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Publisher: Springer-Verlag   (Total: 2345 journals)

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Showing 1201 - 1400 of 2345 Journals sorted alphabetically
J. of Coal Science and Engineering (China)     Hybrid Journal   (SJR: 0.188, h-index: 8)
J. of Coastal Conservation     Hybrid Journal   (Followers: 7, 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: 5, 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   (Followers: 1, 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: 8, SJR: 1.087, h-index: 74)
J. of Comparative Physiology B : Biochemical, Systemic, and Environmental Physiology     Hybrid Journal   (Followers: 4, SJR: 1.126, h-index: 59)
J. of Compassionate Health Care     Open Access   (Followers: 2)
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: 24, 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: 2, SJR: 0.995, h-index: 78)
J. of Computers in Education     Hybrid Journal   (Followers: 10)
J. of Computing in Higher Education     Hybrid Journal   (Followers: 13, 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: 11, 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: 10, SJR: 0.231, h-index: 9)
J. of Crop Science and Biotechnology     Hybrid Journal   (Followers: 7)
J. of Cross-Cultural Gerontology     Hybrid Journal   (Followers: 6, SJR: 0.631, h-index: 29)
J. of Cryptographic Engineering     Partially Free   (Followers: 5, 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: 4, SJR: 0.539, h-index: 29)
J. of Database Marketing & Customer Strategy Management     Hybrid Journal   (Followers: 8, SJR: 0.149, h-index: 8)
J. of Derivatives & Hedge Funds     Hybrid Journal   (Followers: 8, SJR: 0.114, h-index: 5)
J. of Developmental and Physical Disabilities     Hybrid Journal   (Followers: 8, SJR: 0.574, h-index: 29)
J. of Digital Imaging     Hybrid Journal   (Followers: 10, 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: 2, 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: 43, 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: 4, SJR: 0.22, h-index: 3)
J. of Economic Growth     Hybrid Journal   (Followers: 28, 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: 17, SJR: 0.418, h-index: 23)
J. of Economics and Finance     Hybrid Journal   (Followers: 6, SJR: 0.272, h-index: 19)
J. of Educational Change     Hybrid Journal   (Followers: 7, 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: 5, 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: 9)
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   (SJR: 0.145, h-index: 11)
J. of Evolutionary Economics     Hybrid Journal   (Followers: 9, 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: 46, 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: 6, SJR: 0.396, h-index: 32)
J. of Family Violence     Hybrid Journal   (Followers: 35, 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: 23, 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: 3, SJR: 0.495, h-index: 27)
J. of Forestry Research     Hybrid Journal   (Followers: 5, 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: 12, 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: 6, SJR: 1.64, h-index: 99)
J. of General Internal Medicine     Hybrid Journal   (Followers: 16, 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: 5, SJR: 0.902, h-index: 39)
J. of Genetics     Open Access   (Followers: 4, 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: 11)
J. of Grid Computing     Hybrid Journal   (Followers: 1, SJR: 1.414, h-index: 37)
J. of Hand and Microsurgery     Hybrid Journal   (Followers: 1)
J. of Happiness Studies     Hybrid Journal   (Followers: 23, SJR: 0.881, h-index: 39)
J. of Hematopathology     Hybrid Journal   (Followers: 4, SJR: 0.2, h-index: 13)
J. of Heuristics     Hybrid Journal   (Followers: 5, SJR: 1.308, h-index: 50)
J. of High Energy Physics     Hybrid Journal   (Followers: 19, 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: 3, 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: 12, SJR: 0.127, h-index: 12)
J. of Industrial Microbiology and Biotechnology     Hybrid Journal   (Followers: 15, 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: 1, SJR: 0.673, h-index: 46)
J. of Information Technology     Hybrid Journal   (Followers: 53, SJR: 1.474, h-index: 55)
J. of Information Technology Teaching Cases     Hybrid Journal   (Followers: 9)
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: 9, SJR: 0.338, h-index: 33)
J. of Insect Behavior     Hybrid Journal   (Followers: 8, 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: 2, 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: 32, SJR: 4.208, h-index: 130)
J. of Intl. Entrepreneurship     Hybrid Journal   (Followers: 9, SJR: 0.549, h-index: 23)
J. of Intl. Migration and Integration / Revue de l integration et de la migration internationale     Hybrid Journal   (Followers: 13, 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: 18, SJR: 0.394, h-index: 27)
J. of Logic, Language and Information     Hybrid Journal   (Followers: 7, 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: 5, 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: 14, SJR: 0.805, h-index: 33)
J. of Management Control     Hybrid Journal   (Followers: 4, 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: 21, SJR: 0.228, h-index: 8)
J. of Market-Focused Management     Hybrid Journal   (Followers: 2)
J. of Marketing Analytics     Hybrid Journal   (Followers: 4)
J. of Material Cycles and Waste Management     Hybrid Journal   (Followers: 3, SJR: 0.449, h-index: 22)
J. of Materials Engineering and Performance     Hybrid Journal   (Followers: 22, SJR: 0.544, h-index: 40)
J. of Materials Science     Hybrid Journal   (Followers: 20, SJR: 0.836, h-index: 123)
J. of Materials Science : Materials in Electronics     Hybrid Journal   (Followers: 5)
J. of Materials Science : Materials in Medicine     Hybrid Journal   (Followers: 5)
J. of Mathematical Biology     Hybrid Journal   (Followers: 11, SJR: 1.011, h-index: 71)
J. of Mathematical Chemistry     Hybrid Journal   (Followers: 4, SJR: 0.497, h-index: 45)
J. of Mathematical Fluid Mechanics     Hybrid Journal   (Followers: 7, SJR: 1.22, h-index: 22)
J. of Mathematical Imaging and Vision     Hybrid Journal   (Followers: 4, SJR: 0.901, h-index: 53)
J. of Mathematical Modelling and Algorithms     Hybrid Journal   (Followers: 2, 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: 15, SJR: 1.062, h-index: 20)
J. of Maxillofacial and Oral Surgery     Hybrid Journal   (Followers: 2)
J. of Mechanical Science and Technology     Hybrid Journal   (Followers: 6, SJR: 0.589, h-index: 26)
J. of Medical and Biological Engineering     Hybrid Journal   (Followers: 1, 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   (Followers: 1, 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: 2, 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: 9, 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: 14, 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: 3, 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: 2)
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: 3, 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: 15, 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: 10, SJR: 0.863, h-index: 27)
J. of Nonlinear Science     Hybrid Journal   (Followers: 1, 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: 6, 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: 2)
J. of Ocean University of China (English Edition)     Hybrid Journal   (Followers: 1, SJR: 0.237, h-index: 11)
J. of Oceanography     Hybrid Journal   (Followers: 9, 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: 7, 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)
J. of Orthopaedic Science     Hybrid Journal   (Followers: 6, SJR: 0.708, h-index: 48)
J. of Paleolimnology     Hybrid Journal   (Followers: 5, SJR: 0.984, h-index: 64)
J. of Parasitic Diseases     Hybrid Journal   (Followers: 2, SJR: 0.298, h-index: 9)
J. of Pediatric Neuropsychology     Hybrid Journal   (Followers: 3)
J. of Pest Science     Hybrid Journal   (Followers: 1, SJR: 1.341, h-index: 28)
J. of Pharmaceutical Health Care and Sciences     Open Access  

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Journal Cover European Surgery
  [SJR: 0.171]   [H-I: 15]   [6 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  [2345 journals]
  • Surgery of acute severe ulcerative colitis. Subtotal colectomy: when and
           how to do it?
    • Authors: Rosario Fornaro; Elisa Caratto; Michela Caratto; Camilla Sticchi; Alexander Salerno; Rita Bianchi; Stefano Scabini; Marco Casaccia
      Pages: 108 - 112
      Abstract: Summary Purpose The aim of this review is to focus attention on the role of surgery in the management of acute ulcerative colitis (UC). UC is a chronic inflammatory disease of the mucosa of the large intestine. Methods We have examined the data from the literature of the past 20 years and we have analyzed the role of emergency surgery. A medical literature search was conducted using Medline, Embase, Ovid Journals, and Science Direct. Results Acute severe colitis (ASC) occurs in 12–25% of patients affected by UC. Patients with ASC should be managed by a multidisciplinary team. Aggressive medical or surgical treatment is undertaken with the final aim of reducing mortality. Intravenous corticosteroids are the mainstay of therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids after 3 days. In the event that there has been no response to medical rescue therapy after 4–7 days, the patient must undergo urgent colectomy surgery. Prolonged observation is counterproductive as over time it increases the risk of toxic megacolon and of perforation burdened with a very high mortality rate. Conclusions The best possible treatment is represented by subtotal colectomy with ileostomy and preservation of a long rectal stump. Emergency colectomy is characterized by high morbidity and low mortality rates.
      PubDate: 2017-06-01
      DOI: 10.1007/s10353-016-0458-5
      Issue No: Vol. 49, No. 3 (2017)
       
  • Preoperative nutritional counseling versus standard care prior to
           bariatric surgery
    • Authors: Stavros A. Antoniou; Anastasia Anastasiadou; George A. Antoniou; Frank-Alexander Granderath; Antonios Kafatos
      Pages: 113 - 117
      Abstract: Summary Background Little is known about the effect of preoperative nutritional counseling on operative outcomes of bariatric surgery. Aim To identify and evaluate the effect of nutritional counseling on perioperative morbidity and postoperative weight loss. Methods The database of Medline was queried in May 2016. Randomized controlled trials comparing nutritional counseling of any form with standard care and providing data on perioperative morbidity or weight loss were considered. Pooled risk ratio (RR) or mean difference with 95% confidence intervals (CI) were computed. Results Three randomized controlled trials were identified. The RR for postoperative complications was 0.80 (95% CI 0.22–2.86) and the mean weight loss was −11.62 kg (95% CI 0.72 to −23.96). There was high evidence of heterogeneity among reports. No data on operative morbidity were available. Conclusion Current data are not adequately robust to support preoperative nutritional intervention as an effective modality to prevent perioperative morbidity and to achieve more optimal postoperative weight control. In the absence of opposing evidence, nutritional counseling prior to surgery may be conventionally recommended.
      PubDate: 2017-06-01
      DOI: 10.1007/s10353-016-0459-4
      Issue No: Vol. 49, No. 3 (2017)
       
  • Oxidative stress and angiogenesis in primary hyperparathyroidism
    • Authors: Mariusz Deska; Ewa Romuk; Oliwia Anna Segiet; Grzegorz Buła; Witold Truchanowski; Dominika Stolecka; Ewa Birkner; Jacek Gawrychowski
      Pages: 118 - 126
      Abstract: Summary Background The inappropriate elevation of parathormone (PTH), which regulates the process of angiogenesis in parathyroid tissue, causes the changes of activity of enzymes responsible for the removal of free radicals. Parathyroidectomy (PTX) in patients with primary hyperparathyroidism (PHPT) lowers the level of PTH and leads to the reduction of risk of cardiovascular and all-cause mortality by normalization of the antioxidant status. Therefore, the aims of the study were to assess the activity of antioxidant enzymes and free radical reaction products in patients after parathyroidectomy, and to evaluate the correlation between the systemic oxidative stress and angiogenic parameters. Materials and methods Patients with PHPT treated surgically were enrolled into the study. Total antioxidant capacity (TAC), total oxidative status (TOS), oxidative stress index (OSI), superoxide dismutase (SOD), ceruloplasmin (CER), lipid hydroperoxides (LHP) and malondialdehyde (MDA) were measured before and after parathyroidectomy. The immunohistological expression of angiogenic factors in parathyroid specimens was assessed by the BrightVision method from ImmunoLogic using murine monoclonal anti-human: anti-VEGF, anti-CD31 and anti-CD106 antibodies. Results The significant increase of TAC, CER, reduction of TOS, MDA, SOD, especially for cytoplasmic form, and significant decrease of OSI, LHP were observed after PTX. There was no significant correlation between changes of oxidative stress markers and angiogenic parameters: VEGF, CD-31, CD-106 in parathyroid tissue. The correlation level was low and medium. Conclusions Parathyroidectomy causes down-regulation of lipid peroxidation processes and leads to reduction of oxidative stress in patients with PHPT. The decrease in the OSI is the results of down-regulation of oxidative stress in the postoperative period. The change of the antioxidant status has no impact on angiogenesis processes in parathyroid tissue.
      PubDate: 2017-06-01
      DOI: 10.1007/s10353-016-0457-6
      Issue No: Vol. 49, No. 3 (2017)
       
  • A method for shaping a smooth gastric tube
    • Authors: Masahiro Kimura; Hideyuki Ishiguro; Tatsuya Tanaka; Kouji Mizoguchi
      Pages: 84 - 88
      Abstract: Summary Background The quality of the gastric tube commonly used for reconstruction after esophagectomy can influence postoperative progress. Moreover, formation of a gastric tube cannot generally be re-performed. To create a smooth gastric tube, various devices and two or more staplers are used; the use of two or more staplers means that an intersection exists. The intersection is inherently weak, and needs reinforcement as a potential site of leakage. Methods To verify the optimal orientation relative to the previous stapler, we experimented using the stomach of a pig. Difficulty was encountered inserting the stapler when orientation relative to the previous stapler was changed. The shape of the gastric wall and the staples after firing were observed. Results The intersection of the first and second staplers is complicated as the angle increases and the modification required to the stomach also increases. In the part that is not an intersection, almost all of the staples had a perfect form. At 0°, half of the staples had perfect forms, but the remaining half of the staples were distorted in shape. At 90°, none of the staples had perfect shape. Insertion of the stapler was easy and little modification of the stomach wall was needed with the radial stapler. Conclusion Herein we describe some to note at the time of gastric tube creation and our technique for the formation of a well-shaped gastric tube in which the unstapled intersection seems to maintain a natural curve and is not prone to leakage. The use of a radial stapler, in addition to a linear stapler, is a very useful and safe method for the formation of the gastric tube.
      PubDate: 2017-04-01
      DOI: 10.1007/s10353-016-0454-9
      Issue No: Vol. 49, No. 2 (2017)
       
  • Prediction of 30-day mortality after emergency surgery for colorectal
           perforation
    • Authors: Tomoyuki Abe; Ken Shirabe; Norifumi Harimoto; Tomonobu Gion; Takashi Nagaie; Kiyoshi Kajiyama
      Pages: 89 - 94
      Abstract: Summary Background We aimed to validate the use of two physiologic and operative severity scoring systems for the enumeration of mortality and morbidity (Portsmouth, P‑POSSUM; colorectal, Cr-POSSUM) for the prediction of 30-day mortality after emergency surgery for colorectal perforation. Methods We retrospectively reviewed the records of a consecutive series of patients who had undergone emergency surgery for colorectal perforation between April 2001 and July 2007 at our hospital. The study population was stratified into two groups according to whether the patients survived longer than 30 days postoperatively or died within 30 days of surgery. Two scoring systems (P-POSSUM and Cr-POSSUM) were used to predict mortality risk in each patient based on patient- and disease-related risk factors. The prediction capability for each scoring system was calculated based on the area under the receiver-operator characteristic curve. Results The 30-day mortality rate was 12% (8/66 patients). Significant differences between patients who died within 30 days postoperatively and those who survived were noted regarding age, but not regarding comorbidities or preoperative laboratory data. Patient-related factors, rather than surgical factors, had a significantly greater influence on postoperative outcomes (p = 0.025), but the operative severity score did not contribute significantly. The P‑POSSUM score was a significant predictor of 30-day mortality (p = 0.0075). Conclusions Our findings demonstrate that P‑POSSUM and Cr-POSSUM can both be used to predict mortality after emergency surgery for colorectal perforation. While not explicitly developed for colorectal surgery, P‑POSSUM represents a promising tool for monitoring outcomes after emergency surgery for colorectal perforation.
      PubDate: 2017-04-01
      DOI: 10.1007/s10353-016-0460-y
      Issue No: Vol. 49, No. 2 (2017)
       
  • Erratum zu: Bariatrische Eingriffe in der Therapie des Diabetes mellitus
           Typ II
    • Authors: Stephan Kriwanek; Nada Loibner; Philipp Patri; Mathias Hofmann
      Pages: 99 - 99
      PubDate: 2017-04-01
      DOI: 10.1007/s10353-016-0463-8
      Issue No: Vol. 49, No. 2 (2017)
       
  • Hypercalcemia resistant to cinacalcet caused by a mediastinal
           hyperplastic parathyroid gland in a renal transplant patient
    • Authors: Manabu Okada; Kenta Futamura; Takahisa Hiramitsu; Makoto Tsujita; Norihiko Goto; Shunji Narumi; Yoshihiko Watarai; Toshihiro Ichimori; Yoshihiro Tominaga
      Abstract: Summary Background Renal hyperparathyroidism is a common complication in patients with chronic kidney disease. Cinacalcet, a kind of calcimimetic, has been reported to be an effective and safe treatment option in renal transplant patients with hyperparathyroidism. However, some patients require parathyroidectomy due to resistance to cinacalcet treatment. It is uncertain when we should give up treatment with cinacalcet and perform parathyroidectomy for persistent hyperparathyroidism. Case report We experience the first documented case in which cinacalcet-resistant hypercalcemia was caused by a mediastinal hyperplastic parathyroid gland after renal transplantation. The patient received total parathyroidectomy with autograft 4 years before renal transplantation. The levels of serum calcium and parathyroid hormone were controlled well with 25 mg daily of cinacalcet. Despite continuous treatment with cinacalcet, the patient developed hypercalcemia, hypercalciuria and nephrocarcinosis after renal transplantation. A mediastinal parathyroid lesion was revealed by imaging. Eventually, parathyroidectomy was performed for the mediastinal gland for the purpose of preventing new stone formation in the renal graft. Conclusion It was suggested that prompt parathyroidectomy is preferable rather than prolonged medical treatment for hypercalcemia resistant to cinacalcet caused by persistent hyperparathyroidism after renal transplantation. Furthermore, we should be extremely careful about hypercalcinuria and nephrocalcinosis when we prescribe cinacalcet for patients under hypercalcemia.
      PubDate: 2017-06-19
      DOI: 10.1007/s10353-017-0484-y
       
  • Effects of papaverine on healing of colonic anastomosis in rats
    • Authors: Salim Ilksen Basceken; Yusuf Sevim; Cihangir Akyol; Egemen Cicek; Ferit Aydın; Akin Firat Kocaay; Ozge Tugce Pasaoglu; Volkan Genc; Hatice Pasaoglu; Atil Cakmak
      Abstract: Summary Background Anastomotic leak is the most devastating complication after colorectal surgery, and the blood supply is a very important factor in anastomotic healing. Papaverine is a vasodilatory and antispasmodic agent which has been used in many ischemic conditions because of its potentially protective effects. The aim of this study is to investigate the effects of papaverine on healing colon anastomosis. Methods Forty 8‑ to 10-week-old female Wistar Albino rats were used in this study. Rats were randomized into 4 groups: control group; ischemia-reperfusion and anastomosis group; ischemia-reperfusion and anastomosis + intraperitoneal one dose papaverine group; and ischemia-reperfusion and anastomosis + intraperitoneal daily (10 days) papaverine group. Anastomotic bursting pressures, the hydroxyproline measurements and macroscopic adhesion gradings were evaluated. Results There was a significant difference between papaverine-administered groups and ischemia-reperfusion and anastomosis group for anastomotic bursting pressures, hydroxyproline measurements and macroscopic adhesion grading (p < 0.05). Conclusion In the rat model, papaverine had a favorable effect on anastomotic healing.
      PubDate: 2017-06-12
      DOI: 10.1007/s10353-017-0481-1
       
  • Does BMI affect the detection of sentinel lymph nodes with indocyanine
           green in early breast cancer patients?
    • Authors: Stephanie Rauch; Anton Haid; Zerina Jasarevic; Christoph H. Saely; Alexander Becherer; Etienne Wenzl
      Abstract: Summary Background Sentinel node biopsy (SNB) has proved to be a useful and safe method for axillary staging in the surgical management of early breast cancer. Sentinel node (SN) detection rates with blue dye (patent blue) and radioisotopes (99m-Tc), either alone or particularly in combination, are high (95% to 100%). Even better detection rates were reported with fluorescent dyes like indocyanine green (ICG). This study was designed to show whether sentinel node detection and mapping of lymphatics with ICG might depend on the body mass index (BMI). Methods Between February 2014 and April 2015, SNB with blue dye, 99m-Tc, and ICG navigation was conducted for 100 consecutive procedures in patients scheduled for surgery of early breast cancer. ICG injection, lymphatic mapping with the Photodynamic Eye (PDE; Hamamatsu Photonics, Hamamatsu, Japan), and identification of the sentinel nodes with blue dye and ICG were followed by a final search for more lymph nodes with a gamma probe. Data were collected prospectively. Results In all patients, up to six sentinel nodes (mean 2.49) were detected. No statistical correlation was found between the BMI and the identification of lymphatics or the detection of lymph nodes with ICG. Lymphatics were successfully identified preoperatively in no more than 79 cases. In 6 patients, a gamma probe was needed for detection. Adverse events or allergic reactions were absent throughout. Conclusions SN detection and lymphatic mapping with ICG were not related to the BMI. Pending answers to as yet unsolved questions, the combined use of blue dye and 99m-Tc imaging should, however, be continued.
      PubDate: 2017-06-09
      DOI: 10.1007/s10353-017-0480-2
       
  • 58th Annual Meeting Of The Austrian Society Of Surgery
    • PubDate: 2017-05-15
      DOI: 10.1007/s10353-017-0479-8
       
  • Effects of teduglutide on histological parameters of intestinal
           anastomotic healing
    • Authors: Beatriz P. Costa; Maria A. Cipriano; Ana C. Gonçalves; Ana M. Abrantes; Paulo Matafome; Raquel Seiça; Ana B. Sarmento-Ribeiro; M. Filomena Botelho; Francisco Castro-Sousa
      Abstract: Summary Background Intestinal anastomotic failure continues to be one of the most relevant surgical incidents. Teduglutide is an enterotrophic long-acting equivalent of glucagon-like peptide-2 (GLP-2) recommended for the treatment of adult patients with short bowel syndrome. This study evaluates the effects of short-term teduglutide administration on histological parameters of intestinal anastomotic healing in an animal model. Methods Wistar rats (n = 31) were submitted to ileal resection and standard anastomosis, with or without postoperative teduglutide ministration, and sacrificed at the third or seventh day with tissue and blood sampling. Intestinal anastomotic healing was assessed with the modified Houdart–Hutschenreiter classification after hematoxylin and eosin staining. Collagen content and distribution were evaluated with the Gordon and Sweet technique; neoangiogenesis and epithelial proliferation indexes with anti-CD31 and anti-Ki67 immunostaining, respectively. GLP-2 plasma levels were determined by quantitative enzyme immunoassay. Results Teduglutide administration was associated with higher levels of reepithelialization (P = 0.022) and a higher neoangiogenesis index (neovessel density = 16.0 ± 10.8/mm2 vs. 5.3 ± 3.4/mm2; P = 0.0001) at the seventh postoperative day. Lower expression of type I collagen (P = 0.015) and higher content of type III collagen (P = 0.007) in the submucosa were also documented at the seventh day in teduglutide-treated animals. Drug administration was not associated with statistically significant differences of GLP-2 plasma levels. Conclusion These findings indicate a positive impact of teduglutide on the reepithelialization and neoangiogenesis events of the proliferative phase of intestinal anastomotic repair. Additional studies are necessary to clarify its effects on the fibrogenesis process.
      PubDate: 2017-04-19
      DOI: 10.1007/s10353-017-0478-9
       
  • Behind and beyond surgery
    • Authors: F. M. Riegler
      PubDate: 2017-03-31
      DOI: 10.1007/s10353-017-0477-x
       
  • Minimally invasive sublay mesh repair of incisional and primary abdominal
           wall hernias using the MILOS technique
    • Authors: W. Reinpold; M. Schröder; A. Schröder; C. Berger; J. Nehls; W. Stoltenberg; F. Köckerling
      Abstract: Summary Introduction Primary ventral and incisional hernia repair is a routine operation in general surgery. The most widely used techniques, however, have some disadvantages and risks. In order to minimize complications and postoperative pain, we developed the endoscopically assisted mini and less open sublay (MILOS) operation. Methods The surgical steps of this novel technique are described here. The operation is performed via a small incision transhernially with light-armed laparoscopic instruments either under direct visualization or endoscopic view. After creating an extraperitoneal space of at least 8 cm and CO2 insufflation, total extraperitoneal preperitoneal mesh repair (TEP) of ventral and incisional hernias can be performed. Results The results and complication rates of 715 MILOS operations for incisional hernias are presented. The data of all MILOS operations were prospectively documented in the German hernia database “Herniamed.” Conclusion The MILOS technique facilitates minimally invasive transhernial repair of primary ventral and incisional hernias using large retromuscular/preperitoneal meshes; the technique is associated with a very low morbidity rate and with less chronic pain.
      PubDate: 2017-03-22
      DOI: 10.1007/s10353-017-0475-z
       
  • Behind and beyond surgery
    • Authors: F. M. Riegler
      PubDate: 2017-03-15
      DOI: 10.1007/s10353-017-0474-0
       
  • Endoscopic-assisted linea alba reconstruction
    • Authors: Ferdinand Köckerling; Marinos Damianos Botsinis; Christine Rohde; Wolfgang Reinpold; Christine Schug-Pass
      Abstract: Summary Background Patients with symptomatic umbilical, trocar, and/or epigastric hernias and concomitant rectus abdominis diastasis represent a growing clinical problem. The optimal management of this complex hernia situation is the subject of debate in the literature. This paper reports the early results of an innovative surgical technique aimed at managing this hernia situation. Methods Endoscopic-assisted linea alba reconstruction (ELAR) with mesh augmentation is a surgical technique long known in the literature for its good outcome for incisional hernia repair (myofascial release, overlapping herniorrhaphy, Gibson’s operation, shoelace repair, anterior rectus sheath repair, dynamic patch plasty) via a small access route. The early results for 140 patients are presented here. Results Two patients (1.4%) developed postoperative complications requiring redo surgery. These were two cases of diffuse secondary bleeding without an identifiable bleeding source, in one patient with liver cirrhosis and portal hypertension and in another patient receiving treatment with platelet aggregation inhibitors. All other complications were successively managed with conservative treatment. After 1 year, two of 30 patients reported occasional pain, including pain at rest in one patient. Conclusion The ELAR technique with mesh augmentation is an innovative, minimally invasive surgical procedure for treatment of patients with a complex abdominal wall hernia comprising symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis.
      PubDate: 2017-03-10
      DOI: 10.1007/s10353-017-0473-1
       
  • What are the needs for education in hernia surgery for the future?
    • Authors: R. Lorenz; B. Stechemesser; W. Reinpold; F. Mayer; F. Köckerling; W. Schröder; R. Fortelny
      Abstract: Summary Introduction Hernia surgery has undergone rapid development in the past decades. The ever greater array of surgical techniques and materials together with the demand for individualized treatment concepts thus present a special challenge not only to qualified surgeons but also when devising education programs for trainee surgeons. To that effect, continuing education and training concepts must be reviewed and possibly new concepts formulated. This study now reports on the findings from a survey on continuing education and training in hernia surgery, while presenting and evaluating the existing concepts. Materials and Methods In 2014 the German Hernia Society (DHG) in cooperation with the Federal Association of German Surgeons (BDC) conducted a broad-based online survey among surgeons on the future of continuing education in hernia surgery. Since 2011 basic courses in hernia surgery have been in place in Germany, and since 2014 in Austria too. In the meantime, further Hernia School levels have also been introduced. We compared the learning effects identified for participants of the two Hernia compact courses in Salzburg in 2014 and 2016. Besides, special questionnaires were designed to explore new and topical issues. Results In total, 1296 surgeons in Germany took part in the BDC / DHG online survey on the future of continuing education in hernia surgery. The vast majority (more than 80%) of respondents deemed the establishment of a systematic, step-by-step and structured continuing education program to be useful or very useful. Evaluation of the basic training courses already conducted revealed that both the theoretical knowledge and practical experience of participants improved thanks to these courses. Conclusion From the perspective of surgeons there is an urgent need for a systematic, structured and step-by-step concept for continuing education hernia surgery. This should include, in addition to theoretical and practical aspects, eLearning, video tutorials, and simulation models. Since to date there is a lack of empirical data, continuous evaluation of the training courses is an important component for further development of such courses. This can markedly enhance the theoretical knowledge and practical experience of participants. Besides, systematic survey of participants helps to continuously tailor the curriculum to future needs.
      PubDate: 2017-02-28
      DOI: 10.1007/s10353-017-0469-x
       
  • Impact of ultrasound examination shortly after kidney transplantation
    • Authors: Christoph Schwarz; Jakob Mühlbacher; Georg A. Böhmig; Marin Purtic; Eleonore Pablik; Lukas Unger; Ivan Kristo; Thomas Soliman; Gabriela A. Berlakovich
      Abstract: Summary Background Ultrasound is routinely performed at our transplant unit within the first 48 h of kidney transplantation (KTX). The objective of this study was to evaluate the association of ultrasound results and, in particular, elevated resistance indices (RIs) with the occurrence of surgical complications and allograft outcomes. Methods The study included all kidney allograft recipients undergoing transplantation at our center between January 2010 and December 2011 (N = 329). Ultrasound examination was performed on 315 recipients (95.7%). Results Delayed graft function was more common in subjects with a high RI (≥0.7) than in patients with an RI < 0.7 (47.2 vs. 28.2%; p = 0.032). A lack of arterial signal was detected in eight patients (2.5%), of whom five had a vascular complication that required surgical therapy. In 12 patients (3.8%), RI was 1 without any other signs of vascular impairment. Even though such values can be a sign of venous thrombosis, no case was observed in any of these patients. Conclusions The results of our study suggest that ultrasound evaluation of the transplanted kidney shortly after transplantation is a valuable tool not only for detecting vascular complications but also as a predictor of graft outcome regarding delayed graft function.
      PubDate: 2017-02-16
      DOI: 10.1007/s10353-017-0467-z
       
  • Caudate resection for primary and metastatic liver tumors
    • Authors: Georgios C. Sotiropoulos; Petros Charalampoudis; Paraskevas Stamopoulos; Nikolaos Machairas; Eleftherios D. Spartalis; Stylianos Kykalos; Gregory Kouraklis
      Abstract: Summary Background Surgical procedures involving the caudate lobe of the liver are characterized as the most demanding operations in liver surgery. Methods Liver resections including the caudate lobe performed at our institution by one senior hepatobiliary surgeon in a 2-year period were reviewed for the purposes of this study. Indications comprised primary and metastatic liver lesions. Results In a total of 60 hepatectomies, 12 patients underwent caudate lobe resection (20%). This was either isolated resection of segment I (n = 3) or combined with right, left, extended left hepatectomy or atypical resections in one, three, one, and four instances, respectively. Vascular resections/reconstructions were necessary in six cases (three cases each for portal vein and vena cava). All but one patient were directly extubated. Median hospital stay was 10.5 days. Surgical complications were classified as Dindo–Clavien grades I (n = 4), II (n = 4), IIIa (n = 1), IIIb (n = 2), and IV (n = 1). Conclusion Surgery for tumors located in the caudate lobe is feasible and can be safely performed by experienced teams.
      PubDate: 2017-02-15
      DOI: 10.1007/s10353-017-0466-0
       
  • Laparoscopic appendectomy using only two 5 mm trocars
    • Authors: Hugo Bonatti
      Abstract: Summary Background Laparoscopic appendectomy is now the standard and most surgeons use two 5 mm and one 10–12 mm port; the latter placed into the umbilicus. Various attempts have been made to reduce the number and sizes of ports for this procedure. Case report A 22-year-old male with acute right lower quadrant pain came to our emergency room. His white blood count (WBC) was 15000 l/ml and on CT scan signs of acute appendicitis were found. He was taken to the operating room. His abdomen was accessed with a Verres in the left upper quadrant (LUQ) and once pneumoperitoneum was established a 5 mm trocar was placed under visual control into the left lower quadrant (LLQ). A phlegmonous appendix was found attached to the right abdominal wall. The Verres needle was exchanged for another 5 mm trocar. A Maryland grasper was used to bluntly create a window between appendix base and mesoappendix. The appendiceal artery was dissected out and secured with a 5 mm clip and the mesoappendix was cut off the appendix. Two endoloops were lassoed around the appendix and tied at the appendix base and the specimen was amputated between the ties. The appendix was pulled with the distal tie towards the LUQ port, which was removed. The appendix base was grabbed with a Kelly clamp and the specimen was pulled through the port site. Pneumoperitoneum was released and the LLQ port removed and the skin closed. The patient was discharged after 2 h and had a completely uneventful recovery. Conclusion In selected cases with favorable anatomy, laparoscopic appendectomy with two 5 mm ports may be possible. Miniaturizing this procedure while carefully weighing patient safety and costs should be a goal for laparoscopic appendectomy.
      PubDate: 2017-02-10
      DOI: 10.1007/s10353-017-0465-1
       
  • Fecal occult blood test/fecal carcinoembriogenic antigen dual rapid test
           as a useful tool for colorectal cancer screening
    • Authors: Maru Kim; Hyung-Jin Kim; In Kyu Lee; Seong-Taek Oh; Kyungja Han
      Abstract: Summary Background There are several screening tools for colorectal cancer (CRC). Most are limited in their application. The fecal occult blood test (FOBT) is a first-step screen for CRC that is limited by low sensitivity. This study aimed to prove the efficacy of combined FOBT and fecal carcinoembryogenic antigen (fCEA) as a CRC screening test. Methods Stool samples were collected preoperatively from 166 CRC patients expected to undergo elective surgery and from normal control patients. A fecal CEA/FOBT dual kit was created and the results from the use of this dual kit were compared against other clinicopathologic parameters. Results FOBT was positive in 103 of the 166 (62.0%) CRC patients and fCEA was positive in 114 (68.7%) patients, showing a statistically positive relationship. Among 63 FOBT negative patients, 29 (17%) cases were CEA positive. Thus, the CEA/FOBT dual test could detect CRC in 79.5% of the patients (132/166). The sensitivity and specificity of the dual FOBT/CEA test was 79.5% and 97.9%, respectively. Conclusions The FOBT/CEA dual test has increased sensitivity compared to the FOBT test and may have merit as a screening device for colorectal cancer. Population-based studies are required to confirm this potential.
      PubDate: 2017-02-03
      DOI: 10.1007/s10353-017-0464-2
       
 
 
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