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A F Leong

Publications and source records attributed to A F Leong.

At least 19 recordsLinked to original sources
PubMed2000

Postoperative intra-abdominal free gas after open colorectal resection.

PURPOSE: An erect chest radiograph for subdiaphragmatic free gas can be a useful adjunct in detecting a defect in gastrointestinal continuity. The usefulness of this test after laparotomy has not been defined, because the period of persistence of free gas is unknown. We set out to determine the length of time for natural absorption of postlaparotomy pneumoperitoneum in a prospective cohort study. METHOD: Plain erect chest radiographs were performed on the second and fourth postoperative day and daily thereafter until the disappearance of subdiaphragmatic free gas after laparotomy. RESULTS: Seventy-five consecutive patients were studied after informed consent. The mean age was 62.1 (standard error of the mean, 1.7) years. On the fifth postoperative day, sixth postoperative day, and seventh postoperative day, 71.6, 80, and 89 percent of patients, respectively, had no visible subdiaphragmatic gas. Five patients had gas persisting beyond the tenth postoperative day. Two of these patients did not have an anastomosis. The use of drainage tubes did not affect significantly the mean time to disappearance of subdiaphragmatic free gas (4.5 vs. 4.9 days; P = 0.45: t-test). The duration of surgery, body mass index, and time to resume bowel function had no significant effect on gas disappearance. Two patients had a clinical leak on the fifth postoperative day. This was manifested as an increase in the collection of subdiaphragmatic gas during the course of a day. CONCLUSION: By the sixth postoperative day 80 percent of patients had no subdiaphragmatic free gas on an erect chest radiograph regardless of the presence of a drainage tube. The erect chest radiograph may therefore be a simple and readily available adjunct in the evaluation of postoperative abdominal pain, especially after the sixth postoperative day when a similar prior examination is done routinely on the fourth postoperative day for comparison.

Anastomosis, Surgical↗
PubMed2000

Selective total mesorectal excision for rectal cancer.

PURPOSE: Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. METHODS: One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. RESULTS: Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. CONCLUSION: These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.

Adult↗
PubMed2000

Ambulatory manometry in patients with colonic J-pouch and straight coloanal anastomoses: randomized, controlled trial.

PURPOSE: Bowel function after ultralow anterior resection may be improved by a colonic J-pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J-pouch. METHODS: Forty-seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J-pouch was constructed with 6-cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery. RESULTS: Values are expressed below as mean and (standard error of the mean). Patients with colonic J-pouch were found to have less frequent stools (4.6 (0.3) vs. 7.1 (0.9) stools/day; P < 0.05) and stool clustering (35 vs. 63.2 percent; P < 0.05) and were less unlikely to soil when passing flatus (85 vs. 35.3 percent; P < 0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J-pouch group (30.3 (3.7) vs. 18 (2.6) mmHg; P < 0.05). Stool frequency was predicted by the mean rectal pressures (t = 3.368; P = 0.003). However, higher mean rectal pressures were tolerated by the colonic J-pouch for each daily bowel movement (6.7 (0.6) vs. 4.4 (0.5) mmHg/stool; P = 0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3) vs. 26 (2.3) mmHg; P = 0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6-cm colonic J-pouches. CONCLUSIONS: A colonic J-pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow-up.

Adenocarcinoma↗
PubMed1999

Minimizing recurrence after sigmoid volvulus.

BACKGROUND: This study was a retrospective review of a series of patients with sigmoid volvulus to identify risk factors for recurrence and recommend appropriate treatment. METHODS: Thirty-five patients with sigmoid volvulus were treated over 8 years. RESULTS: Six patients had emergency surgery for peritonitis. Twenty-eight of the other 29 patients had successful endoscopic decompression; 15 of these patients had elective surgery during the same admission. Twelve of the 14 patients who refused operation after endoscopic decompression developed recurrent volvulus, a median of 2.8 months later. Eight subsequently agreed to surgery and underwent elective operation following repeat decompression. Of 29 patients who had surgery, 27 had sigmoid colectomy (two were initial Hartmann procedures) and two had subtotal colectomy. Six patients who had sigmoid colectomy developed recurrent volvulus. Concomitant megacolon and megarectum at the time of initial surgery were significant predictors of recurrence. CONCLUSION: Subtotal colectomy, carried out as the primary procedure if there is concomitant megacolon or megarectum, might reduce the risk of recurrent sigmoid volvulus.

Adolescent↗
PubMed1999

Surgery may be curative for patients with a localized perforation of rectal carcinoma.

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.

Adult↗
PubMed1999

Palliative surgery for locally recurrent colorectal cancer.

BACKGROUND: Recurrent colorectal cancer carries a poor prognosis. Radical re-resection is the only chance for long-term survival but suitable candidates are few. AIM: To determine the patterns of recurrence after potentially curative colorectal surgery and analyse the results of palliative surgery for patients with local recurrence. METHODS AND RESULTS: Between May 1989 and May 1995, 1,287 case records of patients with colorectal carcinoma were entered into a customized computer database. Of these, 1,103 underwent potentially curative resections (Duke's stage A, B and C). At a median of 40 months (range 2-72) following surgery, 173 patients had recurrent disease detected (98 males; 75 females) at a median of 14 months (range 3-30) after the index surgery. Twelve percent had recurrent distal and locoregional disease while 6.8% had locoregional recurrent disease alone. Thirty-seven patients with locally recurrent disease underwent surgery. Of these, only 7 patients with local recurrences were suitable candidates for resections. The remaining 30 underwent palliative surgery for emergent indications of obstruction (28) and bleeding (2). The symptoms were palliated surgically by an entero-enterostomy (13), defunctioning stoma (12), lysis of adhesions (1), exploratory celiotomy (2) and formalin application (2). Seventeen patients are alive at follow-up. Twenty patients died at a median of 4 months after surgery (range 1-15). All patients had palliation of their symptoms. CONCLUSION: Low incidences of local recurrences can be achieved after potentially curative resections for colorectal carcinoma. When recurrences occur, a small number can be salvaged with a re-resection which is the procedure of choice. Palliative procedures for emergent indications of obstruction and bleeding can give good palliation despite the absence of the possibility of cure.

Adolescent↗
PubMed1999

Stoma management in a tropical country: colostomy irrigation versus natural evacuation.

People with ostomies in Singapore were initially resistant to colostomy irrigation. This study, a prospective crossover study of 26 patients who underwent abdominoperineal resection, compared colostomy irrigation with the natural evacuation method. During the colostomy-irrigation phase of the study, all 26 patients reported an improvement in continence and fewer problems with sleep, sex, and skin complications compared to the natural-evacuation phase. The study also found a reduction in monthly expenses with colostomy irrigation compared to natural evacuation. Patient satisfaction scores were also superior during the colostomy-irrigation phase. This difference in satisfaction scores was less marked in those who were more than 1-year postsurgery than in those who were less than 1-year postsurgery. The difference in satisfaction between colostomy irrigation and natural evacuation scores was statistically significant in the group that was less than 1-year postsurgery, but not in the group that was more than 1-year postsurgery. The study concluded that colostomy irrigation after abdominoperineal resection is superior to natural evacuation in terms of cost and patient satisfaction and should be introduced soon after surgery.

Adult↗
PubMed1998

Clinical outcome and bowel function following total abdominal colectomy and ileorectal anastomosis in the Oriental population.

UNLABELLED: Total abdominal colectomy with ileorectal anastomosis is a commonly performed surgical procedure. The postoperative outcome of these patients, however, has not been studied in detail in the Asian population. AIM: The purpose of this study was to analyze the functional outcome of patients following total abdominal colectomy and ileorectal anastomosis. METHOD: All patients subjected to a total abdominal colectomy with ileorectal anastomosis during a six-year period from February 1989 to October 1995 were reviewed. RESULTS: Sixty-six patients (male:female, 40:26) with a mean age of 55.2 (range, 20-88) years underwent total abdominal colectomy with ileorectal anastomosis. Median follow-up after surgery was 26 (range, 4-78) months. Indications for surgery were synchronous or metachronous tumors (18), complicated pancolonic diverticular disease (15), obstructed tumors with impending perforation (13), familial adenomatous polyposis (7), slow-transit constipation (6), and others (7). Mean operative time was 137 +/- 48 minutes. Mean postoperative hospitalization was 13.3 +/- 11.9 days. Time to first bowel movement and commencement of solid diet were 4.7 +/- 1.8 and 7.2 +/- 2.4 days, respectively. Four patients had prolonged postoperative ileus. Average stool frequencies per day were 5.5 at one week, 4.3 at one month, 3.9 at six months, 3.2 at one year, and 2.9 at two years postoperatively. Thirty-three patients (50 percent) required antidiarrheal treatment for a transient period, but none required long-term therapy. Ninety-seven percent of all patients rated the functional outcome as good to excellent, and 3 percent said it was fair. There was two perioperative mortalities. Five cases required re-laparotomy, three for anastomotic complications and two for hemoperitoneum. Five patients had recurrent admissions for adhesion colic, which resolved with nonsurgical therapy. Ten patients succumbed on follow-up, six to tumor recurrence, two to unrelated cancers (stomach and bladder), and three to medical conditions. CONCLUSION: The functional outcome of ileorectal anastomosis is generally rated as good to excellent by patients. Acceptable bowel function and control is regained within six months of the operation and levels off at one year after surgery, and no patient requires long-term antidiarrheal medication.

Adenomatous Polyposis Coli↗
PubMed1998

Diminutive cancers of the colon and rectum: comparison between flat and polypoid cancers.

A comparative study of polypoid and flat colorectal cancers less than 20 mm in size was made. A review of the characteristics of 56 polypoid cancers and 29 flat cancers treated between April 1989 and January 1996 was performed. Both groups of cancers showed similar age and location distribution. Polypoid cancers were more likely to be well differentiated (38%) than were flat cancers (17%) (P < 0.05). Flat cancers were more likely to have reached the serosa (52% vs 12%; P < 0.01) and also demonstrated a higher frequency of lymph node involvement (41% vs p 9%) (P < 0.01) when compared to polypoid cancers. Flat colorectal cancers belong to a distinct subset which demonstrates greater biological aggressiveness than polypoid cancers of equivalent size.

Aged↗
PubMed1998

Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial.

BACKGROUND: Marsupialization of anal fistulotomy wounds leaves less raw unepithelialized tissue to granulate and may improve wound healing. METHODS: Some 103 consecutive patients with uncomplicated intersphincteric or trans-sphincteric fistula in ano were recruited into a randomized controlled trial. Fistula tracts were identified and laid open under general anaesthesia. The patients were randomized to have either the wounds left open (LO group) or wound edges marsupialized to the fistula tract with interrupted absorbable sutures (MS group). Anal manometry was performed before operation, and 6 weeks and 3 months after surgery. RESULTS: Some 52 patients were randomized to the LO group and 51 to the MS group. There were no differences in the age, sex, fistula type and fistula length distribution between the groups. Mean follow-up times were 9 and 10.2 months respectively. Wounds in the MS group healed faster (mean(s.e.m.) 6.0 (0.4) weeks) than those in the LO group (10.0(0.5) weeks) (P < 0.001). Only one patient (2 per cent) in the MS group was incontinent of liquids after operation compared with six (12 per cent) in the LO group. There was less impairment in maximum anal squeeze pressure at 3 months after marsupialization compared with leaving fistulotomy wounds open (P < 0.05). Apart from a slightly longer operative time required for marsupialization, the hospitalization and complication rates were the same. CONCLUSION: Anal fistulotomy wounds healed faster after marsupialization. Anal squeeze pressures were better preserved and this may improve anal continence.

Adult↗
PubMed1998

Young age is not a poor prognostic marker in colorectal cancer.

BACKGROUND: There is still considerable controversy and debate regarding the features and prognosis of colorectal cancer in young patients. METHODS: One hundred and ten patients (5.1 per cent) under the age of 40 years with colorectal cancer (group Y; male: female ratio 48:62) were compared with 2064 patients with colorectal cancer aged 40 years or more (group O; 917 women, 1147 men). Mode of presentation, stage at diagnosis, tumour characteristics and survival were analysed. RESULTS: Predisposing malignant conditions and family history of colorectal cancer were present in 20.9 per cent of patients in group Y versus 2.2 per cent in group O (P < 0.001). Common chief complaints included change in bowel habits, bleeding from the rectum and a significantly higher incidence of abdominal pain in group Y. There was no difference in stage at presentation between the two groups (the proportion of Dukes stage A, B, C and 'D' lesions in group Y was 8.2, 24.5, 37.3 and 30.0 per cent respectively versus 10.5, 27.9, 33.4 and 28.1 per cent in group O). Tumour site and characteristics were similar in both groups. The incidence of mucinous/signet ring cell and poor grade tumours was 6.9 and 11.8 per cent respectively in group Y and 4.5 and 10.5 per cent in group O. With a mean follow-up of 31.8 months, the overall 5-year survival rate was 54.8 per cent in group Y and 54.1 per cent in group O. Comparing stage for stage, survival was not significantly different in the two groups. However, the adjusted hazard ratios of the age groups Y, M (40-59 years), S (60-79 years), and E (80 years and above) were 1.3, 1 (baseline for calculations), 1.4 and 2.4 respectively, suggesting an adverse outcome for patients in group Y compared with patients aged 40-59 years. CONCLUSION: This study revealed no difference in tumour characteristics and survival in patients with colorectal cancer aged less than 40 years compared with those aged above 40 years. However, a higher hazard ratio in the youngest group may connote a worse prognosis than that for those aged 40-59 years. A significant family history of colorectal cancer and predisposing conditions in the young warrants aggressive screening, surveillance and treatment of the underlying conditions. The detection of colorectal cancer in young patients should be no different from that in the old but demands a high index of suspicion.

Adult↗
PubMed1998

Management of colonic lipomas.

BACKGROUND: Little is known of colonic lipomas, especially in an Asian population, and their management is controversial. METHODS: A computerized colonoscopy database was analysed and patients with colonic lipomas were reviewed. RESULTS: There were 16 colonic lipomas (incidence of 0.15%) in a series of 10658 consecutive colonoscopies. There were seven men and nine women, with a mean age of 61.8 years (range: 28-80 years). The size of the lipomas ranged from 1.5 to 6 cm; all those larger than 3.5 cm were symptomatic (P = 0.05). The most common symptom was mild bleeding per rectum. Right-sided lipomas were palpable while left-sided lipomas presented with obstructive symptoms. Colonoscopic removal by hot biopsy or snare polypectomy was possible where the lipomas were 2.5 cm and pedunculated. Surgery was performed in six patients (four open, two laparoscopic) for symptoms and to exclude malignancy. There was no morbidity or mortality. CONCLUSIONS: Small or pedunculated lipomas may be safely removed colonoscopically and the diagnosis confirmed histologically. Larger lipomas require surgical resection for relief of symptoms or to exclude malignancy.

Adult↗
PubMed1998

Local recurrence following rectal resection for cancer.

Recurrent rectal carcinoma following surgery carries an extremely poor prognosis and subsequent intervention is usually palliative. The incidence of local recurrence (LR) following curative surgery for rectal cancer has been reported to range from 3.7 to 50%. Current treatment strategy for rectal cancer aims at minimizing LR by either pre-operative radiotherapy or adjuvant chemoradiotherapy. Three hundred and fifty-four patients underwent surgical resection for rectal cancer in our department between April 1989 and March 1994, of which 47 (13%) were Dukes A, 88 (25%) Dukes B, 143 (40%) Dukes C and 76 (22%) Dukes D. Two hundred and seventy-eight (79%) patients were defined as having had curative resection (Dukes A, B and C). Overall, total LR occurred in 43 (12.2%) of 354 patients, while LR following curative resection occurred in 16 (9.4%) of the 278 patients. The incidence of LR became higher with increasing depth of invasion and lymph nodal involvement as shown by its direct relationship to stage of disease: Dukes A (0%), B (5.7%), C (14.6%) and D (22.3%). Local recurrence following resection for rectal cancer in our series is low. Pre-operative radiotherapy or adjuvant chemoradiotherapy may not further reduce this low incidence of LR significantly and its role needs to be re-evaluated for institutions with low local recurrence rates.

Adult↗
PubMed1997

Hartmann's procedure vs. abdominoperineal resection for palliation of advanced low rectal cancer.

UNLABELLED: In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmann's procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmann's procedure vs. abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4-8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6 +/- 10.3 years) had Hartmann's procedure, and 26 patients (12 females; mean age, 68.8 +/- 8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (+/-17.5) and 18.6 months (+/-12.9) in Hartmann's procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4 +/- 26.7 minutes for Hartmann's procedure group and 124.6 +/- 27.1 minutes for the abdominoperineal resection group (P > 0.05; not significant). Postoperatively, Hartmann's procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmann's procedure group was ambulant after a mean of 2.4 days vs. a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmann's procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmann's procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmann's procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.

Abdomen↗
PubMed1997

Biofeedback is effective treatment for levator ani syndrome.

PURPOSE: The effects of biofeedback (BF) on pain relief and anorectal physiology in patients with levator ani syndrome (LAS) were prospectively studied. METHOD: Sixteen consecutive patients (9 men, 7 women; mean age, 50.1 (range, 39-66) years) with LAS were treated with BF from July 1993 to October 1995. Mean duration of pain was 32.5 (standard error of the mean, 6.7) months. All underwent a full course of BF using a manometric balloon technique. Mean follow-up was 12.8 (standard error of the mean, 2.6) months. Pain score and anorectal physiology tests were administered prospectively by an independent observer before and after BF. RESULTS: After BF, the pain score was significantly improved (before BF: median, 8 (range, 6-10); after BF: median, 2 (range, 1-4); P < 0.02). Analgesic requirements were also significantly reduced (all 16 patients needed nonsteroidal anti-inflammatory drugs (NSAID) before BF; only two patients needed NSAID after BF; P < 0.03). There were no significant changes to the anorectal physiology parameters after BF. To date, there have been no side effects or regressions. CONCLUSION: Although BF had a negligible effect on anorectal physiologic measurements in LAS, it was effective in pain relief, with no side effects.

Anal Canal↗
PubMed1997

A preliminary comparison of a consecutive series of open versus laparoscopic abdomino-perineal resection for rectal adenocarcinoma.

AIM: To compare a consecutive series of patients who underwent laparoscopic abdomino-perineal resection (LAPR) versus conventional open abdomino-perineal resection (CAPR). MATERIAL AND METHODS: Sixteen patients (8 females) and 11 patients (4 females) underwent LAPR and CAPR respectively. RESULTS: The median operative time was 110 (65-210) mins and 100 (80-185) mins for LAPR and CAPR respectively (P = 0.43). The median amount of blood loss were 200 (100-1000) mls and 100 (60-800) mls for LAPR and CAPR respectively. There was no significant difference in the need for post operative analgesics and time to first stoma function but the LAPR group showed significant improvement in starting fluids, diet, ambulation and discharge from hospital. CONCLUSION: The laparoscopic technique may be an acceptable alternative to conventional abdomino-perineal resection for the patient requiring anal resection for rectal cancer.

Abdomen↗
PubMed1997

Randomized controlled trial of open and closed haemorrhoidectomy.

BACKGROUND: This study was a prospective randomized comparison of healing following open and closed haemorrhoidectomy. METHODS: Sixty-seven consecutive patients (mean(s.e.m.) age 45(1.7) years; 35 men, 32 women) with three prolapsed piles were randomized to open haemorrhoidectomy (n = 34) or closed haemorrhoidectomy (n = 33). RESULTS: Mean(s.e.m.) follow-up was 8.7(0.2) months. There were no differences in the linear analogue pain scores, analgesic requirements and length of hospitalization after open haemorrhoidectomy and closed haemorrhoidectomy. Complete wound healing took significantly longer after closed haemorrhoidectomy (mean(s.e.m.) 6.9(0.7) weeks) compared with open haemorrhoidectomy (4.9(0.4)weeks) (P < 0.05). This was related to wound dehiscence in eight patients. Complication rates, however, were similar except for prolonged serous discharge from unhealed wounds. The anal manometry findings after both procedures were equivalent. CONCLUSION: Open haemorrhoidectomy leads to faster and more reliable wound healing, although this did not result in less pain or fewer complications.

Female↗