Analysis of the anxiety and depression in patients with gallbladder polyps, gallbladder stones and post-cholecystectomy / 中华消化杂志

Objective:To investigate the anxiety and depression in patients with gallbladder polyps, gallbladder stones and post-cholecystectomy.Methods:From December 2020 to August 2021, consecutive patients who visited the Department of Gastroenterology, First Affiliated Hospital of Air Force Medical University, were enrolled and divided into normal gallbladder group, gallbladder polyp group, gallbladder stone group and post-cholecystectomy group, with 100 patients in each group. Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) were used to evaluate patients′ anxiety or depression. Quality of life, sleep quality and severity of gastrointestinal symptom were assessed by short form 36 (SF-36), Pittsburgh sleep quality index (PSQI) scale and gastrointestinal symptom rating scale (GSRS) respectively. The incidence of anxiety or depression of patients in the 4 groups were compared, and the related risk factors of anxiety and depression were analyzed. Chi-square test and multiple logistic regression were used for statistical analysis.Results:Among 400 patients, 89 patients (22.2%) suffered from anxiety; and the incidences of anxiety of normal gallbladder group, gallbladder polyp group, gallbladder stone group and post-cholecystectomy group were 9.0% (9/100), 19.0% (19/100), 25.0% (25/100) and 36.0% (36/100) respectively. There was statistically significant difference in the incidence of anxiety among the 4 groups ( χ2=22.12, P<0.001). The incidence rates of anxiety of the gallbladder polyp group, gallbladder stone group and post-cholecystectomy group were all higher than that of the normal gallbladder group, and the differences were all statistically significant ( χ2=4.15, 9.07 and 20.90, P=0.042, 0.003 and <0.001). The incidence of anxiety of post-cholecystectomy group was higher than that of gallbladder polyp group, and the difference was statistically significant ( χ2=7.25, P=0.007). Among the 400 patients, 70 patients (17.5%) suffered from depression. The incidence rates of depression of the normal gallbladder group, gallbladder polyp group, gallbladder stone group and post-cholecystectomy group were 5.0% (5/100), 10.0% (10/100), 24.0% (24/100) and 31.0% (31/100) respectively. There was statistically significant difference in the incidence of depression among the 4 groups ( χ2=30.27, P<0.001). The incidences of depression of the gallbladder stone group and post-cholecystectomy group were both higher than that of the normal gallbladder group and gallbladder polyp group, and the differences were statistically significant ( χ2=14.56, 22.90, 6.94 and 13.53, P<0.001, <0.001, =0.008 and <0.001). The results of multivariate analysis showed that history of cholecystectomy, history of coronary heart disease, consumption of overnight food ≥3 times per week, PSQI score ≥ 8 and GSRS score ≥9 were independent risk factors for anxiety ( OR, 95%confidence interval: 4.02, 1.60 to 10.13; 10.01, 2.15 to 46.68; 4.15, 1.87 to 9.19; 4.69, 2.58 to 8.52; 3.02, 1.64 to 5.58; P=0.003, 0.003, <0.001, <0.001, and <0.001). Gallbladder stones history of cholecystectomy, consumption of overnight food ≥3 times per week, consumption of fresh fruit < 200 g/d, PSQI score ≥8 and GSRS score ≥9 were independent risk factors for depression ( OR, 95%confidence interval: 4.40, 1.38 to 14.06; 4.97, 1.54 to 16.12; 4.23, 1.61 to 11.08; 3.78, 1.32 to 10.85; 5.59, 2.78 to 11.27, 4.19, 1.94 to 9.04; P=0.012, 0.007, 0.003, 0.014, <0.001 and <0.001). Conclusions:The incidences of anxiety and depression in patients with gallbladder stones or post-cholecystectomy are higher than that of people with normal gallbladder. A history of cholecystectomy is the independent risk factor for anxiety and depression. Gallbladder stones is the independent risk factor of depression. Clinical attention should be paid to the mental state of patients with gallbladder polyps, gallbladder stones, especially post-cholecystectomy.

Cáncer de vesícula biliar, una visión actual / Gallbladder cancer, a current view

Introducción. El diagnóstico de cáncer de vesícula biliar se realiza generalmente de forma incidental durante el estudio de las piezas quirúrgicas o cuando la enfermedad está avanzada y se expresa por su diseminación. Muy pocas veces se diagnostica de forma preoperatoria. Corresponde a la neoplasia más común de las vías biliares y su incidencia varía de acuerdo a la región geográfica. La región andina en Latinoamérica presenta una de las mayores incidencias a nivel mundial. Métodos. Se realizó una revisión narrativa de la literatura, para presentar una información actualizada en lo referente a los factores de riesgo (incluyendo las alteraciones genéticas y moleculares), al diagnóstico y al tratamiento de esta patología. Basados en los datos actuales, presentamos algunas recomendaciones dirigidas al diagnóstico temprano, que permita un manejo más adecuado de nuestros pacientes. Resultados. Se han implicado nuevos factores de riesgo relacionados con la etiología del cáncer de vesícula biliar, como la obesidad, factores genéticos y moleculares. A pesar de la disponibilidad de los métodos diagnósticos imagenológicos, no ha ocurrido una importante variación porcentual en cuanto al estadio al momento del diagnóstico. Conclusiones. El manejo quirúrgico del cáncer de vesícula biliar está indicado en los estadios más tempranos de la enfermedad y es importante evaluar las opciones terapéuticas en pacientes con enfermedad avanzada. Se considera de suma importancia el estudio anatomopatológico de la pieza quirúrgica y la revisión del informe por parte del cirujano.

Introduction. The diagnosis of gallbladder cancer is generally made incidentally during the study of the surgical pieces or when the disease is advanced and is expressed by its dissemination. It is rarely diagnosed preoperatively. It corresponds to the most common neoplasm of the bile ducts and its incidence varies according to the geographical region. The Andean region in Latin America presents one of the highest incidents worldwide. Methods. A narrative review of the literature was carried out to present updated information regarding risk factors (including genetic and molecular alterations), diagnosis and treatment of this pathology. Based on current data, we present some recommendations aimed at early diagnosis, which allows a more adequate management of our patients. Results. New risk factors related to the etiology of gallbladder cancer have been implicated, such as obesity, genetic and molecular factors. Despite the availability of diagnostic imaging methods, there has not been a significant percentage variation in terms of stage at diagnosis. Conclusions. Surgical management of gallbladder cancer is indicated in the earliest stages of the disease and it is important to evaluate therapeutic options in patients with advanced disease. The pathological study of the surgical piece and the review of the report by the surgeon are considered of utmost importance.

Frequency of Gallbladder Stones Among Patients Underwent Abdominal Ultrasound in a Tertiary Hospital in Sana’a City, Yemen

@#Introduction: The Gallbladder stone (GBS) disease is most commonly asymptomatic that may lead to several complications such as ascending cholangitis and obstructive jaundice. In this study the frequency of gallbladder stones among patients referred for abdominal ultrasound at the University of Science and Technology hospital (USTH), Sana’a – Yemen, have been estimated during the period between January and June 2013. Methods: This study is a record-based and conducted at the radiology department in USTH, on cases underwent abdominal ultrasound during the period from January – June 2013. Information were collected from abdominal ultrasonography reports. Results: In this study 4935 patients’ records are included. Of them, 2541 were males and 2394 were females. The frequency of patients with GBS was 5.53%. Multiple stones were observed in 3.57% of patients and 4.34% patients had large stones with size ≥ 5 mm. Females had significantly higher frequency of GBS (8.0%: 191/2394) than males (3.2%: 82/2541) (P < 0.001). It was found that, no significant difference between males and females in harboring small stones (< 5mm) (P = 0.251). However, significantly higher frequency of large GBS (≥ 5 mm) was found among females compared to males (P < 0.001). The frequencies of GBS, small size of GBS and large size of GBS have significantly increased with increasing age (P < 0.001). Conclusion: In this study it was found that females had significantly higher frequency of GBS than males. No significant difference between males and females in harboring small stones. There was a significantly higher frequency of large GBS was found among females compared to males. The frequencies of GBS, small size of GBS and large size of GBS have significantly increased with increasing age.

Analysis on microbial community diversity in gallbladder stone and mucosa based on Illumina Miseq platform / 重庆医学

Objective To investigate the microbial community diversity in stone and mucosa from the patients with gallbladder stone.Methods The gall bladder mucosal samples in 60 cases(case group) of gallbladder stone treated by cholecystectomy amd 11 cases (control group)of liver right anterior lobe hemangioma in this hospital from January to December 2014 were selected for conducting the bacterial culture.The stone and mucosa in the patients with negative culture results were performed the Illumina Miseq sequencing analysis.Results A total of 71 cases were included in the study.The microbial community DNA in the control group samples was not detected out.The bacterial DNA detection rate of samples in the case group was 94.2％;in regardless of the type of sample,the most dominant was Phylum Proteobacteria.The composition proportion of stone and mucosal microbial community in the patients with same type of stone was relatively consistent,whereas different types of composition had large difference.Conclusion Using the Illumina Miseq sequencing analysis can effectively evaluate the gallbladder microbial community diversity in the patients with gallbladder stone.

The Value and Discussion of Cystic Duct Variation Diagnosed by MRCP / 昆明医科大学学报

Objective To observe the normal anatomy and variation of cystic duct by MRCP, and to explore the correlation between anatomic variation and gallbladder stones. Methods To have a retrospective analysis of 371 MRCP patients which meet the requirement of imaging, and to compare the differences between anatomic variation and gallbladder stones with normal cystic duct. Results Among 371 patients, 63 had anatomic variations, A among which,22 had compound variations with 85 variation points in total.The percentage of mutation rate was 16.98%. 53 patients with variation of cystic duct had gallbladder stones, and 182 patients without variation of cystic duct had gallbladder stones. Conclusions MRCP can clearly display different variations of cystic duct, and the patients with variation of cystic duct have higher risks in gallbladder stones than the patients without variations.

The clinical effect of inhibition about gallstone stone after extracorporeal shock wave by Liver gallstones sheet / 中国生化药物杂志

Objective To observe the clinical effect of inhibition about gallstone stone after extracorporeal shock wave by Liver gallstones sheet. Methods 60 patients diagnosed gallstone stone from July 2015 to November 2016, randomly divided into treatment group and control group. he treatment group received oral treatment of liver gallstones sheet, control group without special treatment, patients were followed up and recorded gallbladder wall thickness, gallbladder function and gallstone patients were relapse situation, using statistical methods to analyze data. Results After one year observation of patients gallbladder wall thickness, gallbladder function scores were (2.79±0.34,57.70±4.80) than the control group (3.14±0.39,53.13±5.01), and the differences were statistically significant (P<0.05). After one year observation group gallstone recurrence rate was 10.0%, far lower than the control group, 43.3%, and the difference was statistically significant (P<0.05). Conclusion It is worthy of further research and application and it has a good clinical results for the liver gallstones sheet after extracorporeal shock wave lithotripsy inhibition of gallstone stone.

Case-control study on necessity of cholecystectomy for patients with bile duct stones combined with gallbladder stones after clearance of stones / 中华消化内镜杂志

Objective To discuss necessity of cholecystectomy for patients with stones in their bile ducts and gallbladders in the absence of absolute operation indications of cholecystectomy after clearance of bile duct stones with ERCP. Methods Data of less than 70-year-old patients with stones in their bile ducts and gallbladders but without absolute operation indications of cholecystectomy admitted to the First People′s Hospital of Hangzhou from January 2012 to December 2014 were retrospectively analyzed. Patients were divided into cholecystectomy group and gallbladders in situ group after bile duct stones removal with ERCP. The hospitalization time, recurrent biliary events, complications of operation were compared between two groups. Results A total of 128 patients were included and followed up for(24.031±9.170)months with 64 cases in conservative group and 64 cases in cholecystectomy group. Incidence of recurrent biliary events in the cholecystectomy group and conservative group were 7.8%(5/64)and 10.9%(7/64)(P=0.544). Among cases of recurrent biliary events,incidences of cholangitis in the two groups were 7.8%(5/64)and 4.7%(3/64)respectively(P= 0.465), incidences of pancreatitis were 0(0/64)and 1.6%(1/64) respectively(P=0.315), incidences of common bile duct stones were 7.8%(5/64)and 7.8%(5/64)respectively(P = 1). No recurrent cholecystitis occurred. There were no differences in ERCP-related complications between the cholecystectomy group[23.4%(15/64)]and the conservative group[12.5%(8/64)](P=0.107). But 4 patients(6.3%)in cholecystectomy group had LC-related complications during the follow-up period, 3 cases of infection and 1 ileus. The hospital stay in conservative group was shorter than that in cholecystectomy group(5.906± 4.614 days VS 14.313± 6.312 days, P<0.001). The hospitalization expenses in two groups were(45 196± 12 518)yuan and(22 160± 11 755)yuan(P<0.001). Conclusion Conservative methods yield to shorter hospitalization and lower expenses without cholecystectomy-related complications. Conservative management for gallbladder stones after ERCP for biliary duct stones is recommended for patients who had no absolute operation indications of cholecystectomy.

Combination of open and laparoscopic surgery in treatment of elderly patients with gallbladder stones combined with common bile duct stones / 中国内镜杂志

Objective To investigate the clinical effects and safety of combination of open and laparoscopic surgery in treatment of elderly patients with gallbladder stones combined with common bile duct stones. Methods 140 elderly patients with gallbladder stones combined with common bile duct stones from May 2014 to May 2015 were randomly divided into control group (65 patients) with traditional open surgery and observation group (65 pa﹣tients) with combination surgery; then compared the perioperative clinical indicators, the total removal rate of stone, the postoperative analgesic used rate and postoperative complications incidence of the two groups. Results The oper﹣ation time, intraoperative blood loss volume, the exhaust time for first time and hospital staying time of observation group was significantly better than control group (P 0.05). The postoperative analgesic used rate of observation group was sig﹣nificantly lower than control group (P< 0.05). The postoperative complications incidence of observation group was significantly lower than control group (P< 0.05). Conclusion Compared with traditional open surgery, combination surgery in treatment of elderly patients with gallbladder stones combined with common bile duct stones can efficient﹣ly shorten the operation time, speed up the recovery process, reduce the degree of trauma and postoperative pain and helpful to prevent the postoperative complications.

Comparison of Three Treatment Methods for Cholecystolithiasis with Commom Bile Duct Stones / 昆明医科大学学报

Objective To summarize the clinical experience of three different treatments for gallbladder and common bile duct stones.Methods The clinical data of 180 cases of gallbladder stones combined with bile duct stones undergoing surgery from May 2010 to May 2013 were retrospectively analyzed.They were divided into three groups,A group of 60 patients underwent a period of endoscopic sphincterotomy (EST),under the second phase of laparoscopic cholecystectomy (LC);Group B 60 patients underwent laparoscopic cholecystectomy (LC) + laparoscopic common bile duct exploration surgery (LCBDE) + T tube drainage;Group C 60 patients underwent conventional open cholecystectomy (OC) + bile duct exploration (OCBDE) + T tube drainage.Results A group of 53 cases completed surgery successfully,5 cases of remaining 7 patients failured in the first phase surgery,2 cases of the 5 patients did LC + LCBDE,3 of the 5 patients underwent conventional surgery.Two patients underwent the conventional surgery in the second phase surgery.B group of 57 cases completed surgery successfully,three cases convert to open surgery.All of the group C completed the surgery successfully.Group A complication was the most in the three groups (P＜0.05);group B had the shortest time of hospitalization (P＜0.05),the complication rate was lower than that in group A (P＜0.05),the complication had no significant difference between A and B.(P and group B ＞ 0.05),group B had shortest operation time (P＜0.05);no statistically significant differences were found among three groups in fasting time.Conclusion Three treatment methods have advantages as well as disadvantages,a reasonable treatment should be selected according to the specific circumstances.

Association between Clonorchis sinensis infection and the subtypes of mixed gallbladder stones / 中华肝胆外科杂志

Objective A systematic study to classify mixed gallbladder stones to determine their relationship with Clonorchis sinensis infection.Methods 349 consecutive patients with mixed gallbladder stones were enrolled into this study and their gallstones were studied.The material composition of gallbladder stones was analyzed using Fourier Transform Infrared spectroscopy,and the distribution and microstructure of the material components were studied using Scanning Electron Microscopy.The composition and distribution of the elements were analyzed by an X-ray energy spectrometer.Gallbladder stones were classified accordingly,and the stones were then grinded for microscopic examination.The stones were divided into two groups based on the results of detection of clonorchis sinensis eggs.Patients were also divided into two groups according to the patients' region (high-incidence and low-incidence regions of Clonorchis sinensis infection).The diversity of the subtypes of mixed gallbladder stones was compared.Results 14 subtypes were found,including Bilirubinate-calcium carbonate mixed stones (n =134),Cholesterol-bilirubinate mixed stones (n =87),Bilirubinate-phosphate mixed stones (n =39),Cholesterol-calcium carbonate mixed stones (n =30),Cholesterol-bilirubinate-calcium carbonate mixed stones (n =15),etc.Bilirubinate-calcium carbonate mixed stones were the main subtype of egg-positive mixed gallbladder stones and the patients were from high-incidence regions.Cholesterol-bilirubinate mixed stones were the main subtype of egg-negative mixed gallbladder stones and patients were from low-incidence regions.The differences of the subtypes constituent between the high-incidence and low-incidence regions groups were significant (P ＜ 0.05),and between the egg-positive and egg-negative groups were also significant (P ＜ 0.05).Conclusions The most common subtypes of mixed gallbladder stones were bilirubinate-calcium carbonate mixed stones,while the second was cholesterol-bilirubinate mixed stones.Clonorchis sinensis infection was mainly associated with Bilirubinatecalcium carbonate mixed stones.

Optimal timing for laparoscopic cholecystectomy after endoscopic sphincterotomy / 中华肝胆外科杂志

Objective To determine whether it is better to carry out laparoscopic cholecystectomy (LC) immediately or 3 days after endoscopic sphincterotomy (EST) in patients with common bile duct stones and gallbladder stones.Methods A retrospective study was conducted on 160 patients who had common bile duct stones and gallbladder stones treated from July 2013 to July 2015 in the First People's Hospital of Huizhou.These patients were divided into a control group and an observation group,with 80 patients in each group.The control group underwent LC immediately after EST,while the observation group underwent LC 3 days after EST.The levels of blood amylase before LC,operation time,intraoperative bleeding volume,postoperative time to first flatus,postoperative complication after EST,postoperative hospitalization stay,total hospitalization stay and total hospital costs and incidences of postoperative complication after LC were compared between the two groups.Results The time periods of total hospitalization stay in the observation group and the control group were (18.2 ±3.5) d and (12.3 ±3.0) d,respectively (P＜0.05).The total costs in the two groups were (32 164 ±9 125) RMB and (22 375 ±7 860) RMB,respectively (P ＜ 0.05).The overall incidences of postoperative complication [patients (％)] were 5 (6.3) and 9 (11.3),respectively (P ＜ 0.05).The differences on preoperative serum amylase levels,LC operative time,blood loss,postoperative time to first flatus and postoperative hospitalization stay were not significantly different (P ＞ 0.05).Conclusion LC carried out on day 3 after EST to treat common bile duct stones and gallbladder stones was clinically more efficacious.

The clinical value of ultrasonography in the diagnosis of fetal gallstones / 中国基层医药

Objective To explore the clinical value of ultrasound in the diagnosis of fetal gallbladder stones and the mechanism of fetus gallstones.Methods 21 020 pregnant women were taken routine ultrasound,and the results were analyzed.Results Of 21 020 pregnant women,15 cases were suspected fetal gallbladder stones,including 10 males,5 females.The detection rate was 7.14/10 000.11 cases were close to gestational age,2 cases were greater than the actual gestational age and 2 cases were smaller than the actual gestational age.The echogenic in the fetal gallbladder showed granular,lumpy,banded.Occasionally,posterior echo enhancement was found rear.In 15 cases of suspected fetal gallbladder stones,12 cases disappeared two weeks after birth and the other 3 cases disappeared in the six months after the birth.Conclusion Ultrasound can confirm diagnosis of fetal gallbladder.There is important value in the diagnosis of suspected fetal gallbladder stones.The mechanism for echogenic might be fetal common bile duct reflux of intestinal contents.

Syslematic classification of gallbladder stones / 中华肝胆外科杂志

Objective To develop a classification of gallbladder stones,to analyze the clinical characteristics of each type of stone and to provide a theoretical basis for the formation of different types of gallbladder stones.Method 925 consecutive patients with gallbladder stones were enrolled and their gallstones were studied.The material composition of the gallbladder stones was analyzed using fourier transform infrared spectroscopy and the distribution and microstructure of the material components were observed using scanning electron microscopy.The composition and distribution of the elements were analyzed by an X-ray energy spectrometer.Gallbladder stones were classified accordingly.Results The gallbladder stones were classified into 8 types and more than ten subtypes,including cholesterol stones (n =334),pigment stones (n =246),calcium carbonate stones (n =167),phosphate stones (n =14),calcium stearate stones (n =11),protein stones (n =3),cystine stones (n =1) and mixed stones (n =149).Mixed stones were those stones with two or more than two kinds of material components and the content of each component was similar.A total of 11 subtypes of mixed stones were found in this study.Conclusion The systematic classification of gallbladder stones indicated that different types of stones had different characteristics in terms of infrared spectrogram,microstructure,elemental composition and distribution,thus providing an important basis for the mechanistic study of gallbladder stones.

Association between hyperlipemia and gallbladder stones / 吉林大学学报(医学版)

Objective To study the relationship between plasma lipids and gallbladder stones(GD).Methods The plasma lipids levels were determined and GD was diagnosed by ultrasonic instrument in 5 982 subjects,then the occurrence of GD was compared between hyperlipemia and no-hyperlipemia.Results The detectable rate of GD of the hyperlipemia was 9.86% and that of the no-hyperlipemia was 7.00%,the difference was significant(P0.05,OR=1.223,95%CI:1.127-2.748).Conclusion The prevalence rate of GD in hyperlipemia patients is higher than that in normal plasma lipids subjects.The sick risk of GD in patients with hypercholesterolemia is much higher than that in persons with normal total cholesterol levels.Sex has no influence on the formation of GD in hyperlipemia patients.

Analysis of Gallbladder Stones in Chungbuk

PURPOSE: Approximately 10% of the general population in western countries have gallstones. The compositions of gallstones, however, vary with location and ethnicity. The purpose of this study is to analyze the gallbladder stones of patients in Chungbuk and mainly to compare the compositions of the gallstones with those in other reports. METHODS: The patients in this study included gallbladder stone patients (N=318) who were operated on in Chungbuk National University Hospital from January 1992 to December 1997. By gross inspection of their cut surface structures, the gallstones were classified as pure cholesterol stones, mixed stones, brown stones, and black pigment stones. The chemical compositions of the stones (N=35) that were collected during January and February 1997 were analyzed using high- pressure liquid chromatography (HPLC). RESULTS: By inspection, 31 (9.7%) stones were classified as pure cholesterol stones, 54 (17%) as mixed stones, 27 (8.5%) as brown stones, and 206 (64.8%) as black pigment stones. The results of HPLC analysis were as follows; 5 (15%) stones had cholesterol contents higher than 90% of their composition, 5 (15%) stones 50 to 90%, and 25 (70%) stones less than 20%. CONCLUSION: Of the galldder stones of patients in Chungbuk 73.3% were pigment stones. This result was compatible with the HPLC results (70% of the stones have less than a 20% cholesterol content). The classification of the gallbladder stones of the patients in Chungbuk shows that the incidence of black pigment stones is very high while that of cholesterol stones is low. The difference is even greater when compared with the data in other papers published in Korea. The causes of the difference be remained to be clarified.

Early results of extracorporeal shock wave lithotripsy for gallbladder stones

Extracorporeal shock wave lithotripsy combined with medical therapy for stone dissolution is a safe and effective treatment in selected patients with cholelithiasis. This conclusion was derived at from studies on non-surgical approaches, such as stone dissolution by oral administration of bile acids and that employing extra corporeal shock wave treatment on human gallstones implanted in the gallbladders of dogs. Gallstone disintegration has been reported by Sachman in 30% of patients within two months after lithotripsy, in 48% at the two to four months, in 63% at four to eight months, in 78% at eight to twelve months and in 91% at twelve to eighteen months. Various data differ as to the number, size and radiologic characteristics of gallstones To date, there has been no single report about ESWL treatment of gallstones in the Philippines. In this regard, we used this non-surgical procedure to treat 55 patients with cholelithiasis at the Stone Treatment Center from January 1989 to December 1989. To substantiate the early results of gallstone lithotripsy in the Philippines. We are hereby presenting our evaluation. In order to identify which patients would be suitable candidates for this modality of treatment, we analyzed and compared the results of patients with gallstones differing in radiologic characteristics, size and number. Results as to fragmentation rate, stone clearance, treatment failures as well as complications are hereby presented.