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Is Cystogastrostomy a Definitive Operation for Pancreatitis Associated Pancreatic Fluid Collections? SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:18-21. [PMID: 36730232 DOI: 10.1097/sle.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pancreatic-enteric drainage procedures have become standard therapy for symptomatic pancreatic pseudocysts and walled-off pancreatic necrosis. The need for pancreatic resection after cyst-enteric drainage procedure in the event of recurrence is not well studied. This study aimed to quantify the percentage of patients requiring resection due to recurrence after surgical cystogastrostomy and identify predictors of drainage failure. METHODS A single-institution retrospective review was conducted to identify all patients undergoing surgical cystogastrostomy between 2012 and 2020. Demographic, disease, and treatment characteristics were identified. Failure of surgical drainage was defined as the need for subsequent pancreatic resection due to recurrence. Characteristics between failure and nonfailure groups were compared with identifying predictors of treatment failure. RESULTS Twenty-four cystogastrostomies were performed during the study period. Three patients (12.5%) required a subsequent distal pancreatectomy after surgical drainage. There was no difference in comorbidities between drainage alone and failure of drainage groups. Mean cyst size seemed to be larger in patients that underwent drainage alone versus those that needed subsequent resection (15.2 vs 10.3 cm, P =0.05). Estimated blood loss at initial operation was similar between groups (126 vs 166 mL, P =0.36). CONCLUSION Surgical pancreatic drainage was successful in the initial management of pancreatic fluid collections. We did not identify any predictors of failure of initial drainage. There was a trend suggesting smaller cyst size may be associated with cystgastrostomy failure. Resection with distal pancreatectomy for walled-off pancreatic necrosis and pancreatic pseudocysts can be reserved for cases of failure of drainage.
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Suggs P, NeCamp T, Carr JA. A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients. ANNALS OF SURGERY OPEN 2020; 1:e024. [PMID: 37637446 PMCID: PMC10455460 DOI: 10.1097/as9.0000000000000024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis. Summary Background Data Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods. Methods A meta-analysis of 5500 patients. Results Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods. Conclusions In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.
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Affiliation(s)
- Patrick Suggs
- From the The Department of General Surgery, St. Joseph Mercy Medical Center, Ann Arbor, MI
| | - Timothy NeCamp
- The Department of Statistics, University of Michigan, Ann Arbor, MI
| | - John Alfred Carr
- The Department of Trauma Surgery, Mid-Michigan Medical Center, Midland, MI
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Abstract
Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.
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Affiliation(s)
- Steven Shamah
- University of Chicago Medical Center, CERT Division, 5700 South Maryland Avenue, MC 8043, Chicago, IL 60637, USA
| | - Patrick I Okolo
- Division of Gastroenterology, Lenox Hill Hospital, 100 East 77th Street, 2nd Floor, New York, NY 10075, USA.
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Simo KA, Niemeyer DJ, Swan RZ, Sindram D, Martinie JB, Iannitti DA. Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement. Surg Endosc 2014; 28:1465-72. [PMID: 24671349 DOI: 10.1007/s00464-013-3317-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 11/05/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach. METHODS We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed. RESULTS From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections. CONCLUSION This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.
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Affiliation(s)
- Kerri A Simo
- Section of Hepatobiliary and Pancreas Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Lerch MM, Stier A, Wahnschaffe U, Mayerle J. Pancreatic pseudocysts: observation, endoscopic drainage, or resection? DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:614-21. [PMID: 19890418 DOI: 10.3238/arztebl.2009.0614] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 01/12/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis. They are diagnosed with imaging studies and can be treated successfully with a variety of methods: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, laparoscopic surgery, or open pseudocystoenterostomy. METHODS Relevant publications that appeared from 1975 to 2008 were retrieved from the MEDLINE, PubMed and EMBASE databases for this review. RESULTS Endoscopic pseudocyst drainage has a high success rate (79.2%) and a low complication rate (12.9%). Percutaneous drainage is mainly used for the emergency treatment of infected pancreatic pseudocysts. Open internal drainage and pseudocyst resection are surgical techniques with high success rates (>92%), but also higher morbidity (16%) and mortality (2.5%) than endoscopic treatment (mortality 0.7%). Laparoscopic pseudocystoenterostomy, a recently introduced procedure, is probably similar to the endoscopic techniques with regard to morbidity and mortality. CONCLUSIONS An interdisciplinary approach is best suited for the safe and effective stage-specific treatment of pancreatic pseudocysts. The different interventional techniques that are currently available have yet to be compared directly in randomized trials.
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Affiliation(s)
- Markus M Lerch
- Klinik und Poliklinik für Innere Medizin A, Universitätsklinikum der Ernst-Moritz-Arndt-Universität, Greifswald, Germany.
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Jagad RB. Laparoscopic closure of small bowel perforation: Technique of small bowel anchoring to the abdominal wall. J Minim Access Surg 2009; 5:47-8. [PMID: 19727380 PMCID: PMC2734901 DOI: 10.4103/0972-9941.55109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 07/13/2009] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION More and more complicated laparoscopic abdominal surgeries are now being performed across the world. Laparoscopic suturing of the bowel perforations is being performed by experienced surgeons. We have developed our own technique of small bowel anchoring to the abdominal wall before suturing the perforation. OUR MODIFICATION A single stitch is taken at the corner of the perforation. The long end of the suture is retrieved by a suture retrieval needle and the small bowel is anchored to the abdominal wall. Rest of the bowel perforation is suture by the intracorporeal knot-tying technique. ADVANTAGES Anchoring the bowel to the abdominal wall helps in fixation of the bowel to be sutured. This helps specifically for large perforation. Suturing and knot tying is relatively easy by this technique.
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Affiliation(s)
- Rajan B Jagad
- Department of Surgery, New Civil Hospital and Government Medical College, Surat, Gujarat, India
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Makris KI, St Peter SD, Tsao KJ, Ostlie DJ. Laparoscopic intragastric stapled cystgastrostomy of pancreatic pseudocyst in a child. J Laparoendosc Adv Surg Tech A 2008; 18:771-3. [PMID: 18803524 DOI: 10.1089/lap.2007.0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The current management for pancreatic pseudocysts in children is predicated on adult techniques and includes open, endoscopic, percutaneous, and laparoscopic drainage. In this paper, we report our technique using two intragastric cannulas for the creation of a laparoscopic stapled pancreatic cystgastrostomy.
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Debridement and drainage of walled-off pancreatic necrosis by a novel laparoendoscopic rendezvous maneuver: experience with 6 cases. Gastrointest Endosc 2008; 67:871-8. [PMID: 18367186 DOI: 10.1016/j.gie.2007.10.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 10/30/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is a known complication of acute and chronic pancreatitis. Indications for treatment of WOPN are infection, a rapid increase in size, pain, or biliary or duodenal obstruction. Endoscopic transgastric treatment of pseudocysts with liquid content is successful in approximately 90% of patients; however, the treatment of WOPN is less satisfactory. OBJECTIVE A demonstration of a novel minimally invasive approach to adequately remove and drain pancreatic necrosis. DESIGN Between June 2004 and June 2006, a nonrandomized observational study was conducted with 6 consecutive patients. WOPN was treated by a minimally invasive laparoendoscopic rendezvous technique. SETTING All patients were examined at the university hospital in Freiburg, Germany. PATIENTS Six patients were treated for WOPN of an average diameter of 13 cm (range 9-20 cm). In 5 cases, the WOPN was a consequence of acute pancreatitis; there was 1 case of chronic pancreatitis. The average interval between diagnosis and initial treatment was 14 weeks (range 6-20 weeks). RESULTS Conventional surgery was avoided in 5 patients (83%) over a median follow-up of 14 months (range 1.5-27 months). Six endoscopic sessions (range 4-11) were performed during the entire treatment period. One patient needed emergency surgery on day 4 after the intervention for a perforation because of gastric-wall separation from the necrotic cavity. There was 1 lethal gastric variceal bleeding, which occurred when a gastrostomy tube was removed 46 days after the initial treatment. LIMITATION The small number of patients. CONCLUSIONS In selected cases, minimally invasive laparoendoscopic treatment of WOPN is possible without the need of laparotomy or laparoscopy.
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Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2008; 87:1447-60, ix. [PMID: 18053841 DOI: 10.1016/j.suc.2007.09.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The management of pancreatic pseudocysts has changed greatly over the last decade. As laparoscopic and endoscopic techniques continue to evolve, their use in the treatment of pseudocysts has gained acceptance, whereas the role of percutaneous drainage has become more limited. The literature on laparoscopic, endoscopic, and percutaneous management of pancreatic pseudocyst is reviewed here and, based on these data, a treatment algorithm is suggested.
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Affiliation(s)
- Simon Bergman
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, 558 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
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Aljarabah M, Ammori BJ. Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series. Surg Endosc 2007; 21:1936-44. [PMID: 17717626 DOI: 10.1007/s00464-007-9515-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Revised: 04/06/2007] [Accepted: 05/07/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PPs) are the current minimally invasive management options. This article reviews the evidence available on their effectiveness. METHODS A computerized search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from 1974 to 2005. RESULTS A total of 118 and 569 patients featured, respectively, in 19 and 25 reports underwent 118 and 583 laparoscopic and endoscopic drainage procedures, respectively. Pancreatic pseudocysts were considerably larger in the laparoscopic series (mean, 13 vs. 7 cm; p < 0.0001). The success rates for achieving resolution of the PPs in the laparoscopic and endoscopic series were 98.3% and 80.8% respectively, with morbidity rates of 4.2% and 12% and mortality rates of 0% and 0.4%, respectively. During follow-up period (mean, 13 vs 24 months; p < 0.0001), PPs recurred for 2.5% of the patients in the laparoscopic series and 14.4% of the patients in the endoscopic series, and the reintervention rates were 0.9% and 11.8%, respectively. CONCLUSIONS The laparoscopic and endoscopic approaches to internal drainage of PPs are safe. Although laparoscopic drainage appears to carry a higher success rate and lower rates of morbidity and recurrence, the heterogeneity of the published reports and the varied follow-up periods limit direct comparisons. Data from longer follow-up periods and randomized comparative trials are needed.
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Affiliation(s)
- M Aljarabah
- Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Abstract
The combination of laparoscopy and flexible endoscopy has expanded the minimally invasive approaches to both benign and malignant gastrointestinal disease. This article reviews the current applications of combined approaches to gastric, colonic, and pancreatic pathology.
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Affiliation(s)
- Michael J Rosen
- Department of Surgery, Case Medical Center, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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The laparoscopic approach for inflammatory pancreatic diseases. Eur Surg 2006. [DOI: 10.1007/s10353-006-0245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rosen MJ, Heniford BT. Endoluminal gastric surgery: the modern era of minimally invasive surgery. Surg Clin North Am 2005; 85:989-1007, vii. [PMID: 16139032 DOI: 10.1016/j.suc.2005.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Laparoendoluminal techniques are the next frontier in modern surgery. They provide a minimally invasive approach to gastric diseases that enables organ preservation while maintaining open surgical principles. Laparoscopic direct access to the stomach provides a magnified, high-resolution image for precise excision using widely available laparoscopic instrumentation. Further improvements in flexible endoscopic equipment, combined with the infusion of robotic instrumentation, will aid in overcoming the technical demands of this procedure and fuel the growth of endo-luminal gastric surgery. Based on the currently available data, inappropriately selected patients, endoluminal gastric surgery affords the patients a definitive surgical procedure with all the advantages of a minimally invasive approach.
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Fernández-Cruz L, Cesar-Borges G, López-Boado MA, Orduña D, Navarro S. Minimally invasive surgery of the pancreas in progress. Langenbecks Arch Surg 2005; 390:342-54. [PMID: 15999286 DOI: 10.1007/s00423-005-0556-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2004] [Accepted: 03/15/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic pancreatic surgery should be considered as an advanced laparoscopic procedure and should be performed only in institutions with experience in pancreatic surgery by a team with advanced laparoscopic skills. AIM This review discusses the current status of the laparoscopic approach for inflammatory pancreatic diseases and for benign-appearing pancreatic tumors. RESULTS Laparoscopic surgery has been shown to be beneficial in patients with inflammatory tumors located in the body-tail of the pancreas for chronic pancreatitis. Furthermore, patients with pancreatic pseudocysts may be managed with laparoscopic internal drainage (to the stomach, duodenum, or jejunum). Also, laparoscopic or retroperitoneoscopic necrosectomy has been used with success in patients with necrotizing pancreatitis. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms and neuroendocrine pancreatic tumors. CONCLUSIONS The laparoscopic pancreatic approach was recently shown to be feasible and safe. Laparoscopy may contribute to reduced operation time and perioperative blood loss, and reduces surgical stress because of developments in devices, improvements in procedures, and advanced techniques.
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Affiliation(s)
- Laureano Fernández-Cruz
- Department of Surgery, IMD, Biliary and Pancreatic Unit, Hospital Clinic i Provincial de Barcelona, University of Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
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Ramachandran CS, Agarwal S, Dip DG, Arora V. Laparoscopic Surgical Management of Perforative Peritonitis in Enteric Fever. Surg Laparosc Endosc Percutan Tech 2004; 14:122-4. [PMID: 15471016 DOI: 10.1097/01.sle.0000129387.76641.29] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.
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Affiliation(s)
- C S Ramachandran
- Department of Surgery and Laparoscopic Surgery, Sir Ganga Ram Hospital, RajinderNagar, New Delhi, 110060, India.
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