Surgical Delivery Research Articles

Perifoveal Chorioretinal Atrophy after Subretinal Voretigene Neparvovec-rzyl for RPE65-Mediated Leber Congenital Amaurosis

To report an anatomic change following subretinal injection of voretigene neparvovec-rzyl (VN) for RPE65-mediated Leber congenital amaurosis. Multicenter, retrospective chart review. Patients who underwent subretinal VN injection at each of 4 participating institutions. Patients were identified as having perifoveal chorioretinal atrophy if (1) the areas of atrophy were not directly related to the touch-down site of the subretinal cannula; and (2) the area of atrophy progressively enlarged over time. Demographic data, visual acuity, refractive error, fundus photographs, OCT, visual fields, and full-field stimulus threshold (FST) were analyzed. Outcome measures included change in visual acuity, FST, visual fields, and location of atrophy relative to subretinal bleb position. A total of 18 eyes of 10 patients who underwent subretinal injection of VN were identified as having developed perifoveal chorioretinal atrophy. Eight of 10 patients (80%) developed bilateral atrophy. The mean age was 11.6 years (range, 5-20 years), and 6 patients (60%) were male. Baseline mean logarithm of the minimum angle of resolution visual acuity and FST were 0.82 (standard deviation [SD], 0.51) and-1.3 log cd.s/m2 (SD, 0.44), respectively. The mean spherical equivalent was-5.7 diopters (D) (range,-11.50 to+1.75 D). Atrophy was identifiable at an average of 4.7 months (SD, 4.3) after surgery and progressively enlarged in all cases up to a mean follow-up period of 11.3 months (range, 4-18 months). Atrophy developed within and outside the area of the subretinal bleb in 10 eyes (55.5%), exclusively within the area of the bleb in 7 eyes (38.9%), and exclusively outside the bleb in 1 eye (5.5%). There was no significant change in visual acuity (P= 0.45). There was a consistent improvement in FST with a mean improvement of-3.21 log cd.s/m2 (P < 0.0001). Additionally, all 13 eyes with reliable Goldmann visual fields demonstrated improvement, but 3 eyes (23.1%) demonstrated paracentral scotomas related to the atrophy. A subset of patients undergoing subretinal VN injection developed progressive perifoveal chorioretinal atrophy after surgery. Further study is necessary to determine what ocular, surgical delivery, and vector-related factors predispose to this complication.

Analysis of the results of a retrospective cohort study of the course of pregnancy, childbirth and the postpartum period in high-risk patients to identify factors of unfavorable outcomes and build a predictive model of fetal loss

Prenatal prognosis is an important part of obstetric care, which aims to reduce fetal and neonatal losses. A differentiated approach to the management of different risk groups allows you to optimize existing approaches.The objective: to identify antenatal factors that correlate with perinatal losses, by conducting a retrospective cohort study of women at high perinatal risk, to build a multifactorial prognostic model of adverse pregnancy outcomes.Materials and methods. A retrospective cohort study was conducted from 2014 to 2016 on the basis of the medical center LLC «Uniclinic», Medical Genetics Center «Genome», Clinic of Reproductive Genetics «Victoria», Kyiv City Maternity Hospital №2. 2154 medical cards of pregnant women from the group of high perinatal risk were selected and analyzed. Of these, 782 pregnant women were included in the final protocol after verification of compliance with the criteria.Results. Cesarean delivery occurred in 115 cases (14.7%). In 50 cases (6.4%) the caesarean section was performed in a planned manner, in 65 (8.3%) – in an emergency. In 39 (5%) cases, the indication for surgical delivery was acute fetal distress. Antenatal fetal death occurred in 11 (1.4%) cases: one case in terms of &lt;34 weeks and &lt;37 weeks of gestation, the remaining 9 cases – in terms of&gt; 37 weeks. Intranatal death of two fetuses (0.3%) was due to acute asphyxia on the background of placental insufficiency. In the early neonatal period, 14 (1.8%) newborns died. Hospitalization of the newborn to the intensive care unit for the first 7 days was registered in 64 (8.2%) cases.The need for mechanical ventilation was stated in 3.96% (31/782) of newborns. The method of construction and analysis of multifactor models of logistic regression was used in the analysis of the relationship between the risk of perinatal losses (antenatal death, intranatal death, early neonatal death) and factor characteristics.Conclusion. Signs associated with the risk of perinatal loss: the presence of chronic hypertension, preeclampsia in previous pregnancies, type of fertilization (natural or artificial), the concentration of PAPP-A (MoM), the concentration of free β-HCG (MoM) in the second trimester, average PI in the uterine arteries in 28–30 weeks of pregnancy, PI in the middle cerebral arteries in 28–30 weeks of pregnancy, episodes of low fetal heart rate variability in the third trimester of pregnancy, episodes of high fetal heart rate variability in the third trimester of pregnancy. The model, built on selected features, allows with a sensitivity of 73.1% (95% CI: 52.2% – 88.4%) and a specificity of 72.7% (95% CI: 69.3% – 75.9%) to predict risk perinatal loss.

Treatment approach, hospital practice patterns, and receipt of multimodality therapy as measures of quality for locally advanced gastric cancer.

Adequate lymphadenectomy (AL) during surgical resection and delivery of multimodality therapy (MMT) are considered important for optimizing oncologic outcomes in patients with locally advanced gastric cancer. Both neoadjuvant and adjuvant approaches to MMT delivery are considered acceptable treatment strategies. Our goal was to evaluate the association between MMT treatment approach, hospital practice patterns, and survival and to explore whether AL and MMT might represent measures of quality for locally advanced gastric cancer. A national cohort study of 5433 patients with locally advanced gastric cancer (≥cT2 and/or cN+) treated at 987 hospitals within the National Cancer Database (2006-2015). Patients were categorized as receiving a neoadjuvant therapy (NT) or adjuvant therapy (AT) approach. Patients were also categorized based on receipt of AL (≥15 nodes) and MMT (surgery with any preoperative, perioperative, or postoperative AT). Hospitals were stratified based on the predominant treatment approach and the proportion of patients that achieved performance benchmarks (AL ≥ 80%; MMT ≥ 75%). Multivariable Cox shared frailty modeling was used to evaluate the association with the overall risk of death. Overall, 54.5% of patients were treated with an AT and 45.6% with an NT approach. Relative to surgery alone, receipt of MMT by either approach was associated with decreased risk of death (NT-hazard ratio [HR]: 0.75, 95% confidence interval: [0.65-0.86]; AT-HR: 0.80 [0.71-0.90]). Relative to care at mixed pattern hospitals, care at predominantly AT hospitals was associated with an increased risk of death (HR: 1.28 [1.12-1.47]). Relative to patients whose care achieved no quality measures, AL (HR: 0.75, [0.67-0.82]) and MMT (HR: 0.68 [0.60-0.76]) were each associated with a reduced risk of death. Receipt of both measures was associated with an even greater reduction (HR: 0.47 [0.40-0.56]). Hospital performance on AL, MMT, or both measures was not associated with the risk of death. Because over half of patients are treated with surgery first (many having surgery alone) and care at hospitals favoring a surgery first approach is associated with worse outcomes, quality improvement (QI) efforts should focus on increasing the use of NT strategies. Furthermore, delivery of AL and MMT together may represent an actionable, generalizable target for gastric cancer QI efforts because it improves survival and is unrelated to the context in which care is provided.

Use of plasmapheresis in treatment of patients with unfavorable anamnestic pregnancy outcomes coupled to antiphospholipid antibodies

Aim: to evaluate efficacy of plasmapheresis combined with low molecular weight heparins (LMWH) and acetylsalicylic acid (ASA).Materials and Methods. 327 plasmapheresis sessions were performed for 75 patients: 17 (22.6 %) patients during preparation for pregnancy, 11 (19.0 %) pregnant women in the first trimester, 33 (56.9 %) pregnant women in the second trimester, and 34 (58.6 %) pregnant women in the third trimester. Study inclusion criteria were as follows: high titers of antiphospholipid antibodies (APA) as well as included non-inclusion criteria in pregnant women with miscarriages and unfavorable anamnestic pregnancy outcome. 36 (62.1 %) women had pregnancy loss in anamnesis. All patients received low-dose ASA and LMWH therapy; 15 (25.86 %) pregnant women also received courses of intravenous immunoglobulins in the first and second trimesters.Results. 47 pregnant women had delivery, whereas 10 of women had pregnancy in progress. Term delivery was in 40 (85.1 %) patients, so that 23 (48.9 %) pregnant women had delivery per vias naturales. The average weight of the fetus was 3364.00 ± 393.76 g, height - 52.13 ± 1.82 cm. In 100 % cases, Apgar score was 8 points. 24 (51.1%) pregnant women had delivery via cesarean section. The average blood loss comprised 528.64 ± 166.10 ml. The average fetal weight in group after surgical delivery was 2982.14 ± 582.88 g, average height - 49.14 ± 4.09 cm, the Apgar score - 7.69 ± 0.47 points. Preterm births were observed in 7 (14.9%) cases, all via cesarean section. In 1 case, early fetal death was at gestational age of 8/9 weeks; according to the karyotyping data, a fetal chromosomal abnormality was detected. No severe obstetric complications were observed.Conclusions. Combining plasmapheresis with low dose LMWH and ASA therapy demonstrated high efficacy in treating obstetric APS manifested as high percentage of favorable pregnancy outcomes and low number of obstetric complications.

What factors shape surgical access in West Africa? A qualitative study exploring patient and provider experiences of managing injuries in Sierra Leone

IntroductionSurgical access is central to universalising health coverage, yet 5 billion people lack timely access to safe surgical services. Surgical need is particularly acute in post conflict settings like Sierra...

Surgical care in district hospitals in sub-Saharan Africa: a scoping review

ObjectiveTo provide a general overview of the reported current surgical capacity and delivery in order to advance current knowledge and suggest targets for further development and research within the region...

Comparative analysis of neonatal complications after cesarean section to M. Stark and modified cesarean section in premature birth and congenital malformations of the fetus

The urgency of the problem lies in the large proportion of premature babies in the structure of perinatal morbidity and mortality. According to the WHO, the frequency of premature birth in the world varies widely - from 4.5% to 16% [1, 2, 5]. It is known that for premature infants, children with congenital malformations in the presence of obstetric indications is more careful surgical delivery [4, 5].Therefore, the improvement of the technique of abdominal delivery in premature birth and congenital malformations of the fetus creates a certain additional reserve for improving perinatal outcomes

Sex-Based Heterogeneity in the Clinicopathological Characteristics and Prognosis of Breast Cancer: A Population-Based Analysis.

PurposeTo better understand the differences in clinicopathological features and prognosis between male breast cancer (MBC) and female breast cancer (FBC).Material and MethodsData on patients diagnosed with breast cancer from January 1, 2010, to December 31, 2016, were obtained from the Surveillance, Epidemiology, and End Results database. Selected patients were classified into MBC and FBC, of which population demographics and clinicopathological features at baseline were successively extracted for analysis. Comparative analysis was performed to explore the differences in baseline characteristics, followed by propensity-score matching to calibrate the objective distinctions for adjusted analysis. Survival analysis was carried out to investigate divergences presented in prognosis from the two cohorts, and risk factors for prognosis were successively identified using univariate and multivariate COX regression analyses.ResultsA total of 407341 individuals were eligible, including 3111 MBC (0.7%) and 404230 FBC (99.3%) patients. Comparatively, patients with MBC tended to be older at diagnosis, with a higher confirmation of ductal carcinoma, a higher histological grade, a higher TNM stage, a higher proportion of luminal-like subtype, a higher rate of lung metastasis, a lower incidence of liver involvement, and a lower rate of surgical, radiation, and chemotherapeutic delivery. The overall prognosis of MBC was significantly worse than that of FBC, with a decreasing divergence both in median overall survival (65.5 months vs. 72.7 months, P<0.0001) and median breast cancer-specific survival (75.4 months vs. 77.8 months, P<0.0001). However, these discrepancies were not consistent among patients from different subgroups stratified by molecular subtype, age at diagnosis, or disease stage.ConclusionIn this study, sex-based heterogeneity in clinicopathological characteristics and prognostic profiles was observed in the overall population of patients with breast cancer and was significantly variable among different subgroups. A male-specific design with reasonable endpoints for a clinical trial protocol will be warranted in the future.

ISTHMOCELE: ETIOLOGY, CLINIC, DIAGNOSIS AND TREATMENT (Literature review)

Modern obstetrics is characterized with a loyal approach to surgical delivery, which has significantly affected the activity of maternity hospitals: the number of complications in childbirth from both the mother and fetus has decreased. The formed scar on the uterus is determined differently when examining the women in the postoperative period. Isthmocele is a hypogenic area in the myometrium within the site of postoperative scar in the form of a "niche", diverticulum or sac after cesarean section. It can lead to the development of diseases: abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, infertility, adenomyosis, bladder dysfunction, as well as be the cause of ectopic pregnancy, uterine rupture, abnormalities in the placenta attachment of. Risk factors for isthmocele include low uterine incisions, a history of cervical removal, cervical dilatation of more than 5 cm, more than five hours of delivery, etc. For the first time the diagnosis of "isthmocele" is made at ultrasonic research, more often transvaginal one. The diagnosis is confirmed by hysteroscopy or constructive surgery. An important criterion for ismocele is the degree of deficiency, i.e. the ratio between the the biometry thickness on the scar and adjacent to the scar the myometrium area. Depending on the woman's reproductive plans, conservative or surgical treatment of isthmocele is recommended, using autologous stem cells to regenerate muscle tissue. Conservative treatment involves taking oral contraceptives. Surgical treatment includes the imposition of a two−row single−wing suture. The use of stem cells in the postoperative period allows a rise in the frequency of pregnancies in women with a scar on the uterus in the case of the isthmocele formation. Key words: isthmocele, cesarean section, myometrium, autocells.

Is It Necessary to Perform a Routine Antibiotic Prophylaxis before an Elective Surgery of Cesarean Section?

INTRODUCTION: According to the data by World Health Organization, the broad and often insufficiently substantiated prescription of antibiotics, including for prophylactic purposes, has led to the growth of antibiotic-resistant microflora, which is a dangerous and intractable problem of modern medicine. Despite the undoubted benefits of antibiotics in the management of wound infection and endometritis after cesarean section, the routine prophylactic administration of antibacterial drugs can not only carry the risk of growth of resistant nosocomial microflora, but also have doubtful effects on the health of a newborn. PURPOSE OF THE STUDY: The purpose of the study was to justify the possibility of carrying out elective cesarean section operations without routine antibiotic prophylaxis. MATERIALS AND METHODS: An analysis of 333 cases of elective cesarean section operations carried out in the obstetric department in the period from 2017 to 2019 was performed. Routine antibiotic prophylaxis before surgery was not prescribed in 118 healthy patients with an uncomplicated history and a smooth course of the gestational process. The remaining 215 women received a single intravenous injection of 1 g of cefazolin sodium intraoperatively, after extraction of the fetus. A comparative analysis of the clinical groups was carried out according to the following criteria: vaginal microbiocenosis before surgical delivery, duration, and features of the operation, clinical blood count on days 1 and 5 of the post-operative period, condition of postoperative sutures, the presence of discharge from the wound, signs of infectious complications from the uterus or other organs, uterine involution rate, duration of hospital stay before and after surgery, follow-up history for 1 month after discharge from the maternity ward. The data obtained were subjected to statistical processing. RESULTS: We have found no significant differences in the course and number of complications in the postpartum period in the compared clinical groups. The statistically significant transient leukocytosis observed on the 1st day of the postoperative period in patients who did not undergo antibiotic prophylaxis before the surgery seems to be associated with a more pronounced adaptive reaction and was not combined with any clinical symptoms of development of infection. CONCLUSION: No relationship has been identified between the routine prescription of antibiotics before or during an elective cesarean section and the risk of developing infectious complications in the post-operative period. Antibiotic prophylaxis before surgery should be carried out differentially, taking into account the history and features of the course of this pregnancy.

Penicillin Allergy Evaluation in Pregnancy Impacts Antibiotic Utilization and Neonatal Clinical Outcomes

Penicillin (PCN) allergy is commonly reported, but many are erroneously labeled. Pregnancy is associated with high antibiotic usage, with indications including prophylaxis for surgical Caesarean section delivery and group B streptococcus (GBS) colonization, a leading cause of neonatal sepsis. PCN allergy evaluation has the potential to significantly impact both maternal and neonatal clinical outcomes, however, proactive drug allergy evaluations during pregnancy remain underutilized.

Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda

Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery. A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase. Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018. A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment. Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Implementation of the Canadian National Standards in Breast Cancer Surgical Care: Gaps, Barriers, Enablers and Opportunities.

Background: Diagnosis and surgical treatment decision making for breast cancers has become increasingly complex. Recently, Canadian Partnership Against Cancer (CPAC) published pan-Canadian evidence-based surgical standards for the care of breast cancer patients. This study was undertaken to assess the degree to which these standards were currently met in practice and to further understand the determinants of their implementation nationally. Methods: This study was undertaken in two parts—(1) National survey of breast cancer surgeons to assess the perceived extent of implementation of these standards in their institution and province; (2) Formation of a focus group with a representative sample of breast surgeons across Canada to further understand the barriers and facilitators towards future breast standards implementation. Results: 35 surgeons participated in the survey: 66% were from community hospitals. There were four categories of standards that were the most significantly lacking across the country—(a) processes related to quality assurance, (b) turnaround time for pathology results (c) psychosocial and health-related support for the breast cancer patient and (d) breast reconstruction for patients undergoing mastectomy. The focus group included participants from all ten Canadian provinces. For each standard, the 134 determinants fell into three main categories—individual physician (n = 27, 20%); organizational (n = 46, 34%), and system (n = 61, 46%). While specific determinants were present for each category, surgical standards were more likely to be implemented in practice if (1) they aligned with organizational priorities standards; (2) the individual physicians or physician groups were accountable to the organization and/or cancer jurisdiction regarding compliance with the standard; and (3) if infrastructure or resources existed within the organization or system for the reliable collection of relevant, meaningful, practice changing data combined with the capability of benchmarking, peer–peer comparisons and timely feedback to the surgeons. Conclusion: The results of this study demonstrated variation, barriers and opportunities for the national implementation of CPAC’s breast cancer surgery standards and identified determinants of high-quality breast surgical care delivery.

Unique Pain Management Needs for Pregnant Women with Pre-existing PTSD and Other Mental Health Disorders

This review describes how the presence of maternal mental health disorders influences peripartum pain. It provides practical guidance for tailored anesthetic plans that address the unique needs of pregnant women with such disorders. The role of maternal mental health conditions in the peripartum experience and postpartum course for the mother-baby dyad is an evolving area of interest in the current psychiatric and obstetric literature. It is only recently, however, that providers are beginning to understand how pre-existing maternal posttraumatic stress disorder (PTSD), anxiety, or depression influences how these patients perceive pain during labor or cesarean section. There is, unfortunately, a lack of understanding and consistency in the approach to pain management for these patients. Emphasis on recognition of these unique patient needs and tailoring of peripartum pain management strategies is crucial in helping to achieve a positive birth experience and minimize increased postpartum mental health symptom severity and/or chronic pain for these patients. Peripartum pain during labor and/or surgical delivery can be influenced by a pre-existing history of mental health conditions. Specialized pain assessment and management strategies should accommodate the unique needs of these patients.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal.

The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic. A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis. There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008]. During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

HELLP-СИНДРОМ: ОСОБЕННОСТИ ТЕЧЕНИЯ

The article describes a clinical case of HELLP-syndrome in the early postpartum period. The relevance of the presented case determines by the complexity of differential diagnosis and the high risk of complications. HELLP-syndrome establishes on the basis of the results of clinical, laboratory and instrumental studies after surgical delivery in an emergency. The article describes the features of the clinical course, the results of laboratory and instrumental studies against the background of therapy in the conditions of the resuscitation-anesthesiology and observation departments of the health care institution "Minsk City Clinical Hospital № 1". The importance of timely diagnosis of the presented pregnancy complication with early pathogenetic therapy, rapid and careful delivery of such women is noted.

ОЦЕНКА ПОКАЗАТЕЛЕЙ, ХАРАКТЕРИЗУЮЩИХ ОКАЗАНИЕ ХИРУРГИЧЕСКОЙ ПОМОЩИ В СТАЦИОНАРЕ ПАЦИЕНТАМ СТАРШЕ ТРУДОСПОСОБНОГО ВОЗРАСТА В РОССИЙСКОЙ ФЕДЕРАЦИИ

Significance: Population ageing challanges the majority of the world including the Russian Federation. Older people are more subject to operative interventions, including high tech interventions. The purpose of the study is to analyze indicators characterizing the level of surgical care deivery to older patients in the Russian hospitals in 2011-2019. Material and methods. Indicators characterising surgical care delivery in hospitals were analyzed including: the number of patients operated; the number of operations performed, including high tech interventions; the number of deaths after surgery, including after high tech interventions; frequency of postoperative complications; postoperative mortality among older patients (women - 55 years and older, men - 60 years and older). The authors used data of the federal statistical observation form No. 14 "Information onabout performance of units of medical organizations providing inpatient medical care" for the period from 2011 to 2019. Statistical (calculations of extensive and intensive indicators) and analytical methods were applied. Results. The share of older patients out of all patients operated in 2019 in the Russian hospitals equalled to 35.2% (vs 23.1% in 2011), including high tech interventions (18.9% of all operations). Conclusion: among older patients the study has identified: an 18.8% increse in the number of patients discharged from hospitals; a 5.6% increase in the number of patients operated; a 63.5% increase in the number of operations in the hospital, including a 2.6 fold increase in the number of operations using high technologies; a 73.4 % increase in the number of operated patients who died in the hospital; including a 3.8 fold increase in the number of patients died after operations using high technologies; postoperative mortality rate of patients increased from 2.21 to 2.39%. The rate of postoperative complications associated with all operations decreased from 1.06 to 0.64%, including decrease from 1.74 to 0.97% in postoperative complications associated with operations using high technologies.

Appraisal of caesarean section incidence and indications at manipal teaching hospital, Pokhara, Nepal

Background: Worldwide lower segment caesarean section (LSCS) is the most commonly performed obstetric operation. Though it’s a lifesaving procedure it is sometime associated with both short and long term risk which can extend many years beyond current delivery and affect health of mother, fetus and future pregnancy.&#x0D; Aims and Objective: The study aims to examine the incidence and indication of caesarean section at Manipal teaching hospital.&#x0D; Materials and Methods: A retrospective descriptive study of 2140 cases was carried out at a teaching hospital in Pokhara, Nepal. Data regarding total number of vaginal delivery and caesarean section performed in 1 year duration from August 2019 to July 2020 was obtained from the operation record book and medical record section of hospital. Other information regarding age, parity, gestational period and indication of cesarean section were obtained and depicted in tabulated form. The collected secondary data has been analyzed employing frequencies and percentage.&#x0D; Results: During the one year study period, 2140 deliveries were made out of which 1170 (54.7%) cases underwent caesarean section. Out of those cases 78.8% of women underwent emergency LSCS. Most of the women were in the age group of 21-30 years (69.2%). In 81.2% cases caesarean was done between 38-42 weeks gestation. 52.3% of cases were multigravida, 43.8% were primigravida and only 3.1% were grand multigravida. Most common indication of caesarean were fetal distress (23.7%), previous LSCS (23%), cephalopelvic disproportion (15.6%), oligohydramnios (11%) followed by breech, preeclampsia, eclampsia and non-progress of labour.&#x0D; Conclusion: This study revealed that the incidence of caesarean section was high in the hospital and majority of the patients who underwent caesarean section had an emergency caesarean section. The commonest indications were fetal distress and repeat cesarean section. The issue requires further investigation to identify reasons for high CS rate and raises necessity of policy guidelines and intervention in order to prevent possible unjustified use of surgical delivery.

Диагностика и хирургическая коррекция истмоцеле после кесарева сечения

Objective. To compare the efficacy of different methods of surgical correction of isthmocele after caesarean section. Patients and methods. The study included 56 patients aged 29–41 years, who were divided into three groups: group 1 (n = 16) – patients who underwent surgical laparoscopy with suturing the uterine wound with single-row separate muscularmuscular sutures; group 2 (n = 23) – patients after repair of the uterus with a double-row continuous seromuscular and muscular-muscular suture performed by laparoscopy; group 3 (n = 17) consisted of patients who underwent laparotomy and suturing the uterine wound with a double-row continuous suture. Results. We developed a three-stage plastic and reconstructive surgical laparotomic and laparoscopic program in case of the uterine scar incompetence, which improved the quality of life in all patients. Pregnancy occurred 9–14 months after plastic and reconstructive surgery on the uterus and resulted in timely surgical delivery in 4 (25%) patients in group 1, in 7 (30.4%) patients in group 2 and in 3 (17.6%) patients in group 3. Two (12.5%) patients in group 1 and three (13.04%) patients in group 2 were observed during pregnancy with a period of 10–28 weeks. Conclusion. The use of laparoscopy ensured better visualization of anatomical structures (vessels, nerves, ureters, bladder), which led to a decrease in intraoperative blood loss, in the risk of damage to adjacent organs and in the development of adhesions, and to accelerated postoperative rehabilitation of patients. Key words: double-row suture, istmocele, laparoscopy, metroplasty

Investigation of uterine vessel perfusion of the failure uterus scar after cesarean section

In modern conditions, due to the increased frequency of cesarean section, which is not only a method of surgical delivery of pregnant women, but also surgery, there are problems in the reproductive health of operated women.Given the solution of many aspects of re-cesarean section, the issues of determining the diagnostic criteria for failure of uterus scar, their diagnostic value and use in practical medicine remain debatable.The objective: the investigate the features of uterine perfusion in pregnant women after a previous cesarean section and develop criteria for predicting the failure of the uterus scar.Materials and methods. A comprehensive two-stage (before and during pregnancy) examination of 180 women with a uterus scar after a previous cesarean section for the period from 2014–2019. Women were divided into groups and subgroups depending on the time of pregnancy.Results. Based on the conducted clinical and anamnestic data and the results of ultrasound examinations of the operated uterus, we detected changes in the blood flow of the uterine arteries and developed an arterial perfusion index in pregnant women. Using the proposed index, the features of arterial perfusion in women of childbearing age, depending on the time of pregnancy and the failure of the uterus scar after a previous cesarean section. This allowed us to determine the limit values of this indicator for each group of women, in which the value of this indicator differed significantly from healthy women. The proposed limit levels of uterine perfusion allow to diagnose uterine perfusion disorders during pregnancy at different times.Conclusion. Determining the arterial perfusion index in pregnant women expands the diagnostic capabilities of physician in determining the condition of the postoperative uterus scar after a previous cesarean section and is an additional preventive measure to determine its failure. The output of the values of this indicator beyond the predicted threshold values will require additional diagnostic actions on the part of the physicians to find additional combined pathology that may affect uterine blood perfusion.