1
|
Ter Meulen BC, Maas ET, van der Vegt R, Haumann J, Weinstein HC, Ostelo RWJG, van Dongen JM. Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25:247. [PMID: 38561748 PMCID: PMC10983727 DOI: 10.1186/s12891-024-07366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION Dutch National trial register: NTR4457 (March, 6th, 2014).
Collapse
Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands.
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
| | - Rien van der Vegt
- Department of Pain Medicine and Anesthesiology Zaans MC, Zaandam, The Netherlands
| | - Johan Haumann
- Department of Pain Medicine and Anesthesiology, OLVG, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam and the Amsterdam Movement Sciences Research Institute, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Sipek J, Pokorna P, Sima M, Styblova J, Mixa V. Disposition of levobupivacaine during intraoperative continuous caudal epidural analgesia in a preterm neonate. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:81-84. [PMID: 37997373 DOI: 10.5507/bp.2023.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Continuous caudal epidural analgesia used intraoperatively in children is an effective and safe technique. However, in preterm neonates, developmental factors may significantly affect levobupivacaine disposition, leading to variable pharmacokinetics, pharmacodynamics, and potential large-variable systemic toxicity of local anesthetics. OBJECTIVE To our knowledge, this is the first case report describing the disposition of levobupivacaine used for intraoperative caudal epidural analgesia in a preterm neonate treated for the postoperative pain profile. METHOD 4-days old neonate (postmenstrual age 35+5, weight 2140 g) with congenital anal atresia received continuous caudal epidural long-term analgesia (loading dose 1.694 mg/kg, initial infusion 0.34 mg/kg/hour) before correction surgery. The blood samples were obtained at 1.0, 1.5, 6.5, 12, and 36.5 h after the start of epidural infusion. The pharmacokinetic profile of levobupivacaine was determined by using the Stochastic Approximation Expectation Maximization algorithm. COMFORT and NIPS pain scores were used for the assessment of epidural analgesia. RESULTS The levobupivacaine absorption rate constant, apparent volume of distribution, apparent clearance, and elimination half-life were 10.8 h-1, 0.9 L, 0.086 L/h, and 7.3 h, respectively. CONCLUSION The results confirm our hypothesis of altered pharmacokinetics in the preterm neonate. Therefore, levobupivacaine therapy in these patients should be carefully monitored. Since therapeutic drug monitoring of levobupivacaine is not established in clinical routines, we suggest monitoring the intraoperative pain profile using validated scores. TRIAL REGISTRATION EudraCT number: 2020-000595-37.
Collapse
Affiliation(s)
- Jan Sipek
- Department of Anaesthesia, Resuscitation and Intensive Medicine, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
| | - Pavla Pokorna
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Martin Sima
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jitka Styblova
- Department of Paediatric Surgery, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
| | - Vladimir Mixa
- Department of Anaesthesia, Resuscitation and Intensive Medicine, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
| |
Collapse
|
3
|
Ter Meulen BC, van Dongen JM, Maas E, van de Vegt MH, Haumann J, Weinstein HC, Ostelo R. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica: A Randomized Controlled Trial. Clin J Pain 2023; 39:654-662. [PMID: 37712323 DOI: 10.1097/ajp.0000000000001155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk). METHODS This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up. RESULTS There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids. DISCUSSION Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.
Collapse
Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Esther Maas
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | | | - Johan Haumann
- Department of Anesthesiology and Pain Medicine, OLVG, Amsterdam, The Netherlands
| | | | - Raymond Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| |
Collapse
|
4
|
Larsson M, Sartipy U, Franco-Cereceda A, Spigset O, Loevenich M, Öwall A, Jakobsson J. Extrapleural infusion of levobupivacaine versus levobupivacaine-sufentanil-adrenaline after video-assisted thoracoscopic surgery (VATS): A randomised controlled trial. Acta Anaesthesiol Scand 2023; 67:1256-1265. [PMID: 37344999 DOI: 10.1111/aas.14300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/11/2023] [Accepted: 06/07/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Peripheral blocks are increasingly used for analgesia after video-assisted thoracic surgery (VATS). We hypothesised that addition of sufentanil and adrenaline to levobupivacaine would improve the analgesic effect of a continuous extrapleural block. METHODS We randomised 60 patients undergoing VATS to a 5-mL h-1 extrapleural infusion of levobupivacaine at 2.7 mg mL-1 (LB group) or levobupivacaine at 1.25 mg mL-1 , sufentanil at 0.5 μg mL-1 , and adrenaline at 2 μg mL-1 (LBSA group). The primary outcome was the cumulative morphine dose administered as patient-controlled analgesia (PCA-morphine) at 48 and 72 h. The secondary outcomes were pain according to numerical rating scale (NRS) at rest and after two deep breaths twice daily, peak expiratory flow (PEF) daily, quality of recovery (QoR)-15 score at 1 day and 3 weeks postoperatively, serum levobupivacaine concentrations at 1 h after the start and at the end of the intervention, and adverse events. RESULTS At 48 h, the median cumulative PCA-morphine dose for the LB group was 6 mg (IQR, 2-10 mg) and for the LBSA group 7 mg (IQR, 3-13.5 mg; p = .378). At 72 h, morphine doses were 10 mg (IQR, 3-22 mg) and 12.5 mg (IQR, 4-21 mg; p = .738), respectively. Median NRS score at rest and after two deep breaths was 3 or lower at all time points for both treatment groups. PEF did not differ between groups. Three weeks postoperatively, only the LB group returned to baseline QoR-15 score. The LB group had higher, but well below toxic, levobupivacaine concentrations at 48 and 72 h. The incidence of nausea, dizziness, pruritus and headache was equally low overall. CONCLUSION For a continuous extrapleural block, and compared to plain levobupivacaine at 13.5 mg h-1 , levobupivacaine at 6.25 mg h-1 with addition of sufentanil and adrenaline did not decrease postoperative morphine consumption. The levobupivacaine serum concentrations after 48 and 72 h of infusion were well below toxic levels, therefore our findings support the use of the maximally recommended dose of levobupivacaine for a 2- to 3-day continuous extrapleural block.
Collapse
Affiliation(s)
- Mark Larsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Section for Cardiothoracic Anaesthesia and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Maja Loevenich
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Anders Öwall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Section for Cardiothoracic Anaesthesia and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Jakobsson
- Institution for Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| |
Collapse
|
5
|
Zhang Y, Shi K, Yang X, Chen W, Wang T, Kang Y, Gong D, Qian Z, Zhang W. Sustained release of levobupivacaine from temperature-sensitive injectable hydrogel for long-term local anesthesia in postoperative pain management. Biomaterials 2023; 299:122129. [PMID: 37167892 DOI: 10.1016/j.biomaterials.2023.122129] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Abstract
Postoperative pain is a major concern for most of the surgical patients, and an inadequate postoperative pain control may cause a series of complications. With an effective pain control and lesser side effects, local anesthetics are preferred for use in postoperative pain management. However, the action duration of current local anesthetics is too short to meet the requirements of postoperative analgesia. In this study, an injectable levobupivacaine (LB)-loaded thermo-sensitive hydrogel system based on biodegradable poly(D,L-lactide)-poly(ethylene glycol)-poly(D,L-lactide) (PLEL) was developed for long-acting local anesthetic, in which the soluble charged cation form of LB (LB HCl) was partly alkalified to the poorly soluble base form (LB base). This hybrid LB loaded PLEL system (hLB/PLEL) is a free flowable liquid at room temperature and changes into a semi-solid hydrogel once injection in response to the physiological temperature. Then, the dissolved LB HCl could release firstly from the hydrogel contributing to a quick work, and the insoluble LB base dissolved and released gradually as the decrease of the pH during the biodegradation of PLEL hydrogel, resulting in a long-term LB release in local. The drug release behavior, pharmacokinetic, and biocompatibility of the thermo-sensitive hLB/PLEL were studied in vitro and in vivo. The anesthetic effects of hLB/PLEL system were evaluated in the rat models of sciatic nerve block, subcutaneous infiltration anesthesia and postoperative pain as well. This hLB/PLEL system generated a significantly prolonged analgesic effect in rat models, which produced approximately 7 times longer duration than 0.75% LB HCl and effectively relieved the spontaneous pain for 3 days. In general, the presented hLB/PLEL system can not only achieve a fast-acting but also sustainably release LB to block the nerve and significantly extend the effect of local analgesia, which means a promising candidate for long-acting postoperative pain management.
Collapse
Affiliation(s)
- YuJun Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, 610041, China
| | - Kun Shi
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xi Yang
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wen Chen
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - TianHong Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, 610041, China
| | - Yi Kang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, 610041, China
| | - DeYing Gong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, 610041, China
| | - ZhiYong Qian
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - WenSheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, 610041, China.
| |
Collapse
|
6
|
Cianci P, Tartaglia N, Fersini A. Pain control after laparoscopic cholecystectomy. A prospective study. Ann Ital Chir 2020; 91:611-616. [PMID: 32543463 DOI: pmid/32543463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this study is to evaluate three different analgesic procedures after laparoscopic cholecystectomy for pain control. MATERIAL OF STUDY The study involved 183 patients who underwent laparoscopic cholecystectomy with the same technique for the induction and maintenance of the general anesthesia. They were divided into three different postoperative pain treatment groups: continuous infusion of Tramadol and Ketorolac with elastomeric pump, intraperitoneal topical instillation of Levobupivacaine, and intraperitoneal aerosolization of Levobupivacaine. RESULTS No differences were found in the demographics. shorter operating time was observed in group 1. Eight hours after surgery in groups 2 and 3, there was an increase in pain compared to patients in the first group. The request for postoperative analgesic assistance was lower in groups 1 and 2. DISCUSSION Various topical and intravenous ways for analgesic actions have been used to improve the pain control after laparoscopic procedures, individually and in comparison between them. The main result of our research is that the use of levobupivacaine employed in the topical intraperitoneal application anesthesia by instillation and nebulization, do not improve the postoperative pain in the first 24 hours after LC, compared with intravenous analgesic elastomeric pump. CONCLUSIONS Despite the positive data found in the literature, our observations have not shown a better pain control after laparoscopic cholecystectomy with the use of intraperitoneal analgesia compared to intravenous. KEY WORDS Gallstone disease, Gallbladder bladder, Laparoscopic cholecystectomy, Postoperative pain, Stones.
Collapse
|
7
|
Korat PS, Kapupara P. Analgesic Effect of Local Infiltration of the Surgical Wound Containing Levobupivacaine, Ibuprofen, and Epinephrine in Rats Undergoing Laparotomy. Folia Med (Plovdiv) 2018; 60:254-260. [PMID: 30355815 DOI: 10.1515/folmed-2017-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/28/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Inappropriate use of drugs and their combinations for analgesics has made it difficult to determine the optimal drug combinations for pain mangement. AIM To reduce postoperative pain effectively and safely. MATERIALS AND METHODS Laparotomy was performed in an adult rat under isoflurane anesthesia. During surgery, the surgical wounds were infiltrated with 50 μL solution containing 0.3% w/v levobupivacaine, 2 mg/mL ibuprofen, and 8 mg/mL epinephrine (treatment group) over the sutured muscle wound before skin closing, and compared to infiltration of that of the normal saline (vehicle group). The 10-fold higher dose of the same combination of medications was injected systemically as a control. Postoperative pain assessed by rodent grimace scales scoring. One-way ANOVA following Dunnett multiple comparisons test was used at 95% of confidence level. RESULTS There was decreased pain for the treatment group (p = 0.025, q = 4.527) and the control group (p = 0.031, q = 4.178) only 24 h after the end of the successful infiltration. The rodent GS scale scoring showed the fall in pain was started within three hours post-surgery in the treatment group. There was decreased pain in the treatment group (p = 0.048, q = 3.527) and the control group (p = 0.043, q = 3.891) only as compared to vehicle group 24 h after the end of the successful infiltration. CONCLUSION The infiltration of the surgical wound with levobupivacaine, ibuprofen, and epinephrine combination was effective in the healing of wounds after laparotomy.
Collapse
Affiliation(s)
- Prashant S Korat
- Department of Pharmacy, Sunrise University, Alwar, Rajasthan,India
| | - Pankaj Kapupara
- School of Pharmacy, RK University, Rajkot-360020, Gujarat,India
| |
Collapse
|