CM Chiesa-Estomba,JR Lechien,LA Vaira,A Brunet,G Cammaroto,M Mayo-Yanez,A Sanchez-Barrueco,C Saga-Gutierrez
Publication date 01-05-2024
A Zwierz
Publication date 01-05-2024
D Kalfert
Publication date 01-05-2024
Z Polat,M Elmalı,AT Sayit,C Kalkan,M Danacı,M Kefeli
Publication date 01-05-2024
P De Luca,A Di Stadio,A Scarpa,F Ricciardiello,P Viola,M Radici,A Camaioni
Publication date 01-05-2024
A Penella,C Muntaner-Virgili,J Marcoval,X González-Compta,M Mesalles-Ruiz,M García Wagner,F Cruellas,M Hamdan,J Nogués,J Notario
Publication date 01-05-2024
Purpose To investigate the clinical manifestations, management and outcomes of Leishmania lesions in the ear–nose–throat (ENT) region, and its relationship with tumor necrosis factor (TNF)-α blocking drugs. Methods Single-center retrospective observational study. Patients diagnosed with cutaneous and mucosal leishmaniasis in the otorhinolaryngologic area at a tertiary referral center over a period of 8 years. Results Three cases of Leishmania lesions in the ear and two in the nose were encountered at our institution. All patients were under treatment with TNF-α blocking drugs. Diagnosis was challenging, and it was important to have a clinical suspicion in order to use accurate detection techniques. All patients received systemic treatment and achieved a complete resolution of the lesions. Conclusions With the increasing use of biologic treatments like TNF-α blockers, this type of infection will be increasingly frequent in endemic areas and also worldwide. It is important to include leishmaniasis in the differential diagnosis of inflammatory/infectious lesions in the ENT region.
Pubmed PDF WebP Ambrosch
Publication date 01-05-2024
J Faulkner,A Arora,P McCulloch,S Robertson,A Rovira,S Ourselin,JP Jeannon
Publication date 01-05-2024
Purpose Transoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius. Methods Following IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted. Results 30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius’ unique capabilities, although limitations in distal access were observed. Conclusions TORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.
Pubmed PDF WebGeen auteurs bekend
Publication date 01-05-2024
Purpose This multicentric, retrospective study aimed to analyze the short-term safety and effectiveness of the mCLIP Partial Prosthesis. Methods Patients underwent tympanoplasty with implantation of a mCLIP Partial Prosthesis. Follow-up examination included ear microscopy and pure-tone audiometry to determine the post-operative pure tone average of the frequencies 0.5, 1, 2 and 3 k Hz (PTA4). The post-operative PTA4 air bone gap (ABG) was used to evaluate the audiological outcome. A post-operative minimum and maximum follow-up period was not defined. Thus, the follow-up times of each study center were different, which resulted in different follow-up times for the audiological analysis and for adverse events (AE). Results 72 (66 adults, 6 children) patients were implanted with the mCLIP Partial Prosthesis. 68 (62 adults, 6 children) patients underwent audiological examination; all 72 patients were examined for adverse events. All patients (N = 68): 72.1% of the patients showed a PTA4 ABG of ≤ 20 dB. Individual post-operative bone conduction (BC) PTA4 thresholds were stable in 67 patients. The mean post-operative follow-up time was 78 ± 46 days. Children (N = 6): 5 out of 6 children showed a PTA4 ABG of ≤ 20 dB. None of the children reported a BC PTA4 deterioration of > 10 dB HL after the implantation. The mean post-operative follow-up time was 101 ± 45 days. Adverse events (all patients, N = 72): 15 (14 adults, 1 child) patients had AEs (27 AEs and 2 Follow-Ups). The mean post-operative follow-up time was 375 days. Conclusion Clinical data show satisfactory audiological parameters after implantation of the mCLIP Partial Prosthesis. The prosthesis is safe and effective for implantation in children and adults. Trial registration number NCT05565339, 09 September 2022, retrospectively registered.
Pubmed PDF WebJ Song,Y Wen,L Liang,Y Lv,T Liu,R Wang,K Hu
Publication date 01-05-2024
Objective Severe radiation-induced oral mucositis (sRIOM) can seriously affect patients’ quality of life and treatment compliance. This study was to investigate the utility of the systemic immune-inflammatory index (SII) and prognostic nutritional index (PNI) in predicting sRIOM in patients with locally advanced nasopharyngeal carcinoma (LANPC). Methods 295 patients with LANPC were retrospectively screened. The pre-radiotherapy SII and PNI were calculated based on peripheral blood samples. A receiver operating characteristic (ROC) curve was used to determine the cut-off value. Logistic regression was used for univariate and multivariate analyses. Patients were classified into three groups based on the SII–PNI score: score of 2, high SII (> cut-off value) and low PNI (≤ cut-off value); score of 1, either high SII or low PNI; score of 0, neither high SII nor low PNI. Results The SII–PNI demonstrated significant predictive ability for sRIOM occurrence, as evidenced by an area under the curve (AUC) of 0.738. The incidence rates of sRIOM with SII–PNI score of 2, 1, and 0 were 73.86%, 44.35%, and 18.07%, respectively. Multivariate analysis confirmed that the SII–PNI score was an independent risk factor for sRIOM. Conclusion The SII–PNI score is a reliable and convenient indicator for predicting sRIOM in patients with LANPC.
Pubmed PDF WebY Wang,T Shen,Y Wang
Publication date 01-05-2024
Objective The primary objective of this study was to find the association between dietary zinc intake and the prevalence of olfactory disorders using data from the National Health and Nutrition Examination Survey (NHANES). Methods A cross-sectional study was conducted using the 2013–2014 NHANES data. A linear regression model was constructed with dietary zinc intake as the independent variable and olfactory dysfunction as the dependent variable. Initially, in the unadjusted model, weighted logistic regression analysis was carried out for continuous variables, and stratified analysis was conducted for categorical variables. Subsequently, three models were created to perform subgroup analysis by adjusting for different confounding factors, further investigating the relationship between dietary zinc intake and olfactory dysfunction. Finally, restricted cubic spline (RCS) models adjusting for all confounding factors were utilized to study the nonlinear associations of age and dietary zinc intake with olfactory dysfunction and their relevant thresholds. Results A total of 2958 samples were analyzed in this study. Weighted logistic regression analysis displayed a negative relationship between dietary zinc intake and the prevalence of olfactory dysfunction in the population of non-Hispanic whites and other Hispanics, as well as in individuals with body mass index (BMI) ≥ 25 kg/m2 (OR < 1, P < 0.05). The P values for the multiplicative interaction terms adjusting for all confounding factors were not significant (P for interaction > 0.05). In the three regression models adjusting for different confounding factors, dietary zinc intake was significantly negatively related to olfactory dysfunction in all populations (Crude: OR 0.63, 95% CI 0.44–0.91; Model I: OR 0.58, 95% CI 0.38–0.90; Model II: OR 0.59, 95% CI 0.35–1.00). Subgroup analysis based on BMI showed a remarkable negative relationship between dietary zinc intake and olfactory dysfunction in the group with BMI of 25–30 kg/m2 (Crude: OR 0.50, 95% CI 0.28–0.90, P = 0.012; Model I: OR 0.49, 95% CI 0.24–1.00, P = 0.021) and the group with BMI ≥ 30 kg/m2 (Crude: OR 0.55, 95% CI 0.33–0.92, P = 0.013; Model I: OR 0.51, 95% CI 0.29–0.88, P = 0.005; Model II: OR 0.51, 95% CI 0.29–0.91, P = 0.004). RCS analysis revealed a remarkable nonlinear association of age and dietary zinc intake with olfactory dysfunction (P-non-linear < 0.05). The prevalence of olfactory dysfunction was considerably higher in individuals aged 60 and above compared to those under 60 years old. Daily dietary zinc intake within the range of 9.60–17.45 mg was a protective factor for olfactory dysfunction, while intake outside this range increased the prevalence of olfactory dysfunction. Conclusion Daily dietary zinc intake within the range of 9.60–17.45 mg has a protective effect against olfactory dysfunction. Intake outside this range increases the prevalence of olfactory dysfunction. The prevalence of olfactory dysfunction is significantly higher in individuals aged 60 and above compared to those under 60 years old. For individuals with a BMI of 25–30 kg/m2 and a BMI ≥ 30 kg/m2, dietary zinc intake is negatively correlated with olfactory dysfunction. Therefore, it is recommended that these populations increase their dietary zinc intake to develop healthier lifestyles and maintain olfactory health.
Pubmed PDF WebI Speck,E Gundlach,S Schmidt,N Spyckermann,A Lesinski-Schiedat,AK Rauch,A Aschendorff,K Thangavelu,K Reimann,S Arndt
Publication date 01-05-2024
Purpose Our aim was to investigate the course of the hearing capacity of the better-hearing ear in single-sided deafness (SSD) and asymmetric hearing loss (AHL) over time, in a multicenter study. Methods We included 2086 pure-tone audiograms from 323 patients with SSD and AHL from four hospitals and 156 private practice otorhinolaryngologists.
We collected: age, gender, etiology, duration of deafness, treatment with CI, number and monosyllabic speech recognition, numerical rating scale (NRS) of tinnitus intensity, and the tinnitus questionnaire according to Goebel and Hiller. We compared the pure tone audiogram of the better-hearing ear in patients with SSD with age- and gender-controlled hearing thresholds from ISO 7029:2017. Results First, individuals with SSD showed a significantly higher hearing threshold from 0.125 to 8 k Hz in the better-hearing ear compared to the ISO 7029:2017. The duration of deafness of the poorer-hearing ear showed no relationship with the hearing threshold of the better-hearing ear. The hearing threshold was significantly higher in typically bilaterally presenting etiologies (chronic otitis media, otosclerosis, and congenital hearing loss), except for Menière’s disease. Second, subjects that developed AHL did so in 5.19 ± 5.91 years and showed significant reduction in monosyllabic word and number recognition. Conclusions Individuals with SSD show significantly poorer hearing in the better-hearing ear than individuals with NH from the ISO 7029:2017. In clinical practice, we should, therefore, inform our SSD patients that their disease is accompanied by a reduced hearing capacity on the contralateral side, especially in certain etiologies.
SJ Kim,JW Moon,Y Cho,HM Lee
Publication date 01-05-2024
Purpose Local allergic rhinitis (LAR) is characterized by a localized nasal allergic response without evidence of systemic atopy. LAR is an underdiagnosed entity and is a diagnostic and therapeutic challenge for clinicians. This study aimed to investigate the prevalence and clinical characteristics of patients with LAR to house dust mites (LAR-HDM) in Korea. Methods We performed a retrospective chart review of 336 adult patients with rhinitis symptoms who visited the Rhinologic Clinic at Korea University Guro Hospital from October 2019 to April 2021. Using results of the skin prick test, serologic test, and nasal provocation test, patients were classified as allergic rhinitis (AR) to HDM (AR-HDM), AR to other allergens, non-allergic rhinitis (NAR), or LAR-HDM. We excluded patients with AR to other allergens and compared the clinical characteristics of the remaining three groups. Patient demographic data were reviewed, and patients’ nasal symptoms, olfactory function, serum total IgE, and severity of accompanying rhinosinusitis were evaluated. Results In total, 336 patients were examined. AR-HDM was diagnosed in 138 (41.1%) patients, AR to other allergens in 36 (10.7%) patients, NAR in 21 (42.0%) patients, and LAR-HDM in 21 (6.3%) patients. The mean age of patients with LAR-HDM was significantly higher than that of patients with AR-HDM. There were no significant differences in sex, smoking history, asthma, and family history of allergic diseases between the groups. Compared to NAR patients, there were significantly more patients with LAR-HDM who had persistent nasal symptoms. The frequency of nasal itching and sneezing was significantly higher in the LAR-HDM group than in the NAR group. The olfactory function score in the LAR-HDM group was significantly worse than that in the AR-HDM group, and the Lund-Mackay score was significantly higher in the LAR-HDM group than in the other groups. Conclusion Clinical history and nasal symptoms are very similar in LAR-HDM and AR-HDM. Clinicians should take more care to differentiate them. LAR-HDM should also be considered in patients with persistent and severe nasal symptoms without systemic atopy.
Pubmed PDF WebA Alahmadi,M Yousef,A Ibrahim,N Shahadah,A Hafez,Y Abdelsamad,F Alzhrani
Publication date 01-05-2024
Background The objective-based methods for intraoperative monitoring have been suggested to assess the coupling and the outcomes of Vibrant Soundbridge (VSB). Although several techniques were proposed, they have not been widely adopted due to their complexity and invasiveness. Purpose This study aimed to investigate the accuracy of a new coupling quality index using an intraoperative ABR threshold via AcoustiAP and its correlation with the perioperative measures. Methods This is a prospective study conducted at a tertiary center. The medical records were retrieved for all patients who underwent VSB implantation and had an intraoperative objective assessment for the coupling efficiency. AcoustiAP was used to evaluate the intraoperative ABR thresholds, which were assessed directly after the floating mass transducer (FMT) placement using acoustic CE-Chirp signals. The Vibrogram was used for the postoperative audiological evaluation. A new coupling quality index was calculated based on the intraoperative ABR thresholds. Results Ten patients were eligible for the present study. The ABR thresholds for good coupling ranged from 35 to 60 d BnHL. The loose coupling thresholds ranged considerably from 40 to 100 d BnHL. Overall, the median intraoperative ABR threshold at good coupling was 42.5 (40–60) d BnHL and 60 (40–100) d BnHL at loose coupling. The analysis showed that there was a significant change in the coupling quality index at the good and loose coupling points (24.3 ± 14 vs 38.8 ± 18.2, respectively, p < 0.001). At a cut-off value of 22.6 dB, the coupling quality index had a sensitivity of 70% and specificity of 90% for discriminating good and loose coupling. Conclusion This study provides evidence for the utility of intraoperative ABR measurements in predicting the coupling efficiency in patients with VSB. Our results showed that the coupling quality index had an acceptable accuracy in discriminating between good and poor coupling, which can help clinicians optimize the fitting process for individuals and may ultimately lead to improved patient outcomes.
Pubmed PDF WebGR Francisco,JLB Simões,G de Carvalho Braga,PH Guerra,MD Bagatini
Publication date 01-05-2024
Purpose Prader–Willi syndrome is a serious genetic condition, capable of causing endocrinological imbalance, which has as one of its main treatments the growth hormone therapy. However, this therapy still causes some uncertainty concerning its effects on the respiratory parameters of those patients, especially in cases of obstructive sleep apnea, therefore, presenting a need for the analysis of the relationship between the therapy and the otolaryngologic condition. Methods A systematic review following the PRISMA model was developed, with searches for keywords made in the databases Pub Med (MEDLINE), Scopus, and Web of Science and registration in the PROSPERO platform (CRD42023404250). Results Three randomized controlled trials were considered eligible for inclusion in the review. None of the studies demonstrated statistically significant modifications in the obstructive sleep apnea parameters of Prader–Willi patients related to the growth hormone administration. Conclusions Growth hormone therapy is safe for Prader–Willi syndrome patients when analyzing their obstructive sleep apnea parameters.
Pubmed PDF WebM Güllüev,A Yücel,B Demirci,D Kaplan,LE Özdemir
Publication date 01-05-2024
Purpose Tonsillectomy is a common surgery performed for indications such as chronic tonsilitis, tonsil hypertrophy and obsructive sleep apnea. Although posttonsillectomy bleeding (PTB) is rare and can be controlled with simple interventions in many patients, it is one of the most feared complications of tonsillectomy surgery. In our study, we investigated the effects of changes in hemogram and coagulation values and seasonal effects on PTB. Methods Pediatric and adult patients who underwent tonsillectomy with cold knife method between August 2020 and August 2023 in our clinic were retrospectively reviewed. Demographic data, hemogram and coagulation values of the patients in the control and study groups were recorded and the differences between the two groups in terms of these parameters were evaluated. Results Our study included 991 patients aged 1–51 years. The rate of PTB was calculated as 2.82%. No patient with primary PTB was found. The duration of bleeding development was 7.03 days. Age, WBC and neutrophil values were statistically significantly higher in the study group. There were no significant differences between two groups in terms of gender, season and other hemogram and coagulation parameters. Conclusions Age, high WBC and neutrophil levels were determined as possible risk factors for PTB. Seasonal and gender distribution, aPTT and INR values were similar in the two groups. In order to prevent and predict bleeding, detailed infection investigation should be performed and the risk of bleeding should be considered to increase with increasing age.
Pubmed PDF WebA Almothahbi,M Bukhari,M Almohizea,N Alsubaie,TF Alharbi,HM Alhazzani,F Zagzoog
Publication date 01-05-2024
Purpose To provide a comprehensive review of the current strategies in the management of laryngeal hemangiomas, with an aim to introduce a management algorithm that aligns with the variable clinical presentations and anatomical complexities of these lesions. Methods We conducted an extensive literature search across major databases using specific and general terms, combined with Boolean operators, to ensure comprehensiveness. Articles from January 2004 to August 2023 were included, with findings categorized by management approach. Results Laryngeal hemangiomas exhibit a spectrum of manifestations, ranging from asymptomatic lesions to those causing severe airway obstruction. Optimal management demands an individualized approach tailored to the patients unique presentation and anatomical considerations. Diverse treatment modalities, each with distinct indications, advantages, and limitations, are explored. Notable highlights encompass the prominent role of Beta-blockers, notably Propranolol, in addressing problematic infantile hemangiomas, the nuanced efficacy of laser therapies contingent upon hemangioma type and depth, and the critical relevance of tracheotomy in emergencies. Novel approaches like transoral robotic surgery and transoral ultrasonic surgery, demonstrate promise in specific scenarios. We propose a management algorithm based on the complexity and presentation of laryngeal hemangiomas, emphasizing individualized treatment strategies, thereby addressing the unique challenges and nuances of each case. Conclusion Laryngeal hemangioma management requires personalized approaches informed by diverse therapies, clinical expertise, and collaboration. The review introduces an algorithm spanning observation to advanced interventions, adapting to each case’s complexity. Ongoing research promises innovative treatments.
Pubmed PDF WebS Hepkarsi,I Kaya,T Kirazli
Publication date 01-05-2024
Purpose Idiopathic sudden sensorineural hearing loss (ISSHL) can cause acute damage not only to the auditory function, but also to the vestibular function in addition to damage to the hearing function. The aim of this study was to perform vestibular assessment using caloric test and video head impulse test in patients with idiopathic sudden sensorineural hearing loss. In addition, to evaluate the relationship of dizziness with vestibular tests and post-treatment responses of vestibular tests. Methods This is an observational, longitudinal and prospective study, including patients diagnosed with idiopathic sudden sensorineural hearing.
Patients were divided into two groups according to the presence of vestibular complaints at presentation: Group 1: Patients with vestibular complaints, Group 2: Patients without vestibular complaints. All subjects underwent pure tone audiometry (PTA) testing, cold caloric test and video head impulse test (vHIT) during their admission and on the 10th day, 3rd month, and 1st year of their follow-up outpatient clinic controls. A unilateral weakness (UW) in the caloric test response was quantified according to the Jongkees formula. Results A positive and significant relationship was found between the degree of hearing loss according to the ASHA criteria pre-treatment and the level of improvement created according to Siegel criteria at the 10th day, 3rd month, 1st year after treatment (respectively p = 0.001, p = 0.001, p < 0.001). When both short-term and long-term results were evaluated after treatment, a positive improvement in the degree of hearing loss was observed. A statistically significant difference was observed between Groups 1 and 2 when the pre-treatment, at 10 days, 3 months and 1 year after treatment the caloric test UW value was compared (respectively p = 0.020, p = 0.004, p = 0.004, p = 0.004). A statistically significant difference was observed between Groups 1 and 2 when the pre-treatment, at 10 days, 3 months and 1 year after treatment vHIT lateral canal VOR value was compared (respectively p = 0.000, p = 0.001, p = 0.000, p = 0.004). When both short-term and long-term results were evaluated after treatment, a positive improvement was observed in both caloric test results and lateral vHIT VOR values. Pre-treatment, post-treatment 10th day, 3rd month, 1st year vHIT anterior and posterior canal VOR values were found to be VOR˃0.8 in all patients. No difference was observed in anterior and posterior canal VOR values. Conclusion Vertigo in patients with ISSHL “as objectively confirmed through caloric testing and vHIT” can be considered a sign of severe cochlear damage. Our study demonstrated a significantly increased risk of vestibular affect in patients with ISSHL, especially in the presence of vertigo. Thus, we conclude that the focus in ISSHL should not only be on the cochlea but also on the vestibular system.
SD Mes,MA van der Jagt,JC Jansen,APM Langeveld,EV Sjögren,BJ Heijnen
Publication date 01-05-2024
Purpose Arytenoid adduction as an addition to medialisation thyroplasty is highly advocated by some surgeons in selected cases but deemed less necessary by others in patients with unilateral vocal fold paralysis. This study aims to evaluate the additional benefits on voice outcome of arytenoid adduction in patients with unilateral vocal fold paralysis undergoing medialisation thyroplasty using intra-operative voice measurements. Design/methods A prospective study was conducted. Voice audio recordings were obtained at 4 moments; 1. direct prior to the start of surgery, 2. during surgery after medialisation thyroplasty, 3. during surgery after medialisation and arytenoid adduction, 3 months postoperative. At these same timepoints patients rated their own voice on a numeric rating scale between 0 and 10. The blinded recordings were rated by consensus in a team of experienced listeners, using the Grade of the GRBAS scale. Furthermore, the Voice Handicap Index was administered before and at 3 months after surgery. Results Ten patients who underwent medialisation and arytenoid adduction at our tertiary referral hospital between 2021 and 2022, were included. One patient was excluded after surgery. The intraoperative measurements showed a Grade score of 1.4 preoperatively, improving to 1.2 after medialisation, 1.2 after medialisation and arytenoid adduction, and further improving to 0.4 at 3 months postoperative, which was a not statistically significant improvement (p = 0.2). The intraoperative subjective numeric rating scale showed a statistically significant improvement from 3.9 preoperatively, to 6.1 after medialisation, 7.1 after medialisation and arytenoid adduction and a 7.6 at 3 months postoperative (p = 0.001). The Voice Handicap Index total score showed a statistically significant improvement from 71 points before surgery to 13 at 3 months after surgery (p = 0.008). Conclusions Our study using intraoperative voice measurements indicate that the addition of arytenoid adduction to medialisation thyroplasty is a benefit in selected patients although more studies are needed due to the many limitations inherent to this field of investigation.
Pubmed PDF WebKB Elnahal,MA Hassan,AM Maarouf
Publication date 01-05-2024
Objectives To analyze and compare the available data about the outcomes of endoscopic and microscopic type I tympanoplasty. Data sources Pub Med, Cochrane library Ovid, Scopus, Google scholar, and Clinical Trials. Methods We conducted a meta-analysis in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We included comparative studies describing type I tympanoplasty, and comparing surgical outcomes of the endoscope with the microscope in terms of efficacy and safety. Results Our systematic search yielded 22 studies meeting the inclusion criteria and eligible for analysis. The pooled graft uptake rates and audiological results of endoscopic and microscopic tympanoplasty demonstrated non-significant differences. In contrast, endoscopic type I tympanoplasty outperforms microscopic tympanoplasty regarding a highly significant decrease not only in pooled mean operative time but also in the pooled complications rate. Conclusions Based on our meta-analysis, the surgical outcomes of endoscope-assisted and microscope-assisted type I tympanoplasty in terms of postoperative hearing outcomes and the graft uptake rate were comparable. On the contrary, operative time and complications rate proved to be significantly reduced with endoscopy compared to microscopy. Hence, the endoscope is as efficient as the microscope in type I tympanoplasty but less invasive, fewer in complications and shorter in operative time.
Pubmed PDF Web