Background Pneumoperitoneum during laparoscopic surgery is associated with significant hemodynamic changes represented by increasing heart rate, vascular resistance, and blood pressure. This study aimed to compare the safety of each of magnesium sulfate, dexmedetomidine, and lignocaine on hemodynamic responses during pneumoperitoneum. Patients and methods In all, 120 patients were enrolled in the study. They were electively planned for laparoscopic cholecystectomy. Their ages were in the range of 21–60 years. Men were 38.3% and women 61.67%. American Society of Anesthesiologists I: 74.17% and II: 25.83%. The patients were randomly allocated into four groups: each of 30 patients. Group M administered magnesium sulfate preoperatively as loading followed by infusion 50 mg/kg/h, group D received dexmedetomidine preoperatively as loading followed by infusion 0.5 µg/kg/h, group L was given lignocaine preoperatively as loading followed by infusion 1 mg/kg/h, and group C received normal saline. Results A significant difference was noticed as regards heart rate changes and mean arterial blood pressure increase between the groups of magnesium sulfate, dexmedetomidine, lignocaine, and the control group at the time of drug administration, after intubation, throughout pneumoperitoneum at 5 min intervals, postpneumoperitoneum, and in the postoperative period after 10 min (P<0.001). Conclusion Magnesium sulfate and dexmedetomidine infusions have comparable effects. Lignocaine was less effective in the attenuation of the hypertensive response of pneumoperitoneum and reducing the dose requirements of opioids during laparoscopic cholecystectomy.

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Background Pediatric intensive care unit (PICU) has a specific location for the management of seriously ill children. Aim of the work The purpose of the study was to compare two models [Pediatric Risk of Mortality III (PRISM III) and the Pediatric Index of Mortality 3 (PIM3) scores] for the prediction of mortality in PICU in KSA. Patients and methods A prospective, cohort study was conducted and two mortality scores, PRISM III and PIM3, were applied on 68 children admitted to the PICU at As-Salama Hospital, Al Khobar, KSA over a period of 1 year from January till December 2016. Results The mean age was 7.6±5.3 years with more men than women and the mean length of hospital stay was 9.8±7.0 days. The overall expected mortality using the PRISM III score was 6.7% whereas that by PIM3 was 7.4% and the observed mortality was 17.6%. Both tests underpredicted mortality at all probability levels. However, the degree of underprediction was less when the predicted mortality was more than 25%. Both tests showed excellent discrimination with a value of 0.94 (95% confidence interval, 0.86–1.0) with 94.1% sensitivity and 72.0% specificity; and of 0.93 (95% confidence interval, 0.87–0.99) with 82.4% sensitivity and 84.0% specificity, respectively. The Hosmer and Lemeshow goodness-of-fit test showed good calibration for PRISM III score (χ²=4.57, P=0.148) but poor calibration for PIM3 score (χ²=8.66, P=0.01). Conclusion Both PRISM III and PIM3 scores underpredicted mortality at all probability levels. They offered good discrimination; however, the performance of the scoring system in the PICU patients was poor. PRISM III score showed good calibration while PIM3 score showed poor calibration.

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Background Anterior displaced anus (ADA) is a common anomaly in female children. There are several operative techniques for its treatment. Aim The aim of this study was to present experience with anal shift procedure for the treatment of ADA in female children. Patients and methods This is a prospective study that was conducted at the Pediatric Surgical Unit, Al-Azhar University Hospital, Damietta, during the period from October 2015 to September 2017. Fifteen female children with ADA underwent surgical correction by anal shift procedure. The anus position index was measured before and after the operation. Medical records of all patients were reviewed regarding operative time, intraoperative or postoperative complications, and conversion to other procedure. Parents’ satisfaction about cosmetic results of the technique was evaluated using a subjective score ranging from 0 to 4, where 0=no satisfaction, 1=fair satisfaction, 2=good satisfaction, 3=very good satisfaction, and 4=excellent satisfaction. All cases were followed up for a mean follow-up period of 12±2 months (range: 8–18 months). Results A total of 15 female children with ADA were corrected with anal shift procedure. Their mean age was 3.06±1.03 years (range: 1–5 year). Anal functions were normal with acceptable anal position indices at the end of follow-up period for all patients. Complications were mild and treated conservatively. Only one case had superficial disruption of anterior incision, and secondary sutures were done with good result. Conclusion Anal shift procedure appears to be a safe, simple, and effective surgical procedure for correction of ADA in female children.

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Objectives To evaluate the outcome of septoplasty and the effect of bilateral anterior nasal packing (NP) on surgical outcome and postoperative (PO) arterial blood gas levels. Patients and methods A total of 90 patients underwent septoplasty: group I included patients who received PO bilateral anterior NP at the end of surgery for 48 h and group II included patients free of NP. Patients were evaluated clinically using the Nasal Obstruction and Septoplasty Effectiveness scale and underwent septoplasty using Cottle’s technique. Arterial blood samples were obtained preoperatively and before NP removal for estimation of arterial blood pH, bicarbonate (HCO₃⁻), partial pressure of O₂ (PaO₂) and CO₂ (PaCO₂), and O₂ saturation (SaO₂) levels. Pain severity was assessed using numeric rating scale at 6 h, D-1, and D-2 PO, and during the first 48 h PO, nasal bleeding in group II was estimated. After NP removal, pack removal-associated pain and amount of bleeding were determined. Results Operations were conducted uneventfully with nonsignificant difference between groups. At 48 h PO, mean PaO₂, PaCO₂, and SaO₂ levels were significantly lower in all patients than preoperative levels, with significantly lower SaO₂ and PaCO₂ levels in patients of group I than group II. Numeric rating scale pain scores in both groups showed progressive significant decrease till 48 h PO, with significantly lower scores in group II. Removal of NP resulted in pain scored by more than or equal to 4 in 30 patients and induced minimal bleeding, which was significantly lower than bleeding occurred in patients of group II throughout the 48 h PO. All patients enjoyed significant reduction of Nasal Obstruction and Septoplasty Effectiveness score, with nonsignificant difference between both groups. Conclusion NP after septoplasty reduced amount of PO bleeding, but pain associated with NP presence and removal-induced deleterious effect on patients’ satisfaction with deleterious effect on arterial blood O₂ and CO₂ levels but with nonsignificant effect on arterial blood pH or HCO₃ concentration.

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Background Tuberculosis (TB) is an infectious disease affecting the world population for thousands of years. Aim The aim was to study and compare the pattern of TB in Suez and Damietta Chest Hospitals through the period from 2007 to 2016. Patients and methods This is a retrospective study that was carried out at Damietta and Suez Chest Hospitals and dispensaries and included all cases of TB from January 2007 to December 2016. Data were collected from TB registration units. Direct observed therapies strategy in chest hospitals and dispensaries started since January 1999. Results A total of 1208 (62.3%) cases were men and 732 (37.7%) were women. The highest rate of infection was reported in age group of 20–29 years (45.7%); the lowest affected age group was that greater than 60 years (5.1%). Type of TB was pulmonary in 76.1% and extrapulmonary in 23.9%. The main presenting symptom was cough presented in 50.8%, hemoptysis in 20.3%, chest pain in 14.7%, and fever in 14.2%. The sputum smear was positive in 89.3% and negative in 10.7%; and there was significant increase of positive smear in Damietta when compared with Suez Governorates (92.1 vs. 86.2%, respectively). The most common extrapulmonary lesion was pleural effusion (40.5%); then lymph node (19.4%) and the least was cold abscess (2.6%). Diabetes was reported in 11.5% and prolonged corticosteroid therapy in 6.5%. The condition at discharge was improvement in 85.5%, failure in 6.6%, relapse in 4.8%, and death in 3.1%. Both groups were comparable as regards the studied variables. Conclusion There was progressive decrease of total TB cases in both Damietta and Suez Governorate from 2007 to 2016 and both governorates were comparable.

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Objective The aim of this study was to evaluate methods of diagnosis and management of leakage after sleeve gastrectomy to decrease morbidity and mortality of this complication. Background Leakage is the commonest and most feared early complication in bariatric procedures. Leakage can occur from any site of staple line. Incidence of leakage after sleeve gastrectomy is in the range of 1–3%. Risk factors for leaks and complications were increasing weight, male sex, multiple comorbidities, previous abdominal procedures, or revisional surgery. Tachycardia with a heart rate in excess of 120 beats per minute was a good indicator of leakage. Patients and methods The study was conducted on 12 cases that had leakage after sleeve gastrectomy, where four cases were diagnosed early and were managed by re-exploration and repair of the site of leakage with feeding jejunostomy and eight cases were diagnosed late and managed as follows: five cases by gastric stent and pigtail for drainage of collection, two cases by exploration, and one case by pigtail insertion and conservative treatment. Results In this study, four cases experienced mortality owing to delay in diagnosis and septicemia. Two cases develop gastropleural fistula. There was long hospital stay. Two cases developed incisional hernia, and one case developed deep venous thrombosis (DVT). Conclusion Management of leakage in bariatric procedures requires early diagnosis and precise decision making tailored according to every case.

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Background Pain experienced after abdominal surgery is derived from abdominal wall incision. Transversus abdominis plane (TAP) block is a novel approach for blocking abdominal wall neural afferents. Aim of study To evaluate the analgesic effects of ultrasound-guided TAP block and caudal block in lower abdominal surgeries in pediatrics compared with general anesthesia (GA). Patients and methods This prospective, randomized, controlled, single-blinded study was conducted on 60 pediatric patients of the American Society of Anesthesiologists physical status I and II, aged 2–6 years. Patients were randomized into three equal groups. Groups I and II received ultrasound-guided TAP and caudal block, respectively, whereas group III received GA and opioid analgesia. The primary outcome was intraoperative analgesic effects manifested by changes in hemodynamics and catecholamines. Secondary outcomes included postoperative analgesia and complications. Results There was a highly significant decrease in heart rate 5 min after skin incision in both TAP and caudal groups compared with the GA group. However, there were nonsignificant differences between groups as regards systolic and diastolic blood pressures at baseline and 5 min after skin incision. There was a highly significant decrease in both norepinephrine and epinephrine in TAP and caudal groups compared with the GA group at 5 min after skin incision. Similar findings were reported 60 min after recovery. Postoperatively, Face, Legs, Activity, Cry, Consolability values were significantly higher in the caudal group compared with the GA and TAP groups. The side effects were statistically higher in the GA group. Till 12 postoperative hours the patients who received the TAP block did not require analgesic medication compared to the seven patients who received the caudal block. Patients who received GA significantly required analgesia after 4 h postoperatively. Conclusion Ultrasound-guided TAP block is a good option for providing intra- and postoperative analgesia with no side effects in children undergoing lower abdominal surgeries.

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Objective This is a prospective comparative study between polyetheretherketone (PEEK) cages and dynamic cervical implants (DCI) to evaluate the safety, the effectiveness, and the clinical outcome with radiological outcome for patients with single-level degenerated cervical disc disease treated by anterior cervical discectomy. Patients and methods We studied 30 patients with single-level cervical disc disease. Preoperative evaluation included plain cervical radiography including dynamic views. MRI was carried out to confirm the clinical diagnosis. Results Our study showed that the procedures of two groups were safe and easy without major complications and do not show significant differences between DCI and anterior cervical discectomy and fusion (ACDF) with PEEK cages in terms of improvement in clinical symptoms, blood loss, or operation time; however, DCI was associated with better postoperative neck disability index scores and also resulted in better overall cervical range of motion and segmental range of motion at the treated level than ACDF with PEEK cage. ACDF with PEEK cage is still the gold standard technique for treatment of cervical degenerative disc disease. It improves patient activity and provides a stable segment. However, it fails to restore normal cervical biomechanics and does not prevent adjacent segment disease. Conclusion DCI is considered as a new strategy and an intermediate stage between ACDF and total disc replacement.

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Background Dexmedetomidine is a highly selective (eight time more selective than clonidine), specific, and potent α2-adrenergic agonist having analgesic, sedative, antihypertensive, and anesthetic sparing effects when used in systemic routes. Patients and methods Forty patients of both sexes, aged between 25 and 70 years; American Society of Anesthesiologists I–II, who were submitted to elective upper limb surgery by supraclavicular brachial plexus block were included in the present study. They were selected during the period from March 2016 to June 2017. The patients were divided randomly by sealed envelopes into two equal groups (n=20). Group I: 20 patients received 30 ml bupivacaine 0.25%. Group II: 20 patients received 30 ml bupivacaine 0.25% plus 100 μg dexmedetomidine. Results The duration was reported in group II 13.13±1.10 and 16.50±1.63 min for the onset of sensory and motor blocks, respectively, and in group I 14.90±1.18 and 18.63±1.12 min for the onset of sensory and motor blocks, respectively. There was significant decrease of median pain score in group II when compared with group I at 4, 8, 12, 16, 20, and 24 h postoperatively. Conclusion Dexmedetomidine had significantly better postoperative analgesic effects, longer duration of sensory and motor blockade, and earlier onset of action. However, it had unwanted side effects in the form of transient bradycardia and hypotension.

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Background Polymorphisms in the gene encoding the cytochrome P-450 2C9 enzyme (CYP2C9) are known to contribute to variability in sensitivity to Marevan. CYP2C9 is the enzyme primarily responsible for the metabolic clearance of s-enantiomer of Marevan. The vitamin K epoxide reductase complex 1 (VKORC1) is the target of coumarin anticoagulants, and its common genetic variants result in altered sensitivity to Marevan. VKORC1 polymorphisms are associated with a need for lower doses of Marevan during long-term therapy. Aim of work This study aimed to assess the allelic frequencies and to investigate the relationship between ‘CYP2C9’ and ‘VKORC1’ genotype and vitamin K antagonist anticoagulation. Patients and methods This study was conducted on 40 patients. There were 24 females and 16 males, with a male to female ratio of 2 : 3. Their ages ranged from 28 to 72 years. All the studied patients were laboratory investigated with international normalized ratio, complete blood count, and detection of VKORC1 and CYP2C9 by PCR reverse hybridization method using PGX thrombo strip assay (Vienna Lab.). Results Regarding the distribution of patients according to frequency of deep venous thrombosis (DVT) attacks, 16 (40%) patients showed single attack of DVT and 24 (60%) patients showed recurrent attacks. Patients with single attack of DVT comprised 12 (75%) females and four (25%) males, with male to female ratio of 1 : 3. As for the patients with recurrent attacks of DVT, there were 13 (54.2%) female and 11(45.8%) male patients, with a male to female ratio of 1 : 1.2. Conclusion Detection of genetic polymorphisms in CYP2C9 and VKORC1 genes before onset of warfarin therapy greatly influenced response to warfarin and shortened the time required to reach target international normalized ratio, and hence reduced the risk of recurrence of DVT.

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Background Intravenous regional anesthesia (IVRA) is an old anesthetic technique for surgical procedures on the upper and lower limbs. It is a safe and effective type of anesthesia for hand surgery of 1 h duration or less. There are many modifications of IVRA due to tourniquet pain, and intraoperative and postoperative analgesia. Objective The objective of this study was to assess the effectiveness of lornoxicam and nitroglycerine as adjuvants to lidocaine in IVRA by using single forearm tourniquet in cases of hand surgeries. Patients and methods Seventy-five patients undergoing hand surgeries where randomly classified into three equal groups: group L received 20 ml of lidocaine 1% with 2 ml normal saline; group LL received 20 ml of lidocaine 1% with lornoxicam 8 mg (2 ml); and group LN received 20 ml of lidocaine 1% with nitroglycerine 100 µg (2 ml). Results The onset time of sensory and motor blocks was statistically significantly shorter in the nitroglycerine group (3.2±0.2 and 3.7±0.9 min, respectively) than other groups. The onset time of tourniquet pain was delaying in group LL than other groups. There was statistically significant increase in the duration of postoperative analgesia in group LL (90.35±5.72 min) compared with groups LN (48.55±0.52 min) and L (25.7±2.7 min). There were statistically significant increases in patient and surgeon satisfactions in group LN in comparison with groups LL and L. Conclusion The addition of lornoxicam and nitroglycerine to lidocaine for IVRA improves the speed of onset and the quality of anesthesia, decreases tourniquet pain, and decreases the analgesic requirements during the first 24 h postoperatively without side effects. The addition of lornoxicam to lidocaine was superior in delaying the onset of tourniquet pain and delaying the postoperative analgesia request. The single forearm tourniquet is safe with no obvious side effects.

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Purpose To evaluate the implantation of secondary low-power sulcus piggyback posterior chamber intraocular lenses (PCIOLs) for the correction of unaccepted postoperative refractive surprises or anisometropia. Patients and methods We retrospectively reviewed 17 cases with uncomplicated cataract extraction using phacoemulsification with in-the-bag PCIOL implantation and undesired residual postoperative refractive error. Patients underwent secondary piggyback intraocular lens implantation with add-on monofocal SECURA-sPB through a 3.2-mm clear corneal incision. The primary outcome measure was uncorrected distance visual acuity. Moreover, we evaluated intraoperative or postoperative complications. Results The mean age of patients was 65.2±10.1 years. The mean time to piggyback lens insertion was 6.5±3.1 months, and the mean follow-up period was 14.4±4.6 months. The mean preoperative uncorrected distance visual acuity was 20/80, and it increased significantly to be 20/30 postoperatively (P<0.001). The mean preoperative cylinder was 1.30±0.70 D, and it decreased significantly to be 0.54±0.45 postoperatively (P<0.001). The mean preoperative spherical deviation from emmetropia was 3.4±0.73 D, and the postoperative arithmetic prediction error mean was −0.32±0.55 D. No major intraoperative or postoperative complications were recorded. Conclusion Low-power add-on sulcus PCIOLs provided safe and effective refractive results in pseudophakic patients with refractive surprises.

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Background Brachial plexus block is a regional anesthesia technique for different surgeries in the upper limb. It is useful as a sole regional anesthesia technique or combined with general anesthesia. The adjuvants to local anesthetics may be improving the quality and duration of analgesia of the brachial plexus block. Objective To evaluate the efficacy of nalbuphine and midazolam as adjuvants to bupivacaine in the infraclavicular brachial plexus block. Patients and methods The study was carried out on 70 patients of the American Society of Anesthesiologist, physical status I, II of both sexes, 20–60 years old and scheduled to forearm and hand surgeries. The patients were classified into three equal groups. Group B: using 20 ml of bupivacaine (3 mg/kg) with 1 ml of saline. Group M: using 20 ml of bupivacaine (3 mg/kg) with midazolam 5 mg (1 ml). Group N: using 20 ml of bupivacaine (3 mg/kg) with nalbuphine 1 ml (10 mg). Results The onset time of sensory and motor blocks were significantly shorter in the adjuvant groups N and M compared with group B. There was a significant increase in the duration of postoperative analgesia in group N compared with groups M and B. Conclusion The addition of nalbuphine and midazolam to bupivacaine in the infraclavicular brachial block improves the speed of sensory and motor onset, the quality of anesthesia, and decreases the analgesic requirements during the first 24 h postoperatively without obvious side effects. The addition of nalbuphine to bupivacaine was superior in delaying the postoperative analgesia requirement.

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Aim The aim of this study was to evaluate surgical outcome of pars plana vitrectomy on patients with persistent diffuse diabetic macular edema (dDME) in the presence or absence of complete posterior vitreous detachment (PVD). Patients and methods Pars plana vitrectomy was performed on 37 eyes of 37 patients with dDME. They were divided into two groups: group I consisted of 21 eyes of 21 patients with dDME and attached posterior vitreous face. Group II consisted of 16 eyes of 16 patients with dDME and detached posterior vitreous face. Both visual acuity (VA) as logMAR values and central macular thickness using optical coherence tomography were measured before,1, 3, and 6 months postvitrectomy. Results The baseline VA was 0.8±0.17 and 0.7±0.39 logMAR in groups I and II, respectively. One month after vitrectomy, VA significantly improved to 0.5±0.23 (P=0.002) and to 0.5±0.24 (P=0.015) in groups I and II, respectively. The VA was 0.4±0.13 (P=0.001), 0.5±0.19 (P=0.003) 3 months postvitrectomy and was 0.4±0.25 (P=0.005) and 0.5± 0.22 (P=0.014) after 6 months in groups I and II, respectively. The mean foveal thickness before surgery was 598.6±105.4 and 520.87±103.15 µm in groups I and II, respectively. After 3 months it significantly improved to 235.25±110.2 µm (P=0.0001) and 280.23±112.3 µm (P=0.002), whereas after 6 months it was 220.13±98.15 and 270.62±85.15 µm in groups I and II, respectively. Conclusion Vitrectomy with removal of the posterior hyaloid face and the premacular vitreous pocket may achieve resolution of dDME and improve vision in some patients who failed to respond to conventional treatment. The visual and anatomical outcomes seem to be better in eyes with early stages of diabetic macular edema and good preoperative VA.

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Background Transcranial Doppler detection of microemboli is widely described, and thromboembolism is a major cause of morbidity in patients with prosthetic heart valves. They require lifelong anticoagulation to minimize thrombotic complications. This study was undertaken to assess the clinical relevance of microembolic signals (MESs) and their relation to anticoagulation. Patients and methods Thirty patients with single mitral mechanical prosthetic valve were included. All of them were selected with low intensity of international normalization ratio (INR). After 2-week interval, INR intensities were stabilized to the recommended levels. Transcranial Doppler monitoring for MES detection was done to the same patients, before and after the stabilization of INR intensities. Results Microemboli were detected in 86.7% of patients before and after the INR level adjustment, with mean number of 57.63±13.12 before adjust. The numbers were significantly lowered after the adjustment of INR, as the emboli number became 24.1±9.12. Conclusion Compared with previously thought findings, the study results were different, as there was a significant effect of the anticoagulation on the number of MESs detected in patients with mechanical valve replacement, but without effect in MES incidence, denoting that, there were a variety of MESs rather than thrombotic. Further assessment by MES differentiation to define solid ones will be indicated.

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Background Ischemic heart diseases are considered as the first cause of death around the world. Mesenchymal stem cells are considered to be a novel therapy that can achieve real success in myocardial infarction (MI). Objective Evaluating the homing capability of human umbilical cord blood stem cells (HUCBSCs) in the injured myocardium and its role in the development of MI in adult male rats. Materials and methods Fifty adult male albino rats were divided into five groups (n=10): control, MI, MI pretreated with HUCBSCs, MI posttreated with HUCBSCs within 24 h, and MI posttreated with HUCBSCs within 1 week. Serum cardiac troponin I and creatine kinase-myoglobin binding levels were evaluated to assess MI induction. Gene expression of human β actin gene was assessed to evaluate HUCBSCs homing and rat caspase-3 gene was assessed to evaluate apoptosis. Myocardial histopathological examination was done to assess fibrosis. Echocardiographic left ventricular dimensions and function and mean arterial blood pressure were assessed. Results β actin gene expression was higher in all HUCBSCs injected groups compared with normal and MI groups. Administration of HUCBSCs decreased caspase-3 gene expression and fibrosis and improved cardiac function and mean arterial blood pressure in all HUCBSCs injected groups compared with the MI group and these effects were more in pretreated group than both posttreated groups. Expression of rat caspase-3 gene, histopathological assessment, and echocardiography results showed more improvement in posttreated within 24 h group than posttreated within 1-week group. Conclusion HUCBSCs have high homing capability in injured myocardium and they could be used as a preventive therapy in case of ischemia to protect the heart from implications of MI. Moreover, it could be an effective therapy especially if administered within 24 h after MI. Further studies are recommended to highlight the preventive role of HUCBSCs and its clinical application especially in cases of unstable angina.

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Background Early detection of ovarian cancer is troublesome owing to the obscurity of conspicuous clinical symptoms. Hence, 75% of patients with ovarian cancer usually present and are diagnosed at an advanced stage (International Federation of Gynecology and Obstetrics stage IIIC or IV). Objective This study was conducted to evaluate the surgical and oncological consequences of patients with advanced ovarian cancer (International Federation of Gynecology and Obstetrics III/IV) who were subjected to either primary debulking surgery (PDS) followed by chemotherapy or primary chemotherapy (PC) followed by interval debulking surgery (IDS). Patients and methods We retrospectively reviewed the medical files of patients with advanced ovarian cancer who were admitted to the Surgical Oncology Unit, Bab-Elsharya University Hospital, between September 2008 and October 2013. Patients subjected to PDS succeeded by six cycles of chemotherapy, 6 weeks prior PDS, were enrolled in the PDS group, whereas patients subjected to three cycles of PC followed by IDS were enrolled in the PC-IDS group. Results This study recruited 104 consecutive patients with advanced ovarian cancer who received either PDS (52 participants) or PC-IDS (52 participants). The median overall survival time was 29.3 and 30.1 months in PDS and PC-IDS groups, respectively. Moreover, no significant difference was observed between patients subordinated to PDS (18.2%) and PC-IDS (15.41%) regarding overall survival rates (log-rank test, P=0.273). Conclusion PC-IDS can be an alternative procedure in the management of advanced ovarian cancer owing to not only similar survival rates but also with the advantages relative to PDS regarding postoperative morbidities.

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