Clinical and Oncological Outcomes Following Percutaneous Cryoablation vs. Partial Nephrectomy for Clinical T1 Renal Tumours: Systematic Review and Meta-Analysis.

Percutaneous cryoablation (PCA) can be an alternative to partial nephrectomy (PN) in selected patients with stage T1 renal tumours. Existing meta-analyses regarding ablative techniques compared both laparoscopic and PCA with PN. That is why we decided to perform a meta-analysis that focused solely on PCA. The aim of this study was to compare the complications and functional and oncological outcomes between PCA and PN. A systematic literature search was performed in January 2024. Data for dichotomous and continuous variables were expressed as pooled odds ratios (ORs) and mean differences (MDs), both with 95% confidence intervals (CIs). Effect measures for the local recurrence-free survival (LRFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS) were expressed as pooled hazard ratios with 95% CIs. Among 6487 patients included in the 14 selected papers, 1554 (23.9%) and 4924 (76.1%) underwent PCA and PN, respectively. Compared with the PN group, patients undergoing PCA had significantly lower overall and major postoperative complication rates. There was no difference in renal function between PCA and PN groups. When analysing collective data for cT1 renal carcinoma, PCA was associated with worse LRFS compared with PN. However, subgroup analysis revealed that in the case of PCA, LRFS was not decreased in patients with cT1a tumours. Moreover, patients undergoing robotic-assisted PN had improved LRFS compared with those undergoing PCA. No significant differences were observed between PCA and PN in terms of MFS and CSS. Finally, PCA was associated with worse OS than PN in both collective and subgroup analyses. In conclusion, PCA is associated with favourable postoperative complication rates relative to PN. Regarding LRFS, PCA is not worse than PN in cT1a tumours but has a substantially relevant disadvantage in cT1b tumours. Also, RAPN might be the only surgical modality that provides better LRFS than PCA. In cT1 tumours, PCA shows MFS and CSS comparable to PN. Lastly, PCA is associated with a shorter OS than PN.

Patients with Positive Lymph Nodes after Radical Prostatectomy and Pelvic Lymphadenectomy-Do We Know the Proper Way of Management?

Lymph node invasion in prostate cancer is a significant prognostic factor indicating worse prognosis. While it significantly affects both survival rates and recurrence, proper management remains a controversial and unsolved issue. The thorough evaluation of risk factors associated with nodal involvement, such as lymph node density or extracapsular extension, is crucial to establish the potential expansion of the disease and to substratify patients clinically. There are multiple strategies that may be employed for patients with positive lymph nodes. Nowadays, therapeutic methods are generally based on observation, radiotherapy, and androgen deprivation therapy. However, the current guidelines are incoherent in terms of the most effective management approach. Future management strategies are expected to make use of novel diagnostic tools and therapies, such as photodynamic therapy or diagnostic imaging with prostate-specific membrane antigen. Nevertheless, this heterogeneous group of men remains a great therapeutic concern, and both the clarification of the guidelines and the optimal substratification of patients are required.

A serological survey of Toxoplasma gondii in polish pigs from organic farms, other housing systems and in pigs of different age groups.

BACKGROUND: The consumption of raw or undercooked meat, especially pork, and offal containing infective tissue cysts is suspected to be a significant route of infection with Toxoplasma gondii. Although the use of "animal-friendly pig production systems" ensuring direct contact with the natural environment offers ethical benefits, it limits the ability to ensure animal health; it may also increase the probability of infections by pathogens such as T. gondii, and thus their entry into the food chain. This study determines the seroprevalence of T. gondii in pigs from different housing systems and farms with different hygiene standards in Poland, as well as among pigs of different age groups from farms with high hygiene standards. In total 760 pig serum samples were examined for the presence of specific antibodies using the PrioCHECK® Toxoplasma Ab porcine commercial ELISA test (Prionics, Switzerland). RESULTS: Test results with PP ≥ 20% were regarded as positive, as indicated by the manufacturer. Antibodies to T. gondii were found in 193 of 760 (25.4%) tested sera. Regarding different housing systems, antibodies were found in 117 pigs: of these, 52.6% (61/116) were from organic farms, 40.9% (47/115) from farms with low hygiene standards, 5.4% (9/167) from farms with high hygiene standards and 0% (0/40) from a farm with a high level of biosecurity. Regarding age groups, antibodies were found in 76 animals on farms with high hygiene standards: 11.1% (7/63) were pigs younger than 3 months, 0% (0/60) aged 3-4 months, 12.3% (7/57) aged 5-6 months (final fattening stage) and 43.7% (62/142) were sows aged 9 months and older. CONCLUSIONS: Antibodies to T. gondii were most often found in pigs from organic and low-hygiene farms, as well as in pigs aged 9 months and older. Meat derived from seropositive animals can pose a potential source of infection for humans. As maternal antibodies to T. gondii can be present in the blood of piglets aged up to 3-4 months, serological examination is unjustified in piglets up to this age.

Nine-Year Follow-Up of a Huge Retroperitoneal Alveolar Soft-Part Sarcoma: A Case Report.

BACKGROUND Alveolar soft-part sarcoma is an uncommon mesenchymal tumor accounting for approximately 0.7% of soft tissue sarcomas in adults. It mainly affects young adults, with a peak incidence between 15 and 35 years old. Available data indicate that surgical resection with adjuvant therapy using tyrosine kinase inhibitor may be considered the standard treatment. The rarity of the disease and resultant data scarcity makes it difficult to establish treatment guidelines. CASE REPORT We present the 9-year follow-up of a 24-year-old patient with an initially advanced (stage IV), huge, 21-cm alveolar soft-part sarcoma of the retroperitoneum. During the observation period, the patient developed pulmonary, brain, and bone metastases. In the course of treatment, she underwent excision of the main tumor, excision of satellite tumors, and brain metastasectomies, and was treated with sunitinib, pazopanib, and radiotherapy. No similar case reports were found in the PubMed database. CONCLUSIONS Our multimodal approach resulted in a long period of stable disease. Late progression may occur; therefore, frequent and thorough imaging evaluation of such patients is crucial. Our case is one of the largest ASPS tumors reported, and her long-term successful treatment makes this report valuable, considering the scarcity of data regarding treatment of ASPS. Further large-cohort, multi-center studies are necessary to establish the best treatment.

Quality of Life of Patients After Laparoscopic Pyeloplasty Due to Ureteropelvic Junction Obstruction: A Long-Term Observation.

This study aims to define the quality of life (QoL) of patients who had undergone laparoscopic pyeloplasty due to ureteropelvic junction obstruction. The QoL was investigated in 26 patients after pyeloplasty, on average, at a 7.5-year follow-up. The operation was performed in a single center between 2002 and 2009 and its effectiveness was confirmed by diuretic renography. The QoL was assessed using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Additionally, we used an own questionnaire, created for this study, specifically assessing the health-related quality of life after pyeloplasty. Overall, 96% of patients were satisfied with the surgical procedure and all would agree to have another pyeloplasty procedure if needed. In one case, dissatisfaction was caused by persisting postoperative pain. All patients but one, dissatisfied due to persisting pain, reported that the postoperative pain intensity was not a problem that would impact the QoL or professional activity. We conclude that laparoscopic pyeloplasty did not adversely affect the patients' QoL, which might stem from beneficial functional outcomes making the patients satisfied with treatment results.

Thrombosis of atypical location: how to treat patients in the era of direct oral anticoagulants?

In 4% of cases, venous thromboembolism (VTE) involves organ­related venous territories such as splanchnic, renal, gonadal, and cerebral venous segments, and is often called venous thromboembolism of atypical location (VTE­AL). Recommendations regarding the method, intensity, and duration of anticoagulant therapy for VTE­AL are not well established. Direct oral anticoagulants (DOACs) have been a promising alternative to vitamin K antagonists in the treatment of acute VTE. However, all major clinical trials on DOACs excluded patients with VTE­AL. Therefore, data on the use of DOACs in patients with VTE­AL are still limited to case reports and small clinical series, with a relative predominance of publications on splanchnic vein thrombosis including mesenteric, splenic, portal, and hepatic vein thrombosis. The only randomized clinical trial comparing a clinical outcome of patients with acute portal vein thrombosis randomized to either rivaroxaban or warfarin treatment yielded significantly impaired results due to the use of an atypical rivaroxaban dose. A prospective registration of clinical outcome for DOACs used in patients with VTE­AL, in those with VTE of typical location, and in those with VTE­AL treated with enoxaparin showed similar VTE recurrence and major bleeding rates in all 3 groups. High cancer prevalence, typical for VTE­AL, significantly impacted survival as well as VTE recurrence rates and major bleeding outcomes in this study. In general, although still limited, the results for DOAC use in VTE­AL are encouraging and we do not hesitate to use DOACs, particularly rivaroxaban or apixaban, in selected patients with VTE­AL.

Management of gastrointestinal stromal tumors: A 10-year experience of a single surgical department.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive system. The primary location of GISTs is mainly the gastrointestinal system. Clinical symptoms are nonspecific and mainly depend on the location and size of the tumor. OBJECTIVES: The aim of this study was to conduct a clinical and pathological analysis of 18 cases of GISTs from the medical records of the Department of Surgery at the 4th Military Teaching Hospital in Wroclaw, Poland. MATERIAL AND METHODS: The medical records were of women and men at the age of 36-84 years who were treated in the Surgical Clinic. The medical data that was gathered included clinical records, histopathological results and the type of surgical treatment. The study also encompassed the anatomical location and size of the tumor as well as microscopic examination of the tumor. RESULTS: In most cases, GISTs were located in the stomach. The most common symptoms were stomachaches and signs of bleeding into the digestive system. Usually, the tumor presented a diameter of <5 cm and a low grade of malignancy. Out of 18 patients, 16 were treated with laparoscopic resection, whereas in the remaining 2 cases, multiorgan resections were carried out, because the tumor was locally advanced. CONCLUSIONS: It is essential to distinguish stromal tumors from other mesenchymal tumors, since GISTs are among the cancers that have a high risk of malignant progression. The conditions for successful treatment are a properly established histopathological diagnosis, accompanied by immunohistochemical tests for CD117, and a combination of antibodies for a differential diagnosis of other mesenchymal tumors.

Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location.

OBJECTIVES: To assess the outcome of direct oral anticoagulants (DOACs), specifically Xa inhibitors: rivaroxaban and apixaban, for the treatment of venous thromboembolism (VTE) of atypical location (VTE-AL), portal, mesenteric, hepatic, splenic, gonadal, renal, and cerebral veins, prospectively collected data of Mayo Thrombophilia Clinic Registry were used. METHODS: Patients with acute VTE-AL treated with DOACs, enrolled between March 1, 2013, and February 1, 2017, were compared with patients with VTE of typical location (VTE-TL: deep vein thrombosis of extremities and/or pulmonary embolism) receiving DOACs and with patients with VTE-AL treated with enoxaparin. RESULTS: Out of 623 patients with acute VTE receiving the study drug within 14 days of diagnosis, there were 63 with VTE-AL: 36 on DOAC, 23 on enoxaparin, and 4 on warfarin; 352 received DOAC for VTE-TL. The VTE-AL treated with DOAC/enoxaparin included the following: splanchnic (26/22), ovarian (8/2), renal (3/5), and cerebral veins (1/1), respectively. Recurrence rate (per 100 person-years) for the VTE-AL group receiving DOAC was 7.3, which was not different when compared with those for VTE-TL (2.4; P=.13) and VTE-AL groups receiving enoxaparin (23.7; P=.37). Major bleeding rate in the VTE-AL group receiving DOAC was not different compared with those for VTE-TL (7.2 vs 3.0; P=.26) and VTE-AL groups on enoxaparin (22.4; P=.31). Mortality was higher in the VTE-AL group on DOAC compared with the VTE-TL group (21.45 [95% CI, 7.87-46.69] vs 8.26 [95% CI, 5.35, 12.20]; P=.03). All patients with VTE-AL with events had cancer. CONCLUSION: The VTE recurrence and bleeding rates for rivaroxaban and apixaban used in VTE-AL are not different from those in patients with VTE-TL and similar to that for enoxaparin.

Testicular vein thrombosis: Incidence of recurrent venous thromboembolism and survival.

PURPOSE: Testicular vein thrombosis (TVT) etiology, recurrence, and survival were compared with lower extremity deep vein thrombosis (DVT) in order to determine whether treatment guidelines for DVT could be applied to TVT. PATIENTS AND METHODS: An inception cohort of patients with confirmed TVT (January 1995-October 2015) was compared to a control group of patients with lower extremity DVT matched by age, gender, and diagnosis date. RESULTS: Thirty-nine men with TVT were identified; 15 (38%) with isolated TVT. Left testicular vein was affected in 77% patients; there were no cases of bilateral TVT. Cancer was over twofold more common in TVT patients (59% vs 28%, P = .01). Most cancers (78%) involved organs in proximity to the testicular vein. Although TVT patients were less frequently treated with anticoagulants (49% vs 97%, P = .0001), recurrence rates were similar to DVT group (TVT 4.2 vs DVT 1.1 per 100 patient-years, P = .11). Despite higher cancer prevalence, survival rates were similar between groups (31% vs 28%; P = .34). Major bleeding events were rare (one patient per group). CONCLUSIONS: Identifying TVT should prompt a search for a regional malignancy. Despite the high cancer prevalence and low utilization of anticoagulants, recurrent venous thrombosis and mortality rates are similar to DVT patients.

Cystic echinococcosis in Poland: genetic variability and the first record of Echinococcus granulosus sensu stricto (G1 genotype) in the country.

Cystic echinococcosis is one of the most important zoonotic diseases affecting humans and livestock worldwide, and is endemic in Poland. A set of six isolates on larval stages of Echinococcus granulosus sensu lato tapeworms collected from three humans, two pigs and one sheep from Polish foci of CE was examined by DNA sequencing of two mitochondrial genes (cox1, rrnS). The results demonstrated the presence of E. canadensis and E. granulosus sensu stricto in the investigated hydatid cysts. The former species was found in all five isolates from pigs and humans derived from central Poland. In a sheep hydatid cyst originating from Lesser Poland Voivodeship in southern Poland, E. granulosus s. s. (G1 genotype) was identified. This is the first report of an unambiguously autochthonous infection with E. granulosus s. s. in Poland. The global distribution and host affiliations of the commonly occurring G1 microvariant with nucleotide change 56C/T in cox1, detected here in Polish sheep, are discussed. The finding that sheep harboured E. granulosus s. s. may have important consequences for developing effective hydatid control programmes in Poland due to its longer maturation rate in dogs compared with E. canadensis G7. This may lead to greater expenditures for purchasing anthelmintics to provide an appropriate dosing regime in sheep-raising areas of the country.

Mucinous cystadenoma of the appendix - case report.

Tumors of the appendix are extremely rare and constitute about 0.4% of all tumors of the gastrointestinal tract. The most common benign neoplasm is mucinous cystadenoma, which can be found in 0.6% of all excised appendices and it rarely produces any symptoms. We present the case of a female patient who underwent surgery in the Department of Surgery due to suspicion of an appendicular abscess. On the postoperative pathology study, the diagnosis of a tumor of the appendix (mucinous cystadenoma) was made. Mucinous cystadenoma is rarely included in the differential diagnosis of a non-specific abdominal pain accompanied by non-characteristic laboratory test results and imaging studies. There are no unequivocal guidelines and algorithms of managing this disease. Long-term prognosis is good in the case of a benign tumor.

A giant pleural poorly differentiated synovial sarcoma (PDSS) in a 64-year-old woman.

The article presents the rare case of a 64-year-old woman, who was admitted to our thoracic surgery department with a giant tumor in a right hemithorax measuring 88 mm × 137 mm × 188 mm, revealed by a thoracic CT scan. An anterolateral thoracotomy with a radical tumor resection was performed. The final pathological diagnosis of the poorly differentiated synovial sarcoma (PDSS) was made. The adjuvant radiotherapy of 60 Gy in 30 fractions was applied postoperatively. One year after operation patient remains in good health. The literature review on pleural synovial sarcoma has been shortly presented.

An evaluation of the diagnostic efficacy of fine needle aspiration biopsy in patients operated for a thyroid nodular goiter.

BACKGROUND: Thyroid cancer (TC) comprises 1% of all carcinomas and is the most common malignancy of the endocrine system. The disease is more common in women, with its peak morbidity observed in 40-50-year-old patients. The main risk factors include radiation, iodine deficiency, hereditary background, and genetic mutations. Among all diagnosed thyroid nodules, 5%-30% will evolve into cancer. The gold-standard procedure in the preoperative evaluation of a nodular goiter, apart from ultrasonography, is fine needle aspiration (FNA) biopsy. The FNA biopsy is favored for its simplicity, safety, and high specificity and sensitivity rates. AIM: The aim of our study was to evaluate the clinical efficacy of FNA based on the patients' register. MATERIALS AND METHODS: In the Department of Surgery at the 4th Military Teaching Hospital in Wroclaw, 2,133 patients underwent thyroid surgery for thyroid goiter between 1996 and 2015. One hundred and eight cases of TC were diagnosed and of these, 66 patients had a preoperative FNA. RESULTS: Fourteen FNA biopsies (21%) revealed cancer, all of which were confirmed in the postoperative histopathology, although six cases of FNA-diagnosed cancer revealed a different histological type postoperatively. Eighteen FNA biopsies (27%) were suspected of being malignant. A disturbingly high rate of "benign" FNA biopsies (32 cases; 48%) revealed TC after surgery. CONCLUSION: It is of great importance that the quality and quantity of FNA biopsies that are performed have been improved, especially due to the wide adoption of the Bethesda cytological evaluation system. FNA biopsy remains an obligatory and valuable diagnostic tool in thyroid nodules, but it is still insufficient as a standard procedure. A preoperative biopsy should always be related to all the available clinical data in order to provide the best treatment option for each patient individually.

A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum.

INTRODUCTION: Meckel's diverticulum is the most common congenital anomaly of the gastro intestinal tract, present in about 2% of population. CASE OUTLINE: The article presents the case of a 44-year-old otherwise healthy man with anemia, who was diagnosed lower gastrointestinal bleeding. An abdominal CT scan revealed a clearly demarcated solid tumor in hypogastric region, measuring 65 x 45 mm. A laparotomy through lower midline incision was performed. A surgical resection of a lesion of a Meckel's diverticulum was carried out and a final diagnosis of gastrointestinal stromal tumor was made.The patient made an uneventful recovery. CONCLUSION: The preoperative diagnosis of a complicated Meckel's diverticulum may be challenging. CT is usually an adequate method to diagnose tumors arising from Meckel's diverticulum.

Incidental gallbladder cancer after cholecystectomy: 1990 to 2014.

INTRODUCTION: Cancer of the gallbladder is a serious diagnostic and therapeutic problem. According to the literature, 30% of cases are not confirmed before surgery. Other cases are detected incidentally by histopathology. Clinical trials and meta-analyses show that incidental gallbladder cancer (iGBC) occurs in 0.19%-2.8% of patients after cholecystectomy. The aim of this study was to analyze the incidence and severity of iGBC in cholecystectomy procedures performed in the surgical department at the 4th Military Teaching Hospital in Wroclaw during the years 1990-2014. PATIENTS AND METHODS: In the years 1990-2014, a total of 7,314 cholecystectomies were performed in the surgical department because of cholecystolithiasis: 6,145 were performed using the laparoscopic approach (84.02%), 867 were performed as open surgery (11.8%), and 302 cases required conversion (5.1%). In this group, 5,214 of the patients were females (71.3%) and 2,100 were males (28.7%), with an average age of 54.7 years. RESULTS: We found 64 iGBC cases which were confirmed by histopathology. This represented 0.87% of all cases. In this group, 50 patients were females (78.1%) and 14 were males (21.8%), with an average age of 67.1 years. Of this group, 40 patients underwent a classic cholecystectomy, while 24 underwent laparoscopic procedures, out of which 13 cases ultimately required traditional surgery. The histopathology showed 15 carcinomas that were classified as G1 (23.4%), 28 were G2 (43.75%), and 21 were G3 (32.8%). CONCLUSION: iGBC detected after a cholecystectomy due to cholecystolithiasis is a rare disease. We found iGBC in 0.87% of cases, which is on a comparable scale to the world literature. In the case of cancer, we frequently found it necessary to convert to an open surgical procedure. This cancer is more common in females and in people over 60 years of age.

Results of Sentinel Lymph Node Biopsy in Patients with Breast Cancer in 10-Year Own Material of the 4th Military Teaching Hospital with Polyclinic in Wroclaw.

UNLABELLED: At present, sentinel lymph node biopsy is a standard procedure to assess the advancement of breast cancer and cutaneous melanoma. The aim of the study was to assess the role of the sentinel lymph node biopsy in the treatment of patients with breast cancer in our own material. MATERIAL AND METHODS: Analyzed was medical documentation of 258 patients with initially operable breast cancer, qualified for operation with sentinel lymph node biopsy in 2004-2014 in the Department of Surgery of the 4th Military Teaching Hospital. A few hours prior to the planned surgery, radioisotope (technitium-99 sulfur colloid) was applied in the area of tumor or under the areola. 1-2 hours after administering the tracer, the lymphoscintigraphy with the labelling of the sentinel lymph node on the skin was performed. RESULTS: On the basis of the gathered material, obtained were the following parameters: sensitivity - 100%, and specificity - 94.6%. Four cases were false negative (5.5%). CONCLUSIONS: 1. Marking the sentinel lymph node in breast cancer, based on the single visualisation method with the use of radioisotope, is a useful and effective technique. 2. The factor influencing the results of the sentinel lymph node biopsy (true positive and negative results and false negative result) was the number of the excised lymph nodes except for the sentinel lymph node. 3. Patients with estrogen receptor expression had often metastases to sentinel lymph node (145 cases - 56%). 4. The false negative rate, i.e. 5.5% in our material, is within the limits of acceptability given in the literature. 5. The sentinel lymph node biopsy performed by the experienced surgical team is a reliable diagnostic tool with a low complication rate.

Subcutaneous emphysema of the neck, chest, and abdomen as a symptom of colonic diverticular perforation into the retroperitoneum.

We describe a rare case of a patient with colonic diverticular perforation manifested only by subcutaneous emphysema of the neck, chest, and abdomen, as visualized by a computed tomography (CT) scan. The 76-year-old female patient with a history of internal diseases was urgently admitted to the Clinic of Internal Diseases due to a urinary tract infection. During the hospitalization, further diagnostic procedures were performed due to palpable subcutaneous emphysema of the neck, chest, and abdomen. Computed tomography examination revealed massive intra-abdominal, intramuscular, and subcutaneous emphysema. A decision was made to perform exploratory laparotomy; the procedure exposed an inveterate diverticular perforation of the sigmoid-rectal flexure as well as air-inflated retroperitoneal tissue. The perforated colon was resected, and a stoma was formed. On the 15(th) postoperative day, the patient died due to cardiorespiratory failure. Although subcutaneous emphysema is a common symptom in everyday medical practice, its etiology remains complex. One should consider this clinical presentation of colonic diverticular perforation, especially in elderly patients in whom the perforation signs may be clinically less marked.

Glomus Tumor of the Stomach - A Case Report and A Literature Review.

The study presented a case of a patient with a glomus tumor of the stomach, a mesenchymal neoplasm manifesting with upper gastrointestinal bleeding (Forrest IB). The patient was operated twice. First, he underwent elective laparotomy, during which Billroth I (Rydygier's method) gastric resection was performed. This his was followed by Billroth II resection with Braun's anastomosis. Histopathological examination revealed glomus tumor tissue. Literature data on the glomus tumor of the stomach are presented.

Management of corneal melting in a patient with long-standing rheumatoid arthritis ­ case report.

Corneal melting is a rare ocular complication of rheumatoid arthritis, associated with poor prognosis. Rapid course of the disease and unpredicted treatment response, which depends on a patient general state and disease severity, make every case a challenge and requires a cooperation between ophthalmologists and rheumatologists. We present a case of a 58-year-old woman with corneal melting, who was successfully treated with systemic corticosteroids and methotrexate, along with ocular surgery.

Endoscopic esophageal self-expanding stent implantation WallFlex™ (Boston Scientific) in the management of a gastrocutaneous fistula, as a complication of sleeve bariatric gastrectomy.

The study presented a case of a gastrocutaneous fistula, as a result of bariatric sleeve gastrectomy. The discussion considered the main pathogenesis, etiology, diagnostics and endoscopic treatment using the implantation of covered esophageal stents. Special attention was placed upon the multifactorial origin of this life-threatening clinical condition, typical for bariatric surgery.