Pancreas
&
Volume 43, Number 3, April 2014
Ferenc Somogyva´ri, PhD Department of Medical Microbiology and Immunology University of Szeged Hungary
Yvette Ma´ndi, MD, DSci Department of Medical Microbiology and Immunology University of Szeged Hungary [email protected]
REFERENCES 1. Mayerle J. A novel role for leucocytes in determining the severity of acute pancreatitis. Gut. 2009;58:1440Y1441. 2. Roth J, Vogl T, Sorg C, et al. Phagocyte-specific S100 proteins: a novel group of proinflammatory molecules. Trends Immunol. 2003;24:155Y158. 3. Pietzsch J, Hoppmann S. Human S100A12: a novel key player in inflammation? Amino Acids. 2009;36:391Y389. 4. Foell D, Frosch M, Sorg C, et al. Phagocyte-specific calcium-binding S100 proteins as clinical laboratory markers of inflammation. Clin Chim Acta. 2004;344:37Y51. 5. Meijer B, Gearry RB, Day AS. The Role of S100A12 as a systemic marker of inflammation. Int J Inflam. 2012; doi: 10.1155/2012/907078. 6. Schnekenburger J, Schick V, Kru¨ger B, et al. The calcium binding protein S100A9 is essential for pancreatic leukocyte infiltration and induces disruption of cell-cell contacts. J Cell Physiol. 2008;216:558Y567. 7. Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139:69Y81. 8. Li Q, Meng HX, Zhang L, et al. Correlation between single nucleotide polymorphisms in a calprotectin subunit gene and risk of periodontitis in a Chinese population. Ann Hum Genet. 2006;71:312Y324. 9. Rungroj N, Sritippayawan S, Thongnoppakhun W, et al. Prothrombin haplotype associated with kidney stone disease in Northeastern Thai patients. Urology. 2011;77:e17Ye23.
External Validation of the New Japanese Severity Score in Turkish Patients With Acute Pancreatitis To the Editor:
T
he incidence of acute pancreatitis (AP) has increased during the past 2 decades. Approximately 20% of these patients have a progressive disease, which eventually
* 2014 Lippincott Williams & Wilkins
develops into a severe AP (SAP) along with various serious complications. Multiple organ dysfunction is commonly seen in these patients, with overall mortality rates of approximately 30% to 40%. Thus, early prediction of severity may assist physicians to appropriate therapy.1 The Japanese Severity Score (JSS) is definitely useful for the prediction of severity in AP and is now used generally in Japan. However, the JSS is very complicated and is not easy to use because it consists of 18 factors. So, a simpler score was needed and the JSS was revised in 2008. The new JSS is composed of 9 prognostic factors.2 The aim of this study was to evaluate the predictive accuracy of the new JSS in Turkish patients with AP. This retrospective cohort study included 102 consecutive patients with AP during an 18-month period. Of the 102 patients with AP, 43 patients were men and 59 patients were women. The median age of the patients was 56.4 years (range, 17Y89 years). The causes of AP were alcoholic (n = 27), biliary (n = 69), and idiopathic (n = 6) conditions. The diagnosis of AP was based on the clinical manifestation of acute upper abdominal pain associated with a raised serum amylase level greater than 3 times the normal value or with elevated serum lipase levels and radiological evidences compatible with AP. Cases admitted more than 24 hours later than the onset of symptoms were excluded from the study. The main outcomes measured in this study were severity and mortality. We determined the severity of the disease according to the 2012 revision of the Atlanta classification.3 This classification defines 3 degrees of severity, namely, mild AP, moderately SAP (mSAP), and SAP. Mild AP was defined by the absence of organ failure and the absence of local or systemic complications. Moderately SAP was defined by the presence of transient organ failure or local or systemic complications in the absence of persistent organ failure. Severe AP was defined if it was with persistent organ failure. Three organ systems were assessed to define organ failure, namely, respiratory, cardiovascular, and renal. Organ failure was defined as a score of 2 or more for one of these 3 organ systems using the modified Marshall scoring system.4 Data related to calculations of the Ranson score and new JSS (Table 1) at admission were collected by a physician unaware of the study end points. We treated patients according to the accepted standard management of AP. The SPSS 11.5 for Windows (Chicago, Ill) was used for statistical analysis. Descriptive
Letters to the Editor
statistics were presented as mean (SD). The demographic characteristics of the groups were compared using W2 and Fisher exact tests and were displayed in cross tables. Group differences were lated by the t test, analysis of variance, Mann-Whitney U test, or Kruskal-Wallis test. We measured the performance of score using receiver operating characteristic (ROC) curves, and the overall performance of the ROC analysis was quantified by computing the area under the curve (AUC) and 95% confidence intervals. An area of 1 indicated perfect performance, whereas 0.5 indicated a performance that was not different than chance. Sensitivity, specificity, as well as positive and negative predictive values are presented for the results of ROC analyses concerning optimal cutoffs. According to the Atlanta criteria, 68 patients were classified as mild AP, 16 patients were classified as mSAP, and 18 patients were classified as SAP. A total of 13 patients (12.7%) died, 10 patients had multiple organ failure, and 3 patients had extensive necrotizing pancreatitis.
Prediction of Severity The Ranson scores and new JSS in SAP were significantly higher than those in the mild attacks on admission (P G 0.001). The AUC for the prediction of the severity in the new JSS was 0.889; the Ranson score was 0.878. The optimum cutoff levels of the Ranson score and new JSS were both 3 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 75%, 81.6%, 80.65%, and 76.64%, respectively.
Prediction of Mortality The AUC for the prediction of the mortality rate in the new JSS was 0.805; the Ranson score was 0.609. The optimum cutoff level of the new JSS was 5 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 72.8%, 60.5%, 69%, and 69.9%, respectively. Predicting the course of an attack of AP still represents a challenge for the physician. The most widely used severity score specific to pancreatitis to assess disease severity has been the Ranson score. Despite the widespread use of the Ranson score as a guide to these interventions in patients with pancreatitis, the Ranson score has never proven superior to clinical intuition or any other quantification schemes in predicting the outcome or need for any particular intervention. The Ranson score evaluates parameters related to age, liver function, and fluid balance of the patient. However, the www.pancreasjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
487
Pancreas
Letters to the Editor
Variables 1. BE level e j3 mEq/L or shock 2. PaO2 e 60 mm Hg (room air) or respiratory failure 3. Blood urea nitrogen level Q 40 mg/dL or creatinine level Q 2 mg/dL 4. Lactate dehydrogenase level Q 2 folds of upper normal limit 5. Platelet count e 1 105/mm3 6. Calcium level e 7.5 mg/dL 7. C-reactive protein level Q 15 mg/dL 8. Systemic inflammatory response syndrome score Q 3 9. Age Q 70 years old
488
www.pancreasjournal.com
Perforation of the Descending Colon in Severe Acute Pancreatitis A Case Report and Literature Review
study, concerning the prediction of prognosis, the sensitivity of the APACHE II score was the highest but the specificity of the APACHE II score was the lowest. In conclusion, the new JSS is a useful scoring system to predict severity and mortality in Turkish patients with AP. The authors declare no conflicts of interest. Kaz1m S¸enol, Salih Burak Gu¨ndog˘du, ¨ zkan, Bulut O 1 Bar s¸ Saylam, Mesut Tez,
Volume 43, Number 3, April 2014
7. Hanley JA, McNeil BJ. The meaning and the use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29Y36.
TABLE 1. Variables Related to Calculations of the New JSS
total score cannot be reached until the end of 48 hours; it is reported that prediction of the worsening of the disease can be made in 70% to 80% of cases by using a scoring system. Prospective studies and metaanalyses have shown that for the determination of severity of pancreatitis, the Ranson score is not as reliable as thought before.5,6 The second type of scoring system has been the application of the nonspecific physiological scoring systems, which were originally designed for use in general populations of patients with critical illness. The Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Simplified Acute Physiology Score II, as well as Mortality Probability Models II systems can be used for this purpose.6 In Turkey, the Ranson score is the most frequently used scoring system to determine the severity of AP. Therefore, in this study, we compared the JSS with Ranson score. The previous JSS consists of 18 factors, compared with other scoring systems. There were several items that do not necessarily reflect the disease state. C-reactive protein, the current standard serum marker for the assessment of severity, was not included, and there were several items that measure quickly in a primary institution. Moreover, adding up the sum of the points was very complicated because the points have different values (1 or 2 points) for each item. For these reasons, a simpler score that could be easily applied with high accuracy needed to be developed and the new JSS composed of 9 prognostic factors was devised.2 In the study of Ueda et al,2 the AUC for the prediction of mortality rate in the new JSS was 0.822; the Ranson score was 0.820. Between the 2 scoring systems, the AUC was greatest in the new JSS. The optimum cutoff levels of the Ranson score and new JSS were both 5 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 73%, 77%, 56%, and 87%, respectively. These results are similar to the results of our study. Interestingly, in this
&
MD MD MD MD MD
Ankara Numune Education and Research Hospital Ankara,Turkey [email protected]
REFERENCES 1. Lu CW, Liu LC, Hsieh YC, et al. Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis. J Gastroenterol. 2013. 2. Ueda T, Takeyama Y, Yasuda T, et al. Utility of the new Japanese severity score and indications for special therapies in acute pancreatitis. J Gastroenterol. 2009;44:453Y459. 3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitisV2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102Y111. 4. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638Y1652. 5. Osvaldt AB, Viero P, Borges da Costa MS, et al. Evaluation of Ranson, Glasgow, APACHE-II, and APACHE-O criteria to predict severity in acute biliary pancreatitis. Int Surg. 2001;86:158Y161. 6. Go¨0men E, Klc YA, Yoldaz O, et al. Comparison and validation of scoring systems in a cohort of patients treated for biliary acute pancreatitis. Pancreas. 2007;34:66Y69.
To the Editor: olonic involvement is a rare but a potentially life-threatening complication of severe acute pancreatitis (AP). The colon seems to be involved in 1% of patients with AP and in 6% to 40% in a severe necrotizing form.1 Diagnosing colonic involvement is difficult unless accompanied by clinical manifestations of perforation or hemorrhage. We report an unusual case of a descending colonic perforation associated with severe AP.
C
CASE REPORT A 59-year-old male patient presented to the emergency department with a shortterm onset of severe abdominal pain and vomiting. History was significant for gallstone pancreatitis. On admission, the patient seemed diaphoretic with a respiration rate of 32, a heart rate of 135, a blood pressure of 130/70, and a temperature of 37.9-F. The examination was remarkable for abdominal distension with diffuse tenderness and guarding. The admission workup noted for an amylase level of 982, a lipase level of 396, a lactate level of 2.2, a white blood cell count of 24, and a guaiac-positive stool. The patient was admitted to the medical intensive care unit with a diagnosis of AP. The computed tomography of the abdomen and pelvis showed an evidence of severe AP with extensive inflammatory stranding around the pancreas, free fluid in the paracolic gutters, and a calcified gallbladder stone with no evidence of biliary dilatation or free air (Fig. 1). The patient worsened clinically and was subsequently intubated. Despite an adequate antibiotic coverage, the patient continued to spike fevers, and on hospital day 11, a repeat computed tomography scan showed evidence of severe necrotizing pancreatitis with retroperitoneal perforation of the proximal segment of the descending colon with leakage of contrast into the anterior pararenal space and extraluminal air (Fig. 1). An urgent surgical consult was obtained, and the patient underwent an exploratory laparotomy. Numerous adhesions between the small intestine and the greater omentum with * 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
&
Volume 43, Number 3, April 2014
Ferenc Somogyva´ri, PhD Department of Medical Microbiology and Immunology University of Szeged Hungary
Yvette Ma´ndi, MD, DSci Department of Medical Microbiology and Immunology University of Szeged Hungary [email protected]
REFERENCES 1. Mayerle J. A novel role for leucocytes in determining the severity of acute pancreatitis. Gut. 2009;58:1440Y1441. 2. Roth J, Vogl T, Sorg C, et al. Phagocyte-specific S100 proteins: a novel group of proinflammatory molecules. Trends Immunol. 2003;24:155Y158. 3. Pietzsch J, Hoppmann S. Human S100A12: a novel key player in inflammation? Amino Acids. 2009;36:391Y389. 4. Foell D, Frosch M, Sorg C, et al. Phagocyte-specific calcium-binding S100 proteins as clinical laboratory markers of inflammation. Clin Chim Acta. 2004;344:37Y51. 5. Meijer B, Gearry RB, Day AS. The Role of S100A12 as a systemic marker of inflammation. Int J Inflam. 2012; doi: 10.1155/2012/907078. 6. Schnekenburger J, Schick V, Kru¨ger B, et al. The calcium binding protein S100A9 is essential for pancreatic leukocyte infiltration and induces disruption of cell-cell contacts. J Cell Physiol. 2008;216:558Y567. 7. Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139:69Y81. 8. Li Q, Meng HX, Zhang L, et al. Correlation between single nucleotide polymorphisms in a calprotectin subunit gene and risk of periodontitis in a Chinese population. Ann Hum Genet. 2006;71:312Y324. 9. Rungroj N, Sritippayawan S, Thongnoppakhun W, et al. Prothrombin haplotype associated with kidney stone disease in Northeastern Thai patients. Urology. 2011;77:e17Ye23.
External Validation of the New Japanese Severity Score in Turkish Patients With Acute Pancreatitis To the Editor:
T
he incidence of acute pancreatitis (AP) has increased during the past 2 decades. Approximately 20% of these patients have a progressive disease, which eventually
* 2014 Lippincott Williams & Wilkins
develops into a severe AP (SAP) along with various serious complications. Multiple organ dysfunction is commonly seen in these patients, with overall mortality rates of approximately 30% to 40%. Thus, early prediction of severity may assist physicians to appropriate therapy.1 The Japanese Severity Score (JSS) is definitely useful for the prediction of severity in AP and is now used generally in Japan. However, the JSS is very complicated and is not easy to use because it consists of 18 factors. So, a simpler score was needed and the JSS was revised in 2008. The new JSS is composed of 9 prognostic factors.2 The aim of this study was to evaluate the predictive accuracy of the new JSS in Turkish patients with AP. This retrospective cohort study included 102 consecutive patients with AP during an 18-month period. Of the 102 patients with AP, 43 patients were men and 59 patients were women. The median age of the patients was 56.4 years (range, 17Y89 years). The causes of AP were alcoholic (n = 27), biliary (n = 69), and idiopathic (n = 6) conditions. The diagnosis of AP was based on the clinical manifestation of acute upper abdominal pain associated with a raised serum amylase level greater than 3 times the normal value or with elevated serum lipase levels and radiological evidences compatible with AP. Cases admitted more than 24 hours later than the onset of symptoms were excluded from the study. The main outcomes measured in this study were severity and mortality. We determined the severity of the disease according to the 2012 revision of the Atlanta classification.3 This classification defines 3 degrees of severity, namely, mild AP, moderately SAP (mSAP), and SAP. Mild AP was defined by the absence of organ failure and the absence of local or systemic complications. Moderately SAP was defined by the presence of transient organ failure or local or systemic complications in the absence of persistent organ failure. Severe AP was defined if it was with persistent organ failure. Three organ systems were assessed to define organ failure, namely, respiratory, cardiovascular, and renal. Organ failure was defined as a score of 2 or more for one of these 3 organ systems using the modified Marshall scoring system.4 Data related to calculations of the Ranson score and new JSS (Table 1) at admission were collected by a physician unaware of the study end points. We treated patients according to the accepted standard management of AP. The SPSS 11.5 for Windows (Chicago, Ill) was used for statistical analysis. Descriptive
Letters to the Editor
statistics were presented as mean (SD). The demographic characteristics of the groups were compared using W2 and Fisher exact tests and were displayed in cross tables. Group differences were lated by the t test, analysis of variance, Mann-Whitney U test, or Kruskal-Wallis test. We measured the performance of score using receiver operating characteristic (ROC) curves, and the overall performance of the ROC analysis was quantified by computing the area under the curve (AUC) and 95% confidence intervals. An area of 1 indicated perfect performance, whereas 0.5 indicated a performance that was not different than chance. Sensitivity, specificity, as well as positive and negative predictive values are presented for the results of ROC analyses concerning optimal cutoffs. According to the Atlanta criteria, 68 patients were classified as mild AP, 16 patients were classified as mSAP, and 18 patients were classified as SAP. A total of 13 patients (12.7%) died, 10 patients had multiple organ failure, and 3 patients had extensive necrotizing pancreatitis.
Prediction of Severity The Ranson scores and new JSS in SAP were significantly higher than those in the mild attacks on admission (P G 0.001). The AUC for the prediction of the severity in the new JSS was 0.889; the Ranson score was 0.878. The optimum cutoff levels of the Ranson score and new JSS were both 3 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 75%, 81.6%, 80.65%, and 76.64%, respectively.
Prediction of Mortality The AUC for the prediction of the mortality rate in the new JSS was 0.805; the Ranson score was 0.609. The optimum cutoff level of the new JSS was 5 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 72.8%, 60.5%, 69%, and 69.9%, respectively. Predicting the course of an attack of AP still represents a challenge for the physician. The most widely used severity score specific to pancreatitis to assess disease severity has been the Ranson score. Despite the widespread use of the Ranson score as a guide to these interventions in patients with pancreatitis, the Ranson score has never proven superior to clinical intuition or any other quantification schemes in predicting the outcome or need for any particular intervention. The Ranson score evaluates parameters related to age, liver function, and fluid balance of the patient. However, the www.pancreasjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
487
Pancreas
Letters to the Editor
Variables 1. BE level e j3 mEq/L or shock 2. PaO2 e 60 mm Hg (room air) or respiratory failure 3. Blood urea nitrogen level Q 40 mg/dL or creatinine level Q 2 mg/dL 4. Lactate dehydrogenase level Q 2 folds of upper normal limit 5. Platelet count e 1 105/mm3 6. Calcium level e 7.5 mg/dL 7. C-reactive protein level Q 15 mg/dL 8. Systemic inflammatory response syndrome score Q 3 9. Age Q 70 years old
488
www.pancreasjournal.com
Perforation of the Descending Colon in Severe Acute Pancreatitis A Case Report and Literature Review
study, concerning the prediction of prognosis, the sensitivity of the APACHE II score was the highest but the specificity of the APACHE II score was the lowest. In conclusion, the new JSS is a useful scoring system to predict severity and mortality in Turkish patients with AP. The authors declare no conflicts of interest. Kaz1m S¸enol, Salih Burak Gu¨ndog˘du, ¨ zkan, Bulut O 1 Bar s¸ Saylam, Mesut Tez,
Volume 43, Number 3, April 2014
7. Hanley JA, McNeil BJ. The meaning and the use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29Y36.
TABLE 1. Variables Related to Calculations of the New JSS
total score cannot be reached until the end of 48 hours; it is reported that prediction of the worsening of the disease can be made in 70% to 80% of cases by using a scoring system. Prospective studies and metaanalyses have shown that for the determination of severity of pancreatitis, the Ranson score is not as reliable as thought before.5,6 The second type of scoring system has been the application of the nonspecific physiological scoring systems, which were originally designed for use in general populations of patients with critical illness. The Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Simplified Acute Physiology Score II, as well as Mortality Probability Models II systems can be used for this purpose.6 In Turkey, the Ranson score is the most frequently used scoring system to determine the severity of AP. Therefore, in this study, we compared the JSS with Ranson score. The previous JSS consists of 18 factors, compared with other scoring systems. There were several items that do not necessarily reflect the disease state. C-reactive protein, the current standard serum marker for the assessment of severity, was not included, and there were several items that measure quickly in a primary institution. Moreover, adding up the sum of the points was very complicated because the points have different values (1 or 2 points) for each item. For these reasons, a simpler score that could be easily applied with high accuracy needed to be developed and the new JSS composed of 9 prognostic factors was devised.2 In the study of Ueda et al,2 the AUC for the prediction of mortality rate in the new JSS was 0.822; the Ranson score was 0.820. Between the 2 scoring systems, the AUC was greatest in the new JSS. The optimum cutoff levels of the Ranson score and new JSS were both 5 or higher. Sensitivity, specificity, positive predictive value, and negative predictive value in the new JSS were 73%, 77%, 56%, and 87%, respectively. These results are similar to the results of our study. Interestingly, in this
&
MD MD MD MD MD
Ankara Numune Education and Research Hospital Ankara,Turkey [email protected]
REFERENCES 1. Lu CW, Liu LC, Hsieh YC, et al. Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis. J Gastroenterol. 2013. 2. Ueda T, Takeyama Y, Yasuda T, et al. Utility of the new Japanese severity score and indications for special therapies in acute pancreatitis. J Gastroenterol. 2009;44:453Y459. 3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitisV2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102Y111. 4. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638Y1652. 5. Osvaldt AB, Viero P, Borges da Costa MS, et al. Evaluation of Ranson, Glasgow, APACHE-II, and APACHE-O criteria to predict severity in acute biliary pancreatitis. Int Surg. 2001;86:158Y161. 6. Go¨0men E, Klc YA, Yoldaz O, et al. Comparison and validation of scoring systems in a cohort of patients treated for biliary acute pancreatitis. Pancreas. 2007;34:66Y69.
To the Editor: olonic involvement is a rare but a potentially life-threatening complication of severe acute pancreatitis (AP). The colon seems to be involved in 1% of patients with AP and in 6% to 40% in a severe necrotizing form.1 Diagnosing colonic involvement is difficult unless accompanied by clinical manifestations of perforation or hemorrhage. We report an unusual case of a descending colonic perforation associated with severe AP.
C
CASE REPORT A 59-year-old male patient presented to the emergency department with a shortterm onset of severe abdominal pain and vomiting. History was significant for gallstone pancreatitis. On admission, the patient seemed diaphoretic with a respiration rate of 32, a heart rate of 135, a blood pressure of 130/70, and a temperature of 37.9-F. The examination was remarkable for abdominal distension with diffuse tenderness and guarding. The admission workup noted for an amylase level of 982, a lipase level of 396, a lactate level of 2.2, a white blood cell count of 24, and a guaiac-positive stool. The patient was admitted to the medical intensive care unit with a diagnosis of AP. The computed tomography of the abdomen and pelvis showed an evidence of severe AP with extensive inflammatory stranding around the pancreas, free fluid in the paracolic gutters, and a calcified gallbladder stone with no evidence of biliary dilatation or free air (Fig. 1). The patient worsened clinically and was subsequently intubated. Despite an adequate antibiotic coverage, the patient continued to spike fevers, and on hospital day 11, a repeat computed tomography scan showed evidence of severe necrotizing pancreatitis with retroperitoneal perforation of the proximal segment of the descending colon with leakage of contrast into the anterior pararenal space and extraluminal air (Fig. 1). An urgent surgical consult was obtained, and the patient underwent an exploratory laparotomy. Numerous adhesions between the small intestine and the greater omentum with * 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
