1
|
Elshazly M, Shaban A, Gouda N, Rashad M, Soaida SM. Ultrasound-guided lumbar erector spinae plane block versus caudal block for postoperative analgesia in pediatric hip and proximal femur surgery: a randomized controlled study. Korean J Anesthesiol 2023; 76:194-202. [PMID: 36274252 DOI: 10.4097/kja.22421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/21/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND According to previous research, 20% of infants experience prolonged postsurgical pain 6-12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries. METHODS Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia. RESULTS The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups. CONCLUSIONS The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.
Collapse
Affiliation(s)
- Mohamed Elshazly
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - AbdelKhalek Shaban
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevine Gouda
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahitab Rashad
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherif M Soaida
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
2
|
Karagözlü Akgül A, Canmemiş A, Eyvazov A, Hürel H, Kiyan G, Umuroğlu T, Tuğtepe H. Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair. Balkan Med J 2022; 39:239-245. [PMID: 35669925 PMCID: PMC9326942 DOI: 10.4274/balkanmedj.galenos.2022.2022-1-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial. Aims: To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias. Study Design: Retrospective cross-sectional study. Methods: Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups. Results: The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group. Conclusion: This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.
Collapse
Affiliation(s)
- Ahsen Karagözlü Akgül
- Department of Pediatric Surgery, Division of Pediatric Urology, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Arzu Canmemiş
- Clinic of Pediatric Urology Ministry of Health, Göztepe Prof Dr Süleyman Yalçın Hospital, İstanbul, Turkey
| | - Ali Eyvazov
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Hilal Hürel
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Gürsu Kiyan
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Tümay Umuroğlu
- Department of Anaesthesiology and Reanimation, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Halil Tuğtepe
- Department of Pediatric Surgery, Division of Pediatric Urology, Faculty of Medicine Marmara University, İstanbul, Turkey
| |
Collapse
|
3
|
Priyadarshini K, Behera BK, Tripathy BB, Misra S. Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial. Reg Anesth Pain Med 2022; 47:217-221. [PMID: 35039439 DOI: 10.1136/rapm-2021-103201] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB) provides analgesia for both upper and lower abdominal surgery. Very few randomized controlled trials in children have assessed the efficacy of QLB in IHR. Thus, this study was designed to find the comparative effectiveness of QLB versus TAP and II/IH blocks in children undergoing open IHR. MATERIALS AND METHODS Sixty children scheduled for open IHR were randomly allocated in groups of 20 to receive either ultrasound-guided TAP block with 0.4 mL/kg of 0.25% ropivacaine, II/IH nerve block with 0.2 mL/kg of 0.25% ropivacaine, or QLB with 0.4 mL/kg of 0.25% ropivacaine. Anesthesia was standardized for all patients, and an experienced anesthesiologist performed the blocks after anesthesia induction. PRIMARY OUTCOME Time to first analgesia. SECONDARY OUTCOMES Postoperative pain scores, intraoperative and postoperative opioid consumption, cumulative paracetamol usage, block performance time, and block-related complications. RESULTS The median time to first analgesia was 360 (120), 480 (240), and 720 (240) min in the TAP block, II/IH block, and QLB groups, respectively; and was significantly longer in the QLB versus TAP (p<0.001) and II/IH (p<0.001) groups. The time to first analgesia was not significantly different between the TAP and II/IH groups (p=0.596). The mean postoperative tramadol consumption was 11 (12.7), 4 (7.16), and 3 (8) mg in the TAP, II/IH, and QLB groups, respectively (p=0.023); and it was lowest in the QLB group. No significant differences were found between the groups for other secondary outcomes. CONCLUSIONS QLB provides a prolonged period of analgesia and leads to decreased opioid consumption compared with TAP blocks and II/IH nerve blocks in children undergoing open IHR. TRIAL REGISTRATION NUMBER CTRI/2019/09/021377.
Collapse
Affiliation(s)
| | | | | | - Satyajeet Misra
- Anesthesiology, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
| |
Collapse
|
4
|
Ozen V, Ozen N. Ultrasound-Guided Pudendal Nerve Block versus Ultrasound-Guided Dorsal Penile Nerve Block for Pediatric Distal Hypospadias Surgery. Urol Int 2022; 107:370-376. [PMID: 35144265 DOI: 10.1159/000521718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The primary aim of the study was to use the duration until the first postoperative analgesic requirement after two different block techniques to compare the analgesic effect. The secondary aims were to compare the two methods for postoperative Children's Hospital Eastern Ontario Pain Scale (CHEOPS) scores, complications, and parental satisfaction level. MATERIALS AND METHODS This prospective, observational study was conducted with male patients aged 1-7 years in the ASA I-II group, who were scheduled for hypospadias surgery between November 2019 and April 2020. Ultrasound (US)-guided pudendal nerve block (PNB) or US-guided dorsal penile nerve block (DPNB) was administered under general anesthesia before the operation. Postoperative analgesic need, postoperative pain, complications, and parental satisfaction were noted. The STROBE checklist was followed for reporting. RESULTS The study was conducted with 30 patients in total, divided into 15 patients receiving PNB and 15 patients receiving DPNB. The effective minimum block duration was longer in the pudendal group at 22.22 ± 0.61 h than in the DPNB group at 22.19 ± 0.57 h. Additional analgesic was required in 4 subjects in the pudendal group and 5 in the DPNB group. There was no statistically significant difference in terms of the variables between the two groups (p > 0.05). DISCUSSION US-guided DPNB and PNB were shown to provide successful postoperative analgesia and to have similar effectiveness in pediatric patients undergoing hypospadias surgery in this first prospective study of its kind in the literature. CONCLUSIONS US-guided DPNB and PNB have been demonstrated to provide effective, safe, and long-term postoperative analgesia in pediatric patients who have undergone hypospadias surgery. Parental satisfaction in both groups is positively influenced by the minimum postoperative analgesia requirement, the long-term analgesic effect, and the lack of any complications.
Collapse
Affiliation(s)
- Volkan Ozen
- Department of Anesthesiology and Reanimation, Prof. Dr. Cemil TASCIOGLU City Hospital, Istanbul, Turkey
| | - Nurten Ozen
- Department of English Nursing, Florence Nightingale Hospital School of Nursing, Demiroglu Bilim University, Istanbul, Turkey
| |
Collapse
|
5
|
Ekstein M, Weinbroum AA, Ben-Chaim J, Amar E, Schvartz R, Klein Y, Bar-Yosef Y. Comparison of Caudal Block vs. Penile Block vs. Intravenous Fentanyl Only in Children Undergoing Penile Surgery: A Prospective, Randomized, Double Blind Study. Front Pediatr 2021; 9:654015. [PMID: 33842412 PMCID: PMC8033002 DOI: 10.3389/fped.2021.654015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: Penile surgery is commonly performed in pediatric surgical centers. There is no consensus regarding which analgesic method is most effective in controlling pain in these children. Methods: Consecutive children between 4 months and 16 years of age who underwent elective penile surgery were recruited. After inhaled induction of anesthesia, children were randomized to one of three methods of intraoperative analgesia: caudal block, IV fentanyl titrated to surgical response and spontaneous respiration, or dorsal penile nerve block (DPNB). All patients were given inhaled agents; fentanyl was added if either block was insufficient. Demographic data, analgesic use and pain scores were recorded by a blinded investigator in the PACU and ward. Pain scores, analgesic requirement, and recovery parameters of returning to normal activity level, eating, and voiding post-operatively for up to 4 days, were compared. Results: 116 children were recruited. Pain scores in the post anesthesia care unit were significantly lower in the DPNB and caudal block groups compared to the fentanyl group for the first 30 postoperative min. Pain scores and analgesic use were subsequently similar among the three groups for the rest of the study period. There was no statistical difference in time to eat, return to normal activity or in parental satisfaction scores among the groups. There was a trend toward earliest time to void in the DPNB group. Conclusions: Regional blocks most effectively controlled pain for 30 min after surgery. The choice of intra-operative analgesia protocol had no effect on later pain and recovery parameters.
Collapse
Affiliation(s)
- Margaret Ekstein
- Department of Anesthesiology & Critical Care & Pain, Tel Aviv University, Tel Aviv, Israel
| | - Avi A Weinbroum
- Department of Anesthesiology & Critical Care & Pain, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Ben-Chaim
- Department of Pediatric Urology, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Amar
- Department of Orthopedics, Tel-Aviv Medical Center Affiliated With Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Reut Schvartz
- Department of Anesthesiology & Critical Care & Pain, Tel Aviv University, Tel Aviv, Israel
| | - Yifat Klein
- Department of Anesthesiology & Critical Care & Pain, Tel Aviv University, Tel Aviv, Israel
| | - Yuval Bar-Yosef
- Department of Pediatric Urology, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
6
|
Ozen V, Yigit D. Caudal epidural block versus ultrasound-guided dorsal penile nerve block for pediatric distal hypospadias surgery: A prospective, observational study. J Pediatr Urol 2020; 16:438.e1-438.e8. [PMID: 32507565 DOI: 10.1016/j.jpurol.2020.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/05/2020] [Accepted: 05/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The surgery of hypospadias is very painful in the postoperative period and requires long-term analgesia. A dorsal penile nerve block (DPNB) and caudal epidural block (CEB) are commonly used regional anesthesia techniques for postoperative pain control. OBJECTIVES The primary aim of the prospective, observational study was to use the duration until the first postoperative analgesic requirement after two different block techniques to compare the analgesic effect. The secondary aims were to compare the two methods for postoperative Children's Hospital Eastern Ontario Pain Scale (CHEOPS) scores, complications and parental satisfaction level. STUDY DESIGN This study was conducted with male patients aged 1-5 years in the ASA I-II group, who were scheduled for hypospadias surgery. A CEB or ultrasound (US)-guided DPNB with the in-plane technique was administered under general anesthesia before the operation. Postoperative analgesic need, postoperative pain, complications and parental satisfaction were noted. STROBE checklist was followed for reporting. RESULTS The study was conducted with 26 patients in total, divided into 13 patients receiving CEB and 13 patients receiving DPNB. The mean CHEOPS score (p = 0.003) and 12th hour CHEOPS score (p = 0.003) were statistically significantly higher in the CEB group than the DPNB group. The need for additional postoperative analgesia was higher in the CEB group than the DPNB group (p < 0.001). No complications were seen in two groups. DISCUSSION Dorsal penile nerve block with the US-guided in-plane technique provided effective and long-lasting postoperative analgesia for hypospadias surgery. CONCLUSION The postoperative analgesia was better with DPNB than with CEB in hypospadias surgery, particularly in the first 12 h. Parental satisfaction was higher with DPNB thanks to the minimum postoperative analgesia requirement and lack of complications. CLINICALTRIALS. GOV IDENTIFIER NCT04215874.
Collapse
Affiliation(s)
- Volkan Ozen
- Prof.Dr. Cemil Tascioglu City Hospital, Department of Anesthesiology and Reanimation. Kaptan Paşa, SSK Okmeydanı Hst. No:25, 34384, Şişli, İstanbul, Turkey.
| | - Dogakan Yigit
- Prof.Dr. Cemil Tascioglu City Hospital, Department of Pediatric Surgery, Kaptan Paşa, SSK Okmeydanı Hst. No:25, 34384, Şişli, İstanbul, Turkey.
| |
Collapse
|
7
|
Zhu C, Zhang S. Response to the letter from Dr Yifeng Ren et al. Reg Anesth Pain Med 2019; 45:390-391. [PMID: 31806681 DOI: 10.1136/rapm-2019-101021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/08/2019] [Accepted: 11/20/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Change Zhu
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai, China
| | - Saiji Zhang
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai, China
| |
Collapse
|
8
|
Ren Y, Shi W, Niu C, Zheng X. Letter to the editor for the article titled ‘Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis’. Reg Anesth Pain Med 2019; 45:390. [DOI: 10.1136/rapm-2019-100994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 11/04/2022]
|
9
|
Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter? Am J Ther 2019; 26:e314-e320. [PMID: 28767453 DOI: 10.1097/mjt.0000000000000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery. STUDY QUESTION We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes. DATA SOURCES Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied. STUDY DESIGN Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded. RESULTS Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02). CONCLUSIONS None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.
Collapse
|
10
|
Goel P, Jain S, Bajpai M, Khanna P, Jain V, Yadav DK. Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis. Indian J Urol 2019; 35:222-229. [PMID: 31367075 PMCID: PMC6639986 DOI: 10.4103/iju.iju_252_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not. METHODS Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias. RESULTS Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30-2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48-2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias. CONCLUSIONS In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.
Collapse
Affiliation(s)
- Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Jain
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Khanna
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
11
|
Abdullayev R, Sabuncu U, Uludağ Ö, Selcuk Kusderci H, Oterkus M, Buyrukcan A, Duran M, Bulbul M, Apaydin HO, Aksoy N, Abes M. Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit. Cureus 2019; 11:e4348. [PMID: 31187013 PMCID: PMC6541153 DOI: 10.7759/cureus.4348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Caudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia. Materials and methods Data of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained. Results Data of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001). Conclusion Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.
Collapse
Affiliation(s)
- Ruslan Abdullayev
- Anesthesiology and Reanimation, Marmara University School of Medicine, İstanbul, TUR
| | - Ulku Sabuncu
- Anesthesiology and Reanimation, Tepecik Research and Educational Hospital, Izmir, TUR
| | - Öznur Uludağ
- Anesthesiology and Reanimation, Adiyaman University Educational and Research Hospital, Adıyaman, TUR
| | | | - Mesut Oterkus
- Anesthesiology and Reanimation, Kafkas University Medical Faculty Hospital, Kars, TUR
| | - Aysel Buyrukcan
- Anesthesiology and Reanimation, Kusadasi State Hospital, Izmir, TUR
| | - Mehmet Duran
- Anesthesiology and Reanimation, Adiyaman University Educational and Research Hospital, Adiyaman, TUR
| | - Mehmet Bulbul
- Obstetrics and Gynecology, Adiyaman University Educational and Research Hospital, Adiyaman, TUR
| | - Hasan Ogunc Apaydin
- Pediatric Surgery, Adiyaman University Educational and Research Hospital, Adiyaman, TUR
| | - Nail Aksoy
- Pediatric Surgery, Kafkas University Medical Faculty Hospital, Kars, TUR
| | - Musa Abes
- Pediatric Surgery, Adiyaman University Educational and Research Hospital, Adiyaman, TUR
| |
Collapse
|
12
|
Hecht S, Piñeda J, Bayne A. Ultrasound-guided Pudendal Block Is a Viable Alternative to Caudal Block for Hypospadias Surgery: A Single-Surgeon Pilot Study. Urology 2018; 113:192-196. [DOI: 10.1016/j.urology.2017.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
|
13
|
Nishida T, Mihara T, Ka K. Predictors for incidence of increased time spent in hospital after ambulatory surgery in children: a retrospective cohort study. J Anesth 2017; 32:98-103. [DOI: 10.1007/s00540-017-2437-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 12/04/2017] [Indexed: 11/25/2022]
|
14
|
Chan KH, Shah A, Moser EA, Szymanski K, Whittam BM, Misseri R, Kaefer M, Rink R, Cain MP. Comparison of Intraoperative and Early Postoperative Outcomes of Caudal vs Dorsal Penile Nerve Blocks for Outpatient Penile Surgeries. Urology 2017; 118:164-171. [PMID: 29122625 DOI: 10.1016/j.urology.2017.08.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/10/2017] [Accepted: 08/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare intraoperative and 1-hour postoperative outcomes in caudal vs dorsal penile nerve block (DPNB) patients undergoing penile surgeries. MATERIALS AND METHODS We performed a retrospective cohort study of boys <10 years old undergoing penile procedures (2013-2015) using the Pediatric Regional Anesthesia Network, Pediatric Health Information System databases, and our medical records. The primary outcome was a maximum Faces Limbs Activity Crying Consolability pain score of >3. Secondary outcomes were intraoperative-postanesthesia care unit (PACU) narcotics, preincision anesthesia time, adjusted operating room charges, and complications. We performed bivariate and multivariable analyses controlling for demographic and procedural characteristics and clustering by surgeon. RESULTS Of 738 patients (mean age 2.1 years), 74.1% had a caudal block. DPNB patients were more likely to have a maximum pain score of >3 (19.5% vs 8.1%, P <.0001), receive intraoperative (33.0% vs 2.9%, P <.0001) and PACU (15.7% vs 7.5%, P = .0009) narcotics, and had shorter preincision anesthesia times (19.5 vs 27.9 minutes, P <.0001) and lower adjusted operating room charges ($9,402 vs $12,760, P <.0001). In a bivariate logistic regression, DPNB patients had 2.7 times the odds of a maximum pain score of >3 (95% confidence interval 1.7-4.4, P <.0001) and 5.2 times the odds of intraoperative and PACU narcotic administration (95% confidence interval 3.3-8.1, P <.0001). In multivariable analyses, caudal patients had longer preincision anesthesia times (27.9 ± 7.4 vs 19.5 ± 6.6 minutes, P <.0001) and higher adjusted operating room charges ($12,760 ± 4077 vs $9,402 ± 3741, P = .01). CONCLUSION Caudal blocks may offer a small advantage in the immediate postoperative period, although cost-effectiveness is unproven.
Collapse
Affiliation(s)
- Katherine H Chan
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN; Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.
| | - Aali Shah
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, IN
| | - Elizabeth A Moser
- Department of Biostatistics, Indiana University School of Medicine and Richard M. Fairbanks School of Public Health, Indianapolis, IN
| | - Konrad Szymanski
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin M Whittam
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Rosalia Misseri
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Martin Kaefer
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Richard Rink
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Mark P Cain
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
15
|
Saavedra-Belaunde JA, Soto-Aviles O, Jorge J, Escudero K, Vazquez-Cruz M, Perez-Brayfield M. Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery? J Pediatr Urol 2017; 13:45.e1-45.e4. [PMID: 27956108 DOI: 10.1016/j.jpurol.2016.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/24/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations. OBJECTIVE The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block. STUDY DESIGN A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis). RESULTS Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure). DISCUSSION Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias. CONCLUSION The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.
Collapse
Affiliation(s)
| | - Omar Soto-Aviles
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Juan Jorge
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | | | | | - Marcos Perez-Brayfield
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA; HIMA San Pablo, Bayamon, PR, USA
| |
Collapse
|
16
|
Kim MH, Im YJ, Kil HK, Han SW, Joe YE, Lee JH. Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study. Anaesthesia 2016; 71:773-8. [PMID: 27156500 DOI: 10.1111/anae.13463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2016] [Indexed: 11/26/2022]
Abstract
This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty.
Collapse
Affiliation(s)
- M H Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y J Im
- Department of Urology, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - H K Kil
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S W Han
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y E Joe
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J H Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
17
|
Ayob F, Arnold R. Do caudal blocks cause complications following hypospadias surgery in children? Anaesthesia 2016; 71:759-63. [PMID: 27156640 DOI: 10.1111/anae.13490] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Ayob
- Department of Anaesthesia, University Hospital Lewisham, London, UK
| | - R Arnold
- Department of Anaesthesia, University Hospital Lewisham, London, UK.
| |
Collapse
|
18
|
Kajbafzadeh AM, Sabetkish S, Mahboubi AH, Sabetkish N. Single incisional approach for reconstruction of hypospadias and concomitant inguinal hernia. J Pediatr Urol 2014; 10:45-51. [PMID: 23806276 DOI: 10.1016/j.jpurol.2013.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 05/29/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To demonstrate the feasibility, cosmetic outcome and therapeutic values of our single incisional approach in patients with both hypospadias and inguinal hernia (IH) in comparison with standard multiple incisional techniques. MATERIALS AND METHODS Sixty hypospadias-IH repairs were performed from February 2005 to February 2012. These patients were divided into two groups according to their age and hypospadias location. They were then separated randomly into multiple incision (MIG) and single incision (SIG) groups. Early and late complications were taken into consideration. Postoperative pain, need for analgesics, operative time, hospital stay and cosmetic results were recorded for further evaluation. RESULTS Patients were followed up at 6-month intervals for up to 2 years postoperatively. Early and late complication rates were approximately the same in the two groups. 73.3% of patients in MIG and 96.6% in SIG attained an excellent cosmetic result according to two external surgeons. There was no case with poor cosmetic outcome in either group. More analgesic consumption was demanded in MIG patients. CONCLUSION This method of surgery is reproducible with better cosmetic outcome and a slightly shorter hospital stay. It could be a viable option in the management of children with hypospadias and concomitant IH. Negligible postoperative pain and short operative time are the other advantages.
Collapse
Affiliation(s)
- Abdol-Mohammad Kajbafzadeh
- Pediatric Urology Research Center, Department of Pediatric Urology, Children's Hospital, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
| | - Shabnam Sabetkish
- Pediatric Urology Research Center, Department of Pediatric Urology, Children's Hospital, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
| | - Amir Hassan Mahboubi
- Pediatric Urology Research Center, Department of Pediatric Urology, Children's Hospital, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
| | - Nastaran Sabetkish
- Pediatric Urology Research Center, Department of Pediatric Urology, Children's Hospital, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
19
|
Naja ZM, Ziade FM, Kamel R, El-Kayali S, Daoud N, El-Rajab MA. The effectiveness of pudendal nerve block versus caudal block anesthesia for hypospadias in children. Anesth Analg 2014; 117:1401-7. [PMID: 24257391 DOI: 10.1213/ane.0b013e3182a8ee52] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Caudal block (CB) has some disadvantages, one of which is its short duration of action after a single injection. For hypospadias repair, pudendal nerve block (PNB) might be a suitable alternative since it has been successfully used for analgesia for circumcision. We evaluated PNB compared with CB as measured by total analgesic consumption 24 hours postoperatively. METHODS In this prospective, double-blinded study, patients were randomized into 2 groups, either receiving CB or nerve stimulator-guided PNB. In the PNB group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. In the CB group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. Analgesic consumption was assessed during the first 24 hours postoperatively. The "objective pain scale" developed by Hannalah and Broadman was used to assess postoperative pain. RESULTS Eighty patients participated in the study, 40 in each group. The mean age in the PNB group was 3.1 (1.1) years and in the CB group was 3.2 (1.1) years. The mean weights in the PNB and CB groups were 15.3 (2.8) kg and 15.3 (2.2) kg, respectively. The percentage of patients who received analgesics during the first 24 hours were significantly higher in the CB (70%) compared with the PNB group (20%, P < 0.0001). The average amount of analgesics consumed per patient within 24 hours postoperatively was higher in the CB group (paracetamol P < 0.0001, Tramal P =0.003). CONCLUSION Patients who received PNB had reduced analgesic consumption and pain within the first 24 hours postoperatively compared with CB.
Collapse
Affiliation(s)
- Zoher M Naja
- From the *Anesthesia and Pain Management Department, Makassed General Hospital; †Health and Environmental Science Department, Faculty of Public Health, Lebanese University; ‡Chief of Division of General Pediatrics, Pediatrics Department, Saint George Hospital University Medical Center, Beirut, Lebanon; and §Anesthesia Department, Mowasat University Hospital, Damascus, Syria; and ‖Pediatrics Department, Makassed General Hospital, Beirut, Lebanon
| | | | | | | | | | | |
Collapse
|
20
|
Kundra P, Yuvaraj K. Hypospadias surgery and locoregional anesthesia. Paediatr Anaesth 2013; 23:567-8. [PMID: 23647849 DOI: 10.1111/pan.12179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Pankaj Kundra
- Department of Anaesthesiology & Critical Care; Jawaharlal Institute of Postgraduate Medical Education and Research (J.I.P.M.E.R); Pondicherry India
| | - Kotteeswaran Yuvaraj
- Department of Anaesthesiology & Critical Care; Jawaharlal Institute of Postgraduate Medical Education and Research (J.I.P.M.E.R); Pondicherry India
| |
Collapse
|
21
|
Abstract
Paediatric anaesthesia and paediatric regional anaesthesia are intertwined. Almost all surgeries unless contradicted could be and should be supplemented with a regional block. The main objective of this review is to elaborate on the recent advances of the central neuraxial blocks, such as application of ultrasound guidance and electrical stimulation in the pursuit of safety and an objective end point. This review also takes account of the traditional technique and understand the benefits as well the risk of each as compared with the recent technique. The recent trends in choosing the most appropriate peripheral block for a given surgery thereby sparing the central neuroaxis is considered. A penile block for circumcision or a sciatic block for unilateral foot surgery, rather than caudal epidural would have a better risk benefit equation. Readers will find a special mention on the recent thoughts on continuous epidural analgesia in paediatrics, especially its rise and fall, yet its unique importance. Lastly, the issue of block placements under sedation or general anaesthesia with its implication in this special population is dealt with. We conducted searches in MEDLINE (PubMed) and assessed the relevance of the abstracts of citations identified from literature searches. The search was carried out in English, for last 10 years, with the following key words: Recent advances in paediatric regional anaesthesia; ultrasound guidance for central neuraxial blocks in children; role of electrical stimulation in neuraxial blocks in children; complications in neuraxial block. Full-text articles of potentially relevant abstracts were retrieved for further review.
Collapse
|
22
|
Abstract
Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).
Collapse
Affiliation(s)
- Martin Jöhr
- Pediatric Anesthesia, Department of Anesthesia, Kantonsspital, Luzern, Switzerland.
| | | |
Collapse
|
23
|
Psoas compartment block for acute postoperative pain management after hip surgery in pediatrics: a comparative study with caudal analgesia. Reg Anesth Pain Med 2011; 36:121-4. [PMID: 21270724 DOI: 10.1097/aap.0b013e31820d41f3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lower-limb peripheral nerve blocks in pediatrics have gained much more popularity in the last few decades. Our purpose of this study was to compare the postoperative analgesic effects between psoas compartment block (PCB) and caudal block in small children undergoing open hip reduction/osteotomies. METHODS Forty American Society of Anesthesiologists physical status I-II children aged 1 to 6 years planned to undergo open hip reduction/osteotomies were administered general anesthesia and then randomly assigned to receive 1 of 2 regional anesthetics: caudal block (group C, n=20) or PCB (group P, n=20). Ropivacaine 0.25% with epinephrine (5 μg/mL) was used in both blocks. The primary outcome of the study was the total consumption of morphine in the first 24 postoperative hrs. Secondary outcomes included dose of intraoperative fentanyl, occurrence of intraoperative hypotension or bradycardia, postoperative pain scores, time to first morphine analgesia, and occurrence of postoperative vomiting or urine retention. RESULTS The cumulative dose of morphine administered in the ward in the first postoperative 24 hrs and the time to first rescue morphine dose were higher in group C than in group P (P<0.001). There were no differences between the 2 groups regarding intraoperative and postoperative complications except for the incidence of urine retention, which was higher in group C than in group P (P=0.037). CONCLUSIONS Use of single-shot PCB is superior to single-shot caudal block regarding length of postoperative analgesia and cumulative dose of morphine in small children undergoing open hip reduction/osteotomies.
Collapse
|
24
|
|
25
|
Beyaz SG. Comparison of Postoperative Analgesic Efficacy of Caudal Block versus Dorsal Penile Nerve Block with Levobupivacaine for Circumcision in Children. Korean J Pain 2011; 24:31-5. [PMID: 21390176 PMCID: PMC3049974 DOI: 10.3344/kjp.2011.24.1.31] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/25/2011] [Accepted: 01/27/2011] [Indexed: 11/23/2022] Open
Abstract
Background Circumcision is a painful intervention frequently performed in pediatric surgery. We aim to compare the efficacy of caudal block versus dorsal penile block (DPNB) under general anesthesia for children undergoing circumcision. Methods This study was performed between July 1, 2009 and October 16, 2009. Fifty male children American Society of Anesthesiolgists physical status classification I, aged between 3 and 12 were included in this randomized, prospective, comparative study. Anesthetic techniques were standardized for all children. Patients were randomized into 2 groups. Using 0.25% 0.5 ml/kg levobupivacain, we performed DPNB for Group 1 and caudal block for Group 2. Postoperative analgesia was evaluated for six hours with the Flacc Pain Scale for five categories; (F) Face, (L) Legs, (A) Activity, (C) Cry, and (C) Consolability. For every child, supplemental analgesic amounts, times, and probable local or systemic complications were recorded. Results No significant difference between the groups (P > 0.05) was found in mean age, body weight, anesthesia duration, FLACC pain, and sedation scores (P > 0.05). However, on subsequent measurements, a significant decrease of pain and sedation scores was noted in both the DPNB group and the caudal block group (P < 0.001). No major complication was found when using either technique. Conclusions DPNB and caudal block provided similar postoperative analgesic effects without major complications for children under general anesthesia.
Collapse
Affiliation(s)
- Serbülent Gökhan Beyaz
- Departmant of Anesthesia and Reanimation, Sevgi Women's and Children's Hospital, Ordu, Turkey
| |
Collapse
|