscopy  or saline infusion  sonohysterography , and/or removal of any current  IUD ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13716", "text": "Depending on the treatment that is chosen, endometrial ablation is sometimes conducted after treatment with hormones, such as  norethisterone  or  Lupron  to reduce the thickness of the endometrium. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13717", "text": "Endometrial ablation may be done in-office or in an operating room. The procedure begins with  cervical dilation , which temporarily stretches the cervix to make room for the ablation instruments and/or  hysteroscope  to enter the uterus. Dilation can be induced medically with  pharmacologic agents , or mechanically with a series of metal tools of increasing diameter. After sufficient dilation, the ablation instrument is introduced into the uterine cavity, which is used to partially or fully destroy the endometrial lining. A hysteroscope may be used to assist in visualization of this process and/or ensure that final results are adequate. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13718", "text": "The technique utilized to remove or destroy the endometrium varies with endometrial ablation operations. Options consist of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13719", "text": "After the ablation procedure is complete, any concomitant procedures that patients have opted for will also be completed. A common procedure after endometrial ablation is  IUD  insertion, as effective contraception following endometrial ablation is highly recommended. Other concomitant procedures may include  myomectomy  and/or  tubal ligation . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13720", "text": "Endometrial ablation is often an outpatient procedure that does not require an overnight hospital stay. Patients may experience cramping,  vaginal discharge , and/or urinary changes during the recovery process. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13721", "text": "A number of treatment options are available, all of which work by inserting tools into the cervix to destroy the ablate the endometrium. [ 12 ]  Commonly used ablation systems include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13722", "text": "Older methods utilize hysteroscopy to insert instruments into the uterus to destroy the lining under visualization using a  laser , or  microwave  probe."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13723", "text": "The U.S.  Food and Drug Administration  approves and audits clinical studies to test and evaluate the effectiveness of all endometrial ablation treatments. Two patient effectiveness outcomes are measured at one year following treatment: 1) success rate = the\u00a0% of people who have their bleeding reduced to a normal period level or less, and 2)  amenorrhea  rate = the\u00a0% of people that have their bleeding eliminated.  According to the results of the  randomized controlled trials  performed for the FDA approval of the different treatment options, effectiveness success rates range from a high of 93% to a low of 67%, and the amenorrhea rates range from a high of 72% to a low of 22%. [ 15 ]  Compared with hysterectomy, ablation was less effective at reducing pain and excess bleeding; however, it also resulted in fewer adverse events. [ 2 ]  Satisfaction rates following hysterectomy and ablation were similar. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13724", "text": "Although rare, the procedure can have complications [ 5 ]  including:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13725", "text": "A  hymenotomy  is a  medical procedure  involving the  surgical  removal or opening of the  hymen . It is often performed on patients with an  imperforate  or  septate  hymen, or other situations where the hymen is unusually thick or rigid such as microperforate hymen.  In the case of a female with a hymen without any opening, an opening may be created in order to facilitate  menstruation .  In situations where the opening is extremely small or the band(s) of a septate hymen limit access to the vaginal opening, the woman may elect for hymenotomy to allow for comfortable  sexual penetration  of her vagina, or to relieve pain or discomfort that occurs when inserting/removing tampons. Sexual intercourse would not normally be adversely affected by a hymenotomy. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13726", "text": "A  hysterotomy  is an incision made in the  uterus . [ 1 ]  This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester (or  abortion ) and delivering the fetus during  caesarean section . It is also used to gain access and perform surgery on a fetus during pregnancy to correct  birth defects , and it is an option to achieve  resuscitation  if  cardiac arrest  occurs during pregnancy and it is necessary to remove the fetus from the uterus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13727", "text": "There are several types of incisions that can be made, including a midline vertical incision and a low transverse incision. The incision is made using a scalpel and is about 1-2 cm long, but it can be longer depending on the procedure that is performed. [ 2 ]  Other types of incisions are low transverse incision with T-extension in the midline, low transverse incision with J-extension, and low transverse incision with U-extension. These are used when low transverse incisions do not provide enough space in order to remove the contents in the uterus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13728", "text": "This incision also comes with possible risks and complications when the incision is made and during repair, including blood loss (possibly leading to  anemia ), wound infection, fertility problems,  premature labor , postoperative pain, and many others. [ 3 ]  In addition, a rare form of  ectopic pregnancy  known as scar ectopic pregnancy can occur. This is when there is abnormal implantation of an embryo onto the scar of the uterus. There is an increased risk of this complication occurring due to trauma from previous procedures utilizing hysterotomies, such as caesarean section and dilation, though the mechanism is unknown. [ 4 ]  Closure of the hysterotomy incision made can be done with either a staple or a suture. Sutures are most commonly used, specifically double layer sutures. [ 5 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13729", "text": "A hysterotomy is used to remove a fetus from the uterus, similar to a procedure known as  caesarean section , in order to terminate a pregnancy in the second trimester of later. [ 6 ]  It is typically used as last resort if  dilation and curettage , dilation and  electric vacuum aspiration , or manual vacuum aspiration fails to work. Dilation and curettage refers to the opening or widening of the cervix and scooping and scraping the tissues that are inside of the uterus. Electric vacuum aspiration utilizes a vacuum to remove the embryo that is in the uterus, but this method is more expensive than manual vacuum aspiration. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13730", "text": "Although fetal delivery through caesarean section is a very common surgery done in the world, it comes with several risks including bleeding, infection,  thromboembolism , and soft-tissue injury. During a caesarean section, a hysterotomy is utilized to make an incision in the uterus and remove the fetus. [ 8 ]  Gestational age, newborn birth weight, and danger presenting risks are all taken into account on whether or not a classic hysterotomy or low transverse incision will be made. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13731", "text": "A  resuscitative hysterotomy  is performed during or near the occurrence of a cardiac arrest, in which an incision is made to remove the fetus from the uterus. This is done in order to save the fetus, as well as to revive the person whose uterus was carrying the fetus. This is traditionally done if the fetus is of 24 weeks or older, at which it is viable outside of the uterus. [ 10 ]  The primary goal is to save the pregnant person, and in order to insure the highest survival rate, the goal of fetus delivery time is within 5 minutes after the patient goes under arrest and/or two cycles of CPR. [ 11 ]  During pregnancy, the pregnant uterus may compress the  inferior vena cava  and  abdominal aorta , causing reduced blood flow to the uterus and to the pregnant person. Removing the fetus can restore blood flow to the pregnant person. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13732", "text": "Hysterotomy is a technique used during  fetal surgery  to access the fetus in the pregnant uterus in order to treat a birth defect such as  spina bifida . [ 13 ]  A standard hysterotomy remains the gold-standard for the closure of a fetal spina bifida because it is the safest and most effective when compared to mini-hysterectomies and a percutaneous two-layer  fetoscopy . [ 14 ]  A mini-hysterotomy procedure is favored for extreme cases of preterm delivery and any complications regarding maternal, fetal, and/or neonatal because of the reduced risks and complications. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13733", "text": "The technique used to repair the hysterotomy is dependent on the surgeon's preference. The method of repair and type of suture affects the risks and complications of receiving a hysterotomy.  Hysterotomy incision repair can be done within the  intraperitoneal space  ( in situ ) or the uterus can be temporarily removed for repair (exteriorization). Both types of uterine positioning for repair yielded similar lengths of hospital stay, risk of infection, and estimated blood loss. Recovery following uterine exteriorization was found to induce more nausea [ 16 ]  and be more painful, requiring more post-operative  analgesia . Return of bowel function was faster with  in situ  repair. [ 17 ]  It was found that between unlocked single-layer closure and double-layer closure, there is no difference in risk of uterine rupture, [ 3 ]  however the risk of rupture is increased with a locked single-layer suture. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13734", "text": "Following the repair of the incision, a scar defect may form, which is defined as a thinning of uterine muscle at the incision site. These uterine scar defects are associated with increased risk of uterine rupture and scar separation. [ 19 ] [ 20 ]  Scar defects may increase the risk of complications such as abnormal bleeding, pain,  ectopic pregnancy , and  infertility . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13735", "text": "Caesarean sections require a large incision of the uterus, which can lead to complications such as blood loss, postoperative pain, anaemia due to continuing blood loss, fever and possible wound infection, breastfeeding issues, difficulty passing urine, future fertility problems, and/or possible complications in future pregnancies including uterine rupture. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13736", "text": "In fetal surgery, without inhibition of uterine contractions, uterine irritability and  premature labor  are complications that occur very frequently in of hysterotomy cases. [ 21 ]  It can be inhibited by  anti-contraction  medications. [ 22 ]  Preterm birth and early membrane rupture (PPROM) are common risks for fetal therapies. For most cases, fetoscopic surgery, which minimizes the damage to the uterus, is preferred to mitigate risks and complications. Membrane sealing and fixation has been investigated for reducing PPROM risk, but it has not been found to be clinically beneficial. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13737", "text": "Scar ectopic pregnancy is a rare form of ectopic pregnancy, however, when it does occur it causes complications in pregnancy such as abnormal uterine bleeding and uterine rupture. The mechanism of how scar ectopic pregnancy still remains unknown. However, the possibility that defects may form to the scarring from previous procedures/traumas such as caesarean section, dilation, hysterotomy, abnormal placentation can cause scar ectopic pregnancy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13738", "text": "There are two categories of complications with surgical abortions, minor and major. Minor complications are procedural pain, bleeding, infection and common anesthesia complications. The more serious and major complications include hemorrhage, sepsis, peritonitis, deep vein thrombosis and death. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13739", "text": "There are many different types of hysterotomies depending on the location and direction of the incision. Typically, a low transverse incision is preferred during a caesarean section. This area of the uterus has less  vasculature  and therefore provides lower risk of hemorrhage during the procedure for the patient. Incisions in the lower area of the uterus is also associated with lower risks of uterine rupture. There may be times in which the lower transverse incision does not provide adequate space and therefore, expansions of the low transverse incisions have led to the creation of the low transverse incision with T-extension in the midline, low transverse incision with J-extension, and low transverse incision with U-extension. [ 3 ]  A low vertical incision and a midline incision, also known as a classic caesarean incision, may be preferred during a labor that is preterm. Since the lower uterine segment is not yet fully developed during a preterm labor, these two incisions are preferred in order to provide adequate space for manipulations during delivery of the fetus. A low transverse incision would not provide adequate space and could entrap the fetal head therefore risking intercranial hemorrhage, morbidity and mortality for the fetus. [ 2 ]  A midline incision may be preferred as well when the fetus lies transversely across the patient's uterus or if the placenta lies in the area where the low transverse incision is made. In practice, however, the midline incision is rarely used. [ 3 ]  Other hysterotomy incisions include a high transverse incision and a fundal incision. [ 2 ]  A fundal incision may be used if the placenta is placed behind the anterior wall of the uterus and therefore making typical incisions much more risky for hemorrhage. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13740", "text": "A hysterotomy can be performed by various methods. Typically a small incision is made with a scalpel about 1\u20132 cm long. During a blunt expansion, the incision is expanded by the surgeon's index fingers or other blunt dissection tools. During a sharp expansion, bandage scissors are used to cut a larger incision. [ 25 ]  Some professionals will say that the sharp expansion allows for a more controlled entry into the uterus and a faster delivery of the fetus. Other professionals will say the blunt expansion allows for reduced risk of hemorrhaging or excessive bleeding and improves healing for the patient. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13741", "text": "A hysterotomy is completed by closing the uterus either by using a stapler or by suture, no significant differences have been noted to show one technique takes precedent over another. [ 5 ]  \u00a0The muscular outer layer of the uterus in all samples of closures showed some inflammation and thickening/scarring of the tissue. [ 26 ]  In the event a midline incision is used, three layers of sutures are performed to repair the uterine wall. An interrupted suture is used to close the first and second layer and a continuous locking suture or figure-of-eight suture is used to close the third layer. [ 2 ]  Since in practice the low transverse incision is typically made, the incision is also typically closed with two layers of sutures. Though, there is a debate on whether the suture should be close with a single layer or a double layer of sutures. Double layer of sutures can promote improved healing, hemostasis and less risk of uterine rupture in the next pregnancy, whereas single layer of sutures allows for less operation time, less tissue disruption and decreased exposure to foreign suture material. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13742", "text": "Intersex medical interventions  ( IMI ), sometimes known as  intersex genital mutilations  ( IGM ), [ 1 ]  are  surgical , hormonal and other medical interventions performed to modify atypical or  ambiguous genitalia  and other  sex characteristics , primarily for the purposes of making a person's appearance more typical and to reduce the likelihood of future problems. The  history of intersex surgery  has been characterized by controversy due to reports that surgery can compromise sexual function and sensation, and create lifelong health issues. [ 2 ] [ 3 ]  The medical interventions can be for a variety of reasons, due to the enormous variety of the  disorders of sex development . Some disorders, such as salt-wasting disorder, can be life-threatening if left untreated.  [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13743", "text": "Interventions on intersex infants and children are increasingly recognized as  human rights  issues. Intersex organizations, and human rights institutions increasingly question the basis and necessity of such interventions. [ 5 ] [ 6 ]  In 2011,  Christiane V\u00f6lling  won the first successful case brought against a surgeon for non-consensual surgical intervention. [ 7 ]  In 2015, the  Council of Europe  recognized, for the first time, a right for intersex persons not to undergo sex-assignment treatment [ 8 ]  and Malta became the first country to prohibit involuntary or coerced modifications to sex characteristics. [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13744", "text": "The goals of surgery vary with the type of intersex condition but usually include one or more of the following:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13745", "text": "Physical health rationales:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13746", "text": "Psychosocial rationales:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13747", "text": "Both sets of rationales may be the subject of debate, particularly as the consequences of surgical interventions are lifelong and irreversible. Questions regarding physical health include accurately assessing risk levels, necessity and timing. Psychosocial rationales are particularly susceptible to questions of necessity as they reflect parental, social, and cultural concerns. There remains no clinical consensus or clear evidence regarding surgical timing, necessity, type of surgical intervention, degree of difference warranting intervention and evaluation method. [ 12 ] [ 13 ] [ 14 ]  Such surgeries are the subject of significant contention, including community activism, [ 15 ]  and multiple reports by international human rights [ 8 ] [ 16 ] [ 17 ] [ 18 ]  and health [ 2 ]  institutions and national ethics bodies. [ 5 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13748", "text": "Interventions include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13749", "text": "Surgical interventions can broadly be divided into   masculinizing surgical procedures  intended to make genitalia more like those of typical XY-males, and  feminizing surgical procedures  intended to make genitalia more like those of typical XX-females. There are multiple techniques or approaches for each procedure. Some of these are needed for variations in degrees of physical difference. Techniques and procedure have evolved over the last 60 years. Some of the different techniques have been devised to reduce complications associated with earlier techniques. There remains a lack of consensus on surgeries, and some clinicians still regard them as experimental. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13750", "text": "Some children receive a combination of procedures. For example, a child regarded as a severely undervirilized boy with a  pseudovaginal perineoscrotal hypospadias  may have midline urogenital closure, third degree hypospadias repair, chordee release and  phalloplasty , and  orchiopexy  performed. A child regarded as a severely virilized girl with  congenital adrenal hyperplasia  (CAH) may undergo both a partial clitoral recession and a  vaginoplasty . [ 21 ] [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13751", "text": "Orchiopexy and hypospadias repair are the most common types of genital corrective surgery performed in infant boys. In a few parts of the world  5-alpha-reductase deficiency  or defects of  testosterone  synthesis, or even rarer forms of  intersex  account for a significant portion of cases but these are rare in North America and Europe. Masculinizing surgery for completely virilized individuals with XX sex chromosomes and  CAH  is even rarer. [ medical citation needed ]  An early procedure was performed by London surgeon Thomas Brand in 1779. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13752", "text": "Orchiopexy  for repair of undescended  testes  ( cryptorchidism ) is the second most common surgery performed on infant male genitalia (after  circumcision ). The surgeon moves one or both testes, with blood vessels, from an  abdominal  or  inguinal  position to the  scrotum . If the inguinal canal is open it must be closed to prevent  hernia . Potential surgical problems include maintaining the blood supply. If vessels cannot be stretched into the scrotum, or are separated and cannot be reconnected, a testis will die and atrophy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13753", "text": "Hypospadias  repair  may be a single-stage procedure if the hypospadias is of the first or second degree ( urethral  opening on glans or shaft respectively) and the  penis  is otherwise normal. Surgery for third-degree hypospadias (urethral opening on  perineum  or in urogenital opening) is more challenging, may be done in stages, and has a significant rate of complications and unsatisfactory outcomes. [ 25 ]  Potential surgical problems: For severe hypospadias (3rd degree, on perineum) constructing a urethral tube the length of the phallus is not always successful, leaving an opening (a \"fistula\") proximal to the intended urethral opening. Sometimes a second operation is successful, but some boys and men have been left with chronic problems with fistulas, scarring and contractures that make urination or erections uncomfortable, and loss of sensation. It is increasingly recognized that long-term outcomes are poor. [ 26 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13754", "text": "Epispadias  repair  may involve comprehensive surgical repair of the genito-urinary area, usually during the first seven years of life, including reconstruction of the urethra, closure of the penile shaft and mobilisation of the corpora."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13755", "text": "Urogenital closure  closure of any midline opening at the base of the penis. In severe  undervirilization  a boy may have a \"pseudovaginal pouch\" or a single urogenital opening in the midline of the  perineum . Potential surgical problems: The most complicated aspect of closure involves moving the urethra to the phallus if it is not already there (i.e., repairing a perineal hypospadias). Fistulas, scarring, and loss of sensation are the main risks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13756", "text": "Gonadectomy  (also referred to as \"orchiectomy\") removal of the gonads. This is done in three circumstances. (1) If the  gonads  are  dysgenetic  testes or streak gonads and at least some of the boy's cells have a  Y chromosome , the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing  gonadoblastoma . (2) In rare instances when an XX child has completely virilizing  congenital adrenal hyperplasia  (Prader stage 5), the  ovaries  can be removed before puberty to stop  breast  development and/or  menstruation . (3) Gonadectomy can be performed in the equally rare instance of a child with  true hermaphroditism  virilized enough to raise as male, in which ovaries or  ovotestes  can be removed. A lifetime of hormone replacement will be required, to avoid  osteoporosis  and enable sexual functioning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13757", "text": "Chordee  release  is the cutting of ventral penile skin and connective tissue to free and straighten the penis. A mild chordee, manifest as a well-formed penis \"bent\" downward by subcutaneous connective tissue, may be an isolated birth defect easily repaired by releasing some of the inelastic connective tissue on the ventral side of the shaft. In a complete chordee the phallus is \"tethered\" downward to the perineum by skin. A more severe chordee is often accompanied by a hypospadias and sometimes by severe undervirilization: a perineal \"pseudovaginal pouch\" and bifid (\"split\") scrotum with an undersized penis. This combination, referred to as  pseudovaginal perineoscrotal hypospadias , is in the spectrum of ambiguous genitalia due to a number of conditions.  Scarring and contracture are occasional complications, but most unsatisfactory outcomes occur when a severe hypospadias needs to be repaired as well. Long-term complications can include fistulas between  colon  or upper  rectum  and skin or other cavities, or between urethra and perineum. Loss of sensation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13758", "text": "Cloacal  repair  is among the most complex of the surgeries described here.  Bladder exstrophy  or more severe  cloacal exstrophy  is a major birth defect involving inadequate closure and incomplete midline fusion of multiple pelvic and perineal organs as well as the front of the  pelvis  and lower abdominal wall. The penis and scrotum are often widely  bifid  (the two embryonic parts unjoined). The penis often cannot be salvaged, although the testes can be retained. Repair may involve closure of the bladder, closure of the anterior abdominal wall,  colostomy  (temporary or permanent) with reconstruction of the rectum. If the halves of the phallus cannot be joined, they may be removed. The smallest defect in this spectrum is an  epispadias . Surgical repair for this is primarily a phalloplasty. [ 28 ]  Potential surgical problems: Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term colostomy or  vesicostomy . In many cases a functional penis cannot be created. Scarring is often extensive and the lower torso severely disfigured even with fairly good outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13759", "text": "Phalloplasty  is a general term for any reconstruction of the penis itself, especially for more unusual types of injuries, deformities, or birth defects. The principal difficulty is that erectile tissue is not easily constructed and this limits the surgeon's ability to make more than minor size changes. Construction of a narrow tube lined with mucosa (a urethra) is a similar challenge.  Minor revisions of the skin are rarely followed by problems. More complicated reconstruction may result in scarring and contracture, which can distort the shape or curvature of the penis, or interfere with erections or make them painful."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13760", "text": "Hysterectomy  is removal of a  uterus . It is rare that a uterus or  M\u00fcllerian duct  derivatives would need to be removed from a child being raised as a boy: see  persistent M\u00fcllerian duct syndrome . The most common scenario is accidental discovery of persistent M\u00fcllerian derivatives or a small uterus during abdominal surgery of a normal boy for  cryptorchidism ,  appendectomy , or bowel disease. Removal would not involve genital surgery. A rarer indication would be that of a completely virilized XX child with  congenital adrenal hyperplasia  (Prader stage 5) being raised as a male;  ovaries  and uterus must be removed to prevent  breast  development and  menstruation  by early adolescence. Risks are simply those of abdominal surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13761", "text": "Testicular prostheses  are saline-filled plastic ovoids implanted in the scrotum. They have no function except to provide the appearance and feel of testes. Several sizes are available, but most are implanted in adolescence to avoid repeated procedures to implant larger sizes at puberty. Prostheses made of  silastic  are no longer available due to safety and perception-of-safety concerns. Potential surgical problems: Foreign body reactions, rarely with infection or erosion of scrotal skin, are minimal but constitute the most significant complication."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13762", "text": "Penile augmentation surgery  is surgery intended to enlarge a small penis. Early attempts in the 1950s and 1960s involved constructing a tube of non-erectile flesh extending a small penis but the penis did not function. In recent years a small number of urologists have been offering an augmentation [ clarification needed ]  procedure that involves moving outward some of the buried components of the corpora so that the penis protrudes more. The girth is augmented with transplantation of the patient's fat. This procedure is designed to preserve erectile and sexual function without surgically altering the urethra. This type of surgery is not performed on children and primarily produces a small increase in the size of a normal penis, but would be less likely to produce a major functional change in a severe  micropenis . Potential surgical problems include reabsorption of the fat, scarring resulting in interference with erectile function, and issues with physical sensation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13763", "text": "Concealed penis  where a normal penis is buried in suprapubic fat. In most cases, when the fat is depressed with the fingers, the penis is seen to be of normal size. This is common in overweight boys before the penile growth of puberty. Surgical techniques have been devised to improve it. [ 29 ]  The most common problems post-surgery are recurrence with continued weight gain and scarring."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13764", "text": "In the last 50 years, the following procedures were most commonly performed to make the genitalia more typically female: virilization due to  congenital adrenal hyperplasia ; genital variations due, for example, to  cloacal exstrophy ; genital variations in infants with XY or mixed chromosomes to be raised as girls, such as  gonadal dysgenesis , partial and complete  androgen insensitivity syndrome ,  micropenis , cloacal and  bladder exstrophy . In the 21st century, feminizing surgery to support reassignment of XY infants with non-ambiguous micropenis has been largely discontinued, and surgical reassignment of XY infants with exstrophy or other significant variations or injuries is diminishing. See  history of intersex surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13765", "text": "Clitorectomy  amputation or removal of most of the  clitoris , including  glans , erectile tissue, and  nerves . This procedure was the most common clitoral surgery performed prior to 1970, but was largely abandoned by 1980 because it usually resulted in loss of clitoral sensation. Potential surgical problems: The primary effect of this surgery is a drastic reduction in ability to experience  orgasm . The appearance is not very normal. Regrowth of unwanted erectile tissue has sometimes presented problems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13766", "text": "Clitoroplasty , like phalloplasty, is a term that encompasses any surgical reconstruction of the clitoris, such as removal of the corpora. Clitoral recession and reduction can both be referred to as clitoroplasty. Potential surgical problems: Major complications can include scarring, contractures, loss of sensation, loss of capacity for orgasm, and unsatisfactory appearance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13767", "text": "Clitoral recession  involves the repositioning of the erectile body and glans of the clitoris farther back under the symphysis pubis and/or skin of the preputium and mons. This was commonly done from the 1970s through the 1980s to reduce protrusion without sacrificing sensation. Outcomes were often unsatisfactory, and it fell into disfavor in the last 15 years. [ 31 ]  Potential surgical problems: Unfortunately the subsequent sensations were not always pleasant, and erection could be painful. Adults who had a clitoral recession in early childhood often report reduced capacity for enjoyment of sexual intercourse, though similar women who had not had surgery also report a high rate of sexual dysfunction. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13768", "text": "Clitoral reduction  was developed in the 1980s to reduce size without reducing function. Lateral wedges of the erectile tissue of the clitoris are removed to reduce the size and protrusion. The neurovascular tissue is carefully spared to preserve function and sensation. Nerve stimulation and sensory responses are now often performed during the surgery to confirm function of the sensory nerves. [ 31 ] [ 33 ]  Clitoral reduction is rarely done except in combination with vaginoplasty when substantial virilization is present. Potential problems: The degree to which the goal of preserving sexual sensations is attained is a subject of controversy regarding the necessity of such treatments, and lack of firm evidence of good outcomes. [ 3 ] [ 6 ]  The success of more contemporary approaches was challenged by Thomas in 2004: \"confidence in the superiority of modern surgery is almost certainly misplaced as the crucial components of current clitoral reduction surgery are not fundamentally different from those used in specialist centres 20 years ago\". [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13769", "text": "Vaginoplasty , the construction or reconstruction of a  vagina , can be fairly simple or quite complex, depending on the initial anatomy. If a normal internal uterus, cervix and upper vagina (the  M\u00fcllerian derivatives ) exist, and the outer virilization is modest, surgery involves separating the fused labia and widening the vaginal introitus. With greater degrees of virilization, the major challenge of the procedure is to provide a passage connecting the outer vaginal opening to the cervix which will stay wide enough to allow coitus. XY girls or women with partial  androgen insensitivity syndrome  will have a blind vaginal pouch of varying degrees of depth. Sometimes this can be dilated to a usable depth. Sometimes surgery is performed to deepen it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13770", "text": "The most challenging surgery with the highest complication rate is construction of an entirely new vagina (a \"neovagina\"). The most common instance of this is when a child will be assigned and raised as a female despite complete virilization, as with Prader 5  CAH , or (in the past) when a genetic male infant with a severely defective penis was  reassigned  as a female. One method is to use a segment of colon, which provides a lubricated mucosal surface as a substitute for the vaginal mucosa. Another is to line the new vagina with a skin graft. [ 35 ] [ 36 ] [ 37 ]  Potential surgical problems: Stenosis (narrowing) of the constructed vagina is the most common long-term complication and the chief reason that a revision may be required when a girl is older. When a neovagina is made from a segment of bowel, it tends to leak mucus; when made with a skin graft, lubrication is necessary. Less common complications include fistulas, uncomfortable scarring, and problems with urinary continence. [ 32 ] [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13771", "text": "Gonadectomy  is removal of the gonads. If the  gonads  are  dysgenetic  testes or streak gonads and at least some of the cells have a  Y chromosome , the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing  gonadoblastoma . If the gonads are relatively \"normal\" testes, but the child is to be assigned and raised as female, (e.g., for intersex conditions with severe undervirilization, or major malformations involving an absent or unsalvageable penis) they must be removed before puberty to prevent virilization from rising testosterone."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13772", "text": "Testes in  androgen insensitivity  are a special case: if there is any degree of responsiveness to testosterone, they should be removed before puberty. On the other hand, if androgen insensitivity is complete, the testes may be left to produce estradiol (via testosterone) to induce breast development, but there is a slowly increasing risk of cancer in adult life. Streak gonads without a Y chromosome cell line need not be removed but will not function. Finally, the gonads in  true hermaphroditism  must be directly examined; atypical gonads with Y line or potential testicular function should be removed but in rare instances a surgeon may try to preserve the ovarian part of an ovotestis. [ 40 ]  Potential surgical problems: A lifetime of hormone replacement will be required, to avoid  osteoporosis  and enable sexual functioning."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13773", "text": "Cloacal exstrophy  and  bladder exstrophy repair  is needed regardless of the  sex of assignment  or  rearing . Simple bladder exstrophy in a genetic female does not usually involve the  vagina . Cloacal exstrophy in a genetic female usually requires major surgical reconstruction of the entire  perineum , including  bladder ,  clitoris , symphysis pubis, and both the vaginal introitus and  urethra . However, the  uterus  and  ovaries  are normally formed. Severe bladder exstrophy or cloacal exstrophy in genetic males often renders the phallus widely split, small, and unsalvageable. The scrotum is also widely split, though testes themselves are usually normal. From the 1960s until the 1990s, many of these infants were assigned and raised as females, with fashioning of a vagina and gonadectomy as part of the perineal reconstruction. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13774", "text": "Potential surgical problems: Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term  colostomy  or  vesicostomy . Creating a functional urethra is difficult and poor healing, with scarring, stricture, or fistula can require a vesicostomy to prevent urinary incontinence. Construction of a functional  internal  and  external anal sphincter  can be equally difficult when this has been disrupted as well. Functional problems can warrant a temporary or long-term colostomy. The added challenge for the most severely affected genetic females, and for genetic males who are being raised as females, is construction of a neovagina. Scarring is extensive and the lower torso disfigured even with the best outcomes. Finally, it has become apparent that some XY males (without intersex conditions) who are  reassigned  and raised as females have not developed a female gender identity and have sought reassignment back to male. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13775", "text": "There is widespread evidence of  prenatal testing and hormone treatment  to prevent intersex traits. [ 42 ] [ 43 ]  In 1990, a paper by Heino Meyer-Bahlburg titled  Will Prenatal Hormone Treatment Prevent Homosexuality?  was published in the Journal of Child and Adolescent Psychopharmacology. It examined the use of \"prenatal hormone screening or treatment for the prevention of homosexuality\" using research conducted on foetuses with  congenital adrenal hyperplasia  (CAH). Dreger, Feder, and  Tamar-Mattis  describe how later research constructs \"low interest in babies and men \u2013 and even interest in what they consider to be men's occupations and games \u2013 as \"abnormal\", and potentially preventable with prenatal dex [amethasone]\". [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13776", "text": "The ethics of  preimplantation genetic diagnosis  to select against intersex traits was the subject of 11 papers in the October 2013 issue of the  American Journal of Bioethics . [ 44 ]  There is widespread evidence of  pregnancy terminations  arising from prenatal testing, as well prenatal hormone treatment to prevent intersex traits. [ 45 ] [ 46 ] [ 47 ] [ 48 ] [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13777", "text": "In April 2014,  Organisation Intersex International Australia  made a submission on genetic selection via  preimplantation genetic diagnosis  to the  National Health and Medical Research Council  recommending that deselection of embryos and foetuses on grounds of intersex status should not be permitted. It quoted research by Professors  Morgan Holmes , Jeff Nisker, associate professor  Georgiann Davis , and by Jason Behrmann and Vardit Ravitsky. [ 50 ]  It quotes research showing  pregnancy termination  rates of up to 88% in  47,XXY  even while the  World Health Organization  describes the trait as \"compatible with normal life expectancy\", and \"often undiagnosed\". [ 51 ] [ 52 ]   Behrmann and Ravitsky find social concepts of sex, gender and sexual orientation to be \"intertwined on many levels. Parental choice against intersex may thus conceal biases against same-sex attractedness and gender nonconformity.\" [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13778", "text": "The  DSM-5  included a change from using gender identity disorder to  gender dysphoria . This revised code now specifically includes intersex people who do not identify with their sex assigned at birth and experience clinically significant distress or impairment, using the language of  disorders of sex development . [ 54 ]  This move was criticised by intersex advocacy groups in Australia and  New Zealand . [ 55 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13779", "text": "A 2006 clinician \"Consensus Statement on Intersex Disorders and Their Management\" attempted to prioritise psychosocial support for children and families, but it also supports surgical intervention with psychosocial rationales such as \"minimizing family concern and distress\" and \"mitigating the risks of stigmatization and gender-identity confusion\". [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13780", "text": "In 2012, the Swiss National Advisory Commission on Biomedical Ethics argued strongly in favour of improved psychosocial support, saying: [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13781", "text": "The initial aim of counselling and support is therefore to create a protected space for parents and the newborn, so as to facilitate a close bond. In addition, the parents need to be enabled to take the necessary decisions on the child's behalf calmly and after due reflection. In this process, they should not be subjected to time or social pressures. Parents' rapid requests for medical advice or for corrective surgery are often a result of initial feelings of helplessness, which need to be overcome so as to permit carefully considered decision-making."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13782", "text": "It is important to bear in mind and also to point out to the parents that a diagnosis does not in itself entail any treatment or other medical measures, but serves initially to provide an overview of the situation and a basis for subsequent decisions, which may also take the form of watchful waiting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13783", "text": "...interventions have lasting effects on the development of identity, fertility, sexual functioning and the parent-child relationship. The parents' decisions should therefore be marked by authenticity, clarity and full awareness, and based on love for the child, so that they can subsequently be openly justified vis-\u00e0-vis the child or young adult."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13784", "text": "A joint international statement by  intersex community organizations  published in 2013 sought, amongst other demands:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13785", "text": "Recognition that medicalization and stigmatisation of intersex people result in significant trauma and mental health concerns.\nIn view of ensuring the bodily integrity and well-being of intersex people, autonomous non-pathologising psycho-social and peer support be available to intersex people throughout their life (as self-required), as well as to parents and/or care providers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13786", "text": "Specialists at the Intersex Clinic at University College London began to publish evidence in 2001 that indicated the harm that can arise as a result of inappropriate interventions, and advised minimising the use of childhood surgical procedures. [ 57 ] [ 58 ] [ 59 ] [ 60 ] [ 61 ] [ 62 ] [ 63 ] [ 64 ] [ 65 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13787", "text": "A 2004 paper by  Heino Meyer-Bahlburg  and others examined outcomes from early surgeries in individuals with XY variations, at one patient centre. [ 66 ]  The study has been used to support claims that \"the majority of women... have clearly favored genital surgery at an earlier age\" but the study was criticized by Baratz and Feder in a 2015 paper for neglecting to inform respondents that:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13788", "text": "(1) not having surgery at all might be an option; (2) they might have had lower rates of reoperation for  stenosis  if surgery were performed later, or (3) that significant technical improvements that were expected to improve outcomes had occurred in the 13 or 14 years between when they underwent early childhood surgery and when it might have been deferred until after puberty. [ 67 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13789", "text": "In 2006, an invited group of clinicians met in Chicago and reviewed clinical evidence and protocols, and adopted a new term for intersex conditions:  Disorders of sex development  (DSD) in the journal article  Consensus Statement on Intersex Disorders and their Management . [ 56 ]  The new term refers to \"congenital conditions in which development of chromosomal, gonadal, or  anatomical sex  is atypical.\" [ 56 ]  The term has been controversial and not widely adopted outside clinical settings: the World Health Organization and many medical journals still refer to  intersex  traits or conditions. [ 68 ]  Academics like  Georgiann Davis  and  Morgan Holmes , and clinical psychologists like  Tiger Devore  argue that the term DSD was designed to \"reinstitutionalise\" medical authority over intersex bodies. [ 6 ] [ 69 ] [ 70 ] [ 71 ]  On surgical rationales and outcomes, the article stated that:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13790", "text": "It is generally felt that surgery that is carried out for cosmetic reasons in the first year of life relieves parental distress and improves attachment between the child and the parents. The systematic evidence for this belief is lacking. ... information across a range of assessments is insufficient ... outcomes from clitoroplasty identify problems related to decreased sexual sensitivity, loss of clitoral tissue, and cosmetic issues ... Feminising as opposed to masculinising genitoplasty requires less surgery to achieve an acceptable outcome and results in fewer urological difficulties... Long term data on sexual function and quality of life among those assigned female as well as male show great variability. There are no controlled clinical trials of the efficacy of early (less than 12 months of age) versus late surgery (in adolescence and adulthood), or of the efficacy of different techniques\" [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13791", "text": "Data presented in recent years suggests that little has changed in practice. [ 72 ]  Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and \"recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences\". [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13792", "text": "A 2014 civil society submission to the  World Health Organization  cited data from a large German  Netzwerk DSD/Intersexualit\u00e4t  study:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13793", "text": "In a study in L\u00fcbeck conducted between 2005 and 2007 ...  81% of 439 individuals had been subjected to surgeries due to their intersex diagnoses. Almost 50% of participants reported psychological problems. Two thirds of the adult participants drew a connection between sexual problems and their history of surgical treatment. Participating children reported significant disturbances, especially within family life and physical well-being \u2013 these are areas that the medical and surgical treatment was supposed to stabilize. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13794", "text": "A 2016 Australian study of persons born with atypical sex characteristics found that \"strong evidence suggesting a pattern of institutionalised shaming and coercive treatment of people\". Large majorities of respondents opposed standard clinical protocols. [ 73 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13795", "text": "A 2016 follow-up to the 2006 Consensus Statement, termed a  Global Disorders of Sex Development Update  stated,"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13796", "text": "There is still no consensual attitude regarding indications, timing, procedure and evaluation of outcome of DSD surgery. The levels of evidence of responses given by the experts are low (B and C), while most are supported by team expertise... Timing, choice of the individual and irreversibility of surgical procedures are sources of concerns. There is no evidence regarding the effect of surgically treated or non-treated DSDs during childhood for the individual, the parents, society or the risk of stigmatization... Physicians working with these families should be aware that the trend in recent years has been for legal and human rights bodies to increasingly emphasize preserving patient autonomy. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13797", "text": "A 2016 paper on \"Surgery in disorders of sex development (DSD) with a gender issue\" repeated many of the same claims, but without reference to human rights norms. [ 13 ]  A commentary to that article by  Alice Dreger  and Ellen Feder criticized that omission, stating that issues have barely changed in two decades, with \"lack of novel developments\", while \"lack of evidence appears not to have had much impact on physicians' confidence in a standard of care that has remained largely unchanged.\" [ 74 ]  Another 2016 commentary stated that the purpose of the 2006 Consensus Statement was to validate existing practices, \"The authoritativeness and \"consensus\" in the Chicago statement lies not in comprehensive clinician input or meaningful community input, but in its utility to justify any and all forms of clinical intervention.\" [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13798", "text": "Management practices for intersex conditions have evolved over the last 60 years. In recent decades surgical practices have become the subject of public and professional controversy, and evidence remains lacking. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13799", "text": "Argued or putative advantages of infant surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13800", "text": "Argued or putative advantages of surgery in adolescence or later:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13801", "text": "Others argue that the key questions are not ones of early or late surgery, but questions of consent and autonomy. [ 75 ] [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13802", "text": "Parents are frequently considered able to consent to feminizing or masculinizing interventions on their child, and this may be considered standard for the treatment of physical disorders. However this is contested, particularly where interventions seek to address psychosocial concerns. A  BMJ  editorial in 2015 stated that parents are unduly influenced by medicalized information, may not realize that they are consenting to experimental treatments, and regret may be high. [ 20 ]  Research has suggested that parents are willing to consent to appearance-altering surgeries even at the cost of later adult sexual sensation. [ 77 ]  Child rights expert  Kirsten Sandberg  states that parents have no right to consent to such treatments. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13803", "text": "Reports published in the early 1990s state that 20-50% of surgical cases result in a loss of sexual sensation. [ 79 ] [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13804", "text": "A 2007 paper by Yang, Felsen and Poppas provided what the authors believe is the first study of clitoral sensitivity after clitoris reduction surgery, but the research was itself the subject of ethical debate. Postoperative patients aged older than five years were \"considered candidates\" for clitoral sensitivity testing, and 10 of 51 patients were tested, with 9 undergoing extended vibratory sensory testing. The initial tests were performed on the inner thigh,  labia majora ,  labia minora ,  vaginal introitus  and clitoris, with a \"cotton tip applicator\" and extended tests with a biothesiometer, a medical device used to measure sensitivity thresholds. Values were recorded. The authors note that there are no control data \"for assessment of the viability and function of the clitoris in unaffected women.\" [ 81 ]  The ethics of these tests have been criticized by bioethicists, [ 82 ]  and subsequently defended by the  Office for Human Research Protections . [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13805", "text": "Loss of sexual function and sensation remains a concern in a submission by the Australasian Paediatric Endocrine Group to the Australian Senate in 2013. [ 3 ]  Clinical decision-making has prioritized perceived advantages from infant clitoral reduction surgery over the potential disadvantages of reduced or distorted sexual sensation. Human rights institutions stress the informed consent of the individual concerned."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13806", "text": "In the cases where nonfunctional testes are present, or with partial androgen insensitivity syndrome, there is a risk that these develop cancer. They are removed by  orchidectomy  or monitored carefully. [ 84 ]  In a major Parliamentary report in Australia, published in October 2013, the Senate Community Affairs References committee was \"disturbed\" by the possible implications of current practices in the treatment of cancer risk. The committee stated: \"clinical intervention pathways stated to be based on probabilities of cancer risk may be encapsulating treatment decisions based on other factors, such as the desire to conduct normalising surgery\u2026 Treating cancer may be regarded as unambiguously therapeutic treatment, while normalising surgery may not. Thus basing a decision on cancer risk might avoid the need for court oversight in a way that a decision based on other factors might not. The committee is disturbed by the possible implications of this...\" [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13807", "text": "Gender identity and sexuality in intersex children have been problematized, and subjective judgements are made about the acceptability of risk of future gender dysphoria. [ 13 ] [ 85 ]  Medical professionals have traditionally considered the worst outcomes after genital reconstruction in infancy to occur when the person develops a gender identity discordant with the sex assigned as an infant. Most of the cases in which a child or adult has voluntarily changed sex and rejected  sex of assignment  and  rearing  have occurred in partially or completely virilized genetic males who were reassigned and raised as females. This is the management practice that has been most thoroughly undermined in recent decades, as a result of a small number of spontaneous self-reassignments to male. Reducing the likelihood of a gender \"mismatch\" is also a claimed advantage of deferring reconstructive surgery until the patient is old enough to assess gender identity with confidence."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13808", "text": "Human rights institutions question such approaches as being \"informed by redundant social constructs around gender and biology\". [ 86 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13809", "text": "Parents may be advised that without surgery, their child will be  stigmatized , [ 87 ]  but they may make different choices with non-medicalized information. [ 88 ]  However, there is no evidence that surgeries help children grow up psychologically healthy. [ 12 ] [ 89 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13810", "text": "Unlike other aesthetic surgical procedures performed on infants, such as corrective surgery for a  cleft lip  (as opposed to a  cleft palate ), genital surgery may lead to negative consequences for sexual functioning in later life (such as loss of sensation in the genitals, for example, when a  clitoris  deemed too large or penis is reduced/removed), or feelings of freakishness and unacceptability, which may have been avoided without the surgery. Studies have revealed how surgical intervention has had psychological effects, affecting well-being and quality of life. Genital surgeries do not ensure a successful psychological outcome for the patient and might require psychological support when the patient is trying to distinguish a gender identity. [ 90 ]  The Swiss National Advisory Commission on Biomedical Ethics states that, where \"interventions are performed solely with a view to integration of the child into a family and social environment, then they run counter to the child's welfare. In addition, there is no guarantee that the intended purpose (integration) will be achieved.\" [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13811", "text": "Opponents of all \"corrective surgery\" on atypical sex characteristics suggest to change social opinion regarding the desirability of having genitalia that look more average, rather than perform surgery to try to make them more like those of other people."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13812", "text": "Photographs of intersex children's genitalia are circulated in medical communities for documentary purposes, and individuals with intersex traits may be subjected to repeated genital examinations and display to medical teams. Problems associated with experiences of medical photography of intersex children have been discussed [ 91 ]  along with their ethics, control and usage. [ 92 ]  \"The experience of being photographed has exemplified for many people with intersex conditions the powerlessness and humiliation felt during medical investigations and interventions\". [ 92 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13813", "text": "Additionally, parents are not often consulted on the decision-making process when choosing the sex of the child, and they may be advised to conceal information from their child. The Intersex Society of North America stated that \"For decades, doctors have thought it necessary to treat intersex with a concealment-centered approach, one that features downplaying intersex as much as possible, even to the point of lying to patients about their conditions.\" [ 93 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13814", "text": "In 2015, an editorial in the  BMJ  described current surgical interventions as experimental, stating that clinical confidence in constructing \"normal\" genital anatomies has not been borne out, and that medically credible pathways other than surgery do not yet exist. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13815", "text": "The  Council of Europe  highlights several areas of concern in relation to intersex surgeries and other medical treatment:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13816", "text": "The Council of Europe argues that secrecy and shame have perpetuated human rights abuses and a lack of social understanding of the reality of intersex people. It calls for respect for \"intersex persons' right not to undergo sex assignment treatment\". [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13817", "text": "Alice Dreger , a US professor of Clinical Medical Humanities and Bioethics, argues that little has changed in actual clinical practice in recent years. [ 72 ]  Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and \"recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences\". [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13818", "text": "Institutions like the Swiss National Advisory Commission on Biomedical Ethics, [ 5 ]  the  Australian Senate , [ 6 ]  the Council of Europe, [ 8 ] [ 94 ]   World Health Organization , [ 2 ] [ 95 ]  and UN  Office of the High Commissioner for Human Rights [ 96 ]  and Special Rapporteur on Torture [ 16 ]  have all published reports calling for changes to clinical practice."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13819", "text": "In 2011,  Christiane V\u00f6lling  won the first successful case brought against a surgeon for non-consensual surgical intervention. The Regional Court of Cologne, Germany, awarded her \u20ac100,000. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13820", "text": "In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations. [ 9 ] [ 10 ] [ 11 ] [ 97 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13821", "text": "In June 2017,  Joycelyn Elders ,  David Satcher , and  Richard Carmona , three former Surgeons General of the United States published a paper at the  Palm Center , [ 98 ] [ 99 ] [ 100 ]  calling for a rethink of early genital surgeries on children with intersex traits. The statement reflected on the history of such interventions, their rationales and outcomes, stating:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13822", "text": "When an individual is born with atypical genitalia that pose no physical risk, treatment should focus not on surgical intervention but on psychosocial and educational support for the family and child. Cosmetic genitoplasty should be deferred until children are old enough to voice their own view about whether to undergo the surgery. Those whose oath or conscience says \u201cdo no harm\u201d should heed the simple fact that, to date, research does not support the practice of cosmetic infant genitoplasty."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13823", "text": "Irving Operation  is a gynaecological operative technique for permanent sterilization in women. It was proposed to reduce the failure rate of  Pomeroy procedure  for female sterilization. In Irving operation, the proximal part of  fallopian tube  is buried back into the myometrium, thereby obstructing its lumen. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13824", "text": "The Irving operation was proposed by Dr. Irving in 1924. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13825", "text": "A transverse incision is made on the abdomen and fallopian tube is identified. While holding the fallopian tube with an  Allis clamp , a hemostat is used to open the  mesosalpinx . Using absorbable sutures, proximal portion of fallopian tube is tied, and a segment of fallopian tube is removed. The proximal part of the fallopian tube is pulled into the defect. The distal portions of the Fallopian tube are ligated and left in place. The abdomen is closed in layers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13826", "text": "Irving operation can be reversed with tubal reversal microsurgery. Pregnancy rate after tubal reversal in Irving operation is around 60 percent. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13827", "text": "The  Manchester operation ,  Manchester repair  or simply  Fothergill operation  is a technique used in  gynaecologic  surgeries. It is an operation for  uterine prolapse  by fixation of the  cardinal ligaments . Its purpose is to reduce the  cystourethrocele  and to reposition the uterus within the  pelvis . The major steps of the intervention are listed below:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13828", "text": "High amputation of cervix during this procedure may cause cervical incompetence. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13829", "text": "Success rate of Manchester operation was re-evaluated at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey for clinical characteristics, complications, and satisfaction scores of patients. A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13830", "text": "Metroplasty  (also called  Strassman metroplasty,   uteroplasty  or  hysteroplasty ) is a  reconstructive surgery  used to repair  congenital anomalies  of the  uterus , including  septate uterus  and  bicornuate uterus . The surgery entails removing the abnormal tissue that separates the  cornua  of the uterus, then using several layers of stitches to create a normal shape. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13831", "text": "Nymphotomy  is the surgical procedure of  incision  into the  labia minora . Surgical removal of the labia minora is called  nymphectomy . In  plastic surgery , the term  labiaplasty , which describes  plastic surgery  of the  labia  (often in the form of  labia minora reduction ) is now more commonly used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13832", "text": "The term  nymphectomy  is also used to describe removal of parts of the labia as part of  female genital cutting ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13833", "text": "Oophorectomy  ( / \u02cc o\u028a . \u0259 f \u0259 \u02c8 r \u025b k t \u0259 m i / ; from  Greek   \u1fa0\u03bf\u03c6\u03cc\u03c1\u03bf\u03c2 ,  \u014doph\u00f3ros , 'egg-bearing' and  \u1f10\u03ba\u03c4\u03bf\u03bc\u03ae ,  ektom\u1e17 , 'a cutting out of'), historically also called  ovariotomy , is the  surgical  removal of an  ovary  or ovaries. [ 1 ]  The surgery is also called  ovariectomy , but this term is mostly used in reference to non-human animals, e.g. the surgical removal of ovaries from laboratory animals.  Removal of the ovaries of females is the biological equivalent of  castration  of males; the term  castration  is only occasionally used in the medical literature to refer to oophorectomy of women. In  veterinary medicine , the removal of ovaries and uterus is called  ovariohysterectomy  ( spaying ) and is a form of  sterilization ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13834", "text": "The first reported successful human oophorectomy was carried out by (Sir)  Sydney Jones  at  Sydney Infirmary , Australia, in 1870. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13835", "text": "Partial oophorectomy  or  ovariotomy  is a term sometimes used to describe a variety of surgeries such as ovarian cyst removal, or resection of parts of the ovaries. [ 3 ]  This kind of surgery is fertility-preserving, although ovarian failure may be relatively frequent. Most of the long-term risks and consequences of oophorectomy are not or only partially present with partial oophorectomy."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13836", "text": "In humans, oophorectomy is most often performed because of diseases such as  ovarian cysts  or  cancer ; as  prophylaxis  to reduce the chances of developing ovarian  cancer  or breast  cancer ; or in conjunction with  hysterectomy  (removal of the uterus). In the 1890s people believed oophorectomies could cure menstrual cramps, back pain, headaches, and chronic coughing, although no evidence existed that the procedure impacted any of these ailments. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13837", "text": "The removal of an ovary together with the  fallopian tube  is called  salpingo-oophorectomy  or  unilateral salpingo-oophorectomy  ( USO ). When both ovaries and both fallopian tubes are removed, the term  bilateral salpingo-oophorectomy  ( BSO ) is used. Oophorectomy and salpingo-oophorectomy are not common forms of  birth control  in humans; more usual is  tubal ligation , in which the fallopian tubes are blocked but the ovaries remain intact. In many cases, surgical removal of the ovaries is performed concurrently with a hysterectomy. The formal medical name for removal of a woman's entire reproductive system (ovaries, fallopian tubes, uterus) is \"total abdominal hysterectomy with bilateral salpingo-oophorectomy\" (TAH-BSO); the more casual term for such a surgery is \"ovariohysterectomy\". \"Hysterectomy\" is removal of the uterus (from the Greek \u1f51\u03c3\u03c4\u03ad\u03c1\u03b1 hystera \"womb\" and \u03b5\u03ba\u03c4\u03bf\u03bc\u03af\u03b1 ektomia \"a cutting out of\") without removal of the ovaries or fallopian tubes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13838", "text": "Oophorectomy for benign causes is most often performed by abdominal  laparoscopy . Abdominal  laparotomy  or robotic surgery is used in complicated cases [ clarification needed ]  or when a malignancy is suspected. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13839", "text": "According to the  Centers for Disease Control , 454,000 women in the United States underwent oophorectomy in 2004. The first successful operation of this type, account of which was published in the  Eclectic Repertory and Analytic Review  (Philadelphia) in 1817, was performed by  Ephraim McDowell  (1771\u20131830), a surgeon from  Danville, Kentucky . [ 5 ]  McDowell was dubbed as the \"father of ovariotomy\". [ 6 ] [ 7 ]  It later became known as Battey's Operation, after  Robert Battey , a surgeon from  Augusta, Georgia , who championed the procedure for a variety of conditions, most successfully for  ovarian epilepsy . [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13840", "text": "Most bilateral oophorectomies (63%) are performed without any medical indication, and most (87%) are performed together with a hysterectomy. [ 9 ]  Conversely, unilateral oophorectomy is commonly performed for a medical indication (73%; cyst, endometriosis, benign tumor, inflammation, etc.) and less commonly in conjunction with hysterectomy (61%). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13841", "text": "Special indications include several groups of women with substantially increased risk of ovarian cancer, such as high-risk  BRCA mutation  carriers and women with endometriosis who also have frequent  ovarian cysts . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13842", "text": "Bilateral oophorectomy has been traditionally done in the belief that the benefit of preventing ovarian cancer would outweigh the risks associated with removal of ovaries. However, it is now clear that prophylactic oophorectomy without a reasonable medical indication decreases long-term survival rates substantially [ 10 ]  and has deleterious long-term effects on health and well-being even in post-menopausal women. [ 11 ]  The procedure has been postulated as a possible treatment method for female sex offenders. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13843", "text": "The procedure is sometimes performed at the same time as  hysterectomy  in transgender men and  non-binary  people. The long term effects of oophorectomy in this population are not well studied. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13844", "text": "Oophorectomy can significantly improve survival for women with high-risk  BRCA mutations , for whom  prophylactic  oophorectomy around age 40 reduces the risk of ovarian and  breast cancer  and provides significant and substantial long-term survival advantage. [ 14 ]  On average, earlier intervention does not provide any additional benefit but increases risks and adverse effects."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13845", "text": "For women with high-risk  BRCA2  mutations, oophorectomy around age 40 has a relatively modest benefit for survival; the positive effect of reduced breast and ovarian cancer risk is nearly balanced by adverse effects. The survival advantage is more substantial when oophorectomy is performed together with prophylactic  mastectomy . [ 15 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13846", "text": "The risks and benefits associated with oophorectomy in the BRCA1/2 mutation carrier population are different than those for the general population. Prophylactic risk-reducing salpingo-oophorectomy (RRSO) is an important option for the high-risk population to consider. Women with BRCA1/2 mutations who undergo salpingo-oophorectomy have lower all-cause mortality rates than women in the same population who do not undergo this procedure. In addition, RRSO has been shown to decrease mortality specific to breast cancer and ovarian cancer. Women who undergo RRSO are also at a lower risk for developing ovarian cancer and first occurrence breast cancer. Specifically, RRSO provides BRCA1 mutation carriers with no prior breast cancer a 70% reduction of ovarian cancer risk. BRCA1 mutation carriers with prior breast cancer can benefit from an 85% reduction. High-risk women who have not had prior breast cancer can benefit from a 37% (BRCA1 mutation) and 64% (BRCA2 mutation) reduction of breast cancer risk. These benefits are important to highlight, as they are unique to this BRCA1/2 mutation carrier population. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13847", "text": "In rare cases, oophorectomy can be used to treat  endometriosis  by eliminating the menstrual cycle, which will reduce or eliminate the spread of existing endometriosis as well as reducing pain. Since endometriosis results from an overgrowth of the uterine lining, removal of the ovaries as a treatment for endometriosis is often done in conjunction with a hysterectomy to further reduce or eliminate recurrence. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13848", "text": "Oophorectomy for endometriosis is used only as last resort, often in conjunction with a hysterectomy, as it has severe side effects for women of reproductive age. However, it has a higher success rate than retaining the ovaries. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13849", "text": "Partial oophorectomy (i.e., ovarian cyst removal not involving total oophorectomy) is often used to treat milder cases of endometriosis when non-surgical hormonal treatments fail to stop cyst formation. Removal of ovarian cysts through partial oophorectomy is also used to treat extreme pelvic pain from chronic hormonal-related pelvic problems."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13850", "text": "Oophorectomy is an intra-abdominal surgery and serious complications stemming directly from the surgery are rare. When performed together with hysterectomy, it has influence on choice of surgical technique as the combined surgery is much less likely to be performed by vaginal hysterectomy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13851", "text": "Laparotomic  adnexal  surgeries are associated with a high rate of adhesive small bowel obstructions (24%). [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13852", "text": "An infrequent complication is injuring of the  ureter  at the level of the  suspensory ligament of the ovary . [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13853", "text": "Oophorectomy has serious long-term consequences stemming mostly from the hormonal effects of the surgery and extending well beyond menopause. The reported risks and adverse effects include premature death, [ 21 ] [ 22 ]  cardiovascular disease, cognitive impairment or dementia, [ 23 ]   parkinsonism , [ 24 ]   osteoporosis  and bone fractures, decline in psychological well-being, [ 25 ]  and decline in sexual function.  Hormone replacement therapy  does not always reduce the adverse effects. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13854", "text": "Oophorectomy is associated with significantly increased all-cause long-term mortality except when performed for cancer prevention in carriers of high-risk BRCA mutations. This effect is particularly pronounced for women who undergo oophorectomy before age 45. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13855", "text": "The effect is not limited to women who have oophorectomy performed before menopause; an impact on survival is expected even for surgeries performed up to the age of 65. [ 26 ]  Surgery at age 50-54 reduces the probability of survival until age 80 by 8% (from 62% to 54% survival), surgery at age 55-59 by 4%. Most of this effect is due to excess cardiovascular risk and hip fractures. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13856", "text": "Removal of ovaries causes hormonal changes and symptoms similar to, but generally more severe than,  menopause . Women who have had an oophorectomy are usually encouraged to take hormone replacement drugs to prevent other conditions often associated with menopause. Women younger than 45 who have had their ovaries removed with prophylactic bilateral oophorectomy face a mortality risk 170% higher than women who have retained their ovaries. [ 22 ]  Retaining the ovaries when a hysterectomy is performed is associated with better long-term survival. [ 21 ]  Hormone therapy for women with oophorectomies performed before age 45 improves the long-term outcome and all-cause mortality rates. [ 22 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13857", "text": "Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones  estrogen  and  progesterone , and lose about half of their ability to produce  testosterone , and subsequently enter what is known as \"surgical  menopause \" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). In natural menopause the ovaries generally continue to produce low levels of hormones, especially androgens, long after menopause, which may explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms that may continue until the natural age of menopause. [ 28 ]  These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone,  progesterone , or a combination. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13858", "text": "When the ovaries are removed, a woman is at a seven times greater risk of cardiovascular disease, [ 29 ] [ 30 ] [ 31 ]  but the mechanisms are not precisely known. The hormone production of the ovaries currently cannot be sufficiently mimicked by drug therapy. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, in response to and as part of the complex  endocrine system ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13859", "text": "Oophorectomy is associated with an increased risk of  osteoporosis  and bone fractures. [ 32 ] [ 33 ] [ 34 ] [ 35 ] [ 36 ]   A potential risk for oophorectomy performed after menopause is not fully elucidated. [ 37 ] [ 38 ]   Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced  bone density . [ 39 ]   In women under the age of 50 who have undergone oophorectomy,  hormone replacement therapy  (HRT) is often used to offset the negative effects of sudden hormonal loss such as  early-onset osteoporosis  as well as menopausal problems like  hot flashes  that are usually more severe than those experienced by women undergoing natural menopause."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13860", "text": "Oophorectomy substantially impairs sexuality. [ 40 ]  Substantially more women who had both an oophorectomy and a hysterectomy reported  libido  loss, difficulty with sexual arousal, and vaginal dryness than those who had a less invasive procedure (either hysterectomy alone or an alternative procedure), and hormone replacement therapy was not found to improve these symptoms. [ 41 ]   In addition, oophorectomy greatly reduces testosterone levels, which are associated with a greater sense of sexual desire in women. [ 42 ]  However, at least one study has shown that psychological factors, such as relationship satisfaction, are still the best predictor of sexual activity following oophorectomy. [ 43 ]  Sexual intercourse remains possible after oophorectomy and coitus can continue.  Reconstructive surgery remains an option for women who have experienced benign and malignant conditions. [ 44 ]   :\u200a1020\u20131348"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13861", "text": "The side effects of oophorectomy may be alleviated by medicines other than hormonal replacement. Non-hormonal biphosphonates (such as  Fosamax  and  Actonel ) increase bone strength and are available as once-a-week pills. Low-dose  selective serotonin reuptake inhibitors  such as  Paxil  and  Prozac  alleviate vasomotor menopausal symptoms, i.e., \"hot flashes\". [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13862", "text": "In general, hormone replacement therapy is somewhat controversial due to the known  carcinogenic  and  thrombogenic  properties of  estrogen ; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality-of-life issues as a consequence of early surgical menopause. The ovarian hormones estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions; it is believed by some doctors that hormone therapy programs mitigate surgical menopause side effects such as increased risk of cardiovascular disease, [ 46 ]  and female sexual dysfunction. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13863", "text": "Short-term hormone replacement with estrogen has negligible effect on overall mortality for high-risk BRCA mutation carriers. Based on computer simulations, overall mortality appears to be marginally higher for short-term HRT after oophorectomy or marginally lower for short-term HRT after oophorectomy in combination with mastectomy. [ 48 ]  This result can probably be generalized to other women at high risk in whom short-term (i.e., one- or two-year) treatment with estrogen for hot flashes may be acceptable."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13864", "text": "Ovarian drilling , also known as multiperforation or  laparoscopic  ovarian diathermy, is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. [ 1 ]  It differs from ovarian wedge resection, which involves the cutting of tissue. Minimally invasive ovarian drilling procedures have replaced wedge resections. [ 2 ]  Ovarian drilling is favored over wedge resection because cutting into the ovary might result in adhesions, potentially complicating postoperative outcomes. [ 3 ]  Ovarian drilling and ovarian wedge resection are treatment options to reduce the amount of  androgen  producing tissue in women with  polycystic ovarian syndrome  (PCOS). [ 4 ]  PCOS is the primary cause of anovulation, which results in female infertility. [ 5 ]  The induction of mono-ovulatory cycles can restore fertility. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13865", "text": "The oral drug  clomiphene citrate  (CC) is the first-line treatment for PCOS-related infertility, yet one-fifth of women are resistant to the drug and fail to ovulate. [ 7 ]  Patients are considered resistant if the treatment fails for six months at the appropriate dosage. [ 1 ]   Women who are resistant to the medication clomiphene citrate are commonly treated with medications that induce ovulation such as gonadotrophins. [ 8 ]  Medications that induce ovulation such as CC can also be associated with multiple pregnancies and problems with the women's cycle and this therapy is very expensive due to the route of administration (daily by injection) and the requirement for regular ultrasounds,  laparoscopic  ovarian drilling is sometimes considered by medical professionals for treating anovulation. [ 8 ]  Known side effects and risks include the need for  anesthesia , the risk of infection, and a risk of adhesions forming. [ 8 ]  There may sometimes be a smaller risk of the person losing ovarian function. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13866", "text": "Ovarian drilling is a surgical alternative to CC treatment or recommended for women with  WHO Group II ovulation disorders . [ 6 ]  Other non-surgical medical options in the treatment of PCOS include the oestrogen receptor modulator  tamoxifen ,  aromatase inhibitors , insulin sensitising drugs, and hormonal ovarian stimulation. [ 9 ]  The effectiveness of the surgical procedure is similar to CC or gonadotropin treatment for induced ovulation for PCOS patients, but results in fewer multiple pregnancies per ongoing pregnancy regardless if the technique is unilaterally or bilaterally performed. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13867", "text": "If patients do not become pregnant six months after ovulation has been reestablished from ovarian drilling treatment, drug treatments may be reintroduced or  in vitro fertilisation  (IVF) may be considered. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13868", "text": "Part of the criteria of PCOS diagnosis includes elevated levels of androgens in the bloodstream or other signs of androgen excess ( hyperandrogenism ). [ 1 ]  The procedure causes a drop in serum  androgen  levels and possibly in  estrogen  levels. [ 5 ]  After ovarian follicles and stroma are destroyed, there is a reduction in these hormone levels. [ 11 ]  The procedure results in a decrease in plasma  luteinizing hormone  (LH) and in pulsations as well as a periodic drop in  inhibin B  levels. [ 1 ]  The most plausible theory states that the reduction of these hormone concentrations leads to an increase in the secretion of  follicle-stimulating hormone  (FSH) and sex hormone-binding  globulin , leading to effective follicular maturation and ovulation. [ 5 ] [ 1 ]  Low serum  oestradiol  concentrations are associated with decreased  aromatase  activity. [ 1 ]  Inflammatory growth factors such as  insulin-like growth factor-1  are produced due to injury and aid the effects of FSH through greater blood flow and gonadotropin delivery. [ 11 ]  Circulating and intrafollicular levels of  anti-M\u00fcllerian hormone  (AMH), which can help quantify recruitable ovarian follicle activity, are reduced after laparoscopic ovarian drilling in women with PCOS. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13869", "text": "When the clinician determines that ovarian drilling is appropriate and the woman decides to undergo this treatment, consent is obtained. The risks are communicated to the woman. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13870", "text": "The most commonly performed method is with a monopolar needle or hook because of the equipment's availability and simple installation. [ 6 ]  Other common instrumentation consists of the use of a bipolar electrical surgical electrodes or a CO 2 , argon, or ND-YAG  laser . [ 14 ]  This instrumentation has the ability to produce the intended results with a very focal approach. Typically, a 100 W electrical cautery dissector is first used to cross the ovarian cortex, then electrocoagulation is performed at 40 W, however rates range from 30 to 400 W. [ 1 ]  The surgical punctures are performed on the ovarian cortex and are usually 4\u201310\u00a0mm deep and 3\u00a0mm wide. [ 10 ] [ 11 ]  The number of punctures is related to subsequent ability to conceive\u2014it has been found that five to ten punctures are more likely to produce the intended conception. [ 13 ]  Ovarian drilling is performed laparoscopically and either transumbilical ( culdoscopy ) or transvaginal ( fertiloscopy ). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13871", "text": "Though preferable to creating incisions on the ovary, ovarian drilling does have some risks. These are: pelvic adhesion formation,  hemorrhage ,  gas embolism ,  pneumothorax ,  premature ovarian failure , long-term ovarian function, developing  hyperstimulation syndrome , adhesion formation,  infertility  and  multiple births . [ 2 ] [ 13 ] [ 6 ] [ 15 ]  Transvaginal hydrolaparoscopy (THL) ovarian drilling may minimize the risk of iatrogenic adhesion formation and decreased ovarian reserve (DOR), which can impinge upon fertility. [ 16 ]  LOD does not contribute to the risk of decreased ovarian reserve. [ 12 ]  There is risk of electrical accidents with monopoly current. [ 1 ]  A rare complication of LOD is major vascular injury, mostly on the small vessels in the anterior abdominal wall when the Veress needle and trocar are inserted at the beginning of the procedure. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13872", "text": "Ovarian drilling has lower rates of  ovarian hyperstimulation syndrome  and of  multi-fetal gestation . [ 17 ] [ 8 ]  The advantages of the procedure also include its singular treatment, as opposed to several trials of ovulation inductions. [ 2 ]  Other benefits of this technique include cost-effectiveness and that it can be performed as an  outpatient procedure . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13873", "text": "Ovarian drilling was first used in the treatment of PCOS in 1984 and has evolved as a safe and effective surgery. [ 11 ]  After performing laparoscopic electrosurgical ovarian drilling in CC-resistant patients in 1984, Gj\u00f6nnaess found that this technique increased ovulation rates to 45 percent and pregnancy rates to 42 percent. [ 18 ]  In 1988, laparoscopic multiple punch resection of ovaries on the hypothalamo-pituitary axis, slightly modified from Gj\u00f6nnaess's operation, caused a reduction in LH pulsation and pituitary responsiveness in the treatment of PCOS. [ 19 ]  In 1989, ovarian drilling was conducted with argon, carbon dioxide (CO 2 ) or  potassium-titanyl-phosphate  (KTP) laser vaporization causing spontaneous ovulation in 71 percent of those treated. [ 14 ]  The procedure has been modified and popularized in the treatment of patients with CC-resistance. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13874", "text": "Presacral neurectomy  is one of the treatments for chronic pelvic pain and  dysmenorrhea . Lapraroscopic presacral neurectomy is an initial surgical intervention for chronic pelvic pain when medical therapy fails. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13875", "text": "The sensory pathways from the pelvic viscera pass through the  superior hypogastric plexus   and  inferior hypogastric plexus  to the spinal columns. The excision of presacral nerve trunk results in the obstruction of the pain pathway from the hypogastric plexi to the spinal cord. Presacral neurectomy denervates the uterus and causes loss of some bladder sensation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13876", "text": "Presacral neurectomy is offered to patients for whom medical therapy for chronic pain relief has failed. The efficacy of the procedure is around 75-80%. Less than 1% of all patients have major complications following the surgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13877", "text": "A  resuscitative hysterotomy , also referred to as a  perimortem Caesarean section  ( PMCS ) or  perimortem Caesarean delivery  ( PMCD ), is a  hysterotomy  performed to  resuscitate  a woman in middle to late  pregnancy  who has entered  cardiac arrest . [ 1 ]  Combined with a  laparotomy , the procedure results in a  Caesarean section  that removes the  fetus , thereby abolishing the  aortocaval compression  caused by the pregnant uterus. [ 1 ]  This improves the mother's chances of  return of spontaneous circulation , and may potentially also deliver a viable  neonate . [ 1 ]  The procedure may be performed by  obstetricians ,  emergency physicians  or  surgeons  depending on the situation. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13878", "text": "Where cardiac arrest occurs in a pregnant woman, irrespective of the condition of the  fetus , the procedure should be performed immediately if  basic  and  advanced life support  attempts are proving unsuccessful at achieving return of spontaneous circulation, and the woman's uterus is deemed capable of causing aortocaval compression. [ 1 ] [ 3 ] [ 4 ]  The threshold for this is passed when the uterus is so large that the  fundus  may be  palpated  at the level of the woman's  umbilicus ; for a  singleton  pregnancy, this occurs at around 20 weeks of  gestational age [ 3 ] [ 4 ]  (but may be earlier in  multiple pregnancy ). Although hysterotomy is crucial for resuscitation of the mother in such situations, if the gestational age is less than approximately 24 to 25 weeks the procedure will necessarily lead to the death of the fetus (or fetuses), as this is estimated to be the lower limit for  fetal viability . [ 4 ]  If the fetus is over 24 weeks' gestation, Caesarean delivery also offers the best chance of rescue for the neonate. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13879", "text": "If the mother's medical condition is such that there is no reasonable prospect of maternal resuscitation or viability (for example, after a nonsurvivable injury, or an unwitnessed arrest with prolonged pulselessness), then the procedure may be attempted immediately as a means of saving the unborn fetus primarily. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13880", "text": "The procedure should not be performed if the uterus is not judged to be large enough to cause maternal haemodynamic changes through aortocaval compression, as there is no potential benefit to the mother and the fetus or fetuses will not be viable in such an early stage of pregnancy. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13881", "text": "Potential structures that may be damaged during the procedure are as for Caesarean section, including the fetus itself and the maternal bowel, bladder, uterus and uterine blood vessels. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13882", "text": "Once the decision to operate has been made, the procedure should be performed immediately at the site where cardiac arrest has taken place and standard basic and advanced life support resuscitation methods should continue throughout. [ 3 ]  These should include manual displacement of the uterus towards the patient's left side, to reduce aortocaval compression. [ 2 ]  If the arrest occurs in a healthcare facility that has staff on site who are capable of performing a resuscitative hysterotomy (such as at a hospital), the patient should not be moved to an  operating theatre  as this will delay the procedure. [ 3 ]  Out-of-hospital cardiac arrests may need to be transported to a healthcare facility first if qualified staff are not immediately available. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13883", "text": "Other than a  scalpel , no specialised surgical equipment is needed for a resuscitative hysterotomy. [ 3 ]  The  American Heart Association  recommends that healthcare facilities that may be required to treat a case of maternal cardiac arrest should keep in stock an emergency equipment tray for the purpose, including a scalpel with a No. 10 blade, a Balfour  retractor , surgical  sponges ,  Kelly  and Russian  forceps , a  needle driver ,  sutures  and suture scissors - but the procedure should commence regardless of whether the tray is available. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13884", "text": "Basic  aseptic  measures, such as pouring  antiseptic  solution over the woman's  abdomen  prior to incision, may be considered as long as this adds no delay. [ 3 ]  An assistant should manually displace the gravid uterus to the woman's left throughout the procedure until the fetus has been delivered, to assist the simultaneous efforts of those resuscitating the woman. [ 3 ]  Either a classical midine  incision  or a  Pfannenstiel incision  may be used depending on operator preference; the former may theoretically give better exposure, but practising obstetricians or surgeons may be more comfortable with a Pfannenstiel approach as this is more commonly used for Caesarean sections. [ 3 ]  Once the uterus is opened, the fetus is delivered and should be resuscitated by a separate team. [ 3 ]  It may be possible to then use the abdominal incision to deliver direct cardiac massage through the (intact) diaphragm. [ 2 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13885", "text": "After the placenta is delivered, the uterus is massaged to stimulate contraction and is closed with a running locking absorbable suture and the abdomen is then closed; alternatively, the wound may be temporarily packed with sterile gauze, with definitive closure delayed until specialist obstetric help arrives or until the patient is fit for transport to a formal operating theatre. [ 2 ] [ 3 ]   Uterotonic  agents like  oxytocin  may be considered, balancing potential reduction of  haemorrhage  with the tendency of oxytocin to cause  hypotension . [ 3 ]   Antibiotics  should be administered to reduce infection risk if maternal survival is thought feasible at this stage of the resuscitation. [ 3 ]  If there is return of spontaneous circulation, additional uterotonic agents will likely be needed due to bleeding from uterine atony. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13886", "text": "The American Heart Association first added resuscitative hysterotomy to its recommended guidelines for  cardiopulmonary resuscitation  and emergency cardiac care in 1992, based on limited  case report  evidence. [ 4 ]  Many case reports have since been published reporting that, in maternal cardiac arrest, evacuation of the uterus is often associated with abrupt return of spontaneous circulation or other improvement in the mother's condition. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13887", "text": "A  retropubic paravaginal repair  is the surgical procedure to reattach the anterior lateral  vaginal wall  and its connective tissue to its normal position in the  pelvis  to correct  pelvic organ prolapse . It may be necessary to preserve normal function of pelvic organs after the vagina has detached from its normal position and has moved along with underlying tissues away from the pelvic sidewall. A common finding in repairing this condition is that the  arcus tendineus fasciae  has become detached. The procedure is usually performed by a  gynecological   surgeon  using pelvic surgery techniques. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13888", "text": "Women who experience  stress incontinence  and who need a paravaginal repair often receive a Burch colposuspension to correct the problem. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13889", "text": "Sacrohysteropexy  is a surgical procedure to correct  uterine prolapse . It involves a resuspension of the prolapsed uterus using a strip of synthetic mesh to lift the uterus and hold it in place. It allows for normal  sexual function  and preserves  childbearing function . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13890", "text": "Sacrohysteropexy  can be performed as an open operation or  laparoscopically  (via keyhole incisions). The advantages of laparoscopic approach include superior visualisation of the anatomy with laparoscopic magnification, decreased hospital stay, reduced postoperative pain, more rapid recovery and smaller incisions. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13891", "text": "The aim of laparoscopic hysteropexy is to restore and reinforce normal uterine support by suspending the  uterus  from the  sacral promontory  using  polypropylene  mesh. The mesh is strongly attached at two points: namely the uterus/ cervix  and the anterior longitudinal  ligament  over the sacral promontory. Hysteropexy restores the normal support of the  vagina , suspending the uterus back in its anatomical position by reinforcing weakened ligaments with a mesh. This procedure allows the length of the vagina to be restored without compromising its calibre, and is therefore likely to have a favourable functional outcome. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13892", "text": "The advantages of this operation over  hysterectomy , as well as preservation of  fertility , are a stronger repair, with less risk of recurrent prolapse. Cuts to the vagina itself are also avoided so it is likely there is less risk of subsequent sexual problems. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13893", "text": "Salpingectomy  refers to the surgical removal of a  fallopian tube .  This may be done to treat an ectopic pregnancy or  cancer , to prevent cancer, or as a form of  contraception ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13894", "text": "This procedure is now sometimes preferred over its ovarian tube-sparing counterparts due to the risk of  ectopic pregnancies .  For contraceptive purposes, this procedure is irreversible and more effective than  tubal ligation ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13895", "text": "Salpingectomy is different from and predates both  salpingostomy  and  salpingotomy . The latter two terms are often used interchangeably and refer to creating an opening into the tube (e.g. to remove an  ectopic pregnancy ), but the tube itself is not removed. [ 1 ]  Technically, the creation of a new tubal opening ( os , after the  Latin  word for 'mouth') by surgery would be a  salpingostomy , while the incision into the tube to remove an ectopic is a  salpingotomy . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13896", "text": "Salpingectomy was performed by  Lawson Tait  in 1883 in women with a bleeding  ectopic pregnancy ; it is now established as a routine and lifesaving procedure [ clarification needed ] . Other indications for a salpingectomy include infected tubes (as in a  hydrosalpinx ) or as part of the surgical procedure for tubal cancer. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13897", "text": "A bilateral salpingectomy will lead to  sterility , and was used for that purpose; however, less invasive, possibly reversible procedures have become available as  tubal occlusion procedures . Bilateral salpingectomies continue to be requested by some  voluntarily childfree  people over tubal ligation because it reduces the risk of developing cancer; this is called  prophylactic salpingectomy . [ 2 ]  It can be performed non-electively on women who are at a high risk of developing ovarian cancer, as a preventative measure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13898", "text": "Salpingectomy has traditionally been done via a  laparotomy ; more recently however,  laparoscopic  salpingectomies have become more common as part of  minimally invasive surgery . The tube is severed at the point where it enters the  uterus  and along its mesenteric edge with hemostatic control. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13899", "text": "Salpingectomy is commonly done as part of a procedure called a  salpingo- oophorectomy , in which one or both  ovaries , as well as one or both fallopian tubes, are removed in one operation (a bilateral salpingo-oophorectomy (BSO) if both ovaries and fallopian tubes are removed).  If a BSO is combined with an abdominal  hysterectomy  (there are different methods of hysterectomy available), the procedure is commonly called a TAH-BSO: total abdominal hysterectomy with a bilateral salpingo-oophorectomy. Sexual intercourse remains possible after salpingectomy, surgical and radiological cancer treatments, and chemotherapy. Reconstructive surgery remains an option for women who have experienced benign and malignant conditions. [ 3 ]   :\u200a1020\u20131348"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13900", "text": "Salpingectomies were performed in the United States in the early 20th century in accordance with  eugenics legislation . From  Buck v. Bell  (1927):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13901", "text": "The Virginia statute providing for the sexual sterilization of inmates of institutions supported by the State who shall be found to be afflicted with an hereditary form of insanity or imbecility, is within the power of the State under the  Fourteenth Amendment . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13902", "text": "Buck v. Bell , while not expressly overturned, was implicitly overturned by  Skinner v. Oklahoma  (1942), in which the Court held that a person's choices whether to aid in the propagation of the human species was a cognizable fundamental right guaranteed under the 14th Amendment of the Constitution, a liberty retained by the people under the 9th Amendment of the Constitution."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13903", "text": "In  medicine ,  salpingo-oophorectomy  is the removal of an  ovary  and its  fallopian tube . [ 1 ] [ 2 ]  This procedure is most frequently associated with prophylactic surgery in response to the discovery of a  BRCA mutation , particularly those of the normally  tumor suppressing   BRCA1  gene (or, with a statistically lower negative impact, those of the tumour suppressing  BRCA2  gene), which can increase the risk of a woman developing  ovarian cancer  to as high as 65% (as high as 25% for a mutated  BRCA2  gene). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13904", "text": "Transvaginal mesh , also known as  vaginal mesh implant , is a net-like surgical tool that is used to treat  pelvic organ prolapse (POP)  and  stress urinary incontinence (SUI)  among female patients. The  surgical mesh  is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13905", "text": "A number of mesh materials with varying absorbability has been explored to maximise the  biocompatibility  as well as the repair efficacy of mesh. Depending on the target vaginal space, the application of transvaginal mesh differs in terms of mesh shape, surgical incision and the position of mesh. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13906", "text": "Since 2019, transvaginal mesh has been banned by the US  Food and Drug Administration  (FDA) due to the high prevalence of complications, including mesh erosion, pain and pelvic infection. [ 3 ] [ 4 ]  Complications may arise from concomitant surgery and inappropriate surgical techniques, while they can also be prevented with uterus preservation. [ 5 ] [ 6 ]  Transvaginal mesh was once used widely for nearly 25% of prolapse interventions until the FDA ban, yet approximately 1 out of 15 patients required a mesh removal in the past decade. [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13907", "text": "Based on how transvaginal mesh reacts inside the patient\u2019s body, the implant is classified into 4 subtypes: [ 10 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13908", "text": "The selection of mesh subtype to be placed in patients requires consideration of patients' preference and risk analysis, including evaluation of recurrence risk and complication risk by surgical personnel. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13909", "text": "Transvaginal mesh is used to repair symptomatic  pelvic organ prolapse  that causes pain and discomfort among patients and to treat  stress urinary incontinence . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13910", "text": "Transvaginal mesh prevents pelvic organs, such as the  bladder ,  uterus  and  rectum  from sagging into the vagina due to weak pelvic muscles by acting as a  hammock  underneath. [ 3 ]  Depending on the organs involved, it can be placed on the anterior, posterior, or top wall of vagina transvaginally. In some special cases of  vaginal vault prolapse , the vagina may collapse after the  removal of the uterus  and a transvaginal mesh can be positioned on top of the vagina to fix it in place. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13911", "text": "Transvaginal mesh, also called bladder sling in this case, holds up the  urethra  when pelvic muscles weaken. [ 3 ]  This prevents  bladder leakage  during physical movements that increases bladder pressure. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13912", "text": "Compared to traditional native tissue repair surgery, transvaginal mesh, especially when placed in anterior vaginal area, has improved POP repair outcomes but similar SUI repair outcomes. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13913", "text": "Advantages over native tissue repair are mainly associated with improved surgical procedures, for example, simpler and less invasive procedures, higher reproducibility of techniques and durability. However, transvaginal mesh remains as a refuted method due to its adverse complications. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13914", "text": "As pelvic organ prolapse and stress urinary incontinence can be present separately or simultaneously, surgical mesh is implanted into  vesicovaginal  and  rectovaginal  region through the vaginal route in different approaches, to manage patients\u2019 condition properly."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13915", "text": "The goal of POP repair with transvaginal mesh is to increase longevity in patients by reconstructing organ position and preventing pelvic organs from bulging into the vagina. [ 3 ]  Generally, the position and incisions for transvaginal mesh are determined by the corresponding pelvic muscle defect, which differs from patient to patient. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13916", "text": "The implantation usually starts with anterior  colpotomy , which is an incision on the anterior vaginal wall to assess the vesicovaginal space in front of the vagina. [ 3 ] [ 5 ]  For patients who have undergone  hysterectomy  or will be preserving their  uterus , only longitudinal anterior incision can be performed. [ 5 ] \u00a0For patients who are also receiving a concomitant  hysterectomy , an anterior  colpotomy , a Cross-T-shaped incision that cuts around the cervix, or a single incision around the cervix and across the vagina will be performed. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13917", "text": "In consideration of the patient's specific conditions, the transvaginal mesh can be positioned in front of the vaginal wall ( cystocele  correction), behind the vaginal wall ( rectocele  correction), or on top of the vagina ( uterine prolapse  correction). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13918", "text": "For cystocele corrections, horizontal arms will be inserted on the lateral bladder walls through the  obturator foramen  by an  Emmet needle . [ 5 ]  Meanwhile, vertical straps will be placed onto the fibrous thickenings of  pelvic fascia  anteriorly and posteriorly in order to reposition the bladder. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13919", "text": "Alternatively, an incision on the posterior vaginal wall will be needed to place the mesh through the  perineal skin  for rectocele correction. [ 5 ]  To hold the rectum upright, the horizontal straps are inserted into space surrounding the rectum, brought out of the body and pulled below the anus. [ 13 ]  If both corrections are required, transvaginal mesh can be cut into two pieces before operation and adjusted for accurate reconstruction. [ 5 ]  After putting the prolapsed organs back to its original position and reinforcing the vaginal wall, the incision is closed with  sutures . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13920", "text": "Transvaginal mesh surgery is expected to show improved pelvic support after the first few weeks, particularly for non-absorbable meshes which have a higher biocompatibility and permanent outcome. [ 9 ]  For absorbable meshes, longer recovery time and lower durability are expected as native tissues need to grow into the pores to support the weakened organs. [ 11 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13921", "text": "Transvaginal mesh, also known as midurethral or bladder neck sling for  SUI  repair, can be used to support the urethra or the neck of the bladder in two surgical approaches, namely the  retropubic  and  transobturator . In the retropubic approach, two incisions above the  pubic bone  and one incision in the vagina are performed. [ 14 ]  The transvaginal mesh is then placed under the urethra through the  retropubic space , which is anterior to bladder and posterior to  pubic symphysis , and brought out to the  suprapubic area . [ 15 ]  In the  transobturator  approach, two incisions in the  groin  area and one incision in the vagina are performed. [ 14 ]  The transvaginal mesh is inserted through the  obturator foramen  to avoid damage of pelvic organs, and brought out to the skin in the groin area. [ 15 ]  Since 2008, mini-slings with single vaginal incision have been introduced to reduce complications without comprising the successful rate. [ 14 ] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13922", "text": "Intraoperative complications are of low risk and include vaginal or pelvic  hematoma , bleeding, rectal injury and bladder injury. [ 5 ] [ 17 ]  In contrast, postoperative complications are most frequent among patients and are mainly related to the mesh. [ 3 ]  The high incidence of postoperative complications of transvaginal mesh has led to its ban by the FDA in 2019. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13923", "text": "Mesh erosion describes the exposure, extrusion or protrusion of the mesh exteriorly at the surgery scar. [ 3 ]  Generally, it is the most common postoperative complication and 10.3% of the patients experience mesh erosion within 12 months for pelvic organ prolapse (POP) repair. [ 3 ] [ 4 ] [ 19 ]  Mesh erosion can be classified into 2 main types according to the location of erosion: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13924", "text": "Postoperative vaginal extrusion is defined as a mesh extrusion through the  vaginal mucosa  and is the most common form of mesh erosion. [ 3 ] [ 4 ]  Patients with this complication usually present with discomfort in the vagina as a result of mucosal irritation, abnormal  vaginal discharge , or pelvic pain. [ 4 ]  For sexually active patients, their partners may even feel pain during  intercourse , causing notice of the presentation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13925", "text": "The most common site for vaginal extrusion is usually in the midline of the surgical incision site since major causes of vaginal extrusion include suture disruption,  subclinical infection  and damage at the surrounding tissue. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13926", "text": "As vaginal extrusion worsen due to delayed healing,  conservative treatment  with oestrogen or antibiotics and recommendation for  sexual abstinence  is usually suggested to alleviate the symptoms. [ 6 ] [ 4 ] \u00a0If conservative treatment fails due to large mesh exposure (i.e. > 0.5mm), partial mesh excision is suggested with symptoms expected to resolved in 71-95% of the patients. [ 6 ] [ 4 ] [ 20 ] [ 21 ]  If partial mesh excision fails, a more invasive complete mesh excision will be considered to avoid further complications, especially for those with severe complications. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13927", "text": "Postoperative erosion into the urethra or bladder is less common and presents within 18 month after mesh surgery. [ 7 ] [ 4 ]  Patients with this complication typically show urge incontinence, stress urinary incontinence,  urinary retention ,  hematuria  or  dysuria . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13928", "text": "Complete inspection of urethra by  cystoscopy  can help diagnose this complication and the mesh must be excised. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13929", "text": "Postoperative pain is usually experienced at pelvic, groin, thigh region or during sexual intercourse. Furthermore, it can be caused by mesh erosion or  subclinical infection . [ 3 ] [ 4 ]  One hypothesised  aetiology  for mesh-related pain is that inflammatory response induces the shrinkage of mesh, leading to  vaginal tightening . [ 3 ] [ 4 ] [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13930", "text": "To treat postoperative pain, an examination in the pelvic region is performed to determine the cause of pain. [ 4 ]  If there are no significant examination findings, pain relief drugs, such as  nonsteroidal anti-inflammatory medicine , will be first prescribed to patients. [ 4 ]  If the pain persists for months,  local anesthetics  with  corticosteroids  can be injected at the site of pain. [ 4 ]  For more severe cases, mesh excision with targeted physical therapy can be considered as a last resort. [ 4 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13931", "text": "Although postoperative infection seldom occur among patients who have undergone mesh surgery, it is still an  inherent risk  for any surgical implantations and results in severe implications. [ 4 ] [ 5 ] [ 6 ]  In cases of severe infection, complete mesh excision is highly commended. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13932", "text": "Other common complications include urinary problems, abnormal bleeding,  organ perforation  while some rare complications, such as recurrent pelvic organ prolapse, neuro-muscular problems, vaginal scarring and emotional problems are also observed. [ 7 ] [ 3 ] [ 4 ]  From 2008 to 2010, three deaths were associated with transvaginal mesh surgery for  POP  repair due to  bowel perforation  and abnormal bleeding. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13933", "text": "The number and extent of concomitant surgeries increase with the complication risks. [ 5 ] [ 6 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13934", "text": "However, for patients who require concurrent mesh slings, concomitant  hysterectomy  is often necessary. [ 5 ] [ 6 ] [ 25 ]  Certain incision methods for  hysterectomy , such as an inverted T incision, will also increase the risk of complications significantly. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13935", "text": "The size of the incision and extent of sling tension should be minimized to reduce risk of complications. [ 6 ] [ 4 ] [ 25 ]  This is often determined by the surgical skills of surgeons. [ 6 ] [ 4 ] [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13936", "text": "Uterine preservation and minimal incision size should be performed as they prevent damage to the urogenital system. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13937", "text": "Initially used in the 50s to mend  abdominal hernias ,  gynecologists  started to use meshes to repair pelvic organ prolapse (POP) and stress urinary incontinence (SUI) in the 90s. [ 18 ]  Over time, manufacturers seized the demand for specific mesh with desired shapes for POP and SUI repair, resulting in the first SUI and POP-specific mesh to be cleared by the FDA as class II moderate-risk devices in 1996 and 2002. [ 26 ]  In 2006, approximately one-third of POP patients opted for mesh implantation, in which over 90% mesh surgeries were performed transvaginally, rather than traditional native tissue repair or with other devices. [ 9 ]  Due to the popular response, mesh products evolved into surgical mesh kits with the addition of new insertion tools, such as tissue fixation anchors. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13938", "text": "Starting from 2008, the FDA took escalating actions to deal with the growing adverse effects and low repair efficacy of transvaginal mesh for POP repair. In 2011, it issued an FDA Safety Communication, pointing out concerns for transvaginal mesh. [ 18 ]   In 2016, the FDA reclassified transvaginal mesh for POP repair into a class III high-risk device, requiring manufacturers to submit a premarket approval application to keep transvaginal mesh products on the market. [ 18 ]  After an advisory committee meeting, the FDA announced that the safety and effectiveness of transvaginal mesh for POP are not scientifically assured and all transvaginal mesh products, except midurethral slings, were banned to protect the health of female patients on 16 April 2019. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13939", "text": "Currently, there are several legal actions against major transvaginal mesh manufacturers like  Johnson & Johnson  and  Boston Scientific  to compensate complications. [ 9 ]  A class of 700 Australian women sued Johnson & Johnson for selling defective transvaginal meshes. [ 9 ]  Similar self-claimed victims in the United Kingdom and the United States have sparked off more than 100,000 transvaginal mesh-related lawsuits. [ 9 ]  Up until now,\u00a0Johnson & Johnson and Boston Scientific have agreed for payments in total of $8 billion to resolve the claims. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13940", "text": "Tubal reversal , also called  tubal sterilization reversal ,  tubal ligation reversal , or  microsurgical tubal reanastomosis , is a surgical procedure that can restore  fertility  to women after a  tubal ligation . By rejoining the separated segments of the  fallopian tube , tubal reversal can give women the chance to become  pregnant  again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus (a 'tubal reimplantation'). In other cases, when the end of the tube (the 'fimbria') has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13941", "text": "The  fallopian tube  is a muscular tube extending from the  uterus  and ending with attached fimbria next to the  ovary . The tube is attached to the ovary by a thin tissue called the mesosalpinx. The inner tubal lining is lined with  cilia . These are microscopic hair-like projections that beat in waves that push fluid down the tube towards the uterus thereby helping move the egg or  ovum  to the uterus in conjunction with muscular contractions of the tube. The fallopian tube is normally about 10\u00a0cm (4\u00a0inches) long and consists of several regions that become wider as the tube gets farther away from the uterus. Starting from the uterus and proceeding outward, these are the:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13942", "text": "Tubal reversal surgeries require the techniques of  microsurgery  to open and reconnect the fallopian tube segments that remain after a tubal sterilization, reimplant remaining segments, or create new fimbria. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13943", "text": "Following a  tubal ligation , there are usually two remaining fallopian tube segments - the proximal (close) tubal segment that emerges from the  uterus  and the distal (far) tubal segment that ends with the  fimbria  next to the  ovary . After opening the blocked ends of the remaining tubal segments, a variety of microsurgical techniques are utilized to recreate a functional tube. The newly created tubal openings are drawn next to each other by placing sutures in the connective tissue that lies beneath the fallopian tubes ( mesosalpinx ). The retention suture prevents the tubal segments from pulling apart while the tube heals. Microsurgical sutures are used to precisely align the tubal lumens (inside canal of tube), the muscular portion ( muscularis externa ), and the outer layer ( serosa ) of the tube. Most surgeons try to avoid the use of stents which can damage the delicate cilia that line the tube and create the flow of fluid that is needed to push the egg and embryo into the uterus. Other surgeons use a narrow flexible  stent  to gently thread through the tubal segments or into the uterine cavity in order to line up the tubes in order to reconnect them. In either case, once the microsurgical repair is completed dye is injected through the cervix into the uterus and out through the tubes to ensure that the fallopian tube is open from the uterine cavity to its fimbrial end. The surgeons who use stents then gently withdraw them from the fimbrial end of the tube after the repair is completed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13944", "text": "In a small percentage of cases, a tubal ligation procedure leaves only the distal (far) portion of the fallopian tube and no proximal (close) tubal segment. This can occur when any method of tubal ligation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called  tubal reimplantation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13945", "text": "Fimbriectomy is a very uncommon type of tubal ligation that is performed by removing the end (fimbria) of the fallopian tube leaving only the tubal segment attached to the uterus. After fimbriectomy, if the remaining tubal segment is long enough, the end of the tube can be opened and 'new' fimbria can be created by a procedure called a neofimbrioplasty. These \"new\" fimbria are not actually fimbria, but they are the cilia from the inside of the fallopian tube that have been exposed by everting the tubal lumen much like the petals of a rose are exposed once the rose blooms. These 'new' fimbria are much less effective at collecting (catching) an egg that has been released from the ovary than the real fimbria that had been removed during the fimbriectomy performed by the surgeon who did the original tubal ligation. During a neofimbrioplasty the tubal end is opened and folded back ( marsupialized ) so that the tubal end remains open and exposing the internal lining of the tube."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13946", "text": "Mini-laparotomy for tubal reversal surgery involves making a small, 2 to 3 inch incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the thin scar nearly invisible after it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding  the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery.  Operating with microsurgical instruments allows precision in  suturing of the tubal segments."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13947", "text": "In this Process, The area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multi layer, micro surgical technique is used to suture these segments together. After the tubes are repaired, a  chromopertubation  is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open. The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line. Failing to properly align the tubal segments, or damaging these delicate structures, can make the difference between a successful and an unsuccessful operation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13948", "text": "Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure ( laparoscopy ), using small, specially-designed instruments to repair and reconnect the fallopian tubes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13949", "text": "After general anesthesia has been administered, a 5mm (less than 3/8-inch) tube ( trocar ) is inserted inside the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The  laparoscope  (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than  1 \u2044 4 -inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13950", "text": "Once the connection ( anastomosis ) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13951", "text": "Patients are sent home the same day of surgery. The few stitches that are placed will be under the skin and will be absorbed by the body, without need for removal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13952", "text": "Patients should wait two months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of  ectopic pregnancy  (pregnancy inside the fallopian tube instead of in the uterus)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13953", "text": "When performed by a trained laparoscopic tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery \u2013 namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars. [ 4 ]  Laparoscopic surgery can be more expensive than an open surgery using a 2 to 3 inch incision because it requires additional surgical equipment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13954", "text": "Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13955", "text": "The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13956", "text": "Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13957", "text": "A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal.  Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13958", "text": "An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13959", "text": "Essure sterilization  was a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera ( hysteroscope ) through the  cervix  and into the uterine cavity. Two small, metallic coils are then inserted into each tubal  ostia  and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a  hysterosalpingogram  should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed. Essure was discontinued in 2018 due to a large number of reported  serious adverse events . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13960", "text": "Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation. During a tubouterine implantation procedure, the blocked portion of the fallopian tube containing the Essure sterilization device is surgically resected. The remaining portion of each healthy fallopian tube is then reintroduced into the newly created openings. This procedure can restore the natural function of the fallopian tube and allow for natural conception. The first case of successful outpatient tubouterine implantation to reverse Essure sterilization was published in 2012. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13961", "text": "Surgeons who published the first case report of successful Essure reversal subsequently published a larger cohort study of 70 patients who underwent outpatient tubouterine implantation to reverse Essure sterilization and 36% of patients reported pregnancy through natural conception. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13962", "text": "Dr. Charles Monteith, Medical Director of A Personal Choice Tubal Reversal Center, has collected non-published data on the risks of outpatient Essure reversal surgery. [ citation needed ]  Between 2009 and 2018, Monteith performed 469 outpatient tubouterine implantation procedures to reverse Essure sterilization. He documented intraoperative, postoperative, and pregnancy risks associated with his procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13963", "text": "Intraoperative risks observed were failure to complete the planned procedure (either Essure removal and tubal occlusion or Essure removal and bilateral tubouterine implantation) <1%, fracture of Essure devices during removal (approximately 10% risk with manual traction and < 1% with en bloc dissection), transfer to hospital <1%, referral to Emergency room or hospital within 24 hours of surgery <1%, bleeding requiring blood transfusion or hospitalization for operative complication 0%, anesthesia complication 0%, and death 0%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13964", "text": "Postoperative risks observed were major surgical site infection 0%, minor surgical site infection <1%, need for a second operation/procedure within 30 days <1%, and persistent symptoms requiring additional surgery < 10%."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13965", "text": "Pregnancy related risks were failure to become pregnant and possible tubal closure (estimated to be <60%) and ectopic pregnancy 5%.\nAll patients were advised to have a planned cesarean delivery before the onset of labor and the risk of uterine rupture was observed to be 4%. The majority of uterine ruptures occurred at 36/37 weeks gestation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13966", "text": "Factors associated with more difficult surgical procedures were patient obesity (BMI \u2265 30), presence of uterine leiomyomas, and uterine adhesive disease primarily from prior cesarean delivery. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13967", "text": "Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to  Essure  sterilization. The Adiana procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually closing. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13968", "text": "Adiana sterilization is similar to Essure sterilization and the Adiana procedure causes blockage of the proximal isthmic portion. Adiana sterilization can surgical reversed with tubouterine implantation. The first case of successful outpatient tubouterine implantation to reverse Adiana sterilization was published in 2011. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13969", "text": "Hologic Corporation discontinued the procedure in March 2012, resolving ongoing litigation with Conceptus concerning patent infringement claims. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13970", "text": "Tubal reversal success rates vary widely depending upon many factors. [ 12 ]  These include the women's ages, methods of tubal ligation that they had performed, experience of the surgeon and techniques for repairing the tubes, length of follow-up after reversal surgery among other factors. Overall, for those who are less than 35 years of age at the time of reversal, more than 70% achieve intrauterine pregnancy, with most pregnancies occurring within 18 months after surgery. [ 12 ]  Overall, for those who are 35 years of age or more, approximately 55% will achieve an intrauterine pregnancy. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13971", "text": "Tuboplasty  refers to a number of surgical operations that attempt to restore patency and functioning of the  fallopian tube (s) so that a pregnancy could be achieved. As tubal infertility is a common cause of  infertility , tuboplasties were commonly performed prior to the development of effective  in vitro fertilization  (IVF) or repair of any type of tube-like structure, including the  Eustachian tube  in the head and neck. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13972", "text": "Different types of tuboplasty can be distinguished: [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13973", "text": "Above surgical procedures are performed through either a  laparotomy  or  laparoscopy  approach.\nTechniques include the use of  microsurgery ,  laser ,  electrocautery ,  hydrodissection , mechanical  dissection , and use of surgical  stents , hoods, adhesions barriers, and more. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13974", "text": "Results depend on the underlying pathology and the skill of the surgeon.  Pregnancy rates  may range from 0\u201348% (Rock, 1985). [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13975", "text": "Ectopic pregnancy  is a complication  after a tuboplasty. It may require a  salpingectomy  (removal of a tube)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13976", "text": "Schroder is credited to have performed the first tuboplasty when he created an ampullary cuff and thus reopened an occluded tube in 1884. [ 2 ]  The first postoperative pregnancy was reported by Martin in 1891, however it aborted. For about a century tuboplastic procedures were the main approach to correct tubal infertility situations. With the development of IVF technology, IVF has increasingly supplanted tuboplasty as a treatment for tubal infertility. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13977", "text": "Myomectomy , sometimes also called  fibroidectomy , refers to the surgical removal of  uterine leiomyomas , also known as fibroids. In contrast to a  hysterectomy , the  uterus  remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13978", "text": "The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction.  The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13979", "text": "Treatment options for uterine fibroids include observation or medical therapy, such a  GnRH agonist ,  hysterectomy ,  uterine artery embolization , and  high-intensity focused ultrasound  ablation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13980", "text": "A myomectomy can be performed in a number of ways, depending on the location, size and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13981", "text": "Traditionally a myomectomy is performed via a  laparotomy  with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes six to eight weeks."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13982", "text": "Using the  laparoscopic approach  the uterus is visualized and its fibroids located and removed.\nStudies have suggested that laparoscopic myomectomy leads to lower  morbidity  rates and faster recovery than does laparotomic myomectomy. [ 2 ]  As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids.  A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10\u00a0cm. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13983", "text": "A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to  hysteroscopic  removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients with submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5\u00a0cm. [ 4 ]  However, larger lesions have also been treated by hysteroscopy. [ 5 ]  Recovery after hysteroscopic surgery is but a few days."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13984", "text": "Complications of the surgery include the possibility of significant blood loss leading to a  blood transfusion , the risk of  adhesion  or scar formation around the uterus or within its cavity, and the possible need later to deliver via  cesarean section . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13985", "text": "It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42\u201355% of patients undergoing a myomectomy. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13986", "text": "It is well known that myomectomy surgery is associated with a higher risk of  uterine rupture  in later pregnancy. [ 8 ]  Thus, women who have had myomectomy (with the exception of small submucosal myoma removal via hysteroscopy, or largely pedunculated myoma removal) should get  Cesarean  delivery to avoid the risk of uterine rupture that is commonly fatal to the fetus."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13987", "text": "To reduce bleeding during myomectomy, the use of  misoprostol  in the vagina and the injection of  vasopressin  into the uterine muscle are both effective. [ 9 ]  There is less evidence supporting the usefulness chemical dissection (such as with  mesna ), vaginal insertion of  dinoprostone , a  gelatin \u2013 thrombin  matrix,  tranexamic acid , infusion of  vitamin C , infiltration of a mixture of  bupivacaine  and  epinephrine  into the uterine muscles, or the use of a  fibrin  sealant patch. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13988", "text": "Leiomyomata tend to grow during pregnancy but only the large ones causing endometrial cavity distortion could interfere with the growing pregnancy directly. [ 10 ]  Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a  caesarean section  to gain access to the baby. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13989", "text": "For removing uterine fibroids, myomectomy and uterine artery embolisation seem to be equally effective in improving  quality of life , as measured 4-yours after surgery. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13990", "text": "Vaginal evisceration  is an  evisceration  of the  small intestine  that occurs through the  vagina , typically subsequent to  vaginal hysterectomy , and following  sexual intercourse  after the surgery. It is a  surgical emergency . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13991", "text": "Vaginal evisceration is typically obvious upon presentation, as intestine (typically  ileum ) can be seen protruding from the  introitus . Other symptoms include a sense of pressure in the pelvis and  vaginal bleeding . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13992", "text": "Complications of surgery can include injury to the  bladder ,  rectum , or  ureter , especially in cases where there has been tissue  necrosis . Surgeons typically perform intraoperative  cystoscopy  with dye to assess potential bladder or ureter injuries. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13993", "text": "Vaginal evisceration is a serious complication of  dehiscence  (where a surgical wound reopens after the procedure), which can be due to trauma. [ 1 ]  63% of reported cases of vaginal evisceration follow a  vaginal hysterectomy  (where the uterus removal surgery is performed entirely through the vaginal canal). [ 2 ]  Most instances of vaginal evisceration following a laparoscopic hysterectomy result from sexual intercourse among women approaching  menopause , and from the combination of heightened pressure within the abdomen and weakened vaginal muscles among those who have experienced menopause. [ 3 ] [ 4 ]  Other risk factors include regular  Valsalva maneuver , advanced age,  obesity ,  smoking ,  immunosuppressive therapy ,  vaginoplasty ,  anemia , poor surgical technique,  malnutrition , and postoperative/perioperative infection. [ 5 ] [ 6 ]  One case has been reported as of 2015 where placement of a  pessary  caused an evisceration. [ 5 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13994", "text": "Dehiscence is more common in laparoscopic hysterectomy than in open hysterectomy. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13995", "text": "When performing a vaginal hysterectomy, surgeons should aim to avoid damaging surrounding tissue or drying the vaginal cuff. Surgeons should take extra care to align the tissues, and include sufficient undamaged tissue. Instead of  single-layer figure-of-eight sutures , two-layer sutures can aid in preventing vaginal evisceration. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13996", "text": "Emergently, vaginal eviscerations are treated by keeping the exposed intestines moist and wrapped, while waiting for definitive surgical treatment. [ 1 ]  Vaginal evisceration is usually treated by  removing damaged tissue  along the edges of the  vaginal cuff , re-suturing the opening, and giving the patient broad-spectrum  antibiotic prophylaxis . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13997", "text": "Surgery can be conducted via a  laparotomy , though research from the 2010s shows that a transvaginal or laparoscopic approach can also be used safely and successfully if an infection has not developed. If left untreated, it can cause  peritonitis  or injury to the exposed bowel, including  strangulation  or  mesenteric tears .  Cellulitis ,  abscesses ,  hematomas , and other complications can appear at the same time as an evisceration. Abscesses and hematomas can be resolved after surgery with a  surgical drain . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13998", "text": "Post-surgical treatment includes continuation of antibiotics and, in some  postmenopausal  people, vaginal estrogen to speed recovery. After surgery, people with vaginal evisceration are advised to avoid intercourse until the surgical site is fully healed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_13999", "text": "Though it is a rare complication, as the popularity of laparoscopic hysterectomy has risen, the rate of vaginal evisceration has also risen. Vaginal cuff dehiscence occurs in 0.24\u20130.39% of cases; of these, vaginal evisceration occurs in 35%\u201367%. [ 1 ]  When all surgical procedures are considered, the rate of vaginal evisceration is 0.032\u20131.2%. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14000", "text": "The first report of vaginal evisceration in the medical literature was published in 1864 by Belgian obstetrician L\u00e9on Hyernaux; it occurred secondary to traumatic rupture of the vagina during an unsuccessful attempt at  forceps delivery . The patient, a 42-year-old woman, survived and made a complete recovery. [ 6 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14001", "text": "Vaginectomy  is a surgery to remove all or part of the  vagina . It is one form of treatment for individuals with  vaginal cancer  or  rectal cancer  that is used to remove tissue with cancerous cells. [ 1 ]  It can also be used in  gender-affirming surgery . Some people born with a vagina who  identify  as  trans men  or as  nonbinary  may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like ( metoidioplasty ), construct of a full-size penis ( phalloplasty ), or create a relatively smooth, featureless genital area ( genital nullification ). [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14002", "text": "If the  uterus  and  ovaries  are to remain intact, vaginectomy will leave a canal and opening suitable for draining  menstrual discharge . Otherwise, as in genital nullification, a  hysterectomy  must be performed to avoid the danger of retaining menstrual discharge within the body. [ 7 ]  In the latter case, thorough removal of vaginal lining is necessary to avoid continued secretion within the body. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14003", "text": "In addition to vaginectomy in humans, there have been instances of vaginectomy in other animals to treat vaginal cancer. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14004", "text": "Total or partial vaginectomy along with other procedures like laser vaporization can be used in the treatment of  vaginal intraepithelial neoplasia . These procedures remove the cancerous tissue and provide tissue samples to help identify underlying/invasive cancer while maintaining structure and function of the vagina. This surgery along with radiation therapy used to be the optimal treatment for high-grade vaginal intraepithelial neoplasia. However, high rates of recurrence and severe side effects such as vaginal shortening, bleeding and sepsis have narrowed its uses. A partial upper vaginectomy is still the treatment of choice for certain cases of vaginal intraepithelial neoplasia as it has success rates ranging from 69 to 88%. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14005", "text": "A vaginectomy is often necessary to remove all cancerous tissue associated with  rectal cancer . Depending on the extent of rectal cancer, a total or partial vaginectomy may be indicated to improve long-term survival. Following the surgery and removal of rectal tumors, vaginal and rectal reconstructive surgery can improve healing and may help with self-image and sexual function. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14006", "text": "Although there has not been a consensus on the standard treatment for penis construction in transgender men, a vaginectomy is a vital step in many of the various techniques. Depending on the reconstructive surgeon and which method is used, the basic outline of the procedure involves taking skin from an area of the body like the forearm or abdomen followed by glans sculpture, vaginectomy, urethral anastomosis,  scrotoplasty  and finished with a  penile prosthesis  implantation. The ideal outcome of this procedure, as described by the  World Professional Association for Transgender Health  (WPATH), is to provide an aesthetically appealing penis that enables sexual intercourse and sensitivity. Complications do arise from this procedure which may include tissue death, urethral complications, and infection. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14007", "text": "Radial Forearm Free Flap (RAFFF) is one of the techniques considered for  total phallic construction . [ 12 ]  Developed and performed in 1984, RAFFF consists of three stages and a complete vaginectomy is the second stage of RAFFF. The preferred technique is ablation vaginectomy with simultaneous scrotoplasty, which will close the  labia majora  along the midline. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14008", "text": "An anterior pelvic exenteration with total vaginectomy (AETV) is a procedure that removes the  urinary system  (kidneys, ureters, bladder, urethra) as well as the gynecologic system ( ovaries ,  fallopian tubes ,  uterus ,  cervix ,  vagina ) and is used as treatment of recurrent gynecologic cancers. A total  pelvic exenteration  can also be used as treatment which involves the removal of the  rectum  in addition to the urinary and gynecologic systems. The decision between the two procedures depends on extent of the cancer. Potential benefits of an AETV over a total pelvic exenteration include reduced risk of intestinal injury. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14009", "text": "Neovaginectomy has been performed to remove the  neovagina  following  vaginoplasty , for instance in  transgender women  who experience neovaginal complications or those who choose to  detransition . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14010", "text": "The safety of vaginectomy can depend on individual medical conditions and the subsequent risks they pose. For example, for people with  diabetes  mellitus, potential contraindications for vaginectomy include wound-healing difficulty; for people who prefer to not undergo  hormone therapy , potential contraindications include gonad removal ( oophorectomy  or  orchiectomy ). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14011", "text": "Many people who undergo vaginectomy do so for sexual health and intimacy. However, risks of vaginectomy include post-operative sensory issues that range from lack of sensation to excessive sensation, such as  hypersensitivity  or even  pain . [ 16 ]  To address this, skin grafting is often done with vaginectomy to allow recovery of sexual function. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14012", "text": "Other risks may involve consequences of the procedure itself. For example, possible injuries include  rectal  injury (due to the proximity of the structures), development of a  fistula  (an abnormal connection between two body parts), or, for people who have phalloplasty done in conjunction with vaginectomy, irritation or even erosion of the skin of the  phallus . Some of these locations may be suture sites; irritation of these sites may increase likelihood of infection. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14013", "text": "There are pre- and post-operative steps that can be taken to minimize complications from vaginectomy. For example, other procedures that are often performed in conjunction with vaginectomy, such as metoidioplasty and phallourethroplasty, can be performed in two stages to increase the likelihood of a favorable cosmetic outcome. [ 19 ]  Also, waiting for a period of time after completing a procedure, usually a minimum of 4 months, ensures that the person undergoing the surgery is clear of infections or risk thereof. Thus, procedures towards the end of the gender-affirming process, such as  penile prosthesis placement , are usually done separately. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14014", "text": "For people with vaginal cancer, vaginectomy can be done partially, instead of radically, depending on the individual person's need as determined by the tumor's size, location, and stage. For example, some people had simple  hysterectomy  (a procedure that removes a uterus) and then discovered  cervical cancer . At this point, upper vaginectomy - along with other suggested procedures such as  lymphadenectomy  (a procedure that removes lymph nodes) - may be suggested to people who would prefer to keep  ovarian  function intact. [ 20 ]  This is an option depending on the invasiveness and severity of the disease and is specifically for individuals with stage I cancer in the upper vagina. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14015", "text": "Vaginectomy procedures are described by the amount of vaginal tissue removed from an individual which is dependent on the reason for surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14016", "text": "For vaginectomy as a treatment to cancer, tissue is removed in response to the extent of the cancer. [ 7 ]  A partial vaginectomy removes only the outer most layers of tissue and is performed if the abnormal cells are only found at the skin level. For example, individuals with rectal cancer that has spread to vaginal tissue may undergo a partial vaginectomy in which the posterior wall of the vagina near the anus is removed. A surgeon will make an incision on the abdomen in order to reach the vagina for removal. The operation to remove vaginal tissue will typically happen with at the same time as a  colostomy  and a  abdominoperineal resection  in which a portion of the colon is rediverted into a colostomy bag and the rectum is removed. A partial vaginectomy leaves much of the muscles in the vagina intact and can be followed by a vaginal reconstruction surgery. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14017", "text": "If more invasive cancer is found, a more complete vaginectomy is performed to remove all cancerous tumors and cells. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14018", "text": "In vaginectomy for gender-affirming surgeries, the tissue from the vaginal wall is removed while outer labial flaps are sometimes left in place for other reconstructive surgeries. [ 24 ]  The procedure gives people who were assigned female sex at birth but do not identify as female, such as transsexual men and transmasculine or otherwise nonbinary individuals, genitalia that aids in reducing gender dysphoria and affirming their gender identity through their physical appearance. [ 3 ] [ 19 ]  Counseling is often provided to people considering gender-affirming surgeries prior to procedures in order to limit regret later down the line. [ 25 ]  In the context of gender-affirming surgery, procedures are categorized as either colpocleisis or total vaginectomy. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14019", "text": "Colpocleisis only removes a layer of epithelium or the outer most tissue in the vaginal canal. The walls of the vaginal canal are then sutured shut, but a small channel and the perineum area between the vagina and anus is typically left open to allow for discharge to be emitted from the body. A colpoclesis procedure is sometimes preceded by an oophorectomy and or a hysterectomy to remove the ovaries and uterus which reduces risks of complications from leaving these structures intact and reduces the amount of vaginal discharge. If the ovaries and uterus are left intact there are greater levels of vaginal discharge remain that can contribute to further gender dysphoria in individuals. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14020", "text": "Total vaginectomy is becoming the more common form of vaginectomy in gender-affirming surgeries. It involves removal of the full thickness of vaginal wall tissue and can be approached vaginally, as in a transvaginal or transperineal vaginectomy, or abdominally through the area near the stomach, as in an abdominal vaginectomy. In addition to a greater degree of tissue removal, total vaginectomy also involves a more complete closure of the space in the vaginal canal. In comparison to colpocleisis, it is more often preceded by separate oophorectomy and hysterectomy procedures and proceeded by a separate gender reconstruction surgery such as to create a neophallus. [ 6 ]   Total vaginectomy surgery is sometimes performed using  robotic assistance  which allows for increased speed and precision for a procedure with less blood loss and a quicker recovery time. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14021", "text": "Individuals should expect to experience some pain in the first week after the operation. The average hospital stay after operation was a week and all individuals are discharged with a  catheter , which is removed after 2\u20133 weeks. [ 8 ]  At discharge, individuals learn how to take care of the incisions and  must limit their physical activity for the initial 2\u20133 weeks. Swelling of the abdominal area or abdominal pain are signs of complications during recovery. Some common complications that occur are urethral  fistulas  and  strictures  in individuals who undergo vaginectomy and phallic reconstruction for gender-affirming surgeries. This is due to poor blood supply and improper width of the new urethra. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14022", "text": "Vaginal surgeries have been around throughout medical history. Even before the invention of  modern surgical  techniques such as  anesthesia  and sterile tools, there have been many reports of vaginal surgery to treat problems such as  prolapse , vaginal  fistula , and  poor bladder control . For example, the first documented vaginal hysterectomy was performed in 1521 during the Italian Renaissance. [ 28 ]  Surgical techniques and medical knowledge developed slowly over time until the invention of anesthesia and antisepsis allowed for the age of modern surgery in the mid-nineteenth century. Since then, many techniques and instruments were developed specifically for vaginal surgery like the standardization of  sutures  in 1937 which greatly improved survival rates by lowering risk of infection. [ 29 ]  Noble Sproat Heaney developed the \"Heaney Stitch\" in 1940 to standardize the technique for vaginal  hysterectomy . The first documented case of radical vaginal surgery was in February 2003 where a person underwent a radical hysterectomy with vaginectomy and reconstruction. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14023", "text": "Vaginectomies are also performed outside of the human species. Similarly to humans, animals may also undergo vaginectomies to treat cancer of the vagina.  Domesticated animals and pets such as dogs, cats, and horses are more likely to receive a vaginectomy because of its complicated procedure. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14024", "text": "Total and partial vaginectomies are not commonly done on dogs as they are complex and are not considered first line therapy however, if other procedures do not work a vaginectomy can be performed on a dog. The most common reasons for a dog to get a vaginectomy include cancer and chronic infection of the vagina. Tumors on the vagina and vulva of the dog accounts for 2.5%-3% of cancers affecting dogs and vaginectomies are one of the treatments to remove and cure the dog. [ 31 ]  Possible complications from the surgery include loss of bladder control, swelling, and improper skin healing. [ 9 ]  However, loss of bladder control was fixed spontaneously within 60 days of the operation and the dogs survived at least 100 days with no disease. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14025", "text": "Warren operation  is a surgery performed to correct  anal incontinence . It is done by  disrupting the anterior segment of the  anal sphincter ,  perineal body  and  rectovaginal septum . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14026", "text": "This technique was first described by Warren in 1875, and got subsequently named after him. It was also called 'Warren flap method' and 'Warren apron technique'. The technique was further modified by Farrar for high lacerations of the rectovaginal septum. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14027", "text": "Unlike other surgeries for anal incontinence, a preliminary  colostomy  is not necessary for Warren operation. The surgery is planned in such a way that it takes place 2\u20133 days after the cessation of menstrual flow, such that there is ample time for the surgical wound to heal until the next menses. Succinylsulfathiazole is the recommended intestinal antiseptic given two days before the surgery since it keeps the stool soft in the post-operative period. Enema is given early on the day of surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14028", "text": "The surgery is performed in jack-knife position, making the vagina and anorectum more accessible. Spinal anaesthesia is usually preferred. After exposing the cervix and posterior wall of the rectum using a Sim's speculum, a Kocher clamp is placed in the posterior vaginal wall just below the cervix. The incision diverges outwards to the anal margin, encloses the anterior third of anal orifice and forms a triangular flap. The mucosal flap is then freed by sharply dissecting into the rectal orifice. Chromic catgut sutures are now places from within outward, including levator muscle fascia, perineal body, Colle's fascia, bulbocavernosus muscles and levator ani. The sutures are pulled up under tension and tied. The retracted ends of external sphincter muscle are now brought closer to the anterior midline of the anus. The ends of the sphincter are sutured together to perineal body. Two sutures are placed in the rectal fascia to lessen the tension on the sphincter ends. The vaginal mucosa is then closed with continuous suture. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14029", "text": "Cryosurgery  (with  cryo  from the  Ancient Greek   \u03ba\u03c1\u03cd\u03bf   ' icy cold ' ) is the use of extreme cold in  surgery  to destroy abnormal or diseased tissue; [ 1 ]  thus, it is the surgical application of  cryoablation .\nCryosurgery has been historically used to treat a number of diseases and disorders, especially  a variety of benign and malignant skin conditions . [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14030", "text": "Warts ,  moles ,  skin tags ,  solar keratoses ,   molluscum , [ 4 ]   Morton's neuroma [ 5 ]  and small  skin cancers  are candidates for cryosurgical treatment. Several  internal disorders  are also treated with cryosurgery, including  liver cancer ,  prostate cancer , lung cancer, oral cancers,  cervical  disorders and, more commonly in the past,  hemorrhoids . Soft tissue conditions such as  plantar fasciitis [ 6 ]  (jogger's heel) and  fibroma  (benign excrescence of connective tissue) can be treated with cryosurgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14031", "text": "Cryosurgery works by taking advantage of the destructive force of freezing temperatures on  cells . When their  temperature  sinks beyond a certain level  ice crystals  begin forming inside the cells and, because of their lower  density , eventually tear apart those cells. Further harm to malignant growth will result once the  blood vessels  supplying the affected tissue begin to freeze."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14032", "text": "Cryosurgery is used to treat a variety of benign skin  lesions  including: [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14033", "text": "Cryosurgery may also be used to treat low risk skin cancers such as  basal cell carcinoma  and  squamous cell carcinoma  but a biopsy should be obtained first to confirm the diagnosis, determine the depth of invasion and characterize other high risk histologic features. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14034", "text": "A common method of freezing lesions is by using  liquid nitrogen  as the cryogen. The liquid nitrogen may be applied to lesions using a variety of methods, such as dipping a cotton or synthetic material tipped applicator in liquid nitrogen and then directly applying the cryogen onto the lesion. [ 3 ]  The liquid nitrogen can also be sprayed onto the lesion using a spray canister. The spray canister may utilize a variety of nozzles for different spray patterns. [ 3 ]  A cryoprobe, which is a metal applicator that has been cooled using liquid nitrogen, can also be directly applied onto lesions. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14035", "text": "Carbon dioxide is also available as a spray and is used to treat a variety of benign spots. Less frequently, doctors use  carbon dioxide  \"snow\" formed into a cylinder or mixed with  acetone  to form a slush that is applied directly to the treated tissue. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14036", "text": "Recent advances in technology have allowed for the use of  argon  gas to drive ice formation using a principle known as the  Joule-Thomson effect . This gives physicians excellent control of the ice and minimizes complications using ultra-thin 17  gauge  cryoneedles. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14037", "text": "A mixture of  dimethyl ether  and  propane  is used in some \" freeze spray \" preparations such as  Dr. Scholl's  Freeze Away. The mixture is stored in an  aerosol spray  type container at room temperature and drops to \u221241\u00a0\u00b0C (\u221242\u00a0\u00b0F) when dispensed. The mixture is often dispensed into a straw with a cotton-tipped swab. Similar products may use  tetrafluoroethane  or other substances. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14038", "text": "A number of medical supply companies have developed  cryogen  delivery systems for cryosurgery. Most are based on the use of liquid nitrogen, although some employ the use of proprietary mixtures of gases that combine to form the cryogen."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14039", "text": "Cryosurgery is also used to treat internal and external tumors as well as tumors in the bone. To cure internal tumors, a hollow instrument called a cryoprobe is used, which is placed in contact with the tumor. Liquid  nitrogen  or  argon  gas is passed through the cryoprobe.  Ultrasound  or  MRI  is used to guide the cryoprobe and monitor the freezing of the cells. This helps in limiting damage to adjacent healthy tissues. A ball of ice crystals forms around the probe which results in freezing of nearby cells. When it is required to deliver gas to various parts of the tumor, more than one probe is used. After cryosurgery, the frozen tissue is either naturally absorbed by the body in the case of internal tumors, or it dissolves and forms a scab for external tumors. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14040", "text": "Cryosurgery is a  minimally invasive  procedure, and is often preferred to other types of surgery because of its safety, ease of use, minimal pain and scarring as well as low cost; [ 3 ]  however, as with any medical treatment, there are risks involved, primarily that of damage to nearby healthy tissue. Damage to  nerve tissue  is of particular concern but is rare. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14041", "text": "Cryosurgery cannot be used on lesions that would subsequently require biopsy as the technique destroys tissue and precludes the use of  histopathology . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14042", "text": "More common complications of cryosurgery include blistering and edema which are transient. [ 3 ]  Cryosurgery may cause complications due to damage of underlying structures. Destruction of the  basement membrane  may cause scarring and destruction of hair follicles can cause  alopecia  or hair loss. [ 3 ]  Occasionally,  hypopigmentation  may occur in the area of skin treated with cryosurgery, however, this complication is usually transient and often resolves as  melanocytes  migrate and repigment the area over several months. [ 8 ]  Bleeding can also occur, which can be delayed or immediate, due to damage of underlying arteries and arterioles. [ 3 ]  Tendon rupture and cartillage necrosis can occur, particularly if cryosurgery is done over bony prominences. [ 3 ]  These complications can be avoided or minimized if freeze times of less than 30 seconds are used during cryosurgery. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14043", "text": "Patients undergoing cryosurgery usually experience redness and minor-to-moderate localized pain, which most of the time can be alleviated sufficiently by oral administration of mild  analgesics  such as  ibuprofen ,  codeine  or  acetaminophen  (paracetamol).  Blisters  may form as a result of cryosurgery, but these usually scab over and peel away within a few days."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14044", "text": "Electrodesiccation and curettage  ( EDC ,  ED & C , or  ED+C ) is a  medical procedure  commonly performed  by  dermatologists ,  surgeons  and  general practitioners  for the treatment of  basal cell cancers  and  squamous cell cancers  of the skin. [ 1 ]  It provides  desiccation ,  coagulation / cauterization , and  curettage  to remove lesions from the  skin ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14045", "text": "A round dull instrument ( curette ) of varying sizes (1\u00a0mm to 6\u00a0mm) is used to scrape off the cancer down to the dermis. [ 2 ] [ 3 ] [ 4 ]   The scraping is then paused while an  electrosurgical  device like a  hyfrecator  is used next.  Electrocoagulation (electrodesiccation) is performed over the raw surgical ulcer to denature a layer of the dermis and the curette is used again over the surgical ulcer to remove denatured dermis down to living tissue.  In the case of skin cancers, the cautery and electrodesiccation is usually performed three times, or until the surgeon is confident that reasonable  margins  have been achieved. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14046", "text": "The cure rate is highly user dependent. [ 5 ]  The more aggressive the surgeon is at performing EDC, the higher the cure rate. Like standard excision, the wider the  surgical margin , the higher the cure rate. Cure rate for small cancer is higher than cure rate for larger cancers. Cure rate for nodular  basal cell cancer  is higher than for infiltrative basal cell cancer. Essentially, all the prognostic factors that apply to  Mohs surgery  and standard surgical excision will also apply to EDC. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14047", "text": "The method is quick and easy to perform under local anesthetic.  Used correctly, it can allow for adequate to good cosmetic result on small tumor in certain area.  No sutures are used, so a follow-up visit might not be necessary.  Minimal expense is required.  If recurrence occur, rapid diagnosis is possible as the roots are exposed to the surface, and not buried by surgical closure methods (flaps, etc.). [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14048", "text": "As the  surgical margin  is not confirmed by  pathology , the free surgical margin can not be confirmed by an objective  pathology  report.  The recurrence rate for EDC is considered by many ( National Comprehensive Cancer Network ) to be too high for use on many facial regions, and on recurrent  skin cancer . [ 6 ] [ 7 ]    As a surgical ulcer is created and is larger than the original tumor, healing time may be delayed and subsequent scarring obvious. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14049", "text": "Mohs surgery , developed in 1938 by a  general surgeon ,  Frederic E. Mohs ,  is microscopically controlled surgery used to treat both common and rare types of  skin cancer . During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery is the gold standard method for obtaining complete margin control during removal of a skin cancer (complete circumferential peripheral and deep margin assessment -  CCPDMA ) using  frozen section   histology . [ 1 ]  CCPDMA or Mohs surgery allows for the removal of a skin cancer with very narrow  surgical margin  and a high cure rate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14050", "text": "The cure rate with Mohs surgery cited by most studies is between 97% and 99.8% for primary  basal-cell carcinoma , the most common type of skin cancer. [ 2 ] :\u200a13\u200a  Mohs procedure is also used for  squamous cell carcinoma , but with a lower cure rate. Recurrent basal-cell cancer has a lower cure rate with Mohs surgery, more in the range of 94%. [ 2 ] :\u200a7\u200a  It has been used in the removal of  melanoma -in-situ (cure rate 77% to 98% depending on surgeon), and certain types of  melanoma  (cure rate 52%). [ 2 ] :\u200a4\u200a [ 3 ] :\u200a211\u201320"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14051", "text": "Other indications for Mohs surgery include  dermatofibrosarcoma protuberans ,  keratoacanthoma , spindle cell tumors,  sebaceous carcinomas ,  microcystic adnexal carcinoma ,  merkel cell carcinoma ,  Paget's disease of the breast ,  atypical fibroxanthoma , and  leiomyosarcoma . [ 3 ] :\u200a193\u2013203\u200a [ 4 ]  Because the Mohs procedure is micrographically controlled, it provides precise removal of the cancerous tissue, while healthy tissue is spared. Mohs surgery can also be more cost effective than other surgical methods, when considering the cost of surgical removal and separate histopathological analysis. However, Mohs surgery should be reserved for the treatment of skin cancers in anatomic areas where tissue preservation is of utmost importance (face, neck, hands, lower legs, feet, genitals). [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14052", "text": "Mohs surgery is most commonly used on the head and neck, where its use conserves normal tissue and decreases the risk of recurrence.  For these reasons, it is also considered for skin cancers on hands, feet, ankles, shins, nipples, or genitals. [ 4 ] [ 5 ]   Mohs surgery should not be used on the trunk or extremities for uncomplicated, non-melanoma skin cancer of less than one centimeter in size. [ 4 ] [ 5 ]  On these parts of the body, the risks exceed the benefits of the procedure. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14053", "text": "In 2012, the American Academy of Dermatology published appropriate use criteria (AUC) on Mohs micrographic surgery in collaboration with the following organizations: American College of Mohs Surgery; American Society for Mohs Surgery; and the American Society for Dermatologic Surgery Association. More than 75 physicians contributed to the development of the Mohs surgery AUC, which were published in the Journal of the American Academy of Dermatology and  Dermatologic Surgery . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14054", "text": "The Australasian College of Dermatologists, in concert with the Australian Mohs Surgery Committee, has also developed evidence based guidelines for Mohs Surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14055", "text": "The Mohs procedure is a pathology sectioning method that allows for the complete examination of the surgical margin. It is different from the standard  bread loafing  technique of sectioning, where random samples of the surgical margin are examined. [ 6 ] :\u200a112\u20133\u200a [ 2 ] :\u200a3\u20134\u200a [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14056", "text": "Mohs surgery is performed in four steps:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14057", "text": "The procedure is usually performed in a physician's office under local anesthetic. A small scalpel is utilized to cut around the visible tumor. Unlike a normal surgical excision, a Mohs surgery cut is performed at a beveling between 10 and 45 degrees to allow visibility of all skin layers during pathological diagnosis. [ 8 ]  A very small surgical margin is utilized, usually with 1 to 1.5\u00a0mm of \"free margin\" or uninvolved skin. The amount of free margin removed is much less than the usual 4 to 6\u00a0mm required for the standard excision of  skin cancers . [ 9 ]  After each surgical removal of tissue, the specimen is processed, cut on the  cryostat  and placed on slides, stained with H&E and then read by the Mohs surgeon/pathologist who examines the sections for cancerous cells. If cancer is found, its location is marked on the map (drawing of the tissue) and the surgeon removes the indicated cancerous tissue from the patient. This procedure is repeated until no further cancer is found. [ 10 ]   The vast majority of cases are then reconstructed by the Mohs surgeon. Some surgeons utilize 100 micrometres between each section, and some utilize 200 micrometres between the first two sections, and 100 micrometres between subsequent sections (10 crank of tissue set at 6 to 10 micrometre is roughly equal to 100 micrometres if one allows for physical compression due to the blade)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14058", "text": "The trend in skin surgery over the last 10 years has been to continue  anticoagulants  while performing skin surgery. Most cutaneous bleeding can be controlled with  electrocautery , especially bipolar forceps. The benefit gained by ease of  hemostasis  is weighed against the risk of stopping anticoagulants; and it is generally preferred to continue anticoagulants. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14059", "text": "Few specialists dispute the cure rate for Mohs, especially pathologists familiar with the procedure. [ 6 ] :\u200a116\u200a  Extensive studies performed by Mohs involving thousands of patients with both fixed tissue and fresh tissue cases have been reported in the literature. [ 12 ]  Other surgeons repeated the studies with also thousands of cases, with nearly the same results. [ 2 ] [ page\u00a0needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14060", "text": "Clinical 5 year cure rates with Mohs surgery:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14061", "text": "These are only a small number of cases reported by Mohs, and numerous other articles by other authors have shown tremendous cure rates for primary basal-cell carcinoma. Studies by Smeet, et al. showing a Mohs cure rate of about 95%, and another study in Sweden showing Mohs cure rate of about 94%. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14062", "text": "Some of Mohs' data revealed a cure rate as low as 96%, but these were often very large tumors, previously treated by other modalities. Some authors claim that their 5-year cure rate for primary basal-cell cancer exceeded 99% while other noted more conservative cure rate of 97%. The quoted cure rate for Mohs surgery on previously treated basal-cell cancer is about 94%. [ 2 ] :\u200a6\u20137\u200a  Reasons for variations in the cure rate include the following."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14063", "text": "Mohs surgery is not suitable for all  skin cancers . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14064", "text": "Mohs micrographic surgery is the most reliable form of margin control; utilising a unique frozen section histology processing technique \u2013 allowing for the complete examination of 100% of the surgical margin. The method is unique in that it is a simple way to handle soft, hard-to-cut tissue. It is superior to serial bread loafing at a 0.1\u00a0mm interval for improved false negative error rate, requiring less time, tissue handling, and fewer glass slides mounted."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14065", "text": "The clinical quotes for cure rate of Mohs surgery are from 97% to 99.8% after 5 years for newly diagnosed basal-cell cancer (BCC), decreasing to 94% or less for recurrent basal-cell cancer. Radiation oncologists quote cure rates from 90 to 95% for BCCs less than 1 or 2\u00a0cm, and 85 to 90% for BCCs larger than 1 or 2\u00a0cm. The  Surgical excision  cure rate varies from 90 to 95% for wide margins (4 to 6\u00a0mm) and small tumors, to as low as 70% for narrow margins and large tumors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14066", "text": "Some commentators argue that skin cancer surgery, including Mohs surgery, is overutilised as rates of skin cancer surgery are increasing worldwide. It is unclear if this relates to higher rates of skin cancer, increased vigilance in diagnosis, and increased availability of the procedure, or patient and doctor preferences. The incidence of Mohs surgery increased significantly over the decade between 2004 and 2014. In a sample of 100 Mohs surgeries, the total cost ranged from US$474 to US$7,594, with the higher costs for hospital-based complex procedures. In Australia, the direct out of pocket cost to patients may vary from $0 to $4000. When the non-Mohs surgery is performed by multiple doctors including pathologists the costs may be increased further. This is especially true when the cancer is incompletely excised and requires repeat surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14067", "text": "Originally, Mohs used a chemical paste (an  escharotic  agent) to cauterize and kill the tissue. It was made of  zinc chloride  and  bloodroot  (the root of the plant  Sanguinaria canadensis , which contains the alkaloid  sanguinarine ). The original ingredients were 40.0 g  Stibnite , 10.0 g  Sanguinaria canadensis , and 34.5 ml of saturated zinc chloride solution. [ 12 ] :\u200a3\u20136"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14068", "text": "This paste is similar to  black salve  or \"Hoxsey's paste\" (see  Hoxsey Therapy ), a fraudulent  patent medicine , but its usage is different. Hoxsey used the paste for long periods, a harmful practice that was rapidly discredited. [ 16 ]  Mohs left the paste on the wound only overnight, and the following day, the cancer and surrounding skin would be anesthetized and the cancer removed. The specimen was then excised, and the tissue examined under the microscope. If cancer remained, more paste was applied, and the patient would return the following day. Later, local anesthetic and frozen section histopathology applied to fresh tissue allowed the procedure to be performed the same day, with less tissue destruction, and similar cure rate. [ 2 ] :\u200a3\u20134"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14069", "text": "Photorejuvenation  is a skin treatment that uses  lasers ,  intense pulsed light , or  photodynamic therapy  to treat  skin conditions  and remove effects of  photoaging  such as  wrinkles , spots, and textures.  The process induces controlled  wounds  to the skin. This prompts the skin to heal itself, by creating new cells. This process\u2014to a certain extent\u2014removes the signs of photoaging. [ 1 ]  The technique was invented by Thomas L Roberts, III using  CO 2  lasers  in the 1990s. [ 2 ] [ 3 ]  Observed complications have included  scarring ,  hyperpigmentation ,  acne , and  herpes ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14070", "text": "Skin rejuvenation can be effected through various modalities, including thermal, chemical, mechanical, injection, and light. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14071", "text": "Laser resurfacing is a  laser surgery  technique that disassociates  molecular bonds . It is used for the treatment of wrinkles,  solar lentigenes ,  sun damage ,  scarring  ( acne scars  and surgical scars),  stretch marks ,  actinic keratosis , and  telangiectasias .  It can be combined with  liposuction  to help tighten and smooth over the new contours after removal of excess fat. Resurfacing can be ablative, which vaporizes tissue and creates wounds, or non-ablative which keeps the skin intact."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14072", "text": "Laser resurfacing is usually done with a 2940\u00a0nm  Er:YAG laser  or a 10,600\u00a0nm CO 2  laser.  Complete resurfacing was first done with a CO 2  laser. Both erbium and CO 2  are used to treat deep  rhytides ,  sun damage  and  age spots . Through the heating of the deep  dermis ,  fibroblasts  are stimulated to form new  collagen  and  elastin  helping to bring increased turgor and thickness to the skin. A variety of modes have been developed including Nd:Yag lasers and a plasma device. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14073", "text": "CO 2  resurfacing has been shown to have an increased risk of  hypopigmentation  and scarring than erbium lasers. This is due to the high degree of coagulation and thus heat production that occurs as a nature of the CO 2  wavelength."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14074", "text": "Fractional laser  photothermolysis  (FP) is a form of laser-based skin resurfacing, with several devices on the market, such as  Fraxel . A fractional laser delivers laser light to the skin. Hundreds or thousands of laser pinpoints may be used per square inch, leaving healthy skin between the  ablated  areas."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14075", "text": "Complications observed in a study of 961 treatments included  acne  and  herpes  outbreaks. [ 6 ]  There have been anecdotal negative accounts of bad scarring and  hyperpigmentation . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14076", "text": "Erbium and CO 2  fractional systems have a better safety profile than lasers of the past. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14077", "text": "Intense Pulsed Light  (IPL) uses flashlamps (and not lasers) to produce high intensity light over broad visible and infrared wavelengths with filters that select the desired range.  IPL is used to treat dyschromia, rosacea, melasma, acne, photodamage, vascular and pigmented lesions, and rhytides. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14078", "text": "One study conducted by a group of four researchers from the  Weill Cornell Medical College of Cornell University  in 2004 found IPL to be a \"non-invasive, non-ablative method for rejuvenating photoaged skin with minimal adverse events\". [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14079", "text": "Other studies, however, have noted that exposing cells to direct heat can cause  DNA  damage\u2014not only in those cells, but also in surrounding tissue that was not directly exposed, and concluded treatments can cause microscopic thermal injuries, and that further research is warranted. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14080", "text": "IPL is effective for pigmentation and telangiectasias, but has lesser results for wrinkles. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14081", "text": "Photodynamic therapy  (PDT) uses photosensitive compounds that are activated by light.  It is used to treat  actinic keratoses , acne, photoaging, and skin cancer."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14082", "text": "Skin biopsy  is a  biopsy  technique in which a  skin lesion  is removed to be sent to a  pathologist  to render a microscopic  diagnosis .  It is usually done under  local anesthetic  in a physician's office, and results are often available in 4 to 10 days.  It is commonly performed by  dermatologists .  Skin biopsies are also done by family physicians, internists, surgeons, and other specialties.  However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose  Mohs surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14083", "text": "There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy.  The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion.  Like most biopsies,  patient consent  and  anesthesia  (usually  lidocaine  injected into the skin) are prerequisites. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14084", "text": "A shave biopsy is done with either a small  scalpel  blade or a curved razor blade.  The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while others have great difficulty securing the devices.  Ideally, the razor will shave only a small fragment of protruding tumor and leave the skin relatively flat after the procedure.   Hemostasis  is obtained using light  electrocautery ,  Monsel's solution , or  aluminum chloride .  This is the ideal method of diagnosis for  basal cell cancer .  It can be used to diagnose  squamous cell carcinoma  and  melanoma-in-situ , however, the doctor's understanding of the growth of these last two cancers should be considered before one uses the shave method.  The punch or incisional method is better for the latter two cancers as a false negative is less likely to occur (i.e. calling a squamous cell cancer an  actinic keratosis  or  keratinous  debris).  Hemostasis for the shave technique can be difficult if one relies on electrocautery alone.  A small \"shave\" biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone.  Pressure dressing or chemical  astringent  can help in hemostasis in patients taking  anticoagulants . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14085", "text": "A punch biopsy is done with a circular blade ranging in size from 1\u00a0mm to 8\u00a0mm. The blade, which is attached to a pencil-like handle, is rotated down through the epidermis and dermis, and into the  subcutaneous fat , producing a cylindrical core of tissue. [ 1 ]  An incision made with a punch biopsy is easily closed with one or two  sutures .\nSome punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel.  The 1\u00a0mm and 1.5\u00a0mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method.  Minimal bleeding is noted with the 1\u00a0mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. The disadvantage of the 1\u00a0mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5\u00a0mm biopsy is preferred in most cases.  The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4\u00a0mm punch. [ citation needed ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14086", "text": "In an incisional biopsy a cut is made through the entire  dermis  down to the subcutaneous fat.  A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel.  Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin).  Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutaneous tissue can be obtained than a punch biopsy.  Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound.  Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization.  Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14087", "text": "An excisional biopsy is essentially the same as incisional biopsy, except the entire lesion or tumor is included.  This is the ideal method of diagnosis of small melanomas (when performed as an excision).  Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically.  This  excisional  biopsy is often done with a narrow  surgical margin  to make sure the deepest thickness of the melanoma is given before prognosis is decided.  However, as many  melanoma -in-situs are large and on the face, a physician will often choose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy.  An initial small punch biopsy of a melanoma might say \"severe cellular atypia, recommend wider excision\".  At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a \" false positive \" clinical diagnosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14088", "text": "In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to  microtomy . Dashed lines here mean that either side could be used. The entire specimen may be sliced and submitted if the risk of malignancy is high. [ 3 ]  Otherwise the rest may be saved in  fixation  in case microscopy indicates further sampling. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14089", "text": "A curettage biopsy can be done on the surface of tumors or on small epidermal lesions with minimal to no  topical anesthetic  using a round  curette  blade.  Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted.  The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells.   Liquid nitrogen  or  cryotherapy  can be used as a topical anesthetic, however, freezing artifacts can severely hamper the diagnosis of malignant skin cancers. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14090", "text": "Needle aspiration biopsy  is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe.  It is a method used to diagnose tumor deep in the skin or  lymph nodes  under the skin.  The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis.  A fine needle aspirate can be done with simply a small  bore  needle and a small syringe (1 cc) that can generate rapid changes in suction pressure.  Fine needle aspirate can be used to distinguish a cystic lesion from a  lipoma .  Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide.  Many centers have dedicated teams used in the harvest of fine needle aspirate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14091", "text": "A saucerization biopsy is also known as \"scoop\", \"scallop\", or \"shave\" excisional biopsy, [ 4 ]  or \"shave\" excision.  A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion. [ 5 ] [ 6 ] [ 7 ]  An author published the result of this method and advocated it as better than standard excision and less time-consuming.  The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy.  This saves the added time for hemostasis, instruments, and suture cost.  The great disadvantage, seen years later, is the numerous scallop scars, and the appearance of a lesion called a \" recurrent melanocytic nevus \"; many \"shave\" excisions do not penetrate the dermis or subcutaneous fat enough to include the entire melanocytic lesion, and residual melanocytes regrow into the scar.  The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevi may result in the dermatoscopic appearance of a melanoma. [ 8 ] [ 9 ] [ 10 ] [ 11 ]  When a second physician later examines the patient, he or she has no choice but to recommend re-excision of the scar.  If one does not have access to the original pathology report, it is impossible to distinguish a recurring nevus from a severely  dysplastic  nevus or melanoma.  As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of them showing residual pigmentation.  The second issue with the shave excision is fat  herniation ,  iatrogenic   anetoderma , and  hypertrophic  scarring.  As the deep shave excision either completely removes the full thickness of the dermis or greatly diminishes the dermal thickness, subcutaneous fat can herniate outward or pucker the skin out in an unattractive way.  In areas prone to friction, this can result in pain, itching, or hypertrophic scarring. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14092", "text": "A  pathology  report is highly dependent on the quality of the biopsy that is submitted. It is not unusual to miss the diagnosis of a skin tumor or a skin biopsy due to a poorly performed or inappropriately performed skin biopsy. The clinical information provided to the pathologist will also affect the final diagnosis. An example would be a rapidly growing dome shaped tumor of the sun exposed skin. Despite doing a large wedge incision, a pathologist might call the biopsy keratin debris with characteristics of actinic keratosis. But provided with an accurate clinical information, he/she might consider the diagnosis of a well differentiated  squamous cell carcinoma  or  keratoacanthoma . It is not infrequent for two, three or more biopsies to be performed by different doctors for the same skin condition, before the correct diagnosis is made on the final biopsy. The method, depth, and quality of clinical data will all affect the yield of a skin biopsy. For this reason, doctors specializing in skin diseases are invaluable in the diagnosis of skin cancers and difficult skin diseases. Specific stains (PAS, DIF, etc.), and certain type of sectioning (vertical and horizontal) are often requested by an astute physician to make sure that the pathologist will have all the necessary information to make a good histological diagnosis. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14093", "text": "Pediatric  surgery  is a  subspecialty  of  surgery  involving the surgery of  fetuses ,  infants ,  children ,  adolescents , and  young adults . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14094", "text": "Pediatric surgery arose in the middle of the 1879 century [ clarification needed ]  as the surgical care of  birth defects  required novel techniques and methods, and became more commonly based at children's hospitals. One of the sites of this innovation was the  Children's Hospital of Philadelphia . Beginning in the 1940s under the surgical leadership of  C. Everett Koop , newer techniques for endotracheal  anesthesia  of infants allowed surgical repair of previously untreatable birth defects. By the late 1970s, the infant death rate from several major congenital malformation  syndromes  had been reduced to near zero."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14095", "text": "Subspecialties of pediatric surgery itself include:  neonatal  surgery and  fetal surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14096", "text": "Other areas of surgery also have pediatric specialties of their own that require further training during the residencies and in a fellowship: pediatric cardiothoracic (surgery on the child's heart and/or lungs, including heart and/or lung transplantation), pediatric nephrological surgery (surgery on the child's kidneys and ureters, including renal, or kidney, transplantation), pediatric neurosurgery (surgery on the child's brain, central nervous system, spinal cord, and peripheral nerves), pediatric urological surgery (surgery on the child's urinary bladder and other structures below the kidney necessary for ejaculation), pediatric emergency surgery, surgery involving fetuses or embryos (overlapping with obstetric/gynecological surgery, neonatology, and  maternal-fetal medicine ), surgery involving adolescents or young adults, pediatric hepatological (liver) and gastrointestinal (stomach and intestines) surgery (including liver and intestinal transplantation in children), pediatric orthopedic surgery (muscle and bone surgery in children), pediatric plastic and reconstructive surgery (such as for burns, or for congenital defects like cleft palate not involving the major organs), and pediatric oncological (childhood cancer) surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14097", "text": "Common pediatric diseases that may require pediatric surgery include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14098", "text": "The  American Pediatric Surgical Association  is an American professional organization dedicated to  pediatric surgery . It was established in 1970 and had over 1,200 members as of 2015. Its official journal is the  Journal of Pediatric Surgery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14099", "text": "The  Annals of Pediatric Surgery  is a quarterly  peer-reviewed   medical journal  covering research on  pediatric   surgery . It was established in October 2005 and is the official journal of the  Egyptian Pediatric Surgical Association . [ 1 ]  The  editor-in-chief  is  Essam A. Elhalaby  Tanta University )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14100", "text": "The journal is abstracted and indexed in  Scopus . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14101", "text": "This article about a  pediatrics   journal  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14102", "text": "The  British Association of Paediatric Surgeons  (BAPS) is a registered charity that aims to advance the study and practice of  paediatric surgery ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14103", "text": "The organisation was founded in the UK 1953 and included oversees members. [ 1 ]  The idea for the group came up when a group of four British surgeons -  Denis Browne , Robert Zachary, David Waterston and Peter Rickham - attended a meeting of the  American Academy of Pediatrics  the year before. At the time, there were only a few dozen known paediatric surgeons across the world, so they were all invited to join BAPS. [ 2 ]  Its first meeting was held in 1954. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14104", "text": "Aims of the Society have been listed as to the advance the study, practice, and research in child surgery, to promote the teaching of surgery in children, both under-graduate and post-graduate, and advise on the training of paediatric surgeons, advice on matters concerning the children surgical services in the British Isles, and to the promote friendship with overseas paediatric surgeons. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14105", "text": "BAPS is one of several national paediatric surgical organisations affiliated with the  Journal of Pediatric Surgery . [ 4 ]  The organisation awards the  Denis Browne Gold Medal  to recognize outstanding achievement in the field. [ 5 ]  The award is named for  Sir Denis Browne , the first president of the association. The first award, given in 1968, went to surgeon  Robert Edward Gross . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14106", "text": "The  Journal of Pediatric Surgery  is a monthly  peer-reviewed   medical journal  covering  pediatric surgery . It was established in 1966 and is published by  Elsevier . It is the official journal of the Section on Surgery of the  American Academy of Pediatrics , the  British Association of Paediatric Surgeons , the  American Pediatric Surgical Association , the  Canadian Association of Paediatric Surgeons , and the  Pacific Association of Pediatric Surgeons . The  editor-in-chief  is G.W. Holcomb III, MD ( University of Missouri at Kansas City School of Medicine ). According to the  Journal Citation Reports , the journal has a 2015  impact factor  of 1.733. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14107", "text": "Pan-African Paediatric Surgical Association (PAPSA)  is an organisation established in 1994 to promote the practice of  paediatric surgery  in  Africa , improvement of research, interchange of ideas and sharing of knowledge and expertise for the benefit of the children of Africa. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14108", "text": "As of 2024 [update] , there have been 16 annual Paediatric Surgical Conferences [ 2 ]  under PAPSA."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14109", "text": "Professor Emmanuel A. Ameh is the President of PAPSA and Professor Milind Chitnis is the general secretary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14110", "text": "During the 38th  British Association of Paediatric Surgeons  (BAPS) conference in  Budapest  in 1991, the concept of an Association representing Africa was proposed with 9 paediatric surgeons from Africa who attended the meeting. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14111", "text": "As the idea needed international recognition and support, the  World Federation of Associations of Pediatric Surgeons  (WOFAPS) gave  support during the development phases of the as yet to be established Association. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14112", "text": "World Federation of Associations of Pediatric Surgeons (WOFAPS)  is an organisation established on 15 October 1974 in  Brazil [ 1 ]  to promote the ethical study of pediatric research and to promote  Pediatric Surgery  as a distinct specialty of general surgery. The Kyoto Declaration of Pediatric Surgery, written in 2001, established the mission of the Federation to focus on the development and education of surgeons serving children, in all parts of the world. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14113", "text": "Several surgeons and associations supported the endorsement of the proposal for the \"International Union of Pediatric Surgeons\" proposed by Denys Pellerin in  Paris  in 1963. But the progress was slow. On 15 October 1974, WOFAPS was founded in  S\u00e3o Paulo , Brazil, during a Pediatric Surgery Congress with representatives from 43 Countries under the Presidency of Prof. Virgilio Carvalho Pinto and Secretary General Prof. Jose Pinus. Harvey Beardmore from  Canada  was elected the first President of the WOFAPS. [ 3 ]  while Prof Jose \"Pepe\" Boix Ochoa was again re-elected as General Secretary (a post he would hold for 35 years!!)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14114", "text": "Until 1983, only 23 associations belonged to the WOFAPS, but the organization has grown to include over 100 member countries today. It is recognized and participates in International Associations of Pediatric Surgery as a member as well as the International Pediatric Association, as well as other organizations such as  UNICEF ,  UNESCO  and  WHO . This has been due to the past leadership and efforts of the members. [ 4 ]  Notable associations that have joined the WOFAPS include  American Pediatric Surgical Association , EUPSA, the  British Association of Paediatric Surgeons  and the  Deutsche Gesellschaft f\u00fcr Kinderchirurgie \u00a0[ de ] , as well as more geographically distributed associations, for example the  Pan-African Paediatric Surgical Association ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14115", "text": "The WOFAPS is a representation of Pediatric Surgical Associations and it does not represent any political ideas nor does it make any racial or religious distinction. The WOFAPS is governed by its Constitution and its official office is in  Bern , Switzerland. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14116", "text": "The  WOFAPS Foundation  is a subsidiary of WOFAPS that offers  Scholarships  to International Young Pediatric Surgeons [ 6 ]  from developing countries who have demonstrated strong interests in teaching and research. The WOFAPS foundation is headed by Prof. Prem Puri, [ 7 ]  previous president of WOFAPS and Lifetime Achievement Award recipient in 2013. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14117", "text": "The board is currently led by Prof Alp Numanoglu (South Africa) acting as president, Prof Shilpa Sharma (India) as general secretary and Prof Udo Rolle (Germany) is the president elect for the current term (2022-2025). The WOFAPS executive board consists of 15 Pediatric Surgeons voting members representing all continents and one non voting member as Prof Mahmoud Elfiky (Egypt)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14118", "text": "The WOFAPS World Congress is held every three years. However, the WOFAPS joins a regional meeting with another pediatric surgical association every year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14119", "text": "Cardiac surgery , or  cardiovascular surgery , is  surgery  on the  heart  or  great vessels  performed by cardiac  surgeons . It is often used to treat complications of  ischemic heart disease  (for example, with  coronary artery bypass grafting ); to correct  congenital heart disease ; or to treat  valvular heart disease  from various causes, including  endocarditis ,  rheumatic heart disease , [ 1 ]  and  atherosclerosis . [ 2 ]  It also includes  heart transplantation . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14120", "text": "The earliest operations on the  pericardium  (the sac that surrounds the heart) took place in the 19th century and were performed by  Francisco Romero  (1801) in the city of  Almer\u00eda  (Spain), [ 4 ]   Dominique Jean Larrey  (1810),  Henry Dalton  (1891), and  Daniel Hale Williams  (1893). [ 5 ]  The first surgery on the heart itself was performed by  Axel Cappelen  on 4 September 1895 at  Rikshospitalet  in Kristiania, now  Oslo . Cappelen  ligated  a bleeding  coronary artery  in a 24-year-old man who had been stabbed in the left  axilla  and was in deep  shock  upon arrival. Access was through a left  thoracotomy . The patient awoke and seemed fine for 24 hours but became ill with a  fever  and died three days after the surgery from  mediastinitis . [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14121", "text": "Surgery on the  great vessels  (e.g.,  aortic coarctation  repair,  Blalock\u2013Thomas\u2013Taussig shunt  creation, closure of  patent ductus arteriosus ) became common after the turn of the century. However, operations on the  heart valves  were unknown until, in 1925,  Henry Souttar  operated successfully on a young woman with  mitral valve stenosis . He made an opening in the appendage of the left  atrium  and inserted a finger in order to palpate and explore the damaged  mitral valve . The patient survived for several years, [ 8 ]  but Souttar's colleagues considered the procedure unjustified, and he could not continue. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14122", "text": "Alfred Blalock ,  Helen Taussig , and  Vivien Thomas  performed the first successful palliative  pediatric  cardiac operation at  Johns Hopkins Hospital  on 29 November 1944, in a one-year-old girl with Tetralogy of Fallot. [ 11 ]   Their work on patient  Eileen Saxon  was dramatically portrayed by  HBO  in the 2004  television film   Something The Lord Made  as the birth of modern cardiac surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14123", "text": "Cardiac surgery changed significantly after  World War II . In 1947,  Thomas Sellors  of  Middlesex Hospital  in London operated on a  Tetralogy of Fallot  patient with  pulmonary stenosis  and successfully divided the stenosed  pulmonary valve . In 1948,  Russell Brock , probably unaware of Sellors's work, [ 12 ]  used a specially designed dilator in three cases of pulmonary stenosis. Later that year, he designed a punch to resect a stenosed  infundibulum , which is often associated with Tetralogy of Fallot. Many thousands of these \"blind\" operations were performed until the introduction of  cardiopulmonary bypass  made direct surgery on valves possible. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14124", "text": "Also in 1948, four surgeons carried out successful operations for mitral valve stenosis resulting from  rheumatic fever .  Horace Smithy  of Charlotte used a  valvulotome  to remove a portion of a patient's mitral valve, [ 13 ]  while three other doctors\u2014 Charles Bailey  of  Hahnemann University Hospital  in Philadelphia;  Dwight Harken  in Boston; and Russell Brock of  Guy's Hospital  in London\u2014adopted Souttar's method. All four men began their work independently of one another within a period of a few months. This time, Souttar's technique was widely adopted, with some modifications. [ 9 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14125", "text": "The first successful intracardiac correction of a  congenital heart defect  using  hypothermia  was performed by lead surgeon Dr.  F. John Lewis [ 14 ] [ 15 ]  (Dr.  C. Walton Lillehei  assisted) at the  University of Minnesota  on 2 September 1952. In 1953,  Alexander Alexandrovich Vishnevsky  conducted the first cardiac surgery under  local anesthesia . In 1956, Dr. John Carter Callaghan performed the first documented open-heart surgery in Canada. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14126", "text": "Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. \"Open\" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14127", "text": "Dr.  Wilfred G. Bigelow  of the  University of Toronto  found that procedures involving opening the patient's heart could be performed better in a bloodless and motionless environment. Therefore, during such surgery, the heart is temporarily stopped, and the patient is placed on  cardiopulmonary bypass , meaning a machine pumps their blood and oxygen. Because the machine cannot function the same way as the heart, surgeons try to minimize the time a patient spends on it. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14128", "text": "Cardiopulmonary bypass was developed after surgeons realized the limitations of  hypothermia  in cardiac surgery: Complex intracardiac repairs take time, and the patient needs blood flow to the body (particularly to the brain), as well as heart and lung function. In July 1952,  Forest Dodrill  was the first to use a mechanical pump in a human to bypass the left side of the heart whilst allowing the patient's lungs to oxygenate the blood, in order to operate on the mitral valve. [ 19 ]   In 1953, Dr.  John Heysham Gibbon  of  Jefferson Medical School  in Philadelphia reported the first successful use of  extracorporeal circulation  by means of an  oxygenator , but he abandoned the method after subsequent failures. [ 20 ]  In 1954, Dr. Lillehei performed a series of successful operations with the controlled cross-circulation technique, in which the patient's mother or father was used as a \"heart-lung machine\". [ 21 ]  Dr.  John W. Kirklin  at the  Mayo Clinic  was the first to use a Gibbon-type pump-oxygenator. [ 20 ] [ 22 ] Russell M. Nelson  became the first surgeon to perform an open heart surgery in  Utah  in 1955. [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14129", "text": "Nazih Zuhdi performed the first total intentional hemodilution open-heart surgery on Terry Gene Nix, age 7, on 25 February 1960 at Mercy Hospital in Oklahoma City. The operation was a success; however, Nix died three years later. [ 24 ]  In March 1961, Zuhdi, Carey, and Greer performed open-heart surgery on a child, aged  3 + 1 \u2044 2 , using the total intentional hemodilution machine."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14130", "text": "In the early 1990s, surgeons began to perform  off-pump coronary artery bypass , done without cardiopulmonary bypass. In these operations, the heart continues beating during surgery, but is stabilized to provide an almost still work area in which to connect a conduit vessel that bypasses a blockage. The conduit vessel that is often used is the saphenous vein. This vein is harvested using a technique known as  endoscopic vein harvesting  (EVH)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14131", "text": "In 1945, the Soviet pathologist Nikolai Sinitsyn successfully transplanted a heart from one frog to another frog and from one dog to another dog."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14132", "text": "Norman Shumway  is widely regarded as the father of human  heart transplantation , although the world's first adult heart transplant was performed by a  South African  cardiac surgeon,  Christiaan Barnard , using techniques developed by Shumway and  Richard Lower . [ 25 ]  Barnard performed the first transplant on  Louis Washkansky  on 3 December 1967 at  Groote Schuur Hospital  in  Cape Town . [ 25 ] [ 26 ]   Adrian Kantrowitz  performed the first pediatric heart transplant on 6 December 1967 at Maimonides Hospital (now  Maimonides Medical Center ) in Brooklyn, New York, barely three days later. [ 25 ]  Shumway performed the first adult heart transplant in the United States on 6 January 1968 at  Stanford University Hospital . [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14133", "text": "Coronary artery bypass grafting  (CABG), also called revascularization, is a common surgical procedure to create an alternative path to deliver blood supply to the heart and body, with the goal of preventing  clot formation . This can be done in many ways, and the  arteries  used can be taken from several areas of the body. [ 27 ]  Arteries are typically harvested from the chest, arm, or wrist and then attached to a portion of the coronary artery, relieving pressure and limiting  clotting factors  in that area of the heart. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14134", "text": "The procedure is typically performed because of  coronary artery disease  (CAD), in which a plaque-like substance builds up in the coronary artery, the main pathway carrying oxygen-rich blood to the heart. This can cause a blockage and/or a rupture, which can lead to a  heart attack . [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14135", "text": "As an alternative to open-heart surgery, which involves a five- to eight-inch incision in the  chest wall , a surgeon may perform an  endoscopic  procedure by making very small incisions through which a camera and specialized tools are inserted. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14136", "text": "In  robot-assisted heart surgery , a machine controlled by a cardiac surgeon is used to perform a procedure. The main advantage to this is the size of the incision required: three small port holes instead of an incision big enough for the surgeon's hands. [ 30 ]  The use of robotics in heart surgery continues to be evaluated, but early research has shown it to be a safe alternative to traditional techniques. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14137", "text": "As with any surgical procedure, cardiac surgery requires postoperative precautions to avoid complications. Incision care is needed to avoid infection and minimize  scarring .  Swelling  and  loss of appetite  are common. [ 32 ] [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14138", "text": "Recovery from open-heart surgery begins with about 48 hours in an  intensive care unit , where  heart rate ,  blood pressure , and oxygen levels are closely monitored.  Chest tubes  are inserted to drain blood around the heart and lungs. After discharge from the hospital,  compression socks  may be recommended in order to regulate blood flow. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14139", "text": "The advancement of cardiac surgery and cardiopulmonary bypass techniques has greatly reduced the mortality rates of these procedures. For instance, repairs of congenital heart defects are currently estimated to have 4\u20136% mortality rates. [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14140", "text": "A major concern with cardiac surgery is neurological damage.  Stroke  occurs in 2\u20133% of all people undergoing cardiac surgery, and the rate is higher in patients with other risk factors for stroke. [ 37 ]  A more subtle complication attributed to cardiopulmonary bypass is  postperfusion syndrome , sometimes called \"pumphead\". The  neurocognitive  symptoms of postperfusion syndrome were initially thought to be permanent, [ 38 ]  but turned out to be transient, with no permanent neurological impairment. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14141", "text": "In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the  EuroSCORE . It takes a number of health factors from a patient and, using precalculated  logistic regression  coefficients, attempts to quantify the probability that they will survive to discharge. Within the  United Kingdom , the EuroSCORE was used to give a breakdown of all  cardiothoracic surgery  centres and to indicate whether the units and their individuals surgeons performed within an acceptable range. The results are available on the  Care Quality Commission  website. [ 40 ] [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14142", "text": "Another important source of complications are the neuropsychological and psychopathologic changes following open-heart surgery. One example is  Skumin syndrome \u00a0[ fr ] , described by  Victor Skumin  in 1978, which is a \"cardioprosthetic psychopathological syndrome\" [ 42 ]  associated with  mechanical heart valve implants  and characterized by irrational fear,  anxiety ,  depression ,  sleep disorder , and  weakness . [ 43 ] [ 44 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14143", "text": "Pharmacological and  non-pharmacological  prevention approaches may reduce the risk of atrial fibrillation after an operation and reduce the length of hospital stays, however there is no evidence that this improves mortality. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14144", "text": "Preoperative  physical therapy  may reduce postoperative pulmonary complications, such as  pneumonia  and  atelectasis , in patients undergoing elective cardiac surgery and may decrease the length of hospital stay by more than three days on average. [ 46 ]  There is evidence that quitting  smoking  at least four weeks before surgery may reduce the risk of postoperative complications. [ 47 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14145", "text": "Beta-blocking medication is sometimes prescribed during cardiac surgery. There is some low certainty evidence that this perioperative blockade of beta-adrenergic receptors may reduce the incidence of  atrial fibrillation  and  ventricular arrhythmias  in patients undergoing cardiac surgery. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14146", "text": "Aortic valve repair  or  aortic valve reconstruction  is the reconstruction of both form and function of a dysfunctional  aortic valve . Most frequently it is used for the treatment of  aortic regurgitation . [ 1 ]  It can also become necessary for the treatment of  aortic aneurysm , less frequently for congenital  aortic stenosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14147", "text": "An aortic valve repair will realistically be possible in the absence of calcification or shrinking (retraction) of the aortic valve. Thus, congenital aortic stenosis may be treated by aortic valve repair. [ 2 ]  In acquired aortic stenosis valve replacement will be the only realistic option. In most instances, aortic valve repair will be performed for aortic regurgitation (insufficiency). [ 3 ]  Aortic valve repair may also be performed in the treatment of aortic aneurysm or aortic dissection if either aneurysm or dissection involves the aorta close to the valve. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14148", "text": "Indications for aortic valve repair:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14149", "text": "The goal of the operation is the improvement of life expectancy and treatment of heart failure as the consequence of dysfunction of the aortic valve. The goal may also be to avert complications of the aorta (rupture or dissection) in the treatment of aneurysm. Repair is a more recent alternative to replacement; in many instances replacement will be the only realistic option because of severe destruction of the valve. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14150", "text": "While replacement of the aortic valve is a safe and reproducible procedure it may still be associated with the long-term occurrence of so-called valve-related complications. The probability of these complications depends on the age of the patient and the type of operation. [ 7 ]  Typical complications are blood clot formation on the valve or dislodgment of thrombus (embolism); bleeding complications are commonly a consequence of \"blood-thinning\" medication needed to prevent clots ( anticoagulation ). Biologic/tissue replacement valves have a tendency to degenerate, and there is also an increased risk of infections of valve prosthesis (prosthetic valve  endocarditis )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14151", "text": "Compared to the results of valve replacement there will be a minimal tendency towards clot formation after aortic valve repair, and anticoagulation is commonly not necessary, thus minimizing the possibility of bleeding complications. The likelihood of infection of the repaired aortic valve is much lower compared to what is seen after aortic valve replacement. [ 8 ]  A repair procedure may not last forever, but in many instances the durability of an aortic valve repair will markedly exceed that of a biological prosthesis. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14152", "text": "The details of the aortic valve repair procedure depend on the possibility of congenital malformation of the valve, the type and degree of secondary deformation, and the existence of an aortic aneurysm. The goal of the procedure is the restoration of a normal form of the aortic valve, which will then lead to near-normal function and good durability of the repair. A  transesophageal echocardiogram  during the operation and prior to the repair will be important to define the exact deformation of the aortic valve and thus the mechanism of regurgitation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14153", "text": "In order to best accommodate the complex geometry of the aortic valve, these procedures are generally performed through open-heart surgery. Minimally invasive procedures limit the ability to precisely judge the form of the aortic valve and will lead to a higher uncertainty regarding function and durability of aortic valve repair. As for aortic valve replacement, the heart-lung machine is usually connected to the patient via aorta and right  atrium . The heart is arrested through  cardioplegia , and the form of the aortic valve is carefully analyzed. Currently documented predicted values for certain aspects of the form of the aortic valve. [ 9 ]  are available. Using these parameters and a good transesophageal echocardiogram the precise mechanism of regurgitation can be determined in most cases. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14154", "text": "Congenital aortic valve stenosis can be treated by aortic valve repair if there is no relevant calcification. [ 2 ]  In this scenario the aortic valve will almost always be unicuspid and the valve configuration must be altered as part of the procedure in order to improve opening of the valve. Because of the unicuspid form of the valve the repair concept will be similar to that of the regurgitant unicuspid valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14155", "text": "The traditional treatment of congenital aortic stenosis is balloon valvuloplasty or surgical commissurotomy. Both approaches will frequently not eliminate the narrowing of the valve; in addition, they will lead to a variable degree of aortic valve regurgitation which places an additional burden on the heart. In both interventions some of the valve tissue is opened; the peculiar form aspects of unicuspid aortic valves are not taken into consideration. [ 11 ]  The repair approach differs from commissurotomy mainly in that not only valve tissue is divided to improve opening, but also at least an additional commissure (suspension point of the valve) is created for the aortic valve. Thus, a bicuspid valve is created which results in near-normal function of the aortic valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14156", "text": "The most reproducible concept is the creation of a bicuspid aortic valve with two normal  commissures  and two  cusps . Tissue of the aortic valve is removed or detached from the aorta in places where it is clearly abnormal. The location of a second commissure of normal height is determined; using a patch or the original cusp tissue the cusps are then sutured to the aortic wall in order to create cusps of sufficient tissue and adequate form reaching the new commissure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14157", "text": "In tricuspid aortic valves the anatomy is principally normal; if there is an aneurysm of the ascending aorta the principles of aortic aneurysm will have to be applied. Without aneurysm, the cause of regurgitation is frequently stretching of one or two of the valve components (cusps). Such stretching can be combined with the presence of congenital tissue fenestrations. Additionally, enlargement of the aortic annulus can contribute to valve dysfunction. Shrinkage of the cusps is less frequent in industrial countries; this is currently not well treatable by repair. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14158", "text": "In surgical treatment, the extent of cusp stretching is exactly determined and then corrected by sutures. Enlargement of the annulus requires its size reduction and stabilization by an annuloplasty. In the case of annular dilatation, the annulus has to be reduced; currently, the largest experience exists with a strong suture that is placed around the annulus and tied to the desired size. Stretching is corrected by plicating sutures to the point that all cusps have a normal configuration. At the end of the operation, the cusp margins should be at an identical height. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14159", "text": "In bicuspid aortic valve anatomy, there is congenital fusion of two cusps. This fused cusp is exposed to higher than normal stress and will stretch over time as a consequence. This results in aortic valve regurgitation. Annular enlargement is very frequent in this context, and it increases the tendency to leak. As a result of long-standing dysfunction also the normal cusp may undergo deformation and stretch. In half of the affected individuals there is also an aneurysm of the ascending aorta which has to be treated appropriately. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14160", "text": "Since the bicuspid anatomy commonly has an almost normal valve function (unless deformed) it is left bicuspid; the repair procedure simply corrects the secondary deformations that led to regurgitation.\nSimilar to tricuspid aortic valves, the cusps must be measured to rule out shrinkage. The annulus is commonly enlarged, it must be reduced and stabilized by an annuloplasty. [ 12 ]  Tissue redundancy through stretching is corrected by sutures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14161", "text": "The unicuspid aortic valve may not only result in relevant stenosis (narrowing), it may also primarily lead to regurgitation. In a proportion of the affected individuals, an aneurysm of the ascending aorta may be present which may need treatment as well. The repair procedure will change the configuration of the valve by creating at least one additional commissure. Commonly the unicuspid valve is changed into a bicuspid configuration; the resulting valve function will be close to normal. Cusp tissue is resected where it is grossly abnormal. Using patch tissue, the cusps are enlarged so they reach the second (new) commissure. If the annulus is enlarged it must be reduced and stabilized. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14162", "text": "Aortic regurgitation in a quadricuspid valve is commonly caused by the additional (4th) commissure, which holds back cusp tissue and keeps it from closing adequately. Currently, the most reliable concept for repair of a quadricuspid valve seems to be its conversion into a tricuspid valve. [ 13 ]  In some cases a bicuspid configuration may be appropriate. In order to achieve this cusp, tissue is detached from the aorta and the valve is then brought into adequate form."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14163", "text": "The enlargement of the  ascending aorta  may lead to aortic valve regurgitation because the outward tension on the cusps prevents their adequate closure. Regurgitation may also (in part) be due to congenital malformation of the aortic valve or concomitant stretching of a tricuspid aortic valve. Life expectancy may be limited by severe aortic regurgitation. The aneurysm of the ascending aorta may also become so large that it can develop rupture or dissection as life-threatening complications. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14164", "text": "The operation must address the aneurysm by replacing the enlarged part of the aorta. Since the aortic valve is very sensitive in its form and function to any changes of the aortic dimensions, the operation will in most cases also have to address the valve, i.e. apply the principles of aortic valve repair. This principle applies to tricuspid valves as well as bicuspid or unicuspid aortic valves. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14165", "text": "The goal of the operation is to eliminate the aneurysm and to preserve or repair the aortic valve. The operation may include replacement of the aortic root. Replacement of the root is usually not necessary if its diameter is less than 40 to 45\u00a0mm. In those instances replacement of the ascending aorta is sufficient. If root diameter exceeds 45\u00a0mm it will have to be replaced in many instances. There are mainly 2 operative techniques currently used, [ 16 ] [ 17 ]  and both lead to similar results. [ 18 ] [ 19 ]  With both techniques the aortic valve must be carefully assessed after replacement of the root; repair of any aortic valve abnormalities is necessary in order to achieve good and durable valve function. [ 19 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14166", "text": "There are two options: tubular ascending aortic replacement or replacement of the aortic root."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14167", "text": "Tubular ascending aortic replacement"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14168", "text": "The aorta is divided above the aortic valve and root. The avascular graft is then sutured to the aortic root. The form of the aortic valve may have been changed by this maneuver, it thus has to be carefully checked. Often stretching of a cusp becomes apparent at that point, and this will have to correct by sutures (see 3.3.1, 3.3.2)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14169", "text": "Replacement of the aortic root"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14170", "text": "After the heart has been arrested, the enlarged aorta is removed close to the insertion line of the aortic valve cusps. The origins of the coronary arteries must be detached from the aorta. For the procedure, according to  Magdi Yacoub [ 16 ]  a graft is tailored to create 3 tongues that replace the aneurysmatic aortic wall in the root. The graft is then sutured to the cusp insertion lines. Some surgeons combine this procedure with an  annuloplasty . [ 12 ] [ 21 ]  For the procedure according to  Tirone David , [ 17 ]  the aortic valve is mobilized even further from the surrounding tissues. The avascular graft is then positioned around the valve, and the valve is fixed inside the graft with sutures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14171", "text": "With both techniques, the form of the aortic valve must be carefully assessed after completed root replacement. [ 22 ]  In most instances some cusp stretching will be found which would result in prolapse and relevant regurgitation afterward if uncorrected. Thus an aortic valve repair procedure will frequently be necessary according to the principles of tricuspid or bicuspid aortic valve repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14172", "text": "Contrary to valve replacement with mechanical prostheses inhibition of the blood clotting system ( anticoagulation ) is not necessary after aortic valve repair. Blood-thinning may only be necessary if atrial fibrillation occurs or persists in order to prevent blood clot formation in the left atrium. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14173", "text": "Following aortic valve replacement, prophylactic administration of  antibiotics  is recommended for interventions involving mouth and throat (e.g. dental surgery). [ 4 ]  It is unclear whether this is also necessary after aortic valve repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14174", "text": "First attempts at aortic  valve repair  were undertaken even before heart valve prostheses were developed. In 1912 the French surgeon  Theodore Tuffier  widened a stenotic (narrowed) aortic valve. The colleagues of  Dwight Harken  reported in 1958 on their experience with aortic valve repair for aortic regurgitation by narrowing the  annulus  of the  aortic valve . [ 23 ]  In those times, both surgeons and cardiologists had minimal information on the exact nature and severity of dysfunction of the aortic valve. This changed with the development of  echocardiography  by  Inge Edler  and  Carl Hellmuth Hertz  in the early 1950s. Nonetheless, the development of heart valve prostheses made replacement the standard approach because of its reproducibility. The first ball-cage valve was implanted in 1961 by the American surgeons   Albert Starr  and  Lowell Edwards , [ 24 ]  and in the next decades many mechanical and biological  prostheses  were developed and used. The positive results with the repair of the  mitral valve  stimulated surgeons in the 1980s and 1990s to develop surgical techniques that could be applied for the different causes of aortic regurgitation. Stepwise improvements were introduced in the subsequent years; today many regurgitant aortic valves can be treated by repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14175", "text": "Aortic valve replacement  is a  cardiac surgery  procedure whereby a failing  aortic valve  is  replaced  with an  artificial heart valve . The aortic valve may need to be replaced because of  aortic regurgitation  (back flow), or if the valve is narrowed by  stenosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14176", "text": "Current methods for aortic valve replacement include  open-heart surgery ,  minimally invasive cardiac surgery (MICS) ,  surgical aortic valve replacement  (SAVR) and  percutaneous or transcatheter aortic valve replacement  (TAVR; also PAVR, PAVI, TAVI)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14177", "text": "A cardiologist can evaluate whether a  heart valve repair  or  valve replacement  would be of benefit. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14178", "text": "During the late 1940s and early 1950s, the first surgical approaches towards treating aortic valve stenosis had limited success. The first attempts were valvotomies, (i.e. cutting the valve while the heart is pumping). A ball valve prosthesis placed on the  descending thoracic aorta  (heterotopically) was developed by Hufnagel, Harvey and others to address aortic stenosis, but had disastrous complications. Later, with the innovation of cardiopulmonary bypass, the ball valve prosthesis was placed orthotopically (i.e. in same place as the original aortic valve). This first generation of prosthetic valves was durable, but needed intense anti-coagulation, and cardiac hemodynamics were compromised. During the mid-1950s, a single-leaflet prosthesis was developed by Bahnson  et al . In early 1960, Ross and  Barratt-Boyes  used allografts. Tissue prosthetic valves were introduced in 1965 by Binet in Paris, but they degenerated quickly because the tissue was insufficiently preserved. Carpentier solved this problem by introducing glutaraldehyde-preserved stent-mounted porcine valves. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14179", "text": "The aortic valve is one of the two  semilunar valves  of the heart with three cusps. It separates the heart from the  aorta . Each cusp is attached to the aortic wall creating a sinus called an  aortic sinus . The origins of the two  coronary arteries  are sited in two aortic sinuses. Cusps also known as leaflets are separated by  commissures . The posterior leaflet is in continuation with the anterior leaflet of the mitral valve (the tissue is called the aorto-mitral curtain). [ 4 ]  The aortic valve is opened during systole, the driving force for it to open is the difference in pressure between the contracting left ventricle of the heart and the aorta. During cardiac diastole (when the heart chamber gets bigger) the aortic valve closes. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14180", "text": "Aortic stenosis most commonly is the result of calcification of the cusps. Other reasons for stenosis are the  bicuspid valve  (some patients have only two cusps at the aortic valve instead of the usual three) and rheumatic aortic stenosis (now rare in the West). Obstruction at the level of the aortic valve causes increased pressure within the heart's left ventricle. This can lead to hypertrophy and ultimately dysfunction of the heart. While x-ray and ECG might indicate aortic stenosis, echocardiography is the diagnostic procedure of choice. US findings also help in grading the severity of the disease. In cases of symptomatic severe aortic stenosis, AVR is warranted. In cases of asymptomatic but severe aortic stenosis, more factors should be taken into consideration. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14181", "text": "Aortic regurgitation, on the other hand, has many causes: degeneration of the cusps, endocarditis, bicuspid aortic valve, aortic root dilatation, trauma, connective tissue disorders such as Marfan syndrome or Ehlers-Danlos lead to imperfect closure of the valve during diastole, hence the blood is returning from the aorta towards the left ventricle of the heart. Acute aortic regurgitation (caused by endocarditis, aortic dissection or trauma) ends up in pulmonary edema, because of the acute increase in left ventricle (LVEDP) that does not have time to adjust to the regurgitation. Chronic regurgitation, by contrast, gives the heart time to change shape, resulting in  eccentric hypertrophy , which has disastrous effects on the myocardium. Ultrasound is here also the best diagnostic mobility, either it is transthoracic or transesophageal.  [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14182", "text": "As long-term data on the survival and quality of life of people following valve replacement have become available, evidence-based guidelines for aortic valve replacement have been developed. These help healthcare professionals decide when aortic valve replacement is the best option for a patient. Two widely accepted sets of guidelines used by surgeons and cardiologists are the American Heart Association and American College of Cardiology Guidelines for the Management of Patients with Valvular Heart Disease, [ 8 ]  and the European Society of Cardiology and the European Association for Cardio\u2011Thoracic Surgery Guidelines for the management of valvular heart disease. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14183", "text": "Aortic stenosis  is treated with aortic valve replacement in order to avoid  angina ,  syncope , or  congestive heart failure . Individuals with severe aortic stenosis are candidates for aortic valve replacement once they develop symptoms or when their heart function is impacted. Some people with asymptomatic aortic stenosis may also be candidates for aortic valve replacement, especially if symptoms appear during  exercise testing . [ 9 ]  Patients with moderate aortic valve stenosis who need another type of cardiac surgery (i.e.  coronary artery bypass surgery ) should also have their valve addressed by the surgical team if  echocardiography  unveils significant heart problems. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14184", "text": "Low gradient aortic stenosis with concomitant left ventricular dysfunction poses a significant question to the anesthesiologist and the patient. Stress echocardiography (i.e. with dobutamine infusion) can help determine if the ventricle is dysfunctional because of aortic stenosis, or because the myocardium lost its ability to contract. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14185", "text": "Many people with  aortic insufficiency  often do not develop symptoms until they have had the condition for many years. [ 12 ]  Aortic valve replacement is indicated for symptoms such as  shortness of breath , and in cases where the heart has begun to enlarge (dilate) from pumping the increased volume of blood that leaks back through the valve. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14186", "text": "There are two basic types of replacement heart valve: tissue (bioprosthetic) valves and mechanical valves. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14187", "text": "Tissue heart valves are usually made from animal tissue (heterografts) mounted on a metal or polymer support. [ 14 ]  Bovine (cow) tissue is most commonly used, but some are made from porcine (pig) tissue. [ 15 ]  The tissue is treated to prevent rejection and calcification (where calcium builds up on the replacement valve and stops it working properly). [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14188", "text": "Occasionally, alternatives to animal tissue valves are used: aortic  homografts  and pulmonary  autografts . An aortic homograft is an aortic valve from a human donor, retrieved either after their death or from their heart if they are undergoing a heart transplant. [ 17 ]  A pulmonary autograft, also known as the  Ross procedure  is where the aortic valve is removed and replaced with the patient's own  pulmonary valve  (the valve between the right ventricle and the pulmonary artery). A pulmonary homograft (a pulmonary valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. This procedure was first performed in 1967 and is used primarily in children, as it allows the patient's own pulmonary valve (now in the aortic position) to grow with the child. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14189", "text": "Tissue valves can last 10\u201320 years. [ 18 ]  However, they tend to deteriorate more quickly in younger patients. [ 19 ]  New ways of preserving the tissue for longer are being investigated. One such preservation treatment is now being used in a commercially available tissue heart valve. In sheep and rabbit studies, the tissue (called RESILIA tissue) had less  calcification  than control tissue. Mid-term data on the safety and haemodynamic performance of the Inspiris RESILIA aortic bioprosthesis are encouraging. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14190", "text": "Stented and stentless tissue valves are available. Stented valves come in sizes from 19\u00a0mm to 29\u00a0mm. [ 22 ]  Stentless valves are directly sutured at the aortic root. The major advantage of stentless valves is that they limit  patient\u2013prosthesis mismatch  (when the area of the prosthetic valve is too small in relation to the size of the patient, increasing the pressure inside the valve [ 23 ] ) and can be helpful when dealing with small aortic root. However, stentless valves take more time than stented valves to implant. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14191", "text": "Mechanical valves are made from synthetic materials, such as titanium or  pyrolytic carbon . [ 25 ]  Their durability is long life, while tissue valves can last for up to 15\u201320 years. [ 26 ] [ 27 ] [ 13 ]  Since the risk of blood clots forming is higher with mechanical valves than with tissue valves, patients with mechanical heart valves are required to take anticoagulant (blood-thinning) drugs, such as  warfarin , long-life, making them more prone to bleeding (1% per year). [ 13 ]  The sound of the valve can be heard very rarely, often as clicks, and might be disturbing. [ 28 ]  The choice of prosthetic valve should be individualized, carefully considering each patient's unique circumstances. In that context, the new generation aortic mechanical valve (On-X) offers a potential lifetime solution without need for a repeat operation, while minimizing the risks of long-term anticoagulation due to reduced anticoagulation target INR of 1.5 to 2.0. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14192", "text": "Valve choice is a balance between the lower durability of tissue valves and the increased risk of blood clots and bleeding with mechanical valves. Guidelines suggest that patient age, lifestyle and medical history should all be considered when choosing a valve. Tissue valves deteriorate more rapidly in young patients and during pregnancy, but they are preferable for women who wish to have children because pregnancy increases the risk of blood clots. Typically, a mechanical valve is considered for patients under 60 years old, while a tissue valve is considered for patients over the age of 65 years. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14193", "text": "Surgical aortic valve replacement is conventionally done through a  median sternotomy , meaning the incision is made by cutting through the breastbone ( sternum ). Once the protective membrane around the heart ( pericardium ) has been opened, the patient is cannulated (aortic cannulation by a cannula placed on the  aorta  and a venous canulation by a single atrial venous cannula inserted through the right atrium). The patient is put on a  cardiopulmonary bypass  machine, also known as the heart\u2013lung machine. This machine breathes for the patient and pumps their blood around their body while the surgeon replaces the heart valve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14194", "text": "Once on cardiopulmonary bypass, the patient's heart is stopped ( cardioplegia ). This can be done with a Y-type cardioplegic infusion catheter placed on the aorta, de-aired and connected to the cardiopulmonary bypass machine. Alternatively, a retrograde cardioplegic cannula can be inserted at the coronary sinus. Some surgeons also opt to place a vent in the left ventricle through the right superior pulmonary vein, because this helps to prevent left ventricular distention before and after cardiac arrest. When the set-up is ready, the aorta is clamped shut with a cross-clamp to stop blood pumping through the heart and cardioplegia is infused. The surgeon incises the aorta a few milometers above the sinotubular junction (just above the coronary ostia, where the coronary arteries join the aorta) \u2013 a process known as aortotomy. After this, cardioplegia is delivered directly through the ostia. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14195", "text": "The heart is now still and the surgeon removes the patient's diseased aortic valve. The cusps of the aortic valve are excised, and calcium is removed (debrided) from the aortic annulus. The surgeon measures the size of the aortic annulus and fits a mechanical or tissue valve of the appropriate size. Usually the valve is fixed in place with sutures, although some sutureless valves are available. If the patient's aortic root is very small, the sutures are placed outside of the aortic root instead of at the annulus, to gain some extra space. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14196", "text": "Once the valve is in place and the aorta has been closed, patient is placed in a  Trendelenburg position  and the heart is de-aired and restarted. The patient is taken off the cardiopulmonary bypass machine.  Transesophageal echocardiogram  (an ultrasound of the heart done through the esophagus) can be used to verify that the new valve is functioning properly. Pacing wires are usually put in place, so that the heart can be manually controlled should any complications arise after surgery. Drainage tubes are also inserted, to drain fluids from the chest. These are usually removed within 36 hours, while the pacing wires are generally left in place until right before the patient is discharged from the hospital. [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14197", "text": "After surgical aortic valve replacement, the patient will usually stay in an  intensive care unit  for 12\u201336 hours. Unless complications arise, the patient is then able to go home after approximately four to seven days. [ 32 ]  Common complications include disturbances to the heart's rhythm ( heart block ), which typically require the permanent insertion of a  cardiac pacemaker . [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14198", "text": "Recovery from aortic valve replacement takes about three months if the patient is in good health. Patients are advised not to lift anything heavier than 10\u00a0lbs for several weeks, and not to do any heavy lifting for 4\u20136 months after surgery to avoid damaging their breastbone. Often patients will be referred to participate in  cardiopulmonary rehabilitation , which optimizes recovery and physical function in patients with recent cardiac surgeries. This can be done in an outpatient setting. [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14199", "text": "Surgery usually relieves the aortic disease symptoms that led the patient to the operating room. The survival curve of patients who undergo aortic valve replacements is slightly inferior to the curve of their corresponding healthy same-aged same sex population. [ 35 ]  Pre-operative severe left ventricular hypertrophy is a contributing factor to morbidity. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14200", "text": "The risk of dying as a result of aortic valve replacement is estimated at 1\u20133%. [ 36 ] [ 37 ] [ 38 ]  Combining aortic valve replacement with coronary artery bypass grafting increases the risk of mortality. [ 36 ]  Older patients, as well as those who are frail and/or have other health problems ( comorbidities ), have a higher risk of experiencing complications. [ 37 ]  Possible problems include  cardiac infarction  or failure,  arrhythmia  or  heart block  typically requiring the permanent insertion of a  cardiac pacemaker , mediastinal bleeding,  stroke  and infection. Late complications include  endocarditis , thromboembolic events ( blood clots ), prosthetic valve dysfunction and paravalvular leak (blood flowing between the edge of the prosthetic valve and the cardiac tissue). [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14201", "text": "When dealing with a small aortic annulus, the surgeon might have to insert a prosthetic aortic valve of small size, with an orifice too small in relation to the size of the patient (patient\u2013prosthesis mismatch). This increases the pressure of the blood flowing through the valve, and can lead to worse outcomes. [ 23 ]  Various techniques, including stentless valves, have been utilized to avoid this problem. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14202", "text": "Since the late 1990s, some cardiac surgeons have been performing aortic valve replacement using an approach referred to as minimally invasive cardiac surgery (MICS). [ 40 ]  Using this approach, the surgeon replaces the valve through a smaller chest incision (6\u201310\u00a0cm) than that for a median sternotomy. MICS typically requires shorter recovery times, and produces less visible scarring. [ 41 ]  Alternatively, aortic valve replacement can be performed with right minithoracotomy approach via the 2nd or 3rd intercostal space. There is growing evidence that this approach can reduce postoperative morbidity allowing less blood loss, less pain,\nfaster recovery, and a shorter hospital stay with no difference in mortality. [ 42 ]  This approach can be particularly valuable in higher risk and elderly patients. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14203", "text": "Another alternative for many high-risk or elderly patients is transcatheter aortic valve replacement (TAVR, also known as TAVI, transcatheter aortic valve implantation). Rather than removing the existing valve, the new valve is pushed through it in a collapsed state. It is delivered to the site of the existing valve through a tube called a catheter, which may be inserted through the femoral artery in the thigh (transfemoral approach), or using a small incision in the chest and then through a large artery or the tip of the left ventricle (transapical approach). [ 44 ]  Fluoroscopy and  transthoracic echocardiogram  (TTE) are visual aids used to guide the process. [ 44 ]  Once the collapsed replacement valve is in place it is expanded, pushing the old valve's  leaflets  out of the way. [ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14204", "text": "Guidelines suggest TAVR for most patients aged 75 years and older, and surgical aortic valve replacement for most younger patients. [ 46 ]  Ultimately, the choice of treatment is  based on many factors. [ 47 ] [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14205", "text": "Systematic reviews  have addressed this comparison: [ 48 ] [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14206", "text": "Aortic valvuloplasty , also known as  balloon aortic valvuloplasty (BAV) , is a procedure used to improve blood flow through the  aortic valve  in conditions that cause  aortic stenosis , or narrowing of the aortic valve. It can be performed in various patient populations including fetuses, newborns, children, adults, and pregnant women. [ 1 ] [ 2 ]  The procedure involves using a  balloon catheter  to dilate the narrowed aortic valve by inflating the balloon. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14207", "text": "Guidelines and indications are specific to different patient populations. For adults with aortic stenosis, guidelines suggest that balloon aortic valvuloplasty (BAV) is to be used as a temporary procedure to improve blood flow through the aortic valve to alleviate symptoms and stabilize clinically before having more invasive procedures done, including  aortic valve replacement  (AVR) or  transcatheter aortic valve implantation  (TAVI). The most common conditions that deem patients too unstable for AVR or TAVI are  pulmonary edema  and  cardiogenic shock , which BAV attempts to correct to stabilize the patient before definitive surgery. [ 1 ] [ 3 ] [ 4 ] [ 5 ]  For adult patients with aortic stenosis who need noncardiac related surgeries, BAV can be indicated to decrease the risk of the operation in certain high-risk patients. [ 1 ] [ 3 ]  BAV has been used in adult patients who have shortness of breath and the cause is unclear between aortic stenosis or from a primary lung problem. These patients undergo BAV and if their shortness of breath improves, the cause is deemed to be likely from aortic stenosis and they can undergo AVR or TAVI to correct the aortic stenosis definitively. [ 3 ] [ 4 ]  BAV can also be used as  palliation  therapy to improve symptoms in patients who cannot undergo AVR or TAVI due to contraindications. [ 3 ] [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14208", "text": "BAV has been performed on fetuses with  congenital heart defects  involving the aortic valve to improve blood flow within the heart. It is not definitive treatment, but is performed in an attempt to prevent a condition called  hypoplastic left heart syndrome . [ 1 ]  For neonates and children with congenital aortic valve stenosis, BAV is commonly the first type of procedure performed to relieve the stenosis, but is not always a definitive treatment option. [ 6 ] [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14209", "text": "Guidelines suggest performing BAV in pregnant patients with severe aortic stenosis evident by severe symptoms. Changes in blood flow and circulation during pregnancy make it more likely for complications and symptoms to arise in patients with aortic stenosis. When BAV is indicated, it is suggested to attempt to wait until the  third trimester  to avoid harm to the fetal  thyroid  from the  contrast dye  needed during the procedure. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14210", "text": "Aortic valvuloplasty relies on placing a catheter with a balloon at the tip in the aortic valve, which is then inflated to widen the narrowed valve. [ 1 ]  In order to reach the aortic valve, a  blood vessel  is punctured to introduce the catheter and advance it into the aortic valve. The most common site of entry is the  femoral artery  in the groin, but the  carotid artery  in the neck can also be used. The  umbilical artery  is used when the procedure is performed on a fetus. [ 1 ] [ 7 ]  There has also been success using the  radial artery  in the wrist to gain access. [ 7 ]   Ultrasound  is commonly used to visualize the vessel being accessed to avoid potential complications. [ 3 ]  A  wire  is typically used to guide the balloon catheter from the access site to the aortic valve. [ 1 ]  Different size balloons are used depending on the age of the patient. [ 1 ]  In order for the balloon to remain in the proper position while it is being inflated in the aortic valve, blood flow through the valve needs to be temporarily reduced. This is typically achieved by increasing the heart rate through  electrical stimulation of the heart muscle  or through medications that decrease blood pumping from the  left ventricle . [ 1 ]  The blood pressure and flow across the aortic valve is monitored and repeated inflation of the balloon is sometimes needed to successfully dilate the aortic valve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14211", "text": "After BAV in adults, it is common to have both clinical and symptomatic improvement early on. Clinically, the pressure across the aortic valve is reduced, there is increased blood flow, and the area of the aortic valve is increased due to mechanical dilation of the balloon. Many patients have a reduction of the symptoms associated with severe aortic stenosis, commonly reported as an improvement of their  NYHA functional class , which is a way to categorize the severity of heart failure based on reported symptoms. [ 8 ]  The early benefits of BAV in adults typically do not last. The aortic valve becomes narrow again within months. [ 8 ] [ 1 ]  These patients may progress to more definitive treatment such as AVR or TAVI if they are eligible and clinically stable. [ 4 ] [ 1 ]  BAV in adults has risks and complications associated with it due to the risk of the procedure itself as well as the commonly high-risk patient population that undergoes BAV. Major bleeding,  stroke ,  aortic regurgitation , and death have been reported. [ 8 ]  Other complications reported include but are not limited to  infection , damage to the artery being accessed,  heart arrhythmias , and decreased  kidney function . [ 3 ] [ 1 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14212", "text": "It is typical for children to require reintervention after having BAV, whether it be a repeat BAV or more definitive treatment with surgical aortic valve replacement. [ 6 ]  Many do not require surgical aortic valve replacement until later on in life, with many patients reaching adulthood before this occurs. [ 9 ] [ 1 ]  The outcomes are worse for neonates and infants. This is largely because earlier intervention is required in these patients due to being less clinically stable. [ 1 ]  A common complication of BAV in children is  aortic regurgitation , which decreases in frequency the older the child is when the procedure occurs. [ 1 ]  Other complications include  arrhythmias , damage to the artery being accessed, as well as death. [ 1 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14213", "text": "For pregnant patients, data is lacking regarding outcomes of BAV. It is recommended that these patients requiring BAV progress to aortic valve replacement when suitable. Specific risks of performing BAV in pregnant patients include potential harm to the fetus from  radiation exposure . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14214", "text": "Apicoaortic Conduit (AAC) , also known as  Aortic Valve Bypass (AVB) , is a cardiothoracic surgical procedure that alleviates symptoms caused by blood flow obstruction from the  left ventricle  of the heart.  Left ventricular outflow tract obstruction (LVOTO) is caused by narrowing of the  aortic valve  ( aortic stenosis ) and other valve disorders.  AAC, or AVB, relieves the obstruction to blood flow by adding a bioprosthetic valve to the circulatory system to decrease the load on the aortic valve.  When an apicoaortic conduit is implanted, blood continues to flow from the heart through the aortic valve.  In addition, blood flow bypasses the native valve and exits the heart through the implanted valved conduit. The procedure is effective at relieving excessive pressure gradient across the natural valve. High pressure gradient across the aortic valve can be  congenital  or acquired. A reduction in pressure gradient results in relief of symptoms."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14215", "text": "The figure depicts a typical apicoaortic configuration with a left ventricle connector sutured to the  apex of the heart , and a conduit containing a bioprosthetic valve  anastomosed  to the descending  thoracic aorta . Blood exits the  left ventricle  either through the natural valve or the bypass conduit. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14216", "text": "The concept of an apicoaortic conduit to bypass valvular  aortic stenosis  (AS) was conceived by Carrel  [ 1 ]  in 1910, and performed experimentally by Sarnoff and colleagues on dogs in 1955. [ 2 ]  In 1962-63, Templeton implanted prostheses similar to those originally described by Sarnoff in five patients with severe aortic valve stenosis; one patient survived more than 10 years. In 1975, Bernhard and coworkers reported a reoperation in which a conduit was implanted between the left ventricle and the thoracic aorta. [ 3 ]  The procedure was also developed in the late 1970s as a way to treat complex left ventricular outflow tract obstructions (LVOTO) in children and young adults. [ 4 ]   [ 5 ]  AAC is no longer performed on children as the  Ross procedure  has superseded it. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14217", "text": "Today, AAC is performed clinically on elderly  aortic stenosis  patients, and has gained in popularity in recent years. In the past 25 years, a number of case series on adults have been published. [ 7 ]   [ 8 ]   [ 9 ]   [ 10 ]   [ 11 ]   [ 12 ]   [ 13 ]   [ 14 ]   [ 15 ]  As of 2010, the estimated total number of AAC cases performed worldwide in the last 30 years is greater than 1500. The procedure has not been adopted widely because it is technically challenging and blood loss can be significant. The most difficult part of the procedure is the insertion of a left ventricle connector into the  apex of the heart . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14218", "text": "AAC requires specialized implants and installation tools. Hancock Laboratories, now part of Medtronic (Minneapolis, MN), developed and released a set of left ventricle connectors, valved conduits, and installation  trocars  in the 1970s. The Hancock left ventricle connectors, with inner diameters of 12 to 22 mm, have been used clinically for the vast majority of AAC procedures reported in the literature. For the valved conduit, surgeons have used the Medtronic Hancock Model 105 or 150 valved conduits which contain a complete porcine aortic valve. Other surgeons have constructed valved conduits on the back table using a variety of bioprosthetic valves such as the Medtronic Freestyle valve. The Hancock trocars for creating a hole in the left ventricle are rarely used clinically. Surgeons typically assemble their own tools to core and remove a plug of muscle from the left ventricular wall."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14219", "text": "In 2011, Correx (Waltham, MA) [ 16 ]  released a complete kit for AVB with an installation tool that enables coring and insertion of a left ventricle connector on a beating heart while maintaining  hemostasis .  Cardiopulmonary bypass  (CPB) is not required. The kit is CE Marked and available in Europe. Several cases have been done in Canada under the Special Access Programme. [ 17 ]  This kit is not currently available for use or sale in the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14220", "text": "The general procedure has evolved over the years as surgeons gained experience and improved techniques.   [ 18 ]  A video of an AVB procedure performed by Dr. Jim Gammie of the University of Maryland Medical Center can be found here. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14221", "text": "The patient is placed on the table in the supine position. Anesthesia is induced, and the patient is intubated with a double-lumen endotracheal tube, which facilitates one-lung ventilation and allows the surgeon to work within the left chest. The patient is positioned with his or her left side up (see figure). A left anterior-lateral  thoracotomy  is performed between the fifth and sixth ribs to expose the heart and provide access to the  descending aorta . A portion of a rib may be removed to enable easier access and to minimize the chance of a rib fracture. The left lung is deflated and retracted. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14222", "text": "With the descending aorta exposed, the surgeon applies a side clamp to the aorta, effectively pinching and isolating one side of the great vessel. Blood continues to flow to the body's lower half through the unisolated remainder of the aorta.  A lengthwise slit is made through the pinched face, and the open end of the valved conduit is carefully sutured to the slit. Once the suture line is checked for leaks, the aortic partial side clamp is removed and the valved conduit fills with blood up to the bioprosthetic valve. The valve acts as a check valve, thereby maintaining hemostasis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14223", "text": "The surgeon next opens the  pericardium  and exposes the  apex of the heart . The surgeon closely examines the surface of the heart and chooses and marks an insertion site near the apex. A ring of sutures reinforced with pledgets is installed around the insertion site. The free ends of the sutures are looped through a sewing ring on the left ventricle connector. At this point, CPB is typically initiated, although a few surgeons are able to complete the left ventricle installation off-pump (without CPB).\nA circular core of  myocardium  is cut and removed using specialized coring tools. Care must be taken to avoid damaging structures inside the left ventricle such as the  interventricular septum , and the  chordae tendineae . The left ventricle connector is filled with sterile saline to displace any air and then inserted into the hole. The sutures are sequentially tightened and tied off to permanently secure the left ventricle connector to the apex. CPB is terminated. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14224", "text": "With blood now flowing through the bypass conduit, the left ventricular outflow tract obstruction (LVOTO) is effectively relieved. 60% to 70% of the heart's output flows through the bypass to the aorta. The load on the heart is markedly reduced, and symptoms such as  dyspnea ,  syncope , and chest pain disappear."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14225", "text": "Patients historically referred for apicoaortic conduit surgery have been considered high risk or ineligible for conventional  aortic valve replacement . The literature reports generally favorable outcomes for apicoaortic surgery given the age, frailty, and  comorbidities  of the patient population. Patients typically improve from  New York Heart Association Functional Classification  III or IV to Class I or II. AVB effectively relieves the LVOTO caused by  aortic stenosis ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14226", "text": "There is long-term stability of the left ventricular  hemodynamics  after AVB, with no further biologic progression of native aortic valve stenosis.  Once the pressure gradient across the native valve is substantially reduced, the narrowing and calcification of the native valve halts. In one study of 47 patients whose average age was 82 years, the mean gradient across the native valve was reduced from 46 +/- 14 mm HG to 17 +/- 7 mm HG. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14227", "text": "Throughout the published literature, perioperative  stroke  is uncommon. This is because the native valve and ascending aorta are not manipulated in any way. Calcified layers and other debris do not break free and migrate to the brain. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14228", "text": "The literature also reports that postoperative stroke is rare. Whenever a prosthetic device such as a valve is introduced into the bloodstream, there is an ongoing risk of  thrombus  formation which can lead to an  embolism  should the thrombus become mobile. Computational flow studies [ 21 ]  conclude that the presence of an aortic valve bypass conduit has no effect on cerebral blood flow. All blood flow to the brain continues to flow across the native valve. Should a thrombus form on the bioprosthetic valve in the bypass conduit, it will likely migrate to the lower half of the body and not to the brain. This fact is believed to reduce the long-term risk of cerebral thromboembolism (stroke) with AAC."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14229", "text": "The published literature reports that the need for pacemaker after AAC is very rare as the (electrical) conduction center of the heart near the aortic valve is not disturbed in any way."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14230", "text": "AAC avoids the risk of leakage around a replacement heart valve ( aortic insufficiency ), a serious complication of alternate treatments such as  aortic valve replacement  (AVR) and  percutaneous aortic valve replacement  (PAVR or TAVI). With AAC, the native aortic valve is left completely undisturbed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14231", "text": "With  aortic valve replacement  (AVR) as the accepted standard of care for critical AS, patients receiving apicoaortic conduits have often been refused AVR and as such are considered \"no option\" patients. AAC is also sometimes chosen by surgeons and cardiologists over other treatments, such as AVR and  percutaneous aortic valve replacement  (PAVR or TAVI), to treat critical AS. Patients who could benefit from AAC or AVB include those who: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14232", "text": "Arterial switch operation  ( ASO ) or  arterial switch , is an  open heart   surgical  procedure used to correct  dextro-transposition of the great arteries  ( d-TGA ). [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14233", "text": "Its development was  pioneered  by  Canadian   cardiac  surgeon  William Mustard  and it was named for  Brazilian  cardiac surgeon  Adib Jatene , who was the first to use it successfully. It was the first method of d-TGA repair to be attempted, but the last to be put into regular use because of  technological  limitations at the time of its  conception ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14234", "text": "Use of the arterial switch is  historically  preceded by two  atrial switch  methods: the  Senning  and  Mustard procedures . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14235", "text": "The atrial switch, which was an attempt to correct the physiology of transposition, had significant shortcomings that the arterial switch improved upon, in particular a reduced kinking of the  coronary arteries  when combined with the  LeCompte maneuver . The end result is that the aorta is repositioned behind the pulmonary arteries, functionally lengthening it and causing less angulation at the coronary origins. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14236", "text": "The Jatene procedure is ideally performed during the second week of life, before the  left ventricle  adjusts to the lower  pulmonary   pressure  and is therefore unable to support the  systemic circulation . [ 5 ]  In the event of  sepsis  or delayed  diagnosis , a combination of  pulmonary artery banding  ( PAB ) and  shunt  construction may be used to increase the left ventricular mass sufficiently to make an arterial switch possible later in  infancy . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14237", "text": "The success of ASO procedure is largely dependent on the facilities available, the skill and experience of the surgeon, and the general health of the  patient . Under preferable conditions, the  intra-operative  and  post-operative  success rate is 90% or more, with a comparable survival rate after 5 years. [ 7 ]  Approximately 10% of arterial switch recipients develop residual pulmonary  stenosis  post-operatively, which can lead to  right heart   failure  if left untreated; [ 8 ]  treatment usually involves  endovascular stenting  and/or  xenograft  patching. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14238", "text": "If the procedure is anticipated far enough in advance (with  prenatal  diagnosis, for example), and the individual's  blood  type is known, a family member with a compatible  blood type  may  donate  some or all of the blood needed for  transfusion  during the use of a  heart-lung machine  ( HLM ). The patient's  mother  is normally unable to donate blood for the transfusion, as she will not be able to donate blood during  pregnancy  (due to the needs of the  fetus ) or for a few weeks after giving  birth  (due to  blood loss ), and the process of collecting a sufficient amount of blood may take several weeks to a few months. However, in cases where the individual has been diagnosed but surgery must be delayed, maternal (or even  autologous , in certain cases) blood donation may be possible, as long as the mother has a compatible blood type. In most cases, though, the patient receives a donation from a  blood bank . A blood transfusion is necessary for the arterial switch because the HLM needs its \"circulation\" filled with blood and an infant does not have enough blood on their own to do this (in most cases, an adult would not require blood transfusion). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14239", "text": "The patient will require a number of  imaging  procedures in order to determine the individual  anatomy  of the great arteries and, most importantly, the  coronary arteries . These may include  angiography ,  magnetic resonance imaging  ( MRI ), and/or  computed tomography  ( CT scan ). The coronary arteries are carefully mapped out in order to avoid unexpected intra-operative complications in transferring them from the native aorta to the neo-aorta. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14240", "text": "As with any procedure requiring general anaesthesia, arterial switch recipients will need to  fast  for several hours prior to the surgery to avoid the risk of aspiration of vomitus during the induction of anesthesia. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14241", "text": "As the patient is anesthetized, they may receive the following  drugs , which continue as necessary throughout the procedure:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14242", "text": "The heart is accessed via  median sternotomy  and its  pericardium  is removed so the coronary and great arteries can be seen. The  ductus arteriosus  and main right  pulmonary artery , up to and including the first branches in the  hilum  of the right  lung , are separated from the surrounding supportive  tissue  to allow mobility of the  vessels . Cardiopulmonary bypass is then initiated and the  body  is  cooled  to prevent the  brain damage  otherwise associated with low blood flow during the surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14243", "text": "While the patient is cooling, the ductus arteriosus is  ligated  at both the aortic and pulmonary  ostia , then  transected  at its center; the main left pulmonary artery including its first branches in the left  hilum , is separated from surrounding connective tissue. When the patient is fully cooled, the ascending aorta is clamped and  cardioplegia  is achieved by delivering cold blood to the heart via the ascending aorta (below the  cross clamp ). The aorta and pulmonary arteries are  surgically cut . The vessels are again examined, and the pulmonary root is inspected for  left ventricular outflow tract obstruction . If a  ventricular septal defect  is present, it is also repaired via the  aortic  or  pulmonary valve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14244", "text": "The great arteries are usually arranged using the  LeCompte maneuver , with the aortic cross clamp positioned to hold the pulmonary artery  anterior  to the ascending aorta. On imaging, the pulmonary arteries will classically have the appearance of being draped over the aorta. Sometimes, however, patient anatomy prevents this and the aorta great vessels are kept in the non-anatomic 'anterior aorta' arrangement. The coronary arteries  infundibular  branches and the aortic root extending the  sinus of Valsalva  are then surgically cut off the native aorta and transplanted onto the pulmonary root to make a neo-aorta."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14245", "text": "The bypass machine is then turned off, an  incision  is made in the right atrium, through which the  congenital  or  palliative   atrial septal defect  is repaired. In septal defects where a  Rashkind balloon atrial septostomy  was used, the ASD should be able to be closed with sutures, but cases involving large congenital atrial septal defects or  Blalock-Hanlon atrial septectomy , a patch can be used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14246", "text": "If there is a  ventricular septal defect  which has not yet been repaired, this is also fixed through the atrial incision and  tricuspid valve , again using sutures for a small defect or a patch for a large defect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14247", "text": "When the septal defects have been repaired and the atrial incision is closed, the patient is again placed on cardiopulmonary pass. The left ventricle is then vented and the cross clamp removed from the aorta, enabling full-flow to be re-established and rewarming to begin. At this point the patient will receive an additional dose of Regitine to keep  blood pressure  under control. The previously harvested pericardium is then used to patch the coronary  explantation  sites, and to extend and widen the neo-pulmonary root, which allows the pulmonary artery to be anastamosed without residua tension; the pulmonary artery is then transplanted to the neo-pulmonary root."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14248", "text": "The patient is fitted with  chest tubes , temporary  pacemaker  leads, and  ventilated  before  weaning  from the HLM is begun."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14249", "text": "The  rib cage  is relaxed and the external surgical  wound  is bandaged, but the  sternum  and chest incision are left open to provide extra room in the  pleural cavity , allowing the heart room to swell and preventing pressure caused by  pleural effusion ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14250", "text": "The sternum and chest can usually be closed within a few days; however, the chest tubes, pacemaker, ventilator, and drugs may still be required after this time. The patient will continue to fast for up to a few days, and  breastmilk  or  infant formula  can then be gradually introduced via  nasogastric tube  ( NG tube ); the primary  goal  after a successful arterial switch, and before  hospital  discharge, is for the  infant  to gain back the weight they have lost and continue to gain weight at a normal or near-normal rate. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14251", "text": "Scottish   pathologist   Matthew Baillie  first described  TGA  in 1797, presumably as a  posthumous  diagnosis. [ 9 ]  Without surgical correction, preoperative mortality in the neonate is approximately 30% within the first week of life and up to 90% within the first year; [ 7 ]  the survivors would have been those with one or more  concomitant   intracardiac   shunts  (ASD,  patent ductus arteriosus  ( PDA ),  patent foramen ovale  ( PFO ), and/or VSD), and are unlikely to have survived past  adolescence . [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14252", "text": "In 1950,  American  surgeons  Alfred Blalock  and  C. Rollins Hanlon  introduced the  Blalock-Hanlon atrial septectomy , which was then routinely used to palliate patients. [ 11 ]  This would have effectively reduced early mortality rates, particularly in cases with no concomitant shunts, but is unlikely to have reduced late mortality rates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14253", "text": "Mustard first conceived of, and attempted, the anatomical repair (arterial switch) for d-TGA in the early 1950s. His few attempts were unsuccessful due to technical difficulties posed by the  translocation  of the coronary arteries, and the idea was abandoned. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14254", "text": "Swedish cardiac surgeon  \u00c5ke Senning  described the first corrective surgery for d-TGA (the  Senning procedure ) in 1959, which involved using the  atrial septum  to create an  intratrial   baffle  that redirected  bloodflow  at the  atrial  level; Senning yielded a high success rate using this procedure, significantly lowering both early and late mortality rates. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14255", "text": "Due to the technical complexity of the Senning procedure, others could not duplicate his success rate; in response, Mustard developed a simpler alternative method (the  Mustard procedure ) in 1964, which involved constructing a baffle from  autologous   pericardium  or  synthetic  material, such as Dacron. [ 14 ]  This procedure yielded early and late mortality rates comparable to the Senning procedure; however, a  late morbidity rate  was eventually discovered in relation to the use of synthetic graft material, which does not grow with the recipient and eventually causes  obstruction . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14256", "text": "In 1966, American surgeons  William Rashkind  and  William Miller  transformed the palliation of d-TGA patients with the innovative  Rashkind balloon atrial septostomy , which, unlike the  thoracotomy  required by a septectomy, is performed through the  minimally invasive  surgical technique of  cardiac catheterization . [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14257", "text": "The late morbidity rate is  high in atrial switch, combined with advances in  microvascular surgery , created a renewed interest in Mustard's original concept of an arterial switch procedure. The first successful arterial switch was performed on a forty-two-day-old d-TGA + VSD infant by Jatene in 1975. [ 17 ]  Egyptian cardiac surgeon  Magdi Yacoub  was subsequently successful in treating TGA with AN intact  interventricular septum  when preceded by pulmonary artery banding and systemic-to-pulmonary shunt palliation. [ 6 ] [ 18 ]  Austrian surgeon  B. Eber  was the first to recount a small series of successful arterial switch procedures, and the first large successful series was reported by  Guatemalan  surgeon  Aldo R. Casteneda . [ 19 ]  In the postoperative period, increased incidence and degree of supravalvular pulmonary stenosis. [ 20 ]  Eliminating the pericardial patch for pulmonary artery reconstruction and using a direct connection reduced the incidence of this complication. [ 8 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14258", "text": "By 1991, the arterial switch had become the procedure of choice, and it remains the standard modern procedure for d-TGA repair. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14259", "text": "As long-term results of arterial switch are being reported, newer sets of potential surgical problems are becoming evident. Progressive neo-aortic dilation (pulmonary valve at birth) has been observed. However, this dilation does not necessarily translate into aortic regurgitation (AR) and need for surgery in all patients. Older age at time of ASO, presence of ventricular septal defect, and previous PA banding have been found to be risk factors for AR. [ 4 ] [ 22 ]   supravalvular pulmonary stenosis  was commonly observed in the postoperative period. A direct connection of the pulmonary artery reduced the incidence of this complication  [ 23 ] [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14260", "text": "The world's smallest infant to survive an arterial switch was Jerrick De Leon, born 13 weeks premature. At the time of the operation on February 6, 2005, he weighed just over 1.5 pounds (700\u00a0grams). [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14261", "text": "An  artificial heart valve  is a  one-way valve   implanted  into a person's  heart  to replace a  heart valve  that is not functioning properly ( valvular heart disease ). Artificial heart valves can be separated into three broad classes: mechanical heart valves, bioprosthetic tissue valves and engineered tissue valves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14262", "text": "The human heart contains four valves:  tricuspid valve ,  pulmonary valve ,  mitral valve  and  aortic valve . Their main purpose is to keep blood flowing in the proper direction through the heart, and from the heart into the major blood vessels connected to it (the  pulmonary artery  and the  aorta ). Heart valves can malfunction for a variety of reasons, which can impede the flow of blood through the valve ( stenosis ) and/or let blood flow backwards through the valve ( regurgitation ). Both processes put strain on the heart and may lead to serious problems, including  heart failure . While some dysfunctional valves can be treated with drugs or repaired, others need to be replaced with an artificial valve. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14263", "text": "A heart contains four valves (tricuspid, pulmonary, mitral and aortic valves) which open and close as blood passes through the heart. [ 3 ]  Blood enters the heart in the right atrium and passes through the  tricuspid valve  to the right ventricle. From there, blood is pumped through the  pulmonary valve  to enter the lungs. After being oxygenated, blood passes to the left atrium, where is it pumped through the  mitral valve  to the left ventricle. The left ventricle pumps blood to the aorta through the  aortic valve ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14264", "text": "There are many potential causes of heart valve damage, such as birth defects, age related changes, and effects from other disorders, such as rheumatic fever and infections causing  endocarditis .  High blood pressure  and heart failure which can enlarge the heart and arteries, and scar tissue can form after a  heart attack  or injury. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14265", "text": "The three main types of artificial heart valves are mechanical, biological (bioprosthetic/tissue), and tissue-engineered valves. In the US, UK and the European Union, the most common type of artificial heart valve is the bioprosthetic valve. Mechanical valves are more commonly used in Asia and Latin America. [ citation needed ]  Companies that manufacture heart valves include Edwards Lifesciences, [ 5 ]  Medtronic, [ 6 ]  Abbott (St.\u00a0Jude Medical), [ 7 ]  CryoLife, [ 8 ]  and LifeNet Health. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14266", "text": "Mechanical valves come in three main types \u2013 caged ball, tilting-disc and bileaflet \u2013 with various modifications on these designs. [ 10 ]  Caged ball valves are no longer implanted. [ 11 ]  Bileaflet valves are the most common type of mechanical valve implanted in patients today. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14267", "text": "The first artificial heart valve was the caged ball valve, a type of  ball check valve , in which a ball is housed inside a cage. When the heart contracts and the blood pressure in the chamber of the heart exceeds the pressure on the outside of the chamber, the ball is pushed against the cage and allows blood to flow. When the heart finishes contracting, the pressure inside the chamber drops and the ball moves back against the base of the valve forming a seal."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14268", "text": "In 1952,  Charles A. Hufnagel  implanted caged ball heart valves into ten patients (six of whom survived the operation), marking the first success in prosthetic heart valves. [ citation needed ]  A similar valve was invented by Miles 'Lowell' Edwards and  Albert Starr  in 1960, commonly referred to as the Starr-Edwards silastic ball valve. [ 13 ]  This consisted of a silicone ball enclosed in a  methyl metacrylate  cage welded to a ring. The Starr-Edwards valve was first implanted in a human on August 25, 1960, and was discontinued by Edwards Lifesciences in 2007. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14269", "text": "Caged ball valves are strongly associated with blood clot formation, so people who have one required a high degree of  anticoagulation , usually with a target  INR  of 3.0\u20134.5. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14270", "text": "Introduced in 1969, the first clinically available tilting-disc valve was the  Bjork-Shiley valve . [ 15 ]  Tilting\u2011disc valves, a type of  swing check valve , are made of a metal ring covered by an  ePTFE  fabric. The metal ring holds, by means of two metal supports, a disc that opens when the heart beats to let blood flow through, then closes again to prevent blood flowing backwards. The disc is usually made of an extremely hard carbon material ( pyrolytic carbon ), enabling the valve to function for years without wearing out. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14271", "text": "Introduced in 1979, bileaflet valves are made of two semicircular leaflets that revolve around struts attached to the valve housing. With a larger opening than caged ball or tilting-disc valves, they carry a lower risk of blood clots. They are, however, vulnerable to blood backflow. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14272", "text": "The major advantage of mechanical valves over bioprosthetic valves is their greater durability. [ 16 ]  Made from metal and/or  pyrolytic carbon , [ 10 ]  they can last 20\u201330 years. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14273", "text": "One of the major drawbacks of mechanical heart valves is that they are associated with an increased risk of  blood clots . Clots formed by red blood cell and platelet damage can block blood vessels leading to  stroke . People with mechanical valves need to take anticoagulants (blood thinners), such as  warfarin , for the rest of their life. [ 16 ]  Mechanical heart valves can also cause  mechanical hemolytic anemia , a condition where the  red blood cells  are damaged as they pass through the valve. [ citation needed ]   Cavitation , the rapid formation of microbubbles in a fluid such as blood due to a localized drop of pressure, can lead to mechanical heart valve failure, [ 17 ]  so cavitation testing is an essential part of the valve design verification process."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14274", "text": "Many of the complications associated with mechanical heart valves can be explained through  fluid mechanics . For example, blood clot formation is a side effect of high  shear stresses  created by the design of the valves. From an engineering perspective, an ideal heart valve would produce minimal pressure drops, have small regurgitation volumes, minimize turbulence, reduce prevalence of high stresses, and not create flow separations in the vicinity of the valve. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14275", "text": "Implanted mechanical valves can cause foreign body rejection. The blood may coagulate and eventually result in a hemostasis. The usage of anticoagulation drugs will be interminable to prevent thrombosis. [ 18 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14276", "text": "Bioprosthetic valves are usually made from animal tissue (heterograft/ xenograft ) attached to a metal or polymer support. [ 11 ]  Bovine (cow) tissue is most commonly used, but some are made from porcine (pig) tissue. [ 19 ] [ non-primary source needed ]  The tissue is treated to prevent rejection and  calcification . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14277", "text": "Alternatives to animal tissue valves are sometimes used, where valves are used from human donors, as in aortic  homografts  and pulmonary  autografts . An aortic homograft is an aortic valve from a human donor, retrieved either after their death or from a heart that is removed to be replaced during a heart transplant. [ 12 ]  A pulmonary autograft, also known as the  Ross procedure , is where the aortic valve is removed and replaced with the patient's own  pulmonary valve  (the valve between the right ventricle and the pulmonary artery). A pulmonary homograft (a pulmonary valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. This procedure was first performed in 1967 and is used primarily in children, as it allows the patient's own pulmonary valve (now in the aortic position) to grow with the child. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14278", "text": "Bioprosthetic valves are less likely than mechanical valves to cause blood clots, so do not require lifelong anticoagulation. As a result, people with bioprosthetic valves have a lower risk of bleeding than those with mechanical valves. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14279", "text": "Tissue valves are less durable than mechanical valves, typically lasting 10\u201320 years. [ 20 ]   This means that people with bioprosthetic valves have a higher incidence of requiring another aortic valve replacement in their lifetime. [ 16 ]  Bioprosthetic valves tend to deteriorate more quickly in younger patients. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14280", "text": "In recent years, scientists have developed a new tissue preservation technology, with the aim of improving the durability of bioprosthetic valves. In sheep and rabbit studies, tissue preserved using this new technology had less  calcification  than control tissue. [ 22 ]  A valve containing this tissue is now marketed, but long-term durability data in patients are not yet available. [ 23 ] [ non-primary source needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14281", "text": "Current bioprosthetic valves lack longevity, and will calcify over time. [ 24 ]  When a valve calcifies, the valve cusps become stiff and thick and cannot close completely. [ 24 ]  Moreover, bioprosthetic valves can't grow with or adapt to the patient: if a child has bioprosthetic valves they will need to get the valves replaced several times to fit their physical growth. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14282", "text": "For over 30 years researchers have been trying to grow heart valves  in vitro . [ 25 ]  These tissue\u2011engineered valves involve seeding human cells on to a scaffold. [ 25 ]  The two main types of scaffold are natural scaffolds, such as decellularized tissue, or scaffolds made from degradable polymers. [ 26 ]  The scaffold acts as an  extracellular matrix , guiding tissue growth into the correct 3D structure of the heart valve. [ 26 ] [ 25 ]  Some tissue-engineered heart valves have been tested in clinical trials, [ 26 ]  but none are commercially available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14283", "text": "Tissue engineered heart valves can be person-specific and 3D modeled to fit an individual recipient [ 27 ]  3D printing is used because of its high accuracy and precision of dealing with different biomaterials. [ 27 ]  Cells that are used for tissue engineered heart valves are expected to secrete the extracellular matrix (ECM). [ 24 ]  Extracellular matrix provides support to maintain the shape of the valves and determines the cell activities. [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14284", "text": "Scientists can follow the structure of heart valves to produce something that looks similar to them, but since tissue engineered valves lack the natural cellular basis, they either fail to perform their functions like natural heart valves, or function when they are implanted but gradually degrade over time. [ citation needed ]  An ideal tissue engineered heart valve would be non-thrombogenic, biocompatible, durable, resistant to calcification, grow with the surrounding heart, and exhibit a physiological hemodynamic profile. [ 29 ]  To achieve these goals, the scaffold should be carefully chosen\u2014there are three main candidates: decellularized ECM (xenografts or homografts), natural polymers, and synthetic polymers. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14285", "text": "Mechanical and tissue valves are made of different materials. Mechanical valves are generally made of titanium and carbon. [ 30 ]  Tissue valves are made up of human or animal tissue. The valves composed of human tissue, known as allografts or homografts, are from donors' human hearts. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14286", "text": "Mechanical valves can be a better choice for younger people and people at risk of valve deterioration due to its durability. It is also preferable for people who are already taking blood thinners and people who would be unlikely to tolerate another valve replacement operation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14287", "text": "Tissue valves are better for older age groups as another valve replacement operation may not be needed in their lifetime. Due to the risk of forming blood clots for mechanical valves and severe bleeding as a major side effect of taking blood-thinning medications, people who have a risk of blood bleeding and are not willing to take warfarin may also consider tissue valves. Other patients who may be more suitable for tissue valves are people who have other planned surgeries and unable to take blood-thinning medications. People who plan to become pregnant may also consider tissue valves as warfarin causes risks in pregnancy. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14288", "text": "An artificial heart valve should ideally function like a natural heart valve. [ 11 ]  The functioning of natural heart valves is characterized by many advantages:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14289", "text": "The performance of an artificial heart valve can be tested  in vitro  before clinical use by means of a  pulse duplicator . [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14290", "text": "Artificial heart valves are expected to last from 10 to 30 years. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14291", "text": "The most common problems with artificial heart valves are various forms of degeneration, including gross billowing of leaflets, ischemic mitral valve pathology, and minor chordal lengthening. [ 24 ]  The repairing process of the artificial heart valve regurgitation and stenosis usually requires an open-heart surgery, and a repair or partial replacement of regurgitant valves is usually preferred. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14292", "text": "Researchers are investigating catheter-based surgery that allows repair of an artificial heart valve without large incisions. [ 33 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14293", "text": "Researchers are investigating Interchangeable Prosthetic Heart Valve that allows redo and fast-track repair of an artificial heart valve.  [ 34 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14294", "text": "Atrial septostomy  is a  surgical procedure  in which a small hole is created between the upper two chambers of the  heart , the  atria . This procedure is primarily used to palliate  dextro-Transposition of the great arteries  or d-TGA (often imprecisely called  transposition of the great arteries ), a life-threatening  cyanotic   congenital heart defect  seen in infants. It is performed prior to an  arterial switch operation . Atrial septostomy has also seen limited use as a surgical treatment for  pulmonary hypertension . [ 1 ]  The first atrial septostomy (then less precisely called a septectomy) was developed by  Vivien Thomas  in a canine model and performed in humans by  Alfred Blalock . The Rashkind balloon procedure, a common atrial septostomy technique, was developed in 1966 by American cardiologist  William Rashkind  at the  Children's Hospital of Philadelphia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14295", "text": "There are two types of this procedure:  balloon atrial septostomy  (also called  endovascular atrial septostomy ,  Rashkind atrial balloon septostomy , or simply  Rashkind's procedure ) and  blade atrial septostomy  (also called  static balloon atrial septostomy )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14296", "text": "In a normal  heart ,  oxygen -depleted blood (\"blue\") is pumped from the  right side of the heart , through the  pulmonary artery , to the  lungs  where it is oxygenated. This is the  pulmonary circulation  part of blood flow. The oxygen-rich (\"red\") blood then returns to the  left heart , via the  pulmonary veins , and is pumped through the  aorta  to the rest of the body, including the heart  muscle  itself. This is the  systemic circulation  part of blood flow, the other loop of an interconnected normal  cardio - pulmonary  system. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14297", "text": "With d-TGA, certain major blood vessels are connected improperly, so oxygen-poor blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps oxygen-rich blood continuously back into the lungs through the pulmonary artery. This is a life-threatening situation due to the resultant  low oxygen levels  throughout the body. Atrial septostomy allows more of the oxygen-rich blood to circulate throughout the body. The procedure is a temporary measure meant to help the patient survive until further corrective surgery can be done."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14298", "text": "In the separate case of pulmonary hypertension, abnormally high blood pressure in the blood vessels within and connected to the lungs puts stress on the right side of the heart, potentially leading to  right heart failure . Atrial septostomy relieves some of this pressure, but at the cost of lower oxygen levels in the blood ( hypoxia ). As with d-TGA, this surgery is not a definitive solution to the underlying medical problem. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14299", "text": "The majority of atrial septostomies are performed on infants with d-TGA or other  cyanotic heart defects . In these cases, a  balloon catheter  is guided through a large  vein  into the  right atrium , during  cardiac catheterization . The catheter is threaded into the  foramen ovale , a naturally existing hole between the atria that normally closes shortly after birth. The balloon at the end of the catheter is inflated so as to enlarge the foramen ovale enough that it will no longer become sealed. This allows more oxygenated blood to enter the  right heart  (especially in the case of d-TGA) where it can be pumped to the rest of the body. The balloon is deflated and the catheter is removed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14300", "text": "Sometimes the initial surgery is not entirely successful, or there are other factors that make a simple balloon atrial septostomy impossible, such as an older patient whose foramen ovale has already closed. This is when a blade atrial septostomy is performed. The details of the procedure are largely the same, except that a small blade on the end of the  catheter  is first used to create an opening between the right and left atria, before the insertion of the balloon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14301", "text": "The Rashkind balloon atrial septostomy is performed during  cardiac catheterization  (heart cath), in which a  balloon catheter  is used to enlarge a  foramen ovale ,  patent foramen ovale  (PFO), or  atrial septal defect  (ASD) in order to increase  oxygen saturation  in patients with  cyanotic   congenital   heart defects  (CHDs). It was developed in 1966 by  American   surgeons   William Rashkind  and  William Miller  at the  Children's Hospital of Philadelphia ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14302", "text": "William Rashkind was not a surgeon, but a pediatric cardiologist at the Children's Hospital of Philadelphia.  He was one of the fathers of the field of interventional catheterization, and he developed not only this life-saving technique and device for neonates with transposition of the great arteries, but also devices to close atrial septal defects (ASDs) and persistent patent ductus arteriosus (PDA).  He was the chief of the Division of Pediatric Cardiology at the Children's Hospital of Philadelphia until his death in 1986 from malignant melanoma."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14303", "text": "As with any surgery, there are certain risks to atrial septostomy, including tearing of the cardiac tissue,  arrhythmias , and rarely, death."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14304", "text": "Atrial switch  is a  heart operation  performed to treat  dextro-Transposition of the great arteries . [ 1 ] [ 2 ]  It involves the construction of an atrial baffle which redirects the blood coming into the atria to restore the connection between systemic and pulmonary circulation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14305", "text": "Two variants of the atrial switch operation developed \u2013 the  Senning procedure  (1950s) which uses the patient's own tissue ( pericardium ) to construct the baffle, and the  Mustard procedure  (1960s), which uses a synthetic material. [ 4 ]  It has largely been replaced by the  arterial switch operation . [ 4 ]  The operation is more commonly performed in developing countries, where the condition frequently presents late. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14306", "text": "Bakulev Scientific Center for Cardiovascular Surgery  ( Russian :  \u041d\u0430\u0443\u0447\u043d\u044b\u0439 \u0446\u0435\u043d\u0442\u0440 \u0441\u0435\u0440\u0434\u0435\u0447\u043d\u043e-\u0441\u043e\u0441\u0443\u0434\u0438\u0441\u0442\u043e\u0439 \u0445\u0438\u0440\u0443\u0440\u0433\u0438\u0438 \u0438\u043c. \u0410.\u041d. \u0411\u0430\u043a\u0443\u043b\u0435\u0432\u0430 ) is attached to the  Russian Academy of Medical Sciences  and is one of the leading  cardiovascular surgery -related facilities of the  Russian Federation . The center consists of  Burakovskiy Institute of Cardiac Surgery  and the Institute of Coronary and Vascular Surgery, both located in  Moscow , as wells as it has a filial branch in  Perm  - Perm Heart Institute. In 2005 the Center started the first phase of research into the transplant of  marrow cells  in patients with  acute myocardial infarction . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14307", "text": "The Center was founded in 1956 by  Soviet  surgeon  Aleksandr Bakulev , being officially named the Thoracal Surgery Institute of the Academy of Medical Sciences of the USSR (\u0418\u043d\u0441\u0442\u0438\u0442\u0443\u0442 \u0433\u0440\u0443\u0434\u043d\u043e\u0439 \u0445\u0438\u0440\u0443\u0440\u0433\u0438\u0438 \u0410\u043a\u0430\u0434\u0435\u043c\u0438\u0438 \u043c\u0435\u0434\u0438\u0446\u0438\u043d\u0441\u043a\u0438\u0445 \u043d\u0430\u0443\u043a \u0421\u0421\u0421\u0420) at the time. In 1961 the facility was renamed to the Institute of Cardiovascular Surgery and in 1967, following Bakulev's death, gained his name. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14308", "text": "The network community  Dissernet  has pointed out that the Center has repeatedly (>45 cases) awarded the Ph.D level degrees based on heavily plagiarised and sometimes falsified theses. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14309", "text": "55\u00b045\u203242\u2033N   37\u00b022\u203236\u2033E \ufeff / \ufeff 55.76167\u00b0N 37.37667\u00b0E \ufeff /  55.76167; 37.37667"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14310", "text": "Balloon septostomy  is the widening of a  foramen ovale ,  patent foramen ovale  ( PFO ), or  atrial septal defect  ( ASD ) via  cardiac catheterization  ( heart cath ) using a  balloon catheter . This procedure allows a greater amount of  oxygenated   blood  to enter the  systemic circulation  in some cases of  cyanotic   congenital   heart defect  ( CHD ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14311", "text": "After the catheter is inserted, the deflated balloon catheter is passed from the  right atrium  through the foramen ovale, PFO or ASD into the left atrium, it is then  inflated  and pulled back through to the right atrium, thereby enlarging the opening and allowing greater amounts of blood to pass through it. The resulting man-made opening is one of many forms of  shunting , and is often referred to as an ASD."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14312", "text": "This is normally a  palliative  procedure used to prepare a patient for, or sustain them until, a  corrective surgery  can be performed. At this time the ASD is closed using either  sutures  or a  cardiac patch , depending on the size and/or nature of the opening. The procedure is often unsuccessful in infants and children older than one month because of a thickened septum. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14313", "text": "Dhaniram Baruah  is an Indian  heart surgeon  from Assam, known for his work in the field of  xenotransplantation . He is popularly known as India's  Pig Heart Doctor . [ 1 ]  On 1 January 1997, he became the first heart surgeon in the world to transplant a pig's heart in a human body. [ 2 ]  Although the recipient died subsequently, it was a precursor to the first successful pig-to-human heart transplant performed 25 years later by  Bartley P. Griffith  in January 2022. [ 3 ]  While Griffith used a genetically modified pig's heart, Barua had transplanted a normal pig heart. [ 4 ]  Barua is also the founder of Dr Dhaniram Baruah Heart Institute & Research Centre. [ 5 ]  He can only communicate through hand gestures after a  brain stroke  left him unable to speak. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14314", "text": "Throughout his career Barua has courted controversies due to his maverick ideas and unconventional methods. [ 7 ]  The pig heart transplanted by Barua in his patient Purna Saikia worked for seven days, after which due to implications of infections, and the transplant was rejected by the recipient's body. Barua was sent to jail for 40 days in 1997 for negligence and violation of medical ethics. His clinic and research center was burnt down by an angry mob. He was also called a mad man and ostracised from the local community. But undeterred he continued his experiments, and claimed that successful transplantation of a pig heart in a human body was feasible. He later claimed damages from the Government for his humiliation and unjust treatment. [ 8 ]  He also claimed to have found a cure for HIV/AIDS. [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14315", "text": "Barua claims to have cured 86 patients of HIV/AIDS for which no conventional medicine is available. [ 12 ]  He has written a two-volume book titled \"AIDS Reaching the Unreachable with Baruah Combat Genes\". [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14316", "text": "The  Batista procedure  (also called a reduction left ventriculoplasty) was an experimental heart procedure that proposed the reversal of the effects of remodeling in cases of end-stage  dilated cardiomyopathy  refractory to conventional medical therapy. The hypothesis of the operation appears to be that reduction (resection) of marginally viable ventricular mass may result in superior geometric remodeling thus conferring better performance when faced with ventricular failure. In spite of promising initial results, the method was soon found to be of little if any benefit, and it is no longer considered a recommended treatment for the disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14317", "text": "The Batista procedure was invented by Brazilian physician and cardiac surgeon  Randas Batista  in 1994 for use in patients with non-ischemic  dilated cardiomyopathy . Many of his patients were victims of  Chagas disease . Chagas disease represents a parasitic nonischemic cardiomyopathy targeting parasympathetic inflow to the heart. Chagas cardiomyopathy thus represents a unique method of study of diastolic heart failure. It may be addressed by removal of a portion of viable tissue from the left ventricle to reduce its size (partial left ventriculectomy), with or without repair or replacement of the mitral valve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14318", "text": "Although several studies showed benefits from this surgery, studies at the  Cleveland Clinic  concluded that this procedure was associated with a high early and late failure rate. At 3 years only 26 percent were event-free and survival rate was only 60 percent. [ 2 ]  Most hospitals in the US have abandoned this operation and it is no longer included in heart failure guidelines. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14319", "text": "The  Bentall procedure  is a type of  cardiac surgery  involving composite graft replacement of the  aortic valve ,  aortic root , and  ascending aorta , with re-implantation of the  coronary arteries  into the graft.  This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with  Marfan syndrome .  The Bentall procedure was first described in 1968 by  Hugh Bentall  and Antony De Bono. [ 1 ]  It is considered a standard for individuals who require aortic root replacement, and the vast majority of individuals who undergo the surgery receive  mechanical valves . [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14320", "text": "Since its inception, the Bentall procedure has been considered a gold standard of aortic valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14321", "text": "Importantly, the use of mechanical vs biologic valves are not predictive of quality of life overall, morbidity and mortality. [ 5 ] [ 6 ]  General guidelines for the repair of valvular heart disease indicate the medical team takes into consideration the following patient factors for the determination of best conduit to use: age, life expectancy, lifestyle choices (diet, exercise, hobbies, risk of potential falls/ physical trauma), medical history (history of stroke or blood clots), likelihood of surgical or transcatheter repeat procedure, and of course patient preference."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14322", "text": "The Bentall procedure is considered for patients who may have Marfan syndrome, aortic dissection, aortic root aneurysm, aortic regurgitation of the valve. calcification of the aortic valve, and congenital anomalies. [ 1 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14323", "text": "Early Morbidity and Mortality \nWithin 30 days of hospitalization, morbidity and mortality after Bentall procedure are associated with complications stemming from  cardiac arrhythmia ,  pneumonia ,  acute respiratory distress syndrome (ARDS) ,  sepsis , graft infection, wound infection, neurologic/ cerebrovascular accident and  stroke , hemorrhage/ bleeding,  myocardial infarction ,  pericardial effusion , organ damage/ deterioration. [ 8 ]  Overall, these complications are seen in < 6% of patients undergoing this procedure, with risk of complications being greatly associated with other preexisting risk factors and comorbidities. [ 3 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14324", "text": "Like early morbidity and mortality, infection of a graft after Bentall Procedure is rare affecting < 5% of cases, but can be of very serious consequence to the patient. [ 8 ] [ 9 ]  Many of these patients who develop infections have multiple comorbidities and risk factors existing before the surgery including diabetes, suppression of the immune system, preexisting cardiovascular issues outside of the direct indication for a Bentall procedure and cancer. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14325", "text": "Graft infection from a Bentall procedure presents similarly to many infections after a major cardiac surgery, with indications in various degrees of severity. Symptoms can include fever, chills, loss of appetite, weight loss, malaise with clinical indications including septic emboli, abscess, left ventricular fistulae, transient ischemic attack. [ 7 ] [ 9 ]  These can occur weeks to years after the Bentall procedure itself."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14326", "text": "If a patient is suspected to have a graft infection, they should immediately seek medical attention. Evaluation of an infection may include blood work including  CBC ,  CMP ,  blood cultures . Further assessment and imaging may involve  transesophageal echocardiography ,  CT scan ,  CT Angiography ,  PET scan . [ 9 ] [ 10 ]  Depending on the modality, evidence of infection includes: increased glucose uptake,  pseudoaneurysm , fistula, fluid/ attenuation around the graft (indicating increased inflammation), or other increased signs of inflammation around the graft; these findings are then taken into account and assessed in the context of the clinical/ symptomatic picture of the patient. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14327", "text": "If a graft infection is highly likely, treatment involves admission to a hospital setting and administration of IV antibiotics. If the infection does not resolve, a graft infection may eventually require either an attempt at graft salvage or a revision surgery for the removal of the infected graft. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14328", "text": "Valve sparing aortic root replacement (VSARR)  is an alternative procedure to the composite aortic valve graft (CAGVR, Bentall procedure). A notable benefit of VSARR is the reduced need for anticoagulation, as the patient's own aortic valve is spared and does not need to be replaced with a mechanical or bioprosthetic valve. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14329", "text": "The VSARR is relatively new compared to the Bentall procedure and is performed about two thirds less often, associated with the increased skill and learning curve needed to navigate the procedure. [ 11 ]  Additionally, literature overall has shown unclear longevity and longitudinal patient outcomes compared to the Bentall procedure. Recently, there is some evidence VSARR has superior survival rates at 10 and 15 years along with reduced early mortality. [ 11 ]  Moreover, while there is a decreased reoperation rate in the first 5 years seen with the Bentall procedure, the need for reoperation after Bentall and VSARR are then comparable thereafter. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14330", "text": "Vocabulary:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14331", "text": "Endovascular procedures have been gaining popularity, especially within the last decade, due to their faster healing times and often lower risk of complications. The creation of the Endo-Bentall device showcases a Bentall procedure, but performed in a minimally invasive setting. [ 13 ]  This is an option for high risk patients otherwise not a candidate for a traditional open procedure. The Endo-Bentall device is made up of three parts: a self-expanding  transcatheter aortic valve (TAVR)  +  aortic endovascular stent graft (TEVAR)  and wire-reinforced fenestrations. [ 13 ]  Candidacy of this procedure is determined by an interdisciplinary team which may include cardiac and vascular surgeons, as well as interventional cardiologists. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14332", "text": "There are several limitations of using the Endo-Bentall, including: incorporating coronary arteries, modifying TAVR devices to be better suited for treating aortic valve insufficiency and regurgitation, and addressing a need for dedicated bridging stents. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14333", "text": "Beyond the Endo-Bentall, modern literature points to some promising future directions for the repair of the ascending aorta and aortic arch, including: steerable device delivery sheaths, dedicated bridging stents, grafts that can adjust for deployability/ improved positioning, grafts with better anti-embolic protection, left ventricle wires that minimize trauma to the heart, and fusion imaging optimization. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14334", "text": "The  Blalock\u2013Hanlon procedure  was created by Alfred Blalock and C. Rollins Hanlon. It was described in 1950. [ 1 ]  Alfred Blalock was an American surgeon most known for his work on the Blue Baby syndrome. [ 2 ]  C. Rollins Hanlon was also an American surgeon but was best known for his work in cardiology. [ 3 ]  The procedure that these two men created, known as the Blalock\u2013Hanlon procedure, was a new concept termed atrial septectomy. This procedure had been experimented on the right atrium of dogs before Dr. Blalock and Dr. Hanlon had performed it on humans. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14335", "text": "It involves the intentional creation of a septal defect in order to alter the flow of oxygenated blood.  It was devised as a palliative correction for  transposition of the great vessels ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14336", "text": "The Blalock\u2013Hanlon procedure was a cardiothoracic procedure created in the 1950s. The Blalock\u2013Hanlon procedure was created to enhance intracardiac combinations. [ 5 ]  A majority of the surgeries using this procedure were performed in pediatrics on infants ranging from one day to five months of age. [ 5 ]  Of all the children who had this surgery, only one had to undergo a second operation to repair damage not fixed during the Blalock\u2013Hanlon procedure. [ 6 ]  According to Behrendt, Orringer, and Stern, there were only ten early deaths out of the forty-eight children the operation was performed on. [ 5 ]  The deaths were of children that were less than one month old due to extensive measures taken during the operation. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14337", "text": "The procedure also had a relatively high mortality rate of only twenty-one percent while it was performed however, because of the excessive mortality rate it is no longer used in today's medical society. [ 5 ]  This procedure was a combination of two circulations (Pulmonary and Systematic). [ 4 ]  Due to the intracardiac mixing, the procedure can cause postoperative arrhythmias, cerebral thrombosis, adhesions develops in the pericardial space, and many infants will face death between the septectomy. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14338", "text": "The  Blalock\u2013Thomas\u2013Taussig shunt  ( BTT shunt ), [ 1 ]  previously known as the  Blalock\u2013Taussig Shunt  ( BT shunt ), [ 2 ]  is a surgical procedure used to increase blood flow to the lungs in some forms of  congenital heart disease [ 3 ]  such as  pulmonary atresia  and  tetralogy of Fallot , which are common causes of  blue baby syndrome . [ 3 ]  The procedure involves connecting a branch of the  subclavian artery  or  carotid artery  to the  pulmonary artery . In modern practice, this procedure is temporarily used to direct blood flow to the lungs and relieve cyanosis while the infant is waiting for corrective or definitive surgery when their heart is larger. The BTT shunt is used in the first step of the three-stage palliation (the  Norwood procedure )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14339", "text": "While the originally described Blalock\u2013Thomas\u2013Taussig shunt directly connected the subclavian and pulmonary arteries, in contemporary practice a modified version of the procedure, the mBTT shunt, is more commonly used. [ 2 ] [ 4 ]  In the modified Blalock\u2013Thomas\u2013Taussig shunt, a length of artificial tubing typically made from  PTFE  ( Gore-tex ) is sewn between either the subclavian or the carotid artery and the corresponding side branch of the pulmonary artery. [ 4 ]  This modification removes the need to cut off blood supply and makes it easier to regulate the blood flow to the lungs. Some centers now use a shunt directly from the right ventricle to the pulmonary artery, a  Sano shunt . This is done to avoid the reduced diastolic blood flow in the  coronary circulation  associated with the mBTT shunt. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14340", "text": "The original procedure was named for  Alfred Blalock , surgeon, Culloden, GA (1899\u20131964),  Helen B. Taussig , cardiologist, Baltimore/Boston (1898\u20131986) and  Vivien Thomas  (1910\u20131985) who was at that time Blalock's laboratory assistant. They all helped to develop the procedure. Taussig, who treated hundreds of infants and children with this disorder, had observed that children with a cyanotic heart defect and a  patent ductus arteriosus  (PDA) lived longer than those without the PDA. It, therefore, seemed to her that a shunt that mimicked the function of a PDA might relieve the tetralogy patients' poor oxygenation. In 1943, having broached the possibility of a surgical solution to  Robert Gross  of Boston without success, Taussig approached Blalock and Thomas in their Hopkins laboratory in 1943. According to the account of the original consultation between the three provided in Vivien Thomas' 1985 autobiography  Partners of the Heart , Taussig carefully described the anomaly of Tetralogy of Fallot, but made no suggestion about the specific surgical correction required, observing merely that it should be possible to get more blood to the lungs, \"as a plumber changes pipes around.\"  Although Taussig was not aware of it at that time, Blalock and Thomas had already experimented with such an  anastomosis , one that Blalock had conceived years earlier for a different purpose but which had the unanticipated effect of re-routing blood to the lungs. The operation involved the joining of the subclavian artery to the pulmonary artery. After meeting with Taussig, the two men set about perfecting the operation in the animal lab, with Thomas performing the subclavian-to-pulmonary anastomosis alone in some 200 laboratory dogs, then adapting the instruments for the first human surgery from those used on the experimental animals and coaching Blalock through the first 100 operations on infants. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14341", "text": "Thomas' autobiographical account, corroborated by the participants in the early tetralogy operations ( Denton Cooley  and the late William P. Longmire, Jr., intern and resident respectively during the surgery) has led to the recent conclusion that Thomas' contribution, both experimentally and clinically, was so critical that he should have received credit for the procedure along with Blalock and Taussig. However, because of the racial prejudices of the time, and the academic custom which generally precluded mention of non-degreed lab assistants (Thomas had no formal education beyond high school), he did not receive the honor of having the shunt named after him. The 2004 HBO television movie  Something the Lord Made , based on  Washingtonian  writer Katie McCabe's 1989 article of the same name, was made about his role in the historic Blue Baby surgery, as was the 2003 public television documentary  Partners of the Heart. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14342", "text": "Cardiomyoplasty  is a surgical procedure in which healthy  muscle  from another part of the body is wrapped around the  heart  to provide support for the failing heart. [ 1 ]  Most often the  latissimus dorsi muscle  is used for this purpose. A special pacemaker is implanted to make the skeletal muscle contract. If cardiomyoplasty is successful and increased cardiac output is achieved, it usually acts as a bridging therapy, giving time for damaged  myocardium  to be treated in other ways, such as remodeling by cellular therapies. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14343", "text": "Cellular cardiomyoplasty  is a method which augments myocardial function and cardiac output by directly growing new muscle cells in the damaged myocardium (heart muscle). Tissue engineering, which is now being categorized as a form of regenerative medicine, can be defined as biomedical engineering to reconstruct, repair, and improve biological tissues. Research efforts in tissue engineering have been ongoing and it is emerging as one of the key areas of medical research. Furthermore, there are vast developments in tissue engineering, which involve leveraging of technologies from biomaterials, molecular medicine, biochemistry, nanotechnology, genetic and biomedical engineering for regeneration and cell expansion targets to restructure and/or repair human organs. Injection of cardiomyogenic and/or angiogenic stem cells have been proposed as alternatives to existing treatments. For cardiovascular application, skeletal myoblasts are of great interest as they can be easily isolated and are associated with high proliferation rate. These cells have also been demonstrated to be  hypoxia -resistant."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14344", "text": "Bone marrow contains different cell populations, which exhibit excellent plasticity toward cardiogenic and endothelial cells. These cell populations are endothelial progenitor cells, hematopoietic stem cells and mesenchymal stem cells.  Adipose tissue host progenitor cells with reported interesting cardiomyogenic and vasculogenic potential in the sense that they improve heart functions and reduce infarction size in rodent animal models.  Subcutaneous adipose tissue is also a source of mesenchymal stem cells and have demonstrated positive outcomes in terms of cardiovascular tissue remodeling. Mammal hearts also host naturally occurring cardiac stem cells which may be capable of differentiating themselves into cardiomyocytes, endothelial cells and cardiac fibroblasts. [ 4 ]  This self-regeneration capacity gives rise to alternatives to classical cellular therapies whereby administration of growth factors such as Thymosin \u03b24 for cell activation and migration are solely necessary. Largely democratized in terms of population information, embryonic stem cells are known for their strong capacity for expansion and differentiation into cardiomyocytes, endothelial cells and cardiac fibroblasts."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14345", "text": "However, if non autologous, immunosuppression therapy is associated with such treatment. Hence, research has been focused on induced pluripotent stem cells (iPSCs) from somatic human tissue. Further to cell and necessary relevant growth factor selection, cell delivery is an important issue.  Indeed, the intracoronary route is the most straightforward cell delivery route as associated with intramyocardial cellular retention; retention rates are however low, i.e. exceed 10%. Washed off cells reach other organs or die, which can be an issue at the time of prepare ICH module 8. Other alternative injection routes have been studied, namely injection  via sternotomy, endomyocardial  and intracoronary routes. Nevertheless, all methods aforementioned have been associated with limited cardiac function improvements and limited cell survival once implanted in the fibrous myocardium."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14346", "text": "To resume, stem cells and delivery routes aforementioned are suitable for cardiomyoplasty as demonstrated safe with some degree of benefit for the patient. However, cardiac remodelling remains limited due to limited cell residency, impact of mechanical forces onto cell survival and tissue hypoxia. Furthermore, lack of cellular electrochemical coupling can lead to arrhythmias. Another point of consideration concerns the use of embryonic stem cells, whereby indifferentiation yields uncontrolled proliferation and possible consequent formation of teratomas. Also iPSCs have been associated with viral infection and eventual oncogenicity. Cardiac tissue engineering is a new technology based on the use of combinations of cells with regenerative capacity, biological and/or synthetic materials, cell signaling agents to induce the regeneration of an organ or damaged tissue. In an ideal scenario, regenerated tissue would reproduce sophisticated asymmetric helicodoidal architecture of the myocardium with the production of specialized extracellular matrix to stimulate vascularization in the implanted tissue. From a cellular perspective, [ 5 ]  available techniques are monolayer cell construct onto temperature-sensitive polymer, where their detachment is driven by behavior of the mechanical properties of the synthetic support without the need of any enzymatic digestion such as trypsin. Cardiomyocites sheets have also been successfully implanted with an observed contractile function as a result of inter-cellular communication between the host and graft. However, from a practical point of view, such approach lacks of translational character as all studies share the lack of reproducibility, i.e. a construct of similar characteristics of the native tissue does not guarantee the same results. Another approach resides in the use of hydrogels. Natural hydrogels such as Matrigel, [ 6 ]  collagen and fibrin have been used as entrapment matrices, wherein the cells to be injected are embedded. However the associated high pressure of injection is associated with a high mortality rate for the cells thereby negatively impacting the benefit ratio of this approach. Furthermore, from a technical point of view, due to the polydispersity of these natural hydrogels, purification is a requisite but very difficult step. Synthetic hydrogels, such as  polyethylene glycol , polylactic acid, polylactic acid-co-glycolic acid, polycaprolactone, polyacrylamide and polyurethane have been proposed.  Metalloproteinase-sensitive polyethylene is of particular interest. Indeed, this polymer modulates its mechanical and biophysical properties accordingly to enzymatic activities associated with cardiomyogenic differentiation of implanted cells. To date, no hydrogel matrix is FDA-approved for stem cell therapy use despite a large number of biomaterials currently commercially available."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14347", "text": "A general comment on hydrogel based technologies:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14348", "text": "Natural hydrogel are well tolerated by the host and cells due to their mimicking the natural ECM in terms of backbone and microstructure. However they suffer from batch to batch variation (a drawback for current Good Manufacturing Practices (cGMPs) required for clinical application), high degradation rates, and poor tenability. Synthetic hydrogels are reproducible, tunable and amenable regulatory and manufacturing protocols. [ 7 ] [ 8 ] [ 9 ]  Their chemical modification permits the integration of cellular attachment sites and a certain control over degradation rates. Semi-synthetic hydrogels share characteristics of both classes. Indeed, they permit either the modification of the purified natural biopolymers or by coupling the synthetic component with integrin and/or growth factor binding sites."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14349", "text": "Cardioplegia  is a solution given to the heart during cardiac surgery, to minimize the damage caused by  myocardial ischemia  while the heart is paused."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14350", "text": "The word  cardioplegia  combines the Greek  cardio  meaning the \"heart\", and  plegia  \"paralysis\". [ 1 ]  Technically, this means arresting or stopping the heart so that surgical procedures can be done in a still and bloodless field. Most commonly, however, the word  cardioplegia  refers to the solution used to bring about  asystole  of the heart, or heart paralysis. One of the first physicians to use the term cardioplegia was Dr. Lam in 1957. However his work on the myocardial protection was preceded serendipitously by  Sydney Ringer  in the late 1800s. At that time Ringer and colleagues noticed that tap water had the ability to increase contractility of the heart, likely due to its high calcium content. Sydney Ringer also commented on the importance of potassium ion concentration on depressing intrinsic heart rhythm. Through a series of experiments performed on frog and canine hearts, reversible arrest was achieved with potassium ions with the consequence of ventricular fibrillation and observed  myocardial   necrosis . These early experiments started nearly 50 years of work that has led to variety of  perfusion  strategies available today."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14351", "text": "The main goals of hypothermic cardioplegia are:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14352", "text": "The most common procedure for accomplishing asystole is infusing cold cardioplegic solution into the  coronary circulation . This process protects the  myocardium , or heart muscle, from damage during the period of ischemia. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14353", "text": "To achieve this, the patient is first placed on  cardiopulmonary bypass . This device, otherwise known as the heart-lung machine, takes over the functions of gas exchange by the lung and blood circulation by the heart. Subsequently, the heart is isolated from the rest of the blood circulation by means of an occlusive cross-clamp placed on the  ascending aorta  proximal to the  innominate artery .  During this period of heart isolation, the heart is not receiving any blood flow, thus no oxygen for metabolism.  As the cardioplegia solution distributes to the entire myocardium, the ECG will change and eventually asystole will ensue. Cardioplegia lowers the metabolic rate of the heart muscle, thereby preventing cell death during the ischemic period of time."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14354", "text": "Cardioplegic solution is the means by which the ischemic myocardium is protected from cell death. This is achieved by reducing myocardial metabolism through a reduction in cardiac work load and by the use of hypothermia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14355", "text": "Chemically, the high potassium concentration present in most cardioplegic solutions decreases the membrane resting potential of cardiac cells. The normal  resting potential  of ventricular myocytes is about -90 mV. [ 4 ]  When extracellular cardioplegia displaces blood surrounding myocytes, the membrane voltage becomes less negative and the cell depolarizes more readily. The depolarization causes contraction, intracellular calcium is sequestered by the sarcoplasmic reticulum via ATP-dependent Ca 2+  pumps, and the cell relaxes (diastole).  However, the high potassium concentration of the cardioplegia extracellular prevents repolarization. \nThe resting potential on ventricular myocardium is about \u221284\u00a0mV at an extracellular K +  concentration of 5.4\u00a0mmol/L. Raising the K +  concentration to 16.2\u00a0mmol/L raises the resting potential to \u221260\u00a0mV, a level at which muscle fibers are inexcitable to ordinary stimuli.  When the resting potential approaches \u221250\u00a0mV,  sodium channels are inactivated, resulting in a diastolic arrest of cardiac activity. [ 5 ]  Membrane inactivation gates, or  h   Na +  gates, are voltage dependent. The less negative the membrane voltage, the more  h  gates that tend to close. If partial depolarization is produced by a gradual process such as elevating the level of extracellular K + , then the gates have ample time to close and thereby inactivate some of the Na +  channels.  When the cell is partially depolarized, many of the Na +  channels are already inactivated, and only a fraction of these channels is available to conduct the inward Na +  current during phase 0 depolarization. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14356", "text": "The use of two other cations, Na +  and Ca 2+ , also can be used to arrest the heart.  By removing extracellular Na +  from perfusate, the heart will not beat because the action potential is dependent upon extracellular Na +  ions.  However, the removal of Na +  does not alter the resting membrane potential of the cell.  Likewise, removal of extracellular Ca 2+  results in a decreased contractile force, and eventual arrest in diastole. An example of a low [K + ] low [Na + ] solution is  histidine-tryptophan-ketoglutarate .  Conversely, increasing extracellular Ca 2+  concentration enhances contractile force.  Elevating Ca 2+  concentration to a high enough level results in cardiac arrest in systole.  This unfortunate irreversible event is referred to as \"stone-heart\" or rigor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14357", "text": "Hypothermia is the other key component of most cardioplegic strategies.  It is employed as another means to further lower myocardial metabolism during periods of  ischemia . The  Van 't Hoff equation  allows calculation that oxygen consumption will drop by 50% for every 10\u00a0\u00b0C reduction in temperature. This  Q 10  effect combined with a chemical cardiac arrest can reduce myocardial oxygen consumption (MVO 2 ) by 97%. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14358", "text": "Cold cardioplegia is given into the heart through the aortic root. Blood supply to the heart arises from the aortic root through  coronary arteries . Cardioplegia in diastole ensures that the heart does not use up the valuable energy stores ( adenosine triphosphate ). Blood is commonly added to this solution in varying amounts from 0 to 100%. Blood acts a buffer and also supplies nutrients to the heart during ischemia."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14359", "text": "Once the procedure on the heart vessels ( coronary artery bypass grafting ) or inside the heart such as  valve replacement  or correction of  congenital heart defect , etc. is over, the cross-clamp is removed and the isolation of the heart is terminated, so normal blood supply to the heart is restored and the heart starts beating again."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14360", "text": "The cold fluid (usually at 4\u00a0\u00b0C)  ensures that the heart cools down to a temperature of around 15\u201320\u00a0\u00b0C, thus slowing down the metabolism of the heart and thereby preventing damage to the heart muscle. This is further augmented by the cardioplegia component which is high in potassium."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14361", "text": "When solution is introduced into the  aortic root  (with an  aortic cross-clamp  on the distal aorta to limit systemic circulation), this is called antegrade cardioplegia.  When introduced into the  coronary sinus , it is called retrograde cardioplegia. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14362", "text": "Whilst there are several cardioplegic solutions commercially available; there are no clear advantages of one cardioplegic solution over another. Some cardioplegias, such as del Nido or Histidine-Tryptophan-Ketoglutamate solutions, offer an advantage over blood and other crystalloid cardioplegia as they only require one administration during short cardiac surgeries, compared to multiple doses required by blood and other crystalloid. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14363", "text": "In coronary surgery, there are various alternatives to cardioplegia to perform the operation. One is  off-pump  coronary surgery where the surgery is done without the need of a cardiopulmonary bypass machine. Another is to use cross-clamp fibrillation whereby the heart fibrillates whilst on cardiopulmonary bypass in order to perform the distal anastomoses. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14364", "text": "Cardiac surgical cases were performed with the aid of a cardiopulmonary pump, without cardioplegia or other means of protecting the heart. High mortality rates due to cardiac injury though, made surgeons to look on how to protect the heart. In 1955  D.G. Melrose  suggested \u2018\u2019elective cardiac arrest\u2019\u2019, a technique already used for other purposes, in order to protect the heart from ischemia- since cardiac muscle is not working, oxygen demands should be low. In the 1960\u2019s other groups introduced ice slur applied all over the heart\u2019s surface. The rationale was to decrease the temperature of the heart, thus to reduce oxygen demands further. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14365", "text": "The next decades many investigators (Bretschneider, Kirch and others)  came up with various solutions that could pause the heart without damaging cardiac muscle. In the same period, surgeons found out delivery roots for cardioplegia, other than the commonly used antegrade. Buckberg in North America and Menasche in Europe, introduced retrograde cardioplegia method, via a catheter inserted in Coronary Sinus and thus perfusing the heart in a retrograde fashion. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14366", "text": "Cardiothoracic anesthesiology  is a subspeciality of the medical practice of  anesthesiology , devoted to the preoperative, intraoperative, and postoperative care of adult and pediatric patients undergoing cardiothoracic surgery and related invasive procedures."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14367", "text": "It deals with the  anesthesia  aspects of care related to  surgical  cases such as  open heart surgery ,  lung  surgery, and other operations of the human  chest . These aspects include  perioperative  care with expert manipulation of patient cardiopulmonary physiology through precise and advanced application of  pharmacology , resuscitative techniques, critical care medicine, and invasive procedures. This also includes management of the  cardiopulmonary bypass  (heart-lung) machine, which most cardiac procedures require intraoperatively while the heart undergoes surgical correction. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14368", "text": "All anesthesiologists obtain either a  Doctor of Medicine  (MD) or  Doctor of Osteopathic Medicine  (DO) degree prior to entering post-medical school graduate medical education. After satisfactory completion of an  Accreditation Council for Graduate Medical Education  (ACGME) or  American Osteopathic Association  (AOA) accredited one year  internship  in either  internal medicine  or  surgery  and a three-year  residency  program in all subspecialties of  anesthesiology ,  formal advanced training in Cardiothoracic Anesthesiology is available via a one-year  fellowship . Cardiothoracic Anesthesia Fellowship - Department of Anesthesiology - Miller School of Medicine at the University of Miami   Society of Cardiovascular Anesthesiologists ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14369", "text": "The first Cardiothoracic Anesthesiology fellowship was formed at Harvard Medical School and the Massachusetts General Hospital in 1971.  Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine - Fellowships  Since then, Cardiothoracic Anesthesiology has become an  ACGME  approved fellowship (2007), and there are 64 ACGME accredited programs and 212 match positions for the 2017-2018 application year. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14370", "text": "This fellowship consists of at least eight months of adult Cardiothoracic Anesthesiology, one month dedicated to transesophageal echocardiography, one month in cardiothoracic intensive care unit and two months of elective rotation which includes inpatient or outpatient cardiology or pulmonary medicine, invasive cardiology, medical or surgical critical care and extracorporeal perfusion technology. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14371", "text": "Fellows are offered the opportunity to participate in clinical research and encouraged to present at national or international conferences after completion of a research project. The arenas of research can be as diverse as neuroprotection, [ 3 ]  myocardial protection, [ 4 ]  blood conservation strategies, [ 5 ]  and port access surgery."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14372", "text": "Fellows are trained to provide perioperative anesthetic management for patients with severe cardiopulmonary pathology. Some of the cardiac surgeries they train for include the following:  coronary artery bypass surgery  (CABG) both on cardiopulmonary bypass as well as on a beating heart,  heart valve  surgery, aortic reconstruction requiring deep hypothermic arrest, mechanical ventricular assist device (VAD) placement, thoracic  aortic aneurysm  repair,  aortic dissection  repair, heart transplants, lung transplants, heart/lung transplants, and adult congenital heart surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14373", "text": "Adequate exposure and experience provided in the management of adult patients for cardiac pacemaker and automatic implantable cardiac defibrillator placement, surgical treatment of cardiac arrhythmias, and the complete gamut of invasive cardiologic (catheter-based) and electrophysiological procedures is expected as well."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14374", "text": "Fellows also gain experience in perioperative medical (anesthetic) management of the cardiac patient, including management of intra-aortic balloon pumps (IABP) and ventricular assist devices (VAD), post-operative ICU care, blood transfusion medicine, electrophysiology, and transthoracic echocardiography.  Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine - Fellowships"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14375", "text": "Many fellowships also offer opportunity to become familiar with anesthetic techniques for pediatric cardiac surgery and minimally invasive cardiac surgery, however no formal case numbers for ACGME accreditation are required. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14376", "text": "In addition to the focused cardiac training, additional clinical experience within the full one-year fellowship includes anesthetic management of adult patients undergoing thoracic and vascular surgery. Fellows are trained to manage all type of thoracic surgeries which include  video-assisted thoracoscopic surgery  (VATS), [ 7 ]  open  thoracotomy , and advanced airway procedures involving the trachea. Fellows achieve expertise in different techniques of lung isolation and ventilation\nincluding double-lumen endotracheal tubes, bronchial blockers, Univent tubes under guidance of fiber optic bronchoscopy, and advanced jet ventilation. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14377", "text": "The complex nature of cardiothoracic surgery necessitates extra training to acquire the skills needed to be a cardiothoracic anesthesiology consultant. Fellows are trained to achieve expertise in the advanced monitoring techniques including invasive blood pressure, arterial blood gas analysis, cardiac output monitoring, jugular venous oxygen saturation, cerebral oximetry, Bispectral Index (BIS), [ 9 ]  Transcranial doppler (TCD), [ 10 ]  and Near infrared spectroscopy (NIRS). [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14378", "text": "Finally, invasive procedures completed by the cardiothoracic anesthesiology fellows include but are not limited to arterial line placement (femoral, axillary, brachial, radial), central venous cannulation (internal jugular, femoral, subclavian), pulmonary artery catheter placement, transvenous pacemaker placement, thoracic epidural analgesia, fiberoptic endotracheal tube placement, 2D/3D transesophageal echocardiography, intraspinal drainage placement, and advanced ultrasound guidance of vascular access. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14379", "text": "Echocardiography  produces a real-time image of the heart via ultrasound imaging, and can be performed in two or three dimensions. There are two ways of performing echocardiography depending on placement of echocardiography probe: transthoracic or transesophageal. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14380", "text": "In transthoracic echocardiography (TTE), the probe is placed over the patient's chest wall, while in transesophageal  echocardiography (TEE or TOE  in the UK), the probe is placed into the esophagus. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14381", "text": "Regardless of technique, each probe contains a transducer. While transmitting signals, it converts electrical energy to acoustic energy. When receiving signals, it converts acoustic energy to electrical energy, which is processed by the machine to form an image. Various techniques are employed to manipulate the data, including Doppler imaging. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14382", "text": "Transesophageal echocardiography  has rapidly become the most powerful monitoring technique and diagnostic tool for the management of cardiac surgical patients, primarily due to the  transesophageal echocardiogram  probe location and ability to be used intraoperatively.  It provides the detailed information about the structure and function of the heart/great vessels in real time, allowing the cardiothoracic anesthesiologist to precisely manage patient physiology while providing updates and direction to members of the surgical team throughout the pre, intra, and post operative time frame of patient care. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14383", "text": "After successful completion of the fellowship with subspecialty training in TEE, cardiothoracic anesthesiology fellows may sit for examination leading to board certification in echocardiography.  The examination, also known as the  Advanced PTEeXAM , is administered by  the National Board of Echocardiography (NBE).\n National Board of Echocardiography - PTEeXAM . In addition to passing the test, fellows can become board certified only after performing 150 exams as well as reviewing an additional 150 exams with a board certified cardiologist/cardiothoracic anesthesiologist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14384", "text": "Cardiopulmonary bypass (CPB) is a technique in which heart-lung machine temporarily takes over the function of the heart and lungs during surgery. The CPB is operated by the  perfusionist . During the heart operation, the perfusionist takes over the heart function. The perfusionist works in close relation with the anesthesiologist and the surgeon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14385", "text": "Blood is drained from the venous (deoxygenated) circulation, and is cycled through the CPB machine. While in the machine, the blood is filtered, heated or cooled, and infused with oxygen. Subsequently, it is pumped back into the arterial (oxygenated) circulation, thereby bypassing the heart and lungs and maintaining the  perfusion  of the vital organs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14386", "text": "While the step by step process for preparation and initiation of CPB can vary between institution and type of surgery, a typical scenario is as follows."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14387", "text": "After a  median sternotomy , a surgical retractor is placed by the surgeon to optimize exposure of the  heart . At this time,  heparin  is given to thin the blood to prevent  thrombus  from forming while on CPB. The surgeon places a  cannula  in the right atrium, vena cava, or femoral vein to withdraw blood from the venous circulation. The perfusionist uses gravity to drain the venous blood into the CPB machine, and a separate cannula, usually placed in the aorta or femoral artery, is used to return blood to the arterial circulation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14388", "text": "The process of preparation, initiation, and separation of cardiopulmonary bypass is a critical time during cardiac surgery. Some studies have even considered formalizing this period of time, much like the \"sterile cockpit\" process in critical steps of aviation  Is the \"sterile cockpit\" concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass . The communication, while a team effort, is led and directed by the cardiothoracic anesthesiologist, as the surgeon is focused  on acquiring and maintaining adequate exposure. This can even extend to placement of the cannulae for CPB preparation, as the cardiothoracic anesthesiologist often directs the surgical placement via real-time TEE data. As such, this responsibility demands that the cardiothoracic anesthesiologist have a thorough knowledge of the advanced physiology, principles, practical application and management of CPB."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14389", "text": "After completion of the \"on bypass\" surgical correction, preparations are made to separate the patient from CPB. In other words, the heart and lung are prepared to receive, oxygenate, and pump the blood which had immediately previous been done by the CPB machine. Separation can be complicated by the CPB machine, the patient's inherent pathology/physiology, surgical correction, and the dynamic interaction of all three. Cardiopulmonary bypass has effects on the patient's hematology, physiology, and immunology, which must be acutely managed by the cardiothoracic anesthesiologist in order to ensure effective separation from CPB."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14390", "text": "Patients with cardiothoracic pathology who present for non-cardiothoracic surgery are at increased risk for serious perioperative complications. Cardiothoracic anesthesiologists are often consulted by their colleagues to provide expert management during intraoperative hemodynamic instability or  cardiac arrest  by evaluating heart function with the aid of TEE and placement of other invasive advanced hemodynamic monitors, such as pacing swans. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14391", "text": "A  cardiotomy  is a  surgical procedure  where an  incision  is made in the  heart . It can be used for  suction  during  heart surgery . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14392", "text": "A  catheterization laboratory , commonly referred to as a  cath lab , is an examination room in a hospital or clinic with  diagnostic imaging  equipment used to visualize the arteries of the heart and the chambers of the  heart  and treat any  stenosis  or abnormality found."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14393", "text": "Most catheterization laboratories are \"single plane\" facilities, those that have a single  X-ray  generator source and an  X-ray image intensifier  for  fluoroscopic  imaging. [ 1 ]  Older cath labs used  cine film  to record the information obtained, but since 2000, most new facilities are  digital . The latest digital cath labs are biplane (have two X-ray sources) and use  flat panel detectors . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14394", "text": "Cardiac catheterization laboratories are usually staffed by a multidisciplinary team. This may include a medical practitioner (normally either a consultant  cardiologist  or  radiologist ), cardiac  physiologist ,  radiographer  and  nurse . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14395", "text": "The consultant cardiologist is responsible for gaining arterial access, inserting a sheath into either the  radial  or  femoral artery , passing a wire and  catheter  into the coronary artery and selectively injecting  contrast media  into the coronary arteries. They then interpret the images taken to ascertain where the narrowed or blocked artery has the problem. They use a variety of techniques and imaging tools to measure the size of things such as balloons and  stents ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14396", "text": "Cardiac physiologists usually set up what is known as a  transducer  to monitor pressure in the arteries. They also have a live view of the patients  ECG  so they can tell whether or not there is a problem caused by the insertion of the catheter into the heart to the electrical pathways. [ 5 ] [ 6 ]  The physiologist will also set up a temporary pacemaker if the procedure is an angioplasty or a  percutaneous coronary intervention  (PCI). Finally, they also set up  defibrillators  on to the patient for emergency use if needed. In some locations, some of these responsibilities may be carried out by other personnel, such as trained nurses or technologists. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14397", "text": "Cardiac catheterization  is a general term for a group of procedures that are performed in the cath lab, such as  coronary angiography . Once a catheter is in place, it can be used to perform a number of procedures including  angioplasty , PCI ( percutaneous coronary intervention ) angiography,  transcatheter aortic valve replacement ,  balloon septostomy , and an  electrophysiology study  or  catheter ablation . Devices such as  pacemakers  may be fitted or  rotablation  to remove plaque can be performed. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14398", "text": "A  commissurotomy  ( / \u02cc k \u0252 m \u0259 \u0283 \u0259r \u02c8 \u0252 t \u0259 m i / ) is a  surgical  incision of a  commissure  in the body, as one made in the heart at the edges of the commissure formed by  cardiac valves , or one made in the brain to treat certain psychiatric disorders."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14399", "text": "Patients with  scleroderma , a disease that thickens and hardens the skin, sometimes require oral commissurotomy to open the corners of the mouth, the commissures, to allow dental treatment. This procedure often leaves characteristic scars."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14400", "text": "Commissurotomy of  cardiac valves  is called  valvulotomy , [ 1 ]  and consists of making one or more incisions at the edges of the commissure formed between two or three valves, in order to relieve constriction such as occurs in  valvular stenosis , especially  mitral valve stenosis . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14401", "text": "In  neurosurgery , as a treatment for severe epilepsy, the corpus callosum, or the area of the brain that connects the two hemispheres, would be completely bisected. By eliminating the connection between the two hemispheres of a patient's brain, electrical communication would be cut off greatly diminishing the amount and severity of the epileptic seizures. For some, seizures would be completely eliminated. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14402", "text": "Though no effect on behavior was observed after commissurotomy was performed on monkeys, it gave peculiar effects on human perception. Different functions of cognition are predominantly located on one of the hemispheres. For example, Brocas area, crucial for forming sentences, is on most people situated in the left hemisphere ventral to the facial motor cortex. The left hemisphere is referred to as the \"talking\" hemisphere and the right the \"silent\". A commisurotomy prevents any sensory input to the silent hemisphere from reaching the talking hemisphere. Since the left visual field is processed in the right hemisphere, a person with a commissurotomy is unable to describe objects to the left, because the \"talking\" hemisphere has not seen anything. It appears as though the person had not seen anything at all, and it does not bother him either. It can be demonstrated that stimuli to the right hemisphere for example give emotional response, but because of the severed corpus callosum it cannot be verbalized. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14403", "text": "Coronary artery bypass surgery , also known as  coronary artery bypass graft  ( CABG , pronounced \"cabbage\"), is a surgical procedure to treat  coronary artery disease  (CAD), the buildup of plaques in the arteries of the heart. It can relieve  chest pain  caused by CAD, slow the progression of CAD, and increase life expectancy. It aims to bypass  narrowings  in heart arteries by using arteries or veins  harvested  from other parts of the body, thus restoring adequate blood supply to the previously  ischemic  (deprived of blood) heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14404", "text": "There are two main approaches. The first uses a  cardiopulmonary bypass machine , a machine which takes over the functions of the heart and lungs during surgery by circulating blood and oxygen. With the heart in   cardioplegic arrest , harvested arteries and veins are used to connect across problematic regions\u2014a construction known as  surgical anastomosis . In the second approach, called the  off-pump coronary artery bypass  (OPCAB), these anastomoses are constructed while the heart is still beating. The anastomosis supplying the  left anterior descending branch  is the most significant one and usually, the  left internal mammary artery  is harvested for use. Other commonly employed sources are the right internal mammary artery, the  radial artery , and the  great saphenous vein ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14405", "text": "Effective ways to treat chest pain (specifically,  angina , a common symptom of CAD) have been sought since the beginning of the 20th century. In the 1960s, CABG was introduced in its modern form and has since become the main treatment for significant CAD. Significant complications of the operation include bleeding, heart problems ( heart attack ,  arrhythmias ),  stroke , infections (often  pneumonia ) and  injury to the kidneys ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14406", "text": "Coronary artery bypass surgery aims to prevent death from  coronary artery disease  and improve quality of life by relieving  angina , the associated feeling of chest pain. [ 1 ]  The decision to perform surgery is informed by studies of CABG's efficacy in different patient subgroups, based on the lesions' anatomy or how well the heart is functioning. These results are compared with that of other strategies, most importantly  percutaneous coronary intervention  (PCI). [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14407", "text": "Coronary artery disease is caused when  coronary arteries  of the heart accumulate  atheromatous plaques , causing  stenosis  (narrowing) in one or more arteries and risking  myocardial infarction , the interruption of blood supply to the heart. CAD can occur in any of the major vessels of the  coronary circulation : the left main stem, left ascending artery, circumflex artery, and right coronary artery, and branches thereof. CAD symptoms vary from none, to chest pain only when exercising (stable angina), to chest pain even at rest (unstable angina). It can even manifest as a myocardial infarction; if blood flow to the heart is not restored within a few hours, whether spontaneously or by medical intervention, the blood-deprived part of the heart becomes  necrotic  (dies) and is scarred. It may lead to other complications such as  arrhythmias , rupture of the  papillary muscles of the heart , or sudden death. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14408", "text": "There are various methods of detecting and assessing CAD. Apart from history and clinical examination, noninvasive methods include  electrocardiography  (ECG) at rest or during exercise, and  X-ray of the chest .  Echocardiography  can quantify heart functioning by measuring, for example, enlargement of the  left ventricle , the  ejection fraction , and the situation of the  heart valves . The most accurate ways to detect CAD are the  coronary angiogram  and the  coronary CT angiography . [ 4 ]  An angiogram can provide detailed anatomy of coronary circulation and lesions. The significance of each lesion is determined by the diameter loss. A diameter loss of 50% translates to a 75% cross-sectional area loss, considered moderate by most groups. Severe stenosis constitutes a diameter loss of 2/3 or more\u2014a greater-than-90% loss of cross-sectional area. [ 5 ]  To more accurately determine the severity of stenosis, interventional cardiologists may also employ  intravascular ultrasound , which can determine the severity and provide information on the composition of the atheromatous plaque. With the technique of  fractional flow reserve , the pressure after the stenosis is compared to mean aortic pressure. If the ratio is less than 0.80, then the stenosis is deemed significant. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14409", "text": "People with angina during exercise are usually first treated with medical therapy. Noninvasive tests help estimate which patients might benefit from undergoing coronary angiography. Generally, if portions of cardiac wall are receiving less blood than normal, coronary angiography is indicated; then, lesions are identified and inform a decision to undergo PCI or CABG. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14410", "text": "CABG is generally preferred over PCI when there is a significant burden of plaque on the coronary arteries, that is extensive and complex, due to survival benefit. Other indicators that a patient will benefit more from CABG rather than PCI include: decreased left-ventricle function;  left main disease ;  diabetes ; and complex triple system disease (including LAD, Cx and RCA), especially when the lesion in the LAD is at its proximal part. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14411", "text": "During an acute heart event, known as  acute coronary syndrome , it is paramount to quickly restore blood flow to heart tissue. Typically, patients arrive at the hospital with chest pain. They are first treated with drugs, particularly the strongest drugs that prevent clots within vessels (dual anti-platelet therapy:  aspirin  and  clopidogrel ). Patients at risk of ongoing ischemia undergo PCI to restore blood flow and thus oxygen delivery to the struggling heart. [ 7 ]  If PCI failed to restore blood flow because of anatomical considerations or other technical problems, urgent CABG is indicated to save heart tissue. The timing of the operation plays a role in survival: It is preferable to delay the surgery if possible (three days if the infarction affecting the total thickness of the cardiac muscle, and six hours if it does not). [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14412", "text": "CABG is also indicated when there are  mechanical complications of an infarction  ( ventricular septal defect ,  papillary muscle  rupture or myocardial rupture). [ 8 ]  There are no absolute contraindications of CABG, but severe disease of other organs such as the liver or brain, limited life expectancy, and patient fragility are considered. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14413", "text": "CABG is also performed when a patient is to undergo another cardiac surgical procedure, most commonly for  valve disease , and angiography reveals a significant lesion of the coronary arteries. [ 9 ]  CABG can also address  dissection  of coronary arteries, where a rupture of the coronary layers creates a pseudo- lumen  (cavity) and diminishes blood delivery to the heart. Such a dissection may be caused by pregnancy, tissue diseases like  Ehlers\u2013Danlos syndromes  and  Marfan syndrome , cocaine abuse, or PCI. A coronary aneurysm may also indicate CABG: A  blood clot  might develop within the vessel and travel downstream. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14414", "text": "CABG and percutaneous coronary intervention (PCI) are the two methods to restore blood flow caused by stenotic lesions of the coronary arteries. The choice of method is still a matter of debate, but it is clear that in the presence of complex lesions, significant left main disease, or diabetes, CABG yields better long-term survival and outcomes. [ 11 ] [ 10 ]  Strong indications for CABG also include symptomatic patients and impaired left ventricle function. [ 10 ]  CABG offers better results than PCI in left main disease and in CAD that affects multiple vessels, because of the protection arterial conduits offer to the native arteries of the heart, by producing  vasodilator  factors and preventing the advancement of plaques. Studies published in 2023 show that CABG in patients with left main disease is associated with lower mortality and fewer adverse events compared to PCI. [ 12 ] [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14415", "text": "Patients with unprotected left main disease\u2014when the runoff of the left main artery is not protected by a patent graft since a previous CABG operation\u2014have been studied as a group. A 2016 European study found that in these patients, CABG outperforms PCI in the long run (5 years). Another 2016 study found that PCI has similar results to CABG at 3 years, but that CABG becomes better than PCI after 4 years. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14416", "text": "A 2012 trial and followup in diabetic patients demonstrated a significant advantage to CABG over PCI. The relative advantage remained evident at 3.8-year and 7.5-year follow ups, which found particular benefits in smokers and younger patients. [ 16 ]  A 2015 trial compared CABG and the latest technological advancement of PCI, second-generation  drug-eluting stents  in multivessel disease. Their results indicated that CABG is a better option for CAD patients. [ 17 ]  A trial published in 2021, comparing results after one year, also concluded that CABG is a safer option than PCI. [ 18 ]  A large study published in 2023 showed that PCI patients had higher mortality than CABG patients with left main coronary artery disease. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14417", "text": "Routine preoperative examination aims to check the status of systems and organs besides the heart. The examination typically includes a chest X-ray to check the lungs, a  complete blood count , and kidney and liver function tests. Physical examination to determine the quality of the grafts or the safety of removing them, such as  varicosities in the legs , or the  Allen test  in the arm is performed to be sure that blood supply to the arm will not be critically disturbed. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14418", "text": "A patient taking anticoagulants\u2014 aspirin ,  clopidogrel ,  ticagrelol  and others\u2014will stop taking them several days before, to prevent excessive bleeding during and after the operation. Warfarin is also stopped for the same reason and the patient starts taking  heparin products  after the  INR  falls below 2.0. [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14419", "text": "After the angiogram is reviewed by the surgical team, targets are selected (that is, which native arteries will be bypassed and where the anastomosis should be placed). Ideally, all major lesions in significant vessels should be addressed. Most commonly, the left internal thoracic artery (LITA; formerly, left internal mammary artery, LIMA) is anastomosed to the left anterior descending artery (LAD) because the LAD is the most significant artery of the heart and supplies blood to a larger portion of myocardium than other arteries. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14420", "text": "A conduit can be used to graft one or more native arteries. In the latter case, an end-to-side anastomosis is performed. In the former, using a sequential anastomosis, a graft can then deliver blood to two or more native vessels of the heart. [ 21 ]  Also, the proximal part of a conduit can be anastomosed to the side of another conduit. It is preferred not to harvest too much conduit because it might necessitate re-operation. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14421", "text": "The intubated patient is brought to the  operating theater . Lines (e.g., peripheral IV cannulae, central lines such as internal jugular cannulae) are inserted for drug administration and monitoring. A description of a traditional CABG follows. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14422", "text": "An  incision in the sternum  is made while  vessels  are being  harvested , either from the arms or chest or from the leg, usually from the internal mammary artery or the saphenous vein. The LITA is harvested through the sternotomy. There are two common ways of mobilizing the LITA: the pedicle (i.e., a pedicle consisting of the artery plus surrounding fat and veins) and the skeletonized (i.e., freed of other tissues). Before the LITA is divided in its more distal part, the anticoagulant heparin is administered to the patient via a peripheral line, to prevent clots. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14423", "text": "After harvesting, the  pericardium \u2014the sac that surrounds the heart\u2014is opened and stay sutures are placed to keep it open.  Purse string  sutures are placed in the aorta to prepare the insertions of the cannula into the aorta, and a catheter which  temporarily arrests the heart  using a solution high in potassium. Another purse string is placed in the right atrium for the venous cannula. Once the cannulas and the catheter are placed, cardiopulmonary bypass (CPB) is commenced. Deoxygenated blood arriving to the heart from veins is forwarded to the CPB machine to get oxygenated, then delivered to the aorta to keep the rest of the body saturated. The blood is often cooled to 32\u201334\u00a0\u00b0C (90\u201393\u00a0\u00b0F) to slow  metabolism  and minimize the demand for oxygen. A clamp is placed on the aorta between the cardioplegic catheter and aortic cannula, so that the flow of cardioplegic solution may be controlled by adjusting the clamp. Within minutes, the heart stops beating. [ 21 ] [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14424", "text": "With the heart still, the tip of the heart is taken out of pericardium so that native arteries lying on the posterior side of the heart are accessible. Usually, distal anastomoses are constructed first (first to the right coronary system, then to the circumflex) and then the sequential anastomosis if necessary. Surgeons check the anastomosis for patency (whether it is sufficiently open) or leaking. They then insert the graft within the pericardium, sometimes attached to the cardioplegic catheter. The anastomosis of the LIMA to the LAD is usually the last distal anastomosis to be constructed; while it is being constructed the blood rewarming process starts (by the CPB). [ 21 ]  After the anastomosis is completed and checked for leaks, the proximal anastomoses of the conduits, if any, are next. They can be done either with the clamp still on, or after removing the aortic clamp and isolating a small segment of the aorta by placing a partial clamp. That said, aortas burdened by plaques might be damaged or release atheromatous debris by being overhandled. [ 21 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14425", "text": "After the proximal anastomoses are done, the clamp is removed and the aorta and conduits de-aired. Pacing wires, which supply a current to assist the heartbeat, might be placed. If the heart and other systems are functioning, CPB is discontinued and cannulae are removed.  Protamine  is administered to reverse the effect of the anticoagulant heparin. After possible bleeding sites are checked,  chest tubes  are placed and the sternum is closed. [ 21 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14426", "text": "Off-pump coronary artery bypass  (OPCAB) surgery avoids using the CPB machine by stabilizing small segments of the heart at a time. The surgical team and anesthesiologists must coordinate and take great care to not manipulate the heart too much, lest they compromise the stability of blood flow. Compromise should be detected immediately and appropriate action taken. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14427", "text": "Keeping a healthy heartbeat may involve maneuvers like placing atrial wires to protect from  bradycardia , or by placing stitches or incisions into the pericardium to help exposure. Snares and tapes are used to facilitate exposure. The aim is to avoid distal ischemia caused by blockage of the vessel supplying distal portions of the left ventricle, so usually LITA to LAD is the first to be anastomosed and others follow. For the anastomosis, a fine tube blowing humidified CO 2  keeps the surgical field clean of blood. Also, a shunt might be used so the blood can travel past the site of anastomosis. After the distal anastomoses are completed, proximal anastomoses to the aorta are constructed with a partially closed aortic clamp. The rest of the process is similar to on-pump CABG. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14428", "text": "When CABG is performed as an emergency because of a myocardial infarction, the highest priority is to salvage the struggling myocardium. Before operation, an  intra-aortic balloon pump  (IABP) might be inserted to relieve some of the burden of pumping blood, effectively reducing the amount of oxygen needed by myocardium. During operation, the standard practice is to place the patient on CPB as soon as possible and revascularize the heart with three saphenous veins. A calcified aorta also poses a problem because it is very dangerous to clamp. In this case, the operation can be done as an off-pump CAB using both  inferior mesenteric arteries  (IMA) or Y, T and sequential grafts. Deep arrest may be induced with  hypothermia , lowering the temperature of the body to slightly above 20\u00a0\u00b0C (68\u00a0\u00b0F). [ 25 ]  In cases where a significant artery is totally blocked, it may be possible to remove the plaque and use the same hole in the artery to perform an anastomosis. This technique is called endarterectomy and is usually performed at the right coronary system. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14429", "text": "Re-operations of CABG (another CABG operation after a previous one) pose difficulties. The heart may be positioned too close to the sternum and thus at risk when cutting the sternum again, so an  oscillating saw  is used. The heart may be covered with strong adhesions to adjusting structures. Doctors must decide whether aging grafts should be replaced. Manipulation of vein grafts is avoided because it risks dislodgement of plaque. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14430", "text": "Minimally invasive direct coronary artery bypass  (MIDCAB) strives to avoid a large incision in the sternum. It utilizes off-pump techniques to place a graft, usually of the LIMA at the LAD. The LIMA is freed through an  incision between the left ribs  (thoractomy), or even using an endoscope placed in the left chest. [ 28 ]  Robot-assisted coronary revascularization, which is not yet widely used, avoids the sternum incision to prevent infections and bleeding. Both conduit harvesting and the anastomosis are performed with the aid of a robot, through a thoracotomy. Usually, the procedure is combined with  hybrid coronary revascularization , in which methods of CABG and PCI are both employed. Anastomosis of the LIMA to the LAD is performed in the operating theater and other lesions are treated with PCI\u2014either at the operating room immediately following the anastomosis, or several days later. [ 29 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14431", "text": "After the procedure, the patient is usually transferred to the  intensive care unit  (ICU), where intubations are removed if not already done in the operating theater. They usually exit the ICU by the following day, and four days later, if no complications occur, the patient is discharged from the hospital. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14432", "text": "A series of drugs are commonly used in early post-operative care.  Dobutamine , a beta agent, can increase the cardiac output and is administered some hours after the operation. Beta blockers are used to prevent atrial fibrillation and other supraventricular arrhythmias. Pacing wires attached to both atria, inserted during the operation, may help prevent atrial fibrillation. Aspirin (80\u00a0mg) is used to prevent graft failure. [ 30 ]   Angiotensin-converting enzyme (ACE) inhibitors  and  angiotensin receptor blockers (ARBs)  are used to control blood pressure, especially in patients with low cardiac function (<40%).  Amlodipine , a calcium channel blocker, is used for patients whose radial artery was used as a graft. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14433", "text": "After the discharge, patients may experience insomnia, low appetite, decreased sex drive, and memory problems. This effect is usually transient and lasts 6 to 8 weeks. [ 30 ]  A tailored exercise plan is usually beneficial. [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14434", "text": "CABG is the best procedure to reduce mortality from severe CAD and improve quality of life. [ 31 ] [ 32 ] :\u200a153\u200a  Operative mortality strongly relates to the patient's age. According to a study by Eagle  et al ., patients 50\u201359 years old have an operative mortality rate of 1.8%, while patients older than 80 have a rate of 8.3%. [ 33 ]  Other factors that increase mortality are being female, re-operation, dysfunction of the left ventricle, and  left main disease . [ 33 ]  CABG usually relieves angina, but in some patients it reoccurs. Around 60% of patients will be angina-free 10 years after their operation. [ 33 ]  Myocardial infarction is rare five years after a CABG, but its risk increases with time. [ 34 ]  The risk of sudden death for CABG patients is low. [ 34 ]  Quality of life is also high for at least five years, then can slowly start to decline. [ 35 ]  However,  the use of bilateral mammary artery in patients of younger age and those without specific comorbidities (diabetes, obesity, steroid use) can provide excellent long-term survival and quality of life. [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14435", "text": "The beneficial effects of CABG are clear at the cardiac level. Left-ventricle function is improved and malfunctioning segments of the heart\u2014dyskinetic (moving inefficiently) or even akinetic (not moving)\u2014can show signs of improvement. Both systolic and diastolic functions are improved and keep improving for up to five years in some cases. [ 37 ]  Left-ventricle function and myocardial perfusion during exercise also improves after CABG. When the left ventricle is severely impaired before operation (ejection fraction below 30%), however, benefits are less impressive in terms of segmental wall movement but still significant because other parameters might improve as LV function improves; the pulmonary hypertension might be relieved and lengthen survival. [ 37 ] [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14436", "text": "Determining the total risk of the procedure is difficult because of the diversity of patients undergoing CABG; different subgroups have different risk, but younger patients see better results than older ones. A CABG using two, rather than one,  internal mammary arteries  (IMAs) may offer greater protection from CAD, but results are not yet conclusive. [ 33 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14437", "text": "Conduits that can be used for CABG may be arteries or veins. Arteries have a superior long-term patency (expandedness), but veins are more commonly used due to their practicality. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14438", "text": "Arterial grafts originate from the part of the internal thoracic artery (ITA) that runs near the edge of  sternum , and can easily be mobilized and anastomosed to the native target vessel of the heart. The left artery is most often used because it is closer to the heart, but the right artery is sometimes used, depending on patient and surgeon preferences. The ITAs  are advantageous because of their endothelial cells, which produce  endothelium-derived relaxing factor  and  prostacyclin , protecting the artery from atherosclerosis and thus stenosis or occlusion. Disadvantages include a high rate of complications, such as deep sternal wound infections, in some subgroups of patients\u2014mainly obese and diabetic ones. The  left radial artery  and  left gastroepiploic artery  can be also used. Long-term patency is influenced by the type of artery used and intrinsic factors of the cardiac arterial circulation. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14439", "text": "Veins used are mostly  great saphenous veins  and, in some cases, the  lesser saphenous vein . Their patency rate is lower than that of arteries.  Aspirin  protects grafts from occlusion; adding  clopidogrel  does not improve rates. [ 41 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14440", "text": "CABG and PCI are the two methods to revascularize stenotic lesions of the cardiac arteries. The preferences for each patient is still a matter of debate but in the presence of complex lesions and significant Left Main Disease, and in diabetic patients, CABG seems to offer better results in patients than PCI. [ 11 ] [ 10 ]  Strong indications for CABG also include symptomatic patients and those with impaired LV function. [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14441", "text": "The most common complications of CABG are postoperative bleeding, heart failure,  atrial fibrillation  (a form of arrhythmia),  stroke , kidney dysfunction, and infection of the wound near the sternum. [ 38 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14442", "text": "Postoperative bleeding occurs in 2\u20135% of cases and may require returning to the operating room; [ 42 ]  the most common indicator is the amount of blood being drained by  chest tubes , which are inserted during the operation to drain fluid or air from the chest. Bleeding may originate from the  aorta , the anastomosis, an insufficiently sealed branch of the conduit, or from the sternum. Other causes include platelet abnormalities or  their failure to clot \u2014perhaps due to the bypass or to the rebound  heparin  effect, which occurs when the anti-coagulant heparin is administered at the beginning of surgery and reappears in the blood after its neutralization by  protamine . [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14443", "text": "Low cardiac output syndrome  (LCOS) can occur in up to 14% of CABG patients. According to its severity, LCOS is treated with  inotropes , an intra-aortic balloon pump (IABP), optimization of pre-load and afterload, or correction of blood gauzes and electrolytes. The aim is to maintain a systolic blood pressure above 90 \u00a0 mmHg  and a  cardiac index  of more than 2.2\u202fL/min/m 2 . [ 38 ]  LCOS is often transient. [ 42 ]  Myocardial infarction can occur after the operation because of either technical or patient-specific factors. Its incidence is difficult to estimate due to varying definitions, but most studies place its occurrence at between 2% and 5%. The incidence is also dependent on whether it is isolated CABG (average, 4%, range, 0.3%\u201310%) or a combined operation (average, 2.0%, range, 0.7%\u201312%). [ 44 ]  New electrocardiogram features, such as Q waves or ultrasound-documented alternation of cardiac wall motions, are indicative. Ongoing ischemia might prompt emergency angiography and PCI or re-operation. [ 45 ] [ 42 ]  Immediate coronary angiography offers the most expeditious modality not only for diagnosis but also for potential reintervention. [ 46 ]  Echocardiography is less valuable for the detection or confirmation of postoperative myocardial ischemia. [ 47 ]  Arrhythmias can also occur, most-commonly  atrial fibrillation  (incidence of 20\u201340%) that is treated with correcting electrolyte balance, and rate and rhythm control. [ 42 ] [ 38 ]  However, arrhythmia such as ventricular tachycardia or fibrillation can be a sign of postoperative myocardial ischemia that is treated depending on the cause. [ 48 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14444", "text": "Adverse neurological effects occur after CABG in about 1.5% of patients. [ 42 ]  They can manifest as type-1 deficits\u2014focal deficits such as stroke or  coma \u2014or type-2 global deficits such as delirium caused by CPB, hypoperfusion, or cerebral embolism. [ 38 ]  Cognitive impairment has been reported in up to 80% cases after CABG at discharge and lasts for a year in up to 40% of cases. The cause remains unclear; CPB is an unlikely cause because even in CABG patients without CPB, as in off-pump CABG, and PCI patients, the incidence is the same. [ 38 ] [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14445", "text": "Infections, such as wound infections in the sternum (superficial or deep) are most commonly caused by  Staphylococcus aureus , and may complicate the post-operation process. The harvesting of both two thoracic arteries is a risk factor because it significantly impairs the perfusion of blood through the sternum. [ 38 ]   Pneumonia  can also occur. [ 42 ]  Complications in the  gastrointestinal tract  have been described and are most commonly due to medications administered during the operation. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14446", "text": "In the early 20th century, surgical interventions aiming to relieve angina and prevent death were either sympathectomy \u2014 a cut on the  sympathetic chain  that supplies the heart\u2014or pericardial abrasion, with the hope adhesions would create significant collateral circulation. Sympathectomy produced disappointing and inconsistent results. [ 50 ]  French surgeon  Alexis Carrel  was the first to anastomose a vessel\u2014a branch of the  carotid artery \u2014to a native artery in the heart of a dog, but the experiment could not be reproduced. [ 51 ]  In the mid-20th century, revascularization efforts continued. Beck C. S. used a carotid conduit to connect the descending aorta to the  coronary sinus , the biggest vein of the heart. In the \"Vineberg Procedure\",  Arthur Vineberg  used skeletonized LITA, placing it in a small tunnel he created next to the LAD and hoping spontaneous collateral circulation would form. This occurred in canine experiments but not in humans. Goetz RH was the first to perform an anastomosis of the ITA to LAD in the 1960 using a sutureless technique. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14447", "text": "The development of coronary angiography in 1962 by  Mason Sones  helped medical doctors to identify patients in need of operation, and which native heart vessels should be bypassed. [ 52 ]  In 1964, Soviet cardiac surgeon  Vasilii Kolesov  performed the first successful internal thoracic artery\u2013coronary artery anastomosis, followed by  Michael DeBakey  in the United States. Argentine surgeon  Ren\u00e9 Favaloro  standardized the procedure. Their advances made CABG the standard of care of CAD patients. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14448", "text": "The modern era of the CABG began in 1964 when Soviet cardiac surgeon  Vasilii Kolesov  performed the first successful internal thoracic artery\u2013coronary artery anastomosis. The same year, American surgeon  Michael DeBakey  used a saphenous vein to create an aorta-coronary artery bypass. Argentinean surgeon  Ren\u00e9 Favaloro  advanced and standardized the CABG technique using the patient's saphenous vein. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14449", "text": "The introduction of arresting the heart during operation (cardioplegia) made CABG much less risky. A major obstacle of CABG was ischemia and infarction occurring while the heart was stopped to allow surgeons to construct the distal anastomosis. In the 1970s, potassium-based cardioplegia was used. Cardioplegia minimized the oxygen demands of the heart, thus reducing the effects of ischemia. Refinement of cardioplegia in the 1980s made CABG less risky, lowering mortality during operation. [ 54 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14450", "text": "In the late 1960s, after the work of Ren\u00e9 Favaloro, the operation was performed in only a few centers, but was anticipated to more broadly change the outcome of coronary artery disease. By 1979, there were 114,000 procedures per year in the US. The introduction of percutaneous coronary intervention (PCI) did not obsolesce CABG; rates of both procedures continued to increase, but PCIs grew more rapidly. In the following decades, CABG was extensively studied and compared to PCI. The absence of a clear advantage of CABG over PCI led to a small decrease in numbers of CABGs in some countries (like the US) by 2000. In Europe\u2014mainly Germany\u2014CABG was increasingly performed. As of 2023 [update] , research comparing the two techniques is continuing. [ 55 ]  Meta-analysis published in 2023 suggests that CABG provides a consistent survival benefit over PCI with drug-eluting stents (DES). [ 56 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14451", "text": "Favaloro's work is fundamental to the history of graft selection. He established the use of bilateral ITAs as superior to vein grafts. Surgeons examined the use of other arterial grafts\u2014splenic, gastroepiploic mesenteric, subscapular and others\u2014but none matched the patency rates of ITA. In 1971, Carpentier introduced the use of the radial artery, which was initially prone to failure, but the development of harvesting techniques in the following 20 years significantly improved patency. [ 57 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14452", "text": "Pigs, sheep, and dogs have been used as experimental models, for the development of CABG. [ 58 ]  Performing CABG to treat a sick animal though is extremely rare.  [ 59 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14453", "text": "The  Damus\u2013Kaye\u2013Stansel (DKS) procedure  is a cardiovascular surgical procedure used as part of the repair of some  congenital heart defects . [ 1 ]  This procedure joins the  pulmonary artery  and the  aorta  in situations where the  systemic circulation  is obstructed. It is commonly used when a patient has the combination of a small  left ventricle  and a  transposition of the great arteries  (TGA); in this case, the procedure allows blood to flow from the  left ventricle  to the aorta."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14454", "text": "The DKS procedure is named for three physicians \u2013 Paul Damus,  Michael Peter Kaye , and H. C. Stansel \u2013 who independently reported the procedure in the literature in the 1970s. At that time, the procedure was used for patients who had TGA with a  ventricular septal defect  (VSD). By the late 2000s, the procedure was employed in situations where the right ventricle is bigger than the left ventricle and the left ventricle connects to the  pulmonary artery  instead of the  aorta ; examples include  double inlet left ventricle , TGA with  tricuspid atresia  and TGA with  hypoplastic left heart syndrome . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14455", "text": "In the original DKS procedure, surgeons separated the  main pulmonary artery  (MPA) just below the point where it divides into the right and left pulmonary arteries. The end of the MPA was then joined to the side of the  ascending aorta , allowing blood from the left heart to communicate directly with the aorta. The procedure was later accomplished via a \"double-barrel\" technique that resulted in a new aorta with two valves. Later, a modified DKS was reported in which an aortic flap technique was utilized. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14456", "text": "Arthur DeBoer , (July 2, 1917-July 31, 2007), was an American  cardiologist  specializing in  cardiac surgery  at  Northwestern University 's  Feinberg School of Medicine . DeBoer was one of the pioneer cardiac surgeons in  Chicago  and was on staff at Wesley Memorial Hospital (later called  Northwestern University Hospital ).  DeBoer was the hospital's first chief of cardiothoracic surgery, and performed the first  open heart operation  at Wesley Memorial Hospital in 1958. [ citation needed ]  He served as Chair of Northwestern's Department of Cardiovascular Surgery until 1975.  [ 1 ]  He was also a pioneer in research on  congenital heart defects ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14457", "text": "He was born to John and Lucy DeBoer in  Gallatin County, Montana , and was a graduate of Montana Normal School (now  University of Montana Western ) earning his B.E. Degree in 1938.  He earned a B.S. Degree from  University of Montana  while teaching school. He graduated from  Northwestern University Medical School  in 1946 and after serving his internship at Wesley Hospital he served in the U.S. Army Medical Corps in Asia. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14458", "text": "This biographical article related to a physician in the United States is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14459", "text": "Decellularized homografts  are  donated  human  heart valves  which have been modified via  tissue engineering . Several techniques exist for  decellularization  with the majority based on detergent or enzymatic protocols which aim to eliminate all donor cells while preserving the mechanical properties of the remaining matrix. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14460", "text": "Aortic valve  disease affects the valve between the  left ventricle  and the  aorta , and can be present as a  congenital condition  at birth or caused by other factors. Several therapeutic options are open to patients once the indication for  aortic valve replacement  has been confirmed. One option is replacement using a  mechanical valve . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14461", "text": "This, however, necessitates a strict lifelong  anticoagulation  regime to avoid cerebral  thromboembolism . These blood thinners hold an inherent risk for severe bleeding episodes, which affects both professional and leisure activities and the majority of patients opt to not use mechanical valves for this reason. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14462", "text": "Biological  prostheses , i.e.  pericardial heart valves  of animal origin ( xenogenic ), offer a viable alternative. However, in particular for young patients, it has been found that xenogenic valves do not provide satisfactory durability and rapid valve degeneration can occur within months. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14463", "text": "A further avenue open to patients is a so-called  Ross operation , an extensive surgical procedure in which the diseased aortic valve is replaced by the patient's  pulmonary valve  ( autograft ). The pulmonary valve then needs to be replaced by a heart valve prosthesis. A drawback of this method is that it can frequently result in a \"two-valve\" diseased heart, as almost all autografts are impaired by progressive dilatation in the long term, and the pulmonary valve prosthesis, often a conventional  cryopreserved   homograft , is subject to the same rate of degeneration as all biological valves. This can thereby lead to frequent reoperations [ 3 ]  which have a substantially higher mortality rate due to postoperative adhesions. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14464", "text": "The lack of durable heart valve prostheses for young patients has driven forward research in  tissue engineering  approaches for valve replacement. Current tissue-engineering concepts are based on either artificial  polymeric  or biological scaffolds, derived from donated human tissue ( allogeneic ) or animals (xenogenic). While more readily available, there have been reports of dramatic failure in the use of xenogeneic matrices in  paediatric  patients, leading to scepticism regarding their application. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14465", "text": "Total artificial tissue-engineered heart valve concepts are currently under development and would solve many unmet clinical demands, such as the permanent availability of different sizes and lengths. These concepts have shown good results in the technical implementation of valved polymeric conduit production and have successfully been used for  in vitro  and  in vivo  seeding of different (stem) cell lines. However,  preclinical  testing in long-term animal models has yet to deliver satisfactory results due to a lack of mechanical, leading to early failure of the valvular function. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14466", "text": "Aortic valve replacement using a  homograft  in orthotopic position was first performed over 50 years ago on 24 July 1962 by  Donald Ross  at  Guy's Hospital ,  London  and has been assessed in prospective randomized studies, e.g. in comparison to the Ross procedure. [ 7 ]  Aortic valve replacement using conventional  cryopreserved  homografts is currently performed only in about 3% of all patients, mostly to treat acute aortic valve  endocarditis .1 Severe  calcification  of conventional homografts frequently occurs and is the main reason for its restrictive use, however, current guidelines confirm homografts as a valid alternative for young patients requiring anatomical reconstruction of the outflow tract. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14467", "text": "DPH have been clinically implanted since 2002 in paediatric patients. [ 8 ]  The indications mainly include patients with pulmonary diseases such as pulmonary valve stenosis, atresia or insufficiency. They have shown excellent early to midterm clinical performance, challenging conventional  cryopreserved  homografts as the \"gold standard\" for pulmonary valve replacement in congenital heart disease. [ 9 ] [ 10 ]  Compared to cryopreserved homograft, decellularized pulmonary homografts have shown less degeneration and had to be explanted less. [ 11 ]  The main limitation is the low availability of such homografts and the higher costs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14468", "text": "DAH developed at  Hannover Medical School  (MHH) have shown sufficient mechanical stability for the systemic circulation at the greatest possible extent of antigen elimination and have been validated in long-term animal models. [ 12 ]  The first DAH was implanted in human in the year 2008. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14469", "text": "A multicenter european study of aortic valve replacement with the use of DAH in 106 pediatric patients published in 2020 showed outcome data comparable to Ross procedure and mechanical aortic valve implantation and better results compared to cryopreserved homografts. In comparison to Ross procedure, early mortality rates were lower in DAH patients (2,2% versus 4,2%), however this trend was not statistically significant. Complications due to coronary reimplantation during DAH implantation occurred in 3.8% and progressive valve degeneration in 10%. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14470", "text": "A multicenter european study in both pediatric and adult patients compared DAH with Ross procedure and showed almost identical results regarding valve degeneration and freedom from explantation. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14471", "text": "The  Dor procedure  is a medical technique used as part of  heart surgery  and originally introduced by the French cardiac surgeon Vincent Dor (b.1932). [ 1 ]  It is also known as endoventricular circular patch plasty (EVCPP)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14472", "text": "In 1985, Dor introduced EVCPP as a viable method for restoring a dilated left  ventricle  (LV) to its normal, elliptical geometry. The Dor procedure uses a circular suture and a  Dacron  patch to correct LV  aneurysms  and exclude scarred parts of the  septum  and ventricular wall and would prove to be the best option amongst the other methods of ventricular remodeling, i.e. Cooley\u2019s linear suturing and Jatene\u2019s circular external suturing. [ citation needed ]  EVCPP is a relatively easy procedure that covers all aspects of successful heart restoration\u2014restores ventricular shape, increases ejection fraction, decreases the left ventricular end systolic volume index (LVESVI), and allows for complete coronary revascularization."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14473", "text": "The  myocardium  consists of a single, vascular, continuous tissue that wraps around itself, spiraling up from the apex of the heart, to form a helix with elliptically shaped ventricles. [ 2 ]  This spiral produces an oblique muscle fiber orientation, meaning that the fibers form a more ventricle \u2018x\u2019 shape, so that when fibers shorten 15%, it produces a 60% ejection fraction. Because of its elliptical shape and defined apex, the ventricle is subjected to a relatively low level of lateral stress."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14474", "text": "A dilated left  ventricle  is generally due to the effects of a myocardial infarction. An occlusion, or blockage, results in either akinetic (non-beating) or dyskinetic (irregular beating) tissue downstream from the occlusion. This tissue is virtually useless. However, the volume of blood that fills the ventricle prior to contraction, or end-diastolic volume, remains constant, so the tissue that still functions has to do more work to eject the blood, as the Frank-Starling Laws demand."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14475", "text": "The tension on the functioning tissue increases as it compensates for the work of the necrotic tissue, so, as per  Laplace's law , the radius of the ventricle increases and the thickness of the ventricular wall decreases. The apex of the heart becomes circular,  hypertrophy  ensues in the viable myocardial tissue, and the valve opening widens. As the ventricle dilates, the muscle fiber orientation, which is critical to a good ejection fraction, becomes transverse, or more horizontal. Subsequently, the ejection fraction decreases; a 15% shortening produces only a 30% ejection fraction. The lateral stress on the ventricle increases. Overall, the dilated left ventricle cannot produce a strong enough contraction.\nNonviable myocardial muscle mass (NVMMM) implies a distinct, inexpensively reproduced  signature (electrocardiography and echocardiography) of several contemporary myocardial performance determinants when compared to viable myocardial muscle mass (VMMM). Ratio between the two in heart failure on a time curve is a determinate of compensatory geometric remodeling of the myocardium.\nFick/Frank/Starling describes gas diffusion, fluid and compliance relationships of the myocardium, primarily in systole. Geometric derangement induced by nonviable myocardium (see myocardial infarction) is exponentially impacted and proportional to the weight of the performance determinant measured.  Viable/Nonviable myocardial mass fraction is substantially  reduced by surgical interventions such as Dor and Batista."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14476", "text": "Doctors take a cardiac  MRI  to determine extent and location of the damage. Occasionally this reveals that the patient may be better suited for biventricular pacing or a  defibrillator , but if the  cardiologist  determines that the Dor procedure is necessary, then the patient must display other symptoms to indicate that they would be a good candidate, including:  angina ,  heart failure ,  arrhythmias  or a combination of the three, large areas of akinesis or dyskensis, ejection fraction of less than forty percent"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14477", "text": "Contraindications include: dysfunctional right ventricle,  pulmonary hypertension , dysfunction at the base of the heart,  systolic  pulmonary artery pressure greater than 60mmHg (in the absence of severe mitral regurgitation)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14478", "text": "Surgeons usually perform the Dor procedure following a  coronary artery bypass graft  (CABG). EVCPP consumes only approximately twenty minutes of the three- to four-hour procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14479", "text": "To begin a basic remodeling, the surgeon makes an incision at the center of the depressed area on the LV wall and removes blood clots and endocardial scar tissue. To restore the heart to its elliptical shape, an endoventricular suture is put in place and a longitudinal tuck is made to return the cardiac apex from the posterior to the front. The suture also serves as guidance for the patch location. The surgeon then inserts a balloon into the ventricular cavity to ensure correct size and sutures a Dacron patch, deflating the balloon and removing it before complete closure. The non-viable fibrous tissue is pulled over the patch, and surgical glue is occasionally used to complete the closure. \nWhen the  lesion  is placed on the anteroseptoapical wall of the heart, it will include the  septum  and apex more extensively than the lateral wall. As a result, the suture is placed deeply within the septum, and the new neck of the suture, which holds the Dacron patch, extends from the septum. Dor explicates this procedure in detail. \nWhen the lesion is placed on the posterolateral wall of the heart, a triangular patch is used and stabilized by the posterior  mitral annulus . This placement of the lesion allows for mitral valve replacement to be easily conducted by the transventricular approach. (The surgeon does not have to incise the atrium, rather can replace the valve through the already incised ventricle.)"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14480", "text": "It is recommended that the patient be placed on a mild anti-coagulant post operation to reduce the risk of blood clots. Some surgeons suggest the use of stronger anti-coagulants."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14481", "text": "The disadvantage to the Dor procedure is that it places synthetic tissue inside the LV cavity. However, it is possible to replace the Dacron patch with autologous tissue. The surgeon can make a semicircular patch, mobilized with a septal hinge, out of the endocardial scar or use autologous patches of the  pericardium ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14482", "text": "The Dor procedure requires a hospital stay of approximately 8 days, which is only one day longer than CABG, and the early mortality rate is about 5.6%. Post-operation, the patient does not have any lifestyle constraints other than those associated with CABG.  There is a 4% chance the patient will require another cardiac operation: 18% of patients who underwent CABG had recurrent heart failure. [ 3 ]  Because the Dor procedure restores the left ventricle to its correct, elliptical orientation, it results in a mean ejection fraction increase of 12.5%. This number continues to improve over the patient\u2019s lifetime, and patients can expect to live an extra 4\u201310 years, which is 3.3% longer than CABG alone with virtually no extra risk. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14483", "text": "Vessel harvesting  is a  surgical technique  that may be used in conjunction with a  coronary artery bypass graft  (CABG). For patients with  coronary artery disease , a  vascular bypass  may be recommended to reroute blood around blocked arteries to restore and improve  blood flow  and  oxygen  to the heart. To create the  bypass graft , a surgeon will remove or \"harvest\" healthy blood vessels from another part of the body, either  arteries  from an arm or the chest, or  veins  from a leg. [ 1 ]  This vessel becomes a  graft , with one end attaching to a blood source above and the other end below the blocked area, creating a \"conduit\" channel or new blood flow connection across the heart."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14484", "text": "The success of a coronary artery bypass graft may be influenced by the quality of the conduit and how it is handled or treated during the vessel harvest and preparation steps prior to grafting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14485", "text": "Success can be measured in terms of:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14486", "text": "Coronary artery bypass graft surgery has been in practice since the 1960s. Historically, vessels\u2014such as the  great saphenous vein  in the leg or the  radial artery  in the arm\u2014were obtained using a traditional \"open\" procedure that required a single, long incision from groin to ankle, or a \"bridging\" technique that used three or four smaller incisions. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14487", "text": "The most minimally invasive technique is known as  endoscopic vessel harvesting  (EVH), often described as  endoscopic vein harvesting  when a  saphenous vein  is used. This type of procedure requires a single 2\u00a0cm incision plus one or two smaller incisions of 2\u20133\u00a0mm in length."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14488", "text": "Each method involves carefully cutting and sealing off smaller blood vessels that branch off the main vessel conduit prior to removal from the body. This practice does not harm the remaining blood vessel network, which heals and maintains sufficient blood flow to the  extremities , allowing the patient to return to normal function without noticeable effects. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14489", "text": "There is no evidence on the risk of surgical site infection and wound dehiscence when using staples or sutures to close the wound after vein graft harvesting. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14490", "text": "Endovascular vessel harvesting (EVH) uses small incisions and specialized  minimally invasive  instruments to internally view, cut and seal side branches and remove the healthy blood vessel with minimal trauma to the vessel or surrounding tissues. In  clinical studies , EVH has shown important benefits, including a reduced risk of infection [ 3 ] [ 4 ]  and wound complications; [ 3 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ]  less postoperative pain and swelling; [ 5 ] [ 15 ] [ 16 ]  and faster recovery [ 8 ] [ 11 ] [ 17 ] [ 18 ] [ 19 ]  with minimal scarring. [ 16 ] [ 17 ]  The reduction in pain allows patients to get back on their feet and return to normal mobility much sooner, [ 11 ] [ 17 ] [ 18 ] [ 19 ]  and have a reduced length of hospital stay. Thus they may be able to begin their cardiac rehabilitation program sooner."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14491", "text": "Developed in 1995, adoption of EVH accelerated in 2005 after the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) concluded that EVH should be the standard of care for vessel harvest. [ 20 ] [ 21 ]  EVH is now the de facto standard of care, and is performed at most hospitals in the United States. However, a 2009 study published by Dr. Renato Lopes et al. in the  New England Journal of Medicine  concluded that the clinical outcomes of EVH were inferior to open vessel harvesting (OVH), [ 22 ]  prompting a flurry of articles in mainstream media. This study was performed between 2002 and 2007. Some clinicians challenged the study's conclusion, while others questioned the  methodology  of the study. Other seasoned clinicians wondered if EVH adoption and practitioners' experience have affected the data, as practitioners' experiences, techniques and technologies have evolved since the study began in 2002. Many clinicians called for more long-term studies to be conducted."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14492", "text": "In randomized clinical trials as well as other studies looking specifically at EVH, [ 6 ] [ 16 ] [ 17 ] [ 18 ] [ 23 ] [ 24 ] [ 25 ] [ 26 ]  the endoscopic harvesting technique has been found to offer comparable graft patency at six months\u2014meaning that, in these studies, EVH did not compromise the grafted vessel's ability to remain open and unblocked."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14493", "text": "In 2011, a large study by Dr. Lawrence Dacey et al. was published in  Circulation  supporting the use of endoscopic vessel harvesting in  cardiac surgery . [ 27 ]  The study compared more than 8,500  propensity-adjusted  patients and revealed that EVH significantly reduced wound complications without compromising long-term survival or freedom from repeat revascularization. These findings contradicted the conclusion drawn by Lopes et al. that EVH is inferior to OVH with respect to long-term survival. EVH was not associated with increased mortality or need for repeat revascularization at four years follow up. [ 27 ]  An accompanying editorial in  Circulation  further concluded that \"EVH is here to stay\" and predicted that \"OVH will be obsolete in a few years.\"  [ citation needed ]  Dacey's study supported the findings of two other large, observational studies and reaffirmed the significant benefits of EVH in reducing wound complications. [ 28 ] [ 29 ]  Totaling more than 16,000 patients tracked, these three studies provide strong evidence that EVH is a safe and viable technique to use to obtain a saphenous vein conduit for CABG surgery. Additional support that EVH does not adversely affect the integrity of the conduit and has equivalent clinical outcomes has recently been published by Krishnamoorthy et al. in  Circulation . [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14494", "text": "As mentioned above, the success of  CABG  surgery may be influenced by the quality of the \"conduit\" vessel and how it is handled or treated during the harvest and preparation steps prior to grafting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14495", "text": "The harvested blood vessel used in coronary artery bypass graft surgery must be free from damage to ensure proper long-term function and good patient outcomes. [ 31 ]  Conduit quality is a significant factor in long-term patient results. Conduit quality is not always visibly evident when looking at the exterior of the harvested vessel. Damage to the  endothelium , the interior of the vessel, has been shown to increase the likelihood of graft occlusion or blockage. [ 32 ] [ 33 ]  Specifically, damage can be caused during the procedure by:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14496", "text": "To preserve and optimize conduit quality, clinical specialists take care to avoid unnecessary thermal injury, overhandling and overdistension, and ensure proper storage conditions for the harvested vessel."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14497", "text": "Thermal Injury"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14498", "text": "Comprehensive training and a careful approach are needed when cutting and removing side branches from the main vessel being harvested. As branches are cut, they must be sealed, or cauterized, to prevent bleeding after disconnection from the main vessel. In surgical practice it is common to use a form of heat or electrical energy to  cauterize , or seal tissues in order to stop bleeding. If not properly controlled, the application of heat or energy to seal off the branch vessels can cause unintended thermal injury to the surrounding cells including the  endothelium  of the main vessel or conduit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14499", "text": "There are two main forms of electrical energy used for cutting and sealing off branch vessels during harvesting: bipolar radio frequency (RF) and direct current (DC)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14500", "text": "Bipolar RF"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14501", "text": "Bipolar RF tools pass  alternating electric current  (AC) through the tissue \u2013 in this case, the branch vessel \u2013 located between two electrodes. As the energy passes through the vessel tissue, water molecules within the cells begin to vibrate rapidly, creating heat, resulting in tissue  vaporization  and  coagulation . The amount of cutting (vaporization) and sealing (coagulations) is defined by the wave form of the RF energy passed through the tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14502", "text": "Direct Current"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14503", "text": "With  direct current  devices, current flows to the heating elements contained within a set of \"jaws\" that clamp down on the branch vessel. The amount of heat generated by the heating elements defines the cutting and sealing. The combination of the heat and pressure results in a single, simultaneous cut-and-seal motion."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14504", "text": "The distance between the location at which the side branch is cut and the main conduit is especially critical to minimize thermal injury to the main vessel during dissection. On some devices, a mechanical feature is used to physically distance the main conduit from the cautery device."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14505", "text": "Overhandling"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14506", "text": "It is important to minimize handling, which may damage or cause strain on the internal endothelial layer of the conduit. Harvester training and experience reduce the likelihood of damage. The risk of damage can also be lessened with techniques such as EVH (rather than bridging), or by using EVH devices that minimize the amount of torque or stretch to the main conduit during harvesting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14507", "text": "Overdistension"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14508", "text": "When a vessel is prepared for use as a bypass graft, a standard syringe is typically used to flush the vessel and check for leaks. Using uncontrolled pressure to flush or clear the vessel can result in damage to the internal cellular lining of the vessel, known as the endothelium. [ 34 ]  Limiting the maximum pressure that can be applied to the vessel may prevent injury and improve the overall quality and long term patency of the graft. Pressure-limiting syringes are available, and they have been clinically shown to protect against overdistension. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14509", "text": "Storage Conditions"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14510", "text": "Studies have indicated that endothelium and  smooth muscle  cells are affected by the type of storage solution, and may play a role in long-term vessel  patency . [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14511", "text": "EuroSCORE  (European System for Cardiac Operative Risk Evaluation) is a risk  model  which allows the calculation of the risk of death after a heart operation. The model asks for 17 items of information about the patient, the state of the heart and the proposed operation, [ 1 ]  and uses logistic regression to calculate the risk of death. [ 2 ]  It is free to use online."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14512", "text": "First published in 1999, [ 3 ]  the model has been adopted worldwide, becoming the most widely used risk index for  cardiac surgery , [ 4 ]  and its use is believed to have contributed substantially to the improvement in the results of heart surgery seen at the beginning of the millennium. The original models are now aging, [ 5 ]  and a new model - EuroSCORE II - was announced at the EACTS meeting in Lisbon in 2011 and published in the  European Journal of Cardiothoracic Surgery  in April 2012. The updated calculator is available online at the official EuroSCORE website."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14513", "text": "EuroSCORE II has substantially improved the calibration of the older models and at least maintained and perhaps further improved on their  discriminatory  power. It has largely replaced the two older models of EuroSCORE and is now the predominant worldwide heart surgery risk model. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14514", "text": "Risk models are used for two main reasons. The first is that a risk model such as EuroSCORE allows the calculation of the risk of death before undertaking a heart operation. This is important as it serves to guide the clinician and the patient about the advisability of an operation by helping to weigh the risk against the benefits. The second is as a method of quality control. By calculating the expected risk of death for a population of patients having heart operations, this can be compared with the number of actual deaths. This comparison can be used as a measure of the quality of the performance of the hospital, unit or surgeon in question. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14515", "text": "The statistical basis for EuroSCORE and EuroSCORE II is the well-established  logistic regression . The available EuroSCORE papers supply logistic regression coefficients but without any measure of uncertainty and the raw data from which the calculations have been made are not available to the public."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14516", "text": "The  Fontan procedure  or  Fontan\u2013Kreutzer procedure  is a  palliative  surgical procedure used in children with univentricular hearts. It involves diverting the  venous   blood  from the  inferior vena cava  (IVC) and  superior vena cava  (SVC) to the  pulmonary arteries . The procedure varies for differing congenital heart pathologies. For example, in  tricuspid atresia , the procedure can be done where the blood does not pass through the morphologic  right ventricle ; i.e., the systemic and pulmonary circulations are placed in series with the functional single ventricle. By contrast, in  hypoplastic left heart syndrome , the heart is more reliant on the more functional right ventricle to provide blood flow to the systemic circulation. The procedure was initially performed in 1968 by  Francis Fontan  and Eugene Baudet from Bordeaux, France, published in 1971, simultaneously described in July 1971 by Guillermo Kreutzer from Buenos Aires, Argentina, presented at the Argentinean National Cardilogy meeting of that year and finally published in 1973. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14517", "text": "The Fontan Kreutzer procedure is used in pediatric patients who possess only a single functional ventricle, either due to lack of a heart valve (e.g.  tricuspid  or  mitral atresia ), an abnormality of the pumping ability of the heart (e.g.  hypoplastic left heart syndrome  or  hypoplastic right heart syndrome ), or a complex congenital  heart disease  where a bi-ventricular repair is impossible or inadvisable. The surgery allows blood to be delivered to the lungs via central venous pressure rather than via the right ventricle. [ 3 ]  Patients typically present as neonates with cyanosis or congestive heart failure. [ 4 ]  Fontan completion is usually carried out when the patient is 2\u20135 years of age, but is also performed before 2 years of age. [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14518", "text": "There are four variations of the Fontan procedure: [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14519", "text": "The  Fontan-Kreutzer  procedure is the third procedure in the staged surgical palliation. [ 8 ]  It is performed in children born with congenital heart disease without two functional ventricles and an effective parallel blood flow circuit. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14520", "text": "The first stage is known as the  Norwood  procedure. This stage generally involves combining the pulmonary artery and aorta to form a larger vessel for blood to get to the body. An artificial tube or shunt can be placed from this larger vessel to the pulmonary arteries so that blood can get from the heart to the lungs. The wall between the left and right atrium can be removed to allow the mixing of oxygenated and de-oxygenated blood. [ 10 ] [ 11 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14521", "text": "The second stage is called the  hemi-Fontan  or the  Bidirectional Glenn  procedure . This intermediary stage incorporates the shifting of oxygen-poor blood from the top of the body to the lungs. [ 13 ]  The  superior vena cava  (SVC), which carries blood returning from the upper parts of the body, is disconnected from the heart and instead redirects the blood into the pulmonary arteries. [ 13 ]  The  inferior vena cava  (IVC), which carries blood returning from the lower body, continues to connect to the  right atrium . [ 14 ] [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14522", "text": "The third stage is called the  Fontan-Kreutzer  procedure  which involves redirecting the blood from the  inferior vena cava  to the lungs. [ 8 ]  At this point, the oxygen-poor blood from upper and lower body flows through the lungs without being pumped (driven only by the pressure that builds up in the veins or central venous pressure). This improves the lower than normal oxygen levels and results in one functional ventricle that is responsible  for supplying blood to the rest of the body. There are currently three various modern techniques for the Fontan procedure which include: Atriopulmonary connection, lateral tunnel total cavopulmonary connection, and extracardiac conduit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14523", "text": "After Fontan Kreutzer completion, blood must flow through the lungs without being pumped by the heart.  Therefore, children with high  pulmonary vascular resistance  may not tolerate a Fontan procedure.  Often,  cardiac catheterization  is performed to check the resistance before proceeding with the surgery.  This is also the reason a Fontan procedure cannot be done immediately after birth; the pulmonary vascular resistance is high  in utero  and takes months to drop.\nFontan procedure is also contraindicated in those with pulmonary artery hypoplasia and significant mitral insufficiency. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14524", "text": "In the short term, children can have trouble with  pleural effusions  (fluid building up around the lungs).  This can require a longer stay in the hospital for drainage with  chest tubes .  To address this risk, some surgeons make a fenestration from the venous circulation into the atrium.  When the pressure in the veins is high, some of the oxygen-poor blood can escape through the fenestration to relieve the pressure.  However, this results in  hypoxia , so the fenestration may eventually need to be closed by an  interventional cardiologist ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14525", "text": "In a 2016 review, Dr. Jack Rychik, head of the Single Ventricle Survivorship Program at  Children's Hospital of Philadelphia  summarized the long-term consequences of Fontan circulation as an \"indolent and progressive state of heart failure\" with predictable long-term consequences on several organ systems. [ 15 ]  Chronic  venous hypertension  from the stasis and lowered cardiac output are assumed to be at the root of lymphatic complications such as  chylothorax ,  protein losing enteropathy  and  plastic bronchitis . These complications may occur in the immediate post-operative period as well as in the medium and long term. New interventional and surgical strategies have been investigated to relieve the lymphatic complications associated with the Fontan circulation. [ 16 ]  Concerns about damage to the liver have emerged more recently, as the Fontan circulation produces congestion and  lymphedema  in this organ. This can lead towards progressive  hepatic fibrosis  and other complications of  Fontan-associated liver disease . [ 17 ]  Screening protocols and treatment standards are emerging in the light of these discoveries. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14526", "text": "Because of structural and electrochemical changes related to scarring after the procedure,  arrhythmias  are common.  Pacemakers  are placed in as many as 7% of patients who undergo the Fontan procedure. [ 18 ]  While the need for pacemakers may be related to the underlying cardiac anomaly, there is sufficient evidence that the surgery itself lead to the need for cardiac pacing."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14527", "text": "The Fontan procedure is  palliative  \u2014 not curative \u2014 but more than 80% of the cases  can result in normal or near-normal growth, development, exercise tolerance, and good quality of life. [ 19 ]  However, 10% or more of patients may eventually require  heart transplantation , [ 20 ]  and given the long-term consequences of chronic venous hypertension and insidious organ damage, freedom from morbidity is unlikely in the long term. New approaches to the management of failing Fontans or other clinical deterioration have included lymphatic decompression surgical procedures & intervention,  Ventricular assist devices  or other mechanical support therapies as either bridge to transplantation or destination therapies. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14528", "text": "Renal complications may occur. This is attributed to the circulatory changes in blood flow as well as possible exposure to nephrotoxic medications, iodine contrast agents, and long term cyanotic and ischemic nephropathy. Abnormalities including chronic kidney disease and impaired renal function have been shown with measured renal function. [ 22 ]  Popular markers, such as proteinuria and microalbuminuria, are used in the measurement renal function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14529", "text": "It is estimated in 2018 there was an 85% for a survival rate of thirty years following a Fontan procedure and there are approximately 50,000 to 70,000 people in the world with Fontan circulation. [ 23 ]  It is approximated that 40% of people with Fontan circulation are \u226518 years of age. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14530", "text": "A normal heart system has a series circuit with the right ventricle pumping blood into the pulmonary circulation. After exchanging gases, the blood is delivered to the left ventricle (and systemic arteries) through the pulmonary veins. In Fontan circulation, the right ventricle does not exist (or is bypassed), and the venae cavae are attached directly to the pulmonary artery. [ 24 ]  After oxygenation, the blood is pumped into the aorta by the unique, single ventricle. Because of the missing right ventricle, the force driving blood through the lungs is strongly reduced. This causes engorgement of the venous circulation, the most frequent complication of the Fontan procedure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14531", "text": "Fontan circulation can influence the  peripartum  or pregnant physiologic states. Pregnancy has historically been discouraged in Fontan patients due to high rates of miscarriage, cardiovascular compromise, or increased mortality. Many complications have been attributed to flawed placental function. However, improvements of the Fontan operation have resulted in pregnancies with lower incidence of heart and vascular compromise in the mother. [ 25 ]  Complications that may occur in the fetus may include, but are not limited to: oligohydramnios, preterm birth, low birth weight, small size for gestational age, or still birth. Maternal complications can include, but are not limited to: heart failure, thromboembolism, arrhythmias, and preeclampsia. [ 22 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14532", "text": "The Fontan procedure was initially described in 1971 by  Dr. Francis Fontan  (1929\u20132018) from Bordeaux, France.  Prior to this, the surgical treatment for tricuspid atresia consisted of creating a  shunt  between a systemic artery and the  pulmonary artery  ( Blalock-Taussig shunt ) or the  superior vena cava  and the pulmonary artery (Glenn shunt).  These procedures were associated with high mortality rates, commonly leading to death before the age of one year. [ 26 ]    In an attempt to improve this, Fontan was engaged in research between 1964 and 1966 endeavouring to fully redirect flow from the superior and inferior vena cavae to the pulmonary artery. [ 27 ]  His initial attempts in dogs were unsuccessful and all experimental animals died within a few hours; however, despite these failures, he successfully performed this operation in a young woman with  tricuspid atresia  in 1968 with Dr. Eugene Baudet. [ 26 ]  The operation was completed on a second patient in 1970, and after a third case the series was published in the international journal  Thorax  in 1971. [ 28 ]  Dr. Guillermo Kreutzer from Buenos Aires, Argentina (b. 1934), without any knowledge of Fontan's experience, performed a similar procedure in July, 1971 without placing a valve in the Inferior Vena Cava inlet and introduced the concept of \"fenestration\" \u2013 leaving a small atrial septal defect to serve as a pop-off valve for the circulation. [ 29 ] [ 26 ]  Techniques have been improved to include the lateral tunnel and use of an extracardiac conduit for congenital heart diseases beyond tricuspid atresia (hypoplastic left heart syndrome, etc). [ 30 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14533", "text": "Glenn procedure  is a  palliative   surgical procedure  performed for patients with  Tricuspid atresia . It is also part of the surgical treatment path for  hypoplastic left heart syndrome  and  hypoplastic right heart syndrome .  [ 1 ] [ 2 ] [ 3 ]  This procedure has been largely replaced by  Bidirectional Glenn procedure . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14534", "text": "It connects the superior  vena cava  to the right pulmonary artery. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14535", "text": "Bartley P. Griffith  (born 1949) is an American  heart surgeon . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14536", "text": "Griffith joined Muhammad Mohiuddin's MD Xenoheart laboratory in 2018. Together, they were able to demonstrate that the heart of a genetically altered pig could support life when transplanted into an orthotopic position in the chest for up to 9 months. Griffith and Mohiuddin performed the first successful  xenotransplantation  of a  genetically modified  pig heart to a human on January 7, 2022. [ 3 ]  The recipient was 57-year-old David Bennett Sr. The procedure occurred at the  University of Maryland Medical Center . [ 4 ]  Due to complications, David Bennett Sr died on March 8, 2022. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14537", "text": "On September 20, 2023, Bartley P. Griffith performed his second pig heart transplant. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14538", "text": "This biographical article related to medicine in the United States is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14539", "text": "A  heart transplant , or a  cardiac transplant , is a  surgical   transplant  procedure performed on patients with end-stage  heart failure  or severe  coronary artery disease  when other medical or surgical treatments have failed. As of 2018 [update] , the most common procedure is to take a functioning  heart , with or without both lungs, from a recently deceased  organ donor  ( brain death  is the standard [ 1 ] ) and implant it into the patient. The patient's own heart is either removed and replaced with the donor heart ( orthotopic procedure ) or, much less commonly, the recipient's diseased heart is left in place to support the donor heart (heterotopic, or \"piggyback\", transplant procedure)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14540", "text": "Approximately 3,500 heart transplants are performed each year worldwide, more than half of which are in the US. [ 2 ]  Post-operative survival periods average 15 years. [ 3 ]  Heart transplantation is not considered to be a cure for heart disease; rather it is a life-saving treatment intended to improve the quality and duration of life for a recipient. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14541", "text": "American medical researcher  Simon Flexner  was one of the first people to mention the possibility of heart transplantation. In 1907, he wrote the paper \"Tendencies in Pathology,\" in which he said that it would be possible one day by surgery to  replace diseased human organs  \u2013 including arteries, stomach,  kidneys  and heart. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14542", "text": "Not having a human donor heart available,  James D. Hardy  of the  University of Mississippi Medical Center  transplanted the heart of a chimpanzee into the chest of dying  Boyd Rush  in the early morning of Jan. 24, 1964. Hardy used a defibrillator to shock the heart to restart beating. This heart did beat in Rush's chest for 60 to 90 minutes (sources differ), and then Rush died without regaining consciousness. [ 6 ] [ 7 ] [ 8 ]  Although Hardy was a respected surgeon who had performed the world's first human-to-human lung transplant a year earlier, [ 9 ] [ 10 ]  author Donald McRae states that Hardy could feel the \"icy disdain\" from fellow surgeons at the Sixth International Transplantation Conference several weeks after this attempt with the chimpanzee heart. [ 11 ]  Hardy had been inspired by the limited success of  Keith Reemtsma  at  Tulane University  in transplanting chimpanzee kidneys into human patients with kidney failure. [ 12 ]  The consent form Hardy asked Rush's stepsister to sign did not include the possibility that a chimpanzee heart might be used, although Hardy stated that he did include this in verbal discussions. [ 7 ] [ 12 ] [ 13 ]  A  xenotransplantation  is the technical term for the transplant of an organ or tissue from one species to another."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14543", "text": "Dr Dhaniram Baruah  of  Assam , India was the first heart surgeon to transplant a pig's heart in human body. [ 14 ]  However the recipient died subsequently. The world's first successful pig-to-human heart transplant was performed in January 2022 by surgeon  Bartley P. Griffith  of USA. [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14544", "text": "The world's first human-to-human heart transplant was performed by  South African  cardiac surgeon  Christiaan Barnard  utilizing the techniques developed by American surgeons  Norman Shumway  and  Richard Lower . [ 16 ] [ 17 ]  Patient  Louis Washkansky  received this transplant on December 3, 1967, at the  Groote Schuur Hospital  in  Cape Town , South Africa. Washkansky, however, died 18 days later from  pneumonia . [ 16 ] [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14545", "text": "On December 6, 1967, at  Maimonides Hospital  in Brooklyn, New York,  Adrian Kantrowitz  performed the world's first  pediatric  heart transplant. [ 16 ] [ 20 ]  The infant's new heart stopped beating after 7 hours and could not be restarted. At a following press conference, Kantrowitz emphasized that he did not consider the operation a success. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14546", "text": "Norman Shumway performed the first adult heart transplant in the United States on January 6, 1968, at the  Stanford University Hospital . [ 16 ]  A team led by  Donald Ross  performed the first heart transplant in the United Kingdom on May 3, 1968. [ 22 ]  These were  allotransplants ,  the technical term for a transplant from a non-genetically identical individual of the same species.  Brain death  is the current ethical standard for when a heart donation can be allowed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14547", "text": "Worldwide, more than 100 transplants were performed by various doctors during 1968. [ 23 ]  Only a third of these patients lived longer than three months. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14548", "text": "The next big breakthrough came in 1983 when  cyclosporine  entered widespread usage. This drug enabled much smaller amounts of  corticosteroids  to be used to prevent many cases of rejection (the \"corticosteroid-sparing\" effect of cyclosporine). [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14549", "text": "On June 9, 1984, \"JP\" Lovette IV of  Denver ,  Colorado , became the world's first successful pediatric heart transplant.  Columbia-Presbyterian Medical Center  surgeons transplanted the heart of 4-year-old John Nathan Ford of Harlem into 4-year-old JP a day after the Harlem child died of injuries received in a fall from a fire escape at his home. JP was born with multiple heart defects. The transplant was done by a surgical team led by Dr. Eric A. Rose, director of cardiac transplantation at  New York\u2013Presbyterian Hospital . Drs. Keith Reemtsma and Fred Bowman also were members of the team for the six-hour operation. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14550", "text": "In 1988, the first \"domino\" heart transplant was performed, in which a patient in need of a lung transplant with a healthy heart would receive a  heart-lung transplant , and their original heart would be transplanted into someone else. [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14551", "text": "Worldwide, about 3,500 heart transplants are performed annually. The majority of these are performed in the United States (2,000\u20132,300 annually). [ 2 ]   Cedars-Sinai Medical Center  in Los Angeles, California, currently is the largest heart transplant center in the world, having performed 132 adult transplants in 2015 alone. [ 28 ]  About 800,000 people have  NYHA Class IV heart failure symptoms  indicating advanced heart failure. [ 29 ]  The great disparity between the number of patients needing transplants and the number of procedures being performed spurred research into the transplantation of non-human hearts into humans after 1993.  Xenografts  from other species and  artificial hearts  are two less successful alternatives to  allografts . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14552", "text": "The ability of medical teams to perform transplants continues to expand. For example,  Sri Lanka 's first heart transplant was successfully performed at the  Kandy General Hospital  on July 7, 2017. [ 30 ]  In recent years, donor heart preservation has improved and Organ Care System is being used in some centers in order to reduce the harmful effect of cold storage. [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14553", "text": "During heart transplant, the  vagus nerve  is severed, thus removing  parasympathetic  influence over the  myocardium . However, some limited return of  sympathetic nerves  has been demonstrated in humans. [ 32 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14554", "text": "Recently, Australian researchers found a way to give more time for a heart to survive prior to the transplant, almost double the time. [ 33 ] \nHeart transplantation using donation after circulatory death (DCD) was recently adopted and can help in reducing waitlist time while increasing transplant rate. [ 34 ]  Critically ill patients that are unsuitable for heart transplantation can be rescued and optimized with mechanical circulatory support, and bridged successfully to heart transplantation afterwards with good outcomes. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14555", "text": "On January 7, 2022,  David Bennett , aged 57, of Maryland became the first person to receive a gene-edited pig heart in a transplant at the  University of Maryland Medical Center . Before the transplant, David was unable to receive a human heart due to the patient's past conditions with heart failure and an irregular heartbeat, causing surgeons to use the pig heart that was genetically modified. [ 36 ] [ 37 ]  Bennett died two months later at University of Maryland Medical Center on March 8, 2022. [ 38 ] [ 39 ] \nOn April 19, 2023 Stanford Medicine surgeons performed the first beating-heart transplants from cardiac death donors. [ 40 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14556", "text": "On December 11, 2024, in  Padua , Italy, the world's first heart transplant from a non-beating donor to a fully beating heart was performed. [ 41 ] [ 42 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14557", "text": "Some patients are less suitable for a heart transplant, especially if they have other  circulatory  conditions related to their heart condition. The following conditions in a patient increase the chances of  complications . [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14558", "text": "Absolute contraindications:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14559", "text": "Relative contraindications:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14560", "text": "[ 45 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14561", "text": "Patients who are in need of a heart transplant but do not qualify may be candidates for an  artificial heart [ 2 ]  or a  left ventricular assist device  (LVAD)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14562", "text": "Potential complications include: [ 46 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14563", "text": "Since the transplanted heart originates from another organism, the recipient's immune system will attempt to reject it regardless if the donor heart matches the recipient's blood type (unless if the donor is an isograft). Like other solid organ transplants, the risk of rejection never fully goes away, and the patient will be on immunosuppressive drugs for the rest of their life. Usage of these drugs may cause unwanted side effects, such as an increased likelihood of contracting secondary infections or develop certain types of cancer. Recipients can acquire kidney disease from a heart transplant due to the side effects of immunosuppressant medications. Many recent advances in reducing complications due to tissue rejection stem from mouse heart transplant procedures. [ 49 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14564", "text": "People who have had heart transplants are monitored in various ways to test for possible organ rejection. [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14565", "text": "A 2022 pilot study [ 51 ]  examining the acceptability and feasibility of using video directly observed therapy to increase medication adherence in adolescent heart transplant patients showed promising results of 90.1% medication adherence compared to 40-60% typically. Higher medication variability levels can lead to greater organ rejections and other poor outcomes."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14566", "text": "The prognosis for heart transplant patients following the orthotopic procedure has improved over the past 20 years, and as of June 5, 2009 the survival rates were: [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14567", "text": "In 2007, researchers from the  Johns Hopkins University School of Medicine  discovered that \"men receiving female hearts had a 15% increase in the risk of adjusted cumulative mortality\" over five years compared to men receiving male hearts. Survival rates for women did not significantly differ based on male or female donors. [ 53 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14568", "text": "Heart valve repair  is a  cardiac surgery  procedure, carried out to repair one or more faulty  heart valves . In some  valvular heart diseases  repair where possible is preferable to  valve replacement . A  mechanical heart valve  is a replacement valve that is not itself subject to repair."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14569", "text": "Valvuloplasty  is the widening of a  stenotic valve  using a  balloon catheter . Types include: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14570", "text": "Commissurotomy  of  heart valves  is called a  valvulotomy ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14571", "text": "Mitral valve repair  is mainly used to treat  stenosis  (narrowing) or  regurgitation  (leakage) of the  mitral valve . [ citation needed ]  A mitral balloon valvuloplasty enlarges the valve opening to allow greater oxygenated blood flow into the left ventricle, and since severe mitral regurgitation can be a major complication, degrees of stenosis, regurgitation, and valve anatomical features are taken into consideration before the procedure. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14572", "text": "Aortic valve repair  is a  surgical procedure  used to correct some  aortic valve  disorders as an alternative to  aortic valve replacement . [ 2 ]  Aortic valve repair is performed less often and is more technically difficult than  mitral valve repair .\nThere are two surgical techniques of aortic-valve repair:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14573", "text": "Tricuspid valve repair is used to correct  tricuspid regurgitation . [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14574", "text": "The first two percutaneous ultrasound-guided fetal balloon valvuloplasties, a type of  in utero  surgery  for severe  aortic valve  obstruction, were reported in 1991. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14575", "text": "A  heart\u2013lung transplant  is a procedure carried out to replace both failing  heart  and  lungs  in a single operation. Due to a shortage of suitable donors and because both heart and lung have to be transplanted together, it is a rare procedure; only about a hundred such transplants are performed each year in the United States. [ United States-centric ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14576", "text": "The patient is  anesthetised . When the donor organs arrive, they are checked for fitness; if any organs show signs of damage, they are discarded and the operation cancelled."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14577", "text": "Once suitable donor organs are present, the surgeon makes an incision starting above and finishing below the sternum, cutting all the way to the bone. The skin edges are retracted to expose the sternum. Using a bone saw, the sternum is cut down the middle. Rib spreaders are inserted in the cut, and spread the ribs to give access to the heart and lungs of the patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14578", "text": "The patient is connected to a  heart\u2013lung machine , which circulates and oxygenates blood. The surgeon removes the failing heart and lungs. Most surgeons endeavour to cut blood vessels as close as possible to the heart to leave room for trimming, especially if the donor heart is of a different size than the original organ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14579", "text": "The donor heart and lungs are positioned and sewn into place. As the donor organs warm up to body temperature, the lungs begin to inflate. The heart may  fibrillate  at first \u2013 this occurs because the  cardiac muscle  fibres are not contracting synchronously. Internal paddles can be used to apply a small electric shock to the heart to restore proper rhythm."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14580", "text": "Once the donor organs are functioning normally, the heart\u2013lung machine is withdrawn, and the chest is closed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14581", "text": "Most candidates for heart\u2013lung transplants have life-threatening damage to both their heart and lungs. In the US, most prospective candidates have between twelve and twenty-four months to live. At any one time, there are about 250 people registered for heart\u2013lung transplantation at the  United Network for Organ Sharing  (UNOS) in the US, of which around forty will die before a suitable donor is found. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14582", "text": "Conditions which may necessitate a heart\u2013lung transplant include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14583", "text": "Candidates for a heart\u2013lung transplant are usually required to be:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14584", "text": "Most patients spend several days in  the intensive care unit  after the operation. If there are no complications (e.g.,  infection ,  rejection ), some are able to return home after just two weeks in hospital. Patients will be given  anti-rejection drugs  and  antibiotics  to prevent infection as the anti-rejection drugs weakens the immune system. A schedule of frequent follow up visits is necessary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14585", "text": "The success rate of heart\u2013lung transplants has improved significantly in recent years. The British  National Health Service  states that the survival rate is now around 85%, one year after the transplant was performed. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14586", "text": "In 2004, there were only 39 heart\u2013lung transplants performed in the entire United States and only 75 worldwide. By comparison, in that same year there were 2,016 heart and 1,173 lung transplants. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14587", "text": "Norman Shumway  laid the groundwork for heart lung transplant with his experiments into heart transplant at  Stanford  in the mid-1960s. [ citation needed ]  Shumway conducted the first adult heart transplant in the US in 1968. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14588", "text": "The first successful heart transplant was performed in South Africa in 1967. [ 4 ]  The first successful heart\u2013lung transplant was performed at Stanford in the United States, by  Bruce Reitz  on  Mary Gohlke  in 1981. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14589", "text": "Magdi Yacoub  performed the first heart-lung transplant in the United Kingdom in 1983. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14590", "text": "Australia's first heart-lung transplant was conducted by  Victor Chang  at  St Vincent's Hospital, Sydney  in 1986. [ 7 ]  Iran's first heart-lung transplant was performed in Tehran in 2002. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14591", "text": "Warren C. Jyrch  (June 22, 1921, in  Illinois  \u2013 March 2, 1971, in  Chicago ,  Illinois [ 1 ] ) is known for being the first ever  hemophiliac  to ever attempt and survive an  open heart surgery . [ 2 ]  Due to the dangers of being a hemophiliac the surgery to replace Jyrch's  heart valve  was very risky. Another constraint of this surgery was the amount of blood needed, \"2,400 pints of blood were necessary for Jyrch\u2019s operation.\" Jyrch worked as an accountant for  Rock Island Railroad . He died on March 2, 1971, due to a  stroke ; it was later discovered that his death was not related to his surgery months before. Jyrch left behind his wife Helen, and his three daughters, Christine, Eileen, and Paula. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14592", "text": "The  Kawashima procedure  is used for  congenital heart disease  with a single effective ventricle and an  interrupted  inferior vena cava  (IVC).  It was first performed in 1978 and reported in 1984. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14593", "text": "Technically it is very similar to the  bidirectional Glenn procedure  used to direct half the body's venous blood flow into the lungs.  However, in patients with interrupted IVC, most of the blood from the lower body actually joins the blood from the upper body before returning to the heart via the  superior vena cava  (SVC).  Therefore, the redirection of SVC blood to the lungs (as in the Glenn) results in much more than half the venous blood flow  being diverted. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14594", "text": "After Kawashima, the only de-oxygenated blood returning to the heart is from the abdominal organs (via the  hepatic veins ).  As a result, there is much less  hypoxia  than after Glenn, and the heart is pumping less additional blood than after Glenn.  However, the hypoxia can worsen over time (because of the development of microscopic  AVMs  in the lungs that allow blood to pass through without being oxygenated), [ 2 ]  and therefore these children still may need a complete  Fontan procedure  in the end. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14595", "text": "The  LeCompte maneuver  is a technique used in  open heart surgery , primarily on infants and children. The maneuver entails cutting the main  pulmonary artery  and moving it  anterior  to the  aorta  before reattaching the pulmonary artery during the following reconstruction of the  great vessels . [ 1 ] [ 2 ]  It allows the surgeon to reconstruct the  right ventricular outflow tract  without needing to connect the proximal and distal sections with a  graft . [ 2 ] [ 3 ]  It also enables the surgeon to avoid compressing the  coronary arteries  and relieves compression of the  bronchi  in cases where the pulmonary artery is severely  dilated  or  aneurysmal . If both pulmonary arteries are not mobilized adequately, they can become stretched, leading to  pulmonic stenosis . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14596", "text": "Commonly, the maneuver is used during an  arterial switch  procedure (in which the pulmonary artery and aorta switch positions) or in surgery to correct  absent pulmonary valve syndrome . [ 1 ] [ 4 ]  It is also used in corrective surgeries for  Tetralogy of Fallot  where the pulmonary valve is anomalous,  persistent truncus arteriosus  with  aortopulmonary window  that affects the  aortic arch , left-to-right shunts, anomalous right pulmonary artery, and  ALCAPA  (anomalous left coronary artery from the pulmonary artery). Other surgeries that regularly employ the LeCompte maneuver include the  Yasui procedure ,  REV procedure , and  Nikaidoh operation , all of which are used to reconstruct hearts with an anomalous left ventricular outflow tract. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14597", "text": "The technique was first used in 1981 and described in 1982. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14598", "text": "Minimally invasive cardiac surgery , encompasses various aspects of cardiac surgical procedures (aortic valve replacement, mitral valve repair, coronary artery bypass surgery, ascending aorta or aortic root surgery) that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy. [ 1 ] [ 2 ]   MICS CABG  (Minimally Invasive Cardiac Surgery/Coronary Artery Bypass Grafting) or  the McGinn technique  is  heart surgery  performed through several small incisions instead of the traditional open-heart surgery that requires a  median sternotomy  approach, and can be performed in patients with multivessel coronary artery disease. [ 3 ]  MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14599", "text": "Advantages of minimally invasive heart surgery are less blood loss, reduced post-operative discomfort, faster postoperative recovery and lower risk of infections, reduced duration of mechanical ventilation as well as eliminating the possibility for sternal non-union. This procedure makes heart surgery possible for patients who were previously considered too high risk for traditional surgery due to age or medical history. [ 5 ] [ 6 ]  Patients referred for this procedure may have coronary artery disease (CAD); aortic, mitral or tricuspid valve diseases; or previous unsuccessful stenting."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14600", "text": "A recent meta-analysis of randomized controlled trials by Amin et al (2024) showed that minimally invasive mitral valve surgery (MIMVS) reduced the number of days spent in the hospital and demonstrated a trend towards lower postoperative pain scores, but it did not decrease the risk of all-cause mortality or the number of patients needing blood product transfusions. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14601", "text": "MICS CABG is performed through one 5\u20137\u00a0cm incision in the 4th  intercostal  space (ICS). In some cases the  thoracotomy  may be necessary in the 5th ICS instead. A soft tissue refractor is used to allow for greater visibility and access. MICS CABG may be completed in an \"anaortic\" or no-touch off-pump technique, which has demonstrated reduced postoperative stroke and mortality compared to traditional CABG. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14602", "text": "Two access incisions are also made at the 6th intercostal space and xiphoid process to allow for instruments to position and stabilize the heart. [ 4 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14603", "text": "The McGinn proximal technique is performed with the blood pressure lowered to 90-100 systolic which reduces stress to the aorta. A series of tools are used to position and stabilize vessels. The technique uses devices to support the surrounding heart tissues while vital surgery takes place. This is also known as off-pump CABG (OPCAB). OPCAB voids the use of cardiopulmonary bypass (CPB), which requires the heart to be stopped (arrested) with cardioplegia solution. Off-pump is also known as beating heart surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14604", "text": "Minimally invasive heart surgery has been used as an alternative to traditional surgery for the following procedures:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14605", "text": "A cannula with a pump and vacuum action is fed up through an artery in the groin to reduce the stress on the heart so that it may still function during the operation. This pump flows at 2-3 liters per minute to support circulation and eliminates the need for  cardioplegia  to arrest the heart. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14606", "text": "Hybrid coronary  revascularization  is a common procedure that takes advantage of coronary stenting in combination with CABG. Hybrid coronary bypass is a relatively new procedure and alternative to traditional bypass surgery that is defined by the performance of coronary bypass surgery and coronary stenting of different areas of a patient's heart. MICS CABG allows utilization of the left internal mammary artery (IMA; aka left internal thoracic artery, left ITA) to bypass the left anterior descending artery (LAD), which is termed as left IMA-LAD, as a preferable anastomosis whenever indicated and technically feasible (Loop et al.) and has been proven to benefit in event free survival (Acinapura et al.). The other one or two arteries will be stented, when appropriate, allowing cardiologists and cardiothoracic surgeons to work together. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14607", "text": "After a minimally invasive procedure, patients recover more quickly than from sternotomy and develop fewer complications. Most patients can expect to resume everyday activities within a few weeks of their operation. After surgery, patients are administered an anaesthetic pain pump and drains that will be removed prior to discharge. Patients are encouraged to move around as much as possible after their operation to recover quickly. Once discharged from hospital, patients require no further post-operative assistance. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14608", "text": "Minimally invasive heart surgery is a safe and broadly applicable technique for performing a wide range of complex heart procedures, including single or multiple heart valve procedures, bypass surgery, and congenital heart repairs."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14609", "text": "Eliminating the need for median sternotomy greatly reduces the trauma and pain associated with open-chest surgery and improves quality of life for patients. In the hospital, reduced post-operative discomfort enables patients to quickly begin a shorter recovery process. Most patients ambulate more easily and participate more actively in their personal care. Additionally, this approach lowers risk of complications such as bleeding, infection and eliminates the risk of sternal non-union. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14610", "text": "Minimally invasive heart surgery improves cosmetic results. Rather than a prominent 10-inch scar down the middle of the chest, patients are left with smaller marks to the side of the ribs. For women, in many cases, this scar is completely unnoticeable as it sits below the breast. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14611", "text": "Benefits Include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14612", "text": "At the 2014 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Boston, Dr. Joseph T McGinn presented a study titled \"Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases,\" which found a low rate of conversion to sternotomy and low rate of complications. Assessing survival and adverse cardiac events up to 8.0 years (average 2.9\u00b12.0 years), MICS CABG is a safe, reproducible operation that yields survival (96.1\u00b10.9%) and durability comparable to conventional CABG. [ 14 ] [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14613", "text": "The Journal of Thoracic and Cardiovascular Surgery published a study on November 1, 2013, that confirmed MICS CABG as safe, feasible, and associated with excellent graft patency rates at 6 months post surgery, with graft patency of 92% for all grafts and 100% for left internal thoracic artery grafts. Coronary artery bypass graft patency was studied through computed tomography angiography. 92% of patients were free from angina and none of the participants experienced any aortic complications, repeat revascularizations, cerebrovascular accidents, myocardial infarctions or death. The two-year study included 91 participants between the ages 48 and 79, averaging a hospital stay of 4 days (range, 3\u20139 days). Clinical Trial Registration Unique identifier: NCT01334866. [10] [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14614", "text": "At 2012 American Heart Association's Scientific Sessions and Resuscitation Science Symposium, a study titled \"Minimally Invasive CABG: Results to 6 Years\" was presented, demonstrating MICS CABG feasibility and established alternative for multivessel sternotomy CABG. It was also noted that the procedure is associated with a short hospital length of stay, no deep wound infections and is safe. The study also proved survival and durability on par with sternotomy. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14615", "text": "At the 2010 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Berlin, Germany, duel center data was presented the standardization of MICS CABG in performance and reproducibility of its results. Its safety and effective alternative for performing surgical myocardial revascularization on the beating heart (OPCAB) is emphasized. \"Shortened hospital stay is starting to be realized and its application to high risk and complex patients is now being done.\" [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14616", "text": "A 2009 publication in Circulation, titled \"Minimally Invasive Coronary Artery Bypass Grafting: Dual-Center Experience in 450 Consecutive Patients\" concluded MICS CABG as a feasible procedure with excellent short-term outcomes. At that time the study noted, \"this operation could potentially make multivessel MICS CABG safe, effective and more widely available.\" [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14617", "text": "Minimally invasive cardiac surgery was pioneered by Dr Joseph T McGinn, Jr. The first minimally invasive heart cardiac surgery was performed in the United States on January 21, 2005, at The Heart Institute at Staten Island University Hospital in Staten Island, New York by a team led by Dr. Joseph T. McGinn. This technique is an off-pump coronary artery bypass surgery. The procedure is much less invasive than traditional bypass surgery because it is performed through three small incisions rather than the traditional sternotomy. Since its first procedure, over 1000 MICS CABG procedures have been performed at The Heart Institute and elsewhere around the world. [ 6 ]  Other centers that utilize the MICS CABG technique for coronary heart disease are the University of Ottawa Heart Center (ON, Canada), Houston Methodist DeBakey Heart Center (Houston, TX), and Vanderbilt University Medical Center (Nashville, TN). [ 19 ] [ 20 ] [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14618", "text": "Minimally invasive direct coronary artery bypass (MIDCAB)  is a surgical treatment for  coronary heart disease  that is a less invasive method of  coronary artery bypass surgery  (CABG). [ 1 ]  MIDCAB gains surgical access to the heart with a smaller  incision  than other types of CABG. MIDCAB is sometimes referred to as \"keyhole\"  heart surgery  because the operation is analogous to operating through a  keyhole ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14619", "text": "MIDCAB is a form of  off-pump coronary artery bypass surgery  (OPCAB), performed \"off-pump\" \u2013 without the use of  cardiopulmonary bypass  (the heart-lung machine).  MIDCAB differs from OPCAB in the type of incision used for the surgery; with traditional CABG and OPCAB a  median sternotomy  (dividing the  breastbone ) provides access to the heart; with MIDCAB, the surgeon enters the chest cavity through a  mini-thoracotomy  (a 2-to-3\u00a0inch incision between the ribs)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14620", "text": "MIDCAB surgery is no longer reserved for only anteriorly placed single- or double-vessel diseases, because such lesions are usually managed with  angioplasty . The surgery has recently begun to be used in multi-vessel coronary disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14621", "text": "People with multi-vessel coronary disease, who desire a minimally invasive approach to surgery may be eligible for  hybrid bypass .  A hybrid approach combines coronary bypass (using the MIDCAB approach) and coronary  stenting ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14622", "text": "Minimized extracorporeal circulation  ( MECC ) is a kind of  cardiopulmonary  bypass ( heart-lung machine ), a part of  heart surgery . [ 1 ]  The introduction of extracorporeal circulation has facilitated  open heart surgery . The development of modern techniques in extracorporeal circulation is the result of the combined efforts of physiologists, physicians, and engineers. During the first half of the 20th century scientists refined their methods in the development of extracorporeal circulation so that it could be used in humans."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14623", "text": "In 1937 Gibbon reports the first successful use of extracorporeal circulation in animals (in this case, cats). On May 6, 1953 Gibbon performed his first successful operation using an extracorporeal circuit in an 18-year-old woman who had a large  atrial septum defect  with a large  left-to-right shunt . It was Lillehei  who one year later introduced the bubble oxygenator, simple and inexpensive, opening the doors of open heart surgery to all surgeons around the world."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14624", "text": "The first commercial minimized extracorporeal circulation was the CorX System from Cardiovention, a start-up company from the USA. This system included an integrated  centrifugal pump  \u2013 polypropylene  oxygenator , a complete  heparin -coated surface and a low priming volume. One of the most effective Mini-Systems (MECC Maquet) was introduced almost at the same time (1999). The increasing application in clinical practice explains this machine's success. The benefits of this type of extracorporeal circulation are that a lower consumption of blood and blood products is observed in the  peri-operative  and post-operative phase and that a lower  inflammatory response  is being measured in peri-operative blood samples in comparison to conventional  cardiopulmonary bypass ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14625", "text": "Mitral valve annuloplasty  is a surgical technique for the repair of leaking  mitral valves . Due to various factors, the two leaflets normally involved in sealing the mitral valve to retrograde flow may not  coapt  properly. Surgical repair typically involves the implantation of a device surrounding the mitral valve, called an annuloplasty device, which pulls the leaflets together to facilitate coaptation and aids to re-establish mitral valve function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14626", "text": "Mitral regurgitation  is the most common form of mitral valve dysfunction. Today more than 2.5 million Americans are estimated to be affected by mitral regurgitation. This number is expected to double by the year 2030. Every year, 300,000 people worldwide undergo open heart surgery for  mitral valve repair , 44,000 people in the US alone. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14627", "text": "Since it was initially established 40 years ago by Professor  Alain Carpentier , mitral valve annuloplasty has been continuously improved and is considered the gold standard for the treatment of most etiologies of mitral valve dysfunction today. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14628", "text": "The goal of mitral valve annuloplasty is to regain mitral valve competence by restoring the physiological form and function of the normal mitral valve apparatus. [ 3 ]  Under normal conditions the mitral valve undergoes significant dynamic changes in shape and size throughout the  cardiac cycle . These changes are primarily due to the dynamic motion of the surrounding mitral valve annulus, a collageneous structure which attaches the mitral leaflets and the left  atrium  to the  ostium  of the left ventricle and the  aortic root . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14629", "text": "Throughout the cardiac cycle, the annulus undergoes a sphincter motion, narrowing down the orifice area during  systole  to facilitate coaptation of the two leaflets and widens during  diastole  to allow for easy diastolic filling of the left ventricle. This motion is further enhanced by a pronounced three-dimensional configuration during systole, the characteristic saddle shape. These changes throughout the cycle are believed to be key to optimize leaflet coaptation and to minimize tissue stresses. The challenge of mitral valve annuloplasty is to improve the diseased and distorted shape of the mitral valve and to reestablish the physiological configuration, while preserving normal annular dynamics. Today, cardiac surgeons can select from a variety of annuloplasty devices, flexible, semi-rigid, or rigid, incomplete or complete, planar or saddle-shaped, adjustable and non-adjustable. While the general goal of all devices is the same, namely to increase leaflet coaptation and to support the posterior annulus against dilation, flexible bands are designed to maintain the three-dimensional contour of the native annulus and some of its natural dynamics. The goal of semi-rigid rings is to maintain coaptation and valve integrity during systole, while allowing for good hemodynamics during diastole. Rigid rings are designed to provide rigid support in large dilation and under high-pressure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14630", "text": "Annuloplasty devices usually come in different sizes. The surgeon can estimate the dimensions of the patient\u2019s mitral valve and decide on an appropriate ring size. Depending on the disease etiology, different approaches are taken. Surgeons can decide to \"undersize\" the device, \"truesize\" the device, or \"oversize\" it. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14631", "text": "Annuloplasty devices are classified by the U.S.  Food and Drug Administration  (FDA) as  class II  medical devices. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14632", "text": "Mitral valve repair  is a  cardiac surgery  procedure performed by  cardiac surgeons  to treat  stenosis  (narrowing) or  regurgitation  (leakage) of the  mitral valve . The mitral valve is the \"inflow valve\" for the left side of the  heart .  Blood  flows from the  lungs , where it picks up oxygen, through the  pulmonary veins , to the  left atrium  of the heart. After the left atrium fills with blood, the mitral valve allows blood to flow from the left atrium into the heart's main pumping chamber called the left  ventricle . It then closes to keep blood from leaking back into the left atrium or lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets, known as cusps."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14633", "text": "The techniques of mitral valve repair include inserting a cloth-covered ring around the valve to bring the leaflets into contact with each other ( annuloplasty ), removal of redundant/loose segments of the leaflets (quadrangular resection), and re-suspension of the leaflets with artificial ( Gore-Tex ) cords."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14634", "text": "Procedures on the mitral valve usually require a  median sternotomy , but advances in non-invasive methods (such as  keyhole surgery ) allow surgery without a sternotomy (and resulting pain and scar).   Minimally invasive mitral valve surgery  is much more technically demanding and may involve higher risk."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14635", "text": "Occasionally, the mitral valve is abnormal from birth ( congenital ). More often the mitral valve becomes abnormal with age ( degenerative ) or as a result of  rheumatic fever . In rare instances the mitral valve can be destroyed by infection or a bacterial  endocarditis . Mitral regurgitation may also occur as a result of  ischemic heart disease  (coronary artery disease) or non-ischemic heart disease (dilated cardiomyopathy)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14636", "text": "In 1923 Dr.  Elliott Cutler  of the  Peter Bent Brigham Hospital  performed the world\u2019s first successful heart valve surgery \u2013 a mitral valve  repair . The patient was a 12-year-old  comatose  girl with  rheumatic mitral stenosis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14637", "text": "The development of the heart-lung machine in the 1950s paved the way for  replacement  of the mitral valve with an  artificial valve  in the 1960s. For decades after,  mitral valve replacement  was the only surgical option for patients with a severely diseased mitral valve. However, there are some significant downsides to a  prosthetic mitral valve . Infection of the valve can occur, which is dangerous and difficult to treat. Patients with mechanical heart valves are required to take  blood thinners  for the rest of their lives, which presents a risk of bleeding complications. The artificial mitral valve has an elevated risk of stroke. Patients with mechanical heart valves who use warfarin for anticoagulation have to be on long-term anticoagulation therapy.  This means they must go to the clinic and have a lab blood draw done, typically once a month but more frequently if the level needs to be closely monitored until it is in the therapeutic range.  The therapeutic range for most adults with a mechanical valve is an  INR  of 2.5\u20133.5. [ 2 ]  Finally, artificial tissue valves will wear out \u2013 on average lasting between 10 and 15 years, requiring further surgery at an advanced age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14638", "text": "In the past two decades, some surgeons have embraced surgical techniques to repair the damaged native valve, rather than replace it. These techniques were pioneered by a French heart surgeon,  Dr. Alain F. Carpentier . A repair still involves major cardiac surgery but for many patients presents the significant advantage of avoiding  blood thinners  and may provide a more durable result. However, some studies suggest that blood thinners like Warfarin can reduce a \u201ccomposite of bleeding and  thromboembolic complications \u201d and potentially postoperative complications, as those taking Warfarin have shown \u201csuperior long-term survival estimates.\u201d [ 3 ]   Not all damaged valves are suitable for repair; in some, the state of valve disease is too advanced and replacement is necessary.  Often, a surgeon must decide during the operation itself whether a  repair  or a  replacement  is the best course of action.  For patients with the most common type of mitral valve disease, termed \"degenerative\" or \"myxomatous\" mitral valve disease, repair rates are very high and long term durability is excellent. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14639", "text": "There has been great debate about timing of surgery in patients with asymptomatic mitral valve regurgitation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14640", "text": "The traditional surgical approach to a mitral valve repair is a full or partial  sternotomy , in which the surgeon cuts through the breastbone at the center of the chest to access the heart.  There are  minimally invasive  (port access) options available pioneered by Hugo Vanerman in Belgium.  The minimally invasive approach does not involve cutting the breastbone, but instead uses multiple incisions in the side of the chest and the leg. Cardiac surgeons are not unanimous about the relative merits of sternotomy versus the minimally invasive approach. The minimally invasive approach can produce a less prominent scar, is beneficial for very obese patients, and may allow the patient to return to their normal activity sooner than a sternotomy. But some cardiac surgeons argue that unless performed by the most experienced cardiac centers, minimally invasive surgery can involve a longer time on a bypass machine, a lower repair rate, and higher (although still low) risk of stroke. One cardiac surgery professor said, \"I think the only benefit is for  cosmesis  for the patient and the benefit is for marketing and growing our practices for ourselves because it\u2019s a good way to grow one's practice.\" [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14641", "text": "Robotic mitral valve repair operations are also being utilized throughout the United States."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14642", "text": "In the 2000s there have been several trials of a newer strategy of mitral valve repair that does not require major cardiac surgery. Through a catheter inserted in the groin, the valve leaflets are clipped together. This technique \u2013  percutaneous  mitral valve repair \u2013 is available in Europe but still in clinical trial in the United States. It is a highly specialized technique only available at select hospitals. Early trial results suggest that it may be a beneficial approach for patients who are at high risk from conventional surgery. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14643", "text": "As early as January 2000 a team of doctors [ 8 ]  at the  Instituto de Cardiolog\u00eda y Cirug\u00eda Cardiovascular  in  La Habana ,  Cuba  have performed beating heart mitral valve repair or replacement. The beating heart mitral valve replacement technique is as safe as the arrested heart technique, and is the recommended alternative to arrested heart technique. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14644", "text": "Mitral valve replacement  is a procedure whereby the diseased  mitral valve  of a patient's heart is  replaced  by either a mechanical or tissue (bioprosthetic) valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14645", "text": "The mitral valve may need to be replaced because: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14646", "text": "Causes of mitral valve disease include  infection ,  calcification  and inherited  collagen disease . Current mitral valve replacement approaches include  open heart surgery  and  minimally invasive cardiac surgery  (MICS)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14647", "text": "The mitral valve is a bileaflet valve sited between the left  atrium  and left  ventricle , responsible for preventing blood flowing from the ventricle to the atrium when the heart contracts. It is elliptical, and its area varies from 5.0 to 11.4\u00a0cm 2 . The valve leaflets are separated by two  commissures , and each leaflet of the valve (anterior leaflet, the large one, and posterior leaflet, the small one) has three sections (p1, p2, p3). Histologically, each leaflet is composed of the solid fibrosa, the spongiosa at the atrial surface and another fibroelastic layer covering the leaflets. [ 1 ]  Two  papillary muscles  originating from the base of the left ventricle hold the mitral leaflets in place through  chordae tendinae , which insert the edge of the leaflets, preventing them from leaking during left ventricle  systole . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14648", "text": "During normal mitral valve function fluid jets from the  left atrium  through the mitral valve into the  left ventricle . The  vortex  created from this jetting travels towards the apex of the left ventricle because of the  asymmetric  shape of the mitral valve leaflets. This vortex rotates clockwise until the isovolumetric contraction of the left ventricle opens the aortic valve and redirects the fluid flow from the apex of the left ventricle to the  systemic circulation  and the rest of the body. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14649", "text": "The asymmetry of the mitral valve is very important in the diastolic flow patterns of transmitral flow. Additionally the entire systems; the mitral annulus, papillary muscles and the chordae tendinea all play a vital role in forming a sophisticated vortex that optimizes the fluid flow in the left heart. Simulations have been performed showing how all of these aspects of the mitral valve contribute to the normal vortex formation in the left heart. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14650", "text": "The most common cause of mitral stenosis is rheumatic fever, seen mostly in the developing world. Other causes are mitral degenerative disease, severe calcification (elderly), congenital deformities, malignant carcinoid syndrome,  neoplasm , left atrial appendage  thrombus , endocarditic vegetations, certain inherited metabolic diseases, or complications of previous procedures at the aortic valve. [ 5 ]  Mitral stenosis causes left atrial pressure to increase, which, if left untreated, can lead to ventricular dilation,  hypertrophy ,  atrial fibrillation , and  thrombus  creation. Symptoms include shortness of breath ( dyspnea ) on exertion, when lying flat ( orthopnea ) or during the night ( paroxysmal nocturnal dyspnea ), and fatigue. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14651", "text": "If mitral leaflets don't coapt (close) effectively, blood flows backwards (regurgitation) from the left ventricle towards the left atrium during systole. The most common causes are myxomatous degeneration (Barlow disease), ischemic heart disease, dilated cardiomyopathy, rheumatic valve disease, mitral annular calcification, infective endocarditis, congenital anomalies, endocardial fibrosis, myocarditis, and collagen-vascular disorders. [ 7 ]  The most used system to classify mitral valve regurgitation is Carpentier's classification, which separates mitral regurgitation into three types, depending on the leaflet motion in relation to the mitral annular plane: [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14652", "text": "There are two main types of artificial mitral valve: mechanical valves and tissue (bioprosthetic) valves. [ 8 ]  They come in various sizes (commonly starting from an external diameter of 19\u00a0mm and increasing by 2\u00a0mm per model). [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14653", "text": "Mechanical valves are made from metal and/or pyrolitic carbon, [ 10 ]  and can last 20\u201330 years. [ 11 ]  The risk of blood clots forming is higher with mechanical valves than with bioprosthetic valves. As a result, patients with mechanical valves must take blood-thinning medication (anticoagulants) for the rest of their lives, making them more prone to bleeding. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14654", "text": "There are three types of mechanical valves:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14655", "text": "Bileaflet valves are the most common type of mechanical valve, offering desirable haemodynamics. [ 12 ]  The two leaflets of a bileaflet disc valve open during  diastole  and close during  systole . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14656", "text": "Bioprosthetic valves are made from animal tissues. Most people with bioprosthetic valves don\u2019t need to take anticoagulants long term. However, bioprosthetic valves may only last 10\u201315 years. [ 11 ]  They tend to deteriorate more quickly in younger patients. [ 11 ]  Valve failure prevalence at 10 years is 30%, increasing to 35\u201365% at 15 years. [ 13 ]  New tissue preservation technologies are being studied to try to increase the durability of bioprosthetic valves. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14657", "text": "The choice of valve depends upon the patient's age, medical condition, preferences, and lifestyle. [ 11 ]  Typically, patients younger than 65 years old will receive a mechanical valve unless they are unable to take long-term anticoagulation, and patients older than 70 years will receive a bioprosthetic valve. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14658", "text": "The most common approach for surgeons to reach the heart is a  median sternotomy  (vertically cutting the breastbone), but other incisions can be employed, such as a left or right thoracotomy. [ 15 ]  After the heart is exposed, the patient is put on a  cardiopulmonary bypass  machine, also known as a heart\u2013lung machine. This machine breathes for the patient and pumps their blood around their body \u2013 bypassing the heart \u2013 while the surgeon replaces the heart valve. Next, an aortic clamp is placed on the aorta, and the heart is stopped ( cardioplegia ). [ 15 ]  Depending on the pathology of the mitral valve and surgeon's preference, various approaches can be used to access the mitral valve. The interatrial groove approach involves incising the left atrium posterior to the interatrial groove. The transatrial oblique approach is utilized when the left atrium is small. In this approach, the right atrium is opened and another incision is made at the interatrial septum. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14659", "text": "The valve is excised 4\u20135\u00a0mm from the annulus, leaving intact the attached chordae unless they are calcified or otherwise diseased. The valve is replaced by a mechanical or bioprosthetic valve. The replacement valve is sewn into the annulus with interrupted or horizontal mattress sutures with the pledgets on the atrial side. [ 17 ]  The atrial walls are closed, taking care not to trap air within the chambers of the heart. [ 18 ]  The heart is restarted, and the patient is taken off the heart\u2013lung machine. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14660", "text": "Following surgery, patients are typically taken to an  intensive care unit  for monitoring. They may need a  respirator  to help them breathe for the first few hours or days after surgery. The patient should be able to sit up in bed within 24 hours. After two days, the patient may be moved out of the intensive care unit. Patients are usually discharged after 7\u201310 days. If the mitral valve replacement is successful, patients can expect their symptoms to improve significantly. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14661", "text": "Some scarring occurs after surgery. After median sternotomy, the patient will have a vertical scar on their chest above their breastbone. If the heart is accessed from under the left breast there will be a smaller scar in this location. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14662", "text": "Patients with a bioprosthetic mitral valve are prescribed anticoagulants, such as  warfarin , for 6 weeks to 3 months after their operation, while patients with mechanical valves are prescribed anticoagulants for the rest of their lives. Anticoagulants are taken to prevent blood clots, which can move to other parts of the body and cause serious medical problems, such as a  heart attack . Anticoagulants will not dissolve a blood clot but they do prevent other clots from forming or prevent clots from becoming larger. [ 21 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14663", "text": "Once their wounds have healed, patients should have few, if any, restrictions from daily activities. People are advised to walk or undertake other physical activities gradually to regain strength. Patients who have physically demanding jobs will have to wait a little longer than those who don\u2019t. Patients are also restricted from driving a car for six weeks after the surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14664", "text": "As with other cardiac procedures, mitral valve replacement is associated with risks, such as bleeding, infection, thromboembolism, renal shutdown,  cardiac tamponade ,  stroke , or reaction to anesthesia. [ 22 ]  The risk of death is about 1%. [ 23 ]  Risks depend on a patient\u2019s age, general health, specific medical conditions, and heart function. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14665", "text": "Pedrizetti  et al. [ 25 ]  studied the fluid mechanics in the left heart in 40 randomized patients with mechanical and tissue artificial heart valves. Using  echocardiography  they quantitatively analyzed the velocity field in the left heart and found that the patients with artificial mitral valves had a consistent counterclockwise  circulation , as opposed to the normal clockwise circulation that is characteristic of normal transmitral flow. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14666", "text": "To further characterize this counterclockwise circulation a  numerical simulation  was performed which backed up the data taken from the echocardiograph study. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14667", "text": "This flipped vortex circulation could lead to further complications in the patient who had mitral valve replacement surgery as it was observed to cause stagnation points, crossed flows, increased energy requirements and pressure shifts from the lateral to the septal wall in the left heart. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14668", "text": "Since the 1990s, surgeons have been working on less invasive approaches to mitral valve surgery, known as minimally invasive cardiac surgery (MICS). Minimally invasive mitral valve replacement involves a small incision (5\u20138\u00a0cm) just below the right breast. The benefits of MICS over conventional surgery include reduced hospital stay and blood transfusion requirements, and a smaller scar. [ 26 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14669", "text": "Rather than removing the existing valve, transcatheter mitral valve replacement [ 27 ]  involves wedging a new valve into the site of the existing valve. The replacement valve is delivered to the site of the existing valve through a tube called a catheter. The catheter may be inserted through the femoral artery in the thigh, or through a small incision in the chest. [ 28 ]  Once the replacement valve is in place, it is expanded, pushing the old valve\u2019s leaflets (the sections that open and close) out of the way. [ 29 ] [ 30 ] [ 31 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14670", "text": "Many mitral valves can be repaired instead of replaced. In fact,  mitral valve repair  is recommended by international guidelines wherever possible. [ 32 ] [ 33 ]  Advantages of mitral valve repair over replacement include lower surgical mortality (~1% for repair  vs  ~5% for replacement [ 34 ] ), lower rates of  stroke  and  endocarditis  (an infection of the heart\u2019s inner lining), equivalent or better long\u2011term durability, [ 35 ] [ 36 ] [ 37 ]  and improved long-term survival. [ 35 ]  Patients who have their valve repaired have a similar life expectancy to the general population. [ 38 ]  In addition, patients may not need to take anticoagulants long term following mitral valve repair. [ 39 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14671", "text": "For individuals with few symptoms, or those with contraindications to surgery, options exist for medical treatment in both  mitral insufficiency  and  mitral valve stenosis , although they won't cure the conditions. Such medical treatments include  diuretics , [ 40 ] [ 41 ]   vasodilators , [ 41 ] [ 40 ]  and  ACE inhibitors . [ 40 ] [ 42 ] [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14672", "text": "The  Mustard procedure  was developed in 1963 by Dr.  William Mustard  at the  Hospital for Sick Children . It is similar to the previous  atrial   baffle  used with a  Senning procedure , the primary difference being that the Mustard uses a graft made of  Dacron  or  pericardium , while the Senning uses native heart tissue."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14673", "text": "The procedure was developed to treat  transposition of the great vessels , eponymously known as  blue baby syndrome . This is a condition in which the  aorta  and  pulmonary artery  are attached to the heart in an opposite order from what is usually present at birth, resulting in the aorta being the outflow tract for the  right ventricle  and the pulmonary artery serving as the outgoing path for blood from the  left ventricle . [ 1 ]  The technique was adopted by other surgeons and became the standard operation for the dextro variant of transposition. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14674", "text": "The procedure was developed with support from the  Heart and Stroke Foundation of Canada ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14675", "text": "In his autobiography,  South African  cardiac surgeon  Christiaan Barnard  claims to have been the first to perform the operation, with Mustard only following 'several years later'. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14676", "text": "Prior to the development of the  Senning procedure  in the 1950s,  blue baby syndrome  from transposition was usually fatal.  The defect causes blood from the  lungs  to flow back to the lungs and blood from the body to flow back to the body.  As a result, the babies are   blue  at birth because of  insufficient blood oxygen . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14677", "text": "In a normal heart, the sequence of blood is from  vena cava  to right ventricle, then to the lungs and finally from lungs to the left ventricle to be circulated throughout the body. In patients with transposition, the order is from cava to left atrium and ventricle, then to the lungs and finally to the right side of the heart to be pumped out to systemic circulation. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14678", "text": "The Mustard Procedure allows total correction of transposition of the great vessels. It creates a baffle to redirect deoxygenated caval blood to the left atrium, which then pumps blood to the left ventricle, which in turn delivers this deoxygenated blood to the lungs. The effect is that the left ventricle is a functional right, and the right ventricle a functional left."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14679", "text": "The Mustard procedure was largely replaced in the late 1980s by the  Jatene procedure  (arterial switch), in which the native arteries were switched back to normal flow, so that the RV (right ventricle) would be connected to the pulmonary artery and the LV (left ventricle) would be connected to the aorta.  This surgery had not been possible prior to 1975 because of difficulty with re-implanting  coronary arteries  which perfuse the actual heart muscle itself ( myocardium ), and even after it was first performed the excellent results from the Mustard operation meant that it was a long time before the Jatene procedure took over. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14680", "text": "The Mustard procedure improved an 80%  mortality rate  in the first year of life to an 80% survival at age 20. Long-term follow-up studies now extend to more than 40 years post-operation [ 4 ]  and there are numerous patients thriving in their 50s. A Facebook group, Mustard or Senning Survivors, [ 5 ]  gathers several hundred global survivors in their 20s to 50s into a single community, supporting adults born with TGA that have had a Mustard, Senning, Rastelli or Nikaidoh heart procedure. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14681", "text": "The  Norwood procedure  is the first of three palliative surgeries for patients with  hypoplastic left heart syndrome  (HLHS) and other complex heart defects with  single ventricle  physiology intended to create a new functional single ventricle system. [ 1 ]  The first successful Norwood procedure involving the use of a cardiopulmonary bypass was reported by Dr.  William Imon Norwood , Jr. and colleagues in 1981. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14682", "text": "Variations of the Norwood procedure, or Stage 1 palliation, have been proposed and adopted over the last 30 years; however, its basic components have remained unchanged. The purpose of the procedure is to utilize the right ventricle as the main chamber pumping blood to the body and lungs. A connection between left and right atria (collecting chambers of the heart) is established via atrial septectomy, allowing blood arriving from the lungs to travel to the right ventricle. Next a connection between the right ventricle and aorta is created using a tissue graft from the main pulmonary artery. [ 4 ]  Lastly, an aortopulmonary shunt is created to provide blood flow to the lungs from the systemic circulation. The most common shunts are the  Modified Blalock Taussig  shunt (MBTS) or right ventricle- to pulmonary artery shunt (RVPA or  Sano shunt )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14683", "text": "Most patients who undergo a Norwood procedure will proceed to further stages of single ventricle palliation. A second surgery, also known as the  Glenn procedure , occurs at 4\u20136 months of age. The third surgery is the  Fontan procedure , occurring when patients are 3\u20135 years of age. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14684", "text": "Norwood procedure is most commonly performed to treat  hypoplastic left heart syndrome , double outlet right ventricle,  double inlet left ventricle , and other single ventricle congenital heart defects. [ 5 ]  Variations are also used for palliation of  mitral  and  tricuspid atresia [ 6 ]  and subsets of  transposition of great arteries  (TGA). [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14685", "text": "Without surgical repair, infants born with a single ventricle cardiac defect face almost certain mortality in the first year of life. [ 8 ] [ 9 ] [ 10 ]  In these conditions, the most urgent problem is that the heart is unable to pump blood to the systemic circulation (i.e. to the body). The goal of these three surgeries is to ultimately connect the single ventricle to the systemic circulation. To accomplish this, blood flow to the lungs is disrupted, and therefore an alternative path must be created to provide blood flow to the lungs. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14686", "text": "There are numerous factors that increase the risk of the Norwood procedure and are relative contraindications. Those factors include  Low birth weight , extremely premature delivery, poor ventricular function,  Intraventricular hemorrhage , severe non-cardiac congenital defects, and genetic syndromes with poor prognosis. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14687", "text": "While the Norwood procedure is the standard of care for single ventricle cardiac defects, there are other treatment options for patients depending on their unique anatomy. [ 12 ]  One option is the Hybrid procedure which is done via cardiac catheterization and surgery. [ 13 ] [ 14 ]  A stent is placed in the  ductus arteriosus  to keep it patent and bands are placed over both the left and right pulmonary arteries to limit pressure and over-circulation to the lungs. [ 15 ]  Another option is cardiac transplantation, although this is uncommon due to the limited availability of neonatal donor hearts. [ 16 ] [ 17 ]  Families can also elect to pursue comfort care for their newborns, especially if there are concomitant anatomic defects or genetic syndromes with poor prognosis. [ 9 ] [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14688", "text": "Entry to the body cavity for the Norwood procedure is gained by a vertical incision above the  sternum . Separation of the sternum is necessary.  This surgery is complex and may vary slightly depending on the  diagnosis  and overall condition of the  heart . The surgery on the heart can be divided into two main steps. [ 19 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14689", "text": "The main  pulmonary artery  is separated from the left and right portions of the pulmonary artery and joined with the upper portion of the  aorta .  Widening of the  pulmonary artery  is often necessary, and may be accomplished by using the patient's existing  biological tissue , or appropriate animal tissue.  This allows the  blood , a mixture of  oxygenated  and deoxygenated, to be pumped to the body via the morphologic right ventricle, through the  pulmonary valve . At this point in the surgery, the right ventricle is directly connected to systemic circulation through the Neoaorta or the reconstructed aortic outflow track. Second step of the procedure establishes blood flow to the lungs. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14690", "text": "Variations to this step have been proposed over the years, however only two have been adapted in general practice over the last 20 years. In both cases a conduit is used to direct blood flow into the lungs, however anatomic anchoring varies. There are two different types of shunts used during the procedure:  Modified Blalock Taussig  or (MBTS) and right ventricle- to pulmonary artery shunt (RVPA or  Sano shunt ). MBTS shunt provides connection from the pulmonary artery to  brachiocephalic artery  or  subclavian artery , while the RVPA conduit provides connection from right ventricle to pulmonary artery. [ 21 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14691", "text": "The Single Ventricle Reconstruction trial conducted in 2005 compared the two conduits at one, three and five year intervals. Although RVPA shunts performed better at the one and three year end points, five year follow up demonstrated no difference between survival or improvement in freedom from transplantation. [ 22 ] [ 23 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14692", "text": "After Norwood procedure infants enter the interstage which typically lasts up to 5 months. During this period the patients are medically optimized using diuretics and vasodilators. [ 24 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14693", "text": "The Norwood procedure is a complex and high-risk surgery with high rates of morbidity and mortality despite advancements in surgical technique, perioperative care, and postoperative monitoring. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14694", "text": "Immediate post surgical complications have been reported by multiple studies to involve hemorrhage, vocal cord paralysis due to close proximity of the recurrent laryngeal nerve to the cardiac sack, cardiac arrhythmias as a result of potential cardiac tissue manipulation and damage, and protein-losing enteropathy. [ 26 ] [ 5 ]  Other surgical complications include low cardiac output syndrome, atrioventricular valve regurgitation, aortic valve insufficiency, ventricular dysfunction, seizures, stroke, shunt thrombosis, infection, cardiac arrest, and death. [ 5 ] [ 27 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14695", "text": "The interstage period is the period after the Norwood procedure and before stage II pallation (Glenn procedure, typically 4\u20136 months of age). This time is very high-risk for infants because the single ventricle must pump to both the systemic and pulmonary circulations, with mortality rates ranging from 2%-20%. [ 25 ] [ 28 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14696", "text": "Due to the balance required to maintain adequate blood flow to the systemic and pulmonary circulations, infants in the interstage period face multiple risks:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14697", "text": "Long-term survival rates for children with single ventricle physiology are improving as medical and surgical advancements continue. In the major SVR trial (Single Ventricle Reconstruction) the transplant-free survival rate was only 54-59% amongst patients who underwent the Norwood procedure. [ 32 ]  These patients experience ongoing health challenges and require lifelong cardiology follow-up. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14698", "text": "Children with single-ventricle physiology who undergo the Norwood procedure often experience neurodevelopmental impairment. [ 33 ]  Neurodevelopmental and behavioral impairments are the most common long-term morbidity for children with single ventricle cardiac defects. [ 34 ]  Children's hospitals have begun to implement multidisciplinary neurodevelopmental care teams as part of the standard of care for this population. [ 35 ]  The impact of these interventional programs remains an active area of research. [ 35 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14699", "text": "Factors affecting neurodevelopment in these children include: [ 33 ] [ 36 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14700", "text": "Children who undergo the Norwood procedure may experience a range of neurodevelopmental issues, such as:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14701", "text": "First ever series of documented Norwood procedures were performed by Dr. William Imon Norwood between 1979 and 1981. [ 41 ]  Dr. Norwood was an American physician who completed his fellowship in cardiothoracic pediatric surgery at Boston Children's Medical Center (BCMC), Boston Massachusetts. [ 42 ]  During his time at BCMC he became interested in the most complex congenital heart defects, particularly HLHS. Under direct supervision of his program mentor Dr. Aldo Castanedo, he performed and later perfected what would become the three stage Norwood palliation. After successful publication of his work in 1981, Dr. Norwood joined the Project Hope stationed in Krakow, Poland. There, he continued to develop and refine his work: he was responsible for Poland's first ever Fontan procedure in a patient with single ventricle pathology. [ 43 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14702", "text": "Off-pump coronary artery bypass  ( OPCAB ),  or  beating-heart surgery , is a form of  coronary artery bypass graft  (CABG) surgery performed without  cardiopulmonary bypass  (heart-lung machine) as a treatment for  coronary heart disease . It was primarily developed in the early 1990s by Dr. Amano Atsushi. Historically, during bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. When a  cardiac surgeon  chooses to perform the CABG procedure off-pump (OPCAB) the heart is still beating while the graft attachments are made to bypass a blockage."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14703", "text": "Off-pump coronary artery bypass was developed partly to avoid the complications of cardiopulmonary bypass during cardiac surgery. It had been believed that cardiopulmonary bypass causes a post-operative cognitive decline known as a  postperfusion syndrome  (informally called \"pumphead\"), but research has shown no long-term difference between on and off pump coronary artery bypass [ 1 ]  in patients of lower risk. This is probably because the pump is not the main cause of brain damage but is due to  the formation of a  clot  or  embolus ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14704", "text": "Sometimes, the fatty type materials that collects to form a blockage or line on the walls of an artery may break loose during CABG procedure manipulation.  This debris can result in clots, or emboli, that may interrupt the flow of blood to the brain, causing neurological damage or even stroke.  Data analysis from beating-heart surgery patients shows a significant reduction in the release of this debris with correspondingly lower stroke rates."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14705", "text": "The fatty emboli which cause brain damage are generated when the large artery from the heart (aorta) is manipulated and although these are reduced in most off-pump coronary bypass surgeries they are not eliminated because the aorta is still used as a site to attach some of the grafts. A growing number of OPCAB surgeons, however, are avoiding the aorta completely, known as \"anaortic\" or no-touch coronary bypass surgery, by taking all their grafts from sites other than the aorta (e.g. the internal mammary arteries.). [ 2 ] [ 3 ]  This results in a very low risk of stroke, actually less than occurs during  percutaneous coronary intervention . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14706", "text": "In addition to off-pump surgery being associated with the clinical benefits of a reduced risk of stroke or memory problems, patients also typically have a faster recovery and shorter hospital stay, fewer  blood transfusions , and fewer unwanted inflammatory/immune response issues."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14707", "text": "Minimally invasive direct coronary artery bypass surgery  (MIDCAB) is a form of OPCAB that involves an incision rather than cutting into the sternum. [ 5 ]  An advanced form of this is  totally endoscopic coronary artery bypass surgery   (TECAB) that uses  robotic surgery . [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14708", "text": "Off-pump surgery can be more technically challenging. The technique has a steep  learning curve , but with adequate training and experience,  the quality of the  anastomoses  has been shown to be similar to on-pump results in surgeons with comparable experience"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14709", "text": "On February 18, 2012, Amano Atsushi performed a successful off-pump coronary artery bypass operation on  Emperor Akihito . [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14710", "text": "The  Onassio Cardiac Surgery Centre  ( Greek :  \u03a9\u03bd\u03ac\u03c3\u03b5\u03b9\u03bf \u039a\u03b1\u03c1\u03b4\u03b9\u03bf\u03c7\u03b5\u03b9\u03c1\u03bf\u03c5\u03c1\u03b3\u03b9\u03ba\u03cc \u039a\u03ad\u03bd\u03c4\u03c1\u03bf ) or simply  Onassio  ( \u03a9\u03bd\u03ac\u03c3\u03b5\u03b9\u03bf ) is a model hospital, specialized in adult and pediatric heart diseases, and is a donation of the non-profit  Alexander S. Onassis Foundation  to the Greek State. [ 1 ]  It is a non-profit legal entity under private law and operates under the supervision of the Greek Ministry of Health and Social Insurance. It is located in Kallithea, Athens, at the end of  Syngrou Avenue  (Syngrou 356). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14711", "text": "The Onassio Cardiac Surgery Center was the scene where the last act of the active political life of  Andreas Papandreou , prime minister of Greece and protagonist of its public life for decades, took place. For 4 months, from 29 November 1995 to 21 March 1996, Papandreou was hospitalized at Onassio [ citation needed ] , submitting his resignation as prime minister on 15 January 1996."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14712", "text": "One of the goals of the \"Alexander S. Onassis\" Charitable Foundation (which was founded in 1975 by the daughter of  Aristotle Onassis ,  Christina ) was the creation of a modern cardiac surgery center in Athens, since, while cardiac surgeries had already begun to be performed in Greece, the capabilities of state hospitals could not meet the needs of the Greek population, resulting in the ever-increasing exodus of a large number of heart patients abroad. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14713", "text": "Construction work began in October 1987 (the foundation stone was laid on October 8, 1987, by the then Prime Minister Andreas Papandreou, who was to become the most famous patient of Onassios) and was completed in September 1992. On October 6, 1992, the official opening of the operation took place of the center. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14714", "text": "Onassio cost a total of 75 million dollars (at the exchange rate prevailing in 1992) and is located on an area of 8,000 sq.m. A large part of the total cost was allocated to furnishing the center with the most advanced technical means of operation and the most modern scientific instruments. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14715", "text": "Henry Opitek  (January 6, 1911 \u2013 March 13, 1981 [ 1 ] ) became the first patient to survive open heart surgery in 1952."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14716", "text": "On July 3, 1952, Opitek, a 41-year-old male suffering from shortness of breath, made medical history at  Harper University Hospital  in  Michigan . The  Dodrill-GMR  heart machine, considered by some to be the first operational  mechanical heart  was successfully used while performing heart surgery on Opitek.  Forest Dewey Dodrill , a surgeon at Wayne State University's Harper Hospital in Detroit, used the machine to bypass Opitek's  left ventricle  for 50 minutes while he opened the patient's  left atrium  and worked to repair the  mitral valve . In Dodrill's post operative report he notes, \"To our knowledge, this is the first instance of survival of a patient when a mechanical heart mechanism was used to take over the complete body function of maintaining the blood supply of the body while the heart was open and operated on.\" [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14717", "text": "A  cardiovascular perfusionist ,  clinical perfusionist  or  perfusiologist , and occasionally a  cardiopulmonary bypass doctor [ 1 ] [ 2 ]  or  clinical perfusion scientist , [ 3 ]  is a  healthcare professional  who operates the  cardiopulmonary bypass  machine (heart\u2013lung machine) during  cardiac surgery  and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status. [ 4 ]  As a member of the cardiovascular surgical team, the perfusionist also known as the clinical perfusionist helps maintain  blood flow  to the body's tissues as well as regulate levels of  oxygen  and  carbon dioxide  in the blood, using a heart\u2013lung machine. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14718", "text": "Perfusionists form part of the wider cardiovascular surgical team which includes  cardiac surgeons ,  anesthesiologists , and  residents . [ 5 ]  Their role is to conduct  extracorporeal circulation  as well as ensure the management of physiologic functions by monitoring the necessary variables. The perfusionist provides consultation to the physician in selecting appropriate equipment and techniques to be used. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14719", "text": "Other responsibilities include administering blood products, administering  anesthetic agents  or drugs, measuring selected laboratory values (such as  blood cell count ), monitoring  circulation , monitoring  blood gases , surveil  anticoagulation , induction of  hypothermia , and hemodilution. [ 4 ] [ 6 ]  Sometimes, perfusionists are granted administrative tasks such as purchasing supplies or equipment, as well as personnel and departmental management. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14720", "text": "Perfusionists can be involved in a number of cardiac surgical procedures, select vascular procedures and a few other surgical procedures in an ancillary role. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14721", "text": "Perfusionists  may participate in curative or staged palliative procedures to treat the following pediatric pathologies:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14722", "text": "Adult surgical procedures may include:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14723", "text": "Select ancillary procedures in which perfusion techniques and/or perfusionists may be involved include  isolated limb perfusion ,  intraperitoneal hyperthermic chemoperfusion  and  tracheal resection/repair ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14724", "text": "In the  United States , a four-year  bachelor's degree  is a prerequisite for admission into an accredited perfusion program, typically with a concentration in  biology ,  chemistry ,  anatomy  and  physiology , varying depending on specific perfusion program. [ 7 ]  As of 2022, there are 18 accredited perfusion training programs, of which ten are  master's degrees , seven are  certificate programs , and one is a bachelor's degree. [ 8 ]  Training typically consists of two years of academic and clinical education. [ 9 ]  A perfusion student will typically begin his or her training in a  didactic fashion  in which the student will closely follow instructions from a certified clinical perfusionist in the confines of a cardiac surgery procedure. Academic coursework may be concurrent or precede this clinical instruction. Early in their clinical training, the perfusion student may have little involvement outside of an observational role. However, as time progresses, more tasks may be incrementally delegated to them. Upon graduating from a perfusion program, the graduate must begin the certification process. In the interim, the perfusion graduate is typically referred to as board-eligible, which is sufficient for employment in cardiac surgery with the understanding that achieving certified status is required for long-term employment. Most employers have stipulations on the duration of board-eligible status."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14725", "text": "To become certified as a certified clinical perfusionist, a perfusionist must undergo a two-part exam administered by the  American Board of Cardiovascular Perfusion . The first part is the Perfusion Basic Science Exam and the second part the Clinical Applications in Perfusion Exam. The exam process is open to a perfusion student that has graduated or about to graduate from an accredited perfusion education program. In addition, a perfusion student must have participated in a minimum of 75 perfusions during the course of their training before sitting for the Perfusion Basic Science Exam and performed 40 independent perfusions after graduation before sitting for the Clinical Applications in Perfusion Exam. [ 10 ]  Upon passing the Clinical Applications in Perfusion Exam, the perfusionist is designated a certified clinical perfusionist."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14726", "text": "Following certification, perfusionists must be recertified every year by attaining minimum clinical and educational requirements. [ 11 ]  Proof of fulfillment of these recertification requirements must be submitted to the American Board of Cardiovascular Perfusion and are mandatory to maintain certified status to use the designation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14727", "text": "As of February 2010, there were 3,766 certified perfusionists in the United States and approximately 300 certified perfusionists in Canada. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14728", "text": "In  Canada , there are three training programs:  Burnaby  in  Western Canada ,  Toronto  and  Montreal  in  Eastern Canada .  British Columbia Institute of Technology  in Burnaby offers an advanced specialty certificate in cardiovascular perfusion to graduates of its two-year program. Applicants must be certified respiratory therapists, critical care nurses, or cardiac professionals with two years or more of current experience in cardiac critical care. Applicants to the  Michener Institute  program in Toronto must have a  bachelor's degree  at minimum, with or without respiratory therapy, nursing or other clinical certification. The master's program is two years. The perfusion program of the  Universit\u00e9 de Montr\u00e9al  is a three-year bachelor's degree of 90 credits in biomedical science of which 27 credits are specific to clinical perfusion and in addition a dipl\u00f4me d\u2019\u00e9tudes sup\u00e9rieurs sp\u00e9cialis\u00e9es (DESS) of 30 credits in clinical perfusion of one-year at the master level."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14729", "text": "In the  United Kingdom  and  Ireland , a bachelor's degree in a science subject (usually life or clinical sciences) is a prerequisite to enrolment on the two-year perfusion training course. Trainees must complete a two-year MSc program at the  University of Bristol  while employed as a trainee perfusionist by a sponsoring hospital trust. This post is paid as an annex U AfC band 7. They complete academic assessments (essays and exams), while in the workplace moving from a purely observational role to one in which they are capable of managing the patient while they are on cardiopulmonary system with minimal supervision. Once a trainee has been the primary perfusionist in 150 clinical procedures, they must undertake a practical exam. For this exam, the candidate is observed by two external examiners whilst building and priming a cardiopulmonary circuit, then using it during a surgical operation. After the practical exam, trainees must complete a 40-minute  viva voce  exam, which tests their academic knowledge. After this is successfully completed, they are awarded an MSc in Clinical Perfusion Science and the status of accredited clinical perfusion scientist. They must maintain this by performing a minimum of 40 clinical procedures per year."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14730", "text": "In some states of  Australia  and  New Zealand , a perfusionist must have at least a science degree (usually in health sciences) as an entry requirement before training. Further didactic training is in a practical format at a hospital whilst doing a three-year course via correspondence and e-learning, with the Australian and New Zealand College of Perfusionists (ANZCP). The final examination for a clinical perfusionist is administered by the ANZCP over two days. This involves three hours of written assessment, two hours of multiple choice questions, and four half-hour  viva voce . Perfusion training is determined by the hospital at which the perfusionist is employed and may involve a hospital accredited training program which is determined by the health department to be the equivalent of ANZCP certification program."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14731", "text": "In Australia perfusion can also be provided by a medically trained  physician  who has undertaken additional subspecialty training. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14732", "text": "In  India , there are different programs for educating perfusionists. A three-year bachelor's degree program (most common) with one-year internship, a two-year post-graduate diploma  are available. Bachelor's and master's degree in some reputed institutions (i.e. PGI Chandigarh, AIIMS New Delhi, jipmer,  Gandhi Medical College, Bhopal , naryana groups Bangalore, Sawai Mansingh Medical College Jaipur, Sher-e-Kashmir Institute of Medical Sciences, Srinagar). Recently, the Board of Cardiovascular Perfusion of India introduced certification. [ clarification needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14733", "text": "In  China ,  Egypt , and some South American countries, a clinical perfusionist is a medical doctor who has completed subspecialty training. [ citation needed ] \nIn  Argentina , a perfusionist is a medical doctor, usually a  cardiologist , who has undertaken additional sub-specialty training. They are often referred to as  hemodinamistas  (hemodynamics specialists)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14734", "text": "In  Europe , perfusionist education standards are set by the European organisation of perfusion, EBCP (The European Board of Cardiovascular Perfusion) and has been implemented in many European countries. The length of the eduacation and training varies between 1 and 4 years, depending on requirements for entering the program. [ 14 ] \nIn the northern countries of Europe,  Scandinavia  including  Sweden ,  Denmark  and  Norway , perfusionists are educated at  Aarhus University  at the Scandinavian School of Cardiopulmonary Technology. [ 15 ]  Most perfusionist candidates are educated intensive care nurses/anaesthetic nurses and the education includes a Master Thesis in Cardiopulmonary Technology. [ 16 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14735", "text": "The  pericardial heart valve  was invented by  Marian Ionescu , a British surgeon working at the General Infirmary in Leeds, England. [ 1 ]  He created this artificial bioprosthetic  heart valve  as a three-cusp structure made of chemically treated bovine  pericardium  attached to a  Dacron  cloth-covered  titanium  frame. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14736", "text": "The experimental and  in vitro  testing of this novel device took place in 1970, and in March 1971, Ionescu began, for the first time, the implantation of the pericardial valve in all three  cardiac  positions in humans. Between 1971 and 1976 the valves had been made in Ionescu's own hospital laboratory. Throughout these five years of usage in 212 patients the performance of the pericardial valve was thoroughly evaluated. The results showed that this original valve exhibited the best  haemodynamic  performance, at rest and during exercise, [ 3 ]  when compared with the reported results of all other artificial valves in existence. It demonstrated a very low risk of embolisation even in the absence of long term  anticoagulation  treatment of the patients. [ 2 ]  There were no cases of valve  thrombosis , intra-vascular  haemolysis  or sudden, unexpected valve failure. The durability of the valve was good at 5 years of follow-up. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14737", "text": "Based on these results, the Shiley Laboratory in Irvine, California, began to manufacture this valve and to distribute it worldwide under the name of the 'Ionescu - Shiley Pericardial Xenograft.'"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14738", "text": "From 1976 onwards a series of modifications were made in order to improve the qualities and the performance of the pericardial xenograft. The selection and preparation of the bovine  pericardium  were standardised and rigorously controlled. For tissue fixation at zero pressure a solution of 0.5% purified glutaraldehyde was used. It contained an optimal proportion of  monomers  and  polymers  and an ideal cross-link density was obtained by controlling the concentration and the  pH  of the solution as well as its temperature and exposure time of the tissue to its action. The thickness and pliability of the pericardium were standardized and the direction of macroscopically visible fibres matched for each three cusps of a particular valve. The supporting stent was changed. The titanium was replaced with machined  Delrin  which is an acetyl  homopolymer  with low 'creep' properties due to a stable  molecular memory . It is flexible and shock absorbent, essential qualities for a tissue heart valve support.\nThis new stent contained a radio-opaque marker at its base for easy identification. The contour of the scalloped posts was modified and the height of the stent reduced. The entire Delrin structure was covered with seamless Dacron velour and at a later stage, the margins of the scalloped edges were covered with a thin layer of pericardium in an attempt to prevent or reduce the abrasion of the leaflets when in contact with this margin during valve closure. The sewing rim was bolstered for better and safer attachment to the heart annuli and its shape was anatomically contoured into two different configurations to better fit in the aortic and the atrio-ventricular positions. Two other additions were made: an integral valve holder which prevents the touching of the valve's cusps, and a 'freeze-watch' indicator as a safe\u2014guard against exposing the valves during transportation or storage at temperatures below 4 degrees Celsius. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14739", "text": "The geometry of the valve was slightly modified due to changes in the shape of the stent and by removing the outside pledgets around the posts. This gave a more streamlined shape of the whole structure. These modifications had been progressively introduced and all of them were incorporated in the 'Ionescu - Shiley Low Profile Pericardial Xenograft' valve, which became available in 1983."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14740", "text": "Approximately 200,000 pericardial valves manufactured by Shiley Laboratories were distributed around the world between 1976 and 1987 and it is presumed that most of them were implanted in patients. [ 5 ]  The use of this valve generated a lot of interest expressed in several specialist symposia, academic meetings, and numerous scientific articles published over the years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14741", "text": "The appropriation and organisation of this enormous material and the classification and interpretation of data has been a very difficult and complex task, especially because - contrary to what it is claimed - there remains a great deal of variation in standards of reporting in all essential chapters of a scientific work. In some cases it is quite impossible to follow such standards as it will be described later. Despite all these difficulties and impediments, a general view of the performance of the pericardial valve as close to reality as possible could be obtained."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14742", "text": "One should however keep in mind that any single investigator should resist the temptation to write a review of such a complex matter as tissue heart valves, and to cover the subject completely and fairly. One should also remember that if we study complex and variable conditions, averages must be rejected because they confuse while aiming to unify, and distort while aiming to simplify."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14743", "text": "From the material available it is evident that the reported hospital mortality and, up to a certain point, late mortality are similar among the various publications of different authors, and do not directly reflect on the quality of the valve used."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14744", "text": "The Ionescu pericardial valve had a large central opening almost equal with the inner surface area of the supporting stent. This, plus the pliability of the pericardial tissue, confer this valve exceptional  hydraulic  qualities. Haemodynamic studies by several authors [ 3 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ]  investigating patients with pericardial valves demonstrated that in all respects the haemodynamic function of this valve is superior to that reported for the porcine valves and, generally speaking, equal to that of the best mechanical prostheses. The haemodynamic results reported by other investigators are very similar to those by Tandon's group. Some authors stressed the advantage of very low  pressure gradients  across small pericardial valves (viz: 17, 19 and 21mm diameter) for implantation in small aortic roots without the need of complex surgical techniques for root enlargement. [ 7 ] [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14745", "text": "Tandon and associates [ 10 ] [ 11 ]  performed pre- and postoperative haemodynamic investigations at rest and during exercise in 110 patients. There were 51 with  aortic valve  replacement, 44 with  mitral  replacement, 3 with  tricuspid  and 12 who received multiple valve replacement. Following a technique and protocol developed at  Leeds General Infirmary , from the group of 110 patients investigated, 13 patients with aortic and 6 with mitral valve replacement were subjected to multiple, sequential haemodynamic studies at rest and during exercise at the following intervals: aortic: preoperatively and at 9.9, 42.2 and 68.3 months postoperatively; mitral: preoperatively and at 11.2, 42.3 and 68.7 months postoperatively. The results obtained showed that the considerable improvement recorded at the first postoperative investigation was maintained up to 68 months following valve replacement. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14746", "text": "In order to demonstrate visually the reasons for the great haemodynamic difference between the pericardial and porcine valves, Ionescu recorded in a ' pulse duplicator ' the opening characteristics of two porcine valves (Hancock Modified Orifice and the recently modified Edwards valve) and two pericardial valves ( the Standard and the Low-Profile Shiley valves)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14747", "text": "All four valves were manufactured for clinical use and all had an implantation diameter of 25mm. The valves were tested under identical conditions in the mitral compartment of the pulse duplicator and photographs were taken at the peak of  diastole . The flow rates were for each frame, from left to right: 0, 100, 200, 300 and 400 ml per second. The opening of the cusps of both types of pericardial valves is synchronous and regular, without three-dimensional flexure and the low-profile pericardial valve shows an even larger opening when compared with the standard pericardial valve. There are no crevices or dead spaces behind the open cusps of the pericardial valves. The difference between the porcine and the pericardial valves is flagrant in all respects. (Fig )"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14748", "text": "Many authors had studied, in-vitro, the hydrodynamic performance of the pericardial valve and found that it possesses better functional characteristics than the porcine valves and similar to those of the best prostheses. [ 13 ] [ 14 ] [ 15 ]  In summary, the excellent haemodynamic function of the pericardial valve is one of its great advantages and sets it aside from all other tissue valves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14749", "text": "While dealing with a very large number of reports from different hospitals with various numbers of patients who received pericardial valves and were followed up for differing durations of time, from five to ten years, and especially because the reporting did not follow an 'established' albeit loose 'standard' of identification, description and grading of the events, it is better to enumerate the results from some of the more representative series reported and draw only general conclusions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14750", "text": "The following data show the results as given in actuarial percentages of freedom from embolism."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14751", "text": "TABLE I. Freedom from embolism"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14752", "text": "From perusing innumerable publications on the results of heart valve replacement with pericardial valves concerning the rate of embolic complications, one may formulate several conclusions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14753", "text": "A clear picture concerning the exactitude of thrombotic and embolic complications of artificial heart valves, and especially of pericardial valves, seems to be very difficult. The knowledge at present is superficial and incomplete concerning the real causes and the risk and contributing factors to this complex phenomenon. Consequently, it has never been practical to try to standardise definitions, and even more complicated to establish lines of treatment. Everyone talks of 'causes' and 'risk factors' but no-one possesses any scientific evidence to this effect."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14754", "text": "The so-called 'risk factors' for embolisation, with the exception of  atrial fibrillation , can be called, at best, 'scientific illusions'. Consequently, any scientific, logical way of establishing a therapeutic means for preventing such phenomena due to unknown or incompletely understood causes is doomed to remain empirical, and the end results uncertain. [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 24 ]  There are myriads of reports for and against anticoagulant treatment for patients with tissue heart valve replacement. In addition, heart valve replacement patients are followed-up by a 'committee' made up successively by the  surgeon , the  cardiologist , the  general practitioner  in this or another town, etc. The impression of knowledge or our acceptance of ignorance compound this matter further. The only solution, for patients and doctors alike, would be an artificial heart valve which carries a very low risk of clotting, and therefore would not require, in the majority of cases, anticoagulant treatment."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14755", "text": "One main drawback in the recent 'scientific' literature on pericardial valves is that the essential data for arriving at an intelligent interpretation of results is missing. There is no description of the pre-operative condition of the patients concerning cardiac rhythm, various arrhythmias, atrial fibrillation, anticoagulant treatment, previous systemic emboli, etc., and scant information about the post-operative condition: cardiac rhythm, the nature and duration of anticoagulation, the time of occurrence of embolic phenomena and the magnitude and sequelae, if any."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14756", "text": "All this is already in the past, now, for practical purposes, one can conclude that the pericardial valve carries a very small risk of embolisation, much smaller than that of the porcine valves even in the absence of anticoagulant treatment. The risk of pericardial valve thrombosis is exceedingly remote. The very few cases reported have not been thoroughly investigated as far as the cause or the contributing factors, related or not to the valve, are concerned. Anticoagulant related haemorrhage was extremely rarely reported because few patients received  prothrombin  depressants for long periods of time (Sublata Causa Tollitur Effectus)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14757", "text": "There are several reports on tissue valves stating that the incidence of emboli was higher among patients receiving anticoagulation. In addition, it was observed that the rate of embolisation appears to be decreasing with the passage of time with the pericardial valves, unlike the experience with porcine valves in the mitral position where the risk remained constant during the whole period of follow-up in spite of different schemes of long-term anticoagulation. [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14758", "text": "The favourable embolic rate and virtual lack of valve thrombosis of the pericardial valve appears to be due to the quality of the tissue, and especially to the design of the valve with a smooth and synchronous movement of the three cusps and the streamlined structure conferring the valve optimal hydrodynamic characteristics even at low flow rates. [ 14 ] [ 18 ] [ 20 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14759", "text": "Infective endocarditis is a severe condition which occurs on native as well as on artificial valves. Both mechanical prosthetic devices and tissue heart valves are affected. The incidence of endocarditis, in western countries, ranges from 1.5 to 6.2 cases per 100,000 people per annum. The cumulative rate of prosthetic valve endocarditis is 1.5 to 3.0% at one year following valve replacement and 3 to 6% at five years, the risk being the greatest during the first six months after valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14760", "text": "Prosthetic valve endocarditis arising within two months of valve surgery is generally the result of intra-operative contamination of the prosthesis or a bacteraemic post-operative complication. The nosocomial nature of these infections is reflected in their primary microbial causes: coagulase-negative staphylococci, S. aureus, facultative gram negative bacilli, diphtheroids and fungi."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14761", "text": "Epidemiologic evidence suggests that prosthetic valve endocarditis due to coagulase negative staphylococci that presents between 2 and 12 months after surgery is often nosocomial in origin but with a delayed onset. [ 25 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14762", "text": "This short introduction may help to reflect on the various and sometimes opposing view-points concerning the 'origin' of prosthetic valve endocarditis. As in most recent scientific reports, some descriptions of tissue valve endocarditis suffer from the same lack of clarity and standardization in the presentation of facts and do not give all relevant details for a better understanding of events and their causes. From eight published articles of large series of patients with Ionescu-Shiley Pericardial valves, only one report presents a higher than average number of valvular bacterial infections. [ 26 ]  The other seven publications describe the rate of infection with figures of similar magnitude."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14763", "text": "TABLE II. Freedom from infective endocarditis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14764", "text": "Footnotes to the table:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14765", "text": "(A):  The authors make a remark: Prior to heart valve replacement 86 patients suffered from infective endocarditis but only 9 of these patients developed recurrent infection following pericardial valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14766", "text": "(B):  Of the 17 cases of infection, 15 occurred between 1976 and 1981 and only 2 cases between 1981 and 1985. Ionescu's group took draconian measures in trying to jugulate post-operative infections which they considered to be, in great part, nosocomial in origin. Those measures were directed at systematic pre-operative dental examination and treatment, search for any hidden, potential foci of infection - urological, upper and lower respiratory tract, judicious selection of antibiotic cover of the patient before, during and following heart valve replacement operations and strict monitoring of all signs of infection in the post-operative period. It appears that these measures had borne fruit."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14767", "text": "(C):  On two occasions, Holden successfully implanted pericardial valves in patients with infective endocarditis and he advocates the use of such valves in similar situations because the pericardial valves are considered to be more resistant to infection than other devices. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14768", "text": "(D):  This group considers that in its hands the pericardial valves were more prone to infection than the porcine valves, and also when compared to the results with pericardial valves published by other surgeons."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14769", "text": "In conclusion, it is obvious that the risk of infective endocarditis in pericardial valves is not dissimilar from that encountered in porcine valves at least up to ten years after valve insertion. It can also be considered that the minor variations occurring in the published reports are due to local hospital differences, surgical technique, general handling of the valves and other factors."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14770", "text": "One rarely finds a patient who was treated medically for proven endocarditis on his own valve who does not require valve replacement sooner or later. There is no fundamental reason why any pericardial valve should become infected more frequently than another one except if the patient becomes septicaemic and the infecting organisms will reach the valve area. It appears illogical to claim that because one surgeon reported a higher incidence of infective endocarditis with one type of valve, that there could be any significant differences between 'his' valves and those implanted by other surgeons. The difference is in the number of patients with circulating infecting micro-organisms capable of infecting the valve area."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14771", "text": "Most authors do not consider infective endocarditis as a valve-related failure and do not include cases of infection in such statistics. The pericardial valve does not behave in a different way from other tissue valves as far as infection is concerned, with probably one exception. In the impression of some surgeons, the pericardium itself seems to be more resistant to infection than the porcine valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14772", "text": "The durability of the pericardial valve, like that of all other artificial heart valves, depends on multiple factors, one of the most important being the environment in which the artificial valves function."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14773", "text": "Primary or intrinsic tissue failure occurred with pericardial valves and it has been reported in several publications. Unfortunately, many reports do not contain some of the essential data and details necessary for building a clear image of this crucial aspect of valve performance. Table III tabulates some of the available data on primary tissue failure."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14774", "text": "TABLE III. Primary tissue failure"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14775", "text": "Remarks for primary tissue failure"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14776", "text": "(A):  The ages of the patients range from 8 to 90 years (mean 57). 74% were over 70 years of age. The age of the two patients with valve failure (calcification) was not mentioned."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14777", "text": "(B):  The most important element in this large series is the demonstration that one of the most important factors in valve calcification is the age of the patient at the time of valve implantation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14778", "text": "(C):  In this series, the authors mention, in addition, 4 cases of entanglement of sutures around the struts. These 4 patients were re-operated upon at between one week and 50 months following the first valve operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14779", "text": "(D):  The authors stated that all 8 failures were due to valve calcification and that 2 of them had additional tears. They find that their results with 'calcification' in all failed valves are contrary to Gabbay's results  [ 34 ]  where failures occurred mainly through cusp tears."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14780", "text": "This table is only an attempt to give a general impression and to provide a basis for a more detailed interpretation of results. However, several conclusions can be formulated on the complex, varied, and in some cases controversial results published. As very often, a good amount of significant data is missing and this complicates the task of being precise and fair in interpreting the results."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14781", "text": "It appears that the great majority of pericardial valves function correctly until about 6 to 7 years post implantation. Beyond seven years of follow-up, the actuarial figures for freedom from valve failure start to decrease. In the table, the risk of valve failure seems to be greater in the aortic position as reported by some authors. In reality, the general consensus among surgeons, in various presentations and formal discussions, shows the contrary."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14782", "text": "At 10 years, and beyond, the pericardial valve did function well in the aortic position, as reported by various authors., [ 35 ] [ 36 ] [ 37 ] [ 38 ]  Several pericardial valves were explanted from the aortic position at 16, 17 and 18 years following implantation, and a few valves between 21 and 23 years. [ 35 ] [ 38 ]  Pericardial valves in the mitral position fared less well beyond 5 \u2013 6 years, as reported in some series, but not in others. Ravichandran [ 35 ]  reported a series of 34 patients (with 41 valves) who were re-operated upon for removal of failed Ionescu-Shiley pericardial valves. The failures occurred at a mean duration since 'implantation' of 11.3 years (mean range 3\u201317 years). There were 30 mitral and 11 aortic valves involved, and the majority were moderately or heavily calcified. Watanabe  [ 39 ]  describes a case of an Ionescu-Shiley bioprosthesis which functioned 24years in the mitral position of a patient."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14783", "text": "The known modes of tissue valve failure are: tearing of the pericardium, calcification of the valve and, exceptionally, fibrosis of the cusps. Tears represent approximately 25% and calcification 75% of primary failure. In some cases both pathologies could be encountered in the same valve. This proportion varies considerably and could be seen reversed in some series of patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14784", "text": "The causes for pericardial tears were described in detail [ 34 ] [ 37 ]  and can be summarised as an abrasive mechanism produced by the rubbing of the pericardium over the Dacron-covered margin of the supporting stent. Such tears progress slowly until a part of one of the cusps becomes flail and the amount of regurgitation increases. This explains the fact that there is no sudden catastrophic failure with the pericardial valve, except when the initial, obvious clinical signs and symptoms of incipient malfunction have been missed or disregarded by the treating physician or the patient. There may be, in a minority of cases, some slightly different mechanisms of pericardial damage at points of three-dimensional flexure or perforation caused by the excessively long ends of sutures used in aortic valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14785", "text": "Several techniques have been used in order to reduce or abolish 'abrasion', as will be described later. [ 37 ]  Within the limitation of the intrinsic durability of the chemically treated bovine pericardium, various modifications, physical and chemical, could be employed to eliminate this type of failure and considerably extend the functioning life of this valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14786", "text": "Valve calcification is a local representation of a general biologic phenomenon which occurs under specific conditions in various parts of the body, especially in younger individuals. Valve calcification is known to have taken place in all types of tissue valves. Because some important details are not given in the reported series (age of patients, timing of occurrence, position of the valve, etc.) it is difficult to form a clear-cut conclusion in all situations."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14787", "text": "One report on a large series of patients followed for six years, presented at a symposium in 1985, [ 27 ]  gave clear and complete information regarding the relationship between valve calcification and the age of the patients at the time of valve implantation. The authors showed that in the groups of patients aged between 10 and 59 years, the incidence of valve calcification ranged from 31.8% (in the age group of 10 to 20 years) to 1.8% (in the group aged 50 to 59 years) to reach zero calcification in patients older than 70 years. Similar conclusions about the relationship between age and valve related complications were published about porcine valves. [ 40 ] [ 41 ]  The clear demonstration of this inverse relationship between the age of the patient and the rate of valve calcification 'sounded an alarm bell' and started to change the way in which tissue valves (porcine aortic and bovine pericardium) should be used in the future, and indicated the direction in which potential future research should be concentrated in order to make tissue valves universally acceptable by young and old patients without problems. At this moment in time,(2011), tissue valves are almost exclusively used in patients older than 65 years because in old age the process of calcification is considerably slowed down and also because the life of the valves may outlast the life of those patients who reach a 'respectable' age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14788", "text": "Several attempts have been made in order to abolish or at least to delay the occurrence of calcification. Two chemical processes were put forward: the T6 by Hancock Laboratory and the PV2 by Edwards Laboratory. The two chemical interventions had been tested in animals and in humans with unconvincing results. Subcutaneous implants, in rats, of cusps of porcine valves and strips of pericardium showed some positive results. [ 42 ]  However, care should be exercised in extrapolating such data obtained from subcutaneous implants to intracardiac location and function of valves in humans."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14789", "text": "Jones  [ 43 ]  and associates using the well known sheep model, which is a rapidly, universally and highly calcifying model, implanted porcine and pericardial valves either 'standard' or pre-treated with the Hancock T6 or the Edwards PV2 processes. The results showed that these processes mitigated the calcification of porcine valves but did not have any effect on the pericardial valves. Gallo [ 44 ]  conducted similar experiments using the same model as Jones and Ferrans and implanted  Hancock porcine valves , with and without the T6 treatment, in the mitral and tricuspid positions of sheep. He found no significant difference in the amount of cusp calcification between the standard and the T6 treated valves, whether in the mitral or in the tricuspid position."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14790", "text": "Although very little is known about the exact causes of this extremely complex process of calcification, attempts are made to treat it."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14791", "text": "Macro and microscopic pathology studies of failed porcine bioprostheses by Schoen and Cohn [ 45 ]  showed in detail the process of tissue degeneration in valves with tears, calcification, or both. They consider that patients with porcine aortic bioprosthetic valves follow a clinically satisfactory course for around five years after operation. Late deterioration of these valves frequently necessitates re-operation. They estimate the rate of failure at approximately 15 to 25%, 7 to 10 years after valve implantation. Gallo and his associates [ 41 ]  describe in detail the rate of occurrence and timing of primary tissue failure with the Hancock porcine valve, and show a similar percentage of failures. The actuarial freedom from valve failure in the mitral position at 10 years is 69%, and in the aortic position only 53%. The rate of tissue valve failure accelerated from the third post-operative year in the mitral position, and from the fifth year in the aortic position with a precipitous fall during the 8th and 9th years of follow-up. They believe that the patient can be told that he or she has a 30% chance of requiring re-operation because of the porcine valve degeneration within the next 10 years. This general calculation does not take into account the other causes of valve 'problems' which may lead to re-operation or some other morbidity during that period of time. Goffin [ 46 ]  showed in a comparative histological study of explanted porcine and pericardial valves that the microscopic pathologic changes were similar in these two types of tissue. Grabenwoger [ 47 ]  found similar pathologic changes in the failed Sorin Pericarbon pericardial valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14792", "text": "These long-term studies showed that both the tissue of pig valves and that of calf pericardium behave in a similar manner when used for valve replacement in humans. In a simplified way, the main difference between these two types of valves is the haemodynamic superiority of the pericardial valve and its smaller risk for embolisation. But the overwhelming advantage of the pericardial valve remains the fact that, being a man-made device, it lends itself to a variety of changes in order to improve its performance."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14793", "text": "In most published reports about tissue heart valve replacement, there are differences in the presentation of data and of the results in all aspects of a particular topic between the various publications. In almost all chapters of valve function, with the exception of haemodynamic and hydraulic measurements - which are scientifically obtained and mathematically expressed - there are differences from author to author. Why in the hands of one surgeon, the same type of tissue valve fails in one patient at 24 months, and in another one it lasts 243 months? Microscopic studies performed on porcine and pericardial valves, explanted because of failure between 12 months and 6 years, all showed gross histological changes in the structure of tissue. [ 45 ]  In view of these changes in those valves, how did some of the porcine and pericardial valves continue to function well beyond 10 years? Why did the rate of occurrence of bacterial endocarditis differ from one hospital to another, and the embolic rate vary from surgeon to surgeon?"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14794", "text": "An overview of the publications on this topic may lead to the formulation of some tentative answers. There are, generally speaking, several potential factors which may affect variously the durability of tissue valves, and which may explain the discrepancy among published results. Carlos Duran [ 48 ]  summarised some of them in the following way:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14795", "text": "Great damage can be inflicted on a bioprosthesis at the time of its implantation. One of the not so rare causes is allowing the cusps of the valve to become dry \u2013 to look like parchment - during the time of placement of sutures. Some errors occurred exceptionally: The plastic identification tag remained attached to the valve and became stuck to the left ventricle wall; the sutures meant to secure the introducer were not removed and all three cusps of a valve were limited in their movement; entangling sutures around the stent struts, sometimes around two struts: (one of the incidents was published under the title of 'Fatal bioprosthetic regurgitation immediately after mitral and tricuspid valve replacement with Ionescu-Shiley bioprosthesis'). [ 50 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14796", "text": "During 1986, Shiley made a substantial and original modification to the pericardial valve. The stent was redesigned. It was made of two wafer-thin, unequal, flexible  Delrin  components: an outside, standard-shaped frame and an inner, smaller structure. The pericardial cusps were mounted inside the outer frame and were kept in position by the inner frame which is smaller and much thinner than the outer one. Through this arrangement, the lower parts of the pericardial cusps exit from the supporting frame at its bottom, and therefore the pericardium does not bend over the upper margin of the stent, eliminating the possibility of abrasion during the closure phase of the valve. As it was learned from clinical and from in-vitro studies, abrasion of the pericardium was a cause of valve failure when the tissue was attached on the outside of the stent. [ 34 ] [ 37 ]  The in-vitro testing of this modified pericardial valve showed almost identical hydrodynamic results when compared with the existing pericardial valve. [ 51 ]  Accelerated life-testing showed that failure of this new valve occurred some 3 to 4 times later than that of existing valves. When valve failure occurred, it was not due to abrasion but through progressive fraying of the pericardium. Encouraged by these results, Shiley decided to start manufacturing this modified, improved valve called the 'Ionescu-Shiley Pericardial Optimograft'. [ 52 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14797", "text": "At about that time, grave problems were encountered by Shiley with the increasing number of sudden failure of the Bjork-Shiley mechanical disc valve. [ 53 ]   Pfizer  laboratories, the drug manufacturer and owner of Shiley, stopped all manufacturing activities of Shiley Laboratory, with a view to liquidate the company. Consequently, not only was the Bjork-Shiley valve (the culprit) affected by this action, but all other products \u2013 valves, oxygenators, catheters, etc. - went out of production."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14798", "text": "It was said (by Mr Larry Wettlaufer: Vice-President at Shiley Inc. 1987) that Ionescu did not want to go to another valve manufacturer with his 'Optimograft' and that he preferred his Himalayan climbing expeditions instead."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14799", "text": "A careful appraisal of the results and the evolution of the two types of tissue valves created and used during the past four decades brings into focus the similarities but mainly the discrepancies which set them apart as structures and as functioning valves. The porcine valve was subjected to several modifications which reached the limits imposed by the fixed geometry of the pig's aortic valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14800", "text": "The pericardial valve, the embodiment of the concept of 'man-made' devices, lends itself to an infinite permutation of changes of shape and physico-chemical interventions in order to improve its function, and indeed this is what happened. Almost 10 years after the creation, by Ionescu, of the pericardial valve, the concept behind it attracted several specialised laboratories to study this valve, to modify and improve it and bring it anew in the clinical field of usage, under different shapes and names, but always following the same general concept: glutaraldehyde-treated bovine pericardium mounted on a flexible frame as a three-cusp valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14801", "text": "Building the second generation of pericardial valves was possible, first of all, because there existed a first generation. The originality of the concept, the successes and failures, the flaws and positive aspects of the original pericardial valve and the experience accumulated with its use over the first 10 to 15 years created the incentive and showed the way for changes, modifications and potential improvements in building the valves of a second generation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14802", "text": "Of the several pericardial valves built since 1980, some have been abandoned early and only three have stood the test of time. These three modified and improved pericardial valves were made respectively by Mitral Medical Inc. (now part of the Sorin group), Edwards Laboratories (now Edwards Lifesciences) [ 54 ]  and the Sorin Group. [ 55 ]  All three laboratories have devised different techniques of valve construction with the aim of reducing or abolishing the risk of tissue abrasion. The specialists at Mitral Medical Inc. retained the technique of mounting the pericardium outside the stent as in the original Ionescu valve, but found other ways of reducing abrasion. The Edwards engineers used an ingenious way of mounting the pericardium inside the stent albeit with a minimum loss of useful opening flow area. The Sorin technicians devised yet another way of mounting the pericardium in a double layer so as to have the stent margin padded with a pericardial sheet (similar to one of Shiley's modifications [ 37 ] )."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14803", "text": "The Edwards valve became available in 1980. The device made in the configuration for mitral replacement had to be withdrawn, after implantation in a small number of patients, because of excessive flexibility of the stent causing mitral incompetence. A new redesigned version of this valve was reintroduced in 1984. [ 56 ]  The Mitroflow valve, as first manufactured by Mitral Medical in 1982, had to be redesigned because it showed a failure mode similar to the first generation of pericardial valves. Since 1991 a modified version of this valve was introduced and has been used in a large number of patients. [ 56 ]  The additional changes made in the configuration of these two valves demonstrate, once again, the advantage of the versatility of the 'man-made concept' of the pericardial valve."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14804", "text": "The haemodynamic characteristics of these 3 types of valve [ 57 ] [ 58 ]  are similar to the excellent results found with the original Ionescu-Shiley valve as described by Tandon's group. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14805", "text": "The minor differences in gradients and in calculated surface area do not show a significant difference at clinical level. The adjacent image portrays the opening characteristics of 4 pericardial valves - Hancock (no longer available), Mitroflow, Edwards and Shiley. The cusps of these valves open synchronously up to a very large surface area only minimally different from one valve to another. All 4 valves were manufactured for clinical use and all were 25mm in diameter. The valves were photographed under identical conditions in the mitral side of a 'pulse duplicator' and the flow rates, at peak of diastole were: for each frame, from left to right: 0, 100, 200, 300, and 400\u00a0ml/s."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14806", "text": "Regarding infective endocarditis, embolic complications and bleeding due to anticoagulant treatment, there is only scant data in the publications analysed for this article. It is presumed, and not without good reason, that the main emphasis was placed by the authors on structural valve deterioration (SVD). It can also be considered logical that these three types of pericardial valves, having a similar structure and dynamic function as the original Ionescu pericardial valve, such complications, 'grosso modo', would have occurred at about the same rate as reported by the users of the Ionescu valve as already reported in this article."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14807", "text": "The scientific publications on these three, second generation pericardial valves are not only few in number but they lack some of the necessary, standardised data for a complete, clear and fair evaluation of the results. In order to avoid generalities and averages, the data reporting SVD is presented in the form of tables."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14808", "text": "Table IV. Mitroflow Pericardial Valve"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14809", "text": "A = Aortic; M = Mitral; D = Mitral and Aortic, T = Tricuspid, SVD = Structural Valve Deterioration."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14810", "text": "The lack of standardised data presented in the various publications makes interpretation difficult. The discrepancy of the actuarially presented results between the various publications is evident."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14811", "text": "Table V. Edwards Pericardial Valve"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14812", "text": "A= Aortic; M= Mitral; T = Tricuspid; SVD = Structural Valve Deterioration; SBE = Subacute Bacterial Endocarditis"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14813", "text": "The inverse relationship between the age of the patients and the rate of SVD is obvious in most reports."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14814", "text": "There are very significant differences among the various publications concerning the figures of actuarial freedom from SVD. Published data from Dr. Carpentier on structural dysfunction of the valve which carries his name would have been useful, but a search through the relevant medical literature, has not revealed any such publications."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14815", "text": "Table VI. Sorin Pericarbon Pericardial Valve"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14816", "text": "A =Aortic; M = Mitral; D = Mitral and Aortic; T = Tricuspid; P = Pulmonary; SVD = Structural Valve Deterioration."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14817", "text": "(i)  This figure should be interpreted with caution because the study was of only 39 patients with mitral replacement and only 2 patients were at risk at 10 years. The patients' ages were not supplied in detail."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14818", "text": "(ii)  This study describes only the pathology of failed valves in 9 patients (out of a series of 144), 51 \u201379 years old (mean 69) followed-up for 6 \u2013 8 years. The description of clinical use and results of the 144 patients who received Sorin Pericarbon Pericardial Valves would have been of great interest, but a search through the relevant medical literature has not found any such publication from the surgical team."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14819", "text": "There are very few published reports containing sufficient data in order to be useful. One can only note, without much comment, the gross difference between the SVD shown in these three tables."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14820", "text": "A scientific comparison among these 3 second generation valves, and between them and the Ionescu-Shiley valves is practically impossible. The number of patients in the published series varies considerably."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14821", "text": "For the Shiley valves there had been an almost equal distribution of mitral and aortic replacements. For the new generation valves, the ratio was about 5:1 in favour of the aortic valve. The much smaller number of mitral valve replacements is due in part to the reduction of mitral valve disease in the general population and, at the same time, because of the increase in the number of patients with degenerative aortic valve disease in a progressively aging population. Another reason appears to be the perception of some surgeons that pericardial valves in the mitral position are more susceptible to SVD, than in the aortic position. The time-frame of their usage also varies. Surgical techniques and experience in general have evolved over the past 40 years. The lessons from the past might have borne fruit. The experience with the Shiley valves shows that 75-80% of valve failure was due to calcification and only 20-25% failed because of abrasion and possibly because of design flaws. The knowledge about the type of valve failure - abrasion and, especially, calcification - have placed tissue valves in a new perspective and gave the surgeons a different outlook. The greatest achievement after the first 10\u201315 years of usage of the first pericardial valves, was the realisation of the inverse relationship between patient age and valve calcification. This was known before, from the porcine valve experience, but it has not received sufficient emphasis until the use of pericardial valves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14822", "text": "The data presented in the above three tables allow one to draw some conclusions based on existing factual results but also on overall general impressions."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14823", "text": "The second generation of pericardial valves have only occasionally failed due to tissue abrasion, although tears have still occurred."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14824", "text": "Calcification of the tissue occurred later in elderly patients because mineralisation develops later and advances slower in old age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14825", "text": "These modified valves have been used preferentially, if not exclusively, in older patients and in a considerably larger proportion for aortic valve replacement rather than in the mitral position where the risk of SVD was, and remains, higher. These elements distort significantly all chance of a comparison with the series of Shiley valves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14826", "text": "During the 1970s and 80s, Shiley pericardial valves had been used in patients of all ages, and particularly in patients under the age of 65 years. During the 1990s and into the following decade, the mean age of patients receiving the second generation of pericardial valves varied between 67.2 and 72 years, a very significant difference in age."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14827", "text": "The technical improvements made in the second generation of valves has apparently reduced the risk of cusp abrasion. This advantage was not fully exploited because these valves were used only in a small proportion in young patients who would have benefited more from this technical advancement. Despite claims that all 3 types of second generation valves were treated with 'so-called' anticalcification processes, the clinical results have not shown any benefit from such chemical treatment. The only reason for the reduced rate of calcification - and therefore of structural valve deterioration - in patients receiving these second generation valves was the advanced age of the patients who received them. The age of the patients was shifted from a mean of around 50 years with Shiley valves, to a mean of between 67 and 72 years with the second generation valves."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14828", "text": "It is regretable that pericardial valves, which are known to carry a very low risk of embolisation, were not used more often in the mitral position where the need and benefit would have been greater."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14829", "text": "However, in general, the second generation pericardial valves represent a progress in the armoury of devices for the treatment of heart valve disease. If the process of valve calcification could be controlled, these pericardial valves would become the panacea for patients in need of heart valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14830", "text": "In general, it is known that success depends on knowing how long it will take to succeed. For the time being, one has to accept that most of the aspects of the present are accessible only to Prophesy, about the future, the understanding of the phenomenon 'calcification' and its prevention, may lay somewhere beyond the horizon."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14831", "text": "A short history of the introduction in clinical use of valves made of animal tissue for heart valve replacement in humans allows us to appreciate the evolution of this chapter of cardiac surgery and to imagine future potential developments in this field."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14832", "text": "1965  Duran and Gunning in Oxford, England, published their experimental work of implanting porcine aortic valves in dogs and the previous year they had already performed the first successful porcine aortic valve replacement in one human patient. [ 73 ] [ 74 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14833", "text": "1965  Binet and associates in Paris, France, began the use of porcine aortic valves for aortic valve replacement in humans. [ 75 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14834", "text": "1967  Ionescu and associates in Leeds, England, used for the first time porcine aortic valves mounted on an original valve support for mitral valve replacement in humans. [ 76 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14835", "text": "1969  Hancock Laboratory in Irvine, California introduces the first commercially available porcine aortic valve for use in patients. [ 77 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14836", "text": "1969  Carpentier and associates in Paris, France, advocate the use of glutaraldehyde for chemical treatment of porcine aortic valves. [ 78 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14837", "text": "1971  Ionescu and others in Leeds, England, creates the first bovine pericardial heart valve and begins its implantation in humans. [ 79 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14838", "text": "1980  Since the early 1980s several modified pericardial valves have been built. Three of them with improved characteristics are being successfully used, as shown in this article."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14839", "text": "The two important creative stages in tissue heart valves (from 1964 to 1971) took place in a short space of seven years and that since 1971 when the concept of 'man-made pericardial valves' was created, no other significant invention has occurred in this field except the use of bovine pericardium in the construction of transcatheter valves for aortic valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14840", "text": "The porcine valve was used successfully under several names, made by different laboratories, with various modifications and slight improvements without becoming essentially different from the original, native, pig's valve shape. However, the porcine valve, although far from perfect, was very useful in helping a large number of patients over many years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14841", "text": "The bovine pericardial valve had been created in 1971 and over the following 4 decades, with various modifications and improvements made by different\n, it became, due to its superior overall qualities, the tissue valve of choice for the great majority of surgical groups around the world."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14842", "text": "The pericardial valve is not simply another valve, it is the embodiment of a concept of tissue valve construction. At present the bovine pericardium is being used, tomorrow perchance an even better material will be found."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14843", "text": "In this respect, Ionescu made, in one of his early papers, a significant and rather prophetic statement:"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14844", "text": "The physico-chemical and biological properties of the natural porcine aortic valve have been profoundly altered by various interventions in order to adapt it for therapeutic means. In this way, the porcine valve has lost all its primordial characteristics except its shape which remains unchanged and unchangeable. The pericardial valve, on the other hand, has been conceived as an entirely 'man-made' valve and therefore its shape and general characteristics can be altered through a multitude of interventions in order to optimise its function [ 80 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14845", "text": "Adhuc sub judice lis est:  Quintus Horatius Flaccus (68-8 BC)  [ 81 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14846", "text": "Contrary to what is mentioned in this article, a short publication, co-authored by A. Carpentier, was found. [ 82 ]  It presents a small series of 61 patients who received isolated aortic valve replacement with Carpentier-Edwards pericardial valves. The authors state that at 6 years of follow-up 'there have been no cases of  periprosthetic  leak, no cardiac insufficiency and no thromboembolism' This short article does not contain any other 'significant' information."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14847", "text": "In a recent publication Dr. Denton A Cooley, who used a very large number of Ionescu-Shiley Pericardial Xenografts, mentioned the following: I still have surviving patients with functioning Bjork-Shiley and Ionescu-Shiley valves, some of which were implanted 30 or more years ago. [ 83 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14848", "text": "There are now more than 40 years since Doctor Ionescu introduced, for the first time, the glutaraldehyde treated bovine pericardium in clinical use in the form of a three cusp heart valve (The Ionescu-Shiley Pericardial Xenograft). It is of interest to know that now, 40 years later, the bovine pericardium is still used in three medical/surgical devices."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14849", "text": "1. The second generation of Pericardial Xenografts as described in the above article are used in large numbers."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14850", "text": "2. For the manufacture of \"Transcatheter Aortic Valve Implantation\" devices which are used in progressively larger numbers of selected patients, especially in Europe."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14851", "text": "3. For the manufacturing of cardiac ventricular chambers in an experimental artificial heart under testing in a French laboratory."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14852", "text": "A  pericardial window  is a  cardiac surgical  procedure to create a  fistula  \u2013 or \"window\" \u2013 from the  pericardial space  to the  pleural cavity . [ 1 ]  The purpose of the window is to allow a  pericardial effusion  or  cardiac tamponade  to drain from the space surrounding the  heart  into the  chest cavity . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14853", "text": "Pericardial window may be used to treat  pericardial effusion  and  cardiac tamponade . [ 2 ] [ 3 ]  It is the most common procedure to treat pericardial effusion, particularly if caused by  cancer . [ 4 ]  Untreated, these can lead to  death . The pericardial window decreases the incidence of postoperative pericardial tamponade and new-onset  atrial fibrillation  after  open-heart surgery . [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14854", "text": "Creation of a pericardial window is a major  surgical procedure . [ 6 ]  To remove  pericardial fluid , other more minor techniques should be considered first, such as  pericardiocentesis . [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14855", "text": "Pericardial window is usually performed under  general anaesthetic  by a  cardiac surgeon . They may make an open  surgical incision  of up to 10  cm . [ 6 ]  This is usually located below the  xiphoid process  of the  sternum  (sub-xiphoid). [ 4 ]  Alternatively, access may be gained  thoracoscopically  with a smaller surgical incision. [ 3 ] [ 7 ]  A small hole of between 1 cm and 2 cm is cut in the  pericardium , which is the membrane that surrounds the  heart . [ 6 ]  This allows for any  pericardial fluid  and other fluid to escape from the pericardium. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14856", "text": "Pericardial window was first performed by  Baron   Dominique Jean Larrey  in  1829 . [ 6 ] [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14857", "text": "Pericardial windows are commonly used in  veterinary medicine  to treat pericardial effusion. [ 7 ]  Whereas a sub-xiphoid skin incision is preferred in humans, a left para-xiphoid skin incision is preferred in  cats . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14858", "text": "Pericardiectomy  is the surgical removal of part or most of the  pericardium . [ 1 ] [ 2 ]  This operation is most commonly used to relieve  constrictive pericarditis , or to remove a pericardium that is  calcified  and  fibrous . [ 2 ]  It may also be used for severe or recurrent cases of  pericardial effusion . [ 3 ]  Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14859", "text": "Pericardiectomy is used to treat  constrictive pericarditis , which is caused by a variety of conditions. [ 2 ] [ 3 ]  It is also used to treat recurring cases of  pericardial effusion . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14860", "text": "Pericardiectomy should not be used if more minor procedures are more appropriate, such as a  pericardial window . [ 6 ]  Pericardiectomy may not be appropriate for patients who already have a poor prognosis, as its medical benefit is reduced. This is because pericardiectomy has a higher rate of  complications  and a higher  mortality . [ 6 ]  More conservative treatment may use  diuretics ,  digoxin ,  steroids ,  NSAIDs , or  antibiotics  to change  cardiovascular physiology  without treating the underlying pathology, which is appropriate for those not suitable for major surgery. [ 7 ]  Some patients may undergo conservative treatment for a number of months before pericardiectomy is considered truly necessary. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14861", "text": "Pericardiectomy can cause a number of cardiac issues, such as  arrhythmia , low cardiac output syndrome, and  myocardial infarction  (in rare cases). [ 2 ]  There is some risk of damage to the  pleural cavities  around the  lungs , which can lead to  pneumonia , or  pleural effusion . [ 2 ]  It also presents typical  surgical risks , such as  infection ,  anaesthesia  complications,  blood clots , and  bleeding . [ 2 ] [ 3 ]  There is a low risk of  haemorrhage  if the heart is  perforated  whilst removing the pericardium. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14862", "text": "Outcomes after surgery depend significantly on the underlying cause of illness, and the function of the  kidneys ,  left ventricle , and  pulmonary arteries . [ 5 ]  Recovery from pericardial effusion treated with pericardiectomy is typically very good. However, its use for treating constrictive pericarditis has a fairly high  mortality rate , initially between 5% and 15%. [ 3 ] [ 4 ]  The 5-year survival rate is around 80%. [ 3 ]  The most common complication after surgery is reduced  cardiac output , which occurs in between 14% and 28% of patients. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14863", "text": "Pericardiectomy takes place by removing the infected, fibrosed, or otherwise damaged pericardium. The procedure begins when the  surgeon  makes an incision in the skin over the  breastbone  and divides the breastbone to expose the pericardium, known as a  median sternotomy . [ 3 ] [ 6 ]  Alternatively, a larger incision known as a  thoracotomy  may be used. [ 6 ]  During the surgery, the surgeon will hold the pericardium, cut the top of this fibrous covering of the  heart , drop it into the specimen bag, and re-cover the heart. The breastbone is then wired back together and the incision is closed, completing the procedure. When the portion of pericardium lying between the two  phrenic nerves  is excised, it is called total pericardiectomy. In cases where total pericardiectomy is not possible, subtotal pericardiectomy is performed or, in extreme cases, a cruciate incision on the pericardium is performed. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14864", "text": "Heart function often recovers very quickly after pericardiectomy is performed, [ 8 ]  although the surgery itself can cause reduced cardiac output in the short term. [ 4 ]  After surgery, many patients will have a  chest drain  to remove  pericardial fluid . [ 2 ]  Hospital recovery takes several days, with  surgical suture  removed after a week. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14865", "text": "After pericardiectomy, the heart takes on a more rounded shape due to the lack of stretch with the  diaphragm . [ 9 ]  This does not appear to cause any cardiac issues, but may be detected with  echocardiography . [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14866", "text": "Postperfusion syndrome , also known as \" pumphead \", is a constellation of  neurocognitive  impairments attributed to  cardiopulmonary bypass  (CPB) during  cardiac surgery .  Symptoms of postperfusion syndrome are subtle and include defects associated with attention, concentration, short-term memory, fine motor function, and speed of mental and motor responses. [ 1 ]   Studies have shown a high incidence of neurocognitive deficit soon after surgery, but the deficits are often transient with no permanent neurological impairment. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14867", "text": "A study by Newman et al. at  Duke University Medical Center  showed an increased incidence of cognitive decline after  coronary artery bypass surgery  (CABG), both immediately (53 percent at discharge from  hospital ) and over time (36 percent six weeks, 24 percent at six months, and 42 percent at five years). [ 3 ]   This study shows an association of neurocognitive decline with CABG, but does not show  causation ; the study lacks a  control group  and is considered  level II-3 evidence . Also, the statistical calculation of cognitive decline has been demonstrated as the least reliable due to practice effects, measurement error and the regression to the mean phenomenon. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14868", "text": "Subsequent studies have compared \"on-pump\" CABG to  off-pump coronary artery bypass  (OPCAB)\u2014essentially establishing controls to compare the incidence of neurocognitive decline in CABG with and without the use of CPB.  A small study (60 patients total, 30 in each treatment arm) by Zamvar et al. demonstrated neurocognitive impairment was worse for the on-pump group both 1 week and 10 weeks postoperatively. [ 5 ]   A larger study (281 patients total) by Van Dijk et al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months. [ 2 ]   Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life,  stroke  rate, or all-cause  mortality  at 3 and 12 months.  A study by Jenson et al. published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or conventional on-pump CABG. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14869", "text": "A study by McKhann et al. [ 6 ]  compared the neurocognitive outcome of people with  coronary artery disease  (CAD) to heart-healthy controls (people with no cardiac risk factors).  People with CAD were subdivided into treatment with CABG, OPCAB and non-surgical medical management. The three groups with CAD all performed significantly lower at baseline than the heart-healthy controls.  All groups improved by 3 months, and there were minimal intrasubject changes from 3 to 12 months.  No one consistent difference between the CABG and off-pump patients was observed.  The authors concluded patients with long-standing coronary artery disease have some degree of cognitive dysfunction secondary to  cerebrovascular  disease before surgery; there is no evidence the cognitive test performance of bypass surgery patients differed from similar control groups with coronary artery disease over a 12-month follow-up period.  A related study by Selnes et al. [ 7 ]  concluded patients with coronary artery bypass grafting did not differ from a comparable nonsurgical control group with coronary artery disease 1 or 3 years after baseline examination. This finding suggests that late cognitive decline after coronary artery bypass grafting previously reported by Newman et al. may not be specific to the use of cardiopulmonary bypass, but may also occur in patients with very similar risk factors for cardiovascular and cerebrovascular disease. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14870", "text": "In 2020, Australian film director  Andrew Pike  released  Pumphead , a documentary about the condition. The film explores the experiences of eight patients following major heart surgery, describing their experiences with postperfusion syndrome. The filmmaker Andrew Pike experienced pumphead himself, following open-heart surgery in 2011. [ 8 ]  The film introduces the concept of  post-traumatic growth , as a positive psychological change that can follow traumatic experiences such as pumphead. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14871", "text": "Pulmonary Artery Banding  ( PAB ) was introduced by Muller and Dammann in 1951 as a surgical technique to reduce excessive pulmonary blood flow in infants suffering from  congenital heart defects . [ 1 ]  PAB is a  palliative  operation as it does not correct the problems, but attempts to improve abnormal heart function, relieve symptoms and reduce high pressure in the lungs. The use of PAB has decreased over the years due to advancements in definitive surgical repairs, however PAB still has widespread clinical use. PAB is commonly used in patients when definitive surgical repair is not feasible. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14872", "text": "The technique was first described by Muller and Dammann at  UCLA  in 1951. [ 4 ]  In recent years, the use of this technique has declined as studies have indicated that early definitive repair is preferable to this form of palliation. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14873", "text": "The heart is separated into four chambers. Deoxygenated blood enters into the right chambers of the heart and continues through the pulmonary arteries to be oxygenated in the lungs. Oxygenated blood returns into the left side of the heart and out to the rest of the body, known as the  systemic circulation . In congenital heart defects such as  ventricular septal defects  (VSD) and  Atrioventricular septal defects  (AVSD), there may be one or multiple holes in the walls separating adjacent chambers. This causes left-to-right shunting of blood as oxygenated blood can flow back to the right side of the heart, resulting in a mixture of oxygenated and deoxygenated blood. Increased amounts of blood on the right side of the heart cause an excess of blood flow into the lungs ( pulmonary circulation ) and increased pulmonary resistance due to the buildup of pressure. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14874", "text": "The goal of PAB is to reduce pulmonary artery pressure and excess pulmonary blood flow. PAB involves the insertion of a band around the pulmonary artery to reduce blood flow into the lungs. A variety of banding materials are used; one commonly used material is  polytetrafluoroethylene . [ 7 ]  The band is wrapped around the main pulmonary artery and fixed into place. Once inserted, the band is tightened, narrowing the diameter of the pulmonary artery to reduce blood flow to the lungs and reduce pulmonary artery pressure. PAB followed by later repair is a common surgical alternative when early definitive repair is high-risk. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14875", "text": "One major difficulty with PAB is assessing the optimal tightness of band, [ 9 ]  as minimal changes to the diameter of the pulmonary artery can have drastic effects on resistance and blood flow. The pulmonary band can also migrate away from the original placement and lead to  stenosis , [ 10 ]  in which the blood vessel becomes too narrow. There have also been reports of hardening of the vessels around the band due to buildup of calcium deposits and scarring of the pulmonary artery wall beneath the band, which can also inhibit blood flow. [ 11 ]  Additional surgeries to adjust band tightness occur in up to one-third of patients. [ 12 ]  Erosion of the band through the pulmonary artery has been reported, which can lead to the formation of blood clots. This is more evident in bands made of umbilical tape or silk rather than Silastic or Teflon bands. [ 13 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14876", "text": "Due to the varying complications, different modifications of PAB have been developed to improve outcomes. Adjustable pulmonary artery banding has been available since 1972, [ 14 ]  allowing variable constriction.  FloWatch  (Leman Medical, Geneva, Switzerland: www.lemanmedical.com), an adjustable band, was created and has successfully been tested to overcome complications due to non-optimal sizing of the band.  FloWatch  is a wireless, battery-free, implantable device that allows the band size to be adjusted without the need for additional surgeries or other invasive procedures. [ 15 ]  The narrowing of the pulmonary artery can be controlled weeks or even months after the operation. [ 16 ]  Reports also show that the recovery period in patients that obtained the  FloWatch  device was faster and smoother in comparison to those that received the traditional PAB method. [ 17 ]  However  FloWatch  is only suitable for children with a body weight ranging from 3\u00a0kg to10kg. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14877", "text": "The  Rastelli procedure  is an  open heart   surgical  procedure developed by  Italian   physician  and  cardiac  surgery  researcher ,  Giancarlo Rastelli , in 1967 at the  Mayo Clinic , and involves using a pulmonary or aortic homograft conduit to relieve pulmonary\nobstruction in double outlet right ventricle with pulmonary stenosis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14878", "text": "On July 26, 1968, the first successful surgery was carried out at the Mayo Clinic by Dr. Robert Wallace."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14879", "text": "It is used to correct certain combinations of  congenital   heart defects  ( CHD s):"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14880", "text": "The Rastelli procedure is typically performed between one and two years of age. Since d-TGA, overriding aorta and DORV are  cyanotic heart defects , the child is palliated with a  Blalock\u2013Thomas\u2013Taussig shunt  in the meantime."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14881", "text": "Oxygenated blood is directed from the  left ventricle  to the  aorta  using a  Gore-Tex  patch. The VSD is also sealed with the patch. The  pulmonary valve  is surgically closed."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14882", "text": "From the  right ventricle  to the  pulmonary bifurcation , a synthetic  conduit  and a valve are constructed, which lets oxygen depleted blood to flow into the lungs for reoxygenation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14883", "text": "In the last seven years of the study, there were seven early deaths (7%) and no surgical fatalities. Univariable analysis revealed that a straddling tricuspid valve (P =.04) and longer aortic crossclamping periods (P =.04) were risk factors for early mortality."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14884", "text": "There were 17 late deaths and a patient who had undergone heart transplantation after an average follow-up of 8.5 years."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14885", "text": "44 patients underwent reoperations for conduit  stenosis , 11 for left ventricular outflow tract obstruction and 28 for interventional  catheterization  to alleviate conduit stenosis."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14886", "text": "There were nine patients with late arrhythmias and five patients who experienced sudden deaths."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14887", "text": "At 5, 10, 15 and 20 years, avoidance of death or transplantation (Kaplan-Meier) was 82 percent, 80 percent, 68 percent and 52 percent, respectively."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14888", "text": "At 5, 10 and 15 years of followup, the rates of death or reintervention (catheterization or surgical therapy) were 53 percent, 24 percent and 21 percent, respectively. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14889", "text": "Overall, the Rastelli procedure has a low initial fatality rate."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14890", "text": "Conduit blockage, left ventricular outflow tract obstruction and  arrhythmia , on the other hand, are linked to significant late morbidity and mortality. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14891", "text": "Almost half of the patients who received the Rastelli operation required heart transplantation or died two decades later."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14892", "text": "A  resuscitative thoracotomy  (sometimes referred to as an  emergency department thoracotomy (EDT) ,  trauma thoracotomy  or, colloquially, as \" cracking the chest \") is a  thoracotomy  performed to aid in the  resuscitation  of a  major trauma  patient who has sustained severe  thoracic  or  abdominal trauma . [ 1 ]  The procedure allows immediate direct access to the  thoracic cavity , permitting rescuers to control  hemorrhage , relieve  cardiac tamponade , repair or control major injuries to the heart, lungs or thoracic  vasculature , and perform direct  cardiac massage  or  defibrillation . The procedure is rarely performed and is a procedure of last resort. [ 2 ] :\u200a462\u200a [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14893", "text": "A resuscitative thoracotomy is indicated when severe injuries within the thoracic cavity (such as  hemorrhage ) prevent the physiologic functions needed to sustain life. The injury may also affect a specific organ such as the heart, which can develop an  air embolism  or a  cardiac tamponade  (which prevents the heart from beating properly). The primary indication for a resuscitative thoracotomy is a patient with  penetrating  chest trauma who has entered or is about to enter  cardiac arrest . [ 4 ]  Other indications for the use of this procedure include the appearance of blood from a  chest tube  that returns more than 1500\u00a0mL of blood during the first hour of placement, or \u2265200\u00a0mL of blood per hour two to four hours after placement. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14894", "text": "For resuscitative thoracotomy to be indicated, signs of life must also be present, including  cardiac electrical activity  and a  systolic blood pressure  >70\u00a0mm Hg. [ 2 ] :\u200a462\u200a [ 6 ]  In  blunt trauma , if signs of life, such as eye dilatation, are found en route to the hospital by first responders, but not found when the patient arrives, then further resuscitative interventions are contraindicated; however; when first responders find signs of life (respiratory or motor effort, cardiac electrical activity, blood pressure, or pupillary activity) [ 7 ]  and  cardiopulmonary resuscitation  time is under 15 minutes, the procedure is indicated. [ 8 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14895", "text": "The use of a  focused assessment with sonography for trauma  may be performed to determine the need of the procedure by finding free floating fluid in the thoracic cavity. [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14896", "text": "A left anterolateral thoracotomy is the common method of opening the chest, as it provides rapid access, can be easily extended into the right hemithorax, and provides access to most of the important anatomical structures during resuscitation including the  aorta . [ 10 ]  First an incision is made along the fourth or fifth  intercostal space  (between the ribs), intercostal muscles and the parietal  pleura  are divided, and then the ribs are retracted to provide visualization. [ 6 ]  When the incision covers both the right and left hemithoraxes it is referred to as a \"clamshell\" thoracotomy. The clamshell thoracotomy is used when there is a right sided  pulmonary  or  vascular  injury, or when greater access or visualization is desired. [ 2 ] :\u200a242"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14897", "text": "Usually those who undergo resuscitative thoracotomy do not recover\u2014only 10% of those receiving it after sustaining a blunt injury, and 15\u201330% of those with penetrating trauma survive. [ 10 ] [ 11 ] [ 2 ] :\u200a240\u200a  Patients with thoracic stab wounds and patients who arrive at the emergency department with signs of life are associated with the highest rates of survival. Patients with  polytrauma  and patients who present without signs of life are associated with the lowest rates of survival. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14898", "text": "The procedure was first utilized during the late 1800s by Schiff in conjunction with open cardiac massage. Shortly after it was also used by Block to treat heart  lacerations , and the first suture repair performed in 1900. [ 13 ]  Before external  defibrillation  and  cardiopulmonary resuscitation  came in the 1960s, emergency thoracotomy was the preferred way to treat cardiac arrest. [ 2 ] :\u200a236"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14899", "text": "Retrograde autologous priming  ( RAP ) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the  blood transfusion  requirements during  cardiac surgery . [ 1 ]  It is also generally considered a blood conservation method used in most patients during the  cardiopulmonary bypass  (CPB). [ 1 ]  The processing of RAP includes three main steps, and the entire procedure of RAP (about 1L CPB prime volume) could be completed within 5 to 8 minutes. [ 2 ]  This technique is proposed by Panico in 1960 for the first time and restated by Rosengart in 1998 to eliminate or reduce the risk of hemodilution during CPB. [ 2 ]  Moreover, to precisely determine the clinical efficacy of RAP, many related studies were conducted. Most results of researches indicate that RAP is available to provide some benefits to reducing the requirements for  red blood cell  transfusion. [ 2 ]  However, there are still some studies showing a failure of RAP to limit the hemodilution after the open heart operation. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14900", "text": "The requirement of blood transfusion during open-heart surgical operations is almost inevitable because the  metabolism  must be continuously kept working through the peripheral blood flow. [ 4 ]  Cardiopulmonary bypass (CPB) is a medical technique to oxygenate the blood and remove the  carbon dioxide  during the cardiac operation. [ 4 ]  It can be seen as a \u201cpump\u201d to serve as a  heart-lung machine  whose function is sustaining blood circulatory and transporting  oxygen  to red blood cells before blood is flowing backwards the arterial circulation. [ 4 ]  It is also can be considered a kind of  extracorporeal  circulation. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14901", "text": "There are two primary methods, homologous blood transfusion and  autologous blood transfusion , to reduce the massive blood loss resulted from different surgeries. [ 5 ]  Homologous blood transfusion refers to using blood from other compatible donors to improve the oxygen-carrying capacity for blood by raising the number and concentration of blood red cells. [ 6 ]  Autologous transfusion uses patients' own blood which is stored previously. [ 5 ]  Compared to autologous blood transfusion, the homologous blood transfusion has more side effects, such as postoperative  Infection ,  immunosuppression  and viral  transmission . [ 7 ]  These  adverse effects  facilitate the development of approaches to conserve the blood during cardiac surgery. [ 1 ]  These methods contain preoperative autologous blood donation (PABD), acute normovolemic hemodilution (ANH) and  cell salvage . [ 1 ]  There are two main ways to salvage red blood cells. Cell processing and direct injection. Cell processors are red cell washing devices like the Cell Saver that collect anticoagulated shed or recovered blood, wash and separate the  red blood cells  (RBC) by centrifugation. Filtration devices like HemoClear microfilter, constitute the second major type of blood salvage in operating rooms. In general, ultrafiltration devices filter the patient's anticoagulated whole blood. [ 8 ]  Direct transfusion is a blood salvaging method associated with  cardiopulmonary bypass  (CPB) circuits or other extracorporeal circuits (ECC) that are used in surgery such as coronary artery bypass grafts ( CABG ), valve replacement, or surgical repair of the great vessels. Following bypass surgery, the ECC circuit contains a significant volume of diluted whole blood that can be harvested in transfer bags and re-infused into patients."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14902", "text": "Furthermore, the number of patients requiring red blood transfusions could be anticipated by observing a variety of variables before cardiac surgery. [ 2 ]  The  red cell mass , as a critical factor, it matches the assumption that the blood transfusion is commonly demanded by patients who have a low red cell mass during CPB. [ 2 ]  At the same time, these patients are more likely to have low  hematocrit  values. [ 2 ]  Patients expect to reduce the blood product used during surgery because the red blood transfusion generally has a negative physiologic impact and highly related cost. [ 2 ]  Especially when CPB is applied in surgical operations, there will be a large number of blood transfusions required due to blood loss and hemodilution. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14903", "text": "Furthermore, a significant risk caused by the homologous blood transfusion in open-heart surgeries is hemodilution. [ 1 ]  The hemodilution is the primary hematologic interference which results in  coagulopathy  and decreased capability of carrying oxygen in the blood. [ 9 ]  The root cause of this situation is the decreased blood concentration and  viscosity  in the body. [ 10 ]  During the cardiopulmonary bypass, blood is mixed directly through the homologous blood transfusion, but homologous blood may be not compatible, acceptable or available. [ 10 ]  Thus, there is a\u00a0 high incidence of distinct degrees of hemodilution with CPB. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14904", "text": "RAP is a blood conservation technique to decrease the priming volume of cardiopulmonary bypass and then reduce the level of the hemodilution. [ 1 ]  \u00a0To be more specific, some cardiopulmonary bypass circuit prime are replaced by autologous circulating blood at the beginning of bypass in both venous  cannula  and arterial cannula. [ 1 ]  The final objective of RAP is reducing the number of patients requiring blood transfusion during CPB. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14905", "text": "There is a type of  glycoprotein  growth factor - erythropoietin that can be used to mitigate the hemodilution by increasing the total number of red blood cells. [ 11 ]  Compared with  erythropoietin , RAP is more rapid and inexpensive. [ 1 ]  Because RAP aims to directly influence the CPB prime volume instead of red cell masses, but for patients who have extremely low red cell masses, like  anaemic  patients and some particular groups, such as women and elderly, they would have greatly decreased hematocrit values and need a larger amount of blood transfusions. [ 1 ]  As a consequence, these patients are thought to be more suitable to use erythropoietin rather than RAP. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14906", "text": "The specific procedure of RAP was firstly described by Rosengart and DeBois to restrict the hemodilution during CPB. [ 12 ]  When arterial cannulae and venous cannulae are prepared, the  crystalloid  prime (approximately 1L) is drained into a re-circulation bag. [ 12 ]  Before the beginning of the CPB, the crystalloid priming fluid is displaced by the autologous blood. [ 12 ]  There are three key steps for RAP to have a role to play. [ 12 ]  The first step is that crystalloid is flowing from the  arterial line  into the transfer bag. [ 12 ]  And then autologous blood flows through the arterial line and filter after the placement of arterial cannulae. [ 12 ]  The second step is crystalloid prime in the venous reservoir and  oxygenator  is replaced by blood through pressure gradients. [ 12 ]  Lastly, the remaining crystalloid priming fluid is collected and displaced from the venous line into the CPB bag on the onset of CPB. [ 13 ]  In each step, about 300ml CPB crystalloid prime volume is replaced by blood into the transfer bag. The entire process could be commonly finished within 5 to 8 minutes. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14907", "text": "Although RAP is an effective and safe technique to reduce the hemodilution during CPB, there are still some potential risks of RAP."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14908", "text": "The first risk is related to blood  viscosity . [ 1 ]  The blood viscosity refers to the resistance to the movement of blood. It is vital to sustaining the vascular  homeostasis  in disease prevention and medical treatment. [ 14 ]  Besides, the blood viscosity is greatly influenced by distinct factors, such as haematocrit, the degree of aggregation of the blood red cells and temperature. [ 14 ]  Some researchers support the inverse relationship between temperature and blood viscosity. [ 15 ]  They calculated that the blood viscosity increased by two percent for each degree of the temperature drop. [ 15 ]  And then it would bring in hematologic concentration and increased hematocrit. [ 1 ]  During CPB, blood viscosity can rise 10% to 30% at low temperature. [ 1 ]  Thus, an appropriate degree of hemodilution is considered to be helpful to reduce the increased blood viscosity and the adverse effect of  microcirculation . [ 1 ]  Furthermore, this kind of degree of hemodilution is often given by an entire crystalloid prime. [ 1 ]  When some crystalloid prime is replaced by RAP during CPB, the blood viscosity may increase and then generate a negative impact on patients undergoing cardiac surgery. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14909", "text": "The second potential risk is about  hemodynamic  instability. [ 1 ]  The hemodynamic instability could be defined as the  perfusion  failure, which gives rise to unstable  blood pressure . It is characterized by some clinical features, such as  circulatory shock  and advanced  heart failure . [ 16 ]  When RAP is used, the large amount of crystalloid prime is extracted, and then the withdrawal theoretically results in the hemodynamic instability. [ 1 ]  The hemodynamic instability is a treatable condition if  phenylephrine  and crystalloid administration could be applied. [ 2 ]  However, the therapeutic effectiveness of RAP reduces because of the crystalloid administration to some extent. If hemodynamic instability cannot be eliminated throughout the treatment, RAP must be stopped. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14910", "text": "In 2004, a retrospective cohort research was designed to test the clinical effectiveness of RAP during CPB. [ 3 ]  Two hundred and fifty-seven participants were allocated into the  experimental group  which used RAP as a routine medical technique to conserve blood. In the meantime, two hundred and eighty-eight participants were grouped without RAP. [ 3 ]  The period for this research is twenty-four months. [ 3 ]  A significantly small reduction of requirements for blood transfusion is founded in the RAP group, and no difference is observed between two groups for the number of  packed red cell blood  units. This result supports that RAP is failing to provide benefits to the blood protection during cardiac surgery. [ 3 ]  However, in a subsequent 2006 study by the same authors, it was found that RAP patients had improved post-operative outcomes and significantly fewer post-operative cardiac arrests."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14911", "text": "A multimodal method might be beneficial to conserving crucial  organ perfusion  and decreasing requirements of blood transfusions. [ 2 ]  Moreover, approaches which are objective to restrict intraoperative  fluid balance  positiveness may also contribute to reduced blood transfusions because positive intravenous fluid balance plays a critical role in limiting hemodilution during open-heart operations. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14912", "text": "Plasma  concentration filters are functional to remove extra fluid at the onset of CPB. [ 2 ]  Hemoconcentration can be defined as the increased concentration of blood cells that results from the decreased plasma volume. Hemoconcentration may lead to some potential  complications , such as  embolism , infection and  haemolysis . [ 2 ]  To avoid the lack of circulating volume, the additional CPB is usually used during  hemofiltration . [ 2 ]  However, the additional CPB may mitigate the effect of hemofiltration, and the efficacy of hemofiltration on blood transfusion is not significantly clear. [ 2 ]  So the  ultrafiltration  cannot be verified as a useful blood conservation technique to reverse hemodilution and maintain blood balance. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14913", "text": "Autologous blood cell salvage is a therapeutic approach to recover the blood during cardiac surgery. Today, it is also widely used in many other high risk of surgeries around the world. [ 2 ]  Some reports suggest that if autologous blood cell salvage is routinely used in open heart surgeries, the requirements for blood transfusions can be effectively reduced. [ 2 ]  Moreover, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists guidelines argued that the routine use of intraoperative blood salvage is beneficial to blood conservation during CPB. [ 20 ]  However, it is not available to patients who have infection or  malignancy . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14914", "text": "The  Ross procedure , also known as  pulmonary autograft , is a  heart valve replacement operation  to treat severe  aortic valve disease , such as in children and young adults with a  bicuspid aortic valve . [ 1 ]  It involves removing the diseased  aortic valve , situated at the exit of the  left side of the heart  (where the  aorta  begins), and replacing it with the person's own healthy  pulmonary valve  (autograft), removed from the exit of the  heart's right side  (where the  pulmonary artery  begins). [ 4 ]  To reconstruct the right-sided exit, a pulmonary valve  from a cadaver  (homograft), or a stentless  xenograft , is used to replace the removed pulmonary valve. [ 1 ] [ a ]  Compared to a  mechanical valve replacement , it avoids the requirement for  thinning the blood , has favourable  blood flow dynamics , allows growth of the valve with growth of the child and has less risk of  endocarditis . [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14915", "text": "It is not performed if  Marfan syndrome , pulmonary valve disease, or immune problems like  lupus  are present. [ 3 ]  Other contraindications include severe  coronary artery disease  and severe mitral valve disease. [ 3 ]  Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root is present. [ 6 ]  Complications include  endocarditis , degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [ 1 ] [ 2 ]  It risks having a disease of two valves instead of one. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14916", "text": "The procedure requires technical expertise. [ 4 ]  It can be performed using the traditional subcoronary method or more commonly the root replacement technique, which requires re-implanting the coronary arteries. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14917", "text": "After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. [ 10 ]  It may need reoperating on at a later date. [ 7 ]  Complications occur in 3 to 5% of cases, with early death rate almost negligible in very experienced centres. [ 3 ]  80% to 90% of cases survive 10 years. [ 3 ]  As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14918", "text": "The procedure was first performed using the subcoronary method in 1967 by  Donald Ross , for whom the procedure is named. [ 8 ] [ 11 ]  The root replacement method was introduced in the early 1970s. [ 8 ]  It was continued and modified by others such as  Magdi Yacoub , who used fresh valves from the explanted hearts of transplant recipients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14919", "text": "Several adaptations of the Ross procedure have evolved, but the principle is essentially the same; to replace a diseased  aortic valve  with the person's own  pulmonary valve  (autograft), and replace the person's own pulmonary valve with a pulmonary valve  from a cadaver  (homograft) or a stentless  xenograft . [ 1 ] [ 4 ]  It is an alternative to a  mechanical valve replacement , particularly in children and young adults. [ 7 ]  It avoids the need for  thinning the blood , has favourable  blood flow dynamics  and the valve grows as the person grows. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14920", "text": "The most common reason for performing the Ross procedure in children and young adults is for bicuspid aortic valve. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14921", "text": "It is not performed in  Marfan syndrome , if pulmonary valve disease, or if immune problems like  lupus . [ 3 ]  Other contraindications include severe  coronary artery disease  and severe mitral valve disease. [ 3 ]  Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14922", "text": "The procedure requires technical expertise, and risks converting a single-valve disease into double-valve disease. [ 4 ]  It may need re-operating on at a later date. [ 7 ]  Complications include  endocarditis , degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14923", "text": "Before the operation, preparations include  transthoracic echocardiography  and measurements of the  ascending aorta  and the pulmonary valve. [ 10 ]  Under  general anaesthesia , the chest is cut  open in the midline . [ 3 ]  The heart and aorta are exposed before the  heart is temporarily stopped  and its function taken over  cardiopulmonary bypass . [ 3 ]  Subsequent steps include removing the diseased aortic valve and mobilizing the  coronary arteries , followed by harvesting and preparing the person's own healthy pulmonary valve, before implanting it within the  left ventricular outflow tract , the exit of the  left side of the heart  (where the  aorta  begins). [ 1 ] [ 10 ]  Then the coronary arteries are reimplanted, before the pulmonary homograft is implanted in the  right ventricular outflow tract , the exit of the  heart's right side  (where the  pulmonary artery  begins). [ 1 ] [ 10 ]  The pulmonary autograft is joined to the ascending aorta. [ 1 ] [ 10 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14924", "text": "Cryopreserved  pulmonary homografts were most often used for a long time until the introduction of  decellularized homografts . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14925", "text": "If the left sided outflow root needs to be enlarged to fit the pulmonary autograft, the procedure is called Ross-Konno. [ 3 ]  An alternative to a pulmonary homograft is the stentless  xenograft  roots such as the Freestyle Porcine Aortic Root by  Medtronic . [ 2 ] [ 12 ]  An external Dacron graft can be used to reinforce the pulmonary autograft. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14926", "text": "After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. [ 10 ]  Aftercare includes regular echocardiography and lifelong endocarditis prophylaxis. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14927", "text": "Complications occur in 3% to 5% of cases with one to 3% chance of early death. The death rate is almost negligible in very experienced centres. 80% to 90% of cases survive 10 years, and 70% to 80% may live up to 20 years. [ 3 ]  As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14928", "text": "Replacing a diseased aortic valve with an aortic valve from a cadaver was first performed by  Donald Ross  in England in June 1962, and shortly after in July 1962 by  Brian Barratt-Boyes  in Auckland, New Zealand. [ 11 ] [ 13 ]  In 1967 Ross took the normal pulmonary valve of a person with severe aortic valve disease, and placed it in the aortic position where the diseased aortic valve was removed. [ 11 ]  To reconstruct the missing pulmonary outflow tract, a homograft stored and sterilised from a cadaver was used to replace the removed pulmonary valve. [ 11 ]  In 1972, Ross introduced the technique using the root replacement method. [ 13 ]  For 30 years he was almost the only surgeon performing the procedure, until it gained popularity. [ 11 ]   Marian Ionescu  in Leeds, in an attempt to seek other materials, unsuccessfully tried  fascia lata  from the person's own thigh to create a living valve. [ 11 ]  He then tried successfully with cattle pericardium fixed with  glutaraldehyde , and the procedure became widespread before then falling out of favour as they failed. [ 11 ]  Then came pig valves (xenograft) before the 1980s trend for mechanical valves. [ 11 ]  The Ross procedure was continued and modified by  Magdi Yacoub , who used fresh valves from the explanted hearts of transplant recipients. [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14929", "text": "It has also been called the double-switch Ross procedure. [ 14 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14930", "text": "In 1997, to replace a  bicuspid aortic valve , the Ross procedure was performed on  Arnold Schwarzenegger . [ 15 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14931", "text": "The procedure was more popular in the 1990s and then declined in use over the subsequent 20 years. [ 16 ]  Data relating to the procedure is held in the Ross registry. [ 17 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14932", "text": "The procedure has been carried out in pigs and sheep for the purpose of research. [ 18 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14933", "text": "A  Sano shunt  is a shunt from the  right ventricle  to the  pulmonary circulation . [ 1 ] [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14934", "text": "In contrast to a  Blalock\u2013Taussig shunt , circulation is primarily in  systole . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14935", "text": "It is sometimes used as the first step in a  Norwood procedure . [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14936", "text": "This procedure was pioneered by the  Japanese   cardiothoracic surgeon   Shunji Sano \u00a0[ ja ]  in 2003. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14937", "text": "Eileen Saxon , sometimes referred to as \"The Blue Baby\", was the first patient that received the operation now known as  Blalock\u2013Thomas\u2013Taussig shunt ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14938", "text": "She had a condition called  Tetralogy of Fallot , one of the primary congenital defects that lead to  blue baby syndrome . In this condition, defects in the great vessels and wall of the heart lead to a chronic lack of  oxygen  in the blood. In Eileen's case, this made her lips and fingers turn blue, with the rest of her skin having a very faint blue tinge. She could only take a few steps before beginning to breathe heavily."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14939", "text": "On November 29, 1944, Saxon was the first living human to receive a groundbreaking operation. [ 1 ] [ 2 ]  (now known as a  Blalock-Thomas-Taussig shunt ) suggested by  pediatric   cardiologist   Helen B. Taussig  and administered by  Alfred Blalock , with  Vivien Thomas , who had perfected the surgery in laboratory tests on animals, standing over his shoulder to advise him on performing the surgery. [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14940", "text": "The surgery had been designed and first performed on laboratory dogs by Thomas, who taught the technique to Blalock. Although Thomas perfected the technique, he could not perform the surgery because he was not a doctor."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14941", "text": "The surgery was not completely successful, since Eileen Saxon became  cyanotic  again a few months later. Another shunt was attempted on the opposite side of the chest, but she died a few days afterwards, very close to her second birthday. Though Saxon died, she lived long enough to demonstrate that the operation would work. The team later discovered the operation worked best in older children. Saxon herself could not have waited any longer. By the time the first shunt was attempted on her, she was in danger of dying."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14942", "text": "Eileen Saxon's surgery was re-enacted in the documentary  Partners of the Heart , produced by  Spark Media , and broadcast on  American Experience  in 2003.  [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14943", "text": "The 2004 movie produced by  HBO ,  Something The Lord Made , is a dramatic feature based on the Saxon baby operation."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14944", "text": "The  Senning procedure  is an  atrial switch  heart operation performed to treat  transposition of the great arteries . It is named after its inventor, the Swedish cardiac surgeon  \u00c5ke Senning  (1915\u20132000), also known for implanting the first permanent cardiac  pacemaker  in 1958."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14945", "text": "This procedure, a form of  atrial switch , was developed and first performed by Senning in 1957 as a treatment for d-TGA ( dextro-Transposition of the great arteries ) before improvements in  cardiopulmonary bypass  made more curative surgical techniques feasible. [ 1 ]  In this congenital heart defect, the venous circulation drains into the right ventricle but from this chamber, blood is directed towards the systemic circulation through the aorta. This is also expressed by the term ventriculoarterial discordance, that is the ventricles are connected to the wrong great artery (the right ventricle to the aorta, thus pumping blood from the systemic venous back into the systemic arterial circulation).\nThus, d-TGA is not to be confused with  l-TGA , where there is both atrioventricular and ventriculoarterial discordance. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14946", "text": "In the absence of a shunt, patients with d-TGA could not survive because there would be no flow of oxygenated blood (coming from the pulmonary veins) to the rest of the body after the normal prenatal shunts physiologically close a few weeks after birth.\nThis congenital heart defect caused babies to \"turn blue\" due to the lack of oxygen flowing through the blood. [ 2 ] [ 3 ]  Before this technique became available, in 1950, two cardiac surgeons, Blalock and Hanlon, had developed a palliative procedure that consisted of opening the atrial septum. [ 1 ]  Since, in TGA, the atrial septum prevents oxygenated blood from reaching the systemic circulation, this simpler procedure leads to improvements in systemic arterial O2 saturation. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14947", "text": "With the Senning surgical repair, a baffle \u2013 or conduit - is created within the atria that reroutes the deoxygenated blood coming from the inferior and superior vena cavae to the mitral valve and therefore to the pulmonary circulation  [ 4 ]  This is accomplished by creating a systemic venous  conduit that channels deoxygenated blood from the superior and inferior vena cava towards the mitral valve. After this complex plastic reconstruction using flaps from the right atrial tissue and the interatrial septum, it lets the oxygenated pulmonary venous blood flow to the tricuspid valve and from there to the systemic circulation. The anatomic left ventricle continues to pump into the pulmonary circulation and the anatomic right ventricle will work as the systemic pump, in other words, the ventriculo-arterial mismatch is left unrepaired.\nIn the Senning's operation, atrial tissue is used to create the baffle. No prosthetic material is introduced. A complex work of incising and refolding the native atrial tissue - which is so technically complex that has been referred to as \"origami\", is necessary to build the venous baffle. Indeed, the Senning technique was difficult to reproduce and was not widely embraced. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14948", "text": "In 1963, Mustard described an alternative technique, the  Mustard procedure , in which the atrial septum is excised, and the atrial baffle is created by the placement of a single elephant trunk-shaped patch made of pericardial tissue. This technique then became the standard operation for TGA as it was technically less demanding."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14949", "text": "Currently, the arterial switch or  Jatene procedure  is the preferred surgical corrective method. In this technique, the great arteries are excised and reimplanted to the corresponding ventricles. The Brazilian surgeon Jatene performed the first procedure in 1975. The coronary arteries are also explanted from the anatomical aorta, which lies on the venous side and reattached to the systemic great vessel. Indeed, the initial difficulties that prevented an earlier adoption of this approach were mostly the inability to transfer the coronary arteries, besides problems with early forms of cardiopulmonary bypass that made cardiac surgery in early infancy less safe than in the present times  [ 4 ]  Some individuals with d-TGA are not candidates for an arterial switch, particularly because of late diagnosis, coexistent VSD with associated pulmonary hypertension, inadequate left ventricular function, or complex coronary abnormalities. [ 1 ]  Moreover, the Senning procedure is used as part of the double switch surgical correction of l-TGA ( Senning-Rastelli procedure)."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14950", "text": "The acute mortality associated with the Senning procedure is reported to be around 5-10%. Patient selection and the complexity of the congenital malformation are determinants of mortality risk. Patients who have undergone such surgical correction of the congenital transposition are exposed to long-term risks of cardiovascular events. In particular, sinus node dysfunction, atrial arrhythmias, ventricular arrhythmias including sudden cardiac arrhythmic death, heart failure due to anatomically right ventricular failure, or venous obstruction at the level of the baffle or caval anatomy have been described. The high chance of developing arrhythmias results in up to 25% of patients who have undergone a Senning or Mustard procedure having a pacemaker by adulthood. [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14951", "text": "Long-term studies have disclosed that although from the functional capacity standpoint the Senning and the Mustard operation are similar, there is a higher risk of sinus node disease and arrhythmias with the latter. [ 6 ]  Overall, in most studies, survival is good into the second decade post-procedure. 78% of patients were alive after 16 years in a large follow-up study from the Netherlands. [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14952", "text": "Before the utilization of surgical repair, Kirklin reports that the mortality associated with unrepaired TGA was 55%, 85%, and 90% mortality rates at 1 month, 6 months, and 1 year, respectively. These numbers correspond to all types of TGA. [ 8 ]  A major factor affecting long-term morbidity and mortality is the coexistence of a  ventricular septal defect  (VSD). Patients with a concomitant VSD may have also developed pulmonary vascular disease."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14953", "text": "Septal myectomy  is a  cardiac surgery  treatment for  hypertrophic cardiomyopathy  (HCM). [ 1 ]  The open-heart surgery entails removing a portion of the  septum  that is obstructing the flow of blood from the left  ventricle  to the  aorta . [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14954", "text": "The most common alternatives to septal myectomies are treatment with medication (usually  beta  or  calcium blockers ) or non-surgical thinning of tissue with  alcohol ablation . Ordinarily, septal myectomies are performed only after attempts at treatment with medication fail. The choice between septal myectomy and alcohol ablation is a complex medical decision. [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14955", "text": "Septal myectomy was established by  Andrew G. Morrow  in the 1960s. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14956", "text": "Septal myectomy is associated with a low perioperative mortality and a high late survival rate.  A study at the  Mayo Clinic  found surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation.   The results are shown below: [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14957", "text": "Either alcohol ablation or myectomy offers substantial clinical improvement for patients with  hypertrophic obstructive cardiomyopathy . One non-randomized comparison suggested that hemodynamic resolution of the obstruction and its sequelae are more complete with myectomy. [ 5 ]  Whether one or the other treatment is preferable for certain patient types is debated among cardiovascular scientists. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14958", "text": "Totally endoscopic coronary artery bypass surgery (TECAB)  is an entirely  endoscopic   robotic surgery  used to treat  coronary heart disease , developed in the late 1990s. It is an advanced form of  minimally invasive direct coronary artery bypass surgery , which allows bypass surgery to be conducted  off-pump  without opening the ribcage. The technique involves three or four small holes in the chest cavity through which two robotic arms, and one camera are inserted. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14959", "text": "TECAB surgery uses the da Vinci tele-robotic  stereoscopic 3-D imaging  system. The system consists of a robotic \"slave\" system at the bedside. The robot relays its information to an external surgical control unit, where a  cardiac surgeon  has a three-dimensional view of the chest cavity, and twin controllers for the robotic arms. The procedure frequently involves  grafting  of the  internal mammary artery  to the  diseased coronary artery , and therefore does not require external harvesting of blood vessels. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14960", "text": "Valve replacement  surgery is the replacement of one or more of the  heart valves  with either an  artificial heart valve  or a bioprosthesis ( homograft  from human tissue or  xenograft  e.g. from pig). It is an alternative to  valve repair ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14961", "text": "There are four procedures"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14962", "text": "Current aortic valve replacement approaches include closed heart surgery, Very invasive cardiac surgery (VICS) and Very invasive, Scapulae-based aortic valve replacement."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14963", "text": "Catheter replacement of the aortic valve (called trans-aortic valve replacement or implementation [TAVR or TAVI]) is a minimally invasive option for those suffering from  aortic valve stenosis . TAVR is commonly performed by guiding a catheter from the groin to the narrowed valve via the aorta using realtime x-ray technology. A metal stent containing a valve is then deployed using a balloon to press the stent into the valve in effect opening the stenosed (or narrowed) valve and lodging the stent in place. The procedure was first approved in the United States in November 2011  [ 1 ]  as an alternative for people deemed a poor candidate for open approach replacement; however, TAVR has been successfully implemented into practice in other countries prior to 2011. [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14964", "text": "In those between 50 and 70 years of age bioprosthetic and mechanical aortic valves have similar overall outcomes with respect to stroke and survival. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14965", "text": "Valve-sparing aortic root replacement  (also known as the  David procedure ) is a  cardiac surgery  procedure which is used to treat  Aortic aneurysms  and to prevent  Aortic dissection . [ 1 ]  It involves replacement of the  aortic root  without replacement of the  aortic valve .  Two similar procedures were developed, one by  Sir Magdi Yacoub , [ 2 ]  and another by  Tirone David . [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14966", "text": "The valve-sparing aortic root replacement allows for direct narrowing of enlarged aortas, which change the fluid dynamics of outbound blood from the heart, while preserving the natural tissues of the aortic valve, which means the patient does not have to rely on  anticoagulants . Common features of both techniques of the replacement process are the clamping of the aorta and the use of a length of  Dacron  tube (also known as an \"aortic graft\"), typically 5 cm, to constrict the aortic root to the normal diameter, while the patient is cooled to 20\u00b0C and placed on life support. The procedure typically takes 4 to 6 hours in healthy patients. [ 1 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14967", "text": "Established by  Sir Magdi Yacoub  in the mid-1990s, the process involves cutting the aorta superior of (slightly downstream of) the  aortic valve  and attaching the tube, one end of which has been shaped into a three-lobed wavy ring, directly to the  commissures  connecting the aortic valve to the aortic wall. In other words, the \"sinotubular junction\" holding the aortic valve in place is reformed with the tube flush with the outermost valve tissue, and extending between the valve's cusps. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14968", "text": "Established by  Tirone E. David  and  Christopher Feindel  at the  Toronto General Hospital  in 2007, [ 8 ]  this technique differs in the shape of the Dacron tube's end, which here is a ring with a flat edge, and its location, with the sinotubular junction \"inserted\" into the tube. In other words, the tube acts like a \"corset\" on the outside of the wall surrounding the aortic valve, though the tube's attachment points are the same as in the Yacoub method. [ 9 ] [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14969", "text": "A 2023 literature review of David method patient outcomes after 2010 found that the chances of complications such as endocarditis and stroke, were reduced to 0.3%, while survival rates were 99% within a year and 89% within a decade afterward. The most common reason for follow-up (typically needed in 5 years) was minor chest bleeding, reported by 5.4% of patients. [ 12 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14970", "text": "A  valvulotomy ,  valvotomy , [ 1 ]   valvuloplasty , or  valvoplasty  is a procedure used in heart valve surgery that consists of  making one or more incisions  at the edges of the  commissure  formed between the two (mitral valve), or three  tricuspid  valve leaflets. This relieves the constriction of  valvular stenosis  (especially  mitral valve stenosis ). [ citation needed ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14971", "text": "As with many other kinds of surgery, a valvulotomy may be carried out using by either  open  or  minimally invasive  approaches, and sometimes (but not invariably) the terms  surgery  and  surgical  are understood to refer only to the open types, with the minimally invasive types then being referred to as  interventional  procedures. The minimally invasive approach is through the  lumen  of a  vessel  with a  catheter , which is why it is often called a transluminal or transcatheter approach. Such approaches begin with a small skin incision to access a vessel that will lead to the heart, making them  percutaneous  approaches, and they use balloons whose inflation moves the valve leaflets. Thus, all together, they are called by names such as  percutaneous balloon valvulotomy ,  percutaneous balloon mitral valvuloplasty ,  percutaneous aortic balloon valvotomy , and so forth."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14972", "text": "Vasoplegic syndrome  or  vasoplegia syndrome  ( VPS ) is a  postperfusion syndrome  characterized by low systemic  vascular resistance  and a high  cardiac output ."}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14973", "text": "VPS occurs more frequently after on pump  CABG  surgery versus off pump CABG surgery. [ 1 ]   Hypothermia  during  surgery  may also increase ones risk of developing VPS post operatively. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14974", "text": "Vasoplegic syndrome is defined as low systemic  vascular resistance  (SVR index <1,600 dyn\u2219sec/cm 5 /m 2 ) and high cardiac output (cardiac index >2.5 L/min/m 2 ) within the first 4 postoperative hours. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14975", "text": "There is some evidence to support the use of  methylene blue  in the treatment of this condition. [ 4 ] [ 5 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14976", "text": "One case series reports a rate of 1 in 120 cases. [ 6 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14977", "text": "Ventriculectomy , or  ventricular reduction , is a type of operation in  cardiac surgery  to reduce enlargement of the  heart  from  cardiomyopathy  or ischemic aneurysm formation. In these procedures, part of the  ventricular  wall is resected. [ 1 ]  A  Batista procedure  is a partial left ventriculectomy that is used to treat advanced heart failure. [ 1 ]  This procedure is not widely used because outcomes are often unsatisfactory. [ 2 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14978", "text": "The  Yasui procedure  is a pediatric heart operation used to bypass the  left ventricular outflow tract  (LVOT) that combines the aortic repair of the  Norwood procedure  and a shunt similar to that used in the  Rastelli procedure  in a single operation. [ 1 ] [ 2 ]  It is used to repair defects that result in the physiology of  hypoplastic left heart syndrome  even though both ventricles are functioning normally. These defects are common in  DiGeorge syndrome  and include  interrupted aortic arch  and  LVOT obstruction  (IAA/LVOTO);  aortic atresia - severe stenosis  with  ventricular septal defect  (AA/VSD); and aortic atresia with interrupted aortic arch and  aortopulmonary window . This procedure allows the surgeon to keep the  left ventricle  connected to the  systemic circulation  while using the  pulmonary valve  as its outflow valve, by connecting them through the ventricular septal defect. The Yasui procedure includes a modified  Damus\u2013Kaye\u2013Stansel procedure  to connect the  aortic  and  pulmonary roots , allowing the  coronary arteries  to remain perfused. [ 1 ]  It was first described in 1987. [ 3 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14979", "text": "A Yasui procedure can be done instead of a  Norwood operation  in some cases of LVOT obstruction to avoid committing a child to a single-ventricle heart, or it can follow a Norwood operation when the surgeon uses a staged approach. It is also used when the  Ross procedure  or  Konno procedure  are not feasible in children who have had other surgeries to repair  coarctation of the aorta  or interrupted aortic arch. [ 4 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14980", "text": "The Yasui procedure is done via a  median sternotomy  and uses  cardiopulmonary bypass . If there is a  patent ductus arteriosus , the surgeon begins by closing it. The surgeon then connects the separated parts of the aorta together. The surgeon then transects the  pulmonary artery  and  aorta  and frees them from surrounding tissue, then makes an incision into the  right ventricle  to allow them to assess the ventricular septal defect and remove excess muscle bundles in cases of extensive  right ventricular hypertrophy . If the ventricular septal defect is smaller than the pulmonary valve, the surgeon will enlarge the defect. The surgeon then uses a patch, commonly made of bovine (cow)  pericardium  or the child's own tissue, to create a tunnel between the ventricular septal defect and the pulmonary valve. This allows for blood to flow from the left ventricle to the pulmonary valve. After creating this tunnel, the surgeon connects the aortic and pulmonary roots (Damus-Kaye-Stansel anastomosis). [ 1 ]"}
{"_id": "WikiPedia_Surgical_specialties$$$corpus_14981", "text": "Children typically have good cardiac function and survival after the Yasui procedure, similar to other operations for the same conditions. However, children may require re-operation to replace the conduit in their heart if they outgrow it. Long-term survival depends on other factors, such as genetic disease. [ 2 ] [ 5 ] [ 6 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_1", "text": "' General'  surgery  is a  surgical specialty  that focuses on  alimentary canal  and  abdominal  contents including the  esophagus ,  stomach ,  small intestine ,  large intestine ,  liver ,  pancreas ,  gallbladder ,  appendix  and  bile ducts , and often the  thyroid gland . General surgeons also deal with diseases involving the  skin ,  breast ,  soft tissue ,  trauma ,  peripheral artery disease  and  hernias  and perform  endoscopic  as such as  gastroscopy ,  colonoscopy  and laparoscopic procedures."}
{"_id": "WikiPedia_General_surgery$$$corpus_2", "text": "General surgeons may sub-specialise into one or more of the following disciplines: [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_3", "text": "In many parts of the world including  North America ,  Australia  and the  United Kingdom , the overall responsibility for  trauma care  falls under the auspices of general surgery. Some general surgeons obtain advanced training in this field (most commonly surgical critical care) and specialty certification surgical critical care. General surgeons must be able to deal initially with almost any surgical emergency. Often, they are the first port of call to critically ill or gravely injured patients, and must perform a variety of procedures to stabilize such patients, such as thoracostomy,  cricothyroidotomy , compartment fasciotomies and emergency  laparotomy  or  thoracotomy  to  stanch  bleeding. They are also called upon to staff surgical intensive care units or trauma intensive care units. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_4", "text": "All general surgeons are trained in emergency surgery. Bleeding, infections, bowel obstructions and organ perforations are the main problems they deal with.  Cholecystectomy , the surgical removal of the gallbladder, is one of the most common surgical procedures done worldwide. This is most often done electively, but the gallbladder can become acutely inflamed and require an emergency operation. Infections and rupture of the  appendix  and small bowel obstructions are other common emergencies."}
{"_id": "WikiPedia_General_surgery$$$corpus_5", "text": "This is a relatively new specialty dealing with  minimal access techniques  using cameras and small instruments inserted through 3- to 15-mm  incisions.  Robotic surgery  is now evolving from this concept (see below). Gallbladders, appendices, and colons can all be removed with this technique. Hernias are also able to be repaired laparoscopically.  Bariatric surgery  can be performed laparoscopically and there a benefits of doing so to reduce wound complications in  obese  patients. General surgeons that are trained today are expected to be proficient in laparoscopic procedures."}
{"_id": "WikiPedia_General_surgery$$$corpus_6", "text": "General surgeons treat a wide variety of major and minor colon and rectal diseases including inflammatory bowel diseases (such as  ulcerative colitis  or  Crohn's disease ),  diverticulitis , colon and rectal cancer, gastrointestinal bleeding and hemorrhoids."}
{"_id": "WikiPedia_General_surgery$$$corpus_7", "text": "General surgeons can specialise in Upper Gastro-intestinal (or  foregut ) surgery, which includes the surgical treatment of diseases of the  stomach  and  oesophagus ,  liver ,  pancreas  and  gallbladder . [ 2 ]  In the UK, Upper GI surgeons can subspecialise further as benign surgeons, dealing with  hiatus hernias  and gallbladder diseases, bariatric surgeons, providing surgical care for  weight management  and metabolic diseases, or oesophago-gastric surgeons, dealing with complex problems related to the upper gastrointestinal tract (the foregut), including cancer. Surgical care of complex liver and pancreatic problems (including  liver cancer  and  pancreatic cancer ) is undertaken by  Hepatobiliary and Pancreatic Surgery  sub-specialists."}
{"_id": "WikiPedia_General_surgery$$$corpus_8", "text": "General surgeons perform a majority of all non-cosmetic breast surgery from lumpectomy to  mastectomy , especially pertaining to the evaluation, diagnosis and treatment of  breast cancer ."}
{"_id": "WikiPedia_General_surgery$$$corpus_9", "text": "General surgeons can perform vascular surgery if they receive special training and certification in vascular surgery. Otherwise, these procedures are typically performed by vascular surgery specialists. However, general surgeons are capable of treating minor vascular disorders."}
{"_id": "WikiPedia_General_surgery$$$corpus_10", "text": "General surgeons are trained to remove all or part of the thyroid and  parathyroid glands  in the neck and the  adrenal glands  just above each  kidney  in the abdomen. In many communities, they are the only surgeon trained to do this. In communities that have a number of subspecialists, other subspecialty surgeons may assume responsibility for these procedures."}
{"_id": "WikiPedia_General_surgery$$$corpus_11", "text": "Responsible for all aspects of pre-operative, operative, and post-operative care of abdominal organ transplant patients.  Transplanted organs include liver, kidney, pancreas, and more rarely small bowel."}
{"_id": "WikiPedia_General_surgery$$$corpus_12", "text": "Surgical oncologist refers to a general surgical oncologist (a specialty of a general surgeon), but thoracic surgical oncologists, gynecologist and so forth can all be considered surgeons who specialize in treating cancer patients.  The importance of training surgeons who sub-specialize in cancer surgery lies in evidence, supported by a number of clinical trials, that outcomes in surgical cancer care are positively associated to surgeon volume (i.e., the more cancer cases a surgeon treats, the more proficient he or she becomes, and his or her patients experience improved survival rates as a result). This is another controversial point, but it is generally accepted, even as common sense, that a surgeon who performs a given operation more often, will achieve superior results when compared with a surgeon who rarely performs the same procedure. This is particularly true of complex cancer resections such as  pancreaticoduodenectomy  for pancreatic cancer, and  gastrectomy  with extended (D2) lymphadenectomy for gastric cancer. Surgical oncology is generally a 2-year fellowship following completion of a general surgery residency (5\u20137 years)."}
{"_id": "WikiPedia_General_surgery$$$corpus_13", "text": "Most cardiothoracic surgeons in the U.S. (D.O. or M.D.) first complete a general surgery residency (typically 5\u20137 years), followed by a cardiothoracic surgery fellowship (typically 2\u20133 years). However, new programmes are currently offering cardiothoracic surgery as a residency (6\u20138 years)."}
{"_id": "WikiPedia_General_surgery$$$corpus_14", "text": "Pediatric surgery is a subspecialty of general surgery. Pediatric surgeons do surgery on patients under age 18. Pediatric surgery is 5\u20137 years of residency and a 2-3 year fellowship."}
{"_id": "WikiPedia_General_surgery$$$corpus_15", "text": "In the 2000s,  minimally invasive surgery  became more prevalent. Considerable enthusiasm has been built around  robot-assisted surgery  (also known as  robotic surgery ), despite a lack of data suggesting it has significant benefits that justify its cost. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_16", "text": "In Canada, Australia, New Zealand, and the United States general surgery is a five to seven year  residency  and follows completion of  medical school , either  MD, MBBS, MBChB , or  DO  degrees. In Australia and New Zealand, a residency leads to eligibility for Fellowship of the  Royal Australasian College of Surgeons . In Canada, residency leads to eligibility for certification by and Fellowship of the  Royal College of Physicians and Surgeons of Canada , while in the United States, completion of a residency in general surgery leads to eligibility for board certification by the  American Board of Surgery  or the  American Osteopathic Board of Surgery  which is also required upon completion of training for a general surgeon to have operating privileges at most hospitals in the United States."}
{"_id": "WikiPedia_General_surgery$$$corpus_17", "text": "In the  United Kingdom , surgical trainees may apply to enter training after five years of medical school and two years of the  Foundation Programme . During the two year core surgical training programme (\"phase 1\"), doctors are required to sit the Membership of the  Royal College of Surgeons  (MRCS) examination. On award of the MRCS by one of the four surgical colleges, surgeons may hold the title ' Mister ' or ' Miss / Ms. / Mrs ' rather than doctor. This tradition dates back hundreds of years in the United Kingdom from when only physicians attended medical school and surgeons did not, but were rather associated with  barbers  in the  Barber Surgeon's  Guild. The tradition is also present in many  Commonwealth  countries including  New Zealand  and some states of  Australia . After completion of phase 1 training, trainees may apply for a nationally awarded Higher Surgical Training (HST) programme, which lasts six years and is now divided into two further phases (phases 2 and 3). Trainees are expected to declare a sub-specialty before the end of phase 2, and training during phase 3 focuses on that sub-specialty. Before the end of HST, the examination for  Fellowship of the Royal College of Surgeons  (FRCS) must be taken in general surgery plus the subspeciality. Upon completion of training, the surgeon will be eligible for entry on the  GMC  Specialist Register. They may then apply to work both in the  NHS  and independent sector as a consultant surgeon, although many trainees complete further fellowships. [ 4 ]  The implementation of the European Working Time Directive limited UK surgical residents to an average 48-hour working week. [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_18", "text": "The term  abdominal surgery  broadly covers  surgical  procedures that involve opening the  abdomen  ( laparotomy ).  Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see  stomach ,  kidney ,  liver , etc.) Diseases affecting the abdominal cavity are dealt with generally under their own names."}
{"_id": "WikiPedia_General_surgery$$$corpus_19", "text": "The most common abdominal surgeries are described below."}
{"_id": "WikiPedia_General_surgery$$$corpus_20", "text": "Complications of abdominal surgery include, but are not limited to:"}
{"_id": "WikiPedia_General_surgery$$$corpus_21", "text": "Sterile technique,  aseptic  post-operative care,  antibiotics , use of the  WHO Surgical Safety Checklist , and vigilant post-operative monitoring greatly reduce the risk of these complications.  Planned surgery performed under sterile conditions is much less risky than that performed under emergency or unsterile conditions.  The contents of the bowel are unsterile, and thus leakage of bowel contents, as from trauma, substantially increases the risk of infection."}
{"_id": "WikiPedia_General_surgery$$$corpus_22", "text": "Globally, there are few studies comparing  perioperative mortality  following abdominal surgery across different health systems. One major prospective study of 10,745 adult patients undergoing emergency  laparotomy  from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. [ 2 ]  In this study the overall global mortality rate was 1.6 percent at 24\u2009hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent). Of the 578 patients who died, 404 (69.9 percent) did so between 24\u2009hours and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days."}
{"_id": "WikiPedia_General_surgery$$$corpus_23", "text": "Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1,000 procedures performed in these settings. Internationally, the most common operations performed were  appendectomy ,  small bowel resection ,  pyloromyotomy  and correction of  intussusception . After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23)) and middle-HDI (4.42 (1.44 to 13.56)) countries compared with high-HDI countries. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_24", "text": "Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_25", "text": "There is low-certainty evidence that there is no difference between using scalpel and  electrosurgery  in infection rates during major abdominal surgeries. [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_26", "text": "An  abdomino   perineal   resection , formally known as  abdominoperineal resection of the rectum  and  abdominoperineal excision of the  rectum  is a  surgery  for  rectal cancer  or  anal cancer . It is frequently  abbreviated  as  AP resection ,  APR  and  APER ."}
{"_id": "WikiPedia_General_surgery$$$corpus_27", "text": "See image on National Cancer Institute website \nThe principal indication for AP resection is a rectal carcinoma situated in the distal (lower) one-third of the rectum. [ 1 ]  Other indications include recurrent or residual anal carcinoma ( squamous cell carcinoma ) following initial, usually definitive combination chemoradiotherapy."}
{"_id": "WikiPedia_General_surgery$$$corpus_28", "text": "APRs involves removal of the  anus , the  rectum  and part of the  sigmoid colon  along with the associated (regional)  lymph nodes , through incisions made in the  abdomen  and  perineum . The end of the remaining  sigmoid colon  is brought out permanently as an opening, called a  stoma , which is used by the patient in conjunction with a  colostomy  pouch, on the surface of the abdomen."}
{"_id": "WikiPedia_General_surgery$$$corpus_29", "text": "This operation is one of the less commonly performed by  general surgeons , although they are specifically trained to perform this operation. As low case volumes in rectal surgery have been found to be associated with higher complication rates, [ 2 ] [ 3 ]  it is often centralised in larger centres, [ 4 ]  where case volumes are higher."}
{"_id": "WikiPedia_General_surgery$$$corpus_30", "text": "There are several advantages in terms of outcomes if the surgery can be performed laparoscopically [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_31", "text": "An APR, generally, results in a worse  quality of life  than the less invasive  lower anterior resection  (LAR). [ 6 ] [ 7 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible."}
{"_id": "WikiPedia_General_surgery$$$corpus_32", "text": "William Ernest Miles  (1869\u20131947), an English surgeon first performed the surgery of removing the rectum in 1907. He assumed that the rectal cancer can spread in both upwards and downward directions, thus necessitating the removal of the entire rectum together with the anal sphincters, resulting in a permanent stoma by connecting the proximal end of the descending colon to the skin. Mile's operation became the gold standard for treating rectal cancer because his technique successfully reduced the rate of cancer recurrence. [ 8 ] [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_33", "text": "To reduce the incidence of death and suffering of the patients associated with the APR procedure,  Henri Albert Hartmann  introduced the anterior resection of the rectum by preserving the distal rectum and anal sphincters, while producing end-sigmoid colostomy. There were attempts to restore bowel continuity by joining the proximal colon with the rectum, but the high incidence of leakage from the anastomotic site caused an increased risk of death to patients. It was only in 1948, Claude Dixon successfully connected the proximal bowel to the rectum, thus allowing patients to have a 64% 5-year survival rate. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_34", "text": "An  abscess  is a collection of  pus  that has built up within the  tissue  of the body, usually caused by bacterial infection. [ 6 ] [ 7 ]  Signs and symptoms of abscesses include redness, pain, warmth, and swelling. [ 1 ]  The swelling may feel fluid-filled when pressed. [ 1 ]  The area of redness often extends beyond the swelling. [ 8 ]   Carbuncles  and  boils  are types of abscess that often involve  hair follicles , with carbuncles being larger. [ 9 ]  A  cyst  is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall. Abscesses can also form internally on internal organs and after surgery."}
{"_id": "WikiPedia_General_surgery$$$corpus_35", "text": "They are usually caused by a  bacterial infection . [ 10 ]  Often many different types of bacteria are involved in a single infection. [ 8 ]  In many areas of the world, the most common bacteria present is  methicillin-resistant Staphylococcus aureus . [ 1 ]  Rarely,  parasites  can cause abscesses; this is more common in the  developing world . [ 3 ]  Diagnosis of a skin abscess is usually made based on what it looks like and is confirmed by cutting it open. [ 1 ]   Ultrasound  imaging may be useful in cases in which the diagnosis is not clear. [ 1 ]  In abscesses around the  anus ,  computer tomography  (CT) may be important to look for deeper infection. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_36", "text": "Standard treatment for most skin or soft tissue abscesses is cutting it open and drainage. [ 4 ]  There appears to be some benefit from also using  antibiotics . [ 11 ]  A small amount of evidence supports not packing the cavity that remains with  gauze  after drainage. [ 1 ]  Closing this cavity right after draining it rather than leaving it open may speed healing without increasing the risk of the abscess returning. [ 12 ]  Sucking out the pus with a needle is often not sufficient. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_37", "text": "Skin abscesses are common and have become more common in recent years. [ 1 ]  Risk factors include  intravenous drug use , with rates reported as high as 65% among users. [ 2 ]  In 2005, 3.2 million people went to American emergency departments for abscesses. [ 5 ]  In Australia, around 13,000 people were hospitalized in 2008 with the condition. [ 13 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_38", "text": "Abscesses may occur in any kind of tissue but most frequently within the skin surface (where they may be superficial pustules known as  boils  or deep skin abscesses), in the  lungs ,  brain ,  teeth , kidneys, and tonsils. Major complications may include spreading of the abscess material to adjacent or remote tissues, and extensive regional tissue death ( gangrene ). [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_39", "text": "The main symptoms and signs of a skin abscess are  redness , heat, swelling, pain, and loss of function. There may also be high temperature (fever) and chills. [ 15 ]  If superficial, abscesses may be fluctuant when  palpated ; this wave-like motion is caused by movement of the pus inside the abscess. [ 16 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_40", "text": "An internal abscess is more difficult to identify and depend on the location of the abscess and the type of infection. General signs include pain in the affected area, a high temperature, and generally feeling unwell. [ 17 ] \nInternal abscesses rarely heal themselves, so prompt medical attention is indicated if such an abscess is suspected. An abscess can potentially be fatal depending on where it is located. [ 18 ] [ 19 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_41", "text": "Risk factors for abscess formation include  intravenous drug use . [ 20 ]  Another possible risk factor is a prior history of disc  herniation  or other spinal abnormality, [ 21 ]  though this has not been proven."}
{"_id": "WikiPedia_General_surgery$$$corpus_42", "text": "Abscesses are caused by  bacterial infection , parasites, or foreign substances.\nBacterial infection is the most common cause, particularly  Staphylococcus aureus . The more invasive  methicillin-resistant Staphylococcus aureus  (MRSA) may also be a source of infection, though is much rarer. [ 22 ]  Among spinal subdural abscesses, methicillin-sensitive  Staphylococcus aureus  is the most common organism involved. [ 21 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_43", "text": "Rarely  parasites  can cause abscesses and this is more common in the developing world. [ 3 ]  Specific parasites known to do this include  dracunculiasis  and  myiasis . [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_44", "text": "Anorectal abscesses can be caused by non-specific obstruction and ensuing infection of the glandular crypts inside of the  anus  or  rectum . Other causes include  cancer , trauma, or  inflammatory bowel diseases .  [ 23 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_45", "text": "An  incisional abscess  is one that develops as a complication secondary to a  surgical incision . It presents as redness and warmth at the margins of the incision with purulent drainage from it. [ 24 ]  If the diagnosis is uncertain, the wound should be aspirated with a needle, with aspiration of pus confirming the diagnosis and availing for  Gram stain  and  bacterial culture . [ 24 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_46", "text": "Abscesses can form inside the body. The cause can be from trauma, surgery, an infection, or a pre-existing condition. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_47", "text": "An abscess is a  defensive reaction  of the tissue to prevent the spread of infectious materials to other parts of the body. [ 25 ] [ 26 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_48", "text": "Organisms or foreign materials destroy the local  cells , which results in the release of  cytokines . The cytokines trigger an  inflammatory response , which draws large numbers of  white blood cells  to the area and increases the regional blood flow. [ 26 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_49", "text": "The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object. [ 26 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_50", "text": "An abscess is a localized collection of pus (purulent inflammatory tissue) caused by suppuration buried in a tissue, an organ, or a confined space, lined by the pyogenic membrane. [ 28 ]   Ultrasound  imaging can help in a diagnosis. [ 29 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_51", "text": "Abscesses may be classified as either  skin abscesses  or  internal abscesses . Skin abscesses are common; internal abscesses tend to be harder to diagnose, and more serious. [ 15 ]  Skin abscesses are also called cutaneous or subcutaneous abscesses. [ 30 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_52", "text": "For those with a history of intravenous drug use, an  X-ray  is recommended before treatment to verify that no needle fragments are present. [ 20 ]  If there is also a fever present in this population,  infectious endocarditis  should be considered. [ 20 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_53", "text": "Abscesses should be differentiated from  empyemas , which are accumulations of pus in a preexisting, rather than a newly formed, anatomical cavity. [ 31 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_54", "text": "Other conditions that can cause similar symptoms include:  cellulitis , a  sebaceous cyst , and  necrotising fasciitis . [ 3 ]  Cellulitis typically also has an erythematous reaction, but does not confer any purulent drainage. [ 24 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_55", "text": "The standard treatment for an uncomplicated skin or soft tissue abscess is the act of opening and draining. [ 4 ]  There does not appear to be any benefit from also using  antibiotics  in most cases. [ 1 ]  A small amount of evidence did not find a benefit from packing the abscess with gauze. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_56", "text": "The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, incising and draining the abscess is standard treatment. [ 4 ] [ 32 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_57", "text": "Most people who have an uncomplicated skin abscess should not use antibiotics. [ 4 ]  Antibiotics in addition to standard incision and drainage is recommended in persons with severe abscesses, many sites of infection, rapid disease progression, the presence of  cellulitis , symptoms indicating bacterial illness throughout the body, or a health condition causing  immunosuppression . [ 1 ]  People who are very young or very old may also need antibiotics. [ 1 ]  If the abscess does not heal only with incision and drainage, or if the abscess is in a place that is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_58", "text": "In those cases of abscess which do require antibiotic treatment,  Staphylococcus aureus  bacteria is a common cause and an anti-staphylococcus antibiotic such as  flucloxacillin  or  dicloxacillin  is used. The  Infectious Diseases Society of America  advises that the draining of an abscess is not enough to address community-acquired  methicillin-resistant  Staphylococcus aureus  (MRSA), and in those cases, traditional antibiotics may be ineffective. [ 1 ]  Alternative antibiotics effective against community-acquired MRSA often include  clindamycin ,  doxycycline ,  minocycline , and  trimethoprim-sulfamethoxazole . [ 1 ]  The  American College of Emergency Physicians  advises that typical cases of abscess from MRSA get no benefit from having antibiotic treatment in addition to the standard treatment. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_59", "text": "Culturing the wound  is not needed if standard follow-up care can be provided after the incision and drainage. [ 4 ]  Performing a wound culture is unnecessary because it rarely gives information which can be used to guide treatment. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_60", "text": "In North America, after drainage, an abscess cavity is usually packed, often with special iodoform-treated cloth. This is done to absorb and neutralize any remaining exudate as well as to promote draining and prevent premature closure. Prolonged draining is thought to promote healing. The hypothesis is that though the heart's pumping action can deliver immune and regenerative cells to the edge of an injury, an abscess is by definition a void in which no blood vessels are present. Packing is thought to provide a wicking action that continuously draws beneficial factors and cells from the body into the void that must be healed. Discharge is then absorbed by cutaneous bandages and further wicking promoted by changing these bandages regularly. However, evidence from emergency medicine literature reports that packing wounds after draining, especially smaller wounds, causes pain to the person and does not decrease the rate of recurrence, nor bring faster healing, or fewer physician visits. [ 33 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_61", "text": "More recently, several North American hospitals have opted for less-invasive loop drainage over standard drainage and wound packing. In one study of 143 pediatric outcomes, a failure rate of 1.4% was reported in the loop group versus 10.5% in the packing group (P<.030), [ 34 ]  while a separate study reported a 5.5% failure rate among the loop group. [ 35 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_62", "text": "Closing an abscess immediately after draining it appears to speed healing without increasing the risk of recurrence. [ 12 ]  This may not apply to anorectal abscesses as while they may heal faster, there may be a higher rate of recurrence than those left open. [ 36 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_63", "text": "Appendiceal abscess are complications of appendicitis where there is an infected mass on the appendix. This condition is estimated to occur in 2\u201310% of appendicitis cases and is usually treated by surgical removal of the appendix (appendicectomy). [ 37 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_64", "text": "Even without treatment, skin abscesses rarely result in death, as they will naturally break through the skin. [ 3 ]  Other types of abscess are more dangerous. Brain abscesses may be fatal if untreated. When treated, the mortality rate reduces to 5\u201310%, but is higher if the abscess ruptures. [ 38 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_65", "text": "Skin abscesses are common and have become more common in recent years. [ 1 ]  Risk factors include  intravenous drug use , with rates reported as high as 65% among users. [ 2 ]  In 2005, in the United States 3.2 million people went to the emergency department for an abscess. [ 5 ]  In Australia around 13,000 people were hospitalized in 2008 for the disease. [ 13 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_66", "text": "The  Latin  medical  aphorism  \" ubi pus, ibi evacua \" expresses \"where there is pus, there evacuate it\" and is classical advice in the culture of Western medicine. [ 39 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_67", "text": "Needle exchange programmes  often administer or provide referrals for abscess treatment to  injection drug users  as part of a  harm reduction  public health strategy. [ 40 ] [ 41 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_68", "text": "An abscess is so called \"abscess\" because there is an  abscessus  (a going away or departure) of portions of the animal tissue from each other to make room for the suppurated matter lodged between them. [ 42 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_69", "text": "The word carbuncle is believed to have originated from the Latin:  carbunculus , originally a small coal; diminutive of  carbon- ,  carbo : charcoal or ember, but also a  carbuncle stone , \"precious stones of a red or fiery colour\", usually  garnets . [ 43 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_70", "text": "The following types of abscess are listed in the medical dictionary: [ 44 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_71", "text": "An  accessory  bile duct  is a  conduit  that transports  bile  and is considered to be  supernumerary  or auxiliary to the  biliary tree . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_72", "text": "It may be described by its location relative to the  gallbladder  as supravesicular [ 2 ] [ 3 ]  (superior to the gallbladder body) or subvesicular [ 4 ] [ 5 ]  (inferior to the gallbladder body)."}
{"_id": "WikiPedia_General_surgery$$$corpus_73", "text": "In the surgical literature, the term  duct of Luschka  is used to refer to an accessory bile duct.  They are small ducts that distinctly enter the gallbladder bed, or small tributaries of minor intrahepatic radicals of the right hepatic ductal system. [ 6 ]  Originating from the hepatic parenchyma the accessory bile duct may enter a large bile duct or the gallbladder at any location. [ 7 ]  Rarely it is found to be connected directly to the GIT. [ 8 ]  They may not always drain bile and sometimes can have blind distal ends. [ 2 ]  One study showed them originating from the liver parenchyma of the right anterior inferior dorsal subsegment or from the connective tissue of the gallbladder bed. The study showed the distal connections ending at the hepatic right anterior inferior dorsal branch, hepatic right anterior branch, right hepatic duct, or common hepatic duct. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_74", "text": "The term  duct of Luschka  is ambiguous, as it may refer to supravesicular [ 2 ] [ 3 ]  or subvesicular ducts. [ 4 ] [ 5 ]  Supravesicular ducts are typically in the gallbladder bed. A 2012 review suggested that the term  duct of Luschka  should be abandoned because of this ambiguity and replaced by the more specific term  subvesical bile duct . [ 9 ]  As well, the exact origin and drainage locations of the relevant duct(s) varied greatly between patients."}
{"_id": "WikiPedia_General_surgery$$$corpus_75", "text": "Of 116 articles, 54 provided detailed anatomic information identifying 238 subvesical ducts, most of which represented accessory ducts. The origin and drainage of these ducts were limited primarily to the right lobe of the liver, but great variation was seen."}
{"_id": "WikiPedia_General_surgery$$$corpus_76", "text": "Although they may not drain any liver  parenchyma , they can be a source of a bile leak or biliary  peritonitis  after  cholecystectomy  in both adults and children. If an accessory bile duct goes unrecognized at the time of the gallbladder removal, 5\u20137 days post-operative the patient will develop bile  peritonitis , [ 10 ]  an easily treatable complication with a morbidity rate of 44% if left untreated."}
{"_id": "WikiPedia_General_surgery$$$corpus_77", "text": "Often diagnosed by  HIDA scan , a bile leak from an accessory bile duct post-op can be treated with a temporary biliary stent [ citation needed ]  to redirect the bile from the liver into the intestine and allow the accessory duct to spontaneously seal itself or using a drainage guided by radiology. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_78", "text": "The term is named after German anatomist  Hubert von Luschka  (1820-1875) [ 12 ] [ 13 ]  who described the first case in 1863. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_79", "text": "An  acute abdomen  refers to a sudden, severe  abdominal pain . [ 1 ]  It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate  surgical treatment ."}
{"_id": "WikiPedia_General_surgery$$$corpus_80", "text": "Common causes of an acute abdomen include a  gastrointestinal perforation ,  peptic ulcer disease ,  mesenteric ischemia ,  acute cholecystitis ,  appendicitis ,  diverticulitis ,  pancreatitis , and an abdominal hemorrhage. However, this is a non-exhaustative list and other less common causes may also lead to an acute abdomen. [ 2 ]  In pregnant patient, a  tubo-ovarian abscess , ruptured ovarian cyst or a ruptured  ectopic pregnancy  are common causes of an acute abdomen. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_81", "text": "Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries (SMA and IMA respectively), both of which are direct branches of the aorta. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_82", "text": "Clinically, patients present with diffuse abdominal pain, bowel distention, and bloody diarrhea. On physical exam, bowel sounds will be absent. Laboratory tests reveal a neutrophilic leukocytosis, sometimes with a left shift, and increased serum amylase. Abdominal radiography will show many air-fluid levels, as well as widespread edema. Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone  infarction , and subsequent  anastomosis  of the remaining healthy tissue. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_83", "text": "Traditionally, the use of  opiates  or other pain medications in patients with an acute abdomen has been discouraged before the clinical examination because of the concern that pain medications may mask the signs and symptoms of the condition and therefore may lead to a delay in diagnosis. However, the scientific literature has shown that early administration of pain medications, including opiates, in those with acute abdomen does not lead to delayed diagnosis, delayed treatment or errors in management (the incorrect surgical treatment administered or performing un-necessary surgery). [ 5 ] [ 6 ] [ 2 ]  In a meta-analysis of those with acute appendicitis, early administration of opiates was found to alter treatment approach (with a slightly higher rate of appendectomy in those who received opiates) but diagnostic accuracy and surgical outcomes were unaffected by pain medication use. [ 7 ]  Clinical guidelines also recommend early analgesic use before a cause is established. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_84", "text": "Medical imaging  aids in the diagnosis of potential causes of an acute abdomen. A  CT scan  or  ultrasound  of the abdomen and pelvis are the preferred imaging modalities in the evaluate of an acute abdomen. [ 8 ]  The use of  radiocontrast agents  with CT scans improve diagnostic accuracy. [ 2 ]  Some authors advocate for the use of  CT angiography  with contrast of the abdomen and pelvis as the preferred imaging modality. [ 2 ]  An ultrasound is the preferred imaging modality in pregnant patients as CT scans expose the fetus to ionizing radiation which may lead to adverse pregnancy outcomes. [ 2 ]  An  abdominal x-ray  may show  free air  in the abdominal cavity due to a perforation in the gastrointestinal tract. However, abdominal x-ray is not recommended as part of the diagnostic evaluation in acute abdomen due to its low sensitivity and specificity. [ 8 ] [ 2 ]  Delays in medical imaging acquisition and interpretation greater than 2 hours are associated with an increased risk of complications and death. [ 2 ] [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_85", "text": "In a population based study of  Medicare  patients in the United States, Black patients who were admitted to the hospital for an acute abdomen requiring general surgery consultation were 14% less likely to receive surgical consultation as compared to White patients. These racial disparities in care persisted (with an 11% difference) when socioeconomic factors were standardized. [ 10 ]  In another population based study in the United States, Black patients and patients from other racial minority groups were 22-30% less likely to receive pain medication for an acute abdomen as compared to White patients. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_86", "text": "The  Alvarado score  is a clinical scoring system used in the diagnosis of  appendicitis . [ 1 ]   Alvarado scoring has largely been superseded as a clinical prediction tool by the  Appendicitis Inflammatory Response score . [ 2 ] [ 3 ] [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_87", "text": "Also known by the  mnemonic  MANTRELS, the scale has 6 clinical items (3  signs  and 3  symptoms ) and 2 laboratory measurements, each given an additive point score, with a maximum of 10 points possible. [ 5 ]   It was introduced in 1986 by Dr. Alfredo Alvarado and although meant for pregnant females, it has been extensively validated in the non-pregnant population.  A known limitation of the score is that only 20% of elderly patients present with classic findings on which the score focuses. [ 5 ]  A modified Alvarado score is at present in use. [ 6 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_88", "text": "Elements from the person's  history , the  physical examination  and from laboratory tests: [ 7 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_89", "text": "The two most important factors, tenderness in the right lower quadrant and leukocytosis, are assigned two points, and the six other factors are assigned one point each, for a possible total score of ten points. [ 7 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_90", "text": "A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates probable appendicitis, and a score of 9 or 10 indicates very probable acute appendicitis. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_91", "text": "The original Alvarado score describes a possible total of 10 points, but those medical facilities that are unable to perform a differential white blood cell count, are using a Modified Alvarado Score with a total of 9 points which could be not as accurate as the original score. The high diagnostic value of the score has been confirmed in a number of studies across the world. The consensus is that the Alvarado score is a noninvasive, safe, diagnostic method, which is simple, reliable, repeatable, and able to guide the clinician in the management of the case. However, a recent study demonstrated a sensitivity of only 72% of the Modified Alvarado Score for detection of appendicitis which has led to criticism of the usefulness of the score. Scores of less than five in children were useful for eliminating appendicitis from the differential diagnosis. [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_92", "text": "It carries high significance in the diagnosis of acute appendicitis. [ 10 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_93", "text": "Online calculator of the Alvarado Score"}
{"_id": "WikiPedia_General_surgery$$$corpus_94", "text": "An  appendectomy  ( American English ) or  appendicectomy  ( British English ) is a  surgical operation  in which the  vermiform appendix  (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute  appendicitis . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_95", "text": "Appendectomy may be performed  laparoscopically  (as  minimally invasive surgery ) or as an open operation. [ 2 ]  Over the 2010s, surgical practice has increasingly moved towards routinely offering laparoscopic appendicectomy; for example in the  United Kingdom  over 95% of adult appendicectomies are planned as laparoscopic procedures. [ 3 ]  Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline  laparotomy ."}
{"_id": "WikiPedia_General_surgery$$$corpus_96", "text": "Complicated (perforated) appendicitis should undergo prompt surgical intervention. [ 1 ]   There has been significant recent trial evidence that uncomplicated appendicitis can be treated with either antibiotics or appendicectomy, [ 4 ] [ 5 ]  with 51% of those treated with antibiotics avoiding an appendectomy after 3 years. [ 6 ]  After appendicectomy the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours post-operatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days. [ 1 ]  An interval appendectomy is generally performed 6\u20138 weeks after conservative management with antibiotics for special cases, such as perforated appendicitis. [ 7 ]  Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not shown to increase risk of perforation or other complications. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_97", "text": "In general terms, the procedure for an open appendectomy is:"}
{"_id": "WikiPedia_General_surgery$$$corpus_98", "text": "The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ. [ 9 ]  A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation. [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_99", "text": "These incisions are placed for appendectomy:"}
{"_id": "WikiPedia_General_surgery$$$corpus_100", "text": "Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better  cosmesis ; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. [ 10 ]  Recent research has led to the development of  natural orifice transluminal endoscopic surgery  (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_101", "text": "Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar  et al.  described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2\u2013 or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates  et al.  and Roberts  et al.  have described variants of an  intracorporeal  sling-based single-port laparoscopic appendectomy with good clinical results. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_102", "text": "Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. [ 12 ]  With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. [ 11 ]   The additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_103", "text": "Pediatric patients have a mobile cecum, which allows externalization of the cecal appendix through the umbilicus in most cases. This has led to the development of surgical techniques such as laparoscopic-assisted transumbilical appendectomy, which allows the entire surgery to be performed with a single umbilical incision and has significant advantages in terms of both recovery and aesthetic outcome. [ 13 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_104", "text": "Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy. [ 14 ]  These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester. [ 2 ]  If appendicitis develops in a  pregnant  woman, an appendectomy is usually performed and should not harm the  fetus . [ 15 ]  The risk of premature delivery is about 10%. [ 16 ]  The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_105", "text": "There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_106", "text": "Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress. [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_107", "text": "One area of concern related to the LA during pregnancy is  pneumoperitoneum . This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_108", "text": "A study from 2010 found that the average hospital stay for people with appendicitis in the United States was 1.8 days. For people with a perforated (ruptured) appendix, the average length of stay was 5.2 days. [ 18 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_109", "text": "Recovery time from the operation varies from person to person. Some take up to three weeks before being completely active; for others, it can be a matter of days. In the case of a laparoscopic operation, the patient has three stapled scars of about an inch (2.5\u00a0cm) in length, between the navel and pubic hair line. When an open appendectomy has been performed, the patient has a 2\u2013 to 3-inch (5\u20137.5\u00a0cm) scar, which will initially be heavily bruised. [ 19 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_110", "text": "One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI). [ 20 ]  Signs and symptoms indicative of a superficial SSI are redness, swelling, and tenderness surrounding the incision and are most likely to arise on post-operative day 4 or 5. These symptoms oftentimes precede fluid drainage from the incision. Tenderness extending beyond the redness that surrounds the incision, in addition to the development of cutaneous  vesicles  or bullae may be indicative of a deep SSI. [ 20 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_111", "text": "Patients with complicated appendicitis (perforated appendicitis) are more likely to develop a SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital in addition to increased cost of the operation. [ 21 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_112", "text": "About 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating-room procedures in 2011. [ 22 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_113", "text": "The first recorded successful appendectomy was performed in September 1731 by English surgeon William Cookesley on Abraham Pike, a chimney sweep. [ 23 ] [ 24 ]  The second was on December 6, 1735, at  St. George's Hospital  in London, when French surgeon  Claudius Amyand  described the presence of a perforated appendix within the  inguinal hernial  sac of an 11-year-old boy. [ 8 ]  The organ had apparently been perforated by a pin the boy had swallowed. The patient, Hanvil Andersen, made a recovery and was discharged a month later. [ 25 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_114", "text": "Harry Hancock performed the first  abdominal surgery  for appendicitis in 1848, but he did not remove the appendix. [ 26 ]  In 1889 in New York City,  Charles McBurney  described the presentation and pathogenesis of appendicitis accurately and developed the teaching that an early appendectomy was the best treatment to avoid perforation and  peritonitis ."}
{"_id": "WikiPedia_General_surgery$$$corpus_115", "text": "Some cases of autoappendectomies have occurred. One was attempted by  Evan O'Neill Kane  in 1921, but the operation was completed by his assistants. Another was  Leonid Rogozov , who in 1961 had to perform the operation on himself as he was the only doctor on a remote Antarctic base. [ 27 ] [ 28 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_116", "text": "On September 13, 1980,  Kurt Semm  performed the first  laparoscopic  appendectomy, opening up the path for a much wider application of minimally invasive surgery. [ 29 ] [ 30 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_117", "text": "While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study  analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined \"only uncomplicated episodes of acute appendicitis\" that involved \"visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home.\" The lowest charge for removal of an appendix was $1,529 and the highest $182,955, almost 120 times greater. The median charge was $33,611. [ 31 ] [ 32 ]  While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some sort of  medical insurance . [ 33 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_118", "text": "A study by the  Agency for Healthcare Research and Quality  found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance. [ 18 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_119", "text": "Appendicitis  is  inflammation  of the  appendix . [ 2 ]  Symptoms commonly include right lower  abdominal pain ,  nausea ,  vomiting , and  decreased appetite . [ 2 ]  However, approximately 40% of people do not have these typical symptoms. [ 2 ]  Severe complications of a ruptured appendix include widespread, painful  inflammation of the inner lining of the abdominal wall  and  sepsis . [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_120", "text": "Appendicitis is primarily caused by a blockage of the  hollow portion  in the appendix. [ 10 ]  This blockage typically results from a  faecolith , a calcified \"stone\" made of feces. [ 6 ]  Some studies show a correlation between appendicoliths and disease severity. [ 11 ]  Other factors such as inflamed  lymphoid tissue  from a viral infection,  intestinal parasites ,  gallstone , or  tumors  may also lead to this blockage. [ 6 ]  When the appendix becomes blocked, it experiences increased pressure, reduced blood flow, and bacterial growth, resulting in inflammation. [ 6 ] [ 12 ]  This combination of factors causes tissue injury and, ultimately, tissue death. [ 13 ]  If this process is left untreated, it can lead to the appendix rupturing, which releases bacteria into the  abdominal cavity , potentially leading to severe complications. [ 13 ] [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_121", "text": "The diagnosis of appendicitis is largely based on the person's signs and symptoms. [ 12 ]  In cases where the diagnosis is unclear, close observation,  medical imaging , and laboratory tests can be helpful. [ 4 ]  The two most commonly used imaging tests for diagnosing appendicitis are ultrasound and computed tomography (CT scan). [ 4 ]  CT scan is more accurate than ultrasound in detecting acute appendicitis. [ 15 ]  However, ultrasound may be preferred as the first imaging test in children and pregnant women because of the risks associated with radiation exposure from CT scans. [ 4 ]  Although ultrasound may aid in diagnosis, its main role is in identifying important differentials, such as ovarian pathology in females or mesenteric adenitis in children."}
{"_id": "WikiPedia_General_surgery$$$corpus_122", "text": "The standard treatment for acute appendicitis involves the  surgical removal of the inflamed appendix . [ 6 ] [ 12 ]  This procedure can be performed either through an open incision in the abdomen ( laparotomy ) or using minimally invasive techniques with small incisions and cameras ( laparoscopy ). Surgery is essential to reduce the risk of complications or potential death associated with the rupture of the appendix. [ 3 ]   Antibiotics  may be equally effective in certain cases of non-ruptured appendicitis, [ 16 ] [ 7 ] [ 17 ]  but 31% will undergo appendectomy within one year. [ 18 ]  It is one of the most common and significant causes of sudden abdominal  pain . In 2015, approximately 11.6 million cases of appendicitis were reported, resulting in around 50,100 deaths worldwide. [ 8 ] [ 9 ]  In the United States, appendicitis is one of the most common causes of sudden abdominal pain requiring surgery. [ 2 ]  Annually, more than 300,000 individuals in the United States undergo surgical removal of their appendix. [ 19 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_123", "text": "The presentation of acute appendicitis includes acute abdominal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins to irritate the adjoining abdominal wall. This leads the pain to localize at  the right lower quadrant . This classic migration of pain may not appear in children under three years. This pain can be triggered by a sharp pain feeling. Pain from appendicitis may begin as dull pain around the navel. After several hours, the pain usually migrates towards the right lower quadrant, where it becomes localized. Symptoms include localized findings in the right  iliac fossa . The abdominal wall becomes very sensitive to gentle pressure ( palpation ). There is pain in the sudden release of deep tension in the lower abdomen ( Blumberg's sign ). If the appendix is retrocecal (localized behind the  cecum ), even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix). This is because the  cecum , distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is typically a complete absence of abdominal rigidity. In such cases, a digital  rectal examination  elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area ( McBurney's point ), called  Dunphy's sign . [ medical citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_124", "text": "Acute appendicitis seems to be the result of a primary obstruction of the  appendix . [ 20 ] [ 10 ]  Once this obstruction occurs, the appendix becomes filled with  mucus  and swells. This continued production of mucus leads to increased pressures within the lumen and the walls of the appendix. The increased pressure results in  thrombosis  and  occlusion  of the small vessels, and stasis of  lymphatic flow . At this point, spontaneous recovery rarely occurs. As the occlusion of blood vessels progresses, the appendix becomes  ischemic  and then  necrotic . As  bacteria  begin to leak out through the dying walls,  pus  forms within and around the appendix (suppuration). The result is appendiceal rupture (a 'burst appendix') causing  peritonitis , which may lead to  sepsis  and in rare cases,  death . These events are responsible for the slowly evolving abdominal pain and other commonly associated symptoms. [ 13 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_125", "text": "The causative agents include  bezoars , foreign bodies,  trauma , [ 21 ] [ 22 ]   lymphadenitis  and, most commonly, calcified fecal deposits that are known as  appendicoliths  or  fecaliths . [ 23 ] [ 24 ]  The occurrence of  obstructing fecaliths  has attracted attention since their presence in people with appendicitis is higher in developed than in developing countries. [ 25 ]  In addition, an appendiceal fecalith is commonly associated with complicated appendicitis. [ 26 ]  Fecal stasis and arrest may play a role, as demonstrated by people with acute appendicitis having fewer bowel movements per week compared with healthy controls. [ 24 ] [ 27 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_126", "text": "The occurrence of a fecalith in the appendix was thought to be attributed to a right-sided fecal retention reservoir in the colon and a prolonged transit time. However, a prolonged transit time was not observed in subsequent studies. [ 28 ]   Diverticular disease  and  adenomatous polyps  was historically unknown and  colon cancer  was exceedingly rare in communities where appendicitis itself was rare or absent, such as various African communities. Studies have implicated a transition to a  Western diet  lower in  fiber  in rising frequencies of appendicitis as well as the other aforementioned colonic diseases in these communities. [ 29 ] [ 30 ]  And acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. [ 31 ]  Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis. [ 32 ] [ 33 ] [ 34 ]  This low intake of dietary fiber is in accordance with the occurrence of a right-sided fecal reservoir and the fact that dietary fiber reduces transit time. [ 35 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_127", "text": "The physician will ask questions to get the  health history , assess the patient's  symptoms , do a complete  physical exam , and order both laboratory and imaging tests. [ 36 ]  Appendicitis symptoms fall into two categories, typical and atypical. [ 37 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_128", "text": "Typical appendicitis is characterized by a migratory  right iliac fossa  pain associated with nausea, and anorexia, which can occur with or without vomiting and localized muscle stiffness/ generalized  guarding . [ 37 ]  It is possible the pain could localize to  the left lower quadrant  in people with  situs inversus totalis . [ 38 ]  The combination of migrated  umbilical  pain to the right  lower quadrant , loss of appetite for food, nausea, unsustained  vomiting , and mild  fever  is classic. [ 37 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_129", "text": "Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Irritation of the peritoneum (inside lining of the abdominal wall) can lead to increased pain on movement, or jolting, for example going over  speed bumps . [ 39 ]  Atypical histories often require imaging with ultrasound or CT scanning. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_130", "text": "During the early stages of appendicitis diagnosis, it is common for  physical exams  to present inconspicuous findings. Signs of inflammation become noticeable as the disease progresses. These signs may include [ 40 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_131", "text": "While there is no laboratory test specific for appendicitis, a  complete blood count  (CBC) is done to check for signs of infection or inflammation. Although 70\u201390 percent of people with appendicitis may have an elevated  white blood cell (WBC) count , many other abdominal and pelvic conditions can cause the WBC count to be elevated. [ 48 ]  However, a high  WBC count  may not alone represent a solid indicator of appendicitis but rather an inflammation  [ 15 ]  but the neutrophil ratio was more sensitive and specific for acute appendicitis. [ 49 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_132", "text": "In children,  neutrophil-lymphocyte ratio (NLR) \ndemonstrates a high degree of accuracy in the diagnosis of acute appendicitis and distinguishes complicated appendicitis from the simple one. [ 50 ] \n75\u201378 percent of the patients have  neutrophilia . [ 42 ]  Delta-neutrophil index (DNI) is a valuable parameter\u00a0that helps in the diagnosis of histologically normal appendicitis and distinguishing\u00a0between simple and complicated appendicitis. [ 51 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_133", "text": "A  C-reactive protein (CRP) blood test  will be ordered by the doctor to find out if there are any further causes of inflammation. [ 36 ]  The C-reactive protein/albumin (CRP/ALB) ratio can be a reliable predictor of complicated appendicitis. [ 52 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_134", "text": "The  urinalysis  is important for ruling out a urinary tract infection as the cause of abdominal pain. The presence of more than 20 WBC per high-power field in the urine is more suggestive of a urinary tract disorder. [ 48 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_135", "text": "If the patient is a female, a  pregnancy test  will be ordered. [ 36 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_136", "text": "In children, the clinical examination is important to determine which children with abdominal pain should receive immediate surgical consultation and which should receive diagnostic imaging. [ 53 ]  Because of the health risks of exposing children to radiation, ultrasound is the preferred first choice with CT scan being a legitimate follow-up if the ultrasound is inconclusive. [ 54 ] [ 55 ] [ 56 ]  CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a  sensitivity  of 94%,  specificity  of 95%. Ultrasonography had an overall  sensitivity  of 86%, a  specificity  of 81%. [ 57 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_137", "text": "Abdominal ultrasonography , preferably with  doppler sonography , is useful to detect appendicitis, especially in children. Ultrasound can show the free fluid collection in the right iliac fossa, along with a visible appendix with increased blood flow when using color Doppler, and noncompressibility of the appendix, as it is essentially a walled-off abscess. Other secondary sonographic signs of acute appendicitis include the presence of echogenic mesenteric fat surrounding the appendix and the acoustic shadowing of an appendicolith. [ 58 ]  In some cases (approximately 5%), [ 59 ]  ultrasonography of the  iliac fossa  does not reveal any abnormalities despite the presence of appendicitis. This false-negative finding is especially true of early appendicitis before the appendix has become significantly distended. Also, false-negative findings are more common in adults where larger amounts of fat and bowel gas make visualizing the appendix technically difficult. Despite these limitations, sonographic imaging with experienced hands can often distinguish between appendicitis and other diseases with similar symptoms. Some of these conditions include  inflammation  of  lymph nodes  near the appendix or pain originating from other pelvic organs such as the ovaries or Fallopian tubes. Ultrasounds may be either done by the radiology department or by the emergency physician. [ 60 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_138", "text": "Where it is readily available,  computed tomography  (CT) has become frequently used, especially in people whose diagnosis is not obvious on history and physical examination. Although some concerns about interpretation are identified, a 2019 Cochrane review found that the sensitivity and specificity of CT for the diagnosis of acute appendicitis in adults was high. [ 62 ]   Concerns about radiation tend to limit use of CT in pregnant women and in children, especially with the increasingly widespread usage of MRI. [ 63 ] [ 64 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_139", "text": "The accurate diagnosis of appendicitis is multi-tiered, with the size of the appendix having the strongest  positive predictive value , while indirect features can either increase or decrease sensitivity and specificity. A size of over 6\u00a0mm is both 95% sensitive and specific for appendicitis. [ 65 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_140", "text": "However, because the appendix can be filled with fecal material, causing intraluminal distention, this criterion has shown limited utility in more recent meta-analyses. [ 66 ]  This is as opposed to ultrasound, in which the wall of the appendix can be more easily distinguished from intraluminal feces. In such scenarios, ancillary features such as increased wall enhancement as compared to adjacent bowel and inflammation of the surrounding fat, or fat stranding, can be supportive of the diagnosis. However, their absence does not preclude it. In severe cases with perforation, an adjacent  phlegmon  or  abscess  can be seen. Dense fluid layering in the pelvis can also result, related to either  pus  or  enteric spillage . When patients are thin or younger, the relative absence of fat can make the appendix and surrounding fat stranding difficult to see. [ 66 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_141", "text": "Magnetic resonance imaging  (MRI) use has become increasingly common for diagnosis of appendicitis in children and pregnant patients due to the radiation dosage that, while of nearly negligible risk in healthy adults, can be harmful to children or the developing baby. [ 67 ]  In pregnancy, it is more useful during the second and third trimester, particularly as the enlargening uterus displaces the appendix, making it difficult to find by ultrasound. The periappendiceal stranding that is reflected on CT by fat stranding on MRI appears as an increased fluid signal on T2 weighted sequences. First-trimester pregnancies are usually not candidates for MRI, as the fetus is still undergoing  organogenesis , and there are no long-term studies to date regarding its potential risks or side effects. [ 68 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_142", "text": "In general, plain abdominal radiography (PAR) is not useful in making the diagnosis of appendicitis and should not be routinely obtained from a person being evaluated for appendicitis. [ 69 ] [ 70 ]  Plain abdominal films may be useful for the detection of  ureteral   calculi ,  small bowel obstruction , or  perforated ulcer , but these conditions are rarely confused with appendicitis. [ 71 ]  An opaque  fecalith  can be identified in the right lower quadrant in fewer than 5% of people being evaluated for appendicitis. [ 48 ]  A  barium enema  has proven to be a poor diagnostic tool for appendicitis. While failure of the appendix to fill during a barium enema has been associated with appendicitis, up to 20% of normal appendices do not fill. [ 71 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_143", "text": "Several scoring systems have been developed to try to identify people who are likely to have appendicitis. [ 72 ]  The performance of scores such as the  Alvarado score  and the Pediatric Appendicitis Score, however, are variable. [ 73 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_144", "text": "The Alvarado score is the most known scoring system. A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan or ultrasound exam may be used to reduce the rate of negative appendectomy."}
{"_id": "WikiPedia_General_surgery$$$corpus_145", "text": "Even for clinically certain appendicitis, routine  histopathology  examination of appendectomy specimens is of value for identifying unsuspected pathologies requiring further postoperative management. [ 74 ]  Notably,  appendix cancer  is found incidentally in about 1% of appendectomy specimens. [ 75 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_146", "text": "Pathology diagnosis of appendicitis can be made by detecting a  neutrophilic  infiltrate of the  muscularis propria ."}
{"_id": "WikiPedia_General_surgery$$$corpus_147", "text": "Periappendicitis (inflammation of tissues around the appendix) is often found in conjunction with other abdominal pathology. [ 76 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_148", "text": "Children:  Gastroenteritis ,  mesenteric adenitis ,  Meckel's diverticulitis ,  intussusception ,  Henoch\u2013Sch\u00f6nlein purpura , lobar  pneumonia ,  urinary tract infection  (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset  Crohn's disease  or  ulcerative colitis ,  pancreatitis , and abdominal trauma from  child abuse ;  distal intestinal obstruction syndrome  in children with cystic fibrosis;  typhlitis  in children with leukemia."}
{"_id": "WikiPedia_General_surgery$$$corpus_149", "text": "Women: A pregnancy test is important for all women of childbearing age since an  ectopic pregnancy  can have signs and symptoms similar to those of appendicitis. Other obstetrical/ gynecological causes of similar abdominal pain in women include  pelvic inflammatory disease ,  ovarian torsion ,  menarche , dysmenorrhea,  endometriosis , and  Mittelschmerz  (the passing of an egg in the ovaries approximately two weeks before menstruation). [ 78 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_150", "text": "Men:  testicular torsion"}
{"_id": "WikiPedia_General_surgery$$$corpus_151", "text": "Adults: new-onset  Crohn disease ,  ulcerative colitis , regional enteritis,  cholecystitis ,  renal colic , perforated  peptic ulcer ,  pancreatitis ,  rectus sheath hematoma  and  epiploic appendagitis ."}
{"_id": "WikiPedia_General_surgery$$$corpus_152", "text": "Elderly:  diverticulitis , intestinal obstruction,  colonic carcinoma ,  mesenteric ischemia , leaking  aortic aneurysm ."}
{"_id": "WikiPedia_General_surgery$$$corpus_153", "text": "The term \" pseudoappendicitis \" is used to describe a condition mimicking appendicitis. [ 79 ]  It can be associated with  Yersinia enterocolitica . [ 80 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_154", "text": "Acute appendicitis [ 81 ]  is typically managed by  surgery . While antibiotics are safe and effective for treating uncomplicated appendicitis, [ 16 ] [ 7 ] [ 82 ]  31% of people had a recurrence within a year and required an eventual appendectomy. [ 83 ]  Antibiotics are less effective if an  appendicolith  is present. [ 84 ]  While 51% of patients who were treated with antibiotics did not need an appendectomy three years after treatment, [ 85 ]  the cost effectiveness of surgery versus antibiotics is unclear [ 86 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_155", "text": "Using antibiotics to prevent potential postoperative complications in emergency appendectomy procedures is recommended, and the antibiotics are effective when given to a person before, during, or after surgery. [ 87 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_156", "text": "Pain medications (such as  morphine ) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the patient's care. [ 88 ]  Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children, and some recommended that they not be given until the surgeon was able to examine the person. [ 88 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_157", "text": "The  surgical  procedure for the removal of the appendix is called an  appendectomy . Appendectomy can be performed through open or laparoscopic surgery. Laparoscopic appendectomy has several advantages over open appendectomy as an intervention for acute appendicitis. [ 89 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_158", "text": "For over a century, laparotomy (open appendectomy) was the standard treatment for acute appendicitis. [ 90 ]  This procedure consists of the removal of the infected appendix through a single large incision in the lower right area of the abdomen. [ 91 ]  The incision in a laparotomy is usually 2 to 3 inches (51 to 76\u00a0mm) long."}
{"_id": "WikiPedia_General_surgery$$$corpus_159", "text": "During an open appendectomy, the person with suspected appendicitis is placed under general  anesthesia  to keep the muscles completely relaxed and to keep the person unconscious. The incision is two to three inches (76\u00a0mm) long, and it is made in the right lower abdomen, several inches above the  hip bone . Once the incision opens the abdomen cavity, and the appendix is identified, the  surgeon  removes the infected tissue and cuts the appendix from the surrounding tissue. After careful and close inspection of the infected area, and ensuring there are no signs that surrounding tissues are damaged or infected.  In case of complicated appendicitis managed by an emergency open appendectomy, abdominal drainage (a temporary tube from the abdomen to the outside to avoid abscess formation) may be inserted, but this may increase the hospital stay. [ 92 ] [ needs update ]  The surgeon will start closing the incision. This means sewing the muscles and using  surgical staples  or  stitches  to close the skin up. To prevent infections, the incision is covered with a  sterile bandage  or surgical adhesive."}
{"_id": "WikiPedia_General_surgery$$$corpus_160", "text": "Laparoscopic appendectomy was introduced in 1983 and has become an increasingly prevalent intervention for acute appendicitis. [ 93 ]  This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7\u00a0mm) long. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body, and it is designed to help the surgeon inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using  surgical instruments . Laparoscopic surgery requires  general anesthesia , and it can last up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including a shorter post-operative recovery, less post-operative pain, and a lower superficial surgical site infection rate. However, the occurrence of an intra-abdominal abscess is almost three times more prevalent in laparoscopic appendectomy than open appendectomy. [ 94 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_161", "text": "In pediatric patients, the high mobility of the cecum allows externalization of the appendix through the umbilicus, and the entire procedure can be performed with a single incision. Laparoscopic-assisted transumbilical appendectomy is a relatively recent technique but with a long published series and very good surgical and aesthetic results. [ 95 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_162", "text": "The treatment begins by  keeping the person who will be having surgery from eating or drinking  for a given period, usually overnight. An  intravenous drip  is used to hydrate the person who will be having surgery.  Antibiotics  given intravenously such as  cefuroxime  and  metronidazole  may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours), general anaesthesia is usually used. Otherwise,  spinal anaesthesia  may be used."}
{"_id": "WikiPedia_General_surgery$$$corpus_163", "text": "Once the decision to perform an  appendectomy  has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. (With all surgeries there are risks that must be evaluated before performing the procedures.) The risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%. [ 96 ]  The most usual complications that can occur are pneumonia,  hernia  of the incision,  thrombophlebitis , bleeding and  adhesions . Evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in outcomes to the person with appendicitis. [ 97 ] [ 98 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_164", "text": "The surgeon will explain how long the recovery process should take. Abdomen hair is usually removed to avoid complications that may appear regarding the incision."}
{"_id": "WikiPedia_General_surgery$$$corpus_165", "text": "In most cases, patients going in for surgery experience nausea or vomiting that require medication before surgery. Antibiotics, along with pain medication, may be administered before appendectomies."}
{"_id": "WikiPedia_General_surgery$$$corpus_166", "text": "Hospital lengths of stay typically range from a few hours to a few days but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition: if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally much faster if the appendix does not rupture. [ 99 ]  It is important that people undergoing surgery respect their doctor's advice and limit their physical activity so the tissues can heal. Recovery after an appendectomy may not require diet changes or a lifestyle change."}
{"_id": "WikiPedia_General_surgery$$$corpus_167", "text": "The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in 2010, the average appendicitis hospital stay was 1.8 days. For stays where the person's appendix had ruptured, the average length of stay was 5.2 days. [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_168", "text": "After surgery, the patient will be transferred to a  postanesthesia care unit , so their vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function correctly. Patients are recommended to sit on the edge of the bed and walk short distances several times a day. Moving is mandatory, and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks but can be prolonged to up to eight weeks if the appendix has ruptured."}
{"_id": "WikiPedia_General_surgery$$$corpus_169", "text": "Most people with appendicitis recover quickly after surgical treatment, but complications can occur if treatment is delayed or if  peritonitis  occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around ten years old), the recovery takes three weeks."}
{"_id": "WikiPedia_General_surgery$$$corpus_170", "text": "The possibility of peritonitis is the reason why acute appendicitis warrants rapid evaluation and treatment. People with suspected appendicitis may have to undergo a  medical evacuation . Appendectomies have occasionally been performed in emergency conditions (i.e., not in a proper hospital) when a timely medical evacuation was impossible."}
{"_id": "WikiPedia_General_surgery$$$corpus_171", "text": "Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more challenging to diagnose and is more apt to be complicated even when operated early. In either condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated."}
{"_id": "WikiPedia_General_surgery$$$corpus_172", "text": "Another entity known as the appendicular lump is talked about. It happens when the appendix is not removed early during infection, and the omentum and intestine adhere to it, forming a palpable lump. During this period, surgery is risky unless there is pus formation evident by fever and toxicity or by ultrasound. Medical management treats the condition."}
{"_id": "WikiPedia_General_surgery$$$corpus_173", "text": "An unusual complication of an appendectomy is \"stump appendicitis\": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy. [ 100 ]  Stump appendicitis can occur months to years after initial appendectomy and can be identified with imaging modalities such as ultrasound. [ 101 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_174", "text": "The history of appendicitis traces back to ancient medical texts, though its clear clinical understanding emerged in the 19th century. Berengario da Carpi provided the first recorded description of the appendix in the 16th century, followed by  Andreas Vesalius  and  Gabriele Falloppio . Clinical understanding progressed in the 18th and 19th centuries, marked by Lorenz Heister's autopsy findings, Claudius Aymand's surgical intervention, and J. Mestivier's operation for appendicitis. Prior to the use of the term  appendicitis , it was described with terms including  perityphlitis ,  typhlitis ,  paratyphlitis , and  extra-peritoneal abscess of the right iliac fossa . [ 102 ]  The term \"appendicitis\" was coined by the American physician  Reginald Heber Fitz  in 1886, leading to standardized diagnosis and treatment, including Charles McBurney's identification of McBurney's point. Modern appendectomy techniques evolved in the early 20th century, coinciding with advancements in pathology, notably demonstrated by Ludwig Aschoff in 1908. [ 103 ] [ 104 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_175", "text": "Appendicitis is most common between the ages of 5 and 40. [ 106 ]  In 2013, it resulted in 72,000 deaths globally, down from 88,000 in 1990. [ 107 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_176", "text": "In the United States, there were nearly 293,000 hospitalizations involving appendicitis in 2010. [ 14 ]  Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization among children ages 5\u201317 years in the United States. [ 108 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_177", "text": "Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without. [ 109 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_178", "text": "Billroth I , more formally  Billroth's operation I , is an  operation  in which the  pylorus  is removed and the distal  stomach  is  anastomosed  directly to the  duodenum . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_179", "text": "The operation is most closely associated with  Theodor Billroth , but was first described by  Polish   surgeon   Ludwik Rydygier . [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_180", "text": "The surgical procedure is called a  gastroduodenostomy . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_181", "text": "Bowel obstruction , also known as  intestinal obstruction , is a mechanical or  functional obstruction  of the  intestines  which prevents the normal movement of the products of  digestion . [ 2 ] [ 5 ]  Either the  small bowel  or  large bowel  may be affected. [ 1 ]  Signs and symptoms include  abdominal pain ,  vomiting ,  bloating  and not passing  gas . [ 1 ]  Mechanical obstruction is the cause of about 5 to 15% of cases of  severe abdominal pain of sudden onset  requiring admission to hospital. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_182", "text": "Causes of bowel obstruction include  adhesions ,  hernias ,  volvulus ,  endometriosis ,  inflammatory bowel disease ,  appendicitis ,  tumors ,  diverticulitis ,  ischemic bowel ,  tuberculosis  and  intussusception . [ 1 ] [ 2 ]  Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and volvulus. [ 1 ] [ 2 ]  The diagnosis may be made on plain  X-rays ; however,  CT scan  is more accurate. [ 1 ]   Ultrasound  or  MRI  may help in the diagnosis of children or  pregnant  women. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_183", "text": "The condition may be treated conservatively or with  surgery . [ 2 ]  Typically  intravenous fluids  are given, a  nasogastric (NG) tube is placed through the nose into the stomach  to decompress the intestines, and  pain medications  are given. [ 2 ]   Antibiotics  are often given. [ 2 ]  In small bowel obstruction about 25% require surgery. [ 6 ]  Complications may include  sepsis , bowel  ischemia  and  bowel perforation . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_184", "text": "About 3.2 million cases of bowel obstruction occurred in 2015 which resulted in 264,000 deaths. [ 3 ] [ 7 ]  Both sexes are equally affected and the condition can occur at any age. [ 6 ]  Bowel obstruction has been documented throughout history, with cases detailed in the  Ebers Papyrus  of 1550 BC and by  Hippocrates . [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_185", "text": "Depending on the level of obstruction, bowel obstruction can present with  abdominal pain ,  abdominal distension , and  constipation . Bowel obstruction may be complicated by  dehydration  and  electrolyte abnormalities  due to vomiting; respiratory compromise from pressure on the  diaphragm  by a distended abdomen, or  aspiration  of vomitus; bowel  ischemia  or  perforation  from prolonged distension or pressure from a foreign body and subsequently  sepsis  due to  bowel flora . [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_186", "text": "In small bowel obstruction, the  pain  tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation. [ 10 ]  Common physical exam findings may include signs of  dehydration , abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_187", "text": "In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation. [ 12 ]  Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. [ 13 ]  Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of  volvulus  and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable  hernia , abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass. [ 6 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_188", "text": "The main diagnostic tools are  blood tests ,  X-rays  of the abdomen, CT scanning, and  ultrasound . If a mass is identified,  biopsy  may determine the nature of the mass. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_189", "text": "Radiological  signs of bowel obstruction include bowel distension (small bowel loops dilated >3 cm) and the presence of multiple (more than 2) air-fluid levels on supine and erect abdominal  radiographs . [ 16 ]  Ultrasounds may be as useful as CT scanning to make the diagnosis. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_190", "text": "Contrast enema  or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with  sensitivity  of 97% and  specificity  of 96%. [ 18 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_191", "text": "Colonoscopy , small bowel investigation with ingested camera or push  endoscopy , and  laparoscopy  are other diagnostic options."}
{"_id": "WikiPedia_General_surgery$$$corpus_192", "text": "Differential diagnoses  of bowel obstruction include:"}
{"_id": "WikiPedia_General_surgery$$$corpus_193", "text": "Causes of  small bowel  obstruction include: [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_194", "text": "After abdominal surgery, the incidence of small bowel obstruction from any cause is 9%. In those where the cause of the obstruction was clear, adhesions are the single most common cause (more than half). [ 22 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_195", "text": "Causes of large bowel obstruction include: [ 23 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_196", "text": "Outlet obstruction is a sub-type of large bowel obstruction and refers to conditions affecting the anorectal region that obstruct  defecation , specifically conditions of the pelvic floor and anal sphincters. Outlet obstruction can be classified into four groups. [ 24 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_197", "text": "Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management. [ 25 ] [ 26 ]  Patients are monitored by the surgical team for signs of improvement and resolution of the obstruction on imaging; if the obstruction does not clear then surgical management for the treatment of the causative lesion is required. [ 27 ]  In malignant large bowel obstruction, endoscopically placed self-expanding metal  stents  may be used to temporarily relieve the obstruction as a bridge to surgery, [ 28 ]  or as  palliation . [ 29 ]  Diagnosis of the type of bowel obstruction is normally conducted through initial plain  radiograph  of the abdomen, luminal contrast studies,  computed tomography scan , or  ultrasonography  prior to determining the best type of treatment. [ 30 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_198", "text": "Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer. [ 31 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_199", "text": "In the management of small bowel obstructions, a commonly quoted surgical aphorism is: \"never let the sun rise or set on small-bowel obstruction\" [ 32 ]  because about 5.5% [ 32 ]  of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies ( volvulus , closed-loop obstructions,  ischemic bowel , incarcerated  hernias , etc.). [ 2 ]  Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of  peritonitis  such as rebound tenderness,  elevated heart rate , fever, and elevated inflammatory markers on lab work, such as  lactic acid . [ 33 ] [ 34 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_200", "text": "A small flexible tube ( nasogastric tube ) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting.  Intravenous therapy  is utilized and the urine output may be monitored with a  catheter  in the  bladder . [ 35 ] [ 36 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_201", "text": "Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and  X-ray images  are made to ensure he or she is not getting clinically worse. [ 37 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_202", "text": "Conservative treatment involves insertion of a  nasogastric tube , correction of dehydration and  electrolyte  abnormalities.  Opioid  pain relievers may be used for patients with severe pain but alternate pain relievers are preferred as opioids can decrease bowel motility. [ 38 ] Antiemetics  may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required."}
{"_id": "WikiPedia_General_surgery$$$corpus_203", "text": "Most patients improve with conservative care in 2\u20135 days. When the obstruction is cancer, surgery is the only treatment. Those with  bowel resection  or  lysis  of adhesions usually stay in the hospital a few more days until they can eat and walk. [ 39 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_204", "text": "Small bowel obstruction caused by  Crohn's disease , peritoneal  carcinomatosis , sclerosing  peritonitis ,  radiation enteritis , and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery."}
{"_id": "WikiPedia_General_surgery$$$corpus_205", "text": "The prognosis for non-ischemic cases of SBO is good with mortality rates of 3\u20135%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%. [ 40 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_206", "text": "Cases of SBO related to cancer are more complicated and require additional intervention to address the  malignancy , recurrence, and  metastasis , and thus are associated with a more poor prognosis. [ 41 ]  Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction. [ 42 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_207", "text": "All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery. [ 43 ]  More than 90% of patients also form adhesions after major abdominal surgery. [ 44 ] \nCommon consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility. [ 44 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_208", "text": "Endoscopic stenting  is a medical procedure by which a  stent , a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by  endoscopy . They are usually inserted when a disease process has led to narrowing or obstruction of the organ in question, such as the  esophagus  or the  colon ."}
{"_id": "WikiPedia_General_surgery$$$corpus_209", "text": "There are various types of endoscopic stents: plastic stents, uncovered self-expandable metallic stents, partially covered self-expandable metallic stents, and fully covered self-expandable metallic stents. [ 1 ]   Self-expandable metallic stents  \"play an important role in the management of malignant obstructing lesions in the gastrointestinal tract.\" [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_210", "text": "A stent may be inserted into the  common bile duct  during an  endoscopic retrograde cholangiopancreatography , especially if  gallstone  removal is deemed too risky. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_211", "text": "Some complications of metallic stents are: stent migration (occurring in 20 to 40% of the cases). Stents with anchoring flaps or flared ends can reduce the risk of migration. Cholecystitis can be a complication for stenting of malignant biliary stricture. Stent occlusion may occur from tumor or tissue overgrowth, or due to sludge deposits, causing the development of cholangitis. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_212", "text": "In  medicine , a  distal splenorenal shunt procedure  ( DSRS ), also  splenorenal shunt procedure  and  Warren shunt , [ 1 ]  is a  surgical procedure  in which the  distal   splenic vein  (a part of the  portal venous system ) is attached to the left  renal vein  (a part of the  systemic venous system ).  It is used to treat  portal hypertension  and its main complication ( esophageal varices ). [ 2 ]  It was developed by  W. Dean Warren ."}
{"_id": "WikiPedia_General_surgery$$$corpus_213", "text": "DSRS is typically done with splenopancreatic and gastric disconnection (ligation of the  gastric veins  and  pancreatic veins  (that drain into the  portal vein ) and complete detachment of the  splenic vein  from the  portal venous system ), as it improves the outcome. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_214", "text": "Survival with a  transjugular intrahepatic portosystemic shunt  (TIPS) versus a DSRS is thought to be approximately similar, [ 4 ] [ 5 ]  but still an area of intensive research. [ 6 ] [ 7 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_215", "text": "Both TIPS and DSRS lead to decreased rates of  variceal bleeding  at the expense of  hepatic encephalopathy ; however, TIPS appears to have more shunt dysfunction and lead to more encephalopathy and bleeds. [ 5 ]  DSRS appears to be more cost effective than TIPS. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_216", "text": "An  epidural abscess  refers to a collection of pus and infectious material located in the  epidural space  superficial to the  dura mater  which surrounds the  central nervous system . Due to its location adjacent to brain or spinal cord, epidural abscesses have the potential to cause weakness, pain, and paralysis."}
{"_id": "WikiPedia_General_surgery$$$corpus_217", "text": "A  spinal epidural abscess  (SEA) is a collection of pus or inflammatory granulation between the  dura mater  and the  vertebral column . [ 1 ]   Currently the annual incidence rate of SEAs is estimated to be 2.5\u20133 per 10,000 hospital admissions.  Incidence of SEA is on the rise, due to factors such as an aging population, increase in use of invasive spinal instrumentation, growing number of patients with risk factors such as diabetes and intravenous drug use. [ 1 ]   SEAs are more common in posterior than anterior areas, [ 2 ]  and the most common location is the  thoracolumbar  area, where  epidural space  is larger and contains more fat tissue. [ 3 ] \nSEAs are more common in males, and can occur in all ages, although highest prevalence is during the fifth and seventh decades of life. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_218", "text": "Combined treatment of emergency surgery and antibiotics is the preferred treatment for the spinal epidural abscess, removing existing pus (which is tested for microorganisms to select the most appropriate antibiotic) and removing pressure from the spinal cord and nerve roots. Antibiotic therapy should start after obtaining pus for microbiological investigation. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_219", "text": "A  cranial epidural abscess  involves pus and granulation tissue accumulation in between the dura mater and cranial bone. These typically arise (along with  osteomyelitis  of a cranial bone) from infections of the ear or paranasal sinuses. They rarely can be caused by distant infection or an infected  cerebral venous sinus thrombosis .  Staphylococcus aureus  is the most common pathogen. Symptoms include pain at the forehead or ear, pus draining from the ear or sinuses, tenderness overlying the infectious site, fever, neck stiffness, and in rare cases focal seizures.  Treatment requires a combination of antibiotics and surgical removal of infected bone. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_220", "text": "article/232570  at  eMedicine"}
{"_id": "WikiPedia_General_surgery$$$corpus_221", "text": "A  gastrojejunocolic fistula  is a disorder of the human  gastrointestinal tract . It may form between the transverse colon and the upper  jejunum  after a  Billroth II  surgical procedure.  (The Billroth procedure attaches the jejunum to the remainder of the stomach.) Fecal matter thereby passes improperly from the colon to the stomach, and causes  halitosis . [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_222", "text": "Patients may present with  diarrhea , [ 1 ]   weight loss  and  halitosis  as a result of fecal matter passing through the  fistula  from the colon into the stomach."}
{"_id": "WikiPedia_General_surgery$$$corpus_223", "text": "This  gastroenterology  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_General_surgery$$$corpus_224", "text": "A  glomectomy  is an excision of a  glomus body  or a  glomus cell , usually in the case of a  glomus tumor . This operation was formerly performed for the treatment of severe, chronic  asthma , [ 1 ]  but has since been abandoned for this purpose due to its lack of efficacy. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_225", "text": "In  human anatomy , the  greater sac , also known as the  general cavity (of the abdomen)  or  peritoneum of the  peritoneal cavity  proper , is the cavity in the  abdomen  that is inside the peritoneum but outside the  lesser sac ."}
{"_id": "WikiPedia_General_surgery$$$corpus_226", "text": "It is connected with the lesser sac via the  omental foramen , also known as the  foramen of Winslow  or  epiploic foramen , which is anteriorly bounded by the portal triad \u2013  portal vein ,  hepatic artery , and  common bile duct ."}
{"_id": "WikiPedia_General_surgery$$$corpus_227", "text": "The  ileojejunal bypass  is an  experimental   surgery  designed as a remedy for  morbid obesity . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_228", "text": "It was first performed on a series of patients at White Memorial Hospital,  Los Angeles, California , in the mid-to-late 1970s. It has since been discarded, as the complications from the surgery, including malnutrition, vitamin deficiencies, protein and albumin deficiency, liver and renal failure, and kidney stones, highly outweighed the benefits. Many patients who received this surgery consequently underwent reversal surgery."}
{"_id": "WikiPedia_General_surgery$$$corpus_229", "text": "This  surgery  article is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_General_surgery$$$corpus_230", "text": "Intra-abdominal infection  ( IAI , also spelled  intraabdominal ) is a group of  infections  that occur within the  abdominal cavity . They vary from  appendicitis  to  fecal peritonitis . [ 1 ]  Risk of death despite treatment is often high. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_231", "text": "IAIs can be classified into uncomplicated and complicated infections. Uncomplicated infections often involved the infection of single organ and can be controlled by surgical removal of the source of infection, and antibiotics is not required after the surgery to control the infection. In complicated infections, the infection spread to a part or to the whole of the  peritoneum , causing  peritonitis . Meanwhile, peritonitis can be classified into primary, secondary, and tertiary peritonitis. Primary peritonitis is the diffuse bacterial infection of the peritoneum while the integrity of the gastrointestinal tract is preserved (in cases of  ascites ); secondary peritonitis is the infection of peritoneum where the integrity of gastrointestinal tract is compromised; tertiary peritonitis is reinfection of peritoneum 48 hours after apparently good surgical control of secondary peritonitis. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_232", "text": "Those with suspected with IAIs usually have acute onset of abdominal pain with signs of local or generalised  inflammations  such as pain,  tenderness  (pain on touching), fever,  tachycardia  (increased heart rate), or  tachypnea  (increased breathing rate). In more severe cases, such as organ failure, signs such as  hypotension  (low blood pressure),  oliguria  (reduced urine output), sudden onset of  altered level of consciousness , and  lactic acidosis  will appear. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_233", "text": "In case of  appendicitis , signs such as fever, positive  psoas sign , migration of pain from umbilicus to the  right iliac fossa  increases the likelihood of the disease; while signs such as vomiting before the pain reduces its likelihood to occur. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_234", "text": "CT scan and ultrasound has been used routinely to complete the assessment of IAIs. CT scan has higher sensitivity and specificity than ultrasound to access the condition. However, CT scan poses radiation risk to the subject. [ 2 ]  MRI scan is less readily available than CT scan or ultrasound in hospitals to diagnose IAIs. However, it has been proposed to be used in those who are pregnant and have inconclusive findings on ultrasound. The sensitivity and specificity of MRI in diagnosing acute appendicitis are 94% and 96% respectively. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_235", "text": "Laparoscopic surgery has also been used to diagnose the cause of IAIs when imaging is unhelpful. Besides, the laparoscopic surgery can also initiate treatment in the same setting. The accuracy is very high, in the range of 86 to 100%. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_236", "text": "The  lesser sac , also known as the  omental bursa , is a part of the  peritoneal cavity  that is formed by the  lesser  and  greater omentum .  Usually found in mammals, it is connected with the  greater sac  via the  omental foramen  or  Foramen of Winslow . In mammals, it is common for the lesser sac to contain considerable amounts of fat."}
{"_id": "WikiPedia_General_surgery$$$corpus_237", "text": "If any of the marginal structures rupture their contents could leak into the lesser sac. If the stomach were to rupture on its anterior side though the leak would collect in the  greater sac . [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_238", "text": "The lesser sac is formed during  embryogenesis  from an infolding of the greater omentum. The open end of the infolding, known as the  omental foramen  is usually close to the stomach. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_239", "text": "A  lower anterior resection , formally known as  anterior resection of the rectum and colon  and  anterior excision of the rectum  or simply  anterior resection  (less precise), is a common surgery for  rectal cancer  and occasionally is performed to remove a diseased or ruptured portion of the intestine in cases of  diverticulitis . It is commonly  abbreviated  as  LAR . [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_240", "text": "LARs are for cancer in the  proximal  (upper) two-thirds of the rectum which lends itself well to resection while leaving the rectal sphincter intact. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_241", "text": "LARs, generally, give a better  quality of life  than  abdominoperineal resections  (APRs). [ 2 ] [ 3 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible. APRs lead to a permanent colostomy and do not spare the sphincters. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_242", "text": "Low anterior resection syndrome (LARS) comprises a collection of symptoms mainly affecting patients after surgery for rectal cancer characterized by fecal incontinence (stool and gases), fecal urgency, frequent bowel movements and bowel fragmentation, while some patients only experience constipation and a  feeling of incomplete bowel emptying . [ 4 ] [ 5 ] [ 6 ]    The cause is unclear, and has been thought to be due to nerve damage, or possibly due to loss of the  rectoanal inhibitory reflex. [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_243", "text": "Many of the symptoms of LAR syndrome improve over a period of many months. [ 7 ]  The nerves that control the natural contractions of the colon and rectum run along the colon and can be damaged or cut during the surgery. [ citation needed ]   After such damage, the nerves can regrow, but only slowly."}
{"_id": "WikiPedia_General_surgery$$$corpus_244", "text": "Digestive system surgery , or  gastrointestinal surgery , can be divided into upper GI surgery and lower GI surgery. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_245", "text": "Upper gastrointestinal surgery , often referred to as  upper GI surgery , refers to a practice of  surgery  that focuses on the upper parts of the  gastrointestinal tract . There are many operations relevant to the upper gastrointestinal tract that are best done only by those who keep constant practice, owing to their complexity. Consequently, a  general surgeon  may specialise in 'upper GI' by attempting to maintain currency in those skills."}
{"_id": "WikiPedia_General_surgery$$$corpus_246", "text": "Upper GI surgeons would have an interest in, and may exclusively perform, the following operations:"}
{"_id": "WikiPedia_General_surgery$$$corpus_247", "text": "Surgery on the digestive system's organs is referred to as digestive system surgery, gastrointestinal surgery, or gastrointestinal (GI) surgery. Nutrients from the food we eat are processed and absorbed by the digestive system. Surgery could be required to remedy or treat certain problems or diseases that affect the digestive tract."}
{"_id": "WikiPedia_General_surgery$$$corpus_248", "text": "There are many different types of digestive system operations, some of the more popular ones being:\n1. Appendectomy: The surgical removal of the appendix, typically as a result of acute appendicitis, an appendix inflammation.\n2. Gastric bypass: A weight-loss procedure that includes separating the stomach into an upper pouch that is smaller and a lower pouch that is bigger. Then, a section of the stomach and small intestine are skipped in favor of rearranging the small intestine to link to both pouches. As a result, the stomach can contain less food and nutrients are not as well absorbed, which causes weight loss.\n3. Cholecystectomy: Surgically removing the gallbladder, frequently as a result of painful gallstones or other problems.\n4. Colectomy: The removal of the colon (large intestine) whole or in part. This procedure is typically done to address problems including colorectal cancer, diverticular disease, or inflammatory bowel disease.\n5. Resection of the liver in part: This procedure is frequently carried out to treat liver tumors or to remove damaged liver tissue.\n6. Esophagectomy: Removal of the esophagus in whole or in part, usually to treat esophageal cancer.\n7. Pancreatic Surgery: procedures involving the pancreas, such as the Whipple surgery (pancreaticoduodenectomy), which is used to treat some forms of pancreatic cancer and other serious pancreatic diseases.\n8. Hernia Repair: A hernia, which is the protrusion of an organ or tissue through a weak spot in the abdominal wall, is treated surgically."}
{"_id": "WikiPedia_General_surgery$$$corpus_249", "text": "These operations can be carried out using conventional open surgical procedures or minimally invasive techniques like laparoscopic or robotic-assisted surgery, which require smaller incisions and result in quicker recoveries. Surgery of the digestive system is a complicated topic that calls for specialized education and experience. To make educated decisions regarding their healthcare, individuals must speak with a trained surgeon about their unique situation, treatment options, and potential hazards."}
{"_id": "WikiPedia_General_surgery$$$corpus_250", "text": "A  Meckel's diverticulum , a true  congenital   diverticulum , is a slight bulge in the  small intestine  present at birth and a  vestigial  remnant of the  vitelline duct . It is the most common malformation of the  gastrointestinal tract  and is present in approximately 2% of the population, [ 1 ]  with males more frequently experiencing symptoms."}
{"_id": "WikiPedia_General_surgery$$$corpus_251", "text": "Meckel's diverticulum was first explained by  Fabricius Hildanus  in the sixteenth century and later named after  Johann Friedrich Meckel , who described the embryological origin of this type of diverticulum in 1809. [ 2 ] [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_252", "text": "The majority of people with a Meckel's diverticulum are  asymptomatic . An asymptomatic Meckel's diverticulum is called a  silent  Meckel's diverticulum. [ 4 ]  If symptoms do occur, they typically appear before the age of two years. [ 5 ]  The most common presenting symptom is painless  rectal bleeding  such as  melaena -like black offensive stools, followed by  intestinal obstruction ,  volvulus  and  intussusception . Occasionally, Meckel's diverticulitis may present with all the features of  acute appendicitis . [ 6 ]  Also, severe pain in the  epigastric region  is experienced by the person along with bloating in the epigastric and umbilical regions. At times, the symptoms are so painful that they may cause sleepless nights with acute pain felt in the foregut region, specifically in the  epigastric  and  umbilical  regions. [ citation needed ]  In some cases, bleeding occurs without warning and may stop spontaneously. The symptoms can be extremely painful, often mistaken as just stomach pain resulting from not eating or constipation. [ citation needed ]  Rarely, a Meckel's diverticulum containing ectopic pancreatic tissue can present with abdominal pain and increased serum amylase levels, mimicking acute pancreatitis. [ 7 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_253", "text": "The lifetime risk for a person with Meckel's diverticulum to develop certain  complications  is about 4\u20136%. Gastrointestinal bleeding,  peritonitis  or  intestinal obstruction  may occur in 15\u201330% of symptomatic people (Table 1). On rare occasions the diverticulum can herniate through the abdominal wall also known as a  Littre hernia.  Only 6.4% of all complications require surgical treatment, and untreated Meckel's diverticulum has a  mortality rate  of 2.5\u201315%. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_254", "text": "Table 1 \u2013 Complications of Meckel's Diverticulum: [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_255", "text": "Bleeding of the diverticulum is most common in young children, especially in males who are less than 2 years of age. [ 10 ]  Symptoms may include bright red blood in stools ( hematochezia ), weakness, abdominal tenderness or pain, and even  anaemia  in some cases. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_256", "text": "Bleeding may be caused by:"}
{"_id": "WikiPedia_General_surgery$$$corpus_257", "text": "The appearance of stools may indicate the nature of the bleeding:"}
{"_id": "WikiPedia_General_surgery$$$corpus_258", "text": "Inflammation of the diverticulum can mimic symptoms of appendicitis, i.e., periumbilical tenderness and intermittent crampy abdominal pain. Perforation of the inflamed diverticulum can result in peritonitis. Diverticulitis can also cause  adhesions , leading to intestinal obstruction. [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_259", "text": "Diverticulitis may result from:"}
{"_id": "WikiPedia_General_surgery$$$corpus_260", "text": "Symptoms:  Vomiting, abdominal pain and severe or complete  constipation . [ 18 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_261", "text": "Anomalies between the diverticulum and umbilicus may include the presence of a fibrous cord,  cyst , fistula, or sinus, leading to: [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_262", "text": "Neoplasms  (tumors) in Meckel's diverticulum may cause bleeding, acute abdominal pain, gastrointestinal obstruction, perforation or intussusception. They may be  benign  or  malignant . [ 14 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_263", "text": "The omphalomesenteric duct (omphaloenteric duct, vitelline duct, or yolk stalk) normally connects the embryonic midgut to the yolk sac ventrally, providing nutrients to the midgut during embryonic development. The vitelline duct narrows progressively and disappears between the 5th and 8th weeks of gestation. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_264", "text": "In Meckel's diverticulum, the proximal part of vitelline duct fails to regress and involute, which remains as a remnant of variable length and location. [ 16 ]  The solitary diverticulum lies on the antimesenteric border of the ileum (opposite to the  mesenteric attachment ) and extends into the umbilical cord of the embryo. [ 8 ]  The left and right vitelline arteries originate from the primitive  dorsal aorta , and travel with the vitelline duct. The right becomes the  superior mesenteric artery  that supplies a terminal branch to the diverticulum, while the left involutes. [ 17 ]  Having its own blood supply, Meckel's diverticulum is susceptible to obstruction or infection."}
{"_id": "WikiPedia_General_surgery$$$corpus_265", "text": "Meckel's diverticulum is located in the  distal   ileum , usually within 60\u2013100\u00a0cm (2\u00a0feet) of the  ileocecal valve . This  blind segment  or small pouch is about 3\u20136\u00a0cm (2\u00a0inch) long and may have a greater  lumen  diameter than that of the  ileum . [ 20 ]  It runs antimesenterically and has its own blood supply. It is a remnant of the connection from the  yolk sac  to the small intestine present during  embryonic development . It is a  true diverticulum , consisting of all three layers of the  bowel  wall:  mucosa ,  submucosa  and  muscularis propria . [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_266", "text": "As the vitelline duct is made up of  pluripotent  cell lining, Meckel's diverticulum may harbor abnormal tissues, containing embryonic remnants of other tissue types.  Jejunal ,  duodenal  mucosa or  Brunner's tissue  were each found in 2% of  ectopic  cases.  Heterotopic  rests of  gastric  mucosa and  pancreatic  tissue are seen in 60% and 6% of cases respectively. Heterotopic means the displacement of an organ from its normal anatomic location. [ 21 ]  Inflammation of this Meckel's diverticulum may mimic appendicitis. Therefore, during appendectomy, ileum should be checked for the presence of Meckel's diverticulum, if it is found to be present it should be removed along with appendix. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_267", "text": "A  memory aid  is the rule of 2s: [ 22 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_268", "text": "However, the exact values for the above criteria range from 0.2\u20135 (for example, prevalence is probably 0.2\u20134%). [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_269", "text": "It can also be present as an indirect  hernia , typically on the right side, where it is known as a \" Hernia of  Littr\u00e9 \". A case report of strangulated  umbilical hernia  with Meckel's diverticulum has also been published in the literature. [ 23 ]  Furthermore, it can be attached to the umbilical region by the vitelline ligament, with the possibility of vitelline cysts, or even a patent vitelline canal forming a vitelline  fistula  when the umbilical cord is cut. Torsions of intestine around the intestinal stalk may also occur, leading to obstruction,  ischemia , and  necrosis ."}
{"_id": "WikiPedia_General_surgery$$$corpus_270", "text": "A  technetium-99m  ( 99mTc )  pertechnetate  scan, also called Meckel scan or nuclear scintigraphy scan, is the investigation of choice to diagnose Meckel's diverticula in children. This scan detects  gastric mucosa ; since approximately 50% of symptomatic Meckel's diverticula have ectopic gastric or pancreatic cells contained within them, [ 24 ]  this is displayed as a spot on the scan distant from the stomach itself. In children, this scan is highly accurate and  noninvasive , with 95% specificity and 85% sensitivity; [ 17 ]  however, in adults the test is only 9% specific and 62% sensitive. [ 25 ]  This scan is more accurate in children because gastric mucosa is found in 90% of bleeding diverticula; which is the most common symptom in children, not adults.  [ 26 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_271", "text": "Patients with these misplaced gastric cells may experience  peptic ulcers  as a consequence. Therefore, other tests such as  colonoscopy  and screenings for  bleeding disorders  should be performed, and  angiography  can assist in determining the location and severity of bleeding. Colonoscopy might be helpful to rule out other sources of bleeding but it is not used as an identification tool. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_272", "text": "Angiography  might identify brisk bleeding in patients with Meckel's diverticulum. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_273", "text": "Ultrasonography  could demonstrate omphaloenteric duct remnants or cysts. [ 27 ]   Computed tomography  (CT scan) might be a useful tool to demonstrate a blind ended and inflamed structure in the mid-abdominal cavity, which is not an appendix. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_274", "text": "In asymptomatic patients, Meckel's diverticulum is often diagnosed as an incidental finding during  laparoscopy  or  laparotomy . [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_275", "text": "Treatment is surgical, potentially with a laparoscopic  resection . [ 17 ]  In patients with bleeding, strangulation of bowel, bowel perforation or  bowel obstruction , treatment involves surgical resection of both the Meckel's diverticulum itself along with the adjacent bowel segment, and this procedure is called a \"small bowel resection\". [ 17 ]  In patients without any of the aforementioned complications, treatment involves surgical resection of the Meckel's diverticulum only, and this procedure is called a simple  diverticulectomy . [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_276", "text": "With regards to asymptomatic Meckel's diverticulum, some recommend that a search for Meckel's diverticulum should be conducted in every case of  appendectomy /laparotomy done for  acute abdomen , and if found, Meckel's diverticulectomy or resection should be performed to avoid secondary complications arising from it. [ 28 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_277", "text": "Meckel's diverticulum occurs in about 2% of the population. [ 21 ]  Prevalence in males is 3\u20135 times higher than in females. [ 20 ]  Only 2% of cases are symptomatic, which usually presents among children at the age of 2. [ 8 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_278", "text": "Most cases of Meckel's diverticulum are diagnosed when complications manifest or incidentally in unrelated conditions such as laparotomy, laparoscopy or contrast study of the small intestine. Classic presentation in adults includes intestinal obstruction and inflammation of the diverticulum (diverticulitis). Painless rectal bleeding most commonly occurs in toddlers. [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_279", "text": "Inflammation in the ileal diverticulum has symptoms that mimic appendicitis, therefore its diagnosis is of clinical importance. Detailed knowledge of the pathophysiological properties is essential in dealing with the life-threatening complications of Meckel's diverticulum. [ 17 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_280", "text": "In  human anatomy , the  omental foramen  ( epiploic foramen ,  foramen of Winslow  after the anatomist  Jacob B. Winslow , or uncommonly  aditus ;  Latin :  Foramen epiploicum ) is the passage of communication, or foramen, between the  greater sac , and the  lesser sac  of the  peritoneal cavity ."}
{"_id": "WikiPedia_General_surgery$$$corpus_281", "text": "It has the following borders:"}
{"_id": "WikiPedia_General_surgery$$$corpus_282", "text": "As the portal vein is the most posterior structure in the hepatoduodenal ligament, and the inferior vena cava lies under the posterior wall, the epiploic foramen can be remembered as lying between the two great veins of the abdomen."}
{"_id": "WikiPedia_General_surgery$$$corpus_283", "text": "This article incorporates text in the  public domain  from  page 1156  of\u00a0the 20th edition of   Gray's Anatomy   (1918)"}
{"_id": "WikiPedia_General_surgery$$$corpus_284", "text": "A  Paget's abscess , named by eminent British surgeon and pathologist Sir  James Paget , is an  abscess  that recurs at the site of a former abscess which had resolved. [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_285", "text": "This article about a  disease , disorder, or medical condition is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_General_surgery$$$corpus_286", "text": "Pelvic abscess  is a  collection of pus  in the  pelvis , typically occurring following lower abdominal  surgical procedures , or as a complication of  pelvic inflammatory disease  (PID),  appendicitis , or lower genital tract infections. [ 1 ]  Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  It can lead to sepsis and death. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_287", "text": "Blood tests typically show a  raised white cell count . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Ultrasound ,  CT-scan  or  MRI  may be used to locate the abscess and assess its dimensions. [ 1 ]  Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT . [ 3 ]  Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_288", "text": "Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  There may be urinary frequency,  diarrhoea , or persistent  feeling of needing to pass stool . [ 4 ]  Other symptoms may include fatigue, nausea, and vomiting. [ 2 ]  Clinical features might not be apparent until the pelvic abscess has grown in size. [ 2 ]  The lower abdomen is generally tender; one or both sides. [ 2 ]  A bulging of the front wall of the rectum might be felt on digital examination via the rectum or vagina. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_289", "text": "Complications include sepsis and  peritonitis . [ 1 ]  In the longterm, a  fistula  may develop. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_290", "text": "Pelvic abscess typically occurs following  gynecological surgery  and  abdominal surgery ; hysterectomy, laparotomy, caesarian section, and induced abortion. [ 1 ]   It may occur as a complication of  pelvic inflammatory disease  (PID),  appendicitis ,  diverticulitis ,  inflammatory bowel disease  (IBD), trauma, pelvic organ cancer, or lower genital tract infections. [ 1 ] [ 3 ]  The abscess may be in the  pouch of Douglas ,  fallopian tube ,  ovary , or  parametrium . [ 1 ]  It begins as inflammation or a  collection of blood  in the pelvis. [ 1 ]  Other risk factors include immunodeficiency, pregnancy,  hydrosalpinx ,  endometrioma , poorly controlled  diabetes ,  kidney disease ,  obesity , and genital tract abnormalities. [ 1 ] [ 2 ]  Opening the rectum to resect a  rectal cancer  may lead to developing a pelvic abscess. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_291", "text": "PID in females may lead to a  tubo-ovarian abscess , where the abscess may be in the  fallopian tube  or  ovary . [ 1 ] [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_292", "text": "In children, it is more frequently associated with IBD and appendicitis. [ 5 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_293", "text": "Blood tests typically show a  raised white cell count , often with a high  ESR  and  C-reactive protein . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Medical imaging  to assess the dimensions and locate the abscess may include  ultrasound ,  CT-scan  or  MRI . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_294", "text": "Other conditions that appear similar include  ectopic pregnancy , PID, appendicitis,  kidney stone ,  bowel obstruction , and sepsis following  miscarriage  or  termination of pregnancy . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_295", "text": "Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT ,  through the skin ,  via the rectum , or  transvaginal  routes. [ 3 ]  Occasionally antibiotics may be used without surgery; if the abscess is at a very stage and small. [ 2 ]  Until sensitivities are received, a broad spectrum antibiotic is generally required. [ 2 ]  Sometimes, a laparotomy of laparoscopy is required. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_296", "text": "Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]  Treatment also includes  adequate hydration . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_297", "text": "Further surgery such as is sometimes required to treat the underlying cause; such as salpingo-oophorectomy for tubo-ovarian abscess. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_298", "text": "Pelvic abscess responds well to antibiotics and hydration. [ 1 ]  The outcome is less successful in the presence of fistula. [ 2 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_299", "text": "It is uncommon. [ 2 ]  The incidence of pelvic abscess is less than 1% in an individual undergoing obstetric and gynecological operative procedure. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_300", "text": "A  retrograde appendicectomy  is a form of  surgery  to remove an  appendix  that is retrocaecal and adherent [ 1 ]  or otherwise inaccessible, so that the  appendicectomy  is performed in a retrograde fashion. [ 2 ]  In cases of acute appendicitis, antegrade appendicectomy is the preferred option, but in cases where the base of the appendix is accessible but is difficult to identify or deliver its more distal portion, a retrograde appendicectomy becomes necessary. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_301", "text": "Firstly, the base is divided between artery forceps then the appendiceal vessels are then ligated, the stump ligated and invaginated, and gentle traction on the caecum will enable the surgeon to deliver the body of the appendix, which is then removed from base to tip. [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_302", "text": "In  general surgery , a  Roux-en-Y anastomosis , or  Roux-en-Y , is an end-to-side  surgical anastomosis  of  bowel  used to reconstruct the  gastrointestinal tract .  Typically, it is between  stomach  and small bowel that is  distal  (or further down the  gastrointestinal tract ) from the cut end. [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_303", "text": "The name is derived from the  surgeon  who first described it ( C\u00e9sar Roux ) [ 1 ]  and the  stick-figure  representation.  Diagrammatically , the Roux-en-Y anastomosis looks a little like the  letter   Y . [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_304", "text": "Typically, the two upper limbs of the Y represent (1) the  proximal  segment of stomach and the distal small bowel it joins with and (2) the blind end that is surgically divided off, and the lower part of the Y is formed by the  distal  small bowel beyond the anastomosis. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_305", "text": "Roux-en-Ys are used in several operations and collectively called  Roux operations . [ 1 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_306", "text": "When describing the surgery, the  Roux limb  is the  efferent  or antegrade limb that serves as the primary recipient of food after the surgery, while the  hepatobiliary  or  afferent  limb that anastomoses with the biliary system serves as the recipient for biliary secretions, which then travel through the excluded small bowel to the distal anastomosis at the mid jejunum to aid digestion. The altered anatomy can contribute to indigestion following surgery. [ 2 ]  The procedure has also been associated with an increased incidence of  iron-deficiency anemia . Iron-deficiency anemia develops in up to 45% of people who have had a Roux-en-Y anastomosis. [ 3 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_307", "text": "Subphrenic abscess  is a disease characterized by an accumulation of infected fluid between the  diaphragm ,  liver , and  spleen . [ 2 ]   This  abscess  develops after surgical operations like  splenectomy .\nPresents with cough, increased respiratory rate with shallow respiration, diminished or absent breath sounds, hiccups, dullness in percussion, tenderness over the 8th\u201311th ribs, fever, chills, anorexia and shoulder tip pain on the affected side. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death.\nPatients who develop peritonitis may get localized abscesses in the right or left subphrenic space. The right side is more common due to the high frequency of ruptured appendices and perforated duodenal ulcers.\nTwo common approaches to draining a subphrenic abscess are 1) incision inferior to or through the bed of the 12th rib (no need to create an opening in the pleura or peritoneum) 2) an anterior subphrenic abscess is often drained through a subcostal incision located inferior and parallel to the right costal margin.  [ 3 ]  It is also associated with  peritonitis . [ 4 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_308", "text": "This article related to  pathology  is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_General_surgery$$$corpus_309", "text": "This article about a medical condition affecting the respiratory system is a  stub . You can help Wikipedia by  expanding it ."}
{"_id": "WikiPedia_General_surgery$$$corpus_310", "text": "A  tracheo-esophageal puncture  (or  tracheoesophageal puncture ) is a surgically created hole between the  trachea  (windpipe) and the  esophagus  (food pipe) in a person who has had a total  laryngectomy , a surgery where the  larynx  (voice box) is removed. The purpose of the puncture is to restore a person\u2019s ability to speak after the vocal cords have been removed. This involves creation of a  fistula  between the trachea and the esophagus, puncturing the short segment of tissue or \u201ccommon wall\u201d that typically separates these two structures.  A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for  esophageal speech ."}
{"_id": "WikiPedia_General_surgery$$$corpus_311", "text": "A laryngectomized person is required to breathe through a permanent breathing hole in the neck, called a  tracheostoma . When a laryngectomized person occludes the tracheostoma, completely blocking exhaled air to leave the body through that pathway, exhaled air is directed through the voice prosthesis. This air enters the esophagus and escapes through the mouth. During this process, as the air passes through the upper tissues of the esophagus and lower throat, it allows for vibration of the tissues of the pharyngo-esophageal segment (also called PE-segment, neoglottis or pseudoglottis). This vibration creates a sound that serves to replace the sound the  vocal cords  previously produced. Other methods of  alaryngeal speech  (speech without vocal cords) are esophageal speech, and  electrolaryngeal speech . Studies show that tracheo-esophageal speech is found to be closer to normal speech than esophageal speech [ 1 ] [ 2 ] [ 3 ]  and is often reported to be better, both in terms of naturalness as well as how well it is understood, when compared to esophageal speech [ 4 ] [ 5 ]   and electrolarynx speech. [ 6 ] \nThe first report on a tracheo-esophageal puncture dates back to 1932 [ 7 ]  when a laryngectomized patient was said to use a hot ice pick to create a tracheo-esophageal puncture in himself. This enabled him to speak by forcing air through the puncture when closing off the tracheostoma with a finger."}
{"_id": "WikiPedia_General_surgery$$$corpus_312", "text": "There are two tracheo-esophageal puncture procedure types: Primary and secondary puncture. Initially, the procedure was described as a secondary procedure [ 8 ]  and later also as a primary procedure. [ 9 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_313", "text": "This procedure is performed during the total laryngectomy surgery. After removal of the larynx and creation of the tracheostoma, the puncture is made through the back wall of the trachea into the front wall of the esophagus. The main advantages of a primary puncture are: 1) that a second surgery to create the puncture is avoided (including the related costs and risks) and: 2) that the patient will be able to speak within a few weeks after total laryngectomy. [ 10 ] [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_314", "text": "There are cases where a primary procedure cannot be performed. For example, this procedure cannot be used when there is complete separation of the tracheo-esophageal wall where the puncture would otherwise be placed (for example, in case a portion of the esophagus is removed requiring an anastomosis, or \u201creconnection\u201d of structures in the region).  In that case, a sufficient period of recovery and wound healing would be required. A secondary puncture could then be placed. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_315", "text": "This procedure refers to a puncture that is placed anytime after the total laryngectomy surgery. The decision to use a primary or secondary puncture can vary greatly. Secondary puncture can be performed when: 1) primary puncture was not possible, 2) for re-puncture after closure of a previous tracheo-esophageal puncture, 3) because of physician or patient preference, and 4) in case failure of esophageal or electrolarynx speech if this was chosen as the initial speech option. [ citation needed ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_316", "text": "There are two different methods that can be used to place the  voice prosthesis :\nPrimary placement: A voice prosthesis is placed into the puncture [ 12 ] [ 13 ]  immediately after it is created. During the immediate postoperative period, the patient is fed through a feeding tube, either inserted directly into the stomach or through a more temporary version than extends from the nose into the stomach. This tube is removed when the patient is able to eat enough by mouth to maintain nutritional needs; this can be as early as the second day following surgery. [ 11 ]  Speech production with the voice prosthesis is initiated when the surgical area has healed, after clearance by the surgeon. The advantages of this method are:\n1) the voice prosthesis stabilizes the TE wall,\n2) the flanges of the device protect the puncture against leakage of fluids, stomach acids and other stomach contents,\n3) there is no irritation or pressure from a stenting catheter, used to maintain the puncture opening until a voice prosthesis can be placed,\n4) patients become quickly familiar with their prosthesis care as they receive instructions while hospitalized,\n5) the patient will not have to undergo an outpatient procedure during which the voice prosthesis needs to be fitted,\n6) many patients can learn to speak before the start of any post-operative radiation therapy (if indicated)\n7) the patient can focus on voice production immediately, as wound healing allows. [ 11 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_317", "text": "Another advantage is that generally, the voice prosthesis placed at the time of surgery lasts relatively long and requires no early frequent replacements. [ 14 ] [ 15 ]  The only disadvantage is that the patient will need to use a feeding tube for a few days."}
{"_id": "WikiPedia_General_surgery$$$corpus_318", "text": "Delayed placement: Instead of the voice prosthesis, a catheter (red rubber, Silastic Foley catheter,  Ryle's tube ) is introduced through the puncture into esophagus. [ 10 ]  The tube is sometimes utilized for feeding the patient during the immediate post operative period, or the patient has a standard feeding tube for feeding. The voice prosthesis is placed after the patient is able to eat sufficiently by mouth and speech production is initiated when healing has completed, after clearance by the surgeon. The advantage of this method is that the patient may be fed through the catheter, not requiring standard tube feeding. The primary disadvantage is that the patient will have to undergo an outpatient procedure to have the voice prosthesis placed. Another disadvantage can be the need for more frequent replacements early after fitting of the voice prosthesis due to changes in the length of the puncture. [ 16 ]"}
{"_id": "WikiPedia_General_surgery$$$corpus_319", "text": "Indications  include voice rehabilitation for patients who are undergoing a total laryngectomy (primary puncture) or patients who have had a total laryngectomy in the past (secondary puncture).\n Contra-indications  are mainly related to the use of the voice prosthesis and not the puncture procedure itself. It is important to have healthy tissue at the puncture site. This  will help ensure the voice prosthesis is properly supported. Poor tissue condition at the puncture site can be a contra-indication for TE puncture. It is also important that the patient candidacy be taken into account. Patients must be able to understand and manage proper prosthesis maintenance and monitor for complications or device problems. Bleeding disorders, anxiety disorders, dementia, poor vision and poor manual dexterity are all factors that may negatively interfere with successful voice restoration using tracheo-esophageal techniques and should be discussed further with an appropriate healthcare provider who is knowledgeable in this topic. [ citation needed ]"}