The International Network of Obstetric Survey System.

OBJECTIVE: To informed about international surveillance network severe maternal morbidity and mortality - INOSS. DESIGN: Literature review. SETTINGS: 1st Department of Gynaecology and Obstetrics Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: Literate review of articles published till august 2019. RESULTS: The International Network of Obstetric Survey Systems (INOSS) is an international network that connects countries with the same or similar system of surveillance of acute severe maternal morbidity and mortality. The INOSS was established in year 2010 by twelve countries. Nowadays 19 countries are involved in the INOSS. The cooperation between member countries is focused on the acquisition of relevant data about rare severe acute maternal morbidities. INOSS in 2017 year unified definitions of 8 severe acute maternal morbidities according Delphi method: eclampsia, amniotic fluid embolism, peripartum hysterectomy, severe primary postpartum haemorrhage, uterine rupture, abnormally invasive placenta, spontaneous hemoperitoneum in pregnancy, and cardiac arrest in pregnancy. CONCLUSION: The international cooperation allows the acquisition of relevant epidemiologic data and the optimalization of the treatment according the evidence-based medicine.

The management and genetic background of pityriasis rubra pilaris: a single-centre experience.

BACKGROUND: Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory dermatosis with multifactorial aetiology. It is known that particular caspase recruitment domain family member 14 (CARD14) gene mutations are associated with familial PRP and certain forms of psoriasis. Additionally, few data are available about the role of CARD14 gene variants in sporadic PRP. The clinical picture is variable for the different types of PRP, therefore choosing the adequate treatment is often difficult, furthermore there are no specific guidelines for therapy. OBJECTIVE: Our aim was to survey the efficacy of the applied therapies and to screen the CARD14 gene variants in our PRP patients. METHODS: In this retrospective study, patients diagnosed with PRP between 2006 and 2016 at our clinic were involved. Besides the follow-up study of the treatments, the genetic analysis of CARD14 gene was performed. RESULTS: We analysed 19 patients, among whom 17 were diagnosed with type I, one with type III, and one with type V PRP. The majority of the patients were successfully treated with acitretin in combination with systemic corticosteroids, and the remaining patients were treated with other systemic therapies with diverse effects. The genetic screening of CARD14 gene revealed two previously described mutations (rs114688446, rs117918077) and six polymorphisms (rs28674001, rs2066964, rs34367357, rs11653893, rs11652075, rs2289541). Ten of 19 patients carried different CARD14 genetic variants either alone or in combination. CONCLUSION: Based on our experience, we propose that acitretin and an initial combination of short-term systemic corticosteroid therapy could be a successful treatment option for PRP. Although we identified several CARD14 variants in almost half of our cases, we did not find a correlation between the therapeutic response and the genetic background. Our data support the previous observation that CARD14 genetic variants are not specific to PRP, although they may indicate chronic inflammation.

Maternal morbidity and mortality in Slovak Republic in the years 2007-2015.

OBJECTIVE: Analysis of maternal morbidity and mortality in Slovak Republic in the years 2007-2015. DESIGN: Prospective epidemiological perinatological nation-wide. SETTINGS: 1st Department of Gynaecology and Obstetrics Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: The analysis of selected maternal morbidity and mortality data prospective collected in the years 2007-2015. RESULTS: Cesarean section rate progressively increased from 24.1% in the year 2007 up to 30.8% in the year 2013 and up to year 2015 decreased to 30.2%. Vacuum-extraction frequency was 1.3% in the year 2007 and to the year 2015 increased up to 1.6%. Forceps frequency was the same in the year 2007 and 2015: 0.6%. In the years 2008-2015 frequency of perineal tears 3th and 4th degree increased from 0.44% to 0.68% and frequency of episiotomies decreased from 74.7% to 57.2%. In the years 2012-2015 incidence of total severe acute maternal morbidity per 1,000 births was 5.85, peripartum hysterectomy 0.78, severe postpartum bleeding 2.03, transport to anaesthesiology department/intensive care unit 1.26, eclampsia 0.2, HELLP syndrome 0.6, abnormal placental invasion 0.38, uterine rupture 0.45, severe sepsis in pregnancy and puerperium 0.14 and frequency of nonfatal amniotic fluid embolism was 2/100,000 maternities. Total maternal mortality ratio in this period was 11.5 and pregnancy-related deaths ratio 9.9 per 100,000 live births. CONCLUSION: The highest cesarean section rate in Slovakia, 30.8 %, was in the year 2013, but in the next years slowly decreased. Frequency of episiotomies decreased in followed period too. Incidence of severe acute maternal morbidity was 5.85 per 1,000 births. Maternal mortality ratio in Slovakia was one of the highest in European Union and not corresponding with good level of perinatal mortality. Improving of cesarean section rate and episiotomy, incidence of severe acute maternal morbidity and maternal mortality still need to be improved in Slovak Republic.

Analyses of severe acute maternal morbidity in Slovakia during years 2012-2016.

AIM: Severe acute maternal morbidity (SAMM) is a state of the woman, when she nearly died, but survived. The aim of study was to find out the exact incidence of SAMM in Slovakia, establishment of functional surveillance system and improve quality of health care. MATERIALS AND METHODS: The regular annual analyses of SAMM cases in Slovakia from January 1st 2012 to December 31st 2016. Observed SAMM included: peripartum haemorrhage, peripartum hysterectomy, uterine rupture, abnormally invasive placenta, HELLP syndrome, eclampsia, sepsis, transport to intensive care unit or anaesthesiology and non-fatal amniotic fluid embolism. RESULTS: The response rate of questionnaires was 84.8 %. The overall confirmed incidence of SAMM was 6.35/1,000 births (95% CI 6.03-6.67). The most often causes of SAMM were: peripartum haemorrhage (2.1/1,000 births), transport to intensive care unit or anaesthesiology (1.46/1,000 births), peripartum hysterectomy (0.84/1,000 births) and HELLP syndrome (0.63/1,000 births). The average age of women with SAMM was 30.3 years (14-46) and average parity was 1.16 (0-15). CONCLUSION: The incidence of SAMM and especially incidence of peripartum haemorrhage and peripartum hysterectomy in Slovakia is one of the highest in Europe. To decrease incidence and improve management and outcome of patients, regular audit of SAMM is needed (Tab. 3, Fig. 2, Ref. 30).

Perinatal mortality and morbidity in Slovak Republic in the years 2007-2015.

OBJECTIVE: Comparison of perinatal mortality in Slovak Republic in three periods during the years 2007-2015. DESIGN: Epidemiological perinatal nation-wide. SETTINGS: 1st Department of Gynaecology and Obstetrics Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: The analysis of prospectively collected selected perinatal data in the years 2007-2015. RESULTS: In the year 2007 there were 63 obstetrics units, 51,146 deliveries and that of live births 51,650 in Slovak Republic. The number of obstetrics units decreased to 54 in the years 2015, but total number of deliveries increased to 55,139 and that of live births increased to 55,643. Preterm deliveries rate increased from 7.3% in the year 2007 to 8.5% in the year 2010 and decreased to 7.5% in the year 2015. Perinatal mortality rate decreased from 6.2 in the year 2007 to 4.8 in the year 2013, and increased again in the years 2014 and 2015 to 5.3 and 5.6 per 1,000 still- and live-births respectively. During the years 2007-2015 stillbirth participate at perinatal mortality with 64%, low birth weight with 64% and severe congenital anomalies with 20%. Transport in utero to perinatological centres in the years 2007-2015 has increased from 57% to 66% for infants 1000-1499 g and from 75% to 79% for infants below 1000 g. CONCLUSION: In the year 2013 perinatology in Slovak Republic reached the best result in perinatal mortality rate 4.8 (0.48%), but in next two years has increased over 5. Prenatal detection of severe congenital abnormalities, transport in utero very low birth weight infants, centralisation of high-risk pregnancies and obstetric and neonatal intensive care units equipment need still to be improved in Slovak Republic. Keywords perinatal mortality, preterm delivery, multiple pregnancy, neonatal intensive care unit, low birth weight, very low birth weight.

Active surveillance of incidence and risk factors of hemolysis, elevated liver enzymes and low platelets syndrome in Slovakia.

OBJECTIVE: Hemolysis, Elevated Liver Enzymes, Low Platelets syndrome (HELLP syndrome) is one of the actively haunted maternal morbidity through Slovak Obstetric Survey System (SOSS), the organisation for surveillance of severe maternal morbidity and mortality in Slovakia. METHODS: The questionaires were sent in 55 Obstetric Units in Slovakia. The analyzed and here presented data had been collected cases those happened in the period from 1.1.2012 till 31.12.2014. Controls were women from SR during observed years, who delivered without HELLP syndrome. RESULTS: The return rate of questionnaires was 89.67 %, thus covering 146 972 deliveries during the study period in Slovakia. The exact incidence of HELLP syndrome was 0.63/1000 deliveries (CI 95 % 0.51-0.78). Risk factors were age > 30 (OR = 1.63), nuliparous (OR = 2.96), pregnancy after assisted reproduction technology (OR = 8.29) and multiple pregnancy OR = 9.19). The mean gestation age at delivery was 33.8th weeks. Vaginal delivery was by 10 (10.8 %) patients with HELLP syndrome and in the 83 (89.2 %) patients pregnancy was terminated with acute caesarean section. There were reported 45 050 cases (30.7 %) of the caesarean section in the control group throughout the study period. CONCLUSION: The older age, nulliparity, multiple pregnancy and pregnancy after assisted reproduction techniques was identified as a significant risk factors of HELLP syndrome (Tab. 5, Fig. 1, Ref. 21).

[Analysis of maternal morbidity and mortality in Slovak Republic in the years 2007-2012]. / Analýza materskej morbidity a mortality v Slovenskej republike v rokoch 2007-2012.

OBJECTIVE: Analysis of maternal morbidity and mortality in Slovak Republic (SR) in the years 2007-2012. DESIGN: Epidemiological perinatological nation-wide. SETTINGS: 1st Department of Gynaecology and Obstetrics School of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: The analysis of selected maternal morbidity and mortality data prospective collected in the years 2007-2012 from all obstetrics hospitals in the Slovak Republic. RESULTS: Caesarean section rate progressively increased from 24.1% in the year 2007 up to 30.3% in the year 2012. In the year 2012 the frequency of vacuum-extraction was 1.4%, forceps 0.6%, perineal tears 3th and 4th degree 0.49% and episiotomy 65%. Incidence of total severe acute maternal morbidity was 6.34 per 1,000 births. Incidence (per 1,000 births) of transport to anaesthesiology department/intensive care unit was 2.32, postpartum hysterectomy 0.72, HELLP syndrome 0.63, eclampsia 0.29, abnormal placental invasion 0.37, uterine rupture 0.27, severe sepsis in pregnancy and puerperium 0.21. In the years 2007-2012 frequency of fatal amniotic fluid embolism was 2.46/100,000 maternities or 2.43/100,000 live-births. Maternal mortality ratio in this period was 14 per 100,000 live births and pregnancy-related deaths ratio was 11.9 per 100,000 live births. CONCLUSION: In the year 2012 Slovakia reached the highest caesarean section rate in her own history - 30.3%. Incidence of severe acute maternal morbidity was 6.34 per 1,000 births. Maternal mortality ratio in Slovakia was one of the highest in European Union. Decreasing of caesarean section rate and episiotomy, incidence of severe acute maternal morbidity and maternal mortality still need to be improved in Slovak Republic.

[Comparison of perinatal mortality in Slovak Republic in the years 2007-2009 and in the years 2010-2012]. / Porovnanie perinatálnej mortality v Slovenskej republike v rokoch 2007-2009 a v rokoch 2010-2012.

OBJECTIVE: Comparison of perinatal mortality in Slovak Republic in the years 2007-2009 and in the years 2010-2012. DESIGN: Epidemiological perinatal nation-wide. SETTING: 1st Department of Gynaecology and Obstetrics School of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: The analysis of selected perinatal data prospectively collected in the years 2007-2009 and in the years 2010-2012. RESULTS: In the year 2007 there were 63 maternity hospitals, 51,146 deliveries and that of live births 51,650 in Slovak Republic. In the years 2010-2012 decreased the number of maternity hospitals, total number of deliveries and that of live births from 57 to 55, from 55,362 to 54,996 and from 55,901 to 55,643 respectively. Preterm deliveries rate increased from 7.4 to 7.7% and multiple pregnancies rate from 1.4% to 1.5% in the years 2010-2012 compared to years 2007-2009. Perinatal mortality rate decreased from 6.2 in the year 2007 to 5.1 per 1,000 still and live births in the year 2012. During the years 2007-2012 stillbirth participate in perinatal mortality 64%, low birth weight 65% and severe congenital anomalies 19%. Transport in utero to perinatal centres decreased in the years 2007-2012. It was from 64% to 56% for infants with very low birth weight and from 75% to 70% for infants with extremely low birth weight. CONCLUSION: In the year 2012 Slovak perinatology reach the best result in perinatal mortality rate 5.1 (0.51%). Centralisation of high-risk pregnancies, transport in utero very low birth weight infants, prenatal detection of severe congenital abnormalities and obstetric and neonatal intensive care units equipment need still to be improved in Slovak Republic.

[Idiopathic bilateral patellar tendon rupture]. / Rupture bilatérale idiopathique du tendon rotulien.

In the absence of systemic disease, specific treatment or sport tendonitis, simultaneous bilateral patellar tendon rupture is rare. Often missed on the first glance, it represents a diagnostic difficulty that should not be overlooked at the initial medical visit. The loss of active extension of the lower limb and a radiographic patella alta, even in a bilateral context, should raise suspicion of this diagnosis. It is then necessary to search for predisposing causes and to evoke the differential, or frequently associated, diagnoses. The present report illustrates these diagnostic difficulties and summarizes some clinical considerations that might help to avoid neglecting these different elements at the first medical visit (positive diagnosis, associated lesions, favouring factors).

Effect of hyaluron derivate gel in prevention of postsurgical peritoneal adhesions--an experimental study in pigs.

BACKGROUND/AIMS: The aim of this study was to assess the efficacy of a hyaluronic acid derivate gel in reducing adhesions in pigs undergoing laparoscopic abdominal cavity surgery. METHODOLOGY: 20 domestic female pigs underwent laparoscopy in general anesthesia. 4 defined serosal defects have been made (hepatoduodenal ligament, parietal, anterior stomach wall and jejunal mesentery). The defects have been covered with 20 mL Hyalobarrier Gel in 10 randomly selected pigs. 2 weeks postoperatively the pigs got reoperated for evaluation of potential adhesions. RESULTS: 17 pigs remained for evaluation. 2 pigs died during introduction of anesthesia, one at the end of the operation. None of the pigs died due to a reaction to the gel. We found adhesions in 33% of the gel group (n=3 out of 9) and in 87.5% in the group without gel (7 out of 8): p < 0.05. Most of the adhesions have been found at the parietal defect (7 out of 17 at all). CONCLUSIONS: The hyaluronic acid gel was highly efficacious and reduced the number and extent of adhesions throughout the abdomen following laparoscopic peritoneal surgery significantly.

Smartphone Use Among Postpartum Women and Implications for Personal Health Record Utilization.

Personal health records (PHRs) have the potential to improve incomplete health records. However, internet access through traditional methods may be limited for populations most at risk for fragmented care. A convenience sample of postpartum women at a community hospital and tertiary-care academic center in New York City completed a self-administered survey. Most (75.2%, n = 200) women approached participated. The majority (70.0%) were Latina, 53.5% were Spanish speakers, 23.4% were uninsured, and 41.6% were publicly insured. Smartphone ownership (85.6%) including a data plan (80.0%) was high. While insurance and educational level were associated with decreased odds of internet access at home, access via cellphone only differed by age. Nearly all (94%) women wanted PHR access and interest only differed by language. Even the minority (20.0%) of women with concerns, reported high (93.8%) interest. High smartphone ownership, use of phone for internet access, and interest in PHR access, suggest the potential of optimizing PHR use via mobile technologies.

Penetrating pelvic trauma: Initial assessment and surgical management in emergency.

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

Short- versus long-sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis.

BACKGROUND: This study aimed to compare an 18-s fast spin echo magnetic resonance image sequence (coronal thick-section two-dimensional breathhold) with a three-dimensional axial and coronal thin-section sequence and its secondary reconstruction, and to assess its value in the diagnosis of bile duct pathologies, particularly common bile duct stones (CBDS) before laparoscopic cholecystectomy. METHODS: This study prospectively included 72 patients. Because of protocol violations, 14 of these patients had to be excluded. Thus, 58 patients (29 Man and 29 women with a mean age of 51 years) who had cholecystolithiasis or suspected choledocholithiasis were evaluated. Magnetic resonance cholangiopancreatography (MRCP) was performed for all patients with a fast sequence (18 s) and a long sequence (coronal oblique and axial respiratory triggered; 16 min). Two radiologists, blinded with respect to diagnosis, evaluated all the radiographic images. The MRCP results were confirmed for all the patients: 20 by endoscopic retrograde cholangiopancreatography, 46 by intraoperative cholangiography, and 2 by percutaneous transhepatic cholangiography. RESULTS: According to the findings, 16 patients (28%) had CBDS, 6 patients (10%) had common bile duct stenosis, and 36 patients (62%) had a clear bile duct. With regard to CBDS, the short sequence had 100% specificity, 94% sensitivity, and an overall accuracy of 98%. Its negative predictive value was 98%, and its positive predictive value was 100%. The long sequence had a specificity of 100% and a sensitivity of 100%. CONCLUSION: Because of its high sensitivity and specifity, MRCP has the potential to be the diagnostic method of choice for CBD evaluation. The short sequence is not suitable for the diagnosis of all CBD pathologies, but in cases of suspected CBDS, more than 80% of the patients could be diagnosed correctly, and the complete sequence could be dropped.

When the tendon autograft is dropped accidently on the floor: A study about bacterial contamination and antiseptic efficacy.

BACKGROUND: Inadvertent contamination of the autograft can occur during anterior cruciate ligament (ACL) reconstruction if the autograft is dropped on the floor during surgery. A study was undertaken to determine the incidence of contamination when a graft is dropped on the operating room floor and the efficacy of antimicrobial solutions to decontaminate it. METHODS: Samples from 25 patients undergoing ACL reconstruction with a hamstring tendon were sectioned and dropped onto the floor. Cultures were taken after immersion in antiseptic solutions (a chlorhexidine gluconate solution (group 1), a povidone-iodine solution (group 2), and a sodium hypochlorite solution (group 3)). A fourth piece (group 0) was cultured without being exposed to any solution. Cultures of a floor swab were taken at the same time. RESULTS: The floor swab cultures were positive in 96% of cases. The rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1 and 2 and group 0 (p<0.05) but not between groups 3 and 0. CONCLUSIONS: Immersing a graft dropped on the floor during surgery in a chlorhexidine gluconate solution or povidone-iodine solution significantly reduces contamination of the graft. Soaking of the hamstring autograft in one of these solutions is recommended in the case of inadvertent contamination. CLINICAL RELEVANCE: Laboratory investigation (level 2).

Hydrothermal synthesis of the first organically templated open-framework uranium phosphate.

[(C2H5)2NH2]2[(UO2)5(PO4)4] was prepared from U3O8, HONEt2 and phosphoric acid under hydrothermal conditions (180 degrees C, 5 days) and represents the first three-dimensional open-framework uranium phosphate prepared to date.

Laparoscopic resection of an accessory spleen in a patient with chronic lower abdominal pain.

During a diagnostic laparoscopy in a patient with chronic lower abdominal pain we found a pediculated accessory spleen (AS) near the left adnex. The pedicle was dissected by ultrascision, it was cut by an Endo GIA, and the AS was extracted. AS occurs in 25-40% of the population. They are always situated on the left side: hilum of the spleen, splenic artery, pancreas, splenocolic ligament, greater omentum, mesenterium, adnexal region, and scrotum. In most cases they are asymptomatic. In hematological disorders they can take over the function of the original spleen after splenectomy. Sometimes, AS can mimic tumors in other organs, such as pancreas, kidney, or liver. Likewise, there are descriptions of AS in the scrotum, the spermatic cord, the adnexes, the uterus, the stomach, the small intestine, or the heart. In rare cases they can cause pain because of cysts, abscesses, hemorrhage, or spontaneous rupture. In acute pedicle torsion an infarction can be caused presenting as acute abdomen, which is most often seen in young patients. In our case the pain was caused by pedicle torsions or mechanical irritation of the adnex. The cause of the changing localization of the pain was the long pedicle. In describing this case, we point out the advantage of diagnostic laparoscopy in patients with chronic lower abdominal pain.

Novel technique of laparoscopic azygoportal disconnection for treatment of esophageal varicosis: preliminary experience with five patients.

BACKGROUND: Liver cirrhosis leads frequently to the development of ascites and a formation of varicose veins in the esophagus. The latter presents increased mortality risk. Recently, significant progress in laparoscopic technology enabled devascularization of the proximal stomach in a less invasive way. The results experienced by five patients are presented. METHODS: Laparoscopic azygoportal disconnection was performed by means of novel technique (Danis procedure) in five men with esophagus varices bleeding (2nd to 11th events) and liver cirrhosis stage Child-Pugh B and C. This procedure was performed after all other methods had either failed to prevent recurrent bleeding or were refused by the patient. Five ports were positioned on the upper abdominal wall. The veins in the lesser omentum were divided by means of the LigaSure-Atlas device. The stomach coronary vein was visualized, and all the proximal branches toward the esophagus as well as the short gastric vessels were divided. The diaphragm hiatus was opened, and the distal esophagus was dissected. The paraesophageal venous collaterals also were divided, and the remaining varicose veins of the esophagus were interrupted by transmural stitching. RESULTS: All the patients survived the minimally invasive procedure. Two of them died 9 and 16 months after surgery, respectively, because of liver insufficiency. No bleeding event from varicose veins in the esophagus occurred postoperatively. CONCLUSION: Laparoscopic azygoportal disconnection is a less invasive method for prevention of rebleeding from varicose veins in the esophagus. Further studies are necessary to confirm these preliminary results.

Anterior luxtasphincteric stapled rectumresection.

BACKGROUND/AIMS: Sphincter saving deep anterior rectumresection improved the live quality of the rectal cancer patients. With the technical progress the resection level could be moved significant distally. The initial experiences are referred with the use of the stapler with flexible shaft in six patients operated due to very deep rectal cancer. METHODOLOGY: After the usual rectum mobilization the Proximate access AX55 mm (Ethicon) is positioned onto the stretched rectum. The flexible shaft has to be curved to the front and the jaw has to be angled parallel to the handle. The partially closed jaw of the stapler is then pushed towards the anus and then fired. The rectum is the resected. The operation is completed with EEA stapled anastomosis. RESULTS: Excellent results in all six patients could be noticed 3-18 months after the procedure. No cancer recurrence occurred. Functional sphincter investigation was performed in two patients with result of physiologic sphincter function. Stolen frequency has been stabilised between 2-8 a day. CONCLUSION: Improved transabdominal stapled method of rectum resection guarantees comfortable and oncologically safe resection of the distal rectum with maintenance of the sphincter function.

The "balanced" operation for life threatening complications of severe "non responding" form of gastroesophageal reflux disease. A case report.

The fate of patients developing life-threatening complications of the Barret's non-responding ulcer during an acute treatment is lacking in the literature. Medical therapy with proton pump inhibitors (PPI) for severe forms of gastroesophageal reflux disease fails in 15-20%. Emergency operation is indicated in failed cases. We present an operation which restores anatomical and functional deviations causing reflux disease. Two patients required early surgery due to bleeding and penetration of Barret's ulcer during PPI therapy. Both patients had reflux disease, a Savary Miller stage of IV, and/or the M3; U1; S0; E3 and M3; U3; S0; E3 stage of "MUSE" assessment respectively. The modified "balanced operation" was performed consisting of a truncal vagotomy, hiatus hernia reposition, posterior crura repair, fundoplication and extramucosal pyloroplasty. Both patients had excellent outcomes after surgery. Visick I and II, or M3; U0; S0; E1 and M3; U0; S0; E0 respectively and remained well over the year without any medication. The modified "balanced" operation seems to be the method of choice for treatment of severe, "non responding" form of GERD when complications occur. Various pathophysiological factors such as hyperacidity, the cardia valve and gastric emptying are affected simultaneously. The rationale for the performance of all steps of the "balanced" operation is based on the fact that we do not know before the operation, which steps will be necessary to produce a good result.

Laparoscopic transgastric pancreatic pseudocystogastrostomy--first experience with extraluminal approach.

BACKGROUND/AIMS: Transgastric cystogastrostomy (Jurasz procedure) became a standard procedure in the treatment of mature pancreatic pseudocysts contacting the stomach. The first experience with laparoscopically performed transgastric cystogastrostomy under performing anterior gastrostomy is discussed. METHODOLOGY: Five ports were used. The anterior stomach wall was opened 2 cm in length. The communication channel with the pseudocyst was created by means of precise coagulation of the posterior stomach as well as the pseudocyst wall. The pseudocyst was evacuated and the stoma was completed by stapling with the EndoGIA lineal stapler 3 cm in length. The anterior stomach wall was also closed with EndoGIA stapler. RESULTS: Excellent results could be achieved. The pseudocyst resoluted within 1 month after the operation, and the anastomosis healed completely. The patient was discharged on the 8th post-operative day. The follow-up for 1 year was free of complications. CONCLUSIONS: Laparoscopic pseudocystogastrostomy appears to be a reliable method for treatment of large size mature pancreas pseudocysts because it is a minimally invasive procedure with standardized stapler-performed anastomosis. However, this initial experience has to be confirmed with a large number of patients.