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Publisher: Springer-Verlag (Total: 2352 journals)

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Showing 1201 - 1400 of 2352 Journals sorted alphabetically
J. of Clinical Geropsychology     Hybrid Journal   (Followers: 1)
J. of Clinical Immunology     Hybrid Journal   (Followers: 14, SJR: 1.332, h-index: 75)
J. of Clinical Monitoring and Computing     Hybrid Journal   (Followers: 1, SJR: 0.661, h-index: 37)
J. of Clinical Psychology in Medical Settings     Hybrid Journal   (Followers: 14, SJR: 0.46, h-index: 34)
J. of Cluster Science     Hybrid Journal   (SJR: 0.416, h-index: 31)
J. of Coal Science and Engineering (China)     Hybrid Journal   (SJR: 0.188, h-index: 8)
J. of Coastal Conservation     Hybrid Journal   (Followers: 5, SJR: 0.474, h-index: 25)
J. of Coatings Technology and Research     Hybrid Journal   (Followers: 5, SJR: 0.425, h-index: 25)
J. of Combinatorial Optimization     Hybrid Journal   (Followers: 6, SJR: 1.093, h-index: 34)
J. of Communications Technology and Electronics     Hybrid Journal   (Followers: 2, SJR: 0.29, h-index: 16)
J. of Community Genetics     Hybrid Journal   (SJR: 0.727, h-index: 14)
J. of Community Health     Hybrid Journal   (Followers: 8, SJR: 0.921, h-index: 44)
J. of Comparative Physiology A: Neuroethology, Sensory, Neural, and Behavioral Physiology     Hybrid Journal   (Followers: 9, SJR: 1.087, h-index: 74)
J. of Comparative Physiology B : Biochemical, Systemic, and Environmental Physiology     Hybrid Journal   (Followers: 5, SJR: 1.126, h-index: 59)
J. of Compassionate Health Care     Open Access   (Followers: 3)
J. of Computational Analysis and Applications     Hybrid Journal   (SJR: 0.291, h-index: 19)
J. of Computational Electronics     Hybrid Journal   (Followers: 4, SJR: 0.511, h-index: 20)
J. of Computational Neuroscience     Hybrid Journal   (Followers: 25, SJR: 1.068, h-index: 60)
J. of Computer and Systems Sciences Intl.     Hybrid Journal   (SJR: 0.27, h-index: 13)
J. of Computer Science and Technology     Open Access   (Followers: 5, SJR: 0.437, h-index: 31)
J. of Computer Virology and Hacking Techniques     Hybrid Journal   (Followers: 6, SJR: 0.151, h-index: 2)
J. of Computer-Aided Molecular Design     Hybrid Journal   (Followers: 3, SJR: 0.995, h-index: 78)
J. of Computers in Education     Hybrid Journal   (Followers: 12)
J. of Computing in Higher Education     Hybrid Journal   (Followers: 12, SJR: 0.363, h-index: 21)
J. of Consumer Policy     Hybrid Journal   (Followers: 7, SJR: 0.704, h-index: 30)
J. of Contemporary Mathematical Analysis     Hybrid Journal   (SJR: 0.237, h-index: 5)
J. of Contemporary Physics (Armenian Academy of Sciences)     Hybrid Journal   (Followers: 10, SJR: 0.197, h-index: 6)
J. of Contemporary Psychotherapy     Hybrid Journal   (Followers: 5, SJR: 0.397, h-index: 23)
J. of Control Theory and Applications     Hybrid Journal   (Followers: 2, SJR: 0.359, h-index: 19)
J. of Control, Automation and Electrical Systems     Hybrid Journal   (Followers: 9, SJR: 0.231, h-index: 9)
J. of Crop Science and Biotechnology     Hybrid Journal   (Followers: 3)
J. of Cross-Cultural Gerontology     Hybrid Journal   (Followers: 6, SJR: 0.631, h-index: 29)
J. of Cryptographic Engineering     Partially Free   (Followers: 4, SJR: 0.989, h-index: 11)
J. of Cryptology     Hybrid Journal   (Followers: 3, SJR: 1.443, h-index: 55)
J. of Cultural Economics     Hybrid Journal   (Followers: 2, SJR: 0.539, h-index: 29)
J. of Database Marketing & Customer Strategy Management     Hybrid Journal   (Followers: 10, SJR: 0.149, h-index: 8)
J. of Derivatives & Hedge Funds     Hybrid Journal   (Followers: 7, SJR: 0.114, h-index: 5)
J. of Developmental and Physical Disabilities     Hybrid Journal   (Followers: 7, SJR: 0.574, h-index: 29)
J. of Digital Imaging     Hybrid Journal   (Followers: 6, SJR: 0.578, h-index: 35)
J. of Direct Data and Digital Marketing Practice     Hybrid Journal   (Followers: 8, SJR: 0.154, h-index: 6)
J. of Dynamical and Control Systems     Hybrid Journal   (Followers: 1, SJR: 0.4, h-index: 26)
J. of Dynamics and Differential Equations     Hybrid Journal   (SJR: 1.418, h-index: 31)
J. of Earth Science     Hybrid Journal   (Followers: 9, SJR: 0.483, h-index: 16)
J. of Earth System Science     Open Access   (Followers: 49, SJR: 0.448, h-index: 32)
J. of East Asian Linguistics     Hybrid Journal   (Followers: 6, SJR: 0.537, h-index: 20)
J. of Echocardiography     Hybrid Journal   (Followers: 5, SJR: 0.22, h-index: 3)
J. of Ecology and Environment     Open Access   (Followers: 1)
J. of Economic Growth     Hybrid Journal   (Followers: 21, SJR: 3.273, h-index: 63)
J. of Economic Interaction and Coordination     Hybrid Journal   (SJR: 0.263, h-index: 12)
J. of Economics     Hybrid Journal   (Followers: 12, SJR: 0.418, h-index: 23)
J. of Economics and Finance     Hybrid Journal   (Followers: 5, SJR: 0.272, h-index: 19)
J. of Educational Change     Hybrid Journal   (Followers: 6, SJR: 0.961, h-index: 21)
J. of Elasticity     Hybrid Journal   (Followers: 6, SJR: 0.851, h-index: 45)
J. of Electroceramics     Hybrid Journal   (SJR: 0.577, h-index: 57)
J. of Electronic Materials     Hybrid Journal   (Followers: 4, SJR: 0.609, h-index: 75)
J. of Electronic Testing     Hybrid Journal   (Followers: 2, SJR: 0.372, h-index: 27)
J. of Electronics (China)     Hybrid Journal   (Followers: 4, SJR: 0.112, h-index: 9)
J. of Elementary Science Education     Hybrid Journal   (Followers: 8)
J. of Elliptic and Parabolic Equations     Hybrid Journal  
J. of Engineering Mathematics     Hybrid Journal   (SJR: 0.347, h-index: 37)
J. of Engineering Physics and Thermophysics     Hybrid Journal   (Followers: 1, SJR: 0.288, h-index: 11)
J. of Engineering Research     Open Access   (Followers: 1, SJR: 0.145, h-index: 5)
J. of Engineering Thermophysics     Hybrid Journal   (Followers: 4, SJR: 0.763, h-index: 9)
J. of Environmental Studies and Sciences     Partially Free   (Followers: 2)
J. of Ethology     Hybrid Journal   (Followers: 2, SJR: 0.609, h-index: 25)
J. of Evolution Equations     Hybrid Journal   (SJR: 0.826, h-index: 26)
J. of Evolutionary Biochemistry and Physiology     Hybrid Journal   (Followers: 1, SJR: 0.145, h-index: 11)
J. of Evolutionary Economics     Hybrid Journal   (Followers: 7, SJR: 0.492, h-index: 52)
J. of Experimental and Theoretical Physics     Hybrid Journal   (Followers: 3, SJR: 0.458, h-index: 39)
J. of Experimental Criminology     Hybrid Journal   (Followers: 50, SJR: 1.445, h-index: 28)
J. of Failure Analysis and Prevention     Hybrid Journal   (Followers: 5, SJR: 0.261, h-index: 15)
J. of Family and Economic Issues     Hybrid Journal   (Followers: 3, SJR: 0.396, h-index: 32)
J. of Family Violence     Hybrid Journal   (Followers: 41, SJR: 0.639, h-index: 56)
J. of Financial Services Marketing     Hybrid Journal   (Followers: 3, SJR: 0.273, h-index: 10)
J. of Financial Services Research     Hybrid Journal   (Followers: 24, SJR: 0.572, h-index: 36)
J. of Fixed Point Theory and Applications     Hybrid Journal   (SJR: 0.644, h-index: 13)
J. of Fluorescence     Hybrid Journal   (Followers: 3, SJR: 0.465, h-index: 56)
J. of Food Measurement and Characterization     Hybrid Journal   (SJR: 0.307, h-index: 4)
J. of Food Science and Technology     Hybrid Journal   (Followers: 6, SJR: 0.441, h-index: 29)
J. of Forest Research     Hybrid Journal   (Followers: 2, SJR: 0.495, h-index: 27)
J. of Forestry Research     Hybrid Journal   (Followers: 3, SJR: 0.304, h-index: 14)
J. of Fourier Analysis and Applications     Hybrid Journal   (Followers: 1, SJR: 1.18, h-index: 42)
J. of Friction and Wear     Hybrid Journal   (Followers: 7, SJR: 0.373, h-index: 7)
J. of Fusion Energy     Hybrid Journal   (Followers: 3, SJR: 0.387, h-index: 19)
J. of Gambling Studies     Hybrid Journal   (Followers: 7, SJR: 1.171, h-index: 57)
J. of Gastroenterology     Hybrid Journal   (Followers: 11, SJR: 1.651, h-index: 88)
J. of Gastrointestinal Cancer     Hybrid Journal   (Followers: 3, SJR: 0.304, h-index: 39)
J. of Gastrointestinal Surgery     Hybrid Journal   (Followers: 10, SJR: 1.64, h-index: 99)
J. of General Internal Medicine     Hybrid Journal   (Followers: 17, SJR: 1.804, h-index: 134)
J. of General Plant Pathology     Hybrid Journal   (SJR: 0.554, h-index: 22)
J. of Genetic Counseling     Hybrid Journal   (Followers: 6, SJR: 0.902, h-index: 39)
J. of Genetics     Open Access   (Followers: 5, SJR: 0.458, h-index: 28)
J. of Geodesy     Hybrid Journal   (Followers: 8, SJR: 2.173, h-index: 56)
J. of Geographical Sciences     Hybrid Journal   (Followers: 1, SJR: 0.8, h-index: 23)
J. of Geographical Systems     Hybrid Journal   (Followers: 4, SJR: 0.822, h-index: 39)
J. of Geometric Analysis     Hybrid Journal   (Followers: 2, SJR: 1.491, h-index: 27)
J. of Geometry     Hybrid Journal   (Followers: 1, SJR: 0.272, h-index: 15)
J. of Global Optimization     Hybrid Journal   (Followers: 4, SJR: 0.992, h-index: 60)
J. of Global Policy and Governance     Hybrid Journal   (Followers: 10)
J. of Grid Computing     Hybrid Journal   (Followers: 1, SJR: 1.414, h-index: 37)
J. of Happiness Studies     Hybrid Journal   (Followers: 26, SJR: 0.881, h-index: 39)
J. of Hematopathology     Hybrid Journal   (Followers: 3, SJR: 0.2, h-index: 13)
J. of Heuristics     Hybrid Journal   (Followers: 4, SJR: 1.308, h-index: 50)
J. of High Energy Physics     Hybrid Journal   (Followers: 17, SJR: 1.052, h-index: 153)
J. of Homotopy and Related Structures     Hybrid Journal   (SJR: 0.232, h-index: 2)
J. of Housing and the Built Environment     Hybrid Journal   (Followers: 7, SJR: 0.648, h-index: 28)
J. of Huazhong University of Science and Technology [Medical Sciences]     Hybrid Journal   (SJR: 0.344, h-index: 19)
J. of Ichthyology     Hybrid Journal   (Followers: 2, SJR: 0.304, h-index: 10)
J. of Immigrant and Minority Health     Hybrid Journal   (Followers: 12, SJR: 0.759, h-index: 37)
J. of Inclusion Phenomena and Macrocyclic Chemistry     Hybrid Journal   (Followers: 1, SJR: 0.331, h-index: 46)
J. of Indian Council of Philosophical Research     Hybrid Journal  
J. of Indian Philosophy     Hybrid Journal   (Followers: 9, SJR: 0.127, h-index: 12)
J. of Industrial Microbiology and Biotechnology     Hybrid Journal   (Followers: 16, SJR: 0.966, h-index: 80)
J. of Industry, Competition and Trade     Hybrid Journal   (Followers: 8, SJR: 0.327, h-index: 15)
J. of Infection and Chemotherapy     Hybrid Journal   (Followers: 2, SJR: 0.673, h-index: 46)
J. of Information Technology     Hybrid Journal   (Followers: 54, SJR: 1.474, h-index: 55)
J. of Information Technology Teaching Cases     Hybrid Journal   (Followers: 10)
J. of Infrared, Millimeter and Terahertz Waves     Hybrid Journal   (Followers: 2, SJR: 1.25, h-index: 36)
J. of Inherited Metabolic Disease     Hybrid Journal   (Followers: 2, SJR: 1.389, h-index: 77)
J. of Inorganic and Organometallic Polymers and Materials     Partially Free   (Followers: 10, SJR: 0.338, h-index: 33)
J. of Insect Behavior     Hybrid Journal   (Followers: 7, SJR: 0.569, h-index: 39)
J. of Insect Conservation     Hybrid Journal   (Followers: 10, SJR: 0.872, h-index: 43)
J. of Intelligent and Robotic Systems     Hybrid Journal   (Followers: 3, SJR: 0.629, h-index: 43)
J. of Intelligent Information Systems     Hybrid Journal   (Followers: 1, SJR: 0.691, h-index: 43)
J. of Intelligent Manufacturing     Hybrid Journal   (Followers: 3, SJR: 1.397, h-index: 54)
J. of Interventional Cardiac Electrophysiology     Hybrid Journal   (SJR: 0.93, h-index: 43)
J. of Intl. Business Studies     Hybrid Journal   (Followers: 37, SJR: 4.208, h-index: 130)
J. of Intl. Entrepreneurship     Hybrid Journal   (Followers: 12, SJR: 0.549, h-index: 23)
J. of Intl. Migration and Integration / Revue de l integration et de la migration internationale     Hybrid Journal   (Followers: 14, SJR: 0.308, h-index: 13)
J. of Intl. Relations and Development     Hybrid Journal   (Followers: 20, SJR: 0.793, h-index: 22)
J. of Labor Research     Hybrid Journal   (Followers: 19, SJR: 0.394, h-index: 27)
J. of Logic, Language and Information     Hybrid Journal   (Followers: 6, SJR: 0.288, h-index: 25)
J. of Low Temperature Physics     Hybrid Journal   (Followers: 3, SJR: 0.531, h-index: 52)
J. of Machinery Manufacture and Reliability     Hybrid Journal   (Followers: 2, SJR: 0.203, h-index: 7)
J. of Mammalian Evolution     Hybrid Journal   (Followers: 6, SJR: 1.134, h-index: 37)
J. of Mammary Gland Biology and Neoplasia     Hybrid Journal   (Followers: 2, SJR: 2.252, h-index: 83)
J. of Management and Governance     Hybrid Journal   (Followers: 9, SJR: 0.805, h-index: 33)
J. of Management Control     Hybrid Journal   (Followers: 5, SJR: 0.605, h-index: 6)
J. of Marine Science and Application     Hybrid Journal   (Followers: 2, SJR: 0.439, h-index: 11)
J. of Marine Science and Technology     Hybrid Journal   (Followers: 3, SJR: 0.235, h-index: 19)
J. of Maritime Archaeology     Hybrid Journal   (Followers: 17, SJR: 0.228, h-index: 8)
J. of Market-Focused Management     Hybrid Journal   (Followers: 2)
J. of Marketing Analytics     Hybrid Journal   (Followers: 5)
J. of Material Cycles and Waste Management     Hybrid Journal   (Followers: 2, SJR: 0.449, h-index: 22)
J. of Materials Engineering and Performance     Hybrid Journal   (Followers: 23, SJR: 0.544, h-index: 40)
J. of Materials Science     Hybrid Journal   (Followers: 22, SJR: 0.836, h-index: 123)
J. of Materials Science : Materials in Electronics     Hybrid Journal   (Followers: 4)
J. of Materials Science : Materials in Medicine     Hybrid Journal   (Followers: 4)
J. of Mathematical Biology     Hybrid Journal   (Followers: 9, SJR: 1.011, h-index: 71)
J. of Mathematical Chemistry     Hybrid Journal   (Followers: 3, SJR: 0.497, h-index: 45)
J. of Mathematical Fluid Mechanics     Hybrid Journal   (Followers: 8, SJR: 1.22, h-index: 22)
J. of Mathematical Imaging and Vision     Hybrid Journal   (Followers: 5, SJR: 0.901, h-index: 53)
J. of Mathematical Modelling and Algorithms     Hybrid Journal   (Followers: 1, SJR: 0.414, h-index: 23)
J. of Mathematical Sciences     Hybrid Journal   (SJR: 0.272, h-index: 23)
J. of Mathematics Teacher Education     Hybrid Journal   (Followers: 16, SJR: 1.062, h-index: 20)
J. of Maxillofacial and Oral Surgery     Hybrid Journal   (Followers: 3)
J. of Mechanical Science and Technology     Hybrid Journal   (Followers: 5, SJR: 0.589, h-index: 26)
J. of Medical and Biological Engineering     Hybrid Journal   (Followers: 3, SJR: 0.387, h-index: 18)
J. of Medical Humanities     Hybrid Journal   (Followers: 22, SJR: 0.299, h-index: 18)
J. of Medical Systems     Hybrid Journal   (SJR: 0.717, h-index: 44)
J. of Medical Toxicology     Hybrid Journal   (Followers: 5, SJR: 0.874, h-index: 28)
J. of Medical Ultrasonics     Hybrid Journal   (Followers: 2, SJR: 0.18, h-index: 13)
J. of Medicine and the Person     Hybrid Journal  
J. of Membrane Biology     Hybrid Journal   (Followers: 1, SJR: 0.738, h-index: 82)
J. of Micro-Bio Robotics     Hybrid Journal   (SJR: 0.28, h-index: 3)
J. of Microbiology     Hybrid Journal   (Followers: 8, SJR: 0.741, h-index: 43)
J. of Mining Science     Hybrid Journal   (Followers: 4, SJR: 0.317, h-index: 16)
J. of Molecular Evolution     Hybrid Journal   (Followers: 6, SJR: 0.952, h-index: 108)
J. of Molecular Histology     Hybrid Journal   (Followers: 4, SJR: 0.755, h-index: 48)
J. of Molecular Medicine     Hybrid Journal   (Followers: 11, SJR: 2.165, h-index: 113)
J. of Molecular Modeling     Hybrid Journal   (Followers: 4, SJR: 0.466, h-index: 50)
J. of Molecular Neuroscience     Partially Free   (Followers: 11, SJR: 0.988, h-index: 69)
J. of Mountain Science     Hybrid Journal   (Followers: 2, SJR: 0.418, h-index: 15)
J. of Muscle Research and Cell Motility     Hybrid Journal   (Followers: 1, SJR: 1.264, h-index: 55)
J. of Nanoparticle Research     Hybrid Journal   (Followers: 3, SJR: 0.583, h-index: 84)
J. of Natural Medicines     Hybrid Journal   (SJR: 0.602, h-index: 28)
J. of Near-Death Studies     Hybrid Journal   (Followers: 1)
J. of Nephrology     Hybrid Journal   (Followers: 4, SJR: 0.689, h-index: 55)
J. of Network and Systems Management     Hybrid Journal   (SJR: 0.466, h-index: 26)
J. of Neural Transmission     Hybrid Journal   (Followers: 2, SJR: 1.034, h-index: 86)
J. of Neuro-Oncology     Hybrid Journal   (Followers: 2, SJR: 1.274, h-index: 90)
J. of Neuroimmune Pharmacology     Hybrid Journal   (Followers: 1, SJR: 1.662, h-index: 45)
J. of Neurology     Hybrid Journal   (Followers: 16, SJR: 1.429, h-index: 105)
J. of NeuroVirology     Hybrid Journal   (Followers: 1, SJR: 0.979, h-index: 69)
J. of Nondestructive Evaluation     Hybrid Journal   (Followers: 9, SJR: 0.863, h-index: 27)
J. of Nonlinear Science     Hybrid Journal   (SJR: 1.887, h-index: 42)
J. of Nonverbal Behavior     Hybrid Journal   (Followers: 5, SJR: 0.723, h-index: 47)
J. of Nuclear Cardiology     Hybrid Journal   (SJR: 1.024, h-index: 68)
J. of Nutrition, Health and Aging     Hybrid Journal   (Followers: 24, SJR: 0.919, h-index: 60)
J. of Obstetrics and Gynecology of India     Hybrid Journal   (Followers: 4, SJR: 0.214, h-index: 6)
J. of Occupational Rehabilitation     Hybrid Journal   (Followers: 16, SJR: 0.811, h-index: 51)
J. of Ocean Engineering and Marine Energy     Hybrid Journal   (Followers: 3)
J. of Ocean University of China (English Edition)     Hybrid Journal   (Followers: 1, SJR: 0.237, h-index: 11)
J. of Oceanography     Hybrid Journal   (Followers: 10, SJR: 0.796, h-index: 52)
J. of Ocular Biology, Diseases, and Informatics     Hybrid Journal   (SJR: 0.183, h-index: 11)
J. of Optical and Fiber Communications Reports     Hybrid Journal   (Followers: 4)
J. of Optics     Hybrid Journal   (Followers: 8, SJR: 0.214, h-index: 8)
J. of Optimization Theory and Applications     Hybrid Journal   (Followers: 5, SJR: 0.898, h-index: 65)
J. of Ornithology     Hybrid Journal   (Followers: 23)
J. of Orofacial Orthopedics / Fortschritte der Kieferorthopädie     Hybrid Journal   (SJR: 0.574, h-index: 33)

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Journal Cover European Surgery
  [SJR: 0.171]   [H-I: 15]   [8 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 1682-4016 - ISSN (Online) 1682-8631
   Published by Springer-Verlag Homepage  [2352 journals]
  • Reality and truth in surgery
    • Authors: Martin Riegler
      Pages: 41 - 44
      PubDate: 2018-04-01
      DOI: 10.1007/s10353-018-0517-1
      Issue No: Vol. 50, No. 2 (2018)
       
  • An improved laparoscopic technique for myotomy and fundoplication in
           patients with achalasia
    • Authors: Trevor J. D’Netto; Gregory L. Falk; Sophia C. Little
      Pages: 4 - 7
      Abstract: Summary Background Achalasia is preferentially treated by esophageal myotomy. We present a potentially more secure technique of myotomy and fundoplication incorporating a three-stitch cardiopexy on the right of the esophagus and a left lateral fixation at the angle of His. Method The process of dissection, fixation and repair is described in detail using intraoperative photographs to illustrate each step. Conclusion This technique is especially suited to achalasia patients with abnormalities of the hiatal anatomy. This paper offers an improvement to a well-practiced technique, which is presented in significant detail. It is of particular interest as it may improve outcomes for achalasia treatment thanks to a more secure technique.
      PubDate: 2018-02-01
      DOI: 10.1007/s10353-017-0510-0
      Issue No: Vol. 50, No. 1 (2018)
       
  • Integrating interventional oncology in the treatment of liver tumors
    • Authors: D. Putzer; P. Schullian; E. Braunwarth; M. Fodor; F. Primavesi; B. Cardini; T. Resch; R. Oberhuber; M. Maglione; C. Margreiter; S. Schneeberger; S. Stättner; D. Öfner-Velano; W. Jaschke; R. J. Bale
      Abstract: Summary Background Percutaneous ablation techniques offer a vast armamentarium for local, minimally invasive treatment of liver tumors, nowadays representing an established therapeutic option, which is integrated in treatment algorithms, especially for non-resectable liver tumors. The results of ablative treatment compare very well to surgical treatment in liver lesions, and confirm that these techniques are a valuable option for bridging for transplantation. Different techniques have been established to perform tumor ablation, and the feasibility varies according to the procedure and technical skills of the operator, depending on the size and location of the liver lesion. In recent years, stereotactic multi-needle techniques using 3D trajectory planning, general anesthesia, and tube disconnection during needle placement have had a strong impact on the application range of ablation for liver tumors. Conclusion It is well known that creating a sufficient ablation margin and overlapping ablation zones is one key issue to enable ablation of large liver lesions with tumor-free margins (A0 ablation in analogy to R0 resection). Image fusion during treatment and follow-up assure highly accurate staging procedures and interventional planning. Novel aspects Review on the standards in ablation techniques for the treatment of liver tumors. Update on different ablation techniques, indications, and contraindications for percutaneous liver tumor treatment. Summary of recently published reports on liver tumor ablation.
      PubDate: 2018-04-13
      DOI: 10.1007/s10353-018-0521-5
       
  • Perioperative management of liver surgery—review on pathophysiology of
           liver disease and liver failure
    • Authors: Lukas Gasteiger; Stephan Eschertzhuber; Werner Tiefenthaler
      Abstract: Summary An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.
      PubDate: 2018-04-13
      DOI: 10.1007/s10353-018-0522-4
       
  • Should surgical ex vivo lymphadenectomy be a standard procedure in the
           management of patients with gastric cancer'
    • Authors: Mihai Dan Boşcaiu; Mihnea Dragomir; Bogdan Trandafir; Vlad Herlea; Cătălin Vasilescu
      Abstract: Summary Background The total number of retrieved and analyzed lymph nodes is known to impact on survival of patients with gastric cancer. Multiple factors are responsible for the high variability of total lymph node yields. Among these factors, the use of surgical ex vivo lymphodissection may be significant for optimizing the lymph node count. Methods This article includes our personal experience regarding ex vivo lymphodissection and a meta-analysis which included all the articles related to this topic. We compared two groups of patients with gastric adenocarcinoma who underwent gastrectomy with at least D2 lymphodissection. In the first group, the lymph node count was performed by the pathologist. As for the second, the surgeon performed an ex vivo lymphodissection of the resected specimens before submitting these to the pathologist for further analysis. For the systematic literature review and the meta-analysis, the PubMed database was thoroughly searched, and in order to assess the inter-study heterogeneity, we used I2 and chi2 tests. Results The total lymph node yield proved to be significantly higher in the ex vivo lymphodissection group than in the non-ex vivo lymphodissection group (37.4 versus 23.2, p < 0.001). The meta-analysis confirmed our results: the cumulative mean difference between ex vivo lymphodissection and non-ex vivo lymphodissection group is 11.52 (p < 0.00001); inter-study heterogeneity was statistically significant (I2 > 58%, chi2 = 9.63, df = 4, p = 0.05). Conclusion Surgical ex vivo lymphodissection increases the total lymph node yield and may lead not only to a more accurate staging of gastric cancer, but also to an improved clinical outcome.
      PubDate: 2018-03-28
      DOI: 10.1007/s10353-018-0519-z
       
  • The modified Glasgow prognostic score in Crohn’s disease—does it
           predict short-term outcome'
    • Authors: Stanislaus Argeny; Anton Stift; Michael Bergmann; Martina Mittlböck; Svenja Maschke; Stefan Riss
      Abstract: Summary Background The modified Glasgow prognostic score (mGPS) has recently gained increased attention as a prognostic marker for malignant disease survival and postoperative short-term complications. Due to lacking data, the present study was conducted to correlate the mGPS with the postoperative course in patients following surgery for Crohn’s disease. Methods We enrolled 341 patients who underwent intestinal resection for symptomatic Crohn’s disease at a tertiary referral centre between 2000 and 2014. All relevant data were obtained from the institutional database and individual chart review. Thirty-day morbidity was defined according to the Clavien–Dindo classification. Results A total of 79 (23.17%) postoperative complications were identified (grade I and II: n = 54, 15.84%; grade III and IV: n = 23, 6.74%; grade V: n = 2, 0.59%). The mGPS did not show any correlation with an eventful postoperative course following surgery (no complication: median mGPS: 1, range 0–2; complications: median mGPS: 1, range 0–2; p = 0.8521). In addition, the occurrence of an anastomotic leakage was not associated with a higher mGPS (p = 0.8592). Patients with an acute indication for surgery (n = 29, 11.44%) had higher median mGPS (median: 2, range 0–2) in contrast to patients who were operated on electively (median: 1, range 0–2; p = 0.0003). No other correlation between surgical characteristics and mGPS was detected. Conclusions In the present study, we could clearly demonstrate that an acute indication for surgery in symptomatic Crohn’s disease is associated with higher mGPS scores. However, the mGPS did not correlate with postoperative complications. Further studies are required to define the prognostic value of mGPS in Crohn’s disease patients.
      PubDate: 2018-03-22
      DOI: 10.1007/s10353-018-0518-0
       
  • A gastrointestinal stromal tumour mimicking solid pseudopapillary
           neoplasia of the pancreas—a case report
    • Authors: C. Müller; A. Beer; F. Wrba; T. Brodowicz; N. Bastati; A. Ba-Ssalamah; M. Schindl
      Abstract: Summary Background Diagnosis of large, heterogenous lesions of the pancreas with solid and cystic components is often challenging. The spectrum of differential diagnoses is broad, and clinical as well as radiological findings may be similar. Methods Detailed analysis of a clinical case and review of literature Results We present the case of a 28-year-old woman with a large, heterogenous tumour of the pancreatic head that was incidentally found in routine ultrasound during pregnancy. The presence of a solid pseudopapillary neoplasm (SPN) was suspected because of typical clinical and radiological characteristics. The patient underwent partial pancreatoduodenectomy and surprisingly, histological work-up confirmed a pancreatic extra-gastrointestinal stromal tumour (EGIST). Conclusion As clinical and radiological findings may be misleading in a large, heterogenous tumour of the pancreas, a biopsy with histological proof of diagnosis is recommended, especially in situations where a neoadjuvant treatment may be considered.
      PubDate: 2018-03-08
      DOI: 10.1007/s10353-018-0516-2
       
  • Shaping the future of liver surgery
    • Authors: D. Pereyra; P. Starlinger
      Abstract: Summary Background While liver surgery has become a safe and feasible operation technique, the incidence of postoperative liver dysfunction still remains a central problem. Approximately 10% of patients undergoing liver resection were shown to develop liver dysfunction, which is associated with an increased risk of morbidity and mortality. Yet, to date there is no effective treatment option for postoperative liver dysfunction available. The development of postoperative liver dysfunction was linked to a disruption in the liver’s potential to regenerate. Thus, it is importance to elucidate the underlying mechanisms of liver regeneration and to find potential therapeutic targets for the treatment of patients with postoperative liver dysfunction. Methods A review of the literature was carried out. Results We report on potential future interventions for improvement of liver regeneration after surgical resection. Moreover, we evaluate the benefits and drawbacks of hepatic progenitor cell therapy and hematopoietic stem cell therapy. However, the most significant improvement seems to come from molecular targets. Indeed, von Willebrand factor and its pharmacologic manipulation are among the most promising therapeutic targets to date. Furthermore, using the example of platelet-based therapy, we stress the potentially adverse effects of treatments for postoperative liver dysfunction. Conclusion The present review reports on the newest advances in the field of regenerative science, but also underlines the need for more research in the field of postoperative liver regeneration, especially in regard to translational studies.
      PubDate: 2018-03-06
      DOI: 10.1007/s10353-018-0515-3
       
  • Esophagectomy for stage IV achalasia
    • Authors: Alberto Aiolfi; Emanuele Asti; Carlo Galdino Riva; Luigi Bonavina
      Abstract: Summary Background Achalasia is a rare esophageal motility disorder characterized by defective lower esophageal sphincter relaxation and esophageal body aperistalsis. Endoscopic balloon dilation and laparoscopic myotomy are effective initial treatments in patients with early-stage disease. Indications for upfront esophagectomy in stage IV disease are still debated. Methods Retrospective, observational, single center study including consecutive patients who underwent esophagectomy for end-stage achalasia. A literature search was performed additionally. Results Out of 385 patients referred to our department for achalasia, 6 (1.6%) had previous unsuccessful surgical myotomy and underwent esophagectomy for stage IV disease. There were 4 females and the median age was 54.4 years (range 33–69). Most commonly reported symptoms were regurgitation (100%), dysphagia (83%), chest pain (67%), and recurrent episodes of pneumonia and/or chronic cough (50%). Two patients were incidentally diagnosed with squamous-cell carcinoma in the surgical specimen. A hybrid Ivor-Lewis esophagectomy was the most commonly performed operation. The median operative time was 320 min (range 290–365). The median in-hospital stay was 13 days. No anastomotic leaks occurred. The overall postoperative morbidity rate was 33% and there was no mortality. A total of 1422 esophagectomies for end-stage achalasia were reported in the literature. The stomach was the most commonly used esophageal substitute (94%). The anastomotic leak rate varied from 0 to 17%, and the postoperative mortality from 0 to 5.4%. Conclusion Selected stage IV achalasia patients with recurrent and disabling symptoms after previously failed Heller myotomy and/or endoscopic treatments should be offered minimally invasive esophagectomy.
      PubDate: 2018-02-23
      DOI: 10.1007/s10353-018-0514-4
       
  • Gender-related differences in patients with colon cancer resection
    • Authors: Rüdiger Braun; Claudia Benecke; Jan Nolde; Markus Kleemann; Markus Zimmermann; Tobias Keck; Tilman Laubert
      Abstract: Summary Background In recent years, studies have revealed gender-related differences in many fields of medicine. Data on oncologic surgical patients show different pathologic, perioperative, and long-term outcomes between men and women with conflicting results. Very limited data are available on gender-related differences in colorectal cancer patients. Methods We analyzed a cohort of patients who had surgery for colon cancer at our center between 01/1990 and 12/2015. Clinical, pathological, perioperative, and long-term survival data were retrieved from a prospective database and gender-related differences were calculated for the overall cohort as well as for open and laparoscopic sub-cohorts. Results In total, 1786 patients, 909 (50.9%) male, 877 (49.1%) female, were included. Women had clinical symptoms more often, but histopathologic and resection parameters as well as tumor location did not differ significantly between groups. The majority (n = 1609, 90.1%) underwent resection with anastomosis (male vs. female n.s.). Laparoscopic surgery was performed in 640 (35.8%, male vs. female n.s.). Men had a higher rate of anastomotic leakage (n = 50 [5.5%] vs. n = 30 [3.7%], p = 0.034). Other complications also occurred significantly more often in males. Analysis of open and laparoscopic surgery showed significant differences in complication rates only within the open group. The 5‑ and 10-year overall survival rates did not differ significantly. Conclusions Female and male patients encounter different rates of perioperative complications when undergoing surgery for colon cancer. In times where individualized treatment regimens are attempted to be established, future studies should take gender-related differences more into account. This study describes (1) gender-related differences in complication rates in the defined cohort of colon cancer patients, (2) higher rates of gender-related differences with regard to open versus laparoscopic procedures, and (3) equal long-term survival rates with regard to gender and laparoscopic versus open surgery.
      PubDate: 2018-02-16
      DOI: 10.1007/s10353-018-0513-5
       
  • Feasibility evaluation of an action camera for video documentation in open
           abdominal surgery
    • Authors: A. M. Luu; T. Herzog; W. Uhl; O. Belyaev
      Abstract: Summary Background Intraoperative video recording in abdominal surgery has become indispensable for educational and scientific reasons. Documentation of open surgery is still technically demanding. Since no perfect camera system exists, modern action cameras may offer a solution to this problem. Methods A head-mounted ActionPro X7 camera (ACTIONPRO, Roethenbach, Germany) was tested in 50 open abdominal surgeries. Results Full HD (High Definition) videos were of excellent quality and allowed a first-person view of the operation field. Short battery life of approximately 80 min, wearing discomfort, and recurrent connectivity problems were significant limitations. Conclusions Modern action cameras can provide high-quality videos in open abdominal surgery. They offer an inexpensive and widely available alternative for surgical video documentation. Novel aspects (1) First-time usage of an action camera in major open abdominal surgery. (2) Handsfree filming allowing easy documentation of versatile technical approaches and special intraoperative observations. (3) High-quality footage filmed with a cost-effective camera.
      PubDate: 2018-02-16
      DOI: 10.1007/s10353-018-0512-6
       
  • Delphi comes to Milan to stop oracles on GERD and Barrett’s
           esophagus
    • Authors: Martin Riegler
      PubDate: 2018-01-18
      DOI: 10.1007/s10353-018-0511-7
       
  • Hilar en bloc resection for hilar cholangiocarcinoma in patients with
           limited liver capacities—preserving parts of liver segment 4
    • Authors: Sven Jonas; Felix Krenzien; Georgi Atanasov; Hans-Michael Hau; Matthias Gawlitza; Michael Moche; Georg Wiltberger; Johann Pratschke; Moritz Schmelzle
      Abstract: Summary Background A right trisectionectomy with portal vein resection represents the conventional approach for hilar cholangiocarcinoma. Here, we present a technical modification of hilar en bloc resection in order to increase the remnant volume by partially preserving liver segment 4. Methods The caudal parenchymal dissection line starts centrally between the left lateral and left medial segments. Cranially, the resection line switches to the right towards Cantlie’s line and turns again upwards perpendicularly. Hence, segment 4a and subtotal segment 4b are partially preserved by this novel technique. The left hepatic duct is dissected at the segmental ramification and reconstruction is performed as a single hepaticojejunostomy. The feasibility of the novel parenchyma-sparing approach for hilar cholangiocarcinoma was proven in a case series and medical records were reviewed retrospectively. Results Ten patients (6 male, 4 female) underwent segment 4 partially preserving right trisectionectomy for hilar cholangiocarcinoma. Estimated future liver remnant volume was significantly increased (FLRV 38.3%), when compared to standard right trisectionectomy (FLRV 23.9%; p < 0.01). Three of 10 liver resections were associated with major surgical complications (≥IIIb; n = 3); categorized according to the Dindo–Clavien classification. No patient died due to complications associated with postoperatively impaired liver function. Tumor-free margins could be achieved in 8 patients while median overall survival and disease-free survival were 547 and 367 days, respectively. Conclusion This novel parenchyma-sparing modification of hilar en bloc resection by partially preserving segment 4 allows to safely increase the remnant liver volume without neglecting principles of local radicality.
      PubDate: 2018-01-02
      DOI: 10.1007/s10353-017-0507-8
       
  • Sequestration mucoceles presenting as rectal tumors following stapled
           hemorrhoidectomy
    • Authors: Yeqian Huang; Assad Zahid; Christopher J. Young
      Abstract: Summary Background Gastrointestinal tract mucoceles rarely occur after stapled anastomoses. Their presentation can be incidental and mimic anastomotic tumors. Case reports Two males, both of whom had undergone Milligan–Morgan excisional hemorrhoidectomy (EH) 15 and 12 years prior to stapled hemorrhoidectomy (SH), presented 12 and 10 years after SH, respectively, with incidentally found low rectal tumors. Both patients were assessed by the surgeon who performed the SH, and after examination and investigation, they were found to have sequestration mucoceles which were drained and observed respectively, with no further long-term problems. Conclusion These two cases illustrate the potential for development of sequestration mucoceles post-SH, both unique and uncommon, and serve to remind us of the benefits of a thorough medical and surgical history, and the extended range of differential diagnoses for rectal tumors in the era of extensive use of surgical staples.
      PubDate: 2018-01-02
      DOI: 10.1007/s10353-017-0508-7
       
  • Pseudoachalasia secondary to pleural mesothelioma
    • Authors: Pamela Milito; Michael Denis Kelly; Emanuele Asti; Luigi Bonavina
      Abstract: Summary Background Pseudoachalasia due to an occult malignant tumor accounts for about 5% of patients presenting with clinical features of achalasia. Pleural mesothelioma is a rare cause of pseudoachalasia and may present without respiratory symptoms or chest pain. Methods We present two cases of pseudoachalasia from pleural mesothelioma diagnosed by laparoscopic biopsy over a 10-year period. Results In both patients, the onset of the disease was atypical, with dysphagia and weight loss being the predominant symptoms; no dyspnea or chest pain was reported. Prolonged (>40 years) occupational exposure to asbestos was reported only by one of the patients. Treatment was palliative and consisted of endoscopic stenting and chemotherapy. Conclusion The diagnosis of pseudoachalasia is not always straightforward. Laparoscopy is a safe and effective method for obtaining a biopsy.
      PubDate: 2017-12-22
      DOI: 10.1007/s10353-017-0509-6
       
  • How many parathyroid glands can be identified during thyroidectomy'
    • Authors: Elisabeth Gschwandtner; Rudolf Seemann; Claudia Bures; Lejla Preldzic; Eduard Szucsik; Michael Hermann
      Abstract: Summary Background The purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome. Methods Parathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months. Results The mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not. Conclusion Even an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.
      PubDate: 2017-12-13
      DOI: 10.1007/s10353-017-0502-0
       
  • Bile leak from the gallbladder fossa after liver transplantation
    • Authors: Hugo J. R. Bonatti; Michael R. Corey; Joshua T. Taylor; Sunil K. Geevarghese
      Abstract: Summary Background Bile leaks are common complications following liver transplantation (LT). The majority of leaks involve the anastomosis but other sites should be considered. Bile leaks are associated with biliary peritonitis and intra-abdominal abscess formation. Subvesical bile ducts formerly called ducts of Luschka are aberrant bile ducts in the gallbladder fossa. Leaks from this structure have been reported following laparoscopic cholecystectomy. Only three cases of leaks from this duct after LT have been thus far reported. Case report A 43-year-old man with a MELD (model for end stage liver disease) score of 29 underwent an uncomplicated LT for hepatitis C–cirrhosis and reformed alcohol abuse. Four days after discharge he developed significant abdominal pain and leukocytosis of 16,000/ml; AST was 23 IU/l and total bilirubin 2.0 mg/dl. A computed tomography scan showed massive ascites and a perihepatic hematoma. Paracentesis (5 l) revealed 10,000 nucleated cells, 98% neutrophils, and a bilirubin level of 3.4 mg/dl. Antibiotics were started; endoscopic retrograde cholangiopancreatography showed a patent anastomosis but a small leak from a side branch of the right hepatic duct. A transampullary common bile duct stent was placed. The patient developed increasing abdominal pain, ileus, and underwent laparotomy during which the perihepatic hematoma was evacuated and a bile leak from a subvesical bile duct was identified and oversewn. Cultures grew Escherichia coli and antibiotics were continued. The patient recovered from the complication and the biliary stent was removed after the leak had completely sealed. The patient is alive with a well-functioning graft 4 years after the procedure. Conclusion Leaks from subvesical bile ducts are rare complications in LT recipients, but should be recognized as a source of intra-abdominal infection.
      PubDate: 2017-11-30
      DOI: 10.1007/s10353-017-0505-x
       
  • Metastasis to the esophagus from primary adenocarcinoma of the lung
    • Authors: Simone Zanghì; Stefano Siboni; Emanuele Asti; Antonella Festa; Luigi Bonavina
      Abstract: Summary Background Metastasis to the esophagus is a rare event that can occur by direct infiltration of malignancies from nearby organs or, more infrequently, via lymphatic or hematogenous spread. Methods We reviewed the hospital charts of a patient presenting with dysphagia in whom a distant metastasis to the esophagus from a primary lung adenocarcinoma was documented. A review of the pertinent literature was performed. Results A 74 year-old man with previous history of lung cancer and transoral septum stapling for Zenker’s diverticulum presented with subtotal dysphagia and chest pain. On upper gastrointestinal endoscopy, a vegetating mass of the middle esophagus, covered by fragile and bleeding mucosa, was found. Esophageal biopsies demonstrated metastasis from a poorly differentiated lung adenocarcinoma with evidence of thyroid transcription factor (TTF) positive neoplastic cells. A computed tomography scan revealed a radiopaque mass in the upper right lung. Combination chemotherapy was initiated and a partially covered stent was placed endoscopically. Conclusions A distant metastatic tumor to the esophagus with mucosal infiltration is an exceptional event. In our patient, immunohistochemistry was useful to confirm the diagnosis of primary lung carcinoma.
      PubDate: 2017-11-24
      DOI: 10.1007/s10353-017-0501-1
       
  • A propensity score matched case-control comparative study of totally
           laparoscopic distal gastrectomy and laparoscopic-assisted distal
           gastrectomy for early gastric cancer
    • Authors: Sung Don Oh; Sung Jin Oh; Byoung Jo Suh; Jin Yong Shin; Jong Kwon Park
      Abstract: Summary Background Intracorporeal anastomosis remains a difficult procedure. This study was designed to clarify the advantage of totally laparoscopic distal gastrectomy (TLDG) compared with laparoscopic-assisted distal gastrectomy (LADG) regarding short-term surgical outcomes. Methods We retrospectively identified 273 patients who were preoperatively diagnosed with early gastric cancer and underwent LADG or TLDG between March 2010 and May 2016. A propensity score matching analysis was used to create patient groups matched for sex, age, body mass index, previous abdominal surgery history, and American Society of Anesthesiologist score. Results The TLDG group showed statistically shorter operative time (250.9 ± 4.6 min vs. 281.8 ± 7.3 min, p = 0.000), lower estimated blood loss (77.6 ± 3.3 ml vs. 122.4 ± 6.2 ml, p = 0.000), and shorter time to first flatus after surgery (2.9 ± 0.1 days vs. 3.2 ± 0.1 days, p = 0.001) compared with the LADG group. However, there was no specific superiority in terms of the inflammatory profiles on postoperative days 1, 2, 4, and 7 between the two groups. Complication rates were also similar in the two groups (13.3% LADG vs. 6.1% TLDG). Conclusion This study shows that TLDG for early gastric cancer is a safe surgical procedure and superior in cosmesis compared with LADG.
      PubDate: 2017-11-06
      DOI: 10.1007/s10353-017-0495-8
       
  • Risk reduction of hypocalcemia after thyroidectomy
    • Authors: Cathleen J. O’Neill; M. Jinih; S. Boyle; S. A. Brennan; M. Majeed; A. A. Achakzai; H. P. Redmond
      Abstract: Summary Background Hypocalcemia is a well-described complication associated with total thyroidectomies. We investigated the role of early intraoperative parathyroid hormone (PTH) measurement and relative differences in PTH in predicting those patients at risk of postoperative hypocalcemia. Methods This was a retrospective study. Inclusion criteria were all patients undergoing completion/total thyroidectomy from March 2016 to March 2017 under a single surgeon. All patients had PTH assay performed at induction of anesthesia and intraoperatively (IOPTH) following thyroid excision. The differences in mean between preoperative vs. intraoperative PTH were assessed using a Wilcoxon rank-sum test. Relationships between PTH and ∆PTH with postoperative calcium levels were assessed using Pearson’s correlation and a binomial regression analysis was also performed. Results The cohort comprised 25 female and three male patients. The mean IOPTH level was significantly lower than the preoperative levels (18.6 ± 19.4 vs. 52.11 ± 46.3; two-tailed p <0.0001). The mean postoperative calcium level was significantly lower than the preoperative calcium level (2.22 ± 0.2 mmol/l vs. 2.29 ± 0.16 mmol/l, respectively, p = 0.162). Attempted correlation of IOPTH levels with postoperative calcium yielded a Pearson’s correlation coefficient R of 0.064 (p = 0.748). A weakly negative correlation was found between ∆PTH and postoperative calcium, R = −0.216. Binomial logistic regression analysis was not statistically significant for this cohort (X2 = 10.8; p = 0.216). Conclusion We found no association between PTH levels and postoperative calcium levels. ∆PTH may be a superior parameter in predicting postoperative hypocalcemia in total thyroidectomy. Post hoc analysis of existing study databases could further demonstrate the advantage of ∆PTH in risk stratification.
      PubDate: 2017-11-03
      DOI: 10.1007/s10353-017-0496-7
       
 
 
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