Home Current issue Ahead of print Search About us Editorial board Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 38  |  Issue : 3  |  Page : 604-609

Evaluation of ligation of intersphincteric fistula tract technique in treatment of simple transsphincteric fistula


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of General Surgery, Nasser Institute Hospital, Cairo, Egypt

Date of Submission25-Apr-2019
Date of Acceptance25-Apr-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Ahmed A.H Khattab
Albagoor, Menoufia, 32915
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_92_19

Rights and Permissions
  Abstract 


Objective To evaluate the success rate of ligation of intersphincteric fistula tract (LIFT) operation in the treatment of simple transsphincteric anal fistula.
Background LIFT is a new effective sphincter-preserving technique. One of the main advantages of the technique is the low possibility of an impaired sphincter function (as there is no resection of the sphincter).
Patients and methods This is a prospective descriptive clinical study of 30 patients with simple transsphincteric anal fistula. In this variety of fistula, the tract passes from the intersphincteric plane through the external sphincter into the ischioanal fossa, and to the skin. Patients with transsphincteric anal fistulas of cryptoglandular origin with no previous surgical interventions were included. Patients with anal fistulas from another sources, such as Crohn’s disease, tuberculosis, anal cancer, and recurrent fistulas, were excluded. All patients underwent the same technique and were evaluated for 6 months postoperatively.
Results We evaluated 30 patients. Their mean age was 42.1 years. The outpatient follow-up was 6 months. The healing time observed in this study ranged from 5 to 8 weeks after the procedure (mean±SD) 6.47±1.19. A primary healing rate of 80% (24 patients) was observed, and the recurrence rate was 20% (six patients). Recurrence occurred in the incision for ligation of the fistulous tract, that is, the fistula turned into intersphincteric type. The postoperative wound infection occurs in five (16.7%) patients. Postoperative urine retention occurred in one (3.3%) patient. No bleeding occurred in any patient. No patient experienced postoperative incontinence to stool.
Conclusion LIFT was effective sphincter-preserving technique in the treatment of simple transsphincteric anal fistulas.

Keywords: anal fistula, ligation of intersphincteric fistula tract, simple transsphincteric anal fistula, sphincter preserving


How to cite this article:
Elsebai OI, Ammar MS, Abdelhaleem MS, Khattab AA. Evaluation of ligation of intersphincteric fistula tract technique in treatment of simple transsphincteric fistula. Egypt J Surg 2019;38:604-9

How to cite this URL:
Elsebai OI, Ammar MS, Abdelhaleem MS, Khattab AA. Evaluation of ligation of intersphincteric fistula tract technique in treatment of simple transsphincteric fistula. Egypt J Surg [serial online] 2019 [cited 2019 Nov 18];38:604-9. Available from: http://www.ejs.eg.net/text.asp?2019/38/3/604/264355




  Introduction Top


Anal fistula is a difficult problem that physicians have struggled with since the time of Hippocrates [1]. Anal fistula constitutes an epithelized path establishing a communication between the rectum or anal canal and perianal region. Fistula incidence is estimated in 8.6/100 000 individuals with predominance in males by 2 : 1. The disease is more frequent between the third and fifth decades of life. In up to 90% of the cases, the origin of the fistula is cryptoglandular. In only 10%, Crohn’s disease, trauma, malignancies, infection, or radiation therapy can be the cause of disease [2]. The etiology of persisting perianal suppuration and fistula formation is the presence of anal glands or epithelial debris in the central and intersphincteric spaces. These buried ‘epithelial element’, in the presence of infection, act as multiple sequestra which harbor and maintain the infective process. Infection starts in central space and works its way to the other anorectal spaces, leading to different types of fistulas [3]. The clinical manifestations of anal fistula are anal itching, discomfort, and pain, associated with a recurrent mucopurulent discharge sometimes with blood [2]. In 1961, Parks and Stitz [4] divided fistulas into intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. The Standards Committee for the American Society of Colon and Rectal Surgeons published practice parameters for the management of perianal abscess and anal fistula in 2011 in which fistulas can also be classified as ‘simple’ or ‘complex’ with simple fistulas including intersphincteric and low trans-sphincteric fistulas that cross 30% of the external sphincter. Complex fistulas include high transsphincteric fistulas with or without a high blind tract, suprasphincteric and extrasphincteric fistulas, horseshoe fistulas, and those associated with inflammatory bowel disease, radiation, malignancy, preexisting incontinence, or chronic diarrhea, as well. Given the attenuated nature of the anterior sphincter complex in women, fistulas in this location deserve special consideration and may be considered complex as well [5]. The ideal surgical treatment for anal fistula should eradicate sepsis and promote healing of the tract, while preserving the sphincters and the mechanism of continence [6]. For the simple fistulae, conventional surgical treatment such as lay open of the fistula tract as a complete transection of the tissue between the fistula tract and anoderm is very effective [6]. Fistulectomy involves coring out of the fistula. It allows better definition of fistula anatomy, especially the level at which the tract crosses the sphincters [7]. Some surgeons will continue to use the cutting seton, convinced of its merits, whereas others are completely against its use, claiming high incontinence and recurrence rates [8]. Recently, a number of new sphincter-preserving techniques have been developed and proposed, all with the common goal of minimizing the injury to the anal sphincters and optimizing the functional outcome [6],

Ligation of intersphincteric fistula tract (LIFT) is a new sphincter-preserving technique for the treatment of transsphincteric fistulas that was described by Rojanasakul et al. [9], with an initial healing rate of 94.4%. The procedure consists of opening and dissection of the intersphincteric space and identification of the fistula tract crossing that space. The tract is then ligated and cut, leaving both internal and external sphincter intact [10]. Subsequent studies have revealed a healing rate ranging from 68 to 83%, with an average healing time from 6 to 7 weeks. Modifications of the LIFT technique have been described to increase its success rate. A recent study of 41 cases compared the LIFT technique with LIFT along with the additional step of coring fistulectomy, which was done from the external opening till the anal sphincter [11]. No significant difference in success rate was noted (85 vs. 81%).

Another study of 41 patients, to determine whether adding an advancement flap to the LIFT technique would help in increasing the success rate, revealed an overall healing rate of 71% [12]. Reinforcing the LIFT with a bioprosthetic graft, has been used to significantly improve the success rate of LIFT (75–94%) [13],[14]. There have been many articles comparing the result of LIFT with other sphincter-preserving technique .The results with advancement flap as a standalone procedure range from 59 to 72% [15],[16]. Continence can deteriorate in 9–14% of patients after this procedure. The success rates of fibrin glue are however very diverse and low. In a paper, which reviewed papers from 1966 to 2004, showed a success rate that varied from 0 to 100% [6]. Subsequent papers have revealed success rate between 38 and 41% for simple fistulas and a much lower rate for complex fistulas [17],[18]. In 2006, Meinero and Mori [19] described the video-assisted anal fistula treatment technique for fistula-in-ano. He published his results in 2012. The procedure was performed in 136 patients over a period of 5 years. In a mean follow-up of 13 months, primary healing was achieved in 72 (73.5%) patients at the end of 3 months. At the end of 1 year, 87.1% of fistulas had healed [20]. Autologous adipose-derived stem cells can be used in combination with fibrin glue for management of fistula. The results at 1 year vary from 50 to 71% [21],[22].

The aim of this study was to evaluate the success rate of LIFT operation in the treatment of simple transsphincteric anal fistula.


  Patients and methods Top


This is a prospective descriptive clinical study that included 30 patients complaining of simple anal fistula, of age ranging from 20 to 60 years old and from both sexes attending the Menoufia University Hospital and Nasser Institute Hospital during the period from May 2017 to May 2018, and all patients underwent treatment with LIFT technique. Inclusion criteria were patients with cryptoglandular, simple transsphincteric fistula. Exclusion criteria were active anorectal sepsis; intersphincteric, suprasphincteric and extrasphincteric fistulas; horseshoe fistulas; rectovaginal fistula; traumatic fistula; and those associated with inflammatory bowel disease, specific infection (e.g. tuberculosis), radiation, malignancy, preexisting incontinence or chronic diarrhea, patients younger than 18 years, and pregnancy. Informed consents were obtained from all patients included in the study. The study was approved by the Local Ethics Committee of General Surgery Department of Faculty of Medicine Menoufiya University and Nasser Institute Hospital. Medical history and clinical data were obtained from each patient with special emphasis on the presenting symptoms. The examination included perineal inspection, palpation, digital rectal examination, and proctoscopic evaluation. Continence status of the patients of the study was assessed by Wexner incontinence score system. (The scale takes into account the frequency of the incontinence, the type of incontinence (solid stool, liquid, or gas), the use of a pad, and the effect on daily living. Scoring for the scale ranges from 0 to 20. Patients with a score below 8 have mild incontinence; 9–14, moderate incontinence; and 15–20, severe incontinence. A score of 9 or higher has been associated with a negative effect on quality of life [23]. All patients were admitted to the hospital at least 1 day before surgery. The anal region was shaved. On the morning of the operation, the rectum was evacuated with the aid of a disposable enema. All patients were operated under spinal anesthesia after antibiotic prophylaxis with ceftriaxone 1 g intravenously and metronidazole 500 mg intravenously at time of induction. With the patient in lithotomy position, inspection and identification of the site of external opening was done, and proctoscopy was applied for detection of internal opening and the fistula tract. Injection of methylene blue in the external opening to identify the presence and site of internal opening was done. A probe was passed in the external opening to define the direction of the fistula tract to the internal opening and to classify the fistula according to Park’s classification. A curvilinear incision was made just outside the intersphincteric groove. Dissection was continued in the intersphincteric plane until the fistula track was encountered. After its isolation, the probe was removed and the track was ligated with absorbable sutures (3/0 Vicryl) close to the internal and external anal sphincters. The track was then transected between the two ligation points. The wound was loosely closed with interrupted, absorbable sutures. Subsequently, both external and internal openings were gently curetted to remove any granulation tissue and then left open for drainage ([Fig. 1]) [24]. The operating time for the procedure was calculated from the start of the methylene blue test to the beginning of dressing of the postoperative wound. The patients were evaluated weekly for 8 weeks then once monthly for 4 months (total follow-up of 6 months) at the outpatient clinic and were assessed for severity of postoperative pain on a scale of 0–10 with the help of the Visual Analogue Scale (VAS), time of hospital stay, postoperative time needed for complete healing, continence status (by Wexner score system), recurrence, and postoperative complications (urine retention, bleeding and wound infection). The results had been collected, evaluated, calculated, tabulated, and statistically analyzed using a computer statistical package SPSS 19.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics in the form of mean, SD, number and percentage were applied.
Figure 1 Ligation of intersphincteric fistula tract.

Click here to view



  Results Top


This study was conducted on 30 patients, comprising 20 (66.7%) male and 10 (33.3%) female. The mean±SD age was 42.1±18.6 years. All patients were complaining of cryptoglandular, simple transsphincteric anal fistula and all were treated by LIFT operation. Discharge was the main complaint, and it was present in all patients in the study. Pain was present in 22 (73.3%) patients in the study. Swelling was present in 22 (73.3%) patients in the study. Pruritus ani was present in only 12 (40%) patients in the study ([Table 1]). The operative time ranging between 35 and 40 min, with a mean±SD of 38.0±2.54. There were no intraoperative complications. In each case, the patient was discharged within 24 h. The post-LIFT outpatient follow-up was 6 months. Severity of postoperative pain was assessed on a scale of 0–10 with the help of the VAS. The VAS mean±SD was 3.3±1.4. Subsidence of pain (VAS mean<1) was noted at ∼3 weeks postoperatively. The healing time observed in this study ranged from 5 to 8 weeks after the procedure (mean±SD 6.47±1.19). In this series of cases, a primary healing rate of 80% (24 patients) was observed, and the recurrence rate was 20% (six patients) ([Fig. 2]). Postoperative wound infection occurred in five (16.7%) patients. Postoperative urine retention occurred in one (3.3%) patient. No bleeding occurred in any patient. No patient experienced postoperative incontinence ([Table 2]).
Table 1 Distribution of sociodemographic data among study group and the main presenting complaints

Click here to view
Figure 2 Success rate in our study.

Click here to view
Table 2 Outcomes of ligation of intersphincteric fistula tract procedure

Click here to view



  Discussion Top


The three primary criteria for determining success or failure of fistula surgery are the following: recurrence, delayed healing, and incontinence [25]. A number of new sphincter-preserving techniques have been developed and proposed, all with the common goal of minimizing the injury to the anal sphincters and optimizing the functional outcome [6]. The technique that has perhaps gained the most traction in recent years is the LIFT procedure. It was first described in 1993 by Matos et al. [26]. It gained popularity after it was revised and reborn in 2007 by Rojanasakul et al. [9] and reported impressive healing rate (>94%), with no complications for transsphincteric fistulas [9]. Since then, LIFT was familiar to clinicians. Long-term success rates from studies with a long-term follow-up period report healing rates of 40–95% for LIFT [27]. This study was designed to evaluate success rate of LIFT operation in the treatment of simple transsphincteric anal fistula. In this study, a primary healing rate of 80% was observed. In American studies that included patients who failed a previous treatment, the healing rate ranged from 55 to 64% [28]. In Australia, Ooi et al. [29] who also included in the sample patients with recurrent perianal fistulas (40% of the sample), achieved primary healing in 68.0% of cases. On the contrary, Shanwani et al. [30] reported cure in 82% of their sample. European studies showed resolution rates of 71–83% for primary healing, and in some of them up to 100% healing in the sample, in those studies that considered secondary healing patients [18]. This demonstrates that the healing rates obtained in this study were within the expected. The follow-up period in this series was 6 months, and the recurrence rate was 20%. In studies of Yassin et al. [28] and Liu et al. [31], the mean follow-up was 19 and 28 months, respectively, and the recurrence rate was 36 and 32%, respectively. Possibly the lower relapse seen in this paper is inferior to the other studies presented here owing to a shorter follow-up. Although most LIFT recurrences presented early, some occurred beyond 6 months and as late as 12 months after the initial procedure. Hence, the time of follow-up cannot be ignored. Currently published median follow-up ranges from 5 to 9 months, but several authors have found that late recurrences can occur 7–8 months after the surgical procedure [32]. Thus, the short-term observation may be an overestimate of the success rate. Even if the external and internal orifice is healed, it is still possible for incomplete closure presumably with a risk for recurrence. Follow-up extended to 2 or more years should clarify this point [32]. Extended follow-up is needed to better understand the long-term outcome of LIFT. Of the six patients who did not achieve a primary healing in our study, all showed recurrence in the incision for ligation of the fistulous tract, that is, their defects turned into intersphincteric fistulas, and could be subsequently treated by fistulotomy with complete resolution and with no fecal incontinence. This development has already been reported by others and can be considered as an advantage of the method, which enables a primary cure in most cases, but, when this does not occur, it at least reduces the complexity of the fistulous tract [29],[33]. The healing time observed in this study ranged from 5 to 8 weeks after the procedure (mean±SD, 6.47±1.19). Ooi et al. [29] and Shanwani et al. [30] reported a mean healing time of 6 and 5 weeks, respectively. Wound infection was defined as the presence of erythema, induration surrounding the wound, or constitutional symptoms such as fever. In this study, the postoperative wound infection occurred in five (16.7%) patients. Wound infection occurs owing to bad hygiene of the patients; this infection was treated early by antibiotics and regular dressing, and there was a good response. The wound was carefully examined for bleeding. In this study, no bleeding occurred in any patient. This was owing to good hemostasis and use of diathermy during operations. In this study, postoperative urine retention occurred in one (3.3%) patient. This condition occurred temporarily in the operative day and relieved soon after analgesics and hot bath. One of the main advantages of this technique is a low or zero possibility of an impaired sphincter function (as there is no section of the sphincter). All patients in this study were assessed according to Wexner incontinence score in the follow-up period. No patient experienced postoperative incontinence to stool.


  Conclusion Top


LIFT was effective sphincter-preserving technique in the treatment of simple transsphincteric anal fistulas. One of the main advantages of the technique is the low possibility of an impaired sphincter function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Köckerling F, Alam NN, Narang SK, Daniels IR, Smart NJ. Treatment of fistula-in-ano with fistula plug: a review under special consideration of the technique. Front Surg 2015; 2:55.  Back to cited text no. 1
    
2.
Mendes CRS, Ferreira LSM, Sapucaia RA, Lima MA, Araujo SEA. Video-assisted anal fistula treatment: technical considerations and preliminary results of the first Brazilian experience. Arq Bras Cir Dig 2014; 27:77–81.  Back to cited text no. 2
    
3.
Shafik A, Khalil AM, Elsibai O, Abdel-Wahab ES. Anorectal fistula results of treatment by cauterization. Dig Surg 1994; 11:16–19.  Back to cited text no. 3
    
4.
Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Colon Rectum 1976; 19:487–499.  Back to cited text no. 4
    
5.
Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD. Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum 2011; 54:1465–1474.  Back to cited text no. 5
    
6.
Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol 2015; 21:12–20.  Back to cited text no. 6
    
7.
Elsebai OL, Elsesy AA, Ammar MS, Khatan AM. Fistulectomy versus fistulotomy in the management of simple perianal fistula. Menoufia Med J 2016; 29:564–569.  Back to cited text no. 7
  [Full text]  
8.
Raslan SM, Aladwani MA, Alsanea N. Evaluation of the cutting seton as a method of treatment for perianal fistula. Ann Saudi Med 2016; 36:210–215.  Back to cited text no. 8
    
9.
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano: the ligation of inter-sphincteric fistula tract. J Med Assoc Thai 2007; 90:581–586.  Back to cited text no. 9
    
10.
Cetinkaya E, Bulut B, Ersoz S, Guldogan CE, Akgul O, Yuksel BC et al. Clinical experience with LIFT technique for complex anal fistulas. J Gastrointest Dig Syst 2016; 6:425.  Back to cited text no. 10
    
11.
Sirikurnpiboon S, Awapittaya B, Jivapaisarnpong P. Ligation of intersphincteric fistula tract and its modification: results from treatment of complex fistula. World J Gastrointest Surg 2013; 5:123–128.  Back to cited text no. 11
    
12.
Van Onkelen RS, Gosselink MP, Schouten WR. Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Dis Colon Rectum 2012; 55:163–166.  Back to cited text no. 12
    
13.
Ellis CN, Rostas JW, Greiner FG. Long-term outcomes withthe use of bioprosthetic plugs for the management of complex anal fistulas. Dis Colon Rectum 2010; 53:798–802.  Back to cited text no. 13
    
14.
Ellis CN. Outcomes with the use of bioprosthetic grafts to reinforce the ligation of the intersphincteric fistula tract (BioLIFT procedure) for the management of complex anal fistulas. Dis Colon Rectum 2010; 53:1361–1364.  Back to cited text no. 14
    
15.
Mizrahi N, Wexner SD, Zmora O, Da Silva G, Efron J, Weiss EG et al. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum 2002; 45:1616–1621.  Back to cited text no. 15
    
16.
Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 2002; 45:1622–1628.  Back to cited text no. 16
    
17.
Yeung JM, Simpson JA, Tang SW, Armitage NC, Maxwell-Armstrong C. Fibrin glue for the treatment of fistulae in ano − a method worth sticking to? Colorectal Dis 2010; 12:363–366.  Back to cited text no. 17
    
18.
Loungnarath R, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 2004; 47:432–436.  Back to cited text no. 18
    
19.
Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 2012; 16:111.  Back to cited text no. 19
    
20.
Schwandner O. Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease. Tech Coloproctol 2013; 17:221–225.  Back to cited text no. 20
    
21.
Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J et al. Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum 2009; 52:79–86.  Back to cited text no. 21
    
22.
Herreros MD, Garcia-Arranz M, Guadalajara H, De-La-Quintana P, Garcia-Olmo D. FATT Collaborative Group. Autologous expanded adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistulas: a phase III randomized clinical trial (FATT 1: fistula Advanced Therapy Trial 1) and long-term evaluation. Dis Colon Rectum 2012; 55:762–772.  Back to cited text no. 22
    
23.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36:77–97.  Back to cited text no. 23
    
24.
Abcarian AM. Ligation of intersphincteric fistula tract (LIFT). In: Abcarian H, editor. Anal fistula. New York, NY: Springer 2014. pp. 115–119.  Back to cited text no. 24
    
25.
Corman ML. Anal fistula. In: Colon and rectal surgery. Vol. 11 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 295–329.  Back to cited text no. 25
    
26.
Matos D, Lunniss PJ, Phillips RK. Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 1993; 80:802–804.  Back to cited text no. 26
    
27.
Xu Y, Tang W. Ligation of inter-sphincteric fistula tract is suitable for recurrent anal fistulas from follow-up of 16 months. Biomed Res Int 2017; 10:1155–1159.  Back to cited text no. 27
    
28.
Yassin NA, Hammond TM, Lunniss PJ, Phillips RK. Ligation of the intersphincteric fistula tract in the management of anal fistula: a systematic review. Colorectal Dis 2013; 15:527–535.  Back to cited text no. 28
    
29.
Ooi K, Skinner I, Croxford M, Faragher I, McLaughlin S. Managing fistula-in-ano with ligation of the inter-sphincteric fistula tract procedure: the Western Hospital experience. Colorectal Dis 2012; 14:599–603.  Back to cited text no. 29
    
30.
Shanwani AMS, Nor AM, Amri NMK. The ligation of the intesphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano. Dis Colon Rectum 2010; 53:39–42.  Back to cited text no. 30
    
31.
Liu WY, Aboulian A, Kaji AH, Kumar RR. Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano. Dis Colon Rectum 2013; 56:343–347.  Back to cited text no. 31
    
32.
Xu Y, Tang W. Comparison of an anal fistula plug and mucosa advancement flap for complex anal fistulas. ANZ J Surg 2016; 86:978–982.  Back to cited text no. 32
    
33.
Van Onkelen RS, Gosselink MP, Schouten WR. Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy. Colorectal Dis 2013; 15:587–591.  Back to cited text no. 33
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed149    
    Printed19    
    Emailed0    
    PDF Downloaded22    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]