1. Case Presentation, Management, Discussion and Sharing of Information on Dysphagia Jonathan R. Malabanan, M.D. Surgery Resident OMMC DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

2. General Data: F.D. 60 y.o Female Sta. Ana, Manila. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

3. Chief Complaint Dysphagia DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

4. History of Present Illness: 9 months PTA→ (+) dysphagia to solids (+) Chest pain (+) normal ECG 5 months PTA→ (+) weight loss (+) dysphagia to liquids and solids DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

5. 2 wks PTA →(+) feeling of regurgitation (+) progression of above conditions consulted at private Hospital →(+) normal CXR DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

6. →Esophagogram (+) Dilated esophagus with non passage of barium into the stomach. →EGD: Tight contraction of G.E jxn scope inserted up to D2 no mucosal irregularity no mass DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

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10. →Advised to undergo surgery and consulted our hospital due to financial constraint. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

11. PAST MEDICAL HISTORY: S/P Ex- lap, Ectopic Pregancy, 1966 DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

12. 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 “Towards Patient Safety in Surgery”

13. 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 DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

14. Salient Features: 60 y.o Female (+) Progressive dysphagia (+) non cardiac chest pain (+) weight loss (+) Feeling of regurgitation DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

15. Salient Features: (+) Esophagogram Findings: dilated esophagus with non passage of barium into the stomach (+) EGD: Tight contraction of G.E junction, scope inserted up to D2, no mucosal irregularity, no mass DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

16. Algorithm Progressive dysphagia Barium swallow Dilated esophagus, non passage of barium AchalasiaTumor Strictur e Endoscopy: no intraluminal mass tight GE junction no mucosal irregularity DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

17. Clinical Diagnosis DIAGNOSISCERTAINTYTREATMENT PRIMARYAchalasia95%Surgical Medical Mechanical SECONDARYStricture5%Surgical DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

18. PARACLINICAL DIAGNOSTIC PROCEDURE Do I need a paraclinical diagnostic procedure? No. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

19. Pretreatment Diagnosis: Achalasia DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

20. Goals of Treatment 1. Complete resolution of functional distal esophageal obstruction 2. Better long term improvement and prevent complication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

21. Pre Treatment Options BENEFITRISKCOSTAVAILABI LITY Mechanical (Pneumatic Dilation) SR:40-78% RR:20-50% (5 yrs) -Perforation (3-15%) -Scarring P20-30 thouNot available Surgical (myotomy) SR:95%-Perforation (1%) -Hemorrhage P30-40 thouAvailable Medical (Botox, ISDN, Nifedipine) Short duration of effect SR (botox):38% -Hemorrhage -Scarring P20-30 thou Botox: Not available DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC FETNER, MD. Achalasia: Willis or Heller? Department of Surgery, Baylor University Medical Center, Dallas, Texas. 1999;12:227-2

22. Treatment Plan Surgical What Approach? Abdominal or Thoracic? DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

23. Treatment Goal Better exposure of gastro-esophageal junction DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

24. Pre Treatment Options BENEFITRISKCOSTAVAILABILI TY ThoracicInadequate exposure of Gastro- esophageal junction Perforation mediastinitis CTT P40 thouAvailable Abdominalbetter access to gastro- esophageal jxn PerforationP30 thouAvailable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

25. Treatment Plan Abdominal Approach Esophagomyotomy alone or Esophagomyotomy plus fundoplication? DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

26. Treatment Goal Reduce incidence of gastro -esophageal reflux DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

27. Pre Treatment Options BENEFITRISKCOSTAVAILABILI TY Esophagomyo tomy alone Same incidence of gastroesophage al reflux Perforation Hemorrhage P30 thouAvailable Esophagomyo tomy plus fundoplication Reduce incidence of gastro - esophageal reflux By nine fold Perforation Hemorrhage P30 thouAvailable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412–415.

28. Treatment Plan Esophagomyotomy plus fundoplication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

29. Plan of Operation Esophagomyotomy with fundoplication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

30. 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 “Towards Patient Safety in Surgery”

31. Operative Maneuvers Patient supine under GA Asepsis antisepsis Sterile drapes placed Subxiphoid midline incision carried down to the peritoneum Liver inspected, stomach identified DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

32. Operative Maneuvers Left triangular ligament and falciform ligament cut Liver deflected laterally exposing the esophagus. Esophagus gently encircled with the index finger DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

33. Intraop- findings Constricted LES Marked dilatation of lower esophagus DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

34. Operative Maneuvers Left vagus nerve deflected out of area of dissection Myotomy performed extending distally over the stomach 2 cm below the GE junction and 5 cm proximally DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

35. Operative Maneuvers Note of dilatation of the LES area post myotomy -Posterior fundoplication carried out -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”

36. Operation Done: Esophagomyotomy with posterior fundoplication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

37. Final Diagnosis Achalasia S/P Esophagomyotomy with Posterior Fundoplication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

38. Post op Management: Maintained on NPO Adequate analgesia given Antibiotics continued (24 hrs) Adequate pulmonary support Chest physiotherapy Monitoring of early complications DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

39. Sharing of Information DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

40. Achalasia -disorder of lower esophagogastric motility due to failure of the lower esophageal sphincter to relax with swallowing. -Incidence of 1 in 100,000 per year DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

41. Signs & Symptoms Vomiting Progressive dysphagia Weight loss DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

42. Theories Neurogenic Myogenic Hormonal DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

43. Pathogenesis Neurogenic/Myogenic Theory: Degeneration of ganglion cells in the myenteric plexus and loss of nerves innervating the smooth muscle cells of the lower esophageal sphincter. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

44. Pathogenesis Hormonal cause: Reduced VIP( Vasoactive Intestinal Polypeptide) major inhibitory released at the intramural postganglionic neurons of the lower esophageal sphincter DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

45. Diagnostics CXR: widened mediastinum esophageal air fluid level or absence of gastric air DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

46. Diagnostics Barium Swallow: - esophageal dilatation with tapering at the esophageal junction “birds beak deformity” DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

47. Diagnostics Manometry: Characteristic Findings 1. hypertensive lower esophageal sphincter resting pressure 2. absence of peristalsis 3. incomplete or abnormal LES relaxation 4. elevated intraesophageal pressure DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

48. Diagnostics Endoscopy: assess the presence of: –inflammation –mucosal irregularity –or tumors in the esophagus DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

49. Treatment Medical –early stage of disease –patients who are high risk for surgery Isosorbide dinitrate –5-10mg –reduces LES pressure 66% for 90 min Nifedipine –10-20mg –reduces LES 30-40% for >1 hour DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

50. Treatment Botulinum toxin A (Botox) –80μg injected in 4 aliquots LES –potent inhibitor of achetylcholine released from nerve endings –decreasing unopposed LES stimulation DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

51. Treatment Mechanical pneumatic dilation Surgery myotomy DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

52. References: DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC FETNER, MD. Achalasia: Willis or Heller? Department of Surgery, Baylor University Medical Center, Dallas, Texas. 1999;12:227-230 Jedediah A. Kaufman, M.D., Dave R. Lal, M.D. and Brant K. Oelschlager, M.D. Surgical treatment for achalasia. GI Motility online (2006) doi:10.1038/gimo53 Published 16 May 2006 Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412– 415. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

53. MCQ 1. The following are Theories in the pathophysiology of achalasia except? a. Myogenic b. Neurogenic c. Immunologic d. Hormonal e. NOTA DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

54. MCQ 1. The following are Theories in the pathophysiology of achalasia except? a. Myogenic b. Neurogenic c. Immunologic d. Hormonal e. NOTA DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

55. MCQ 2. The following are characteristic manometric findings in Achalasia except? a. increased lower esophageal sphincter b. absence of peristalsis c. widened mediastinum d. incomplete or abnormal LES relaxation e. elevated intraesophageal pressure DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

56. MCQ 2. The following are characteristic manometric findings in Achalasia except? a. increased lower esophageal sphincter b. absence of peristalsis c. widened mediastinum d. incomplete or abnormal LES relaxation e. elevated intraesophageal pressure DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

57. MCQ 3. Act as a potent inhibitor of achetylcholine release from nerve endings thereby decreasing unopposed LES stimulation? a. Isosorbide dinitrate b. Atropine Sulfate c. Nifedipine d. Metoprolol e. Botox DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

58. MCQ 3. Act as a potent inhibitor of achetylcholine release from nerve endings thereby decreasing unopposed LES stimulation? a. Isosorbide dinitrate b. Atropine Sulfate c. Nifedipine d. Metoprolol e. Botox DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

59. MCR Direction: 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 “Towards Patient Safety in Surgery”

60. MCR 4. All of the following are involve in the treatment for Achalasia except? 1. Isosorbide dinitrate 2. Atropine Sulfate 3. Nifedipine 4. Metoprolol DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

61. MCR C.4. All of the following are involve in the treatment for Achalasia except? 1. Isosorbide dinitrate 2. Atropine Sulfate 3. Nifedipine 4. Metoprolol DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

62. MCR 5. Achalasia can be described by which of the following? 1. It is failure or lack of relaxation of the LES. 2. Dysphagia, regurgitation and nocturnal asthma are included in the classic triad 3. A barium esophagogram may demonstrate birds beak configuration at the GE junction. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

63. MCR 5. Achalasia can be described by which of the following? 4. T. cruzi that causes Chaga’s disease destroys Auerbach’s plexus only in the esophagus resulting in failure of LES to relax DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

64. MCR B. 5. Achalasia can be described by which of the following? 1. It is failure or lack of relaxation of the LES. 2. Dysphagia, regurgitation and nocturnal asthma are included in the classic triad 3. A barium esophagogram may demonstrate birds beak configuration at the GE junction. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

65. MCR 5. Achalasia can be described by which of the following? 4. T. cruzi that causes Chaga’s disease destroys Auerbach’s plexus only in the esophagus resulting in failure of LES to relax DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

66. Thank You! DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

67. Journal Appraisal Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for Achalasia: A Prospective Randomized Double-Blind Clinical Trial William O. Richards, MD, * Alfonso Torquati, MD, MSCI, * Michael D. Holzman, MD, MPH, * Leena Khaitan, MD, MPH, * Daniel Byrne, MS, † Rami Lutfi, MD, * and Kenneth W. Sharp, MD * Departments of Surgery and †Medicine and Biostatistics, Vanderbilt University, Medical School, Nashville, Tennessee. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

68. Objective: –We sought to determine the impact of the addition of Dor fundoplication on the incidence of postoperative gastroesophageal reflux (GER) after Heller myotomy. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

69. Summary Background Data: –Based only on case series, many surgeons believe that an antireflux procedure should be added to the Heller myotomy. However, no prospective randomized data support this approach. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

70. Patients and Methods: In this prospective, randomized, double- blind, institutional review board-approved clinical trial, patients with achalasia were assigned to undergo Heller myotomy or Heller myotomy plus Dor fundoplication. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

71. Patients and Methods: Patients were studied via 24-hour pH study and manometry at 6 months postoperatively. Pathologic GER was defined as distal esophageal time acid exposure time greater than 4.2% per 24- hour period. The outcome variables were analyzed on an intention-to-treat basis. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

72. Results: Forty-three patients were enrolled. There were no differences in the baseline characteristics between study groups. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pathologic GER Incidence Heller myotomy47.6% 10/21 Heller myotomy plus Dor fundoplication 9.1% 2/22

73. Results: Heller plus Dor was associated with a significant reduction in the risk of GER (relative risk 0.11; 95% confidence interval 0.02–0.59; P = 0.01). DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

74. Results: Median distal esophageal acid exposure time was lower in the Heller plus Dor (0.4%; range, 0–16.7) compared with the Heller group (4.9%; range, 0.1–43.6; P = 0.001). DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

75. Results: No significant difference in surgical outcome between the 2 techniques with respect to postoperative lower-esophageal sphincter pressure or postoperative dysphagia score was observed. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

76. Conclusions: Heller Myotomy plus Dor Fundoplication was superior to Heller myotomy alone in regard to the incidence of postoperative GER. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

77. Clinical Question: In Achalasia patients, should Heller Myotomy plus Dor Fundoplication be done to decrease the incidence of postoperative GER? DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

78. Tentative Answer Yes. In Achalasia patients, Heller Myotomy plus Dor Fundoplication should be done to decrease the incidence of postoperative GER. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

79. 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 “Towards Patient Safety in Surgery”

80. 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 “Towards Patient Safety in Surgery”

81. 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 “Towards Patient Safety in Surgery”

82. 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 “Towards Patient Safety in Surgery”

83. 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 “Towards Patient Safety in Surgery”

84. Conclusion In Achalasia patients, Heller Myotomy plus Dor Fundoplication should be done to decrease the incidence of postoperative GER. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

85. God bless DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”