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Biomedical subjects

C S Grant

Publications and source records attributed to C S Grant.

At least 19 recordsLinked to original sources
PubMed1995

Selective operative cholangiography. Appropriate management for laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the results of selective intraoperative cholangiography (IOC) in patients undergoing laparoscopic cholecystectomy. DESIGN: Retrospective study. SETTING: Mayo Clinic, Rochester, Minn, from 1990 to 1991. PATIENTS: Five hundred forty-two patients underwent attempted laparoscopic cholecystectomy. Excluding 28 (5.2%) who underwent conversion to laparotomy and 19 (3.5%) who did not respond to a follow-up questionnaire, there were 495 respondents (mean follow-up, 25 months). MAIN OUTCOME MEASURE: Incidence and management of choledocholithiasis, extrahepatic bile duct injuries, and other findings potentially affected by IOC. RESULTS: Twenty patients underwent preoperative endoscopic retrograde cholangiopancreatography for suspected common bile duct abnormalities, and 10 had common bile duct stones removed. Nearly a third (n = 161 [32.5%]) of the patients underwent IOC for laboratory, historical, or operative findings or for training purposes. Common bile duct stones were discovered on IOC in five patients (3.1%), three of whom were treated successfully with postoperative endoscopic therapy; the two others had normal findings on endoscopic retrograde cholangiopancreatography (false-positive results of IOC). In three other patients in whom IOC was unsuccessful or incomplete, symptomatic common bile duct stones developed. Two patients were treated with endoscopic techniques, and one required open common bile duct exploration. Among the 334 patients who did not undergo IOC, symptoms suggestive of retained stones developed in eight (2.4%) (all within 2 months of surgery; mean, 18 days), but stones were found at endoscopy retrograde cholangiopancreatography in only four patients. Two had preoperative criteria for performing IOC. In only three patients (0.6%) from the study population would symptomatic retained common bile duct stones have developed with selective IOC and routinely successful IOC. No common bile duct injuries occurred. CONCLUSIONS: Selective IOC during laparoscopic cholecystectomy is a safe practice when the ductal anatomy is clearly defined and there is no laboratory or clinical evidence of common bile duct abnormalities. Symptomatic retained common bile duct stones will be infrequent, and bile duct injuries will be rare when IOC is performed for the appropriate indications. These data do not support the need for routine IOC, although this procedure is an essential tool for the laparoscopic surgeon.

Adult↗
PubMed1995

Laparoscopic left adrenalectomy for aldosteronoma: early Mayo Clinic experience.

OBJECTIVE: To evaluate early results with laparoscopic left adrenalectomy in patients with an aldosteronoma. DESIGN: We retrospectively reviewed the medical records to Mayo patients in whom laparoscopic left adrenalectomy had been attempted for presumed aldosteronoma. MATERIAL AND METHODS: Data on the diagnosis, details about the procedure, occurrence of associated complications, and duration of recovery period were analyzed for all study patients. RESULTS: Of the nine patients who underwent attempted laparoscopic left adrenalectomy, seven had aldosteronoma. In six of the seven patients, the procedure was successful. No preoperative mortality occurred, and morbidity was limited to prolonged ileus in one patient. Of the other five patients with successful results, all tolerated liquids within 24 hours after the procedure. The mean postoperative hospital stay for the six patients with successful laparoscopic procedures was 2.3 days, and four patients were dismissed within 48 hours after the procedure. CONCLUSION: Laparoscopic adrenalectomy is a safe alternative for the management of aldosteronoma of the left adrenal gland.

Adrenal Cortex Neoplasms↗
PubMed1995

Arguments against routine contralateral mastectomy or undirected biopsy for invasive lobular breast cancer.

BACKGROUND: Management of the contralateral normal-appearing breast in a patient with ipsilateral invasive lobular carcinoma (ILC) is controversial. METHODS: The case histories of patients with histologically proven ILC who underwent definitive surgery at our institution from 1978 to 1991 were retrospectively reviewed. RESULTS: Of the 419 women with ILC, 36 (8.6%) had bilateral cancer, with a cumulative risk of 10% at 10 years. Twenty-five (69%) of these cancers were suspected before operation. From 105 contralateral prophylactic surgical procedures, seven (64%) in-situ and four (36%) invasive cancers were detected. The age at presentation and multifocality of the index cancer were significantly different between patients with unilateral and those with bilateral cancers. No survival difference was noted between patients whose contralateral cancers were suspected clinically and those whose cancers were detected prophylactically. Survival rates between patients with unilateral versus bilateral cancers were also not different. However, patients with contralateral prophylactic surgery had a better prognosis than those with unilateral tumors and no prophylaxis. CONCLUSIONS: Ten percent of patients with ILC experienced bilateral cancers during a period of 10 years. Survival was not influenced by the development of a second cancer, but it improved with surgical prophylaxis.

Adult↗
PubMed1995

Adrenal surgery for hypercortisolism--surgical aspects.

BACKGROUND: Patients with endogenous hypercortisolism are thought to be at high risk for adrenalectomy and may experience significant postoperative surgical mortality/morbidity. METHODS: From 1981 through 1991, 91 patients underwent adrenal resection for endogenous hypercortisolism. Causes were adrenal-dependent Cushing's syndrome (50%), pituitary-dependent Cushing's syndrome (27%), and an ectopic adrenocorticotropic hormone-secreting tumor (23%). Causes of adrenal-dependent Cushing's syndrome were adrenocortical adenoma (72%), bilateral nodular hyperplasia (20%), and adrenocortical carcinoma (8%). Comparative mean length of hospitalization for patients undergoing unilateral anterior versus posterior approach was 8 versus 6 days, and bilateral anterior versus posterior was 11 versus 6 days. RESULTS: Operative mortality was 2.6%. Only one patient had a wound infection, and no patient had either a venous thrombosis or a pulmonary embolism. Delayed wound healing occurred in three patients. CONCLUSIONS: (1) Adrenal surgery can be performed today with low morbidity/mortality. (2) Although there is an effect of hypercortisolism on wound healing, infection, diabetes, hypertension, coronary artery disease, and pulmonary embolism, it was possible to perform adrenalectomy surgically with acceptable morbidity and mortality. (3) These results may serve as a standard against which laparoscopic adrenalectomy may be compared.

Adenoma↗
PubMed1995

Multiple endocrine neoplasia type 2B: more than an endocrine disorder.

BACKGROUND: Multiple endocrine neoplasia type 2B (MEN 2B) is a rare disorder differentiated from MEN 2A primarily by its extraendocrine features. This report describes the clinical spectrum and outcome of MEN 2B. METHODS: Twenty-one patients underwent operation for manifestations of MEN 2B between 1970 and 1993. Median follow-up was 16.9 years. Diagnosis was made through family screening in nine, the development of medullary thyroid carcinoma (MTC) in seven, phenotypic features in four, and constipation in one. Median age at presentation of colonic dysfunction, MTC, and pheochromocytoma was 0.1, 16, and 28 years, respectively. RESULTS: Every patient had MTC. Fifteen (94%) of 16 patients undergoing primary thyroidectomies had multicentric disease, and seven (44%) had nodal metastases. Seven patients (33%) had pheochromocytoma, six bilateral and one malignant. Adrenalectomy was curative in every patient. Nineteen patients (90%) had colonic disturbances, typically chronic constipation from birth. Megacolon developed in 14 patients, and eight required colonic surgery. Every patient had the characteristic phenotype. Dominant features included neuromas of the tongue, buccal mucosa, lips, conjunctivae, and eyelids and a marfanoid habitus. Other features included high arched palate, corneal nerve thickening, and dental and skeletal abnormalities. Four patients died, two of metastatic MTC, one after operation for metastatic MTC, and one as a consequence of colonic perforation. Of 17 survivors, three have hepatic metastases from MTC, eight have nodal metastases, and six are well with normal or mildly elevated calcitonin levels. CONCLUSIONS: MEN 2B is characterized by a relatively aggressive form of MTC, bilateral pheochromocytoma, severe colonic dysfunction, and a multitude of other extraendocrine abnormalities. Early recognition of MEN 2B and early prophylactic thyroidectomy are essential. Colonic dysfunction has previously received little attention, and further investigation of the pathogenesis and treatment of this disorder is warranted.

Adolescent↗
PubMed1995

An immunohistochemical survey for neuroendocrine cells in regional pancreatic lymph nodes: a plausible explanation for primary nodal gastrinomas? Mayo Clinic Pancreatic Surgery Group.

BACKGROUND: The existence of primary gastrinomas in lymph nodes continues to be controversial, because distinction from metastases from occult or regressed primary tumors may be difficult to exclude with certainty. If primary nodal gastrinomas do indeed occur, precursor neuroendocrine cells should be identifiable within lymph nodes. In a effort to detect these cells we undertook an immunohistochemical survey of regional pancreatic lymph nodes by using antibody against chromogranin, a highly specific marker for mature neuroendocrine cells. METHODS: We retrospectively identified consecutive cases from five surgeons in which Whipple resections had been performed for nonendocrine pathologic conditions. All formalin-fixed, paraffin-embedded lymph nodes were identified from these 106 cases, excluding lymph nodes with metastases. Immunoperoxidase staining with monoclonal antibody against chromogranin A was performed on single tissue sections. All slides were reviewed by a single pathologist; chromogranin-positive cells were identified and, when possible, further evaluated immunohistochemically with additional neuroendocrine markers, including sequential synaptophysin staining. RESULTS: A total of 1026 lymph nodes were available for review. Although well-formed intranodal chromogranin-positive nests were not identified, six nodes from three patients contained 13 strongly chromogranin-positive cells representing putative neuroendocrine cells. Mast cells showed weak nonspecific staining with chromogranin but were morphologically distinct. Perinodal adipose tissue contained a single paraganglion and several small neuroendocrine clusters. CONCLUSIONS: Putative neuroendocrine cells are rarely (less than 1%) found in regional pancreatic lymph nodes. Although these may be embryonic rests and might represent precursors of primary nodal gastrinomas, specific hormones have yet to be identified in these cells. Although these data provide support for the concept of primary nodal gastrinomas, this remains a diagnosis of exclusion.

Adult↗
PubMed1995

Operative and postoperative management of the patient with follicular and Hürthle cell carcinoma. Do they differ?

Most characteristics of follicular carcinoma and Hüthle cell carcinoma are similar, but important differences must be recognized (Table 1). The diagnosis usually follows palpation of a thyroid nodule, which, by FNA, can only be interpreted as either a follicular or Hürthle cell neoplasm. Approximately 20% of nodules with this FNA report prove to be malignant, the remaining 80% representing benign follicular or Hürthle cell adenomas, or occasionally adenomatous nodules or Hashimoto's thyroiditis with prominent Hürthle cell nodularity. This distinction poses one of the most difficult challenges to the surgical pathologist. We rely heavily on frozen section differentiation of benign and malignant tumors. Benign adenomas are usually managed with a unilateral total lobectomy, whereas carcinomas and tumors quite suspicious for carcinoma (e.g., tumors with suspicion of either capsular or vascular invasion) are removed with a total or near-total thyroidectomy. This affords not only complete clearance of the tumor, but facilitates postoperative follow-up both diagnostically and therapeutically with 131I.

Adenocarcinoma↗
PubMed1995

Mediastinal parathyroid cysts.

OBJECTIVE: To present our experience with mediastinal parathyroid cysts and summarize previously reported cases. DESIGN: We retrospectively reviewed medical records and reviewed the pertinent literature. MATERIAL AND METHODS: The clinical, operative, and pathologic findings in 7 cases of mediastinal parathyroid cysts encountered at one institution and 31 cases previously reported in the literature are described. RESULTS: Rarely, cysts may arise from an aberrant mediastinal parathyroid gland. Such cysts may manifest as a symptomatic mass, as an asymptomatic finding on roentgenography, or during the assessment of a patient with hyperparathyroidism. The diagnosis may be made by fine-needle aspiration or by excision and pathologic examination. CONCLUSION: Functioning parathyroid cysts represent degeneration of a hyperfunctioning gland, such as an adenoma, and are usually removed through a cervical approach. Nonfunctioning cysts in asymptomatic patients with normal serum calcium levels are considered indeterminate and should be managed accordingly. Excision is usually recommended.

Adult↗
PubMed1994

Breast biopsy: a comparative study of stereotaxically guided core and excisional techniques.

OBJECTIVE: The major objectives of this prospective study were to compare pathologic findings from stereotaxic core and excisional biopsies performed on patients with impalpable breast lesions and to compare the initial mammographic impression with the final histologic diagnosis. SUBJECTS AND METHODS: All patients referred for preoperative localization of impalpable breast lesions between October 29, 1991, and January 15, 1993, were eligible for the study. If the patient and the lesion, on the basis of mammography, were considered suitable for core biopsy, the patient was asked to participate. Four hundred forty-five excisional biopsies were performed. One hundred sixty lesions were evaluated by core biopsy; for 104 of these lesions, five or more core samples were removed. Core biopsies were done with 14-gauge biopsy needles and were followed by a localization procedure. The pathologic features of core and excisional specimens were compared. RESULTS: Biopsy results were compared for 93 (58%) benign and 67 (42%) malignant lesions. Of 104 lesions evaluated with at least five core specimens, 56 (54%) were benign and 48 (46%) were malignant. Results of core biopsy corresponded to those of excisional biopsy for 96% of benign lesions, 83% of malignant lesions, and 90% overall; sensitivity of core biopsy for malignant lesions was 85%. Of 56 lesions for which fewer than five core specimens were obtained, 37 (66%) were benign and 19 (34%) were malignant. Results of core biopsy corresponded to those of excisional biopsy for 81% of benign lesions, 79% of malignant lesions, and 80% overall; sensitivity of core biopsy for malignant lesions was 84%. Specificity of core biopsy for the entire series of benign lesions was 100%. CONCLUSION: For mammographic lesions that are believed to be not malignant or not very likely malignant, stereotaxic core biopsy decreases the need for excisional biopsy.

Biopsy, Needle↗
PubMed1994

Medullary thyroid carcinoma in multiple endocrine neoplasia types 2A and 2B.

BACKGROUND: Considerable emphasis has been placed on early diagnosis and surgery for multiple endocrine neoplasia (MEN)-related medullary thyroid carcinoma (MTC) during the past two decades. Genetic screening now promises earlier and more accurate diagnosis. We examine our experience with MTC in MEN 2A and MEN 2B and assess the benefits of biochemical screening during the past 20 years. PATIENTS AND METHODS: Seventy-seven patients undergoing 63 primary total thyroidectomies and 14 reoperative procedures for MEN-related invasive MTC and/or preinvasive C-cell hyperplasia are reported. Fifty-eight patients had MEN 2A and 19 had MEN 2B; 79% of patients had a family history of MTC; 27% had pheochromocytoma, and 25% had hyperparathyroidism. RESULTS: Patients with MEN 2B had more advanced disease than those with MEN 2A, in spite of presentation at a younger age (15 years versus 24 years). Every patient with MEN 2B had invasive carcinoma, whereas 14% of patients with MEN 2A had C-cell hyperplasia without invasive disease. Nodal metastases were found less frequently in MEN 2A (14%) than MEN 2B (38%), and biochemical cure was achieved in 56% of patients with MEN 2A compared with none in patients with MEN 2B. Among patients with MEN 2A the occurrence of invasive carcinoma increased with age (p = 0.0003); 40% of patients for less than 5 years had invasive MTC compared with 100% at more than 20 years. Cause-specific mortality among patients with MEN and invasive tumors at 6, 12, and 18 years was 2%, 4%, and 7%, respectively, lower than that of patients with sporadic MTC (12%, 17%, and 23%, respectively) treated during the same time period (p = 0.028). CONCLUSIONS: Intensive biochemical screening of MEN 2 kindreds for MTC can result in detection of early disease and a significant prospect of surgical cure. Genetic testing promises additional benefits through more reliable detection of preinvasive disease, allowing prophylactic thyroidectomy in infancy. In MEN 2B, MTC is considerably more aggressive than in MEN 2A. A policy of routine thyroidectomy in infants with MEN 2B, regardless of serum calcitonin levels, is justified.

Adolescent↗
PubMed1994

Long-term outcome of bilateral adrenalectomy in patients with Cushing's syndrome.

BACKGROUND: Bilateral adrenalectomy provides an effective surgical option for patients with Cushing's syndrome. Knowledge of the long-term outcome of the patient who has undergone adrenalectomy is an important factor in determining management strategy in this situation. METHODS: Fifty consecutive patients undergoing bilateral adrenalectomy (1980 to 1991) were studied. Twenty-five had Cushing's disease, 18 ectopic adrenocorticotrophic hormone production, and seven primary adrenal hyperplasia. Median age was 43 years (range, 14 to 82 years); male-to-female ratio was 13:37. At follow-up 17 patients had died; the remaining 33 were interviewed at a median of 62 months after operation. RESULTS: Operative mortality was 4%. Late mortality included two patients with Cushing's disease who died of progressive pituitary disease and eight patients with ectopic adrenocorticotrophic hormone production who died of metastatic disease. Five-year survival was: 100% for patient with adrenal hyperplasia, 86% for patients with Cushing's disease, and 39% for patients with ectopic adrenocorticotrophic hormone production. Of 33 survivors followed for a median of 62 months, three (9%) were hospitalized with acute steroid deficiency. The principal complaint among survivors was chronic fatigue (60%). Only 10 (30%) patients had no symptoms. No steroid-related complications resulted after 16 surgical procedures subsequently performed. Of 20 survivors of Cushing's disease, three had Nelson's syndrome. CONCLUSIONS: Bilateral adrenalectomy for Cushing's syndrome is associated with occasional morbidity and mortality consequent to adrenal insufficiency. These patients suffered a high incidence of chronic physical complaints that may reflect the residual sequelae of chronic Cushing's syndrome. An active program of long-term rehabilitation is essential.

Adolescent↗
PubMed1994

Parathyroid imaging with technetium-99m-sestamibi: an initial institutional experience.

BACKGROUND: The ideal method for preoperative localization of abnormal parathyroid glands has yet to be determined. Technetium-99m-sestamibi, previously used for myocardial perfusion studies, has recently been introduced for parathyroid imaging. METHODS: From August 1991 to September 1993, 44 patients underwent Tc-99m-sestamibi scanning (45 scans) and surgical exploration for hyperparathyroidism at our institution. These 44 patients form the database for this retrospective study. Twenty-eight patients had persistent hyperparathyroidism, six had recurrent disease, three had prior thyroid operation, and seven underwent first time neck operations. The nature of disease was complex and varied: single gland, 26; primary hyperplasia, 5; multiple endocrine neoplasia type 1, 5; familial, 3; secondary or tertiary, 5. One patient with single gland disease and one patient with multiple endocrine neoplasia type 1 had parathyroid carcinoma. All patients had biochemical confirmation of hyperparathyroidism. RESULTS: Twenty-six (58%) of 45 scans accurately predicted the location(s) of all abnormal gland(s) involved (true positive). Surgical removal of these glands was curative. Sixteen (36%) of 45 scans were false negative because they did not show all abnormal glands involved; however, 7 of these 16 scans did localize at least one abnormal gland. The overall sensitivity of this test was 62% when all abnormal glands were considered but increased to 79% with the demonstration of at least one abnormal gland. These values increased to 80% and 90% (p = 0.03), respectively, in the last 20 patients when the injected dose of Tc-99m-sestamibi was increased from 10 to 15 mCi. Thirty-seven of 44 patients were cured after operation. Six of the seven patients who experienced surgical failure had multigland disease, one of which was malignant. Sestamibi scans correctly identified abnormal cervical glands in 18 (58%) of 31 patients and abnormal mediastinal glands in six (75%) of eight patients. CONCLUSIONS: Tc-99m-sestamibi scanning is helpful in the reoperative setting as an adjunct to localizing abnormal parathyroid tissue. A higher percentage of positive tests occurs in patients with mediastinal and single gland disease. A higher dose of Tc-99m-sestamibi (15 mCi) significantly improves test sensitivity.

Adult↗
PubMed1993

Surgical management of primary hyperparathyroidism in multiple endocrine neoplasia types 1 and 2.

BACKGROUND: The surgical management of primary hyperparathyroidism in multiple endocrine neoplasia type 1 (MEN 1) remains controversial. In addition, the rarity of MEN 2A-related hyperparathyroidism has not allowed for a separate strategy for this condition. This study examines our surgical experience with MEN 1- and MEN 2A-related hyperparathyroidism and attempts to define a rational therapeutic approach to each. METHODS: Between 1970 and 1991, 124 patients underwent surgery for MEN-related hyperparathyroidism at our institution. Primary cervical explorations were performed in 84 patients with MEN 1 and 18 with MEN 2A. An additional 22 patients with MEN 1 underwent reoperative surgery. All patients with MEN 2A underwent concomitant thyroidectomy for medullary thyroid cancer. RESULTS: Compared with patients with MEN 1, patients with MEN 2A, had a lower preoperative serum Ca2+ level and fewer symptoms or complications of hypercalcemia. Multiple gland disease was evident in 90% and 83%, respectively, of patients with MEN 1 and MEN 2A. Primary explorations in patients with MEN 1 resulted in surgical cure in 94%, persistent hypercalcemia occurring in no patient undergoing subtotal resection compared with 17% of patients in whom more conservative resections were performed (p = 0.005). In patients with MEN 1, 10-year recurrence of hypercalcemia was 16% for primary explorations and 30% for reoperative procedures. In contrast, all patients with MEN 2A, whether treated by total, subtotal, or lesser resections, were cured after surgery and none had recurrence during a median follow-up of 5.8 years. CONCLUSIONS: In MEN 1 the surgical principles should be (1) identification of all four glands, (2) subtotal resection to ensure cure and facilitate possible reoperation, and (3) excision of supernumerary thymic glands. In MEN 2A we should identify and resect all enlarged glands for cure, but routine subtotal resection need not be performed because this condition is readily cured and recurrence is rare.

Adolescent↗
PubMed1992

The clinical significance of nuclear DNA ploidy pattern in 184 patients with pheochromocytoma.

Flow cytometric nuclear DNA analysis was performed on paraffin-embedded tissue samples taken from 184 patients with pheochromocytoma and paraganglioma treated between 1960 and 1987. The Hedley technique was used for measurement of nuclear DNA content. Thirty-five percent of the tumors were DNA diploid, 33% showed a DNA tetraploid pattern, and 32% had DNA aneuploid pattern. Familial pheochromocytoma and associated endocrine or neoplastic disorders were more common among patients with DNA nondiploid tumors. Eighty-four percent of the tumors that invaded blood vessels and all patients with regional or distant metastases had tumors classified as DNA tetraploid or DNA aneuploid. Of 22 patients who had disease progression, 21 (95%) had tumors with abnormal DNA ploidy pattern (P less than 0.001). All 12 patients who died of cancer-related disease had abnormal DNA ploidy; none of the patients with DNA diploid tumor (n = 64) have died of pheochromocytoma (P less than 0.01). These results suggest that nuclear DNA ploidy pattern is an important and independent prognostic variable for patients with pheochromocytoma and paraganglioma.

Adrenal Gland Neoplasms↗
PubMed1992

Prognostic profile for patients with pheochromocytoma derived from clinical and pathological factors and DNA ploidy pattern.

Eighty-eight patients with pheochromocytoma and paraganglioma treated over a 28 year period (1960-1987) were studied. Based on clinical course, they were divided into three prognostic groups: benign (n = 57); multiple (n = 12); and metastatic (n = 19). Using clinical data, histopathologic findings, and tumor nuclear DNA content a prognostic profile for each group was constructed. The following variables were studied: age, familial pheochromocytoma, associated endocrine or neoplastic disorders, number and location of the lesion at diagnosis, size of the tumor, and the nuclear DNA ploidy pattern. Of these prognostic factors the most significant to predict a future malignant clinical course were large size and local tumor extension at time of surgery. Family history of pheochromocytoma, associated endocrine disorders, and young age at presentation predicted multiplicity. Old age, absence of familial pheochromocytoma or related endocrine disorders and DNA diploid tumors seem to be favorable findings. Using these variables in combination may be helpful for early identification of patients with malignant, multiple, or benign pheochromocytoma and paraganglioma.

Adrenal Gland Neoplasms↗
PubMed1992

Laparoscopic cholecystectomy: operative technique.

Laparoscopic cholecystectomy has become the routine procedure for most patients with symptomatic cholelithiasis. At our institution, a two-surgeon, four-cannula technique is used. In almost all patients, a pneumoperitoneum can be established with use of a closed technique. Adherence to standard operative principles and careful attention to details in the laparoscopic technique will routinely result in the safe completion of laparoscopic cholecystectomy. Cautery provides excellent hemostasis during dissection of the gallbladder from its attachments. Cholangiography through the gallbladder or the cystic duct is easily performed in selected patients. Minimal perioperative care is necessary for patients who undergo laparoscopic cholecystectomy, and the hospitalization time is usually less than 24 hours.

Cautery↗