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Zhang B, Fang Y, Wu D, Xie S, Fang X. Efficacy analysis of enhanced recovery after surgery in laparoscopic-assisted radical resection of type I choledochal cyst. Front Pediatr 2023; 11:1191065. [PMID: 37416818 PMCID: PMC10321127 DOI: 10.3389/fped.2023.1191065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/23/2023] [Indexed: 07/08/2023] Open
Abstract
Objective The objective of this study was to investigate the feasibility and effectiveness of laparoscopic-assisted radical resection of type I choledochal cyst (CC) guided by the principles of enhanced recovery after surgery (ERAS). Methods A retrospective cohort study of type I CC admitted to our hospital between May 2020 and December 2021 were analyzed, a total of 41 patients with choledochal cyst underwent surgery during this period and 30 cases were selected based on inclusion and exclusion criteria. Patients (n = 15) who received the traditional treatment from May 2020 to March 2021 were included in the traditional group. Patients (n = 15) who received ERAS from April 2021 to December 2021 were included in the ERAS group. Both groups underwent surgery performed by the same surgical team. Preoperative data of the two groups were recorded, and relevant data were statistically analyzed and compared. Results There was a statistically significant difference in the dose of opioids. Significant differences were observed between the ERAS and traditional groups in the results of the FLACC pain assessment scale on the 1st and 2nd day after surgery, time of gastric tube, urinary catheter and abdominal drainage tube removal, time of first defecation after operation, time of first eating after operation, time to reach full food intake, results of CRP, ALB, and ALT on the 3rd and 7th postoperative day, postoperative hospital stay, and total treatment cost. No significant differences were observed between the two groups in terms of gender, age, body weight, cyst size, preoperative CRP, ALB, ALT, intraoperative blood loss, operation time, and the number of cases converted to laparotomy. Neither the FLACC pain assessment scale on the 3rd day after surgery, the incidence of postoperative complications, nor the rate of readmission within 30 days showed significant differences. Conclusions Laparoscopic-assisted radical resection of type I CC guided by the principles of ERAS is safe and effective for children. The ERAS concept demonstrated advantages over traditional laparoscopic surgery, including reduced opioid use, shorter time to first postoperative defecation, earlier resumption of postoperative feeding, shorter time to reach full feeding, shorter postoperative hospital stay, and lower total treatment cost.
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Parelkar SV, Makhija DP, Sanghvi BV, Gupta RK, Mudkhedkar KP, Shah RS, Kumar A, Rangnekar A, Shah N. Initial experience with 3D laparoscopic choledochal cyst (CDC) excision and hepatico-duodenostomy (HD) in 21 children. Pediatr Surg Int 2023; 39:189. [PMID: 37133562 DOI: 10.1007/s00383-023-05472-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management. AIM To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details. MATERIALS AND METHOD All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied. RESULTS The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively. CONCLUSION 3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery. LEVEL OF EVIDENCE Treatment study level IV.
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Affiliation(s)
- Sandesh V Parelkar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Deepa P Makhija
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India.
| | - Beejal V Sanghvi
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Rahul K Gupta
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Kedar P Mudkhedkar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Rujuta S Shah
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Abhijit Kumar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Aditi Rangnekar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Nehal Shah
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
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Xie N, Xie H, Tang W. Baseline assessment of enhanced recovery after pediatric surgery in mainland China. Pediatr Surg Int 2022; 39:32. [PMID: 36459300 DOI: 10.1007/s00383-022-05315-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China. METHODS We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD). RESULTS A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%). CONCLUSIONS The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.
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Affiliation(s)
- Nan Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China.
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Schukfeh N, Abo-Namous R, Madadi-Sanjani O, Uecker M, Petersen C, Ure BM, Kuebler JF. The Role of Laparoscopic Treatment of Choledochal Malformation in Europe: A Single-Center Experience and Review of the Literature. Eur J Pediatr Surg 2022; 32:521-528. [PMID: 35764302 DOI: 10.1055/s-0042-1749435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Numerous studies from Asian countries, including large collectives, have reported excellent results after laparoscopic resection of choledochal malformation (CM). However, the role of laparoscopic CM resection is still controversial outside Asia. We aimed to analyze the outcome of laparoscopic CM resection in our institution and to compare our outcome with the data reported in the literature. METHODS All patients who underwent laparoscopic CM resection in our pediatric surgical department from 2002 to 2019 were retrospectively analyzed for surgical details and postoperative complications, which were graded according to the Clavien-Dindo classification. A systematic literature search identified all reports on over 10 cases of laparoscopic pediatric CM resection and surgical details, follow-up, and complication rates were extracted. RESULTS Fifty-seven patients (72% female) with a mean age of 3.6 + 4.1 years underwent laparoscopic CM resection in our department. Conversion rate was 30%. Total complication rate was 28%. The rate of major complications (Clavien-Dindo grade III or more) was 16% and included stricture of the biliodigestive or enteric anastomosis (n = 4), adhesive ileus (n = 3), portal vein thrombosis (n = 1), and recurrent cholangitis with consecutive liver transplantation (n = 1). With increasing experience, complication rates decreased. The majority of publications on laparoscopic CM resections originated from Asia (n = 36) and reported on low complication rates. In contrast, publications originating from non-Asian countries (n = 5) reported on higher complications following laparoscopic CM resection. CONCLUSION Our data indicate that laparoscopic CM resection can be safely performed. The learning curve in combination with the low incidence calls for a centralization of patients who undergo laparoscopic CM resection. There seems to be a discrepancy on complications rates reported from Asian and non-Asian countries following laparoscopic CM resection.
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Affiliation(s)
- Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Reem Abo-Namous
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | | | - Marie Uecker
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Chen S, Lin Y, Xu D, Lin J, Zeng Y, Li L. Da vinci robotic-assisted treatment of pediatric choledochal cyst. Front Pediatr 2022; 10:1044309. [PMID: 36440346 PMCID: PMC9683341 DOI: 10.3389/fped.2022.1044309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To evaluate the advantages and disadvantages of da Vinci robot and laparoscopy in treating pediatric choledochal cysts. METHODS We retrospectively analyzed clinical data from forty-two children diagnosed with choledochal cysts in our hospital from January 2018 to January 2021. Twenty children underwent da Vinci robotic surgery, and the others underwent traditional laparoscopy. We compared differences in general information and preoperative, intraoperative, and postoperative differences between the two surgical groups. RESULTS There was no statistically significant difference in age, gender, weight, type, maximum cyst diameter, preoperative C-reactive protein (CRP) value, postoperative complication rate, and postoperative pain score between the two surgical groups (P > 0.05). The average age of the robot-assisted group was 3.62 ± 0.71 years old (range = 1-12 years). There were nineteen cases of Todani type I, one patients of other types, and the maximum cyst diameter was 35.45 ± 9.32 mm (range = 12-56 mm). In the laparoscopic group, the average age was 3.08 ± 0.82 years old (range = 3-10 years). Twenty-one patients had Todani type I, and one had other types. The maximum cyst diameter was 31.94 ± 8.64 mm (range = 10-82 mm). The robot-assisted group had better abdominal drainage, postoperative CRP value, fasting time, and discharge time than the laparoscopic group (P < 0.05). CONCLUSION Compared with laparoscopy, the da Vinci system has the advantages of less tissue damage, faster recovery, and better healing in the treatment of children with congenital choledochal cysts. With technological advancements and an increased number of experienced surgeons, robotic surgery may become a new trend in surgery.
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Affiliation(s)
- Shan Chen
- Clinical Laboratory Department, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Yang Lin
- Department of Pediatric Surgery, Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Di Xu
- Department of Pediatric Surgery, Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Jianli Lin
- Laboratory Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Yunlong Zeng
- Department of Pediatric Surgery, Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Lizhi Li
- Department of Pediatric Surgery, Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
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Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:157-168. [PMID: 34524519 DOI: 10.1007/s00383-021-05008-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This systematic review examines the feasibility and safety of implementing Enhanced recovery after Surgery (ERAS) protocols in children. STUDY DESIGN A systematic search of Medline, PubMed, and the Cochrane library for papers describing ERAS implementation in children between January 2000 and January 2021. The systematic review was performed according to the PRISMA statement. The meta-analysis was done using R Software (Ver 4.0.2). p value of < 0.05 was considered statistically significant. RESULTS Sixteen studies, describing a total of 1723 patients, were included in the meta-analysis. An average of 15 (range 11-16) relevant components were implemented with an overall compliance close to 84%. The time to initiate feeds and reach full enteral nutrition was reduced in ERAS group with mean difference (MD) of - 21.20 h (95% CI - 22.80, - 19.59, p < 0.01), and - 2.20 days (95% CI - 2.72, - 1.71, p < 0.01), respectively. The use of opioids for postoperative analgesia was reduced with MD of -0.86 morphine equivalents mg/kg (95% CI - 1.40, - 0.32, p < 0.01). The length of hospital stay showed a significant reduction with MD of -2.54 days (95% CI - 2.94, - 2.13, p < 0.01). There was no difference in the complication and readmission rates between the groups. CONCLUSION ERP implementation in pediatric perioperative care is a viable option in a variety of surgical settings. There is clear evidence of a decrease in hospital stay duration with no increase in complication or readmission rates. The length of hospital stay reduced in inverse proportion to the number of ERAS elements implemented. Parental satisfaction is increased by initiating enteral feeding early, minimizing catheter and drain use, and reducing opioid use.
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Arena S, Di Fabrizio D, Impellizzeri P, Gandullia P, Mattioli G, Romeo C. Enhanced Recovery After Gastrointestinal Surgery (ERAS) in Pediatric Patients: a Systematic Review and Meta-analysis. J Gastrointest Surg 2021; 25:2976-2988. [PMID: 34244952 DOI: 10.1007/s11605-021-05053-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/22/2021] [Indexed: 01/31/2023]
Abstract
AIM To systematically review literature and to assess the status of the ERAS protocol in pediatric populations undergoing gastrointestinal surgery. METHODS Literature research was carried out for papers comparing ERAS and traditional protocol in children undergoing gastrointestinal surgery. Data on complications, hospital readmission, length of hospital stay, intraoperative fluid volume, post-operative opioid usage, time to defecation, regular diet, intravenous fluid stop, and costs were collected and analyzed. Analyses were performed using OR and CI 95%. A p value <0.05 was considered significant. RESULTS A total of 8 papers met the inclusion criteria, with 943 included patients. There was no significant difference in complication occurrence and 30-day readmission. Differently, length of stay, intraoperative fluid volume, post-operative opioid use, time to first defecation, time to regular diet, time to intravenous fluid stop, and costs were significantly lower in the ERAS groups. CONCLUSIONS ERAS protocol is safe and feasible for children undergoing gastrointestinal surgery. Without any significant complications and hospital readmission, it decreases length of stay, ameliorates the recovery of gastrointestinal function, and reduces the needs of perioperative infusion, post-operative opioid administration, and costs.
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Affiliation(s)
- Salvatore Arena
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy.
| | - Donatella Di Fabrizio
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
| | - Pietro Impellizzeri
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
| | - Paolo Gandullia
- Gastroenterology and Endoscopy Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Girolamo Mattioli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Unit of Pediatric Surgery, University of Genoa, Genoa, Italy
| | - Carmelo Romeo
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
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Agrawal V, Tiwari A, Sharma D, Mishra R, Acharya H. Comparison of 3D vs 2D laparoscopic-assisted anorectal pull-through (LAARP) for high anorectal malformations in children. Asian J Endosc Surg 2021; 14:424-431. [PMID: 33145992 DOI: 10.1111/ases.12885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The limitation of two-dimensional (2D) laparoscopic techniques includes lack of stereoscopic vision and depth perception which can affect surgical performance, physical and mental comfort of the operating surgeon. 3D laparoscopic surgery is popular in adults; however, its application and experience in the pediatric age group have been limited. We did a comparison of 2D and 3D laparoscopic-assisted anorectal pull-through (LAARP) in male high anorectal malformations (ARM). MATERIAL AND METHOD This prospective cohort study included male children diagnosed with high anorectal malformation (recto-prostatic urethral fistula) who underwent LAARP in infancy after a neonatal colostomy between November 2019 to March 2020. The patients were randomized into a 2D group or 3D group at a 1:1 ratio. Patient demographics and operative/postoperative parameters were recorded. The effect of 3D laparoscopy was assessed in terms of laparoscopy visual parameters (image quality, depth perception, hand-eye coordination, and precision), physical discomfort (5-point Likert scale), and mental strain (State-Trait Anxiety Inventory scale). The statistical tests were performed on SPSS version 16. RESULTS The demographics of both groups, 20 (patients in each), were similar. There was a significant reduction of laparoscopy execution time, physical discomfort (for eye, hand and wrist strain), and overall mental strain in the 3D group. There were similar complications, blood loss, and hospital stay, and no open conversion in two groups. CONCLUSION 3D LAARP is feasible and safe in the surgical treatment of ARM in children. Further studies with assessment by more than one observer are needed to investigate the wider application of 3D in pediatric surgery.
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Affiliation(s)
- Vikesh Agrawal
- Pediatric Surgery Division; Department of Surgery, Netaji Subhash Chandra Bose Government Medical College, Jabalpur, India
| | - Abhishek Tiwari
- Pediatric Surgery Division; Department of Surgery, Netaji Subhash Chandra Bose Government Medical College, Jabalpur, India
| | - Dhananjaya Sharma
- Department of Surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, India
| | - Rajesh Mishra
- Pediatric Surgery Division; Department of Surgery, Netaji Subhash Chandra Bose Government Medical College, Jabalpur, India
| | - Himanshu Acharya
- Department of Surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, India
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Zhang K, Wu L, Gao K, Yan C, Zheng C, Guo C. Strict Surgical Repair for Bile Leakage Following the Roux-en-Y Hepaticojejunostomy. Front Surg 2021; 8:641127. [PMID: 34017852 PMCID: PMC8130580 DOI: 10.3389/fsurg.2021.641127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The optimal bile leakage management strategy in the pediatric population following the initial Roux-en-Y hepaticojejunostomy is still a matter of discussion today. Here, we assessed the roles of bile leakage management and surgical implementation on outcomes for patients with bile leakage. Materials and Methods: A revised protocol for bile leakage management with restricted surgical intervention was implemented at Chongqing Children’s Hospital on March 15, 2013 and Sanxia Hospital on April 20, 2013. We performed a retrospective, historical control analysis for the protocol implementation to compare the short- and long-term outcomes using the corresponding statistical methods. Results: There was a total of 84 patients included in the analysis, including 46 patients in the pre-protocol group and 38 patients in the post-protocol group. No statistical differences for the demographic features were found between the two groups. There was a decrease in redo surgeries in the post-protocol cohort compared to those in the pre-protocol cohort (odds ratio [OR] = 4.48 [95% CI, 1.57–12.77]; p = 0.003). Furthermore, patients in the post-protocol group were less likely to be associated with intensive care unit (ICU) admission (OR = 3.72 [95% CI, 1.11–12.49]; p = 0.024) compared to patients in the pre-protocol group, respectively. There was no mortality between the two groups. Conclusions: A restrictive surgical intervention strategy can effectively reduce the rate of redo surgery and exhibited promising outcomes for bile leakage in terms of postoperative recovery and hospitalization costs.
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Affiliation(s)
- Keying Zhang
- College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing, China
| | - Linfeng Wu
- College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing, China
| | - Kai Gao
- Department of Pediatric General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chengwei Yan
- Department of Pediatric General Surgery, Sanxia Hospital, Chongqing University, Chongqing, China
| | - Chao Zheng
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Traumatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- Department of Pediatric General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
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