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Toloneetal.BMCSurgery2013,13(Suppl2):S11http://www.biomedcentral.com/1471-2482/13/S2/S11
RESEARCHARTICLEOpenAccessTheimpactofageandoralcalciumandvitaminDsupplements
onpostoperativehypocalcemiaaftertotalthyroidectomy.Aprospectivestudy
SalvatoreTolone*,
RuggieroRoberto,GianmattiadelGenio,LuigiBrusciano,DomenicoParmeggiani,VincenzoAmoroso,GiuseppinaCasalino,
IgnazioVerde,AlfonsoBosco,AntonioDAlessandro,RaffaelePirozzi,GianlucaRossetti,
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PaoloLimongelli,LudovicoDocimo
From26thNationalCongressoftheItalianSocietyofGeriatricSurgeryNaples,Italy.19-22June2013
Abstract
Background:Hypocalcemiacausedbytransientordefinitivehypoparathyroidismis
themostfrequentcomplicationaftertotalthyroidectomy(TT).Weaimedtocomparethe
impactofageandtheclinicalusefulnessoforalcalcium
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andvitaminDsupplementsonpostoperativehypocalcemiaafterTT,andtodeterminewhichriskfactorsareimportantforhypocalcemiaincidence.
Methods:Two
hundredconsecutivepatientstreatedbyTTwereincludedprospectivelyinthepresentstudy.
AllpatientssupplementedoralcalciumandvitaminDinthepost-operativetime.The
dataconcerningsymptomaticandlaboratoristichypocalcemiawerecollected.Patientswereevaluated
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accordingtoage,sex,postoperativeserumcalciumlevels,andpreoperativeserumalkalinephosphatasislevels.
Results:Symptomatichypocalcemiadevelopedonlyin19patients
(9.5%),whereaslaboratoryhypocalcemiadevelopedin36patients(18%).Theriskforpostoperative
hypocalcemiawasincreate20-foldforpatientsolderthan50years.
Conclusions:
Ageissignificantlyassociatedwithpostoperativehypocalcemia.Implementingoralcalcium
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andvitaminDaftertotalthyroidectomycanreducetheincidenceofhypocalcemiarelatedtosurgery.
Background
Totalthyroidectomy(TT)
isnowthepreferredoptionforthemanagementofbenignmultinodulargoiter.Postoperative
hypocalcemiaisobservedinuptoonethirdoftotalorcompletionthyroidectomy
patientsandisthemostcommoncomplication,duetoparathyroid
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glandinsufficiency,anditcontinuestochallengeevenexperiencedsurgeonssinceitoftenextendsthedurationofhospitalstayandincreasestheneedfor
biochemicaltests[1-5].Surgicaltechniquehasevolvedtopreserveparathyroidfunctionwhereverpossible.
However,
*Correspondence:[email protected],Department
ofSurgery,SecondUniversityofNaples,ViaS.Pansini5,
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80131,Naples,Italytransienthypoparathyroidismstilloccursowingtoparathyroidmanipulation,devascularization,venousengorgementorinadvertentremovaloftheparathyroidglandswiththethyroid
specimen.
Hypocalcemiaaftertotalthyroidectomyisusuallytransient,andtheincidence
ofpermanenthypoparathyroidismis3%orlessaccordingtotheexperienceofmost
ofthesurgicalunitsstudied[6-8].Despitebeingself-limitingin
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mostpatients,symptomatichypocalcemiaisofparticularconcernbecauseofadelayinitsmanifestationandtheconsequentneedforprolongedpatienthospitalizationor
readmission.Followingtotalthyroidectomy,patientsarecloselyobservedforbleedinginthefirst
24h.Themaindischarge-limitingfactorthereafteristhedevelopmentof
©2013Toloneetal;licenseeBioMedCentralLtd.
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ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited.
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Toloneetal.BMCSurgery2013,13(Suppl2):S11Page2of6http://www.biomedcentral.com/1471-2482/13/S2/S11
hypocalcaemiaaspatientsnotatriskofhypocalcaemia
maybedischargedonday1followingsurgery.
Thecausesof
hypocalcemiaafterTTaremultifactorial,andsomeofthesefactorsincludeiatrogenicsurgical
traumatotheparathyroidglands,incidentalparathyroidectomy,thenumberof
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functioningglandsleftbehind,extentofsurgery,experienceofthesurgeon,hyperthyroidism,retrosternalgoiter,concomitantneckdissection,andthyroidcarcinoma[9,10].Severalauthorshave
attemptedtoidentifyriskfactorsinthedevelopmentofhypocalcemia.Declinesinserum
calcium[7]orintactparathyroidhormone(iPTH)levels[11,12]aftersurgeryhavebeen
suggestedasbeingreliablepredictorsofpostoperativehypocalcemia.Althoughmeasurements
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ofserumcalciumoriPTHallowtheidentificationofpatientswhohavenoriskofhypocalcemiaaftertotalthyroidectomy,itisnotalwayseasy
topredictwhichpatientscanbedischargedearlyfromthehospitalorto
identifythoserequiringclosemonitoringofserumcalciumlevelsorthosethatshould
receivecalciumandvitaminDsupplements.Implementationofprotocolsusing
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postoperativePTHmeasurementhasbeenshowntofacilitateday1dischargeafterthyroidectomy[13].However,rapidPTHmeasurementisnotreadilyavailableinmany
hospitals.
RoutineoralcalciumandvitaminDsupplementshavebeenproposed
topreventthedevelopmentofsymptomatichypocalcemiaandtoincreasethelikelihoodof
earlyhospitaldischargeafterbilateralsurgicaltreatmentofthethyroid
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glandorexplorationoftheparathyroidglands[14,15].VitaminDplaysacriticalroleincalciumhomeostasis[16].Insufficiencyincalciumabsorptiondueto
lowvitaminDconcentrationleadstoanincreaseinparathyroidhormone(PTH)secretion.
IncreasedPTHstimulatesthesynthesisofcalcitriolandtherebyimprovescalciumabsorptionefficiency.
However,eveninpatientswhopracticedapostoperativeimplementationwith
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oralcalciumandvitaminD,theriskofpostoperativehypocalcemiccrisisisnotavoided,suggestingaroleforotherriskfactors.Identifyingsomeof
thisriskfactorscanled,inturn,toareductionincostsassociated
withmultiplebloodsamplingsinmonitoringthedevelopmentofhypocalcemiaaswellas
costsassociatedwithprolongedhospitalization.
Theaimsof
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thisprospectiveclinicalstudyare:(1)tocomparetheimpactofageandtheclinicalusefulnessoforalcalciumandvitaminDsupplementson
postoperativehypocalcemiaafterTT,and(2)todeterminewhichriskfactorsareimportant
forhypocalcemiaincidence.
Methods
Inthesettingofaprospectivestudy,
200consecutivepatients[44men(22%,meanage45±
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14years),156women(78%,meanage43±18years)],undergoingtotal
thyroidectomyintheDivisionofGeneralandBariatricSurgeryatUniversity
ofNaplesS.U.N.betweenMarch2011andFebruary2013,wereenrolled.Allof
thepatientshadnohistoryofpriorthyroidornecksurgery.Patientsrequiring
unilaterallobectomyorsubtotalorcompletionthyroidectomywereexcluded,and
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onlypatientsundergoingtotalthyroidectomywereenrolledintothestudy.Allpatientshadnormalrenalfunctionatthetimeofsurgery.Noneofthepatientshadsignsorsymptomsindicating
metabolicbonedisease,andnoneofthepatientswereonmedications,suchas
oralcalcium/vitaminDsupplementation,anti-resorptiveagents,hormonereplacementtherapyforpostmenopausalwomen,
anabolicagents,thiazidetypediuretics,orantiepilepticagents,knownto
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affectserumcalciummetabolism.IndicationsforsurgeryarelistedinTable1;eachsubjectprovidedaspecificinformedconsent,beforebeingpartofthe
study.Thestudyplanwasreviewedandapprovedbylocalinstitutionalethicalcommittee.
TheTTprocedureconsistsofa3-to5-cmskinincision1
to1.5cmabovethesternalnotch.Afterdivisionof
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theplatysma,thecervicallineaalbaisopenedwithoutdivisionofthestrapmuscles.Thethyroidlobeisdissectedprogressivelyfromthestrapmuscles.After
identificationoftherecurrentlaringeanerveandparathyroidglands,thevascularpediclesof
thethyroidlobeareligatedwiththeHarmonicAce/Focusscalpel(EthiconEndo-SurgeryInc.,
Cincinnati,OH,USA),andthethyroidlobeisremoved[17-20].
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Afteracheckforhemostasis,adrainisplacedinthethyroidbed.Thecervicallineaalbaandplatysmaaresuturedwithabsorbablesutures,and
theskinisclosedbyanintracutaneousrunningsuture.
Patientswere
askedtotakeoralcalcium2g/dtakentwice(1gevery12hours)andvitaminD1g/dtakentwice
(0.5gevery12hours)fromthenightofoperation
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topost-operativeday14.Intravenouscalciumgluconatewasadministeredifsignificantsymptomatichypocalcemiapersistedaftersurgerydespiteoralsupplementation.
Themedicaland
nursingnoteswerecarefullyexaminedfordocumentationofsymptomsofhypocalcaemia.Thetime
ofadministrationofcalcium,vitaminDanaloguesandintravenousfluidsinrelationto
serumcalciumandhypocalcaemicsymptomswasalsonoted.Serumcalcium,
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albumin,creatinine,andalkalinephosphatase
Table1Preoperativediagnosis
DiseaseTOTALN=200Multinodulargoiter168(84%)Carcinoma20
(10%)Basedow12(6%)
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Toloneetal.BMCSurgery2013,13(Suppl2):S11Page3of6http://www.biomedcentral.com/1471-2482/13/S2/S11
levelsweredeterminedthedaybeforesurgery,on
theeveningofsurgery(day0),onthemorningofday1and
thenevery24hoursuntilpatientdischarge.Serumcalciumconcentrationwascorrectedfor
changesinserumalbumin.Serumcalcium,creatinine,albumin,andalkaline
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phosphataseweremeasuredusingautomatedassays.Thereferencerangesforserumcalciuminourlaboratorywere8.5to10.5mg/dL.
Allpatients
wereseenintheoutpatientsdepartment2weeksaftersurgery.Thereportedsymptoms
ofhypocalcaemiaandthetreatmentrequiredtocontrolthesesymptomswerenoted.
Postoperativehypocalcemiawasdefinedaseithersymptomaticorlaboratory.
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Hypocalcemicsymptomsandsigns,fromperioraltinglingandnumbnesstocarpopedalspasmsandtetany,wereregisteredindetail.Laboratoryhypocalcemiawasdefined
asserumtotalcalciumconcentrationsof<8.0mg/dL,evenifrecordedonlyin
asinglemeasurement.
Statistics
DatawereanalyzedusingSPSS
15.0forWindows(SPSSInc,Chicago,IL).Resultswereexpressed
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asmean±SD.ComparisonsofdatausedtheWilcoxonsigned-ranktest,chi-squaretest,andlogisticregressionanalysis.Resultswereconsideredstatisticallysignificantwhen
the2-tailedPvaluewaslessthan0.05.
Results
All
patientsrespectedtheoralsupplementprotocol.Thethyroiddiseasesofthepatientsincluded
inthestudyareshowninTable1.Theoperative
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procedureswerealltotalthyroidectomy.Nomajorcomplicationoccurred
(e.g.persistentvocalcordparalysisandhypoparathyroidism,bleedingrequiringreintervention).Incidentalparathyroidectomywas
foundin3patients(1.5%).Themeans(±SD)forserumalbumin,creatinine,calcium
andalkalinephosphataselevelswere3.8±0.09g/dL,
0.8±
0.1mg/dL,8.9±0.2mg/dl,and162±74
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U/L,respectively.Thepostoperativeserumcalciumlevelwaslowerthanthepreoperativeserumcalciumlevel(8.9±0.2mg/dLvs8.2±0.9mg/dL,P<0.001).
Symptomatichypocalcemiadevelopedonlyin19patients(9.5%),whereaslaboratoryhypocalcemiadevelopedin
36patients(18%).Hypocalcemicsymptomswereminimalin12patients.Intravenouscalciumwas
administeredto7patientswithseverehypocalcemicsymptoms(Table2).
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Regardingtheselattercasesonly,inthesubsequenthystopathologicalanalysisonremovedthyroidtissue,incidentalparathyroidtissueswerefoundinthree.Permanenthypocalcemiadeveloped
innoneofpatients.Hypercalcemiaorothersideeffectsdidnotdevelopin
anyofthepatientsreceivingroutineoralsupplements.
Table2Patients
developinghypocalcemia
HypocalcemiaTotalN=200LaboratoryHypocalcemia
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36(18%)SymptomaticHypocalcemia19(9.5%)RequiringE.V.Calcium7(3.5%)
Ageandserumalkalinephosphataselevelsweresignificantlyhigherinpatientswho
developedhypocalcemiathaninothers(56.7±8yearsand242.21±72
U/Lvs
42.1±9yearsand123.21±41U/L,
P<0.001).Postoperativeserumcalciumlevelsweresignificantlylowerin
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hypocalcemicpatients(7.3±0.4mg/dLvs8.6±0.3mg/dL,P<0.001).Hospitalstaywassignificantlylongerinhypocalcemicpatients(4±1days,range
2-5days)thanothers(2±
0.5days,range1-3days)
(P<0.001).Infemalepatients,theratioofpostoperativehypocalcemiawasfoundto
besignificantlyhigherwhencomparedtomalepatients(24%vs
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8%,P<0.01).Therewasanegativecorrelationbetweenserumcalciumlevelandage(rs-0.501,P<0.001)andfemalegender(rs-0.203,P<0.01)andserumalkalinephosphatase
level(rs-0.498,P<0.001).
Patientageandpreoperativeserumalkalinephosphatase
level,wereindependentsignificantvariablesinthedevelopmentofhypocalcemiaafterthyroidectomy.The
riskforpostoperativehypocalcemiawasincreased20foldforpatientsolder
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than50years(oddsratio[OR]20.2;95%confidenceinterval[CI]10.4-58.3).
Discussion
Thepresentstudyshowsthatpost-operativeoral
calciumandvitaminDsupplementscanreducetheincidenceofhypocalcemiaaftertotal
thyroidectomy.Also,weinvestigatedthepredictionvalueofage,preoperativeserumcalciumand
alkalinephosphataseonpostoperativehypocalcemiaaftertotalthyroidectomy.
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Wefoundthatagewassignificantlyassociatedwithpostoperativehypocalcemia.Negativecorrelationswereobservedbetweentheserumcalciumlevelandage,andserumalkaline
phosphataselevel.Accordingtoalogisticregressionanalysis,agewasasignificantindependent
variableassociatedwithpostoperativehypocalcemia.
Postoperativehypocalcemiaisoneofthe
mostfrequentcomplicationsafterTT[21].Inseveralstudies,the
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incidenceofhypoparathyroidismvariedfrom1.6%toabove50%[7,22].
ThecausesofhypocalcemiaafterTTaremultifactorial,andsomeofthese
causesincludeinjury,devascularization,andunintentionalexcisionofparathyroidglands,thenumberof
functioningglandsleftbehind,theextentofsurgery,theexperienceofthesurgeon,
hyperthyroidism,
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retrosternalgoiter,concomitantneckdissection,andthyroidcarcinoma
[22-27].
However,theroleofimplementationoforalcalciumandvitamin
Disnotnew,anditisconsideredaneffectiveapproachtothe
preventionofhypocalcemia.
Infact,thistreatmentpreventeda
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significantdecreaseofserumcalciumlevelsaswellasthesubsequentdevelopmentofmajorhypocalcemicsymptomsaftertotalthyroidectomy.Thesymptomsreportedbypatients
wereminimalandonlysevenrequiredintravenouscalciumadministrationafterhispersistentsignificant
hypocalcemiafailedtorespondtoimplementationoforalcalciumandvitaminD.However,
inthiscasehypocalcemicstatuswasprobablyduetothe
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accidentalremovalofparathyroidtissueduringsurgery,asshownbyhystologicalanalysis.
Twostudieshaveevaluatedtheefficacyofroutinecalciumsupplements
forthepreventionofhypocalcemiaafterthyroidectomy[28,29].Moore[28]reportedthatonly
4of124patientswhoreceiveddailytreatmentofcalcium(5g)after
bilateralthyroidresectiondevelopedhypocalcemia,and1requiredadministrationof
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intravenouscalcium.Basedonempiricalobservations,theprophylacticuseoforalcalciumtoreducetheriskofhypocalcemiccrisisandincreasethelikelihoodof
earlyhospitaldischargewasrecommended.Bellantoneetal
[29]reportedin
aprospectivecontrolstudythatonly3of26patients(11%)receivingoralcalciumsupplement(3g/d)hadsymptomsrelated
tohypocalcemiaaftertotalthyroidectomy,whereas11of27patients
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(40%)notreceivingcalciumsupplementhadsymptoms.Thesestudiessuggestthatpostthyroidectomyhypocalcemiacanbeconsiderablypreventedbytheroutineadministrationofcalciumsupplements.The
riskforpostoperativehypocalcemiaforpatientsundergoingTTwashigherthanthatfor
patientswithadvancedage.
Recently,therehasbeenagreatdeal
ofinterestinidentifyingperioperativefactorsthatcanpredictthe
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developmentofhypocalcemiaafterthyroidectomy[30,31].Thedrivetowardsashorterhospitalstayfollowingtotalthyroidectomyhasledtoanumberofstudiesevaluating
theuseofplasmabiochemicalmarkerstopredictthedevelopmentofhypocalcaemia.Thyroid
surgeryimpairsPTHsecretionbytheparathyroidglandsresultinginpostoperativeparathyroidinsufficiencyandsubsequent
developmentofhypocalcaemia[32].Themeasurementofserumcalciumconcentration
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followingthyroidectomyhasbeenusedinanattempttopredictthedevelopmentofhypocalcaemia.However,themeasurementoftotalserumcalciumisinaccurate,at
leastinpart,owingtopostoperativehaemodilution[33,34].
Thevalueof
PTHinpredictingpost-thyroidectomyhypocalcemiahasbeenextensivelyinvestigatedand
reported
intheliterature[35,36]AlthoughtheuseofPTHpost-thyroidectomy
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mayallowshorterhospitaladmission,rapidaccesstoresultsofpostop-erativePTHmeasurementisnotwidelyavailableinmosthospitals.Inaddition,thereis
noconsensusonthethresholdforPTHandtheoptimaltimingforits
measurementpost-thyroidectomy.ThePTHmeasurementonthefirstpostoperativedayhasbeenshown
tobeausefulmethodtopredictpost-thyroidectomyhypocalcemia[37].
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SerumPTHconcentration,whenchecked1-6hafterthyroidectomy,hasahigheraccuracyinpredictinghypocalcaemia[38].WhilsttheuseofserumPTHlevels
topredictpost-thyroidectomyhypocalcaemiaiswellestablished,itappearstolackthedesirable
100%accuracyrate.Wewerenotabletoanalysethepostoperativepercentagedecline
inPTHowingtothelackofpreoperativePTHdata.
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However,bothabsolutelevelsandpercentagedeclinehavebeenusedtopredicthypocalcaemiawithsimilaraccuracy,and,althoughsimilar,levelsvarybetweeninstitutions[36].
Also,wethinkthatpost-operativehypocalcemiacanbereducedwhena
preciseminimalsurgicaldissectionisperformed;infact,theuseofharmonicscalpel
canhelptoavoidenergyspread,bloodlossandedema,
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thuslimitingparathyroidfunctionimpairment[17-20].
VitaminDhasacriticalroleincalciumhomeostasis.VitaminDdeficiencyhasbeenfrequentlydocumented
inmedicallyillandfree-livingpopulations[39,40]Advancedageisreportedtobe
amajorriskfactorforvitaminDdeficiency.Agingisassociatedwithalterations
invitaminDmetabolism.Studieshaveobserved
(1)
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anage-relateddecreaseinrenal1-hydroxylaseactivityandintestinalcalciumabsorption,and(2)anage-relateddeclineinthecutaneousaccumulationof7-dehydrocholesterol,which
isconvertedintoprevitamin-D3bysolarultravioletradiation.Insufficientcalciumabsorptiondue
tolowvitaminDconcentrationsleadstoanincreaseinPTHsecretion.Increased
PTHstimulatesthesynthesisofcalcitriolandtherebyimprovescalcium
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absorptionefficiency[39,40].Inpreviousstudies,regimensoforalcalciumaloneandofacalciumandvitaminDcombinationwereeffective.Thestudyfrom
BellantoneetAl[29]alsorevealedthattheadditionofvitaminDto
oralcalciumsupplementswasassociatedwithsignificantlyhigherserumcalciumconcentrationsonpost-operative
days2and3andwithalowerincidenceof
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hypocalcemia.AlthoughithasbeenreportedthatvitaminDadministrationinhibitsiPTHsecretionbynormallyfunctioningparathyroidglands,priorstudiesandourownresults
showedthatiPTHsecretionwasnotaffectedbyvitaminDadministrationinpostthyroidectomy
patients.Therefore,theearlyuseofvitaminDinadditiontocalciumsupplements
canberecommendedforpatientsundergoing
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Toloneetal.BMCSurgery2013,13(Suppl2):S11Page5of6http://www.biomedcentral.com/1471-2482/13/S2/S11
totalthyroidectomy.Thedosagesanddurationsofcalcium
andvitaminDadministrationarealsoofconcern.InastudyfromRoh
andPark[32],routineoralcalciumandvitaminDsupplementswereeffectivein
reducingtheincidence(6%)andseverityofhypocalcemiaaftertotal
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thyroidectomy.Onlyaminorityofpatientsreceivingthesupplementspresentedwithminimalsymptomsrelatedtohypocalcemia,andhigherlevelsofserumcalciumduringthe
firstfewdaysaftertotalthyroidectomyweremeasuredinpatientsreceivingthesupplement.
Inapreviousstudy,wealsodocumentedthatregimensoforalcalciumaloneandofacalciumand
vitaminDcombinationwereeffectiveinmostcasesofthyroidectomy
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performedforbenignthyrodealpathology[41-44].
Conclusions
Thepreventionofsignificantsymptomatichypocalcemiawillallowearlydischargeofpostthyroidectomypatients
fromthehospital.Inturn,earlydischargeeliminatesthenecessityofmultipleblood
samplingsforclosemonitoringofserumcalciumoriPTHlevels.However,therisk
ofpostoperativehypocalcemiaforpatientsundergoingTTwashigherthan
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thatforpatientswithadvancedage.Inthesepatients,anaccurateclinicalandlaboratoristicfollowupduringthepost-operativeperiodisnecessary.
Inconclusion,ourdatasuggestthatpostoperativeoralcalciumandvitaminDsupplements
cantakearolethepreventionofpostoperativehypocalcemiaandforincreasingthe
likelihoodofasafeandearlydischargefromthehospital.
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Listofabbreviations
TT:TotalThyroidectomy;PTH:ParathyroidHormone;iPTH:intactParathyroidHormone
Competinginterests
The
authorsdeclarethattheyhavenocompetinginterests.
Authors contributions
ST,RR,PLhavemadesubstantialcontributionstoconceptionanddesign;RP,
GRhavemadesubstantialcontributionstoacquisitionofdata;GC,
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AB,VA,ADAhavemadesubstantialcontributionstoanalysisandinterpretationofdata;ST,RR,IVhavebeeninvolvedindraftingthemanuscript;RR,
PL,GDG,LB,DPhavebeeninvolvedinrevisingitcriticallyforimportant
intellectualcontent;ST,RRandLDhavegivenfinalapprovaloftheversion
tobepublished.
Authors information
ST:
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ResearchGrantFellowatSecondUniversityofNaples;RR:AssistantProfessorofSurgeryatSecondUniversityofNaples;GDG:AssistantProfessorofSurgeryatSecondUniversity
ofNaples;LB:SeniorDoctoratSecondUniversityofNaples;DP:AssistantProfessorof
SurgeryatSecondUniversityofNaples;VA:SurgicalFellowResidentatSecondUniversityofNaples;GC:
SurgicalFellowResidentatSecondUniversityofNaples;IV:SeniorDoctoratSecond
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UniversityofNaples;AB:SurgicalFellowResidentatSecondUniversityofNaples;ADA:SurgicalFellowResidentatSecondUniversityofNaples;RP:SurgicalFellowResidentatSecondUniversity
ofNaples;GR:SeniorDoctoratSecondUniversityofNaples;PL:AssistantProfessorof
Surgeryat
SecondUniversityofNaples;LD:FullProfessorofSurgeryatSecond
UniversityofNaples.
Declarations
Fundingof
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thisarticlehascomefrompersonalfunds.ThisarticlehasbeenpublishedaspartofBMCSurgeryVolume13Supplement2,2013:Proceedingsfrom
the26thNationalCongressoftheItalianSocietyofGeriatricSurgery.Thefull
contentsofthesupplementareavailableonlineathttp://www.biomedcentral.com/bmcsurg/supplements/13/S2
Published:8
October2013
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