ANZ Journal of Surgery

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Table of Contents for ANZ Journal of Surgery. List of articles from both the latest and EarlyView issues.
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Audit of 117 otoplasties for prominent ear by one surgeon using a cartilage‐cutting procedure

March 3, 2019 - 21:54
Background

The plethora of surgical procedures for prominent ear correction reflects lack of satisfaction with outcomes achieved. This paper describes a cartilage‐cutting otoplasty procedure and reports an audit of its outcomes.

Methods

Discharge coding was used to retrospectively identify patients who had undergone the otoplasty of interest at Middlemore Hospital, Auckland, during the 5 years from March 2010 to the end of February 2015. Hospital records were accessed. Demographic, procedure and patient satisfaction data were recorded and analysed (PASW/SPSS Statistics 18.0). Chi‐square test and t‐test were used to assess associations, with significance accepted at two‐sided P < 0.05.

Results

Sixty‐four patients underwent the specified otoplasty (54.7% females: mean age 9.5 years (standard deviation, SD: 4.2; range: 4–20)), of whom 93.8% had bilateral procedures with mean surgical time of 61 min (SD: 14; range: 34–94). This was significantly shorter (P < 0.001) than for bilateral surgeries by all other techniques and surgeons in the review period. None of the 117 procedures of interest subsequently had suture extrusion or revision surgery. Mean time from surgery to satisfaction determination was 993 days (SD: 521; range: 111–1850) for 43 (67.2%) patients. 23.3% believed that there had been aesthetically insignificant partial recurrence of prominence, typically of one ear only. This was insufficient for all but one patient to consider repeat otoplasty. Surgery outcome was rated ‘very satisfactory’ and ‘satisfactory’ by 90.7% and 9.3% of patients/parents, respectively. All would recommend the surgery to others.

Conclusion

With infrequent complications and recurrence requiring revision, and without long‐term reliance on sutures, the otoplasty reported is time‐efficient, safe and generates high patient satisfaction.

Influence of liver fibrosis on prognosis after surgical resection for resectable single hepatocellular carcinoma

March 3, 2019 - 21:54
Background

Surgical resection (SR) is recommended for single hepatocellular carcinoma (HCC) in patients with well‐preserved liver function. However, unexpected liver fibrosis sometimes found at the SR which leads to a poor outcome. This study investigated the influence of liver fibrosis on prognosis after SR for HCC.

Methods

A total of 189 patients with Child‐Turcotte‐Pugh grade A who underwent curative SR for a single HCC <5 cm were evaluated. Patients were assigned to two groups based on the degree of fibrosis (mild or severe), as determined by histological evaluation.

Results

Severe fibrosis was present in 49 patients (25.9%); these patients had greater posthepatectomy liver failure (P = 0.000) and HCC recurrence (P = 0.016). Severe liver fibrosis (hazard ratio (HR) = 1.849, 95% confidence interval (CI) 1.191–2.869; P = 0.006), microvascular invasion (HR = 1.854, 95% CI 1.183–2.906; P = 0.007), and poor histologic grade (HR = 2.097, 95% CI 1.230–3.574; P = 0.007) were related to HCC recurrence.

Conclusion

Severe fibrosis can be found even in patients with well‐preserved liver function and it leads to poorer early post‐operative and late oncologic outcomes, therefore it should be considered before therapeutic decision making of HCC.

Initial experience with robotic hepatectomy in Singapore: analysis of 48 resections in 43 consecutive patients

March 3, 2019 - 21:54
Background

Presently, the adoption of laparoscopic hepatectomy is rapidly increasingly worldwide. However, the application of robotic hepatectomy (RH) remains limited and its role remains undefined today.

Methods

A retrospective review of 43 consecutive patients who underwent RH at two institutions in the Singapore Health Services Group.

Results

Forty‐three consecutive patients underwent 48 resections during the study period. Seven (16.3%) patients underwent major resections and seven (16.3%) underwent right posterior sectionectomies. Nineteen (44.2%) patients had tumours located in the difficult posterosuperior segments, five had multiple resections and three underwent repeat resections for recurrent tumours. RH was performed for malignant tumours in 32 (74%) patients and 16 (37.2%) had cirrhosis. Seven RH was performed with other concomitant procedures including three colectomies, three hilar lymphadenectomies and one portal vein ligation. The median operation time was 360 min (range 75–825) and the median blood loss was 300 mL (range 25–4500). There was one (2.3%) open conversion for bleeding. The median post‐operative stay was 4 days (range 2–33) and there was one (2.3%) readmission. There was one (2.3%) major (>grade 2 morbidity) in a patient with concomitant anterior resection who underwent reoperation for anastomotic leak. There was no 90 day/in‐hospital mortality. Comparison between RH for tumours in the anterolateral segments versus posterosuperior segments demonstrated no significant difference in perioperative outcomes.

Conclusion

Our initial experience demonstrated that RH is safe, feasible and associated with excellent post‐operative outcomes. It can be performed successfully with low morbidity even for complex resections such as major hepatectomies, posterior sectionectomies, tumours in difficult posterosuperior segments and repeat liver resections.

How to do laparoscopic associating liver partition with portal vein ligation for staged hepatectomy

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 255-256, March 2019.

Does knee position during wound closure alter patella height following total knee arthroplasty?

March 3, 2019 - 21:54

The aim of the study was to evaluate the effect of knee position during surgical closure of capsule, and skin on patella tendon length after total knee arthroplasty. Small but statistically significant differences were identified between flexion and extension groups initially postoperatively but this effect was not sustained at 12 months.


Background

Patella infera is a known complication of total knee arthroplasty, and the method of soft tissue closure is a possible contributing factor. The aim of our study was to evaluate the effect of knee position during surgical closure of capsule, subcutaneous tissue and skin on patella tendon length after total knee arthroplasty.

Methods

A three arm retrospective cohort study was conducted in a single institution over a 3‐year period; 75 patients were divided, by surgeon preference, into three groups (Flexed, Extended and Hybrid) of 25 patients. All groups had standardized prosthesis, intraoperative and postoperative protocols, and differed in knee position at closure. Patellar tendon length was assessed radiologically using Insall Salvati ratio (ISR) and modified Insall Salvati ratio, with a 12‐month follow‐up. Intraclass correlation coefficients were used to assess intraobserver variability.

Results

There was a small but significant difference in preoperative to initial postoperative ISR change between Flexed and Extended groups (Extended group mean ISR change = −0.05; t = −2.31, P = 0.025, independent samples t‐test), which was not sustained at 12 months. The incidence of patella infera was similar in Flexed and Extended groups at 12 months with only one case seen in the Hybrid group.

Conclusion

Our study suggests that knee position during soft tissue closure does not have a sustained impact on patella tendon length after knee replacement. A small but statistically significant reduction in patella height was found in the Extended group initially after surgery but this effect was not sustained at 12 months.

Rates and outcomes of total knee replacement for rheumatoid arthritis compared to osteoarthritis

March 3, 2019 - 21:54

This study shows that the use of primary total knee replacement (TKR) for rheumatoid arthritis (RA) is declining. The rate of revision after TKR in RA patients is lower than those with osteoarthritis, but patients with RA are at increased risk of infection, particularly the male group. For patients diagnosed with RA undergoing TKR, the rate of revision varies with gender but not with age.


Background

Total knee replacement (TKR) has been shown to perform differently in patients with rheumatoid arthritis (RA) when compared to osteoarthritis (OA). In this study, we compare the survivorship between these two groups and examine patient and prosthesis factors that impact the revision rate.

Methods

All RA and OA patients undergoing TKR in Australia from 1 September 1999 to 31 December 2016 were included. Revision rates were assessed using Kaplan–Meier estimates of survivorship. The cumulative percent revision analysed age, gender, prosthesis constraint and revision for infection.

Results

There were 541 744 TKR procedures performed including 7542 patients with RA. RA declined as the primary diagnosis from 2.4% of all TKR in 2003 to 0.9% in 2016. Male sex was an independent revision risk in RA patients (hazard ratio (HR) = 1.66, P < 0.001) and OA patients (3.5 years+: HR = 1.09 (1.04–1.15), P < 0.001). Male RA patients had a higher revision rate for infection than females (HR = 3.14, P < 0.001). Females with RA had a lower cumulative percent revision compared to OA females, but males showed no difference between diagnoses. Revision in RA patients was not influenced by age. Compared to OA, RA patients had a decreased revision rate for those aged <65 years, but not for patients aged ≥65 years.

Conclusion

The rate of revision after TKR in RA patients is lower than those with OA, but patients with RA are at increased risk of infection, particularly the male group. Prosthesis constraint had no influence on revision rate. Mortality in those undergoing TKR with RA was higher than in those with OA.

Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24‐month follow‐up

March 3, 2019 - 21:54
Background

Open reduction and internal fixation is the adequate treatment for capitellar and trochlear fractures. Given the low incidence of this type of fractures, it is difficult to constitute a universally accepted method for fixation. Thus, we hypothesised that combined use of Kirschner wires (K‐wires), absorbable rods and sutures for fixation and post‐operative hinged external fixator for early rehabilitation exercise can restore elbow joint function well.

Methods

This retrospective study included 20 patients with a mean age of 48.3 (range 16–76) years. According to the Dubberley classification, fractures were classified on plain radiographs, computed tomography images and intra‐operative findings. All patients were evaluated by the range of motion of the elbow and the Broberg‐Morrey score.

Results

All fractures had healed without non‐union, and the average time was 13.6 (range 8–17) weeks. The mean follow‐up was 42.5 (range 24–80) months. The mean flexion was 117.1° (range 90°–135°), and the mean extension was 17.5° (range 0°–45°). The mean pronation was 74.4° (range 45°–85°), and the mean supination was 84.3° (range 60°–90°). The average Broberg–Morrey score was 86.2 (range 68–98) points with 10 excellent, 7 good and 3 fair results.

Conclusion

K‐wires, absorbable rods and sutures combined with hinged external fixator are feasible for fixation of capitellar and trochlear fractures. However, due to the absence of a control group (such as Herbert screw fixation), comparative studies are still needed to demonstrate the safety and reliability of K‐wires for fixation.

Robotic‐assisted ventral hernia repair with surgical mesh: how I do it and case series of early experience

March 3, 2019 - 21:54

Robotic‐assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair. We describe our rVHR technique and report on our series of 50 patients and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.


Background

Laparoscopic ventral hernia repair provides several benefits over the open approach. Intraperitoneal surgical mesh placement without fascial defect closure is associated with increased seroma formation and other adverse hernia‐site outcomes. Transfascial sutures and tacs for fascial closure and surgical mesh fixation are associated with greater post‐operative pain. Robotic‐assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair.

Methods

Consecutive patients managed by rVHR from May 2015 to August 2018 were identified from a prospectively maintained robotic database. Retrospective review of this data was performed.

Results

Fifty patients underwent rVHR during the study period. Median body mass index was 31 (interquartile range (IQR) 29–34). Forty‐eight had previous abdominal surgery. Forty‐seven hernias were midline and three were lateral. Regarding hernia width, 15 were <4 cm wide, 32 were 4–10 cm and three were >10 cm. Median total anaesthetic time, docking time and surgical console time were 214 min (IQR 182–252), 5 min (IQR 4–8) and 144 min (IQR 104–174), respectively. No major intra‐operative complications occurred. No documented cases of adhesional complications or chronic post‐operative pain have occurred. To date, two recurrences have occurred in our series. Median length of hospital stay was 3 days (IQR 2–4).

Conclusion

We describe our rVHR technique and report on our series and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.

Lack of online video educational resources for open colorectal surgery training

March 3, 2019 - 21:54

Open surgery presents obstacles to distance learning as methodologies used to record the surgeon's point of view in open surgery remain limited. There are limited resources available online for open colorectal surgery videos. Open surgery videos have a higher number of views compared to laparoscopic surgery.


Background

Video recordings of open surgical procedures could provide a method for enhancing surgical education, analysing operative performance and presenting cases to a wider audience of surgeons. The aim of this pilot study was to systematically search the World Wide Web to determine the availability of open surgery videos and to evaluate their potential training value in terms of the educational content presented.

Methods

A broad search for open right hemicolectomy videos was performed on the three most used English language internet search engines (Google.com, Bing.com and Yahoo.com). All videos of open right hemicolectomy with an English language title were included. Laparoscopic surgery, single‐incision laparoscopic surgery and robotic‐ and hand‐assisted surgery videos were excluded, as were videos from fee charging websites.

Results

A total of 31 relevant websites were identified and 21 open surgery videos were finally included. The characteristics of the patients were presented only in four (19%) videos. A video commentary was present in 12 cases (57.1%) and this was in English language in 11. The median number of views per month was 84.1.

Conclusions

Open surgery videos have a significantly higher number of views per month compared to laparoscopic surgery videos, but current methodologies used to record and render the surgeon's point of view in open operative surgery remain limited.

Clinical value of preoperative CA19‐9 levels in evaluating resectability of gallbladder carcinoma

March 3, 2019 - 21:54
Background

This study evaluated the predictive ability of preoperative carbohydrate antigen 19‐9 (CA19‐9) level in assessing tumour resectability in patients with gallbladder carcinoma (GBC).

Methods

We retrospectively analysed preoperative serum levels of CA19‐9 in 292 patients with potentially resectable GBC between January 2000 and March 2016 in our institution. All final diagnoses were confirmed by pathological examination. The optimal cut‐off point of the CA19‐9 for predicting resectability was determined by the receiver operating characteristic curve. The univariate analysis and multivariate Cox regression model were applied to assess the relationship between the parameters to resectability.

Results

A total of 292 patients with surgical treatment were included, of whom 195 were identified as curative resection (R0 resection), 69 were classified as R1/2 resection and the remaining 28 patients were operated on with palliative surgery. The receiver operating characteristic curve analysis calculated the best CA19‐9 cut‐off point of 98.91 U/mL in the prediction of resectability. Meanwhile, the sensitivity, specificity, positive predictive value and negative predictive value were 76.3%, 70.8%, 85.7% and 56.5%, respectively. In the multivariate logistic regression analysis, CA19‐9 >98.91 U/mL (odds ratio (OR) 6.339, 95% confidence interval (CI) 3.562–11.284, P < 0.001), tumour located on hepatic side (OR 1.787, 95% CI 1.022–3.123, P = 0.042) and advanced American Joint Committee on Cancer stage (OR 2.156, 95% CI 1.180–3.940, P = 0.013) were independent determinants of resectability in patients diagnosed as GBC.

Conclusion

Preoperative CA19‐9 predicts resectability in patients with radiological resectable GBC. Increased preoperative CA19‐9 is related to poor resectability rate.

Prospective randomized comparative study of pigtail catheter drainage versus percutaneous needle aspiration in treatment of liver abscess

March 3, 2019 - 21:54
Background

This prospective randomized comparative study is designed to compare outcomes of ultrasonography‐guided pigtail catheter drainage (PCD) and needle aspiration for the treatment of liver abscesses in terms of days to achieve clinical improvement, 50% reduction in cavity size and duration of hospital stay.

Methods

This is a hospital‐based comparative study conducted in SMS Hospital, Jaipur, India, from May 2015 to May 2017. Sample size was calculated to be 95 subjects in each of the two groups at α error of 0.05 and power of 80%. Independent t‐test was used for statistical analysis.

Results

A total of 190 patients of liver abscess were included in this study and we treated 95 patients with percutaneous needle aspiration (PNA) and remaining patients with PCD along with systemic antibiotics. Mean time for clinical improvement in PNA group (6.96 ± 1.33 days) was higher as compared to PCD group (4.22 ± 1.25 days). The mean time for reduction of cavity size to 50% of original size in PNA group (7.05 ± 1.25 days) was higher as compared to PCD group (4.43 ± 1.27 days). Mean hospital stay of patients in PNA group (12.9 ± 4.02 days) was higher as compared to PCD group (11.44 ± 4.15 days).

Conclusion

Percutaneous catheter drainage is a better modality as compared to PNA especially in larger abscesses which are partially liquefied.

Initial experience with robotic pancreatic surgery in Singapore: single institution experience with 30 consecutive cases

March 3, 2019 - 21:54
Background

Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS.

Methods

This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon.

Results

The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto‐splenectomies (en bloc gastric resection) and 10 spleen‐saving‐RDP. Splenic preservation was successful in 10/11 attempted spleen‐saving‐RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port‐site hernia and no 30‐day/in‐hospital mortalities. The median post‐operative stay was 6.5 (range: 3–36) days and there were six (20%) 30‐day readmissions.

Conclusion

Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy.

Paradox of meritocracy in surgical selection, and of variation in the attractiveness of individual specialties: to what extent are women still disadvantaged?

March 3, 2019 - 21:54
Background

Evidence from outside surgery suggests that meritocracy‐based processes around selection tend to reduce, rather than increase, diversity. In recent years, the surgical training boards have gone to considerable effort to achieve greater transparency and fairness in their selection processes, and to identify those attributes that are believed to best predict future success as a surgeon. This is consistent with the Royal Australasian College of Surgeons Diversity and Inclusion Plan, which places emphasis on gender equity and has goals that include increasing the attractiveness of surgery as a vocation for women, removing impediments to them applying to the surgical training programmes and removing any biases that might disadvantage them during the selection process.

Methods

This study uses the Female Opportunity Index and rate ratio metrics to measure the level of female disadvantage in surgical selection, whether it be by the perception of its attractiveness to women which influences their application rates, or by the likelihood of successful selection for those who have applied, compared with their male counterparts.

Results

There are marked differences between the nine surgical specialties and 13 specialty training boards in both the proportion of women who apply, and the proportion who are successful in gaining entry onto the Surgical Education and Training programmes. The Female Opportunity Index ranged from 0.21 to 0.87, which represents a wide variation between surgical specialties.

Conclusion

These data raise the question as to whether unconscious bias is occurring in an apparently meritocracy‐based selection process in some specialties. The data also suggest that some specialties are relatively unattractive to women, for which the reasons are likely to be complex.

Use of gastrografin in the management of faecal impaction in patients with severe chronic constipation: a randomized clinical trial

March 3, 2019 - 21:54
Background/Aim

Faecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction. Gastrografin is a water‐soluble radiologic contrast agent that may be orally or rectally administered, with proved therapeutic benefits in adhesive small bowel obstruction. Enemas have long been advocated as the best treatment for FI. The purpose of this study was to demonstrate that enteral administration of gastrografin might be more effective than enema in FI treatment inducing intestinal obstruction.

Methods

A double‐blinded, controlled and randomized trial was conducted. Participants received 100 mL of gastrografin (gastrografin group) through nasointestinal tube or enemas (enema group) once daily for six consecutive days. Successful faecal disimpaction, FI time to resolution, Bristol Stool Scale, constipation severity, symptom assessment and adverse events were evaluated.

Results

A total of 124 patients were eligible, but only 83 were enrolled to this trial (mean age: 44 ± 15.8 years). Forty‐two patients received enemas, and 41 patients received gastrografin, with six dropouts in each group. Successful disimpaction was achieved with enemas (69.44%) and gastrografin (88.57%; P = 0.034), mean duration of impaction was strikingly different between the two groups (67.13 versus 31.67, respectively; P < 0.01). Constipation severity and symptom assessment were significantly reduced in the gastrografin group.

Conclusion

Gastrografin given through nasointestinal tube was more effective than enema in the treatment of FI inducing colon obstruction. Gastrografin might be taken into consideration as an effective and safe therapeutic option for FI.

Randomized controlled trial of probiotic use for post‐colonoscopy symptoms

March 3, 2019 - 21:54
Background

Symptoms of bloating, discomfort and altered bowel function persist post‐colonoscopy in up to 20% of patients. A previous randomized controlled trial of probiotics for post‐colonoscopy symptoms has demonstrated a reduction in duration of pain with the use of probiotics. This was performed with air insufflation and the question was asked whether the effect would persist with the use of carbon dioxide to insufflate the colon.

Methods

Eligible patients were recruited and randomized to receive either probiotic or placebo capsules post colonoscopy. A questionnaire was completed documenting the presence of pre‐procedural and post‐procedural symptoms for the following 2 weeks. The results were entered into a database and processed by an independent statistician. The primary outcome was mean pain score and incidence of bloating over the first 7 days and at 14 days post procedure. The secondary outcome was the time to return of normal bowel function.

Results

Two hundred and forty participants were recruited and randomized (120 probiotic and 120 placebo). Data were available for 75 patients in the probiotic and 75 in the placebo group. There was no significant difference between groups in post‐procedural discomfort, bloating nor time to return of normal bowel function. Subgroup analysis of the patients with preexisting symptoms showed a reduction in incidence of bloating with the use of probiotics.

Conclusion

There may be a role for the use of probiotics in the subgroup of patients with preexisting symptoms; however, routine use of probiotics to ameliorate post‐procedural symptoms of carbon dioxide insufflation colonoscopy cannot be advocated.

Surgical outcomes of oesophagectomy or gastrectomy due to cancer for patients ≥75 years of age: a single‐centre cohort study

March 3, 2019 - 21:54
Background

The increasing age of the population and prolonged life expectancy result in a widening of age limit criteria for a variety of surgical procedures. Oesophagectomy and total gastrectomy are complex operations associated with significant risks of post‐operative complications.

Methods

This is a single‐centre cohort study of patients operated with curative intent due to oesophageal or gastric cancer.

Results

From 2007 to 2017, 548 patients underwent surgery with curative intent, with 122 patients (22.3%) classified as elderly (≥75 years). There was no difference in total complication rates between the groups. The adjusted odds ratio for 90‐day mortality after oesophageal resection in the elderly group was 3.65 (95% confidence interval (CI): 1.33–10.03) and after gastrectomy was 1.62 (95% CI: 0.55–4.79). The adjusted hazard ratio for 1‐year mortality after oesophagectomy was 2.29 (95% CI: 1.25–4.19), and after gastrectomy the adjusted hazard ratio was 1.48 (95% CI: 0.75–2.92). In the event of a complication with Clavien–Dindo score IIIb or higher, there was a statistically significant increase of 90‐day mortality to over 50% among elderly patients both after oesophagectomy and gastrectomy (50.0% versus 19.8%; P = 0.005 and 57.1% versus 17.4%; P = 0.012, respectively).

Conclusion

There is a statistically significant increase in 90‐day mortality after oesophageal and gastric cancer surgery in elderly compared with younger patients. Post‐operative complications with high Clavien–Dindo score in patients undergoing oesophagectomy or gastrectomy, with age ≥75 years, are a dramatic risk factor for post‐operative death.

Response to Re: Minimally invasive management of gallstone ileus with cholecystoduodenal fistula

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 267-268, March 2019.

Rectal prolapse in the setting of ascites: a case report

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 269-270, March 2019.

Video recording of surgical operations

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 268-268, March 2019.

Rare pathology of the ileocaecal valve: mature cystic teratoma

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 268-269, March 2019.