ABSTRACT
The objective of this study was to describe the clinical and pathological aspects of diseases of the digestive system in agoutis (Dasyprocta leporina Linnaeus, 1758) diagnosed by the "Laboratório de Patologia Veterinária" (Veterinary Pathology Laboratory) of the "Universidade Federal Rural do Semi-Árido" (UFERSA), from January 2018 to February 2020. During the study period, necropsy and a survey of the clinical history of 27 agoutis were performed, 25.93% (7/27) of which were diagnosed with digestive system diseases. The percentages of digestive tract diseases among the diagnosed were: acute carbohydrate overload (11.12%), gastric ulcer (7.41%), gastric volvulus (3.70%), and intestinal volvulus (3.70%). Studies on the occurrence rate of these diseases, as well as the description of their clinical and anatomopathological aspects, may serve as a basis for guiding the appropriate management in the breeding of these animals.(AU)
O objetivo deste estudo foi descrever os aspectos clínicos e patológicos das doenças do aparelho digestivo em cutias (Dasyprocta leporina Linnaeus, 1758) diagnosticadas pelo Laboratório de Patologia Veterinária da Universidade Federal Rural do Semiárido (UFERSA), de janeiro 2018 a fevereiro de 2020. Durante o período do estudo, foram realizadas necropsias e levantamento da história clínica de 27 cutias, sendo 25,93% (7/27) diagnosticadas com doenças do aparelho digestivo. Os percentuais de doenças do aparelho digestivo foram: sobrecarga aguda de carboidratos (11,12%), úlcera gástrica (7,41%), vólvulo gástrico (3,70%) e vólvulo intestinal (3,70%). Estudos sobre a taxa de ocorrência dessas doenças, bem como a descrição de seus aspectos clínicos e anatomopatológicos, podem servir de base para orientar o manejo adequado na criação dessa espécie.(AU)
Subject(s)
Animals , Digestive System Diseases/pathology , Dasyproctidae , Stomach Ulcer/pathology , Stomach Volvulus/pathology , Intestinal Volvulus/pathology , Diet, Carbohydrate Loading/mortalityABSTRACT
The objective of this study was to describe the clinical and pathological aspects of diseases of the digestive system in agoutis (Dasyprocta leporina Linnaeus, 1758) diagnosed by the "Laboratório de Patologia Veterinária" (Veterinary Pathology Laboratory) of the "Universidade Federal Rural do Semi-Árido" (UFERSA), from January 2018 to February 2020. During the study period, necropsy and a survey of the clinical history of 27 agoutis were performed, 25.93% (7/27) of which were diagnosed with digestive system diseases. The percentages of digestive tract diseases among the diagnosed were: acute carbohydrate overload (11.12%), gastric ulcer (7.41%), gastric volvulus (3.70%), and intestinal volvulus (3.70%). Studies on the occurrence rate of these diseases, as well as the description of their clinical and anatomopathological aspects, may serve as a basis for guiding the appropriate management in the breeding of these animals.
O objetivo deste estudo foi descrever os aspectos clínicos e patológicos das doenças do aparelho digestivo em cutias (Dasyprocta leporina Linnaeus, 1758) diagnosticadas pelo Laboratório de Patologia Veterinária da Universidade Federal Rural do Semiárido (UFERSA), de janeiro 2018 a fevereiro de 2020. Durante o período do estudo, foram realizadas necropsias e levantamento da história clínica de 27 cutias, sendo 25,93% (7/27) diagnosticadas com doenças do aparelho digestivo. Os percentuais de doenças do aparelho digestivo foram: sobrecarga aguda de carboidratos (11,12%), úlcera gástrica (7,41%), vólvulo gástrico (3,70%) e vólvulo intestinal (3,70%). Estudos sobre a taxa de ocorrência dessas doenças, bem como a descrição de seus aspectos clínicos e anatomopatológicos, podem servir de base para orientar o manejo adequado na criação dessa espécie.
Subject(s)
Animals , Dasyproctidae , Digestive System Diseases/pathology , Diet, Carbohydrate Loading/mortality , Stomach Volvulus/pathology , Intestinal Volvulus/pathology , Stomach Ulcer/pathologyABSTRACT
RESUMEN El vólvulo gástrico agudo (VGA) es una entidad infrecuente, con elevada mortalidad de hasta 50%, y su diagnóstico se basa en un alto nivel de sospecha clínica. En el paciente estable se puede plantear manejo no operatorio, pero en el inestable se impone el tratamiento quirúrgico. Presentamos el caso de un paciente con VGA e inestabilidad hemodinámica, en el cual se realizó laparotomía y devolvulación gástrica, pero falleció en el posoperatorio inmediato por shock refractario.
ABSTRACT Acute gastric volvulus (AGV) is an uncommon condition with high mortality (up to 50%) and its diagnosis is based on high level of suspicion. Conservative management can be attempted in stable patients, but the surgical approach is indicated in unstable cases. We report the case of a patient with AGV and hemodynamic instability who underwent laparotomy with reduction of the volvulus but who died in the immediate postoperative period due to refractory shock.
Subject(s)
Humans , Male , Adult , Stomach Volvulus/diagnostic imaging , Postoperative Period , Stomach Volvulus , Mortality , Intestinal Volvulus , Hemodynamics , LaparotomyABSTRACT
Resumen El vólvulo gástrico es una entidad rara que puede presentarse de manera aguda o crónica y se acompaña de síntomas inespecíficos. Es fundamental su rápida identificación, ya que tiene alta mortalidad y el tratamiento oportuno de esta patología determina el pronóstico del paciente. A continuación, presentamos el caso de una paciente femenina de 89 años, que consulta por cuadro clínico de dolor torácico atípico, con documentación en radiografía de tórax de vólvulo gástrico organoaxial, en quien se realiza inicialmente devolvulación endoscópica con éxito. Sin embargo, en las imágenes de control se evidencia recurrencia del vólvulo, por lo cual se realizó manejo quirúrgico con hiatoplastia y funduplicatura tipo Toupet, además de gastrostomía percutánea de fijación, procedimiento realizado sin complicaciones, con los que se logró la devolvulación completa sin recurrencia.
Abstract Gastric volvulus is a rare condition that can occur acutely or chronically and is accompanied by nonspecific symptoms. Its rapid identification is critical since it has high mortality rate and timely treatment determines the patient's prognosis. The following is the case of an 89-year-old female patient who presented with atypical chest pain, with organoaxial gastric volvulus on chest X-ray, in whom endoscopic devolvulation was initially performed successfully. However, control imaging scans revealed recurrence. Therefore, surgical management included hiatoplasty and Toupet fundoplication, as well as percutaneous fixation gastrostomy, a procedure that was completed without complications and resulted in complete devolvulation without recurrence.
Subject(s)
Humans , Female , Aged, 80 and over , Stomach Volvulus , Gastrostomy , Therapeutics , RadiographyABSTRACT
El vólvulo gástrico es una condición potencialmente mortal, consistente en la rotación anormal del estómago sobre un eje sostenido por dos partes fijas. Produce síntomas inespecíficos, lo cual, junto con su baja incidencia, hace difícil el diagnóstico. Se hizo una revisión bibliográfica y se presentan dos pacientes con diagnóstico de vólvulo gástrico. En ambos, la presentación clínica fue aguda, pero con diferentes manifestaciones. El abordaje quirúrgico, en uno, fue mediante técnica abierta y, en el otro, mediante laparoscopia (gastrectomía vertical); esta última, con menor morbimortalidad y repercusión en las funciones fisiológicas y anatómicas del paciente. La vía laparoscópica permite abordajes mínimamente invasivos, poco reportada en la literatura, la cual puede ser una opción adecuada para el abordaje en estos pacientes.
Gastric volvulus is a life-threatening pathology characterized by the abnormal rotation of the stomach on an axis formed by two fixed parts, which causes nonspecific symptoms. Together, the low incidence and clinical presentation, makes it a challenging diagnosis. The aim of this article is to review the literature and to present two patients with acute gastric volvulus with different clinical presentation. The first was treated by an open technique and the second one by laparoscopic technique (vertical gastrectomy) which resulted in a lower morbidity and mortality with less impact on the physiological and anatomical functions. Few cases have been reported in the literature and it may be considered an appropriate option for the approach on these patients
Subject(s)
Humans , Stomach , Stomach Volvulus , Gastrectomy , LaparotomyABSTRACT
Introducción: El vólvulo gástrico es el giro del estómago sobre alguno de sus ejes. Objetivo: Realizar una aproximación diagnóstica mediante estudios especiales, describir los diferentes tipos y sus características. Materiales y métodos: Se realizó una búsqueda en el sistema PACS (por las iniciales en inglés de picture archiving and communication system) institucional (2017 a 2019), seleccionando los estudios más representativos con diagnóstico de vólvulo gástrico; posteriormente, se construyeron esquemas para facilitar la comprensión de los hallazgos. Resultados y conclusiones: Esta información le permitirá al radiólogo y, más aún, al residente, abordar este dilema clínico y reconocer por medio de esta excelente herramienta los hallazgos de los dos subtipos (organoaxial y mesenteroaxial), resaltando la importancia de nominarlo adecuadamente, considerando aquellos pacientes sin indicación quirúrgica de emergencia.
Background: Gastric volvulus is when the stomach turns on one of its axes. Objective: To make a diagnostic approach through special studies, describing the different types and their characteristics. Materials and methods: We conducted a search in the institutional PACS (Picture Archiving and Communication System) (2017 to 2019), selecting the most representative studies, with gastric volvulus diagnosis; subsequently, we built schemes to facilitate the understanding of the findings. Results and Conclusions: This information will allow the radiologist and, even more, the radiology resident, to address this clinical dilemma and recognize through this excellent tool the radiological findings of the two subtypes (organoaxial and mesenteroaxial), highlighting the importance of nominating the position, considering those patients with no emergency surgical indication.
Subject(s)
Fluoroscopy , Stomach Volvulus , Gastrointestinal DiseasesABSTRACT
Gastric volvulus (GV) is an uncommon pathology, with 10-20% of cases occurring in children, typically before one year of age. It often occurs in people with congenital diaphragmatic hernias, intestinal malrotation, eventration of the diaphragm, paraesophageal hernias, wandering spleens, asplenism, or intra-abdominal adhesions. We report a rare case of chronic GV after left hemihepatectomy for hepatoblastoma in a child. The patient was a 9-year-old boy who complained of upper abdominal pain and postprandial upper abdominal distension for one year. At the age of 4 months, he was diagnosed with hepatoblastoma and had undergone left hemihepatectomy. The upper gastrointestinal contrast study revealed chronic organoaxial gastric volvulus. After a surgical procedure involving adhesiolysis and an anterior wall gastropexy, the patient improved and the symptoms resolved. Although GV is a rare disease, it should be suspected in a patient with a previous abdominal surgical history who is complaining of abdominal distension and pain.
Subject(s)
Child , Humans , Male , Abdominal Pain , Diaphragm , Gastropexy , Hepatectomy , Hepatoblastoma , Hernia, Hiatal , Hernias, Diaphragmatic, Congenital , Pathology , Rare Diseases , Stomach Volvulus , Wandering SpleenABSTRACT
Resumen Introducción: La hernia diafragmática complicada de presentación tardía constituye una urgencia quirúrgica. Los objetivos del presente estudio son la descripción de las características del diagnóstico de las hernias diafragmáticas de presentación tardía, tratamiento, resultados y la identificación del punto de corte entre el inicio de los síntomas y el desarrollo de necrosis. Pacientes y Métodos: Estudio retrospectivo de una serie de casos constituida por todos los pacientes operados por hernia diafragmática complicada de presentación tardía entre los años 2006 y 2016. Se midieron variables categóricas y continuas que se presentan con estadística descriptiva. Se utilizaron curvas Receiver Operating Characteristics (ROC) a las 6 y 12 h desde el inicio de los síntomas, para determinar el punto de corte del tiempo de presentación clínica en pacientes sometidos a resección de algún órgano. Una vez establecido el punto de corte se calcularon la sensibilidad; especificidad; las razones de verosimilitud positiva y negativa; los valores predictivos positivo y negativo; y la prevalencia. Resultados: La presentación clínica, estudio, diagnóstico y tratamiento fue similar a lo descrito en la literatura quirúrgica. Se estableció el punto de corte a las 12 h con sensibilidad de 80% y especificidad de 83%. Conclusiones: El diagnóstico y tratamiento de estos pacientes debería ser llevado a cabo antes de las 6 h desde el inicio de los síntomas. Aun cuando el universo descrito es reducido, se sugiere que después de las 12 h desde el momento de la estrangulación, los órganos comprometidos se encontrarán necróticos requiriendo resección quirúrgica.
Introduction: Late presentation of traumatic diaphragmatic hernia constitutes a true surgical emergency. The purposes of this study were to describe the diagnostic characteristics, treatment and outcomes of late presentation diaphragmatic hernias and to identify a cutoff point from the onset of symptoms to necrosis development. Patients and Methods: A retrospective series of cases constituted by all patients subjected to emergency diaphragmatic hernia repair form 2006 to 2016 was studied. Categorical and continuous variables were measured and analyzed with descriptive statistics. Receiver Operating Characteristics (ROC) curves at 6 and 12 hours from the onset of symptoms were used to determine the cutoff point for organ resection. Once stablished the cutoff point, sensitivity, specificity, positive and negative predictive values and prevalence were calculated. Results: Clinical presentation, diagnostic study and surgical treatment were similar to what has been already described. The cutoff point was defined at 12 hours from the onset of symptoms with 80% sensitivity and 83% sensibility. Conclusions: The diagnosis and treatment of these cases should be carried on before the first 6 hours after the onset of symptoms. Even though the universe of this study was small, we may suggest that after 12 hours form the onset of symptoms, the implicated organs would be found necrotic requiring surgical resection.
Subject(s)
Humans , Male , Adolescent , Adult , Young Adult , Hernia, Diaphragmatic, Traumatic/complications , Hernia, Diaphragmatic, Traumatic/diagnostic imaging , Stomach Volvulus/etiology , Thoracic Injuries/complications , Time Factors , Radiography, Thoracic , Tomography, X-Ray Computed , Predictive Value of Tests , Retrospective Studies , ROC Curve , Sensitivity and Specificity , Abdominal Injuries/complications , Necrosis/etiologyABSTRACT
Las hernias hiatales, son defectos anatómicos en el hiato diafragmático. Las de tipo "paraesofágicas" son frecuentes, se sabe que atentan contra la vida de una manera potencial, ya que presentan un alto riesgo de complicación de vólvulo y encarcelación lo que incrementa con la edad. Objetivo: establecer una ruta diagnóstica para mejorar el abordaje clínico de esta patología. Caso Clínico: niño de 4 años, con historia de dolor abdominal de 3 meses de evolución en región mesogástrica, que se acompaña de palidez hiporexia y estreñimiento. Laboratorio: hemoglobina 4.3g/dl, hematocrito 13.9%, diagnóstico de anemia, diagnóstico por endoscopía: hernia hiatal tipo III (mixta), mal rotación de estómago. Se trató con funduplicatura Nissen y posteriormente con dilataciones esofágicas. Conclusión: La hernia hiatal es la anormalidad más frecuente del tracto digestivo alto, las de tipo paraesofágico son infrecuentes y debe ser incluida como diagnóstico diferencial en niños con repetidos episodios de infección respiratoria o vómitos a repetición. El estudio diagnóstico de elección es el esofagograma con medio de contraste.
Subject(s)
Humans , Male , Child, Preschool , Abdominal Pain/diagnosis , Hernia, Hiatal/complications , Hernia, Hiatal/diagnosis , Stomach Volvulus/complicationsABSTRACT
La agenesia del mesenterio es una anomalía rara y por esta razón no se piensa cuando se tiene una historia de dolor crónico abdominal. Se han reportado casos de agenesia de mesenterio, partes de intestino y arteria mesentérica superior, junto con atresia intestinal. Este caso corresponde a un paciente pediátrico con agenesia total de mesenterio asociada con vólvulo del íleon y malrotación intestinal. El dolor abdominal crónico en la población pediátrica es una de las consultas más frecuentes en urgencias. Las causas son múltiples pero es importante establecer el diagnóstico oportuno para evitar desenlaces fatales
Mesenteric agenesis is a rare anomaly often not suspected in a child presenting with chronic abdominal pain. Several cases of mesenteric, bowel and upper mesenteric artery agenesis in association with bowel atresia have been reported. Herein, we report a child with total mesenteric agenesis presenting with ileal volvulus and bowel malrotation. Chronic abdominal pain is one the most common complaints in children presenting for emergency care evaluation. The etiologies are multiple but a timely diagnosis is necessary to prevent fatal outcomes.
Subject(s)
Mesentery , Stomach Volvulus , Abdominal PainABSTRACT
El vólvulo de la vesícula biliar es una enfermedad rara y poco frecuente de difícil diagnóstico de manera preoperatoria, ya que las manifestaciones clínicas son atribuidas a otras enfermedades. Se presenta un caso de una paciente femenina de 84años de edad que ingresó en el servicio de cirugía general con un cuadro de dolor abdominal a tipo cólico en hipocondrio derecho acompañado de náusea y vómitos con restos de alimentos. Se realizó examen físico y se indicó ultrasonido abdominal. Se interpretó como una colecistitis aguda litiásica. Se impuso un tratamiento con ceftriaxone. Dado su evolución no desfavorable, cinco días después de su ingreso se realizó la colecistectomía donde se encuentra órgano volvulado. La biopsia confirma colecistitis aguda gangrenada. La paciente evolucionó satisfactoriamente. Tres días posteriores a la cirugía egresó de la institución(AU)
Gallbladder volvulus is a rare and infrequent disease difficult to diagnose preoperatively, as clinical manifestations are attributed to other diseases. A case is presented of an 84-year-old female patient who entered the general surgery service with abdominal colicky pain to the right hypochondrium accompanied by nausea and vomiting with food remains. A physical examination was performed and abdominal ultrasound was indicated. It was interpreted as acute lithiasic cholecystitis. Ceftriaxone was prescribed. Given the unfavorable evolution five days after admission, the cholecystectomy was performed, where the volvulus was found. The biopsy confirms acute gangrenous cholecystitis. The patient evolved satisfactorily. Three days after the surgery he was discharged from the institution(AU)
Subject(s)
Humans , Male , Aged, 80 and over , Cholecystectomy/methods , Cholecystolithiasis/drug therapy , Cholelithiasis/diagnosis , Gallbladder/diagnostic imaging , Stomach Volvulus/diagnostic imagingABSTRACT
Se presenta el caso clínico de una anciana de 94 años de edad con antecedentes de litiasis vesicular, quien acudió al Hospital General Docente Dr Juan Bruno Zayas Alfonso por presentar dolor abdominal de pocas horas de evolución acompañado de algunos vómitos biliosos y sensación de escalofríos ocasionales. Al examen abdominal se palpa una tumoración redondeada de alrededor de 6 cms, que se encuentra casi a nivel del flanco derecho. Fue intervenida de urgencia y se encontró la vesícula biliar gangrenosa por un vólvulo total del órgano. Se realizó colecistectomía convencional y la paciente tuvo una evolución favorable
The case report of a 94 years elderly with history of gallbladder lithiasis is presented. She went to Dr Juan Bruno Zayas Alfonso Teaching General Hospital due to an abdominal pain with a course of few hours along with some billiary vomits and sensation of occasional shivering. A round tumour of about 6 cms was found in the abdominal test, almost at the level of the right side. She was operated as an emergency and gallbladder was found gangrenous due to a total volvulus of the organ. A conventional cholecystectomy was carried out and the patient had a favorable clinical course
Subject(s)
Humans , Female , Aged, 80 and over , Stomach Volvulus/diagnosis , Stomach Volvulus/therapy , Cholecystectomy , Gallbladder/pathology , LaparotomyABSTRACT
La hernia hiatal tipo IV es la más rara. Se puede reparar por vía abdominal o torácica y por la cirugía laparoscópica mínimo invasiva. Paciente de 67 años de edad, de sexo femenino, que presentaba desde hace más menos 5 meses cuadros de vómitos postprandiales inmediatos con repercusión en el estado nutricional, llega con deshidratación ligera al servicio de urgencias, se realiza panendoscopia digestiva superior de urgencia diagnosticándose una hernia paraesofágica con el estómago intratorácico, se complementó el estudio con una serie esófago-gastroduodenal corroborando el diagnóstico de vólvulo gástrico órgano-axial. Se discute el caso en colectivo y se decide su corrección quirúrgica por vía laparoscópica con evolución satisfactoria(AU)
The hiatal hernia type IV is the weirdest. It can be treated abdominal or thooracic via using lowest invasive laparoscopic surgery. 67 years old patient, famela, who was suffring from postprandial vomiting, affecting her nutritional condition.Patient gets to emergency suffering from light dehydration. An upper digestive panendoscopy is done.Diagnosis: Paraesophageal hernia in intrathoracic stomach the medical examinationwas complemented with a esophagus - gastorduodenal study, assuring the gastric volvulus axial- organ diagnosis. The case is analyzed by medical team and patient was treather surgically through laparoscopic surgery. Patient improved satisfactorily(AU)
Subject(s)
Humans , Female , Aged , Stomach Volvulus/diagnostic imaging , Laparoscopy/methods , Minimally Invasive Surgical Procedures/adverse effects , Hernia, Hiatal/diagnosisABSTRACT
Objetivo: Presentar un caso de vólvulo gástrico obstructivo. Caso clínico: Presentamos el caso de una paciente que inició con un episodio de obstrucción intestinal por una volvulación gástrica. El antecedente de otro episodio antiguo y la radiología de tórax alertaron de una posible hernia diafragmática crónica. La buena respuesta al tratamiento médico inicial permitió un estudio completo y una cirugía programada mediante abordaje laparoscópico.
Aim: To present a patient with gastric volvulus. Case report: A case of a female patient who started with an episode of intestinal obstruction due to gastric volvulus. The history of a former episode and chest radiology alerted us to a possible chronic diaphragmatic hernia. The patient's good response to initial medical treatment allowed a complete study and laparoscopic intervention.
Subject(s)
Humans , Female , Adult , Stomach Volvulus/surgery , Stomach Volvulus/diagnostic imaging , Hernia, Diaphragmatic/complications , Stomach Volvulus/etiology , Surgical Mesh , Tomography, X-Ray Computed , Laparoscopy , Intestinal Obstruction/etiologyABSTRACT
Los vólvulos del colon transverso son una presentación poco frecuente del vólvulo del colon debido a la fijación anatómica que impide su torsión. En la literatura mundial se han presentado menos de 100 casos documentados. A continuación se presentan 2 casos de vólvulo del colon transverso que se sospechan mediante cuadro clínico e imagenológico, son llevados a colonoscopia para devolvulación y se confirman en el intraoperatorio.
Transverse colon volvulus is rare due to the anatomic location which impedes twisting. In the literature of the world, there have been fewer than 100 documented cases. This article presents two cases of transverse colon volvulus. They were suspected because of clinical evidence, images were obtained, colonoscopic reduction was performed and the disorders were confirmed intraoperatively.
Subject(s)
Humans , Male , Female , Middle Aged , Aged, 80 and over , Abdominal Pain , Colon, Transverse , Colonoscopy , Intestinal Obstruction , Stomach VolvulusABSTRACT
Spontaneous gastric perforation in a healthy child is extremely rare; however, its outcome can be life-threatening. Gastric perforation may be caused by inflammation, mechanical injury, ingestion, and vascular compromise. We report a rare case of gastric perforation with unfavorable results in a 13-year-old, previously healthy, boy. We conclude that acute gastric volvulus is a possible cause of gastric perforation in this case.
Subject(s)
Adolescent , Child , Humans , Male , Eating , Inflammation , Intestinal Perforation , Stomach VolvulusABSTRACT
PURPOSE: Open adhesiolysis has been the favored approach regarding surgical management of intestinal obstruction. Following the development of laparoscopic devices and necessary surgical techniques, laparoscopic treatment of intestinal obstruction and adhesion has been tried in highly selected cases. Our study was designed to investigate laparoscopic adhesiolysis to treat intestinal obstruction. METHODS: The clinicopathologic data and surgical outcomes of 14 patients who underwent emergency laparoscopy between January 2007 and April 2015 were retrospectively reviewed. RESULTS: Five patients had a history of abdominal surgery, and twelve patients had adhesive intestinal obstruction. The causes of adhesive intestinal obstruction included tuberculous peritonitis, periappendiceal abscess, serosal fibrosis and chronic inflammation of intestine, gastric volvulus by fibrotic band. Two patients had non-adhesive intestinal obstruction, caused by intussusception and small bowel ulcer with stricture. The mean surgical time was 98.5 minutes, with mean blood loss of 35 ml. One case was converted to open surgery (7.1%). The mean postoperative hospital stay was 6.5 days. The mean time to oral intake was 3.4 days. There were no postoperative complications or deaths. CONCLUSION: When the patients are selected carefully in accordance with the guidelines, in our experience laparoscopic adhesiolysis is safe and feasible.