Persistent posterior seroma after laparoscopic repair of ventral abdominal wall hernias with expanded polytetrafluoroethylene mesh: prevalence, independent predictors and detached tacks : Retrospective review.

PURPOSE: A persistent seroma located posterior to a mesh (PPS) remains a little known complication after laparoscopic ventral hernia repair (LVHR). The aim of this large case series was to analyse the prevalence and clinical course as well as identify related factors and independent predictors of PPS. METHODS: All 1288 adult patients who underwent a LVHR with an expanded polytetrafluoroethylene mesh (ePTFE) between January 2003 and July 2014 were reviewed. Those who underwent an abdominal computed tomography (CT) scan more than 3 months afterwards (n = 166) were included and their scans were analysed. The primary outcome measure was the prevalence of a PPS and its characteristics. The secondary outcome measures were identification of significantly related factors and independent predictors of PPS. RESULTS: A PPS was observed in 14 of 166 analysed CT scans (8.4%). Eleven patients were symptomatic; conservative treatment (wait-and-see policy) was successful in eight. Three underwent relaparoscopy with removal of a thick neoperitoneum. Several instances of tack and/or mesh detachment were identified on CT scans and during relaparoscopy. Independent predictors were: > 3 trocars (RR 5.0, 95% CI 1.6-15.8) and use of a mesh larger than > 300 cm2 (RR 9.9, 95% CI 1.9-51.2). CONCLUSIONS: A PPS is a relatively common complication after LVHR with an ePTFE mesh of usually larger hernias. A "wait-and-see" approach seems justified in most cases. Some require laparoscopic excision of the thick neoperitoneum. A PPS can cause tack and mesh detachment but the clinical consequences are unclear. Recurrences have not been observed in this series.

Obstetric and neonatal outcomes in women aged 40 years or older after in vitro fertilization.

PURPOSE OF INVESTIGATION: The aim of this study was to determine the rate of complications in pregnancy and during delivery, as well as neonatal outcomes, in women who underwent in vitro fertilization (IVF) and who are 40 years of age or older. MATERIALS AND METHODS: This was a prospective study. The study group consisted of 29 women who underwent IVF. The control group consisted of women who had a spontaneous pregnancy. RESULTS: Pregnancy complications occurred in 86.21% of women in the study group, an 46.87% of women in the control group. The proportion of cesarean sections (CS) was 84.62% in the study group, and 21.87% in control group. Birth weight < 1,500 grams and < 2,500 grams was present in 17.16% and 22.86% of newborns in the study group, spectively. In the control group, birth weight < 1,500 grams and < 2,500 grams was present in 5.55% and 8.33% of newborns, respectively. Neonatal intensive care unit admissions included 22.86% newborns from the study group and 8.33% from the control group. CONCLUSION: Pregnancy, delivery, and neonatal complications were more frequent in the study (IVF) group.

Interobserver variability and positive predictive value for ultrasonographic BI-RADS categories requiring pathohistological evaluation.

OBJECTIVE: The objective of this study was an analysis of interobserver variability and positive predictive value (PPV) for BI-RADS categories requiring pathohistological evaluation: 4A, 4B, 4C, and 5. MATERIAL AND METHODS: Interobserver variability for each of descriptors as well as PPV for final BI-RADS categories requiring pathohistological evaluation was measured in a retrospective study which included 30 ultrasonographic reports, with pathohistological verification, randomly selected from ultrasonographic reports from Institute for Oncology and Radiology of Serbia where about 1,100 breast cancers are verified every year. Ten observers, seven gynecologists, and three radiologists, independently rated each ultrasonographic report according to the fourth edition of BI-RADS atlas. Interobserver variability was measured with k coefficient. RESULTS: There was most conformity for a category of orientation (k = 0.79). Substantial degree of conformity was also present for both boundary (k = 0.71) and shape (k = 0.65) categories. Moderate degree of conformity was achieved for posterior features (k = 0.54) and margins (k = 0.41) descriptors, while there was poor conformity in echogenicity (k = 0.38). In case of a final score, common conformity for all BI-RADS 4A, 4B, 4C, and 5 categories was (k = 0.51); it was the greatest for category 5 (k = 0.50), and it was less for categories 4C (k = 0.37), 4B (k = 0.32), and 4A (k = 0.29). CONCLUSIONS: Interobserver conformity for ultrasonographic descriptors and final evaluation of BI-RADS 4A, 4B, 4C, and 5 categories is good. PPV implies that not only division into categories 4 and 5, but also classification into categories 4 and subcategories 4A, 4B, and 4C are justified and clinically applicable.

Delayed presentation of diaphragmatic rupture after blast injury.

A diaphragmatic injury is usually associated with injury to thoracic or abdominal organs due to blunt or penetrating trauma, and is uncommon after blast injury. We describe a patient with respiratory distress due to herniation of the stomach into the chest through a diaphragmatic injury, sustained 1 year previously when he suffered a blast injury while on deployed military operations, but without obvious visceral injury at that time. At emergency laparotomy there was a gastric perforation which was exteriorised as a gastrostomy and the diaphragmatic rupture closed. Postoperative pneumonia and pelvic abscess were both treated successfully and he left the hospital in good condition. Delayed treatment of traumatic diaphragmatic injury leads to an increased risk for herniation and/or strangulation of abdominal organs, which can be life-threatening. Recognising the symptoms indicating diaphragmatic injury is especially important in cases in which the relationship to previous trauma is less clear.

Correlation of human papilloma virus infection with cytology, colposcopy and histopathological examination of the bioptic tissue in low- and high-grade intraepithelial lesions.

INTRODUCTION: It is now believed that the majority of cervical cancer is preceded by long-term infection with high-risk types of the human papilloma virus (HPV). The presence of HPV high-risk types (HR-HPV) in the cells of intraepithelial change multiplies the possibility of its progressive development to high-grade cervical precancer and invasive disease. AIM: This study examined the correlation of HPV infection with cytology, colposcopy, and histopathological examination of the bioptic tissue in low- and high-grade cervical lesions. MATERIALS AND METHODS: This research was conducted as a study section. Data collection was performed during a ten-year period, at the University Clinic of Gynecology and Obstetrics - Narodni Front in Belgrade (Serbia). The basic set included 1,927 patients. Colposcopy, cytology, histopathology, and HPV test verification was made in all patients. Statistical analysis was performed using the SPSS program, version 17.0. Contingency tables were used to assess the degree of correlation of variables and chi-square test was used to determine the level of statistical significance in this study. A p value < 0.05 was considered statistically significant. RESULTS: Among 1,927 women studied, 635 (32.95 %) had abnormal cytological findings and among these, 272 (42.83%) were HR-HPV positive. There was a statistical difference between colposcopic and cytological findings in patients with HR-HPV (x2 = 35.33, p = 0.000). There was also a statistically significant difference between histophatological and colposcopical findings in patients with HR-HPV (x2 = 10,171, p = 0.001). Only HR-HPV types 16 and 18 showed a statistical significance compared to histopathological findings, unlike other HR-HPV. An important finding was that the authors found an abnormal colposcopy in 93.30% patients with low-grade intraepithelial neoplasia and 68.05% patients with low-grade squamous intraepithelial lesion (LSIL) had normal cytology and was 70.15 % HR-HPV negative. CONCLUSION: The findings imply that among high-grade intraepithelial neoplasias, the authors found a high presence of HPV type 16 and 18, and a statistical significant presence of HPV 16 in low-grade intraepithelial neoplasia, unlike other HR-HPV types in low-grade intraepithelial findings. The authors found a significant statistical correlation with abnormal cytology and presence of HPV type 16 in both groups (LSIL and high-grade squamous intraepithelial lesion (HSIL). The authors also found an abnormal colposcopy in 93.30% of patients with low-grade intraepithelial neoplasia, while 68.05% of patients with LSIL had normal cytology and were HR-HPV negative in 70.15% of the cases.

Comparison of electrolytic status (Na+, K+, Ca2+, Mg2+) in preterm and term deliveries.

PURPOSE OF INVESTIGATION: The objective of this study was to evaluate the electrolytic status of Na+, K+, Ca+, and Mg2+ in serum and red blood cells in idiopathic preterm and term deliveries. METHODS: The study included 105 pregnant women diagnosed with idiopathic premature delivery (study group) and 36 pregnant women with physiologically term delivery (controls). Samples of mother's blood were collected and analyzed for the level of electrolytes in the serum/plasma and red blood cells. RESULTS: Measured values of magnesium in red blood cells in the study group were far lower than physiological values, intracellular calcium levels were higher in the study group compared to levels measured in the controls. Sodium concentrations in cells were significantly lower in subjects with premature delivery. CONCLUSION: The magnesium intracellular level is the best representative value of magnesium in the body.

Evaluation of utero-ovarian hemodynamics in relation to fertility and stage of endometriosis.

OBJECTIVE: The aim of this study was to compare hemodynamic changes in the uterine and ovarian arteries between infertile women with moderate and/or severe endometriosis and healthy women. In this prospective study, 99 women in their generative age were subjected to color Doppler ultrasonography to measure hemodynamic parameters from July 2010 to January 2011. The examination was performed during the proliferative or ovulatory phase of the natural menstrual cycle in a random sample of 54 women treated for endometriosis-induced infertility and 45 healthy women were included in control examination procedure. Irrespective of considered stage, endometriosis was most often found in the ovaries, in the sacro-uterine ligaments, peritoneum, and rectovaginally. Resistance to blood flow expressed as the resistance index (RI) in the measured arteries, was significantly higher in severe endometriosis compared to moderate form. Average values of pulsation index (PI) and RI are significantly higher, in both endometriosis stages, compared to measured values in healthy women.

Continuous ambulatory peritoneal dialysis after intra-abdominally placed synthetic mesh for ventral hernia repair.

BACKGROUND: We present a unique experience with a patient who had undergone continuous ambulatory peritoneal dialysis (CAPD) after laparoscopic repair of ventral incisional hernia (LRVIH) with an expanded polytetrafluoroethylene (e-PTFE) mesh (DualMesh(®); WL Gore) and who later suffered from multiple episodes of CAPD-related peritonitis without any signs of mesh infection. METHODS: A 48-year-old man with an open abdominal aortic reconstruction in 1994 for occlusive arterial disease presented with an incisional ventral hernia. He underwent LRVIH using an e-PTFE mesh of 30×20 cm. RESULTS: Postoperatively, he developed renal failure. For various reasons, the only therapeutic option was CAPD. A CAPD-catheter was implanted via laparoscopy, taking care not to compromise the mesh that was completely covered with neoperitoneum. After 3 months of uneventful CAPD, he developed a bacterial peritonitis. Antibiotic treatment failed and the CAPD-catheter was removed. The mesh was left in place and the patient recovered. Later on another CAPD-catheter was implanted via laparoscopy and used for 10 months. Again he developed peritonitis from which he recovered after catheter removal. Mesh was left in place and remained uninfected, probably protected from intra-abdominal bacteria by the neoperitoneum. CONCLUSIONS: The risk of secondary infection of an intra-abdominal mesh seems to diminish largely after neoperitonealization of the mesh. CAPD seems possible in a patient with an intra-abdominal mesh when it is covered with neoperitoneum.

Subsequent abdominal surgery after laparoscopic ventral and incisional hernia repair with an expanded polytetrafluoroethylene mesh: a single institution experience with 72 reoperations.

PURPOSE: Laparoscopic ventral and incisional hernia repair (LVIHR) carries a risk of adhesion formation and can influence subsequent abdominal operations (SAOs). We performed a retrospective study of findings during reoperations of patients who had previously had an LVIHR by using an expanded polytetrafluoroethylene mesh (DualMesh; WL Gore, Flagstaff, AZ, USA). METHODS: The medical records of all 695 patients who had LVIHR at our hospital were reviewed. Patients who underwent SAO for various indications were identified (n = 72) and analyzed. RESULTS: Seven LVIHR patients (1%) had early SAO (within a few days). In six patients (86%), removal of the mesh was required. Intra-operatively, in all six of these patients with peritonitis, there were no adhesions against the implant identified. Late SAOs (after more than 1 month) were performed in 65 patients (9.4%). Only one patient required acute surgical intervention due to an LVIHR-related adhesion (0.15%). Laparoscopy was performed in 83% and laparotomy in 17% of patients. Adhesions against the implant were present in 83% of patients; in 65%, the adhesions involved omentum only, and in 18%, they involved the bowel. Adhesiolysis was always easy and caused no inadvertent enterotomies. SAOs were devoid of postoperative complications. CONCLUSIONS: In this largest series of reoperations after LVIHR, the majority of patients had mild or moderate adhesions against the implant. The specific observations that: (1) no relaparoscopies had to be converted, (2) no inadvertent enterotomies were made during adhesiolysis, and (3) SAOs have practically been devoid of peri- and postoperative complications indicate that SAOs can be safely performed after previous LVIHR with DualMesh.

Impact of the mesh fixation technique on operation time in laparoscopic repair of ventral hernias.

BACKGROUND: Fixation of the prosthesis is one of the critical components of laparoscopic repair of ventral and incisional hernia (LRVIH). The impact of the fixation technique used on operative time has never been analyzed. We compared the duration of the operation according to the fixation technique used in a series of 138 patients with primary umbilical hernia. METHODS: All patients underwent a straightforward repair by using completely standardized techniques. One hundred and seven patients had mesh fixation with a single crown of tackers (ProTack), TycoUSS, Norwalk, CT) and eight transabdominal sutures (TAS). Thirty-one patients had mesh fixation with a double crown of tackers (DC) without TAS. RESULTS: There were no significant differences in age, sex, hospital stay, and morbidity between the two groups. Mean operating time for the technique with TAS was 50.6 min compared to 41.4 min for the DC technique. The mean difference in operating time was 9.2 min. This difference was significant (P=0.002). During a mean follow-up of 26.4 months, there were no recurrences in the entire series. CONCLUSIONS: The difference in operative times between the two operative techniques can be entirely accounted to the difference in the time needed for insertion of eight TAS as compared to the time needed for application of an inner crown of tackers. This strongly indicates that insertion of every single TAS prolongs LRVIH for approximately 1 min. As long as no significant differences between the two fixation techniques are demonstrated on issues of recurrence, complications, and postoperative pain, the time difference we have measured might be an argument in favor of the DC technique, especially when mesh fixation would require a large number of TAS.

Fatal intestinal ischemia after laparoscopic correction of incisional hernia.

BACKGROUND AND OBJECTIVES: Intestinal ischemia is a very rare complication of laparoscopic procedures. In this report, we describe the first case of fatal large bowel ischemia in the aftermath of laparoscopic incisional hernia repair. METHODS: A literature search using PubMed was performed to identify all published cases of intestinal ischemia following laparoscopic procedures. RESULTS: Our search revealed 13 cases of intestinal ischemia following various laparoscopic procedures. Including this one, 10 of 14 cases reported on so far had impaired cardiovascular, hepatic or renal function or atherosclerosis. None of these patients-at-risk survived. In this series, no indications of faulty operative technique could be identified. CONCLUSION: Patient-related risk factors seem to play the most important role in the development of this rare but devastating complication. Preventive measures and methods to identify patients at risk for developing intestinal ischemia during and after laparoscopy are not completely clear. Patient selection, an optimal hydration status, an optimized technique with lowest insufflation pressure possible, and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this complication. Whatever laparoscopic procedure has been performed, intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms.

Possible use of terrestrial mosses in detection of atmospheric deposition of 7Be over large areas.

The activities of naturally occurring radionuclides (7)Be, (214)Bi and (210)Pb were measured in samples of terrestrial mosses collected in Serbia (42 degrees 26'19''N-45 degrees 23'12''N). The objective of this work was to establish if detectable amounts of (7)Be and (210)Pb can be found in mosses and investigate their possible variabilities over some area. These are the first steps in introducing mosses as a medium in possible monitoring of spatial distribution of (7)Be atmospheric deposition. The mean value of 360 Bq/kg of (7)Be activity was found in collected moss samples and some nonuniformity in spatial distribution (a 2.8-fold range in measured values) was observed.

[Abdominal pain following placement of an endoprosthesis in the biliary duct]. / Buikpijnklachten na plaatsing van een endoprothese in de ductus choledochus.

A 76-year-old man presented with diffuse progressive abdominal pain. He had undergone endoscopic retrograde pancreaticocholangiography (ERCP) 5 weeks earlier for jaundice and increased levels of liver enzymes. A dilated biliary duct with multiple concrements had been seen, and a plastic endoprosthesis was placed. During a follow-up ERCP the stent was not found, and the obstruction was still present. Another stent was placed. Abdominal x-ray revealed migration of the first endoprosthesis to the distal jejunum and signs of ileus and free gas. CT showed that the stent was stuck in a perforated diverticulum of the sigmoid, surrounded by an abscess mass. The stent was removed by laparotomy, the perforation was closed, and a double-loop stoma was made. Two weeks after initial recovery, abdominal pain recurred. CT revealed a second dislocated stent with a perforation of the jejunum. Laparotomy was performed again with removal of the stent and repair of the perforation. Migration is a known complication of biliary endoprosthesis placement, and should be considered in cases of abdominal pain after ERCP. Perforations rarely occur and mostly affect areas of the bowel that are fixed or that present obstacles to normal elimination. Two perforations within a short period of time is an extremely rare complication of migration.

Ovarian neoplasms and pregnancy.

The aim of our study was to investigate the incidence of ovarian malignant neoplasms in pregnancy. In the prospective study, during a 2-year period of time, we had the ethical dilemma concerning the conciliar treatment vs the patient's wish to deliver and save the reproductive capabilities. We examined 37 pregnant women; the incidence of ovarian cancer was 13.5% vs 6.5% in other works. Diagnoses were made by ultrasound criteria and physical examinations. Statistically significant results were obtained by Student t test. Mean gestational age was 20.1 weeks and mean age 31.1 years. Treatment depends on the neoplasms type, grade, and presence of the metastatic pathways. In benign neoplasms, we used laparoscopic treatment with minor invasion. Distribution of benign neoplasms was in the same range as that in other works.

Laparoscopic appendicostomy with cecoplication for antegrade colonic enema procedure.

Successful application of antegrade colonic enema procedure in selected patients with intractable constipation requires creation of an easy catheterizable but continent stoma. We describe a new laparoscopic technique for antegrade colonic enema procedure by using the in situ appendix that is combined with a Nissen-like cecoplication around the appendix to create a one-way valve.

Expression of Golli proteins in adult human brain and multiple sclerosis lesions.

It has been suggested that Golli proteins, structurally related to myelin basic proteins (MBPs), have a role in autoimmune processes. We studied the expression of these proteins in multiple sclerosis (MS) and determined that the number of Golli-immunoreactive (ir) cells was significantly higher around lesions of chronic MS than in control white matter. Golli proteins were expressed in the adult oligodendrocyte precursor cells (OPCs), activated microglia/macrophages, and some demyelinated axons around MS lesions. Their expression in adult OPCs indicates remyelination attempts, whereas the expression in the subpopulation of microglia/macrophages suggests roles in the immune processes of MS. In addition, Golli proteins may be markers of axonal transection, which is characteristic for MS.

Identification of Golli and myelin basic proteins in human brain during early development.

The myelin basic protein gene (Mbp) encodes for the major myelin structural proteins and it is included in the Golli-Mbp gene complex. Previously, we observed MBP-like proteins in the human central nervous system (CNS) at developmental stages preceding myelination. In an effort to distinguish between Golli (HOG5 and HOG7) and MBP mRNAs and to determine their spatiotemporal distribution, we performed in situ hybridization using two human Golli specific probes: one corresponding to exon 5a absent from all MBP transcripts, and the other corresponding to exon 5c specific for HOG5. HOG7 transcript was observed first, in 5 gestational week-old embryos, whereas both Golli transcripts were detected at 6-7 weeks gestation in the proliferative zones of the entire CNS. Golli proteins immunoreactivity was observed in microglia and early neurons of the developing telencephalon. During midgestation (17-22 weeks gestation), at the onset of myelination, MBP and Golli mRNAs were observed in the telencephalic subventricular zone and occasionally in the future cerebral cortex. Developmental expression of the human Golli-Mbp indicates that the two Golli proteins have different onset of expression, distribution and possibly function. These results support the hypothesis that at least one of them, HOG7, may be involved in the regulation of early neurogenesis, while both may have additional, still undefined function at the onset of myelination.

Stapled laparoscopic gastropexy for paraesophageal hernia.

A minimally invasive correction of symptomatic paraesophageal hernia in high-risk elderly patients is described with an emphasis on a new method of laparoscopic gastropexy that is simple, reliable, and can be performed rapidly.