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General Surgery

Neurofibroma of the Gallbladder Not Associated with Neurofibromatosis
Tsutomu Namikawa, MD, PhD, Associate Professor, Department of Surgery, Yasuhiro Kawanishi, MD, Medical Staff, Department of Surgery, Yuki Fujieda, MD, Medical Staff, Department of Surgery, Kazune Fujisawa, MD, Assistant Professor, Department of Pathology, Eri Munekage, MD, Assistant Professor, Department of Surgery, Masaya Munekage, MD, PhD, Assistant Professor, Department of Surgery, Hiromichi Maeda, MD, PhD, Assistant Professor, Cancer Treatment Center, Hiroyuki Kitagawa, MD, PhD, Assistant Professor, Department of Surgery, Michiya Kobayashi, MD, PhD, Professor, Cancer Treatment Center, Department of Human Health, and Medical Sciences, Kazuhiro Hanazaki, MD, PhD, Professor, Department of Surgery, Kochi Medical School, Kochi, Japan

 

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An 82-year-old woman had visited her local clinic with a history of abdominal discomfort and dyspepsia related to meals over a period of several months. Esophagogastroduodenoscopy revealed a superficial spreading tumor that, on biopsy, was proven to be an adenocarcinoma, and colonoscopy revealed an ascending mass that was found to be an adenocarcinoma on biopsy, so the patient was referred to our hospital. Abdominal computed tomography revealed a mass in the ascending colon with regional lymph node swelling and a gallbladder stone measuring 1.5 cm in diameter. The patient underwent laparoscopy-assisted distal gastrectomy with cholecystectomy and right colectomy with regional lymph node dissection, resulting in a diagnosis of poorly differentiated adenocarcinoma invading the gastric submucosal layer and moderately differentiated tubular adenocarcinoma invading the colonic serosa with lymph node metastasis. Macroscopic examination of the gallbladder revealed a well-circumscribed, solid tumor measuring 0.3 × 0.3 cm with a firm consistency in the neck portion associated with lithiasis. Microscopic examination of the gallbladder tumor revealed infiltration of spindle-shaped neoplastic cells that were arranged in a fasciculated and woven pattern in abundant intersecting bundles. Immunohistochemical analyses were positive for S-100 protein and neurofilament. Although neurofibromas commonly occur in the superficial skin or subcutaneous region, isolated neurofibroma of the gallbladder is quite rare. To the best of our knowledge, this is only the 11th case of a neurofibroma of the gallbladder to be reported in English literature. In the present case, as in most previously reported cases, the tumor was found incidentally in the resected gallbladder following cholecystectomy for cholecystolithiasis.

 

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Endoluminal Vacuum Therapy as Treatment for Anastomotic Colorectal Leakage

Giovanni Milito, MD, PhD, Associate Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Giorgio Lisi, MD, Resident, Department of Surgery, University Hospital of Borgo Roma, Verona, Italy, Dario Venditti, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Michela Campanelli, MD, Resident, Department of Surgery, University Hospital of Modena, Modena, Italy, Elena Aronadio, MD, Resident, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Simona Grande, Intern, Department of Surgery, University Hospital of Messina, Messina, Italy, Francesca Cabry, MD, Researcher, Department of Surgery, University Hospital of Modena, Modena, Italy, Michele Grande, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy

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Background: The clinical leakage rate after anterior resection varies from 2.8–20%, with a 6–22% mortality rate and a 10–80% risk of permanent stoma. Endo-SPONGE® (B. Braun Melsungen AG, Melsungen, Germany) may treat extraperitoneal anastomotic leakage in the lesser pelvis. It consists of an open-pored sponge inserted into the cavity. A drainage tube fixed to a low vacuum drainage system is then connected to the sponge through the anus.
Material and Methods: Between January 2007 and December 2014, 14 patients with anastomotic leakage following low anterior resection were treated with Endo-SPONGE® and were prospectively evaluated. In all patients, a CT-scan was performed and they received an intravenous antibiotic therapy with piperacillin+tazobactam (4.5g,3 times/daily). Complete healing was defined as endoscopically proven closure of the insufficiency cavity with a normal mucosa.
Results: Stapled straight end to end, colorectal anastomoses were performed in all patients between 3–7 cm above the anal verge, a protective loop ileostomy was performed in every patient. The diagnosis of anastomotic leakage was performed after a median interval of 14 days, the median size of the cavity was 81x46 mm. Fluid collection was drained, percutaneosly in 12 cases, surgically in two patients. The median duration of therapy was 35 days, with 3–14 sponge exchanges for each patient. Median healing time was 37 days. No intraoperative complications were recorded, however, we found five cases of mild anal pain treated medically.
Conclusion: Considering the literature and our results, the Endo-SPONGE® seems an effective, minimally invasive procedure to treat extraperitoneal anastomotic leakage, reducing morbidity, mortality, and hospital stay.

 

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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z
Gianlorenzo Dionigi, MD, FACS, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and, Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Matteo Lavazza, MD, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and, Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Alessandro Bacuzzi, MD, Division of Anesthesia, Ospedale di Circolo, Fondazione Macchi, Varese, Italy, Davide Inversini, MD, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and, Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Vincenzo Pappalardo, MD, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and, Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Ralph P. Tufano, MBA, MD, Division of Head and, Neck Endocrine Surgery, Department of Otolaryngology-Head, and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, Hoon Yub Kim, MD, PHD, Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, Korea, Angkoon Anuwong, MD, Minimally Invasive and, Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand

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We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≤45mL, (3) nodule size ≤5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

 

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Radiofrequency Procedure (SECCA®) for Fecal Incontinence: One-Year Experience
Marco Frascio, MD, Professor of Surgery, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Cesare Stabilini, MD, PhD, Research Fellow, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Marco Casaccia, MD, Professor of Surgery, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Tommaso Testa, MD, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Rosario Fornaro, MD, Research Fellow, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Maria Caterina Parodi, MD, Department of Gastroenterology and Digestive Endoscopy, San Martino Hospital, Genoa, Italy, Ciro Marrone, MD, Department of Gastroenterology and Digestive Endoscopy, San Martino Hospital, Genoa, Italy, Ezio Gianetta, MD, Professor of Surgery, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy, Francesca Mandolfino, MD, PhD, Department of Surgical Sciences and Integrated Methodologies, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy

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Introduction: Radiofrequency is a treatment option for patients suffering from fecal incontinence.
Objective: To assess the one-year follow-up results following the radiofrequency procedure for fecal incontinence.
Design: Prospective, single-center, observational study. Materials and Methods: Twenty-one patients underwent the SECCA® radiofrequency procedure, 19 of who completed the one-year of follow-up (Cleveland Clinic Florida Fecal Incontinence score, Fecal Incontinence Quality of Life Scale (FIQoL), anorectal manometry, and endoanal ultrasound).
Main Outcome Measures: Any change in the Fecal Incontinence Score or Fecal Incontinence Quality of Life scales post SECCA® radiofrequency procedure.
Results: The mean Fecal Incontinence Score significantly improved at three months’ follow-up from 14.5 prior to treatment to 11.9 post-treatment, and was maintained at six months (12). A slight decrease was observed at one year (12.9), which had no impact on the global satisfaction. During the same period, only 1/4 subsets of the Fecal Incontinence Quality of Life score improved. Manometry and endoanal ultrasound did not show significant changes post procedure.
Limitations: Limited number of patients.
Conclusions: Radiofrequency is a valid treatment option for patients with mild-to-moderate fecal incontinence. This treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Fecal Incontinence Score as well as significant improvements in Fecal Incontinence Quality of Life scores at six months, with a slight, though not clinically significant, decrease at one year follow-up.

 

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The Role of Fluorescent Angiography in Anastomotic Leaks
Sarath Sujatha-Bhaskar, MD, Resident Physician, University of California, Irvine School of Medicine, Orange, California, Mehraneh D. Jafari, MD, Health Sciences Assistant Clinical Professor, University of California, Irvine School of Medicine, Orange, California, Michael J. Stamos, MD, Interim Dean/ Professor of Surgery, John E. Connolly Endowed Chair, University of California, Irvine School of Medicine, Orange, California

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Anastomotic leaks following colorectal anastomosis has substantial implications including increased morbidity, longer hospitalization, and reduced overall survival. The etiology of leaks includes patient factors, technical factors, and anastomotic perfusion. An intact anastomotic blood supply is especially crucial in the physiology of anastomotic healing. To date, no established intraoperative methods have been developed that reliably and reproducibly identify and prevent leak occurrence. Recently, fluorescent angiography (FA) with indocyanine green (ICG) has emerged as an innovative modality for intraoperative perfusion assessment. ICG-FA can be performed before or after intestinal resection or, alternatively, after creation of the anastomosis. Angiographic assessment with near-infrared camera filters allows determination of perfusion adequacy, guiding additional intestinal resection and anastomotic revision. Early clinical experiences with ICG-FA demonstrated safety and feasibility. Large, multi-center prospective trials, such as the Perfusion Assessment in Laparoscopic Left-Sided/Anterior Resection Study (PILLAR II), demonstrated ease of use with remarkably low anastomotic leak rates after ICG-FA-guided intraoperative revision. Current randomized control trials featuring utilization in ICG-FA in low anterior resection are currently underway and will further clarify the role of ICG-FA in leak identification and prevention. Apart from colorectal surgery, FA has also been successfully employed in other surgical disciplines such as plastic surgery, vascular surgery, foregut surgery, urology, and gynecology.

 

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Surgical Treatment of Rectovaginal Fistula in Crohn’s Disease:  A Tertiary Center Experience
Giovanni Milito, MD, PhD, Associate Professor, Department of Surgery, University Hospital of Tor Vergata "PTV", Rome, Italy, Giorgio Lisi, MD, Resident, Department of Surgery, University Hospital of Borgo Roma, Verona, Italy, Dario Venditti, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata "PTV", Rome, Italy, Michela Campanelli, MD, Resident, Department of Surgery, University Hospital of Modena, Modena, Italy, Elena Aronadio, MD, Intern, Department of Surgery, University Hospital of Tor Vergata "PTV", Rome, Italy, Michele Grande, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata "PTV", Rome, Italy

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Background: Rectovaginal fistula (RVF) is a disastrous complication of Crohn’s disease (CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a woman’s quality of life. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics, and its published success rates vary with initial success being around 50% rising to 80% with repeated surgery. Several surgical and sphincter sparing approaches have been described for the management of rectovaginal fistula, aimed to minimize the recurrence and to preserve the continence.
Materials and Methods: A retrospective study was performed for RVF repair between 2008 and 2014 in our tertiary centre at the University Hospital of Tor Vergata, Italy. All the patients were affected by Crohn’s disease and underwent surgery for an RVF under the same senior surgeon. All patients were prospectively evaluated.
Results: All 43 patients that underwent surgery for RVF were affected by Crohn’s disease. The median age was 43 years (range 21–53). Four different surgical approaches were performed: drainage and seton, rectal advacenment flap (RAF), vaginal advancement flap (VAF), transperineal approach using porcine dermal matrix (PDM), and martius flap (MF). The median time to success was six months (range 2–11). None of the patients were lost during the 18 months of follow-up. The failure group rate was 19% in contrast with the healing rate group that was 81%. No demographic of disease-related factors were found to influence healing.
Conclusion: The case series of this study supports the dogma that “there are no absolute rules when treating Crohn’s fistula�?. There is no gold standard technique; however, it is mandatory to minimize the recurrence with a sphincter saving technique. Randomized trials are needed to find a standard surgical approach.

 

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Case History Review of 2.467 Anal Fistulae Surgically Treated with the Method of Arnous’s French School
Massimo Giordano, MD, Digestive Surgeon, Proctologic Unit, Villa Igea Private Hospital, Acqui Terme, Italy, Graziella Estienne, MD, Digestive Surgeon, Proctologic Unit, Villa Igea Private Hospital, Acqui Terme, Italy, Francesca Mandolfino, MD, PhD, Digestive Surgeon, Proctologic Unit, Villa Igea Private Hospital, Acqui Terme, Italy

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Introduction: Considering the extensive experience developed in 28 years of medical practice in a specialist facility dedicated to proctological surgery and the treatment of 2.467 patients presenting with an anal fistula, the authors review problems associated with this disease from an aetiopathogenic, classifying, diagnostic, and therapeutic viewpoint.
Materials and Methods: The surgical treatment of Arnous’s French School was adopted. The method envisions slow sectioning of the sphincter by means of elastic constriction, even dividing surgical sessions.
Results: Results were excellent, recording 99.5% of complete healings, while failures and complications numbered 0.3% of incomplete healings, 0.2% of relapses, 2.8% of soiling, and 1.4% of transitory gas incontinence.
Conclusions: Correct diagnosis of the type of fistula, the choice of a perfect surgical technique, and thorough long-term follow-up of the postoperative progress of surgical wounds are the basic premises to achieve the patient’s healing.

 

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Three-Port Laparoscopic Adjustable, Gastric Banding (LAGB): Surgical, Technique and Three Years Follow-Up
Dr. Vincenzo Consalvo, MD, Director, Bariatric Surgery Department, Clinique Clementville, Montpellier, France, Vincenzo Salsano, MD, Director, Bariatric Surgery Department, Clinique du Parc, Montpellier, France, Gerardo Sarno, MD, Surgeon, General Surgery Department, San Giovanni Di Dio e Ruggi D’Aragona, Salerno, Italy

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Background: Adjustable Gastric Banding (AGB) is an effective and reversible bariatric procedure, which is usually performed using a mini-invasive laparoscopic approach. The majority of surgeons use a five-trocar technique, while AGB can be safely carried out with only three trocars. The aim of our study was to compare the outcomes of three-trocar laparoscopic adjustable gastric banding (LAGB) to the results obtained with the conventional technique.
Materials and Methods: A retrospective analysis of our database was carried out to assess the number of LAGB performed with the conventional five-port technique and the number of LAGB performed with the three-port approach. The complication rate and the weight loss of the two groups were compared.
Results: From May 2006 to February 2012, 395 patients underwent LAGB under our care. The conventional technique was performed in 198 patients, while the three ports approach was used in 197 subjects. Complications rate was similar in the two groups and no death was recorded. There was no statistical difference in operative time and weight loss between the groups.
Conclusions: LAGB can be safely performed with a three-port approach. This technique reduces the number of scars and the surgical trauma without differences in weight loss or complication rate.

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Endoluminal Sphincter Augmentation with the MUSE™ System and GERDX™ System in the Treatment of Gastroesophageal Reflux Disease: A New Impact?
Dr. Suyu He, MD, The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, China, Dr. Hubertus Feussner, MD, Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany, Munich, Germany, Dr. Simon Nennstiel, MD, Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Munich, Germany, Dr. Monther Bajbouj, MD, Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Munich, Germany, Dr. Norbert Hüser, MD, Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany., Munich, Germany, Dr. Dirk Wilhelm, MD, Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany, Munich, Germany

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To bridge the gap between the long-term intake of proton pump inhibitors (PPIs) and the potential risks of laparoscopic fundoplication, a number of endoscopic procedures for the treatment of gastro-esophageal reflux disease (GERD) have been developed over the past 30 years. Because of the minimally invasive approach, short operative time, and efficacy in selected patients, endoluminal sphincter augmentation appears to be highly attractive. However, most early devices have proven to be unsafe or failed to provide long-term symptom relief. Accordingly, products for endoluminal sphincter augmentation have undergone several modifications to achieve an increased lower esophageal sphincter (LES) baseline pressure to re-establish the LES as an efficacious anti-reflux barrier. This paper reviews and discusses the two latest products for endoluminal sphincter augmentation, the MUSE™ device (Medigus, Ltd., Omer, Israel) and the GERDX™ system (G-SURG GmbH, Seeon-Seebruck, Germany). While the currently available literature has proven their effectiveness in principle, long-term results are lacking. Further studies and developments are necessary to determine whether these two new devices will truly impact GERD therapy.

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Safety and Cost-Effectiveness in Thyroidectomy Using the HARMONIC Scalpel Compared to Traditional Hemostasis: A Controlled Clinical Assay
Erich O.P. Basurto-Kuba, MD, FACS, Professor of Surgery, Staff Surgeon, Servicio de Cirugía General, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Maybelline Robles-Estrada, MD, General Surgery Resident, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Luis Mauricio Hurtado-López, MD, PhD, Professor of Surgery, General Surgery Department, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Edgar Montes de Oca-Duran, MD, MSc, Staff Surgeon General Surgery Department, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Carlos Campos-Castillo, MD, MSc, Staff Surgeon, General Surgery Department, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Felipe Rafael Zaldívar-Ramírez, MD, MSc, Staff Surgeon, General Surgery Department, Neck Surgery Clinic, Hospital General de México OD, México D.F., México, Abraham Pulido-Cejudo, MD, MSc, Chair of General Surgery Department, Neck Surgery Clinic, Hospital General de México OD, México D.F., México

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Introduction: The aim of this clinical control trial is to analyze the cost-effectiveness and to understand the efficacy of the HARMONIC FOCUS®+ (Ethicon Inc., Somerville, New Jersey) scalpel as the only system to cut and coagulate in thyroidectomy.
Materials and Methods: One hundered patients of the thyroid clinic of the Mexico City General Hospital were included. All patients underwent surgery and were divided into two randomized groups. In Group 1, the HARMONIC scalpel was the only device used for cut and coagulate (50 patients), and in Group 2 clamp, tie, and electrocautery (50 patients) were used. Surgical bleeding, operative time, complications, diagnosis, thyroid size, and hospital stay were evaluated in both groups.
The statistical analysis was done using central trend measurements, Student’s t-, chi-squared, and Fisher’s exact test, with a significance level of p < 0.05. The cost-effectiveness analysis was completed by determining the total cost of the surgical procedure per hour in US dollars, and the evolution to compare efficacy will be the number of re-interventions due to postoperative bleeding.
Results: The use of the HARMONIC scalpel in thyroid surgery had the same results as the traditional method when comparing complications, reoperation, hospital stay, and hypoparathyroidism. In total thyroidectomy patients, the bleeding in Group 1 was 55.16ml ( ± 32.97) and 85.4ml ( ± 69.41) in Group 2, p=0.034. Operative time in Group 1 was 74.6 minutes (± 23.39) and 104.09 minutes (± 34.66) in Group 2, p= 0.0001. In both groups, there were no statistical differences in lobectomy. Cost-effectiveness analysis implies an adequate hemostasis if we are using a hemostatic device, and above all, the avoidance of a re-intervention due to hematoma, and the cost-effectiveness with regard to the re-intervention as a result of a hematoma implies that $161 US more is spent for each re-intervention.
Conclusion: The utilization of the HARMONIC scalpel device is similar to the traditional technique of ligature and knots as far as cost-effectiveness is concerned, due to the fact that the greater expense of the device is compensated by the lower expense in time and surgical re-intervention.

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