Skip to main content
SpringerLink
Log in

Entero-atmospheric Fistula: Tips and Tricks for the Management of a Surgical Nightmare

  • Chapter
  • First Online:
Acute Care Surgery Handbook

Abstract

The widespread use of antibiotics, the progress of intensive care medicine and the better comprehension of the physio-pathology of trauma and Abdominal Compartment Syndrome (ACS) made the open abdomen (OA) a cornerstone step of damage control surgery (DCS). Given the indisputable advantages of OA, the exposure of the abdominal viscera to the outer environment brings itself an unavoidable load of morbidity, where the appearance of an enteroatmospheric fistula (EAF) is the most feared complication. In fact, the onset of an EAF is associated with significant morbidity and mortality, because of its extremely challenging critical care and nutritional management issues. For these reasons, the best way to deal with an EAF is to prevent it and the knowledge of the causes and risk factors for fistula formation is essential. EAF management is complex and demanding and should be tailored upon the specific characteristic of every single case; from the surgeon point of view the corner stone of the treatment is the complete diversion of fistula effluent. Prevention of malnutrition, dehidratation and electrolyte imbalance is of vital importance.

The choice of the proper technique for every patient must be guided by a meticulous determination of fistula anatomy and by a careful assessment of patient’s clinical and nutritional conditions. A welldesigned plan is essential.

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

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Bibliography

  1. Pringle JH. V. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 1908;48:541–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Ogilvie WH. The late complications of abdominal war-wounds. Lancet. 1940;2:253–6.

    Article  Google Scholar 

  3. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;195:532–5.

    Article  Google Scholar 

  4. Rotondo MF, Schwab CW, Mcgonigal MD, Phillips GR, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma Injury Infect Crit Care. 1993;35:375–82; discussion 82–3.

    Article  CAS  Google Scholar 

  5. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am. 1997;77:761–77.

    Article  CAS  PubMed  Google Scholar 

  6. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg. 2007;96:263–71.

    Article  CAS  PubMed  Google Scholar 

  7. Richter S, Dold S, Doberauer JP, Mai P, Schuld J. Negative pressure wound therapy for the treatment of the open abdomen and incidence of enteral fistulas: a retrospective bicentre analysis. Gastroenterol Res Pract. 2013(2013):1–6.

    Google Scholar 

  8. Coccolini F, Biffl W, Catena F, Ceresoli M, Chiara O, Cimbanassi S, Fattori L, Leppäniemi A, Manfredi R, Montori G, Pesenti G, Sugrue M, Ansaloni L. The open abdomen, indications, management and definitive closure. World J Emerg Surg. 2015:10(1):1–10.

    Google Scholar 

  9. Schecter W, Ivatury R, Rotondo M, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg. 2006;203:390–6.

    Article  PubMed  Google Scholar 

  10. Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2014;39:912–25.

    Article  Google Scholar 

  11. Kirshtein B, Mizrahi S. Vacuum-assisted management of enteroatmospheric fistula within the open abdomen. Am Surg. 2014;80:209–10.

    PubMed  Google Scholar 

  12. Miller RS, Morris JA, Diaz JJ, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma Injury Infect Crit Care. 2005;59:1365–71; discussion 71–4.

    Article  Google Scholar 

  13. Bradley MJ, Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, Bee TK, Fabian TC, Whelan JF, Ivatury RR, Group Aoas. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective aast open abdomen registry. JAMA Surg. 2013;148:947–54.

    Article  PubMed  Google Scholar 

  14. Di Saverio S, Tarasconi A, Inaba K, Navsaria P, Coccolini F, Costa Navarro D, Mandrioli M, Vassiliu P, Jovine E, Catena F, Tugnoli G. Open abdomen with concomitant enteroatmospheric fistula: attempt to rationalize the approach to a surgical nightmare and proposal of a clinical algorithm. J Am Coll Surg. 2015;220:E23–33.

    Article  PubMed  Google Scholar 

  15. Di Saverio S, Tarasconi A, Walczak DA, Cirocchi R, Mandrioli M, Birindelli A, Tugnoli G. Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review. Langenbecks Arch Surg. 2016;401:1–15.

    Article  PubMed  Google Scholar 

  16. Marinis A, Gkiokas G, Argyra E, Fragulidis G, Polymeneas G, Voros D. “Enteroatmospheric fistulae” – gastrointestinal openings in the open abdomen: a review and recent proposal of a surgical technique. Scand J Surg. 2013;102:61–8.

    Article  CAS  PubMed  Google Scholar 

  17. Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, Dudrick SJ. Enteric fistulas: principles of management. ACS. 2009;209:484–91.

    Google Scholar 

  18. Evenson A, Fischer J. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10:455–64.

    Article  PubMed  Google Scholar 

  19. Björck M, Bruhin A, Cheatham M, Hinck D, Kaplan M, Manca G, Wild T, Windsor A. Classification–important step to improve management of patients with an open abdomen. World J Surg. 2009;33:1154–7.

    Article  PubMed  Google Scholar 

  20. Quyn AJ, Johnston C, Hall D, Chambers A, Arapova N, Ogston S, Amin AI. The open abdomen and temporary abdominal closure systems – historical evolution and systematic review. Colorectal Dis. 2012;14:E429–38.

    Article  CAS  PubMed  Google Scholar 

  21. Lindstedt S, Malmsjö M, Hlebowicz J, Ingemansson R. Comparative study of the microvascular blood flow in the intestinal wall, wound contraction and fluid evacuation during negative pressure wound therapy in laparostomy using the V.A.C. abdominal dressing and the abthera open abdomen negative pressure therapy system. Int Wound J. Blackwell Publishing Ltd. 2015;12(1):83–8.

    Google Scholar 

  22. Hlebowicz J, Hansson J, Lindstedt S. Microvascular blood flow response in the intestinal wall and the omentum during negative wound pressure therapy of the open abdomen. Int J Colorectal Dis. 2012;27:397–403.

    Article  PubMed  Google Scholar 

  23. Carlson GL, Patrick H, Amin AI, Mcpherson G, Maclennan G, Afolabi E, Mowatt G, Campbell B. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg. 2013;257:1154–9.

    Article  PubMed  Google Scholar 

  24. Navsaria P, Nicol A, Hudson D, Cockwill J, Smith J. Negative pressure wound therapy management of the "open abdomen" following trauma: a prospective study and systematic review. World J Emerg Surg. 2013;8:4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg. 2014;12:1105–14.

    Article  CAS  PubMed  Google Scholar 

  26. Schecter WP. Management of enterocutaneous fistulas. Surg Clin North Am. 2011;91:481–91.

    Article  PubMed  Google Scholar 

  27. Davis KG, Johnson EK. Controversies in the care of the enterocutaneous fistula. Surg Clin North Am. 2013;93:231–50.

    Article  PubMed  Google Scholar 

  28. Chapman R, Foran R, Dunphy JE. Management of intestinal fistulas. AJS. 1964;108:157–64.

    Article  CAS  Google Scholar 

  29. Moore FA, Feliciano DV, Andrassy RJ, Mcardle AH, Booth FV, Morgenstein-Wagner TB, Kellum JM, Welling RE, Moore EE. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992;216(2):172–83.

    Google Scholar 

  30. Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA, Poret HA, Kuhl MR, Brown RO. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215(3):503–11; discussion 11–3. Lippincott, Williams, And Wilkins.

    Google Scholar 

  31. Byrnes MC, Reicks P, Irwin E. Early enteral nutrition can be successfully implemented in trauma patients with an “open abdomen”. Am J Surg. 2010;199:359–62; discussion 63.

    Article  PubMed  Google Scholar 

  32. Yuan Y, Ren J, Gu G, Chen J, Li J. Early enteral nutrition improves outcomes of open abdomen in Gastrointestinal fistula patients complicated with severe sepsis. Nut Clin Pract. 2011;26(6):688–94.

    Google Scholar 

  33. Dissanaike S, Pham T, Shalhub S, Warner K, Hennessy L, Moore EE, Maier RV, O’keefe GE, Cuschieri J. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg. 2008;207:690–7.

    Article  PubMed  Google Scholar 

  34. Tsuei BJ, Magnuson B, Swintosky M, Flynn J, Boulanger BR, Ochoa JB, Kearney PA. Enteral nutrition in patients with an open peritoneal cavity. Nut Clin Pract. 2003;18:253–8.

    Google Scholar 

  35. Majercik S, Kinikini M, White T. Enteroatmospheric fistula: from soup to nuts. Nut Clin Pract. 2012;27(4):507–12.

    Google Scholar 

  36. Yin J, Wang J, Yao D, Zhang S, Mao Q, Kong W, Ren L, Li Y, Li J. Is it Feasible To Implement Enteral Nutrition In Patients With Enteroatmospheric Fistulae? A Single-Center Experience. Nutr Clin Pract. 2014;29:656–61.

    Article  PubMed  Google Scholar 

  37. Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg. 2012;36:524–33.

    Article  PubMed  Google Scholar 

  38. Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen balance, protein loss, and the open abdomen. Crit Care Med. 2007;35:127–31.

    Article  CAS  PubMed  Google Scholar 

  39. Friese RS. The open abdomen: definitions, management principles, and nutrition support considerations. Nutr Clin Pract. 2012;27:492–8.

    Article  PubMed  Google Scholar 

  40. Weissenfluh GM, Brundage SI, Spain DA. Early enteral nutrition after abdominal trauma: effects on septic morbidity and practicality. Nut Clin Pract. 2006;215:479–84.

    Article  Google Scholar 

  41. Willcutts K, Mercer D, Ziegler J. Fistuloclysis: an interprofessional approach to nourishing the fistula patient. J Wound Ostomy Continence Nurs. 2015;42:549–53.

    Article  PubMed  Google Scholar 

  42. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006;93:1045–55.

    Article  CAS  PubMed  Google Scholar 

  43. Stevens P, Foulkes RE, Hartford-Beynon JS, Delicata RJ. Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula. Eur J Gastroenterol Hepatol. 2011;23:912–22.

    Google Scholar 

  44. Ren J, Yuan Y, Zhao Y, Gu G, Wang G, Chen J, Fan C, Wang X, Li J. Open abdomen treatment for septic patients with gastrointestinal fistula: from fistula control to definitive closure. Am Surg. 2014;80:339–47.

    PubMed  Google Scholar 

  45. Girard S, Sideman M, Spain DA. A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities. AJS. 2002;184:166–7.

    Article  Google Scholar 

  46. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: a preliminary report. Arch Surg. 2007;142:793–6.

    Article  PubMed  Google Scholar 

  47. Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Rodriguez SA, Committee AT. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc. 2013;78:209–15.

    Article  PubMed  Google Scholar 

  48. Navsaria PH, Bunting M, Omoshoro-Jones J, Nicol AJ, Kahn D. Temporary closure of open abdominal wounds by the modified Sandwich-Vacuum pack technique. Br J Surg. 2003;90:718–22.

    Article  CAS  PubMed  Google Scholar 

  49. Subramaniam MH, Liscum KR, Hirshberg A. The floating stoma: a new technique for controlling exposed fistulae in abdominal trauma. J TraumaInjury Infect Crit Care. 2002;53:386–8.

    Article  Google Scholar 

  50. Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “fistula vac,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma Injury Infect Crit Care. 2006;60:428–31.

    Article  Google Scholar 

  51. D'hondt M, Devriendt D, Van Rooy F, Vansteenkiste F, D'hoore A, Penninckx F, Miserez M. Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy. AJS. 2011;202:E20–4.

    Article  Google Scholar 

  52. Piazza R, Armstrong S, Vanderkolk W, Eriksson E, Ringler S. A modified “Fistula-Vac” technique: management of multiple enterocutaneous fistulas in the open abdomen. Plastic Reconstruct Surg. 2009;124:453e–5e.

    Google Scholar 

  53. Pang TC, Morton J, Pincott S. Novel technique for isolating and dressing enteroatmospheric fistulae. ANZ J Surg. 2012;82:747–9.

    Article  PubMed  Google Scholar 

  54. Timmons J, Russell F. The use of negative-pressure wound therapy to manage enteroatmospheric fistulae in two patients with large abdominal wounds. Int Wound J. 2013;11:723–9.

    Article  PubMed  Google Scholar 

  55. Al-Khoury G, Kaufman D, Hirshberg A. Improved control of exposed fistula in the open abdomen. J Am Coll Surg. 2008;206:397–8.

    Article  PubMed  Google Scholar 

  56. Pepe G, Magalini S, Callari C, Persiani R, Lodoli C, Gui D. Vacuum assisted closure (Vac) therapy(Tm) as a swiss knife multi-tool for enteric fistula closure: tips and tricks: a pilot study. Eur Rev Med Pharmacol Sci. 2014;18:2527–32.

    CAS  PubMed  Google Scholar 

  57. Verhaalen A, Watkins B, Brasel K. Techniques and cost effectiveness of enteroatmospheric fistula isolation. Wounds. 2010;22:212–7.

    PubMed  Google Scholar 

  58. Ramsay PT, Mejia VA. Management of enteroatmospheric fistulae in the open abdomen. Am Surg. 2010;76:637–9.

    PubMed  Google Scholar 

  59. Layton B, Dubose J, Nichols S, Connaughton J, Jones T, Pratt J. Pacifying the open abdomen with concomitant intestinal fistula: a novel approach. Am J Surg. 2010;199:E48–50.

    Article  PubMed  Google Scholar 

  60. Di Saverio S, Villani S, Biscardi A, Giorgini E, Tugnoli G. Open abdomen with concomitant enteroatmospheric fistula: validation, refinements, and adjuncts to a novel approach. J Trauma Injury Infect Crit Care. 2011;71:760–2.

    Article  Google Scholar 

  61. Rekstad LC, Wasmuth H, Ystgaard B, Stornes T, Seternes A. Topical negative-pressure therapy for small bowel leakage in a frozen abdomen. J Trauma Acute Care Surg. 2013;75:487–91.

    Article  PubMed  Google Scholar 

  62. Heineman JT, Garcia LJ, Obst MA, Chong HS, Langin JG, Humpal R, Pezzella PA, Dries DJ. Collapsible enteroatmospheric fistula isolation device: a novel, simple solution to a complex problem. J Am Coll Surg. 2015;221(2):e7–14.

    Google Scholar 

  63. Wang G, Ren J, Liu S, Wu X, Gu G, Li J. “Fistula patch”: making the treatment of enteroatmospheric fistulae in the open abdomen easier. J Trauma Acute Care Surg. 2013;74:1175–7.

    Article  PubMed  Google Scholar 

  64. Ozer M, Sinan H, Zeybek N, Peker Y. A simple novel technique for enteroatmospheric fistulae: silicone fistula plug. Int Wound J. 2014;11 Suppl 1:22–4.

    Article  PubMed  Google Scholar 

  65. Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-Art R. Operative management of small bowel fistulae associated with open abdomen. Asian J Surg. 2006;29:1–7.

    Article  PubMed  Google Scholar 

  66. Wind J, Van Koperen PJ, Slors JFM, Bemelman WA. Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. AJS. 2009;197:24–9.

    Article  Google Scholar 

  67. Stephensen B, Brown J, Lambrianides A. A novel method for managing enterocutaneous fistulae in the open abdomen using a pedicle flap. J Surg Case Rep. 2012;2012:5.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Al-Nahawi M. A rare approach to entero-atmospheric fistula. Am J Case Rep. 2013;14:476–80.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Gupta R, Singh H, Talukder S, Verma GR. A new technique of closing a gastroatmospheric fistula with a rectus abdominis muscle flap. BMJ Case Rep. 2015:Bcr2015209309-Bcr.

    Google Scholar 

  70. Lambe G, Russell C, West C, Kalaiselvan R, Slade DAJ, Anderson ID, Watson JS, Carlson Gl. Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap. Br J Surg. 2012;99:964–72.

    Google Scholar 

  71. Clark CE, Walker T, Bacon L, Mccoy J, Babaloa O. Staged suspension of an enteroatmospheric fistula: a novel surgical approach. Am Surg. 2013;79:E139–40.

    PubMed  Google Scholar 

  72. Krpata DM, Stein SL, Eston M, Ermlich B, Blatnik JA, Novitsky YW, Rosen MJ. Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. AJS. 2013;205:354–9.

    Article  Google Scholar 

  73. Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, Cuffari S, Carrafiello G. Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience. Int J Surg. 2008;6:51–6.

    Article  CAS  PubMed  Google Scholar 

  74. Demetriades D. A technique of surgical closure of complex intestinal fistulae in the open abdomen. J Trauma Injury Infect Crit Care. 2003;55:999–1001.

    Article  Google Scholar 

  75. Latifi R, Joseph B, Kulvatunyou N, Wynne JL, O’keeffe T, Tang A, Friese R, Rhee PM. Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches. World J Surg. 2011;36:516–23.

    Google Scholar 

  76. Kaushal M, Carlson GL. Management of enterocutaneous fistulas. Clin Colon Rectal Surg. 2004;17:79–88.

    Google Scholar 

  77. Terzi C, Egeli T, Canda AE, Arslan NC. Management of enteroatmospheric fistulae. Int Wound J. 2014;11 Suppl 1:17–21.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy

    Antonio Tarasconi MD, Matteo Mandrioli, Arianna Birindelli MD, Luca Di Donato MD, Alice Piccinini MD & Sara Pellegrini MD

  2. Department of General Surgery, John Paul II Memorial Hospital, Belchatow, Poland

    Dominik A. Walczak MD

  3. General and Emergency Surgery Department, Istituti Ospitalieri di Cremona – ASSL Cremona, Cremona, Italy

    Mario Martinotti MD

  4. Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center – Bologna Local Health District, AUSL, Bologna, Italy

    Gregorio Tugnoli MD, PhD & Salomone Di Saverio MD, FACS, FRCS

Authors
  1. Antonio Tarasconi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Matteo Mandrioli
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arianna Birindelli MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Luca Di Donato MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alice Piccinini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sara Pellegrini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dominik A. Walczak MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mario Martinotti MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gregorio Tugnoli MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Salomone Di Saverio MD, FACS, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Antonio Tarasconi MD .

Editor information

Editors and Affiliations

  1. Emergency and Trauma Surgery Service, C.A. Pizzardi Maggiore Hospital AUSL Bologna, Bologna, Italy

    Salomone Di Saverio

  2. Surgery and Emergency, Maggiore Hospital of Parma, Parma, Italy

    Fausto Catena

  3. General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy

    Luca Ansaloni

  4. General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy

    Federico Coccolini

  5. Trauma, Emergency Medicine, Harvard Medical School Massachusetts General Hospital, Boston, Massachusetts, USA

    George Velmahos

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Tarasconi, A. et al. (2016). Entero-atmospheric Fistula: Tips and Tricks for the Management of a Surgical Nightmare. In: Di Saverio, S., Catena, F., Ansaloni, L., Coccolini, F., Velmahos, G. (eds) Acute Care Surgery Handbook. Springer, Cham. https://doi.org/10.1007/978-3-319-15362-9_28

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-15362-9_28

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-15361-2

  • Online ISBN: 978-3-319-15362-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation