Spontaneous haemoperitoneum in pregnancy: Nationwide surveillance and Delphi audit system.

OBJECTIVE: To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP. DESIGN: A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS). SETTING: Nationwide, the Netherlands. POPULATION: All pregnant women between April 2016 and April 2018. METHODS: This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP. MAIN OUTCOME MEASURES: Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP. RESULTS: In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention. CONCLUSIONS: SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality.

Hemoperitoneum among Pediatric Abdominal Trauma Patients Visiting in Emergency Department of a Tertiary Care Centre: A Descriptive Cross-sectional study.

Introduction: Pediatric abdominal trauma presents a major challenge for first-line responders in the Emergency Department for assessment and management. The Focused assessment sonography for trauma is a readily available, easy-to-use, and affordable tool for detecting hemoperitoneum during the initial assessment of trauma in the Emergency Department for adult traumatic patients. The aim of this study was to find the prevalence of hemoperitoneum among pediatric abdominal trauma patients visiting the Emergency Department of tertiary care centre through Focused assessment with sonography for trauma examination technique. Methods: This was a descriptive cross-sectional study conducted in the Emergency Department of a tertiary care hospital from 7 April 2019 to 7 April 2020. Among 413 pediatric trauma patients, 93 children (1 to 17 years) admitted to the Emergency Department who underwent focused assessment with sonography for trauma examination were included in the study. Ethical approval was obtained from the Institutional Review Committee (Approval number: 111/19). Convenience sampling was used. Point estimate and 90% Confidence Interval were calculated. Results: Among 93 children receiving focused assessment with sonography for trauma imaging in the Emergency Department with a history of blunt abdominal trauma, the prevalence of hemoperitoneum was 18 (19.34%) (12.61-26.09, 90% Confidence Interval). Conclusions: The prevalence of hemoperitoneum was similar to other studies conducted in a similar setting. Keywords: blunt injuries; emergency medicine; focused assessment with sonography for trauma.

Ruptured Corpus Luteum among Women Undergoing Laparotomy for Hemoperitoneum in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Rupture of the corpus luteum, though generally self-limiting in women with normal coagulation, could lead to life-threatening bleeding in patients with prosthetic valves on anticoagulant therapy and described in only a few case reports in the literature. The aim of this study was to find out the prevalence of ruptured corpus luteum among women undergoing laparotomy for hemoperitoneum in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among women undergoing laparotomy for hemoperitoneum in a tertiary centre from 7 April 2017 to 31 March 2021 after obtaining ethical approval from the Institutional Review Committee [Reference number: 328(6-11-E)2/73/74]. All women who underwent laparotomy for hemoperitoneum during the study period were enrolled. Convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 447 women who underwent laparotomy for hemoperitoneum, ruptured corpus luteum was seen in 48 (10.74%) (7.87-13.61, 95% Confidence Interval). Out of which 36 (75%) had prosthetic valves. There was 1 (2.77%) mortality and 3 (8.33%) recurrences. Conclusions: The prevalence of rupture of the corpus luteum among women undergoing laparotomy for hemoperitoneum was similar to other studies done in similar settings. Early diagnosis, emergent reversal of coagulopathy and surgery if needed are the mainstay of management. Keywords: anticoagulant; corpus luteum; hemoperitoneum.

Ruptured Corpus Luteum among Women Undergoing Laparotomy for Hemoperitoneum in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Rupture of the corpus luteum, though generally self-limiting in women with normal coagulation, could lead to life-threatening bleeding in patients with prosthetic valves on anticoagulant therapy and described in only a few case reports in the literature. The aim of this study was to find out the prevalence of ruptured corpus luteum among women undergoing laparotomy for hemoperitoneum in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among women undergoing laparotomy for hemoperitoneum in a tertiary centre from 7 April 2017 to 31 March 2021 after obtaining ethical approval from the Institutional Review Committee [Reference number: 328(6-11-E)2/73/74]. All women who underwent laparotomy for hemoperitoneum during the study period were enrolled. Convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 447 women who underwent laparotomy for hemoperitoneum, ruptured corpus luteum was seen in 48 (10.74%) (7.87-13.61, 95% Confidence Interval). Out of which 36 (75%) had prosthetic valves. There was 1 (2.77%) mortality and 3 (8.33%) recurrences. Conclusions: The prevalence of rupture of the corpus luteum among women undergoing laparotomy for hemoperitoneum was similar to other studies done in similar settings. Early diagnosis, emergent reversal of coagulopathy and surgery if needed are the mainstay of management. Keywords: anticoagulant; corpus luteum; hemoperitoneum.

Spontaneous hemoperitoneum in pregnancy: Italian prospective population-based cohort study.

INTRODUCTION: Spontaneous hemoperitoneum in pregnancy is defined as a sudden non-traumatic intraperitoneal bleeding in pregnancy and up to 42 days postpartum. In the present study we aim to estimate the incidence and investigate the risk factors, the management and the outcomes of spontaneous hemoperitoneum in pregnancy in order to improve its clinical identification and reduce avoidable maternal deaths. MATERIAL AND METHODS: This is a prospective population-based cohort study, set in maternity units from nine Italian regions covering 75% of the national births. The study population comprises all women admitted for spontaneous intraperitoneal hemorrhage during pregnancy and up to 42 days postpartum between November 2017 and March 2020. Incident cases were reported by trained clinicians through electronic data collection forms. Descriptive statistics were performed. The main outcome measures included incidence rate of spontaneous hemoperitoneum in pregnancy, association with potential risk factors, clinical management and maternal and perinatal outcomes. RESULTS: Twenty-nine cases met the adopted definition of spontaneous hemoperitoneum in pregnancy with an estimated incidence rate of 0.04 per 1000 births. An increased risk ratio (RR) of this condition was observed in pregnancies conceived by assisted reproductive technology (RR = 6.60, 95% CI 2.52-17.29), in the case of multiple pregnancies (RR = 6.57, 95% CI 1.99-21.69) and maternal age ≥35 years (RR 2.10, 95% CI 1.01-4.35). In 17/29 cases the bleeding site was intra-pelvic (23.5% in the posterior uterine wall and 35.2% in the left hemipelvis). Laparotomy represented the surgical treatment in 27 cases (93%), and most women underwent a cesarean delivery (92.6%). Median blood loss was 1900 mL, one hysterectomy was necessary, and two women died. Twenty-two preterm births were recorded. CONCLUSIONS: Spontaneous hemoperitoneum in pregnancy is a rare, life-threatening condition associated with high perinatal morbidity and mortality. Maternal age ≥35 years, multiple pregnancies and assisted reproductive technology were associated to a higher risk of the condition. Two women of 29 died and 70% of births occurred preterm.

Contemporary utility of diagnostic peritoneal aspiration in trauma.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield. METHODS: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan. RESULTS: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred. CONCLUSION: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point. LEVEL OF EVIDENCE: Diagnostic, level III.

Nationwide survey (Japan) on spontaneous hemoperitoneum in pregnancy.

AIM: The purpose of this study was to evaluate the current state and clinical characteristics of spontaneous hemoperitoneum in pregnancy (SHiP) in Japan by performing a comprehensive survey. METHODS: We reviewed data on pregnant women who developed SHiP during 2013-2017 (for 5 years), and were admitted to any of the perinatal centers in Japan. The survey assessed maternal background and maternal and neonatal prognosis. We divided the cases into two groups, favorable and poor prognosis groups, and made comparisons between the two groups. RESULTS: Of the 407 facilities in Japan, 267 (66%) facilities responded to our survey. Overall, 31 cases of SHiP were registered. Maternal death occurred in one case (3%) due to liver bleeding with an unknown cause. Of 23 cases with a SHiP onset during pregnancy, 12 (53%) had been misdiagnosed as placental abruption. The prognosis for the fetuses included miscarriage or stillbirth in three cases (10%) and asphyxia in 12 cases (42%). There was no significant correlation between the amount of intra-abdominal blood loss and neonatal prognosis based on umbilical artery pH. Incidences of preterm birth <32 gestational weeks (adjusted odds ratio, 35.75; 95% confidence interval, 3.46-368.82) were higher in the poor prognosis group than that in the favorable group. Endometriosis and artificial reproductive techniques were both associated with 19% of all cases of SHiP. CONCLUSION: SHiP was associated with maternal death and poor fetal prognosis. Prematurity and persistent uterine contractions which might be misdiagnosed as placental abruption seem to contribute to poor fetal prognosis.

Endometriosis and spontaneous hemoperitoneum in pregnancy: evaluation of the magnitude of the risk in women becoming pregnant via in vitro fertilization.

OBJECTIVE: To estimate the frequency of spontaneous hemoperitoneum in pregnancy (SHiP) in women with endometriosis achieving pregnancy with in vitro fertilization (IVF). DESIGN: Retrospective case series. SETTING: Referral academic assisted reproductive technology (ART) center. PATIENT(S): Three hundred and forty-eight women with a history of surgery for endometriosis and women with ovarian endometriomas or deep endometriotic nodules detected at basal transvaginal ultrasound performed before IVF cycle. INTERVENTION(S): Information obtained from patients' charts on basal characteristics, IVF cycle, and pregnancy outcomes, and binomial distribution model created to determine the 95% confidence interval (CI) of the proportion of SHiP. MAIN OUTCOME MEASURE(S): Rate of SHiP. RESULT(S): Overall, 362 pregnancies were included, among which 238 (66%) had a history of previous surgery for endometriosis and 231 (64%) had endometriosis detected at ultrasound (107 women, 30%, had both). Pregnancies were achieved after fresh and frozen cycles in 244 (67%) and 118 (33%) women, respectively. One case of SHiP was recorded, corresponding to a rate of 0.3%. CONCLUSION(S): In the general population of women with endometriosis undergoing IVF, SHiP is uncommon. Future studies should better identify the risk factors for SHiP to disentangle the subgroups of women at higher risk.

Incidences and risk factors of moderate-to-severe ovarian hyperstimulation syndrome and severe hemoperitoneum in 1,435,108 oocyte retrievals.

RESEARCH QUESTION: What are the risk factors affecting the incidences of moderate-to-severe ovarian hyperstimulation syndrome (OHSS) and severe hemoperitoneum in assisted reproductive technology (ART) treatment cycles? DESIGN: A retrospective cohort study was conducted on 1,435,108 oocyte retrieval cycles among Japanese ART registry data between 2007 and 2015. The study included 11,378 cycles with moderate-to-severe OHSS, 1182 cycles with severe hemoperitoneum, including 27 cycles with both conditions, and 1,422,575 cycles without moderate-to-severe OHSS and severe hemoperitoneum. RESULTS: The incidences of moderate-to-severe OHSS and severe hemoperitoneum were 0.79% and 0.08%, respectively, and decreased by 0.57-fold and 0.29-fold from 2007 to 2015, respectively. In cycles with OHSS and cycles with hemoperitoneum women were younger (odds ratios [OR] 0.91 and 0.95, respectively) and had more retrieved oocytes (OR 1.09 and 1.01, respectively) compared with cycles without both complications. The use of a gonadotrophin-releasing hormone (GnRH) agonist protocol for ovarian stimulation was the highest risk factor in cycles with OHSS and hemoperitoneum (OR 1.83 and 1.24, respectively), followed by GnRH antagonist protocol (reference), gonadotrophin with or without oral medicine (OR 0.45 and 0.56, respectively) and natural or oral medicine (OR 0.02 and 0.19, respectively). In fresh embryo transfer, clinical pregnancy was associated with an increased risk of OHSS and hemoperitoneum (OR 1.19 and 2.34, respectively). CONCLUSIONS: The highest risk factors affecting OHSS and hemoperitoneum were the use of a GnRH agonist protocol and clinical pregnancy following fresh embryo transfer. The incidences of OHSS and hemoperitoneum have decreased yearly with a reduction of GnRH agonist use and fresh embryo transfer.

Non-traumatic hemoperitoneum in the ED setting: causes, characteristics, prevalence and sex differences.

PURPOSE: Prevalence and sex differences of non-traumatic hemoperitoneum in the Emergency Department has not been studied in the literature. METHODS: Following IRB approval, multiple keyword searches were used to identify all cases of hemoperitoneum over a 55-month period. Cases were reviewed to confirm and quantify the hemoperitoneum. Maximum attenuation was used to grade blood density. Medical records were reviewed to determine cause, interventions and outcomes in each patient. RESULTS: Of the 171 verified cases of non-traumatic hemoperitoneum, 76% of cases were in women. CT exams in women were positive for hemoperitoneum 0.25% of the time, while 0.13% were positive in men. Regarding size, 25.7% were large, 24.5% were moderate and 49.7% were small. Contrast-enhanced studies had HU values of 103 ± 19 (range 47-146) which were significantly higher than for non-enhanced studies with values of 82 ± 19 (range 43-121, p < 0.001). The most common cause of non-traumatic hemoperitoneum was ruptured ovarian cyst which was found in 58% of women (76 cases). Of these, 69 patients received observation, 6 patients underwent surgery and 1 patient received Vitamin K. For the 95 non-ovarian cyst cases, 65% patients were admitted and then discharged, 22% were discharged from the ED, 12% expired and 1% were transferred to a different hospital. Post-procedure hemorrhage was the second to most common cause in women (24/130 = 18%) and the most common etiology in men (14/41 = 34%). CONCLUSIONS: In women, ovarian cyst rupture was the most common etiology of hemoperitoneum. Post-procedure hemorrhage was second in women and the most common etiology in men. Although unusual causes of hemoperitoneum will be encountered, understanding the most common causes of hemoperitoneum can provide a reasonable starting point when attempting to determine the most likely etiology of hemoperitoneum in any individual patient.

Anatomic site and etiology of hemorrhage in small versus large dogs with spontaneous hemoperitoneum.

OBJECTIVE: To compare anatomic sources and underlying etiology of hemorrhage in small vs large dogs with spontaneous hemoperitoneum (SH). STUDY DESIGN: Retrospective cross-sectional study. ANIMALS: Client-owned dogs with SH at 2 academic institutions. METHODS: Medical records were reviewed for age, breed, sex, weight, and results of imaging, surgery, necropsy, cytology, and histopathology. Dogs were divided according to body weight (≤ 20 kg = small, > 20 kg = large). Confidence intervals were calculated to estimate rates of splenic and hepatic hemorrhage in small and large dog SH populations. Multivariable regression was used to compare prevalence of anatomic sources of hemorrhage and etiology in small vs large dogs. RESULTS: We identified 742 dogs with SH, including 637 in which the anatomic site of hemorrhage was investigated. Splenic hemorrhage was diagnosed in 43.2% (95% CI, 34.3-52.4) of small dogs and 61.3% (95% CI, 57.0-65.6) of large dogs. Small dogs had lower prevalence of splenic hemorrhage (prevalence ratio, 0.70; 95% CI, 0.58-0.87; P < .001) and higher prevalence of hemorrhage from liver (prevalence ratio, 1.72; 95% CI, 1.20-2.47; P = .003) or from another location such as retroperitoneal mass, kidney, or adrenal (prevalence ratio, 2.73; 95% CI, 1.66-4.47; P < .001) vs large dogs. Hemangiosarcoma was associated with splenic hemorrhage and occurred more frequently in large vs small dogs (P = .011). CONCLUSION: Small dogs had a lower rate of splenic hemorrhage and higher rates of hemorrhage from liver and other sites compared to large dogs. Etiologies other than splenic hemangiosarcoma were common, particularly among dogs weighing ≤ 20 kg. CLINICAL SIGNIFICANCE: Clinicians should perform diagnostics and consider body size before making presumptive diagnoses in dogs with SH.

Obstetrical outcome in women with endometriosis including spontaneous hemoperitoneum and bowel perforation: a systematic review.

Increasing evidence suggests that pregnant women with endometriosis have a higher risk of adverse obstetrical complications. The aim of this study was to systematically review the existing literature on this aspect. A PubMed/MEDLINE search was performed from its inception until September 2017 for studies on adverse obstetrical complications in pregnant women with endometriosis, including: preeclampsia, preterm birth, small for gestational age (SGA), antepartum hemorrhage, spontaneous hemoperitoneum, spontaneous bowel perforation, preterm birth, cesarean delivery, stillbirth and postpartum hemorrhage. Overall, the results showed an increased risk of preterm delivery, antepartum hemorrhage, delivery by cesarian section, and the rare complications of spontaneous hemorrhage in pregnancy and spontaneous bowel perforation. There is no firm evidence for any increased risk of preeclampsia, having a child born small for gestational age, stillbirth, or postpartum hemorrhage. In conclusion, pregnant patients with endometriosis should be offered special clinical attention.

Spontaneous hemoperitoneum in pregnancy (SHiP) and endometriosis - A systematic review of the recent literature.

Spontaneous Hemoperitoneum in Pregnancy (SHiP), an unprovoked (nontraumatic) intraperitoneal bleeding in pregnancy (up to 42days postpartum), is associated with serious adverse pregnancy outcomes. To evaluate the clinical consequences of SHiP and its association with endometriosis, a systematic review was conducted according to the PRISMA guidelines. PubMed, Embase.com and Thomson Reuters/Web of Science were searched for articles published since the latest review (August 2008) until September 2016. After assessment for eligibility, forty-four articles were included in this systematic review, describing 59 cases of SHiP. Endometriosis was present in 33/59 cases (55.9%), most often diagnosed prior to pregnancy. An association between the severity of SHiP and the stage of endometriosis could not be found. In the majority of cases, SHiP occurred in the third trimester of pregnancy (30/59 cases (50.8%)); women presented with (sub)acute abdominal pain (56/59 cases (94.9%)), hypovolemic shock (28/59 cases (47.5%)) and/or a decreased level of hemoglobin (37/59 cases (62.7%)). Signs of fetal distress were observed in 24/59 cases (40.7%). Imaging confirmed free peritoneal fluid in (37/59 cases (62.7%)). At time of surgery active bleeding was revealed in 51/56 cases (91,1%), originating from endometriotic implants (11/51 cases (21.6%)), ruptured utero-ovarian vessels (29/51 cases (56.8%)), hemorrhagic nodules of decidualized cells (1/51 cases (2.0%)) or a combination (10/51 cases (19.6%)). Median amount of hemoperitoneum was 1600mL (IQR 1000mL-2500mL). From the 45/59 cases (76.3%) in which surgical interventions was carried out during pregnancy, 7/45 cases (15.6%) reported a successful continuation of pregnancy. 5/59 cases reported recurrence of SHiP (recurrence rate 8.5%). The perinatal mortality rate was 26.9% (18/67 fetus), one maternal death was reported (1/59 cases (1,7%)). In conclusion, SHiP is a very serious complication of pregnancy, highly associated with adverse pregnancy outcomes and particularly relevant to women with endometriosis. Currently preventive measures are lacking, therefore increasing the awareness and recognition of SHiP is crucial to improve pregnancy outcomes.

[Comparison of complications following open, laparoscopic and robotic gastrectomy].

OBJECTIVE: To compare clinically relevant postoperative complications after open, laparoscopic, and robotic gastrectomy for gastric cancer. METHODS: Clinical data of patients with gastric cancer who underwent gastrectomy between January 1, 2014 and October 1, 2016 at Chinese People's Liberation Army General Hospital were analyzed retrospectively. All the patients were diagnosed by upper endoscopy and confirmed by biopsy without distant metastasis. They were confirmed with R0 resection by postoperative pathology. Patients with incomplete data were excluded. The complications among open group, laparoscopic group and robotic group were compared. The continuous variables were analyzed by one-way ANOVA, and categorical variables were analyzed by χ2 test or Fisher exact test. RESULTS: A total of 1 791 patients (1 320 males and 471 females) were included in the study, aged from 17 to 98 (59.0±11.6) years, comprising 922 open, 673 laparoscopic and 196 robotic gastrectomies. There were no significant differences among three groups in baseline data (gender, age, BMI, comorbidity, radiochemotherapy) and some of operative or postoperative data (blood transfusion, number of lymph node dissection, combined organ resection, resection site, N stage, postoperative hospital stay). The blood loss in laparoscopic and robotic groups was significantly lower than that in open group[(185.7±139.6) ml and (194.0±187.6) ml vs. (348.2±408.5) ml, F=59.924, P=0.000]. The postoperative complication occurred in 197 of 1 791(11.0%) patients. The Clavien-Dindo II(, III(a, III(b, IIII(a, and IIIII( complications were 5.5%, 4.0%, 1.2%, 0.1%, and 0.2% respectively. The anastomotic leakage (2.4%), intestinal obstruction(1.3%) and pulmonary infection(1.2%) were the three most common complications, followed by wound infection(0.8%), cardiovascular disease(0.7%), anastomotic bleeding (0.7%), delayed gastric emptying (0.6%), duodenal stump fistula(0.5%), intraperitoneal hemorrhage (0.5%), pancreatic fistula (0.3%), intra-abdominal infection(0.2%), chylous leakage (0.1%) and other complications(1.7%). There were no significant differences among three groups as the complication rates of open, laparoscopic and robotic gastrectomy were 10.6%(98/922), 10.8%(73/673) and 13.3%(26/196) respectively (χ2=1.173, P=0.566). But anastomotic leakage occurred more common after laparoscopic and robotic gastrectomy compared to open gastrectomy [3.1%(21/673) and 5.1%(10/196) vs. 1.3%(12/922), χ2=12.345, P=0.002]. The rate of cardiocerebral vascular diseases was higher in open group[1.3%(12/922) vs. 0.1%(1/673) and 0, χ2=8.786, P=0.012]. And the rate of anastomotic bleeding was higher in robotic group [2.0%(4/196) vs. open 0.4%(4/922) and laparoscopic 0.6%(4/673), χ2=6.365, P=0.041]. In view of Clavien-Dindo classification, III(a complications occurred more common in laparoscopic group [5.5%(37/673) vs. open 3.3%(30/922) and robotic 2.6%(5/196), χ2=6.308, P=0.043] and III(b complications occurred more common in robotic group [3.1%(6/196) vs. open 1.1%(10/922) and laparoscopic 0.7%(5/673), χ2=7.167, P=0.028]. CONCLUSIONS: Morbidities of postoperative complications are comparable among open, laparoscopic and robotic gastrectomy for gastric cancer. However, in consideration of the high difficulty of anastomosis, the minimally invasive surgery should be performed by more experienced surgeons.

Outcomes in laparoscopic cholecystectomy by single incision with SPIDER surgical system are comparable to conventional multiport technique: one surgeon's experience.

BACKGROUND: Single-incision laparoscopic cholecystectomy has emerged as an alternative to conventional multiport laparoscopic cholecystectomy (LC). Technical difficulty, prolonged surgical times and increased complication rates have been reported in single-incision laparoscopic surgery. One of the concerns is lack of triangulation of instruments. The SPIDER® surgical system is a single-incision laparoscopic device that utilizes flexible instruments with the purpose of achieving adequate triangulation. The purpose of this study is to compare the outcomes of SPIDER versus LC. METHODS: A retrospective chart review of patients who underwent LC and SPIDER cholecystectomy by a single surgeon during a concurrent 44-month period at Baptist Health South Florida hospitals was performed focusing on demographics, indication for surgery, complications and incisional hernia rates. Exclusion criteria were concomitant surgery and hernia repair at the time of surgery. RESULTS: A total of 612 patients underwent minimally invasive cholecystectomy: 279 cases for SPIDER cholecystectomy and 333 for multiport LC. Baseline differences in patient characteristics between the SPIDER and LC groups were statistically significant. The SPIDER group had younger and healthier patients (lower ASA classification scores) with predominant diagnosis of cholelithiasis (69 %) compared to the LC group which had more complex cases. Total complications rate for both SPIDER and LC were 0.4 % (n = 1) and 3 % (n = 10), respectively. Conversion to open cholecystectomy occurred in one patient from the LC group (0.3 %). Conversion rate from SPIDER to additional ports or LC was performed in 5 cases (1.8 %) with no conversions to open surgery. Hemoperitoneum was reported in 2 cases, one for each approach, requiring reoperation. CONCLUSION: Single-incision laparoscopic cholecystectomy with SPIDER is a safe and feasible technique with similar outcomes to multiport LC. However, statistical significant difference was reported in baseline characteristics of both groups. No incisional hernias were reported in this case series for either technique.

Beyond infertility: obstetrical and postpartum complications associated with endometriosis and adenomyosis.

The risk of pregnancy and neonatal complications in women with endometriosis and adenomyosis is debatable. A literature review looking at rates, presentation, and management of spontaneous hemoperitoneum, enlargement, abscess, and rupture of an endometrioma, uterine rupture, and bowel perforation in pregnant women with endometriosis was conducted. Moreover, studies addressing differences in early pregnancy (miscarriage), late pregnancy (gestational diabetes mellitus, preeclampsia, prematurity, placenta previa, placental abruption, cesarean section, hemorrhages) and neonatal outcomes (weight at birth) between endometriosis and adenomyosis patients versus control subjects were reviewed. The overall prevalence of endometriosis-related spontaneous hemoperitoneum in pregnancy is estimated to be ∼0.4%. Only four cases of endometrioma rupture in pregnancy have been reported. Although during pregnancy there is no way to anticipate the onset of complications from preexisting endometriosis, it is important, when a specific abdominal pain occurs, to suspect rare but potentially life-threating events. Population-based studies suggest a possible association of endometriosis with preterm birth and placenta previa. Limits of the published studies are noted and discussed.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

Major complications due to transjugular liver biopsy: Incidence, management and outcome.

PURPOSE: The purpose of this study was to retrospectively evaluate the incidence of intraperitoneal bleeding and other major complications of transjugular liver biopsy (TJLB) and analyze their outcome and management. MATERIALS AND METHODS: The clinical files of 341 consecutive patients who had TJLB were retrospectively analyzed. There were 237 men and 104 women (mean age: 51.38±12.8 years; range: 17-89 years). All patients had TJLB because standard percutaneous transhepatic biopsy was contraindicated. Patients' files were reviewed to search for major and minor procedure-related complications during or immediately after TJLB. RESULTS: TJLBs were technically successful in 331/341 patients (97.07%; 95%CI: 94.67-98.58%). Major complications consisted exclusively of intraperitoneal bleeding due to liver capsule perforation and were observed in 2/341 patients (0.59%; 95%CI: 0.07-2.10%). They were treated using transcatheter arterial or venous embolization with a favorable outcome. The most frequent minor complications were abdominal pain (35/341; 10.26%; 95%CI: 7.25-13.99%) and supraventricular arrhythmia (15/341; 4.40%; 95%CI: 2.48-7.15%). No cases of inadvertent injury of the carotid artery were observed. CONCLUSION: Major complications during TJLB are extremely rare and can be managed using arterial or venous embolization with a favorable outcome. Our results reinforce the general assumption that TJLB is a safe and well-tolerated technique.

Primary Ovarian Pregnancy: 43 Years Experience in a Single Institute and still a Medical Challenge.

BACKGROUND: Despite awareness regarding tubal pregnancy, ovarian pregnancy still remains a diagnostic challenge. The correct diagnosis is most frequently made intraoperatively and requires histopathologic confirmation. Therefore, additional diagnostic measurements are needed for earlier and more accurate detection of ovarian pregnancies which will allow more rapid and efficient treatment. OBJECTIVES: To assess the time trends, clinical manifestations, surgical management and post-procedure outcome of 46 primary ovarian pregnancies in a single institution during three time periods. METHODS: In this retrospective study we compared 20 patients with primary ovarian pregnancy during the years 1971- 1989 (first period), 19 patients in 1990-2001 (second period) and 7 patients in 2002-2013 (third period). In all cases the pathology examination confirmed primary ovarian pregnancy. RESULTS: The number of tubal ectopic pregnancies almost doubled, from 637 in the first period to 1279 in the third period (P < 0.001). However, there was a significant fall in the number of ovarian ectopic pregnancies, from 20 cases in the first period to 7 cases in the third (P = 0.009). A significant difference was noted when we compared the postoperative hospitalization time (4.06 ± 1.4 vs. 2.0 ± 0.6 days respectively, P = 0.001) in the second versus the third time period. CONCLUSIONS: Ovarian pregnancy continues to be a diagnostic challenge, associated with a high rate of circulatory collapse, hemoperitoneum and requirements for blood transfusions, all leading to longer hospitalization.

[Postoperative intraperitoneal complications in colon cancer surgery].

The authors studied the clinical characteristics and terms of the development of postoperative intraperitoneal complications in patients undergoing colon cancer surgery. It was stated, that the diversity of clinical data depended on complication characteristics. Results of investigation allowed defining of the most dangerous terms of intraperitoneal complications and risk factors.