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Lian T, Leong D, Ng K, Bajenov S, Sywak M. A Prospective Study of Electromyographic Amplitude Changes During Intraoperative Neural Monitoring for Open Thyroidectomy. World J Surg 2023:10.1007/s00268-023-07000-w. [PMID: 37005926 DOI: 10.1007/s00268-023-07000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Intraoperative nerve monitoring (IONM) of the vagus and recurrent laryngeal nerve (RLN) enables prediction of postoperative nerve function. The underlying mechanism for loss of signal (LOS) in a visually intact nerve is poorly understood. The correlation of intraoperative electromyographic amplitude changes (EMG) with surgical manoeuvres could help identify mechanisms of LOS during conventional thyroidectomy. METHODS A prospective study of consecutive patients undergoing thyroidectomy was performed with intermittent IONM using the NIM Vital nerve monitoring system. The ipsilateral vagus and RLN was stimulated, and vagus nerve signal amplitude recorded at five time points during thyroidectomy (baseline, after mobilisation of superior pole, medialisation of the thyroid lobe, before release at Ligament of Berry, end of case). RLN signal amplitude was recorded at two time points; after medialisation of the thyroid lobe (R1), and end of case (R2). RESULTS A total of 100 consecutive patients undergoing thyroidectomy were studied with 126 RLN at risk. The overall rate of LOS was 4.0%. Cases without LOS demonstrated a highly significant vagus nerve median percentage amplitude drop at medialisation of the thyroid lobe (- 17.9 ± 53.1%, P < 0.001), and end of case (- 16.0 ± 47.2%, P < 0.001) compared to baseline. RLN had no significant amplitude drop at R2 compared to R1 (P = 0.207). CONCLUSIONS A significant reduction in vagus nerve EMG amplitude at medialisation of the thyroid and the end of case compared to baseline indicates that stretch injury or traction forces during thyroid mobilisation are the most likely mechanism of RLN impairment during conventional thyroidectomy.
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Affiliation(s)
- Tony Lian
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia.
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - David Leong
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Karl Ng
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Neurology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Sonya Bajenov
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Mark Sywak
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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Iscan Y, Aygun N, Sormaz IC, Tunca F, Uludag M, Senyurek YG. Is craniocaudal dissection of recurrent laryngeal nerve safer than lateral approach: a prospective randomized study comparing both techniques by using continuous intraoperative nerve monitoring. Ann Surg Treat Res 2022; 103:205-216. [PMID: 36304193 PMCID: PMC9582614 DOI: 10.4174/astr.2022.103.4.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy. Methods One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring. Results Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm3 (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups. Conclusion The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume.
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Affiliation(s)
- Yalin Iscan
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Ismail Cem Sormaz
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Tunca
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Yasemin Giles Senyurek
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Aygun N, Kostek M, Unlu MT, Isgor A, Uludag M. Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization. Front Surg 2022; 9:867948. [PMID: 35574531 PMCID: PMC9095935 DOI: 10.3389/fsurg.2022.867948] [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: 02/01/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite all the technical developments in thyroidectomy and the use of intraoperative nerve monitorization (IONM), recurrent laryngeal nerve (RLN) paralysis may still occur. We aimed to evaluate the effects of anatomical variations, clinical features, and intervention type on RLN paralysis. Method The RLNs identified till the laryngeal entry point, between January 2016 and September 2021 were included in the study. The effects of RLN anatomical features considering the International RLN Anatomical Classification System, intervention and monitoring types on RLN paralysis were evaluated. Results A total of 1,412 neck sides of 871 patients (672 F, 199 M) with a mean age of 49.17 + 13.42 years (range, 18–99) were evaluated. Eighty-three nerves (5.9%) including 78 nerves with transient (5.5%) and 5 (0.4%) with permanent vocal cord paralysis (VCP) were detected. The factors that may increase the risk of VCP were evaluated with binary logistic regression analysis. While the secondary thyroidectomy (OR: 2.809, 95%CI: 1.302–6.061, p = 0.008) and Berry entrapment of RLN (OR: 2.347, 95%CI: 1.425–3.876, p = 0.001) were detected as the independent risk factors for total VCP, the use of intermittent-IONM (OR: 2.217, 95% CI: 1.299–3.788, 0.004), secondary thyroidectomy (OR: 3.257, 95%CI: 1.340–7.937, p = 0.009), and nerve branching (OR: 1.739, 95%CI: 1.049–2.882, p = 0.032) were detected as independent risk factors for transient VCP. Conclusion Preference of continuous-IONM particularly in secondary thyroidectomies would reduce the risk of VCP. Anatomical variations of the RLN cannot be predicted preoperatively. Revealing anatomical features with careful dissection may contribute to risk reduction by minimizing actions causing traction trauma or compression on the nerve.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
- *Correspondence: Nurcihan Aygun
| | - Mehmet Kostek
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Taner Unlu
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- Department of General Surgery, Sisli Memorial Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Waseem T, Ahmed SZ, Zahara FT, Ashraf MH, Azim KM. Selecting the Right Plane of Dissection in Thyroidectomy: Along the Recurrent Laryngeal Nerve or the Thyroid Capsule? A Retrospective Analysis. Int Arch Otorhinolaryngol 2021; 26:e219-e225. [PMID: 35602276 PMCID: PMC9122766 DOI: 10.1055/s-0041-1731812] [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: 08/20/2020] [Accepted: 01/02/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction
Total thyroidectomy remains highly technical, with a significant risk of recurrent laryngeal nerve (RLN) compromise and hypoparathyroidism. After identifying RLN, at the level of the ligament of Berry, local factors may compel the surgeon to either dissect along the nerve or the thyroid capsule.
Objective
The objective of the present study is to compare these two approaches in terms of outcomes and complication rates.
Methods
This is a retrospective analysis from September, 2013 to April 2019 of 511 consecutive patients undergoing thyroidectomy. General demographics and disease parameters were recorded. At the discretion of the surgeon and according to the demands of the local operative factors, the patients either had dissection along the RLN or along the thyroid capsule. Perioperative and postoperative parameters such as blood loss, duration of surgery, hospital stay, pain scores, analgesia requirements and complications were recorded. The groups were compared with the Pearson chi-squared test or with the Fisher exact test. A p-value < 0.05 was considered statistically significant.
Results
The incidence of transient hypocalcaemia and transient RLN compromise were higher when dissection was performed along the nerve as opposed to the plane along the thyroid capsule. Other parameters including operative time, hospital stay, pain scores, analgesia requirement, wound infection, seroma, hemorrhage, and recurrence did not differ between the groups. Subgroup analysis of the patients who presented with complications showed that local factors, malignancy, and extent of surgery correlated positively with complications when dissected along the RLN.
Conclusion
Dissection along the capsule of the thyroid during thyroidectomy is a safer plane in terms of low rate of transient RLN injury and hypoparathyroidism as opposed to dissection along the nerve.
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Affiliation(s)
- Talat Waseem
- Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Safia Zahir Ahmed
- Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Fatima Tuz Zahara
- Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
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Changes in Tracheal Tube Cuff Pressure and Recurrent Laryngeal Nerve Conductivity During Thyroid Surgery. World J Surg 2019; 44:328-333. [DOI: 10.1007/s00268-019-05185-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hii B, Maher D, Yeung M, Paul E, Serpell JW, Lee JC. Thyroidectomy Then and Now: A 50-Year Australian Perspective. World J Surg 2018; 43:1022-1028. [PMID: 30536022 DOI: 10.1007/s00268-018-04885-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since the mid-1800s, thyroidectomy has transformed from a procedure associated with high to near-zero mortality. Nonetheless, surgeons must continue to strive to improve patient care. Using historical records and contemporary data, this study compares the practice and outcomes of thyroid surgery at a tertiary institution during two periods, 50 years apart. METHODS 'The Alfred Hospital Clinical Reports' recorded all cases of surgically managed thyroid disease from 1946 to 1959. These historical cases were compared to contemporary thyroidectomy cases at the Alfred Hospital from 2007 to 2016. Cases were compared for surgical indication and post-operative outcomes. RESULTS There were 746 patients in the historical group (mean age 53 years; 87% female) and 787 patients in the contemporary group (mean age 52 years; 80% female). The most common indication for thyroidectomy in both groups was non-toxic nodular goitre. A greater proportion of the contemporary group were diagnosed with thyroid malignancy (27% vs. 8%; p < 0.001). The contemporary group recorded significantly fewer cases of thyrotoxic crisis (2.1% vs. 0%; p = 0.001), permanent nerve palsy (4.6% vs. 0.4%; p < 0.001) and bilateral nerve palsy (1.2% vs. 0%; p = 0.01). There were no mortalities in the contemporary group, while the historical data recorded three deaths (0.44%). CONCLUSIONS This study compared thyroid surgery in two cohorts separated by a 50-year period. While it is not surprising that outcomes of thyroidectomy have improved, this study uniquely demonstrates trends of thyroid surgery over time and areas in which further improvements may be made.
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Affiliation(s)
- Belinda Hii
- Department of General Surgery, Monash University Endocrine Surgery Unit, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Dominic Maher
- Department of General Surgery, Monash University Endocrine Surgery Unit, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Meei Yeung
- Department of General Surgery, Monash University Endocrine Surgery Unit, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Clinical Haematology Department, Alfred Hospital, Melbourne, VIC, Australia
| | - Jonathan W Serpell
- Department of General Surgery, Monash University Endocrine Surgery Unit, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Surgery, Monash University, Melbourne, VIC, 3004, Australia
| | - James C Lee
- Department of General Surgery, Monash University Endocrine Surgery Unit, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University, Melbourne, VIC, 3004, Australia.
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Fundakowski CE, Hales NW, Agrawal N, Barczyński M, Camacho PM, Hartl DM, Kandil E, Liddy WE, McKenzie TJ, Morris JC, Ridge JA, Schneider R, Serpell J, Sinclair CF, Snyder SK, Terris DJ, Tuttle RM, Wu CW, Wong RJ, Zafereo M, Randolph GW. Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement. Head Neck 2018; 40:663-675. [PMID: 29461666 DOI: 10.1002/hed.24928] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/20/2017] [Indexed: 01/25/2023] Open
Abstract
"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).
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Affiliation(s)
- Christopher E Fundakowski
- Department of Otolaryngology, Temple University, Philadelphia, Pennsylvania.,Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Nathan W Hales
- Department of Otolaryngology, Uniformed Services of the Health Sciences, San Antonio, Texas.,San Antonio Head and Neck, San Antonio, Texas
| | - Nishant Agrawal
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Marcin Barczyński
- Department of Endocrine Surgery, Jagiellonian University, Kraków, Poland
| | | | - Dana M Hartl
- Department of Head and Neck Oncology - Institut de Cancérologie Gustave Roussy, Villejuif, France
| | - Emad Kandil
- Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Whitney E Liddy
- Department of Otolaryngology, Northwestern University, Chicago, Illinois
| | | | - John C Morris
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rick Schneider
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Jonathan Serpell
- Department of Surgery, Monash University, The Alfred Hospital, Prahran, Victoria, Australia
| | - Catherine F Sinclair
- Department of Ear, Nose, and Throat - Head and Neck Surgery, Mount Sinai Health System, New York, New York
| | | | - David J Terris
- Department of Otolaryngology, Augusta University, Augusta, Georgia
| | - R Michael Tuttle
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Che-Wei Wu
- Department of Otolaryngology - Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark Zafereo
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
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Lamadé W, Béchu M, Lauzana E, Köhler P, Klein S, Tuncer T, Rashid NIH, Kahle E, Erdmann B, Meyding-Lamadé U. The weepy nerve-different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model. Langenbecks Arch Surg 2016; 401:983-990. [PMID: 27209314 DOI: 10.1007/s00423-016-1439-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/19/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM). METHODS Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements. RESULTS Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3-171 min). There was no side specificity (left 0.3-171 min, right 0.3-168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3-98.9 min) and less sensitive nerve (26.8-171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3). CONCLUSIONS Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4-146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the "weepy nerve."
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Affiliation(s)
- Wolfram Lamadé
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.
| | - Maren Béchu
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.,Klinik für Neurologie, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Ester Lauzana
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | - Peter Köhler
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Sabine Klein
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Tuncay Tuncer
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | | | - Erich Kahle
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
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