Submit History and Physical managing diabetes journal articles discount 25 mg cozaar free shipping, documentation of medical necessity diabetes type 2 what to eat buy on line cozaar, 90750 operative report as it relates to the requested service diabetes 90 cheap 50mg cozaar free shipping. Submit History and Physical diabetes type 2 and pregnancy purchase cheap cozaar, documentation of medical necessity diabete prevention buy 25mg cozaar fast delivery, 90901 operative report as it relates to the requested service blood glucose meters new zealand order cozaar paypal. Submit History and Physical diabetes symptoms of the feet order 50mg cozaar with mastercard, documentation of medical necessity diabetes vision buy online cozaar, 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation operative report as it relates to the requested service. Submit History and Physical, documentation of medical necessity, 93668 operative report as it relates to the requested service. Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart Submit History and Physical, documentation of medical necessity, 94777 rate per 30-day period of time; review, interpretation and preparation of report only by a operative report as it relates to the requested service. Required Updated 10-04-2020 61/154 these criteria do not imply or guarantee approval. Submit History and Physical, documentation of medical necessity, 0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal operative report as it relates to the requested service. Submit History and Physical, documentation of medical necessity, 0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal operative report as it relates to the requested service. Submit Site of service, History and Physical, documentation of A6021 medical necessity, operative report as it relates to the requested Collagen dressing, sterile, size 16 sq. Submit Site of service, History and Physical, documentation of A6022 medical necessity, operative report as it relates to the requested Collagen dressing, sterile, size more than 16 sq. Submit Site of service, History and Physical, documentation of A6023 medical necessity, operative report as it relates to the requested Collagen dressing, sterile, size more than 48 sq. Submit Site of service, History and Physical, documentation of A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6203 Composite dressing, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6204 Composite dressing, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6205 Composite dressing, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6206 medical necessity, operative report as it relates to the requested Contact layer, sterile, 16 sq. Submit Site of service, History and Physical, documentation of A6207 medical necessity, operative report as it relates to the requested Contact layer, sterile, more than 16 sq. Submit Site of service, History and Physical, documentation of A6208 medical necessity, operative report as it relates to the requested Contact layer, sterile, more than 48 sq. Submit Site of service, History and Physical, documentation of A6209 Foam dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. Code Description Type Plan Review Reviewed For Medical Records Request Requirement Submit Site of service, History and Physical, documentation of A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6212 Foam dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6219 Gauze, non-impregnated, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6221 Gauze, non-impregnated, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6223 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more medical necessity, operative report as it relates to the requested than 16 sq. Submit Site of service, History and Physical, documentation of A6224 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more medical necessity, operative report as it relates to the requested than 48 sq. Submit Site of service, History and Physical, documentation of A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. Submit Site of service, History and Physical, documentation of A6233 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. Code Description Type Plan Review Reviewed For Medical Records Request Requirement Submit Site of service, History and Physical, documentation of A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6239 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6251 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6252 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6253 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6255 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6256 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. Submit Site of service, History and Physical, documentation of A6257 medical necessity, operative report as it relates to the requested Transparent film, sterile, 16 sq. Submit Site of service, History and Physical, documentation of A6258 medical necessity, operative report as it relates to the requested Transparent film, sterile, more than 16 sq. Code Description Type Plan Review Reviewed For Medical Records Request Requirement Submit Site of service, History and Physical, documentation of A6259 medical necessity, operative report as it relates to the requested Transparent film, sterile, more than 48 sq. Submit Site of service, History and Physical, documentation of A6402 Gauze, non-impregnated, sterile, pad size 16 sq. Submit Site of service, History and Physical, documentation of A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. Submit Site of service, History and Physical, documentation of A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. Submit History and Physical, documentation of medical necessity, A6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, operative report as it relates to the requested service. High compression bandage, elastic, knitted/woven, load resistance greater than or equal to Submit Site of service, History and Physical, documentation of A6452 1. Submit History and Physical, documentation of medical necessity, A6545 operative report as it relates to the requested service. B4103 Enteral formula, for pediatrics, used to replace fluids and electrolytes. B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1. D7461 Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1. Required Equipment Updated 10-04-2020 108/154 these criteria do not imply or guarantee approval. E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and Submit records only when a contract exception exists. Required Updated 10-04-2020 113/154 these criteria do not imply or guarantee approval. Submit History and Physical, documentation of medical necessity, E1392 operative report as it relates to the requested service. E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 in. E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in. Submit History and Physical and recent lab work as it relates to the requested service. Code Description Type Plan Review Reviewed For Medical Records Request Requirement J0222 Injection, patisiran, 0. Code Description Type Plan Review Reviewed For Medical Records Request Requirement J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized. Submit service History and Physical and recent lab work as it relates to the requested service. J1569 Injection, immune globulin, (Gammagard liquid), intravenous, nonlyophilized. J1572 Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized. Code Description Type Plan Review Reviewed For Medical Records Request Requirement J9041 Injection, bortezomib (Velcade), 0. K0455 Infusion pump used for uninterrupted parenteral administration of medication. Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen Submit History and Physical, documentation of medical necessity, K0738 cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and operative report as it relates to the requested service. Code Description Type Plan Review Reviewed For Medical Records Request Requirement Q4162 AmnioPro Flow, BioSkin Flow, BioRenew Flow, WoundEx Flow, Amniogen-A, Amniogen-C, 0. Required Updated 10-04-2020 152/154 these criteria do not imply or guarantee approval. Code Description Type Plan Review Reviewed For Medical Records Request Requirement S9992 Transportation costs to and from trial location and local transportation costs. Discrimination is Against the Law Premera Blue Cross Blue Shield of Alaska (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at ocrportal. It is aimed to assist primary care professionals when treating children and guide appropriate escalation. Clinicians are expected to take this guideline fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient or carer. The patient should also be given the appropriate Parent / Carer information leafets. Send child for urgent assessment in with appropriate care and (sats<92%/high resp rate) hospital setting. Some babies (about 3 in 100), especially the very young ones, can have difculty with breathing or feeding and may need to go to hospital. Babies at higher risk of developing a more serious illness with bronchiolitis include: premature babies, babies with heart conditions, and babies who already have a lung condition. We may also have to share some of your information for other purposes, such as research etc. If you have asthma, the bronchi (the airways in the lungs) will be infammed and more sensitive than normal. In an asthma/ wheeze attack the muscle of the air passages in the lungs go into spasm and the lining of the airways swell. In young pre school children, wheezing is usually brought on by a viral infection causing a cold, ear or throat infection. Children who have ongoing/recurrent symptoms may be given the diagnosis of asthma. If they do not start to feel better, give them 2-4 pufs of their reliever inhaler (one puf at a time) every two minutes. If they do not start to feel better after taking their inhaler as above, or if you are worried at any time call 999 5. Most people who have an asthma attack will have warning signs for a few days before the attack. These include having to use the blue reliever inhaler more often; changes in peak fow meter readings, and increased symptoms, such as waking up in the night. This leafet provides advice on when to seek help and what you can do to help your child feel better. Often the fever lasts a short duration and many children can be cared for at home if the child continues to drink, remain alert and does not develop any worrying symptoms. However, if you are worried or your child is getting worse with warning symptoms as listed in this leafet, then you should seek the advice of a healthcare professional. Viral infections are common and cause many childhood problems such as colds, coughs, fu, diarrhoea, rashes etc. Bacterial infections are less common than viral infections but more likely to cause serious illness. If your child is shivering or sweating a lot, change the amount of clothing they are wearing. These medicines can make your child feel more comfortable but they do not treat the cause of the temperature. If this rash is present, seek medical advice urgently to rule out serious infection.
Case report: successful use of hyperbaric oxygen therapy for a complete scalp degloving injury diabetes mellitus journal article purchase cozaar 50mg with visa. Hyperbaric oxygen treatment for skin flap necrosis after a mastectomy: a case study diabetes type 2 kookboek buy 50mg cozaar. The effect of varying ambient oxygen tensions on wound metabolism and collagen synthesis blood glucose under 100 50 mg cozaar with amex. Part 2 diabetes insulin definition purchase cozaar online, Secondary: Tissue consequences of hyperoxygenation and pressurization diabetes symptoms prevention purchase cozaar once a day, 3(4):45-65 diabetes diet holistic purchase cozaar 25 mg without prescription. A study of the influence of high atmosphere pressure and hypothermia on dilution of the blood diabetes mellitus type 2 cellular level cozaar 25mg cheap. The number of distribution of capillaries in muscle with calculation of the oxygen pressure head necessary for supplying the tissue diabetes insipidus forum buy cozaar mastercard. Pathophysiology, apparatus, and methods, including the special techniques of hypothermia and hyperbaric oxygen. Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension. Reduction of skeletal muscle necrosis using intermittent hyperbaric oxygen for treatment of a model compartment syndrome. Tissue oxygen measurements with respect to soft-tissue wound healing with normobaric and hyperbaric oxygen. Functional inhibition of neutrophil B2 Integrins by hyperbaric oxygen in carbon monoxide mediated brain injury. Myocardial infarct size reduction by synergistic effect of hyperbaric oxygen and recombinant tissue plasminogen activator. Basic mechanisms of hyperbaric oxygen in the treatment of ischemia-reperfusion injury. Oxygen-mediated damage during ischemia and reperfusion: Role of the cellular defense against oxygen. Hyperbaric oxygen for crush injuries and compartment syndromes: Surgical considerations. Objective criteria accurately predict amputation following lower extremity trauma. Crush injuries and skeletal muscle-compartment syndromes, Hyperbaric Oxygen Therapy Indications, 12th Ed. Role of hyperbaric oxygen therapy in acute ischemias and crush injuries an orthopedic perspective. Hyperbaric oxygen in the treatment of trauma, ischemic disease of limbs and varicose ulceration. Proceeding of the Third International Conference on Hyperbaric Medicine (1966) ed. Adjuvant hyperbaric oxygen therapy in the management of crush injury and traumatic ischemia: an evidence-based approach. Hyperbaric oxygen therapy in the management of crush injuries: A randomized double-blind placebo-controlled clinical trial. Lipid products in post-ischemic skeletal muscle and after treatment with hyperbaric oxygen. Rabbit model of the use of fasciotomy and hyperbaric oxygen in the treatment of compartment syndrome. The American Heart Association evidence-based scoring system, Circul, (2006), 114:1761 1791. The role of hyperbaric oxygen in the surgical management of chronic refractory osteomyelitis. Editorial; Cost-effective issues in hyperbaric oxygen therapy: Complicated fractures. Handbuch der Speziellen Pathologischen Anatomie und Histologie Erkrankungen des Zentralen Nervensystems I. Involvement of platelets and microthrombi in experimental decompression sickness: similarities with disseminated intravascular coagulation. The relative risk of decompression sickness during and after air travel following diving. Influence of bottom time on preflight surface intervals before flying after diving. An abrupt zero-preoxygenation altitude threshold for decompression sickness symptoms. Zur Pathogenese und Therapie der durch rasche Luftdruckanderungen erzeugten Krankheiten. Vascular leukocyte sequestration in decompression sickness and prophylactic hyperbaric oxygen therapy in rats. Use of short versus long tables in the treatment of decompression sickness and arterial gas embolism. The effectiveness of ground level oxygen treatment for altitude decompression sickness in human research subjects. Effect of severity, time to recompression with oxygen, and retreatment on outcome in forty-nine cases of spinal cord decompression sickness. Clinical Audit and Outcome Measures in the Treatment of Decompression Illness in Scotland. A report to the National Health Service in Scotland Common Services Agency, National Services Division on the conduct and outcome of treatment for decompression illness in Scotland from 1991-1999. Risk factors and treatment outcome in scuba divers with spinal cord decompression sickness. The effect of delay on treatment outcome in altitude-induced decompression sickness. Delayed treatment of decompression sickness with short, no-air-break tables: review of 140 cases. Current management for late normal tissue injury: radiation-induced fibrosis and necrosis. Histologic morphometry confirms a prophylactic effect for hyperbaric oxygen in the prevention of delayed radiation enteropathy. Molecular biology mechanisms in the radiation induction of pulmonary injury syndromes. Endothelial progenitor cell release into circulation is triggered by hyperoxia-induced increases in bone marrow nitric oxide. Osteonecrosis in patients treated with definitive radiotherapy for squamous cell cancers of the oral cavity and naso and oropharynx. Correlation of osteoradionecrosis and dental events with dosimetric parameters in intensity-modulated radiation therapy for head-and-neck cancer. The use of hyperbaric oxygen therapy in bony reconstruction of the irradiated and tissue deficient patient. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an evidence based approach. Review of severe osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of 23 cases. Hyperbaric oxygen therapy for radiation necrosis of the jaw: comments on a randomized study. Hyperbaric oxygen therapy for radionecrosis: clear evidence from confusing data (letter to the editor). Influence of prior hyperbaric oxygen therapy in complications following microvascular reconstruction for advanced osteoradionecrosis. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation issue injury. Prevention of osteoradionecrosis: A randomized prospective clinical trial of hyperbaric oxygen versus penicillin. Hyperbaric oxygen therapy and mandibular osteoradionecrosis: a retrospective study and analysis of treatment outcomes. Adjunctive hyperbaric oxygen in irradiated patients requiring dental extractions: outcomes and complications. Dental extractions in the irradiated head and neck patient: a retrospective analysis of Memorial Sloan-Kettering Cancer Center protocols, criteria, and end results. Intensity-modulated radiotherapy in the standard management of head and neck cancer: promises and pitfalls. Hyperbaric oxygen as an adjunctive treatment for severe laryngeal necrosis: A report of nine consecutive cases. Laryngeal radionecrosis and hyperbaric oxygen therapy: report of 18 cases and review of the literature. Hyperbaric oxygen therapy in the treatment of complications of irradiation in the head and neck area. Hyperbaric oxygen for wound complications after surgery in the irradiated head and neck: a review of the literature and a report of 15 consecutive cases. Postoperative complications after en bloc salvage surgery for head and neck cancer. Hyperbaric oxygen therapy for late sequelae in women receiving radiation after breast conserving surgery. Early hyperbaric oxygen improves outcome for radiation-induced hemorrhagic cystitis. Late bladder complications following radiotherapy of carcinoma of the uterine cervix. Treatment of refractory radiation-induced hemorrhagic proctitis with hyperbaric oxygen therapy. Hyperbaric oxygen therapy for radiation induced proctopathy in men treated for prostate cancer. Treatment of gastrointestinal radiation injury with hyperbaric oxygen Undersea Hyperb Med 2007; 34:35-42. Hyperbaric oxygen treatment of chronic refractory radiation proctitis: a randomized and controlled double-blind crossover trial with long term follow-up. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Hyperbaric oxygen therapy for delayed radiation injuries in gynecological cancers. Hyperbaric oxygen in the treatment of delayed radiation injuries of the extremities Undersea Hyper Med 2000; 27(1):15-19. Treatment of neurological symptoms of radionecrosis of the brain with hyperbaric oxygen: a case series. Presented at the 35th Annual Undersea and Hyperbaric Medical Society Scientific Meeting. Effectiveness of hyperbaric oxygen for the treatment of soft tissue radionecrosis of the brain. Boschetti M, De Lucchi M, Giusti M, Spena C, Corallo G, Goglia U, Ceresola E, Resmini E, Vera L, Minuto F, Ferone D. Partial visual recovery from radiation-induced optic neuropathy after hyperbaric oxygen therapy in a patient with Cushing disease. Effect of hyperbaric oxygen therapy on osseointegration of titanium implants in irradiated bone: A preliminary report. In: Proceedings of the Consensus Conference sponsored by the European Society for Therapeutic Radiology and Oncology and the European Committee for Hyperbaric Medicine. Hyperbaric oxygen does not accelerate latent in vivo prostate cancer: implications for the treatment of radiation-induced haemorrhagic cystitis. Effects of hyperbaric oxygen exposure on experimental head and neck tumor growth, oxygenation, and vasculature. Hyperbaric oxygen inhibits benign and malignant human mammary epithelial cell proliferation. The effect of hyperbaric oxygen therapy on tumour growth in a mouse model of colorectal cancer liver metastases. Hyperbaric oxygen for late radiation-associated tissue necroses: is it safe in patients with locoregionally recurrent and then successfully salvaged head-and-neck cancers Piper, Heather Murphy-Lavoie, Tracy Leigh LeGros 1 Staff Physician, Van Meter and Associates, Harvey, Louisiana 2 Associate Clinical Professor, Section of Emergency Medicine, and Associate Program Director, Louisiana State University Undersea Hyperbaric Medicine Fellowship, Louisiana State University Medical Center, New Orleans, Louisiana 3 Associate Clinical Professor, Section of Emergency Medicine, and Program Director, Louisiana State University Undersea Hyperbaric Medicine Fellowship, Louisiana State University Medical Center, New Orleans, Louisiana References 1. Stachler R, Chandrasekhar S, Archer S, Rosenfeld R, Schwartz S, Barrs D, Brown S, Fife T, Ford P, Ganiats T, Hollingsworth D, Lewandowski C, Montano J, Saunders J, Tucci D, Valente M, Warren B, Yaremchuk K, Robertson P. Oxygen partial pressure measurements in the perilymph and the scala tympani in normo and hyperbaric conditions. Effectiveness of hyperbaric oxygen on sudden sensorineural hearing loss: prospective clinical research. Secondary hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss in the subacute and chronic phases. Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. Treatment of 522 patients with sudden deafness performed oxygenation at high pressure. Hyperbaric oxygen therapy as salvage treatment for sudden sensorineural hearing loss: review of rationale and preliminary report. Sudden deafness: a randomized comparative study of 2 administration modalities of hyperbaric oxygenotherapy combined with naftidrofuryl. Value of the association of normovolemic dilution and hyperbaric oxygenation in the treatment of sudden deafness. Does the addition of hyperbaric oxygen therapy to the conventional treatment modalities influence the outcome of sudden deafness Comparison of therapeutic results in sudden sensorineural hearing loss with / without additional hyperbaric oxygen therapy: a retrospective review of 465 audiologically controlled cases. Usefulness of high doses of glucocorticoids and hyperbaric oxygen therapy in sudden sensorineural hearing loss treatment. Prognostic factors in sudden sensorineural hearing loss: our experience and a review of the literature. Prostaglandin E1 versus steroid in combination with hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. Prostaglandin E1 in combination with hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. Factors influencing the outcome of idiopathic sudden sensorineural hearing loss treated with hyperbaric oxygen therapy. The effect of hyperbaric oxygen therapy to different degree of hearing loss and types of threshold curve in sudden deafness patients. Prediction model for hearing outcome in patients with idiopathic sudden sensorineural hearing loss. Italian experience in hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. Proceedings of the International Joint Meeting on Hyperbaric and Underwater Medicine. Should hyperbaric oxygen be added to treatment in idiopathic sudden sensorineural hearing loss Vasodilators and vasoactive substances for idiopathic sudden sensorineural hearing loss. Hyperbaric oxygen and steroid therapy for idiopathic sudden sensorineural hearing loss. Brain abscess: association with pulmonary arteriovenous fistula and hereditary hemorrhagic telangiectasia: report of three cases. Central nervous system infections associated with hereditary hemorrhagic telangiectasia. Brain abscess: Recent experience at a community hospital 6, 1985, South Med J, Vol. Bagdatoglu H, Ildan F, Ceinalp E, Doganay M, Boyear B, Uzeuneyupoglu Z, Haciyakupoglu S, Karadayi A. The clinical presentation of intracranial abscesses: a study of eighty-eight cases. Supratentorial deep-seated bacterial brain abscess in adults: clinical characteristics and therapeutic outcomes. Mogami H, Hayakawa T, Kanai N, Kuroda R, Yamada R, Ikeda T, Katsurada K, Sugimoto T. Clinical application of hyperbaric oxygenation in the treatment of acute cerebral damage. The effect of hyperbaric oxygen on experimentally increased intracranial pressure. Ischemic tissue oxygen capacitance after hyperbaric oxygen therapy: a new physiologic concept1997, Plast Reconstr Surg, Vol. Stereotactic aspiration and antibiotic treatment combined with hyperbaric oxygen therapy in the management of bacterial brain abscesses. Hyperbaric oxygen therapy for the treatment of brain abscess in children1, 2006, Childs Nervous Syst, Vol. Successful treatment of cervical spinal epidural abscess by combined hyperbaric oxygenation.
Heden P diabetes mellitus type 2 insulin dependent icd 9 buy generic cozaar 50 mg on line, Eriksson E: Skin flap circulation: simultaneous operation with the use of fluorescein dye diabetes prevention metformin purchase cozaar 50 mg amex. Ann Plast Surg 31(4):307 diabetes type 2 in qatar order cozaar 50 mg on-line, fluorometric assessments of skin perfusion in isolated 1993 metabolic disease vector purchase 25mg cozaar fast delivery. Myers B mayo clinic diabetes diet journal discount cozaar 50mg with visa, Donovan W: An evaluation of eight methods of doppler recordings from free flaps blood sugar gold for dogs generic 50mg cozaar with visa. Scand J Plast Reconstr using fluorescein to predict the viability of skin flaps in the Hand Surg 27:81 can diabetes type 2 kill you order 50mg cozaar free shipping, 1993 diabetes insipidus blood glucose purchase discount cozaar online. Plast Reconstr viability by pH, temperature and fluorescein: an experi Surg 105:55, 2000. Holm C, Mayr M, Hofter A, et al: Intraoperative evaluation sion using laser doppler flowmetry: an adjunct to mi of skin-flap viability using laser-induced fluorescence of crovascular augmentation. Eren S, Rubben A, Krein R, et al: Assessment of microcir a new visual blood flow meter utilizing a dynamic laser culation of an axial skin flap using indocyanine green speckle effect. Still J, Law E, Dawson J, et al: Evaluation of the circulation Plast Surg 8:510, 1982. Scand J Plast Reconstr Hand Surg flow ultrasound for delineating microsurgical vessels: a 24:27, 1990. Radiol using osmotically active hydrogel systems for direct clo ogy 173:755, 1989. Plast Reconstr Surg 91(2):213, the method for securing skin for subtotal reconstruction of 1993. Radovan C: Adjacent flap development using expandable tissue expansion: clinical implications for the surgeon. Plast physical changes in the skin in an experimental animal Reconstr Surg 81:204, 1988. Hirshowitz B, Lindenbaum E, Har-Shai Y: A skin-stretching fibers around silicone expander. Clin Plast electron microscopic evaluation of the pectoralis major Surg 21(2):309, 1994. Reinisch J, Myers B: the effect of local anesthesia with therapy: effects on expanded skin. Arch Otolaryngol Head Neck Surg remodeling following prolonged scalp expansion in a 122:1107, 1996. Implant design remains a critical challenge for the successful repair and Received in revised form prevention of recurrent hernias, and despite signicant progress, there is no ideal mesh for every surgery. Commonly encountered complications and strategies to minimize these adverse effects are described, followed by a thorough description of the implant char Keywords: Hernia repair acteristics necessary for successful repair. Finally, available implants are categorized and their advantages Hernia mesh and limitations are elucidated, including non-absorbable and absorbable (synthetic and biologically Hernia prosthesis derived) prostheses, composite prostheses, and coated prostheses. This review not only summarizes the Hernia state of the art in hernia repair, but also suggests future research directions toward improved hernia Citric acid repair utilizing novel materials and fabrication methods. The exact layers of the abdom inal wall differ dependingon the exact location (medial to lateral, or 1. Collagenous connective tis sue, as is found in the dermis layer of the skin, also appears in Hernia repair is among the most common surgical procedures several layers throughout the abdominal wall, such as the subcu performed worldwide, with approximately 20 million procedures taneous fascia, transversalis fascia, and the pre-peritoneal layer performed annually [1]. The structural integrity of the abdominal wall is provided abdominal surgeries as well as co-morbidities including obesity has primarily by the integrated neuromuscular fascia of the transversus led to an increased risk of hernia development and recurrence [2]. These muscle groups impart the abdomen with sufficient up to 800, 000 of these patients will later develop complications in mechanical strength and elasticity to withstand the pressures the form of incisional hernias [3]. Due to the overwhelming pres generated within the cavity by the internal organs [11]. The peri ence of this disease and related, post-operative conditions, the toneum, which covers both the abdominal wall and the internal Global Hernia Repair Devices and Consumables Market is estimated organs contained within, enables the organs to move within the to reach $6. A detailed rendering of the abdominal wall and its components is shown below. Anatomy and physiology of the Hernia Abdominal hernias develop due to areas of structurally compromised tissues within the abdominal wall. In most cases, Hernias can present in a variety of different ways depending on hernias occur when damage is sustained to the inner four layers of their anatomical location as well as any predisposing factors. In the abdominal wall, although this is location-dependent (for general terms, a hernia is classied as the protrusion of organs instance, in the midline a hernia develops when only the midline through an opening in the cavity that is intended to contain them fascia, or linea alba, is damaged). The most common hernias are inguinal, ventral, incisional, musculature within the wall is replaced with scar and connective femoral, umbilical, hiatal, and epigastric [6]. Of the aforementioned, tissues, which are unable to withstand the pressures exerted within inguinal hernias are the most frequent, accounting for nearly two the cavity [11]. Normal everyday actions including laughing, lifting, thirds of all abdominal wall hernia procedures [7]. Inguinal herni coughing and standing can signicantly increase the intra ation consists of abdominal contents protruding through a defect in abdominal pressure exerted on the abdominal wall. The inguinal region is especially with compromised abdominal wall structure, a substantial increase vulnerable to herniation as a result of particular anatomical fea in intra-abdominal pressure is enough to tear or bulge the tures involving several layers of fascia and ligamentous tissue abdomen, resulting in a hernia [11]. Outside of inguinal, almost all result fromseveral pathological conditions, such as congenital birth other hernias of the abdominal wall can be categorized under defects of the abdominal wall as well as excessively high intra ventral hernias, with incisional and congenital being the two main abdominal pressure as a result of obesity, ascites, straining due to sub-classications. Incisional herniation can occur as abdominal benign prostatic hypertrophy or constipation, pregnancy and pul contents protrude through defects created in the musculature from monary diseases in conjunction with chronic coughing [12]. On the other hand, defects formed in the abdominal wall from birth that lead to 2. Usher was particularly interested in Marlex because it was method of abdominal hernia repair. Furthermore, the Marlex mesh provided a pliable to close abdominal wall defects using sutures under tension [14]. R Bard made repair can be successful, these techniques suffer from high reoc from polypropylene [16]. Usher and colleagues provided surgeons with substantially expandedtreatmentoptions for tension-freeabdominal wall hernia 2. Plastic meshes made it possible for surgeons to repair hernias by bridging tissue gaps rather than subjecting them to high According to George and Ellis, suture repair techniques are tensionsutureclosures, resultinginadecreaseinreoccurrences[18]. Metal sutures began to be reinforced with silver coils by Phelps and later with stainless steel meshes by Babcock. Due to the inert nature of the mate Ethicon under the trade name Mersilene, became the rst rial, the Gore-Tex soft tissue patch became especially useful in nonmetallic, polyester material to be used for abdominal wall intra-peritoneal hernia mesh placement. Although Dacron polyester meshes were the rst non-metallic prostheses to be used for abdominal hernia repair, a transition to 3. Prostheses for Hernia repair: necessity and complications polypropylene based materials occurred as they were believed to be more resistant to infection and tissue adhesion [16]. With regards to ratio in patients requiring ex-plantation of prosthesis due to incisional hernias, which occur due to compromised musculature recurrence was signicantly lower (1. Surgeons continue to search for ideal ma terials and methods that can further improve patient outcomes [25]. Resistance to adhesion/stula formation the goal of surgical mesh prostheses for hernia repair is to fortify and replace localized tissue defects in an effort to stabilize An important property of mesh prosthetics is their ability to the abdominal wall for long term relief of symptoms [26]. Since the inltrate host abdominal wall tissues in order to create a strong and introduction of mesh prosthetics in the 1950s, several variations secure repair. In reality, the use of a single mesh can be seen with the adherence of meshes to the bowel [13]. Ideal design capable of functioning effectively in all scenarios is unreal mesh based prostheses for abdominal wall hernias will provide istic. Surgical repair requirements vary depending on the type of fascial defect repair capabilities, integrate into surrounding tissues hernia along with several other parameters such as defect size and by allowing tissue in-growth, and inhibit the formation of applied surgical technique [26]. In general terms, mesh prostheses abdominal tissue adhesions to the mesh surface [38]. Abdominal should possess good handling properties, induce a desired host adhesions are estimated to occur in 90% of all abdominal wall repair response, integrate with surrounding tissues and demonstrate procedures and involve irregular brous strands that attach be sufficient mechanical properties for abdominal wall stabilization tween tissues and organs within the abdominal cavity and the [27, 28]. The occurrence of adhesions in hernia repair is predicated around the introduction of foreign bodies to injured 3. Cyto-compatibility/foreign body response peritoneal surfaces within the abdominal cavity [8, 40, 41]. Design and construction parameters of abdominal wall repair must remain biologically inert and resist biomaterial prostheses can inuence the development of adhesions rejection [30]. Alternatively, biologically derived meshes are capable of dis bacteria resulting in surgical infection [27]. Patients presenting with abdominal wall infections are signals and growth factors within the bio-derived materials [33]. Infections occur as a result of the thesis design and host response that mayact to counter some of the inltration and proliferation of bacteria within the pores of the adverse reactions produced from the materials inherent chemical prosthetic [13]. Recently, there has critical role in the propagation of wound infections in patients been substantial focus on the development of technical improve requiring the use of prostheses for abdominal wall repair [30]. Collagen composition pores smaller than 10 mm allow for the inltration of bacteria while preventing macrophages from entering to combat the infection. Mesh prostheses implanted in the bodycan modify the naturally occurring collagen compositions found in the abdominal wall. Seromas and hematomas develop as a result of the resulting in localized tissues with signicantly decreased me host inammatory response to a foreign body and are dened by chanical stability [35, 36]. Meshes designed to facilitate rapid bri tation in a particular orientation in order to utilize the full benetof nous xation to host tissues are able to minimize dead space be the design [59]. A composite mesh designed with ideal porosities tween prosthesis and native tissues, thereby minimizing the for both the viscera and parietal regions would contain a macro formation of seromas [13, 30]. Prostheses for hernia repair: ideal material and design organs to prevent the formation of adhesions [56, 59]. Weight the design and construction parameters of surgical meshes can greatly alter the behavior of the prosthetic itself and should be fully A previous lack of understanding regarding the biomechanical understood before making appropriate selections for repair. Although one design may present clear recently, improved mesh prosthetics have been designed contain advantages over another, it is difficult to pin-point a single product ing signicantly less material while still providing sufficient me that contains all of the properties of an ideal mesh [48]. In order for surgeons to provide the best possible Fundamentally, the three groups are different in terms of several outcomes for their patients, they must rst understand the physical properties such as thickness, weight, ultimate tensile biomechanical and compositional properties of the mesh designs strength and modulus of elasticity [60]. Lightweight meshes generally contain larger pore sizes (>1 mm), thinner laments, improved elasticity (25e35%), smaller 4. Pore size surface areas, a decrease in overall weight/foreign material and shrink less in physiological conditions compared to their heavy the porosity of a prosthesis refers to the ratio of open to solid weight counterparts [26, 31, 51]. The porosity of an meshes to inhibit the formation of dense scar tissue while still articial prosthesis plays an extremely important role in the overall maintaining sufficient mechanical strength. As a result, the performance of the implant as it is directly proportional to the repaired abdominal wall is able to maintain its exibility and degree of host tissue incorporation [49]. Amid classied the most functions as a dynamic system in spite of the foreign prosthesis frequently used materials for hernia surgery into four different [62]. Type I meshes, con In contrast, heavyweight prosthetics have thick polymer bers, taining pores larger than 75 mm, allow for more profound inltra small pores, high tensile strength and increased surface area [31]. Additionally, Type Consequently, heavyweight meshes are associated with intensied I meshes permit increased soft tissue in-growth and are more adverse effects including profound foreign body response, chronic exible than microporous meshes due to the inhibition of granu pain, brosis, as well as the formation of adhesions, stulae and loma bridging [50]. In summary, the use of lightweight pros pected around the bers of a mesh, bridging occurs when thetics for hernia repair appears to be far more benecial in granulomas become conuent with one another and encapsulate reducing long-term complications such as chronic pain, inam the entire mesh [35, 51]. These results suggest pores larger than 1 mm are able to promote adequate wound that the biological response associated with lightweight meshes is healing while reducing the presence of dense scar tissue formed signicantly more favorable compared to heavyweight meshes from granuloma bridging [24, 52]. Filament structure concurrence with these ndings, studies have shown that the use of large pore meshes in non-contaminated environments can also Prosthetic meshes used for hernia repair are developed from counteract the presence of infections and seromas [54, 55]. Monolament polypropylene meshes Recently, some manufacturers have begun developing adequately satisfy the aforementioned requirements and are the Table 1 Categories of prosthetic pore size [27]. Very Large pore >2, 000 mm Large Pore 1000e2000 mm Heavyweight >90 g/m2 Medium Pore 600e1000 mm Medium weight 50e90 g/m2 Small Pore 100e600 mm Lightweight 35e50 g/m2 Microporous (Foil) <100 mm Ultra-lightweight <35 g/m2 S. Heavy Multilament meshes, which consist of several braided bers, are meshes used for hernia repair that do not account for the natural associated with an increased risk of infection, granuloma formation pliability of surrounding tissues will result in severe restriction of and sinus tract formation, and promote increased inammatory the mobility of the abdominal wall which can lead to discomfort response. Heavyweight meshes generally present elastic multilament meshes as a result of small (~10 mm) interstices ities in the range of 4%e16%, while lightweight counterparts can be produced in-between braided bers. Current and next generation mesh are large enough for the inltration of bacteria, but too small for the design concepts are transitioning towards lighter and more elastic penetration of neutrophil and macrophage cells which are prostheses, which are capable of mimicking the physiological responsible for eliminating the bacteria [30, 32, 66, 67]. Understanding the design properties and character infection is theoretically possible with any mesh, infections istics of modern hernia meshes can allowsurgeons to better predict occurring from monolament meshes generally do not require their functions in vivo. Biomaterials for hernia meshes demonstrated a signicant increase in the adherence of Staphylo coccus aureus bacteria to multilament meshes for all concentra Over the last several decades, the use of mesh prosthetics has tions of bacteria when compared to monolament equivalents [68]. Since the original metal pliable than lightweight monolament prosthetics, manufactures prosthesis introduced in the early 1900s by Witzel and Goepel, are developing a new generation of meshes containing partially progressive development of new materials and methods for hernia absorbable laments which provide additional handling properties repair has occurred [16]. An important property of mesh fabrics is the method in become the gold standard due to a prominent decrease in reoc which they are processed. Knitted meshes are commonly more currence rates when compared to primary suture repair, the porous and exible; however, they lack the mechanical strength of potentially problematic physiological interactions present between woven meshes due to a decrease in lament density [69]. The introduction tionally, the mechanical properties of knitted and woven meshes of a non-native prosthetic material into the human body is quickly can differ depending on the spatial orientation, a concept that will followed by a systematic foreign body response activated by the be discussed in the mechanical properties section. Mechanical strength/elasticity seroma formation, mesh shrinkage or encapsulation, tissue degra dation and chronic pain [33]. At present, the most common treat the human abdominal wall is composed of a laminar structure, ment options for hernia repair involve the use of prosthetic containing several sheet-like muscles and tendinous bers oriented biomaterials (absorbable, non-absorbable, composite, coated, in various directions [70]. This section aims to contraction of the oblique and transverse muscles are signicantly outline and categorize the currently available options for prosthe greater than the stresses generated in longitudinal directions. Non-absorbable prostheses upon the design of a prosthetic capable of mimicking the biome chanical nature of the native tissues. These values polyester) (Table 4), and expanded poly-tetrauoroethylene correspond to a peak intraabdominal pressure of 171 mmHg [73]. Therefore, it can be concluded that the maximum biomaterial for hernia repair [51]. Although all of the aforemen theoretical tensile strength per unit width that prosthetic meshes tioned materials are readily available in a clinical setting as a result must withstand for successful repair of large and small hernias is of their alleged biocompatibility and inertness, some studies sug 32 N/cm and 16 N/cm, respectively [31, 35, 72, 74e76]. First genera gest these materials may activate certain histopathological pro tion heavyweight meshes were crudely over-engineered, contain cesses and immune reactions upon implantation [33]. Junge and associ valuable due to their superior histological properties, strong tissue ates determined the mean vertical elasticity of the abdominal wall in-growth and conformity to the abdominal wall [48]. In general, mean elasticities infection remain pressing concerns regarding the use of pure were determined to be between 11% and 32% in all directions polyester meshes as hernia repair prostheses [48]. Product name Pore size (mm) Weight (g/m)2 Filament structure Prolene (Ethicon) 0. Product name Pore size (mm) Weight(g/m)2 Filament structure Mersilene (Ethicon) 1 [156] 33e40 [35, 156] Multilament [31] Parietex (Covidien) [147] 1. Eberli and associates are devel devices that were capable of serving their intended function while oping collagen based layered biomaterials from porcine bladder minimizing the amount of foreign material left over for the body to submucosa, known as the lamina propria. Researchers have also fabricated mesh prostheses using meshes are reviewed below(Table 6). Overall, the use of absorbable silk proteins isolated from both worms and spiders. Silk derived meshes for hernia repair presents several advantages over con fromworms has been shown to produce various immune responses ventional, permanent prostheses. Most notably, permanent meshes and is considered to be less biocompatible than spider silk due to a can act as vessels for the proliferation of bacteria, which increases lack of natural lubricant coatings [88, 89]. As a result, non Overall, biologically derived prostheses for hernia repair are absorbable meshes may be problematic in pre-contaminated en advantageous in that they contain a dense network of collagen as vironments [84]. Furthermore, studies suggest that the use of non well as several bioactive signals and growth factors. These cues, absorbable meshes in children can hamper normal tissue growth which include, proteoglycan, elastin and hyaluronan, along with [85]. Finally, non-absorbable meshes are associated with increased the physical construct of the matrix itself can promote impressive risk of stula formation, chronic pain and a general restriction of tissue remodeling and wound healing in hernia patients [33]. Biologically derived prostheses the long-term mechanical stability concerns associated with Biologically derived mesh prostheses have been largely devel fully absorbable meshes have prompted a new generation of oped for open abdomen conditions presenting contamination or a composite prostheses to emerge, combining non-absorbable ma high risk of contamination [51]. As a result, these materials promote host rials to create an orientationally dependent prosthesis [51]. In order to promote tissue Biological prostheses can be classied according to their origin: ingrowth while simultaneously attenuating intestinal adhesion/ xenogenic (animal) (Table 7) or allogenic (cadaveric acellular stula formation, combination meshes are constructed with dermal matrices) (Table 8) [33]. Typical issues of bulk erosion Providesabsorbablescaffoldallowing materials for long-termimplantation. Metabolic byproducts of degradation are far less acidic than glycolic and lactic acid visceral (intestinal) side [48].
Kraemer M diabetes type 1 nausea buy cheap cozaar 50 mg line, Ohmann C diabetes test montreal cheapest cozaar, Leppert R diabetes prevention in india discount cozaar 25mg line, Yang Q (2000) Macroscopic assessment of the appendix at diagnostic laparoscopic is reliable blood glucose estimation discount 25mg cozaar visa. Grimes C diabetic diet livestrong buy online cozaar, Bailey C diabetes injection medications new order 50mg cozaar fast delivery, Gergely S diabetes signs on legs cozaar 25 mg for sale, Harris A (2010) Appendiceal faecaliths are associated withh right iliac fossa pain diabetes insipidus sodium buy 50 mg cozaar with amex. Br J Surg 88:251-254 Suggested Readings Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P (2006) Laparoscopy for abdominal emergencies. In press Role of Laparoscopy in the Treatment 6 of Acute Diverticulitis: an Evidence-Based Review Boris Franzato, Stefano Mandala, Grazia Fusco and Carlo Sartori 6. The severity of the disease ranges from light symptomatic diverticulosis to perforated diverticulitis. For years it was thought that the risk of perforation and other complications increased after each recurrence. However, new insights into the natural course of diverticular disease have resulted in a more conservative approach, which is the current trend. Severe complicated divertic ulitis, leading to emergent surgical intervention, is most often the primary pres entation of the disease [3]. Recent studies have shown that recurrent episodes of diverticulitis have a low complication rate in patients treated conservatively for an acute episode of diverticulitis [3, 4]. It seems that elective, prophylactic sig moid resections based on the number of episodes are not always indicated. New diagnostic tools and therapeutic techniques have improved the treatment of diverticular disease. The rise of laparoscopic surgery since the 1990s has resulted, alongside the general advantages of mini-invasive surgery, in decreased morbidity and mortality rates compared to open approaches, making it progressively the pre ferred approach in elective colonic resections [6]. Whether laparoscopy can also be applied to patients with perforated diver ticulitis and generalized peritonitis remains under debate. Laparoscopic sig moid resection cannot always be accomplished completely because of exten sive pericolic inflammation and fecal or purulent contamination, or due to patient conditions and comorbidity. However, several recent studies have shown that a primary anastomosis with or without a deviating ostomy could be performed safely even under these circumstances [4]. We report the results obtained by a single institution, expert in laparoscop ic surgery, with a literature review on actual trends of laparoscopic manage ment in acute diverticular diseas, e and highlight levels of evidence for clinical practice. All the elective patients after diagnostic study were offered a minimally invasive operation. Urgent cases were managed laparo scopically unless the patient had refused laparoscopic surgery, was too hemo dynamically unstable to tolerate a pneumoperitoneum or had cardiopulmonary comorbidity contraindicating a laparoscopic approach. The current study includes all the patients with primary diagnoses of diverticular disease includ ing diverticulosis, acute diverticulitis, and chronic diverticulitis. Only patients undergoing laparoscopic operative management of diverticular disease were considered. Complicated divertic ular disease was thus defined as acute pericolic abscess (Hinchey 1), acute pelvic abscess (Hinchey 2), purulent peritonitis (Hinchey 3), fecal peritonitis (Hinchey 4), fistula, stricture, hemorrhage. Uncomplicated cases were defined as simple diverticulitis refractory to medical management with important symptoms, recurrent or chronic divertic ulitis, and noninflammatory complications of diverticulosis. Indications for elective laparoscopic treatment were recurrent episodes off severe diverticulitis (two or more), with radiologic evidence of importantt colonic alterations (asymmetry, wall thickening, stenosis) and/or complica tions of the disease after initial conservative management. Our standardized operative technique and strategy in diverticulitis have been described elsewhere [8, 9]. Diverticula were mostly in the descending colon and sig moid, in two cases we observed right-sided diverticula. We performed 247 left colectomies, 28 sigmoidectomies, one subtotal colectomy, one ileocecal resection and nine procedures of laparoscopic lavage and drainage. In 15 patients an additional procedure was associated: six chole cystectomies, five adnexectomies, three appendectomies, one hysterectomy. All resected patients received an unprotected primary anastomosis except forr four cases in which a protective ileostomy was performed. Closed suction drainage was used only in particularly difficult cases or if there was any doubt about the quality of the anastomosis, in spite of negative air test. We observed a stabilization of operative times after completion of the team learning curve. Conversion to open procedure was more commonly related to dis ease factors (one Hinchey 4, two severe inflammation, two due to difficulties linked to the exposure of the operative field). A right colon derotation with middle colic and right colic vessel liga tion was performed, followed by a colorectal anastomosis. This patient subsequently developed stenosis of the anastomosis and was successfully treated with endoscopic dilatation. Patients sent for follow up (mean 48 months) showed no recurrence of diverticulitis, no stricture of anas tomosis and no urinary or reproductive system dysfunctions. Contrast enema, on the other hand, has a sensitiv ity of only 82% and a specificity of 81% for diverticulitis [10]. Hinchey 1 indicates the presence of a pericolic abscess, Hinchey 2a indicates distant abscess amenable to percutaneous drainage, Hinchey 2b indi cates complex abscess associated with or without fistula. Elective laparoscopic surgery is an acceptable alternative to conventional sur gery for treatment of Hinchey 1, with abscess larger than 5 cm, and in Hinchey 2a patients, after initial conservative treatment with percutaneous drainage of abscess. Healing Laparoscopic surgery is increasingly preferred in the elective treatment of sigmoid diverticulitis. Several single institutional series have confirmed the feasibility and safety of the laparoscopic approach in elective surgery [1215]. Laparoscopic sigmoidectomy is associated with reduced recovery time, return to bowel function, reduced hospital stay, decreased morbidity [1618] and costs [18, 19] compared with the open technique. Single institutional series by experienced surgeons have reported conversion rates of 2. In addition, there is further evidence of the bene fits of laparoscopic surgery emerging from a prospective randomized trial, which showed a reduction in major complications after laparoscopic surgery when compared with open sigmoidectomy [6]. Reduction of major complica tions included intra-abdominal abscess, anastomotic leakage, pulmonary embolism and myocardial infarction. This aims to convert a generalized purulent peritonitis to a localized divertic ulitis which can be safely treated by broad-spectrum antibiotic therapy [21 23]. Once the acute inflammation has settled, a delayed definitive laparoscop ic resection in elective setting can be performed, thereby completing the total ly minimally invasive management in such patients. In addition to the avoid ance of a laparotomy and stoma, this approach allows a definitive colonic resection in a non-emergency situation, which is the current trend [1, 24]. There is a risk of early re operation if the initial intervention fails to control the abdominal sepsis because of per sistent fistulization despite the closure of the diverticular defect. It is, therefore, important to have strict criteria for patient selection to obtain good results: patients whose perforation is visible at laparoscopic exploration or Hinchey 4 cases should be excluded from lavage-drainage [7, 21, 2527]. These patients may benefit from exteriorization of the perforation or from resection with or without a protective stoma [26]. Some authors pro pose in such cases suturing of the perforation or/and an omental patch or fib rin glue [26] with good results, low complication rate and immediate improve ment of clinical conditions [22, 23]. Again, patients whose exploration of the abdomen is not satisfactory because of adhesions or obstruction and when exploration shows severe peritonitis with numerous false membranes or fecal peritonitis should be considered for conversion into open surgery for a stan dard resection [21, 22, 26] (Hartmann or resection-anastomosis with or with out protective stoma). After peritoneal lavage and drainage, elective sigmoid resection should be planned within 3-6 months. Laparoscopic lavage and drainage has the potential to become in a subgroup of patients the definitive treatment for Hinchey 3. In addition, while most proponents of initial laparoscopic lavage suggest an elective, delayed sigmoidectomy, a multicenter study from Ireland and other small studies reported encouraging results with lavage followed by continued follow-up. These data coming also from different centers [28, 29] suggest that laparoscopic lavage may become, in selected cases, the defin itive treatment for perforated diverticulitis. The explanation could be that an episode of severe diverticulitis may result in a buttressing effect around the affected portion of the colon, thereby protecting it from subsequent attacks [3]. Nevertheless, the number of studies are rather limited and mostly based on small groups of patients, so further investigations are needed to confirm these initial, promising results. There is still not enough evidence to recommend laparoscopic resection for Hinchey 3-4 patients, even though there is increasing evidence that in selected patients and experienced hands it may be considered potentially safe and effec tive with no apparent increase in intra or postoperative complications. Alternatively to laparoscopic lavage in Hinchey 34 patients, emergency colonic resection can be done by laparoscopy in carefully selected cases. The reported mortality and morbidity in patients with an anastomosis seems to be the same as in patients who undergo the Hartmann procedure [4]. These data suggest that in a select group of patients undergoing surgery in the acute stage of diverticulitis, an anastomosis is probably safe, even in the set ting of feculent peritonitis. When performed laparoscopically, colonic resection in the emergency set ting has in some small series [3134] proven to be effective and safe, although the rates of additional radiologic interventions and conversion to an open pro cedure are high [27]. Moreover, for many hospitals it will not be possible to have a surgical team with expertise in colorectal laparoscopic surgery presentt all the time. Therefore, laparoscopy is of unclear or limited value in the emer gency setting caused by perforated diverticular disease and there is still nott enough evidence to recommend this policy in routine practice. This first objective diagno sis of acute diverticulitis is very helpful to better define the indications forr emergent or elective surgery or for conservative management with or withoutt percutaneous drainage of abscesses. If needed, percutaneous drainage of an associated abscess that may allow the surgeon to perform, after the acute disease has settled, an elective single stage resection with a primary bowel anastomosis. If percutaneous drainage fails, laparoscopic lavage and drainage is a good alternative to urgent colonic resection in selected patients, possibly followed by elective laparoscopic resection. The current trend in fact, with the best results in terms of intra and postoperative complications, is to avoid an operation close to the acute attack, where possible, leaving to emergency surgery only Hinchey 3 and 4 patients and those who fail to respond to conservative management. Laparoscopic elective resection is currently considered the best choice for the treatment of non acute diverticular disease with evidence level 1b [33, 35, 36]. In the acute setting, a clinical evaluation has to be carefully performed pre 6 Role of Laparoscopy in the Treatment of Acute Diverticulitis:an Evidence-Based Review 85 operatively in order to select patients for eventual laparoscopic exploration from those to treat directly with a laparotomic approach. Laparoscopic lavage and drainage has a valid role in the treatment of sta ble, fit, Hinchey 3 patients in which no gross perforation is visible, with recentt peritonitis, providing a time window for definitive elective resection. If these conditions are not respected or if laparoscopic exploration reveals a Hinchey 4, it is considered prudent to convert the patient to laparotomy and to perform a colonic resection. Emergency colonic resection can be done by laparoscopy, in carefully selected cases, as some authors report [3134], but evidence for a recommendation is actually too weak. Results obtained in our series of 286 patients come from total standardiza tion of the technique by the operating team, which has an overall experience of 1, 348 colonic resections at September 2010. Like the currentt trend in the treatment of complicated diverticular disease, for the most part in our experience surgical treatment is performed electively. From the technical point of view, a tension-free anastomosis is assured by mobilizing the splenic flexure which is usually done systematically, except in selected cases. The distal dissection is carefully extended to ensure the resec tion of the diseased colon below the rectosigmoid junction, which is shown to be associated with lower recurrence rates. Laparoscopic colonic resection to remove the diseased segment of the colon but not all diverticula is the recom mended procedure. On the basis of our experience and evidence from the literature it can be stated that surgical treatment of complicated diverticular disease carried outt laparoscopically gives good results in terms of morbidity and mortality. Laparoscopy requires its own specific surgical strategy, especially when com plicated cases (abscesses, fistula) are operated. The surgical team must be expert in laparoscopic surgery and colorectal surgery and the technique mustt be standardized so that the incidence of complications, operating time and rates of conversions to open surgery can be minimized. Stocchi L (2010) Current indications and role of surgery in the management of sigmoid di verticulitis. Ambrosetti P, Jenny A, Becker C et al (2000) Acute left colonic diverticulitis compared per formance of computed tomography and water-soluble contrast enema: prospective evaluationn of 420 patients. Myers E, Kavanagh D, Hurley M et al (2008) Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis A feasible alternative. Pugliese R, Di Lernia S, Sansonna F et al (2004) Laparoscopic treatment of sigmoid diverti culitis: a retrospective review of 103 cases. Schwandner O, Farke S, Fischer F et al (2004) Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients. Bretagnol F, Pautrat K, Mor C et al (2008) Emergency laparoscopic management of perfo rated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg 206:654-657 6 Role of Laparoscopy in the Treatment of Acute Diverticulitis:an Evidence-Based Review 87 26. Karoui M, Champault A, Pautrat K (2009) Laparoscopic peritoneal lavage or primary anas tomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a com parative study. Scheidbach H, Schneider C, Rose J et al (2004) Laparoscopic approach to treatment of sig moid diverticulitis: changes in the spectrum of indications and results of a prospective, mul ticenter study on 1, 545 patients. Gervaz P, Inan I, Perneger T et al (2010) A prospective, randomized, single-blind compari son of laparoscopic versus open sigmoid colectomy for diverticulitis. Tonelli F, Di Carlo V, Liscia G, Serventi A (2009) La malattia diverticolare del colon: quan do e come trattarla. Ann Ital Chir 80:3-8 Suggested Readings Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P (2006) Laparoscopy for abdominal emergencies. In press Adhesive Small Bowel Obstruction 7 Fausto Catena, Salomone Di Saverio, Luca Ansaloni, Antonio Pinna, Massimo Lupo, Antonino Mirabella and Vincenzo Mandala 7. In the latter, however, the indication for the laparoscopic approach today is debated among surgeons due to the potential visceral risk associated with this method and also because the scientific evidence currently available in the lit erature supporting the use of the laparoscopic approach over open surgery is poor. The approaches to adhesiolysis for bowel obstruction among general surgeons in the United Kingdom were established in 1993 [2]. Half of all surgeons divided all adhe sions to prevent recurrence of bowel obstruction, whereas the other half limit ed adhesiolysis to only the adhesions responsible for the obstruction. Adhesions are less after transverse or Pfannenstiel incision than after midline incisions and surgery for obstetric rather than gynecologic indications [3]. The risk of anterior abdominal wall adhesions increases with the number of previous laparotomies, although this relationship is not as evident as the relationship between previous laparotomies and adhesiolysis-induced enterotomy [4, 5]. Mean time required for lysis of adhesions was about one-fifth of the total mean operative time. Higher age and higher number of previous laparotomies appeared to be pre dictors of the occurrence of inadvertent enterotomy [5]. Patients with three orr more previous laparotomies had a 10-fold increase in enterotomy compared with patients with one or two previous laparotomies, which strongly suggests more dense adhesion reformation after each reoperation. Historically, laparotomy and open adhesiolysis have been the treatment forr patients requiring surgery for small bowel obstruction. Unfortunately, this often leads to further formation of intra-abdominal adhesions with approxi mately 10% to 30% of patients requiring another laparotomy for recurrentt bowel obstruction [7]. In animal models laparoscopy has been shown to decrease the incidence, extent, and severity of intra-abdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [8]. Laparoscopic adhesiolysis for small bowel obstruction has a number off potential advantages: (1) less postoperative pain; (2) quicker return of intestinal function; (3) shorter hospital stay; (4) reduced recovery time, allowing an earli er return to full activity; (5) fewer wound complications; and (6) decreased post operative adhesion formation [11]. Although data from retrospective clinical controlled trials suggest thatt laparoscopy seems feasible and better in terms of hospital stay and mortality reduction, high quality randomized controlled trials assessing all clinically rel evant outcomes including overall mortality, morbidity, hospital stay and con version are lacking [13]. This large population survey of hospital discharge reports suggests that the less invasive laparoscopic surgical techniques for adhesioly sis have increased over recent years, contributing to the decreased time required in the hospital for both the surgical procedure itself and the recovery time. However, the increased use of laparoscopy during this study period did not appear to be associated with a concomitant reduction in the adhesiolysis hospitalization rate, therefore a common denominator may exist between sur gical trauma and immune response to foreign bodies. When deciding between an open or laparoscopic approach, the first consid eration is that the surgeon be trained and capable of performing advanced laparoscopy. With regards to patient selection, patients with an acute small bowel obstruction and peritonitis or free air requiring an emergent operation are best managed with a laparotomy. Patients without peritonitis who do nott resolve with nonoperative management should be considered for laparoscopic adhesiolysis. In these cases, it is important to consider the bowel diameter, degree of abdominal distention, and location of the obstruction. Patients with a distal and complete small bowel obstruction have an increased incidence of intraoperative complications and increased risk of conversion. Patients with persistent abdominal distention after nasogastric intubation are also unlikely to be treated successfully with laparoscopy.
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