Abdominal Laparoscopy Research Articles

Primary Sclerosing Encapsulating Peritonitis in an Adult Male: A Case Report

Introduction: Primary sclerosing encapsulating peritonitis (PSEP), also referred to as “cocoon abdomen”, is a rare but potentially devastating disease. It is defined as the encapsulation of a segment of the small bowel by a fibro-collagenous membrane leading to acute or sub-acute small bowel obstruction. Though the exact etiology and pathophysiology of this debilitating medical condition are still controversial, PSEP has been reported to be associated with multiple congenital developmental abnormalities. Diagnosis of PSEP is usually delayed as the disease is relatively rare and commonly present with non-specific symptoms associated with non-specific laboratory findings and non-conclusive radiologic features. Patient Concerns: We present a 42-year-old male patient presenting for elective abdominal laparoscopy for his four-year recurrent abdominal pain. Diagnosis: Preoperative diagnosis of PSEP as the cause of his chronic abdominal pain was not made until at laparotomy where a thick fibrotic peritoneal sac encasing the entire small bowel was found. Interventions: Excision of the fibrotic sac with extensive adhesiolysis were done by the general surgeon. Outcomes: The patient experienced a ten-day period of post op ileus after which he had a complete recovery. Conclusion: With the increasing number of cases suffering from this condition being reported in literature, surgeons must be aware of this debilitating disease in the differential diagnosis of abdominal obstruction.

Mesenteric thrombosis in patients with coronavirus disease: comprehensive assessment and treatment

Acute mesenteric circulatory disorder belongs to the most serious diseases of the abdominal cavity. Being an emer­gency condition, it is associated with high mortality. Coronavirus infection is an anthroponotic disease in the group of acute respiratory infections, is characterized by damage to the upper respiratory tract, severe intoxication, coagu­lopathy and in severe cases - multiple organ failure. The aim of the work was to analyze the results of the surgical treatment of mesenteric vascular thrombosis in patients with COVID-19. We have studied the results of diagnostics and treatment of 13 patients (9 males and 4 females) with acute mesenteric thrombosis and COVID-19. We have analyzed patients’ complaints and the clinical picture of the disease, as well as performed general medical examination (routine blood and urine tests, biochemical parameters, coagulogram), X-ray examination of abdominal and thoracic cavities, computed tomography / angiography of abdominal organs, diagnostic laparoscopy, diagnostic mini-laparotomy and laparotomy. The symptoms of the disease include nausea, vomiting, abdominal pain, diarrhea, fever, cough, shortness of breath and belching. The disease was diagnosed by contrast computed tomography. Four patients developed simultaneous thrombosis – stroke, thrombosis of the portal and mesenteric veins, splenic and renal infarction, thrombosis of the superior mesenteric and portal veins. Six patients have been suffering from underlying health conditions, 7 patients – had none. Ten patients underwent surgery (laparotomy with resection of the nonviable intestine), 3 – received conservative treatment (heparin therapy). Six patients died (4 out of 10 – during surgery and 2 out of 3 – during conservative treatment). Postoperative mortality was 40%.

Novel do-it-yourself low-cost abdominal laparoscopy entry simulator for gynaecology trainees

Abstract Introduction The COVID-19 pandemic has affected gynaecology trainees in the United Kingdom by reducing operating theatre experience. Simulators are widely used for operative laparoscopy but not for practising laparoscopic-entry techniques. We devised a low-cost simulator to help trainees achieve the skill. Our aim was to pilot this low-cost simulator to perform Royal College of Obstetricians and Gynaecologists (RCOG) supervised learning events. Methods A single-centre pilot study involving six gynaecology trainees in a structured training session. Interactive PowerPoint teaching was followed by trainees’ demonstration of laparoscopic entry for a supervised learning event and personalized feedback. Participants completed pre- and post-course questionnaires. Results All the trainees found the training useful to the score of 10 (scale of 1–10) and recommended this to be included in Deanery teaching. Personalized feedback was described as the most useful. The simulator was rated as good as a real-life patient relative to the skill being taught. Discussion Gynaecology trainees are affected by lack of hands-on experience in the operating theatre for performing laparoscopic entry. A low-cost abdominal laparoscopy entry simulator can help deliver the RCOG curriculum, enabling trainees to achieve required competencies.

Systematic Review and Meta-Analysis of Perioperative Administration of Acetazolamide for Management of Postoperative Pain after Laparoscopy.

Background and Objective:To perform a systematic review and meta-analysis to evaluate the efficacy of perioperative acetazolamide (ACTZ) administration with laparoscopy for reducing postoperative referred pain.Methods:The following databases were searched from inception to March 1, 2020: Cochrane, PubMed, PubMed Central, Ovid, and Embase. Electronic search used: Acetazolamide AND (laparoscopy OR laparoscopic OR Celioscopy OR Celioscopies OR Peritoneoscopy OR Peritoneoscopies). No limits or filters were used. We included only studies of patients who underwent abdominal laparoscopy (LSC), had a pain assessment at approximately 24 hours postoperatively, and included a treatment with ACTZ group and a no-treatment or minimal-treatment comparison group.Results:Five studies met inclusion criteria, with a combined total of 253 participants, 116 in the ACTZ group and 137 in the control group. A Bayesian hierarchical model was assumed for the study specific treatment effects. Posterior sampling was conducted via Markov Chain Monte Carlo methods, and posterior inference carried out on the hierarchical treatment effect. ACTZ significantly decreased average pain scores compared to control group by −0.726 points (95% confidence interval −1.175–0.264). The posterior probability that ACTZ decreases mean pain scores by ≥ 0.5 was 0.846.Conclusion:Current available evidence demonstrates that perioperative ACTZ may provide a modest improvement in postoperative referred pain following LSC.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Anterior Entry in Patients with Prior Cesarean Section

Study Objective The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Design Case report. Setting Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patients or Participants Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. Interventions vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Measurements and Main Results Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. Conclusion vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible. The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Case report. Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible.

Perioperative chemotherapy in locally advanced gastric cancer in Chile: from evidence to daily practice.

Gastric cancer (GC) is a leading cause of cancer death in Chile. Although recommended in international guidelines since 2006, perioperative chemotherapy was not available to patients in the public health system in Chile until 2016. We conducted an observational study to assess the feasibility of this strategy in public hospitals in Chile (Observational Study of Perioperative Chemotherapy in Locally Advanced Gastric Cancer – PRECISO). Patients with locally advanced, operable GC were offered to receive preoperative chemotherapy with Epirubicin + Cisplatin + Capecitabine (ECX) for three cycles followed by curative surgery. Staging included abdominal CT scan and laparoscopy if peritoneal carcinomatosis was suspected. Postoperative ECX for three cycles was recommended. Between August 2010 and March 2013, 110 patients were screened and 61 enrolled. Median age was 62 years (23–76 years) and most patients had good performance status at baseline (Eastern Cooperative Oncology Group performance status score (ECOG) 0: 42, ECOG 1: 19). Tumour site was proximal in 32 (52%) and medial and distal in 29 (48%) patients. All but four patients (n = 57, 93%) completed three cycles of preoperative chemotherapy. Fifty-six patients were operated and 54 (89%) had a curative resection. Thirty-three patients (54%) had pT0-2, and 18 (30%) had pN0 tumours, with two patients achieving a complete response. As of 20 December 2020, 39 patients died, 32 due to GC, one within 30 days of surgery, two due to intestinal obstruction at 5 and 3 months after surgery and four due to other causes. Five-year survival rate was 38%. We conclude that perioperative chemotherapy is feasible in public hospitals in Chile and should be offered to patients with locally advanced GC.

English

BACKGROUND Aim of the surgeon repairing the ventral hernia is to alleviate the symptoms and prevent complications with minimal recurrence rates. Recent times have seen the popularity of laparoscopic approach but there is reasonable controversy to its optimal approach when compared to conventional method. The present study analyses and correlates the postoperative outcomes of patients who underwent laparoscopic and conventional methods of ventral hernia repair during the last three years. METHODS This is a cross-sectional clinical study in which 87 patients diagnosed with ventral hernia from the Department of General Surgery of Government Medical College and Hospital, Nizamabad from September 2017 to August 2020 were included. 42 patients underwent laparoscopic repair and 45 underwent conventional hernia repair. Patients aged between 35 and 74 years belonging to American Society of Anaesthesiologist (ASA) grade I and II were included. Clinical history, surgical profile and anaesthesia fitness were obtained using standard operating procedures. All patients were followed up to 06 months. Data variables such as age, gender, BMI (Body Mass Index) size of defect, postoperative hospital stay and other complications were collected and analysed. RESULTS Out of 87 patients, laparoscopic group had 27 (59.52 %) females and 15 (35.71 %) males with a female to male ratio of 1.8:1. Whereas conventional hernia repair group had 29 (64.44 %) females and 16 (35.55 %) males with a female to male ratio of 2:1. 38 out of 87 (43.67 %) patients were in the age group of 45 to 54 years. Incisional hernia - infra umbilical type was found in 34 out of 87 (39.08 %) patients while incisional hernia - supra umbilical type was found in 23 out of 87 (26.43 %) patients. Correlating the adverse events between laparoscopic method and conventional methods of ventral hernia repair showed a statistical significance. Pearson correlation coefficient was with R factor of 0.983 and the P value was 0.00001 (P significant at < 0.05) CONCLUSIONS Laparoscopic ventral hernia repair (LVHR) using bio-material mesh for the repair resulted in low postoperative pain, wound infection, graft rejection and higher long-term recurrence free patient satisfaction when compared to conventional hernia repair. KEYWORDS Ventral Hernia, Anterior Abdominal Wall, Laparoscopy, Repair and Recurrences

337 Barriers to Laparoscopic Surgical Training for Abdominal Conditions in Low- and Middle-Income Countries (LMICS): A Systematic Review

Abstract Introduction Resource-deprived low-and-middle-income countries (LMICs) can benefit from the reduced perioperative morbidity of laparoscopic surgery. However, utilisation is low, partly due to paucity of appropriately trained staff. This study aims to explore the barriers to the training of healthcare professionals in laparoscopic techniques in LMICs. Method Medline, Embase, Global Health and Web of Science databases were searched, using the key terms ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Eligible papers were in English, focused on abdominal laparoscopy and addressed barriers to training qualified health professionals. Papers focusing on advanced surgeries, paediatrics, and training in high-income countries were excluded. PRISMA guidelines for systematic reviews were followed. Results Funding was the first of seven key barriers identified, but feasible low-cost methods have been developed in some settings. Equipment limitations and lack of local trainers were highlighted, and expatriates may provide limited quality training opportunities. Stakeholder dynamics can create barriers, as can lack of knowledge on effective training curricula. Surgical departmental structure can limit the practical opportunities of trainees. Conclusions Themes are apparent across LMICs, but local factors reduce their generalisability, highlighting the need for larger-scale studies focusing on specific barriers. National investment in training programmes with research-backed curriculums and increased availability of local trainers and equipment is needed.

Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review.

Laparoscopic surgery has the potential to improve care in resource-deprived low- and-middle-income countries (LMICs). This study aims to analyse the barriers to training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two researchers screened results with mutual agreement. Included papers were in English, focused on abdominal laparoscopy and training in LMICs. PRISMA guidelines were followed; 2992 records were screened, and 86 full-text articles reviewed to give 26 key papers. Thematic grouping identified seven key barriers: funding; availability and maintenance of equipment; local access to experienced laparoscopic trainers; stakeholder dynamics; lack of knowledge on effective training curricula; surgical departmental structure and practical opportunities for trainees. In low-resource settings, technological advances may offer low-cost solutions in the successful implementation of laparoscopic training and improve access to surgical care.

VIDEOCIRURGIA EM CÃE E GATOS – REVISÃO DE LITERATURA

A videocirurgia é um recurso para cirurgias minimamente invasivas que possibilita minimizar o trauma cirúrgico, risco de infecção, dor pós-operatória e o tempo de recuperação, sendo amplamente utilizada em pacientes humanos, e ao longo dos anos vem sendo usada na Medicina Veterinária. Visto que o uso da videocirurgia é considerada recente na Medicina Veterinária, o objetivo do presente trabalho foi realizar uma revisão de literatura sobre o uso da videocirurgia em cães e gatos, nas suas diversas modalidades como endoscopia, artroscopia, laparoscopia torácica e abdominal, e dessa forma, contribuir na atualização do tema. A videocirurgia em cães e gatos possibilita diagnóstico e tratamento de diversas afecções, e sua utilização apresenta potencial crescimento na Medicina Veterinária, visto que o procedimento foi considerado seguro e minimamente invasivo, entretanto, o alto valor do procedimento faz com que a procura por esses serviços seja baixa.

Anesthetic management of the diaphragmatic pacemaker placement surgery. Our experience in the Institut Guttmann

Abstract Background The diaphragm pacemaker (DP) has proven its utility in replacing mechanical ventilation in patients with chronic spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). The DP improves patient quality of life and reduces morbidity and mortality and their associated health care costs. The anesthetic management of these patients and the particularities of the surgical procedure are challenging. The aim of our study is to analyze anaesthetic management and intraoperative complications in patients undergoing DP placement in our hospital. Methods We performed a chart review of patients treated between December 2007 and July 2017, recording the patients' preoperative status, anesthetic management and intraoperative complications. Results The study included 16 patients (5 pediatric) undergoing DP implantation for chronic SCI (63%), ALS (25%) and other neurologic conditions (12%). Abdominal laparoscopy was performed under general anesthesia, with intravenous (87%) or inhalational (13%) induction and maintenance using total intravenous (50%) or balanced (50%) anesthesia. Rocuronium was administered in one case to permit airway management. Complications included: hypotension (50%), difficulties in mechanical ventilation during laparoscopy (31%), pneumothorax (12.5%) and autonomic dysreflexia (6%). Conclusions DP placement under general anaesthesia is a safe intervention in both adult and paediatric patients. Complications derived from both the underlying disease and the surgical technique may appear, and must be rapidly identified and treated to obtain a satisfactory surgical outcome.

Manejo anestésico de la cirugía de implante de marcapasos diafragmático. Experiencia en el Institut Guttmann

BackgroundThe diaphragm pacemaker (DP) has proven its utility in replacing mechanical ventilation in patients with chronic spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). The DP improves patient quality of life and reduces morbidity and mortality and their associated health care costs. The anesthetic management of these patients and the particularities of the surgical procedure are challenging. The aim of our study is to analyze anesthetic management and intraoperative complications in patients undergoing DP placement in our hospital. MethodsWe performed a chart review of patients treated between December 2007 and July 2017, recording the patients’ preoperative status, anesthetic management and intraoperative complications. ResultsThe study included 16 patients (5 pediatric) undergoing DP implantation for chronic SCI (63%), ALS (25%) and other neurologic conditions (12%). Abdominal laparoscopy was performed under general anesthesia, with intravenous (87%) or inhalational (13%) induction and maintenance using total intravenous (50%) or balanced (50%) anesthesia. Rocuronium was administered in one case to permit airway management. Complications included: hypotension (50%), difficulties in mechanical ventilation during laparoscopy (31%), pneumothorax (12.5%) and autonomic dysreflexia (6%). ConclusionsDP placement under general anesthesia is a safe intervention in both adult and pediatric patients. Complications derived from both the underlying disease and the surgical technique may appear, and must be rapidly identified and treated to obtain a satisfactory surgical outcome.

The association between epidural analgesia and mortality in emergency abdominal surgery: A population-based cohort study.

Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery. In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)). We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P=.94) and OR 0.80 (95%CI: 0.67-0.94; P=.01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P=.21) and OR 0.75 (95% CI: 0.62-0.90, P<.01), respectively. No serious adverse events were reported. In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis.

The comparative study on clinical effects of different nephron-sparing surgical methods for T1 and T2a renal cell carcinoma

Objective To compare the clinical effect of three different nephron-sparing surgical methods including peritoneal laparoscopy, retroperitoneal laparoscopy and open surgery for localized renal carcinoma. Methods The clinical data of 139 patients with localized renal carcinoma was retrospectively analyzed from March 2008 to March 2015. According to the methods of operation, they were divided into three groups, peritoneal laparoscopic excision group (35 cases), retroperitoneal laparoscopic excision group (60 cases) and open surgery group (42 cases). The operating time, renal warm ischemia time, blood loss, hospital stay, postoperative recurrence and metastasis were compared among the three groups and were statistically analyzed. Results One case in the abdominal group and the retroperitoneum group were transferred to open surgery because of extensive adhesion around the tumor, except for this study, and 137 cases were eventually included. Operation time of three groups was(145.3±32.4)min, (126.4±33.1)min and(114.0±31.3)min respectively. There was no significant difference in operative time between the abdominal laparoscopy group and the laparoscopic group. The operative time in the two groups was higher than that in the open operation group(P 0.05). The indwelling time of abdominal drainage tube was (7.1±3.2)d, (5.4±2.4)d and (5.3±1.6)d, respectively, and there was no significant difference among the three groups(P>0.05). The hospitalization time of the three groups was (11.6±4.3)d, (10.1±3.6)d and (13.8±3.2)d, respectively. The time of hospitalization in the abdominal laparoscopy group and the retroperitoneoscope group was significantly lower than that in the open operation group, with statistical significance(P 0.05). Follow-up for 2 to 3 years, there was no significant difference in mortality, recurrence and metastasis between the three groups, and there was no significant difference in postoperative complications(P>0.05). Postoperative pathological types suggested clear cell carcinoma in 122 cases, papillary cell carcinoma in 10 cases, chromophobe cell carcinoma in 4 cases, and collecting duct carcinoma in 1 cases. The R. E.N.A.L scoring system was significantly associated with renal ischemia time, operation time, and affected glomerular filtration rate (P 0.05). Conclusions Peritoneal laparoscopic and retroperitoneal laparoscopic nephron-sparing surgery for localized renal carcinoma have the advantages of minimal invasion, quick recovery and equal clinical effect with open surgery, and can substitute for open surgery. Key words: Carcinoma, Renal Cell; Laparoscopy; Urologic Surgical Procedures

A novel method of incisional hernia repair in a diabetic, smoking patient

Incisional hernia is a complication of abdominal surgery, either laparotomy or laparoscopy. Some may become so massive that they hamper a patient’s daily life, and become an embarrassment. The incidence of incisional hernia among diabetic, smoking patients is higher than in the general non-diabetic, non-smoking population. Generally, these massive hernias are repaired using a synthetic or a biological mesh, either alone or to bolster a sheath closure. In diabetics and smokers, infection of the mesh invariably occurs, resulting in removal of the prosthesis and recurrence of the hernia. In this case study, a novel repair using the patient’s own tissues to bolster a sheath closure was explored. A diabetic, smoking patient with a massive incisional hernia after surgery for a perforated peptic ulcer, with resultant sepsis and re-laparotomy 5 years prior to this presentation, had the hernia repaired without a mesh, using his residual skin to bolster the component separation closure repair technique. The use of the patient’s autologous tissue resulted in a stable and firm hernia. In this diabetic, smoking patient, the use of autologous tissue for repair of a massive incisional hernia was found to decrease the complications, and it reduced the cost of the operation. Further study to validate the procedure is needed.

Abdominal Compliance and Laparoscopy: A Review

Background and Objectives:Creating and maintaining a pneumoperitoneum to perform laparoscopy is governed by gas laws and the limiting physical constraints of the abdomen.Methods:A review of how gas, biomechanical and physical properties affect the abdomen and a systematic structured Medline and PubMed search was conducted to identify relevant studies related to the topic.Results:Abdominal compliance is a measure of ease of abdominal expansion and is determined by the elasticity of the abdominal wall and diaphragm. It is the change in intra-abdominal volume per change in intra-abdominal pressure. Caution should be exercised with pressures exceeding 12 millimeters mercury since this is defined as intra-abdominal hypertension.Conclusions:Abdominal compliance has its limits, is unique for each patient and pressure-volume curves cannot be easily predicted. Using the lowest possible pressure to accomplish the surgical task without compromising surgical outcome is the desired goal. The clinical importance is caution and knowing there is a point where more pressure does not increase working space and only increases pressure.

SUBCUTANEOUS C1-INHIBITOR FOR LONG-TERM PROPHYLAXIS IN HEREDITARY ANGIOEDEMA WITH NORMAL C1 INHIBITOR

Introduction Hereditary angioedema (HAE) is a rare disorder characterized by episodes of swelling without urticaria. HAE presents with decreased C1 inhibitor (C1INH) antigen (type I) or function (type II), or with normal C1INH (HAE-nC1INH). Case Description A 25-year-old female presented with intermittent airway, abdominal and extremity angioedema without hives every 2-4 weeks for 3 years, often coinciding with ovulation or menstruation. She had up to 24 emergency room (ER) visits and 5 hospitalizations annually, historically requiring intubation, abdominal laparoscopy and appendectomy. Pathology revealed normal appendix. C4, ANA, tryptase, C1INH antigen level, C1INH function, C1q and Factor XII gene testing were normal. Angioedema was unresponsive to high-dose antihistamines, systemic corticosteroids, and omalizumab. She was diagnosed with suspected HAE-nC1INH. Progesterone contraceptives and fresh frozen plasma were ineffective. On-demand ecallantide or icatibant reduced episode duration but she continued with frequent symptoms. Prophylactic tranexamic acid and subsequently IV C1INH 1000 units every 3-4 days resulted in modest preventative effects but she had ER visits, hospitalizations and decreased quality of life due to angioedema. In September 2017, she transitioned to prophylactic subcutaneous C1INH replacement 60 IU/kg twice weekly and has since experienced only 3 ER visits with rapid recovery, no hospitalizations, international travel and permanent employment. Discussion Plasma-derived human C1-INH has been reported as a successful acute treatment in HAE-nC1INH. A lower threshold for contact system activation might explain the benefit of higher C1INH levels in some HAE-nC1INH patients. Our report demonstrates that SQ C1INH may be effective for long-term prophylaxis in a subset of HAE-nC1INH.

Application of modified laparoscopy in repair of high complex vesical vagina fistula

Objective To evaluate the efficacy of modified abdominal laparoscopy in the repair of complex vesical vaginal fistula after total hysterectomy. Methods The clinical data of 58 cases of urinary bladder and vagina fistula in our hospital from April 2014 to December 2017 were retrospectively analyzed, of which 32 cases were repaired by ordinary abdominal laparoscopy from April 2014 to February 2016 and 26 cases were repaired by modified abdominal laparoscopy from March 2016 to June 2017. On the basis of the original laparoscopy, the modified transabdominal laparoscopy enlarged the free range between the vaginal stump and the bladder, separated the anterior vaginal wall from the bladder completely and dissociated the retrovaginal peritoneum, wrapping around the vaginal stump to make the peritoneum. The median age of ordinary group was 52(range: 33-67)years old, the median course of disease was 12(range: 3-40)months, and the size of fistula was (25.5±10.3) mm. The median age of modified group was 50(range: 37-65)years, the median course of disease was 11.5(range : 3-36) months, and the size of the fistula was (26.3±9.1) mm. The operation time, bleeding volume, the time of hospitalization, the rate of complications and the success rate of the operation were compared. Results The operation time of the two groups was successfully completed. The operation time of the modified group [(164.2±21.2) min] was significantly shorter than that of the common group [(201.4±25.8) min], and the difference was statistically significant (P 0.05). Conclusions The modified transabdominal laparoscopic mode shortens the operation time, and improves the cure rate of the operation. Satisfactory results are recommended for the repair of high complex bladder vagina fistula. Key words: Vesical vaginal fistula; High position; Laparoscopy; Modified operation; Therapeutic effect

ANALYSIS OF HEMATOLOGIC, HEPATIC AND PANCREATIC TOXICITY DURING NEOADJUVANT CHEMORADIOTHERAPY IN PATIENTS WITH LOCALLY ADVANCED GASTRIC CANCER

Purpose.We analyzed the frequency and severity of hematologic, hepatic and pancreatic toxicity during and after completion of neoadjuvant chemoradiotherapy in patients with gastric cancer.Material and methods. Phase II clinical trial was conducted to evaluate the efficacy of the combined modality treatment including neoadjuvant chemoradiotherapy followed by D2 gastrectomy for patients with locally advanced gastric cancer. The main inclusion criteria were: histologically verified gastric cancer, cT3-4N0, cT2-4N1-3; M0. Before starting neoadjuvant therapy, all patients underwent thoracic and abdominal CT and laparoscopy to exclude peritoneal carcinomatosis. A total dose of radiation therapy was 45 Gy (1 + 1.5 Gy/fraction/day with a 4–5 hour interval) concurrently with the modified CAPOX chemotherapy regimen. Gastrectomy or subtotal resection of the stomach was planned 4-6 weeks after the completion of chemoradiotherapy. The toxicity assessment of neoadjuvant chemoradiotherapy was performed using the NCI CTC scale, version 3.0. The assessment of hematological, hepatic and pancreatic toxicities was done.Results.Among the toxicity during and after completion of neoadjuvant chemoradiotherapy, thrombocytopenia, neutropenia and leukopenia (grade 1–2) were the most common, requiring no additional symptomatic therapy. Radiation therapy was completed in 45 (98 %) patients. Chemotherapy was completed in 42 (91 %) patients. The median time between the completion of chemoradiotherapy and surgery was 44 days. Surgery following chemoradiotherapy was performed in 100 % of patients, including R0 resection in 93 % of patients.Conclusion.Preoperative chemoradiotherapy was well tolerated by patients, could be completed in most cases and did not prevent subsequent surgical treatment.

Intussusceptions in children (analysis of literary data and own experiences)

Data of literature about etiopathogenesis, clinical manifestations, diagnostics and approaches to the treatment of children with intussusceptions are presented in this article. Also own experience of treatment 53 children with intussusceptions is presented. Two types of treatment were used – conservative and surgical. It is shown that majority of patients receive conservative therapy. Has been made conclusion that method of choice in diagnostics and method of choice of surgical treatment of patients with intussusceptions are ultrasonography of organs of abdominal cavity and laparoscopy.