Adult ileocecal intussusception induced by adenomatous ileal polyp: case report and literature review.

Intussusception is a rare cause of bowel obstruction in adults, and has generally an organic etiology. However, adenomatous polyp of the small bowel is an uncommon etiology. Moreover, there's a great difference with childhood intussusception in its presentation, etiology and management. We describe herein a case of adult ileocecal intussusception due to an adenomatous ileal polyp with a preoperative diagnosis made on computed tomography. We performed a right hemicolectomy, without attempting to reduce the intussusception, and an end-to-end ileotransverse anastomosis. The pathological examination of the surgical specimen revealed an adenomatous polyp with a high grade dysplasia on the terminal ileum, being the cause of the ileocecal intussusception.

A Novel DPYD Variant Associated With Severe Toxicity of Fluoropyrimidines: Role of Pre-emptive DPYD Genotype Screening.

Background: The fluoropyrimidine anticancer drug, especially 5- fluorouracil (5-FU) and its prodrug capecitabine are still being the backbone of chemotherapeutic regimens for colorectal cancer. Dihydropyrimidine dehydrogenase (DPD) is the crucial enzyme in the catabolism of 5-FU. Over the past 30 years, there is substantial clinical evidence showing that DPD deficiency is strongly associated with severe and fatal fluoropyrimidine-induced toxicity. Patients and methods: A 49-year-old lady with resected stage III carcinoma of sigmoid colon was scheduled to have a course of 5-FU based adjuvant chemotherapy. She developed unexpected acute severe (grade 4) toxicity after the first cycle of chemotherapy. Genomic DNA was isolated from 3 ml peripheral blood cells for full sequencing of DPYD (the gene encoding DPD). Results: Exome sequencing confirmed that she is heterozygous for NM_000110.3: c.321+2T>C of the DPYD gene. To the best of our knowledge, this variant is a novel pathogenic splicing variant of the DPYD gene resulting in a non-functional allele. As she has a heterozygous genotype and considered having decreased DPD activity, we followed the international recommendation and restart chemotherapy with at least 50% reduction for 5-FU dose. We then titrated the 5-FU dose, and she tolerated the subsequent cycles of chemotherapy and completed the whole course of adjuvant chemotherapy. Conclusions: With a pre-emptive test on DPD deficiency before the administration of the fluoropyrimidine drugs, the aforementioned patient's life-threatening event could be avoided. This clinical utility has been confirmed by two recent large-scale studies and called for a drug label update.

[The Study Of Biomedical Waste Management In Sanitary District Of Goudry In Senegal]. / Etude De La Gestion Des Dechets Biomedicaux Dans Le District Sanitaire De Goudiry Au Senegal.

AIM: Of this study was to explore, in the sanitary district of Goudiry, the practice of biomedical waste management and to analyze its impact. MATERIALS AND METHODS: The sample consisted of seven health posts, among a total of 11, drawn by simple random sampling and a health centre (district hospital). Data were collected through structured interviews with all staff, participant observation and from secondary data. RESULTS: The district facilities surveyed produced 111.9 kg (or 16.0 kg/d) over seven days. Waste management is inadequate at all levels. CONCLUSION: Actions needed to improve waste management are sensitization and training of actors, the involvement of all the stakeholders (local authorities, population, health workers), and advocacy with policy makers.

BUT: Il s'agissait d'explorer, au niveau du district sanitaire de Goudiry, la pratique de la gestion des déchets biomédicaux et d'en analyser les conséquences. MATÉRIELS ET MÉTHODES: L'échantillon était constitué de sept Postes de Santé tirés sur 11postes par un sondage aléatoire simple et d'un Centre de Santé dont toutes les unités fonctionnelles ont été incluses dans l'étude. Les données ont été recueillies au travers des entretiens structurés avec l'ensemble du personnel, des observations participantes et de la recherche documentaire. RÉSULTATS: Le District, en sept jours, avait produit 111,9 Kg (soit 16,0 kg/j). La gestion des déchets était inadéquate à tous les niveaux. CONCLUSION: A cet effet, pour améliorer la gestion des déchets, les actions à mener étaient la sensibilisation et la formation des acteurs, l'implication de toutes les parties prenantes (collectivités locales, population, personnel sanitaire), et le plaidoyer auprès des décideurs.

Risques de chute et de dénutrition chez des personnes âgées vivant à domicile à Dakar (Sénégal)

Objectif : Déterminer la prévalence des risques de chutes et de dénutrition, ainsi que l'existence ou non d'un lien entre ces deux risques chez une population âgée de 60 ans ou plus, vivant à domicile, à Dakar au Sénégal. Patients et méthodes : L'étude est de type transversal descriptif. Le risque de dénutrition a été déterminé à partir des résultats du Mini Nutritional Assessment (MNA), le risque de chute par le Timed Up and Go test (TUG), et la co-morbidité évaluée par le Cumulative Illness Rating Scale for Geriatrics (CIRS-G). L'Odds ratio, les lois normales centrées réduites et de Khi2 (χ2) ont été utilisés pour les tests statistiques.Résultats : Le sex-ratio de la population d'étude (n = 83) était de 1,18 en faveur des femmes, avec un âge moyen de 69,92 ans [68,38 ; 71,46]. Deux tiers de la population étaient mariés. La prévalence de la dénutrition, selon le MNA était à 2,4% [0,29 ; 8,43] et le risque de dénutrition évalué à 39,76% [29,23 ; 50,28]. Cette population a été divisée en deux groupes, en excluant les 2 patients dénutris, selon que les individus soient à risque de dénutrition (n = 33) ou en état nutritionnel normal (n = 48). La comorbidité selon le CIRS-G moyen était faible pour ces deux groupes et était de 4,33 pour les individus à risque de dénutrition et à 3,23 chez les individus à état nutritionnel normal. Le risque de chute était de 4,16% si l'état nutritionnel était normal et de 30,30% en cas de risque de dénutrition, avec un Odds ratio à 10 [2,02 ; 49,46] et une différence significative (p < 0,01).Conclusion : Les actions de prévention de la dénutrition, après le dépistage de son risque par MNA, doivent aussi tenir compte du risque de chute dont les conséquences sont souvent très délétères

[Study of the Consumers' preference on the universal health coverage development strategy through health mutual in Ziguinchor Region, Southwest of Senegal]. / Étude de la préférence des usagers sur les stratégies de développement de la couverture sanitaire universelle à travers les mutuelles de santé dans la région de Ziguinchor au sud-ouest du Sénégal.

In Senegal, the informal and rural sector that accounts for over 80% of the population is covered only up to 7% by a health insurance system. That is why, for the implementation of development strategy of the universal health coverage (UHC) through mutual health insurance providers, the Government of Senegal has focused on this sector. The objective of this study was to assess the consumer's preference on the UHC development strategies through mutual health insurance providers. This was a qualitative and exploratory study based on a literature review, and indepth interview with the heads of households. It was also based on focus groups of people with and without health mutual membership, and the Expert Committee meetings. The results showed that the most critical attributes in the decision-making of consumers to join the health mutual in Ziguinchor were the membership units; the content of the benefit package, the payment modalities of the premium, the premium amount, the availability of transportation, the co-payment level, convention arrangement with health facilities, and health mutual governance. For a successful implementation of the UHC development strategy through health mutual organizations, policymakers should explore the possibility of introducing the modality of payment in kind, the revision of the co-payment amount, and the promotion of equity through the introduction of a differentiated premium contribution by income. They should also establish a crossborder strategy with The Gambia and Guinea-Bissau to improve health care access to people living in the borders. The promotion of innovative funding and risk equalization between health insurance schemes is also recommended. In areas where the microfinance institutions are well organized and structured their substitution to health mutuals should be an option the decision-makers have to explore.

[Cardiovascular risk factors associated with erectile dysfunction in the region of Dakar, Senegal]. / Facteurs de risque cardiovasculaires associés au dysfonctionnement érectile dans la région de Dakar, Sénégal.

BACKGROUND: Erectile dysfunction (ED) is often a reason for consultation revealing the existence of cardiovascular risk factors. The objective of this study was to determine the cardiovascular risk factors associated with ED in the Dakar region. METHODS: A descriptive and analytical cross-sectional study was conducted from March 18 to June 2, 2013. The study population was composed of married male subjects who sought care at the Ouakam Geriatric and Gerontology Center and the Grand Yoff General Hospital. Erectile function was assessed with the International Index of Erectile Function using the simplified five-item questionnaire (IIEF 5). R 2.2.9 software was used for the logistic regression multivariate analysis. Associations were measured using the adjusted odds ratio (ORaj) with confidence intervals. RESULTS: A total of 253 men were surveyed during this period. Average age was 16.7±58.2 years, range 24-90 years; 47% were aged under 60 years. ED was diagnosed in 110 patients (43.5%). ED was considered mild (33.6%), moderate (5.5%) or severe (4.3%). ED was more severe in patients older than 60 years. Cardiovascular risk factors associated with ED were diabetes ORaj=2.4 (1.24-4.68), sedentary lifestyle ORaj=3.08 (1.69-5.61), and hypertension ORaj=2.53 (1.33-4.81). CONCLUSION: These results should prompt health care providers to target patients with diabetes, hypertension and sedentary lifestyle for systematic ED screening as a routine practice in order to ensure early and effective care.

[How Bone Densitometry contributes to the diagnosis of Osteoporosis at the Gerontology and Geriatrics Center of Ouakam, Dakar City: 102 observation]. / Apport de l'osteodensitometrie dans le diagnostic de l'osteoporose au Centre de Gerontologie et Geriatrie de Ouakam/ Ville de Dakar: a propos de 102 observations.

INTRODUCTION: This study aims at assessing the morbidity rate and risk factors of osteoporosis. METHODS: This is a cross-sectional study conducted at the Gerontology and Geriatrics Center of Ouakam from 2010 to 2012 with patients who had benefited from a bone densitometry examination. The study variables were: sex, current age, menopausal age, past individual fractures, past family fractures, prolonged corticoid intake, prolonged immobilization, tobacco addiction, and alcoholism. Epi-info version 6 Software was used to process and analyze the data. RESULTS: The study included 102 patients the majority of which were women (75%), with an average age of 74 years; among these people, 31% had individual past fractures and 10% had family fractures; 8% of the patients had used a prolonged corticoid-based therapy and 2% were tobacco-addicts. The average age of menopause was 48 years. The prevalence rate for osteoporosis was 44%, based on Rachis T-score, 20%, based on Femur T-score and 45%, based on Rachis and Femur T-score. It has been noted that being a woman and past individual fractures rated among the major risk factors of osteoporosis. CONCLUSION: These results speak in favor of health authorities setting-up a program to fight osteoporosis centered mainly on primary prevention and screening.

INTRODUCTION: L'objectif de notre travail est d'évaluer la morbidité et les déterminants de l'ostéoporose. MÉTHODES: Il s'agissait d'une étude transversale qui s'est déroulée au Centre de Gérontologie et Gériatrie de Ouakam de 2010 à 2012 chez des patients qui ont bénéficié de l'examen ostéodensitométrique. Les variables étudiés étaient: sexe, âge actuel, âge de la ménopause, antécédent de fracture personnel, antécédent de fracture familial, prise prolongée de corticoïdes, immobilisation prolongée, tabagisme, consommation d'alcool. Le logiciel Epi-info version 6 a été utilisé pour analyse des données. RÉSULTATS: 102 patients ont été inclus dans l'étude avec une prédominance féminine (75%), un âge moyen de 74 ans; 31% des patients avaient des antécédents personnels de fracture et 10% des antécédents familiaux de fracture; 8% des patients présentaient une corticothérapie prolongée et 2% des patients un tabagisme. L'âge moyen de survenue de la ménopause était de 48 ans. La prévalence de l'ostéoporose était de 44% en se basant sur le T score Rachis, de 20% en se basant sur le T score Fémur et de 45 % en se basant sur le T score Rachis et Fémur. Il a été noté que le sexe féminin et les antécédents personnels de fracture constituaient des facteurs de risque de survenue de l'ostéoporose. CONCLUSION: Former les professionnels au depistage et à la prévention de cette affection.

Modulation of cisplatin-induced reactive oxygen species production by fullerene C(60) in normal and transformed lymphoid cells

The early response of normal (Wistar rat thymocytes) and transformed (mice lymphoid leukemia L1210) cells to treatment with anticancer drug cisplatin or to combined treatment with cisplatin and carbon nanostructure fullerene C60 was studied. We demonstrated with fluorescent probes DCFH-DA and TMRE that cisplatin at concentration 1 µg/ml induced reactive oxygen species (ROS) production and decreased the value of mitochondrial membrane potential in both cell types. The combined treatment with cisplatin (1 µg/ml) and fullerene C60 (7.2 µg/ml) was shown to be followed by oppositely directed modulation of ROS production in thymocytes and L1210 cells. Cisplatin-induced ROS production was intensified in L1210 cells, while in thymocytes it was decreased. It is supposed that the different effects of combined treatment are associated with peculiarities of fullerene C60 accumulation and localization in normal and cancer cells.

Perforated mesenteric Meckel's diverticulum in an adult: a real variant?

A Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. It is a real diverticulum that is usually located on the anti-mesenteric edge in the last meter of the ileum. Its location on the mesenteric edge has been rarely reported. It may lead to several complications including perforation that may be life-threatening for the patient. We report herein a case of perforated mesenteric Meckel's diverticulum in an adult patient. Upon surgical exploration by laparotomy, we found a perforated Meckel's diverticulum located on the mesenteric edge of the ileum 60 cm from the ileocoecal junction and 400 ml of seropurulent peritoneal fluid. The patient underwent a segmental ileal resection and an end-to-end anastomosis. The postoperative outcomes were marked by a persistent peritonitis that required successful revision surgery.

[IgG responses to candidate malaria vaccine antigens in the urban area of Dakar (Senegal): evolution according to age and parasitemia in patients with mild symptoms]. / Analyses des réponses IgG dirigées contre des antigènes candidats vaccins dans le paludisme urbain non aggravé à Dakar (Sénégal): variations suivant l'âge et les densités parasitaires.

Malaria remains a major problem in African countries despite substantial decreases in morbidity and mortality due to sustained control programs. Studies for the evaluation of qualitative or quantitative Ab responses to key targets of anti-plasmodium immunity were mostly done in rural endemic setting compared to urban area. In a cohort of 200 patients with mild malaria and living in Dakar, we analyze total and subclasses IgG responses to a panel of P. falciparum blood stage antigens: MSP1p19, MSP3, EB200, GST-5 and R23. A mean age of 15 yrs (4 to 56 yrs) and parasitemia between 0.1 to 17% were found. Levels of IgG anti-MSP3 were higher in patients with low parasitemia (≤1%) and appear negatively correlated to parasite densities (Rho =. 0.54; p= 0.021). This correlation is more significant in children (≤ 15 yrs). In addition, an increase of IgG responses against MSP1p19 is highly observed in adults having a parasitemia less than 1%. In those patients, we find that IgG1 subclasses were predominant (p <0.01). Our study shows an association between Ab responses and parasitemia. This association is dependant to IgG anti-MSP3 in children and IgG anti-MSP1p19 in adults living in urban area.

[Assistance and Support Units for the elderly: A tool for promoting health in seniors: Example of the CAAPA unit of "Sicap Rue 10", in Dakar]. / Cellules D'aide et D'appui aux Personnes Agees : Outil de promotion de la sante des seniors : Exemple la CAAPA de « Sicap Rue 10 ¼ a Dakar.

As a body for reflection, dialogue and integration, the CAAPA Assistance and Support Unit of "Sicap Rue 10" allows the elderly to fully participate in the life of their society while being in good health. The unit has been set up by the local authorities following recommendations from interdepartmental cabinet meeting on 13 November, 200. Nine years after the creation of the unit, it becomes important to evaluate the degree of community participation of the elderly within that unit. This is a qualitative, descriptive and analytic study that took place from 9 October to 23 October, 2010. The two methods used to collect the data are interviewing and focus group. Using Bichmann's scale, which has been modified and adapted, the results have shown an "average-level" participation of the elderly in the creation of the CAAPA unit, its implementation as well as the follow-up and the evaluation of its activities; this participation being "open" in the composition of the piloting committee and "restricted" in mobilizing and managing material and financial resources. Recommendations have been stated for the CAAPA unit to fully play its role.

La Cellule d'Appui et d'Aide aux Personnes Agées (CAAPA) de la SICAP rue 10, instance de réflexion, de concertation et d'intégration permet aux personnes âgées de participer à la vie sociale tout en se maintenant en bonne santé. Elle a été mise en place par les autorités de la dite localité suite aux recommandations du conseil interministériel du 13 novembre 2003. Neuf années après sa mise en œuvre, il est important d'évaluer le degré de participation communautaire des personnes âgées dans le fonctionnement de cette CAAPA. Il s'agit d'une étude qualitative descriptive et analytique qui s'est déroulée du 09 au 23 Octobre 2010. Les techniques de collecte des données utilisées sont l'entretien individuel et le focus group. Grâce à l'échelle de Bichmann modifiée et adaptée, les résultats ont montré une participation des personnes âgées « moyenne ¼ dans la conception de la CAAAPA, la mise en œuvre ainsi que le suivi/évaluation des activités, « ouverte ¼ dans la composition du comité de pilotage et « restreinte ¼ dans la mobilisation et la gestion des ressources matérielles et financières. Des recommandations ont été proposées pour que la CAAPA puisse jouer pleinement son rôle.

[Genetic transformation of the moss Ceratodon purpureus by novel polycationic carriers of DNA].

There is a big progress in application of genetic engineering for improving the biological properties of different organisms. Viral and non-viral carriers are used for delivery of genetic material into target cells. Nanoscale polymeric materials of natural and synthetic origin are the most promising gene delivery agents. These polymers have demonstrated high efficiency of DNA delivery into the mammalian cells, although they were not very effective in plant cells. Here, the procedure for genetic transformation of Ceratodon purpureus (Hedw.) Brid. moss protoplasts is described. Method is based on the application of novel surface-active polymeric carriers of the polyDMAEM structure and controlled length and charge. It allows obtaining more transient and stable moss transformants per microgram of plasmid DNA when compared with known protocol based on using polyethyleneglycol. It is easier, more convenient, and cheaper than the "gene gun" method. Perspectives for further improvement of structure and functional characteristics of novel polymeric carriers are considered for delivery of genetic material into plant cells.

[The Wnt/beta-catenin signaling in embryonic cardiogenesis, postnatal development and myocardium reconstruction].

Wnt/beta-catenin signaling exerts great and diverse influence on the formation, development and vital activity of a great number of vertebrate tissues, including heart tissue. The role of Wnt/beta-catenin signaling and beta-catenin itself in the processes of cardiogenesis and adult myocardium functioning is not fully elucidated to date. In the current review we made the attempt to generalize data from up-to-date literature dealing with participation of this signaling pathway in embryogenesis and postnatal heart development as well as in adult myocardium functioning in normal conditions and during stress adaptation, aging, resulting in hypertrophy and heart remodeling. Based on the experimental articles and reviews we can assume that Wnt/beta-catenin signaling pathway is involved not only in controlling the cardiogenesis but in processes of adaptation and remodeling of adult organ, too. This control can be characterized as complicated and multi-step and beta-catenin appears to be a perspective candidate for new approaches development for the adult myocardium pathologies therapy.

[Surgical treatment tactics for acute varicothrombophlebitis atypical forms].

Changes of phlebohemodynamics under control of ultrasonographic investigation were registered in 237 patients, suffering an acute varicothrombophlebitis (AVTH) of superficial veins of lower extremities (LE). In 21 patients atypical forms of AVTH were revealed, including reflux toward a big subcutaneous vein (BSV) of the leg and/or small subcutaneous vein (SSV); reflux toward insufficient indirect veins on hip and shin; reflux toward insufficient direct perforant veins. For atypical forms of AVTH the urgent operations on hip and shin were performed: crossectomy, short or long stripping, phlebectomy and/or scleroobliteration of tributaries; open subfascial resection (mini-Linton); deferred operations: phlebectomy of the BSV/SSV tributaries, open scleroobliteration, subfascial resection (mini-Linton). Systematization of the AVTH forms in accordance to the LE segments have permitted to determine strategy and tactics of the patients treatment, what have important practical significance.

Adaptation of international guidelines for metastatic colorectal cancer: an asian consensus.

Colorectal cancer (CRC) is among the most common cancers worldwide, but marked epidemiological differences exist between Asian and non-Asian populations. Hence, a consensus meeting was held in Hong Kong in December 2012 to develop Asia-specific guidelines for the management of metastatic CRC (mCRC). A multidisciplinary expert panel, consisting of 23 participants from 10 Asian and 2 European countries, discussed current guidelines for colon or rectal cancer and developed recommendations for adapting these guidelines to Asian clinical practice. Participants agreed that mCRC management in Asia largely follows international guidelines, but they proposed a number of recommendations based on regional 'real-world' experience. In general, participants agreed that 5-fluorouracil (5-FU) infusion regimens in doublets can be substituted with UFT (capecitabine, tegafur-uracil) and S1 (tegafur, 5-chloro-2,4-dihydroxypyridine and oxonic acid), and that the monoclonal antibodies cetuximab and panitumumab are recommended for KRAS wild type tumors. For KRAS mutant tumors, bevacizumab is the preferred biological therapy. FOLFOX (folinic acid, 5-FU, and oxaliplatin) is preferred for initial therapy in Asian patients. The management of mCRC is evolving, and it must be emphasized that the recommendations presented here reflect current treatment practices and thus might change as more data become available.

[The ways of prophylaxis of the gastro-intestinal hemorrhage recurrence].

Through three-years period 57 patients, suffering gastro-intestinal hemorrhage (GIH) of the ulcer genesis, were treated in the clinic. Among them were 37 (64.9%) men and 20 (35.1%) women. The patients have had (56.3 +/- 4.7) yrs old at average. The treatment programm for the patients have included a local arrest of GIH, medicinal therapy, directed on restoration of the circulating blood volume, gastric secretion inhibition, rising of the blood coagulation property. In cases of a middle and severe blood loss the blood preparations were transfused--the erythrocytic mass and freshly frozen plasm. Three patients were operated in the high period of GIH. The GIH recurrence was absent. In 7 - 8 days, if a persistent hemostasis was achieved, the patients were transferred to therapeutic department for the conservative therapy prolongation.

[Effect of inorganic phosphate on the properties of Lactobacilli probiotic strains].

The effect of inorganic phosphate in the culture medium on microbial surface hydrophobicity, susceptibility to antibiotics and its autolytic activity has been investigated. The limitation of inorganic phosphate reduced affinity of bacterial cells to chloroform, ethyl acetate and hexane. The total elimination of inorganic phosphate caused an increase of the affinity of Lactobacillus plantarum strain 11/16 to hexane. Autolytic activity of the strain L. plantarum 195D did not depend on the concentration of inorganic phosphate, whereas its decrease reduced autolysis of the strain L. plantarum 11/16 by 15-20% Antibiotic susceptibility decrease of lactobacilli towards to the effect of fuzidin, furazolidone and rifampicin was shown. At the same time, limitation of inorganic phosphate source in the culture medium increased the antibiotic sensitivity towards ceftriaxone.

[Conclusive pleuropulmonectomy in patients with pulmonary tuberculosis].

The results of performance of conclusive pleuropulmonectomy (CPPE) in 2004-2012 yrs in 16 patients, suffering multiresistant pulmonary tuberculosis are presented. In 75% patients during the first operation the atypical (using apparatuses) pulmonary resection was performed. CPPE was done for fibrous-cavernous tuberculosis in 11 (68.8%) patients, for cirrhotic tuberculosis - in 4 (25.0%), caseous pneumonia - in 1 (6.3%). Intraoperative complications rate was 12.5%. Early postoperative complications have had occurred in 5 (31.3%) patients, and the late - in 3 (18.8%). Total efficacy of CPPE have had constituted 81.3%.

[Optimization of intraoperative conditions in endoscopic biopsy of intrathoracic lymph nodes].

Conducted a retrospective analysis of the results transpleural (videothoracoscopic and videoassisted) biopsy of intrathoracic lymph nodes (ITLN) performed in 91 patients with hilar lymphadenopathy syndrome of various etiologiy for the period from 2003 to 2014. Endoscopic ITLN biopsy performed in the mediastinum in the high risk zone, so patients need to create adequate and safe intraoperative comfort, in particular, the position of lying on side, imposing artificial pneumothorax before surgery, one-lung ventilation, lifting the head end of the operating table at 300. These measures provide optimal con- ditions for handling and minimizing the frequency of intraoperative complications or prevention after surgery.

[Surgical treatment of goiter].

The results of treatment of 468 patients, suffering goiter, were analyzed. Surgical access and the operative intervention volume was chosen on background of analysis of the patients preoperative and intraoperative examination data. Extrafascial method of surgical intervention guarantees the blood loss absence and radicality of the operation, as well as reduction of postoperative complications rate. All the patients after the operation are alive.