Skip to main content
SpringerLink
Log in

Does Mesorectal Preservation Protect the Ileoanal Anastomosis after Restorative Proctocolectomy?

  • original article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background and aims

The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum.

Patients and methods

One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14–169) months after surgery.

Results

Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature.

Conclusion

The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Michelassi F, Lee J, Rubin M, Fichera A, Kasza K, Karrison T et al. Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Ann Surg 2003;238:433–441. discussion 442–445.

    PubMed  Google Scholar 

  2. Delaney CP, Fazio VW, Remzi FH, Hammel J, Church JM, Hull TL et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 2003;238:221–228.

    PubMed  Google Scholar 

  3. Tekkis PP, Fazio VW, Lavery IC, Remzi FH, Senagore AJ, Wu JS et al. Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. Ann Surg 2005;241:262–268. doi:10.1097/01.sla.0000152018.99541.f1.

    Article  PubMed  Google Scholar 

  4. Fazio VW, Tekkis PP, Remzi F, Lavery IC, Manilich E, Connor J et al. Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg 2003;238:605–14. discussion 614–617.

    PubMed  Google Scholar 

  5. Sagap I, Remzi FH, Hammel JP, Fazio VW. Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)—a multivariate analysis. Surgery 2006;140:691–703. discussion 703–704 doi:10.1016/j.surg.2006.07.015.

    Article  PubMed  Google Scholar 

  6. Korsgen S, Keighley MR. Causes of failure and life expectancy of the ileoanal pouch. Int J Colorectal Dis 1997;12:4–8. doi:10.1007/s003840050069.

    Article  PubMed  CAS  Google Scholar 

  7. Heuschen UA, Hinz U, Allemeyer EH, Autschbach F, Stern J, Lucas M et al. Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 2002;235(2):207–216. doi:10.1097/00000658-200202000-00008.

    Article  PubMed  Google Scholar 

  8. Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003;238:229–234.

    PubMed  Google Scholar 

  9. Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006;244:18–26. doi:10.1097/01.sla.0000225031.15405.a3.

    Article  PubMed  Google Scholar 

  10. Grobler SP, Hosie KB, Keighley MR. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992;79:903–906. doi:10.1002/bjs.1800790916.

    Article  PubMed  CAS  Google Scholar 

  11. Kienle P, Weitz J, Benner A, Herfarth C, Schmidt J. Laparoscopically assisted colectomy and ileoanal pouch procedure with and without protective ileostomy. Surg Endosc 2003;17:716–720. doi:10.1007/s00464-002-9159-1.

    Article  PubMed  CAS  Google Scholar 

  12. Sugerman HJ, Sugerman EL, Meador JG, Newsome HH Jr, Kellum JM Jr, DeMaria EJ. Ileal pouch anal anastomosis without ileal diversion. Ann Surg 2000;232:530–541. doi:10.1097/00000658-200010000-00008.

    Article  PubMed  CAS  Google Scholar 

  13. Carlsen E, Schlichting E, Guldvog I, Johnson E, Heald RJ. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg 1998;85(4):526–529. doi:10.1046/j.1365-2168.1998.00601.x.

    Article  PubMed  CAS  Google Scholar 

  14. Kapiteijn E, Putter H, van de Velde CJ. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002;89(9):1142–1149. doi:10.1046/j.1365-2168.2002.02196.x.

    Article  PubMed  CAS  Google Scholar 

  15. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 1982;69(10):613–616. doi:10.1002/bjs.1800691019.

    Article  PubMed  CAS  Google Scholar 

  16. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;44(1):77–80.

    Article  PubMed  CAS  Google Scholar 

  17. de Oca J, Sanchez-Santos R, Rague JM, Biondo S, Pares D, Osorio A et al. Long-term results of ileal pouch-anal anastomosis in Crohn's disease. Inflamm Bowel Dis 2003;9:171–175. doi:10.1097/00054725-200305000-00004.

    Article  PubMed  Google Scholar 

  18. Bauer JJ, Gorfine SR, Gelernt IM, Harris MT, Kreel I. Restorative proctocolectomy in patients older than fifty years. Dis Colon Rectum 1997;40:562–565. doi:10.1007/BF02055379.

    Article  PubMed  CAS  Google Scholar 

  19. Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milsom JW et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995;222:120–127. doi:10.1097/00000658-199508000-00003.

    Article  PubMed  CAS  Google Scholar 

  20. Keighley MR, Grobler S, Bain I. An audit of restorative proctocolectomy. Gut 1993;34:680–684. doi:10.1136/gut.34.5.680.

    Article  PubMed  CAS  Google Scholar 

  21. Krausz MM, Duek SD. Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: twenty years follow-up in 174 patients. Isr Med Assoc J 2005;7:23–27.

    PubMed  Google Scholar 

  22. Mathey P, Ambrosetti P, Morel P, Robert J, Schmidlin F, Marti MC et al. Experience suisse de l'anastomose ileo-anale avec reservoir (AIA). Complications et resultats fonctionnels. Ann Chir 1993;47:1020–1025.

    PubMed  CAS  Google Scholar 

  23. Romanos J, Samarasekera DN, Stebbing JF, Jewell DP, Kettlewell MG, Mortensen NJ. Outcome of 200 restorative proctocolectomy operations: the John Radcliffe Hospital experience. Br J Surg 1997;84:814–818. doi:10.1002/bjs.1800840623.

    Article  PubMed  CAS  Google Scholar 

  24. Carmon E, Keidar A, Ravid A, Goldman G, Rabau M. The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis. Colorectal Dis 2003;5:228–232. doi:10.1046/j.1463-1318.2003.00445.x.

    Article  PubMed  CAS  Google Scholar 

  25. Heuschen UA, Hinz U, Allemeyer EH, Lucas M, Heuschen G, Herfarth C. One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis. Ann Surg 2001;234:788–794. doi:10.1097/00000658-200112000-00010.

    Article  PubMed  CAS  Google Scholar 

  26. Marcello PW, Roberts PL, Schoetz DJ Jr, Coller JA, Murray JJ, Veidenheimer MC. Long-term results of the ileoanal pouch procedure. Arch Surg 1993;128:500–503. discussion 503–4.

    PubMed  CAS  Google Scholar 

  27. McMullen K, Hicks TC, Ray JE, Gathright JB, Timmcke AE. Complications associated with ileal pouch-anal anastomosis. World J Surg 1991;15:763–766. discussion 766–767 doi:10.1007/BF01665312.

    Article  PubMed  CAS  Google Scholar 

  28. Reilly WT, Pemberton JH, Wolff BG, Nivatvongs S, Devine RM, Litchy WJ et al. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Ann Surg 1997;225:666–676. discussion 676–677 doi:10.1097/00000658-199706000-00004.

    Article  PubMed  CAS  Google Scholar 

  29. Young CJ, Solomon MJ, Eyers AA, West RH, Martin HC, Glenn DC et al. Evolution of the pelvic pouch procedure at one institution: the first 100 cases. Aust N Z J Surg 1999;69:438–442. doi:10.1046/j.1440-1622.1999.01552.x.

    Article  PubMed  CAS  Google Scholar 

  30. Ikeuchi H, Shoji Y, Kusunoki M, Yanagi H, Noda M, Yamamura T. Clinical results after restorative proctocolectomy without diverting ileostomy for ulcerative colitis. Int J Colorectal Dis 2004;19:234–438. doi:10.1007/s00384-003-0538-4.

    Article  PubMed  Google Scholar 

  31. Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1998;41:1239–1243. doi:10.1007/BF02258220.

    Article  PubMed  CAS  Google Scholar 

  32. MacRae HM, McLeod RS, Cohen Z, O'Connor BI, Ton EN. Risk factors for pelvic pouch failure. Dis Colon Rectum 1997;40:257–262. doi:10.1007/BF02050412.

    Article  PubMed  CAS  Google Scholar 

  33. Björk J, Akerbrant H, Iselius L, Svenberg T, Oresland T, Pahlman L et al. Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 2001;44:984–992. doi:10.1007/BF02235487.

    Article  PubMed  Google Scholar 

  34. Remzi FH, Church JM, Bast J, Lavery IC, Strong SA, Hull TL et al. Mucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control. Dis Colon Rectum 2001;44:1590–596. doi:10.1007/BF02234377.

    Article  PubMed  CAS  Google Scholar 

  35. von Roon AC, Tekkis PP, Clark SK, Heriot AG, Lovegrove RE, Truvolo S et al. The impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis. Dis Colon Rectum 2007;50:952–961. doi:10.1007/s10350-006-0872-z.

    Article  Google Scholar 

  36. Dayton MT, Larsen KR, Christiansen DD. Similar functional results and complications after ileal pouch-anal anastomosis in patients with indeterminate vs ulcerative colitis. Arch Surg 2002;137:690–694. discussion 694–695 doi:10.1001/archsurg.137.6.690.

    Article  PubMed  Google Scholar 

  37. Pescatori M, Mattana C, Castagneto M. Clinical and functional results after restorative proctocolectomy. Br J Surg 1988;75:321–324. doi:10.1002/bjs.1800750410.

    Article  PubMed  CAS  Google Scholar 

  38. Schluender SJ, Mei L, Yang H, Fleshner PR. Can a meta-analysis answer the question: is mucosectomy and handsewn or double-stapled anastomosis better in ileal pouch-anal anastomosis? Am Surg 2006;72:912–916.

    PubMed  Google Scholar 

  39. Gecim IE, Wolff BG, Pemberton JH, Devine RM, Dozois RR. Does technique of anastomosis play any role in developing late perianal abscess or fistula? Dis Colon Rectum 2000;43:1241–1245. doi:10.1007/BF02237428.

    Article  PubMed  CAS  Google Scholar 

  40. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 2000;43:1487–1496. doi:10.1007/BF02236726.

    Article  PubMed  CAS  Google Scholar 

  41. Johnson E, Carlsen E, Nazir M, Nygaard K. Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis. Eur J Surg 2001;167:40–45.

    PubMed  CAS  Google Scholar 

  42. Pishori T, Dinnewitzer A, Zmora O, Oberwalder M, Hajjar L, Cotman K et al. Outcome of patients with indeterminate colitis undergoing a double-stapled ileal pouch-anal anastomosis. Dis Colon Rectum 2004;47:717–721. doi:10.1007/s10350-003-0116-4.

    Article  PubMed  Google Scholar 

  43. Svaninger G, Nordgren S, Oresland T, Hulten L. Incidence and characteristics of pouchitis in the Kock continent ileostomy and the pelvic pouch. Scand J Gastroenterol 1993;28:695–700. doi:10.3109/00365529309098275.

    Article  PubMed  CAS  Google Scholar 

  44. Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 1998;85:800–803. doi:10.1046/j.1365-2168.1998.00689.x.

    Article  PubMed  CAS  Google Scholar 

  45. Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg 2000;24:851–856. doi:10.1007/s002680010136.

    Article  PubMed  CAS  Google Scholar 

  46. Mowschenson PM, Critchlow JF, Peppercorn MA. Ileoanal pouch operation: long-term outcome with or without diverting ileostomy. Arch Surg 2000;135:463–465. discussion 465–466 doi:10.1001/archsurg.135.4.463.

    Article  PubMed  CAS  Google Scholar 

  47. Thalheimer A, Bueter M, Kortuem M, Thiede A, Meyer D. Morbidity of temporary loop ileostomy in patients with colorectal cancer. Dis Colon Rectum 2006;49:1011–1017. doi:10.1007/s10350-006-0541-2.

    Article  PubMed  Google Scholar 

  48. Platell C, Barwood N, Makin G. Clinical utility of a de-functioning loop ileostomy. ANZ J Surg 2005;75:147–151. doi:10.1111/j.1445-2197.2005.03317.x.

    Article  PubMed  Google Scholar 

  49. Riesener KP, Lehnen W, Hofer M, Kasperk R, Braun JC, Schumpelick V. Morbidity of ileostomy and colostomy closure: impact of surgical technique and perioperative treatment. World J Surg 1997;21:103–108. doi:10.1007/s002689900201.

    Article  PubMed  CAS  Google Scholar 

  50. Garcia-Botello SA, Garcia-Armengol J, Garcia-Granero E, Espi A, Juan C, Lopez-Mozos F et al. A prospective audit of the complications of loop ileostomy construction and takedown. Dig Surg 2004;21:440–446. doi:10.1159/000083471.

    Article  PubMed  CAS  Google Scholar 

  51. Wong KS, Remzi FH, Gorgun E, Arrigain S, Church JM, Preen M et al. Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 2005;48:243–250. doi:10.1007/s10350-004-0771-0.

    Article  PubMed  Google Scholar 

  52. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999;177:463–466. doi:10.1016/S0002-9610(99)00091-4.

    Article  PubMed  CAS  Google Scholar 

  53. Salemans JM, Nagengast FM, Lubbers EJ, Kuijpers JH. Postoperative and long-term results of ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis coli. Dig Dis Sci 1992;37:1882–1889. doi:10.1007/BF01308083.

    Article  PubMed  CAS  Google Scholar 

  54. Jarvinen HJ, Luukkonen P. Experience with restorative proctocolectomy in 201 patients. Ann Chir Gynaecol 1993;82:159–164.

    PubMed  CAS  Google Scholar 

  55. Braun J, Treutner KH, Schumpelick V. Stapled ileal pouch-anal anastomosis with resection of the anal transition zone. Int J Colorectal Dis 1995;10:142–147. doi:10.1007/BF00298536.

    Article  PubMed  CAS  Google Scholar 

  56. Everett WG. Experience of restorative proctocolectomy with ileal reservoir. Br J Surg 1989;76:77–81. doi:10.1002/bjs.1800760125.

    Article  PubMed  CAS  Google Scholar 

  57. McCourtney JS, Finlay IG. Totally stapled restorative proctocolectomy. Br J Surg 1997;84:808–812. doi:10.1002/bjs.1800840621.

    Article  PubMed  CAS  Google Scholar 

  58. Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ, et al. Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial. Ann Surg 2004;240:984–891. discussion 991–992. doi:10.1097/01.sla.0000145923.03130.1c.

    Google Scholar 

  59. Panis Y, Bonhomme N, Hautefeuille P, Valleur P. Ileal pouch-anal anastomosis with mesorectal excision for rectal cancer complicating familial adenomatous polyposis. Eur J Surg 1996;162:817–821.

    PubMed  CAS  Google Scholar 

  60. Hueting WE, Gooszen HG, van Laarhoven CJ. Sexual function and continence after ileo pouch anal anastomosis: a comparison between a meta-analysis and a questionnaire survey. Int J Colorectal Dis 2004;19:215–218. doi:10.1007/s00384-003-0543-7.

    Article  PubMed  CAS  Google Scholar 

  61. Damgaard B, Wettergren A, Kirkegaard P. Social and sexual function following ileal pouch-anal anastomosis. Dis Colon Rectum 1995;38:286–289. doi:10.1007/BF02055604.

    Article  PubMed  CAS  Google Scholar 

  62. Dozois RR, Nelson H, Metcalf AM. Fonction sexuelle apres anastomose ileo-anale. Ann Chir 1993;47:1009–1013.

    PubMed  CAS  Google Scholar 

  63. Tiainen J, Matikainen M, Hiltunen KM. Ileal J-pouch-anal anastomosis, sexual dysfunction, and fertility. Scand J Gastroenterol 1999;34:185–188. doi:10.1080/00365529950173069.

    Article  PubMed  CAS  Google Scholar 

  64. Rink AD, Nagelschmidt M, Radinski I, Vestweber KH. Evaluation of vector manometry for characterization of functional outcome after restorative proctocolectomy. Int J Colorectal Dis 2008;23(8):807–815. doi:10.1007/s00384-008-0473-5.

    Article  PubMed  Google Scholar 

  65. Atkinson KG, Owen DA, Wankling G. Restorative proctocolectomy and indeterminate colitis. Am J Surg 1994;167:516–518. doi:10.1016/0002-9610(94)90248-8.

    Article  PubMed  CAS  Google Scholar 

  66. Foley EF, Schoetz DJ Jr, Roberts PL, Marcello PW, Murray JJ, Coller JA et al. Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage. Dis Colon Rectum 1995;38:793–798. doi:10.1007/BF02049833.

    Article  PubMed  CAS  Google Scholar 

  67. Gullberg K, Liljeqvist L. Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. Int J Colorectal Dis 2001;16:221–227. doi:10.1007/s003840100289.

    Article  PubMed  CAS  Google Scholar 

  68. Hulten L. Problems after ileo-pouch anal anastomosis for ulcerative colitis. How can we prevent it? What can we do. Neth J Med 1994;45:80–85.

    PubMed  CAS  Google Scholar 

  69. Lake JP, Firoozmand E, Kang JC, Vassiliu P, Chan LS, Vukasin P et al. Effect of high-dose steroids on anastomotic complications after proctocolectomy with ileal pouch-anal anastomosis. J Gastrointest Surg 2004;8:547–551. doi:10.1016/j.gassur.2004.01.002.

    Article  PubMed  Google Scholar 

  70. McIntyre PB, Pemberton JH, Beart RW Jr, Devine RM, Nivatvongs S. Double-stapled vs. handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. Dis Colon Rectum 1994;37:430–433. doi:10.1007/BF02076186.

    Article  PubMed  CAS  Google Scholar 

  71. Poggioli G, Marchetti F, Selleri S, Laureti S, Stocchi L, Gozzetti G. Redo pouches: salvaging of failed ileal pouch-anal anastomoses. Dis Colon Rectum 1993;36:492–496. doi:10.1007/BF02050016.

    Article  PubMed  CAS  Google Scholar 

  72. Schippers E, Braun J, Willis S, Schumpelick V. Die direkte ileumpouchanale Anastomose bei der Colitis ulcerosa: Funktion und Komplikationen nach Stapler-Technik. Zentralbl Chir 1998;123:381–387.

    PubMed  CAS  Google Scholar 

  73. Setti-Carraro P, Ritchie JK, Wilkinson KH, Nicholls RJ, Hawley PR. The first 10 years’ experience of restorative proctocolectomy for ulcerative colitis. Gut 1994;35:1070–1075. doi:10.1136/gut.35.8.1070.

    Article  PubMed  CAS  Google Scholar 

  74. Ziv Y, Church JM, Fazio VW, King TM, Lavery IC. Effect of systemic steroids on ileal pouch-anal anastomosis in patients with ulcerative colitis. Dis Colon Rectum 1996;39:504–508. doi:10.1007/BF02058701.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Deparment of Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany

    Andreas D. Rink, Irina Radinski & Karl-Heinz Vestweber

  2. Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Langenbeckstr. 1, 55101, Mainz, Germany

    Andreas D. Rink

Authors
  1. Andreas D. Rink
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Irina Radinski
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Karl-Heinz Vestweber
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andreas D. Rink.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rink, A.D., Radinski, I. & Vestweber, KH. Does Mesorectal Preservation Protect the Ileoanal Anastomosis after Restorative Proctocolectomy?. J Gastrointest Surg 13, 120–128 (2009). https://doi.org/10.1007/s11605-008-0665-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-008-0665-x

Keywords

Search

Navigation