Case Presentation, Management, Discussion and Sharing of
Information on Epigastric Pain
Jonathan R. Malabanan, M.D. Surgery Resident
OMMC
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
General Data:
• L.B. 42 y.o male
• Quiapo, Manila.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Chief Complaint
Epigastric Pain
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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History of Present Illness:
• 1 month PTA→ (+) epigastric pain, on and off associated with postprandial vomiting
(+) consult private MD: Ranitidine
UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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→EGD with biopsy:
nodular mass at pylorus area
multiple erosion from pylorus to the body
Biopsy: poorly differentiated gastric adenocarcinoma
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• 1 wk PTA →(+)persistence of epigastric pain and post-prandial vomiting with associated anorexia
(+) progression of above conditions
advised to undergo CT Scan
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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→Consulted our hospital due to financial constraint.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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PAST MEDICAL HISTORY:
• No DM
• No Hypertension
• No other heredofamilial diseases
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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PHYSICAL EXAMINATION:• GEN SURVEY:
Conscious,coherent,oriented
BP=120/80 CR=80 RR=21 T=36.5• HEENT: Pink conjunctivae, anicteric
sclerae, no cervical lymphadenopathies
• CHEST: SCE, clear breath sounds
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
• CARDIAC: Normal rate, regular rhythm, no murmur
• ABDOMEN: Flabby, NABS, soft, no palpable mass
• EXTREMITIES: Full and equal pulses,no deformities
• DRE: No mass noted, good sphincter tone, with feces on tactating finger
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Salient Features:• 42 y.o male
• (+) epigastric pain, on and off associated with post-prandial vomiting
• (+) anorexia
• (+) UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Salient Features:
(+) EGD with biopsy:
nodular mass at pylorus area
multiple erosion from pylorus to the body
Biopsy: poorly differentiated gastric adenocarcinoma
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
AlgorithmEpigastric Pain
post-prandial vomiting
Gastric ulcer Tumor
EGD with biopsy: nodular mass on pylorus with
mucosal erosion up to the body
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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AlgorithmEpigastric Pain
post-prandial vomiting
Gastric ulcer Tumor
Benign MalignantBiopsy: poorly
differentiated adenocarcinoma
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Clinical Diagnosis
DIAGNOSIS CERTAINTY TREATMENT
PRIMARY Gastric AdenoCA Resectable
85% Surgical
SECONDARY Gastric AdenoCANon resectable
15% Palliative surgeryChemotheraphyRadiation
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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PARACLINICAL DIAGNOSTICPROCEDURE
• Do I need a paraclinical diagnostic procedure?
Yes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Paraclinical Diagnostic OptionsBENEFIT RISK COST AVAILABI
LITYCT Scan Sensitivity: 88
%Specificity: 86 %- Lymph node involvement Direct invasionDistant of metastases
-Radiation P10- 20 thou Not available
Diagnostic ExploreLaparotomy
Sensitivity:Specificity:May proceed with definitive treatment
-Infection-Hemorrhage
P30-40 thou Available
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.
Pretreatment Diagnosis:
Gastric Adenocarcinoma, Pyloric area, Resectable
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Goals of Treatment1. Complete removal of gastric cancer
2. Better long term improvement and prevent complication
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Pre Treatment OptionsBENEFIT RISK COST AVAILABI
LITYSubtotal Gastrectomy
Same5 year survivalShorter hospital stayBetter nutritional status
-Hemorrhage P30-40 thou Available
Total Gastrectomy
5 year survival -HemorrhageIncreased post operative infection rate
P30-40 thou Available
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178
Plan of Operation
• Subtotal Gastrectomy
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Treatment Goal
• Better quality of life and increase survival
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Pre Treatment OptionsBENEFIT RISK COST AVAILABILI
TY
Radical Subtotal Gastrectomy with D1 Dissection
Recurrence:41 %Hospital Stay: 14 days
Infection Rate: 25 %
P40 thou Available
Radical Subtotal Gastrectomy with D2 Dissection
Recurrence: 29 %Hospital Stay: 16 days
Infection Rate: 43 %
P30 thou Available
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914. [PubMed
Plan of Operation
• Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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PREOPERATIVE PREPARATION
• 1. Informed Consent
• 2. Psychosocial Support
• 3. Optimize Patient’s Physical Health
• 4. Screening For Other Medical Problem
• 5. Prepare Materials For OR
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Operative Maneuvers
• Patient supine under GA
• Asepsis antisepsis
• Sterile drapes placed
• Midline vertical abdominal incision long enough to facilitate accurate intra-operative evaluation
• Liver inspected, stomach identified
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Intraop- findings
• A nodular mass noted intraluminally at the pylorus area measuring 3x 4 cm
• No other organ involvement
• Perigastric and left gastric nodes noted
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Operative Maneuvers
• Formal radical subtotal gastrectomy done
with D2 dissection and removal of omentum
Stomach was mobilized with division of right gastroepiploic artery, right gstric and gastrodudenal artery
A 6 cm margin tumor margin proximally was allotted removing more than 50% of the stomach
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Operative Maneuvers
• Formal gastrojejunostomy was done with open end of the stomach attached to the jejunum.
• Jejunum passed in front of the colon and was attached to the stomach
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Operative Maneuvers
-
-Hemostasis -OS and instrument
checked -Layer by layer closure -Dry sterile dressing
placed
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operation Done:
• Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Final DiagnosisGastric Adenocarcinoma, Pyloric Area S/P
Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Post op Management:• Maintained on NPO
• Adequate analgesia given
• Antibiotics continued
• Monitoring of early complications
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Post op Management:• The nasogastric tube is removed upon return
of gastrointestinal transit, and feeding is slowly begun.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Sharing of Information
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Epidemiology-highest incidence is in Japan
-occurs more frequently in males in almost all areas of the world
-slightly increased risk in patients with blood group A
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Signs & Symptoms
• produces no specific symptoms when it is superficial and potentially surgically curable, although up to 50% of patients may have nonspecific gastrointestinal complaints such as dyspepsia.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Risk Factors
-Diets high in salt and cured and smoked food, low in fresh fruit and vegetable
-H. pylori infection
-smoking
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Lauren ClassificationIntestinal Type• glandular and arise from the gastric
mucosa usually in older patients and more commonly in the distal stomach
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Lauren ClassificationDiffuse Type
-associated with invasive growth pattern and appears to arise from lamina propria
-more common in proximal stomach and younger patients
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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SURGICAL MANAGEMENTTumors of the fundus and proximal stomach:
Total gastrectomy with D2 dissection and esophagojejunal reconstruction
Tumors of the body: Total gastrectomy with D2 nodal dissection
Tumors of the distal stomach: Subtotal gastrectomy with D2 nodal dissection
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
In the management of mid to proximal gastric cancers, sparing the tail of the pancreas and the spleen is recommended, if feasible, since it is associated with lesser morbidity and mortality.
D2 resection involves removal of the omental bursa, the hepatoduodenal and retroduodenal nodes (antral lesions) and the splenic artery and hilar nodes and retropancreatic nodes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
ADJUVANT THERAPY
Post-operative Adjuvant chemotherapy: Currently there is not enough evidence that will show benefit for post-operative chemotherapy.
Neo-adjuvant chemotherapy: several studies show promising results but still needs to be studied further. In cases of patients who are candidates for neo-adjuvant chemotherapy, staging using diagnostic laparoscopy is warranted.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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FOLLOW-UP First follow –up within 5 – 7 days after discharge Second follow-up will be 30 days after the
operation. During the first year, frequency of follow-up will
be every 3 months, then every 6 months thereafter.
Yearly endoscopy Diagnostic work-up will be symptom-directed
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
References:
• Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914.
• Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.
• Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178
• Cameron, John. Current Surgical Theraphy. Gastric Adenocarcinoma. Pp.95- 100.
• Treatment Protocol. Department of Surgery. UP- PGH
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCQ1.Which of the following characterizes
intestinal type of gastric ca?
a. associated with invasive growth pattern
b. appears to arise from lamina propria
c. glandular and arise from gastric mucosa
d. more common in proximal stomach
e. more common in younger patients
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCQ2. Most appropriate surgical treatment for
distal gastric ca?a. Total gastrectomy with D2 nodal dissection
b. Total gastrectomy with D1 nodal dissection
c. Subtotal gastrectomy with D2 nodal dissection
d. Total gastrectomy with D2 dissection and esophagojejunal reconstruction
e. Subtotal gastrectomy with D1 nodal dissection
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCQ3. A classic D2 dissection includes nodes
along the following except?
a. hepatic
b. left gastric
c. celiac
d. splenic
e. periaortic
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCRDirection: Write
“A” if 1, 2, and 3 are valid statements.
“B” if only 1 and 3 are valid statements.
“C” if only 2 and 4 are valid statements.
“D” if only 4 is a valid statement.
“E” if all are valid statements.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCR4.With regard to the epidemiologic characteristic
of gastric ca, which of the following is/are true ?
1. The highest incidence is in Japan
2. Occurs more frequently in males
3. Incidence and death rates in US have decreased
4. Higher incidence among patients with blood group O
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCR5. With regard to surgical treatment of gastric
adenoCA, which of the following statements is/are true?
1.Total gastrectomy for antral lesions results in longer survival than does partial gastrectomy
2. Total gastrectomy for palliation is contraindicated
3..Extended LN dissection improves survival rates with stage I and II lesions
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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MCR5. With regard to surgical treatment of
gastric adenoCA, which of the following statements is/are true?
4. Routine splenectomy does not improve survival rates
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Thank You!
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Journal Appraisal
• Subtotal Versus Total Gastrectomy for Gastric Cancer
• Five-Year Survival Rates in a Multicenter Randomized Italian Trial
Ann Surg. 1999 August; 230(2): 170.Federico Bozzetti, MD,* Ettore Marubini, PhD,* Giuliano Bonfanti, MD,* Rosalba Miceli,
PhD,* Chiara Piano,* Leandro Gennari, MD,* and the Italian Gastrointestinal Tumor Study Groupe.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Objective:
– To evaluate the impact of subtotal (SG) versus total (TG) gastrectomy on the oncologic outcome of patients with cancer of the distal stomach from 28 Italian institutions.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Patients and Methods:.
• The present analysis involved 618 patients randomized during surgery to SG (315) or TG (303), provided there was at least 6 cm from the proximal edge of the tumor to the cardia, there was no intraperitoneal or distant spread, and it was possible to remove the tumor entirely. Both surgical treatments included regional lymphadenectomy.
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• Results:
• Four patients died after SG and seven after TG. Median follow-up was 72 months after SG (range 2 to 125) and 75 months after TG (range 7 to 113). Five-year survival probability as computed by the Kaplan-Meier method was 65.3% for SG and 62.4% for TG.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Results:
• The test of equivalence led to the conclusion that the two procedures may be considered equivalent in terms of 5-year survival probability.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Results:
• The analysis of survival using a multivariate Cox regression model showed a statistically significant impact on survival of tumor site, tumor spread within the gastric wall, extent of resection to the spleen plus or minus neighboring organs or structures, and relative frequency of metastasis in resected lymph nodes..
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Conclusions:
• Both procedures have a similar survival probability. The authors believe that SG, which has been reported to be associated with a better nutritional status and quality of life, should be the procedure of choice, provided that the proximal margin of the resection falls in healthy tissue.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Clinical Question:
• Will total gastrectomy increase the survival of patients with gastric ca on distal half as compared to subtotal gastrectomy?
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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• Tentative Answer
• No.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Are the results of the study valid?
Primary Guides:
1. Was the assignment of patients to treatment randomized?
Yes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Are the results of the study valid?
Primary Guides:
2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?
Yes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Are the results of the study valid?
Secondary Guides:
3. Were patients, their clinicians, and study personnel "blind" to treatment?
Yes
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Are the results of the study valid?
Secondary Guides:
4. Were the groups similar at the start of the trial?
Yes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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Are the results of the study valid?
Secondary Guides:
5. Aside from the experimental intervention, were the groups treated equally?
Yes.
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
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God bless
DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”