International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

The effects of Platelet-rich Plasma on healing of partial thickness burns in a porcine model

Platelet-rich plasma (PRP) derived from autologous peripheral blood is rich in platelets that release growth factors and cytokines. We determined the effects of topically applied autologous PRP in a partial thickness porcine burn model. Partial thickness burns were created on the backs and flanks of six domestic pigs (24 burns each) using an aluminium bar preheated to 80° C for 20 seconds. After removing the necrotic epidermis, the burns were randomly treated with a topical antibiotic ointment or a single (day 2), double (days 2 and 7), or triple (days 2, 7, and 14) topical application of PRP that was prepared freshly before application. Periodic imaging and full thickness biopsies were conducted to monitor healing over 28 days. The percentage wound reepithelialization at days 11, 14, 18 and 21 did not differ significantly among the groups. By day 28 all wounds were completely (>95%) reepithelialized, and there were no differences among the groups. Time to complete healing (presented as mean, [SD]) did not differ among the groups (antibiotics, 17.1 [3.5]; single PRP, 17.6 [4.0]; double PRP, 18.4 [3.9]; and triple PRP, 17.7 [3.3] days; ANOVA P=0.43). Scar depth (presented as mean, [SD]) in mm at day 28 by treatment group was: antibiotic 5.0 [1.0], single PRP 5.5 [1.1], double PRP 5.4 [1.1], and triple PRP 5.5 [0.6], ANOVA P=0.026. We conclude that PRP results in similar rates of reepithelialization and scar depth to standard topical antibiotics in a partial thickness porcine burn model.

Hepatic Venous and Inferior Vena Cava Morphology No Longer a Barrier to Living Donor Liver Transplantation for Budd-Chiari Syndrome: Surgical Techniques and Outcomes

BACKGROUND

Living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) has been reported with <10 inferior vena cava (IVC) replacements with vascular/synthetic graft. The goal of this study was to review outcomes of LDLT for BCS at our center, with an emphasis on surgical techniques and postoperative anticoagulation therapy.

METHODS

Between October 2011 and December 2015, a total of 1027 LDLTs were performed. Nine of these patients had BCS. We analyzed their etiologies, operative details, postoperative complications, and outcomes.

RESULTS

The indication was chronic liver disease for all patients. Two patients required retrohepatic IVC replacement with a polytetrafluoroethylene graft due to severe adhesions and thrombosis, respectively. One patient required V-Y plasty for suprahepatic IVC narrowing. Five patients had portal venous thrombosis, 3 treated by thrombectomy, and 1 by renoportal anastomosis. The mean follow-up time was 18 ± 16 months. Only 1 early death occurred due to sepsis. The anticoagulation therapy involved heparin infusion from postoperative day 1, conversion to low-molecular-weight-heparin on postoperative days 3 to 6, followed by warfarin (postoperative days 9-16 to maintain an international normalized ratio of 2-3 long term), along with low-dose aspirin for 6 months. There was no recurrence of thrombosis.

CONCLUSIONS

LDLT for BCS is well documented in literature. Prevention of recurrent thrombosis depends on meticulous surgical technique, perfect and wide outflow anastomoses, and a strict anticoagulation protocol. A synthetic (polytetrafluoroethylene) graft for IVC interposition is a safe and feasible option for reconstruction with good results. Low-dose aspirin with low-molecular-weight-heparin later converted to warfarin provides excellent results and prevents recurrence of thrombosis.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer

INTRODUCTION

Adeno-carcinomas of pancreatic body are usually asymptomatic and progress to advanced stage with involvement of major arteries. Resection of advanced cancer along with en bloc resection of a common hepatic artery and celiac trunk enables a "curative" resections and only possible treatment. However, the celiac axis resection always has a risk of compromising blood supply to liver, resulting in the hepatic insufficiency. We evaluated practicability of a two-stage procedure for the advanced pancreases body cancer, laparoscopic clamping of a common hepatic artery followed by open distal pancreatectomy with en bloc celiac arterial resection to prevent the hepatic insufficiency.

MATERIALS AND SURGICAL TECHNIQUE

Seventy-five-year-old woman diagnosed with a 50-mm pancreatic body mass, invading splenic artery, common hepatic artery, splenic vein, and portal vein at the confluence. STAGE-1: At laparoscopy, after confirming absence of the peritoneal, superficial liver metastases and negative peritoneal cytology; we approached the common hepatic artery through the lesser sac and ligated. STAGE-2: Her liver function tests were normal after 2 weeks, and CT angiography showed complete blockage of the common hepatic artery with sufficient collateral circulation to the liver through inferior pancreatico-duodenal artery and gastro-duodenal artery. We performed an open distal pancreatectomy with en bloc resection of celiac artery. Histopathology examination confirmed R0 resection.

DISCUSSION

The celiac axis resection with distal pancreatectomy improves the chance of R0 resection and potentially, survival of the patient. Preoperative laparoscopic ligation of the common hepatic artery is a safe, effective, and in-expensive technique to prevent postoperative hepatic insufficiency and improves the safety of en bloc celiac artery resection with a distal pancreatectomy. Also these patients have high risk of peritoneal dissemination. Diagnostic laparoscopy is useful to detect occult metastasis, which are missed by per-operative CT scan.

Functional and fibrinogen receptor studies in platelets in pre-eclamptic toxaemia of pregnancy

It is believed that platelets play a key role in the production of pre-eclamptic toxaemia and toxaemia of pregnancy. Toxaemia of pregnancy is described as a condition of chronic DIC where there is thrombocytopenia as well as raised fibrin degradation products. Since fibrinogen receptors are involved in the final stage of the platelet aggregation reaction, we wanted to investigate the platelet receptors for fibrinogen in normal and abnormal pregnancy. Thirty-six normal pregnant women (12 in their 2nd trimester, 24 in their 3rd trimester), 24 pregnant pre-eclamptic toxaemia cases and 16 non-pregnant controls were included in the present study. All patients with pre-eclamptic toxaemia had oedema, proteinuria and hypertension. Flow cytometric study of platelets was undertaken utilizing fluorescein isothiocyanate (FITC)-labelled anti-human fibrinogen antibody in unstimulated and ADP-stimulated (final concentration 0.02 M) platelets. The intensity of platelet fluorescence was classified into three groups and expressed in arbitrary units. The results indicate that there are a higher number of stimulated platelets expressing fibrinogen receptors in the circulation of patients with pre-eclampsia. Thus, it is possible to hypothesize that platelets showing increased fibrinogen receptors aggregate and form microthrombi in smaller vessels in women with pre-eclamptic toxaemia.

Multiple endometrial antigens are targeted in autoimmune endometriosis

Endometriosis is defined as the growth of endometrial glands and stroma in ectopic locations. Its aetiology is multifactorial, but autoimmunity has been shown to play a role in its onset and development. The present study aimed to investigate the presence of both IgG and IgM anti-endometrial antibodies in sera of endometriosis patients in comparison with age-matched controls, and to also investigate the cognate endometrial proteins involved. Sera from these groups were screened by western blot and immunohistochemistry. Thirteen out of the 40 sera tested were positive for IgG isotype, and 10/27 IgG negative patients were positive for IgM isotype. These findings indicate that endometrial antibodies of IgG and IgM classes could be detected in almost 60% of endometriosis patients. Of the various identified endometrial antigens, 30 and 45 kDa antigens were immunodominant in both IgG and IgM positive endometriosis patients. With immunohistochemistry, positive sera showed reactivity in luminal epithelium, glandular epithelium and stroma. These anti-endometrial antibodies might be partially responsible for failure of implantation leading to infertility. Identification of specific targets would be a help in understanding the pathophysiology of endometriosis, and would also help in setting up a non-invasive test for the diagnosis of endometriosis.

The spike osteotomy for hallux valgus: a clinical and radiological evaluation

A distal metatarsal osteotomy with soft tissue correction is a frequently performed operation to correct mild to moderate hallux valgus deformity. This is a prospective study of 28 feet in 25 patients who underwent spike osteotomy of the first metatarsal with medial capsulorraphy for symptomatic hallux valgus. The osteotomy is a distal metatarsal osteotomy with a spike fashioned in the plantar and lateral quarter of the proximal fragment and impacted into the trough created in the center of the distal fragment, providing lateral and plantar shift of the distal fragment. The American Orthopaedic Foot and Ankle Society's rating scale was used for functional assessment, and a visual analog scale gauged pain. The average follow-up was 27 months. The rating scale score improved from a mean preoperative value of 39/100 to 84/100. Twenty-six feet had complete pain relief, whereas 2 feet had a lesser degree of persistent metatarsalgia. A review of preoperative and postoperative radiographs showed that the hallux valgus angle improved from a mean 36 degrees preoperatively to 18 degrees postoperatively. Likewise, the mean 1 to 2 intermetatarsal angle improved from 13 degrees to 7.3 degrees. There was no incidence of avascular necrosis. Fourteen patients (16 feet) rated the outcome as excellent, 10 (11 feet) as good, and 1 patient with asymptomatic mild hallux varus deformity rated the result as fair. These results demonstrate that the spike osteotomy is a suitable operation for treatment of mild to moderate hallux valgus.

Medium-term results of the Charnley low-offset femoral stem

A reduced femoral offset in total hip replacement has been thought to be disadvantageous. We reviewed the results of 54 consecutive primary total hip replacements in 49 patients (mean age of 68 years) performed between August 1990 and December 1994, with a mean follow-up of 8.8 years (sd 2.1). The mean pre-operative femoral offset for these hips was 41 mm (sd 7.4). All patients received a low-offset Charnley stem and a polyethylene cup inserted by a single surgeon. At their latest follow-up, surviving patients had a significant improvement in the performance of their hip. Three had undergone revision, one each for deep infection, recurrent dislocation and late pain with subluxation. No hips had been revised, or were at risk of revision, for aseptic loosening. The mean annual linear rate of wear was 0.2 mm (sd 0.08) for the whole group. There was no correlation between the pre-operative femoral offset and the post-operative rate of wear. Our survivorship estimate was 91% when revision for any reason was taken as an end-point, but 100% if aseptic loosening was considered as the end-point. Our study demonstrates that a low-offset femoral stem can produce good, medium-term results.

Aggressive treatment of metastasis to the parotid

OBJECTIVES

Assess the value of aggressively treating metastatic lesions in the parotid, taking into account the histology of the disease.

STUDY DESIGN

Retrospective analysis of 13 patients diagnosed with metastasis to the parotid treated by one surgeon in a tertiary referral head and neck unit in the United Kingdom.

METHODS

The following variables were reviewed and tabulated: age, sex, histology, latent period to secondary tumour, treatment instituted, postoperative facial nerve outcome, follow-up and survival.

RESULTS

Twelve patients were treated aggressively with at least total parotidectomy and adjunctive therapy, whilst one patient required only a superficial parotidectomy. Ten patients had metastatic cutaneous tumours, and three had metastatic adenocarcinoma. Seven of these 13 patients (53.8 %) are alive and well (six had metastatic cutaneous tumours, one had metastatic adenocarcinoma). Four patients succumbed to tumour (two had metastatic cutaneous tumours and two had metastatic adenocarcinoma), and two patients succumbed from unrelated medical causes (both had metastatic cutaneous tumours). The mean follow-up for those alive is 65.9 months and mean follow-up for those deceased is 15.3 months.

CONCLUSIONS

In the absence of systemic spread, parotid metastases from primary cutaneous squamous cell carcinoma should be treated aggressively, while metastases from non-cutaneous primary tumours should be approached with caution.

A review of cochlear implantation in mitochondrial sensorineural hearing loss

OBJECTIVE

Mitochondrial sensorineural hearing loss (SNHL) may be nonsyndromic (occurring in isolation), associated with the A1555G mutation in the MTRNR1 gene. Mitochondrial SNHL may also be syndromic, associated with the A3243G point mutation in the MTTL1 gene. In syndromic cases-mitochondrial encephalopathy, lactic acidosis, and strokelike episodes (MELAS), maternally inherited diabetes and deafness, Kearns-Sayre syndrome, and chronic progressive external ophthalmoplegia-the SNHL compounds already existing disabilities. The genetic basis for mitochondrial SNHL and postulated sites of pathologic changes are discussed.

DATA SOURCES

Sources used were relevant clinical and basic science publications.

STUDY SELECTION

A search of the entire databases of Medline and Web of Science, using various subject headings and free-text terms, was used to identify patients with mitochondrial disease having cochlear implants.

DATA EXTRACTION

The data from publications were critically reviewed and tabulated to assess implantation outcomes.

DATA SYNTHESIS

The data were not amenable to formal meta-analysis or valid data summarization, other than descriptive statistics.

CONCLUSIONS

There is an increasing awareness of the prevalence of mitochondrial SNHL and its progressive nature. High-risk candidates warrant genetic testing and family screening. Correlating the data for mitochondrial SNHL as a treatable entity is important, and the authors present an overview of these patients successfully rehabilitated by cochlear implantation.

Soft tissue myoepithelioma: a case report

Myoepitheliomas are tumours composed predominantly or exclusively of myoepithelial cells. They are well described, especially within the salivary gland, but their occurrence in soft tissues is less well known and this often results in diagnostic problems. We report a case involving the deep soft tissues of the lower neck behind the clavicle. Grossly, the tumour was well circumscribed with solid and cystic areas. Histology showed a richly vascularised tumour composed of bland round, ovoid or spindle-shaped cells. Various growth patterns were present including solid, nested, microcystic and trabecular arrangements. In some areas there was an alveolar pattern with tumour cells lining fibrous septae. Immunohistochemistry showed diffuse strong positivity for S100 protein, calponin, vimentin and glial fibrillary acidic protein and focal positivity for epithelial membrane antigen, 34betaE12 and AE1/AE3, in keeping with myoepithelial differentiation. Electron microscopy revealed tumour cells surrounded by basal lamina with subplasmalemmal densities and containing cytoplasmic myofilaments. This case report highlights the rare occurrence of myoepitheliomas in deep soft tissues. Pathologists should be aware of this and should consider a myoepithelioma in the differential diagnosis of a soft tissue spindle cell neoplasm.

Cochlear implantation in the obliterated cochlea

We present three cases of acquired deafness, associated with obliterated cochleas, in which the apparently radiologically more favourable side was chosen for implantation. In the first case, because of unexpected obliteration, only a partial insertion was possible. Deteriorating performance and non-auditory stimulation of the facial nerve led to removal of the implant and a contralateral implantation with full insertion under the same anaesthetic gave a good postoperative result. In the second case, CT scanning indicated minimal obliteration, but extensive obliteration was encountered at surgery, which required double-array insertion with a delayed but satisfactory outcome. In the third case, extensive unexpected obliteration was noted at surgery and, in light of the experience gained with the first two cases, it was decided not to proceed but to explore the contralateral side. At surgery on the contralateral side, a patent cochlea was noted with full electrode insertion and an excellent outcome. These cases demonstrate a learning curve for this department and our philosophy now is to explore the contralateral ear rather than accept a partial insertion.

Cochlear implantation in maternal inherited diabetes and deafness syndrome

We describe a rare case of a gradually progressive hearing loss in a patient with maternally inherited diabetes and deafness (MIDD) syndrome successfully rehabilitated with a cochlear implant. The possible aetiology of the hearing loss in these cases is discussed.

Bipolar scissors versus cold dissection tonsillectomy: a prospective, randomized, multi-unit study

OBJECTIVE

To evaluate bipolar scissors tonsillectomy by comparing it with traditional cold dissection tonsillectomy.

STUDY DESIGN

A prospective, randomized, multi-unit study.

SETTINGS

Belfast City Hospital, Royal Victoria Hospital Belfast, and Ulster Hospital Dundonald.

PATIENTS

Two hundred consecutive patients undergoing tonsillectomy for recurrent or chronic tonsillitis between March 2000 and September 2000.

OUTCOME MEASURES

(1) Intraoperative bleeding, (2) operative time, (3) postoperative pain, and (4) complication rates, including primary and secondary hemorrhage.

RESULTS

Seventeen patients were excluded from the study for various reasons. The mean age of the study population was 22 years (range, 10-54 y). Seventy-two percent of patients were female. Twenty-seven percent of patients were children aged 16 years or under. Median intraoperative blood loss was 5 mL for bipolar scissors tonsillectomy and 115 mL for cold dissection tonsillectomy (P < .001). The mean operative time was 13 minutes for bipolar scissors tonsillectomy compared with 20 minutes for the cold dissection method (P < .001). There was no statistically significant difference in the pain scores between the two methods (independent samples t = 1.35; P > .05). The overall primary hemorrhage rate was 2.1%, whereas the overall secondary hemorrhage rate was 16.9%. The hospital readmission rate was 10.3%. The primary and secondary hemorrhage rates were unaffected by the surgical method.

CONCLUSIONS

Bipolar scissors tonsillectomy is a safe technique with a similar morbidity to the cold dissection method. Its use is associated with a significant decrease in both surgical time and blood loss compared with the cold dissection method.

Metastatic breast carcinoma in the parapharyngeal space

The parapharyngeal space is a complex anatomical area, which can give rise to a variety of both primary and metastatic neoplasms. We present an unusual case of metastatic adenocarcinoma of the breast, masquerading as a deep lobe parotid neoplasm, 15 years after the primary presentation. Metastatic breast carcinoma has been previously reported at other sites in the head and neck but this is the first report of metastases in the parapharyngeal space with an oropharyngeal presentation.

Artificial tympanic membrane and ossiculoplasty

We report an unusual case of a subjective hearing improvement, confirmed by audiometry, in a patient using a paper towel prosthesis.

Giant lymph node hyperplasia a diagnostic dilemma in the neck

Giant lymph node hyperplasia (GLNH) or Castleman's disease is a rare pathological entity commonly presenting as a solitary mediastinal tumour (unifocal variant), although other anatomical sites have been reported including the head and neck, abdomen and axilla. Though the head and neck is the second commonest site for this lesion, only 60 cases [1,2] have been reported in the literature. Pre-operative diagnosis of the unifocal variant can be difficult as routine investigations carried out in the clinic setting are often inconclusive. A multicentric form of this disease with a poorer prognosis in comparison to the unifocal lesion has been described by Gaba et al. in 1978 [3]. We present a case of an unusually large, slow growing, asymptomatic, unifocal variant of this tumour restricted to the neck which underwent successful surgical excision. A review of the literature, histopathological characteristics and differential diagnosis is also presented.

Diagnosis and prevalence of bacterial vaginosis

A prospective study of 80 women was undertaken to estimate the prevalence of bacterial vaginosis, and to compare two methods of diagnosing the condition. Bacterial Vaginosis was detected by both Gram stain and compound criteria in 30 women. The prevalence was 37.5%. Gram stain provides a simple and inexpensive method for laboratory confirmation of bacterial vaginosis where facilities for using the compound criteria are not available.

Vesical fistulae--an experience from a developing country

This study analyses patients with vesical fistulae presenting at a teaching, referral hospital over the last ten years. There were 62 cases of vesical fistulae of which 60 were obstetric in origin (44 home and 16 hospital deliveries) and 2 were following gynaecological surgery. Of the hospital deliveries which culminated in fistula formation, 8 were vaginal and 7 forceps deliveries. In one patient, lower segment caesarean section was carried out. After a thorough urological work-up, patients were subjected to standard technique of layered closure (61 by vaginal approach and one by abdominal). Repair was successful in 53 (87.09%) patients. Of the 9 failures, 4 were repeat repairs.

Urological injuries during obstetric and gynaecological surgical procedures

Urological injuries during obstetric and gynaecological operations carried out between Jan. '88 to Dec. '88, at a hospital involved in resident teaching programmes were analysed retrospectively. Each case was reviewed for predisposing factors, location and type of injury, time and method of recognition and management. Fifteen injuries were documented in 892 gynaecological procedures and 296 obstetric procedures. Twelve injuries occurred during gynaecological operations whereas 3 occurred during obstetric operations. Thirteen were bladder injuries and two were ureteric injuries. Infiltrating carcinoma of cervix, pelvic adhesions, adhesions because of previous operations and distorted anatomy, were the important risk factors.