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Bottini GB, Joos V, Steiner C, Zeman-Kuhnert K, Gaggl A. Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making. J Clin Med 2024; 13:2899. [PMID: 38792440 PMCID: PMC11122336 DOI: 10.3390/jcm13102899] [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: 03/26/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.
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Affiliation(s)
- Gian Battista Bottini
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Veronika Joos
- Private Practice for Dentistry and Oral and Maxillofacial Surgery, 5026 Salzburg, Austria
| | - Christoph Steiner
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Katharina Zeman-Kuhnert
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Alexander Gaggl
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
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Logothetou V, Almansa Ruiz JC, Steenkamp G. The use of a sling suture for ventral orbital stabilization after inferior orbitectomy in three dogs. Vet Surg 2024. [PMID: 38440838 DOI: 10.1111/vsu.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE To describe a novel surgical technique for the ventral stabilization of the orbit after inferior orbitectomy by using a sling suture and report outcomes in three dogs. ANIMALS A 7-year-old male neutered Swiss shepherd, a 4-year-old female neutered golden retriever and a 9-year-old female neutered Rhodesian ridgeback. STUDY DESIGN Short case series. METHODS All dogs presented with caudal unilateral maxillary masses. Surgical resection necessitated a caudal maxillectomy and inferior orbitectomy with a combined dorsolateral and intraoral approach. A sling suture was used to support the globe. A nylon suture was placed rostrally through the osteotomized maxilla and caudally through the osteotomized zygomatic arch via predrilled holes. The suture was tightened until the position of the globe subjectively appeared normal and was secured with a surgeon's knot. The periorbita was secured over the nylon suture with poliglecaprone suture material in a simple interrupted or continuous pattern. The surgical approach was routinely closed. RESULTS Follow-up ranged from 7 to 63 days. The surgical wounds healed uneventfully, and no postoperative complications associated with the stabilization technique were noted. No orbital deviation was noted and the zygomatic regions appeared subjectively symmetrical. CONCLUSION The nylon sling suture provided a quick, easy, safe and effective technique to stabilize the ventral orbit during a combined maxillectomy and orbitectomy in dogs.
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Affiliation(s)
| | - José C Almansa Ruiz
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
- Bristol Vet Specialists, Bristol, UK
| | - Gerhard Steenkamp
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
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Hidaka T, Tanaka K, Minami M, Mori H, Okazaki M. Risk Factors for Postoperative Infection After Maxillary Reconstruction Using Skeletal Grafts. J Craniofac Surg 2023; 34:e649-e651. [PMID: 37276336 DOI: 10.1097/scs.0000000000009462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
Skeletal grafts are usually required to reconstruct defects after maxillectomy for acceptable aesthetic and functional results. Postoperative infection is a serious complication; however, few studies have evaluated the vulnerability to infection of various skeletal reconstructive materials used for maxillary reconstruction. A retrospective study was conducted on 53 cases in which maxillary skeletal reconstruction was performed between 2010 and 2021. The postoperative infection rate was compared between various skeletal reconstructive materials, including costal cartilage, scapula, fibula, ilium, cranium, and titanium mesh. In addition, the risk factors for postoperative infection were evaluated using 2-group comparison tests. Of 53 patients, 14 (25.4%) contracted an infection postoperatively. No significant differences were observed in the infection rates among the materials used for skeletal reconstruction. Cases undergoing secondary reconstruction tended to have a higher infection rate (34.4%) than primary reconstruction (14.3%). For nonvascularized skeletal grafts (41 cases), the concomitant use of soft-tissue flaps decreased the infection rate from 30.8% to 17.9%. Costal cartilage was the most frequently used material (31 cases), primarily for orbital floor reconstruction. Regarding the costal cartilage, nasal wall reconstruction had a higher infection rate (100%) than reconstruction of other parts of the maxilla (0.0%-17.9%). Nonvascularized skeletal grafts, mainly costal cartilage grafts, were safely used for maxillary reconstruction. However, caution should be exercised for postoperative infection in secondary cases and in cases where costal cartilage is used for nasal wall reconstruction. Covering nonvascularized skeletal grafts with soft-tissue flaps may be an effective countermeasure.
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Affiliation(s)
- Takeaki Hidaka
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tokyo Medical and Dental University
| | - Kentaro Tanaka
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tokyo Medical and Dental University
| | - Munetaka Minami
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tokyo Medical and Dental University
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tokyo Medical and Dental University
| | - Mutsumi Okazaki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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The Free Serratus-Rib Flap for Orbital Floor Reconstruction After Oncologic Resection. Ann Plast Surg 2020; 84:409-412. [DOI: 10.1097/sap.0000000000002052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Griffin MJ, Sims JR, Spaulding SL, Baik FM, Elahi E, Urken ML. Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures. Head Neck 2019; 42:556-568. [PMID: 31837075 DOI: 10.1002/hed.26015] [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: 05/31/2019] [Revised: 09/20/2019] [Accepted: 10/30/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction. METHODS We present a review of the literature supplemented by clinical case examples. RESULTS We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects. CONCLUSIONS Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.
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Affiliation(s)
- Martha J Griffin
- THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York
| | - John R Sims
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | - Sarah L Spaulding
- THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York
| | - Fred M Baik
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | - Ebrahim Elahi
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark L Urken
- THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
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AL Deek NF, Liao CT, Huang SF, Kan CJ, Chang KP, Fang KH, Tsao CK. The second-time flap from the previously used anterior thigh donor site for head and neck microsurgical reconstruction. J Surg Oncol 2017; 115:392-401. [DOI: 10.1002/jso.24558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/29/2016] [Accepted: 12/22/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Nidal Farhan AL Deek
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chun-Ta Liao
- Department of Otolaryngology and Head and Neck Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Shiang-Fu Huang
- Department of Otolaryngology and Head and Neck Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Jan Kan
- Department of Otolaryngology and Head and Neck Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Kai-Ping Chang
- Department of Otolaryngology and Head and Neck Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Ku-Hao Fang
- Department of Otolaryngology and Head and Neck Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Kan Tsao
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang Gung Medical College and Chang Gung University; Taipei Taiwan
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Assam JH, Quinn TH, Militsakh ON. The maxillary artery as a recipient vessel option for complex midface and anterior skull base microsurgical repair: A cadaveric study. Microsurgery 2016; 37:611-617. [PMID: 27571583 DOI: 10.1002/micr.30095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/15/2016] [Accepted: 08/04/2016] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Variations in the operative situation for complex head and neck defect reconstructions resulting from mechanisms such as trauma, oncologic resection, and prior radiation exposure can result in situations of a vessel-depleted neck. This requires an awareness of alternate, innovative options for use in reconstructive repairs. The purpose of this study was to provide characterization of the third segment of the maxillary artery necessary to consider its use as a recipient vessel in free flap repair of complex midface defects. MATERIALS AND METHODS Seventeen cadaver hemifaces were used for anatomic demonstration of the maxillary artery third segment by a transmaxillary approach to obtain descriptive measures for statistical analysis. RESULTS The average artery intraluminal cross-section diameter was obtained for the sphenopalatine (1.39 ± 0.12 mm) descending palatine (0.94 ± 0.10 mm), and terminal maxillary (1.68 ± 0.17 mm) arterial vessels. The mean transmaxillary depth with was (43 ± 1.2 mm). Mean mobilizable lengths for sphenopalatine, descending palatine, and terminal maxillary arteries were (30 ± 2 mm), (29 ± 2 mm), and (20 ± 2 mm), accordingly. Vessel patterns were characterized using Morton and Kahn classification for sphenopalatine-descending palatine bifurcation as well as the Kwak classification for maxillary artery third segment morphology. CONCLUSIONS In situations where primary recipient vessel sites are unavailable, the maxillary artery represents an innovative option to be considered with suitable recipient artery characteristics.
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Affiliation(s)
- Jed H Assam
- Department of Biomedical Science, Creighton University, Omaha, NE.,University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | - Thomas H Quinn
- Department of Biomedical Science, Creighton University, Omaha, NE
| | - Oleg N Militsakh
- Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Health System, Omaha, NE
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Jung BK, Yun IS, Lee WJ, Lew DH, Choi EC, Lee DW. Orbital floor reconstruction using a tensor fascia lata sling after total maxillectomy. J Craniomaxillofac Surg 2016; 44:648-53. [DOI: 10.1016/j.jcms.2016.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 01/02/2016] [Accepted: 01/27/2016] [Indexed: 11/30/2022] Open
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Defect Components and Reconstructive Options in Composite Orbitomaxillary Defects With Orbital Exenteration. J Oral Maxillofac Surg 2014; 72:1869.e1-9. [DOI: 10.1016/j.joms.2014.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 11/21/2022]
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Abstract
Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.
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Affiliation(s)
- Subramania Iyer
- Department of Plastic, Reconstructive and Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Krishnakumar Thankappan
- Department of Plastic, Reconstructive and Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
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Sampathirao LMCSR, Thankappan K, Duraisamy S, Hedne N, Sharma M, Mathew J, Iyer S. Orbital floor reconstruction with free flaps after maxillectomy. Craniomaxillofac Trauma Reconstr 2014; 6:99-106. [PMID: 24436744 DOI: 10.1055/s-0033-1343777] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 05/06/2012] [Indexed: 10/26/2022] Open
Abstract
Background The purpose of this study is to evaluate the outcome of orbital floor reconstruction with free flaps after maxillectomy. Methods This was a retrospective analysis of 34 consecutive patients who underwent maxillectomy with orbital floor removal for malignancies, reconstructed with free flaps. A cross-sectional survey to assess the functional and esthetic outcome was done in 28 patients who were alive and disease-free, with a minimum of 6 months of follow-up. Results Twenty-six patients had bony reconstruction, and eight had soft tissue reconstruction. Free fibula flap was the commonest flap used (n = 14). Visual acuity was normal in 86%. Eye movements were normal in 92%. Abnormal globe position resulted in nine patients. Esthetic satisfaction was good in 19 patients (68%). Though there was no statistically significant difference in outcome of visual acuity, eye movement, and patient esthetic satisfaction between patients with bony and soft tissue reconstruction, more patients without bony reconstruction had abnormal globe position (p = 0.040). Conclusion Free tissue transfer has improved the results of orbital floor reconstruction after total maxillectomy, preserving the eye. Good functional and esthetic outcome was achieved. Though our study favors a bony orbital reconstruction, a larger study with adequate power and equal distribution of patients among the groups would be needed to determine this. Free fibula flap remains the commonest choice when a bony reconstruction is contemplated.
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Affiliation(s)
| | | | - Sriprakash Duraisamy
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Naveen Hedne
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Mohit Sharma
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jimmy Mathew
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Subramania Iyer
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Iyer S, Thankappan K, Kuriakose MA, Sampathirao LMCSR, Mathew J, Sharma M. Tensor fascia lata-iliac crest-internal oblique free flap for composite orbito-maxillary defect with orbital exenteration. J Plast Reconstr Aesthet Surg 2012; 66:e116-8. [PMID: 23245756 DOI: 10.1016/j.bjps.2012.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/20/2012] [Accepted: 11/21/2012] [Indexed: 10/27/2022]
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Rajapurkar M, Thankappan K, Sampathirao LMCS, Kuriakose MA, Iyer S. Oncologic and functional outcome of the preserved eye in malignant sinonasal tumors. Head Neck 2012; 35:1379-84. [PMID: 22972502 DOI: 10.1002/hed.23137] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2012] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement. METHODS In a retrospective study of 19 consecutive patients who underwent craniofacial resection or maxillectomy with preservation of orbital contents and adjuvant radiotherapy, the oncological outcome in terms of local recurrence and survival was analyzed. The functional outcome in the preserved eye was analyzed for the cases that did not recur in the orbit. RESULTS Nineteen patients were analyzed for their oncologic and functional outcomes. Fifteen patients underwent immediate reconstruction of the orbital support. Eight patients had local recurrences; 11 patients were disease free at the end of the follow-up. Squamous cell carcinoma has a high propensity for local recurrences (ie, 5 of 8 local recurrences were squamous cell carcinoma). Sixteen patients, in whom a satisfactory orbital tumor clearance was obtained, remained recurrence free in the orbit. All the preserved eyes retained adequate function after adjuvant radiotherapy. CONCLUSIONS Adequate local control with preserved visual function can be obtained with surgery and adjuvant radiation in appropriately selected malignant sinonasal tumors with orbital involvement. The preserved eye, if reconstructed appropriately, maintains good overall function with acceptable morbidity.
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Affiliation(s)
- Mayuri Rajapurkar
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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