1
|
Tufegdzic B, Lobo C, Kumar A. Postoperative pain management after abdominal transplantations. Curr Opin Anaesthesiol 2024:00001503-990000000-00195. [PMID: 38841992 DOI: 10.1097/aco.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The aim of this review article is to present current recommendations as well as knowledge gaps and controversies pertaining to commonly utilized postoperative pain management after solid organ transplantation in the abdominal cavity. RECENT FINDINGS Postsurgical pain has been identified as one of the major challenges in recovery and treatment after solid organ transplants. Many perioperative interventions and management strategies are available for reducing and managing postoperative pain. Management should be tailored to the individual needs, taking an interdisciplinary and holistic approach and following enhanced recovery after surgery guidelines. 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. SUMMARY The optimal pain management regimen has not yet been definitively established, and current scientific evidence does not yet support the endorsement of a certain analgesic approach. This objective necessitates the need for high-quality randomized controlled trials.
Collapse
Affiliation(s)
- Boris Tufegdzic
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | | |
Collapse
|
2
|
Behem CR, Wegner JC, Pinnschmidt HO, Greiwe G, Graessler MF, Funcke S, Nitzschke R, Trepte CJC, Haas SA. Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study. Langenbecks Arch Surg 2023; 408:168. [PMID: 37120426 PMCID: PMC10148777 DOI: 10.1007/s00423-023-02900-w] [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: 10/22/2022] [Accepted: 04/17/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE Postoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia. METHODS This was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia. RESULTS Of 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00-17.0] vs. 9.00 [7.00-14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses - including the intraoperative sufentanil dose (0.228 [0.170-0.332] vs. 0.405 [0.315-0.565] μg·kg-1·h-1, p < 0.0001) - were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred. CONCLUSION This retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery - but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.
Collapse
Affiliation(s)
- Christoph R Behem
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Juliane C Wegner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Michael F Graessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sandra Funcke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sebastian A Haas
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| |
Collapse
|
3
|
Adelmann D, Khorashadi M, Zhou G, Kinjo S, Braun HJ, Ascher NL, Braehler MR. "The use of bilateral continuous erector spinae plane blocks for postoperative analgesia after right-sided living donor hepatectomy: A feasibility study". Clin Transplant 2021; 35:e14413. [PMID: 34196437 DOI: 10.1111/ctr.14413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/17/2021] [Accepted: 06/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative pain after living donor hepatectomy is significant. Postoperative coagulopathy may limit the use of epidural analgesia, the gold standard for pain control in abdominal surgery. The erector spinae plane block (ESPB) is a novel regional anesthesia technique that has been shown to provide effective analgesia in abdominal surgery. In this study, we examined the effect of continuous ESPB, administered via catheters, on perioperative opioid requirements after right living donor hepatectomies for liver transplantation. METHODS We performed a retrospective cohort study in patients undergoing right living donor hepatectomy. Twenty-four patients who received preoperative ESPB were compared to 51 historical controls who did not receive regional anesthesia. The primary endpoint was the total amount of oral morphine equivalents (OMEs) required on the day of surgery and postoperative day (POD) 1. RESULTS Patients in the ESPB group required a lower total amount of OMEs on the day of surgery and POD 1 [141 (107-188) mg] compared the control group [293 (220-380) mg; P < .001]. CONCLUSIONS The use of continuous ESPB significantly reduced opioid consumption following right living donor hepatectomy.
Collapse
Affiliation(s)
- Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Mina Khorashadi
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - George Zhou
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Sakura Kinjo
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Hillary J Braun
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nancy L Ascher
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthias R Braehler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
4
|
Thoracic Epidural Analgesia for Postoperative Pain Management in Liver Transplantation: A 10-year Study on 685 Liver Transplant Recipients. Transplant Direct 2021; 7:e648. [PMID: 33437863 PMCID: PMC7793348 DOI: 10.1097/txd.0000000000001101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/11/2020] [Accepted: 11/01/2020] [Indexed: 12/16/2022] Open
Abstract
Thoracic epidural analgesia (TEA) is not widely used for postoperative pain management in liver transplantation due to hepatic coagulopathy-related increased risk of inducing an epidural hematoma. However, an increasing number of patients are transplanted for other indications than the end-stage liver disease and without coagulopathy allowing insertion of an epidural catheter.
Collapse
|
5
|
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.
Collapse
|
6
|
Regional Analgesia Techniques for Adult Patients Undergoing Solid Organ Transplantation. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0274-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
7
|
Koul A, Pant D, Rudravaram S, Sood J. Thoracic epidural analgesia in donor hepatectomy: An analysis. Liver Transpl 2018; 24:214-221. [PMID: 29205784 DOI: 10.1002/lt.24989] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/31/2017] [Accepted: 11/26/2017] [Indexed: 01/06/2023]
Abstract
The purpose of this study is to analyze whether supplementation of general anesthesia (GA) with thoracic epidural analgesia (TEA) for right lobe donor hepatectomy is a safe modality of pain relief in terms of changes in postoperative coagulation profile, incidence of epidural catheter-related complications, and timing of removal of epidural catheter. Retrospective analysis of the record of 104 patients who received TEA for right lobe donor hepatectomy was done. Platelet count, international normalized ratio, alanine aminotransferase, and aspartate aminotransferase were recorded postoperatively until the removal of the epidural catheter. The day of removal of the epidural catheter and visual analogue scale (VAS) scores were also recorded. Any complication encountered was documented. Intraoperatively, central venous pressure (CVP), hemodynamic variables, and volume of intravenous fluids infused were also noted. Statistical analysis was performed by using SPSS statistical package, version 17.0 (SPSS Inc. Chicago, IL). Continuous variables were presented as mean ± standard deviation. A total of 90% of patients had mean VAS scores between 1 and 4 in the postoperative period between days 1 and 5. None of the patients had a VAS score above 5. Although changes in coagulation status were encountered in all patients in the postoperative period, these changes were transient and did not persist beyond postoperative day (POD) 5. There was no delay in removal of the epidural catheter, and the majority of patients had the catheter removed by POD 4. There was no incidence of epidural hematoma. Aside from good intraoperative and postoperative analgesia, TEA in combination with balanced GA and fluid restriction enabled maintenance of low CVP and prevention of hepatic congestion. In conclusion, vigilant use of TEA appears to be safe during donor hepatectomy. Living liver donors should not be denied efficient analgesia for the fear of complications. Liver Transplantation 24 214-221 2018 AASLD.
Collapse
Affiliation(s)
- Archna Koul
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Deepanjali Pant
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Swetha Rudravaram
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Jayashree Sood
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| |
Collapse
|
8
|
Mallek JT, Gravenstein N, Le-Wendling L. Misguided by INR in Liver Disease Patients? Implications for Clinicians Including Pain Proceduralists. Anesth Analg 2018; 127:289-294. [PMID: 29381517 DOI: 10.1213/ane.0000000000002639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jennifer T Mallek
- From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | | | | |
Collapse
|
9
|
Cosgrave D, Galligan M, Soukhin E, McMullan V, McGuinness S, Puttappa A, Conlon N, Boylan J, Hussain R, Doran P, Nichol A. The NAPRESSIM trial: the use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine in elective hepatobiliary surgery: a study protocol and statistical analysis plan for a randomised controlled trial. Trials 2017; 18:633. [PMID: 29284510 PMCID: PMC5747267 DOI: 10.1186/s13063-017-2370-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 11/21/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Intrathecally administered morphine is effective as part of a postoperative analgesia regimen following major hepatopancreaticobiliary surgery. However, the potential for postoperative respiratory depression at the doses required for effective analgesia currently limits its clinical use. The use of a low-dose, prophylactic naloxone infusion following intrathecally administered morphine may significantly reduce postoperative respiratory depression. The NAPRESSIM trial aims to answer this question. METHODS/DESIGN 'The use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine' trial is an investigator-led, single-centre, randomised, double-blind, placebo-controlled, double-arm comparator study. The trial will recruit 96 patients aged > 18 years, undergoing major open hepatopancreaticobiliary resections, who are receiving intrathecally administered morphine as part of a standard anaesthetic regimen. It aims to investigate whether the prophylactic administration of naloxone via intravenous infusion compared to placebo will reduce the proportion of episodes of respiratory depression in this cohort of patients. Trial patients will receive an infusion of naloxone or placebo, commenced within 1 h of postoperative extubation continued until the first postoperative morning. The primary outcome is the rate of respiratory depression in the intervention group as compared to the placebo group. Secondary outcomes include pain scores, rates of nausea and vomiting, pruritus, sedation scores and adverse outcomes. We will also employ a novel, non-invasive, respiratory minute volume monitor (ExSpiron 1Xi, Respiratory Motion, Inc., 411 Waverley Oaks Road, Building 1, Suite 150, Waltham, MA, USA) to assess the monitor's accuracy for detecting respiratory depression. DISCUSSION The trial aims to provide a clear management plan to prevent respiratory depression after the intrathecal administration of morphine, and thereby improve patient safety. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02885948 . Registered retrospectively on 4 July 2016. Protocol Version 2.0, 3 April 2017. Protocol identification (code or reference number): UCDCRC/15/006 EudraCT registration number: 2015-003504-22. Registered on 5 August 2015.
Collapse
Affiliation(s)
| | - Marie Galligan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Era Soukhin
- St Vincent's University Hospital, Dublin, Ireland
| | | | | | | | - Niamh Conlon
- St Vincent's University Hospital, Dublin, Ireland
| | - John Boylan
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Rabia Hussain
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Alistair Nichol
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Monash University, Melbourne, VIC, Australia.,The Alfred Hospital, Melbourne, VIC, Australia
| |
Collapse
|
10
|
Thomas O, Lybeck E, Flisberg P, Schött U. Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma. Perioper Med (Lond) 2017; 6:14. [PMID: 29034090 PMCID: PMC5628458 DOI: 10.1186/s13741-017-0070-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 09/11/2017] [Indexed: 12/18/2022] Open
Abstract
Background Epidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course. Methods Following ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included. Results Three hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting. Conclusions Screening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma. Electronic supplementary material The online version of this article (10.1186/s13741-017-0070-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Owain Thomas
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
| | | | - Per Flisberg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Södra Vallgatan 5, 254 37 Helsingborg, Sweden
| | - Ulf Schött
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, 221 85 Lund, Sweden
| |
Collapse
|
11
|
Aktaş S, Sevmiş Ş, Şeker M, Korkut E, Karakayalı H. Analysis of risk factors affecting coagulopathy after donor hepatectomy in a newly established liver transplant center. Turk J Surg 2017; 33:69-75. [PMID: 28740953 DOI: 10.5152/turkjsurg.2017.3352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/21/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE As might be expected, living donor liver surgery is associated with serious morbidity and mortality risks. Coagulopathy after donor hepatectomy is an important risk factor affecting morbidity. In this study, risk factors affecting the development of coagulopathy after donor hepatectomy was evaluated in a newly-established liver transplant center. MATERIAL AND METHODS A retrospective evaluation of 46 liver donors to whom hepatectomy was applied in Medipol Universty of School of Medicine Department of Organ Transplantation between April 2014 and July 2015 was made. Coagulopathy was defined as prothrombin time ≥15 sec. or platelet count <80000/mm3 on postoperative day 3. Donors were separated into 2 groups as those with (n=24) and without (n=22) coagulopathy. Preoperative, intraoperative and postoperative factors acting on coagulopathy were analyzed. RESULTS In the intergroup analysis, it was seen that remnant liver volume, remnant liver volume % and remnant liver volume to body weight ratio were factors associated with coagulopathy. The cut-off values for these 3 parameters were calculated as 773.5 cm3, 40.5% and 0.915 cm3/kg, respectively. Only remnant liver volume % was determined as a risk factor for coagulopathy after donor hepatectomy on multiple logistic regression analysis. CONCLUSION The results of this study showed that the most important risk factors affecting coagulopathy after donor hepatectomy were the parameters associated with remnant liver volume.
Collapse
Affiliation(s)
- Sema Aktaş
- Department of General Surgery, Medipol University School of Medicine, İstanbul, Turkey
| | - Şinasi Sevmiş
- Department of General Surgery, Medipol University School of Medicine, İstanbul, Turkey
| | - Mehmet Şeker
- Department of Radiology, Medipol University School of Medicine, İstanbul, Turkey
| | - Esin Korkut
- Department of Gastroenterology, Medipol University School of Medicine, İstanbul, Turkey
| | - Hamdi Karakayalı
- Department of General Surgery, Medipol University School of Medicine, İstanbul, Turkey
| |
Collapse
|