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PubMed1988

Extracorporeal shock wave lithotripsy treatment of spinal cord injury patients.

A total of 32 male patients with spinal cord injury underwent extracorporeal shock wave lithotripsy. The mean stone burden was 2.9 cm. (range 0.2 to 8.0 cm.) per renal unit. Of 41 renal units 27 (66 per cent) required ancillary endourological procedures preoperatively and 32 (78 per cent) required a single treatment with extracorporeal shock wave lithotripsy. Urine cultures were positive in 30 of 32 patients (94 per cent) before treatment. All patients with positive preextracorporeal shock wave lithotripsy urine cultures also had positive cultures after treatment. Followup (3-month) was available for 26 of 41 renal units (63 per cent) and showed 19 (73 per cent) to be free of stones or without any radiographic evidence of calcification overlying the collecting system. Seven staghorn calculi were treated with extracorporeal shock wave lithotripsy without prior debulking procedures. Two partial staghorn calculi were treated and rendered free of stones. None of the 5 kidneys with full staghorn calculi was rendered free of stones. We conclude that extracorporeal shock wave lithotripsy is effective for the treatment of unbranched and partial staghorn calculi in the spinal cord injury patient. However, extracorporeal shock wave lithotripsy alone is less effective for the treatment of full staghorn calculi.

Adult↗

PubMed1991

The effect of an extra-articular procedure on allograft reconstructions for chronic ruptures of the anterior cruciate ligament.

A study was performed on the effect of the addition of an extra-articular procedure involving tenodesis of the iliotibial band to a reconstruction with a bone-patellar ligament-bone allograft for the treatment of chronic rupture of the anterior cruciate ligament. One hundred and four patients were divided into two groups for comparison: Group 1 (sixty-four patients) was treated with only an intra-articular replacement with an allograft and Group 2 (forty patients), with both an intra-articular replacement with an allograft and the extra-articular procedure. Preoperatively, there were no statistically significant differences between the two groups in terms of twenty variables, including body weight, level of activity, anterior-posterior displacements, number of previous operations, and duration of follow-up. All of the patients returned for follow-up evaluation twenty-three to fifty-four months (mean, thirty-five months) postoperatively. All were treated with the same postoperative program of immediate motion of the knee and rehabilitation. The results were evaluated with the use of a comprehensive subjective and objective system that rated the twenty factors. Both procedures proved to be effective in decreasing functional limitations and symptoms and in improving the level of sports activity and the over-all scores. The results in Group 2 were significantly better than those in Group 1, as measured with tests done with the KT-1000 arthrometer (p less than 0.01) and with regard to the level of sports activity (p less than 0.05) and the over-all scores (p less than 0.01). There was no postoperative difference between the two groups in terms of the results on pivot-shift or isokinetic testing, patellofemoral crepitus, functional limitations, or symptoms. The program of rehabilitation effectively restored 0 to 135 degrees of motion to all but four knees, which lacked 5 degrees of extension at the most recent follow-up. The over-all rate of failure for both groups was 11 per cent. However, the rate of failure was 16 per cent (ten of sixty-four knees) in Group 1 and only 3 per cent (one of forty knees) in Group 2. This difference was significant (p less than 0.05). The extra-articular procedure appeared to provide support to the healing intra-articular allograft by reducing deleterious forces and tibial displacements, and to restore the secondary restraints provided by the lateral iliotibial band. The results suggest that the combination of the procedures is of value in young, athletically active people who have chronic rupture of the anterior cruciate ligament.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed1992

Comparative measurement sensitivity of short and longer health status instruments.

Short measures of health status are used increasingly in health services research, yet their sensitivities to clinical change have not been compared with longer, established instruments. In this study, 5 health status measures were administered preoperatively and 3 months postoperatively to 54 patients undergoing total hip arthroplasty. These instruments included the Sickness Impact Profile (SIP)--an established, long measure--and 4 short forms: the SF-36, Functional Status Questionnaire, shortened Arthritis Impact Measurement Scales, and Modified Health Assessment Questionnaire. Scores for physical, psychological, and global dimensions were constructed by aggregating subscales. Sensitivity to change, or responsiveness, was expressed with the standardized response mean (SRM), calculated as the mean change in score divided by the standard deviation of the change in score. The sampling distribution of the SRM was estimated with a jackknife procedure. Preoperative scores were moderately to highly correlated across instruments. The physical and global dimension SRMs of the brief health status measures ranged from 0.85 to 1.27 and were as large as or larger than the corresponding SIP SRMs. The SIP had the highest SRM on the psychological dimension. None of the instruments was significantly more sensitive than the others at the critical value (P = 0.005) adjusted for multiple comparisons. The brief health status measures were equally or more responsive than the SIP after total hip arthroplasty in the physical and global dimensions. Much larger samples are required to demonstrate statistically significant differences in SRMs among instruments.

Activities of Daily Living↗

PubMed1989

[Direct endolymphatic administration of antitubercular drugs in patients with inflammatory diseases of the urogenital organs].

Direct endolymphatic administration of broad-spectrum antibiotics was used in treatment of approximately 21 patients with complicated urogenital tuberculosis. The duration of the endolymphatic therapy ranged from 3 to 13 days. In the patients treated with endolymphatic administration of the antibiotics the effects were favourable. The use of the procedure were shown expedient because marked lesions in the urinary tracts, frequent chronic renal failure and the microbial flora resistance to the drugs lowered the efficacy of the treatment with the routine administration of the drugs. The drugs used i.e. klaforan and gentamicin were approved by the USSR Pharmacological Committee. The drugs were administered with dosator NDL-3 in original modification which provided continuous polycollector endolymphatic antibiotic therapy with simultaneous lavage of the lymphatic channel. It was shown expedient to use endolymphatic administration of antibiotics in treatment of complicated urogenital tuberculosis alone or in combination with the preoperative procedures.

Antitubercular Agents↗

PubMed1998

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery.

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.

Adult↗

PubMedDate not supplied

Cardio-esophageal cancer. Is 18Fluorodeoxyglucose positron emission tomography worthwhile?

BACKGROUND/AIMS: 18Fluorodeoxyglucose positron emission tomography has been proposed for the preoperative staging of carcinomas of the esophagus and gastric cardia. The aim of this study was to assess its diagnostic value and its influence on therapeutical decisions. METHODOLOGY: Twenty-eight patients with a cancer of the esophagus or gastric cardia underwent a 18Fluorodeoxyglucose positron emission tomography on a gamma camera with coincidence detection electronics, in addition to our standard preoperative procedures (barium swallow, liver ultrasonography, chest X-ray). Four types of lesions were searched for: primary tumor, abdominal and mediastinal lymph nodes, and distant metastases. Results of 18Fluorodeoxyglucose positron emission tomography were compared to pathological findings. RESULTS: Sensitivity for the primary tumor was 86%. Sensitivity for mediastinal and abdominal lymph nodes was 75 and 54%, respectively, whereas specificity was 100%. Distant metastases were detected in 4 patients: liver metastasis in 2 patients and bone metastasis in 2 patients. Results of 18Fluorodeoxyglucose positron emission tomography influenced therapeutical decisions for 2 patients. CONCLUSIONS: 18Fluorodeoxyglucose positron emission tomography seems to be worthwhile in the preoperative staging of carcinomas of the esophagus and gastric cardia, mainly because it may detect distant metastases.

Aged↗

PubMed2006

Long-term results of Frey's procedure for chronic pancreatitis: a longitudinal prospective study on 40 patients.

Only limited prospective data are available regarding the long-term outcome of local resection of the pancreatic head in combination with longitudinal pancreaticojejunostomy in patients with chronic pancreatitis. From 1997 to 2001, 40 patients affected by chronic pancreatitis were subjected to the Frey's procedure. Preoperative selection criteria included confirmed diagnosis of chronic pancreatitis, dilation of Wirsung's duct to a diameter greater than 6 mm, and the absence of obstructive chronic pancreatitis secondary to fibrotic stenosis at the pancreatic body or tail. Preoperative pain was present in 38 cases (95%), and follow-up was performed in all patients at least once yearly up to 2003 (median 60 months, inter percentile range 20.1-79.6). Postoperative morbidity occurred in three cases (7.5%). The percentage of pain-free patients was 94.7%, 93.7%, 87.5%, and 90% at 1, 2, 3, and 4/5 years after surgical operation, respectively. After surgery, three patients developed diabetes. Both the body mass index and quality of life showed statistically significant improvements at all follow-up intervals. Whenever surgery is indicated, the short-term and long-term outcomes confirm that Frey's procedure is an appropriate means of management for patients with chronic pancreatitis in the absence of doubts of neoplasia and/or distal ductal obstruction.

Adult↗

PubMedDate not supplied

[Minimally invasive radioguided parathyroidectomy].

The use of a hand-held gamma probe during the operation allows a direct approach to the parathyroid adenoma, which is more active than the thyroid. This procedure is significantly less morbid and can be performed in shorter time than standard neck exploration. Hand-held gamma probe already existed at the Department of Oncology and Nuclear Medicine. As a result of a very good cooperation with Department of Internal medicine and Department of Othorhinolaryngology, for the first time in our country minimally invasive radioguided parathyroidectomy was performed on April 16th, 2002. Until now, 15 patients with primary hyperparathyroidism underwent this type of operation. 700 MBq 99m-Tc-SESTAMIBI was injected two hours before the planned operative procedure. Preoperative scintigraphy was performed 10 and 80 minutes after the administration of radiopharmaceutical. This study deals with our first experience of intra-operative localization of parathyroid adenomas using a hand-held gamma probe, as well as our observations concerning the selection of the patients.

Adenoma↗

PubMed1997

[Successful aortic root replacement with pulmonary autograft (Ross) in two cases of congenital aortic stenosis].

Two cases of 7 and 23 year of age with congenital aortic stenosis associated with the small valve annulus underwent successful aortic root replacement with pulmonary autograft (Ross procedure). Preoperative pressure gradient and the valve size were 120 and 80 mmHg, and 16 and 18 mm, respectively. Even with the small native aortic annulus, pulmonary autografts could be implanted to aortic annulus without autograft distortion by the method of total aortic replacement. The right ventricular outflow reconstruction was performed with PTFE-valved bovine pericardial conduit with securing the posterior muscular edge by a strip of autologous aortic wall. Postoperative course in both patients was uneventful without any rhythm disturbances. During the 12 and 14 months of follow-up, both patients were in excellent clinical condition with no evidence of autograft valve regurgitation and functional deterioration of valved conduit. This procedure was thought to be a preferable method of young cases with congenital aortic stenosis.

Adult↗

PubMed2004

Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures.

STUDY DESIGN: A 3-year prospective, cohort study. OBJECTIVES: To compare the incidence and risk factors of dysphagia after anterior cervical (AC), posterior cervical (PC), and posterior lumbar (PL) spine procedures. SUMMARY OF BACKGROUND DATA: Dysphagia is a known risk of AC surgery; however, comprehensive postoperative swallow evaluations have not been performed for a comparative cohort of AC, PC, and PL surgery patients. METHODS: Eighty-three patients were enrolled in the study, including 38 undergoing AC, 19 PC, and 26 PL procedures. Preoperative and postoperative swallowing evaluations were performed by questioning for subjective swallowing complaints and performing objective radiographic examination. Patients with severe dysphagia leading to an increased risk of aspiration were identified and treated until recovery or for 3 to 9 months. RESULTS: Comparison of preoperative and postoperative swallowing complaints revealed a significant increase for AC patients (P < 0.01) and a trend for PC (P = 0.06) and PL (P = 0.09) patients. Eighteen (47%) AC, 4 (21%) PC, but no PL patients demonstrated dysphagia on postoperative videofluoroscopic swallow evaluation. Age (>60 years, P < 0.01) was associated with increased risk of radiologic evidence of dysphagia. Surgical level, instrumentation, operative time, and presence of myelopathy or other comorbidities were not. Over 70% (12 of 17) of AC patients with dysphagia followed recovered within 2 months, while 23% (4 of 17) required some level of compensatory swallowing behavior up to 10 months following surgery. CONCLUSION: Dysphagia is a common occurrence after AC procedures but was also found after PC procedures. Intubation alone was not a risk factor for postoperative dysphagia in this cohort.

Adult↗

PubMed2006

Osteonecrosis of the knee after laser or radiofrequency-assisted arthroscopy: treatment with minimally invasive knee arthroplasty.

BACKGROUND: Osteonecrosis of the knee after various arthroscopic procedures associated with the use of laser or radiofrequency devices has been described in a few case reports. The purpose of this study was to report on a series of nineteen patients with osteonecrosis of the knee after arthroscopic procedures. A literature search was done to compare this series of patients to previously reported cases. In addition, we analyzed the outcome after treatment with minimally invasive knee arthroplasty. METHODS: We studied patients who had development of osteonecrosis of the knee after a routine arthroscopic procedure. Preoperative and postoperative clinical notes, radiographs, and magnetic resonance images of patients were analyzed. Only those patients with no evidence of osteonecrosis on preoperative magnetic resonance imaging who later had development of osteonecrosis and subsequently required a knee arthroplasty were included. We conducted a search of the current literature to compare the results seen in our patient population with those seen in other patients with this entity. Patients were followed both clinically and radiographically for a mean of sixty-two months. RESULTS: A total of nineteen patients met the inclusion criteria. There were fourteen women and five men with a mean age of sixty-nine years. Six patients underwent an arthroscopy with associated holmium or yttrium-aluminum-garnet laser treatment, ten patients had associated radiofrequency treatment, and three patients had microfracture surgery. Subsequent arthroplasty procedures included four unicompartmental knee arthroplasties and fifteen tricompartmental knee arthroplasties. At the time of final follow-up, the mean Knee Society objective score was 95 points. CONCLUSIONS: Arthroscopic procedures may play a role in the development of osteonecrosis of the knee. To our knowledge, this is the largest series of patients to have development of this condition after arthroscopy with associated laser, radiofrequency, or microfracture surgery. The midterm results of knee arthroplasty in this unique patient population are comparable with those of patients undergoing knee arthroplasty for osteoarthritis of the knee. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Aged↗

PubMed1992

Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score.

OBJECTIVE: To relate morbidity and mortality risk to preoperative severity of illness in patients undergoing coronary artery bypass grafting. DESIGN: Retrospective analysis of 5051 patients using univariate and logistic regression to identify risk factors associated with perioperative morbidity and mortality. Prospective application of models to a subsequent 2-year validation cohort (n = 4069). SETTING: Cleveland Clinic Foundation. PATIENTS: All adult patients undergoing coronary artery bypass graft surgery between July 1, 1986, and June 30, 1988 (reference group), and July 1, 1988, and June 30, 1990 (validation group). MAIN OUTCOME MEASURES: Mortality and morbidity (myocardial infarction and use of intra-aortic balloon pump, mechanical ventilation for 3 or more days, neurological deficit, oliguric or anuric renal failure, or serious infection). MAIN RESULTS: Emergency procedure, preoperative serum creatinine levels of greater than 168 mumol/L, severe left ventricular dysfunction, preoperative hematocrit of 0.34, increasing age, chronic pulmonary disease, prior vascular surgery, reoperation, and mitral valve insufficiency were found to be predictive of mortality. In addition to these factors, diabetes mellitus, body weight of 65 kg or less [corrected], aortic stenosis, and cerebrovascular disease were predictive of morbidity. Logistic regression equations were developed, and a simple additive score for clinical use was designed by allocating each of these risk-factor values of 1 to 6 points. Both methods predict mortality. Increased morbidity was demonstrated with increases in score. CONCLUSIONS: The logistic or clinical models developed are superior to the currently available methods for comparing mortality outcome and provide previously unavailable information on morbidity based on preoperative status. The clinical scoring system is useful for preoperative estimates of morbidity and mortality risks.

Aged↗

PubMedDate not supplied

[One- or two-step instrumentation for thoracolumbar scoliosis due to myelomeningocele?].

AIM: This investigation evaluates patients with MMC who underwent a two-stage anterior-posterior correction and stabilisation of thoracolumbar scoliosis due to myelomeningocele. The data were compared with the few reported series of one-stage versus two-stage surgery in the literature. METHOD: From 1.7.1992 to 30.6.1995, 11 consecutive patients with severe thoracolumbar scoliosis due to myelomenigocele were admitted at our hospital. The mean age at operation was 12 years nine months (range nine years nine to 14 years six months). All patients underwent a two-stage anterior and posterior spinal instrumentation. The patients were pre- and postoperatively evaluated. RESULTS: All patients were followed for a mean of 4 years 11 months (range 42 months to 88 months) from the time of the second stage procedure. Preoperatively the mean scoliosis angle was 82 degrees (range 55 degrees to 110 degrees ), this was reduced to a mean of 31 degrees (range 8 degrees - 70 degrees ), at final follow-up, the correction had deteriorated slightly to a mean of 35 degrees (range 12 degrees - 80 degrees ). No patient had increased neurological deficit or showed other major complications, i. e., infection, sepsis due to immunologic disorders at the time of the operation. CONCLUSION: We believe that with the two-stage anterior and posterior instrumentation an effective correction of the scoliosis can be achieved. Compared to other studies this report confirms the low morbidity rate and emphasise the good results of a two staged procedure.

Adolescent↗

PubMed1999

The favorable impact of arrhythmia surgery on total cavopulmonary artery Fontan conversion.

Patients who have undergone atriopulmonary Fontan procedures are at risk for significant atrial arrhythmias and obstructive connections, which have been related to intra-atrial suture lines, atrial enlargement, and somatic growth. Twenty patients (mean age, 17.3 +/- 6.8 years) had conversion to total cavopulmonary artery connection 8.9 +/- 2.1 years after the previous Fontan procedure (for atrial arrhythmias in 19 patients and for obstructive lesions in one). Arrhythmia ablative surgery evolved over the study period from "arrhythmia circuit cryoablation" (cryoablation lesions completing lines of block) to the more standard approaches of modified right-sided Maze and Maze-Cox III procedures. Preoperative functional New York Heart Association class was IV in nine patients, III in nine, and II in two. All patients survived. Two patients had prolonged chest drainage (there was pericardial effusion in one). The average length of hospital stay was 11.3 +/- 5.4 days; chest tubes were removed on day 8.5 +/- 5.4. There were no long-term deaths (mean follow-up period, 20.3 +/- 14.9 months; range, 2 months to 4 years). Late postoperative arrhythmias occurred in two patients who are receiving long-term antiarrhythmic medications. All patients have improved to New York Heart Association class I or II. Total cavopulmonary artery Fontan conversion in association with modified right-sided Maze or Maze-Cox III procedures and pacemaker placement can be accomplished with low morbidity and mortality, and results in functional class improvement and control of life-threatening arrhythmias. Copyright 1999 by W.B. Saunders Company

Journal Article↗

PubMed1995

Use of the bidirectional Glenn procedure in the presence of forward flow from the ventricles to the pulmonary arteries.

BACKGROUND: Relative regression of the pulmonary arterial size has been reported after a conventional bidirectional Glenn procedure. Maintaining a supplemental pulmonary flow could be of surgical value unless the option also militates against the efficacy of the partial right heart bypass. METHODS AND RESULTS: Twenty-seven patients considered unsuitable for a Fontan-type procedure underwent a bidirectional Glenn procedure in the presence of forward flow from the ventricles to the pulmonary arteries, the flow being maintained through the pulmonary trunk in 22 or a systemic-to-pulmonary shunt in 5. There was one surgical death due to atrioventricular valvular regurgitation. Subsequently, 9 patients have successfully undergone a total cavopulmonary connection 2.6 +/- 1.9 years after the initial procedure. Preoperative and postoperative catheterizations revealed changes in arterial oxygen saturation (75 +/- 11% compared with 83 +/- 7%, P < .001) and end-diastolic volumes of the systemic ventricles (from 238 +/- 92% to 188 +/- 97% of the expected normal volume, P < .01), whereas no difference was detected in the mean cross-sectional area of the right and left pulmonary arteries compared with the expected normal value for the right pulmonary artery (from 76 +/- 21% to 81 +/- 20%) or in the ventricular ejection fraction (from 53 +/- 8% to 50 +/- 14%). The relative regression or growth of the pulmonary arterial size was statistically related to the size of the channel for forward flow. CONCLUSIONS: Maintenance of forward flow from the ventricle provides a feasible means, when performing a bidirectional Glenn procedure, of protecting against regression of pulmonary arterial size as well as off-loading the ventricles and improving arterial oxygen saturation.

Adolescent↗

PubMed2002

Complications of percutaneous transhepatic portal vein embolization.

PURPOSE: Percutaneous transhepatic portal vein (PV) embolization (PTPE) is a useful preoperative procedure for extended liver resection. The purpose of the present study was to assess the frequency of technical complications of PTPE and to discuss the risks of this procedure. MATERIALS AND METHODS: PTPE was performed in 46 patients. Forty-seven procedures were performed because an initial puncture failure required that the procedure be performed twice in one patient. The technical success rate and technical complications were assessed. Complications were analyzed with regard to approach methods and puncture sites. Approach methods were categorized as contralateral or ipsilateral. Puncture sites were categorized into anterior, posterior, and lateral segments. The results were compared statistically with use of the Fisher exact test. RESULTS: Technical success was achieved in 45 of 47 procedures (95.7%). Complications occurred in seven of 47 procedures (14.9%), including pneumothorax in two, subcapsular hematoma in two, arterial puncture in one, pseudoaneurysm in one, hemobilia in one, and PV thrombosis in one. Subcapsular hematoma and pseudoaneurysm occurred in the same procedure. No patient died as a result of complications. There was no significant difference between the contralateral and ipsilateral approaches. The incidence of complications was significantly higher in procedures involving puncture of the posterior segment than in those involving puncture of the anterior segment (P =.0374). CONCLUSION: In cases in which the anterior segment cannot be visualized for puncture, PTPE via the lateral segment or transileocolic portal embolization should be considered rather than PTPE via the posterior segment.

Aged↗

PubMed1997

[Substantiation of indications for low-intensity laser irradiation in combined preoperative care of patients with ulcerative gastrointestinal hemorrhage].

Indications for the low-intensive laser application in preoperative procedure scheme were speculated on the ground of complex investigation data in 175 patients with gastrointestinal ulcerative hemorrhage (GIUH). Indications for intravascular laser blood irradiation (IVLBI), for the projectional action on thymus, spleen and their combined application are established. For the reliable hemostasis guarantee the conduction of laser therapy is the most effective one.

Adolescent↗

PubMed1985

[Effect of preoperative intra-arterial infusion of adriamycin on locally advanced breast cancer].

The effect of adriamycin (ADM) infused intraarterially as a preoperative procedure was analyzed retrospectively in 15 patients with primary advanced breast cancer. A high clinical response rate (CR+ PR) of 73% (11/15) was obtained by the treatment, and also remarkable degenerative changes of tumor cells were histologically noted in 10 out of 15 surgical specimens (67%). A correlation between the dose of ADM infused and the rate of tumor regression was observed. A significantly higher concentration of ADM was detected in metastatic lymph nodes and tumors obtained 3-4 weeks after intra-arterial infusion of ADM than that in normal mammary gland. As for side effects, alopecia, leukocytopenia, anorexia, nausea and vomiting occurred at high frequencies. The side effects due to this treatment were considered to be tolerable. Prognostically, a good survival rate was not observed using preoperative treatment with intra-arterial ADM infusion.

Adult↗