Gastrointestinal Duplications Research Articles

Polymelia and concurrent intestinal duplication and cloacal atresia in a broiler chick: case report and literature review.

Congenital malformations are a highly diverse group of conditions reported in both humans and animals, characterized by defects in morphogenesis observed at birth. Although most cases are idiopathic, genetic and environmental factors may be involved. The frequency of such conditions varies with species, geographic regions, and the specific malformation involved. In polymelia, supernumerary limbs are attached to different parts of the body. Gastrointestinal duplications are described less frequently and can be associated with polymelia. Cloacal atresia is among the least-reported malformations in avian species, described only once in a kiwi. Here we describe a case with these 3 malformations in a single broiler chick (Gallus gallus domesticus) and provide a literature review about the occurrence of these malformations in birds. The 3-d-old chick also had an unidentified structure projecting from the pygostyle region. We performed clinical, radiographic, and postmortem examinations. The intestinal duplication was identified only during the postmortem evaluation. Detailed descriptions of avian congenital malformations are scarce. Although similar cases have been reported, we retrieved no cases of concurrent polymelia, intestinal duplication, and cloacal atresia in broiler chickens in our literature search, suggesting that the simultaneous occurrence of these conditions has not been reported previously in this species.

Unusual cause of urinary retention in an infant

Introduction: Gastrointestinal tract duplication cysts constitute a rare group of malformation. Patients with presacral mass present with a diagnostic challenge due to the less obvious presentation. Case Report: We report a 7-month-old boy, who presented with constipation and acute intermittent urinary retention. On per-rectal examination, a palpable mass was felt posteriorly with a narrow base, raising a query of pre-sacral/pelvic mass. Ultrasound pelvis revealed a well-defined, rounded oval-shaped cystic mass noted in the center of the lower pelvis, posteriorly. Computed tomography (CT) scan abdomen confirmed a cystic pelvis mass anterior to the rectum causing mass effect. Magnetic resonance imaging (MRI) of the pelvis was done to define its relationship to the sacral spine. A high-intensity lesion was seen on T2 imaging with no spinal involvement. Hence surgical exploration was done, and per operative diagnosis of rectal duplication was confirmed. Postoperatively child was discharged on the fourth post-operative day and doing well on follow-up. Conclusion: We emphasize a complete examination, including per rectal examination in any child presenting with acute urinary retention to exclude pre-sacral masses.

Cecal duplication cyst in an adult: A case report

Enteric duplication cysts are rare congenital malformations and cecal duplication cysts are rarer which develop only in 0.4% of cases of gastrointestinal tract duplication and only 43 cases have been reported in literature to date. The ileum and ileocecal junction are among the most common sites. We hereby report a case of a 50-year-old female who presented with signs and symptoms of acute intestinal obstruction that was clinically and radiologically interpreted as volvulus for which the patient underwent resection of the cyst and ileocecal anastomosis and was then histopathologically confirmed as cecal duplication cyst.

True pylorus duplication: a case report

True pylorus duplication cysts are particularly rare, the literature describes only a small number of cases. They account for nearly 2.2% of all alimentary tract duplications. Most of the gastric duplications presents at an age younger than one year with one-third diagnosed in the neonatal period. However, they are not limited to that period. We report a case of a true pyloric duplication cyst in a 3-year-old girl who had been experiencing frequent vomiting with occasional abdominal pain for about 15 days prior to her presentation. The patient had an abdominal ultrasound that showed an epigastric cystic mass. CT of the abdomen demonstrated a 3.8×3.8 cm mass with a claw sign proximal to the first part duodenum. The diagnosis of pyloric duplication cyst was confirmed during the operation and with the histopathological examination following the resection. The patient is doing well with an appropriate weight gain at the follow-up appointments. The patient is doing well with an appropriate weight gain at the follow-up appointments. In summary, this is an an unusual case of gastric outlet obstruction that presented outside the usual age period caused by a pyloric duplication cyst. Imaging studies including US and CT are useful aids in the diagnoses of gastrointestinal duplication cysts.

A case of adult gastrointestinal duplication with high serum CA19-9

A case of adult gastrointestinal duplication with high serum CA19-9

Multiple isolated enteric duplication cysts in newborn: An unusual cause of sepsis

Gastrointestinal duplication cysts are uncommon congenital anomaly that may occur anywhere throughout the gastrointestinal system from the mouth to the anus. While cysts occur usually in the small bowel, the stomach ranks third after the small intestine and esophagus. As these cysts may be complicated by infection and other complications such as bleeding or obstruction, they should be treated with complete excision before the symptoms start. Although duplication cysts more often cause symptoms related to signs of obstruction, they may also present with clinical sepsis. In this article, we present a newborn case with a large duplication cyst adjacent to the ileum and the greater curvature of the stomach and a second simple cyst under the liver.

New treatment for gastric duplication cyst: Endoscopic ultrasonography-guided fine-needle aspiration combined with lauromacrogol sclerotherapy: A case report

BACKGROUND Gastric duplication cysts are very rare disease that are mainly diagnosed by endoscopic ultrasonographic fine-needle aspiration biopsy. In the past, this disease was usually treated with traditional surgery and rarely with minimally invasive endoscopic surgery. However, minimally invasive endoscopic therapy has many advantages, such as no skin wound, organ preservation, postoperative pain reduction, early food intake, fewer postoperative complications, and shorter post-procedure hospitalization. CASE SUMMARY We report a case of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) combined with lauromacrogol sclerotherapy for pyloric obstruction due to gastric duplication cysts. CONCLUSION EUS-FNA combined with lauromacrogol sclerotherapy provides a new option for the treatment of gastrointestinal duplication cysts.

Jejunal duplication cyst in a female neonate: a case report.

Duplications are the abnormal portion of the intestine, either externally attached to the intestine or intrinsically placed within the bowel lumen. Their prevalence is noted to be around one in 25000 deliveries. The rare gastrointestinal tract duplication may be located in any part of the gastrointestinal system from the oral cavity to the anus. The most common site of enteric duplication cyst (DC) is the terminal part of the ileum. Hence, duplications in jejunum are rare. Hereby, the authors report a case of jejunal DC in a female neonate which was managed successfully via surgery and adequate post-operative care without any complications. Duplications are more frequently single. They are usually located in the mesenteric border of the associated native bowel and may vary in shape and size. Most of them are cystic, followed by tubular and mixed type, with or without other congenital anomalies. More than 80% of the cases present before the age of 2 years as an acute abdomen or bowel obstruction, but many duplications remain silent unless complications occur, and therefore may not be diagnosed until adulthood. Complications of enteric DC include volvulus, bleeding, and, rarely, malignant degeneration. It is important for paediatric surgeons to include DC in the differential diagnosis if a neonate presents with features of intestinal obstruction.

DUPLICATION OF THE SMALL INTESTINE IN EMERGENCY PEDIATRIC SURGERY

Duplication of the gastrointestinal tract is a rare congenital surgical malformation. The frequency of the anomaly is 1:4500 ofnewborns, the most frequent localization of the duplication is the iliac region of the small intestine – 33%, duplications of the jejunum make up 7-10% of the total number of cases. The complexity of diagnosis and choice of surgical tactics is due to the absence of specifi c symptoms, possible asymptomatic presence for a long time, clinical manifestations characteristic of other diseases. The article presents an example of a clinical case of doubling of the jejunum in a pediatric patient complicated by peptic ulcer and diff use peritonitis. Complaints, features of the diagnostic process at the prehospital stage, selected surgical tactics, and causes of complications were analyzed.Morphologic signs of jejunal duplication are given. The given clinical example proves that the cause of dyspeptic phenomena of long duration and abdominal pain of unknown origin in pediatric patients may be surgical pathology, in particular, doubling of the gastrointestinal tract complicated by infl ammation of the small intestine. Therefore, such patients need the consultation of a pediatric surgeon, search and detection of possible surgical pathology, including doubling of the intestine. The diagnostic methods for detecting this anomaly are radiography, ultrasound, and contrast- enhanced computed tomography (CECT). Perforation in GI duplication is one of the causes of peritonitis that should be considered by emergency pediatric surgeons in their practice. Timely determination of the patient’s gastrointestinal tract duplication allows the emergency surgeon to optimize diagnostic measures, optimal choice of surgical approach, predict the volume of surgical intervention, avoid possible complications, reduce the time and cost of treatment. Since the fi nal confirmation of the diagnosis of gastrointestinal tract duplication is the result of morphological examination, its performance is mandatory.

Congenital heterotopic gastrointestinal duplication cyst of the face: a rare case report

Gastrointestinal duplication (GDC) cysts have various synonyms; choristoma, enterocystoma, and duplication cyst. They are infrequent congenital benign lesions diagnosed mainly in children in the first decade of life, comprising approximately less than 5% of the pediatric population with a predilection for the male sex. It is exceedingly rare in the oral cavity but it is possible, particularly on the tongue, floor of the mouth, and pharynx. From 1895 until 1994, 30 cases of this lesion in the oral cavity were reported. Nowadays, none of the authors reported a GDC in the facial region. We report an exceptional case of heterotopic gastrointestinal duplication cysts (HGDC) in the facial region of a 13 -years -old male teenager who was referred to our medical department for an evaluation of a painless progressive facial asymmetry. In the first instance, the ultrasound facial soft tissue was made with a 6.5 MHz convex transducer, reporting a big anechoic image with regular borders to a 60 x 26 x 56 mm diameter with a 46cc approximate volume. Following this, a non-contrast magnetic resonance image was executed with an open Philips PanoramaⓇ machine performed at 3T, reporting a hyperintense image in T2-weighted (repetition time msec/echo time msec: 5,500/112) sagittal sequence and FLAIR-weighted (5,714/80) axial sequence; and an isointense image in T1-weighted (24/80) coronal sequence to 54 x 30 x 51 mm diameter compatible with space occupant lesion with interior walls. A complete tumor resection was achieved under balanced general anesthesia, and the specimen was sent for histological examination. Microscopic examination showed a cystic cavity lined mostly by mucous secretory gastrointestinal epithelium and other areas by stratified squamous epithelium. The cystic wall was composed of fibrous connective tissue and contains abundant gastric cells. Its deepest portion exhibits a smooth muscle layer. In summary, HGDC is an unusual congenital head and neck lesion, but it should be considered in the differential diagnosis of neonates and children. The diagnosis of gastrointestinal tract duplications may be suggested by imaging studies; however, the correct diagnosis is defined by histopathologic analysis. Due to the risk of destruction potential and malignant transformation, HGDC should be treated surgically by complete excision.

Duplication Cysts and Autoimmune Hemolytic Anemia: An Association or a Coincidence?

Duplication cysts are rare congenital anomalies of the gastrointestinal tract and the occurrence of multiple such cysts is an extremely rare occurrence. Autoimmune hemolytic anemia is an extremely unusual manifestation of these duplication cysts. Herein, we report a case with two duplication cysts (one cyst in the thorax; another in the abdomen) complicated with autoimmune hemolytic anemia. This patient was a five year-old-male child who presented with congestive cardiac failure due to severe anemia (which, on evaluation, was diagnosed as autoimmune hemolytic anemia). Imaging studies (chest radiograph and computed tomography) revealed duplication cysts in the chest and abdomen. Anemia flare-up was noted in the patient despite two months of prednisolone therapy (2 mg/kg/day) and two high dose intravenous methylprednisolone pulse therapy courses (30 mg/kg/day for 5 days each). The steroid refractory autoimmune hemolytic anemia responded to rituximab (375 mg/ m2 body surface area/week for 4 weeks). Four months after tapering off the steroid therapy, the patient did not experience flare-up of the anemia. To the best of our knowledge, this is the youngest and first pediatric age group patient to be reported, with a possible association between gastrointestinal duplication cysts with autoimmune hemolytic anemia.

Diagnostics and surgical management of periampullary duodenal duplication cysts in children: a report of cases

BACKGROUND: Obstructive variants of chronic duodenal obstruction may be caused by congenital malformations, such as rare periampullary duodenal duplication cysts. This localization of gastrointestinal duplications is the rarest and is not described in the domestic literature.
 AIM: This study aimed to present the experience of the management of periampullary duodenal duplication cysts in children.
 CASES REPORT: Seven children with periampullary duodenal duplication cysts underwent surgery between 2007 and 2022. All patients suffered from prolonged abdominal pain, vomiting of food, and bile. Two children had recurrent pancreatitis, and one child underwent repeated operations for high intestinal obstruction and biliary obstruction in other hospitals. An abdominal cyst was suspected in one patient at another hospital, and the child underwent exploratory laparoscopy, but no formation was found. Ultrasound, gastroduodenoscopy, computed tomography, and magnetic resonance imaging were performed on these children. Ultrasound examination showed a peristaltic cystic formation up to 4 cm in diameter with a double wall. Gastroduodenoscopy showed formation in the second portion of the duodenum in the region of the major duodenal papilla. This formation covers the intestinal lumen by two-thirds and up to nearly complete obturation. The relationship between duodenal duplication and the bile and pancreatic ducts was clarified on magnetic resonance cholangiopancreatography: the relationship was suspected in two children. All patients underwent wide transduodenal excision of periampullary duodenal duplication cyst; in four cases, laparoscopic access was used. No intra- and postoperative complications occurred. Histological examination revealed true duplications in all cases. The children were discharged on days 1112. In the follow-up after 3 months and 10 years, no complications were noted.
 CONCLUSIONS: Periampullary duodenal duplication cysts can be a cause of chronic duodenal obstruction. Transduodenal excision of periampullary duodenal duplication cysts is the optimal treatment, and this operation can be performed laparoscopically.

A RARE CASE OF OESOPHAGEAL DUPLICATION CYST IN ADULT

A Duplication cyst of the oesophagus is the 2nd most common congenital anomaly of the Gastrointestinal tract. It has an estimated prevalence of 0.012% with a higher predominance in males, representing the 10- 15% of all gastrointestinal duplication defects. Although it is a common nding in children, diagnosis of an oesophageal duplication in adults is rare. They are often asymptomatic but they may experience symptoms such as stridor or dysphagia corresponding to the lesion within the neck or mediastinum or be complicated by intracystic haemorrhage, rupture & infections. Here we present a case of an adult patient presenting with an oesophageal duplication cyst

A rare case of duplication of the descending colon in a pregnant woman: case report and literature review.

Gastrointestinal duplications are uncommon congenital abnormalities that can occur anywhere throughout the intestinal tract. The small bowel is more interested than the large one. Duplications are schematically classified as spherical and tubular, respectively representing 80% and 20% of cases, with different relationships and communications with the native intestinal wall. Although typically diagnosed during infancy and early childhood, tubular colonic sub-type stays frequently hidden for several years until a complication occurs. we report the case of a T-shaped tubular duplication in a 20-year-old woman at the 30th week of gestation, who underwent an urgent exploratory laparotomy for intestinal occlusion, treated with the resection of the aberrant large bowel. The patient was notable for a long history of constipation and chronic pain. Diagnostic possibilities were limited by the on-going pregnancy. Intestinal duplications are uncommon malformations, and, of these, the T-shaped subtype of the colon is among the rarest ones. In the adulthood, diagnosis is usually established in the operating room during urgent or even emergency surgery performed for abdominal complications. A duplication of the descending colon is extremely rare, and this is, to our knowledge, the only article describing a case found in advanced state of pregnancy.

Gastrointestinal Duplications: A Decade's Experience.

Gastrointestinal (GI) duplications are rare congenital malformations with diverse presentations. They usually present in the pediatric age, especially in the first 2 years of life. To present our experience with GI duplication (cysts) at a pediatric surgery tertiary care teaching institute. It is a retrospective observational study undertaken in the department of pediatric surgery at our center between 2012 and 2022 for GI duplications. All children were analyzed for their age, sex, presentation, radiological evaluation, operative management, and outcomes. Thirty-two patients were diagnosed with GI duplication. Slight male predominance was present in the series (M: F ≈ 4:3). Fifteen (46.88%) patients presented in the neonatal age group; 26 (81.25%) patients were under 2 years. In the majority of cases (n = 23, 71.88%), the presentation was acute onset. Double duplication cysts on opposite sides of the diaphragm were present in one case. The most common location was ileum (n = 17), followed by gallbladder (n = 6), appendix (n = 3), gastric (n = 1), jejunum (n = 1), esophagus (n = 1), ileocecal junction (n = 1), duodenum (n = 1), sigmoid (n = 1), and anal canal (n = 1). Multiple associations (malformations/surgical pathologies) were present. Intussusception (n = 6) was the most common, followed by intestinal atresia (n = 5), anorectal malformation (n = 3), abdominal wall defect (n = 3), hemorrhagic cyst (n = 1), Meckel's diverticulum (n = 1), and sacrococcygeal teratoma (n = 1). Four cases were associated with intestinal volvulus, three cases with intestinal adhesions, and two with intestinal perforation. Favorable outcomes were present in 75% of cases. GI duplications have varied presentations depending on site, size, type, local mass effect, mucosal pattern, and associated complications. The importance of clinical suspicion and radiology cannot be underrated. Early diagnosis is required to prevent postoperative complications. Management is individualized as per the type of duplication anomaly and its relation with the involved GI tract.

Upper gastrointestinal duplication complicated by perforation in a child

Gastrointestinal duplications are rare congenital malformations occurring in embryonic period of development of digestive system. These abnormalities are usually found in infancy or early childhood. Clinical presentation is extremely diverse depending on dimensions, localization and type of duplication. The authors present duplication of antral and pyloric parts of the stomach, the 1st segment of the duodenum and pancreatic tail. Mother with a 6-month-old child turned to the hospital. According to the mother, the child was sick for about 3 days when episodes of periodic anxiety first appeared. Upon admission, abdominal neoplasm was suspected after ultrasound. On the second day after admission, anxiety increased. There was impairment of appetite, and the child rejected food. Abdominal asymmetry in umbilical area was observed. Considering clinical data on intestinal obstruction, emergency transverse right-sided laparotomy was performed. A tubular structure was found resembling intestinal tube was found between the stomach and transverse colon. Surgeon found duplication of antral and pyloric parts of the stomach, the 1st segment of the duodenum and its perforation. During further revision, additional pancreatic tail was diagnosed. En-bloc resection of gastrointestinal duplications was carried out. Postoperative period was uneventful. Enteral feeding was initiated after 5 days, and the patient was transferred to surgical unit. The child was discharged after 12 postoperative days.

A large abdominal cyst in a neonate

Gastrointestinal (enteric) duplication consists of a tubular or cystic structure that develops along the intestinal tube, with an estimated incidence of 1/10,000 in live births and 1/4500 in necropsies of neonates and fetuses. This congenital anomaly can appear in any portion of the intestinal tract; from the mouth to the rectum, with the ileum being the most common location. We herein report the case of a 5-day-old patient with a prenatal diagnosis of megacolon or mesenteric cyst. At laparotomy, a cystic mass attached to the terminal ileum was noted approximately 5 cm from the ileo-caecal valve. This mass was entirely resected and pathology studies classified the specimen as Type 1B intestinal duplication according to the Long classification. Intestinal duplications are rare abnormalities of the embryological development of the gastrointestinal tract and usually present in childhood. The diagnosis can be made during antenatal follow-up. They can be asymptomatic or present with a variety of symptoms in relation to the location, the age of the patient or complications of the duplication. The diagnosis is suggested by abdominal X-rays and ultrasonography, and computerized axial tomography scan with contrast studies, but the definitive diagnosis is made by histopathological examination of the surgical specimen.

Laparoscopic cyst enucleation is a promising technique for treatment of gastrointestinal tract duplications in children

BackgroundLaparoscopic cyst enucleation has its advantages and limitations in treatment of gastrointestinal tract (GIT) duplications. It allows to avoid bowel resection in such locations as ileocecal valve. We introduced laparoscopic cyst enucleation with further bowel plasty using cyst muscle layer and without monopolar coagulation, for cyst dissection we used straight scissors. Materials and methodsOur study included 20 children with GIT duplications, who underwent cyst enucleation from 2018 to 2021. Laparoscopy was performed in all cases with various cyst locations (stomach – 2, duodenum – 3, small bowel – 14, ileocecal area – 1). Mean age of surgery was 40 ± 35,3 days (min 6 days, max 150 days). ResultsMean operation time was 84,4 ± 27,35 min (min – 40 min, max – 160 min). We had no intraoperative complications. All patients received parenteral feeding for 3–5 days after the operation. Postoperative complications occurred in 3 cases: bowel perforation which required enterostomy (10%) and bowel volvulus required resection (5%). To our opinion, perforations occurred due to monopolar coagulation used for cyst enucleation in these children. No complications were observed in patients who underwent enucleation by straight scissors. Mean postoperative hospital stay was 15.6 ± 10.48 days (min – 4 days, max – 58 days). We observed neither stenosis nor any other complications in the long-term follow-up. ConclusionsLaparoscopic cyst enucleation is a feasible and safe approach for GIT duplications. It allows to avoid bowel resection, and the use of straight scissors instead of monopolar coagulation provides less postoperative complications such as perforation. The Level of evidenceIII.

Laparoscopic resection of an intra-abdominal esophageal duplication cyst in the ileum: a case report.

Esophageal duplication cyst (EDC) is a type of gastrointestinal duplication cyst that involves congenital malformations of the gastrointestinal tract. EDCs are frequently found in the mediastinum and thoracoabdominal region, but rarely occur in the abdominal cavity. However, intra-abdominal EDCs are frequently found in the upper abdomen near the abdominal esophagus. Here, we report, for the first time, a case of intra-abdominal EDC that occurred in the ileum. A 14-year-old female patient presented to our hospital with complaints of epigastric pain and vomiting. Abdominal computed tomography (CT) revealed a cystic tumor in the pelvis, suspected of ovarian origin. She was admitted to our gynecology department and underwent emergency surgery. The laparoscopic examination revealed that both ovaries were intact and that a primary tumor had developed from the ileal mesentery. Since the patient's condition was not urgent at the time of the gynecological surgery, the procedure was completed by only performing exploratory laparotomy; the patient was admitted to our department after the surgery. Pelvic magnetic resonance imaging performed on the next day revealed a cystic mass measuring 90 × 65mm with a smooth margin and homogeneous signal intensity, arising posterior to the uterus. The mass was suspected as an intestinal duplication cyst. On another day, after the examinations were completed, we resected the portion of the small intestine containing the tumor by laparoscopy. The patient had a successful postoperative course and was discharged on the 5th postoperative day. Histological examination showed that the cyst was lined by stratified squamous epithelium, contained esophageal glands, and had a two-layer muscularis propria. Therefore, a diagnosis of intra-abdominal EDC was performed. An intra-abdominal EDC cyst is relatively rare; this is the first case reported at the distal ileum.

S2667 Upper Gastrointestinal Bleed From a Gastric Duplication Cyst

Introduction: A gastric duplication cyst (GDC) is an uncommon congenital malformation and a rare cause of upper gastrointestinal bleeding. Herein we present a peculiar case of an 83-year-old female with first ever onset of melena found to have a duodenal bulb fistula connecting to a bleeding extraluminal gastric pouch which was ultimately found to be a large GDC. Case Description/Methods: An 83-year-old female with history of bladder cancer treated with laser ablation, gastroesophageal reflux disease (GERD) on omeprazole, and a reported history of a “second stomach” presented to the emergency department with four days of painless, black, and sticky stools with one episode of non-bloody, nonbilious emesis prior to presentation. Presenting vitals were unremarkable, and pertinent laboratory workup demonstrated hemoglobin of 9.4 grams/deciliter, blood urea nitrogen of 35 milligrams/deciliter (mg/dL), and creatinine of 0.8 mg/dL. Esophagogastroduodenoscopy revealed the appearance of a bulge on the greater curvature of the stomach, and a duodenal bulb fistula was found connected to an actively bleeding extraluminal gastric pouch. The pouch could not be fully intubated endoscopically. Computed tomography angiography abdomen/pelvis displayed a possible gastric variant or duplication with a 2.9 centimeter enhancing mass in the proximal region without active extravasation of blood. She continued on intravenous pantoprazole and had one additional episode of melena but remained stable. She underwent partial gastrectomy, duodenal resection, Roux-en-Y gastrojejunostomy, and cholecystectomy without complications. Pathology showed a gastric duplication cyst lined with benign oxyntic mucosa. She was discharged. (Figure) Discussion: Gastrointestinal (GI) duplication cysts are found throughout the GI tract. They may or may not communicate with the GI lumen. Gastric mucosa is present in 50% of GI duplication cysts; they may remain asymptomatic but complications include ulceration, perforation, fistula formulation, and in rare cases gastrointestinal bleeding. Our patient went 83 years without GI bleed or other significant sequelae from the presence of a large GDC, highlighting the variable and unpredictable clinical course of this rare congenital abnormality.Figure 1.: FigureA: Endoscopic view of duodenal bulb fistula connecting to extraluminal gastric pouch lined with gastric mucosa. FigureB: Resected gastric extraluminal pouch post surgical intervention.