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Gitman M, Bezinover D, Pai SL. Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients. Transplantation 2024:00007890-990000000-00893. [PMID: 39375901 DOI: 10.1097/tp.0000000000005239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024]
Abstract
Analgesia in liver transplantation patients has been traditionally considered a secondary priority where perioperative management principally focused on survival rates in these critically ill patients. With recent advancements in both surgical and medical management, posttransplant survival rates have steadily improved. Outcome measurements are no longer limited to short-term mortality rates and hospital length of stay but are also measured by patient-centered outcomes, such as pain control and quality of life. As living donor liver transplantation has increased access to transplantation, it has also added a different patient population to manage in the perioperative period. For healthy patients undergoing living donor hepatectomies, it is important to reduce the impact of the surgery with proper perioperative pain management. We performed a literature search for articles related to perioperative pain management for liver transplantation living donors and recipients to identify current practices and recent advances. Neuraxial techniques, peripheral nerve blocks, and enteral and parenteral medications were all found to be feasible analgesia modalities for patients undergoing either liver transplant or donor hepatectomy. Patients may also benefit from nonpharmacological interventions and preoperative counseling. No particular perioperative analgesic modality was deemed superior to any other. For liver transplant living donors and recipients, perioperative pain management should emphasize the application of sustainable patient-centered pain control protocols.
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Affiliation(s)
- Marina Gitman
- Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
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Ander M, Mugve N, Crouch C, Kassel C, Fukazawa K, Isaak R, Deshpande R, McLendon C, Huang J. Regional anesthesia for transplantation surgery - A White Paper Part 2: Abdominal transplantation surgery. Clin Transplant 2024; 38:e15227. [PMID: 38289879 DOI: 10.1111/ctr.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/17/2023] [Accepted: 12/06/2023] [Indexed: 02/01/2024]
Abstract
Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of Enhanced Recovery after Surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focused on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations. Specifically, regional anesthesia in liver, kidney, pancreas, intestinal, and uterus transplants or applicable surgeries are discussed.
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Affiliation(s)
- Michael Ander
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Neal Mugve
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Cara Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cale Kassel
- Department of Anesthesiology, Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kyota Fukazawa
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert Isaak
- Department of Anesthesiology, UNC Hospitals, N2198 UNC Hospitals, Chapel Hill, North Carolina, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University/Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Charles McLendon
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
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Kang RA, Ko JS. Living liver donor pain management. Curr Opin Organ Transplant 2023; 28:391-396. [PMID: 37678396 DOI: 10.1097/mot.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW Optimal pain control in living liver donors undergoing hepatectomy is strongly recommended considering their unique status as healthy individuals willingly undergoing surgery for the benefit of the recipient. This review aims to examine and evaluate different strategies aimed at ensuring effective postoperative pain management in living liver donors. RECENT FINDINGS Enhanced recovery after surgery (ERAS) protocols have proven effective in optimizing patient outcomes, including in living liver donor hepatectomy. By implementing these protocols, healthcare professionals can enhance postoperative pain control and accelerate recovery. Multimodal analgesia, which combines different techniques and agents, is crucial in pain management for living liver donors. Regional analgesia techniques, such as spinal anesthesia and various peripheral nerve blocks, have shown efficacy in reducing pain and facilitating early recovery. Systemic nonopioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, ketamine, lidocaine, and dexmedetomidine act synergistically to alleviate pain and reduce inflammation. Minimizing the use of opioids is important to avoid adverse effects, and they should be reserved for rescue medication or breakthrough pain. SUMMARY Applying the principles of ERAS and multimodal analgesia to living liver donors can effectively control pain while promoting early recovery.
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Affiliation(s)
- Ryung A Kang
- Department of Anesthesiology and Pain Management, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Sakai T, Ko JS, Crouch CE, Kumar S, Choi GS, Hackl F, Han DH, Kaufman M, Kim SH, Luzzi C, McCluskey S, Shin WJ, Sirianni J, Song KW, Sullivan C, Hendrickse A. Perioperative management of living donor liver transplantation: Part 2 - Donors. Clin Transplant 2022; 36:e14690. [PMID: 35477939 DOI: 10.1111/ctr.14690] [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: 12/10/2021] [Revised: 02/26/2022] [Accepted: 04/23/2022] [Indexed: 01/10/2023]
Abstract
Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pennsylvania, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Justin Sangwook Ko
- Department of Anesthesiology & Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sathish Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Florian Hackl
- Department of Anesthesiology and Interventional Pain Management, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Dai Hoon Han
- Department of HBP Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Michael Kaufman
- Department of Anesthesiology and Interventional Pain Management, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Seong Hoon Kim
- Organ Transplantation Center, National Cancer Center, Gyeonggi-do, Republic of Korea
| | - Carla Luzzi
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Won Jung Shin
- Department of Anesthesiology & Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joel Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ki Won Song
- Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Cinnamon Sullivan
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Villadiego L, Baker BW. Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen. Nurs Womens Health 2021; 25:357-365. [PMID: 34480867 DOI: 10.1016/j.nwh.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/22/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022]
Abstract
As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.
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Dudek P, Zawadka M, Andruszkiewicz P, Gelo R, Pugliese F, Bilotta F. Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence. J Clin Med 2021; 10:jcm10163662. [PMID: 34441958 PMCID: PMC8397227 DOI: 10.3390/jcm10163662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/07/2021] [Accepted: 08/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.
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Affiliation(s)
- Paula Dudek
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-097 Warsaw, Poland; (P.D.); (P.A.); (R.G.)
| | - Mateusz Zawadka
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-097 Warsaw, Poland; (P.D.); (P.A.); (R.G.)
- Perioperative Medicine, Barts Heart Centre and St. Bartholomew’s Hospital, London EC1A 7BE, UK
- Correspondence:
| | - Paweł Andruszkiewicz
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-097 Warsaw, Poland; (P.D.); (P.A.); (R.G.)
| | - Remigiusz Gelo
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-097 Warsaw, Poland; (P.D.); (P.A.); (R.G.)
| | - Francesco Pugliese
- Department of Anesthesiology and Critical Care, Policlinico Umberto I, “Sapienza” University of Rome, 00161 Rome, Italy; (F.P.); (F.B.)
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I, “Sapienza” University of Rome, 00161 Rome, Italy; (F.P.); (F.B.)
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Cheung BM, Ng PY, Liu Y, Zhou M, Yu V, Yang J, Wang NQ. Pharmacokinetics and safety of liposomal bupivacaine after local infiltration in healthy Chinese adults: a phase 1 study. BMC Anesthesiol 2021; 21:197. [PMID: 34315419 PMCID: PMC8314475 DOI: 10.1186/s12871-021-01407-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/17/2021] [Indexed: 11/15/2022] Open
Abstract
Background Liposomal bupivacaine (LB) is a long-acting formulation of bupivacaine. The safety and efficacy of LB has been demonstrated across surgical procedures. However, pharmacokinetic (PK) parameters and safety of LB in the Chinese population have not been assessed. Methods In this single-arm, single center, phase 1, open-label study, PK and safety of local infiltration with LB 266 mg were assessed in healthy Chinese adults. Eligible participants were aged 18 to 55 years with biologic parents and grandparents of Chinese ethnicity, in generally good health (i.e., no clinically significant abnormalities), and with a body mass index (BMI) 19.0 to 24.0 kg/m2 (inclusive) and body weight ≥ 50 kg. Results Participants (N = 20) were predominantly men (80 %); mean age was 32 years; and mean BMI was 21.8 kg/m2. After LB administration, mean plasma levels of bupivacaine rapidly increased during the first hour and continued to increase through 24 h; plasma levels then gradually decreased through 108 h followed by a monoexponential decrease through 312 h. Geometric mean maximum plasma concentration was 170.9 ng/mL; the highest plasma bupivacaine concentration detected in any participant was 374.0 ng/mL. Twenty-two treatment-emergent adverse events were reported (mild, n = 21; moderate, n = 1). Conclusions After single-dose administration of LB, PK measures were similar to a previously reported profile in US adults. The highest observed peak plasma concentration of bupivacaine was several-fold below the plasma concentration threshold accepted as being associated with neurotoxicity or cardiotoxicity (2000–4000 ng/mL). These data support that LB is well tolerated and safe in individuals of Chinese descent. Trial registration NCT04158102 (ClinicalTrials.gov identifier), Date of registration: November 5, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01407-5.
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Affiliation(s)
- Bernard My Cheung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital Pok Fu Lam, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Pauline Yeung Ng
- Department of Medicine, University of Hong Kong, Queen Mary Hospital Pok Fu Lam, 102 Pok Fu Lam Road, Hong Kong, China.,Department of Adult Intensive Care, Queen Mary Hospital Pok Fu Lam, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ying Liu
- Nuance Biotech Co., Ltd, Room 510, Building 2, CITIC Fortune Plaza, 9 Guangan Road, Fengtai District, Beijing, China
| | - Manman Zhou
- Nuance Biotech Co., Ltd, Room 2106, Ciros Plaza, 388 Nanjing Road W, Huangpu District, Shanghai, China
| | - Vincent Yu
- Pacira BioSciences, Inc., 5 Sylvan Way, Parsippany-Troy Hills, NJ, USA
| | - Julia Yang
- Pacira BioSciences, Inc., Parsippany, NJ, USA.,Present Address: Medical Global Alliance, LLC, 1330 6th Avenue, Manhattan, NY, USA
| | - Natalie Q Wang
- Pacira BioSciences, Inc., 5 Sylvan Way, Parsippany-Troy Hills, NJ, USA
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Hardman MI, Olsen DA, Amundson AW. Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation. Mayo Clin Proc Innov Qual Outcomes 2021; 5:583-589. [PMID: 34195550 PMCID: PMC8240150 DOI: 10.1016/j.mayocpiqo.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective To evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation. Methods A retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre–multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks. Results For PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre–multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01). Conclusion Implementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.
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Affiliation(s)
| | - David A Olsen
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
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Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients. Transplantation 2020; 104:694-699. [PMID: 31815897 DOI: 10.1097/tp.0000000000003053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.
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Intermittent Boluses of Local Anesthetic Through Quadratus Lumborum Catheters for Analgesia in a Living Donor Hepatectomy. Case Rep Anesthesiol 2020; 2019:1246256. [PMID: 31934454 PMCID: PMC6942774 DOI: 10.1155/2019/1246256] [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] [Received: 07/30/2019] [Accepted: 11/11/2019] [Indexed: 11/17/2022] Open
Abstract
The demand for liver transplants in the United States far exceeds the supply of organs. As need has increased, so has use of living donors. Coagulopathy and various side effects often preclude the use of neuraxial regional techniques and opioids for postoperative analgesia in patients with large "J" incisions. Here, we present a 25-year-old male undergoing a living donor hepatectomy who received quadratus lumborum catheters placed percutaneously after closure of incision and prior to emergence to provide excellent analgesia and a viable opioid-sparing approach. Quadratus lumborum catheters are a safe option for a multimodal, opioid-sparing approach to analgesia.
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Hamid HKS. The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United States. Mayo Clin Proc 2019; 94:920-921. [PMID: 31054615 DOI: 10.1016/j.mayocp.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/11/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Hytham K S Hamid
- Department of Surgery, Soba University Hospital, Khartoum, Sudan; Department of Surgery, Mayo University Hospital, Castlebar, Ireland
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