[Pneumatosis cystoides intestinalis: a case report and literature review]. / Kistoznyi pnevmatoz tonkoi kishki: klinicheskii sluchai i obzor literatury.

Pneumatosis cystoides was first described by Du Vernay in 1783. This is a fairly rare disease with nonspecific symptoms and CT data on pneumoperitoneum. The authors present pneumatosis intestinalis in a patient with systemic connective tissue disorder. Free gas in abdominal cavity and dilated intestinal loops were an indication for emergency surgery with subsequent resection of intestine due to signs of ischemic damage. A review of clinical cases allows us to conclude that pneumoperitoneum requires careful differential diagnosis. Free gas in abdominal cavity in patients with cystic pneumatosis is an indication for emergency surgery only in case of complicated course of disease.

Low-impact laparoscopy in colorectal resection-A multicentric randomised trial comparing low-pressure pneumoperitoneum plus microsurgery versus low-pressure pneumoperitoneum alone: The PAROS II trial.

INTRODUCTION: Low-pressure pneumoperitoneum (LLP) in laparoscopy colorectal surgery (CS) has resulted in reduced hospital stay and lower analgesic consumption. Microsurgery (MS) in CS is a technique that has a significant impact with respect to postoperative pain. The combination of MS plus LLP, known as low-impact laparoscopy (LIL), has never been applied in CS. Therefore, this trial will assess the efficacy of LLP plus MS versus LLP alone in terms of decreasing postoperative pain 24 h after surgery, without taking opioids. METHOD: PAROS II will be a prospective, multicentre, outcome assessor-blinded, randomised controlled phase III clinical trial that compares LLP plus MS versus LLP alone in patients undergoing laparoscopic surgery for colonic or upper rectal cancer or benign pathology. The primary outcome will be the number of patients with postoperative pain 24 h after the surgery, as defined by a visual analogue scale rating ≤3 and without taking opioids. Overall, PAROS II aims to recruit 148 patients for 50% of patients to reach the primary outcome in the LLP plus MS arm, with 80% power and an 5% alpha risk. CONCLUSION: The PAROS II trial will be the first phase III trial to investigate the impact of LIL, including LLP plus MS, in laparoscopic CS. The results may improve the postoperative recovery experience and decrease opioid consumption after laparoscopic CS.

Urinary excretion of low-osmolar contrast media during small-bowel follow-through studies in infants is not definitive evidence of bowel perforation.

BACKGROUND: Presence of contrast agent in the urinary system in infants after small-bowel follow-through study with low-osmolar contrast media has been described as a sign of bowel perforation. OBJECTIVE: To evaluate how often the presence of contrast agent in the bladder after small-bowel follow-through is a reliable sign of bowel perforation or necrosis. MATERIALS AND METHODS: From the radiology information system, we retrieved imaging reports of infants evaluated with small-bowel follow-through and findings of contrast agent in the bladder. We retrieved demographic and clinical information from the medical records. Presence of bladder contrast medium was considered true-positive evidence of bowel perforation or necrosis if confirmed by pneumoperitoneum, extraluminal contrast agent, surgery or pathology within 3 days of the small-bowel follow-through. False-positives for bowel perforation or necrosis were based on surgical findings or clinical follow-up. RESULTS: Of the 207 infants who had small-bowel follow-through, 18 infants (12 boys; mean age 50 days, range 14 days to 8.5 months) had contrast medium in the bladder after the small-bowel follow-through. Fifteen of the 18 (83.3%) had a history of prematurity and 11 had prior abdominal surgery. Four of the 18 (22.2%) had bowel perforation or necrosis at surgery or pathology performed more than 3 days after the small-bowel follow-through and were considered indeterminate and excluded. Eight of the remaining 14 infants (57.1%) had bowel perforation or necrosis based on surgical evidence of perforation or pathology confirmation of necrosis (n=6), pneumoperitoneum (n=1) or contrast agent leakage from enterocutaneous fistula (n=1). Six of the 14 (42.9%) were false-positives, without evidence of bowel perforation or necrosis based on clinical follow-up (n=4) or surgery (n=2). CONCLUSION: Demonstration of urinary contrast agent post small-bowel follow-through with low-osmolar contrast medium in newborns/infants with complex medical problems is not a definitive indication of bowel perforation or necrosis. More than one-third of our patients with contrast medium in the bladder did not have bowel perforation or necrosis.

Endoscopic Gastrojejunostomy in Infants and Children.

OBJECTIVE: To evaluate the feasibility of endoscopic gastrojejunal tube (GJT) placement in infants and children. STUDY DESIGN: All children undergoing endoscopic GJT placement between January 2010 and December 2019 were included in this single-center retrospective study. Difficulties with and failure of GJT placement, complication rates, and device longevity, efficacy, and duration were assessed. RESULTS: A total of 107 children, median age 10 months (IQR, 5.0-23.0 months) and median weight 6.6 kg (IQR, 5.3-9.5 kg), underwent endoscopic GJT placement using the gastric stoma to introduce the endoscope (one step: n = 36 of 107; 33.6%). Endoscopic placement was successful in 99%. Eight periprocedure complications occurred, including 1 pneumoperitoneum requiring exsufflation, 2 acute pulmonary hypertension episodes leading to death in 1 case, and 5 episodes of bronchospasm. Minor complications were frequent and mostly mechanical (79%), whereas major complications were rare (5.6%): intussusception (n = 4), intestinal perforation (n = 1), and pneumoperitoneum (n = 1). Ten patients died. Of the 97 patients who lived, 85 (87%) were weaned from jejunal feeding at a median of 179 days (IQR, 69-295 days) after initiation. Among them, 30 (35.2%) required fundoplication. Weight for age z-score was significantly higher at weaning. CONCLUSIONS: GJT placement is feasible in children, even low-weight infants. Complications are frequent but are mostly minor.

The impact of low-pressure pneumoperitoneum on robotic-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion: a case-control study.

PURPOSE: To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD). METHODS: A retrospective case-control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system. RESULTS: Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar. CONCLUSION: With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum.

Preoperative factors affecting the operative outcomes of laparoscopic nephrectomy.

OBJECTIVES: Laparoscopic radical nephrectomy is the standard surgery for localized renal cell carcinoma. Both tumor and patient factors affect the difficulty of laparoscopic radical nephrectomy. Obesity is a major factor influencing technical difficulty in surgical procedures. This study examined preoperative tumor and patient factors affecting the operating time. METHODS: The data of 123 patients who underwent laparoscopic radical nephrectomy at our institution between January 2014 and December 2018 were retrospectively analyzed. The operating time was determined based on the median pneumoperitoneum time. Surgical procedures with a pneumoperitoneum time of ≥130 min were defined as having prolonged pneumoperitoneum time. Multiple logistic regression analyses were performed to identify the preoperative factors affecting the prolonged pneumoperitoneum time, and risk stratification was performed based on these factors. RESULTS: Multiple logistic regression analyses revealed that a total number of renal pedicle blood vessels ≥3 and a visceral fat volume ≥3000 cm3 were associated with prolonged pneumoperitoneum time of laparoscopic radical nephrectomy. Based on the multivariate analysis results, these factors were considered individually, and the cohort was stratified into three risk groups: low (0 point), intermediate (1 point), and high (2 points) risk groups. The pneumoperitoneum time was significantly prolonged as the number of risk factors increased. CONCLUSIONS: We developed a risk stratification model using preoperative factors to predict the prolonged pneumoperitoneum time of laparoscopic radical nephrectomy, which can help select suitable cases that are appropriate for each surgeon's skill level.

Management of Pneumoperitoneum: Role and Limits of Nonoperative Treatment.

OBJECTIVES: The aim of this study was to compare morbidity and mortality between nonoperative and operative treatment of pneumoperitoneum. BACKGROUND: Pneumoperitoneum is a potentially life-threatening condition that has been traditionally treated with surgical intervention. Adequately powered studies comparing treatment outcomes are lacking. METHODS: Chart review and computer-assisted abstraction were used to identify patients with pneumoperitoneum at 5 hospitals from 2010 to 2015. Patients with recent abdominal procedures or contained perforation were excluded. Patients were grouped by treatment modality: comfort measures only (CMO), nonoperative treatment, or operative intervention. CMO included only symptom-palliation, whereas nonoperative therapy included all interventions (antibiotics, peritoneal drains, resuscitation) excluding surgery. Outcomes were mortality, discharge disposition, and 30-day complications. Covariates included demographics, comorbidities, and acuity at presentation. RESULTS: Forty patients received CMO, 202 underwent nonoperative treatment, and 199 underwent operative intervention. CMO patients had 98% 30-day mortality. There was no difference in 30-day (P = 0.64) or 2-year mortality (P = 0.53) between patients treated nonoperatively and operatively. Compared with patients treated operatively, patients treated nonoperatively were more likely to have a colorectal source of pneumoperitoneum (37% vs 31%; P = 0.03). Using logistic regression, operative treatment was associated with increased dependence on enteral tube feeding or total parenteral nutrition [odds ratio (OR) 4.30, 95% confidence interval (CI), 1.99-9.29] and nonhome discharge (OR 3.61, 95% CI, 1.81-7.17). Among patients with clinical peritonitis, operative treatment was associated with reduced mortality (OR 0.17, 95% CI, 0.04-0.80). CONCLUSIONS: Operative intervention is associated with reduced mortality in patients with pneumoperitoneum and peritonitis. In the absence of peritonitis, operative treatment is associated with increased morbidity and nonhome discharge.

Delayed Tension Symptomatic Pneumoperitoneum After POEM Requiring Needle Decompression.

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period. METHODS: Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM. RESULTS: These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it. DISCUSSION: When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens.

Laparoendoscopic Single-Site Surgery for Urachal Remnants: A Single-Center Experience.

INTRODUCTION: Urachal remnants are relatively rare. Generally, urachal remnants are detected in young people, and the removed specimen is small, comprising a good indication for laparoscopic surgery. Laparoendoscopic single-site surgery (LESS) for urachal remnants is considered to be safe and result in an excellent cosmetic outcome. Therefore, we report our single-center experience with LESS for urachal remnants. METHODS: We retrospectively reviewed 30 patients with urachal remnants who underwent LESS from January 2011 to December 2017. The patients' characteristics, surgical data, postoperative pain, and cosmetic assessment results were retrospectively collected and analyzed. RESULTS: Mean total operative time was 151 min, mean pneumoperitoneal surgery time was 83 min, and mean estimated blood loss was 5.0 mL. All patients were started on an oral diet and began ambulating on postoperative day 1. Mean hospital stay was 5.5 days. LESS was completed successfully in all patients, with no conversion to conventional or open surgery. CONCLUSIONS: LESS is a viable option for the surgical treatment of urachal remnants. This technique may result in less pain than conventional techniques. Further accumulation of surgical outcomes (especially regarding safety and cosmesis) is required for LESS to become an established treatment for urachal remnants.

Interventions to reduce shoulder pain following gynaecological laparoscopic procedures.

BACKGROUND: Laparoscopy is a common procedure used to diagnose and treat various gynaecological conditions. Shoulder-tip pain (STP) as a result of the laparoscopy occurs in up to 80% of women, with potential for significant morbidity, delayed discharge and readmission. Interventions at the time of gynaecological laparoscopy have been developed in an attempt to reduce the incidence and severity of STP. OBJECTIVES: To determine the effectiveness and safety of methods for reducing the incidence and severity of shoulder-tip pain (STP) following gynaecological laparoscopy. SEARCH METHODS: We searched the following databases: Cochrane Gynaecology and Fertility (CGF) Specialised Register, the Cochrane Central Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO and CINAHL from inception to 8 August 2018. We also searched the reference lists of relevant articles and registers of ongoing trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) of interventions used during or immediately after gynaecological laparoscopy to reduce the incidence or severity of STP. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Primary outcomes: incidence or severity of STP and adverse events of the interventions; secondary outcomes: analgesia usage, delay in discharge, readmission rates, quality-of-life scores and healthcare costs. MAIN RESULTS: We included 32 studies (3284 women). Laparoscopic procedures in these studies varied from diagnostic procedures to complex operations. The quality of the evidence ranged from very low to moderate. The main limitations were risk of bias, imprecision and inconsistency.Specific technique versus "standard" technique for releasing the pneumoperitoneumUse of a specific technique of releasing the pneumoperitoneum (pulmonary recruitment manoeuvre, extended assisted ventilation or actively aspirating intra-abdominal gas) reduced the severity of STP at 24 hours (standardised mean difference (SMD) -0.66, 95% confidence interval (CI) -0.82 to -0.50; 5 RCTs; 670 participants; I2 = 0%, low-quality evidence) and reduced analgesia usage (SMD -0.53, 95% CI -0.70 to -0.35; 4 RCTs; 570 participants; I2 = 91%, low-quality evidence). There appeared to be little or no difference in the incidence of STP at 24 hours (odds ratio (OR) 0.87, 95% CI 0.41 to 1.82; 1 RCT; 118 participants; low-quality evidence).No adverse events occurred in the only study assessing this outcome.Fluid instillation versus no fluid instillationFluid instillation is probably associated with a reduction in STP incidence (OR 0.38, 95% CI 0.22 to 0.66; 2 RCTs; 220 participants; I2 = 0%, moderate-quality evidence) and severity (mean difference (MD) (0 to 10 visual analogue scale (VAS) scale) -2.27, 95% CI -3.06 to -1.48; 2 RCTs; 220 participants; I2 = 29%, moderate-quality evidence) at 24 hours, and may reduce analgesia usage (MD -12.02, 95% CI -23.97 to -0.06; 2 RCTs; 205 participants, low-quality evidence).No study measured adverse events.Intraperitoneal drain versus no intraperitoneal drainUsing an intraperitoneal drain may reduce the incidence of STP at 24 hours (OR 0.30, 95% CI 0.20 to 0.46; 3 RCTs; 417 participants; I2 = 90%, low-quality evidence) and may reduce analgesia use within 48 hours post-operatively (SMD -1.84, 95% CI -2.14 to -1.54; 2 RCTs; 253 participants; I2 = 90%). We are uncertain whether it reduces the severity of STP at 24 hours, as the evidence was very low quality (MD (0 to 10 VAS scale) -1.85, 95% CI -2.15 to -1.55; 3 RCTs; 320 participants; I2 = 70%).No study measured adverse events.Subdiaphragmatic intraperitoneal local anaesthetic versus control (no fluid instillation, normal saline or Ringer's lactate)There is probably little or no difference between the groups in incidence of STP (OR 0.72, 95% CI 0.42 to 1.23; 4 RCTs; 336 participants; I2 = 0%; moderate-quality evidence) and there may be no difference in STP severity (MD -1.13, 95% CI -2.52 to 0.26; 1 RCT; 50 participants; low-quality evidence), both measured at 24 hours. However, the intervention may reduce post-operative analgesia use (SMD-0.57, 95% CI -0.94 to -0.21; 2 RCTs; 129 participants; I2 = 51%, low-quality evidence).No adverse events occurred in any study.Local anaesthetic into peritoneal cavity (not subdiaphragmatic) versus normal salineLocal anaesthetic into the peritoneal cavity may reduce the incidence of STP at 4 to 8 hours post-operatively (OR 0.23, 95% CI 0.06 to 0.93; 2 RCTs; 157 participants; I2 = 56%; low-quality evidence). Our other outcomes of interest were not assessed.Warmed, or warmed and humidified CO2 versus unwarmed and unhumidified CO2There may be no difference between these interventions in incidence of STP at 24 to 48 hours (OR 0.81 95% CI 0.45 to 1.49; 2 RCTs; 194 participants; I2 = 12%; low-quality evidence) or in analgesia usage within 48 hours (MD -4.97 mg morphine, 95% CI -11.25 to 1.31; 1 RCT; 95 participants; low-quality evidence); there is probably little or no difference in STP severity at 24 hours (MD (0 to 10 VAS scale) 0.11, 95% CI -0.75 to 0.97; 2 RCTs; 157 participants; I2 = 50%; moderate-quality evidence).No study measured adverse events.Gasless laparoscopy versus CO2 insufflationGasless laparoscopy may be associated with increased severity of STP within 72 hours post-operatively when compared with standard treatment (MD 3.8 (0 to 30 VAS scale), 95% CI 0.76 to 6.84; 1 RCT; 54 participants, low-quality evidence), and there may be no difference in the risk of adverse events (OR 2.56, 95% CI 0.25 to 26.28; 1 RCT; 54 participants; low-quality evidence).No study measured the incidence of STP. AUTHORS' CONCLUSIONS: There is low to moderate-quality evidence that the following interventions are associated with a reduction in the incidence or severity, or both, of STP, or a reduction in analgesia requirements for women undergoing gynaecological laparoscopy: a specific technique for releasing the pneumoperitoneum; intraperitoneal fluid instillation; an intraperitoneal drain; and local anaesthetic applied to the peritoneal cavity (not subdiaphragmatic).There is low to moderate-quality evidence that subdiaphragmatic intraperitoneal local anaesthetic and warmed and humidified insufflating gas may not make a difference to the incidence or severity of STP.There is low-quality evidence that gasless laparoscopy may increase the severity of STP, compared with standard treatment.Few studies reported data on adverse events. Some potentially useful interventions have not been studied by RCTs of gynaecological laparoscopy.

Comparison of two methods for endoscopic full-thickness resection of gastrointestinal lesions using OTSC.

Background and aims: The aim of this study was to compare and analyze the feasibility and safety of two methods of endoscopic full-thickness resection (EFTR) for the management of challenging epithelial and subepithelial neoplasms that are not amenable to resection techniques.Material and methods: This was a retrospective case series study of patients who underwent one of two methods of EFTR, resection using ESD knives and post-resection closure with OTSC (Group 1), or closure with OTSC and secondary EFTR with snare (Group 2).Results: Of 11 patients, six were in Group 1 and five in Group 2. The mean time of the EFTR procedure was 76.83 ± 34.97 min in Group 1 which is significantly longer than that of Group 2 (p = .0128). The mean time of OSTC closure and length of hospital stay of Group 1 were also longer compared to Group 2, but the difference was not significant. Complete resection (R0) and technical success rates of Group 1 and Group 2 were 83.3% and 100% (p = .338), respectively. VAS scores of Group 1 immediately after the operation and after 24 h are significantly higher than those of Group 2 (p = .047 and p = .009, respectively). In Group 1, one patient had delayed perforation which led to fever and pneumoperitoneum, and one patient developed abdominal pain. No complications associated with the endoscopic procedure were observed in Group 2.Conclusion: EFTR of pre-resection closure are potentially faster compared with the concept of applying closure after EFTR. Larger prospective controlled studies comparing these two techniques are warranted in the future.

I-Gel is a suitable alternative to endotracheal tubes in the laparoscopic pneumoperitoneum and trendelenburg position.

BACKGROUND: The use of supraglottic airway devices (SADs) in surgeries with laparoscopic pneumoperitoneum and Trendelenburg (LPT) positioning is controversial due to concerns about insufficient pulmonary ventilation and aspiration. In this prospective, randomized-controlled trial, we evaluated whether the i-gel, a new second generation SAD, provides an effective alternative to an endotracheal tube (ETT) by comparing respiratory parameters and perioperative respiratory complications in non-obese patients. METHODS: In a randomized controlled trial, forty anesthetized patients with ASA I-II were divided into equally sized i-gel and ETT groups. We evaluated the respiratory parameters in the supine and LPT position in comparison between the two groups. The leak fraction was our primary outcome, which was defined as the leak volume divided by the inspired tidal volume. The leak volume was the difference between the inspired and expired tidal volumes. We also monitored pulmonary aspiration and respiratory complications during the perioperative period. RESULTS: In the LPT position, there were no differences in the leak fraction (median [IQR]) between the i-gel and ETT groups (6.20[3.49] vs 6.38[3.71] %, P = 0.883). In the i-gel group, notably less leakage was observed in the LPT position than in the supine position (median [IQR]: 7.01[3.73] %). This phenomenon was not observed in the ETT group. The rate of postoperative sore throat was also significantly lower in the i-gel group than in the ETT group (3/17 vs 9/11). No vomitus nor any signs associated with aspiration were noted in our patients after extubation in the follow-up prior to discharge. CONCLUSIONS: The i-gel provides a suitable alternative to an ETT for surgeries with LPT positioning in non-obese patients. TRIAL REGISTRATION: Registered at Clinicaltrials.gov NCT02462915 , registered on 1 June 2015.

[Chilaiditi syndrome - a case report]. / Zespól Chilaiditi ­ opis przypadku.

The abnormality being the result of a certain transposition of the large intestine winding in between diaphragm and the liver, owes it's name to a so called Chilaiditi symptom. This symptom is rarely recognized for at most 0,025-0,28% of the whole population statistics - wise. The Chilaiditi symptom can be examined without any serious (abdominal) pain indication, when conducting the gastrointestinal examination with the implication of the different disorders. When carrying out the diagnostic examination, it is strongly recommended to take notice of patients suffering from the pain in abdominal area, especially in case of the patients with the developed air - structure under the right side copula of the diaphragm. The transposition of the large instestine winding between the diaphragm and the liver, may lead to the blood structure disorders along the part of patient's spot - pressed intestine and be the cause of the other afflictions. The circumstance as such is thus called by the name of Chilaiditi syndrome. The respective recognition of this syndrome may prevent the patient from any unnecessary assignment for a diagnostic and (or) any other therapeutic procedures in place.It may as well minimize the overall diagnostic treatment time lapse - usually concentrated on the pain relief treatment in the aftermath. The patients without examined affliction, (ex.) due to the liver disorders and the awareness of the existence of this syndrome in general, can be an indicator for taking up a decision for when it comes to the liver biopsy. This due to the risk of any perforation of the digestive tract. A CASE REPORT: The report describes case of the 56-year-old male patient, directed onto the surgery department by cause of a quite significant epigastric pain in the right side of the abdomen, however without any of the peritoneal symptoms indicated. The x-ray examination of the chest has indicated presence of the air - structure under the diaphragm copula. Having stated that and without any other signals of the serious abdominal inflammation, this symptom gave trigger for the assumption of the gastrointestinal perforation. As a result, the tomography scan has revealed high curve placement of the diaphragm going along the patient's front lobe of the liver. In the result the Chilaiditi syndrome has been recognized by the patient, where the symptom based treatment has prescribed leading the same to the absolute healing results as an outcome. After leaving the surgery by the patient, it has been made use of the re-directory to the leading gastroenterology practice for any further control checks. In the aftermath of the several year long observation, none of the abdominal pains have been reported back. CONCLUSIONS: Presence of the air - structure under the diaphragm copula without any typical affliction in relation to digestive tract perforation might be the result of transposition of the large intestine winding between diaphragm and the liver - called the Chilaiditi syndrome.

[Pneumoperitoneum after colonoscopy - "to cut or not to cut"]. / Pneumoperitoneum po kolonoskopii - "to cut or not to cut".

Colon perforation is a very serious complication of colonoscopy. The correct diagnosis and management of therapy improve the prognosis of patients. The treatment can be conservative, endoscopic and surgical. In this case report we present microperforation as a complication of polypectomy in the caecum during colonoscopy, followed by laparoscopic surgery.Key words: colonoscopy - complication -perforation polypectomy.

Intestinal perforation in premature neonates: The need for subsequent laparotomy after placement of peritoneal drains.

AIM: In view of recent studies questioning the usefulness of peritoneal drainage (PD) in premature neonates with pneumoperitoneum, suggesting approximately 75% of those treated with PD needed delayed laparotomy, we reviewed the requirement for laparotomy after initial PD at our institution. METHODS: Retrospective cohort of all premature infants with a diagnosis of intestinal perforation (ICD Code P78.0) from 1995 to 2012. Inclusion criteria were pneumoperitoneum on x-ray (isolated perforation or necrotising enterocolitis), birthweight <1800 g and gestational age <33 weeks. RESULTS: Fifty patients met the criteria (38 PD, 12 primary laparotomy). Thirty-two per cent (95% CI 18-49%) received secondary laparotomy after initial PD. There was no significant difference when stratified according to isolated perforation (24%) versus necrotising enterocolitis (56%, P = 0.11). There was no significant difference between PD and primary laparotomy for time to full enteral nutrition, hazard ratio (HR) 0.99 (95% CI 0.48-2.04) or mortality, HR 2.15 (95% CI 0.48-9.63). The HR for mortality was partly confounded by birthweight, birthweight-adjusted HR 1.52 (95% CI 0.32-7.23). CONCLUSIONS: Thirty-two per cent of neonates treated with primary PD received secondary laparotomy, with no significant difference in key outcomes. Primary PD still appears to be of benefit for those without features of necrotising enterocolitis.

A Rare Cause Of Pneumoperitoneum: Perforated Appendicitis.

Peptic ulcer perforation is the most common cause of pneumoperitoneum (75%). The rate of the perforation of acute appendicitis is 20-30% and the rate of its co-occurrence with pneumoperitoneum is 0-7%. In this report, a patient with sub-diaphragmatic free air due to perforated appendicitis.

[Anesthetic Management of Laparoscopic Lower Gastrointestinal Tract Surgery].

This article reviews anesthetic management of lapa- roscopic lower gastrointestinal tract surgery. The recommended anesthetic method is general anesthesia, and tracheal intubation is an appropriate airway control method. It is important to understand hemodynamics and respiratory changes with pneumoperitoneum and Trendelenburg position during operation, especially in a patient with compromised cardiopulmonary functions. It is necessary to consider postoperative analge- sic method. An'enhanced recovery after surgery program may be useful to laparoscopic lower gastrointestinal tract surgery.

[Evaluation of the Effects of Remifentanil Doses on Hemodynamics and Perfusion Index at the Onset of Pneumoperitoneum during Laparoscopic Surgery].

BACKGROUND: The aim of this study was to investigate whether changes in perfusion index (PI) correlate with non-invasive haemodynamic parameters (HR, BP) following the onset of pneumoperitoneum under two doses (moderate-dose (MD) and high-dose (HD)) of remifentanil and to compare its reliability. METHODS: We divided 33 patients who were scheduled for laparoscopic surgery under general anesthesia into two groups according to the dose of continuously infused remifentanil: moderate dose 0.5 µg x kg(-1) x min(1) (MD group, n = 16) and high dose 1.0 µg x kg(-1) x min(-1) (HD group, n = 17). Non-invasive blood pressure (NIBP), HR, and PI were measured before the start of surgery (time 1), after the start of surgery (time 2), before the start of pneumoperitoneum (time 3), and 1 min after the stable state of pneumoperitoneum (time 4). RESULTS: PI decreased from the baseline after pneumoperitoneum in MD group, on the other hand PI did not change in HD group. Between the two groups, the magnitude of the PI changes was statistically different although MBP and HR were not statistically different CONCLUSIONS: PI may be a reliable and easier alternative to conventional haemodynamic parameters for detection of stress response to pneumoperitoneum during remifentanil anaesthesia in adult patients.

[Anesthetic Management in Robotic-assisted Laparoscopic Radical Prostatectomy].

Robotic-assisted laparosopic prostatectomy (RALP) is the only robotic surgical procedure covered by na- tional health insurance in Japan, and its application has been spreading rapidly. This procedure is per- formed with the patient in the steep Trendelenburg position under pneumoperitoneum, and anesthesiolo- gists have to understand the physiological influences and accompanying risks. Regarding the pulmonary function, the lung compliance and functional residual capacity decrease as the airway pressure rises. It is important to appropriately maintain the airway pres- sure and prevent barotrauma and atelectasis. It is also necessary to pay attention to the risk of subcutaneous emphysema, brachial plexus palsy, peroneal neuropa- thy, pharyngeal edema, gas embolism, and postopera- tive ischemic optic nerve disorder. To prevent opera- tive complications, such as anastomotic leak between the bladder and urethra, the restrictive fluid manage- ment until the surgeon completes the vesicourethral anastomosis is recommended. It is important to load transfusion after the completion of anastomosis and pay attention to the water balance in order to prevent postoperative acute kidney injury. For RALP, close coordination among the surgeons, anesthesiologist, and medical staffs is essential for safe perioperative man- agement.