Skip to main content
Erschienen in: Journal of Maxillofacial and Oral Surgery 1/2024

16.09.2023 | REVIEW PAPER

The Local Route of Administration of Dexamethasone in Impacted Mandibular Third Molar Surgery: A Systematic Review and Meta-analysis of Randomised Controlled Trials and a Critical Narrative Review on the Claimed Advantages of the Local Route

verfasst von: Saravanan Rajendiran, B. Krishnan, M. S. Deepthy

Erschienen in: Journal of Maxillofacial and Oral Surgery | Ausgabe 1/2024

Einloggen, um Zugang zu erhalten

Abstract

Introduction

The proponents of local route of Dexamethasone (DXM) administration for impacted mandibular 3rd molar (MM3) surgeries claim advantages over the traditional systemic routes. This systematic review and meta-analysis were aimed to determine whether the route of perioperative administration of DXM influences the inflammatory outcomes of MM3 surgeries.

Methodology

An electronic database search over a 25 year period of randomised trials of DXM in MM3 surgeries was conducted. The mean differences or standardised mean differences were extracted and pooled using the fixed or random-effects model.

Results

Of the sixteen selected trials, four were considered for a meta-analysis. There were no statistically significant differences in the inflammatory outcomes between the local and systemic routes of DXM.

Conclusion

The claimed advantages of the local route of DXM do not appear to be scientifically valid. Clinical trials supported with DXM plasma measurements are needed to confirm the absence of a systemic effect when DXM is administered locally.
Literatur
1.
Zurück zum Zitat Alexander RE, Throndson RR (2000) A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol 90:406–415CrossRef Alexander RE, Throndson RR (2000) A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol 90:406–415CrossRef
2.
Zurück zum Zitat Warraich R, Faisal M, Rana M, Shaheen A, Gellrich NC, Rana M (2013) Evaluation of post-operative discomfort following third molar surgery using submucosal dexamethasone - a randomised observer blind prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 116:16–22CrossRefPubMed Warraich R, Faisal M, Rana M, Shaheen A, Gellrich NC, Rana M (2013) Evaluation of post-operative discomfort following third molar surgery using submucosal dexamethasone - a randomised observer blind prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 116:16–22CrossRefPubMed
3.
Zurück zum Zitat Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Beretta M, Farronato D, Santoro F (2007) Effect of submucosal injection of dexamethasone on post-operative discomfort after third molar surgery: a prospective study. J Oral Maxillofac Surg 65:2218–2226CrossRefPubMed Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Beretta M, Farronato D, Santoro F (2007) Effect of submucosal injection of dexamethasone on post-operative discomfort after third molar surgery: a prospective study. J Oral Maxillofac Surg 65:2218–2226CrossRefPubMed
4.
Zurück zum Zitat Bhargava D, Sreekumar K, Deshpande A (2014) Effects of intra-space injection of twin mix versus intraoral-submucosal, intramuscular, intravenous and per-oral administration of dexamethasone on post-operative sequelae after mandibular impacted third molar surgery: a preliminary clinical comparative study. Oral Maxillofac Surg 18:293–296CrossRefPubMed Bhargava D, Sreekumar K, Deshpande A (2014) Effects of intra-space injection of twin mix versus intraoral-submucosal, intramuscular, intravenous and per-oral administration of dexamethasone on post-operative sequelae after mandibular impacted third molar surgery: a preliminary clinical comparative study. Oral Maxillofac Surg 18:293–296CrossRefPubMed
5.
Zurück zum Zitat Vivek GK, Vaibhav N, Shetty A, Mohammad I, Ahmed N, Umeshappa H (2020) Efficacy of various routes of dexamethasone administration in reducing post-operative sequelae following impacted third molar surgery. Ann Maxillofac Surg 10:61–65CrossRefPubMedPubMedCentral Vivek GK, Vaibhav N, Shetty A, Mohammad I, Ahmed N, Umeshappa H (2020) Efficacy of various routes of dexamethasone administration in reducing post-operative sequelae following impacted third molar surgery. Ann Maxillofac Surg 10:61–65CrossRefPubMedPubMedCentral
6.
Zurück zum Zitat Majid OW, Mahmood WK (2011) Effect of submucosal and intramuscular dexamethasone on post-operative sequelae after third molar surgery: comparative study. Br J Oral Maxillofac Surg 49:647–652CrossRefPubMed Majid OW, Mahmood WK (2011) Effect of submucosal and intramuscular dexamethasone on post-operative sequelae after third molar surgery: comparative study. Br J Oral Maxillofac Surg 49:647–652CrossRefPubMed
7.
Zurück zum Zitat Moraschini V, Hidalgo R, Porto Barboza ED (2016) Effect of submucosal injection of dexamethasone after third molar surgery: a meta-analysis of randomised controlled trials. Int J Oral Maxillofac Surg 45:232–240CrossRefPubMed Moraschini V, Hidalgo R, Porto Barboza ED (2016) Effect of submucosal injection of dexamethasone after third molar surgery: a meta-analysis of randomised controlled trials. Int J Oral Maxillofac Surg 45:232–240CrossRefPubMed
8.
Zurück zum Zitat Troiano G, Laino L, Cicciù M, Cervino G, Fiorillo L, D’amico C, Zhurakivska K, Lo ML (2018) Comparison of two routes of administration of dexamethasone to reduce the postoperative sequelae after third molar surgery: a systematic review and meta-analysis. Open Dent J 12:181–188CrossRefPubMedPubMedCentral Troiano G, Laino L, Cicciù M, Cervino G, Fiorillo L, D’amico C, Zhurakivska K, Lo ML (2018) Comparison of two routes of administration of dexamethasone to reduce the postoperative sequelae after third molar surgery: a systematic review and meta-analysis. Open Dent J 12:181–188CrossRefPubMedPubMedCentral
9.
Zurück zum Zitat O’Hare PE, Wilson BJ, Loga MG, Ariyawardana A (2019) Effect of submucosal dexamethasone injections in the prevention of post-operative pain, trismus, and oedema associated with mandibular third molar surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 48:1456–1469CrossRefPubMed O’Hare PE, Wilson BJ, Loga MG, Ariyawardana A (2019) Effect of submucosal dexamethasone injections in the prevention of post-operative pain, trismus, and oedema associated with mandibular third molar surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 48:1456–1469CrossRefPubMed
10.
Zurück zum Zitat Larsen MK, Kofod T, Christiansen AE, Starch-Jensen T (2018) Different dosages of corticosteroid and routes of administration in mandibular third molar surgery: a systematic review. J Oral Maxillofac Res 9(2):e1CrossRefPubMedPubMedCentral Larsen MK, Kofod T, Christiansen AE, Starch-Jensen T (2018) Different dosages of corticosteroid and routes of administration in mandibular third molar surgery: a systematic review. J Oral Maxillofac Res 9(2):e1CrossRefPubMedPubMedCentral
11.
Zurück zum Zitat Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898CrossRefPubMed Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898CrossRefPubMed
12.
Zurück zum Zitat Pappalardo S, Puzzo S, Cappello V, Mastrangelo F, Adamo G, Caraffa A, Tete S (2007) The efficacy of four ways of administrating dexamethasone during surgical extraction of partially impacted lower third molars. Eur J Inflamm 5:151–158CrossRef Pappalardo S, Puzzo S, Cappello V, Mastrangelo F, Adamo G, Caraffa A, Tete S (2007) The efficacy of four ways of administrating dexamethasone during surgical extraction of partially impacted lower third molars. Eur J Inflamm 5:151–158CrossRef
13.
Zurück zum Zitat Antunes AA, Avelar RL, Martins Neto EC, Frota R, Dias E (2011) Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 15:217–223CrossRefPubMed Antunes AA, Avelar RL, Martins Neto EC, Frota R, Dias E (2011) Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 15:217–223CrossRefPubMed
15.
Zurück zum Zitat Sabhlok S, Kenjale P, Mony D, Khatri I, Kumar P (2015) Randomized controlled trial to evaluate the efficacy of oral dexamethasone and intramuscular dexamethasone in mandibular third molar surgeries. J Clin Diagn Res 9:48–51 Sabhlok S, Kenjale P, Mony D, Khatri I, Kumar P (2015) Randomized controlled trial to evaluate the efficacy of oral dexamethasone and intramuscular dexamethasone in mandibular third molar surgeries. J Clin Diagn Res 9:48–51
16.
Zurück zum Zitat Gopalakrishnan V, Darekar HS, Sahoo NK (2015) Effectiveness of submucosal V/S intramuscular dexamethasone in mandibular third molar surgeries. Int J Med Sci Clin Inv 2:648–655 Gopalakrishnan V, Darekar HS, Sahoo NK (2015) Effectiveness of submucosal V/S intramuscular dexamethasone in mandibular third molar surgeries. Int J Med Sci Clin Inv 2:648–655
17.
Zurück zum Zitat Saravanan K, Kannan R, John RR, Nantha KC (2016) A single pre operative dose of sub mucosal dexamethasone is effective in improving post operative quality of life in the surgical management of impacted third molars: a comparative randomised prospective study. J Maxillofac Oral Surg 15:67–71CrossRefPubMed Saravanan K, Kannan R, John RR, Nantha KC (2016) A single pre operative dose of sub mucosal dexamethasone is effective in improving post operative quality of life in the surgical management of impacted third molars: a comparative randomised prospective study. J Maxillofac Oral Surg 15:67–71CrossRefPubMed
18.
Zurück zum Zitat Gopinath KA, Chakraborty M, Arun V (2017) Comparative evaluation of submucosal and intravenous dexamethasone on post-operative sequelae following third molar surgery: a prospective randomised control study. Int J Oral Care Res 5:191–195CrossRef Gopinath KA, Chakraborty M, Arun V (2017) Comparative evaluation of submucosal and intravenous dexamethasone on post-operative sequelae following third molar surgery: a prospective randomised control study. Int J Oral Care Res 5:191–195CrossRef
19.
Zurück zum Zitat Kumar HHR (2017) Comparison of intravenous and submucosal dexamethasone on post-operative sequale following third molar surgery. J Adv Med Dent Scie Res 5:20–23 Kumar HHR (2017) Comparison of intravenous and submucosal dexamethasone on post-operative sequale following third molar surgery. J Adv Med Dent Scie Res 5:20–23
20.
Zurück zum Zitat Vivek GK, Vaibhav N, Shafath A, Imran M (2017) Efficacy of intravenous, intramassetric, and submucosal routes of dexamethasone administration after impacted third molar surgery: a randomised, comparative clinical study. J Adv Clin Res Insights 4:3–7CrossRef Vivek GK, Vaibhav N, Shafath A, Imran M (2017) Efficacy of intravenous, intramassetric, and submucosal routes of dexamethasone administration after impacted third molar surgery: a randomised, comparative clinical study. J Adv Clin Res Insights 4:3–7CrossRef
21.
Zurück zum Zitat Kaewkumnert S, Phithaksinsuk K, Changpoo C et al (2020) comparison of intraosseous and submucosal dexamethasone injection in mandibular third molar surgery: a split-mouth randomised clinical trial. Int J Oral Maxillofac Surg 49:529–535CrossRefPubMed Kaewkumnert S, Phithaksinsuk K, Changpoo C et al (2020) comparison of intraosseous and submucosal dexamethasone injection in mandibular third molar surgery: a split-mouth randomised clinical trial. Int J Oral Maxillofac Surg 49:529–535CrossRefPubMed
22.
Zurück zum Zitat Moranon P, Chaiyasamut T, Sakdajeyont W, Vorakulpipat C, Klongnoi B, Kiattavornchareon S, Wongsirichat N (2019) Dexamethasone injection into pterygomandibular space versus sublingual space on post-operative sequalae of lower third molar intervention. J Clin Med Res 11:501–508CrossRefPubMedPubMedCentral Moranon P, Chaiyasamut T, Sakdajeyont W, Vorakulpipat C, Klongnoi B, Kiattavornchareon S, Wongsirichat N (2019) Dexamethasone injection into pterygomandibular space versus sublingual space on post-operative sequalae of lower third molar intervention. J Clin Med Res 11:501–508CrossRefPubMedPubMedCentral
23.
Zurück zum Zitat Mahmoud NR (2019) Efficacy of sub-mucosal, intra-masseteric and intra-muscular routes of Dexamethasone administration on post-operative complications following impacted mandibular third molar surgeries, comparative clinical trial. Egy Dent J 65:113–133CrossRef Mahmoud NR (2019) Efficacy of sub-mucosal, intra-masseteric and intra-muscular routes of Dexamethasone administration on post-operative complications following impacted mandibular third molar surgeries, comparative clinical trial. Egy Dent J 65:113–133CrossRef
24.
Zurück zum Zitat Hiriyanna NM, Degala S (2021) Objective and subjective comparison of submucosal and intravenous routes of single-dose preoperative dexamethasone for mandibular third molar surgery-a prospective randomised observer-blind study. Oral Maxillofac Surg 25:207–213CrossRefPubMed Hiriyanna NM, Degala S (2021) Objective and subjective comparison of submucosal and intravenous routes of single-dose preoperative dexamethasone for mandibular third molar surgery-a prospective randomised observer-blind study. Oral Maxillofac Surg 25:207–213CrossRefPubMed
25.
Zurück zum Zitat Benet LZ (1987) Effect of route of administration and distribution on drug action. J Pharmacokinet Biopharm 6:559–585CrossRef Benet LZ (1987) Effect of route of administration and distribution on drug action. J Pharmacokinet Biopharm 6:559–585CrossRef
26.
Zurück zum Zitat Donavan MD (2009) Effect of route of administration and distribution on drug action. In: Florence AT, Siepmann J (Eds). Modern Pharmaceutics. Vol 1, 5th Edn, Basic Principles and Systems: Informa Healthcare USA, Inc, 155–79 Donavan MD (2009) Effect of route of administration and distribution on drug action. In: Florence AT, Siepmann J (Eds). Modern Pharmaceutics. Vol 1, 5th Edn, Basic Principles and Systems: Informa Healthcare USA, Inc, 155–79
27.
Zurück zum Zitat Von Hoff DD, Kuhn JG, Burris HA 3rd, Miller LJ (2008) Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med 26(1):31–38CrossRef Von Hoff DD, Kuhn JG, Burris HA 3rd, Miller LJ (2008) Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med 26(1):31–38CrossRef
28.
Zurück zum Zitat Rohdewald P, Möllmann H, Barth J, Rehder J, Derendorf H (1987) Pharmacokinetics of dexamethasone and its phosphate ester. Biopharm Drug Dispos 8:205–212CrossRefPubMed Rohdewald P, Möllmann H, Barth J, Rehder J, Derendorf H (1987) Pharmacokinetics of dexamethasone and its phosphate ester. Biopharm Drug Dispos 8:205–212CrossRefPubMed
29.
Zurück zum Zitat Bhargava D, Ahirwal R, Koneru G, Srikanth BR, Beena S (2018) A preliminary study on plasma concentration achieved following intrapterygomandibular space injection of dexamethasone as a route of drug delivery with lignocaine inferior alveolar nerve block-correlation of clinical effects. Oral Maxillofac Surg 22:457–461CrossRefPubMed Bhargava D, Ahirwal R, Koneru G, Srikanth BR, Beena S (2018) A preliminary study on plasma concentration achieved following intrapterygomandibular space injection of dexamethasone as a route of drug delivery with lignocaine inferior alveolar nerve block-correlation of clinical effects. Oral Maxillofac Surg 22:457–461CrossRefPubMed
30.
Zurück zum Zitat Messer E, Keller J (1975) The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surg Oral Med Oral Pathol 40:594–598CrossRefPubMed Messer E, Keller J (1975) The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surg Oral Med Oral Pathol 40:594–598CrossRefPubMed
32.
Zurück zum Zitat Selvaraj L, Hanumantha Rao S, Lankupalli AS (2014) Comparison of efficacy of methylprednisolone injection into masseter muscle versus gluteal muscle for surgical removal of impacted lower third molar. J Maxillofac Oral Surg 13:495–498CrossRefPubMed Selvaraj L, Hanumantha Rao S, Lankupalli AS (2014) Comparison of efficacy of methylprednisolone injection into masseter muscle versus gluteal muscle for surgical removal of impacted lower third molar. J Maxillofac Oral Surg 13:495–498CrossRefPubMed
33.
Zurück zum Zitat Montgomery MT, Hogg JP, Roberts DL, Redding SW (1990) The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 48:179–187CrossRefPubMed Montgomery MT, Hogg JP, Roberts DL, Redding SW (1990) The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 48:179–187CrossRefPubMed
34.
Zurück zum Zitat Boonsiriseth K, Klongnoi B, Sirintawat N, Saengsirinavin C, Wongsirichat N (2012) Comparative study of the effect of dexamethasone injection and consumption in lower third molar surgery. Int J Oral Maxillofac Surg 41:244–247CrossRefPubMed Boonsiriseth K, Klongnoi B, Sirintawat N, Saengsirinavin C, Wongsirichat N (2012) Comparative study of the effect of dexamethasone injection and consumption in lower third molar surgery. Int J Oral Maxillofac Surg 41:244–247CrossRefPubMed
35.
Zurück zum Zitat Fernandes IA, de Souza GM, Pinheiro MLP, Falci SGM (2019) Intramuscular injection of dexamethasone for the control of pain, swelling, and trismus after third molar surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 48:659–668CrossRefPubMed Fernandes IA, de Souza GM, Pinheiro MLP, Falci SGM (2019) Intramuscular injection of dexamethasone for the control of pain, swelling, and trismus after third molar surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 48:659–668CrossRefPubMed
Metadaten
Titel
The Local Route of Administration of Dexamethasone in Impacted Mandibular Third Molar Surgery: A Systematic Review and Meta-analysis of Randomised Controlled Trials and a Critical Narrative Review on the Claimed Advantages of the Local Route
verfasst von
Saravanan Rajendiran
B. Krishnan
M. S. Deepthy
Publikationsdatum
16.09.2023
Verlag
Springer India
Erschienen in
Journal of Maxillofacial and Oral Surgery / Ausgabe 1/2024
Print ISSN: 0972-8279
Elektronische ISSN: 0974-942X
DOI
https://doi.org/10.1007/s12663-023-02011-5

Weitere Artikel der Ausgabe 1/2024

Journal of Maxillofacial and Oral Surgery 1/2024 Zur Ausgabe

Häusliche Gewalt in der orthopädischen Notaufnahme oft nicht erkannt

28.05.2024 Häusliche Gewalt Nachrichten

In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.

Fehlerkultur in der Medizin – Offenheit zählt!

28.05.2024 Fehlerkultur Podcast

Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.

Mehr Frauen im OP – weniger postoperative Komplikationen

21.05.2024 Allgemeine Chirurgie Nachrichten

Ein Frauenanteil von mindestens einem Drittel im ärztlichen Op.-Team war in einer großen retrospektiven Studie aus Kanada mit einer signifikanten Reduktion der postoperativen Morbidität assoziiert.

TAVI versus Klappenchirurgie: Neue Vergleichsstudie sorgt für Erstaunen

21.05.2024 TAVI Nachrichten

Bei schwerer Aortenstenose und obstruktiver KHK empfehlen die Leitlinien derzeit eine chirurgische Kombi-Behandlung aus Klappenersatz plus Bypass-OP. Diese Empfehlung wird allerdings jetzt durch eine aktuelle Studie infrage gestellt – mit überraschender Deutlichkeit.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare
CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis
Berufsverband der Deutschen Chirurgie e.V.

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare
CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske
Dr. med. Benjamin Meyknecht
Berufsverband der Deutschen Chirurgie e.V.

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare
CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric
Berufsverband der Deutschen Chirurgie e.V.