Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Conservative treatment of uterine fistula with abdominal abscess after caesarean section S. Y. Han, K. J. Ryu, K. H. Ahn, S. B. Cho, C. H. Lee & S. C. Hong To cite this article: S. Y. Han, K. J. Ryu, K. H. Ahn, S. B. Cho, C. H. Lee & S. C. Hong (2015) Conservative treatment of uterine fistula with abdominal abscess after caesarean section, Journal of Obstetrics and Gynaecology, 35:6, 650-651, DOI: 10.3109/01443615.2014.987115 To link to this article: http://dx.doi.org/10.3109/01443615.2014.987115
Published online: 11 Dec 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Lethbridge]
Date: 08 October 2015, At: 18:46
Journal of Obstetrics and Gynaecology, August 2015; 35: 650–657 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORTS
Conservative treatment of uterine fistula with abdominal abscess after caesarean section S. Y. Han1, K. J. Ryu1, K. H. Ahn1, S. B. Cho2, C. H. Lee3 & S. C. Hong1 1Department of Obstetrics and Gynecology, College of Medicine,
Downloaded by [University of Lethbridge] at 18:46 08 October 2015
Korea University, Seoul, Republic of Korea, 2Department of Radiology, College of Medicine, Korea University, Seoul, Republic of Korea, and 3Department of Science, University of Manitoba, Winnipeg, MB, Canada DOI: 10.3109/01443615.2014.987115 Correspondence: Soon-Cheol Hong, MD, PhD, Department of Obstetrics and Gynecology, Korea University Medical Center, Inchon-ro 73, Seongbuk-gu, Seoul 136-705, Republic of Korea. Tel: 82 2 920 6602. Fax: 82 2 921 5357. E-mail: [email protected]
Introduction
The incidence of caesarean sections, one of the most common surgical procedures performed worldwide, has recently increased (Betran et al. 2007). Commonly reported complications of caesarean sections are post-partum haemorrhage, febrile morbidity, and infections, including endometritis and abscesses (Thigpen et al. 2005). Although rare, pelvic abscesses occur more frequently after caesarean section than after vaginal delivery and are serious complications. Post-operative pelvic abscesses often require treatment by laparotomy to prevent further complications (Gedikbasi et al. 2008). Delayed or inadequate treatment can cause abscess rupture, possibly followed by septic shock and mortality (Cho 2008). Laparotomy can also be useful for managing caesarean section complications, including uterine fistula with abscess formation (Klemm et al. 2005). Herein, we present a case of uterine fistula with abdominal abscess after a caesarean section successfully managed by conservative treatment with ultrasound-guided pigtail catheter insertion.
Case report
A 36-year-old obese woman (body mass index, 38.2 kg/m2) in her second pregnancy (gravida 2, para 1) was admitted to the Korea University Medical Center at 37 weeks’ and 5 days’ gestation with pre-eclampsia. She had developed gestational diabetes mellitus (GDM) that was controlled with insulin. She had history of a caesarean section because of progress failure. A caesarean section was performed at 38 weeks’ gestation, and a female baby, weighing 4,500 g, was delivered with adequate Apgar scores. Skin testing revealed that the patient was allergic to betalactam antibiotics; therefore, antibiotic prophylaxis was delayed until consultation with our Department of Infectious Diseases. Thus, the patient did not receive antibiotics until post-operative day 1. On post-operative day 2, the patient presented a body temperature of 38°C until the next day. Concurrently, the patient acquired contact dermatitis with a superimposed infection that required treatment with continuous intravenous dexamethasone. Laboratory data were as follows: white blood cell count, 11,900 cells/mm3; C-reactive protein level, 126.0 mg/dL; and erythrocyte sedimentation rate, 25 mm/h. Vancomycin was administered after blood culture was performed. On post-operative day 5, the patient’s symptoms exacerbated. Since a drug eruption could not be ruled out, the antibiotic was switched from vancomycin to ertapenem (MSD, NJ, USA). On post-operative
Figure 1. (a) Computed tomographic scan showing fistula formation (white arrow) with abdominal abscess; (b) tubography shows leakage of dye from the abscess pocket into the vagina through the uterine fistula (black arrow); (c) Eleven days after drainage catheter insertion. Computed tomographic scan shows marked decrease in the abscess pocket size in lower abdomen. The fistulous tract cannot be distinguished.
day 12, her symptoms subsided and laboratory values returned to the normal range. The patient was discharged with administration of oral antibiotics. Three days later, she visited the outpatient clinic reporting a puslike vaginal discharge. Ultrasonography (US) evaluation showed a
Downloaded by [University of Lethbridge] at 18:46 08 October 2015
Gynaecology Case Reports 651 suspected abdominal abscess with uterine fistula. After admission, computed tomography showed fluid collection and abscess in the lower abdomen with a uterine fistula (Figure 1a). The initial size of the abscess was 23.5 8 8 cm3 on computed tomography. No other symptoms were reported and we chose to perform a minimally invasive treatment instead of laparotomy. Using US, a 10-French pigtail catheter was inserted to drain the abscess. A fistula, extending from the abscess pocket to the inside of the uterus, was detected during tubography by leakage of dye into the vagina (Figure 1b). Bacterial culture was positive for Enterococcus faecalis. Despite confirmation of the fistula, we continued conservative management. The catheter was maintained in place during 12 days with continuous antimicrobial therapy. This resulted in a marked reduction of the abscess pocket size and spontaneous closure of the fistula (Figures 1c).
Nielsen TF, Hokegard KH. 1983. Postoperative cesarean section morbidity: a prospective study. American Journal of Obstetrics and Gynecology 146:911–916. Thigpen BD, Hood WA, Chauhan S, Bufkin L, Bofill J, Magann E, Morrison JC. 2005. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. American Journal of Obstetrics and Gynecology 192:1864–1868; discussion 1868–1871. Tita AT, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW. 2009. Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstetrics & Gynecology 113:675–682.
Discussion
Soreng Pratibha & Bagai Rajni
Although caesarean sections decrease the rates of peri-natal mortality and morbidity, they are associated with increased incidence of postpartum maternal morbidity (Nielsen and Hokegard 1983). Surgical wound infections occur in 3% of patients undergoing caesarean sections, and pelvic abscesses occur in 2% (Jaiyeoba 2012). Prophylactic antibiotics reduce the risk of infection by 50% (Tita et al. 2009). In this case, the patient had several risk factors for post-operative complications, such as GDM, obesity, pre-eclampsia, delayed antibiotic prophylaxis and continuous intravenous dexamethasone treatment. Intravenous antibiotic treatment alone is successful in 34–87.5% of patients with pelvic abscesses (McNeeley et al. 1998), and surgical drainage is a critical part of treatment (Jaiyeoba 2012). Because of the risk of septic shock and mortality secondary to abscess rupture, laparotomy is usually performed (Gedikbasi et al. 2008). Recently, percutaneous drainage also can be considered as the treatment for abdominal abscess, especially for patients deemed unsuitable for surgery. However, surgical treatment is mainly the initial treatment in cases of complex abscesses with multiple locules, with inaccessible locations, or those complicated with fistula formation or dehiscence of the suture site (Gervais and Dawson 2006). In this case, the patient had considerable physiological burdens to undergo surgical re-intervention and general anaesthesia within such a short interval, particularly because of her underlying comorbidities: GDM, obesity and gestational hypertension. Although the case was complicated by fistula formation between the uterus and abscess, which led to uterine dehiscence, we chose percutaneous drainage with continuous antimicrobial therapy as the initial treatment rather than prompt surgery. This treatment resulted in a complete recovery without laparotomy. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References
Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. 2007. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 21:98–113. Cho FN. 2008. Iatrogenic abscess at uterine incision site after cesarean section: sonographic monitoring. Journal of Clinical Ultrasound 36:381–383. Gervais DA, Dawson SL. 2006. Percutaneous treatment of abdominal abscesses. In: Baum S, Pentecost MJ, editors Abrams’ angiography interventional radiology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; p. 1069–1073. Gedikbasi A, Akyol A, Asar E, Bingol B, Uncu R, Sargin A, Ceylan Y. 2008. Re-laparotomy after cesarean section: operative complications in surgical delivery. Archives of Gynecology and Obstetrics 278:419–425. Jaiyeoba O. 2012. Postoperative infections in obstetrics and gynecology. Clinical Obstetrics & Gynecology 55:904–913. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. 2005. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. Journal of Perinatal Medicine 33:324–331. McNeeley SG, Hendrix SL, Mazzoni MM, Kmak DC, Ransom SB. 1998. Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess. American Journal of Obstetrics and Gynecology 178: 1272–1278.
Uterocutaneous fistula following septic abortion: Can it heal without major surgical intervention? Department of Obstetrics and Gynecology, Tata Motors Hospital, Telco Colony, Kharangajhar, Jamshedpur, Jharkhand, India DOI: 10.3109/01443615.2014.989822 Correspondence: Dr. Pratibha Soreng, Specialist (Obs and Gynae), Tata Motors Hospital, Jamshedpur, 831004 Jharkhand, India. E-mail: drpratibha.soreng@ gmail.com
Introduction
Uterocutaneous fistula is an abnormal communication of skin surface with the uterine cavity. This is a rare condition and was first reported in the medical literature following septic abortion (Gupta et al. 1993). There are two more reports of management of uterocutaneous fistula, following septic abortion (Okoro and Onwere 2008; Sönmezer et al. 2009). These reports suggest major surgery (excision of fistulous tract) as the treatment to cure the patient. We report a unique case of uterocutaneous fistula which developed during the hospital stay following a laparotomy for treatment of peritonitis as a result of septic abortion. Removal of the underlying cause without a major surgical intervention cured the patient.
Case report
A 23-year-old unmarried woman after an amenorrhoea of four months, with the help of an untrained village health worker attempted an induced abortion by inserting an abortifacient (unknown) per vagina. Some conceptus was aborted, but as she developed fever and foul-smelling blood-stained discharge she visited a local doctor and was admitted there for 1 week and received antibiotics. When her condition did not improve she was brought to our hospital for further management. Patient complained of pain lower abdomen, fever and vomiting. On examination, she had features of peritonitis, with fever (38.6°C), tachycardia (102/min), abdominal distension, tenderness, guarding and rigidity over lower abdomen. A speculum examination revealed a foul-smelling blood-stained discharge. Her haemoglobin level was 8 gm% and she had a total leucocyte count of 14000/cu mm. A diagnosis of septic abortion with pelvic peritonitis was made. After initial stabilisation and blood transfusion, a laparotomy was performed through a lower midline incision. At laparotomy, the pelvis was filled with pus, with omentum adherent to pelvic structures. Uterus had a size of around 14 weeks’ gestation with a rent of approximately 2 cm with ragged margins on the right postero-lateral surface of the fundus. Products of conception were removed through the rent, and repair of the uterus was done. Patient continued to have fever in the immediate post-operative period which subsided with a change to appropriate antibiotics. Abdominal stitches were removed on 10th post-operative day but the wound was infected and gaped up to the rectus sheath. With aggressive supervised wound care, a secondary suturing was done after 5 days. Three days later, a discharge was noted from the middle of the wound. Proper wound care was done but on removal of secondary sutures on the 7th day, a 4-mm gap in the middle was noted through which pus was draining, rest of the wound had healed well. On irriga-
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Conservative treatment of uterine fistula with abdominal abscess after caesarean section S. Y. Han, K. J. Ryu, K. H. Ahn, S. B. Cho, C. H. Lee & S. C. Hong To cite this article: S. Y. Han, K. J. Ryu, K. H. Ahn, S. B. Cho, C. H. Lee & S. C. Hong (2015) Conservative treatment of uterine fistula with abdominal abscess after caesarean section, Journal of Obstetrics and Gynaecology, 35:6, 650-651, DOI: 10.3109/01443615.2014.987115 To link to this article: http://dx.doi.org/10.3109/01443615.2014.987115
Published online: 11 Dec 2014.
Submit your article to this journal
Article views: 13
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Lethbridge]
Date: 08 October 2015, At: 18:46
Journal of Obstetrics and Gynaecology, August 2015; 35: 650–657 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORTS
Conservative treatment of uterine fistula with abdominal abscess after caesarean section S. Y. Han1, K. J. Ryu1, K. H. Ahn1, S. B. Cho2, C. H. Lee3 & S. C. Hong1 1Department of Obstetrics and Gynecology, College of Medicine,
Downloaded by [University of Lethbridge] at 18:46 08 October 2015
Korea University, Seoul, Republic of Korea, 2Department of Radiology, College of Medicine, Korea University, Seoul, Republic of Korea, and 3Department of Science, University of Manitoba, Winnipeg, MB, Canada DOI: 10.3109/01443615.2014.987115 Correspondence: Soon-Cheol Hong, MD, PhD, Department of Obstetrics and Gynecology, Korea University Medical Center, Inchon-ro 73, Seongbuk-gu, Seoul 136-705, Republic of Korea. Tel: 82 2 920 6602. Fax: 82 2 921 5357. E-mail: [email protected]
Introduction
The incidence of caesarean sections, one of the most common surgical procedures performed worldwide, has recently increased (Betran et al. 2007). Commonly reported complications of caesarean sections are post-partum haemorrhage, febrile morbidity, and infections, including endometritis and abscesses (Thigpen et al. 2005). Although rare, pelvic abscesses occur more frequently after caesarean section than after vaginal delivery and are serious complications. Post-operative pelvic abscesses often require treatment by laparotomy to prevent further complications (Gedikbasi et al. 2008). Delayed or inadequate treatment can cause abscess rupture, possibly followed by septic shock and mortality (Cho 2008). Laparotomy can also be useful for managing caesarean section complications, including uterine fistula with abscess formation (Klemm et al. 2005). Herein, we present a case of uterine fistula with abdominal abscess after a caesarean section successfully managed by conservative treatment with ultrasound-guided pigtail catheter insertion.
Case report
A 36-year-old obese woman (body mass index, 38.2 kg/m2) in her second pregnancy (gravida 2, para 1) was admitted to the Korea University Medical Center at 37 weeks’ and 5 days’ gestation with pre-eclampsia. She had developed gestational diabetes mellitus (GDM) that was controlled with insulin. She had history of a caesarean section because of progress failure. A caesarean section was performed at 38 weeks’ gestation, and a female baby, weighing 4,500 g, was delivered with adequate Apgar scores. Skin testing revealed that the patient was allergic to betalactam antibiotics; therefore, antibiotic prophylaxis was delayed until consultation with our Department of Infectious Diseases. Thus, the patient did not receive antibiotics until post-operative day 1. On post-operative day 2, the patient presented a body temperature of 38°C until the next day. Concurrently, the patient acquired contact dermatitis with a superimposed infection that required treatment with continuous intravenous dexamethasone. Laboratory data were as follows: white blood cell count, 11,900 cells/mm3; C-reactive protein level, 126.0 mg/dL; and erythrocyte sedimentation rate, 25 mm/h. Vancomycin was administered after blood culture was performed. On post-operative day 5, the patient’s symptoms exacerbated. Since a drug eruption could not be ruled out, the antibiotic was switched from vancomycin to ertapenem (MSD, NJ, USA). On post-operative
Figure 1. (a) Computed tomographic scan showing fistula formation (white arrow) with abdominal abscess; (b) tubography shows leakage of dye from the abscess pocket into the vagina through the uterine fistula (black arrow); (c) Eleven days after drainage catheter insertion. Computed tomographic scan shows marked decrease in the abscess pocket size in lower abdomen. The fistulous tract cannot be distinguished.
day 12, her symptoms subsided and laboratory values returned to the normal range. The patient was discharged with administration of oral antibiotics. Three days later, she visited the outpatient clinic reporting a puslike vaginal discharge. Ultrasonography (US) evaluation showed a
Downloaded by [University of Lethbridge] at 18:46 08 October 2015
Gynaecology Case Reports 651 suspected abdominal abscess with uterine fistula. After admission, computed tomography showed fluid collection and abscess in the lower abdomen with a uterine fistula (Figure 1a). The initial size of the abscess was 23.5 8 8 cm3 on computed tomography. No other symptoms were reported and we chose to perform a minimally invasive treatment instead of laparotomy. Using US, a 10-French pigtail catheter was inserted to drain the abscess. A fistula, extending from the abscess pocket to the inside of the uterus, was detected during tubography by leakage of dye into the vagina (Figure 1b). Bacterial culture was positive for Enterococcus faecalis. Despite confirmation of the fistula, we continued conservative management. The catheter was maintained in place during 12 days with continuous antimicrobial therapy. This resulted in a marked reduction of the abscess pocket size and spontaneous closure of the fistula (Figures 1c).
Nielsen TF, Hokegard KH. 1983. Postoperative cesarean section morbidity: a prospective study. American Journal of Obstetrics and Gynecology 146:911–916. Thigpen BD, Hood WA, Chauhan S, Bufkin L, Bofill J, Magann E, Morrison JC. 2005. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. American Journal of Obstetrics and Gynecology 192:1864–1868; discussion 1868–1871. Tita AT, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW. 2009. Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstetrics & Gynecology 113:675–682.
Discussion
Soreng Pratibha & Bagai Rajni
Although caesarean sections decrease the rates of peri-natal mortality and morbidity, they are associated with increased incidence of postpartum maternal morbidity (Nielsen and Hokegard 1983). Surgical wound infections occur in 3% of patients undergoing caesarean sections, and pelvic abscesses occur in 2% (Jaiyeoba 2012). Prophylactic antibiotics reduce the risk of infection by 50% (Tita et al. 2009). In this case, the patient had several risk factors for post-operative complications, such as GDM, obesity, pre-eclampsia, delayed antibiotic prophylaxis and continuous intravenous dexamethasone treatment. Intravenous antibiotic treatment alone is successful in 34–87.5% of patients with pelvic abscesses (McNeeley et al. 1998), and surgical drainage is a critical part of treatment (Jaiyeoba 2012). Because of the risk of septic shock and mortality secondary to abscess rupture, laparotomy is usually performed (Gedikbasi et al. 2008). Recently, percutaneous drainage also can be considered as the treatment for abdominal abscess, especially for patients deemed unsuitable for surgery. However, surgical treatment is mainly the initial treatment in cases of complex abscesses with multiple locules, with inaccessible locations, or those complicated with fistula formation or dehiscence of the suture site (Gervais and Dawson 2006). In this case, the patient had considerable physiological burdens to undergo surgical re-intervention and general anaesthesia within such a short interval, particularly because of her underlying comorbidities: GDM, obesity and gestational hypertension. Although the case was complicated by fistula formation between the uterus and abscess, which led to uterine dehiscence, we chose percutaneous drainage with continuous antimicrobial therapy as the initial treatment rather than prompt surgery. This treatment resulted in a complete recovery without laparotomy. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References
Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. 2007. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 21:98–113. Cho FN. 2008. Iatrogenic abscess at uterine incision site after cesarean section: sonographic monitoring. Journal of Clinical Ultrasound 36:381–383. Gervais DA, Dawson SL. 2006. Percutaneous treatment of abdominal abscesses. In: Baum S, Pentecost MJ, editors Abrams’ angiography interventional radiology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; p. 1069–1073. Gedikbasi A, Akyol A, Asar E, Bingol B, Uncu R, Sargin A, Ceylan Y. 2008. Re-laparotomy after cesarean section: operative complications in surgical delivery. Archives of Gynecology and Obstetrics 278:419–425. Jaiyeoba O. 2012. Postoperative infections in obstetrics and gynecology. Clinical Obstetrics & Gynecology 55:904–913. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. 2005. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. Journal of Perinatal Medicine 33:324–331. McNeeley SG, Hendrix SL, Mazzoni MM, Kmak DC, Ransom SB. 1998. Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess. American Journal of Obstetrics and Gynecology 178: 1272–1278.
Uterocutaneous fistula following septic abortion: Can it heal without major surgical intervention? Department of Obstetrics and Gynecology, Tata Motors Hospital, Telco Colony, Kharangajhar, Jamshedpur, Jharkhand, India DOI: 10.3109/01443615.2014.989822 Correspondence: Dr. Pratibha Soreng, Specialist (Obs and Gynae), Tata Motors Hospital, Jamshedpur, 831004 Jharkhand, India. E-mail: drpratibha.soreng@ gmail.com
Introduction
Uterocutaneous fistula is an abnormal communication of skin surface with the uterine cavity. This is a rare condition and was first reported in the medical literature following septic abortion (Gupta et al. 1993). There are two more reports of management of uterocutaneous fistula, following septic abortion (Okoro and Onwere 2008; Sönmezer et al. 2009). These reports suggest major surgery (excision of fistulous tract) as the treatment to cure the patient. We report a unique case of uterocutaneous fistula which developed during the hospital stay following a laparotomy for treatment of peritonitis as a result of septic abortion. Removal of the underlying cause without a major surgical intervention cured the patient.
Case report
A 23-year-old unmarried woman after an amenorrhoea of four months, with the help of an untrained village health worker attempted an induced abortion by inserting an abortifacient (unknown) per vagina. Some conceptus was aborted, but as she developed fever and foul-smelling blood-stained discharge she visited a local doctor and was admitted there for 1 week and received antibiotics. When her condition did not improve she was brought to our hospital for further management. Patient complained of pain lower abdomen, fever and vomiting. On examination, she had features of peritonitis, with fever (38.6°C), tachycardia (102/min), abdominal distension, tenderness, guarding and rigidity over lower abdomen. A speculum examination revealed a foul-smelling blood-stained discharge. Her haemoglobin level was 8 gm% and she had a total leucocyte count of 14000/cu mm. A diagnosis of septic abortion with pelvic peritonitis was made. After initial stabilisation and blood transfusion, a laparotomy was performed through a lower midline incision. At laparotomy, the pelvis was filled with pus, with omentum adherent to pelvic structures. Uterus had a size of around 14 weeks’ gestation with a rent of approximately 2 cm with ragged margins on the right postero-lateral surface of the fundus. Products of conception were removed through the rent, and repair of the uterus was done. Patient continued to have fever in the immediate post-operative period which subsided with a change to appropriate antibiotics. Abdominal stitches were removed on 10th post-operative day but the wound was infected and gaped up to the rectus sheath. With aggressive supervised wound care, a secondary suturing was done after 5 days. Three days later, a discharge was noted from the middle of the wound. Proper wound care was done but on removal of secondary sutures on the 7th day, a 4-mm gap in the middle was noted through which pus was draining, rest of the wound had healed well. On irriga-
