1
|
Donoso F, Beckman A, Malinovschi A, Engstrand Lilja H. Predictors of histopathological esophagitis in infants and adolescents with esophageal atresia within a national follow-up programme. PLoS One 2022; 17:e0266995. [PMID: 35427378 PMCID: PMC9012387 DOI: 10.1371/journal.pone.0266995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/25/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Esophageal atresia (EA) is a congenital anomaly of the foregut. Although the survival has improved over the years there is a significant gastrointestinal morbidity affecting physical function and health-related quality of life. The aims of the study were to identify and evaluate predictors of histopathological esophagitis in infants and adolescents with EA. METHODS Single centre, cross-sectional study including one and 15-year-old patients operated for EA that participated in the national follow-up programme between 2012 and 2020 according to a pre-established protocol including upper endoscopy with oesophageal biopsies and 24h-pH-test. Data was collected from patients' medical records and pH-analysis software. Regression models were used to identify predictors of histopathological oesophagitis. Possible predictors were abnormal reflux index, endoscopic esophagitis, hiatal hernia, symptoms of gastroesophageal reflux (GER) and age. RESULTS 65 patients were included, 47 children and 18 adolescents. All children were treated with PPI during their first year of life. Symptoms of GER were reported by 13 (31.7%) of the infant's caregivers, 34 of the children (72.3%) had abnormal reflux index and 32 (68.1%) had histopathological esophagitis. The corresponding numbers for adolescents were 8 (50%), 15 (83.3%) and 10 (55.6%). We found no significant associations between histopathological esophagitis and endoscopic esophagitis, symptoms of GER, hiatus hernia or age group. Abnormal reflux index was an independent predictor of histopathological esophagitis. Seven patients with normal reflux index had histopathological esophagitis, all grade I. CONCLUSIONS We found a high prevalence of histopathological esophagitis despite PPI treatment in accordance with recommendations. No significant difference between the two age groups was seen. Abnormal reflux index was an independent predictor of histopathological esophagitis. However, we cannot recommend the use of pH-metry as a substitute for esophageal biopsies; future studies are needed to elucidate if esophageal biopsies might be postponed in infants with normal reflux index.
Collapse
Affiliation(s)
- Felipe Donoso
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Section of Pediatric Surgery, Uppsala University Children’s Hospital, Uppsala, Sweden
| | - Anna Beckman
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Section of Pediatric Surgery, Uppsala University Children’s Hospital, Uppsala, Sweden
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research. RECENT FINDINGS EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.
Collapse
|
3
|
Duvoisin G, Krishnan U. Gastric Function in Children with Oesophageal Atresia and Tracheoesophageal Fistula. Front Pediatr 2017; 5:76. [PMID: 28447027 PMCID: PMC5388682 DOI: 10.3389/fped.2017.00076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/29/2017] [Indexed: 01/14/2023] Open
Abstract
Oesophageal atresia and tracheoesophageal fistula (OA-TOF) are a multifaceted condition which affects patients throughout their lives. Even though it is one of the most common gastrointestinal malformations, most of the current studies focus on gastro-oesophageal reflux disease, anastomotic strictures, and feeding difficulties. However, there is increasing evidence that a proportion of patients with OA-TOF also have abnormal gastric function. This review aims to provide a comprehensive understanding of studies of gastric function in patients with OA-TOF. The etiology of this abnormality has been hypothesized to be congenital and/or acquired. Several modalities are currently available for the investigation of gastric function, each of them trying to answer specific clinical questions. This review summarizes the studies that have looked at gastric function in the OA-TOF cohort with gastric emptying studies (gastric emptying scintigraphy and 13C octanoic breath test), gastric manometry, electrogastrography, and oral glucose tolerance test. However, these modalities are limited due to poor age-specific normative values and heterogeneous methodologies used. The evaluation of symptoms in this cohort is crucial, modalities for abnormal gastric function are also described. With appropriate investigations and symptoms questionnaires, treatment strategies can be implemented to correct abnormal gastric function and thereby improve the outcomes and quality of life of patients with OA-TOF. This review highlights the need for large international multicentre collaborative studies and high-quality prospective randomized controlled trials to improve our understanding of gastric function in this cohort.
Collapse
Affiliation(s)
- Gilles Duvoisin
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Paediatrics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
| |
Collapse
|
4
|
ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA. METHODS Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
Collapse
|
5
|
Fragoso AC, Ortiz R, Hernandez F, Olivares P, Martinez L, Tovar JA. Defective upper gastrointestinal function after repair of combined esophageal and duodenal atresia. J Pediatr Surg 2015; 50:531-4. [PMID: 25840057 DOI: 10.1016/j.jpedsurg.2014.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/28/2014] [Accepted: 05/29/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Both esophageal atresia (EA) and duodenal atresia (DA) involve deficient anti-reflux barrier, poor esophageal function and eventually, duodenogastric reflux. This study aims at examining the upper gastrointestinal functional status in a cohort of patients with both EA and DA. METHODS A retrospective survey of patients treated for EA and DA between 1965 and 2012 was conducted. Clinical charts, office visits, imaging, upper gastrointestinal endoscopy and esophageal pH metry/impedance were used to assess the long-term condition of the esophagus, the presence of gastroesophageal reflux disease (GERD) and/or the need for fundoplication. RESULTS Twenty out of 581 patients treated for EA had associated DA. Ten/twenty children survived; 1 had primary esophageal replacement. With a median follow-up of 9 years, 8/9 had complicated outcomes and 5 still suffered digestive ailments: 2 GER; 1 eosinophilic esophagitis; 1 nodular gastritis, and 1 wrap herniation. A total of 10 procedures were performed: 8 fundoplications, 1 esophagogastric dissociation and 1 replacement with colon. DISCUSSION The association of EA with DA involves a poor upper digestive function with high risks of GERD and fundoplication failure. The lifelong synergistic play of esophageal, gastric and duodenal dysfunctions in these patients prompts long-term follow-up, and eventually active treatment.
Collapse
Affiliation(s)
- Ana Catarina Fragoso
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid; Faculty of Medicine, University of Porto. Porto, Portugal.
| | - Ruben Ortiz
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Francisco Hernandez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Pedro Olivares
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Leopoldo Martinez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid
| | - Juan A Tovar
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid
| |
Collapse
|
6
|
Michaud L, Sfeir R, Couttenier F, Turck D, Gottrand F. Dumping syndrome after esophageal atresia repair without antireflux surgery. J Pediatr Surg 2010; 45:E13-5. [PMID: 20385264 DOI: 10.1016/j.jpedsurg.2010.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/04/2010] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
Abstract
In childhood, the surgical treatment of gastroesophageal reflux is the main cause of dumping syndrome. We report the cases of 2 children with esophageal atresia who presented with dumping syndrome without any precipitating known factors, such as gastroesophageal reflux surgery or associated microgastria. Our data suggest (1) that dumping syndrome can occur after primary anastomosis of esophageal atresia without antireflux surgery and (2) that dumping syndrome should be considered in every child treated surgically for esophageal atresia presenting with digestive symptoms, malaise, failure to thrive, or refusal to eat.
Collapse
Affiliation(s)
- Laurent Michaud
- Division of Gastroenterology, Hepatology and Nutrition, Jeanne de Flandre Children's Hospital and Lille University Faculty of Medicine, 59037 Lille, France
| | | | | | | | | |
Collapse
|
7
|
Lilja HE, Wester T. Outcome in neonates with esophageal atresia treated over the last 20 years. Pediatr Surg Int 2008; 24:531-6. [PMID: 18351365 DOI: 10.1007/s00383-008-2122-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 12/30/2022]
Abstract
We evaluated the outcome in infants with esophageal atresia (EA) treated in our department over the last two decades. The medical records of 147 infants treated from 1986 to 2005 were reviewed. Patient characteristics, associated anomalies, surgery and complications were recorded. We divided the material into two time-periods: 1986-1995 and 1996-2005; 125 patients or parents were interviewed regarding gastrointestinal function, respiratory symptoms and education. The incidence of major cardiac defects increased from 23 to 29% and the overall survival increased from 87 to 94%. Using Spitz' classification survival increased from 93.5 to 100% in group I and from 68.4 to 77.8% in group II. In group III, during the second time period, survival was 100% in three patients. The incidence of anastomotic leakage and recurrent fistula did not change over time. The rate of anastomotic strictures increased from 53 to 59% between the two time-periods. A primary anastomosis could be done in 85% of the patients during the second period versus 78% of the patients during the first period. Anti-reflux surgery was done in only 11 and 9%, respectively, during the two time-periods. In patients who were 16-20 years old, 40-50% had gastrointestinal and respiratory symptoms. Ninety percent of the patients attended normal school. The major difference between the periods 1986-1995 and 1996-2005 was an increased survival despite an increased incidence of major cardiac defects. Gastrointestinal and respiratory symptoms were frequent. Long-term follow-up and treatment of complications of esophageal atresia is important for this patient group.
Collapse
|
8
|
Abstract
A brief resume of the highlights in the history of oesophageal atresia is presented. This is followed by research into the etiology, ontogeny and embryology, and microbiological studies. A revised classification of risk factors with consequent survival statistics is presented. Lessons learned in the management of the condition over a 40-year period are reported with particular emphasis on the management of the preterm infant with associated severe respiratory distress, right-side aortic arch, upper pouch fistula, 'long-gap' atresia, and the use of gastrostomy and intercostals drains. The incidence and treatment of early and late complications is discussed.
Collapse
Affiliation(s)
- Lewis Spitz
- Institute of Child Health, University College, London Great Ormond Street Hospital for Children NHS Trust, London WC1 N3JH, UK
| |
Collapse
|
9
|
Abstract
AIM The aim of this study was to investigate the motor activity in the stomach of infants with repaired esophageal atresia (EA). METHOD Gastric myoelectrical activity was investigated by cutaneous electrogastrography in 15 infants after the surgical correction of EA. Ten infants with no gastrointestinal upset served as controls. Studies were done before and after a milk feed. The pH of the lower esophagus was measured for 24 hours to assess the gastroesophageal reflux (GER) in the infants with repaired EA. RESULTS After feeding, a significant increase in bradygastria and decrease in tachygastria were observed as compared with the preprandial period. Compared with healthy infants, the electrogram showed pathological patterns in 73.3% (11/15) of EA patients. Twelve of 15 EA patients showed some clinical sign of GER, and 60% of the EA patients proved to be GER-positive on esophageal pH monitoring. There was no difference in the distribution of gastric myoelectrical waves between the GER-positive and GER-negative EA patients either before or after meal. CONCLUSION Cutaneous electrogastrography is a noninvasive, harmless method for obtaining indirect information about the motor function of the stomach. The abnormal changes in physiological gastric myoelectrical activity in EA patients can serve as markers of disturbed neuromuscular function and can play a role in the pathogenesis of feeding disturbances after operative correction of EA. Gastroesophageal reflux, which often occurs after surgical repair of EA, seems to be connected not only with disordered gastric myoelectric activity, but also probably with other factors such as artificially straightened esophagogastric angle or brachyesophagus.
Collapse
Affiliation(s)
- János Bókay
- 1st Department of Pediatrics, Semmelweis University, Budapest 1083, Hungary
| | | | | |
Collapse
|
10
|
Cheng W, Poon KH, Lui VCH, Yong JL, Law S, So KT, Tse K, Tam PKH. Esophageal atresia and achalasialike esophageal dysmotility. J Pediatr Surg 2004; 39:1581-3. [PMID: 15486912 DOI: 10.1016/j.jpedsurg.2004.06.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 14-year-old boy presented with regurgitation, malnutrition, and chronic lung insufficiency with a history of successful repair of esophageal atresia and tracheoesophageal fistula in the newborn period. Barium swallow and manometry results showed achalasia. Hellar operation with antireflux procedure resulted in complete symptomatic relief. Histology and immunohistochemistry including PGP9.5, MAP5, cKit, and nNOS of myotomy specimen showed intact innervation. Although esophageal dysmotility after esophageal atresia repair usually is caused by gastroesophageal reflux and incoordination of peristalsis, the possibility of achalasia should also be considered, because a casual relationship between esophageal atresia and achalasia may exist.
Collapse
Affiliation(s)
- W Cheng
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, People's Republic of China
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Tugay M, Yildiz F, Utkan T, Sarioglu Y, Gacar N. Gastric smooth muscle contractility changes in the esophageal atresia rat model: an in vitro study. J Pediatr Surg 2003; 38:1366-70. [PMID: 14523821 DOI: 10.1016/s0022-3468(03)00397-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE The aim of the study was to investigate the gastric smooth muscle reactivity in the Adriamycin-induced esophageal atresia (EA) rat model. METHODS The fetuses were divided into 3 groups. The control group was exposed to saline. The second group was comprised of fetuses that were exposed to Adriamycin but did not have EA (Adriamycin-no-EA group). The third group was comprised of fetuses that were exposed to Adriamycin and had EA (Adriamycin-EA group). Gastric fundus strips were studied in vitro for their contractile response to receptor activation in the 3 groups. RESULTS Contractile responses of gastric smooth muscle to carbachol and KCl were increased in the Adriamycin-EA group compared with the Adriamycin-no-EA group. Also serotonin-induced contractile response in the Adriamycin-EA group decreased compared with the Adriamycin-no-EA group. Relaxation of gastric smooth muscle strips to isoproterenol was comparably unaffected in the Adriamycin-EA and Adriamycin-no-EA groups. Likewise, no change in the response to agonist studies was observed between the control and Adriamycin-no-EA groups. The relaxant response to papaverine was not different in the 3 groups. CONCLUSIONS This study found changes of receptor-dependent and receptor-independent contraction of the gastric fundus smooth muscle in the fetuses with EA. Therefore, impaired contractile responses may be, at least in part, a contributing factor in the abnormal gastric motility seen in EA.
Collapse
|
12
|
Romeo C, Bonanno N, Baldari S, Centorrino A, Scalfari G, Antonuccio P, Centonze A, Gentile C. Gastric motility disorders in patients operated on for esophageal atresia and tracheoesophageal fistula: long-term evaluation. J Pediatr Surg 2000; 35:740-4. [PMID: 10813339 DOI: 10.1053/jpsu.2000.6048] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND/PURPOSE Disturbed peristalsis is reported frequently after successful repair of esophageal atresia (EA). Delayed gastric emptying could be considered a cause of symptoms of gastroesophageal reflux (GER) in patients with repaired EA. The aim of the current study was to evaluate the incidence of and to characterize gastric motility disorders in a long-term follow-up of patients operated on for EA-tracheoesophageal fistula (TEF) by studying gastric emptying with scintigraphic techniques and comparing the results with gastric manometric data. METHODS Eleven patients, between 12 and 23 years of age (median, 17) operated on for EA-TEF between 1975 and 1985, were studied. The scinthigraphic study was undertaken using a standard solid meal. The manometric study was performed using a 2.3-mm probe with 3 solid-state transducers. RESULTS Dysphagia was present in about 20% of patients. Dyspepsia was recorded in 40% of the patients. A pathological reflux was present in 2 patients. Delayed gastric emptying (T1/2 > 90') was present in 4 patients (36%). Manometric data showed alteration of gastric peristaltic activity in 5 patients (45%). CONCLUSIONS Delayed gastric emptying is frequent in long-term follow-up of patients operated on for EA-TEF. In these patients antral hypomotility also is recorded manometrically. Abnormal gastric motility can be considered as an important factor predisposing to symptoms of GER. A thorough evaluation of gastric function is recommended in symptomatic patients after EA repair.
Collapse
Affiliation(s)
- C Romeo
- Institute of Pediatric Surgery, Policlinico Viale Gazzi, Messina, Italy
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
BACKGROUND/PURPOSE Postoperative nausea and vomiting is common after general anesthesia. The timing of resuming oral input is arbitrary. This study aims to estimate the duration of emetic effects of general anesthesia after day surgery in children with electrogastrography (EGG). METHODS Children between the age of 3 and 12 years undergoing elective nonabdominal surgery were recruited. The standard anesthesia protocol of thiopentone (5 mg/kg), O2 (30%), N2O (70%), and isoflurane (1.5%) was adopted. Caudal block was applied to the patients. A laryngeal mask was used. A mobile electrogastrogram (EGG) machine (Synectic; International Medtronic Synectics, Stockholm, Sweden) was attached to the epigastrium of the patient at least 1 hour before the operation and the recording continued through the operation and for a further 2 hours after the operation. The first half hour of preoperative recording was taken as normal control period. The results were analyzed using paired t test. RESULTS Twenty patients who underwent circumcision under general anesthesia were studied. The mean age was 6.6 years. The mean anesthetic duration was 33.2 min. The tachygastria component (associated with nausea and vomiting) became prominent immediately after induction and returned to normal 1 half hour after cessation of general anesthesia. The dominant frequency instability coefficient of EGG (DFIC) and the dominant power instability coefficient (DPIC) peaked during the first half hour period postoperatively and returned to baseline 1 hour postoperatively (DPIC, P>.05). Bradygastria became prominent during the periods 1 half-hour before and 1 half-hour after the general anesthesia and returned to baseline 1 hour postoperatively (P<.05). CONCLUSIONS Significant EGG changes occur during day-surgery general anesthesia for children undergoing nonabdominal surgery. These changes return to baseline 1 hour after reversal of anesthesia. It is probably safe to restart feeding 1 hour later after day-surgery general anesthesia without causing nausea and vomiting.
Collapse
Affiliation(s)
- W Cheng
- Department of Surgery, The Hong Kong University Medical Centre, Queen Mary Hospital, Hong Kong
| | | | | |
Collapse
|